Every finding on record at Caring House

Based on interview and record review, the facility failed to ensure required written discharge/transfer notification was provided for 2 of 2 sampled residents (R91 and R2) reviewed for discharge and hospitalization, respectively. The facility failed to: (1) provide R91 with written notice of the discharge and did not provide a copy of the discharge notice to the State Long-Term Care Ombudsman; and (2) provide the State Long-Term Care Ombudsman with a copy of R2's transfer notice following R2's transfer to the hospital. These failures resulted in R91 not receiving written information regarding the reason for discharge, effective date, discharge location, appeal rights, and information regarding the State Long-Term Care Ombudsman. In addition, the failure to provide a copy of the discharge/transfer notice to the State Long-Term Care Ombudsman limited the Ombudsman's opportunity to provide timely advocacy and assistance to R91 and R2 regarding their respective discharge/transfer. Findings Resident 91: Review of R91's IDT (Interdisciplinary Team) Discharge Plan and Instructions, dated and signed 6/10/26, documented the facility admitted the resident on 5/30/26 and discharged home on 6/10/26. Record review of R91's discharge records did not show evidence that a written notice of Discharge was given to the resident/representative/Ombudsman that included the reason for discharge, effective date, discharge location, appeal rights, and information regarding the State Long-Term Care Ombudsman. Review of R91's Minimum Data Set (MDS-assessment tool), dated 6/10/26, documented R91 was discharged to home/community with return not anticipated. During an interview on 9/1/26 at 1:54 pm Licensed Practical Nurse (LPN)2 stated that residents who are discharged home are given an IDT Discharge Plan form which includes a section that each specific discipline completes. LPN2 stated that Social Services section usually lists the Ombudsman contact information and other advocacy agencies' information. LPN2 stated that nursing used to provide a Bed Hold notice that contained the Ombudsman and advocacy information, but the Bed Hold notices are no longer given to residents who are discharged home. During an interview on 9/1/26 at 3:07 pm Social Services (SS)1 stated that she has not been in involved in providing written notice of discharge with information on Ombudsman and advocacy agencies when residents are discharged home but believe this may be provided by Admissions Coordinators who assist with admissions and discharges. During an interview on 9/1/26 at 3:14 pm Admissions Coordinator Clinical (ACC)1 and ACC2 stated that they are not involved in providing written notice of discharge with information on Ombudsman and advocacy agencies when residents are discharged home. ACC1 and ACC2 stated that they arrange durable medical equipment when residents go home ACC1 and ACC2 stated that they do go over the notice of discharge that is Admissions Agreement packet when residents are admitted . During an interview on 9/2/26 at 8:50 am Registered Nurse (RN)1 stated that RN2 who completed R91's discharge was not working today but was able to provide information on the discharge process. RN1 stated that nursing did not provide residents discharged home with written discharge notices containing Ombudsman and advocacy agency information. RN1 stated this information was contained in the facility's Bed Hold notice, which was provided to residents transferred to the hospital but not to residents discharged home. RN1 estimated this practice had been implemented approximately six months earlier. During an interview on 9/2/26 at 9:05 am Registered Nurse Unit Manager (RNUM)1 stated that the facility stopped providing written notice that included ombudsman and advocacy agencies when residents are discharged home about a few months ago. During an interview and concurrent record review on 9/2/26 at 9:09 am with Director of Nursing (DON) and Administrator, the DON stated the facility had stopped providing the written discharge notice containing Ombudsman and advocacy agency information to residents discharged home because those residents agreed with the discharge and bed-hold information did not apply. During joint review of the State Operations Manual Appendix PP the DON acknowledged the facility was required to provide written discharge notification to residents discharged home and confirmed the facility had not been providing the required notice. During an interview on 9/3/26 at 2:20 pm Medical Records Supervisor (MRS) stated that because a written discharge notice was not provided to R91, a copy of the notice was not sent to the Ombudsman. During a concurrent interview and record review on 9/3/26 at 3:01 pm Administrator reviewed facility's Transfer or Discharge Notices policy and confirmed R91's planned discharge required written notice, R91 did not receive the notice, and the notice should have been provided. The Administrator also confirmed that the facility's policy required a copy of the Discharge/Transfer notice to be sent to the Ombudsman and confirmed this was not done for R91. Facility policy, Transfer or Discharge Notices, dated 3/2026, documented Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman.Notice of Transfer or Discharge (Anticipated).2. Under the following circumstances, the notice of transfer is given as soon as it is practicable but before the transfer or discharge.b. The resident's health improves sufficiently to allow a more immediate transfer or discharge.3. The resident and representative are notified in writing of the following information: a. The specific reason for the transfer or discharge.b. The effective date of the transfer or discharge; c. The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: (1) the name, address, email, and telephone number of the entity which receives such appeal hearing requests;.e. The name, address, and telephone number of the Office of the State Long-term Care Ombudsman. 4. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative. For R2: Review of the admission Record, also called the face sheet, revealed R2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Review of the Notice of Resident Transfer or Discharge, dated 08/24/26, revealed R2 was notified of the transfer to the hospital for further testing related to positive fecal occult blood test. Review of the Electronic Health Record failed to show documentation that a copy of the Notice of Resident Transfer or Discharge was sent to the representative of the Office of the State Long-Term Care Ombudsman. On 09/02/26 at 10:21 AM, an interview and concurrent medical record review were conducted with Registered Nurse Unit Manager(RNUM)1. RNUM1 reviewed PointClickCare, the facility's cloud-based electronic health record system, and confirmed R2 was transferred to the hospital on [DATE] due to positive fecal occult blood. RNUM1 stated that when a resident transfers out, staff complete the Notice of Resident Transfer or Discharge and send the form to Medical Records. RNUM1 stated, They take care of it from there. On 09/03/26 at 2:06 PM, an interview was conducted with Medical Records Supervisor (MRS). MRS stated they send a report to the Ombudsman monthly. MRS stated that for the month of August, the report was sent during the first week of September. MRS stated the report includes a list of residents who were admitted , sent to the hospital, or discharged from the facility. MRS stated they do not send a copy of the Notice of Resident Transfer or Discharge to the Ombudsman. MRS stated they were not aware of the requirement to send a copy of the notice to the Ombudsman.

Based on interview and record review, the facility failed to implement its Water Management Program when water temperatures were repeatedly below the facility-established control limits for Unit B, one of four units reviewed, and corrective actions were not implemented when monitoring results fell outside the established control limits.This deficient practice had the potential to create conditions conducive to the growth and transmission of Legionella and other waterborne pathogens, placing residents on Unit B at risk for waterborne illness. Findings Include: Review of the facility's Legionella Water Management Program policy, revised May 2026, revealed the facility was committed to the prevention, detection, and control of waterborne contaminants, including Legionella. The policy indicated the facility's Water Management Program was part of the infection prevention and control program and was overseen by the water management team. The water management team included the Infection Preventionist (IP), Administrator, Medical Director or designee, Director of Maintenance, and Director of Environmental Services. The policy indicated the purpose of the Water Management Program was to identify areas in the facility's water system where Legionella bacteria could grow and spread and to reduce the risk of Legionnaires' disease. The program included identification of areas within the water system that could encourage the growth and spread of Legionella or other waterborne bacteria and identification of conditions that could contribute to Legionella growth, including water temperature fluctuations, water pressure changes, and water stagnation. The policy further indicated the Water Management Program would be reviewed at least annually, or sooner when established control limits were consistently not met. Review of the facility's Water Management Plan, dated September 2025, page 4, under Function, revealed the facility was to verify and document the results of monitoring activities, take corrective action for test results outside established parameters, and respond to probable or confirmed waterborne pathogens when control limits were not maintained. Review of the facility's Water Testing Document revealed monitoring results for the loop system in patient care areas and identified a water temperature control range of 108 degrees F to 120 degrees F. Further review identified the following Unit B temperatures below the facility-established lower control limit of 108 degrees F: 07/13/26 – B130: 107 degrees F07/14/26 – B109: 100 degrees F07/15/26 – B130: 107 degrees F07/16/26 – B109: 100 degrees F07/20/26 – B108: 100 degrees F07/22/26 – B108: 100 degrees F07/23/26 – B130: 107 degrees F07/24/26 – B108: 100 degrees F07/27/26 – B130: 107 degrees F07/28/26 – B108: 100 degrees F07/30/26 – B108: 100 degrees F08/03/26 – B108: 100 degrees F08/04/26 – B130: 100 degrees F08/05/26 – B109: 100 degrees F08/17/26 – B108: 100 degrees F08/18/26 – B130: 107 degrees F08/19/26 – B109: 100 degrees F08/21/26 – B130: 100 degrees F08/24/26 – B109: 100 degrees F08/26/26 – B109: 100 degrees F. During an interview on 09/03/26 at 1:13 PM, the IP confirmed she was a member of the facility's water management team. The IP stated the Maintenance Department oversaw the Water Management Program, and water testing was conducted daily. She stated that when deviations occurred, she deferred to Maintenance. The IP stated she was unsure what was being evaluated during the daily water testing and was unable to identify which areas of the facility had identified water system risk factors. The IP acknowledged it was important for the IP to know the details of the facility's Water Management Program. During a joint interview on 09/04/26 at 10:34 AM with Maintenance Staff (S)1, S2, and S3, the facility's water temperature logs were reviewed. The maintenance staff confirmed they were aware of the temperature deviations documented for Unit B and acknowledged the temperatures should have been within the facility's established control range. When asked about the repeated temperatures below the established control limit, the maintenance staff attributed the temperatures to Unit B being the dialysis unit and stated the dialysis staff preferred the lower temperatures. However, there is a separate hallway on Unit B with a resident census of 14. S1 and S3 confirmed there were no alternative water temperature control limits established for Unit B and no corrective action had been taken in response to the temperature deviations. When asked whether Unit B had identified water system risk factors, S1 and S3 stated there were none. Review of the facility's water system diagram with the maintenance staff identified Unit B as an area associated with permissive temperatures and stagnation. During an interview on 09/04/26 at 1:28 PM, the Assistant Administrator confirmed she received the water testing results and reviewed them when they were distributed. The Assistant Administrator stated she did not believe there was a concern with the documented temperatures because residents had not voiced discomfort. She acknowledged that failure to implement measures when water temperatures were outside the established control range could increase the risk for waterborne illness. .

Based on observation, interview, record review, the facility failed to ensure food and dishware were maintained under safe and sanitary conditions when the facility failed to: (1) ensure cleaned bowls were adequately dried and were not stored with standing water; (2) maintain a unit refrigerator at 41 F or below; and (3) ensure opened food items were appropriately dated and food items past their expiration date were removed from 2 of 3 unit refrigerators/freezers (Unit E and Unit F) reviewed. These failures placed all 86 residents who received meals prepared by the kitchen at risk for food-borne illness. Findings: During an interview on 8/31/26 at 8:55 am Food Services Director FSD stated that all residents in the facility received their meals from the kitchen. Review of The Caring House daily census report, dated 8/31/26, showed there were 86 residents in the facility. 1. Cleaned dishware stored with standing water Review of the U.S. Food and Drug Administration (FDA) 2022 Food Code, dated 1/18/23, Section 4-901.11 Equipment and Utensils, Air-Drying Required, documented, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Review of facility's Sanitization Policy, dated 2/20/26, documented Food preparation equipment and utensils. are allowed to air dry whenever practical. Observation on 9/1/26 at 11:07 am showed a rack of bins in the dish drying area of the kitchen. Each bin contained several bowls placed loosely in no uniform orientation. The bowls were not stacked; some were positioned upside down while others were positioned right side up. About four bowls were pulled out of the bin which showed visible water droplets on the interior surfaces and standing water pooled in the bottom of the bowls. The pooled water measured approximately two teaspoons in some of the bowls. Food Services Director (FSD) confirmed water was present and stated it should not have been there. FSD stated the bowls were used cereal during breakfast, had been washed and dried, and were ready for use. FSD confirmed this was the dish drying area of the kitchen and all the dishware and items in the area were ready for use. FSD returned the bowls to the dishwashing area and stated they needed to be rewashed and dried because they were wet. Observation on 9/3/26 at 3:30 pm showed a rack of bins with bowls in same dish drying area of the kitchen with bowls arranged in a similar manner as the previous observation. Three bowls were pulled out of the bin which showed visible standing water pooled on the interior food-contact surface on the bowl. One bowl contained approximately 1/4 cup of standing water with multiple visible white specks floating on the surface of the water. The remaining two bowls contained standing water which was pooled in the bottom of the bowls. During a concurrent observation and interview on 9/3/26 at 3:31 pm, Dietary Aide/Dishwasher (DA/DW)1 stated that all dishware in the area had been washed, dried, and was ready for use. DA/DW1 stated none of the dishware should have water on it because water created a risk for bacteria. DA/DW1 stated dishes were washed and dried in the washing area before being placed in the clean dish storage area. WJ stated that the bowls were used for soup or salad during lunch. DA/DW1 observed the three bowls and stated that water was present but should not have been there. FSD arrived at the area and confirmed the presence of water in the bowls and stated that it looked like there was about a quarter cup of water in one of the bowls, and water should not have been in the bowls. 2. Unit refrigerator temperatures above 41 degrees F Review of facility policy Foods Brought in from Outside Sources and Personal Food Storage Policy, dated 5/2026, documented All refrigerator units will have internal thermometers to monitor for safe food storage temperatures. Units must maintain safe internal temperatures in accordance with state and federal standards for safe food storage temperatures. Staff will monitor and document unit refrigerator temperatures. Review of facility policy Food Receiving and Storage Policy, dated 8/2026, documented food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.#11.Refrigerators should maintain food temperatures at or below 41 degrees F.#13. b. TCS [as defined by FDA 2022 Food Code, TCS are time/temperature control for safety which defines foods requiring strict temperature and time limits to stop harmful bacteria or toxins from growing] foods must be maintained at or below 41 degrees F unless otherwise specified by law.Temperatures of refrigerators should be between 35 to 41 degrees F. Observation of Unit E dining room on 8/31/26 at 11:12 am, 12:19 pm, and 12:28 pm showed one resident in the dining room. During a concurrent observation and interview on 8/31/26 at 1:59 pm the Unit E refrigerator door had a lock on it. Certified Nursing Assistant (CNA)2 unlocked the refrigerator door. A round, analog dial thermometer was positioned on the top shelf of the refrigerator door. The thermometer displayed temperature markings in degrees Fahrenheit ( degrees F) and Celsius ( degrees C). The thermometer needle pointed to approximately 46 degrees F, within the red-colored WARM range. When asked to provide the temperature reading CNA2 stated it was 46 degrees. CNA2 stated that the temperature was too warm and maybe the refrigerator door had been opened too long. At the time of the observation, one resident was present in the dining room and no meal service was in progress. Review of the facility's undated meal schedule, provided in the survey binder, showed Unit E's scheduled meal times were breakfast at 7:30 am, lunch at 12:00 pm, and dinner at 5:30 pm. The refrigerator thermometer temperature reading of approximately 46 degrees F was observed at 1:59 p.m., approximately two hours after the scheduled lunch meal time and approximately three hours and 30 minutes before the scheduled dinner meal time. During a concurrent observation and interview on 8/31/26 at 3:42 pm Licensed Practical Nurse (LPN)2 unlocked Unit E refrigerator. The thermometer was in the same location as previous observation. The thermometer needle pointed to approximately 42 degrees F, within the red-colored WARM range. When asked to provide the temperature reading LPN2 stated it was 42 degrees and should have been 41 degrees F. LPN2 stated the thermometer was located in the refrigerator door and stated that frequent opening of the door might have contributed to the elevated reading. LPN2 moved the thermometer to the top shelf and stated the temperature would be checked again later. At the time of the observation, no resident was present in the dining room and no meal service was in progress. This observation occurred approximately three hours and 42 minutes after the scheduled 12:00 pm lunch service. The two thermometer readings showed the temperature remained above 41 degrees F on two separate observations conducted approximately one hour and 43 minutes apart. During a concurrent observation and interview on 9/1/26 at 9:43 am, CNA2 unlocked Unit E's refrigerator door, the thermometer located in the door had a reading of 44 degrees F, which CNA2 confirmed. During a concurrent observation and interview on 9/1/26 at 9:50 am FSD confirmed the temperature reading was 44 degrees. FSD obtained a temperature of 33 degrees F with a temperature gun, while the thermometer located in the refrigerator door continued to read 44 degrees F. Staff stated the temperature recorded on the refrigerator log that morning was 33 degrees F. During an interview on 9/1/26 at 10:50 am FSD stated that the expectation was for the refrigerator to be maintained at 41 degrees F. During an interview on 9/1/26 at 11:20 am FSD stated the expectation was that food should not remain in the temperature danger zone for two hours. 3. Undated and expired food stored in the unit refrigerator Review of facility policy Foods Brought in from Outside Sources and Personal Food Storage Policy, dated 5/2026, documented Unlabeled/undated food or foods whose date is outside facility policy for food storage (3 days)(30 days for items such as salad dressing, condiments in original container) can be disposed of by staff. Review of facility policy Food Receiving and Storage Policy, dated 8/2026, documented food will be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination.#11.Refrigerators should maintain food temperatures at or below 41 degrees F.#12.Leftover food should be stored in covered containers.and clearly labeled and dated.Leftover food must be used within 3 days or discarded as per 2022 Federal Food Code.#13. b. TCS [as defined by FDA 2022 Food Code, TCS are time/temperature control for safety which defines foods requiring strict temperature and time limits to stop harmful bacteria or toxins from growing] foods must be maintained at or below 41 degrees F unless otherwise specified by law.Temperatures of refrigerators should be between 35 to 41 degrees F.f. All foods should be covered, labeled, and dated and routinely monitored to ensure that foods (including leftovers) will be consumed by their use by dates.or discarded.j. Opened .mayonnaise.in original container will be good for 30 days, unless manufacturer use by [sic] dates comes first. 14. Frozen Foods: c.All foods will be checked to ensure that foods will be consumed by their use by dates or discarded. Unit E refrigerator During a concurrent observation and interview with CNA2 on 8/31/26 at 1:59 pm Unit E refrigerator contained an opened partially filled eight-ounce container of cream cheese with manufacturer's use by date of July 10, 2026, there was no date written on the container to indicate when the container was opened. The refrigerator also contained an opened partially filled 22-ounce jar of mayonnaise with an open date of June 8, 2026, and manufacturer's use by date of August 10, 2026. CNA2 confirmed the dates of the two food containers and stated that both should have removed from the refrigerator. During an interview on 8/31/26 at 2:32 pm FSD stated that kitchen staff checked the unit refrigerators daily and the checks included discarding expired resident personal food items. FSD stated that the facility considered food expired when it was three days past the opened date, 30 days if the item was unopened and remained in the original container, or when it was past the manufacturer's expiration date. FSD stated that the cream cheese and mayonnaise should have been discarded but wasn't. During an interview on 9/4/26 at 9:33 am Administrator stated that dishware should be completely dried and should not have standing water, refrigerators should be at proper temperatures and expired foods should be labeled, dated and discarded when it is past the expiration dates. Unit F Refrigerator: On 08/31/26 at 11:54 AM, during a concurrent observation and interview with Certified Nursing Assistant (CNA)3, the resident refrigerator and freezer were inspected. The refrigerator contained resident food and beverages and was secured with a lock. CNA3 stated staff periodically changed the access code. Food items observed in the refrigerator were dated, with no concerns identified. Observation of the freezer revealed one box of Red [NAME] French Bread 3 Meat Pizzas marked 1/19/26. The manufacturer's packaging identified a Best Before date of May 31, 2026. CNA3 acknowledged that the pizza was past the manufacturer's identified date and stated, It's expired. On 08/31/26 at 11:55 AM, during a concurrent interview, the Registered Nurse Unit Manager (RNUM)3 acknowledged the box of pizza was past the manufacturer's Best Before date and stated that kitchen staff were responsible for checking the refrigerator/freezer to ensure expired food items were removed. RNUM3 also stated that 1/19/26 written on the box of the pizza is the day it was stored inside the refrigerator.

Based on interview and record review, the facility failed to thoroughly investigate an allegation of financial abuse involving Resident (R)12, one of three residents sampled for abuse, after the allegation was reported to facility Administration. The facility failed to conduct and document an investigation of R12's May 2026 allegation of financial abuse. This deficient practice placed R12 at risk for continued financial exploitation and misappropriation of resident property. Findings include: Review of the facility's abuse policy titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised 06/2026, revealed all allegations were to be thoroughly investigated, and the Administrator was responsible for initiating investigations. The policy indicated the individual conducting the investigation was to review documentation and evidence, interview the person reporting the incident and witnesses, interview the resident as medically appropriate, review all events leading up to the alleged incident, and document the investigation completely and thoroughly. Review of a Social Services note dated 05/05/26 at 5:00 PM revealed Social Services (SS)2 documented that, during a visit with R12 and while attempting to facilitate a meeting with Adult Protective Services (APS) regarding a previously established case, R12 made an allegation of financial abuse. The note documented Resident continued in circular conversation, accusing [family member] of stealing money. During an interview on 09/01/26 at 12:27 PM, SS1 stated R12's May 2026 financial allegation had been reported to Administration. Requested the facility provide documentation of its investigation into R12's May 2026 allegation of financial abuse. The facility was unable to provide documentation demonstrating that it had investigated the allegation. During an interview on 09/01/26 at 3:43 PM, the Administrator stated the facility did not investigate R12's allegations made earlier in the year because the allegations did not involve facility staff and APS was already investigating. The Administrator acknowledged the interdisciplinary team (IDT) can do a better job with investigations when these concerns arise.

Based on interview and record review, the facility failed to implement its abuse prevention policies and procedures. Specifically, the facility failed to recognize allegations made by Resident (R)12, one of three residents sampled for abuse, involving a family member/legal representative related to financial abuse should trigger implementation of their policy and ensure reporting and investigating protections were in place. This deficient practice placed R12 at risk for continued financial exploitation and misappropriation of resident property.Cross Reference F609 and F610.Findings include: Review of the facility's abuse policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 05/2026, revealed the facility's abuse prevention program was intended to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone, including family members and legal representatives. The policy further indicated the facility was to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and investigate and report allegations within timeframes required by federal requirements. During an initial resident interview on 08/31/2026 at 9:34 AM R12 expressed concern that his family member who was also his legal guardian, was taking money out of his bank account inappropriately. R12 stated he had talked with the Social Service (SS)1 about this and that SS1 was helping him to address this. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a score of 15 out 15 on a Brief Interview for Mental Status, indicating R12's thinking and memory skills were cognitively intact without signs of cognitive impairment. Review of R12's progress notes revealed earlier allegations of financial abuse. A Social Services note dated 05/05/26 at 5:00 PM revealed SS2 documented Resident continued in circular conversation, accusing [family member/guardian] of stealing money. During an interview on 09/01/2026 at 12:25 PM with Social Services staff, SS1 and SS2, SS1 denied awareness of R12's current allegation of financial abuse by his guardian, stating R12 had told her that his guardian was lying to him and trying to control him, and that Adult Protective Services (APS) had closed their investigation into the guardian. SS1 and SS2 were informed of the current allegations of financial abuse made on 8/31/26. During the interview SS2 confirmed that R12 had made allegations related to his family member/guardian stealing his money in the past. SS2 explained that APS investigated those allegations earlier this year, describing that R12 had contacted APS through community resources, the facility had not reported this to APS. SS2 confirmed that Administration was aware of the allegations R12 had made earlier in the year. On 09/01/26 at 3:30 pm, review of Facility Reported Incidents reported to the Centers for Medicare and Medicaid Services (CMS) revealed the allegations reported to the SS staff had not been reported to CMS. During an interview on 09/01/26 at 3:43 PM, the Administrator stated that those types of allegations should be reported to APS. Upon further discussion he confirmed the facility did not report or investigate the allegations made by R12 earlier in the year because the allegations did not involve facility staff and APS was already investigating. Following the interview the Administrator implemented their policy, reporting the current allegations of financial abuse to APS, the Ombudsman, law enforcement, and CMS and initiating a facility investigation.

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing information posted for residents, families, and the public accurately reflected the number of nursing staff working in the facility. Specifically, the nurse staffing posting for the 08/30/26 AM shift inaccurately reported the number of Certified Nursing Assistants (CNAs) who worked that shift.This deficient practice had the potential to provide residents, families, and the public with inaccurate information regarding the nursing staff available to provide resident care.Findings:On 08/31/26 at 10:30 AM, the daily nurse staffing information was observed posted on the wall across from the facility's front entrance desk.On 09/03/26 at 3:45 PM, during an interview and concurrent review of the daily nurse staffing information, the Staffing Coordinator stated that she was responsible for preparing the staffing information each morning and that the receptionist posted it. The Staffing Coordinator stated that once the information was posted, the facility did not revise the posting to reflect subsequent staffing changes.Review of the staffing records for the 08/30/26 AM shift revealed that 17 CNAs were initially scheduled. The Staffing Coordinator stated that one CNA called off, resulting in 16 CNAs working the shift. However, the daily nurse staffing posting reflected 15 CNAs with a total of 178 hours worked.The Staffing Coordinator acknowledged that the posted number of CNAs did not accurately reflect the actual staffing for the 08/30/26 AM shift and stated, That one is not accurate.

Based on observation, interviews, and record review, the facility failed to provide adequate supervision and follow its elopement policy for 1 of 1 resident (R1) reviewed for supervision. This failure resulted in R1 remaining alone outdoors for approximately 4 hours in extreme heat conditions (100 Fahrenheit (F) - 111 F, with a heat index of up to 114 F). (Heat index is defined as a measurement that combines air temperature and relative humidity to determine how hot the air actually feels to the human body.) The deficient practice placed the resident at risk for heat exhaustion, heat stroke, and/or death and resulted in a situation of immediate jeopardy.On [DATE] at 5:30 PM the Administrator and Assistant Administrator were notified of an Immediate Jeopardy determination for [DATE] for 42 CFR S483.25 (F689) related to the failed supervision and monitoring of one resident, leaving her outdoors in temperatures which reached 114 degrees Fahrenheit for 4 or more hours, placing her at risk for potentially life-threatening heat exhaustion and heat-stroke.On [DATE] at 5:45 PM the Administrator and Assistant Administrator were notified that the immediacy had been removed based on on-site verification that the IJ removal plan was implemented.Following the removal of the immediacy, no noncompliance remained.Findings include:Review of the admission Record revealed that R1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition (such as viral infection or toxins in the blood), type 2 diabetes mellitus with other specified complication (a chronic condition where the body does not use insulin properly or does not produce enough insulin, who has a complicating issue like those affecting the eyes, nerves, or kidneys), hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease (a long-term kidney disease caused by high blood pressure, and the kidneys have permanently lost most of their function and can no longer filter waste products from the blood.)A risk for injury care plan created on [DATE] and reviewed on [DATE] related to R1's poor safety awareness and non-compliance with safety measures due to a history of right femur fracture (broken leg) secondary to a fall, a diagnosis of dementia (progressive or persistent loss of intellectual functioning), and a history of a transient ischemic attack (temporary interruption of blood-flow to the brain) had a goal for the resident to call for assistance with transfers, mobility, and repositioning. Interventions included frequent checks on the resident to assist with transfers and mobility.The quarterly Minimum Data Set assessment dated [DATE] revealed a score of 14 on the Brief Interview for Mental Status, indicating intact cognition. According to the assessment, the resident demonstrated no symptoms of psychosis or behaviors, including wandering. The resident was dependent/required substantial assistance for most activities of daily living, and she utilized a wheelchair for mobility.A Facility Reported Incident, received on [DATE], indicated that R1 was outside in the unit F courtyard for an extended period of time. The facility brought her in on 8/20 around 21:00 [9:00 PM].According to the Follow-up Investigation Report, received on [DATE], At approximately 5:08 PM on [DATE] [R1] wheeled herself out the exit door near her room into the garden area to go see the jalapenos. [R1] had intended to follow [another resident] inside when she discovered one wheel on her wheelchair had rolled off the sidewalk and became stuck in the gravel. [R1] attempted to get the attention of [the other resident] but that resident was in a powered wheelchair and was too far away by the time [R1] discovered she was stuck. Per camera review, [R1] was found at 9:22 PM.Review of the local weather obtained from https://www.local conditions.com, revealed the following temperatures were noted at the location of the facility on [DATE] for the following times:-5:00 PM: 111 F. Humidity:19%. Heat index: 114 F.-6:00 PM: 108 F. Humidity: 20%. Heat index: 111 F.-7:00 PM: 105 F. Humidity: 22%. Heat index: 107 F.-8:00 PM: 103 F. Humidity: 24%. Heat index: 104 F.-9:00 PM: 100 F. Humidity: 25%. Heat index: 101 F.A Health Status Note dated [DATE] at 05:42 AM included that the writer had assisted the resident back inside after her wheelchair had become stuck in the courtyard area. According to the note, the resident did not appear to be in any acute distress. Vital signs obtained were within normal limits: Blood Pressure: 140/78; pulse of 64; and a temperature of 98.0 F. A full skin assessment was completed with no abnormal findings noted. The provider was notified of the incident and STAT (urgent) labs were ordered. The resident was offered oral fluids and snacks. It was noted that the resident was capable of self-propelling throughout the facility and frequently enjoyed spending time in the courtyard garden.On [DATE] at 3:48 PM a Social Service Progress Note included that the writer had met with the resident for a check-in following the incident of the resident's wheelchair stuck outside for several hours last night. According to the note, the resident was alert and oriented. The note stated the resident became appropriately tearful when describing the incident of last night. Resident indicated that she did not speak to anyone for a very long time. I was scared. I did not think anyone cared about me. Writer provided extensive supportive listening and validation as needed. Resident thanked writer repeatedly.An interview with the facility Administrator was conducted on [DATE] at 2:53 PM. He stated that they had no protocols in place for the custodial transfer of residents prior to the incident with R1. He stated that the off-going Certified Nursing Assistant (CNA) had forgotten to tell the on-coming CNAs that the resident had gone out into the garden. He stated that there were a lot of activities that evening, the CNAs assumed that R1 was attending one of them and thought nothing of her not being in her room.On [DATE] at 3:15 PM an observation of the courtyard garden area off the F-unit was conducted with the Director of Nursing (DON). The area had several raised garden beds with various kinds of plants. The DON motioned to one particular planter and stated that R1 liked to come out every day and look at the peppers, as she had done on [DATE]. Per observation, the raised planter beds were surrounded by cement pathways, which in turn were surrounded by rock and gravel landscaping. The DON pointed to the area of the cement pathway where R1's wheelchair had gone off the cement pathway and had gotten stuck in the gravel. Then, she pointed up into the far-left corner of the patio and stated that the camera in that corner was broken. She stated that the resident had been found there, pointing to the area below and to the right of the camera.On [DATE] at 3:12 PM a phone interview was conducted with CNA 39. She stated that towards 5:00 PM on [DATE], as she was passing out dinner trays, she saw R1 rolling herself out towards the garden. She stated that it got busy and chaotic, and she tried to remind herself to remember to go get her [[R1], but she forgot. Everything was so busy in the moment. She stated she didn't think of it because the resident always goes out by herself. She stated that the resident usually stays out for 15-20 minutes and then she comes back in. She stated that it should have been her job to have given a walking report. Where, she explained, CNAs walk from room to room with the oncoming shift and observe each resident at shift change. She stated that some of the CNAs do it and some of them don't want to, so she just gave a verbal report. She stated that she gave report on R1, but that she had forgotten that R1 was outside. Otherwise, she stated that all of the other residents in her section were in their rooms eating. Nobody was out. They were all in their rooms eating. CNA 39 stated she left the facility at 6:14 PM. CNA 39 stated that it was her responsibility to report to the oncoming shift that R1 had gone into the garden and that was her mistake.A phone interview was conducted on [DATE] at 3:57 PM with a CNA 8. She stated that R1 was assigned to her that evening. She said that at approximately 6:10 PM, as she was collecting trays, she noticed R1 was not in her room and hadn't eaten her dinner. She stated that she went back a couple of times and noticed that R1 was still not in her room. She stated that she thought the resident might have been at one the activities that evening, (church or a birthday party.) She stated that some residents were also at a wake. She stated that she had asked the nurse, RN 6, which residents had gone to the wake. CNA 8 stated, They said a bunch of people went to the wake. CNA 8 was asked, Did RN 6 say that a bunch of people went to the wake, or did RN 6 say that R10, R12, and R14 went to the wake? CNA 8 stated, R10, R12, and R14. Did RN 6 say that R1 had gone to the wake? She stated, No. When asked what she did when she found that R1 had not gone to the wake, Did you look for her in the activities? She stated, No. When asked, Whose responsibility was it to find your resident? She stated, Mine.On [DATE] at 4:30 PM a phone interview was conducted with a CNA 27. She stated that when she came on shift, she started going around collecting trays and noticed that R1 had not eaten her dinner. She stated that R1 was not her resident that evening, but she felt like all the residents were her residents. She stated that she thought it was odd that R1 hadn't eaten. She stated that she asked the Licensed Practical Nurse (LPN 12), if he knew where R1 was and he said that nothing had been passed along in report. She stated that she walked around to the activities to look for her and when R1 wasn't there, she just assumed she must have gone to the wake. After that, at around 8:30 PM, the residents started coming back from the activities. She stated that she thought someone must have looked out of the window and seen R1 outside. When asked why someone did not look at the email or posting that stated who was at the wake, she stated that only the nurses could see who was out on pass. She stated that LPN 12 and Registered Nurse (RN 6) were responsible for looking on the computer or on the posting and checking who was out on pass. If R1 was not out on pass, they were supposed to start looking around the building.On [DATE] at 4:43 PM a phone interview was conducted with RN 6. She stated that on [DATE], dinner was at 5:30 PM, so some residents were still eating when she got there; others were done. She stated that R1 was not in her room, which was unusual. She stated that once everyone started to trickle back in after the activity at approximately 8:30 PM, they didn't see R1 return, so she and CNA 8 started looking outdoors and they found her. She stated that she couldn't remember whether the CNAs had reported they couldn't find R1 earlier in the evening. She stated that it may have been reported to LPN 12, but it was not reported to her.During an interview on [DATE] at 5:18 PM with R1 she stated she remembered getting stuck outside by the garden. She stated her wheelchair got stuck off the side of the cement. She said she was out there calling, Help! Help! for a long time, but no one heard her. She said she was real hot and sweating. She said she thought she was going to have to sleep outside in her chair. She stated she feels ok now. She stated she felt safe.On [DATE] at 10:20 AM an interview was conducted with the Recreation Therapy Supervisor (RTS). She provided the Activities calendar for [DATE], which included an Upper Room Church service on Wednesday, [DATE]. She stated that the service started at 7:00 PM and ended at 8:00 PM. She stated that also on the evening of [DATE] there was a surprise birthday party which also started at 7:00 PM. But obviously, no one knew about that. She stated that if anything, the evening activities usually started late. The residents normally had to be reminded, and staff had to go to the units to assist them. She stated that in addition to church and the birthday party, there was also a memorial service that day. She stated that the resident's called it a wake in their culture. She stated that she wasn't sure if it was an outing (where everyone had been invited) or a pass-request event (where individuals had to request to participate.) She stated that she would look into it and get back with additional information.At 10:50 AM on [DATE] the RTS returned with a copy of the email that she stated was sent to all the department leads, unit nurses, and the transportation team. The email was dated [DATE]. She stated that additionally, the email was posted in the nursing stations so that anyone could walk over and look at it. Review of the email included, These residents would like to [attend] services for a family member. The names of three residents were listed. Resident 1's name was not included. The document further stated, We will start loading at 5:00 PM and return by 10:00 PM. Please remember to post this in a prominent place if it hasn't already been posted. Thank you.An interview with LPN 12 was conducted on [DATE] at 1:32 PM. He stated that the residents have activities about twice a week, sometimes three times a week. He stated that on Wednesdays they play BINGO and have a church service. He stated that evening activities start around 7:30 PM, after he arrives. He stated that from what he recalled, R1 was usually in her room, but not this day. He stated that, They (who he defined as the CNAs) told him, That she went to a funeral or something. When asked why he did not look at the email posting in the nursing station which listed the residents who were out on pass, he stated he did look at it and he saw that R1's name was not on it. However, he stated, he was told that she probably went to it. Then, someone (who he defined as a CNA) told him that she went to an activity. He stated that around 8:30 - 9:00 PM he was concerned when R1 did not return from the activities with the other residents. He stated he went to the activities and asked about R1. They said, No, [R1] was not there. So, he said that he went back to the unit and told RN 6. Yeah, so basically she was missing. He said he approached his CNAs and told them to go around and look. He stated that the process was to go around and look, then announce the resident was missing, and then everyone will go around and look. When asked why he waited so long to report that the resident was missing, he stated, It did not take so long. That information was not passed on to me. I was told that the resident went to an activity, so I waited for her to come back. But she did not come back. I was told that she went to a funeral, so I waited for her to come back. When she did not come back, I reported it to my charge nurse. No one said she was missing. That was why I did not report it.During an interview with the DON on [DATE] at 3:26 PM she stated that she was not in the facility that day. She stated she was notified about [R1] at about 9:30 PM that evening. She stated that the nurse could have walked over to the activities email and identified exactly who was out on pass. She stated that staff should not have assumed she was in a specific location, they should have verified where she was. She stated that the process was not for the nurse to ask the CNAs where the residents were. When it was indicated that R1 could have died as a result of being left outside, she stated, Yes.On [DATE] at 10:29 AM an interview was conducted with a Security Officer. She stated that on [DATE] she did her last round at 4:01 PM. She stated that she had to do a quick round because there was a birthday party that night and she knew there would be family coming in, so wanted to be at the front desk. She stated they do not have a receptionist in the evenings. She stated that it was her last patrol, and her shift ended at 8:30 PM. She stated that she did not go over to the F-Unit that night, and that she normally does random checks like that.According to the Centers for Disease Control and Prevention. (2024). Retrieved from htpps://www.cdc.gov/niosh/heat-stress/about/illnesses.html, Heat stoke is the most serious heat-related illness. It occurs when the body can no longer control its temperature: the body's temperature rises rapidly, the sweating mechanism fails, and the body is unable to cool down. When heat stroke occurs, the body temperature can rise to 106 F or higher within 10 to 15 minutes. Heat stroke can cause permanent disability or death if the person does not receive emergency treatment.According to the National Weather Service (NWS), retrieved from https://www.weather.gov/ffc/hichart?utm, a heat index (HI) of 105 to 129 F for people in high risk groups is defined as Danger with Sunstroke, muscle cramps, and/or heat exhaustion likely and heat stroke possible with prolonged exposure and/or physical activity.U.S. Environmental Protection Agency, [DATE] - Extreme heat is defined by unusually hot and humid conditions, or temperatures exceeding 95 F.Review of the facility policy titled Safety and Supervision of Residents, Reviewed/Revised 01/2025, included safety, risks, and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, then adjusts the interventions accordingly. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.The facility policy titled Elopement Prevention and Response, dated 4/2024, included nursing staff must be aware of the resident's location at all times. This includes participating in activities; transport to appointments; authorized passes, etc. If a resident is determined to be missing, unable to be located within 15 minutes or has not been seen by staff within the past 15 minutes, the elopement protocol is activated.During the current onsite survey, the facility provided evidence of corrective actions taken. The actions included:The facility developed and implemented an internal Plan of Correction which included:-Staff education and training on the Custodial Transfer of Responsibility protocol, beginning on [DATE] through [DATE], which will be monitored for 3 months (12/2025.) This applied to R1 and any other resident who may be affected by the deficient practice. This was a change to their systemic practice.-The facility conducted a Mock Elopement Drill on [DATE] with an After Action Review and PowerPoint presentation. This will apply to any other residents who may be affected by the deficient practice.-The Elopement Policy & Procedure was reviewed and updated [DATE].-The facility added the 2025 TCH Elopement protocol to their online training system on [DATE] so that training for staff is ongoing.-The Health Information Management Coordinator will compile forms weekly and report trends to the QAPI Committee monthly for review for a minimum of 3 months.This facility was able to demonstrate substantial compliance at the time of the survey.This deficient practice represents Past Noncompliance.

Based on observation, interviews, and review of records, the facility failed to protect one resident's (R4) right to be free from physical abuse by another resident (R3) for one resident-to-resident altercation reviewed when R3 hit R4.The deficient practice resulted in a violation of R4's right to be free from resident-to resident abuse.Findings include:For R4:Review of the Admissions Record revealed R4 was readmitted to the facility on [DATE] with diagnoses that included vascular dementia, moderate, with other behavioral disturbance (a stage of vascular dementia where cognitive decline significantly impacts daily life, requiring substantial assistance and exhibiting problematic behaviors like agitation, aggression, or mood changes) and displaced mid-cervical fracture of the left femur (fracture in the bone connecting the thigh bone to the hip joint), subsequent encounter for closed fracture with routine healing.The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 7 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. According to the assessment, the resident displayed no behaviors, he was dependent and/or required substantial/maximal assistance for most activities of daily living, and he utilized a walker and wheelchair.A Health Status Note dated 08/02/25 at 10:47 AM included that the resident was hit by a peer in the right upper arm area. When asked what happened, the resident stated, He hit me. The resident was taken to his room for safety as peer would not move from behind the resident. The resident was assessed for injuries. None were noted.For R3:Review of the Admissions Record revealed R3 was readmitted to the facility on [DATE] with diagnoses which included unspecified dementia, unspecified severity, with other behavioral disturbance (a type of dementia where the specific type and severity are unknown, but there are significant behavioral disturbances present) and unspecified psychosis not due to a substance or known physiological condition (a condition where a person experiences psychotic symptoms, such as delusions (false beliefs), hallucinations (seeing or hearing things that are not real), and disorganized thinking and speech.)A Behavior Note dated 03/04/25 at 4:39 PM included that R3 was sitting in the common area and took his leg rest off his wheelchair. The resident began to self-propel towards his room. Another resident was sitting at a table near R3's room doing a crossword puzzle. According to the note, R3 threw the leg rest on the table. The other resident said, Hey, I don't want that, take it with you. R3 raised his voice and said, F#@*k you, $%^&9#@!!. I'll beat your @%$. The writer went towards the table and separated the residents.A Behavior Note dated 04/02/25 at 12:55 PM included Resident is still exit seeking at this time, asking writer to open the damn door. He was kicking the wall and punching the window glass with his fist while still cursing at staff.On 05/24/25 at 7:54 AM a Behavior Note included that the resident was on his way to breakfast when he made his way to his peer's side of the hall. He wheeled himself by his peer's room and yelled, I'm going to kick his rhinestone cowboy @$$ as soon as I catch him. According to the note, the resident continued to the day room where he told staff, As soon as that lady moves, I'm going to bust his head.The quarterly MDS assessment dated [DATE] revealed the resident scored 11 on the BIMS, indicating moderate cognitive impairment. The resident's behavioral symptoms included verbal behaviors directed towards others and rejection of care. According to the assessment, the resident utilized a walker and a wheelchair, and he required supervision/touching assistance for most activities of daily living.A potential to be physically aggressive care plan initiated on 06/06/25 related to a diagnosis of dementia, as evidenced by agitation, exit seeking, hitting staff and other residents, and verbal aggression, had a goal for the resident to demonstrate effective coping skills. Interventions included for staff to intervene before agitation escalated; to guide the resident away from the source of distress; engage calmly in conversation; and if the response was aggressive, staff were to divert attention and separate R3.On 06/15/25 at 5:09 AM a Behavior Note included that at 7:00 PM the resident had been observed yelling and going towards another resident. Staff were able to get between the residents, and snacks and medication were offered, but R3 refused. R3 was redirected to his room. According to the note, staff sat with the resident and played cards. Hours later they were able to give medication and PRN (as needed) Ativan (anti-anxiety).On 06/20/25 at 11:52 PM an Alert Note included that R3 was aggressively hitting and kicking another resident's door, attempting to hit staff physically, cussing and threatening staff verbally, and screaming at staff. According to the note, staff attempted to deescalate the resident, but the resident was too aggressive. Security was called and the resident was redirected and given a 1:1 (a dedicated staff person assigned to R3).A Behavior Note dated 07/17/25 at 11:51 PM included that the resident had been aggressive and verbally abusive. Per the note, the resident had been super jealous that the CNA was taking care of another resident. He stated, Why are they messing around with her, [I] am gonna' kick their @%$. According to the note, when the CNA was out with him, he was calm, but when he sees that the CNA is going to help with any other resident, then he gets angry.Review of an Interdisciplinary Team (IDT) Note dated 07/28/25 at 1:03 PM included the resident was discussed at the IDT meeting that day. The resident's behavior was noted to have been escalating during the past weeks. The note stated that the resident was verbally abusive and physically aggressive to other residents and to staff but targeting 2 specific residents.On 07/31/25 at 8:57 PM a Behavior Note included that at 6:45 PM R3 yelled at another resident who was sitting in the tv area eating snacks, stating he was going to hit him. According to the note, the CNA got between them and R3 started to chase the CNA, attempting to hit her. The resident began heading towards another resident who was sitting a table and stated, I am going to hit him. He is looking at me. R3 was told he could not hit any other resident there and was asked to go to his room and eat a snack. R3 started to head towards the other resident again to try to hit him. The nurse grabbed R3's wheelchair and tried to guide him in the other direction, and R3 attempted to hit the nurse. The charge nurse and security were called and R3 was removed from the unit.On 08/01/25 at 2:26 PM an Alert Note revealed the resident was sent out to the hospital for a psychiatric evaluation at 2:15 PM.A Health Status Note dated 08/02/25 at 1:03 AM revealed R3 returned to the facility at 12:05 AM.On 08/02/25 at 11:04 AM a Behavior Note included that the writer was alerted by the assigned nurse that the resident had hit another resident on the right upper arm. A CNA and activity staff were sitting at the same table with the resident that was hit [R4]. The resident [R3] was unprovoked. He moved from his table and wheeled himself behind the other resident and hit him from behind simply because he [R3] did not want the CNA to be sitting with the other resident and told the CNA that she should have been sitting with him and not the other resident. The other resident was immediately removed from the table to his room. R3 was provided with a 1:1 caregiver to ensure other residents' safety and his safety as well. Per the note, R3 was transported out to the hospital by emergency medical services.On 09/18/25 at approximately 10:00 AM an observation of the video footage from 08/02/25 at 9:00 AM was conducted. The footage had no sound. Per the video, R3 was noted to be seated in his wheelchair in the upper left corner of the dining room by himself, at a table. CNA 42 was seated at a separate table across the room, looking at a magazine/book. After a few minutes had passed, an Activities Aide (AA) brought R4 into the dining room and placed his wheelchair at the table next to CNA 42. The AA sat in a chair on the left side of R4. The AA and CNA 42 began talking. R3 appeared to say something to himself. His face began to grimace and he started moving his wheelchair away from his table towards the center of the room. The AA and CNA 42 did not acknowledge R3 as he moved towards them. As R3 continued to draw closer to their table, the AA and CNA 42 carried on with their conversation without taking notice of R3. R3 wheeled his chair close behind and to the right side of R4 and punched him in the right upper arm/shoulder area. Staff separated the residents immediately.An observation of R4 was conducted on 09/18/25 at approximately 10:10 AM during an activity. R4 was noted to be relaxed and at ease with the event. He appeared to be enjoying himself.On 09/18/25 at 10:47 AM an interview was conducted with CNA 42. She stated that when she first got there on 08/02/25, R3 was sitting at the dining room table, nodding off. She said the previous shift warned her to keep an eye on him and don't get too close to him, because they told her that if she took care of another resident, he would get possessive. She stated that if she got up to care for someone else, it would set off one of his behaviors - either yelling or hitting people. She stated that she had never really seen it for herself until that day. She said that she had been told that he was like a jealous boyfriend, and that if you redirected your attention to someone else, he would get upset. She said that on the morning of 08/02/25 the AA brought [R4] into the dining room and sat him at the table next to her. [R3] began wheeling towards them. She stated that she did not hear [R3] say anything, he just had a disgusted look on his face. I didn't think it was that bad until that day. She stated that she and the AA were talking, and when the AA asked her a question, she heard a noise. I thought [R3's] chair hit [R4's], but environmental services told her that [R3] had hit [R4]. When asked if she thought there was anything she could have done to prevent the incident from happening she stated, Yes. I could have gotten up and asked him where he was going, or if I could help him. An interview was conducted on 09/18/25 at 11:08 AM with CNA 47. She stated that R3 could be verbally aggressive and that anything could trigger him - if you looked at him too long, Little things, if you paid too much attention to other residents. If you were helping another resident in the bathroom, he would barge into the room, bang on the door, or become verbally aggressive. She stated that in his chart he had a Kardex, and it had his behaviors and triggers, so they knew about him. She stated that they would always try to keep R3 busy coloring. On 09/18/25 at approximately 11:15 AM an interview was conducted with CNA 32. She stated R3 would get verbally aggressive, thinking everyone was talking about him. He would yell and tell you to stop talking about him. It started to progress and got worse. She stated that she saw that he appeared to get jealous when they gave attention to other residents. He would start cussing. There was a time he would call them names. She stated that sometimes his behaviors would just come out, there didn't seem to be any triggers. On one occasion, she stated she saw the wound nurse and a CNA go into a resident's room and R3 came behind them and kicked the door. She stated that it seemed like the resident's behaviors had been progressively getting worse for about a month before the incident with R4. During an interview conducted on 09/18/25 at 11:28 AM with LPN 9, she stated that she was familiar with R3. She said that if the resident's assigned person was a woman and she was dealing with other residents, he would get upset because he wasn't getting the attention. She said that if he wanted to go outside, he would get antsy also. She stated that sometimes they could redirect him, but usually not. She stated that staff were supposed to redirect him by talking to him about different topics like baseball. One day, she said he pushed the door open to R4's room and was yelling and demanding attention. She stated that Activities staff were pretty good about taking him out to BINGO and other things. She said the fact that R3 became jealous of R4 at the table with staff was not unusual, but it was the first time R3 had punched another resident. On 09/18/25 at 11:37 AM during an interview, LPN 17 stated that R3 had this tendency of being verbally aggressive. In this last incident, he was saying that the CNA should not be sitting at the same table with the other resident, she should be sitting with him. R3 wheeled by and hit R4 on the shoulder. The residents were separated and R3 had a 1:1 so he would not hit anyone else after that. LPN 17 stated it was not unusual for R3 to be so possessive of the women staff. Normally, he would just cuss but that day he did what he would normally not do. And normally, when he did get possessive over staff, we would get activities involved. When asked if he thought staff could have done anything to keep R3 from hitting R4, LPN 17 stated Sure. I think one of them could have gotten up and given R3 attention. The facility policy titled Abuse Prohibition, Reporting and Investigation, revised 4/25, included the facility prohibits the use of verbal, mental, sexual, physical, or physical abuse, corporal punishment, or involuntary seclusion. Each resident has the right to be free from abuse, neglect, or corporal punishment of any type by anyone. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility will provide a safe resident environment and protect residents from abuse. Procedure(s) included resident to resident abuse: A resident-to-resident altercation should be reviewed as a potential situation of abuse.

Based on interview and record review the facility failed to provide pharmaceutical services to meet the needs of Resident (R) 2, one of five residents reviewed for unnecessary meds, when Staff held R2's long acting insulin 3 times in July unnecessarily, without an order or notifying the physician. This had the potential to cause R2 to experience hyperglycemia (elevated blood sugar). Hyperglycemia can lead to various short-term and long-term complications. Short-term effects include ketoacidosis (A complication of diabetes in which acids build up in the blood to levels that can be life-threatening), dehydration, and confusion. Long-term complications include diabetic retinopathy, nephropathy, neuropathy, cardiovascular disease, and increased risk of infections. Findings: Review of the admission Record revealed the facility admitted R2 most recently on 05/02/2025. Diagnoses included type 2 diabetes mellitus with other specified complications, and hypertensive end stage renal disease with dependence on dialysis. Review of physician orders revealed orders for both a long acting insulin (Glargine) given once a day, and short acting insulin (Lispro) given twice a day. The orders read, Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously [under the skin in fatty tissue] one time a day every. Ordered on 05/08/2025.HumaLOG Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if [blood sugar is] 151 - 200 = [give] 3 Units; 201 - 250 = 5 Units; 251 - 300 = 7 Units; 301 - 350 = 10 Units; 351 - 400 = 12 Units; 401 - 999 = 14 Units. Greater than 400, administer 14 Units and notify provider for further orders, subcutaneously two times a day related to type 2 diabetes mellitus with other specified complication (E11.69) related to type 2 diaetes (sic) mellitus with hyperglycemia (E11.65) Onset: 15-30 mins. Peak 1-2 hrs. Follow Hypoglycemia protocol for BS less than 70mg/dl. For BS over 400mg/dl call provider. Hold Insulin for BS less than 100mg/dl and call provider. Ordered on 05/08/2025. Review of the July 2025 Medication Administration Record (MAR) revealed licensed nurse LPN1 entered code 5 for the Insulin Glargine administration on July 11th, 16th, and 21st. Code 5 means Hold/See Progress Notes. The corresponding progress notes read as follows:07/11/2025 at 4:40 AM - Blood sugar at 7707/16/2025 at 5:05 AM - residents (sic) blood sugar 80 07/21/2025 at 4:44 AM - B/S [blood sugar] 88The notes did not indicate if the resident was having any signs or symptoms of low blood sugar, if the physician was notified or contacted with any concerns. Target blood sugar reading before meals for diabetic persons, according to the Centers for Disease Control and Prevent (CDC) is 80 to 130 mg/dL (milligrams per decaliter); and blood sugar below 70 mg/dL is considered low. During an interview on 07/24/2025 at 1:56 PM the Unit Manager, RN4 was asked about insulin glargine. When asked if it should be held when there was not an order to hold it, or if the blood sugar was above 70 mg/dL she stated it was a long acting insulin and would not lower insulin quickly after administration. She concurrently reviewed the held insulin glargine progress notes and July MAR for R2. She confirmed the code 5 meant the medication was held and a progress note was entered. She stated that holding the insulin glargine on those days were med errors, and the nurse would need coaching, He/She is not following orders. When asked what the nurse should do if they had a concern with the order she stated He/She should notify the provider. Blood sugar reading after holding the insulin glargine were concurrently reviewed as follows:On 07/11/2025 the 11:39 AM blood sugar reading was 303 mg/dL.On 07/16/2025 the 5:23 PM reading was 250 mg/dL.On 07/21/2025 the 11:38 AM reading was 305 mg/dL. Review of facility policy TCH.120.114 titled Insulin Administration with review date 05/2025 revealed that long acting insulin Glargine had an onset time of 3-4 hours, did not peak, and lasted 24 hours.

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR) screenings were coordinated and/or referred for Level II evaluations as required for newly evident Serious Mental Illness (SMI) diagnoses for two of two residents (Resident (R) 9 and R12) reviewed for PASARR requirements out of a total sample of 19 residents. The deficient practice may result in residents with Mental Disorders (MD) and/or Intellectual Disabilities (ID) not receiving specialized services to meet their needs. Findings: For R9: Review of R9's “admission Record, dated 07/25/25 and found in the electronic medical record (EMR) under the “Profile” tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure (CHF), Adjustment Disorder and Other Specified Mental Disorders Due to Known Physiological Condition. Review of R9's “Psychiatric Provider Encounter Progress Note,” dated 11/08/24 and found in the EMR under the “Documents” tab, revealed a diagnosis of Personality Disorder was added to the resident's diagnosis list on 11/08/24. Review of R9's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/30/25 and found in the EMR under the “MDS” tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (which indicated the resident was cognitively intact). The assessment indicated the resident was not receiving any psychotropic medication. The assessment indicated the resident frequently exhibited signs of depression including feeling down, depressed, or hopeless and having little interest or pleasure in doing things. The assessment indicated the resident did not exhibit any behaviors during the assessment period. Review of R9's most recent “Level 1 PASSAR” document, dated 11/14/24 and found in the EMR under the “Documents” tab, revealed the Level 1 PASARR did not include the resident's personality disorder diagnosis added on 11/08/24. An updated and accurate Level 1 PASARR revised to include the resident's personality disorder diagnosis could not be located in R9's medical record. During an interview with Minimum Data Set Nurse (MDS1) on 07/23/25 at 1:04 PM, MDS1 confirmed the MDS Nurses were responsible for updating and ensuring the accuracy of residents' PASARR assessments after their initial admission to the facility. MDS1 stated a resident's Level 1 PASARR was expected to be updated/resubmitted with any change in psychotropic medication or any added psychiatric/major mental illness diagnosis so a determination could be made related to the potential addition of Level 2 PASARR services. MDS1 confirmed a new Level 1 PASARR should have been completed and submitted after R9's diagnosis of personality disorder was added to her record on 11/08/24. MDS1 confirmed she was not able to locate anything in R9's record to indicate this had been done. During an interview with the Administrator and the Director of Nursing (DON) on 07/25/25 at 9:18 AM, both confirmed their expectation was a new Level 1 PASARR was to be completed and submitted with any change in mental health diagnoses or change in the administration of psychiatric medication for a resident. They stated they expected each resident's PASARR to be accurate and both confirmed R9's Level 1 PASARR should have been updated and resubmitted with her new 11/08/24 diagnosis of personality disorder. Review of the facility's “Coordination of Pre-admission Screening and Resident Review (PASARR) Policy,” dated 04/2025 indicated, “The Level 1 screen will be reviewed at each care conference by the interdisciplinary team for accuracy. Any necessary update may be made at this time.” For R8: Review of the Admissions Record revealed R8 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body doesn't use insulin properly and eventually may not produce enough insulin to maintain normal blood glucose levels) without complications and unspecified asthma (a chronic lung disease that makes it harder to move air in and out of the lungs), uncomplicated. Review of the PASARR Level II Determination Letter dated 08/18/21 revealed the resident was determined to qualify for specialized services in accordance with CFR-483.120. The letter additionally instructed to please notify the office of any significant medical and/or psychiatric changes, identified on the Resident Assessment – Minimum Data Set (MDS), or when a Serious Mental Illness (SMI) was newly suspected, that occur during the client's stay at the facility. The PASARR II assessment dated [DATE] indicated the resident's diagnoses included psychotic disorder with delusions due to known physiological conditions (a mental health condition where delusions develop as a direct consequence of a known medical illness or condition affecting brain function), unspecified mental disorder due to known physiological condition (a mental health condition where a specific diagnosis cannot be determined, but it's known to be caused by an underlying physiological issue), and adjustment disorder, unspecified (a diagnosis given when an individual experiences emotional or behavioral symptoms in response to a stressful event, but the symptoms don't clearly fit into one of the more specific types of adjustment disorder. According to the documentation, no specialized services were recommended for the resident at that time. It appeared that all of her needs could and were being met by the facility within their scope of services. Further, the documentation stated that the resident was appropriate for SNF (Skilled Nursing Facility) placement due to her high level of care needed. However, review of the Annual MDS assessment dated [DATE] included a response to A1500, “Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition?” as “No.” A Hospital H&P (History & Physical), Surgery dated 07/23/22 indicated the resident's medical history included schizophrenia. Review of the resident's record provided no evidence of where this diagnosis was made, by whom, or when. The Annual MDS assessment dated [DATE] included a response to A1500, “Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition?” as “No.” On 09/20/23 an Emergency Department Document revealed the resident was seen by ED (Emergency Department) triage for worsening psychosis symptoms. The documentation included that the resident had a history of psychosis with delusions and hallucinations. According to the documentation, her hallucinations had been worsening, and she had been becoming aggressive towards peers and staff at the nursing facility. The documentation indicated that the resident received medical clearance for psychiatric admission. Psychosis qualifiers included “Schizophrenia, unspecified.” Review of the MDS revealed the resident was subsequently readmitted to the facility on [DATE]. However, review of the resident's record did not demonstrate that the state PASARR Coordinator's office had been notified of the new diagnosis as instructed in the Level II determination letter. Review of the Annual MDS assessment dated [DATE] revealed the response to A1500 was, “No,” indicating the resident was not currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition. Review of the Medication Administration Records (MARs) dated January 2025 through July 2025 revealed the resident displayed ongoing behaviors of auditory hallucinations and [self] scratching and skin picking. A PASARR Level I screening dated 07/17/25. The screening indicated the resident's diagnoses included the serious mental illness schizophrenia. According to the screening, the resident's mental disorders included depression, adjustment disorder with mixed anxiety, and depressed mood. Further, the screening indicated the resident displayed no symptoms related to adaptation to change, including self-injury or self-mutilation and/or hallucinations or delusions. Additionally, the screening revealed the resident had not currently, or within the past 2 years, received mental health services including inpatient psychiatric hospitalization. The referral determination demonstrated that no referral was necessary for any Level II services. The document was signed by the MDS Coordinator (MDS 2). On 07/23/25 at 1:24 PM an interview was conducted with MDS 2. When asked why a PASARR Level I screening had been completed 07/17/25, she stated that they had started completing a level I PASARR on the resident annually. When asked if a Level II referral had been sent to the state when the resident developed a new diagnosis for schizophrenia in 2023, she stated that they completed the Level I screening again and did not find the resident appropriate for Level II referral “because the resident did not trigger any elements of the “Symptoms” section of the screening form.” When this writer pointed out the selection “hallucinations or delusions” under the symptoms related to “Adaptation to Change” category, she stated “Oh.” When asked if the screening was an accurate reflection of the resident's status, she stated “No.” On 07/24/25 at 9:38 AM an interview was conducted with the MDS Coordinators (MDS 1, MDS 3, and MDS 2). MDS 2 stated that during the period that surrounded the newest PASARR [07/17/25] she stated that the box should have been checked on the “Symptoms” section of the PASARR because hallucinations and delusions have been ongoing since she has been here. She stated that skin-picking had been going on for about a year, and that it was related to anxiety. When asked about their process, MDS 1 stated that if a resident developed a new psychiatric diagnosis, they would complete a Level I screening again. She stated with any new psychiatric diagnosis, that will trigger a new Level I PASARR. She stated that if the resident had any new diagnosis with symptoms, this would trigger a referral for Level II referral. When asked if the resident should have triggered for a Level II referral based upon the evidence, MDS 1 stated Yes. MDS 2 stated that she thought they had more to learn about PASARR. Review of the policy titled Coordination of Pre-admission Screening and Resident Review (PASRR), reviewed 4/24 included “Preadmission Screening and Resident Review (PASRR)” is a federal requirement to help ensure that individuals who have MD or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified facility be evaluated for a serious MD and/or ID; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. [The facility] shall incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation into a resident's assessment, care planning, and transitions of care. Coordination shall include: 2. Referring all Level II residents and all residents with newly evident or possible serious MD (Mental Disorders), ID (Intellectual Disorders), or related condition for Level II resident review upon a significant change in status assessment. According to the Resident Assessment Instrument (RAI) Manual, revised October 2024, pp. 2-30-31, The nursing facility must provide the SMH (State Mental Health)/ID (Intellectual Disabilities)/DDA (Developmental Diabilities Administration) authority with referrals as described below, independent of the findings of SCSA (Significant Change in Status Assessment). PASRR Level II is to function as an independent assessment process for this population with special needs, in parallel with the facility's assessment process. Nursing facilities should have a low threshold for referral to SMH/ID/DDA , so that these authorities may exercise their expert judgment about when a Level II evaluation is needed. Referral should be made as soon as criteria indicating such are evident -- the facility should not wait until the SCSA is complete. Referral for Level II Resident Review Evaluations is required for individuals previously identified by PASRR to have Mental Illness, Intellectual Disability/Developmental Disability, or a related condition in the following circumstances: Note: This is not an exhaustive list: A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms; A resident with behavioral, psychiatric, or mood related symptoms that have not responded to ongoing treatment. (Cross-reference to F641)

Based on interviews, records, and review of the RAI (Resident Assessment Instrument) manual, the facility failed to ensure that the MDS (Minimum Data Set) assessment accurately reflected the status of 1 out of 2 residents reviewed for falls (R12) and failed to reflect the PASARR (Preadmission Screening and Resident Review) status for 1 out of 2 residents reviewed for PASARR requirements (R8). Specifically, R12's MDS did not reflect a fall with major injury and R8's MDS did not reflect her PASARR Level II status for 3 consecutive years. The deficient practice may result in residents not receiving care appropriate to their individual needs.Findings include:For R12:Review of the admission Record revealed R12 was admitted to the facility on [DATE] with diagnoses which included repeated falls and Parkinson's Disease with dyskinesia (involuntary, uncontrollable movements that can develop as a side effect of long-term levodopa (dopamine agonists) treatment for Parkinson's disease), without mention of fluctuations.An eINTERACT SBAR (Situation, Background, Assessment and Recommendation) Summary for Providers note dated 04/28/25 at 9:40 PM included that the resident was observed by a CNA (Certified Nurse's Aide) walking from his bed to the hallway, falling to the floor, and landing on his left side. According to the note, the resident did not hit his head. Skin tears were noted to the right forearm and left knee. The resident was unable to move the left lower extremity (LLE) without increased pain. Per the note, the provider was notified and gave orders to send the resident out to the hospital.A fall care plan dated 04/28/25 related to a witnessed fall with skin tear had a goal for the resident to have no falls with major injury. Interventions included to monitor/document/report PRN (as needed) x 72 hours to MD (Medical Doctor) for signs or symptoms of pain, bruises, changes in mental status, new onset confusion, sleepiness, inability to maintain posture, or agitation.Review of the X-Ray results dated 04/29/25 revealed no evidence of displaced pelvic fracture and no acute findings in the left femur.On 05/03/25 at 1:12 PM a Health Status Note revealed the resident reported increased pain for LLE. According to the note, the family called and requested that the provider provide additional pain medication. The provider was notified, and orders were received to change Tylenol (non-opioid analgesic) to 1000 mg (milligrams) every 6 hours as needed (PRN) and ibuprofen (Non-steroidal Anti-Inflammatory Drugs) 600 mg every 6 hours PRN.A Health Status Note dated 05/18/25 at 10:40 PM included that the resident had been medicated with PRN medication for complaints of pain to the LLE/hip area. The note stated that the resident was able to move his leg, bear weight, and had no signs of edema or bruising. The resident was informed and reminded about an early morning appointment for CT (Computed Tomography/medical imaging) scan of LLE. The resident voiced understanding.On 05/19/25 at 7:59 AM a Health Status Note included that the resident returned from the CT scan appointment with no new orders. According to the note, the resident had a broken left hip.At 10:51 AM on 05/19/25 an Alert Note indicated a new order was received to transfer the resident to the hospital for further evaluation.Review of the MDS assessment dated [DATE], indicated R12 was discharged with return anticipated.The MDS dated [DATE] revealed that the resident re-entered the facility.Review of the 1st assessment following the 5/23/25 entry, the significant change/5-day MDS, assessment dated [DATE] revealed Question A0310E ( Is this assessment the first assessment (OBRA, Scheduled PPS, or Discharge) since the most recent admission/entry or reentry?) was answered No. Inaccurately answering this question no, disabled Section J1700 (Fall History on Admission/Entry or Reentry.) Therefore, no responses were submitted for the following questions: A. Did the resident have a fall any time in the last month prior to admission/entry or reentry? B. Did the resident have a fall any time in the last 2-6 months prior to admission/entry or reentry? And/or C. Did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry? In Section J1800 the question asked, Has the resident had any falls since admission/entry or reentry or the prior assessment (OBRA (Omnibus Budget Reconciliation Act of 1987) or Scheduled PPS (Prospective Payment System), whichever is more recent? The response was No.During an interview conducted on 07/23/25 with an MDS Coordinator (MDS 2) she stated that she coded the 05/29/25 assessment as a No for section J1800, because the resident had not had any falls since his readmission on [DATE]. She stated that she combined the Significant Change with the 5-Day MDS to reflect the resident's significant change. When asked if the assessment accurately reflected the resident's fall with major injury, she stated No. Review of the RAI manual Section A, page A-6: Coding Instructions for A0310E, Is This Assessment the First Assessment (OBRA, Scheduled PPS, or OBRA Discharge) since the Most Recent Admission/Entry or Reentry? Code 0, no: if this assessment is not the first of these assessments since the most recent admission/entry or reentry. Code 1, yes: if this assessment is the first of these assessments since the most recent admission/entry or reentry. For R8:Review of the Admissions Record revealed R8 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (a chronic condition where the body doesn't use insulin properly and eventually may not produce enough insulin to maintain normal blood glucose levels) without complications and unspecified asthma (a chronic lung disease that makes it harder to move air in and out of the lungs), uncomplicated.Review of the PASARR Level II determination letter dated 08/18/21 revealed the resident was determined to qualify for specialized services in accordance with CFR-483.120. An Annual MDS assessment dated [DATE] included a response to A1500, Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition? as No.The Annual MDS assessment dated [DATE] included a No response to A1500, Is the resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition?Review of the Annual MDS assessment dated [DATE] revealed the response to A1500 was, No, indicating the resident was not currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition.A PASARR Level I screening dated 07/17/25. The screening indicated the resident's diagnoses included the serious mental illness schizophrenia. According to the screening, the resident's mental disorders included depression, adjustment disorder with mixed anxiety, and depressed mood. Further, the screening indicated the resident displayed no symptoms related to adaptation to change, including self-injury or self-mutilation and/or hallucinations or delusions. The screening additionally revealed the resident had not currently, or within the past 2 years, received mental health services including inpatient psychiatric hospitalization. The referral determination demonstrated that no referral was necessary for any Level II services. The document was signed by the MDS Coordinator (MDS 2).On 07/23/25 at 1:24 PM an interview was conducted with MDS 2. When asked why a PASARR Level I screening had been completed 07/17/25, she stated that they had started completing a level I PASARR on the resident annually. After review of the PASARR Level II Determination Letter, MDS 2 was asked if the screening dated 07/17/25 and /or the previous 3 Annual MDS assessments were an accurate reflection of the resident's status, she stated No.On 07/24/25 at 2:13 PM a follow-up interview was conducted with an MDS Coordinator (MDS 3). She reviewed the PASARR determination letter from 2021 which indicated that R8 was Level II positive. She then reviewed the MDS annual assessment dated [DATE] and stated that the assessment stated the resident was not Level II. When asked if the assessment should state that R8 was Level II positive, she replied Yes. She stated that it was important for evaluations to be accurate to ensure the resident is receiving the proper care.On 07/25/25 at 9:54 AM an interview was conducted with the Director of Nursing. She stated that her expectation was for all MDS assessments to be accurate. She stated that inaccuracies may affect the overall care of residents.(Cross-reference to F644)

Based on interview and record review, the facility failed to ensure Resident (R) 38, one of three residents reviewed for beneficiary notices was provided a written Notice of Medicare Non-Coverage (NOMNC), and Advanced Beneficiary Notice of Non-coverage (ABN) when the facility identified R38's Part A benefit last covered day was due to end. This had the potential for R38 and/or their representative to be unaware of their appeal rights or how to activate an appeal. Findings: Review of the admission Record revealed the facility admitted R38 on 02/25/2025. R38 was their own responsible party. R38's spouse was listed as Emergency Contact #1 Review of the Beneficiary Protection Notification Review worksheet provided by the facility indicated R38's Medicare Part A benefit started on 02/25/2025 and the last covered day was 03/26/2025. The Beneficiary Notice worksheet indicated R38 remained in the facility after their last Medicare A covered day. Review of the NOMOC filed in R38's medical record revealed the form included that coverage for physical/occupational/speech therapy, and nursing services would end on 03/26/2025, and R38 had the right to appeal the decision, and who to contact if they chose to appeal. The form read, Please sign below to indicate you received and understood this notice. The form was unsigned. Under Additional Information the form indicated several refusals and that facility staff #80 contacted R38's next of kin on 03/24/2025 who gave a verbal understanding and 'consent for a verbal signature'. The form did not indicate the form was provided to R38 or that R38 was aware of the notice. Review of the ABN filed in R38's medical record revealed starting on 03/27/2025 the facility estimated the cost of Physical/Occupational/Speech Therapy and Daily Skilled Nursing Care services would be $1,500 per day/item or service. The form read, Signing below means that you have received and understand this notice. The form was unsigned by R38 or an authorized representative. Under Additional Information the form indicated facility staff #80 contacted R38's next of kin on 03/24/2025 who gave a verbal understanding, selected Option 3 and gave consent for a verbal signature. Option 3 on the form read, I do not want the care(s) listed above, I understand that I am not responsible for paying, and I cannot appeal to see if Medicare would pay. The form did not indicate the form was provided to R38 or that R38 was aware of the decision. During an interview on 07/24/2025 at 12:01 PM the Director of Finance (DoF) described their process was to send the NOMNC and ABN forms electronically for signatures. DoF confirmed that when a resident or their repetitive was not computer savvy, that posed some challenges. After a concurrent review of R38's form and electronic medical record DoF stated he would confirm if the form was sent. On 07/24/2025 at 12:45 PM DoF followed up and stated the beneficiary notice forms for R38 were not sent, they may have been put at the unit's nursing station, however they did not have a process to verify if that was done, if the resident received it, or obtain a signature after the fact. During an interview on 07/24/2025 at 1:27 PM the Administrator described his expectation was that staff would at least go over the form and explain it to them. He confirmed that they did struggle with families that were not technologically savvy, he would hope they would have the notice available to get a wet signature when they are here. When asked about the importance of ensuring the resident or their representative received the written notice, he acknowledged the written notice could be important for someone who was discharged from benefits since it has who to call to make an appeal.

Based on observation, interview, and record review, the facility failed to ensure one of 19 residents sampled (R35), was able to call for assistance when their call bell was not within reach and R35 was not capable of retrieving and using it. As a result, R35 was not able to call for help until the surveyor alerted the staff. This had the potential for R35's needs to be unmet. FindingsReview of the admission Record revealed the facility admitted R35 most recently on 04/12/2023 with a primary diagnosis of acute posthemorrhagic anemia (a condition where the body experiences a sudden and significant drop in red blood cells and hemoglobin due to a rapid loss of blood). Other diagnoses included disorders of bone density, cerebral infarction (the death of brain tissue due to a prolonged decrease in blood flow, also known as stoke) with left sided hemiplegia and hemiparesis (weakness or paralysis on one side of the body), hearing loss, aphasia (a language disorder that affects a person's ability to communicate), reduced mobility, end stage renal disease (permanent kidney failure) with dependence on dialysis, ischemic cardiomyopathy (a condition where the heart muscle (myocardium) weakens and enlarges due to decreased blood flow, often caused by coronary artery disease), coronary artery disease, mild neurocognitive disorder (a term encompassing conditions characterized by a decline in cognitive abilities, including memory, language, and problem-solving, often due to brain injury or disease), dementia, and diabetes. During an interview and observation with R35 on 07/21/2025 at 3:50 PM, R35 was in bed. Throughout the interview R35's hands were motionless under the covers. Observed the call bell was attached to the side of bed, hanging down below the bed. R35 stated he did not recall how long he had been at the facility. Following the interview the surveyor sat in the hallway near R35's room observing. Between 3:56 PM and 4:06 PM R35 could he heard to call out help nine times. While staff were observed in the hallway, they were not immediately outside of R35's door and did not respond to the vocalizations. The surveyor notified the licensed nurse at the nurses' station, LPN5, at 4:06 PM that R35 had been calling out. Upon walking into R35's room he stated he wanted to get up. LPN5 concurrently observed the call light was hanging off the side of the bed and she stated R35 could not reach the call bell when it was over the side. She explained R35 had an injury to his shoulder on his right side, his dominate side that was not affected by his stroke, and the call bell needed to be placed near or in his hand for him to operate it. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed R35 to have functional impairment on one side both upper and lower extremities. R35's eating ability (to use suitable utensils to bring food to the mouth) was assessed as needing setup or clean-up assistance; and R35 was depend on staff for toileting hygiene, showers/bathing, dressing lower body, and transfers. Review of hospital records dated 07/03/2025 revealed R35 had a fractured right humerus (the long bone of the upper arm). During an interview on 07/24/25 at 10:31 AM nursing assistant CNA60 stated that R35 required assistance with feeding now since his right shoulder injury. During an interview on 07/25/2025 at 10:05 AM Physical Therapist (PT)3 and PT4 confirmed R35 had a history of a stroke with left-sided weakness and relies on his right side. PT3 stated, Since his fracture he is limited on both sides. During a follow up interview with LPN5 on 07/25/2025 at 10:14 AM, LPN5 described the expectation on the floor was for anyone available to respond if a resident is calling out, They need to check on him, why he is calling. She described R35's ability to use his right arm/hand had changed recently, he use to be able to propel his wheelchair and feed himself, now they have to move him and feed him. With respect to the call bell she stated, If it is in his hand I am sure he could [push the button]. She added that after the incident on 07/21/2025 the facility provided R35 with an adaptive call bell that is pressure sensitive. Review of R35's care plan revealed interventions on the fall prevention focus that the call light should be reachable. The creation date read 5/14/2024. The Director of nursing stated on 07/25/2025 at 11:09 AM, [The] call bell should be within reach of the resident, and they are capable of using it.

Based on observations, interviews, review of the [NAME] Drug Guide, and review of records and policies and procedures, the facility failed to provide services to manage the pain for one of two residents sampled for pain (Resident [R]46) consistent with professional standards, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically: 1) Staff did not follow facility policy and procedures for assessment and recognition of R46's pain failing to identify location, intensity, frequency, pattern, and severity for each reported pain occurrence. 2) The facility's failure to provide pain management resulted in harm when R46's pain reached a level, exhibited by crying and being tearful, for a documented two hours and twenty minutes before transferring to a hospital for severe back pain. 3) Staff did not reassess type, location and intensity of pain R46 within 1 hour (HR) of administration of an As Needed (PRN) opioid (narcotic pain medication, oxycodone) in accordance with professional standards. Findings include: Review of the Admission Record located under the Profile tab in the Electronic Medical Record (EMR) revealed that Resident 46 (R) was admitted on [DATE] and readmitted on [DATE] with diagnoses that included pain in thoracic spine, systemic lupus erythematosus (a chronic autoimmune disease that occurs when the body's immune system attacks its own healthy tissues and organs), Sjogren syndrome (a chronic autoimmune disease that occurs when the body's immune system attacks the glands that produce tears and saliva), Ankylosing Spondylitis (a chronic inflammatory disease that causes inflammation in the spine and other joints) of unspecified sites in spine, chronic pain syndrome, age-related osteoporosis (a medical condition characterized by a significant decrease in bone mass and density, resulting in weakened bones that are more susceptible to fractures) without current pathological fracture, fusion of spine, cervicalgia (neck pain), fracture of neck, and limitation of activities due to disability. Review of physician orders found in R46's EMR under the orders tab revealed the following: -Monitor and Record Pain Assessments Q (every) Shift, using 0-10 scale. 0= no pain,1-3 Mild Pain,4-5 Moderate Pain,6-10 Severe Pain. If [the resident is] Unable To Verbalize, Use Wong-Baker's Corresponding Facial Expression. Documentation to Include- Location of Pain, Non-Medication Interventions offered, received PRN medication or med was offered and declined. Non-Medication Interventions, 1. Back Rub 2. Reposition 3. Diversional Activity 4. Received Scheduled Pain Meds. every shift (ordered 09/16/24, discontinued 10/16/24, and reordered 10/16/24). -oxyCODONE HCl ER Oral Tablet ER 12 Hour Abuse Deterrent 10 MG (Oxycodone HCl) Give 1 tablet by mouth one time only for Chronic pain for 1 Day (ordered 09/16/26, ended 09/17/24). -oxyCODONE HCl ER Oral Tablet ER 12 Hour AbuseDeterrent 10 MG (Oxycodone HCl) Give 1 tablet by mouth two times a day for Pain for 3 Days (ordered 09/16/24, end date 09/19/24). -oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Pain 6-10 for 3 Days (ordered 09/16/24, end date 09/19/24). -Lyrica Oral Capsule 100 MG (Pregabalin) Give 100 mg by mouth three times a day related to CHRONIC PAIN SYNDROME (G89.4) (ordered 09/18/24, reordered 10/16/24). -oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Pain 6-10 until 10/04/2024 23:59 (ordered 09/17/24, end date 10/04/24). -oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Pain 6-10 until 10/24/2024 23:59 (ordered 10/04/24, end date 10/24/24). -oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for Pain 6-10 (ordered 10/16/24). -Send to ED for evaluation and treatment one time only for resident request for back pain for 1 Day (ordered 10/10/24). Review of a Care Plan initiated 09/19/24 for chronic pain/discomfort related to Rheumatoid arthritis flare, Lupus Erythematosus, Rheumatoid arthritis and osteoarthritis of multiple sites, and carpal tunnel syndrome included a goal that R46 would state/demonstrate relief or reduction in pain intensity within one hour after receiving interventions. The interventions for this goal included to Administer medications as ordered, for staff to evaluate/record/report effectiveness, and to monitor and record any complaints of pain including the location, frequency, effect on function, intensity, alleviating factors, and aggravating factors. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/24, indicated R46 had no cognitive deficits with a Brief Interview for Mental Status (BIMS) score of 15. The assessment included that R46 had upper and lower extremity impairment on both sides and needed partial/moderate assistance with rolling left to right, going from a sitting to lying position, and from a lying to sitting position. The assessment included that R46 had medical conditions that included arthritis and osteoporosis and that R46 was receiving scheduled and as needed pain medication for pain management. The Pain assessment included that the resident had frequent pain that did not affect sleeping but would occasionally interfere with therapy activities. Review of a Provider Progress Note dated 09/23/24 entered at 01:42 PM located in the Progress Notes under the Progress Notes tab revealed R46 was not satisfied with her current pain management and would like a new referral to see a different pain management clinic. Review of the Medication Administration Record (MAR) for September 2024 located in the Reports of the EMR and review of pain reassessments located in Progress Notes located under the progress notes tab in the EMR revealed R46 had received oxycodone hcl oral 10 milligram tablet by mouth for pain on the following days that was documented as ineffective or unknown effectiveness with reassessments over one hour later: -On 09/24/24 at 01:37 PM staff administered oxycodone for documented pain level of 8/10 with a reassessment of effectiveness of unknown (U) documented 4 hours 54 minutes later, on 09/24/24 at 06:31 PM. Review of an Administration Note dated 09/24/24 entered at 01:37 AM located in the Progress Notes under the Progress Notes tab revealed R46 had 8 out 10 (1 being little or no pain and 10 being the worst pain possible) and that pain was located in the back. Review of another Administration Note dated 09/24/24 entered at 06:31 PM located in the Progress Notes under the Progress Notes tab revealed the PRN [as needed] Administration was: Unknown. Review of a third Administration Note dated 09/24/24 entered at 07:37 PM located in the Progress Notes under the Progress Notes tab revealed R46 had 8 out 10 and that pain was located in the back. -On 09/26/24 at 09:32 AM staff administered oxycodone for documented pain level 9/10 with a reassessment of effectiveness of ineffective (I) documented 3 hours 18 minutes later, on 09/26/24 at 12:54 PM. Review of an Administration Note dated 09/26/24 entered at 12:54 PM located in the Progress Notes under the Progress Notes tab revealed a Registered Nurse (RN) entered the following: PRN Administration was: Ineffective, Resident reports pain is the same but this is her normal pain and medication regime that [they] has been like this for [AGE] years. Follow-up Pain Scale was: 9. -On 09/28/24 at 07:22 PM staff administered oxycodone for documented pain level of 9/10, with a reassessment of effectiveness of ineffective (I) documented 2 hours 34 minutes later, on 09/28/24 at 09:56 PM. Review of an Administration Note dated 09/28/24 entered at 09:56 PM located in the Progress Notes under the Progress Notes tab revealed a Registered Nurse (RN) entered the following: PRN Administration was: Ineffective, Resident reports pain 9/10, states this is her regular, medicated with scheduled med. Follow-up Pain Scale was: 9. -09/28/24 at 11:22 PM staff administered oxycodone for documented pain level pain level of 9/10 with a reassessment of effectiveness of ineffective (I) documented 6 hours 3 minutes later, on 09/29/24 at 05:25 AM. Review of an Administration Note dated 09/29/24 entered at 05:25 AM located in the Progress Notes under the Progress Notes tab revealed a Licensed Practical Nurse (LPN) entered the following: PRN Administration was: Ineffective, Follow-up Pain Scale was: 8. Review of a Administration Note dated 09/29/24 entered at 11:30 AM located in the Progress Notes under the Progress Notes tab revealed R46 had 10 out 10 and that pain was located in the back. -09/29/24 at 11:50 PM staff administered oxycodone for documented pain level of 6/10 with a reassessment of effectives of unknown (U) documented 6 hours 2 minutes later, on 09/30/24 at 05:52 AM. Review of an Administration Note dated 09/30/24 entered at 05:52 AM located in the Progress Notes under the Progress Notes tab revealed a Licensed Practical Nurse (LPN) entered the following: PRN Administration was: Unknown, sleeping. Review of another Administration Note dated 09/30/24 entered at 11:49 AM located in the Progress Notes under the Progress Notes tab revealed R46 had 8 out 10 and that pain was located in the back. -09/30/24 at 05:58 PM staff administered oxycodone for documented pain level of 8/10 with a reassessment of effectives of ineffective (I) documented 3 hours 13 minutes later, on 09/30/24 at 09:05 PM. Review of a Administration Note dated 09/30/24 entered at 05:58 PM located in the Progress Notes under the Progress Notes tab revealed R46 had 8 out 10 and that pain was located in the back. Review of an Administration Note dated 09/30/24 entered at 09:05 PM located in the Progress Notes under the Progress Notes tab revealed a Licensed Practical Nurse (LPN) entered the following: PRN Administration was: Ineffective Follow-up Pain Scale was: 8 Review of the EMR revealed no evidence that any assessments were completed within one hour of medication administration or that the provider was notified of the Ineffectiveness of the pain medication. The EMR did not reveal any evidence of any additional interventions offered when pain medication was ineffective or a provider notification for the infectiveness of the opioid pain medication. Review of the Medication Administration Record (MAR) for October 2024 located in the Reports of the EMR and review of pain reassessments located in Progress Notes located under the progress notes tab in the EMR revealed R46 had received oxycodone hcl oral 10 milligram tablet by mouth for pain on the following days that was documented as ineffective or unknown effectiveness: -10/01/24 at 12:02 AM staff administered oxycodone for documented pain level for pain level of 8/10 with a reassessment of effectiveness of ineffective (I) documented 6 hours 4 minutes later, on 10/01/24 at 06:06 AM. Review of an Administration Note dated 10/01/24 entered at 06:06 AM located in the Progress Notes under the Progress Notes tab revealed a Licensed Practical Nurse (LPN) entered the following: PRN Administration was: Ineffective. Follow-up Pain Scale was: 7. -10/02/24 at 08:18 PM staff administered oxycodone for documented pain level for pain level of 8/10 with a reassessment of effectiveness of unknown (U) documented 2 hours 12 minutes later, on 10/02/24 at 10:30 AM. Review of an Administration Note dated 10/02/24 entered at 10:30 PM located in the Progress Notes under the Progress Notes tab revealed a Licensed Practical Nurse (LPN) entered the following: PRN Administration was: Unknown Resident sleeping. Review of an Administration Note dated 10/09/2024 entered at 12:00 AM in the Progress Notes under the Progress Notes tab revealed R46 had complained of neck and knee pain at a level of 6/10. The note included that R46 was administered : oxyCODONE HCl Oral Tablet 10 MG, 1 tablet by mouth. Review of another Administration Note date 10/09/24 entered at 01:11 AM revealed the oxycodone administered at 12:00 AM was effective and the current pain level for R46 was a 3/10. Review of an Administration Note dated 10/09/2024 entered at 06;00 AM in the Progress Notes under the Progress Notes tab revealed R46 had complained of neck and knee pain at a level of 7/10. The note included that R46 was administered : oxyCODONE HCl Oral Tablet 10 MG, 1 tablet by mouth. Review of another Administration Note date 10/09/24 entered at 07:00 AM revealed the oxycodone administered at 06:00 AM was effective and the current pain level for R46 was a 0/10. Review of a Health Status Note dated 10/09/2024 entered at 07:55 AM by Licensed Practical Nurse (LPN) in the Progress Notes under the Progress Notes tab revealed R46 stated she was having chest pain that started around 04:00 AM. Resident states she considered notifying night shift staff but decided not to, encouraged resident to immediately notify staff of all medical changes/concerns to reduce risks of poor outcomes. Resident states her understanding. Resident denies shortness of breath, confirms feeling pressure to chest and having new onset of upper back pain. Heart rate 92/pulse bounding, other vitals stable. Resp even and unlabored, alert and orientated times 4, and able to make needs known. 911 called and EMS [Emergency Medical Services] evaluation/transport dispatched. Provider made aware. Review of another Health Status Note dated 10/09/2024 entered at 02:00 PM by a Licensed Practical Nurse (LPN) in the Progress Notes under the Progress Notes tab revealed R46 returned from HHK ED via EMS. No new cardiac findings reported. HHK ED provider note states CT scan of chest shows age-indeterminate minimal superior endplate deformity of the T4 for vertebral body. Resident states pain medication was received at ED and is being well managed. She [the resident] denies pain or discomfort to chest, shortness of breath or pain outside of her normal tolerated range. Review of a Health Status Note dated 10/09/2024 entered at 03:56 PM by a Registered Nurse (RN) in the Progress Notes under the Progress Notes tab revealed R46 was medicated for general pain after returning from emergency room with prn Oxycodone 10 mg, 02:00 PM Lyrica and baclofen. The note included that the nurse was unable to sign out 02:00 PM medication on mar because medication resumed after 02:00 PM. Then the note said the resident was given scheduled 02:00 PM medication as ordered. Hob (head of bed) elevated call light in reach. Review of a Health Status Note dated 10/10/2024 entered at 05:35 AM by Licensed Practical Nurse (LPN) in the Progress Notes under the Progress Notes tab revealed R46 was medicated with Oxycodone PRN x 2 r/t increased back pain and arms pain. Resident rated her pain 9 out 10. Resident is tachycardia thru out the night. HR fluctuated between 103-108 bpm. Resident voiced her concerns regarding the x-ray result. Resident had crying episodes r/t increased back pain. Resident was concerned regarding her fracture T3-T4. Resident was restless thru out the night. Resident was crying after she had her brief changed. Writer asked why she was tearful [and] states, I'm in a lot of pain when I was changed. Informed resident that provider will be informed of her recent increased pain. Endorse to oncoming nurse. Review of the EMR revealed no evidence a provider was notified of R46 crying in pain on 10/10/24 from 05:35 AM to 07:55 AM, a total of two hours and twenty minutes. Review of another Health Status Note dated 10/10/2024 entered at 07:55 AM by a Licensed Practical Nurse (LPN) in the Progress Notes under the Progress Notes tab revealed R46 was assessed as a follow up with ED visit yesterday r/t chest and upper back pain, as well as elevated heart rate during this mornings vital assessment. Resident was lying in bed and visibly in pain, crying. She was medicated as ordered prior to assessment. Resident requests to be sent to ER for further evaluation, stating she believes the hospital can manage her pain better during CT scans and xrays ordered by neurosurgeon. Provider made aware. Resident denies shortness of breath or chest pain. Heart rate 117/pulse bounding, other vitals stable. Resp even and unlabored. A&Ox4, able to make needs known. 911 called and EMS dispatched. Provider made aware. Review of a Notice of Resident Transfer or discharge date d 10/10/24 located in the EMR revealed R46 had been transferred to the hospital. The notice included that the transfer is necessary for the resident's welfare and the resident's needs cannot be met by the facility (i.e. urgent medical need). Specifically severe back pain. Review of another Health Status Note dated 10/10/2024 entered at 03:59 PM by Licensed Practical Nurse (LPN) in the Progress Notes under the Progress Notes tab revealed R46 was admitted to the hospital for observation and treatment. Review of a History and Physical from an emergency room visit hospital visit on 10/10/24 located in the MISC tab of the EMR revealed R46 was sent to the hospital for back pain. The History and Physical included that R46 had reported acute worsening pain in back over past few days despite taking home pain meds. Pt reports having fever at home. no chills. denies nausea vomiting. + pain persist. denies joint pain at this time which patient states is usual for acute ra [Rheumatoid arthritis] flare The hospital records included that x-rays were completed without any new fractures. During an interview conducted on 11/05/24 at 01:17 PM, R46 stated they had been removed for the original pain management program which had been working. The resident stated that she was hospitalized in October because the pain went from their back through their chest. R46 stated that now the pain hardly ever gets below a 9/10 because staff do not provide requested pain medications timely. R46 stated when pain meds are NOT given regularly, her pain level is 7/10 and she is not able to perform therapy and ADLs. R46 stated the uncontrolled pain had been going on for weeks. An observation conducted on 11/07/24 at 09:05 AM of medication administration to R46, Registered Nurse 14 (RN) entered the room to provide scheduled morning medications. During the observation, RN14 asked the resident if they were still having pain after giving as needed pain medication earlier that morning. R46 stated the pain was still a 9/10. RN14 was observed continuing with the medication administration but did not ask where the pain was currently located, the intensity, duration, or if it was a different pain than reported in the morning. After the administration, RN14 was asked by the resident to ensure their pain was managed by 10:00 AM to 10:30 AM so that R46 could attend a physical therapy appointment. R14 agreed and left the room. On 11/07/24 at 09:10 AM an interview with concurrent record review was conducted with RN14. When asked when R46 had received the as needed pain medication, RN14 stated she had given on oxycodone at 07:30 PM. When asked how long after oral pain medication should a reassessment be performed, RN14 stated, in about a half hour to 40 minutes. When asked if the pain medication is ineffective what is usually done, RN14 stated they would call the medical provider. RN14 stated that R46 always has a pain level of 9/10 and that the pain reassessment was not done until 09:10 AM because she was busy with another resident. When asked what the components of a pain assessment include, RN14 stated she would ask, where the pain is, the intensity of the pain, the duration of the pain, if the pain was different, intermittent versus constant, and if anything made the pain better. When asked why she did not do that when the resident complained of a 9/10 pain, RN14 stated she assumed the pain was in the resident's back because that is where it normally is located. When asked how pain assessments are documented, RN14 stated that it is in the EMR under the MAR or in a Progress Note but they only document if the medication was effective or not and a pain level. RN14 stated the system doesn't require them to do a full pain assessment unless it is an annual or quarterly pain assessment or a new admission. When asked what the potential outcome could be for not completing a pain assessment, RN14 stated that, if the medication is not working it would be important to make sure there are not other things going on causing serious harm, or complications from the medication. Or if the medication is effective they [physician] may want to cut back. Review of a Progress Note Linked note created on 11/7/24 at 05:52 PM by RN14 included documentation that R46's pain level at 08:30 AM was a 0/10. During an interview on 11/08/24 at 09:27 AM with RN14, she stated that, I think I was rushing, she [the resident] still had pain, I don't why put zero, [the pain] wouldn't be a zero. When asked what would be the potential risk of not documenting pain accurately, RN14 stated the doctor could look at that [the zero] and think the medication is working and possible lower the dose. When asked if she had completed a the pain assessment documented at 08:30 AM, RN14 stated, no. I chose that 08:30 AM time because they [the facility] like the times to match, that is the goal. When asked if she was instructed to document something inaccurately at the end of her shift, RN14 said, no, she just did that. It should be documented when it is done. R14 stated she had to give more pain pills between the 09:10 AM and the end of her shift but did not complete a full pain assessment during the shift from 06:00 AM to 06:30 PM on 11/08/24. On 11/08/24 at 09:44 during an interview with concurrent record review, Registered Nurse 19 (RN) stated that a pain assessment is completed on admission, quarterly, on readmission, and annually with the MDS assessment schedule. RN19 stated that daily pain assessments include the pain level but could not recall if the location is included in the assessment. RN19 stated that providers should be notified if pain medication is not working and PRN pain medications should be assessed for effectiveness within one hour. RN19 stated the expectation is to follow policies, procedures, and professional standards for assessing a resident's pain. RN19 stated that if a nurse cannot document in real time, when they do document it should be truthful to include the assessment, what they gave, when they gave it, and how effective it was. RN19 stated the R46's pain level is normally at a level of 9/10. When asked what the potential danger would be in not accurately assessing or documenting pain for a resident, RN19 said, you wouldn't know if the medication is effective or not. RN19 stated if the provider was to print them [records] off it would potentially affect the care given to the resident. When reviewing the delayed time in completing reassessments of pain after the administration of as needed pain medications, RN19 was asked if the documentation showed professional standards were met. RN19 stated no, and when asked how long after a PRN pain medication is administered should the pain be assessed, RN19 said, one hour. On 11/08/24 at 10:53 AM an interview with concurrent record review was conducted with the Director of Nursing (DON). The DON stated that once a PRN pain medication is given, the evaluation of the effectiveness should be documented between 30 to 60 minutes later. The DON stated that the documentation should be in real time if possible. The DON stated that if a PRN pain medication is ineffective, the expectation is for staff to notify the provider. The DON stated the assessment should get more information like the number (pain level or scale), location, describing what type of pain (throbbing/stabbing/ache), specifically make it [the pain] worse, and is there something to elevate it [the pain]. The DON stated that the complete assessment should be documented in the EMR. When asked what the potential problem would be from not documenting accurate pain levels or completing pain assessments within one hour of administration, the DON stated it would be difficult to know the effectiveness of the medications on the resident's pain. When asked if reassessing PRN pain medication hours after it has been administered followed facility policies and procedures in the treatment of pain, the DON said, no. When asked if documenting inaccurate pain levels is an accepted practice at the facility, the DON said, no. When asked if pain assessments longer than an hour meet professional standards for PRN pain medication administration, the DON said, no. Review of a facility policy titled Pain - CP Assessment and Recognition revised 06/2024 included that the physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures). diabetic neuropathy, oral or dental pathology, and post-stroke syndromes. It also includes a review for any treatments that the resident currently is receiving for pain, including complementary and non-pharmacologic treatments. The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. The staff and physician will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity. Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The staff will reassess the individual's pain and related consequences at regular intervals, at least each shift for acute pain or significant change in level of chronic pain and at least weekly in stable chronic pain. a. review of pain should include frequency, duration and intensity of pain, ability to perform activities of daily living (ADLs). Jeep pattern, mood, behavior, and participation in activities. Periodically the physician will evaluate and summarize the status of an individual with chronic or fluctuating pain including the status of any active conditions that exacerbate pain, consequences or complications of pain, and effectiveness of current interventions for pain. Review of the [NAME] Drug Guide dated 11/2024 revealed that an assessment for oral oxycodone includes to assess type, location and intesnity of pain prior to and 1 hr (peak) after administration. The guide also included that a repeat dose can be safely administered at the time of the peak if previous dose is ineffective and side effects are minimal. Cross Reference F842

Based on observations, interviews, and review of records and facility policies and procedures, the facility failed to ensure medical records were accurate for one of one reviewed resident (Resident [R]46) when Registered Nurse (RN)14 entered an inaccurate pain assessment. The deficient practice could result in resident records not reflecting the actual care and services provided to R46. Findings include: Review of the Admission Record located under the Profile tab in the Electronic Medical Record (EMR) revealed that R46 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included pain in thoracic spine, systemic lupus erythematosus (a chronic autoimmune disease that occurs when the body's immune system attacks its own healthy tissues and organs), Sjogren syndrome (a chronic autoimmune disease that occurs when the body's immune system attacks the glands that produce tears and saliva), Ankylosing Spondylitis (a chronic inflammatory disease that causes inflammation in the spine and other joints) of unspecified sites in spine, chronic pain syndrome, age-related osteoporosis (a medical condition characterized by a significant decrease in bone mass and density). Review of physician orders found in R46's EMR under the orders tab revealed the following: Monitor and Record Pain Assessments every Shift, using 0-10 scale. 0= no pain,1-3 Mild Pain,4-5 Moderate Pain,6-10 Severe Pain. Documentation to include- Location of Pain, Non-Medication Interventions offered, received PRN (as needed) medication or med was offered and declined. The pain medication order included, oxyCODONE HCl Oral Tablet 10 mg (milligram) to give 1 tablet orally every 6 hours as needed for pain of 6-10 ordered on 10/16/24. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/23/24, indicated R46 had no cognitive deficits. The assessment included that R46 had arthritis and osteoporosis and was receiving scheduled and as needed pain medication for pain management. The pain assessment included that the resident had frequent pain that did not affect sleeping but would occasionally interfere with therapy activities. A medication administration observation conducted on 11/07/24 at 09:05 AM for R46, RN14 entered the room to provide scheduled morning medications. During the observation, RN14 asked the resident if they were still having pain after giving as needed pain medication earlier that morning. R46 stated the pain was still a 9/10. RN14 was observed continuing with the medication administration but did not ask where the pain was currently located, the intensity, duration, or if it was a different pain than reported in the morning. After the administration, RN14 was asked by the resident to ensure their pain was managed by 10:00 AM to 10:30 AM so that R46 could attend a physical therapy appointment. R14 agreed and left the room. In an interview on 11/07/24, at 09:10 AM, RN14 stated she had given R46 oxycodone at 07:30 AM. RN14 stated, after oral medication administration, reassessment of pain should be performed in about a half hour to 40 minutes. If the pain medication is ineffective, RN14 stated they would call the medical provider. RN14 stated that R46 always has a pain level of 9/10 and that the pain reassessment was not done until 09:10 AM because she was busy with another resident. When asked how pain assessments are documented, RN14 stated that it is in the EMR under the MAR or in a Progress Note but they only document if the medication was effective or not and a pain level. When asked what the potential outcome could be for not completing a pain assessment, RN14 stated that, if the medication is not working it would be important to make sure there are not other things going on causing serious harm, or complications from the medication. Or if the medication is effective they [physician] may want to cut back. Review of a Medication Administration Record (MAR) for November 2024 revealed R46 had received a PRN Oxycodone on 11/07/24 at 07:30 AM for a pain level of 9/10. The MAR did not indicate a reassessment of the pain medication to indicate if it was effective (E), ineffective (I), or unknown (U). This MAR was printed on 11/07/24 at 09:07 AM. On 11/08/24 at 05:00 AM, a second Review of the MAR for November 2024 revealed that R46 was re-evaluated after the PRN pain medication administration on 11/07/24 at 07:30 AM and was documented as an E which means effective. Review of a Progress Note Linked note by RN14 included documentation that R46's pain level on 11/07/24 at 08:30 AM was a 0/10. The progress note was created by RN14 on 11/07/24 at 05:52 PM (10 hrs after administration of pain medication at 07:30 AM). During an interview and review of R46's 10/07/24 pain reassessment, on 11/08/24 at 09:27 AM, RN14 stated, I think I was rushing, she [R46] still had pain, I don't remember why I put zero [pain level] wouldn't be a zero. RN14 confirmed that the oxycodone administered on 11/07/24 at 07:30 was ineffective. RN14 stated, The doctor could look at that [the zero] and think the medication is working and possible lower the dose [of pain medication]. RN14 explained I chose that 08:30 AM time [to document the pain reassessment] because they [the facility] like the times to match, that is the goal. It should be documented when it is done [reassessment]. On 11/08/24 at 10:53 AM an interview with concurrent record review was conducted with the Director of Nursing (DON). The DON stated that once a PRN pain medication is given, the evaluation of the effectiveness should be documented between 30 to 60 minutes later. The DON stated that the documentation should be in real time if possible and the complete assessment should be documented in the EMR. The DON stated it would be difficult to know the effectiveness of the medications on the resident's pain if reassessment was not completed within one hour of medication administration. According to the DON pain reassessments longer than an hour after pain medication administration and inaccurate documentation of pain level is not an acceptable practice in the facility and does not conform with professional standards. Review of a facility policy titled Health Information Management Documentation of Electronic Health Record Notes revised 06/24, revealed electronic medical records may be used in lieu of paper records when approved by the administrator. Electronic records are an acceptable form of medical record management.

Based on observation, interviews, and record review, the facility failed to protect the resident's right to be free from physical abuse for one of two resident (Resident (R) 3) reviewed for resident-to-resident abuse. R65 abused R3 while in her room, which resulted in a scratch on R3's face. Findings include: Review of the facility's policy titled, Abuse Prohibition, Reporting, and Investigation, dated 08/2024, revealed, . Each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone . Review of R3's Admission Record, located under the Profile tab in the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE] with diagnoses that included vascular dementia, hemiplegia, and hemiparesis following a cerebral infarction affecting the right dominant side. Review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/07/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of two out of 15, which indicated R3 was significantly cognitively impaired. It was recorded that the resident was dependent on staff for all cares and utilized a wheelchair for mobility. Review of R65's Admission Record, located under the Profile tab in the EMR, revealed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbances. Review of R65's annual MDS, with an ARD of 10/18/24, revealed the resident had a BIMS score of three out of 15, which indicated R65 was significantly cognitively impaired. It was recorded that the resident was dependent on staff for all cares and utilized a wheelchair for mobility. Review of a Facility Reported Incident investigation, provided by the Administrator and dated 10/20/24, revealed R3 had been assisted to bed at 7:40 PM. After exiting R3's room, within two minutes, staff heard a scream from R3's room. R65 was observed exiting R3's room. R3 was assessed to have a one-inch scratch to the right side of her nose and stated, She came into my room and scratched my face. I am okay. R65 was interviewed and had no recall of the event. Review of R65's Care Plan, located in the EMR under the RAI tab, revealed R65 was identified to have a Potential for conflict with other residents' d/t [due to] [R65] going into other resident's rooms and getting their property and hoards these objects in her room. [R65] roaming around the unit via wheelchair rummaging in other residents' rooms, drawers, and cabinets. [R65] has physical behavioral symptoms toward others: 10/1/24 [R65] had an episode of trying to approach another resident and attempting to strike another resident but was stopped by the staff right away and was separated right away. Interventions included, . all staff be aware of behavior, redirect, intervene, avoid overstimulation, maintain a calm environment and approach to the resident, psych consult as needed for medication evaluation and treatment. Following the resident-to-resident altercation on 10/20/24, R65 was placed on continuous one-to-one (1-1) supervision, 24 hours per day, seven days a week. R65 was observed to have a one-to-one monitor each day of the survey, from 11/04/24-11/08/24. During an interview on 11/06/24 at 3:47 PM, Certified Nursing Assistant (CNA28) stated, I'm with [R65] for my whole shift 6-6. Night shift is the same thing, 6-6. CNA28 confirmed that she has had to intervene in aggressive behavior by R65 and stated, It's less though with 1-1 right here. During an interview on 11/07/24 at 12:27 PM, Licensed Practical Nurse (LPN11) stated, [R65] is asleep, she didn't sleep last night, was agitated, that's why I'm here outside her door. During an interview on 11/07/24 at 3:14 PM, LPN2 stated, We have all received training on dementia care, no additional training was needed when the one-to-one was implemented. During an interview on 11/07/24 at 3:30 PM, R3's Responsible Person stated, I'm aware of the incident. They said she would have her own nurse. During an interview on 11/08/24 at 10:33 AM with the Director of Nurses (DON) and the Administrator, the Administrator stated, We are looking for alternative placement as the 24-hour one-to-one is not intended to be long term. We are working with [R65]'s Responsible Person who is to tour another possible placement.

Based on interview and record review, the facility failed to ensure a Significant Change in Status (SCSA) Minimum Data Set (MDS) assessment was completed for one of one resident reviewed (Resident [R] 66) who had change of capacity in carrying out activities of daily living (ADL). This deficient practice could affect the provision of appropriate care to meet residents need. Findings: R66 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes mellitus (high blood glucose), and dementia (loss of memory and thinking abilities). During an observation, on 11/05/24, at 11:23 AM and on 11/06/24, at 09:04 AM, R66 was sleeping in her room. In an interview, on 11/05/24, at 12:18 PM, Certified Nursing Assistant (CNA) 3 stated, R66 required Total care which required two staff to assist before she (R66) is only supervision. One staff can assist her. CNA3 added, R66 was Not able to express her need, not so much anymore like before. In an interview on 11/07/24, at 09:29 AM, Licensed Practical Nurse (LPN) 4 stated, When she (R66) had COVID May of 2024 she declined that time. She was sick for few days then I noticed that she's a bit weak. Now she needed more help. The confusion also is another thing. She used to be able to get up at the table, here outside. Seems that since then she declined to a point that she stayed in bed and it's hard to get her up. She's spending more time in bed. We have to encourage her more frequently. She is incontinent now. She changed a lot. Before she still can have understandable conversation but now not anymore. She's not the same (name of R66) anymore. Review of R66's electronic medical records (EMR) indicated the following assessment: The Monthly Summary dated 5/10/24, 06/10/24, 07/10/24, 08/10/24 revealed that R66 required limited assistance with one person assist for bed mobility, transfer, dressing, toilet use and bathing. An increased in the level of assistance indicated in the Monthly Summary dated 09/09/24 and 10/09/24 wherein R66 received an extensive assist that required two [2] person assist for bed mobility, toilet use and bathing. In an interview on 11/07/24, at 09:40 AM, MDS Registered Nurse (MDSRN) 2 confirmed that an MDS SCSA was not completed for R66's and she was not aware of R66's changes in level of assistance with the ADL. MDSRN explained that coordinators completing MDS assessment coordinate with the staff and we are doing IDT (Interdiciplinary Team) and discussed the condition of the resident. In a follow up interview on 11/07/24, at 02:11 PM, the MDSRN stated, There was a gap with the communication. I opened a significant change of status assessment for her. The change seems to start last May [2024] charted by CNA in the ADL Survey Report. MDSRN also added, I also updated her (R66) care plan (for ADL). Review of facility policy titled, Resident Assessment revised in October 2023 indicated, .1.OBRA-Required Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. OBRA assessments include: .d. Significant Change in Status Assessment (SCSA) .12. Information in the MDs assessment will consistently reflect information in the progress notes, plans of care and resident observations/interviews .

Based on interview, and record review the facility failed to ensure staff provided adequate supervision for two residents out of five facility reported events reviewed. Staff left Resident (R) 63 in the shower unsupervised and R63 fell and sustained a minor injury. Staff failed to effectively supervise R42 during a community outing which resulted in R42 becoming agitated and his hand hit R193 on the leg while attempting to transfer. Findings include: Review of facility reported incident AZ00216917, revealed that during a community outing with the Activities Department an incident occurred where one resident (R42) hit another resident (R193). Review of the witness statements revealed the Activities Department took 7 residents to a ball game on 09/29/24, and while trying to get everyone situated in the suite, described as small and crammed, R42 hit R193 on the left knee. Review of the Admission Record revealed the facility admitted R42 on 12/24/20. The document listed the primary diagnosis as unspecified dementia, unspecified severity, with other behavioral disturbance, onset date 12/05/2023. Other diagnoses listed included other specified disorders of brain, personal history of traumatic brain injury, other amnesia, and adjustment disorder with depressed mood. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed R42 to be cognitively intact scoring 15 out of 15 on a Brief Interview for Mental Status. The Functional Abilities Section GG revealed the facility asses R42 has impairment in the lower extremities, used a wheelchair, and required assistance for transfers. The quarterly Social Services assessment dated [DATE] revealed under GOALS, Progress: Care plans include . support for agitation and aggressive behaviors. It indicated that R42 was doing well in this area as R42 had not had recent occurrences of agitation or aggression. On 11/06/24 at 03:47 PM the Activities Director (AD) described that the residents chose the community outings as a group, and the facility provided a one staff to one resident ratio during the outing. In planning, they had to consider accommodation for specific residents going on the outing, such as ensuring the space was accessible, and activities were appropriate to the residents' needs. The facility could typically accommodate up to eight residents on a group outing. When asked about resident incident where R42 hit R193 on 09/29/24, AD confirmed awareness and described when the R42 got upset during the seating at the ball game and hit R193 on the leg. AD was not there, and did not know exactly what happened, however she stated her staff separated R42 from the other residents. AD described that R42 did not have a history of aggression in groups. AD confirmed during the ball game on 09/29/24, they provide one staff for every resident. Review of R42's care plan revealed six focus areas related to behaviors in effect at the time of the ball game outing. The foci included R42 becomes upset with staff when he doesn't 'get his way' . becomes agitated toward staff by striking out during cares . [and] Address the behavioral and safety needs of the resident in accordance with a behavior and safety contract signed by the resident on 4/29/24. The contract included, I prefer not to be told what to do. Please speak to me in a mild manner, I get upset when somebody uses a commanding tone on me. Allow space between us when I am upset . Goals included, Positive behaviors and safety will be maintained while resident is supported through promoting adherence to a behavioral and safety contract. Date Initiated: 09/19/2024; Ensure safety and give [R42] space if he is striking out . will not threaten, physically strike out at staff during cares .; [and] will demonstrate effective coping skills . Interventions planned to help R42 achieve the goals included, Staff will promote understanding of the expectations outlined in the behavioral / safety contract and will provide support .; Avoid power struggles with resident; Maintain a calm and accommodating environment; anticipate resident's needs . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress .; Assess and address for contributing sensory deficits . provide physical and verbal cues to alleviate anxiety. During a phone interview on 11/07/24 at 05:06 PM, Activities Aide (AA) 5 confirmed they attended the outing on 09/29/24 and witnessed when R42's hand hit R193. AA5 described they were standing in front of R42 trying to assist as the residents were being seated. She described R193 was seated next to R42 and while attempting assist R42 he made a quick strike which hit R193's leg. When asked AA5 if they were familiar with R42's care plan, AA5 indicated they were only aware at the time that R42 was from the A unit (the locked dementia care unit). During an interview on 11/08/24 at 11:46 AM the Director of Nursing (DON) confirmed she completed the facility investigation into the incident during the ball game outing. She described the facility has assessed the box suite for accessibility prior the outing and had had some modifications made to the space, and residents who could transfer would use the stadium seating. The event happened in the beginning, during the time everyone was being seated. The space was small, and it was probably noisy. [R42] has a dementia diagnosis, and he may have been overstimulated . He tried to stand himself up and his arm hit [R193's] leg. He was trying to stand when he just stuck down with his arm . she was speaking loud and he was getting agitated, and he tried to stand. A concurrent review of the statement provided by RN5, the nurse who attended the outing, revealed that R42 usually transferred with the aid of a slide board which they did not bring, and staff were attempting to assist a transfer without it. RN5 asked R42 if he was able to stand and he shouted at me 'That is what I am trying to do! Stop yelling at me'. It was loud in the stadium, and I had to talk loud for him to hear me. I asked the CNA [certified nursing assistant 52] how [R42] transfers at the facility because I have not worked with him before and stated he uses a slide board. RN5 directed staff to have R42 stay in the wheelchair. The DON stated staff notified her immediately and they separated R42 from the other residents and assessed R193 to have no injury; and further described appropriate interventions implemented following the event such as one to one monitoring whenever R42 was off the unit, and activity aides are dedicated to the A unit. She confirmed her expectation was the multiple care plans for behavioral issues should be evaluated during care planning and condensed to a comprehensive care plan. 42306 Review of the Admission Record located under the Profile tab in the Electronic Medical Record (EMR) revealed that Resident 63 (R) was admitted on [DATE] with diagnoses that included other sequelae of cerebral infarction, memory deficit following cerebral infarction, neuromuscular dysfunction of bladder, unspecified dementia, degenerative disease of nervous system, and bunion of unspecified foot. Review of a Care Plan initiated on 03/30/23 for Activities of Daily Living (ADLs) for self-care deficit included a goal that demonstrate improved ADL performance as evidenced needing limited assist) with all ADLs. An intervention for this goal included that a minimum of one staff to remain with resident while resident is showering Review of a facility investigation dated 07/10/24 revealed that Certified Nursing Assistant 71 (CNA) had left Resident 63 alone, unsupervised, in the shower on 07/01/24. The investigation included that another CNA (45) noticed 10-15 minutes after CNA71 left R63 alone, the call light was on in the resident's room. When CNA 45 entered the room with CNA 71 they found R63 on the floor of the bathroom. The investigation included that R63 was administered acetaminophen after the fall for headache pain. The investigation included that R63 usually requires substantial/maximum assistance of one to two as indicated for the ability to bathe self including washing, rinsing, and drying self. The investigation also included that CNA 71 received disciplinary action for poor judgement in leaving the resident unattended in the shower. Review of a Health Status Note dated 07/01/2024 entered at 10:06 PM by a Licensed Practical Nurse (LPN) in the Progress Notes under the Progress Notes tab revealed R63 was found lying on the shower floor on his (L) side, shower chair was also lying on its side. Resident denies hitting head on the floor. Skin assessment completed with no apparent injuries noted. The resident's range of motion was within normal limits to all extremities. The note included that the resident denied any pain. Review of another Health Status Note dated 07/01/2024 entered at 10:30 PM included that the resident was found lying on the floor. The note included that the resident stated they were seated in the shower chair and tried to reach for a wash cloth that had fell on the floor causing the resident to slip. Review of Orders written by the provider under the Orders tab in the EMR revealed the following: -STAT CT of the head with neuro consult. New contusion areas to forehead and Left eye orbit area. (ordered 07/02/2024) Review of a Care Plan initiated on 07/09/2024 for Showering included an intervention that Nursing staff will check the water before [NAME] sit for 10 min on the shower chair with just the water running on him per his preference after the shower tasks are complete and supervise him. During an interview on 11/05/24 at 10:08 AM, Resident 63 (R) stated they were in a shower chair when staff left him alone on 7/1/24. He reached for a wash cloth and the body went one way and the wheelchair went the other way. Resident 63 stated he did not get hurt. A call was placed to CNA 71 and a message was left. During an interview on 11/07/24 at 01:19 PM with the Director of Nursing (DON) and Administrator, the DON stated they were notified the morning of 07/02/24 that R63 had been found lying in the shower by staff and at that time they initiated an investigation into an allegation of Neglect based on the information they were provided. The Administrator stated that they took disciplinary action because CNA 71 left R63 alone in the shower. On 11/07/24 at 02:02 PM an interview was conducted via phone with CNA 45. CNA 45 stated that they had left the resident with CNA71 and that at some point CNA71 must have left the room. CNA45 stated that when they were answering the call light for R63, CNA71 was not in the room. CNA45 stated that when they entered the bathroom the resident was found lying on the bathroom floor.

Based on observation, interview, and record review the facility staff, LPN24, failed to implement hand hygiene appropriately for Resident (R) 73 during a medication observation. This practice had the potential to spread infection. Findings: During a medication administration observation on 11/07/24 at 08:44 AM Licensed Nurse LPN24 prepared and administered an intravenous (IV) antibiotic. LPN24 completed a flush of the PICC line (Peripherally inserted central catheter [PICC] line is used to deliver medications and other treatments directly to the large central veins near the heart) prior to the medication administration following aseptic technique. LPN24 then moved the IV pump closer to R29, and the electrical cord fell off the back, disconnecting the pump. LPN24 picked up the cord and reconnected it to the pump stating she would need to change her gloves now. Observed LPN24 doff (remove) gloves, and immediately donned (put on) a new pair of gloves and resumed the IV medication administration. LPN24 did not perform hand hygiene after removing the contaminated gloves. Following the observation LPN24 confirmed she had skipped a step following doffing gloves stating hand hygiene should occur after taking off gloves. During an interview on 11/07/24 at 12:03 PM The facility Infection Preventionist (IP) confirmed their expectation was that hand hygiene occurred between glove changes. Review of policy titled Infection Prevention and Control Program with revision date 06/2024 read under Standard Precautions, Standard precautions represent the infection prevention measure that apply to all resident care, regardless of suspected or confirmed infection status of the resident in any setting where healthcare is being delivered. These evidence-based practices are designed to protect healthcare staff and resident s by preventing the spread of infections among residents and ensure staff do not carry infectious pathogens on their hands or via equipment during resident care . standard precautions include hand hygiene . Staff must perform hand hygiene (even if gloves are used): . performing an aseptic task; . After removing personal protective equipment (e.g., gloves .).

Based on interview and record review, the facility failed to ensure a resident's rights are honored for one of 18 residents reviewed (Resident [R] 92) when facility provided an unwanted resuscitation attempt to R92 who had a Do Not Resuscitate (DNR, medical order that instructs healthcare providers to not perform life saving measures) expressed wishes. This failure resulted R92's healthcare and treatment decision not being honored. Findings: R92 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease (CKD), atrial fibrillation (irregular heart rhythm), and hypertension. Review of R92's Living Will Instruction Form signed on [DATE] indicated, R92 wishes for Comfort Care Only a type of medical treatment that provides comfort and quality of life for patients who are near end of life. The living will also indicate that if R92 will have a terminal condition R92 do not want to received Cardiopulmonary resuscitation (CPR). Review of R92's Provider Progress Note dated [DATE], at 12 NN indicated, Was called into patient room for urgent care by wound RN (Registered Nurse), [name redacted] who found patient unresponsive. Gown and gloves donned. Patient assessed, no carotid pulses felt, no audible heartbeat or spontaneous breaths noted during auscultation with stethoscope. Called out for crash cart, 911 to be called. When asked patient code status, someone called out Full Code. Started compressions, [name redacted] RN took over after 2 rounds, breaths given through self-inflating bag-mask. 2 minutes of CPR completed. Called for AED when code cart arrived, was informed that patient was DNR. Patient pronounced dead at 1203. Ancillary staff, nursing and management at bedside when time of death called. EMS in house approximately 1205. Nursing/administration notified all necessary, family, medical examiner and funeral home. In an interview on [DATE], at 10:48 AM, Assistant Administrator (AA) reviewed R92's Living will and DNR form signed on [DATE]. AA stated, She (R92) does not want CPR and artificial nutrition. AA also reviewed R92's Provider Progress Note dated [DATE], at 12 NN where it was indicated that R92 was provided CPR. AA stated, It's a mistake. She's a DNR. Review of the facility policy titled; Advance Directive last revised on ,d+[DATE] indicated, A Resident, or their designated representative, shall have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive . If a resident (directly or through an advance directive) declines treatment (such as refuses artificial nutrition or IV hydration, despite having lost considerable weight), the resident may not be treated against his or her wishes . The policy also indicated, Pre-Hospital Medical Care Directive (Do Not Resuscitate-DNR) refers to a document signed by the resident and their doctor that informs emergency medical services or hospital emergency personnel not to resuscitate the person who exercised the DNR. Arizona State law a DNR must be on letter sized paper or wallet sized paper on an orange background to be valid (aka-Orange Sheet) .

Based on observation, interview and record review, the facility failed to ensure that the residents' environment was free of accident hazards to prevent injuries; and that residents received adequate supervision and assistive devices to prevent falls. The deficient practice resulted in actual harm due to falls with injury for five residents (Residents 63, 57, 25, 55, and 24) , and injury related to an unkept assistive device (Resident 51). Findings include: 1. Resident 63 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the most current MDS (minimum data set) assessment dated [DATE] revealed that the resident had a BIMS (brief interview of mental status) score of 15 (no cognitive deficits), and had no mood or behavior problems. The same MDS noted that the Resident 63 was totally dependent on staff for most activities of daily living requiring 2-plus person physical assist, including bed mobility, transfer, and toilet use, because of functional impairment on both sides of her upper and lower extremities. During an interview on 12/13/17, Resident 63 stated that she had a fall while being transferred from her bed using a lift was transferred to an acute care hospital because she broke her legs. The resident added that the fall caused her a lot of pain and discomfort. Review of an electronic progress note dated 9/26/17 (at 7:10 a.m.) revealed that at 9:00 p.m. on 9/25/17, a licensed staff was summoned to the resident's room and discovered (the) resident kneeling on the floor with 2 staff holding onto her with (R) knee on the Hoyer frame. Accordingly, the staff stated that when the resident was lifted off the bed using the Hoyer, they did not notice that 1 strap came loose from the hook, and the resident slipped out of the sling so they had to lower her to the floor. The same progress note added that the Resident confirmed that she did not fall, only her her (R) knee was resting on the Hoyer frame. While the resident was described to have complained of pain on her right knee, she refused an x-ray examination. Review of the medical record revealed that the attending physician was notified of the fall at 8:37 p.m. on 9/26/17, almost 24 hours after the incident. Further review of the medical record revealed that Resident 63 continued to complain of stiffness and discomfort on her right knee on 9/26/17 (at 8:37 p.m.), and pain on the same knee on 9/27/17 (at 7:22 a.m.). While an x-ray was offered which again was refused, there was no indication that the resident was informed of the benefits and risks of the refusal including further injuries of the right knee. At 10:27 a.m., on 9/27/17, the resident was described tearful during repositioning with 2 staff members present, and stated that her pain level was 9/10 (where 10 is the most severe). At this time, the resident did agree to have an x-ray which was conducted at the bedside at 6:45 a.m. on 9/28/17, about 20 hours after she had consented. On 9/28/17 (at 12:12 p.m.), another progress note revealed that the x-ray indicated abnormal results and that a physician's order was obtained to transfer the resident to the emergency room . Further review of the medical record revealed that the resident sustained [REDACTED]. Review of the care plan for Falls dated 12/01/17 (edited 12/05/17) revealed the lack of indication that the care plan and its interventions were reviewed and revised based on findings following the fall by Resident 63 on 9/25/17. There was no indication, for example, that the need for safety checks were included as part of the protocol for the use of the lift. The care plan also noted that the risk for falls was related to the resident's immobility and that she required extensive-total assistance with care or positioning. The goal was that Resident 63 will not fall or exhibit signs of drug related side effects or adverse drug reaction. Interventions included Hoyer lift for transfer x 2, will monitor fall risk assessment quarterly, assessing/recording the effectiveness of drug treatment; and monitoring and reporting signs of sedation, [MEDICAL CONDITION], or [MEDICATION NAME] symptoms. No mention about the fall on 9/25/17 was made. Review of facility documents about the incident also revealed that while interviews were conducted with several licensed and unlicensed staff, the interviews were directed toward establishing that the resident did not fall but was assisted on the floor, or that she was lowered to the floor. However, according to another interview, the resident had informed a family member that she fell off the Hoyer (lift). Further, while mention was made that 1 strap came loose from the hook of the Hoyer lift (as was noted in the progress note dated 9/26/17), there was no indication that attempts were made to determine how this had occurred including identifying antecedents that allowed this to happen, and the development of corrective actions to prevent future incidents. 2. On 12/13/17 at 8:42 a.m., Resident 57 was observed up in wheelchair in the dining/activity area eating breakfast with the supervision of a certified nurse aide (CNA 211). The resident was alert but confused and had difficulty hearing. He was also observed able to self-propel his wheelchair. The resident's left arm was covered with protective gerisleeves. On the same day at 9:00 a.m., interview with CNA 211 revealed that Resident 57 bumps his arms readily against bedside drawers and other equipment in his room. The resident's room was observed while resident was in dining area. There was no equipment clutter inside the room and the bed linens had been stripped off at that time. Resident 57 was readmitted in the facility on 4/27/16 with [DIAGNOSES REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 00 indicating severely impaired cognitive status. The MDS also revealed the resident did not exhibit any behavioral symptoms. The resident's functional status with activities of daily living include the following: required extensive assistance with one person physical assist with bed mobility, transfer, dressing: and toilet use; required supervision with setup help only for eating; required limited assistance with one person physical assist with personal hygiene and required total dependence on staff with 2+persons physical assist. Further review of the MDS revealed the resident's balance during transitions from sitting to standing, turning around and moving on and off toilet was not steady and only able to stabilize with staff assistance. His functional range of motion revealed that he has impairment in one side of his upper extremity. The MDS revealed the resident's active [DIAGNOSES REDACTED]. On 12/13/17 at 9:12 a.m. the resident was observed back in his room. where he was assisted by CNA 211 to the toilet. The emergency call light was observed lit up 2 x from the nurses station. Interview with CNA 211 who was standing outside the resident's bathroom stated the resident had a bowel movement (BM) and the resident was the one who pulled the call light cord to request for assistance. The resident was observed in bathroom washing his hands by the sink. CNA 211 stated the resident was continent of bowel and bladder and he can call the nurses when he needed assistance. Review of the annual minimum data set (MDS) assessment dated [DATE] revealed no falls; and the quarterly MDS dated [DATE] revealed one injury but no falls. Review the electronic record revealed that on 12/13/17 the resident acquired a skin tear to the left forearm (LFA). There were no additional documentation to show the cause of the skin tear or any investigation was conducted to prevent further skin tears. Further record review revealed that on 9/20/17 at 6:45 p.m., Resident 57 was found on the floor in supine position between the foot of the bed and his wheelchair behind him close to entrance door. Upon assessment the facility staff found slight redness on he resident's upper back and below the shoulder blade and there was no tenderness when palpated. On 3/3/16 at 2:50 p.m., Resident 57 was observed on the floor. Review of the .John Hopkins Fall Risk Assessment Tool revealed a result of 11 points indicating the resident was a moderate fall risk. The fall care plans and approaches/interventions were not revised to determine the effectiveness of new approaches formulated. Review of the Events of Fall Incidents for the two unwitnessed falls did not reflect a thorough investigation of both events. This was verified with the facility's nursing supervisor on 12/14/17 at 12:30 p.m. She also confirmed that there was no investigation of the resident's skin tear on the LFA on 12/13/17 after reviewing the Event Report that was initiated but not filled out or completed. She further stated the the interdisciplinary team (IDT) fall packet would contain the investigations. Interview with an administrative nursing staff (Staff 190) on 12/14/17 at 1:30 p.m. revealed that the IDT packets were initiated only last month - November, (YEAR). 3. Resident 25 was admitted [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS - an assessment tool) for each of the assessments for the last year showed a BIMS (brief interview of mental status) score of 3 indicating the resident had significant cognitive impairment. The MDS also noted that the resident needed moderate assistance with activities of daily living (ADLs). During a family telephone interview on 12/12/17 at 11:29 a.m., when asked if the resident had ever fallen, the family member stated that she fell at home a lot, and that was why they placed her in the skilled nursing facility. Earlier this year (2017), according to the family member, Resident 25 fell at the facility and that they (the facility) called her to let her know. The family member added that she was told Resident 25 was found on the floor in the night. She had real bad bruises. Her whole left side of her face was bruised. She forgets that she can't walk anymore and then falls. Review of Resident 25's electronic medical record during the survey, under Event, revealed a note dated 11/1/16 at 12:39 a.m. that read in pertinent part as follows: found on floor no pain, said she hit her head. Had reddish knot on right side of head & abrasion to R. (right) elbow. In the PROGRESS NOTES the following read in pertinent part as follows: 4/18/2017 (12:05 AM), On 4/17/17 at (11:35 PM) a CNA found the resident laying on the floor with a bump to the L(eft) forehead, unwitnessed fall, resident alert but confused, stated she 'hurt my head,' assessment done, MD (doctor)and (responsible party) notified, sent to the ER via ambulance. (Resident 25) complained of pain to L forehead. The resident returned to the facility from theER on [DATE] at 12:30 p.m. Progress notes indicated that the (resident) had bruising to under right eye, lump on left forehead, eye and cheek, left eye closed with swelling. Was found to have a UTI (urinary tract infection). (Face) Painful to touch but refused pain medication Monitoring and neuro checks conducted. A care planning conference was conducted with residents family members on 4/20/17; however, there were no changes to care plan and no documentation as to why the care plan remained the same despite the injury the resident sustained [REDACTED].>Review of EVENTS documentation showed only one fall incident report dated 11/1/2016. There was no Event report documented for the 4/17/2017 fall. Review of the facility policy #NSG107.45 titled, .The Caring House Incident Reporting dated revised 09/2017 read in pertinent part as follows: All significant incidents associated with TCH patients . will be documented and reported to the Director of Nursing (DON). A significant incident is defined as any incident that is unexpected or has an unexpected outcome Policy Interpretation and Implementation: .Procedure: 1. Incidents include, but are not limited to: .d. Injuries .resulting from accidents or errors. e. Patient falls when: i) observed (whether injury noted or not), ii) Reported by patient or family (only if patient or nurse feel injury has occurred) . On 12/14/17 at 11:45 a.m., during an interview requesting information on the resident's fall incidents, a medical records staff (Staff 188) provided a care plan for falls that indicated Resident 25 had four falls in the past year on the following dates: a. 10/1/2016 - no information documented; b. 11/1/2016 - no injuries, c. 2/15/17 and 4/17/17 with head injuries. The care plan did not include changes/revision or updates after two of the four falls on 10/1/16 and 2/15/17. On 12/14/17 at 10:43 a.m., when asked if the facility had conducted any fall risk assessment, progress notes, care plan updates, or if any hospital records were available for the falls dated 11/1/16, 2/15/17 and 4/17/17, Staff 188 provided the following; -Fall Risk scores above 10 means the resident was at High Risk for falls. -Fall Risk assessments for the following dates revealed the following scores: -10/14/16 =21; 2/7/17 score =16; 4/7/17 = 24; 7/13/17= 22; 10/13/17= 20; and 11/19/17 = 14. These scores indicated the resident was at continued high risk for falls. Review of the MDS revealed the following in pertinent part: Quarterly assessment dated [DATE] under Section J1700, 1800/1900 indicated the resident had no falls since previous assessment: a care plan for falls was in place with an initial date 1/29/2016. There were no updates after the fall documented on 10/1/2016. Annual assessment dated [DATE] under Section J1800 /J1900 indicated the resident had 2 or more falls with no injuries and 2 or more falls with minor injuries. A care plan was in place with a start date of 11/01/16; however the interventions were the same as on 1/29/16. The goal was not changed even though Resident 25 had four or more falls in the previous look back period. The quarterly assessment dated [DATE] in section J1800/ J1900 indicated the resident had one fall with minor injury since the previous quarter. A care plan was in place with start date of 12/6/15 with revision dated 2/16/2017 - the goal was the same, although the target date had changed to 4/1/17. Further, while, the resident had fallen with a head injury, the facility removed but did not replace the following interventions: utilize pressure sensor when not in bed; provide environmental adaptations; low bed, call light within reach, adequate glare free lighting; area free of clutter; remind resident and reinforce safety awareness; and report to MD side effect associated with resident's medication use. The intervention reminding and reinforcing safety awareness was not relevant to Resident 25 due to her cognitive impairment. The quarterly assessment dated [DATE] under Section J1800/ J1900 indicated the resident had one fall with minor injury since the previous quarter. The fall was dated 4/17/17 and resulted in a head injury. The care plan was in place with the same goals and added intervention to keep personal items and frequently used items within reach; observe frequently and place in supervised area when out of bed; occupy resident with meaningful distractions; music, companion, crafts, etc The resident was unable to obtain personal items for herself. The intervention was not meaningful to the resident. The intervention to observe frequently when out of bed did not address the resident falling out of bed. The quarterly assessment dated [DATE] Under Section J1800 indicated the resident had no falls in the previous quarter. The care plan was in place with the same goal; above interventions continued and the facility restarted interventions that had been removed in (MONTH) (YEAR). 4. Resident 55 was admitted [DATE] with multiple [DIAGNOSES REDACTED]. Review of the minimum data set (MDS - an assessment tool) initial assessment dated [DATE] under Section J1700 revealed, Fall History on admission in the last month=(None); Falls in the last 2 - 6 months = (None): Fracture related to falls in the last 6 months prior to admission = (None). A significant change in condition assessment dated [DATE] under Section J 1800 listed, Falls since admission = Yes; and imder Section J1900, number of falls since admission = Two or more; Injury = NONE: Major Injury = Yes. A quarterly assessment dated [DATE] - Section J1800/1900 indicated One fall since 5/10/17 with no injuries: The most recent quarterly assessment dated [DATE] in section J1800/1900 - One fall since 8/10/17 no injury. During the initial tour of the facility on 12/11/17 at 4:05 p.m., the resident was observed sitting in a recliner chair in the main living area with his eyes closed. He had on regular shoes. A licensed staff member (Staff 191) stated that Resident 55 used a wheelchair for mobility. Observation of the resident's room showed a private room with fall mats observed beside both sides of bed, the bed was in an extremely low position. On 12/13/17 at 2:17 p.m., when asked how long she had known and worked with Resident 55, a certified nurse aide (CNA 59) stated she had worked with him since his admission approximately 11 months ago. CNA 59 stated that due to his cognitive impairment the resident did not remember that he could not walk, and that he tried to get up but then would fall down because he was weak. CNA 59 added that facility staff kept a close watch on him even when he was in his room at night; however, sometimes, the staff had to step away and even if it's just for a minute, the resident sometimes would get up and then would fall. When asked what happened when he broke his nose, CNA 59 stated, When he fell and broke his nose in (MONTH) (2017), he had rolled out of his bed. It was in the low position, but we did not have fall mats beside the bed at the time. Right after that the fall mats were placed. During the survey on different days review of Resident 55's medical record revealed the following: In the Matrix electronic health record (EHR) was a section titled EVENTS which are reports of incidents/events that occurred to the resident. A report dated 12/10/17 at 9:00 p.m., indicated the resident fell out of his wheel chair but did not sustain an injury. A review of EHR showed a care plan for falls initiated on 2/8/17 and revised on 12/11/17. Under the Problem indicating that the resident was At risk for falls, a list of falls with the following dates were noted: a. 2/28/17 - no injury (NI). Review of the Progress notes dated 2/28/17 at 9:57 p.m. read that resident was found on the floor and was sent to the emergency room (ER) for evaluation and treatment. Accordingly, the resident returned from theER on [DATE] at 4:29 a.m. The results of the X-ray showed a [MEDICAL CONDITION] elbow. The staff placed the bed in low position; however the care plan was not updated. b. 3/6/17 and 3/11/17- no injury. No details of these falls were found and the care plan was not updated. c. 4/24/17 - listed a witnessed fall and [MEDICAL CONDITION] after the fall. Resident 55 was sent to the ER and was noted to have no injury. d. 5/18/17 - the resident fell and sustained a skin tear to right forehead; e. 5/22/17 - fell out of bed and sustained a laceration and fracture to bridge of nose, and laceration to the upper lip; f. 6/9/17 fell out of bed; however sustained no injury; g. 2/10/17 - most recent fall; fell out of his wheel chair on the way to his room. There were no updates to the care plan for the above falls. On 12/14/17 at 3:48 p.m., during an interview, when asked for the investigation of the 8 falls unrelated to [MEDICAL CONDITION] the resident sustained [REDACTED]. During a concurrent record review of the Event Report and care plan for Fall Risk, Staff 190 stated that when the Event Report indicated the care plan was updated, facility staff listed the date of the new fall on the problem list but did not update the goals or the interventions despite Resident 55 having 8 falls including 2 major injuries and one minor injury. During an interview with another licensed staff (Staff 186) on 12/15/17 at 10:14 a.m., when asked how long she had worked at the facility, Staff 186 stated that she had worked at the facility in her position for about 3 years. When asked how she was trained for the MDS coordinator position, Staff 186 responded that it was an on-the-job training by the previous MDS coordinator. When asked what the she did with the care plans/assessments for falls, she stated that she trained the nursing staff to update the care plan as needed. Staff 186 added that the facility did not have a fall committee or meet after each fall. While the interdisciplinary team (IDT) developed the care plans as a team, Staff 186 explained that they used care plan books for ideas on creating care plans, and that the IDT met every Thursday and discussed the care plans together. Staff 186 added that the nurses should have been updating the care plans after each fall. During a concurrent review of the Fall Risk care plans for Resident 55 and Resident 25, Staff 186 acknowledged that the problem statement for the falls did not list the problem; the goal was not measurable; and the interventions listed were not individualized and did not take into account the residents' cognitive impairment. There were no changes to the goals, or interventions after the falls the residents sustained. This lack of individualized care planning, analysis of the root cause of the falls, and implementation of effective interventions may have contributed to Resident 25 and Resident 55's repeated falls. Review of the policy in place at the time of the above falls titled Falls and Fall Risk, Managing dated from 2001 MED-PASS, inc (revised (MONTH) 2007) read in pertinent part as follows: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation; Prioritizing Approaches to Managing Falls and Fall Risk read in pertinent part as follows: .4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling until falling is reduced or stopped, or until the reason for the continuation of the falling is identified and unavoidable. 6. in conjunction with the Attending Physician, staff will identify and implement relevant interventions . to try to minimize serious consequences of falling. 5. According to the Resident Face Sheet, Resident 24 was originally admitted to the facility on [DATE]. His pertinent [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS), a standardized screening and assessment tool used for long term care residents dated 7/12/17, Resident 24 was cognitively intact. In Section C - Cognitive Pattern, Resident 24 was coded with a brief interview for mental status score of 15 out of 15 (score of 13-15 indicates cognitively intact). Review of Section G - Functional Status, indicated Resident 24 required extensive assistance from 2 staff for transfers and extensive assist from 1 staff for bed mobility, locomotion on/off the unit, toileting, and personal hygiene. Under Section J - Health Conditions, Resident 24 was coded as having falls prior to the previous MDS assessment. Review of the current (active) comprehensive care plan for Resident 24 initiated on 9/2/17 and edited on 12/12/17, revealed that a care plan for falls was initiated due to at risk for fall related injury as evidenced by unsteady gait, right-sided [MEDICAL CONDITION]([MEDICAL CONDITION] or stroke). The care plan interventions included: anticipate needs by frequent rounding, encourage and escort to activities consistent with resident's interests to enhance physical strengthening needs, provide and monitor use of adaptive devices - wheelchair, provide environmental adaptations - low bed, call light within reach, adequate/glare-free lighting, area free of clutter, report to physician any side effect associated with the resident's medications use, use fall risk screen to identify risk factors and restorative nursing aide to treat patient three times a week for 12 weeks for bilateral upper and lower extremity strengthening, transfer and balance training, and pre-ambulation training to improve current level of function. The restorative program was not initiated until 11/11/17. In addition, the care plan failed to identify the resident's falls that occurred on 5/24/17 and 9/2/17. Further review of the comprehensive care plan demonstrated a lack of new interventions to prevent falls after the resident sustained [REDACTED]. According to the Event Report dated 5/24/17, Resident 24 had an unwitnessed fall in his room which was related to fatigue, secondary to receiving [MEDICAL CONDITION]. The resident was found on the floor in front of his wheelchair after he returned from having a haircut. The Event Report noted that the resident tried to transfer himself from his wheelchair to the bed without asking for assistance. The report read, It appeared that he must have slid down and was found sitting. The fall resulted in scratches to the resident's right elbow measuring 0.4 cm x 0.4 cm, and 0.5 cm x 0.3 cm. The resident also sustained a 13.2 cm scratch on the left side of his back with no bleeding noted. The wound nurse cleaned the areas and applied [MEDICATION NAME] (topical antibiotic ointment). The resident was noted to have mild pain (uncomfortable, annoying - usually able to carry on with daily routines, socialization or sleep), and he denied hitting his head. Neurological checks were started. The Event Report indicated the resident's care plan was updated. Additional information regarding the fall was found in the Resident Progress Note also dated 5/24/17. According to the Resident Progress Note, the medication nurse discovered Resident 24 on the floor in front of his wheelchair. The resident was asked by staff about what had happened and if he tried to get up and get into bed by himself. The resident replied yea (sic). Resident 24 did not notify staff he needed assistance transferring to the bed prior to the fall. Based on review of the Resident Progress Notes dated 5/24/17 through 5/31/17, there was no evidence the interdisciplinary team (IDT) reviewed the fall, evaluated the need for new interventions, or implemented new interventions to help prevent further falls in accordance with facility protocol (see policy below). Review of the Fall Risk Assessments failed to demonstrate staff completed a fall risk assessment after the resident sustained [REDACTED]. According to the Resident Progress Note dated 9/2/17, Resident 24 had a witnessed fall that occurred during Bingo. The resident slid down slowly from his wheelchair to the floor; he did not hit his head. The resident was noted sitting on the floor in the activity room in between the wheelchair foot rest. Two certified nurse aides (CNAs) removed the footrest, and assisted the resident to sit up in his wheelchair. While no injury was noted; however, one hour later the CNA reported seeing a new scratch on the left side of the resident's body (exact location was not specified). The licensed nurse assessed the area and noted a 22-cm scratch on the left side of Resident 24's body. The area was cleansed with normal saline, was patted dry, and [MEDICATION NAME] ointment was applied. The resident's bed was placed in the lowest position, and the CNAs were instructed to make sure Dycem (no-slip, rubber-like material used to stabilize) was placed in his wheelchair seat to prevent him from sliding down. The resident verbalized understanding. The Progress Note indicated frequent rounds were being done to assist in meeting the resident's needs and that staff would continue to monitor the resident. Additional information regarding the fall on 9/2/17 was found in the Event Report, also dated 9/2/17. Resident 24 was playing Bingo in the activity room with the other residents and slowly slid from wheelchair to the floor, as stated by resident, and he obtained a 22-cm scratch from the wheelchair. The section titled, Follow Up Investigation of Incident had listed under other factors - Other: Specify - patient has the dycen (sic) (Rubber cushion) under the pad. Based on review of the Resident Progress Notes dated 9/2/17 through 9/9/17, there was no evidence the IDT reviewed the fall, evaluated the need for new interventions, or implemented new interventions to help prevent further falls. Review of the clinical record failed to demonstrate staff completed a fall risk assessment after Resident 24 sustained the fall with minor injury on 9/2/17. The resident was discharged to the hospital on [DATE] (unrelated to the fall) and was readmitted on [DATE]. A fall risk assessment was not completed until 9/18/17. The fall risk assessment score was 15, which indicated the resident was at high risk for falls. During an interview with an administrative nursing staff (Staff 190) on 12/15/17 at 10:10 a.m. she reported that she was newly appointed to the position and was unable to speak to the falls that occurred on 5/24/17 and 9/2/17. She reviewed the nursing notes, care plan and event reports related to the 5/24/17 fall and stated that she did not see that any new fall interventions initiated in response to the fall. Additionally, Staff 190 was unable to locate an interdisciplinary note related to the 5/24/17 fall and was unable to find fall risk assessments completed in response to the 5/24/17 and 9/2/17 falls. Staff 190 indicated that the facility identified an issue with falls and moving forward, staff were expected to follow the current policy, which included event reporting and highlighting what happened. The unit managers were to start the investigation, interview patients and conduct a root cause analysis. The unit managers were also to complete a fall risk screen (using the John Hopki (TRUNCATED)

Based on observation, record review, and interview, the facility did not develop and implement a comprehensive person-centered care plan for each resident. (Residents 55, 13, and 125) Findings include: 1. Resident #55 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the initial minimum data set (MDS) assessment dated [DATE], Section J1700, noted the following: Fall History on admission in the last month=(None); Falls in the last 2 - 6 months = (None): Fracture related to falls in the last 6 months prior to admission = (None). Further record review revealed that a significant change in condition assessment was conducted on 5/10/17, and under Section J1800 listed, Falls since admission = Yes; and section J1900 number of falls since admission = Two or more; Injury = NONE: Major Injury = Yes. A quarterly assessment dated [DATE] - Section J1800/1900 indicated the the resident had One fall since 5/10/17 with no injuries: The most recent quarterly assessment dated [DATE] under Section J1800/1900 noted: One fall since 8/10/17 no injury. During the initial tour of the facility on 12/11/17 at 4:05 p.m., Resident 55 was observed sitting in a recliner chair in the main living area with his eyes closed. He had on regular shoes. A licensed staff member (Staff 191) stated that the resident used a wheelchair for mobility. Observation of the resident's room showed a private room with fall mats observed beside both sides of bed, and the bed was in the lowest position. During an interview on 12/13/17 at 2:17 p.m., when asked how long she had known and worked with Resident 55, a certified nurse aide (CNA 59) stated that she had worked with the resident since his admission approximately 11 months ago. CNA 59 stated that due to his cognitive impairment the resident did not remember that he could not walk, that he tried to get up but then fell down because he was weak. CNA 59 added that they kept a close watch on him even when he was in his room at night, but sometimes, however, staff had to step away and even if its just for a minute, the resident would sometimes just get up and then would fall. When asked what happened when the resident broke his nose, Staff 59 stated, When he fell and broke his nose in (MONTH) (2017), he had rolled out of his bed. It was in the low position, but we did not have fall mats beside the bed at the time. Right after that the fall mats were placed. During the survey on different days, review of Resident 55's medical record revealed the following: In the Matrix electronic health record (EHR) was a section titled: EVENTS which were reports of incident that occurred to the resident. A report dated 12/10/2017 at 9:00 p.m., indicated that the resident fell out of his wheel chair; however did not sustain an injury. A review of EHR revealed a care plan for falls initiated 2/8/17 and revised 12/11/17. Under the Problem was noted At risk for falls indicating a list of falls with the following dates: a. 2/28/2017 - no injury (NI). Review of the progress notes dated 2/28/17 at 9:57 p.m. read that the resident was found on the floor and was sent to the emergency room (ER) for evaluation and treatment. The resident returned from the emergency room (ER) on 3/1/17 at 4:29 AM. The results of an x-ray examination showed a [MEDICAL CONDITION] elbow. Accordingly, while the staff placed the bed in low position; however, the care plan was not updated. b. 3/6/17 and 3/11/17 (no injuries) - No details of these falls were found and the care plan was not updated. c. 4/24/17 listed a witnessed fall and [MEDICAL CONDITION] after the fall. Resident 55 was sent to ER however sustained no injury. d. 5/18/17, the resident fell and sustained a skin tear to right forehead. e. 5/22/17 - the resident fell out of bed and sustained a laceration and fracture to bridge of nose, and laceration to the upper lip. f. 6/9/17 - the resident fell out of bed; however sustained no injury. g. 12/10/17 - the most recent fall was dated; the resident fell out of his wheel chair on the way to his room. There were no updates to the care plan for the above falls. A care plan for [MEDICAL CONDITION] activity with the problem, At risk for accident/injury was initiated on 2/13/17 (and revised 11/30/2017). The following was listed under problem: Had [MEDICAL CONDITION] during therapy on 4/24/2017. The goal listed, Resident will remain free from injury r/t (related to) [MEDICAL CONDITION], and maintain therapeutic levels of anticonvulsant medication through next review date 5/13/2017. Interventions included monitor for [MEDICAL CONDITION] activity and report to physician; monitor Labs for therapeutic levels of anticonvulsant medication; provide safe environment during [MEDICAL CONDITION] activity (if it occurs), and try to maintain resident in side-lying position; and monitor for s/s (signs and symptoms) of aspiration of any emesis. On 11/30/17, the following was added to the interventions: [MEDICAL CONDITION] precautions: bilateral floor mats on each side of residents bed and report changes in cognition or behavior to MD. 12/14/17 at 3:48 p.m., during an interview, when asked for the investigation of the 8 falls the resident had sustained, a nursing administrative staff member (Staff 190) stated that there were no investigations prior to the 12/10/2017 fall. During a concurrent record review of the Event Report and care plan for the fall risk, Staff 190 stated that when the Event Report indicated the care plan was updated the staff listed the date of the new fall on the problem list; but they did not update the goals or the interventions for Resident 55 despite the resident having 8 falls including 2 major injuries and one minor injury. 12/15/17 10:14 a.m., during an interview, when asked how long the staff had worked at the facility, a licensed staff member (Staff 186) stated she had worked at the facility in her position for about 3 years. When asked how she was trained for the MDS coordinator position, Staff 186 stated it was on-the-job training by the previous MDS coordinator. When asked what she did with the care plans/assessments for falls, Staff 186 stated said she trained the nursing staff to update the care plan as needed, and explained that the facility did not have a fall committee or meet after each fall. Staff 186 stated that the IDT (interdisciplinary team) developed the care plans as a team, that the IDT used care plan books for ideas on creating care plans, and that the IDT met every Thursday and discussed the care plans together. Staff 186 also stated that the nurses should have been updating the care plans after each fall. During the concurrent review of the fall care plan for Resident 55, Staff 186 acknowledged that the problem statement for the falls did not list the problem, the goal was not individual or measurable and the interventions listed were not individualized and did not take into account the resident's cognitive impairment. There were no changes to the goals, or interventions after the falls the residents sustained. 2. According to the Resident Face Sheet, Resident 13 was admitted to the facility on [DATE], and resided on unit A (secured dementia unit). Resident 13's pertinent [DIAGNOSES REDACTED]. During observations on 12/12/17 at 2:50 p.m. and 12/13/17 at 8:10 a.m. Resident 13 was observed to have missing teeth, and broken teeth that were dark in color. Resident 13's annual minimum data set (MDS), a standardized screening and assessment tool used for long term care residents dated 7/1/17, indicated under Section L (Oral/Dental Status), the the resident had obvious or likely cavities or broken natural teeth (cross refer F791: Emergency/Routine Dental Services). Another MDS dated [DATE] indicated, under Care Area Assessment Summary (CAA) for Section L, that the resident had natural teeth; however, some teeth were missing and broken. The documentation noted that the resident's gums and tongue were pink and moist, that there was no indication her teeth were causing any pain or discomfort, and that she was meeting her nutritional needs. Further documentation indicated that the resident was unable to answer any questions and responded by mumbling. The documentation also noted that oral care was provided by nursing personnel due to Resident 13's inability to perform steps to provide her own oral care, and that she was unable to understand instructions related to her cognition. The resident's lips were noted as being dry and chapped, and that due to her advanced age and cognition, she would see the dentist as needed because she was unable to follow instructions or cooperate for a dental consult. The documentation further indicated that the dentist would be consulted if the Resident 13 developed any oral [MEDICAL CONDITION] or ulcerations or had trouble chewing. The resident was noted as being on a mechanically altered diet. The decision to care plan this care area was marked Yes. A review of Resident 13's comprehensive care plans, last reviewed and revised on 10/05/17, failed to reveal a comprehensive care plan had been developed to address the resident's dental status or dental care needs. Resident 13's comprehensive care plans were reviewed with a social service staff (Staff 223) on 12/13/17 at 4:02 p.m. Staff 223 verified that the facility failed to develop a comprehensive care plan for the resident's dental status and dental care needs. Staff 223 added that the MDS nurse was responsible for assessing and care planning the resident's dental status or dental care needs. On 12/14/17 at 8:24 a.m., a review of Resident 13's comprehensive care plans was conducted with a licensed staff member (Staff 180) and revealed that there was no care plan related to the resident's dental status or dental care needs. During an interview on 12/14/17 at 8:24 a.m., Staff 180 stated that she thought the resident had a dental care plan that may have been deleted in error; however, she was not able to find a discontinued care plan related to the resident's dental status or care. She added that the dental section was a new section of the MDS assessment for her to complete, and she was still learning. She also stated that if she saw a resident had broken teeth or issues that needed attention, she would initiate a care plan. Staff 180 stated, if a resident did not have teeth or needed help with dental care, she would create a care plan. She stated she was not sure how she missed initiating a care plan especially because the resident could not take care of her own teeth. She acknowledged there should have been a dental care plan in place to direct care for Resident 13's dental needs. On 12/15/17, a request for the facility's policy related to dental services was made; however, one was not provided prior to the end of the survey. 3. Record review on 12/15/2017 revealed that Resident 125 was admitted on [DATE] to the facility with several [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] documented that Resident 125's 14-day assessment BIMS (brief interview of mental status) score was 15 which indicated no cognitive impairment. According to the skin assessment, the resident developed a facility acquired pressure ulcer/injury to the coccyx and buttocks area on 11/28/17. Further record review revealed that the facility failed to initiate a patient centered care plan with interventions for the facility acquired pressure ulcer/injury from 11/28/2017. As a result the resident's pressure ulcer/injury had evolved to an unstageable wound on the left buttock, and a stage 3 pressure ulcer on the right buttock, according to the clinical record. During an interview on 12/14/17 at 10:12 a.m., Staff 180 validated that the pressure ulcer/injury was facility acquired and that Resident 125 was admitted with intact skin, according to the admission skin assessment conducted on 11/18/17. Staff 180 added that the facility expectation was to update the care plan as soon as an issue was identified. The staff also acknowledged that the care plan was not updated for the resident's pressure ulcer/injury when it was identified. According to the facility policy reviewed on 12/14/17 titled, Care Plans - Comprehensive, revealed that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs was to be developed for each resident.

Based on record review and interview the facility failed to provide care, consistent with professional standards of practice, to prevent development of pressure ulcers for 1 of 15 sampled resident (Resident 125). Finding includes: During a record review on 12/14/17, Resident 125 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Resident 125's admission nursing assessment revealed that on 11/18/17 her skin was intact on the buttocks, coccyx and sacral area. The minimum data set ((MDS) dated [DATE] documented the resident's 14-day assessment's brief interview for mental status score (BIMS) was 15 indicating no cognitive impairments. On 11/22/17, the resident developed a blister on the upper back. On 11/28/17, an open area on the coccyx area was noted. On 12/06/17 the resident's bilateral buttocks had open areas according to the skin assessment documentation. On 12/11/17, a wound care specialist evaluated the resident and documented that the left buttock had an unstageable pressure ulcer/injury wound, and on the right buttock, a stage 3 pressure ulcer was noted. A debridement of the wound was done at bedside and the wound measured 10 cms x 7.5 cms x 1 cm. An attempt to observe the wound and wound care was made but was not fulfilled because the resident was sent to hospital for worsening of the wound. During an interview on 12/14/17 at 10:12 a.m., a licensed staff (Staff 180) indicated that the pressure ulcers were facility acquired and that Resident 125 was admitted with intact skin. When asked to see the care plan, Staff 180 acknowledged that it was not implemented when the actual wound was identified on 11/28/17. The staff further explained that the skin assessments were incomplete and should have been completed by the nurse doing the assessments. Staff 180 also indicated that she had been ill and had failed to complete the facility acquired pressure area CQI/Rick assessment investigation per policy. Staff 180 explained that the CQI/Risk assessment report would have helped the facility identify the root cause to determine the best plan of care for the resident. When asked why Resident 125 did not have a specialty bed to prevent worsening of the pressure ulcer, Staff 180 explained that it was denied initially by Medicare. When a request was made to review the denial letter, none was provided. During a separate interview on 12/14/17 at 10:51 a.m., a nursing administrative staff (Staff 193) validated that Resident 125 did have a stage 3 pressure ulcer which was being taken care of by the wound care team at the facility. Staff 193 indicated that she will look for the Medicare denial letter for the specialty bed. She continued to explain that the resident will be getting the special pressure relieving bed today (on 12/14/17). In another interview on 12/14/17 at 11:12 a.m., a licensed staff (Staff 190) explained that facility staff received inservices on how to conduct skin assessment and are were supposed to report skin concerns immediately to the interdisciplinary team. The staff further explained that the resident did not have the recommended bed due to her lumbar fracture contraindication. Staff 190 stated that the pressure reducing bed will arrive today 12/14/17 and that it was safe for the resident's lumbar fracture. During an interview at 12/14/17 02:12 p.m., a medical provider (Staff 236) stated that Resident 125 was sent out to the hospital because her wound to the buttocks had worsened from the last time she evaluated the wound. The staff confirmed that she was not notified that the wound had worsened until today. Staff 236 described the wound and stated that she can put her fist into the wound bed. In addition the resident was also spiking a fever for the first time since admission. Staff 236 added that the specialty bed was contraindicated for the resident due to her lumbar fracture. When asked who ordered the specialty bed, Staff 236 stated that she was not aware that the bed was being ordered.

Based on record review, interview and observation, facility failed to ensure that pain was managed according to the standards of practice and the resident's goal and preferences for 1 of 15 sampled residents (Resident 125). Finding includes: During an observation concurrent with an interview with a family member on 12/11/17 at 12:00 p.m., Resident 125 was observed screaming extremely loud. In the interview, the family member indicated that Resident 125 was having pain and that her pain was not being managed properly. The family member further indicated that she had communicated this with facility staff but that Resident 125 continues to experience severe pain, and even more pain during care. During an observation concurrent with an interview on 12/14/17 at 10:40 a.m., Resident 125 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] documented that the resident's 14-day assessment which included a brief interview for mental status (BIMS) revealed a score of 15 which indicated that the resident did not have any cognitive deficits. The resident was observed moaning and groaning while lying in bed on her right side. When asked how she was doing, Resident 125 indicated that staff took a long time to give her pain medications and answering her call light. Resident 125 further explained that at times the waiting was at least 1 hour for assistance. The resident also described the pain as being severe all the time. During a record review concurrent with an interview on 12/14/17 at 10:45 a.m., with a licensed staff (Staff 213), she stated that the resident did not convey that she was in pain during the morning medication pass, but did observe the resident moaning and grimacing. When asked if the moaning was a sign of pain, Staff 213 indicated yes, but did not medicate the resident for pain. Review of the clinical record revealed that the last time the resident had a pain medication was on 12/14/17 at 1:57 AM. During an interview on 12/14/2017 at 10:50 a.m., another licensed staff member (Staff 217) indicated that the resident was assessed in the morning and did not have grimacing and did not indicate that she was in pain. Staff 217 further indicated that resident usually have pain during care due to her lumbar fracture. During an interview on 12/14/2017 at 12:00 p.m., with an administrative nursing staff member (Staff 190), she verbalized that her expectation was for the staff to offer pain medication to the residents when observations of moaning and grimacing were present. Staff 190 added that facility staff will be inserviced on nonverbal pain techniques.

Based on observation, interviews and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent recurrent urinary tract infections for one of 18 sampled residents (Resident 8). This failure due to lack of appropriate perineal care resulted in severe discomfort in the [MEDICAL CONDITION] labial and urethra areas due to excoriations and burn-like spots from stool staying on Resident 8's skin. Findings include: Resident 8 was admitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the quarterly minimum data set ((MDS) dated [DATE] revealed resident's cognitive ability was severely impaired with no behavior or mood symptoms. The resident was assessed with [REDACTED]. The resident's functional status was assessed as follows: required extensive assistance with 2+ persons physical assist for bed mobility, transfers and toilet use; required supervision with one person physical assist for walking in room and in corridor, locomotion on and off unit; required limited assistance with one person physical assist in dressing and personal hygiene; supervision with set up help only for eating and extensive assistance with one person physical assist in bathing. The resident was identified as frequently incontinent of bladder and occasionally incontinent of bowel. The active [DIAGNOSES REDACTED]., anxiety disorder, depression, altered mental status and history of personal fall. On 10/28/14 at 1:15 PM, Resident 8 was observed sitting in wheelchair staring at her lunch tray with nursing staff encouraging her to eat. The resident was alert but did not respond when asked about her meal or if she had any complaints. On 10/27/14 at 2:45 PM during the initial tour, a licensed nurse indicated that Resident 8 has a history of recurrent UTIs. The licensed nurse also stated the resident is currently on "cranberry protocol" due to history of chronic UTIs. The resident has been prescribed cranberry tablet for chronic UTI. Review of the Medications Flowsheet from 9/1/14 - 9/30/14 revealed an order for [REDACTED]. Review of the resident care plan dated 8/12/13 revealed a problem of "History of frequent urinary tract infections. (3 - 5 diagnosed urinary tract infections in 4 - 6 months)." The problems of UTIs recurred on 4/8/14, 5/30/14, 8/19/14, 9/16/14 and 10/22/14. The approaches include "obtain an order from the physician to initiate Cranberry and Vitamin C protocol. Dose: 2 Cranberry capsules/tablets p.o. BID and Vitamin C - 500 mg p.o. daily (QD)." Also, under approaches column of the care plan indicated the "dates of the occurrences of UTIs that are diagnosed after protocol has begun." 1) Antibiotic discontinued on 7/17/13 for UTI acquired before admission to facility. 2) [MEDICATION NAME] 100 mg. p.o. QD for 5 days (yeast in urine) 8/19/13 3) 9/16/[MEDICATION NAME] mg. p.o. Q HS for seven days (E.Coli) 4) 4/8/14 Bactrim DS 1 tablet p.o. Q 12 hours for 7 days CS pending (when urine culture was received on 8/14/14 antibiotic had to be changed. On 4/15/14 first antibiotic Bactrim was not effective and changed to [MEDICATION NAME].) 5) 5/30/14 UTI per urinalysis (UA) and culture indicates E. Coli 6) 8/19/14 UTI treated with [MEDICATION NAME] 7) 9/16/14 UTI treated with Cipro 8) 10/22/14 UTI treated with [MEDICATION NAME] Another care plan for UTI dated 6/1/14 with approaches that include obtaining culture specimens and reporting positive results; administer anti-infective(s) as ordered; assess therapeutic effects of medication; monitor for side effects; draw and monitor lab works as ordered; instruct resident importance of adequate nutrition and hydration while receiving anti-infective therapy; implement measures to reduce the risk of cross-contamination. There were no other aggressive approaches that were attempted by the interdisciplinary team other than the Cranberry protocol and antibiotic therapy. There was no evidence in the plan of care creative ways to implement hydration therapy for a resident with cognitive impairment. The Medications Flowsheet from 9/1/10 - 9/30/14 revealed the resident received [MEDICATION NAME] ([MEDICATION NAME]) 20 mg. tablet p.o. once a day for [DIAGNOSES REDACTED]. The resident also received [MEDICATION NAME] (quetiapine) 25 mg tablet once a day at 1600 and 25 mg at bedtime for [DIAGNOSES REDACTED]. The Resident Progress Notes dated 10/04/14 at 17:48 revealed the resident was "resistive with care this a.m. with CNA. Became argumentative... Resident was in bed, and had been incontinent, would not allow CNA to assist in changing clothing. Resident did allow this writer to assist and told CNA to "get out." Review of the Resident Progress Notes dated 10/21/14 at 16:28 stated: "CNA's called said nurse to bathroom to look at resident's labia and vaginal area. Area is red and excoriated and looks like a"burn" from bowel movements not being wiped properly and resident ends up with loose stool all over her skin. Wound care team aware and suggested to use aloe vista for now and will reevaluate in a few days to see how skin looks. Medicated for pain again at this time." Review of the Patient Progress Notes dated 10/22/14 at 12:46 stated:"Attempted x4 to obtain sterile urine specimen from resident without success. Resident labial and urethra are [MEDICAL CONDITION] due to excoriations and burn-like spots from stool staying on skin and going into the vaginal and urethral area during her bowel movements. Resident was running a temperature on Saturday and also yesterday per records and is afebrile today." As of 10/29/14, there was no further assessment of the resident's labial and urethral areas documented in the progress notes. In an interview with a licensed staff on the same day, she indicated that the resident's caregivers have not been monitored in providing perineal care for Resident 8. On 10/31/14 at 9:30 AM, interview with a licensed nurse revealed that infection control issues particularly UTIs are discussed in the facility's Quality Assurance quarterly meetings. She added that the interdisciplinary team plans to discuss the issue of recurrent UTIs with the resident's attending physician and request for referral or urological consult.

Based on interview, clinical record and facility document review, the facility failed to identify environment hazards/risks and implement necessary interventions to prevent accidents as evidenced by: 1. Resident 16 sustained a head injury and fractured wrist as a result of an unwitnessed fall requiring acute hospitalization 2. Resident 1 was not provided adequate supervision and assistance devices to prevent accidents 3. Residents had access to hazardous chemicals and supplies which had potential to cause injury or illness Findings include: 1. Resident 16 was an [AGE] year old admitted to the facility 2/3/2013 with [DIAGNOSES REDACTED]. The MDS (minimum data set), a comprehensive screening tool dated 7/7/2013, indicated Resident 16 had difficulty with time, place and recent memory. "Resident is at risk for agitation and increased confusion." The MDS also indicated Resident 16 required assistance and supervision for bathing, dressing, toileting, and ambulation. Resident 16 was only independent with feeding self during meals. Review of the resident care plan initiated 7/11/2013 revealed "fall" as an acute problem secondary to Resident 16's [DIAGNOSES REDACTED]." The care plan indicated Resident 16 sustained an unwitnessed fall when on "7/22/2012 found on floor in room and complained of left shoulder pain." Care plan instructions for staff did not change with only one exception: "Monitor for bruising or open areas." There was no evidence of any additional individualized interventions to assist Resident 16. On 11/8/2012, the care plan indicated Resident 16 sustained another unwitnessed fall when she was "found on floor, complained of back pain in room." The only additional staff instructions or changes in the care plan were to "monitor for pain and bruises, use pain assessment." Further review of the clinical record revealed Resident 16 was sitting in the activity room on 5/30/2013, playing Bingo and "began to feel woozy or dizzy and her head fell forward onto the table." EMS (Emergency Medical Services) was called and after a rapid assessment, Resident 16 was transferred to the hospital. After a two day length of stay in the hospital, Resident 16 returned to the facility. The final hospital assessment after diagnostic and laboratory testing indicated the syncopal episode (passing out) was due to low blood pressure and a very slow heart rate. The lab results revealed no ischemic changes (muscle damage) in the heart. Resident 16 was transferred back to the facility on [DATE] at 1:04 a.m. The nursing admission note at 1:04 a.m. identified the resident as alert and oriented, independent with ADLs (activities of daily living), transfers, and used a wheelchair as the primary mode of transfer and mobilization. The nursing notes dated 6/3/2013 at 1:03 a.m. and 4:23 p.m. indicated Resident 16 had periods of confusion but was easily redirected. On 6/5/2013 at 4:31 p.m. the nursing staff continued to document the resident needed supervision for transfers and toileting. Review of the nursing assessment tool for fall risk dated 6/1/2013 revealed a score of 4, indicating Resident 16 was not a fall risk despite the clinical record documentation identified high risk factors such as assistance needed to provide basic needs, episodes of dizziness requiring hospitalization , and dementia with short term memory problems. The Fall Prevention Program policy dated 2/2012 revealed that when completing the fall risk assessment it was essential to focus on triggers for falls such as medications, and predisposing diseases. " A resident could score ... as low as a 2 or 4 and be at risk. " The policy also had suggestions listed for prevention of falls including toileting before and after meals, increasing observation and response to call lights. The admission care plan post hospitalization dated 6/1/2013 included the following care problems and interventions: " ADL (activities of daily living) Functional Rehabilitation Potential Consult Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST) as ordered Bathing/Hygiene assist Dressing/Grooming assist Toileting assist Falls/Safety Risk/Elopement Risk Keep call light in reach Encourage use of call light PT referral " The care plan did not address specific safety interventions such as assigning staff supervision for resident, checking frequently on scheduled rounds, and/or toileting times scheduled consistently across shifts to ensure Resident 16 would be assisted each time she had to get out of bed. Review of the nursing note dated 6/6/2013 at 23:50 p.m. (11:50 p.m.), revealed "CNA heard a loud noise ....found Resident 14 sitting in the shower .... Confirms hitting her head, unknown on what, 5 x 2 cm (centimeters) round hematoma to right occipital/parietal (swollen area of clotted blood on the side and back part of head), 6 x 3 cm hematoma to left wrist (swollen area/mass of clotted blood on wrist at blood vessel)." Resident 16 was assessed and assisted back to bed. New physician orders [REDACTED]. Results of the CT scan of the head dated 6/7/2013 revealed 2 changes from the previous CT scan performed during the previous hospitalization on [DATE]. The impressions were: - " Small acute left posterior parietal subdural, intraparenchymal, and subarachnoid hemorrhage (small brain bleed in three layers of brain tissue) " - " Small right posterior parietal cephalohematoma (blood clot toward center of head near the skull) " Results of the 6/7/2013 radiology exam of the left wrist revealed: - " Probably new comminuted impacted fracture of the distal radius (lower end of the forearm bone fracture) " Review of the facility incident report dated 6/7/2013 revealed Resident 16 was " given towels prior to shower " at 10:50 p.m. and was left unattended. No follow-up was documented. The follow-up options on the form included " staff inservice, employee counseled, resident safety teaching , document teaching information, refer to restorative for assessment. All areas were left blank. The only comments listed were " episodes of syncope per H & P (history and physical), sent to ER (emergency room ) ... " Review of the clinical record with an admission date of [DATE] revealed Resident 16 was readmitted to the facility after a 3 day stay in the hospital. The admitting [DIAGNOSES REDACTED]. The fall risk evaluation completed on 6/10/2013 did not identify Resident 16 as a high risk with a score of 8. " Total score of 10 or above represents High Risk. " The admission care plan dated 6/10/2013 identified falls as a problem due to the " fall with fracture on 6/6/2013. " However, the care plan failed to address specific individualized interventions to prevent further injury to Resident 16 as a result of lack of supervision. On 8/16/2013, during an interview beginning at 9:10 a.m., the assistant director of nursing (ADON) stated, " Even if the fall score is 8, the staff will know the resident has history of falls and will monitor her more closely." Consistent monitoring evidence was requested. After review of the medical record and current care plans, the ADON could not locate care plan instructions to staff with specific interventions to prevent further unwitnessed falls for Resident 16. There was no evidence of any change in interventions, toileting schedule and/or timed rounds to anticipate resident's needs. There was no evidence of close monitoring. On 8/16/2013, during an interview beginning at 9:50 a.m., the MDS coordinator provided a copy of the recommendations from the physical therapy evaluation. The evaluation validated that Resident 16 continued to be independent in feeding only. Resident 16 could feed herself after being set up for a meal but was dependent in every other aspect of her care. The MDS coordinator validated these findings. 2. Resident 1 was admitted to the facility on [DATE] for rehabilitation following a severe head injury with temporal skull fracture, a right rib fracture, as well as diabetes mellitus type 2, and hypertension. Review of the medical record revealed that Resident 1 was totally dependent on staff for all activities of daily living, and had a gastrostomy tube through which enteral feedings were administered. The MDS (minimum data set) dated 3/27/13 also noted that the resident had functional limitation in range of motion on one side of the body, and progress notes described the resident as able to mumble a few words, was difficult to understand, but was alert to surroundings and able to follow simple commands. Review of the medical record revealed that Resident 1 was identified as at risk for falls because of decreased cognition and impaired judgment skills. A care plan dated 4/18/13 was initiated with the goal of preventing resident falls and minimizing injury from falls should they occur. Interventions to address the risk included assessing the resident for medical and psychosocial disease exacerbation and ruling out those problems as etiology for falls, as well as the application of a motion sensor to bed to alert staff to the resident's need for assist. Review of the medical record revealed that Resident 1 had several falls including on 5/04/13 when progress notes described the resident as found "laying on the floor mattress, bed is in lowest position." The notes added that an initial assessment was conducted and Resident 1 did not sustain any injury or bruises. On 5/10/13, another progress note revealed that the resident rolled himself at the bedside mattress and that no apparent injury was noted. Review of the medical record revealed that in light of these incidents, the circumstances surrounding the falls were not always determined or that attempts were made to determine the etiology of the falls. In addition, while the care plan, for example, required use of a bed alarm to alert staff, no mention was made about the use of the alarm for both falls or if staff were able to respond to the alarm promptly to prevent the fall. On 6/13/13, Resident 1 was described in progress notes as laying on the floor on his right side with the "wheelchair footrest tilted over (the resident's) feet." The resident was transferred to an acute care hospital but returned to the facility thereafter after the evaluation revealed no injuries. Review of facility documents revealed that while an investigation of the incident was conducted and that the wheelchair was determined to be lightweight and can easily tip over, no mention was made about antecedent behaviors manifested by the resident potentially contributing to the fall. During an interview on 8/15/13, a nursing staff supervisor stated that the resident had been using a highback wheelchair prior to the fall to help maintain upright positioning following a recommendation by physical therapy. Following an investigation after the fall, the licensed staff added that the gerichair was determined more appropriate for the resident because he was more mobile; and Resident 1 had not had a fall from the gerichair. 3. An environmental tour initiated on 8/15/13 approximately 1:00 p.m. accompanied by the maintenance supervisor and a maintenance staff member revealed a janitor's closet on Unit F to be unlocked. The closet contained cleaning "Envirox" cleaning solution in a dispenser, and a container of bleach stored on the floor. The maintenance supervisor stated the closet was supposed to be locked. Inspection of a storage cabinet in the Activities room revealed Purell, (sanitizer) three containers of surface cleaner, two containers of odor eliminator sprays, one container of Lysol spray and, a box of alcohol swabs stored on an upper shelf. Stored beneath the liquid cleaning solutions were disposable food service items including beverage straws, an open packet of napkins, serving bowls, party plates, styrofoam drinking cups, a paper bowl container of sweeteners, and a container of powder thickener (used to thicken resident beverages). The storage of the cleaning items and the positioning of food service items posed a risk of the cleaning items contaminating the food service items beneath them. 4. A lower shelf in a cupboard in the kitchen/dining area on Unit E was found to contain scissors and a spool of wire. This unlocked storage location is easily accessible to residents.

Based on observation, interview and document review, the facility failed to ensure Resident 6 did not develop a pressure ulcer or to incorporate appropriate measures to heal or prevent worsening of the pressure ulcer once it developed. Findings include: Resident 6 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 6 had lower extremity paralysis. During the initial tour conducted on 8/13/13 beginning approximately 8:00 a.m. the resident was observed to be in the bed, on the back, and on a large bed with a low air loss mattress. The unit manager (UM) stated the resident had a stage IV pressure ulcer to the buttock, which became infected. The resident was interviewed on 8/14/13 at 5:05 p.m. Observed to be resting on the back, the resident was asked when the resident got the pressure sore. Resident 6 was unsure when it started but when asked if it was here (in the facility) or before, the resident stated "here." On 8/15/13 approximately 4:15 p.m., the resident having no ability to feel sensations stated, "I can't feel anything, I'm paralyzed." The resident was on a Clinitron bed (a special bed to heal wounds), which was ordered by the physician on 8/14/13. At approximately 4:17 p.m., the nurse was interviewed regarding repositioning of the resident. The nurse stated the resident was "real noncompliant" and that staff would reposition the resident but that the resident would remove the pillows and place self on the back. The clinical record was reviewed and did not contain nutritional orders to support wound healing until 8/15/13, when the resident was prescribed multivitamin with minerals, vitamin C, zinc sulfate and a high protein cookie for wound healing. A care planning conference document dated 8/14/13 read, "wound: continues to L (left) hip + new area to R (right) hip." No other discussion regarding the wound or care plan revision was documented. Observation of the wound care was conducted on 8/16/13 approximately 11:03 a.m. The resident required assistance for repositioning. The wound was observed to be on the left buttock, measured by the wound nurse to be 4.5 cm (centimeters) X 4.5 cm and 4.5 cm deep. A small amount of what appeared to be bone tissue was visible in the wound bed. The wound nurse stated the wound "advanced" because the resident was not on a low air loss mattress in the hospital. A care plan dated 7/19/13 indicated the resident was "readmitted with unstagable pressure ulcer ..." however, documentation in closed records revealed the resident was originally admitted to the facility on [DATE]. No pressure sores were listed at that time. A nursing admission assessment following re-admission, dated 9/01/12 "skin condition" section, noted no pressure ulcers. A minimum data set (MDS) with an assessment reference date (ARD) of 1/4/13 Annual Assessment Section M coded the resident to have no pressure sores but to be at risk for development of pressure sore. A physican's order dated 2/06/13 instructed "coccyx open area-cleans with wound cleanser. Pat dry, apply [MEDICATION NAME] Ag then cover with dry dressing." The subsequent quarterly MDS assessment with an ARD of 4/16/13 coded the resident to have an unstageable pressure sore. The facility failed to intervene promptly and revise care and treatment to prevent and heal an avoidable pressure ulcer for Resident 6.