Every finding on record at Desert Cove Nursing Center

Based on clinical record review, staff and resident interviews, and review of facility policy and procedures, the facility failed to ensure one of three sampled resident (#4) was free from a significant medication error related to antibiotic therapy. The deficient practice could result in adverse resident outcomes and complications related to incorrect medication dosing. Findings include:Resident #4 was admitted to the facility on [DATE] with a diagnosis of a cutaneous abscess of the abdominal wall.The hospital discharge orders dated July 30, 2026 revealed the resident was discharged with an order for Cefepime [antibiotic] 2 grams(gm) every 8 hours for 7 days.The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) Score of 15, which indicated Resident #4 had intact cognition. The MDS further revealed that Resident #4 received antibiotics.The physician's order revealed an order for Cefepime Hydrochloride [antibiotic] 1gm/ 50 milliliters(mL) every 8 hours for 7 days, with a start date of August 1, 2026 and an end date of August 1, 2026. The order did not identify the reason for discontinuation.The physician's orders showed a subsequent order for Cefepime Hydrochloride 1gm/ 50mL every 8 hours for 7 days, with a start date of August 1, 2026 and an end date of August 6, 2026.The Medication Administration Record for August 2026 revealed the resident received a total of 18 doses of Cefepime Hydrochloride 1gm/ 50mL.The care plan revealed a focus area for infection sepsis related to abdominal wall abscess, with intravenous Cefepime 1gm/ 50mL to be administered every 8 hours initiated August 4, 2026. Interventions included to administer antibiotics as ordered.A physician progress note dated August 7, 2026 revealed the Nurse Practitioner (NP) reached out to the Infectious Disease provider regarding the resident's antibiotic regimen, and it was revealed the resident needed Cefepime 2gm rather than 1gmA case management progress note dated August 7, 2026 revealed that the resident had a received a Notice of Medicare Non-Coverage, which was rescinded due to Resident #4 needing an extension of intravenous antibiotics.The physician's orders revealed an order for Cefepime Hydrochloride 2gm/ 100mL every 8 hours for 7 days, with a start date of August 7, 2026 and an end date of August 13, 2026.An interview was conducted on August 21, 2026 at 11:49PM with Resident #4. Resident #4 stated that he was made aware of the medication error on August 6, 2026 by Licensed Practical Nurse (LPN/ Staff #16). Resident #4 stated that nursing staff had begun to hang 2 intravenous medication bags of Cefepime 1gm/50mL after he had received 1 bag per dose for a week. He further stated that when he asked staff about it, they were unable to give him an answer. He stated that when he asked Staff #16, he was informed that the facility had been giving him the wrong dose of medication. Resident #4 stated his original discharge date was August 9, 2026; however, he was informed on August 7, 2026 that he would need to stay at the facility for an additional week to receive intravenous Cefepime 2gm/ 100mL, and was discharged on August 13, 2026.An interview was conducted on August 21, 2026 at 12:18PM with Staff #16. Staff #16 stated that the medication error was identified by the facility's third-party pharmaceutical consultant, and she was instructed by the Director of Nursing (DON/ Staff #121) to hang 2 medication bags to meet the appropriate dose. She further stated that after the Infectious Disease provider was contacted, the resident was informed he would need to stay at the facility for an additional week to complete the dose course of Cefepime 2gm/ 100mL.An interview was conducted on August 21, 2026 at 2:17PM with the consultant pharmacist (Staff #34) that completed the medication regimen review for Resident #4. Staff #34 stated that the regimen review revealed that the admission order for Resident #4 should have been Cefepime 2gm administered every 8 hours; however, the order in the electronic health record read Cefepime 1gm administered every 8 hours.An interview was conducted on August 21, 2026 at 3:45PM with Staff #121. Staff #121 stated that she had become aware of the medication error the day after the original order was transcribed. She further stated that when she went to correct it the first time, she incorrectly transcribed the order again and it went unnoticed. She could not recall exactly when the second error was noticed. She stated that it might have been noticed during discharge planning. However, a previous interview revealed the error was noticed by Staff #34. Staff #121 stated that as a result of the medication error, the resident was kept at the facility for an additional week in order to receive the correct dose. Staff #121 stated that during the admission process, the medication reconciliation was completed by either her or the floor nurse receiving the resident. She further stated that there is a second review done the day after admission to ensure orders are accurate, and that this is when the medication error was identified the first time. However, after the error was identified the first time , Staff#121 transcribed the order incorrectly the second time. A review of the policy titled, Administration of Medication, reviewed September 9, 2025, revealed that the facility is responsible for ensuring medications are administered appropriately per physician's orders. Further, medications should be reviewed regularly.

Based on clinical record review, staff and resident interviews, facility documentation and review of facility policies and procedures, the facility failed to protect the rights of one resident (Resident #46) to be free from physical abuse from another resident (Resident #27). The deficient practice could place residents at risk for resident to resident abuse and potential physical harm.Findings include:-Regarding Resident #46:Resident #46 (Alleged Victim, AV) was initially admitted to the facility on [DATE], and was re-admitted on [DATE], with diagnoses that included acute posthemorrhagic anemia, diaphragmatic hernia, gastric ulcer with hemorrhage, hemiplegia and hemiparesis following cerebral infarction, attention and concentration deficit, anxiety disorder, and other comorbid conditions.A care plan dated May 21, 2026, indicated that the resident exhibited behavioral problems, including yelling and calling out when triggered. Interventions included anticipating and addressing the resident's needs, explaining procedures in detail, and allowing time for the resident to adjust to changes.A behavior care plan revised on May 21, 2026, revealed that Resident #46 had behaviors that included manipulation, yelling, and calling out related to anger, a history of harming others, and poor impulse control. Interventions included anticipating and meeting the resident's needs, assisting the resident in developing more appropriate coping and interaction skills, intervening as necessary to protect the rights and safety of others, and removing the resident from situations by taking him to an alternate location when indicated.The Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #46 required supervision while wheeling his manual wheelchair for 50 feet and partial assistance when wheeling 150 feet. A nursing incident note dated June 27, 2026, at 7:20 a.m., revealed that Resident #46 made his way into the hallway toward the dining room. The note further indicated that a Certified Nursing Assistant (CNA, Staff #105) transported both Resident #46 and Resident #27 down the hallway. while the residents were in close proximity to one another, Resident #27 became agitated and struck Resident #46 on the left side of the chest three times. The CNA immediately separated the residents, and nursing staff completed neurological and skin assessments following the incident.An observation of Resident #46 was conducted on June 29, 2026, at 1:45 p.m. The resident independently wheeled himself to the conference room and recalled the incident in a manner that was generally consistent with the information he reported to nursing staff on June 27, 2026. Resident #46 stated that a CNA wheeled both himself and Resident #27 to the dining room. Resident #46 further stated that Resident #27 was positioned on his left side and that the two wheelchairs were very close together when Resident #27 struck him in a backhand motion with his right fist three times to the left side of his chest. Resident #46 stated that staff separated them immediately and that he (Resident #46) subsequently reported the incident to one of the nurses on the unit.-Regarding Resident #27:Resident #27 (Alleged Perpetrator, AP) was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left nondominant side, aphasia, bipolar disorder, contractures of both hands, and other comorbid conditions.A behavior care plan revised on July 20, 2023, revealed that Resident #27 was at risk for changes in mood and behavior related to medical conditions. Interventions included consulting the resident regarding customary routines and avoiding crowded areas because the resident had difficulty expressing himself when others were in close proximity. An additional behavior care plan revised on May 7, 2024, directed staff to maintain at least an arm's-length distance between Resident #27 and others whenever possible. The care plan further indicated that Resident #27 had the potential to become physically aggressive and strike others due to poor impulse control, nonverbal communication, multiple stroke episodes, confusion, and impaired cognition.The MDS assessment dated [DATE], revealed that Resident #27 had impaired communication, including difficulty making himself understood and understanding others. The MDS further indicated that the resident required supervision while wheeling both 50 feet and 150 feet with turns.A review of Resident #27's nursing notes revealed no documentation regarding the incident that occurred on June 27, 2026. However, nursing documentation dated June 26, 2026, indicated that Resident #27 exhibited physically aggressive behaviors, including biting and hitting certified nursing assistants during morning care, and was redirected by staff.An observation conducted on June 29, 2026, at 1:49 p.m., in Resident #27's room revealed that CNA Staff #75 was providing one-to-one supervision. Staff #75 stated that it was her first day serving as the resident's sitter. At the time of the observation, Resident #27 was lying calmly in bed and displayed no behavioral concerns.During a telephone interview conducted on June 29, 2026, at 1:02 p.m., CNA, Staff #105, who witnessed the altercation, stated that she transported both residents to the dining room on the morning of June 27, 2026. She stated that she maneuvered both wheelchairs simultaneously by placing one hand on each wheelchair. Staff #105 further stated that the residents acknowledged one another and, shortly thereafter, Resident #27 struck Resident #46 three times on the chest. Staff #105 stated that she immediately separated the residents.An interview with Unit Nurse Staff #88 was conducted on June 29, 2026, at 1:12 p.m. Staff #88 stated that she did not witness the incident because she was administering medications at the time. She reported that Resident #46 approached her independently in his wheelchair and stated that Resident #27 had struck him three times on the left side of his chest. Staff #88 stated that she assessed Resident #46 and observed no bruising or visible injuries, and that his vital signs were within normal limits. She further stated that nursing staff implemented measures to ensure the safety of both residents and reported the incident to the Director of Nursing (DON) and the attending physician.An interview with the Director of Nursing (DON), Staff #120, was conducted on June 29, 2026, at 2:45 p.m. Staff #120 stated that she was notified by facility staff that one resident had reported being physically struck by another resident. She stated that the facility's abuse response team immediately reported the allegation to the appropriate authorities within the required timeframes and initiated an internal investigation. Staff #120 further stated that the CNA who witnessed the incident had transported both residents simultaneously by holding one hand on each wheelchair and acknowledged that Staff #105 was a newly hired employee. Staff #120 stated that resident-to-resident physical altercations constituted physical violence and should be prevented at all times. This statement was consistent with information obtained from other nursing staff during the investigation.A review of the facility policy titled Abuse Prevention, revised April 1, 2026, revealed that the facility was committed to preventing and prohibiting all forms of abuse and neglect. The policy further stated that the facility was responsible for establishing a safe environment by identifying, correcting, and intervening in situations in which abuse was more likely to occur. The policy included staff education, maintaining sufficient staffing levels to meet resident needs, and ensuring that assigned staff were knowledgeable regarding each resident's care needs and behavioral symptoms.

Based on clinical record review, interviews, the State Agency's (SA) complaint portal, and review of the facility's policies and procedures, the facility failed to ensure 5 out of 5 residents' (#7, #10, #40, #90, and #100) medications administration were accurately documented in the Medication Administration Record (MAR). The sample size was 5. The deficient practice could cause an unclear indication of whether medication was administered to the right resident. Findings include:-Regarding Resident #7:Resident #7 was admitted on [DATE], with diagnoses that included major depressive disorder, anemia, and sepsis. An order summary dated February 21, 2026, revealed an order for Oxycodone HCL Oral Tablet 5 MG (a Controlled Substance/ an Opioid), give 1 tablet by mouth every 8 hours as needed for pain. A comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating that Resident # 7 had moderate cognitive impairment. The MDS further revealed that in Section N, the resident was taking opioid medications. An Individual Resident's Controlled Substance Record initiated on February 27, 2026, for Oxycodone HCL Oral Tablet 5 MG revealed that the Alleged Perpetrator, Licensed Practical Nurse ( LPN/staff #777), identified that she had administered the medication on March 04, 2026. However, the Medication Administration Record (MAR) for March 2026 for Oxycodone HCL Oral Tablet 5 MG revealed that the medication was not administered on March 04, 2026. A care plan initiated on March 02, 2026, revealed a focus area of expressing pain or discomfort as related to abdominal pain. The care plan also revealed a goal that the resident will not have an interruption in normal activities due to pain, with noted interventions including that the resident would be evaluated for the effectiveness of pain medication. -Regrading Resident #10Resident #10 was admitted on [DATE], with diagnoses that included Muscle Weakness, Cardiomyopathy, and cellulitis. A care plan initiated on February 13, 2026, revealed a focus area of expressing pain or discomfort. The care plan also revealed a goal that the resident will experience pain relief by the review date, and included an intervention noting to administer pain medication as ordered.A comprehensive (MDS) assessment dated [DATE], revealed a (BIMS) score of 13, indicating that Resident # 10 had moderate cognitive impairment. The MDS further revealed that in Section N, the resident was taking opioid medications. An order summary dated February 21, 2026, revealed an order for Oxycodone HCL Oral Tablet 5 MG (a Controlled Substance/ an Opioid), give 1 tablet by mouth every 6 hours as needed for pain. An Individual Resident's Controlled Substance Record initiated on February 19, 2026, for Oxycodone HCL Oral Tablet 5 MG revealed that Staff #777 identified that she had administered the medication on March 04, 2026.A Medication Administration Record (MAR) for March 2026 for Oxycodone HCL Oral Tablet 5 MG revealed that the medication was not administered on March 04, 2026. A witness Interview / Statement Form dated March 10, 2026, revealed that Resident #10 stated that he had not taken any narcotic pain medication since February 22, 2026. -Regarding Resident #40Resident #40 was admitted on [DATE], with diagnoses that included Chronic Kidney Disease, Anxiety disorder, and Heart Failure. A care plan initiated on February 17, 2026, revealed a focus area of expressing pain and discomfort. The care plan also revealed a goal that the resident will experience pain relief and interventions that included to evaluate the effectiveness of pain intervention. A comprehensive (MDS) assessment dated [DATE], revealed a (BIMS) score of 15, indicating that Resident # 14 was cognitively intact. The MDS further revealed that in Section N, that the resident was taking opioid medications. An order summary dated February 17, 2026, revealed an order for Hydromorphone (a Controlled Substance/ an Opioid), give 1Mg/ML tablet by mouth every 1 hours as needed for pain. An Individual Resident's Controlled Substance Record dated February 17, 2026, for Oxycodone HCL Oral Tablet 5 MG revealed that Staff #777 identified that she had administered the medication on March 04, 2026A MAR for March 2026 for Hydromorphone 1 MG/ML revealed that the medication was not administered on March 04, 2026. -Regarding Resident #90:Resident #90 was re-admitted on [DATE], with diagnoses that included Pneumonia, Muscle Weakness, and Hyperlipidemia. An order summary dated January 16, 2026, revealed an order for Oxycodone HCL Oral Tablet 5 MG, give 1 tablet by mouth every 4 hours as needed for pain. The order summary further revealed that this order was discontinued on January 26, 2026.An Individual Resident's Controlled Substance Record dated January 16, 2026, for Oxycodone HCL Oral Tablet 5 MG revealed that Staff #777 identified that she had administered the medication on March 4, 2026. A care plan initiated on January 21, 2026, revealed a focus area of expresses pain or discomfort related to a patella fracture. The care plan also revealed a goal that the resident will express pain relief and in intervention that included evaluating the effectiveness of pain intervention. A Nursing Home Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the Resident was cognitively intact. The MDS further revealed that in Section N, the resident was taking opioid medications. -Regarding Resident #100Resident #100 was admitted on [DATE], with diagnoses that included Depression, Hyperlipidemia, and Muscle Falls. A comprehensive (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that Resident # 100 was cognitively intact. The MDS further revealed that in Section N, the resident was taking opioid medication. A care plan initiated on March 01, 2026, revealed a focus area which noted that the resident is on pain medication therapy related to the disease process. The care plan also revealed a goal that the resident will be free of any discomfort or adverse effects from pain medication and an intervention to administer pain medication as ordered.An order summary dated February 28, 2026, revealed an order for Oxycodone HCL ER (Extended Release) 10 mg tablet, give 1 tablet by mouth two times a day for moderate to severe pain.An Individual Resident's Controlled Substance Record initiated on February 28, 2026, for Oxycodone HCL Oral Tablet 10MG revealed that Staff #777 identified that she had wasted the medication on March 04, 2026 at 2100. A shift schedule dated March 4th, 2026, revealed that Staff # 777 was working 8:00 pm to 6:00 AM the following day with residents #7,#10,#40, #90, and #100. A complaint form submitted to the Arizona Board of Nursing dated March 11, 2026, alleged that Staff #777 was involved in theft, including suspected drug diversion. The complaint form also revealed that on March 4, 2026, Staff #777 documented to administration the discontinuation of hydromorphone for Resident #40, and administered one 5 mg tablet of oxycodone to Resident #10; however, it was not documented in the resident's chart. The complaint form further revealed that a discontinued medication for Resident #90 was administered and was not reflected in the resident's chart. This complaint also revealed that Staff #777 documented disposing of 10 mg of oxycodone for Resident #100 without a second nurse to co-sign.A facility investigation summary dated March 10, 2026, revealed that Staff #777 was suspected of drug diversion. The summary then revealed that on March 10, 2026, the Arizona Board of Nursing, local law enforcement, contacted the nursing agency, and the Medical Director (MD) were notified. The Summary also revealed that the nurse had destroyed a medication without a co-signing nurse as well as discrepancies in the documentation of medication administration. The summary conclusion revealed that the facility had substantiated the allegation of drug diversion based on documentation discrepancies, resident interview, and failure to follow controlled substance handling proceduresAn undated facility document titled Possible Diversion revealed the following : Resident #7: OxyContin 5 mg tablet every 8 hours as needed. Documented that medication was signed out on March 4, 2026, at 9:30 PM; however, no signed documentation of medication administration in PCC (Point Click Care)Resident #10: OxyContin 5 mg tablet every 6 hours as needed. Documented that medication was signed out on March 4, 2026, at 10:00 PM; however, no signed documentation of medication administration in PCC (Point Click Care), and Resident #10 stated that he had not received the medication. Resident #40: Hydromorphone 1mg/ml tablet every hour as needed. Documented that medication was signed out on March 4, 2026, at 9:30 PM; however, no signed documentation of medication administration in PCC (Point Click Care), and the medication was discontinued. Resident #90: OxyContin 5 mg tablet every hour as needed. Documented that medication was signed out on March 4, 2026; however, the medication was discontinued on January 26, 2026. Resident #100: OxyContin 10 mg tablet every 4 hours as needed. Documented that the medication was marked as waste. An undated facility document, noted to be used for training, titled Assisting with a Narcotic Dose revealed that the two staff members will sign off on the narcotic shift-out sheet. The document then revealed that when administering narcotics, it would be documented on the MAR and Narcotic sheet. The document further revealed that the staff member had signed off on the acknowledgment that they had received education regarding the medication discontinuation procedure and narcotic documentation requirement.An interview was conducted on April 15, 2026, at 11:35 AM with a Certified Nursing Assistant (CNA/Staff #34) who stated that if there was a prescribed medication that was stolen from a resident, it would be considered misappropriation, because it involves taking the resident's property. Staff #34 stated that the facility practice is it to keep the medication cart locked. CNA also stated that she would ensure that there are no medications left unattended in the resident rooms. She then stated that Resident #90 would need pain medication for the left knee and had recently undergone surgery. She also stated that Resident #100 would ask for pain medication frequently. She then stated that medication is important for both mental health and overall well-being. An interview was conducted via phone on April 14, 2026, at 1:50 PM with the alleged perpetrator (AP/Staff #777) who stated that on March 04, 2026, she had worked for the facility through their contracted nursing agency. She then stated that during this shift, she was responsible for passing medications, assisting with resident care, and ensuring that all residents were safe and doing well. Staff #777 then stated that the process for medication administration is that staff will ensure the correct medication is given to the right resident at the right time and in the correct dose. She then stated that during that shift, she did administer the medication to the residents, but could not recall if it was documented on the MAR. She further stated that she did not think it mattered at the time to document on the MAR because there were times when she didn't. Staff #777 further stated that one resident refused their narcotic medication, so she has disposed of the medication; however, she did not obtain a second nurse's signature to 'waste' the medication because she forgot to. She also stated that when logging in to the nursing application, she was unable to return to work for the facility. Staff #777 then stated that she attempted to contact the facility to follow up, but did not receive a return call. She also stated that she had received a letter from the Board of Nursing notifying her that they were made aware of what happened. She then stated that for documentation in the narcotic log, they write down the time medication was administered, resident's name, the amount administered, the name of the staff who administered the medication, and date administered. They also documented in the electronic system MAR.An interview was conducted on April 17, 2026, at 2:36 PM with a Licensed Practical Nurse (LPN/Staff #23) who stated that during the medication pass process, staff would verify the resident, dosage, route, and time. She also stated that when administering narcotics, the nurse would document the resident, amount in hand, dosage, and the individual administering the medication on the Resident's Controlled Substance Record. She also stated that once the medication has been administered, it is documented on the MAR. She further stated that when disposing of medication, two nurses are required to sign off on the log. An interview was conducted on April 17, 2026, at 3:02 PM with the staff (LPN/staff #2) who stated that when she was administering non-narcotic medication to Resident #10, the resident had asked when the last time that he had taken Narcotic medication was, because he did not want to become dependent. She stated that when she had looked at the Controlled Substance Record, she noticed that Oxycodone was signed off as administered. She then stated she had gone back into the resident room and told him that it appeared that he had taken the Oxycodone, but the resident insisted that he had not received that medication for about 3 weeks. She then stated she notified the Assistant Director of Nursing (ADON #45), about this, and they had concluded that the medication was signed off on the Controlled Substance Record but not noted on the MAR. She then stated that the process for administering narcotics would include asking if the resident was in pain, and if the resident indicated that they were in pain, she would review the pain medication prescribed to the resident. She also stated that the MAR would identify if there are any parameters that need to be met prior to administering the medication. She further stated that when those parameters were met, she would administer the medication but would note it in the MAR and Controlled Substance Record. She then stated that the process for wasting narcotic medication requires two nurses to dispose of the medication, and they both have to sign that the medication has been disposed. She stated that the event that took place, she would classify as drug diversion, and the risk is that it is unclear if or even who administered the medication. She further stated that it importance to document on the MAR and Controlled Substance Record because it shows that the medication is being given.An interview was conducted on April 15, 2026, at 3:34 PM with the Assistant Director of Nursing, who stated that this incident was brought to her attention on March 10, 2026, by (Staff #2), and she had then notified the Director of Nursing (DON/Staff #76). She stated that the Administrator (Admin/Staff # 88) had reported the concern to the nursing agency and possibly the Board of Nursing. She then stated that she had called the regional office and was directed to do an audit to see if there was a possibility of drug diversion. She then stated that she had found 4 significant discrepancies involving ( Staff #777). She further stated that the audit revealed four significant discrepancies involving (Staff #777). She then stated that an Oxycontin tablet for Resident #10 was signed out on the Controlled Substance Record but was not documented as administered on the MAR. Staff #45 then stated that Hydromorphone 1 mg/mL for Resident #40 was signed out on the Controlled Substance Record but was not reflected as administered on the MAR. She also stated that Oxycodone 5 mg for Resident #90, was signed out on the Controlled Substance Record even though the medication had been discontinued. She further stated that Oxycontin for Resident #100 was documented as wasted; however, there was only one as opposed to the two required signatures to verify the disposal. She then stated that the risk of drug diversion is that the resident may not receive their medication, potentially no resolving their pain. She then stated that the expectation for administering narcotics is that the medication would be administered as ordered, documented on the Controlled Substance Record, and the MAR. An interview was conducted on April 17, 2026, at 4:06 PM with the Former Director of Nursing (Staff #76) and Administrator (Staff #88). Staff # 76 stated that Staff #2 had noticed that the Controlled Substance Record and MAR for Resident #10 had discrepancies. Staff #76 then stated that a facility-wide audit was conducted, which linked back to one medication cart, a particular shift and more specifically, one nurse, staff #777. He then stated that during their audit, they had reviewed the Controlled Substance Records, bubble packed narcotic medication, and MAR's. Staff #76 then stated they had conducted an in-service on March 11, 2026, and March 12, 2026, regarding training on medication management, rights of medication, proper medication storage, and narcotic medication. Staff #76 then stated that the expectation for administering narcotic medication is to assess the resident's pain level and verify the active order. Staff #76 further stated that if the resident's reported pain level aligns with the MAR instructions, the medication should be administered and documented on the MAR. Staff #76 also stated that the resident's pain will be reassessed to evaluate the effectiveness of the narcotic medication. He stated there is no risk to this event because there were no adverse reactions to the medication. Staff #88 stated that Resident #10 occasionally refuses narcotic medication due to concerns about becoming dependent. He further stated that Staff #2 asked Resident #10 whether he had taken any narcotic medication on March 4, 2026, and the resident stated that he had not. He also stated that he had informed the nursing agency and the Arizona Board of Nursing regarding the incident that took place with Staff #777. Staff #88 then stated that the Arizona Board of Nursing had requested documentation from them. Staff # 88 stated that after reporting the incident, the Agency Nurse had prevented Staff #777 from working for them. He also stated they had done an in-service with staff, and staff completed a post-test regarding narcotic count, discontinuation of medication, signing out of the narcotic book, and documenting on the MAR. He then stated that corrective and preventive actions included conducting audits, providing staff education, and verifying the accuracy of the medication cart. He then stated that with this incident, they can not account for whether the residents received medication or not. He also stated that the Arizona Board of Nursing is involved because it involves narcotics and the severity of the incident. He then stated that law enforcement was notified about (Staff #777) signing out medication and failing to document on the MAR. He further stated they had tried to reach out to the (Staff #777), but she contacted them. He stated there really is no potential risk since no one came forward about unmanaged pain. A Policy reviewed on August 29, 2025, titled Nursing Documentation revealed that Ensure nursing documentation is consistent with professional standards of practice.

Based on clinical record review, staff and resident interviews, and review of facility documentation and policies, the facility failed to ensure that professional standards of care were followed regarding the implementation of Physician-ordered speech services for Resident #2. The deficient practice could result in speech issues not identified and treated as appropriate. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses of Other Fracture of Upper and Lower End of Right Fibula, subsequent Encounter for Closed Fracture with Routine Healing, Progressive Supranuclear Ophthalmoplegia/Steele-Richardsonolszewski (SRO), and muscle weakness. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed the Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12, indicating she was cognitively intact. Further review of the MDS revealed Resident #2 was receiving Physical Therapy (PT) and no Speech Therapy (ST) or Occupational Therapy (OT). Review of the revised Care Plan dated November 12, 2025 revealed a focus for Activities of Daily Living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Interventions included to administer therapy services as ordered and assist with mobility and ADLs as needed. Review of a physician order dated November 25, 2025, revealed a speech evaluation due to a diagnosis of increased weakness in voice for one time only for 1 day verbal, with a documented completion date of November 26, 2025. A request for the completed speech evaluation was completed on December 18, 2025 at 1:27pm. When asked for the speech evaluation, the Director of Nursing (DON, Staff #103) stated she was unable to locate the speech evaluation.An interview was conducted on December 18, 2025 at 1:47 p.m. with the Director of Nursing (DON/Staff #103). Staff #103 stated she was unable to obtain the speech evaluation that was requested and stated the evaluation was not completed as documented. Staff #103 stated she provided immediate education to the Licensed Practical Nurse (LPN/Staff #18) regarding proper order entry and documentation after identifying the problem. Staff #103 stated the physician order had been entered incorrectly and included a one-day stop date, which caused the order to automatically reflect as completed regardless of whether the evaluation was performed. Staff #103 stated she was unaware of the order and further stated the order should not have been documented as completed and the appropriate staff should have been notified of the new order. Staff #103 stated that Staff #30 was aware of the family's concern because they had stopped Staff #30 in the hallway. Staff #103 further stated the risks associated by not properly entering orders or notifying appropriate staff creates risks, including residents not receiving required care, potential harm to residents, and miscommunication among staff.An interview was conducted on December 18, 2025 at 2:08 pm with the Speech Therapist (Staff #30). Staff #30 stated, the last time he saw Resident #2 was when she was admitted to the facility. Staff #30 stated, he is always checking his Point Click Care (PCC) and did not see any orders for Resident #2, specifically, for the date of November 25, 2025. Staff #30 stated that if he is unaware of new orders, he cannot provide the services that he is there for as that is his duty. Staff #30 further stated that it would be neglectful if orders are not completed because the staff are not providing the services that the resident needs. An interview was conducted on December 18, 2025 at 2:54 pm with Resident #2. Resident #2 stated she has never received any speech therapy for her voice and the only therapy she is currently receiving is Physical Therapy (PT).Review of the facility policy titled Nursing Documentation issued on August 20, 2019 and reviewed on September 5, 2024 states, This facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse: practice act, and any state laws, governing the scope of nursing practice.

Based on clinical record review, staff and resident interviews, and facility documentation, policies and procedures, the facility failed to ensure that adequate supervision and monitoring was provided for one resident (#76) who was left unattended in the shower room for an extended period of time. The deficient practice could result in avoidable accidents and/or decline in function.Findings include: Resident #76 was re-admitted to the facility on [DATE], with diagnoses that include Acute on Chronic Systolic (Congestive) Heart Failure, Diabetes Mellitus, chronic respiratory failure, difficulty in walking, not elsewhere classified, and muscle weakness. Upon further review, Resident #76 has a history of bilateral below-the-knee amputation (BKA). Review of the care plan dated September 12, 2025, revealed a focus indicating the Resident #76 is at risk for falls related to decreased endurance, strength, and mobility. Interventions include assisting with Activities of Daily Living (ADLs) as needed and call light within reach. Further review of the care plan revealed a focus stating Resident #76 is at risk for impaired skin integrity. Interventions include educating the resident/family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning and follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of the Braden Scale Skin assessment dated [DATE] revealed Resident #76 has existing pressure ulcers and is at risk for Unavoidable Pressure Injury (UPI) development or decline of skin integrity due to bowel/bladder incontinence, Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease (PVD), Chronic Heart and Renal Disease, Diabetes, Thyroid Disease, and Morbid Obesity.Review of the Fall Risk Evaluation dated September 19, 2025, revealed Resident #76 had a score of 12, indicating the resident to be at risk for falls due to medications, health conditions, and mobility. Review of the 5-Day Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. Further review of the MDS revealed the resident needs maximal or substantial assistance with bathing and toileting. Further review of the MDS reveals the resident had a formal skin assessment and was assessed to be at risk of developing pressure ulcers/injuries. Per the MDS, the resident uses a motorized wheelchair with orthotics/prosthetics due to a history of BKA and is on continuous oxygen. Review of the Certified Nursing Assistant (CNA) Tasks for Resident #76 for September 2025 revealed that during bathing, Resident #76 requires one person to maximal assistance when bathing. A phone interview conducted on December 18, 2025, at 1:31 pm with the alleged perpetrator (CNA/Staff #23) revealed that staff must not leave residents unattended in the shower room. If a resident requests privacy, staff may close the shower curtain and instruct the resident to press the call light when assistance is needed. Staff #23 stated she pushed Resident #76, in the shower chair, up to the sink to shave once he had finished showering. Staff #23 stated she got really sick at that moment due to personal health issues and was sent home by the Director of Nursing (DON/Staff #109). Staff #23 stated that Staff #109 instructed her to notify the other staff of Resident #76 before leaving. Staff #23 stated she notified a Licensed Practical Nurse (LPN) and a CNA about Resident #76 being in the shower room. Staff #23 stated, the CNAs on the other side do not talk to each other and must not have relayed the information. An interview was conducted on December 18, 2025, at 3:10 pm with Resident #76. Resident #76 revealed there had been an incident where the staff had left him in the shower room for an hour. Resident stated the staff left him or must've forgotten about him. Resident #76 stated that he was in the shower chair pushed up against the mirror to shave and thought he must have fallen asleep or that's what they have told him. Resident #76 stated that when he woke up, he pulled himself toward the door by grabbing onto things nearby. Resident #76 further stated, when he reached the door, a staff member found him by opening the door. Resident #76 stated that there was no call light nearby. Resident #76 stated Staff #109 had seen him after he got back in bed and completed a head-to-toe assessment. An interview was conducted on December 18, 2025, at 4:04 p.m. with the Director of Nursing (DON/Staff #109). Staff #109 stated she sent Staff #23 home and instructed her to notify other staff regarding Resident #76. Staff #109 stated that when she became aware of the incident, the shower room door was open and Resident #76 was seated in a wheelchair. Staff #109 stated Resident #76 may have previously been seated in a shower chair before she observed him. Staff #109 further stated Resident #76 could be left alone while seated in a wheelchair. Staff #109 further stated that staff are expected not to leave residents unattended; however, she stated she would not be upset if they left them. Staff #109 stated residents should never be left unattended while seated in a shower chair and stated leaving a resident unattended in a shower chair presents a serious risk of injury, including breakdown of skin and falls.Review of the facility policy titled Tub Baths and Showers, revised on May 19, 2025, stated, Stay nearby in case of emergency. Check on the patient every 5 to 10 minutes.

Based on a review of clinical records, observation, and staff interviews, the facility failed to ensure that appropriate infection control practices were implemented and followed for one resident (#33). The deficient practice could result in a spread of preventable illness to residents and staff.Findings include:Resident #33 was admitted to the facility on [DATE], with a diagnosis that included infection and inflammatory reaction due to an indwelling urethral catheter, subsequent use, urinary tract infection, obstructive and reflux uropathy, unspecified.During an observation on December 17, 2025, at 2:50 PM, while standing directly across the hallway in line of resident #33's room, a Certified Nursing Assistant (CNA/Staff#7) observed to enter resident #33's room. Staff #7 was observed entering the resident's bathroom, returning with a canister, and proceeded to empty the catheter bag that was observed hanging from the lower bed rails belonging to resident #33. CNA (Staff #7) was then observed to be wearing gloves, but was not observed to be wearing a gown.An interview was conducted with the CNA (Staff #7) immediately following the observation. The CNA stated she was emptying the resident's catheter and should have been wearing a gown. CNA (staff#7) stated she has received infection control training and has access to personal protective equipment, but was in a hurry and forgot, and just put on her gloves. CNA (staff #7) stated that the risks of not following infection control procedures are if something is in the resident's urine, it could cause cross-contamination to other residents or staff.An interview was conducted on December 17, 2025, at 3:39 PM with Licensed Practical Nurse (LPN/Staff #9). Staff #9 stated that when providing catheter care, Enhanced Barrier Precaution (EBP) needs to be followed and would include the use of a gown, gloves, and a mask. Staff #9 stated the risks of not following EBP recommendations are outbreak of infections, which is bad for the patients, bad for the neighboring patients, and bad for the facility. Staff #9 stated the facility has provided staff training and has also provided online classes and in-services for all staff regarding EBP.An interview was conducted with the Director of Nursing (DON/Staff #1) on September 23, 2025, at 4:00 PM. The DON stated that staff are expected to follow EBP guidelines if they come in contact with any bodily fluids, and this would include when emptying a catheter. The DON stated the CNA should have worn a gown and gloves when providing catheter care and/or emptying the catheter. The DON stated that the risks of not following EBP guidelines are that germs from the catheter can potentially pass on to other residents from staff clothing. Review of the facility policy titled Indwelling Urinary Catheter (Foley) Management, last reviewed September 10, 2024, revealed that staff should wear gloves and gowns during any manipulation of the catheter or collecting system. Review of the facility policy titled Transmission-based Precautions and Isolation Procedures, most recently revised on August 19, 2025, revealed that staff should wear gloves and a gown during high-contact resident care activities that would prevent the transfer of viruses to staff hands and clothing.

The facility failed to wear Personal Protective Equipment (PPE) and properly sanitize hands during resident care and interaction. The deficient practice could spread infection to other residents. -Regarding not wearing Personal Protective Equipment (PPE) Resident #2 was admitted to the facility on [DATE], with diagnoses that included neuromuscular dysfunction of the bladder, cellulitis of the right lower limb, Type 2 Diabetes Mellitus, and acquired absence of the left leg above the knee. During initial pool screening on September 22, 2025, at 7:41 AM, Resident #2 was observed to have a Foley catheter bag hanging on her bed rails. Upon entering the room, a Certified Nurse Assistant (CNA/Staff #89) was observed emptying the contents of the Foley bag into a plastic container. The CNA was observed to be wearing gloves, but was not observed to be wearing a gown. An interview was conducted with the CNA (Staff #89) immediately following the observation. The CNA stated that she only wears a gown when performing catheter care, but not during the procedure of emptying the catheter bag. An interview was conducted on September 23, 2025, at 12:51 PM, with the Director of Nursing (DON/Staff #1). The DON stated staff were to follow EBP guidelines by wearing a gown and gloves when performing any care with conditions such as feeding tubes, catheters, intravenous lines, and wounds. The DON stated specifically that she would expect staff to wear a gown and gloves when emptying a Foley catheter bag. A policy titled Indwelling Urinary Catheter (Foley) Management, last reviewed September 10, 2024, revealed that staff should wear gloves and gowns during any manipulation of the catheter or collecting system. A policy titled Transmission-based Precautions and Isolation Procedures, revised on August 19, 2025, revealed that staff should wear gloves and a gown during high-contact resident care activities that would prevent the transfer of viruses to staff hands and clothing. -Regarding not sanitizing hands between meal tray deliveries On September 22, 2025, at 12:03 PM, two CNAs were observed delivering lunch trays to residents (Staff #89 and #24). Staff #89 was observed delivering meal trays to four different residents' rooms. She was not observed to sanitize her hands between any of the rooms. Staff #24 was observed delivering meal trays to three different residents' rooms. She was not observed to sanitize her hands between any of the rooms. An interview was conducted with the Dietary Manager (Staff #200) on September 23, 2025, at 9:44 AM. She stated she expected staff to sanitize their hands in between delivering meals and meal trays to different residents, stating, I know they're supposed to sanitize between every resident. -Regarding Resident #44 Resident #44 was admitted to the facility on [DATE], with diagnoses including hereditary spastic paraplegia, epilepsy, neuromuscular dysfunction of the bladder, artificial opening of the urinary tract status, and presence of urogenital implants. A review of physician orders, dated October 28, 2024, revealed orders to secure the catheter with an anchoring device to prevent tension and to provide catheter care with warm water and soap every shift. Further physician orders, dated October 29, 2024, included an order for EnhancedBarrier Precautions (EBP) every shift related to a suprapubic catheter. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitive intactness. On September 21, 2025, at 8:20 a.m., Resident #44's room door was observed without Enhanced Barrier Precautions signage and without personal protective equipment (PPE) available at the door. At that time, Resident #44 stated that staff do not wear gowns during catheter changes. On September 22, 2025, at 3:04 p.m., Certified Nursing Assistant (CNA/Staff #119) was interviewed and stated that staff rely on signs at the door to indicate when EBP is in place. If no sign is present, precautions are not implemented. On September 22, 2025, at 3:18 p.m., Registered Nurse (RN/Staff #102) was interviewed and stated that signage at the door indicates when EBP is required, in order to protect residents and staff from potential contamination. On September 23, 2025, at 2:11 p.m., the Assistant Director of Nursing (ADON/Infection Preventionist, Staff #104) stated that the staff is made aware of EPB by a sign outside the door. PPE supplies are also required to be stored outside the resident's door. ADON #104 stated that,after reviewing the clinical record for resident #44, EBP signage and PPE supplies should be located at the door. At 2:23 p.m., ADON #104 visited Resident #44's room, where no signage or supplies were observed. At 2:26 p.m., the DON, Staff #1, was interviewed and confirmed the absence of signage and supplies at Resident #44's room. Staff #1 stated that the lack of supplies and signage posed an infection risk and did not meet the facility's standards. Review of the facility's Infection Prevention and Control Program (IPCP) Plan, revised June 2, 2025, revealed that the program includes the implementation of appropriate transmission-based precautions and use of PPE.

Number of residents sampled: Number of residents cited: Based on observations, staff interviews, and a review of facility policies, the facility failed to ensure that expired medications were properly discarded and not available for use. These deficient practices could result in residents receiving expired medications, and could result in resident injury, medication overdose, or contradictions. The facility census was 69.An observation was conducted of the Central medication room on September 22, 2025, at 02:46 PM with the Assistant Director of Nursing (ADON/staff #104). The following expired medications were identified: Five boxes of unopened one-daily Multivitamin dietary supplement, with an expiration date of April 2025. One unopened box of zinc 50mg, with an expiration date of March 2025. Four unopened boxes of vitamin B-12 100mcs, with an expiration date of July 2025.During this observation, an interview was conducted with the ADON (Staff # 104). Staff #104 stated that all the nurses are responsible for checking and disposing of expired medications. Staff # 104 stated that she conducts weekly checks, and the pharmacy reviews them monthly. Expired meds are either returned to the pharmacy (if accepted) or destroyed using our Drug Buster system. It is expected that expired medications, especially in large quantities, will be promptly and properly disposed of. Staff # 104 stated that it falls below her expectations. Administering expired meds can harm residents, requiring physician notification and at least 72 hours of monitoring for adverse reactions. An interview was conducted with an LPN (Staff # 64) on September 23, 2025, at 2:26 PM, which revealed that all nurses were responsible for checking medications. The medication room is inspected monthly to identify expired meds and reorder low supplies. For narcotics, disposal of a single pill requires two nurses to witness, while full cards or expired narcotics must be handed to the DON or ADON. Expired medications should never be administered, as adverse effects may vary by drug. If an expired medication is given, even without a reaction, the physician and family will be notified immediately. Expired meds should never be left in storage; once identified, they must be destroyed without any delay.An interview was conducted with the Director of Nursing (Staff # 1) on September 23, 2025, at 2:50 PM stated that, as per the facility's policy, medications should be checked regularly, ideally monthly, and destroyed using the Drug Buster if expired. Nurses must check expiration dates when opening new bottles and label all opened OTC medications immediately. There is no designated person for medication storage; all the staff members share this responsibility. Storage rooms and carts should be checked at least monthly. Staff # 1 further stated that there is no formal reminder system; staff are expected to check expiration dates during the handling of medications. Administering expired meds carries risks, including reduced therapeutic effects, depending on the drug. Staff #1 further stated that the recently found expired medications practice was unacceptable and fell far below her expected standards.The facility's policy titled Storage and Expiration Dating of Medications and Biologicals, revised on August 1, 2024, included the following: The facility's policy requires that the facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law, and in accordance with policy.

Number of residents sampled: 2Number of residents cited: 2Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directives were completed and maintained for two residents (#9 and #58). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life.-Regarding Resident #58 Resident #58 was admitted to the facility on [DATE], with diagnoses that included paraplegia, hypertension, major depressive disorder, chronic pain, anxiety disorder, and heart failure. During an initial pool record review on [DATE], evidence of Resident #58's advance directive wishes could not be located in the physician's orders or in the miscellaneous tab of his electronic record. Resident 58's Care Plan, dated [DATE], revealed that the resident was a full code, meaning he wanted cardiopulmonary resuscitation performed in the event of an emergency. An interview was conducted with a Licensed Practical Nurse (LPN/Staff #5) on [DATE], at 12:37 PM. The LPN reviewed Resident #58's electronic medical record and could not locate his code status. The LPN reviewed the resident's paper chart and located a notation indicating that the resident had chosen to be a full code. A physician had not signed the paper. The LPN stated that residents' code status should be documented in the electronic clinical record so staff can quickly refer to it in case of an emergency. On [DATE], at 12:56 PM, an interview was conducted with the Director of Nursing (DON/Staff #1). The DON looked in the electronic medical record and was unable to locate Resident #58's order for his code status. The DON stated the error most likely occurred when the resident returned from a recent hospital stay. She noted that all physician orders are discontinued when the resident is admitted to the hospital and then have to be reinstated upon the resident's return to the facility. The DON stated that Resident #58 was discharged from the hospital on [DATE], and returned to the facility. She stated that his advance directive orders were not reinstated into the system. The risk of not having a physician's order for a resident's advance directives could be that the resident's wishes would not be honored in case of an emergency. Resident #9 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease, asthma, type 2 diabetes, acute kidney failure, hypertension, anemia, urinary tract infection, major depressive disorder, infection and inflammatory reaction due to an indwelling urethral catheter, and hyperlipidemia. An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. There was no evidence of an advance directive for full code or Do Not Resuscitate (DNR) in the MDS. There was no evidence of an order for full code or DNR. There was no evidence in the care plan of an advance directive. There was no evidence of an advance directive document in the clinical record. An interview was conducted on [DATE] at 11:41 a.m. with a Certified Nursing Assistant (CNA/Staff#11) who stated that in case of an emergency, she would know to find a residents code status on the tablet at the nurses station, and that they do not have a physically-stored copy of the residents code status as far as she knew. An interview was conducted on [DATE] at 11:45 a.m. with a Licensed Practical Nurse (LPN/Staff#38) who stated that advance directives were established by alert residents or their Power of Attorney (POA), and upon admission they would have residents sign a paper, the nursing staff would get an order from the doctor, and the advance directive would then be found in the Electronic Health Record (EHR) under documents. The LPN stated that the document would be uploaded to the clinical record right away, and the paper would be stored in a binder within the resident's paper chart. The LPN stated that the MDS coordinator would also get a copy of the advance directives, and in an emergency situation, she would look into the physical chart or the EHR, and she would find the order on the banner. The LPN looked into Resident #9's EHR to find an advance directive and stated that she was not sure if he was a DNR or full code because there was no order or any evidence in the clinical record to show an advance directive was completed. The LPN stated that if the resident were to code, she would call the resident's wife to know what his advance directives were, but she would not have time for that in an emergency. The LPN looked in the paper chart for Resident #9 at the nurses' station and was unable to find an advance directive worksheet that was filled out for the resident in the full paper chart. The LPN spoke to the Nurse Practitioner (FNP/Staff#136) at the nurses' station and made her aware that Resident #9 did not have an advance directive order. The LPN stated that there was no advance directive form completed for Resident #9, as evidenced by the absence of the form in the EHR and paper chart. The LPN stated that the risk of not completing, maintaining, or obtaining an order for advance directives would be putting the patient's life at risk. An interview was conducted on [DATE], at 11:59 a.m. with the FNP, Staff #136, who stated that it was her understanding that Resident #9 was a full code; she did not have an order for the resident's advance directive, but that she was adding one right now. The FNP stated that she knew he was a full code because she saw a provider note that indicated it, but that there was not an order for him to be a full code. An interview was conducted on [DATE], at 12:08 p.m. with the Director of Nursing (DON/Staff#1) who stated that there should always be an advance directive in the hard chart on the unit and in the EHR. The DON stated that an order should be entered into the EHR for a full code or DNR so that it would show up on the banner and profile of the residents. The DON opened the clinical record of Resident #9 and stated that there was an order pending from the FNP, and stated which meant there was no order in the record before that. The DON further stated that the advance directives should have been completed as soon as possible upon admission, and the risk of not completing an advance directive for residents could be that they would not have their preferences honored. Review of a policy titled, Advance Directives and Advance Care Planning, with a review date of [DATE], revealed that the physician must give an order for any changes in the advance directives. The policy further revealed that residents who were competent at the time of admission and who had not previously executed an advance directive were given the opportunity to do so with the assistance of an interdisciplinary team, consisting of, but not limited to: the Medical Director, Executive Director, Director of Nursing, Director of Social Services, Chaplain, and others as appropriate. The policy also revealed that Social Services would ensure that a copy of the advance directive was obtained for the resident's medical record and verified that there was an appropriate physician's order in the resident's medical record as well. The policy revealed that documentation in the Minimum Data Set (MDS) should reflect the appropriate advance directives, and the information would be reviewed or updated. Review of a policy titled, CPR & First Aid, with a revision date of [DATE], revealed the facility would provide cardiopulmonary resuscitation (CPR) to any resident requiring such care in accordance with related physicians' orders, such as DNRs and the resident's advance directives. The policy further revealed that the facility would need to verify the presence of advance directives or the resident's wishes in regards to CPR upon admission, and immediately document it in the resident's medical record and contact the physician to obtain an order. The policy also revealed that the resident preferences and physician orders related to CPR and advance directives would need to be communicated so that staff would immediately know what action to take when an emergency arose.

Based on personnel file review, staff interview, and facility policy review, the facility failed to ensure that 2 of 3 sampled direct-care staff (#87 and #118) maintained valid Cardiopulmonary Resuscitation (CPR) and first aid certifications as per their job descriptions. The deficient practice could result in potential harm to residents due to staff not being knowledgeable about how to provide emergency care to residents.Findings include: Review of a personnel file for a Licensed Practical Nurse (LPN/Staff#87) revealed no evidence of CPR or first aid certification. The personnel file also revealed a job description signed on [DATE], that says an LPN must have CPR certification upon hire or obtain during orientation. CPR certification must remain current during employment. Review of a personnel file for a Certified Nursing Assistant (CNA/Staff#118) revealed no evidence of CPR or first aid certification. The personnel file also revealed a job description signed on [DATE], that says a CNA must have CPR certification upon hire or obtain during orientation. CPR certification must remain current during employment. An interview was conducted on [DATE] and 2:22 p.m. with the admissions assistant and fill-in staffing coordinator (Admissions Assistant/Staff#113) who stated that the facility did not have a CPR and first aid certification for Staff #87 or Staff #118. An interview was conducted on [DATE] and 3:05 p.m. with the Interim Administrator (Administrator/Staff#201) who stated that Staff #118 was a CNA, and that the facility did not have a CPR or first aid certification for her. The administrator also stated that the facility did not have a CPR and first aid certification for Staff #87 who was an LPN, and she would have expected the personnel files to be complete and accurate. The administrator stated that it was her expectation that all direct-care staff including CNAs and LPNs obtain and maintain a CPR and first aid certification, and that it was the practice of the company for them to have a CPR card. The administrator further stated that the risk of direct-care staff not possessing a CPR and first aid certification could be that in an emergency situation, one or more staff responsible for life-saving care would not have the training. Review of a policy titled, Cardiopulmonary Resuscitation (CPR) Policy, with a revision date of [DATE] revealed that the facility would ensure that associates maintained current CPR certifications for Healthcare Providers through a CPR provider whose training was in accordance with accepted national standards, and with the required in-person skills assessment. Review of the Arizona Revised Statutes (A.R.S.) R9-10-403 (C)(1)(A,E, &F) revealed that an administrator shall ensure that policies and procedures are established, documented, and implemented to protect the health and safety of a resident that cover job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for personnel members, employees, volunteers, and students. The A.R.S. further revealed that the established and implemented policies and procedures cover cardiopulmonary resuscitation training including: which personnel members are required to obtain cardiopulmonary resuscitation training, the method and content of cardiopulmonary resuscitation training, the qualifications for an individual to provide cardiopulmonary resuscitation training, the time-frame for renewal of cardiopulmonary resuscitation training, and the documentation that verifies an individual has received cardiopulmonary resuscitation training. The A.R.S. also revealed that the established and implemented policies and procedures cover first aid training.

Based on observation, staff interviews, and policy review, the facility failed to ensure current nurse staffing information was accurate for actual hours worked by licensed direct care nursing staff. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. Findings include:A review of August and September 2025 staff postings compared with the actual hours worked revealed that 3 out of 7 staff postings did not match the actual hours worked by staff. -August 26, 2025: staff posting indicated 6 Certified Nursing Assistants (CNAs) worked 48 hours on the night shift. Review of the total actual hours worked revealed that 5 CNAs worked 60 hours. -September 7, 2025: staff posting indicated 3 Licensed Practical Nurses (LPNs) worked the day shift, but the actual hours worked revealed 2 LPNs worked. The staff posting also indicated there were 4 LPNs who worked the night shift for 42 hours, but the actual hours worked should have been 48. The staff posting indicated 6 CNAs worked 48 hours on the night shift, but the total actual hours worked revealed 5 CNAs worked 60 hours. -September 16, 2025: staff posting indicated 3 LPNs worked the night shift, but actual hours worked revealed 2 LPNs on the night shift. An interview was conducted on September 23, 2025, at 10:57 a.m. with the Interim Administrator (Admin/Staff#201), who stated that the staff postings for August 26, September 7, and September 16, 2025, were all incorrect, and it was her expectation that the postings be correct and accurate. The administrator stated that there was a risk of improper documentation that could lead to a lot of issues, and although there was not necessarily a direct-care risk, there could be inherent risk in the inaccurate representation of staffing. A review of a policy titled, Staffing Posting and PBJ Submission, was revised in September 2025 and revealed that the facility must post the total number and actual hours worked by Registered Nurses (RNs), LPNs, and CNAs directly responsible for resident care per shift.

Based on observations, interviews, and record review, the facility failed to ensure that medications were accurately acquired and administered to meet the needs of one resident (#58). This deficient practice could lead to mismanagement of the residents' symptoms.Resident #58 was initially admitted to the facility on [DATE], and most recently admitted on [DATE], with diagnoses that included paraplegia, hypertension, chronic pain, heart failure, major depressive disorder, and anxiety disorder.During initial pool screening, on September 21, 2025, at 11:58 AM, Resident #58 explained that the facility oftentimes runs out of his scheduled pain medication, leaving the resident to experience extreme pain.Resident #58's initial care plan indicated he was at risk for pain related to neuropathy, chronic pain, and generalized pain. One of the interventions was to administer pain medications as ordered.A review of Resident #58's provider orders revealed an order for Oxycodone, 15 milligrams (mg), one tablet every four hours.A review of the resident's medication administration record (MAR) was conducted for April 2025 through September 2025. The MAR revealed that the resident had not received his scheduled Oxycodone on April 24, 2025, June 24, 2025, July 6, 2025, July 29, 2025, August 22, 2025, and September 8, 2025. Progress notes for those dates revealed that the medication was not available. Additionally, the resident's pain levels had been scored between 9 and 10 on a 0-10 pain scale, with 10 being the worst pain.An interview was conducted with the Director of Nursing (DON/Staff #1) on September 23, 2025, at 1:00 PM. The DON stated that controlled substances, such as Oxycodone, require a signed prescription from the physician. She said there was sometimes a delay between the time the staff requests a new prescription and the time the physician signs it and gets it to the pharmacy. However, she also stated that the physician comes into the building regularly and is willing to sign prescriptions. The DON stated the facility should not be running out of residents' pain medications and that she expected staff to order the refill for the medications sooner, to prevent the issue from occurring.A policy titled Pain Assessment and Management, most recently reviewed on August 29, 2025, indicated that the facility must ensure that pain management was provided to residents consistent with professional standards and the residents' goals and preferences.

Based on observations, record review, and staff interviews, the facility failed to ensure that one resident (#8) was free from significant medication errors. This deficient practice could lead to adverse outcomes for residents.Findings include:Resident #8 was admitted to the facility on [DATE], with diagnoses that included paraplegia, neuromuscular dysfunction of the bladder, diabetes mellitus, hypertensive heart disease, and bipolar disorder.A review of Resident #8's medication administration record (MAR) indicated the resident had the following medications due at 8:00 AM:-Dapagliflozin Propanediol, 10 milligrams (mg), one tablet in the morning-Aspirin EC (enteric coated) Delayed Release, 81 mg, one tablet one time a day-Baclofen, 10 mg, one tablet three times a day-Famotidine, 20 mg, one tablet two times a day-Fluticasone Propionate Nasal Suspension, 50 mcg/act (micrograms per actuation), one inhalation two times a day-Gabapentin, 100 mg, one tablet three times a day-Insulin Glargine 100 units/ml (milliliter), 35 units two times a day-Methocarbamol, 750 mg, one tablet two times a day-Multi-Vitamin, one tablet one time a day-Progesterone, 200 mg, one capsule one time a day-Propranolol HCl, 20 mg, one tablet two times a day-Simethicone Chewable, 80 mg, one tablet four times a day-Vitron-C, 65-125 mg, one tablet two times a [NAME] September 23, 2025, at 10:50 AM, a dressing change was being observed with a Registered Nurse (RN/Staff #111). During the dressing change, Resident #8 informed the wound nurse that she had not received her morning medications.On September 23, 2025, at 11:00 AM, a Licensed Practical Nurse (LPN/Staff #38) entered Resident #8's room to assess her blood glucose level and administer her morning medications. The RN (Staff #111) asked her to return after the dressing change was completed.On September 23, 2025, at 11:30 AM, an interview was conducted with the LPN (Staff #38), who stated she had not administered Resident #8's morning medications. She said she attempted to distribute them at 11:00 AM. The nurse reviewed the MAR and stated the medicines were due at 8:00 AM. The nurse indicated that she had tried to assess Resident #8's blood glucose level earlier in the morning, but the resident had refused. However, she had not attempted to administer the resident's medications at the time they were due.An interview was conducted with the Director of Nursing (DON/Staff #1) on September 23, 2025, at 1:14 PM. The DON reviewed the MAR and stated that Resident 8's medications were charted as administered at 10:57 AM. The DON confirmed that some medicines were scheduled to be administered at 8:00 AM, while others were scheduled to be administered between 6:00 and 10:00 AM. The abovementioned medicines were scheduled to be administered at 8:00 AM. The DON stated that she expected medications to be administered to residents one hour before they were due, up to one hour after they were due. She stated that the medicines that were due at 8:00 AM had been administered late and acknowledged that that was a medication error.A policy titled Administration of Medications, most recently reviewed on September 16, 2024, revealed that medications should be given at the time specified by the provider's order.

Based on observations, record review, and staff interviews, the facility failed to ensure that the medication administration record (MAR) was accurately documented for one resident (#8). This deficient practice could lead to adverse outcomes for residents.Findings include:Resident #8 was admitted to the facility on [DATE], with diagnoses that included paraplegia, neuromuscular dysfunction of the bladder, diabetes mellitus, hypertensive heart disease, and bipolar disorder.A review of Resident #8's MAR indicated the resident had the following medications due at 8:00 AM:-Dapagliflozin Propanediol, 10 milligrams (mg), one tablet in the morning-Aspirin EC (enteric coated), Delayed Release, 81 mg, one tablet one time a day-Baclofen, 10 mg, one tablet three times a day-Famotidine, 20 mg, one tablet two times a day-Fluticasone Propionate Nasal Suspension, 50 mcg/act (micrograms per actuation), one inhalation two times a day-Gabapentin, 100 mg, one tablet three times a day-Insulin Glargine 100 units/ml (milliliter), 35 units two times a day-Methocarbamol, 750 mg, one tablet two times a day-Multi-Vitamin, one tablet one time a day-Progesterone, 200 mg, one capsule one time a day-Propranolol HCl, 20 mg, one tablet two times a day-Simethicone Chewable, 80 mg, one tablet four times a day-Vitron-C, 65-125 mg, one tablet two times a [NAME] September 23, 2025, at 10:50 AM, a dressing change was being observed with a Registered Nurse (RN/Staff #111). During the dressing change, Resident #8 informed the wound nurse that she had not received her morning medications.On September 23, 2025, at 11:00 AM, a Licensed Practical Nurse (LPN/Staff #38) entered Resident #8's room to assess her blood glucose level and administer her morning medications. The RN (Staff #111) asked her to return after the dressing change was completed.On September 23, 2025, at 11:30 AM, an interview was conducted with the LPN (Staff #38), who stated she had not administered Resident #8's morning medications. She said she attempted to distribute them at 11:00 AM. The LPN reviewed the MAR and stated the medicines were due at 8:00 AM. The nurse indicated that she had tried to assess Resident #8's blood glucose level earlier in the morning, but the resident had refused. However, she had not attempted to administer the resident's medications at the time they were due.While reviewing the MAR, it was noted that Resident #8's medications had been charted as having already been administered. The LPN stated that she had charted the medications as administered because she knew which medications Resident #8 would take, even though she had not yet administered them. The LPN acknowledged that that was a charting error.An interview was conducted with the Director of Nursing (DON/Staff #1) on September 23, 2025, at 1:14 PM. The DON reviewed the MAR and stated that Resident 8's medications were charted as administered at 10:57 AM. The DON stated that she expected medications to be charted as administered after the resident took the medicines.A policy titled Administration of Medications, most recently reviewed on September 16, 2024, revealed that medication administrations should be documented in a timely manner following the administration to the resident.

Based on clinical record review, facility documents, staff interviews and facility policy, the facility failed to ensure that 2 residents (#6, 66) were not abused. Findings include:--Regarding the incident between resident #100 and resident #66 -Resident #100 was admitted on [DATE], with diagnoses of Major Depressive Disorder, and Hemiplegia and Hemiparesis following cerebral infarction affecting the right dominant side. A quarterly Minimum Data Set (MDS) dated [DATE], included that this resident had moderately impaired cognition and that the resident used a wheelchair. A care plan dated January 4, 2024, included that resident #100 has impaired cognitive ability with impaired insight and poor recall. Interventions included to cue, reorient, and supervise. A Health Status Note dated March 19, 2024, included that resident #100 was witnessed by a CNA to be pulling on another resident's shirt as the other resident was propelling herself in her wheelchair by this resident. This note included that the other resident yelled, and the Licensed Practical Nurse (LPN) intervened, and this resident let go of the other resident's shirt. A Health Status Note dated April 1, 2024, included that resident #100 was in the dining room and was witnessed propelling herself towards another resident in an aggressive manner staff stopped her and redirected her back to where her lunch was. A Health Status Note dated April 10, 2024, included that at 1210pm, resident #100 was being pushed in her wheelchair by a kitchen aide, and she stated that resident #100 reached to her left and grabbed the left upper arm of another resident in the middle of the 100 hallway and pinched the other resident's arm. This note included that the Kitchen staff member said it was completely unprovoked and that the other resident was not even looking in this resident's direction prior to this occurring. The Kitchen aide stated that resident #100 quickly pinched her arm and let go, and the other resident touched her own upper arm discoloration with scratch marks noted immediately after the incident. This note included that the Kitchen aide asked in Spanish why she grabbed the other resident's arm, and resident #100 said because she is telling lies and saying they are a couple. Resident #100 took herself to her room, and resident #66 went into the dayroom. This note included that a complete body assessment was done for both residents and that family, staff, the physician, and the police were notified. -Resident #66 was admitted on [DATE], with diagnoses of Major Depressive Disorder and dementia. A quarterly MDS dated [DATE], included that this resident was severely cognitively impaired and had episodes of inattention and wandering. This document included that this resident used a wheelchair. A care plan dated June 17, 2023, included that this resident has impaired cognitive ability and/or impaired thought processes related to Alzheimer's dementia. This document included an intervention to cue, reorient, and supervise as needed. An event note dated April 10, 2024 included that at approximately 12:10 PM a dietary aide reported to the nurse that as she was pushing resident #100 in her wheelchair in the hallway toward the nurse's station, when resident #66 was propelling herself the opposite way, and the resident she was pushing reached out and grabbed the left upper arm of resident #66 but immediately let go. This note included that resident #66's left upper arm was checked by the nurse and that she is noted to have 3 discolored purple and red areas on her left upper arm. This note included that resident #66's family and physician were called. A skin check dated April 10, 2024, included that an area of impairment was found after an altercation with another resident that had purple/red discoloration on the left upper arm in 3 areas, which included the left hand, thumb side, and right forearm. An interview was conducted on September 23, 2025, at 1:36 PM with an LPN (staff #5) who said that resident #100 was not aggressive but that she did not like one of the residents who used to be in a room next to hers and that she said it was because she did not have friends like that. This nurse said that resident #100's son talked to her and told her it was because she believed the other resident wanted to be more than friends. This nurse confirmed that the resident was #66 and that the kitchen aide had come to her and said that she had seen resident #100 pinching resident #66. This nurse said that she did not remember who the kitchen aide was. --Regarding the incident between resident #120 and #6:-Resident #120 was admitted on [DATE], with diagnoses of Bipolar disorder, other sequelae of cerebral infarction, and chronic pain syndrome.A quarterly MDS dated [DATE], included that this resident had a memory problem with short- and long-term memory and that this resident was severely impaired in making decisions regarding the tasks of daily life. This document included that this resident had impairment in all extremities. This document included that this resident used a wheelchair and that he required supervision for wheeling 50 feet with 2 turns and to wheel 150 feet.A health status note dated May 1, 2024, included that it was reported to the nurse that resident #120 was sitting outside his room in the hallway facing east, and struck the other resident on her right upper arm with an action figure, and that the victim's sister witnessed from the front desk. This nurse included that a 15-minute patient check was initiated.A psychosocial note dated May 3, 2024, included that resident #120's family was contacted to discuss care plan interventions related to resident #120's impulse control and discussed moving the resident's room. This note included that resident #120 continues to be monitored by staff and is with staff members when out of the room, dining, or in an activity. This note also included that when around other residents in his wheelchair, this resident should remain at least an arm's length away related to poor impulse control.-Resident #6 was admitted [DATE], with diagnoses of aphasia following cerebral infarction, muscle weakness, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side.A quarterly MDS dated [DATE], included that the resident was severely cognitively impaired and that this resident was impaired on one side of the upper and lower extremities. This document included that this resident used a wheelchair and that she required supervision for wheeling 50 feet with 2 turns and partial/moderate assistance to wheel 150 feet.An event note dated August 14, 2023, included that resident #120 was sitting in the lobby in her wheelchair next to resident #6. This note included that a sales representative was exiting the building and did knuckles with resident #120, and that resident #120 then reached over and hit resident #6 in her left arm 2-3 times and on her left neck area. This note included that the receptionist and admission director saw the incident and were able to separate the residents, and both were returned to their rooms. This note included that no injuries were found, that a new placement was being sought for resident #120, and that resident #120 will have staff present whenever he is out of bed.However, a health status note dated April 30, 2024, included that resident #6 was wheeling west down the hallway and got struck by another resident who was sitting outside his room in the hallway facing east. This note included that resident #6 got hit on her right upper arm with an action figure. This note included that the resident's sister witnessed from the front desk, heard her saying Ow, that hurt and that she looked and saw the other resident hit her. This note included that the other resident continued to wheel down the hall and that no other staff or residents observed the incident.An interview was conducted on September 23, 2025, at 10:53 with the family member who had witnessed the April 30, 2024, altercation. This family member said that resident #6 was sitting in the hallway in and resident #120 came by and he had this doll and he was hitting her, and I had told him to stop hitting, and he kept doing it. This family member said that resident #120 was hitting her on the arm and that there were no injuries except a red mark that went away. This family member said that the staff moved resident #120 further back into the nursing home and that resident #120 would always shake his fist at resident #6.An interview was conducted on September 23, 2025, at 1:08 with an LPN (staff #38) who said that resident #6 was forgetful and that she was not aggressive. This nurse said that resident #120 is still in the facility and that he does not speak, but that when he's excited, he will swing his fist that which means that he's happy about you, and that some people take it as aggression. This nurse said that she was told about the altercation and that she believes that resident #120 tried to use his toy to show he was excited and not in a bad way. This nurse said that she asked resident #66 about this incident the next day, and that she did not remember. An interview was conducted on September 23, 2025, at 3:36 PM with the Director of Nursing (DON/staff #1), who said that her expectation is that abuse does not happen. This DON said that she was not in the facility at the time of the incident, as she started work at the facility in May to June of 2024. This DON reviewed the incident between resident #120 and resident #6, and said that it is abuse because a resident is touching someone, and that he should not be touching someone. This DON said that if resident #120 had hit someone with the toy, then it would be abuse. This DON then reviewed the incident between resident #100 and resident #66 and said that pinching is abuse and that this incident sounded like abuse. A policy reviewed May 6, 2025, titled Abuse - Prevention included that it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a resident (#5) was provided care and services for a urinary catheter according to physician orders. The deficient practice could lead to infection.Findings include:Resident #5 was admitted to the facility April 27, 2022, with diagnoses that included paraplegia, hypertension, and other chronic pain, and re-admitted to the facility on [DATE], with diagnoses that included sepsis and infection and inflammatory reaction due to indwelling urethral catheter.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section H revealed the resident had an indwelling catheter, and Section I revealed the resident had the active diagnoses of neurogenic bladder.A care plan for a catheter related to obstructive uropathy initiated October 20, 2022, revealed interventions to provide catheter care every shift and to observe for and report to the physician for signs and symptoms of urinary tract infection (UT)I: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns.An additional care plan initiated September 9, 2025, for a suprapubic catheter related to neurogenic bladder revealed interventions to provide catheter care every shift and to observe for and report to the physician for signs and symptoms of urinary tract infection (UT)I: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns.Another care plan for behavior dated September 9, 2025, revealed that the resident emptied urine from his catheter bag into an unmarked water pitcher. An intervention indicated to anticipate and meet the resident's needs.A physician order dated January 23, 2024, indicated to empty catheter and record amount in the electronic clinical record three times a day for output monitoring.Review of the Medication and Treatment Administration Record (MAR/TAR) for July 2025 revealed a record log for emptying the catheter and recording urine output in milliliters (mL) at 5:00 A.M., 1:00 P.M., and 9:00 P.M. The record revealed the log was blank on the following:-July 25 at 5:00 A.M.-July 28 at 5:00 A.M.The MAR/TAR for August 2025 revealed that the log for emptying the catheter and monitoring output was blank on the following:-August 9, 14, 15, 16, 21, 22, 23, 27, 28, 29, and 30 at 5:00 A.M.-August 21 and August 28 at 9:00 P.M.The MAR/TAR for September 2025 revealed that the log for emptying the catheter and monitoring output was blank on the following:-September 5, 6, 13, and 14 at 5:00 A.M.The clinical record was reviewed and revealed no evidence that the catheter was emptied or that urine output was recorded on the dates/times that the MAR/TAR was blank. Additionally, there was no evidence that the resident refused.An interview was conducted with Resident #5 on September 19, at 8:21 A.M. Resident #5 stated that his catheter was not being emptied as it should. He stated that there have been times where the catheter bag was not emptied for 12-14 hours at a time. He also stated that there have been times where the catheter was not emptied by staff as it should, and that he had to empty the catheter bag himself.An interview was conducted with a certified nursing assistant (CNA / Staff #22) on September 19, 2025, at 11:18 A.M. Staff #22 stated that CNAs are involved with residents' daily catheter care by emptying the catheter bag, and that for some residents, the nurse requests the CNAs to measure the urine output when emptying the catheter bag and notify the nurse of the output.An interview was conducted with a Registered Nurse and Assistant Director of Nursing (ADON / Staff #9) on September 19, 2025, at 11:24 A.M. Staff #9 stated that daily urinary catheter care involves cleaning and flushing the catheter, and to empty the catheter every shift and that some require more frequent emptying. Staff #9 stated that if a resident had a physician order to empty the catheter and monitor the output, then the nurse or the CNA would record the amount of urine that was emptied. Staff #9 stated that if the catheter bag was not emptied regularly or only emptied once a day, then that could cause an infection.An interview was conducted with the Social Services Director (Staff #36) on September 19, 2025, at 11:35 A.M. Staff #36 stated that if a resident raises a concern or complains about something then Staff #36 speaks to the resident and fill out a comment and concern card, and that Staff #36 takes it to the management team to have the issue addressed. Staff #36 stated that Resident #5 will say care items have not been completed by staff, and that Resident #5 had raised a concern about his catheter bag not being emptied.An interview was conducted with the Director of Nursing (DON / Staff #80) on September 19, 2025, at 11:51 A.M. Staff #80 stated that daily catheter care includes cleansing with soap and water, emptying the catheter, and that some require flushing. Additionally, the DON stated that the care is recorded on the MAR / TAR. The DON stated that the importance of daily catheter care is to keep it clean and to prevent infection. Additionally, Staff #80 stated that if a resident had a physician order to empty the catheter bag and monitor the output three times a day then that would be important to prevent infections and to prevent the bag from getting too full with urine backing up into the catheter tube. Also, the DON stated that if the physician order indicated to empty the catheter bag three times a day, and it was only completed once a day, then that would not meet her expectations. The MAR/TAR for August 2025 was reviewed together, and the DON stated that there were blank log entries for multiple dates and times, and that it could mean that the CNA did not get the information to the nurse. The DON stated that there was no other way to tell if the catheter was emptied or not.Review of the facility policy titled Indwelling Urinary Catheter (Foley) Management, revised June 27, 2023, revealed that the facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed: insertion, ongoing care, and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures and ongoing monitoring for changes in condition related to potential catheter acquired UTIs, recognizing, reporting and addressing such changes. Additionally, a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. General guidelines for urinary catheter maintenance include to empty the collecting bag regularly using a separate, clean collecting container for each patient.

Based on interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a resident (#5) was provided assistance with bathing or showering according to the resident's preference and to meet the resident' needs. The deficient practice could lead to a breakdown in skin integrity and/or psychosocial harm of a resident.Findings include:Resident #5 was admitted to the facility April 27, 2022, with diagnoses that included paraplegia, hypertension, and other chronic pain, and re-admitted to the facility on [DATE], with diagnoses that included sepsis and infection and inflammatory reaction due to indwelling urethral catheter.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section GG revealed the resident was dependent on caregivers for showering and/or bathing.A care plan initiated May 1, 2022, and another care plan initiated September 9, 2025, revealed the resident has an activities of daily living (ADL) self-care performance deficit due to limited mobility due to paraplegia. An intervention revealed that the resident is totally dependent on two staff to provide a bath/shower two times a week and as necessary. Facility shower schedules revealed that Resident #5 was scheduled to receive a shower or bath on the following dates:September 5, 2025 with assistance from a certified nursing assistant (CNA / Staff #14)September 8, 2025, from a CNA (Staff #70)September 12, 2025, from a CNA (Staff #14)September 15, 2025 from a CNA (Staff #2) A formal request was submitted to the facility on September 19, 2025, for shower sheets for Resident #5. The facility provided shower sheets and a task log that revealed the following documentation regarding showers for Resident #5 for the timeframe of August 23, 2025 through September 19, 2025:-August 23, 2025: bathing/showering did not occur on the task log, and no evidence of a shower sheet, and no evidence of a resident refusal in the clinical record-August 26, 2025: bathing/showering did not occur on the task log, and no evidence of a shower sheet, and no evidence of a resident refusal in the clinical record-September 6, 2025: bathing support provided with one person assistance on the task log, and no evidence of a shower sheet.-September 13, 2025: bathing/showering did not occur on the task log, documented by a CNA (Staff #39). Additionally, there was no evidence of a shower sheet, and no evidence of a resident refusal in the clinical record.-September 15, 2025: bathing/showering did not occur on the task log, documented by a CNA (Staff #99). Also, there was no evidence of a shower sheet, and no evidence of a resident refusal in the clinical record Review of a time punch report revealed that Staff #99 was not punched in to the facility anytime between September 13-September 16, 2025.An interview was conducted with Resident #5 on September 19, 2025, at 8:13 A.M. Resident #5 stated that he was not receiving his scheduled showers twice a week like he was supposed to and that at one point approximately a year and a half ago, he had gone without a shower for four weeks. Resident #5 stated that in the past, he had raised this concern with the social services director (Staff #36) and that Staff #36 had told him that he had to choose between getting up in his wheelchair or getting a shower. Resident #5 stated that for his past two scheduled showers, no staff had come and offered to give him a shower.An interview was conducted with a CNA (Staff #22) on September 19, 2025, at 11:18 A.M. Staff #22 stated that for bathing or showering, the staff have an assigned list of which staff are supposed to shower which residents. Staff #22 stated that showers or baths are to be documented on shower sheets, and the CNAs document any skin issues observed and then CNAs give the shower sheet to the nurse to sign off. Staff #22 stated that if a resident refuses a shower or bath then she will check with the resident several times throughout the day, and that if the resident still refuses, then the nurse will attempt to get the resident to shower, and if the resident still refuses then it is documented as a refusal on the shower sheet and also in the electronic medical record.An interview was conducted with a Registered Nurse and Assistant Director of Nursing (ADON / Staff #9) on September 19, 2025, at 11:24 A.M. Staff #9 stated that residents are given showers or baths on their assigned shower day, and that if the resident refuses, the CNA would notify the nurse, and the nurse would try to encourage the resident to shower. If the resident still refused, then the Director of Nursing (DON / Staff #80) would be notified. Staff #9 stated that showers or baths would be documented on a shower sheet that the nurse signs off on, and the shower sheet would also include if the resident refused. Staff #9 stated that the importance of regular showering or bathing would be to prevent the breakdown of skin, but that residents also have a right to refuse.An interview was conducted with the Social Services Director (Staff #36) on September 19, 2025, at 11:35 A.M. who stated that she was aware that Resident #5 had complained about not getting showers historically.An interview was conducted with the DON (Staff #80) on September 19, 2025, at 11:51 A.M. The DON stated that the facility's process for giving residents showers or baths is that each resident has two assigned shower days per week, and that showers or baths are documented on shower sheets and in the electronic task log. Additionally, the DON stated that if a resident refuses, then it should be documented as a refusal on the shower sheet or task log or a nurse's progress note. The DON stated that the importance of bathing or showering is that it helps maintain skin integrity and reduces odors.A telephonic interview was conducted on September 19, 2025, at 12:16 P.M. with a CNA (Staff #39) who had documented on September 13, 2025, that a shower or bathing did not occur for Resident #5. Staff #39 stated that she did not offer the resident a shower on September 13, 2025, because that is the night shift staff's assignment.A telephonic interview was conducted on September 19, 2025, at 12:20 P.M. with a CNA (Staff #99) whose electronic signature had documented in the electronic clinical record that a shower or bath did not occur for Resident #5 on September 15, 2025. Staff #99 stated that she has never been assigned to Resident #5 and has never assisted Resident #5. Additionally, Staff #99 stated that she was not in the facility on September 15, 2025, and that another staff member has her login passcode for the electronic clinical record.Another telephonic interview was conducted September 19, 2025, at 12:50 P.M. with a CNA (Staff #14) who was scheduled to assist Resident #5 with a shower on September 12, 2025. Staff #14 stated that she did not offer Resident #5 a shower that date because that resident was not part of her assigned hallway.A follow-up interview was conducted with the DON (Staff #80) on September 19, 2025, at 1:20 P.M. The task log for Resident #5's showering was reviewed, in addition to the time punch report for Staff #99, and the DON stated that she had no idea why there was electronic documentation completed by Staff #99 regarding Resident #5 not getting a shower on September 15, 2025, and that Staff #99 was not in the facility on September 15, 2025.Review of the facility policy titled Activities of Daily Living (ADLs), revised February 12, 2024, revealed that the resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be reported to the nurse. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that's residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: bathing, dressing, grooming, and oral care. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the facility policy titled Tub Baths and Showers, revised May 19, 2025, revealed that tub baths and showers provide personal hygiene, stimulate circulation, and reduce tension for a patient. They also allow observation of the condition of a patient's skin and assessment of joint mobility and muscle strength. The implementation of a tub bath or shower included to document the procedure. Documentation associated with tub baths and showers includes: skin condition, discoloration or redness, tolerance of the procedure, and teaching provided to the patient and family (if applicable).Review of the facility policy titled Nursing Documentation, issued August 20, 2019, revealed this facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse practice act, and any state laws governing the scope of nursing practice. The medical record must reflect the resident's condition and the care and services provided across all disciplines to ensure information is available to facilitate communication among the interdisciplinary team. The medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatment and/or services, and changes in his/her condition, plan of care goals, objectives and/or interventions.

Based on interviews, review of clinical record, and review of facility policy, the facility failed to ensure an allegation of abuse was reported to mandated entities within 2 hours for one resident (#2). The deficient practice could lead to an allegation of abuse not being investigated by all mandated entities timely, resulting in possible ongoing abuse to a resident.-Findings include: Resident #2 was admitted to the facility July 7, 2025, with diagnoses that included encounter for surgical aftercare following surgery on the circulatory system, peripheral vascular disease, type 2 diabetes mellitus, and major depressive disorder.A brief interview for mental status (BIMS) assessment dated [DATE], revealed the resident had a score of 14, indicating intact cognition.A Weekly Skin Integrity Data Collection dated July 19, 2025, revealed the resident's groin had a surgical incision, no redness, no bruising, no swelling to peri-area.An email receipt dated July 19, 2025, revealed that an Adult Protective Services report was submitted at 5:59 p.m.A facility self-report dated July 19, 2025, submitted to the State Agency at 6:13 p.m., revealed that Resident #2 reported to staff that a male Certified Nursing Assistant (CNA) entered her room the morning of July 18, 2025, twice, once with the nurse and once alone. The male CNA asked if she used the bathroom, or needed to be changed, patting the top of her incontinent brief. Resident #2 then stated that she used the bathroom, and the CNA left her room. Resident #2 stated that, at first, she did not think anything of it, but then later decided she should say something. The resident was unable to say who the male CNA was, but that he had a grey beard and was wearing green scrubs. The nurse that worked on July 18, 2025, was interviewed and stated that she was in and out of the resident's room multiple times during her shift and she was not accompanied by any CNA, and that the resident never said anything about the incident. At approximately 4:00 p.m. on July 19, 2025, the resident called the local police department and filed a complaint. A police officer responded and interviewed both the resident and the male CNA that worked yesterday. Per the documentation, after interviewing both parties, the officer had the Assistant Director of Nursing (ADON) take the CNA into the resident's room and asked the resident if she knew the CNA. The resident responded that she did not know the CNA, and had never seen him before.An interview written statement dated June 19, 2025, at 7:00 a.m., signed by the ADON (Staff #26), revealed an interview with a CNA (Staff #60). The statement revealed the ADON spoke with Staff #60 regarding stated allegations by Resident #2. Staff #60 stated he did not go in the resident's room at all on July 18 2025. The ADON informed Staff #60 that he was being sent home pending the investigation, and Staff #60 left the building. At approximately 8:30 a.m., the ADON called and requested that Staff #60 come back to the facility to work. At approximately 9:30 a.m., Staff #60 returned to work and went to the East unit.A time punch detail report revealed that Staff #60 had time punches as follows:-July 18, 2025: Punched in from 6:55 a.m. to 2:10 p.m. and from 2:15 p.m. to 5:42 p.m.-July 19, 2025: Punched in from 6:50 a.m. to 7:28 a.m. and from 9:04 a.m. to 5:35 p.m.A telephonic interview was conducted with a CNA (Staff #19) on July 22, 2025, at 9:44 a.m. Staff #19 stated that she believed she was the first staff that Resident #2 reported the allegation to. Staff #19 stated that sometime between midnight and the early morning hours of July 19, 2025, that she entered Resident #2's room and Resident #2 stated that I feel like I've been molested. Staff #19 stated that Resident #2 said that she sleeps with her nightgown up, and that a male staff entered the room and asked if she got up to use the restroom or if she used an incontinence brief. Staff #19 stated that Resident #2 said that the male staff said he had to check to see if she had urinary incontinence, and then patted the front of her brief over the genital area three times and then left the room. Staff #19 stated that Resident #2 gave a description and a name of the alleged perpetrator, and that Staff #19 reported to the nurse right away. A telephonic interview was conducted on July 22, 2025, at 10:11 a.m., with a Licensed Practical Nurse (LPN / Staff #31), who stated that she was the night nurse that worked the shift between July 18 and July 19, 2025. Staff #31 stated that she was notified of the allegation by a CNA (Staff #19) late in the night shift of July 18-19, 2025. Staff #19 stated that she then spoke to Resident #2 who said that at approximately 8:00 - 10:00 a.m. on July 18, 2025, that Resident #2 was in her room and a male staff entered and asked her if she used the bathroom, and then the male staff reached down and patted the front of her brief three times to see if she was incontinent, and then the male staff left the room. Staff #31 stated that Resident #2 reported a name of the male staff, which was the same first name as Staff #60, and provided a description. Staff #31 stated that she notified the Director of Nursing (DON) right away, and that later the DON responded that she was going to notify the Administrator.An interview was conducted with the DON (Staff #47) on July 22, 2025, at approximately 11:00 a.m. The DON stated that abuse could be verbal, physical, or sexual, and if staff are notified of an abuse allegation, then staff should immediately ensure the safety of the residents, then notify the DON or the Administrator immediately. Once notified, the DON and Administrator report to the mandated entities within two hours, including to the State Agency, to Adult Protective Services, to the ombudsman, and to the police department. Regarding Resident #2's sexual abuse allegation, the DON stated that she was notified on July 19, 2025, at around 4:30 a.m. that Resident #2 reported to a CNA and a nurse that a male staff asked the resident if she used the bathroom or needed to be changed and patted the outside of the resident's brief, either at the top or between the resident's legs. The DON stated that she notified the Administrator, and reported the allegation to the State Agency around 4:00 p.m. on July 19, 2025. The DON stated that there was a delay in reporting the allegation because the ADON (Staff #26) who did the investigation did not feel anything had happened. The DON stated that the alleged perpetrator (Staff #60) arrived to work at approximately 7:00 a.m. on July 19, 2025, and the ADON talked to him and then sent him home pending the investigation. The DON stated that an investigation was conducted and that the ADON also talked to Resident #2, and that no mandated reporting occurred during that time.A telephonic interview was conducted with the ADON (Staff #26) on July 22, 2025, at 11:46 a.m. The ADON stated that she was first notified by the DON around 5:00 a.m. on July 19, 2025, that Resident #2 had stated that a CNA with the same first name as Staff #60 had touched her on her brief. The ADON stated that the DON had asked Staff #26 to go to the facility and stop Staff #60 from entering the facility and interview him to get his statement. The ADON stated that when she interviewed Staff #60, that he stated he had not been in Resident #2's room all day on July 18, 2025. The ADON stated that she also interviewed Resident #2, Staff #19, and attempted to interview Staff #31 however Staff #31 was asleep. The ADON stated that around 8:30 a.m. on July 19, 2025, she notified the DON and the Administrator to provide the information from her investigation and that she did not give any guidance on whether the facility should report the incident to mandated sources.An interview was conducted with the Administrator (Staff #66) on July 22, 2025, at 12:04 p.m. The Administrator stated that abuse could be inappropriate sexual touching or could be verbal abuse. The Administrator stated that if there is an allegation of abuse, that the staff would protect the resident to ensure safety, and that staff obtains statements from staff and residents, and if there is a description of the alleged perpetrator, then the facility would suspend the staff member until the investigation is completed. The Administrator also stated that the facility must report an allegation of abuse to mandated entities including the police, the ombudsman, and the State Agency within 2 hours. The Administrator stated that he was first notified on July 19, 2025, around 5:15 to 5:20 a.m., and that there was an allegation from Resident #2 that she was patted by a male CNA on the front of her brief over her genital region. The Administrator stated that he determined that the allegation was not abuse based on the facility's investigation somewhere around 7:00 in the morning on July 19, 2025 and did not report the allegation to mandated entities that morning. Additionally, the Administrator stated that around 4:00 p.m. that same day, that Resident #2 called the police to report the allegation.Review of the facility policy titled Abuse - Identification of Types, revised June 17, 2024, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at have the capacity to consent. Sexual abuse includes, but is not limited to unwanted intimate touching of any kind especially of breasts or perinea area, and all types of sexual assault or battery, such as rape, sodomy, and coerced nudity.Review of the facility policy titled Abuse - Reporting and Response - No Crime Suspected, revised April 9, 2024, revealed in response to allegations of abuse, the facility must: ensure that all alleged violations involving abuse, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. An individual who reports an alleged violation to facility staff does not have to explicitly characterize the situation as abuse in order to trigger the facility to investigate. Rather, if facility staff could reasonably conclude that the potential exists related to abuse then it would be considered to be reportable and require action. For alleged violations of abuse the facility must report the allegation immediately, but no later than 2 hours after the allegation is made.

Based on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident (# 23) received wound care in accordance with physician orders. This deficient practice can result in diminished quality of life, and suboptimal clinical outcomes. Findings include: Resident # 23 was admitted to the facility April 3, 2023 with diagnoses that included heart failure, cellulitis of left lower limb, Diabetes Type 2 with ulcers, obesity, and muscle weakness. Review of the resident's Break in Skin Integrity care plan, initiated on February 20, 2023 revealed the resident was to have treatment as ordered and weekly skin checks. Review of the Nursing Home Comprehensive Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 15, indicating cognition was intact. The MDS also identified the resident as having an infection of the foot, and a diabetic foot ulcer(s). Review of the residents wound care order, initiated on April 5, 2023, instructed the licensed staff to address the left lower extremity ulcers in the following steps twice daily: 1. Clean the area with normal saline. 2. Paint Purulent areas with medi-honey 3. Cover the open-non-purulent areas with xeroform 4. Paint the diabetic ulcer to the heel with betadine and cover with a non-adherent pad. 5. Wrap with a bulky gauze bandage daily every shift. Review of the resident's wound care order, initiated on April 5, 2023, instructed the licensed staff to address the right inner calf in the following steps daily: 1. Wash the area with normal saline. 2. Paint with Betadine. 3. Cover with bordered gauze. Review of the clinical record, failed to support wound care for the left lower extremity ulcer was performed or refused on: April 6, 2023, April 10-11, 2023, April 17, 2023, April 23, 2023, April 25-26, 2023, and March 1, 2023. Review of the clinical record, failed to support wound care for the right inner calf was performed or refused on: April 6, 2023, April 10-11, 2023, April 13, 2023, April 17, 2023, April 25-26, and March 1, 2023. An interview was attempted with the complainant on April 24, 2025 at approximately 9:00 AM, however the number was no longer in service. During an interview with a Certified Nurse Assistant (CNA/Staff # 71) on April 24, 2025 at approximately 2:00 PM, the CNA revealed that during resident care, if a dressing is missing or falling off, or if any new abnormal skin changes are observed, it is the responsibility of the CNA to report it to the nurse. In an interview with a Registered Nurse (RN/Staff # 2) on April 24, 2025 at approximately 2:10 PM, the RN revealed the facility does not have a dedicated wound care nurse, but rather the licensed nurses incorporate wound care into their shift. In addition, the RN stated that provider orders for wound care are to be followed, or else the resident will have set backs in their healing. The RN stated that setbacks can include the wound becoming worse, larger, and even infected. The RN stated that refusal of dressing changes are documented and reported to management for further follow-up. During an interview with the Director of Nursing (DON/Staff # 21) on April 24, 2025 at 3:25 PM, the DON reviewed the resident's Treatment Administration Record (TAR), and identified shifts where wound care was not performed. The DON stated being unable to find evidence supporting whether or not wound care was conducted or refused on the identified shifts. The DON revealed that facility expectation was not met in ensuring wound care was provided to the resident as ordered. The facility's Nursing Documentation policy, issued August 20, 2019, revealed the resident's medical record must reflect the residents' condition and the care and services provided across all disciplines. In addition, the medical record must contain an accurate representation of the actual experience of the resident and include enough information to provide a picture of the resident's progress. The facility's Resident Rights policy, issued June 8, 2020, revealed the resident has the right to participate in establishing goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure one resident (#26) was free from sexual abuse. The deficient practice resulted in a resident being inappropriately touched by another resident. Findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, psychotic disturbance, mood disturbance, and anxiety. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. Review of the care plan and nursing progress notes revealed no evidence of sexual abuse occurring. Additionally, there were no psychiatric notes or evaluations created following the abuse. Review of physician orders revealed no evidence of new orders following the abuse, including no new orders for psychiatric evaluation. Resident #13 was admitted to the facility initially on August 9, 2024. He was later readmitted to the facility on [DATE] following a short hospital stay. His admitting diagnoses included memory deficit following cerebral infarction, major depressive disorder, and other sexual dysfunction not due to a substance or known physiological condition. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderate cognitive impairment. Review of physician orders revealed an order dated October 17, 2024, which instructed nursing staff to monitor and chart on inappropriate sexual comments. Additionally, the resident was ordered Fluoxetine HCl Capsule 40mg one time a day on October 17, 2024 for depression as evidenced by inappropriate sexual comments. Review of the care plan initiated on August 9, 2024 revealed a focus that Resident #13 had a behavior problem of grabbing female staff inappropriately and making sexual statements toward female staff. The entry, revised on December 20, 2024, included that Resident #13 touched a female peer. New interventions added on December 20, 2024 included that the resident be placed on 15-minute checks, and that the resident would be supervised by staff when in common areas. Review of the progress notes revealed that Resident #13 had multiple documented instances of inappropriate behavior towards others. A health status note dated August 11, 2024 described that during a shower, Resident #13 was grabbing the female staff in appropriate areas. The psychosocial note on August 14, 2024 revealed that the resident had been making inappropriate statements to staff and grabbed staff on the buttocks and breasts. An interview was conducted on January 3, 2025 at 12:33PM with Resident #13, who initially could not recall the incident with Resident #26. When asked if he recalled touching a resident at the Christmas party, Resident #13 stated that he remembered seeing a woman crying, so he kissed her. He denied that anything else occurred. He could not recall who the woman was. An interview was attempted with Resident #26 on January 3, 2025 at 12:48PM, but the resident was too confused to interview and was unable to be directed. An interview was conducted on January 3, 2025 at 11:08AM with a certified nursing assistant (CNA/Staff #2) who stated that he would define touching as sexual abuse. He recalls that he had heard about a sexual incident between Resident #13 and another resident but did not witness it. He stated that Resident #13 had previously shown sexual behaviors towards staff but only knew about one incident with another resident. He stated that Resident #13 now has to be supervised when in common areas, and that he has to watch television in his room now. An interview was conducted on January 3, 2025 at 11:16AM with a Licensed Practical Nurse (LPN/Staff #5) who stated she would consider sexual abuse to include verbally obscene things and touching inappropriately. When asked if any residents had shown sexually inappropriate behavior, the LPN named Resident #13, stating that she has not personally seen anything but has heard rumors that he had shown sexual behaviors toward staff. She further stated that she had heard of a sexual interaction between Resident #13 and another resident on Christmas. She explained that since this incident, Resident #13 cannot be in the dayroom alone with other female residents. An interview was conducted on January 3, 2025 at 11:35AM with the Admissions Assistant (Admin/Staff #11) who stated that during the facility Christmas party on December 20, 2024, she had been moving residents around to take pictures when she noticed that Resident #13 and Resident #26 were sat together in their wheelchairs, facing each other. She stated that she then saw that Resident #13 had his hand down Resident #26's pants. She elaborated that Resident #26 was wearing sweat pants with an elastic waistband, and that Resident #13 had his right hand down the top of the pants of Resident #26, almost to his elbow. Staff #11 further explained that she thought Resident #26 seemed to be okay with it, as she was moving her hand back and forth slowly on his arm. She was unsure how long the two residents had been in this situation, and there were no staff or family in the area to witness it. She stated that there were two residents who may have seen something, but that they were nonverbal and unable to provide a statement. Staff #11 explains that she immediately separated the residents, bringing Resident #26 into the common area, and notified her supervisors. An interview was conducted on January 3, 2025 at 12:14PM with the Director of Nursing (DON/Staff #17) who stated that she would consider unwanted touching from one resident to another to be sexual abuse. She also stated that a resident with a diagnosis of dementia would not have the capacity to consent to an intimate or sexual relationship. The DON also explained that she was informed of the incident between Resident #13 and Resident #26 by the Administrator. She explained that following the incident, both Resident #26 and Resident #13 denied that anything had occurred. She also stated that both residents are cognitively impaired and lack the capacity to consent. Additionally, the DON explained that new interventions were implemented to supervise Resident #13. When asked if Resident #13 had previously shown any sexually inappropriate behaviors, the DON responded that he had inappropriately grabbed a staff member one time only, and that the interventions described in the care plan had been effective at managing this resident's behaviors. The DON further explained that Resident #26 did not appear to be in distress following the incident, so no psychiatric evaluation or care plan revision was conducted for this resident. Review of the facility policy titled, Intimacy Between Residents / Sexual Consent, revealed that the facility will ensure residents have the capacity to consent to sexual activity, and if not, will prohibit the engagement of sexual activity with others. Review of the facility policy titled, Abuse - Prevention, revealed that it is the policy of the facility to prevent and prohibit all types of abuse. Review of the facility policy titled, Abuse - Identification of Types, revealed that it is the policy of the facility to identify abuse. This policy also defines sexual abuse as non-consensual sexual contact of any type with a resident, and gives an example of sexual abuse to be unwanted intimate touching of any kind especially of breasts or perineal area. The policy further explains that sexual contact is nonconsensual if the resident appears to want the contact to occur, but lacks the cognitive ability to consent.

Based on clinical record review, staff interviews and review of policy, the facility failed to ensure 2 residents (#45 and #22) did not sustain injuries related to preventable accidents. The facility census was 62. The deficient practice increased the risk for pain, injury and rehospitalization . Findings include: -Resident #45 admitted to the facility on [DATE] with diagnoses that included cognitive social or emotional deficit following cerebral infarction, dementia without behavioral, psychotic or mood disturbance and tachycardia. An activity of daily living (ADL) self care performance deficit care plan was initiated on 08/27/19 related to activity intolerance, contracture of right hand and bilateral foot drop, muscle weakness, knee contractures and total assistance with ADLs. The goal was for the resident to maintain her current level of function. Intervention included assisting 2 staff with full mechanical lift. The quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored 5 on the Brief Interview for Mental Status, indicating severe cognitive impairment. She required extensive to total 2-person physical assistance for most ADLs including transfers. An event note dated 05/31/23 included that at 2:50 p.m. a loud noise was heard from the resident's room. The note indicated that the resident was observed on the floor after being transferred from the Hoyer lift to her bed. According to the note, the sling was wet from a shower the resident had prior, and the Certified Nursing Assistant (CNA) was operating the Hoyer by herself with no one helping or supervising. The note included that after obtaining help to get the resident off the floor, blood was noted behind the resident's head and her head was bleeding. The note revealed the Director of Nursing (DON) and the doctor were notified and came into the resident's room to assess her. The note included that 911 and the resident's family were called. Upon re-entering the resident's room, the resident's oxygen saturation reading was at 90% and her heart rate was 177. The resident was placed on 4 liters of oxygen and at 3:05 p.m. emergency services arrived and the resident was transported to the hospital. The note indicated that the resident never lost consciousness. On 06/01/23 a health status note included that the resident had been admitted to the intensive care unit (ICU) for a head injury. Review of the hospital History and Physical dated 06/01/23 revealed the resident had been admitted to the trauma ICU in guarded condition. Per the assessment, the resident had a small right falx subdural hematoma, a small right subarachnoid hemorrhage, and a prominent soft tissue hematoma posterior to the left proximal tibia and fibula, measuring approximately 6.4 x 3.2 x 8.4 centimeters. During an interview conducted on 06/06/23 at 10:25 a.m. a Certified Nursing Assistant (CNA/staff #39) stated that she had worked in the facility for about 3 months. She stated that she had to complete computer classes and some lifting tests, to check for proper body alignment, before she could work on the floor. She stated that she did not complete skills training or check-off. She stated that she did not have training on how to use a Hoyer lift and that she did not know which sling to use for which resident. Further she stated that she just used the one in the resident's room. She stated that she would not transfer a resident by herself, but that she could not say anything for anyone else. She stated that she had not ever dropped a resident during a Hoyer transfer. At 10:37 a.m. on 06/06/23 an interview was conducted with resident #45's roommate (resident #2). She stated that she saw the resident fall from the Hoyer on 05/31/23. She stated that the CNA (staff #4) was using the Hoyer lift by herself. She said that staff #4 crossed the sling between the resident's legs before she transferred her, but somehow one of the loops slid off the hook. She stated that the first thing staff #4 did was to look at the sling. She stated that resident #45 had just come out of the shower and had been brought into the room. She stated that the sling was wet, but that both sides were hooked. She stated that resident #45 just slipped right out of it, landed on her bottom and then hit her head. She stated that she thought there were supposed to be two aides transferring the resident in the Hoyer. An interview was conducted on 06/06/23 at 11:00 a.m. with a CNA (staff #4). She stated that if they are short handed they always need to get someone to help them and work as a team. She stated that she has transferred residents by herself using a Hoyer because there was no one to help her. She stated that it was facility policy to always have two people. On 05/31/23, she stated that she was transferring resident #45 by herself. She stated that she was using a grayish, criss cross sling that crosses between the resident's legs and hooks up to the Hoyer. Regarding the incident with resident #45 she stated that she put the sling under the resident and showered her. After the shower, as she was transferring the resident back into her bed, she stated that one of the loops on the sling unpopped and the resident fell on to the floor. She stated that the resident fell on her butt then hit her head. She stated that she went to get the nurse while the resident was on the floor and after the nurse assessed her, the two of them put the resident back into bed. She stated that the doctor was in the facility at the time, so the resident was sent out right away. During the interview staff #4 demonstrated how the loop on the sling had slipped off the hook by indicating the loop had not been fully secured into the base of the hook, but was resting on top of it. She stated that the resident, sling and the Hoyer were wet and the loop had just slipped off. She stated that after the incident she met with the Director of Nursing (DON/staff #74) who told her that it was her fault because she did not have another person in the room with her when the resident fell . She stated that it was decided that she would always have two people to do a Hoyer transfer. On 06/06/23 at approximately 3:30 p.m. an interview was conducted with the DON (staff #74). She stated that her expectation was that two members of staff would assist with Hoyer lift transfers and that it did not meet her expectations for staff #4 to have transferred resident #45 by herself. The Transfer With a Mechanical Lift, Long-Term Care policy, revised May 22, 2023, included the facility will ensure that two associates should be present during the transfer of residents who require a mechanical lift, and at least one of the two associates must be over the age of 18. -Resident #22 admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral, psychotic or mood disturbance, anxiety and type 2 diabetes mellitus. An Occupational Therapy (OT) Evaluation & Plan of Treatment dated 08/12/22 included that the resident had a history of wounds and currently required maximal assistance for wheelchair positioning. According to the evaluation, formal assessment of strength was unable to be completed due to cognitive deficits and language barrier. Per the evaluation, range of motion was spastic in nature, with limitations in bilateral lower extremities and upper extremities and resident was resistant to movement. Further, the resident's neck was in a forward flexed position and her spine was kyphotic in nature. The recommendation included a Tilt in space recliner chair for optimal positioning and ease of transfers, self-feeding and overall improvement of quality of life. An ADL deficit care plan revised on 03/01/23 related to impaired balance and limited mobility due to osteoarthritis had a goal to maintain current level of function without decline in ADLs. Interventions included assistance of one to two staff for transfers. A Rehabilitation Services Multidisciplinary Screening Tool dated 05/15/23 revealed the resident had no functional level changes and that she was not appropriate for skilled therapy intervention at that time. The quarterly MDS assessment dated [DATE] did not include a brief interview for mental status. According to the assessment, the resident displayed no behaviors and she was totally dependent upon staff for ADLs with 1-person physical assistance required for bed mobility and 2+ physical assistance required for transfers. An incident report dated 06/04/23 at 1:34 p.m. included that a CNA found the resident slid down in her wheelchair with her leg bent and twisted in the wheelchair stabilizer/padding. Per the note, the CNA lifted the resident up in the wheelchair and transferred her to bed. According to the note, later in the shift the resident's sister told staff the leg was red and swollen. Nursing called the medical doctor (MD) and received an order to elevate and ice. A health status note dated 06/04/23 at 5:55 p.m. revealed the resident had edema to her left lower leg. The note indicated that the resident was placed in her bed to elevate and monitor and that the resident had no complaint of pain to the extremity, only her right hip. On 06/05/23 at 6:57 a.m. a health status note included that the resident had a swollen left leg. Per the note, the on-call was called and orders were received for two view x-rays of the tibia/fibula STAT. According to the note, a complete blood count with differential and a complete metabolic panel were also ordered STAT. Additional orders included to elevate the leg above the waist and to ice. At 10:50 a.m. on 06/05/23 a communication note included that the resident's family was notified that the resident had just been transferred to the hospital for evaluation and treatment, and that updates would be provided as information was available. On 06/05/23 at 1:17 p.m. an event note included the CNA who cared for the resident on 06/04/23 reported that the resident had slid down in her wheelchair, the CAN also reported that the resident's leg was bent and twisted in the wheelchair leg rest/support cushion. Per the note, the CNA then assisted the resident up into her wheelchair and back into bed. She stated the resident did not seem to be in pain at the time of the incident. An interview was conducted on 06/16/23 at 9:10 a.m. with a CNA (staff #43). She stated that on 06/04/23 she was just coming back from lunch and saw the resident sitting in her chair in the dining room, just getting done eating. She stated that she noticed that the resident was sliding down out of her chair, so she pulled her up. She stated that she stood behind the chair, put her arms under the resident's armpits and pulled her up as she normally would. She stated that the resident's feet looked fine before she pulled her up in the chair. She stated that the resident's feet did not touch the foot pedals because her legs were contracted up. She stated that the resident could not straighten out her legs at all. She stated that the resident's wheelchair was standard, with the sitting position as normally would be. She stated that she did not know whether the resident's leg or foot had been caught and she did not know what or when it happened because the resident did not make any noise when she was pulled up. She stated that it could have happened when she put the resident back into bed. She stated that depending upon the CNA, the resident may or may not be a 2-person assist. She stated that the resident usually makes noises whenever any type of care is provided. She stated that the resident did not make any noise to indicate she had been hurt when the resident was pulled up in the chair or when she was helped back into bed. At 10:26 a.m. on 06/16/23 a phone call was made to the resident's family member. She stated that when she visited the resident on 06/03/23, the resident was ok. On Sunday, 06/04/23, she stated that she went in around 3:00 p.m. to see the resident. She stated that the resident was in bed and that staff told her the resident had laid down after lunch. She stated that she asked the staff to help the resident get out of bed so that she could eat her dinner. She stated that the resident was crying, and found that the resident's left leg was really swollen. She stated that she asked the resident if she had fallen and the resident told her no. She stated that she reported the swelling to the CNA and the nurse. She stated that the swelling was about 3-4 inches above the resident's ankle, in the middle of her leg and that it was really red and swollen and it looked like it would explode. She stated that she told the nurse that she wanted to have the leg x-rayed and that the nurse told her to wait until the following day when the doctor could see her. She stated that the following day, the resident was sent to the hospital for x-rays and the results were 2 fractures in the left lower leg. She stated that the resident had to have surgery and the surgeon placed 2 screws in the leg. She stated the resident was in the hospital for 4-5 days and that she did not want her to come back to this facility. On 06/16/23 at 11:16 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #12) who stated that the resident did not speak English, nodded yes or no and that pain evaluations were conducted based upon facial grimacing. She demonstrated that the resident normally kept her arms drawn into her body tightly, with her hands up into her neck and that the resident had always kept her knees drawn up, in a fetal-like position. She stated that the resident sat up in her wheelchair for meals and that she received assistance with feeding. She stated that the resident's feet did not normally hang down, so staff raised the foot rests up and placed a cushion onto the two bars that hold the foot rests. The LPN stated the cushion was pretty firm and that it had indentations for each of her legs. She demonstrated that the resident's legs were usually positioned in a 45 degree angle. She stated that the resident was a 2-person total assist for transfers and had no lower extremity strength. She stated she could not say how the resident slid down in her chair because of the cushion. She stated that on the afternoon of 06/04/23, the resident's legs were dangling down and there was no cushion. She stated that the resident was not crying. She stated that she asked the CNA to place the resident back into her bed so that she could see the resident's leg. She stated that she did see some edema in the leg, but it was not pitting. She stated there was no redness or discoloration. She said that when she palpated the resident's leg, the resident did not grimace or make any noise. She said she thought that maybe the swelling was from having her legs dangling. She stated that she called the CNA (staff #43) into the room and asked her if she knew anything about the resident's leg or whether anything had happened to the resident that day. She stated that staff #43 put her hands on her hips, looked at the resident's leg and said no, she did not know anything. She stated that later, she found out that staff #43 did know something about the resident's leg. Staff #12 stated that when she came in the following morning, the resident's leg was purple and very swollen. She stated that she and the night nurse reached out to the DON and the provider and she was directed to send the resident out for an x-ray. She stated that later that day, she received a call from a nurse at the hospital who told her that the bone in the residents left lower leg was shattered. She stated she called the DON and told her what the nurse had said and about a day later, an officer came and asked her questions about the resident's injury. She stated that it was at that point that staff #43 finally said something about what may have happened. She stated that this resident should never have been positioned by one person from behind because she was so contracted and frail. She stated that the resident actually required two persons to reposition her in the chair, each person holding her under an arm and knee. During an interview conducted on 06/16/23 at 12:14 p.m. the DON (staff #74) stated that resident #22 was not contracted. She stated that per the last OT evaluation, the resident range of motion was spastic in nature, and included limitations in bilateral lower and upper extremities. She stated that according to the assessment, the resident required maximal assistance with wheelchair positioning; and that maximal assistance meant that the person assisting was doing at least 50% of the work. She stated that the resident could help a little bit during repositioning, but that the staff member was doing most of the work. She stated that the resident was sitting in her old wheelchair on the date of the incident because she liked it better. She stated that one person could reposition her in the chair by pulling back on the blanket the resident sits on. However, she stated that if it had been her she would have gotten another person to assist her. She stated that staff #43 had told her that staff #43 thought the resident was going to fall out of her chair and that was why she got behind the chair and pulled the resident up quickly. Staff #74 stated that it was never appropriate to pull a resident up in her chair like that without looking at her feet prior. She stated that staff #43 told her that the resident was on the edge of her chair and that she quickly came and pulled her back, and then afterward she laid the resident back in bed and that she thought everything was fine. She stated that she told staff #43 that moving forward, she had to report any little missed fall because the resident's little bones could break, and that if anything happened out of the norm to let people know. She stated that she did not remember whether or not she educated the CNA on repositioning residents in their wheelchairs at that time, but that later she had an in-service where she talked about body mechanics and repositioning. She stated that she did not know the extent of resident #22's injury, only that the leg was fractured. She stated that staff #43 should have definitely mentioned that the resident had a near fall in the room and that she had hurriedly pulled her up in her chair. In addition, she stated that staff #43 had told her that the incident happened in the resident's room not the dining room. The Body Mechanics and Resident Care Activities policy, reviewed 09/12/22, included that associates will utilize correct body mechanics to prevent undue strain and possible injury to themselves or the residents with whom they care for. For repositioning in a chair, instructions included to not push on [the resident ' s] knees without friction reduction or manually lift the resident up in a chair. The Limited Lift Program (Safe Patient Handling) policy, revised 08/22/22, included the purpose was to establish protocols that will provide the safest possible methods to lift, transfer or reposition residents. The facility will assess the residents' need for assistance with transfers activities, mobility or repositioning utilizing a validated mobility assessment by either nursing or therapy. Associates will be responsible for utilizing mechanical lift devices, transferring devices, proper body mechanics to lift, transfer, and/or pivot non-ambulatory residents as indicated.

Based on observations, clinical record reviews, staff and resident interviews and policy and procedures, the facility failed to implement their non smoking policy and failed to ensure two residents (#35 and #62) who were assessed to be unsafe to smoke independently were provided supervision while smoking. The facility also failed to ensure that safety equipment was in place in the areas where the residents smoked outside. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Findings include: On January 23, 2017 at 1:44 p.m., the Condition of Immediate Jeopardy (IJ) and SQC were identified. The Administrator (staff #135) was informed of the facility's failure to ensure that supervision was provided for two residents who were assessed to be unsafe to smoke independently, and that smoking materials were being kept by the residents. In addition, there was no safety equipment in place in the areas where the residents smoked outside. The Administrator presented a plan of correction on January 23, 2017 at 3:58 p.m. The Administrator was informed that the plan of correction did not include all of the components to ensure resident safety. The Administrator presented another plan of correction on January 23, 2017 at 5:25 p.m., and was returned for additional information. At 6:34 p.m., a revised plan of correction was presented and was accepted. Multiple observations of the facility implementing their plan of correction were conducted on January 23 and 24, 2018, which included implementation of their non smoking policy, there were no observations of residents smoking, verification that residents did not have possession of any smoking materials, documentation of staff in-services, and staff interviewed were knowledgeable of the non smoking policy. As a result, the condition of Immediate Jeopardy was abated on January 24, 2017 at 9:42 a.m. -Resident #62 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission assessment dated [DATE], included the resident denied tobacco use. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. The MDS included the resident had upper and lower extremity impairment on both sides, and was totally dependent on staff for eating and required extensive assistance with personal hygiene. The MDS also included the resident did not currently use tobacco. A physician's progress note dated October 5, 2017 included the resident had minimal movement of his upper extremities, related to a [DIAGNOSES REDACTED]. Review of the Resident Admission Agreement which was signed by the resident on October 10, 2017, revealed documentation that the facility was a non smoking facility. By signing the admission agreement, the resident acknowledged that he was legally bound by this agreement. In Section 10: Rules and Regulations the following was included: The Resident/Representative understands and agrees that the Resident will refrain from smoking while in the Facility except in designated smoking areas, if any. In addition, the Resident may only smoke if this action does not threaten the health or welfare of others as defined by individual facility policy. The agreement further included, The Resident/Representative understands and agrees that smoking is never permitted in Resident rooms nor any other areas not specifically designated as a smoking permitted area of the Facility. The Resident/Representative also understands and agrees that the Facility may impose additional smoking procedures and/or restrictions to protect the health and safety of Residents and others or as required by law. The facility did not have any designated smoking areas. A nursing progress note dated October 10, 2017 included that on October 9, a resident's family member requested to have the resident's oxygen removed, so the resident could go across the street to smoke a cigar. The note included that the resident's family member was educated on the non smoking policy. The resident was noted to be out of the facility for approximately 30 minutes without oxygen. His oxygen level was obtained upon return to the facility and it was 83% (per the nursing progress notes the resident's oxygen levels were usually between 93-97%). A nursing progress note dated October 25, 2017, revealed the resident was outside of the facility in his power chair and fell on the side walk and no injury was sustained, and that the resident will continue to be monitored. A rehabilitation services post fall screening tool dated October 25, 2017, revealed the resident had a fall off property. The resident was across the street in his power wheelchair smoking. The resident appears to have fallen out of the wheelchair to the ground. No change in status was reported. Per the note, the resident was non-compliant. Review of a nursing progress note dated October 29, 2017 revealed the resident was non compliant with informing staff when leaving the facility. A smoking care plan dated December 13, 2017 included that the resident wishes to smoke and was non compliant with the facility's non smoking policy. Interventions included the resident was to ask for smoking materials which the facility would store and dispense, the resident will utilize a smoking apron, the resident will smoke off grounds, and will utilize a log to sign in and out, when going off site to smoke. Review of a document dated December 13, 2017, which was located in the resident's clinical record stated, This document serves as a risk agreement for resident .Resident chooses to ignore medical advice and engage in tobacco use while he is a resident . The facility is a non smoking facility and the resident has been offered and encouraged by facility staff to transfer to a facility that allows smoking. Resident declines to transfer and chooses to remain. In addition, he accepts that smoking is not allowed on the premises and he will have to leave facility grounds on his own accord in order to smoke off of the property. He has obtained an order from the physician to leave facility grounds. To minimize the risk for harm the resident agrees to abide by the following procedures when he chooses to smoke: 1. Resident must sign himself out when he leaves and back in when he returns. 2. Resident cannot smoke while using oxygen and will leave his oxygen tank at the facility. 3. Resident's vitals will be taken before he leaves grounds to assure he is in stable medical condition. 4. Resident will wear a smoking apron when he leaves the grounds for the purpose of smoking. The document further included, I (resident #62) understand the above mentioned procedures and assume full responsibility for the risks and liability associated with choosing to go off facility grounds to smoke. I understand that I am not allowed to smoke on facility property. I know that I am able to transfer to another location that allows smoking on their premise, but I choose not to. I understand that smoking is not encouraged by my physician and other medical providers .I understand that I expose myself to avoidable risks by leaving the facility grounds to smoke and accept the possible consequences associated with this behavior. The document was signed by the resident, the social worker, an Licensed Practical Nurse (LPN) the Executive Director, and the Long Term Care Case Manager. Review of a smoking safety assessment dated [DATE], identified the resident exhibited poor safety awareness when smoking, and that interventions must be placed to promote safe smoking. The assessment included the resident was able to self-extinguish cigarettes. However, the assessment also included the resident fails to properly utilize an ashtray, the resident drops ashes on self, the resident attempts to keep smoking paraphernalia on self or in room, the resident has [MEDICAL CONDITION] self or clothing related to cigarette smoking, and the resident is non compliant with smoking regulations in the facility. The documentation included that this assessment was to be completed for all residents who smoke, to determine any potential safety risks upon admission, quarterly and upon a significant change in the resident's status. This assessment was not signed by anyone. A nursing progress note dated December 31, 2017 stated the resident continues to go outside to smoke, with a smoking apron on. The note included the resident went outside to smoke at 12:50 p.m., and at 1:45 p.m., the resident was found leaning too far to the right side, almost falling out of the power chair. The resident was able to be repositioned and was then accompanied back into the facility. The note indicated the resident was educated about the risks of smoking and smoking alone, and his inability to straighten himself in the power chair. Review of a rehabilitation services post fall screening tool dated December 31, 2018, revealed the resident had a fall out of power chair outside the facility near a shed. An environmental factor listed as contributing to the fall was leaning out of chair. Interventions included that the resident was educated in maneuvering on sidewalk and staying close to staff support when smoking. The note also included a recommendation that the resident should ask staff for repositioning assistance throughout the day. A quarterly MDS assessment dated [DATE] included the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS included the resident had upper and lower extremity impairment on both sides, and required extensive assistance with eating and was total dependent on staff with personal hygiene. A nursing progress note dated January 5, 2018 included the resident still continues to smoke outside of the facility, and that this was a smoke free facility. The nurse informed the resident of the risks of smoking, precautions and using an apron to ensure safety and understanding of risks. A nursing progress note dated January 7, 2018, included the resident continues to smoke even though this is a smoke free facility. Informed patient of the risks, remove O2 whenever patient leaves to smoke and place apron. An observation was conducted on January 23, 2018 at 11:50 a.m., of resident #62 outside of the facility on a sidewalk, which was next to the parking lot. Resident #62 was observed smoking a cigar in his power chair and there were no staff present. The resident was wearing a smoking apron and was holding a cigar in his left hand. The resident was not wearing any oxygen at this time. The resident was positioned upright in the power chair and was able to move his arm up and down to smoke the cigar. During this observation, the resident stated that he comes out to smoke maybe twice a day and staff are not present. The resident stated he is able to light his own cigar and keeps his smoking materials with him, which includes cigars and a lighter. He stated that when he is ready to go out to smoke, he lets the staff know and they take off his oxygen and give him the smoking apron. While speaking with the resident, it was observed that ashes were accumulating on the end of the cigar (about an inch in length), and the resident then inadvertently brushed the ashes on to the smoking apron and the ashes fell on to the ground. Additional observations were conducted at this time and there was no safety equipment (i.e. fire extinguisher, fire blanket, ash container) in the area where the resident was smoking. Review of the sign out log for resident #62 revealed sections to document the date, the time out/in, oxygen was off, vitals were taken, smoking apron, resident informed of risk, resident signature/initials, and staff initials. Review of the log revealed the resident was signed out anywhere from one to four times a day between December 13, 2017, through January 23, 2018. An interview with a LPN (Licensed Practical Nurse/staff #70) was conducted on January 23, 2018 at 1:28 p.m. She stated resident #62 keeps his smoking material with him in a bag and that he is able to light his own cigarette. She stated the resident has to have his vitals taken and has to get a smoking apron from the staff, before signing himself out to smoke. Staff #70 stated that the resident tells them when he goes out to smoke and staff sign him out on his smoking log. In an interview with the Social Services Director (staff #109) on January 26, 2018 at 12:52 p.m., she stated the resident did not indicate he was a smoker until he was switched from skilled care to long term care. She stated when the facility found out about his smoking habit, an attempt was made to keep the resident safe when he is off grounds smoking. Further, she stated the resident was offered help to transfer to a facility which allows smoking, but the resident declined. In an interview with the Executive Director (staff #135) on January 26, 2018 at 1:32 p.m., he stated that he thought the facility was doing the right thing by protecting the resident while he was smoking. He stated the facility put things in place to try and keep the resident safe, such as giving him a smoking apron, so he would not burn himself. -Resident #35 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission nursing progress note dated December 2, 2017 included the resident wanted to go out and smoke, as soon as he arrived at the facility. Per the note, the nursing staff explained that they were a non smoking facility, thus he would not be allowed to go outside and smoke. The note further included that the resident was non compliant with signing the admission papers. According to a social services note dated December 7, 2017, the resident was a smoker and was aware prior to his arrival that they were a non smoking facility, and that he would be unable to smoke. The resident was offered a Nicotine patch which he refused. The note further included the resident continues to display poor insight into deficits in physical strength and functional ability. Review of a social service addendum note dated December 7, 2017 revealed that staff provided extensive and frequent redirection and education regarding their non smoking policy. A MDS assessment dated [DATE] included the resident had a BIMS score of 14, which indicated the resident was cognitively intact. The MDS further included the resident required two person assistance for transfers and required supervision with locomotion off of the unit. A physician's orders [REDACTED]. A smoking safety assessment was completed on December 29, 2017, which indicated that the resident attempts to keep smoking paraphernalia on his self or in his room, and that the resident was not safe to smoke, without supervision. A care plan dated December 29, 2017 included the resident wishes to smoke and was non compliant with the non smoking policy. A goal included that the resident would remain safe while smoking off the facility grounds. Under approaches it stated to provide the resident with the following while smoking: resident will utilize a smoking apron and smoke off of facility grounds, resident will allow facility staff to store and dispense smoking paraphernalia and ask for smoking materials, and resident will sign himself in an out when going outside to smoke. Review of a log that the facility had developed to track when resident #35 went out on pass to smoke revealed the resident had signed himself out and left the facility twenty three times between December 30, 2017 and January 23, 2018, and had consistently refused a smoking apron. An interview was conducted on January 23, 2018 at 12:06 p.m., with resident #35. He stated that he is a one pack per day smoker for the past twenty years. The resident stated that he was assessed to be allowed to smoke, and goes off the property on the sidewalk to smoke, unescorted in an electric wheelchair. He also stated that he is allowed to keep a lighter and cigarettes in a pouch with him. An observation of the resident was conducted on January 23, 2018 at 2:10 p.m. At this time, a small burn hole on the cuff of the resident's left sleeve was visible. The resident stated it was an old burn hole from home. The resident's smoking paraphernalia was visible and was stored in a lap pouch. Following the identification of IJ, another smoking assessment was completed on January 23, 2018 for resident #35. The assessment included that the resident had not demonstrated the ability to smoke safely, due to the resident failing to utilize ashtrays, dropping ashes on self, keeps smoking paraphernalia on his self or in his room, and has [MEDICAL CONDITION] self or clothing related to cigarette smoking. An interview with a RN (Registered Nurse/staff #90) was conducted on January 23, 2018 at 1:55 p.m. She stated the resident was non compliant with smoking restrictions. She stated he has a physicians order to go out on pass and will often leave to go out to smoke cigarettes. She stated there is a special sign out book for him to sign out and sign in when he returns. She stated the resident has refused to wear a smoking apron when he smokes. Review of the facility's non smoking policy revealed that smoking is not allowed at any time, inside or outside of the building or on the property by residents, staff or visitors. Residents, families and/or responsible parties will be provided information on the facility's non smoking policy upon admission, and as indicated thereafter. All staff will be provided education on the facility's smoking policy during orientation and as indicated thereafter. Upon identification of a resident's non compliance to the smoking policy, the resident's physician, family, or responsible party will be notified. In the event that the resident continues to be non compliant, with the smoking policy, the facility will notify the resident, family and/or responsible party of potential discharge, due to the potential for harm of self and/or others. Upon identification of smoking non compliance, by the resident, family or visitors, staff will intervene immediately, providing instruction on the facility's non smoking policy. In the event of ongoing non compliance by the resident, family or visitors, the facility will consider supervised visitation and/or revocation of visiting privileges. Any and all smoking paraphernalia will be confiscated by the facility and stored until discharge.

Based on observations, staff interviews, review of the facility policies and procedures, and documentation from the Centers for Disease Control (CDC), the facility failed to maintain an effective infection control program, which provided a safe and sanitary environment, in order to help prevent the development and transmission of disease and infection. As a result, the Condition of Immediate Jeopardy (IJ) was identified. Findings include: On September 16, 2014, at 4:25 p.m., the condition of immediate jeopardy was identified. The administrator and director of nursing (DON) were informed of the facility's failure to implement infection control precautions for one resident (#377), who was on contact precautions for Clostridium difficile (C.diff.). Observations were conducted of resident #377, who was observed in the RNA dining room, without gown or gloves, and was also observed returning from physical therapy, also without gown and gloves. Staff did not ensure the resident was following proper precautions to protect other residents and staff. Staff were also observed going in and out of the resident's room, without wearing gowns and/or gloves. The administrator presented a plan of correction on September 16, 2014 at 6:20 p.m. The administrator was informed that the corrective plan did not need to include the residents with C.diff be confined to their room, so an alternate plan was presented and accepted at 6:25 p.m. Multiple observations were conducted of the facility implementing their plan of correction, which included in-services regarding infection control and contact precautions for[DIAGNOSES REDACTED], and observations of staff implementing contact precautions. The condition of immediate jeopardy was abated on September 17, 2014 at 1:05 p.m. -Resident #377 was admitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The laboratory results reported dated September 9, 2014, included that the resident was positive for [DIAGNOSES REDACTED]icile Toxin A and B. An order was obtained for [MEDICATION NAME] (antibiotic) 500 milligrams orally every 8 hours for 14 days was ordered for the resident. Nurses' notes dated September 10, 2014 included the resident needed extensive assistance with activities of daily living. Nurses' notes dated September 15, 2014 included the resident had poor safety awareness. Review of the Seven Day Look Back report for Bowel elimination, included documentation that the resident had been having from 2 to 5 stools a day from September 9 to September 16, 2014. A care plan for[DIAGNOSES REDACTED] dated September 5 and revised on September 9th, included that the resident was incontinent of bowel and bladder and was cognitively impaired. On September 16, 2014, a sign was observed outside of the resident's room that stated to see the nurse before entering the room. There was a card on the cart outside of the resident's room, indicating the resident was on Contact Precautions. The Precautions listed included: Limit transport and movement of patients outside of the room to medically-necessary purposes. When transport or movement in any health care setting is necessary, ensure that infected or colonized areas of the patient's body are contained and covered. During an interview conducted on September 16, 2014 at 1:20 p.m., a License Practical Nurse (LPN) stated that the resident was on contact precautions for[DIAGNOSES REDACTED]. At 11:15 a.m. on September 16, 2014 an observation was made of the resident in the Restorative Dining Room having lunch with other residents with no gloves or gown donned. On September 16, 2014 at 3:15 p.m. the resident was observed in the hallway in his wheelchair without gloves or gown donned. Staff stated the resident had been at therapy. During an interview conducted on September 16, 2014 at 3:45 p.m., the DON stated as long as staff do not come in contact with the stool, staff do not need to don gown or gloves to go into the resident's room. She stated as long as the stool is contained and the resident wore a brief, the resident is allowed out of his room. On September 16, 2014 at 4:30 p.m., a LPN stated unless an individual come in contact with the stool, there would be no need to don gloves or a gown. She further stated this resident comes out of his room for meals in the dining room and for therapy. A Certified Nursing Assistant (CNA) was observed coming out of the resident's room on September 16, 2014 at 4:35 p.m. with a rolling blood pressure machine. She stated she had cleaned the resident of loose stool 15 minutes ago and that she was going to the medication cart to obtain the Sani Clothes (used to kill[DIAGNOSES REDACTED]) to sanitize the blood pressure machine. On the same day, a CNA was observed to remove the resident's dinner tray out of his room and place the tray on top of the cart. At 8:30 p.m. on September 19, 2014, the Director of Therapy Services stated the resident had been coming to the therapy department for therapy. He stated since September 16, the resident has been receiving therapy in his room. The facility's policy on Contact Precautions included that contact precautions will be used during care and treatment of [REDACTED]. Personal protective equipment (PPE) such as gowns and gloves should be worn during procedures and resident care activities. The gown and gloves should be discarded in the appropriate trash container. Good hand washing should be conducted before leaving the resident's room. The policy stated to limit the transport of the resident out of their room to essential purposes only and during transport ensure precautions are maintained to minimize risk of transmission of organisms. Review of the 2007 Centers for Disease Control and Prevention (CDC) guidelines regarding[DIAGNOSES REDACTED] revealed that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands who have touched a contaminate surface or item. For the prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, it stated to use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines also stated to use gloves and gowns when entering patients' room and during care and for all interactions that involve contact with the patient or potentially contaminated areas in the residents environment. In addition, the CDC guidelines included that[DIAGNOSES REDACTED] infected residents continue to shed organisms for a number of days following the cessation of diarrhea. The guidelines stated to implement an environmental and disinfection strategy to ensure the adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. - Resident #387 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On admission there was no documented evidence that the resident was diagnosed with [REDACTED]. A nurse's progress note dated January 27, 2014 at 2:55 a.m. stated, "Pt (patient) was noted to have loose stool, sample sent to the lab, pending results per day nurse. Pt continues to have diarrhea per night CNA (certified nursing assistant) will notify day nurse to follow up with stool sample results." Review of the resident's clinical record revealed a laboratory result dated January 27, 2014 of a stool sample dated January 26, 2014 that indicated the stool sample tested was positive for[DIAGNOSES REDACTED]. Review of the physician's telephone orders dated January 27, 2014 revealed an order for [REDACTED]. Review of the facility's Infection Control Tracking log revealed no tracking of the resident's[DIAGNOSES REDACTED] infection that started on January 27th. It was not captured on the tracking log. During an interview conducted on September 22, 2014, the Director of Nurses stated that she was responsible for tracking infections in the building and that the resident's[DIAGNOSES REDACTED] was missed and not put on the log. She further stated that it is the facility's policy that she does not chart it is a facility caused infection unless the resident has been in the facility for thirty days.

Based on clinical record review, review of facility documentation, review of hospital documentation, observations, staff interviews, and review of the facility policy and procedure, the facility failed to ensure that safety measures were in place for fall prevention for two residents (#389 and #5). Findings include: -Resident #389 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fall risk evaluation revealed that the resident was assessed for fall risk each quarter. On April 23, 2013, the resident scored a 12 on the assessment which indicated that she was at a higher risk for falls. Interventions included having her call light within reach and having her bed in the low position. Further review of the fall risk evaluation revealed that the resident was reevaluated on July 16, 2013, and her score remained at 12 indicating that the resident continued to be at a higher risk for falls. No further interventions were noted on this assessment. Review of the resident's care plan dated July 26, 2013 revealed that the resident was considered to be at risk for fall. There were many interventions in this care plan including that the resident's bed was to be in the low position when staff were not providing care and that the resident should have half side rails for mobility. Review of the nursing notes dated September 23, 2013, revealed that at 5:45 a.m., the resident was observed to be found hanging out of the bed by a certified nursing assistant (CNA). The CNA obtained assistance and the resident was placed back into bed. The resident was unable to communicate what had happened. Nursing notes documented that at 7:45 a.m., the resident began complaining of left leg pain and an X-ray was ordered. The X-ray did not reveal any broken bones. Due to complaints of pain, another X-ray was ordered by the physician on September 23, 2013 of the resident's left hip, femur, and knee. This X-ray revealed that the resident's left femur had a spiral fracture. The physician ordered the resident sent to the emergency room for evaluation and treatment of [REDACTED]. Review of the hospital records revealed that the resident required surgery for [REDACTED]. The X-ray of this fracture indicated that it was a comminuted fracture (the bone had been broken apart) and that the resident's leg had osteoporosis (weakened bones). Following the fall, the facility conducted an investigation. This investigation included a statement from the CNA who found the resident. In her statement she stated the resident's roommate had put on her call light. When answering the call light, she saw resident #389 sliding out of her bed while holding onto the side rail on the edge of the bed. The CNA lowered the bed to the floor so that the resident was in a somewhat sitting position with her legs bent. The CNA then obtained help from a nurse to help assist the resident back into bed. The CNA stated that she had seen the resident around 40-55 minutes prior to the fall and at that time, the resident was comfortable in bed. Continued review of the investigation revealed a licensed practical nurse (LPN) stated that the CNA had come to her for assistance. The resident was on the floor with her left side against the bed. The LPN stated the resident was holding onto her side rail with her left hand and was on her buttock with both her legs bent to the right side. She stated she performed a complete assessment of the resident and that the resident denied pain. The LPN statement included the resident's vitals were within normal limits and that the resident was assisted back to bed. A second CNA gave a statement in which she stated that she came on shift at 6:30 a.m. and did not receive report from the night shift. She got the Sara lift and went to the resident's room to get her up for breakfast. She observed that the resident was not her usual self and that she did not respond when spoken to. As the CNA began to dress her, the resident complained but would not say what was wrong. The CNA assisted her up and realized that she was not standing on her own, so the CNA put her back into her chair. The resident's roommate told the CNA about the fall. The investigation concluded that it was unclear how the resident moved into the awkward position of sliding off the bed. It included the resident did not have any history of fall or non-compliance with transfers, that the resident had been using her call light for assistance when she wanted to get out of bed. According to the investigation the resident was noted to have a history of seizures and it was thought that it was possible that she had a seizure, but this was unknown. The investigation included that it was possible that the resident suffered the bilateral femur fractures when the bed was lowered to the floor and her extremities became unaligned. It was further documented that the CNA encountered a situation that required her to intervene and prevent the resident from having a traumatic fall to the ground. The investigation concluded that this was a non-malicious incident with good intent and was considered to be an unfortunate accident. After the fall, the fall risk evaluation was completed again and this time, the resident scored 14 indicating continued high risk for falls. Again the interventions included to have the bed in the low position. Review of the resident's care plan revealed that on September 24, 2014, the care plan was updated to encourage the resident to keep the bed low as she prefers the bed in the high, unsafe position and to report refusals. Review of the clinical record revealed no evidence that the resident was non-compliant with the low bed prior to the fall. In an interview with the director of nursing (DON) at 7:45 a.m. on September 18, 2014, she stated that this incident was unfortunate in nature and a bit different so she conducted an investigation regarding it. She determined that the CNA found the resident hanging off the bed and felt that the resident could fall off at any moment possibly injuring her head, so she moved fast to lower the resident's bed to the floor causing the resident's legs to be in a weird angle to her body. She believes this caused the fractures. She stated the resident's bed was not in the lowest position at the time of the fall because the resident preferred the bed not in the lowest position. She said that after the fall, the resident was comfortable until staff got her up for the day. She said at this point, the resident complained of pain and was rubbing her lower leg and that is why the first X-ray was of her lower leg. She stated the nurse practitioner then saw her and realized that it was likely her upper leg that was the problem. That is when the second X-ray was done and the fracture of the femur was found. During an interview with a LPN at 8:20 a.m. on September 18, 2014, she stated she was summoned to the room after the resident was lowered to the floor by the CNA. She stated the position that the resident was in was awkward and did not look comfortable. The assessment of the resident did not reveal any issues. She was not able to recall if the resident normally had her bed in the low position or not. In an interview with a CNA at 8:35 a.m. on September 18, 2014, she stated the resident was considered to be a fall risk. She further stated that when the resident was in the bed, the bed was in the low position to help prevent falls. She stated that the resident had control of her bed and could raise or lower it, but she did not recall the resident ever doing that. She did not recall the resident ever wanting her bed to be higher than the low position. An interview was conducted with an LPN at 9:00 a.m. on September 18, 2014. She remembered the resident was a fall risk. She stated that the resident's bed was lowered to prevent injury if she fell out of bed. She did not recall whether the resident liked the bed in a normal or high position. In an interview with a CNA at 9:00 a.m. on September 18, 2014, she stated that she was caring for this resident the night that the incident occurred. She stated the resident was a fall risk, but had not tried to get out of bed on her shift during the year or so that she worked with her. When she found the resident, she was in a really awkward position in the bed with the bottom part of her body hanging off the bed with her feet touching the floor. The bedside table had been knocked over. She was unable to lift the resident by herself, so she lowered the bed and got help from the nurse to put the resident back into bed. She stated that the bed was not in the high position, but was not in the low position either and that the resident had preferred her bed to be this way as she would get upset if her bed was in the low position. She stated that the resident had the controls of her bed and would adjust the angle of the head of the bed, but she never saw her adjusting the height of the bed, instead staff would do this for the resident. She stated that this incident was completely unlike the resident in that she did not try to get out of bed normally. When she lowered the resident's bed to the floor, the resident's knees were to the left, this position did not seem awkward for the resident, but instead the position she found the resident in was the awkward position. -Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fall risk evaluation revealed that the resident was assessed for fall risk on admission and quarterly thereafter. The resident scored 10 or more which, as indicated on the form, anything 10 or above is considered to be at higher risk for falls. On July 8, 2014, the resident scored a 24 on the fall risk evaluation. The resident's care plan dated July 31, 2014 revealed that the resident was noted to be at risk for fall related to injury. The goal was to have his risk of injury due to falls be minimized by using fall interventions. The interventions included that the resident was have a low bed. Review of the nursing notes showed that on August 16, 2014 at 2:10 a.m. in the morning, the resident was found by a certified nursing assistant (CNA) to be on the floor beside his bed holding onto his bed control. The fall risk assessment was updated after the resident's fall. The resident was noted to score of 24 on the assessment which indicated that he continued to be at higher risk for falls. The interventions noted on this assessment were the call light, a bed alarm, and a physical therapy screen, among other interventions. Following the fall, the interdisciplinary team (IDT) completed an incident report which revealed the details of the fall. It was determined that future interventions would be put into place which included the use of a bed alarm and the continued use of previous interventions. A nursing note dated August 22, 2014 stated that the resident required a bed alarm, a low bed, and call light education. This note indicated that the plan of care had been updated with these changes. Review of the clinical record revealed no evidence that the alarm had been implemented. Several observations were made of the resident including two on September 22, 2014, one at 11:15 a.m., another at 12:45 p.m. in which the resident was in bed but did not have a bed alarm in place. A third observation of the resident at 7:45 a.m. on September 23, 2014, the resident continued to be resting in bed without a bed alarm. A CNA was brought into the room and she could not locate the bed alarm. In an interview with a CNA at 7:45 a.m. on September 23, 2014, she said that the resident is considered a fall risk. She said that even though he is considered a fall risk, he does not get out of bed very often but that she used a bed alarm on the resident in case he does try to get up. An interview was conducted with the director of nursing (DON) at 1:20 p.m. on September 23, 2014 in which she said that the IDT team meets daily and reviews all the incidents in the facility including the falls. She said that the team discusses the situation around the fall and then determines which interventions, if any, should be implemented in hopes to prevent future occurrences. She said that these interventions are then implemented and the care plan is updated to reflect these interventions. She said that in regards to this resident and this situation, it is possible that because he was sent to the hospital for a blood transfusion after his fall, the intervention was likely not implemented or added to the care plan. Review of the facility's policy and procedure related to falls management revealed that each resident is assessed throughout the course of treatment for [REDACTED]. An interdisciplinary plan of care will be developed, implemented, reviewed and updated as necessary to reflect the resident's current safety needs and fall reduction interventions. The policy further included that the interdisciplinary team will determine the need for any additional resident specific interventions that need to be implemented to reduce the risk of recurrence and each resident's care plan is updated to reflect the fall reduction interventions.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to assess one resident's skin, (#379) as per physician's orders [REDACTED].#123) pressure ulcer treatments were provided, as per physician's orders [REDACTED]. Findings include: Resident #379 was admitted to the facility August 29, 2014 with [DIAGNOSES REDACTED]. Review of the admission nursing progress note dated the same day, revealed the resident was admitted with an abduction brace to the right hip. The initial data collection tool dated August 29, 2014, included that the resident had a right hip surgical incision and an open lesion on the resident's right heel. There were no additional blisters or pressure ulcers noted. The resident's physician orders [REDACTED]. Review of the treatment administration record (TAR) revealed that the order had been transcribed and included areas for both the day shift and the night shift to document that the skin check had been completed. There were staff initials for both day and night shifts beginning September 1 through September 4, 2014. Further review of both the electronic and traditional medical record, including progress notes and skin check sheets, did not include any documentation of the resident's skin condition under the brace. There were no notes documented on the back of the TAR. A progress note, by the facility's wound nurse dated September 5, 2014 at 2:30 p.m. included that she had been asked by the nursing staff to evaluate a wound on the resident's left upper back, where the top part of the brace came in contact with the resident's skin. The note described a wound that was unable to be staged due to slough covering it, with "purple" just below it. During an interview conducted September 24, 2014, one of the nurses who had worked with the resident described the top part of the brace as hard plastic, and stated that the skin check was difficult to do because the resident was wearing clothes under the brace, and that it fit tightly. She stated that she worked with the resident for one shift, on Labor day, and at that time the skin was intact. She stated that the order to check the skin under the brace was made in an effort to prevent a pressure ulcer. An interview was conducted on September 24, 2014, with a nurse who cared for the resident. She was unable to remember the status of the resident's skin, but stated the order to check the skin under the brace was to prevent a pressure sore. Another interview was conducted on September 24, 2014, with a nurse who had also worked with the resident; all he could remember was that he was told the resident required frequent repositioning. During an interview conducted on September 24, 2014, the wound nurse stated that she could not explain why the other nurses did not document their skin checks, but that they were probably charting "by exception"; without a note, the skin was likely "normal". She acknowledged the lack of any documentation related to the condition of the skin under the brace, but would not reply when asked about four days of both shifts with staff initials indicating "normal" skin followed by her note of an unstageable pressure ulcer the next shift. She repeatedly attempted to explain the wound was caused due to the brace that could not be removed, but would not respond to questions related to repositioning or loosening the brace, instead of removing it. She stated that it would be reasonable to expect that if staff could not adequately do the skin check within the restrictions of the brace, then communication with the charge nurse, herself, or the physician would be expected, in order to fully follow the physician's orders [REDACTED]. Review of the facility pressure ulcer policies did not address the incident as above; the section entitled risk factors included a higher risk for residents with a non-removable dressing or device. The facility's Pressure Ulcer Prevention policy included that the skin should be checked daily and observed for pressure damage caused by medical devices. -Resident #123 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Initial Data Collection Tool dated June 16, 2014, revealed that the resident had multiple pressure ulcers at the time of admission. Review of the care plan for break in skin integrity dated June 16, 2014, revealed that the resident had multiple pressure ulcers and one of the interventions was skin treatment and to see the orders. Review of the Braden Scale for Predicting Pressure Sore Risk dated June 16, 2014, revealed a score of twelve; high risk for pressure ulcers. A physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for June, 2014, revealed that for thirteen shifts the [MEDICATION NAME] was not documented as applied per physician's orders [REDACTED]. Review of the Minimum Data Set (MDS) discharge assessment dated [DATE], revealed that the resident was discharged to the hospital. An interview was conducted on September 18, 2014, with a licensed practical nurse (LPN). The LPN stated that the [MEDICATION NAME] is kept at the resident's bedside and should have been applied and documented as done every shift. She also stated that she does not know why this was not done. Review of the facility's Pressure Ulcer Care Guide revealed "[MEDICAL CONDITION] that are present , or which develop subsequently to admission, are treated according to medical direction and are conscientiously followed. The medical record is reviewed for the history of the ulcer..."

Based on clinical record review, hospital documentation, staff interviews, and review of the facility's policy and procedure, the facility failed to monitor a resident (#88) to prevent an over dose of narcotic medications. Findings include: Resident #88 was admitted [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed physician's orders [REDACTED]. A review of the Medication Administration Record [REDACTED]. Continued review of the MAR indicated [REDACTED]. However, the site where the patch was applied was only documented on for May 9, 2014. Admission nurses' notes documented the resident was alert and oriented. Addition review of nurses' notes dated May 18, 2014 at 12:58 p.m. revealed the resident responded to verbal stimuli but had difficulty maintaining conversation due to making dis-jointed statements. At 3:18 p.m., the nurses' notes documented the resident was lethargic, was having difficulty completing sentences, and that the resident's oxygen saturation was 91% on 5 liters of oxygen. The physician was notified. On May 19, 2014 at 2:30 a.m., the nurses' notes documented that the resident was alert but confused and scheduled for surgery later that morning. Review of hospital documentation dated May 19, 2014, revealed the resident was extremely obtunded, non-responsive, and hypoxic. Due to the resident's condition, the surgical procedure was canceled. Further review of the hospital documentation revealed the resident was found to have multiple [MEDICATION NAME]es applied and that her altered mental status could possibly be due to opiate overdose. Hospital records document the resident was admitted to the hospital where she went into arrest and was transferred to the intensive care unit intubated. During an interview conducted September 23, 2014, a nurse stated before applying a new [MEDICATION NAME] she would remove the old [MEDICATION NAME]. She further stated it would be possible for a patch to be missed if it was not readily visible. On the same day, another nurse stated that she would check the MAR indicated [REDACTED]. During an interview conducted September 23, 2014, the Director of Nurses (DON) stated that the nurses do not need to document the site of the new patch on the MAR. The DON further stated the hospital documentation that the resident had multiple [MEDICATION NAME]es in place did not prove anything. The facility's policy for Medication Administration included "all medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms and help in diagnosis." The facility's policy for Controlled Drugs included "...Appropriate storage, recording, and use of controlled drugs are maintained on all units..."