Every finding on record at Desert Terrace Healthcare Center

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to protect a resident's (#2) right to be free from physical abuse from another resident (#1), for one of three sampled residents. The deficient practice could lead to physical or psychosocial harm of a resident.Findings include:-Regarding Resident #2:Resident #2 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, major depressive disorder, anxiety disorder, acute ischemia of the large intestine, stage 4 pressure ulcer of sacral region, and paraplegia.A care plan focus initiated April 20, 2026, revealed Resident #2 had the potential to demonstrate verbally abusive behaviors due to mental/emotional illness and poor impulse control. Interventions included to analyze and document key times, places, circumstances, triggers, and what de-escalates behavior, to document observed behavior and attempted interventions, for psychiatric consult as indicated, and to assess the resident's understanding of the situation and allow time for the resident to express self and feelings towards the situation.Another care plan focus initiated April 20, 2026, revealed Resident #2 was at risk for impaired cognitive function or impaired thought process due to bipolar disorder, depression, cognitive deficits, history of traumatic brain injury, urinary tract infection, and post-traumatic stress disorder. Interventions included to engage in simple, structured activities that avoid overly demanding tasks, for social services to provide psychosocial support as needed, and resident centered behavioral interventions: (please specify) which was left blank and did not specify any resident centered behavioral interventions.A physician's order dated April 20, 2026, included for Divalproex Sodium oral tablet delayed release 250 mg, to give 1 tablet by mouth two times a day for bipolar disorder as evidenced by mood lability, and to include non-pharmacological interventions and outcome observed.A physician's order dated April 21, 2026, included for a nicotine transdermal patch for 21 mg / 24 hours. The order was discontinued on April 24, 2026.Additionally, a care plan focus initiated April 22, 2026, revealed Resident #2 had a potential for injury due to smoking, and had a behavior of asking other residents for cigarettes. Interventions included to explain smoking policy, to observe smoking while in designated area, and to monitor to assess compliance with facility smoking policy/individual plan.An admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating intact cognition.A Psychiatric Note dated June 9, 2026, revealed a follow-up psychiatric consultation due to the resident's history of bipolar disorder, anxiety disorder, borderline personality disorder, and depression. Recommendations included that Resident #2 had continued behaviors since last visit, therefore the plan was to continue the psychotropic medications.A Nursing note dated June 16, 2026, revealed Resident #2 was observed going from room to room attempting to steal cigarettes, and that the nurse spoke with the resident regarding his behavior. The note revealed the resident became aggressive and belligerent with staff and threatened to pull the nurse's hair braids out. The note included the resident was educated on his behaviors with staff, wandering into other resident rooms, smoking hours, and sharing cigarettes.A Social Services note dated June 17, 2026, revealed Social Services and the Administrator spoke with Resident #2, who then agreed to transfer to another facility and agreed to get on a nicotine patch.The clinical record revealed no evidence of a physician's order for a nicotine patch after the physician's order that was discontinued on April 24, 2026, or that a nicotine patch was administered anytime in June 2026.A Skilled Evaluation note dated June 20, 2026, at 12:13 p.m., revealed Resident #2's mood was pleasant, and no unwanted behaviors were witnessed.The clinical record revealed no evidence of documentation regarding Resident #2 seeking cigarettes from other residents, or an episode of Resident #2 becoming agitated or verbally aggressive/abusive with a smoking monitor on the morning of June 20, 2026.A Skin Check dated June 22, 2026, at 12:42 p.m. revealed Resident #2's skin was warm and dry, skin color within normal limits, and turgor was normal, with no new skin issues found on the evaluation.A Nursing note dated June 20, 2026, at 1:13 p.m. revealed at approximately 9:20 a.m., Resident #2 approached the nurse alleging that another resident was walking in front of Resident #2 near the exit leading to the smoking patio, turned around, and then hit Resident #2 in the face for no reason at all. The note included that the residents were separated for safety, and that Resident #2 was assessed for injury and there was no redness, swelling, or marks noted on his face, and that Resident #2 had no pain or discomfort.Review of the Medication / Treatment Administration Record (MAR / TAR) for June 2026, revealed that Resident #2 was documented as having zero episodes of psychotic behavior as evidenced by delusions on June 20, 2026. Additionally, the MAR / TAR revealed for Divalproex Sodium oral tablet delayed release 250 mg, that zero non-pharmacological interventions (NPI) were administered to the resident for day or night shift on June 20, 2026. Also, there were zero episodes of anxiety as evidenced by restlessness documented for Resident #2 on June 20, 2026.-Regarding Resident #1:Resident #1 was admitted to the facility on [DATE], with diagnoses of schizophrenia, repeated falls, multiple fractures of left ribs, and difficulty in walking.A care plan focus initiated May 6, 2025, revealed Resident #1 was at risk for impaired cognitive function or impaired thought process due to bipolar disorder and schizophrenia. Interventions included to identify oneself at each interaction, to face the resident when speaking and make eye contact, and for social services to provide psychosocial support as needed.Another care plan focus initiated May 6, 2026, was indicated for psychotropic medication use due to schizophrenia as evidenced by paranoia and bipolar disorder as evidenced by mood lability. Interventions included to encourage Resident #1 to express feelings, to take to activities, to provide reassurance, and for psychiatric consult and follow-up as needed.A Psychiatric Note dated March 24, 2026, revealed Resident #1 was being seen for a follow-up at the request of staff. The note included that Resident #1 has had verbal aggression since last visit per staff, and upon interview, Resident #1 said that another resident had irritated him. Recommendations included that Resident #1 was counseled on proper ways to respond when someone is impolite, and the need to be polite and respectful of staff and other residents. The plan included for Resident #1 to have counseling/psychotherapy.An annual MDS assessment dated [DATE], revealed Resident #1 had a BIMS assessment score of 15, indicating intact cognition. Section I - Active Diagnoses revealed Resident #1 had bipolar disorder, psychiatric disorder other than schizophrenia, and schizophrenia.A physician's order dated June 13, 2026, included for hydroxyzine HCl 25 mg oral tablet, to give 1 tablet by mouth every 6 hours as needed for anxiety as evidenced by restlessness, and to include NPI and outcome observed.A Psychiatric Note dated June 16, 2026, revealed over the past weekend, staff reported Resident #1 having increased behaviors of anxiety and agitation, and that he became impatient and verbally aggressive with two certified nursing assistants (CNAs). The plan included to add PRN (as needed) hydroxyzine for increased agitation and anxiety, and to continue psychotherapy and psychotropic medications.A Nursing note dated June 20, 2026, at 1:00 p.m., revealed at approximately 9:20 a.m., the nurse was approached by another resident who alleged that Resident #1 had hit him in the face near the exit leading to the smoking patio. The other resident stated that Resident #1 was walking in front of him, turned around, and hit him in the face. The note revealed that both residents were separated, and that Resident #1 endorsed making physical contact with the other resident, stating that it was provoked because the other resident was calling staff and the smoking monitor foul names. The note included that the provider was notified, and a one to one staff monitor was immediately initiated for Resident #1.Review of the MAR / TAR for June 2026, revealed no doses of hydroxyzine 25 mg tablets were administered, and no NPI were documented for the month of June 2026. The record also included that no episodes of psychotic behavior as evidenced by paranoia were documented on June 20, 2026. Additionally, the record revealed no episodes of behaviors of mood lability were recorded on June 20, 2026.An observation was conducted on June 25, 2026, at 11:24 a.m., with Administrator (Staff #90) of the facility's video camera footage dated June 20, 2026, of the smoking patio just outside the sliding glass door/hallway. The view included the smoking patio, however not the glass sliding door, nor inside the hallway. At approximately 9:04 a.m. Resident #1 left the outdoor smoking patio and walked toward the hallway just inside the sliding glass door. Shortly thereafter, Resident #1 walked back out of the facility to the smoking patio, and Resident #2 followed him in his wheelchair. Staff #5 then approached Resident #2 and appeared to say something to Resident #2, and Resident #2 turned his wheelchair around and returned back inside the facility at approximately 9:05 a.m. Resident #1 was observed to remain on the smoking patio, and at approximately 9:36 a.m., Resident #1 walked back inside the facility.A telephonic interview was conducted on June 25, 2026, at 8:32 a.m. with Resident #2's emergency contact/family member, who stated that she was made aware of the incident on June 20, 2026, by both the facility staff and by Resident #2. The family member stated that her understanding of the incident was that Resident #2 was asking another resident for cigarettes which he was not allowed to do, and a female staff member informed him not to do that. The family member stated that then Resident #2 used expletives directed at the female staff, and that this triggered another resident to then punch Resident #2 in the face.An interview was conducted on June 25, 2026, at 9:37 a.m. with Resident #1, who stated that on June 20, 2026, he had overheard Resident #2 disrespect a staff member earlier in the morning, and Resident #1 would not tolerate it. Resident #1 stated that he was walking in the hall near the outdoor patio, and Resident #2 was there in a wheelchair. Resident #1 stated that Resident #2 asked him what his problem was, and Resident #1 stated you're my f***ing problem, and then Resident #1 punched Resident #2 on the left side of Resident #2's face using his right hand. Resident #1 stated that Resident #2 did not try to block the punch, nor did Resident #2 try to hit him back, and that he (Resident #1) nearly knocked Resident #2 out. Resident #1 stated that he believed there were several residents nearby who witnessed the incident.A telephonic interview was conducted on June 25, 2026, at 10:18 a.m., with a charge nurse/licensed practical nurse (LPN / Staff #43) who stated that over the weekend, at roughly 9:10-9:20 a.m., Resident #2 approached him and informed him that Resident #1 had hit him on the left side of his face. The LPN stated that maybe there was a little redness on Resident #2's face on the left side, and then the LPN stated that maybe his face was red because he had just been outside. The LPN stated that he then interviewed Resident #1 who stated that yes, he had punched Resident #2, because Resident #2 had been rude to the smoking monitor (Staff #5) and had called her names earlier that day. The LPN stated that Resident #1 had a history of being easily triggered by foul language. Additionally, the LPN stated that he interviewed other residents to see if anyone had witnessed the incident, and that one resident (Resident #8) stated that she had witnessed Resident #1 hit Resident #2 while she was on the smoking patio looking back through the glass sliding door into the hallway where the incident occurred.An interview was conducted with an activities staff/smoking monitor (Staff #5) on June 25, 2026, at 10:45 a.m. who stated that on Saturday morning, before she had unlocked the door of the smoking patio for the residents, she observed a female resident rolling a cigarette in the dining room area. Staff #5 stated that she then observed Resident #2 attempting to get a cigarette from the female resident, and Staff #5 was aware that he was not permitted to do that, and so Staff #5 educated Resident #2 that he was not allowed to request cigarettes from other residents. Staff #5 stated that Resident #2 became irate and began yelling profanities at Staff #5, and that Resident #1 was in the vicinity and overheard this. Staff #5 stated that later that morning, around 9:00 a.m. after she unlocked the patio door to allow the residents to smoke, that she was on the patio and assisting residents with getting water, and she overheard a resident yell look they're arguing, and when Staff #5 looked up she saw Resident #1 come out of the hallway through the glass sliding doors, into the outdoor patio area. Staff #5 stated that Resident #1 stated that he had just hit Resident #2, and Staff #5 stated that she replied for Resident #1 not to do that. Staff #5 stated that another resident (Resident #8) stated that she saw Resident #1 hit Resident #2. Staff #5 also stated that after the incident, Resident #1 told her that he had hit Resident #2 because he had overheard Resident #2 speaking disrespectfully to Staff #5 earlier. Staff #5 stated that later that day, Resident #2 approached her and apologized for speaking disrespectfully to her.An interview was conducted with Resident #8 on June 25, 2026, at 10:56 a.m. who stated that on Saturday, June 20, 2025, between 9:00 and 10:00 a.m., she was on the smoking patio and witnessed the incident between Resident #1 and Resident #2. Resident #8 stated that she saw what looked like Resident #1 yelling at Resident #2 in the hallway just inside the glass door from the smoking patio. Resident #2 stated she observed Resident #1 hit Resident #2 in the face with his fist.An interview was conducted with a CNA (Staff #10) on June 25, 2026, at 11:59 a.m., who stated that CNAs monitor for residents' behaviors to determine if anything is new or changed, and that would be reported to the nurse. The CNA stated that an example of physical abuse would be one resident hitting another resident. Regarding Resident #2, the CNA stated that she had heard through verbal report from other staff that he could be mean and aggressive. Regarding Resident #1, the CNA stated that he was behavioral and often called staff names. The CNA stated that she had heard that there was a physical altercation incident between the two residents recently.An interview was conducted with a CNA (Staff #31) on June 25, 2026, at 12:05 p.m., who stated that abuse could be verbal, mental, financial, or physical, and some examples of abuse would be residents using foul language toward each other or hitting each other. The CNA stated that she received verbal report at shift change when she worked on June 21, 2026, that on the previous day, Resident #1 and Resident #2 had a physical altercation incident.An interview was conducted on June 25, 2026, at 12:14 p.m., with a Registered Nurse (RN / Staff #76) who stated that there were different types of abuse, including physical or verbal, and that she would consider one resident hitting another resident a form of abuse. The RN stated that she arrived to work on Sunday, June 21, 2026, and noticed that Resident #1 had a one to one staff member placed with him. The RN stated that she then asked Resident #1 why he had a sitter, and Resident #1 stated that he had hit Resident #2 in the face.An interview was conducted on June 25, 2026, at 1:46 p.m. with the Director of Nursing (DON / Staff #22) on June 25, 2026, at 1:45 p.m., who stated that her understanding of abuse was that it could include mental, physical, emotional, or financial abuse, and was an instance where a resident suffered physical harm or psychosocial harm. The DON stated an example of physical abuse would be any unwanted physical contact, including hitting, spitting, and shoving. The DON stated that the process for preventing abuse was for staff to monitor residents constantly, to notice any indication of changes in behavior, and to put into place any necessary interventions. The DON stated that behavior monitoring was documented primarily on the MAR/TAR, including any NPI that were put into place for residents. Additionally, the DON stated that if a resident had repeated behaviors, then the care plan would be updated to address the behavior. The DON stated that if there was a situation where physical abuse of a resident occurred in the facility, the risk to the resident would be injury or psychosocial harm. Regarding Resident #1, the DON stated that the resident had bipolar disorder, schizophrenia, and insomnia, and had behaviors of being rude to staff members. Regarding Resident #2, the DON stated that he had bipolar disorder, major depressive disorder, and anxiety, and had a history of behaviors including refusing cares, and being verbally disrespectful toward staff. Regarding the incident, the DON stated that she was out of the facility on vacation at the time, and had received a message on June 20, 2026, that Resident #2 was being placed with a one to one staff member. The DON stated she subsequently learned that Resident #2 reported to the charge nurse (Staff #45) that Resident #1 had made physical contact with him, and that she was informed that Resident #2 did not have any skin issues or injuries afterward. The DON stated that she learned that both residents stated that Resident #1 hit Resident #2 and that it was unwanted physical contact. The DON stated she found out after the incident that Resident #1 felt as if Resident #2 was being disrespectful to the staff member, which was the reason Resident #1 hit Resident #2.An interview was conducted with the Administrator (Staff #90) on June 25, 2026, at 2:19 p.m. who stated that the facility staff prevent abuse from occurring by identifying escalation of behaviors, and to get ahead of it before it comes to an actual incident. The Administrator stated that on June 20, 2026, around 9:20 in the morning, he received a phone call from the charge nurse (Staff #43) who informed him that Resident #2 told Staff #43 that Resident #1 hit him in the face. The Administrator stated that Staff #43 conducted interviews to determine if there were witnesses and what occurred. The Administrator stated that over the course of the investigation, he had learned that earlier that day, Resident #2 was calling the smoking monitor (Staff #5) a slew of curse words, and was being disrespectful to her, and this upset Resident #1, who felt that he was sticking up for Staff #5 by hitting Resident #2. The Administrator stated he learned through the course of the investigation that the incident allegedly took place in the hallway just inside the glass door that led to the smoking patio. The Administrator stated that he was not sure if this was an instance of physical abuse because there were no witnesses and no injury to Resident #2 actually noted.A telephonic interview was conducted with Resident #2 on June 25, 2026, at 2:34 p.m. Resident #2 stated that on June 20, 2026, he had said some things, including expletives, to the smoking monitor (Staff #5). Staff #2 stated that because of this, Resident #1 punched him in the face in the hallway. Resident #2 stated that he had pain in his face after the incident and still had pain there at this time, and that his face was red where he had been struck directly after the incident. Resident #2 stated that he told a staff member right after the incident was over. Resident #2 also stated that this incident affected him mentally, and that he did not feel safe afterward.Review of the facility policy titled Abuse: Prevention of and Prohibition Against, revised October 2025, revealed it is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy included that abuse is 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. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Additionally, the policy revealed that physical abuse includes but is not limited to hitting, slapping, pinching, and kicking.

Based on interviews, review of clinical and personnel records, and review of facility policy and procedure, the facility failed to ensure that one sampled licensed nursing staff (#60) possessed a valid Arizona state license to practice as a Registered Nurse (RN) during employment, in accordance with state and federal regulations. The deficient practice could result in an unlicensed individual providing nursing care to residents for an extended period, and could potentially affect the safety and quality of care delivered to all residents receiving services.Findings include:Review of Staff #60's employment application dated March 20, 2025, revealed the applicant indicted she held a valid RN license; however, a hand-written notation revealed upon arrival, to be endorsed in the blank space on the application.A personnel file review revealed the following:A license verification report dated March 31, 2025, from an online database, revealed an active, unencumbered RN license that belonged to a different individual with the same first and last name but a different middle initial.No evidence of a valid state RN license or verification from another state belonging to Staff #60.A termination notice dated March 30, 2026, indicating involuntary termination due to loss of license.Review of staffing schedules and punch details revealed that Staff #60 worked as a floor RN, and her first shift started April 16, 2025, and her last shift was February 11, 2026.A Professional Profile for Staff #60, dated April 8, 2026, included the position of registered nurse (RN), a hire date of March 26, 2025, and a termination date of March 30, 2026.A telephonic interview was conducted with an Arizona State Board of Nursing (AZBN) staff on April 8, 2026, at 11:54 a.m. The AZBN staff stated that the RN (Staff #60) had been an RN license applicant by endorsement for a license from another state. Additionally, The AZBN staff stated that the licensing process required additional steps because Staff #60 was considered foreign-educated. The AZBN staff also stated that the licensing board received documentation that Staff #60 had been employed at the facility and had been practicing as an RN, without the Arizona state license or endorsement to do so. The AZBN staff further stated that Staff #60 had never held an Arizona state licensure to be able to practice as an RN in Arizona, until April 6, 2026. The AZBN staff stated that when the Board received the documentation that Staff #60 had been working without an Arizona state license or endorsement the facility HR Director (staff #166) was notified on February 4, 2026 that staff #60 did not have an active Arizona RN license and should not be working as an RN. The AZBN stated that the facility HR Director confirmed that Staff #60 had been employed and working as an RN. Additionally, the AZBN staff stated that Staff #60 had an active license from another state, issued March 25, 2025, however the other state was not part of the Nurse Licensure Compact, and Staff #60 could not practice in Arizona with that license.An interview was conducted on April 8, 2026, at 12:42 p.m. with a Certified Nursing Assistant (CNA / Staff #12) who stated that if she noticed a change of condition in a resident such as shortness of breath or rapid breathing, that she would notify the floor nurse right away to conduct a resident assessment. The CNA stated that when a change of condition is not assessed by a licensed nurse, the resident could be having a serious condition and could die. The CNA also stated that RN (Staff #60) had worked as a floor nurse at the facility, passing medications, and assessing and caring for residents.An interview was conducted with the Human Resources Director (HR Director / Staff #166) on April 8, 2026, at 12:49 p.m. and a review Staff #60's personnel file for a was conducted with the HR Director. The record review revealed:A passport issued June 26, 2024, revealed the first, middle, and last name of Staff #60.A license verification report dated March 31, 2025, from the online database, for a different individual than Staff #60, with the same first and last name, however a different middle initial.The termination notice dated and signed March 30, 2026.There was no evidence of any other RN license or license verification from another state.During the interview with the HR Director, she stated that she is in charge of obtaining all of the onboarding documents for new staff. She further stated that the facility's process for verifying a nurse's license was to search the nurse's name on the online portal for nursing license verification, and that the process did not include requesting a copy of the nursing license. The HR Director stated that there was no evidence of Staff #60's nursing license in her personnel file, and that the file included licensure verification from the online portal. The HR Director reviewed Staff #60's identification documents, and stated that the middle name of the individual on the nursing license verification form was different than Staff #60, and that the license verified was a different person, and that it must have been oversight. The HR Director stated that she received a call on February 4, 2026, from AZBN staff, who told her that Staff #60 had an RN license from another state, and no RN license in Arizona, and that the AZBN staff recommended that Staff #60 be removed from working as a floor nurse. The HR Director stated that she believed the facility removed Staff #60 from working as a floor nurse. The HR Director reviewed the payroll records of when Staff #60 last worked in the facility as a nurse, and she stated that Staff #60's last day of working in the facility was February 11, 2026. The HR Director stated that she did not know why there had been a delay from February 4, 2026, when she was notified by the AZBN that the staff did not have a license, until February 11, 2026, that Staff #60 had been removed from working the floor. She stated that she thought that the Director of Nursing (DON/Staff #41) and Administrator (staff #9) were working on trying determine what had occurred regarding Staff #60's nursing license. The HR Director further stated that the reason that Staff #60 was terminated was because she was not licensed as an RN in the state of Arizona.An interview was conducted with the Administrator (Staff #9) on April 8, 2026, at 3:05 p.m. who stated that he expected the HR Director would complete all the necessary documentation and steps for a nurse to be hired, including a background check, fingerprint clearance card, citizenship, and verifying the staff's license on the online portal. The Administrator stated that if a hired nurse did not have the required state license, then he would contact his resource for guidance, confer with the Board of Nursing, and do a facility audit to determine what occurred. The Administrator stated that there could be a risk to residents if an unlicensed staff was providing care to residents, and that is why those regulations are in place for required licenses. The Administrator also stated he was made aware that there was an issue with Staff #60's RN license on the same day that the AZBN contacted the HR Director (Staff #166). The Administrator stated that the AZBN told the HR Director that there was no need to remove Staff #60 from working on the floor. The Administrator also stated that he had never directly talked to the AZBN himself. The Administrator also stated that because the AZBN did not give a concrete answer on what was the going on regarding Staff #60's RN license, and the facility staff were still unsure of the status of her license, that it was decided to remove Staff #60 from working the floor approximately one week after being notified by the AZBN. The Administrator stated that he was aware that Staff #60 had a license from another state, and that the licensing issue was for Arizona. The Administrator stated he did not believe that an RN with a license from the other state could practice in Arizona because the other state was not part of the licensing compact. The Administrator further stated that Staff #60 was terminated because the facility was unable to resolve issue regarding Staff #60's RN license.An interview was conducted with the DON (Staff #41) on April 8, 2026, at 3:25 p.m. The DON stated that the facility's process for onboarding a new nurse included the HR Director (Staff #166) completing a background check, license verification, and other onboarding items, however, she was not sure of the exact process. The DON stated that there could be risks to residents if those onboarding steps were not completed accurately, because the staff may not be competent to provide care for the residents. Regarding Staff #60, the DON stated that the HR director was informed by the AZBN that they were looking into an issue with Staff #60's Arizona RN licensure, and that approximately a week after that, Staff #60 and the AZBN informed the facility staff that she was not able to work. The DON also stated that up until that point, she believed Staff #60's was licensed without restriction to practice in Arizona. The DON further stated she knew for sure that Staff #60 had an active RN license in another state, and that she believed that the other state was part of the compact with Arizona which would allow her to practice in Arizona. The DON then reviewed the nursing licensure compact website and stated that the other state was not part of the nursing licensure compact states, and that it would require a license endorsement through Arizona to practice as an RN. The DON stated that it would concern her if the HR Director was not properly vetting staff's licensure prior to staff working on the floor with residents, because the facility needed to ensure those providing care were qualified.An interview was conducted with the Staffing Director (Staff #17) on April 9, 2026, at 1:49 p.m. who stated that he was in charge of scheduling staff to work on the floor. The Staffing Director stated that as soon as the HR Director informed him to schedule new staff, that would mean the staff was cleared to work, and all the onboarding process was completed. The Staffing Director also stated that he was informed that there was an issue with Staff #60's RN licensure and that he had pulled her off of the schedule as soon as he became aware that she did not have a license. The Staffing Director stated that the facility cannot have unlicensed personnel on the floor working with patients.A telephonic interview was conducted on April 9, 2026, at 2:42 p.m. with Staff #60, who stated that she believed she had first applied for her RN license in Arizona some time in 2024, and had not received it. Staff #60 stated that then she applied for an RN license in another state, and quickly received the license within a few weeks, and that it was active effective March 25, 2025. After receiving her license from the other state, around the same time period of March 2025, Staff #60 stated she then applied to have a license through endorsement in Arizona. Staff #60 stated that she was working at the facility and waiting for her license through endorsement to be approved, but was having difficulty because she had to complete a language proficiency test and have her education verified through a third party. Staff #60 stated she received a call on February 12, 2026, from the AZBN, and was asked if she was still working at the facility, to which Staff #60 stated that she was and her last day worked was the day before, on February 11, 2026. Staff #60 stated that the AZBN staff informed her that the AZBN had already instructed the HR Director (Staff #166) that Staff #60 could not work because she did not have a license for Arizona. Staff #60 stated that she believed she could work under the license from the other state, and that she assumed it would be ok. Prior to the phone call with the AZBM on February 12, 2026, Staff #60 stated that the HR Director had asked her the week prior if her Arizona license had arrived yet, to which Staff #60 replied she was still working on meeting the requirements to submit to the AZBN.A follow-up interview was conducted with the DON (Staff #41) on April 9, 2026, at 4:15 p.m. who stated that it was oversight on the facility's part that when the AZBN called on February 4, 2026, to report there was an issue with Staff #60's Arizona RN licensure, that the HR Director's should have verified whether or not Staff #60 could practice as an RN under the other state license. Additionally, the DON stated that there was an error made when Staff #60 was hired, that the license verification for Arizona was actually for another person, not Staff #60.Another follow-up interview was conducted with the Administrator (Staff #9) on April 9, 2026, at 4:39 p.m., who stated that there was a mistake when the HR Director looked up Staff #60's name on the online license verification portal, and the license verification was for another person with the same first and last name, but with a different middle initial. Additionally, Staff #9 stated that the HR Director was also educated to ensure licenses from another state are part of the licensing compact with Arizona. The Administrator stated that this situation with Staff #60 not having an Arizona RN license, and the mistakes made in license verification, did not meet his expectations as far as properly vetting an applicant for hire. He further stated that per the facility policy, Staff #60 had not been qualified to work as an RN at the facility during the timeframe she worked.Review of the facility policy titled, Pre-Employment Investigations, dated January 2024, revealed for any individual applying for a position that requires a state-issued license or certification, the hiring manager or designee should verify that the applicant's license(s) and certification(s) are current and in good standing. The license(s), certificate(s), licensing board license verification website pages or other documents establishing valid licensure should be photocopied/printed and placed in the applicant's confidential application file.

Based on facility documentation, staff interviews, Long Term Care State Operations Manual, and facility policies review the facility failed to ensure that safeguarding of personal funds included a system of written authorization for Resident #8. The deficient practice could result in verbal monetary agreements that do not allow identification and/or investigation of financial misappropriation.Findings included:Resident #8 was admitted to the facility on [DATE], readmitted on [DATE], and had a past medical history that included anxiety disorder, calculus of the ureter, mood affective disorder, and vascular dementia.Review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 11, which indicated that Resident #8 was moderately cognitively impaired.Review of the admission Record Documentation Payer Information, revealed Resident #8 was 'Private Pay'.Review of 'Credit Card Authorization Form', revealed it had been completed by Staff #1 on May 28, 2024, and did not include Resident #8's signature. Additionally, there was no time included in the form indicating at what time the form was completed. The verbiage included beside the title of the form included in parenthesis and capitalized, 'please print'. The form was separated in sections which included Resident #8's pertinent information. Cardholders Name: Resident #8; Payment for (description of Services): Private 05/28, 05/29, 05/29, 2024; Credit Card Account Number, Expiration Date, 3 Digit Security Code were all completed; Total Amount to be charged to Credit Card: 450.00; Completed by: Staff #1; Sign: Via Phone. As well, capitalized lettering below the form included, the verbiage I agree to pay above total amount according to card issuer agreement.Review of the Resident Ledger Report dated May 28, 2024 with [NAME] Date of June 30, 2024, revealed a description of previous balance including Room and Board Charges: May 28-31; 2024 with total amount of: 900.00; Payment amount: 450.00; Balance: 450.00; and Total in May 2024.Review of the Resident Activity Report dated May 31, 2024 revealed Account status: Open; System Note: Account generation - Account created; Group: Private; and Amount due (450.00).Review of the Resident Activity Report dated September 2, 2025 at 2:37 PM, revealed a note written which stated, called Resident's Private Fiduciary (RPF); Resident #8 had since passed away; that, RPF stated also claimed that Resident #8 had money taken while being at the facility, so she (RPF) is unable to pay the facility.An interview was conducted on January 20, 2026 at 3:06 PM with Resident's Private Fiduciary (RPF) who stated that she had become Resident #8's financial power of attorney in April 2025. RPF stated that the facility payed themselves from Resident #8's accounts before she was her designated Private Fiduciary; and that, she stated that she had reported to the police, and facility, of fraud occurring in the resident's accounts while Resident #8 was at the facility at that time. RPF stated that Resident #8 had the bed closest to the window, and a nightstand drawer full of mail/financial documents. RPF stated that the mail contained statements and retirement funds; and that, all the mail was just sitting vulnerable to anyone who came into the room.An interview was conducted on January 20, 2026 at approximately 4:38 PM with Assistant Business Manager (ABM/Staff #1) who stated that her role included helping the manager with billing. ABM stated that residents with insurance will be covered, however since private pay residents are really rare - business office must check to see if they are being covered. ABM confirmed that Resident #8 was not always private pay. ABM stated that she became private pay on May 28, 2024 after her insurance coverage ended on May 27, 2024. ABM stated that later in March 2025, it was suggested by the facility, that a fiduciary should be involved. ABM stated that since the job of the business office is to collect money, they must be aware of how long before residents require assistance with finances.An interview was conducted on January 20, 2026 at approximately 4:38 PM with Business Manager (BM/Staff #10) and ABM/Staff #1. BM stated that her role was to help manage the insurances in the facility and make sure that the facility is getting paid. BM stated that in order to access banking accounts or payment cards, a form needs to be filled-out by the resident and facility staff called, Credit Card Authorization Form. BM stated that this form is always required, and needs to be completely filled out every time the business office runs a monetary transaction. BM stated that by signing the form, the residents are agreeing to give requested information. BM stated that she recalled Resident #8; and, confirmed that her insurance coverage had ended on May 27, 2024. BM stated that on May 28, 2024, Resident #8 had decided to remain in the facility as private pay. BM stated that initially because Resident #8 knew her account information there was no need to help her out with any fiduciary. BM stated she recalled that on May 28, 2024, Resident #8 had an appointment, and although was not physically in the facility at that time -- had insisted in paying the business office over the phone. BM confirmed that on the authorization form, dated May 28, 2024, the line requiring a signature had the words, via phone documented by the ABM. ABM stated that the facility staff did not document the exchange or communication of consent had with Resident #8 anywhere other than with the verbiage, via phone in the signature section of the Credit Card Authorization Form.An interview was conducted on January 21, 2026 at 10:16 AM with Administrator (Staff #20), ABM, and BM. BM confirmed that the Credit Card Authorization Form dated May 28, 2024 was an original copy of the originally completed form by the facility.Another interview was conducted on January 22, 2026 at 2:21 PM with Administrator/Staff #20 who stated that moving forward the facility staff would begin documenting authorization information at the same time as the charges; and that, the 'Credit Card Authorization Forms' would no longer be used because a better system would be in place that is clearer.Review of, State Operations Manual, Appendix PP (Rev 232; Issued 07-23-25), S483.10(f)(10)(i)-(ii), revealed guidance to assure that facility staff are not using oral requests by residents as a way to avoid obtaining written authorization to hold, manage, safeguard and account for resident's funds. The facility must have a system to document the date, time, amount, and who the funds were received from or dispersed to. The facility managing the resident's financial affairs includes money that an individual gives to the facility for the sake of providing a resident with a non-covered service.Review of Job Description titled, Assistant Business Office Manager documentation (dated 11/21/2022), revealed in section resident rights - develop practices to ensure that resident funds are maintained in accordance with current federal and state regulations and guidelines.Review of the facility policy titled, Accounts Receivable Policy and Procedure (revised 1/1/2026), revealed policy establishes a comprehensive framework of internal controls governing cash handling, payment processing, and deposit procedures; ensure accuracy, promote accountability, and uphold financial integrity; the executive director (ED) will be responsible for ensure that there are internal controls and segregation of duties in the business office.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure policies prohibiting financial misappropriation were implemented for Resident #8. The deficient practice could result in lack of measures that prevent financial misappropriation of residents.Findings included:Resident #8 was admitted to the facility on [DATE], readmitted on [DATE], and had a past medical history that included anxiety disorder, calculus of the ureter, mood affective disorder, and vascular dementia.Review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 11, which indicated that Resident #8 was moderately cognitively impaired.Review of the admission Record Documentation Payer Information, revealed Resident #8 was 'Private Pay'.Review of the Resident Activity Report dated April 22, 2025, at 14:52, revealed a note written by Business Manager (BM/Staff #10). Staff #10 which stated called Resident #8's Private Fiduciary (RPF); RPF stated she filed a Victim of Fraud claim in behalf of patient; According RPF patient account has been drained with $265,000.00; RPF is stating that Police is investigating; And RPF also asked for facility to be part of the investigation. RPF is asking for copy of all statements since 01/2024 - to current; A copy where Resident #8 is approved to stay Private at the facility; Staff #10 stated, yes; and that, would be in touch by email and phone call.Review of the Resident Activity Report dated April 22, 2025, at 14:58, revealed another note written by BM/Staff #10 who stated, I talked to the ED (Staff #100) about the phone call with RPF; Explained that RPF had filed a Victim of Fraud claim in behalf of the patient with the police; Explained RPF is asking for facility staff to be in investigated for fraud; and that, Staff #100 stated he will reach out to Staff #200 for advice.Review of the Resident Activity Report dated September 2, 2025 at 14:37 PM, revealed a note written which stated, called Resident's Private Fiduciary (RPF); Resident #8 had since passed away; that, RPF stated also claimed that Resident #8 had money taken while being at the facility, so she (RPF) is unable to pay the facility.An interview was conducted on January 20, 2026 at 3:06 PM with Resident's Private Fiduciary (RPF) who stated that she had become Resident #8's financial power of attorney in April 2025. RPF stated that the facility payed themselves from Resident #8's accounts before she was her designated Private Fiduciary; and that, she stated that she had reported to the police, and facility, of fraud occurring in the resident's accounts while Resident #8 was at the facility at that time. RPF stated that Resident #8 had the bed closest to the window, and a nightstand drawer full of mail/financial documents. RPF stated that the mail contained statements and retirement funds; and that, all the mail was just sitting vulnerable to anyone who came into the room.An interview was conducted on January 20, 2026 at approximately 4:38 PM with Assistant Business Manager (ABM/Staff #1) who stated that her role included helping the manager with billing. ABM stated that residents with insurance will be covered, however since private pay residents are really rare - business office must check to see if they are being covered. ABM confirmed that Resident #8 was not always private pay. ABM stated that she became private pay on May 28, 2024 after her insurance coverage ended on May 27, 2024. ABM stated that later in March 2025, it was suggested by the facility, that a fiduciary should be involved. ABM stated that since the job of the business office is to collect money, they must be aware of how long before residents require assistance with finances.An interview was conducted on January 21, 2026 at 10:16 AM with Administrator (Staff #20) who stated was the operations manager prior to becoming administrator in December 2025 at the facility. Staff #20 stated that when the allegations were made by the RPF, he and the previous administrator (Staff #100) went over the allegations together with RPF, however he would reach out to previous administrator (Staff #100) for further details on what had been documented by the facility at that time.An interview was conducted on January 21, 2026 at approximately 10:31 PM with Business Manager (BM/Staff #10). BM stated that the facility provides abuse training often. Staff #10 state that the different types of abuse included physical, verbal, sexual, financial, and neglect. Staff #10 stated that if she is made aware of abuse allegations - will immediately inform the administrator at the time it was shared with her. Staff #10 confirmed that when the RPF made the allegation of fraud about Resident #8 on April 22, 2025, she relayed the information to the previous administrator at the time Staff #100.An interview was conducted on January 21, 2026 at 10:16 AM with Administrator (Staff #20) who stated had spoken to the previous administrator Staff #100 and that looking back at the allegations of fraud it looked like nothing was done. Staff #20 stated that after speaking with Staff #100, previous administrator had determined that there was nothing to investigate.Review of the facility incident report submitted on January 21, 2026 at 5:40 PM, revealed that on 01/21/2026 (Wednesday) at around 1001, during interview of (Business Office Manager) with Surveyor regarding discharged Resident #8, it was brought to the attention of Staff #20 (Administrator) that resident's private fiduciary had filed a Victim of Fraud Claim on behalf of the resident. Facility initiated investigation upon knowledge of allegation.Another interview was conducted on January 22, 2026 at 8:14 AM with Administrator (Staff #20) who stated he would be conducting a 5-day investigation after facility had filed their self-report regarding the allegations of fraud made by RPF about Resident #8 in April 22, 2025.Review of the facility policy titled, Abuse: Prevention of and Prohibition Against (revised October/2025), revealed it is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation or resident property, and exploitation; Identification facility staff with knowledge of an actual or potential violation of this policy must report violation to his or her supervisor or the Facility administrator immediately; The Facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property; All allegations of abuse, neglect, misappropriation or resident property, and exploitation will be promptly and thoroughly investigated by the administrator or his/her designee; The investigation will include the following: an interview with the person(s) reporting the incident, resident(s), witnesses to the incident, review of the resident's medical record, interview with staff member (on all shifts) who may have information regarding the alleged incident, review of all circumstances surrounding the incident; and that, the investigation, and the results of the investigation, will be documented.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that alleged violations concerning financial misappropriation were reported in accordance with state law for Resident #8. The deficient practice could result in continued financial abuse to residents.Findings included:Resident #8 was admitted to the facility on [DATE], readmitted on [DATE], and had a past medical history that included anxiety disorder, calculus of the ureter, mood affective disorder, and vascular dementia.Review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 11, which indicated that Resident #8 was moderately cognitively impaired.Review of the Resident Activity Report dated April 22, 2025, at 14:52, revealed a note written by Business Manager (BM/Staff #10). Staff #10 which stated called Resident #8's Private Fiduciary (RPF); RPF stated she filed a Victim of Fraud claim in behalf of patient; According RPF patient account has been drained with $265,000.00; RPF is stating that Police is investigating; And RPF also asked for facility to be part of the investigation. RPF is asking for copy of all statements since 01/2024 - to current; A copy where Resident #8 is approved to stay Private at the facility; Staff #10 stated, yes; and that, would be in touch by email and phone call.Review of the Resident Activity Report dated April 22, 2025, at 14:58, revealed another note written by BM/Staff #10 who stated, I talked to the ED (Staff #100) about the phone call with RPF; Explained that RPF had filed a Victim of Fraud claim in behalf of the patient with the police; Explained RPF is asking for facility staff to be in investigated for fraud; and that, Staff #100 stated he will reach out to Staff #200 for advice.Review of the Resident Activity Report dated September 2, 2025 at 14:37 PM, revealed a note written which stated, called Resident's Private Fiduciary (RPF); Resident #8 had since passed away; that, RPF stated also claimed that Resident #8 had money taken while being at the facility, so she (RPF) is unable to pay the facility.An interview was conducted on January 21, 2026 at 10:16 AM with Administrator (Staff #20) who stated was the operations manager prior to becoming administrator in December 2025 at the facility. Staff #20 stated that when the allegations were made by the RPF, he and the previous administrator (Staff #100) went over the allegations together with RPF, however he would reach out to previous administrator (Staff #100) for further details on what had been documented by the facility at that time.An interview was conducted on January 21, 2026 at approximately 10:31 PM with Business Manager (BM/Staff #10). BM stated that the facility provides abuse training often. Staff #10 state that the different types of abuse included physical, verbal, sexual, financial, and neglect. Staff #10 stated that if she is made aware of abuse allegations - will immediately inform the administrator at the time it was shared with her. Staff #10 confirmed that when the RPF made the allegation of fraud about Resident #8 on April 22, 2025, she relayed the information to the previous administrator at the time Staff #100.An interview was conducted on January 21, 2026 at 10:16 AM with Administrator (Staff #20) who stated had spoken to the previous administrator Staff #100 and that looking back at the allegations of fraud it looked like nothing was done. Staff #20 stated that after speaking with Staff #100, previous administrator had determined that there was nothing to investigate; and that, the allegations of fraud were not reported to the state agency.Review of the email dated January 21, 2025 at 1:20 PM, revealed that the facility had no self-reports regarding Resident #8. The document was signed and dated by Director of Nursing (Staff #40).Review of the facility policy titled, Reporting Reasonable Suspicion of a Crime (revised October/2025), revealed that the Facility seeks to protect its residents from being subjected to incidents of crime, and to ensure that any such incidents (or reasonable suspicion of such incidents) are reported in a timely manner to the State Survey Agency (SSA) and local law enforcement; Some examples of crimes include (but are not limited to): Fraud and forgery.Review of the facility policy titled, Abuse: Prevention of and Prohibition Against (revised October/2025), revealed it is the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation or resident property, and exploitation; Identification facility staff with knowledge of an actual or potential violation of this policy must report violation to his or her supervisor or the Facility administrator immediately; The Facility will assist staff in identifying abuse, neglect, and exploitation of residents, and misappropriation of resident property; Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.Review of the facility policy titled, Abuse: Prevention of and Prohibition Against (revised November 23, 2016), revealed the Grievance Official will immediately report all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property to the Administrator; and as required by State law.

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure that medications were not left at the bedside for one Resident #12. The deficient practice could result in harm to the residents, and/or visitors who have access to medications.Findings include:Resident #12 was admitted to the facility on [DATE], readmitted on [DATE], and had a past medical history that included Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Dementia, and Major Depressive Disorder.Review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 13, which indicated that Resident #12 was cognitively intact.Review care plan for Resident #12 revealed no plan allowing resident to self-administer medication.Review of the physician's orders revealed no orders allowing Resident #12 to self-administer medications were documented.Review of electronic medical records, including progress notes and assessments, revealed no interdisciplinary meeting allowing Resident #12 to self-administer medication.Room observation was conducted twice on January 22, 2026 at 10:38 AM which revealed two medications located at the bedside near Resident #12. The names on the two medications included: Fluticasone Propionate Suspension 50 MCG/ACT, and Bacitracin Zinc 400 units.An interview was conducted on January 22, 2026 at 10:38 AM with Resident #12. Resident #12 confirmed that one of the medications was hers; and that, it was the medication that she uses every other day on her toes. Additionally, Resident #12 stated that the other medication was a nasal spray and uses it once in a while.Another observation was conducted on January 22, 2026 at 10:54 AM in conjunction with the Director of Nursing (DON/Staff #40) which revealed the two medications at the bedside near Resident #12.An interview was conducted on January 22, 2026 at 10:54 AM with DON inside Resident #12's room. DON confirmed that residents without orders to self-administer should not have medications left out. DON stated that medications at bedside, would not be ideal. DON stated that the risks included that medications can be taken at a different time than scheduled; and that, it would not meet the facility's expectations. DON reviewed the electronic medical records on the medication cart located near the room, and confirmed that Resident #12 did not have any order to self-administer the medication at the bedside at that time.Review of the facility policy titled, Self-Administration of Medications (revised 04/2023), revealed if resident desires to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. The residents cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. If the interdisciplinary team determines that this resident is unable to carry out this responsibility (this would be dangerous to resident or others), the interdisciplinary team may withdrawal this right. If the resident is a candidate for self-administration of medications, this will be indicated in the chart. Resident will be instructed regarding proper administration of medication by the nurse. Storage and location of drug administration (e.g., resident's room, nurses' station, or activities room) will comply with state and federal requirements for medication storage.Review of the facility policy titled, Medication Access and Storage, E kit access (revised 07/2017), revealed it is the policy of this facility to store all drugs and biological in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications: Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#1) to be free from abuse by another resident (#2). The deficient practice could result in further abuse of residents when appropriate actions are not taken.Findings Include:-Resident #1(alleged victim) was readmitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis of the left non-dominant side, major depressive disorder, and age-related bilateral cataract.The census report revealed that Resident #1 shared the same room with Resident #2 since September 26, 2025.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13.0, indicating that the resident was cognitively intact. The assessment also included that the resident had not exhibited behavioral symptoms.Review of the comprehensive care plan dated September 14, 2023, revealed the resident had a potential for a psychosocial well-being problem related to the disease process, and the resident was at risk for impaired cognitive function. The interventions included to provide necessary cues, stop and return if agitated, and ensure/provide a safe environment.The nursing progress note dated October 5, 2025, revealed that at approximately 4:15 PM, the certified nursing assistant (CNA/Staff #6) reported that Resident #1 had a bloody face and that Resident #2 was walking away from Resident #1. According to the document, the nurse found Resident #1 in the restroom with blood on his face, had superficial wounds to the right forehead, bridge of nose, tip of nose, upper lip, and chin. The documentation included that Resident #2 used his hand to hit the face of Resident #1. Further, the documentation included that Resident #1 wanted to press charges, and the police were called.The care plan was revised on October 5, 2025, to include a resident-to-resident incident report. The intervention included to monitor for psychosocial changes and changes in mood/behavior patterns.The Weekly/PRN Skin Evaluation dated October 5, 2025, revealed lacerations to the right forehead measuring 2.0 by 0.2; bridge of nose measuring 1.4 by 1.5; top of nose measuring 0.8 by 0.1; top of lip measuring 0.4 by 0.1; and chin measuring 0.8 by 0.1.There was no evidence found that Resident #1 was transferred to the hospital.-Resident #2 (alleged perpetrator) was admitted on [DATE], with diagnoses that included cellulitis of the right lower limb and Type 2 Diabetes Mellitus.The IDT (Interdisciplinary Team)-BIMS assessment dated [DATE], revealed Resident#2 had a BIMS score of 15.0, indicating that the resident was cognitively intact.A review of the Nursing progress note dated October 5, 2025, revealed that at approximately 4:15 PM, the CNA (Staff #6) noted Resident #2 was walking away from Resident #1 who had blood on his face. Per the progress note, Resident #2 initially denied hitting Resident #1, but later admitted to hitting Resident #1 due to his use of a racial slur.Another nursing progress note dated October 5, 2025, revealed Resident #2 was discharged from the facility after signing AMA.The undated facility investigation report revealed a Resident-to-Resident incident between Resident #1 and Resident #2 on October 5, 2025. The Licensed Practical Nurse (LPN/Staff #9) reported to the Director of Nursing (DON/Staff #23) and the administrator (Staff #20) that the CNA (Staff #6) who was in the room of Resident #1 and Resident #2 found Resident #1 with a bloody face while Resident #2 was walking away from Resident #1. Per the report, the LPN found Resident #1 in the restroom with blood on his face, and that Resident #1 insisted that Resident #2 used his hand and making contact on his face. The report also revealed that Resident #1 would like to press charges. Continued review of the facility investigation report revealed that Resident #1 had superficial wounds to the right forehead, bridge of nose, top of nose, upper lip, and chin, and that Resident #2 left the facility against medical advice on October 5, 2025. Further, the facility investigation report concluded that, based on their record review and staff interviews, the incident was an unanticipated and isolated incident that happened in an area with adequate staff supervision.On October 22, 2025, at 10:42 AM, an interview was conducted with Resident #1, who stated that last week or a couple of weeks ago, while he was sitting in his wheelchair, he was hit on his left forehead, had a cut, and was bleeding. Resident #1 stated that he had pain for a couple of hours after he got hit.A phone interview was conducted on October 22, 2025, at 10:56 AM with a CNA (Staff #6), who stated that regarding the incident between Resident #1 and Resident #2, the CNA stated that the day before the incident, Resident #2 was yelling at another resident. The incident between Resident #1 and Resident #2 happened a couple of Sundays ago, and she was working that weekend. She stated that Resident #2 was only in the facility for a short time, and Resident #2 was the aggressor during the incident with Resident #1. She said that she was at the nurses' station when she heard a resident yelling, stop hitting him. The CNA stated that the resident who was yelling, stop hitting him, was in the hallway and witnessed the incident. She said that when she entered the room, she saw Resident #1 wheeling himself into the bathroom, and Resident #2 was walking towards her.A phone interview was conducted on October 22, 2025, at 11:36 AM with the LPN (Staff #9), who stated that if abuse occurs, she would stop it and notify the abuse coordinator and the DON. She stated that abuse can be financial, physical, verbal, and seclusion, and that physical abuse was anything that comes into contact with another resident, such as hitting and throwing something at somebody. She stated that she was working the day of the incident, a few weekends ago, when Resident #2 hit Resident #1 on the forehead. She stated that a CNA was alerted by another resident of the incident and that she documented the incident in her progress note. She said that Resident #2 left AMA the same day of the incident, and Resident #1 had cuts and blood on his face.A phone interview with another LPN (Staff #16) was conducted on October 22, 2025, at 11:52 AM. The LPN stated that abuse can be physical, verbal, sexual, financial, and emotional, and if verbal or physical abuse or any type of abuse happens, she will make sure the resident was safe. Regarding the incident between Resident #1 and Resident #2, she said that the incident happened two weeks ago, on a weekend, on a Sunday, and that Resident #1 was hit by his roommate/Resident #2, who left the facility the same day with his family member.During an interview with the DON (Staff #23) on October 22, 2025, at 1:02 PM, the DON stated that she expected the staff to intervene for safety, report any allegation or suspicion of abuse, and notify her and the administrator/abuse coordinator when there is an allegation of abuse immediately. She said that abuse is any allegation, even if not seen, that could be mental, verbal, seclusion, physical, or sexual. She said that an example of physical abuse would be any unwanted contact, like hitting. Regarding Resident #1 and Resident #2 incident that happened on that Sunday, the DON stated that Resident #1 and Resident #2 were roommates. She said that the incident was not witnessed, but Resident #2 reported his hand making contact with the face of Resident #1. The DON stated that Resident #1 had blood on his face and wanted to press charges against Resident #2.Review of facility policy titled, Abuse: Prevention of and Prohibition Against, reviewed and revised in October 2024, revealed that each resident has the right to be free from abuse.Review of facility policy titled, Resident Rights, reviewed in June 2025, revealed that all resident rights be followed per state and federal guidelines as well as other regulative agencies. The Resident has the right: (2) To be free from verbal, sexual, mental, or physical abuse.

Based on observations, staff interviews, review of the clinical record and the facility policy and procedures, the facility failed to ensure nail care was provided for two residents (#18 and #28) out of 89. The deficient practice could result in resident grooming and hygiene needs not being met.-Findings include: Resident #28 was admitted on [DATE] with diagnoses that included generalized muscle weakness, unspecified lack of coordination, cognitive communication deficit, other toxic encephalopathy, type 2 diabetes mellitus and morbid obesity due to excess calories. A minimum data set (MDS) assessment for Resident #28 was completed on August 02, 2025 with a brief interview mental status (BIMS) score of 12, meaning moderate cognitive impairment. Resident #28's care plan had a focus of activities of daily living (ADL) deficit related to weakness. Goal to safely perform bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene tasks. Resident #18 was admitted on [DATE] (initial admission date of August 3, 2011) with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, opioid dependence, cognitive communication disorder, and anxiety disorder. A minimum data set (MDS) assessment for Resident #18 was completed on September 16, 2025 with a brief interview mental status (BIMS) score of 03 which indicated that the resident had severe cognitive impairment. Resident #18 was dependent on staff with personal hygiene with the assistance of x1 staff as indicated by the care plan. An observation was conducted on September 23, 2025 at 10:08 a.m. in Resident #28's room, while the resident was in bed with her feet exposed with no sheet or blanket covering them. Resident #28's toe nails were discolored, yellow brown in color. The toe nails to all 10 toes were overgrown. The great toes (or first toes) bilaterally were overgrown up and curling sideways, towards the other toes on the respective foot. The other nails were curling over the top end of the toes and over onto the pads of the plantar surface of the toes (bottom of the feet). An interview was conducted on September 23, 2025 at 10:08 a.m. with certified nursing assistant (CNA) Staff #33 and revealed that podiatry will be called in to clip the nails. An interview was conducted on September 23, 2025 at 10:12 a.m. with registered nurse (RN) Staff #92 and revealed that the RN did not know the process for clipping nails and had to ask Staff #33 what the process was. A review of orders on September 23, 2025 10:47 a.m. revealed that Resident #28 had an active order that read May see Podiatry of Choice. An observation was conducted on September 24, 2025 at 09:36 a.m. and revealed Resident #28's toe nails were still long and discolored. An interview was conducted on September 25, 2025 at 09:34 a.m. with Resident #28 and revealed that it has been over two months since her toe nails were clipped. Resident #28 does not like to walk and uses a wheel chair. An interview was conducted on September 25, 2025 at 10:11 a.m. with CNA Staff #33 and revealed that the process for clipping nails, depends on the resident. If they are diabetic, the nurse will clip. If nails are long and curving, the podiatrist will clip. An interview was conducted on September 25, 2025 at 12:20 p.m. with licensed practical nurse (LPN) Staff #87 and revealed the process for clipping toe nails, starts with asking a CNA. If the resident is diabetic, you notify the doctor and get an order for a podiatrist to clip the nails. The responsibility for clipping nails belongs to all of the staff. If a resident refuses to have their nails clipped, you document and notify the doctor. The risk for not trimming the long toe nails is infection and they could cut themselves. Medical records Staff #61 is responsible to set up the appointments and transportation. Review of Resident #28's shower sheets revealed that only two shower sheets had documentation that the nails needed to be clipped. The dates were September 5, 2025 and September 20, 2025. The shower sheets were signed off by a nurse on both dates. A review of Resident #28's orders conducted on September 26, 2025 at 08:57 a.m. revealed no orders or documentation for a visit to have their toe nails clipped by the Podiatrist. An interview was conducted on September 26, 2025 at 0940 a.m. with MDS coordinator Staff #96 and revealed that when conducting a head to toe assessment, if a resident is noted to have long toe nails, social services would be notified to schedule an appointment to have the resident's toe nails clipped. An interview was conducted on September 26, 2025 at 1026 a.m. with social services director Staff #76 [NAME] and revealed that she only schedules podiatry, audiology and dental appointments for long term care residents and that the case manager would schedule for skilled residents. An interview was conducted on September 26, 2025 at 1035 a.m. with case manager Staff #81 and revealed that she does not schedule appointments, social services does and was never told because it's not my realm. An interview was conducted on September 26, 2025 at 10:42 a.m. with CNA Staff #33 and revealed the process for filling out the shower sheets. When an issue has not been there before, you let the nurse know. Toe nails are marked every time the resident has a shower. An interview was conducted on September 26, 2025 at 10:54 a.m. with RN, clinical resource Staff #112 and revealed that a licensed nurse can clip the nails or refer to a podiatrist. The nurse would refer to social services and then follow up with an appointment, the podiatrist will come on a schedule and see all the patients that need to be seen. An observation was conducted on September 26, 2025 at 11:07 a.m. with Staff #112 in Resident #28's room and revealed Resident #28's nails were yellow brown, discolored, curved, growing over the tops of the toes and curving over onto the pads of the toes of both feet. Staff #112 revealed that with the length of the nails, they can snag and potentially scratch self. Resident #18 was admitted on [DATE] (initial admission date of August 3, 2011) with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, opioid dependence, cognitive communication disorder, and anxiety disorder. A minimum data set (MDS) assessment for Resident #18 was completed on September 16, 2025 with a brief interview mental status (BIMS) score of 03 which indicated that the resident was severely cognitively impaired. Resident #18 was dependent on staff with personal hygiene with the assistance of x1 staff as indicated via the care plan. An observation was made on September 23, 2025 at 11:36 a.m. in the facility dining room. Resident #18 was observed eating a soft pureed looking food with her left hand. The fingernails were long and food was noted under the nails. The resident's feet were covered in a sock looking foot covering. An observation was made on September 25, 2025 at 09:22 a.m. and revealed that Resident #18's fingernails had been clipped, however it was noted at that time that the resident did not have shoes or socks on and Resident #18's toe nails on both feet were noted to be long and extending over the end of the toes. Review of the shower sheets for Resident #18, from the most recent admission date through September 23, 2025, revealed that the shower sheets were not always filled out completely at the nails clipped or needed clipping. On the shower sheet from September 15, 2025 the certified nursing assistant (CNA) signed the sheet and marked an x in the not needed box for nails clipped. Review of the facilities policy titled, Desert Terrace Healthcare Center Policy/Procedure - Nursing Services, Section: Quality of Care Subject: ADL's-hygiene, grooming, toileting, bathing, oral care, dressing, grooming, mobility, transfers, ambulation, etc. Revised July 2015, revealed, if a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming, toileting and personal oral hygiene will be provided by qualified staff.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#44) was not abused by another resident (#55). The deficient practice could result in residents being physically and emotionally harmed. Findings include: Resident #44 was admitted on [DATE] with diagnoses that included bipolar disorder, generalized anxiety, unspecified mood disorder, and end stage renal disease. The care plan dated March 10, 2023 revealed that the resident has a potential for injury while smoking. The interventions included to observe the resident smoking, while in the designated area. The Minimum Data Set, dated dated dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. An alert note dated April 24, 2023 at 6:56 p.m. revealed that resident #44 was assaulted by another resident on the patio at 5:30 p.m. The resident reported having a disagreement with the other resident and he began to hit him in the back of his head on the right side. The resident refused to go to the hospital. A progress note dated April 24, 2023 at 7:50 p.m. revealed that at approximately 5:30 p.m. the resident was sitting on the smoking patio, when another resident stood up and approached him unprovoked and punched him behind his right ear. The certified nursing assistant immediately separated both residents. The area behind the right ear was noted to have redness. Resident #44 denied any pain and stated did not need to go and be checked out. The resident was placed on a change of condition for monitoring. The provider assessed the resident with no new orders at this time. An Interdisciplinary Team (IDT) meeting note dated April 25, 2023 revealed that on April 24, 2023, the resident was sitting on the smoking patio with the other residents when another resident quickly stood up from his wheelchair and approached this resident, unprovoked, and punched him behind his right ear. A certified nursing assistant (CNA) witnessed the interaction and immediately stepped between the residents separating them. This resident chose to stay on the smoking patio. Resident #44 stated to the CNA that he didn't say anything to the other resident and that resident (#55) just got up and started hitting him. Resident #44 refused a skin assessment, but does have a small reddened area noted behind the right ear. The provider was in the facility and checked the resident. A care plan dated April 25, 2023 revealed that the resident has the potential for a mood problem, behavior problems related to depression, anxiety, bipolar disorder, mood disorder, irritability, and anger. On April 24, 2023, an incident was witnessed with another male resident. Interventions included to monitor/observe in mood/behaviors, fear of other residents and /or staff and notify provider if present. -Resident #55 was admitted on [DATE] with diagnoses that included unspecified mood affective disorder, psychoactive substance abuse, nicotine dependence, and dysphagia. The care plan dated March 10, 2023 revealed that the resident has a potential for injury while smoking. The interventions included to observe the resident while in the designated area. Review of the care plan dated March 14, 2023 revealed that resident #55 took anxiety medication related to anxiety as evidenced by restlessness. Interventions included to monitor/record occurrence of target behavior symptoms (restlessness) and document per facility protocol. Review of the care plan dated March 14, 2023 revealed that resident #55 was prescribed psychotropic medications related to a traumatic brain injury that induces psychosis as evidenced by paranoid delusions. Interventions included to monitor/record occurrence of target behavior symptoms (paranoid delusions) and document per facility protocol. The Minimum Data Set, dated dated dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. A nurse progress note dated April 24, 2024 at 7:25 a.m. revealed that the resident was noted to have a significant change in mental status. The medical doctor was notified and received new orders for UA (Urinalysis)/ CMP (Compressive Metabolic Panel). The nursing note dated April 24, 2023 at 8:28 a.m. stated that the nurse received additional orders for a psych consult and additional labs as well. A physician note dated April 24, 2023 at 1:52 pm (late entry) included a history of present illness, which revealed that the resident had previously exhibited aggressive/violent behavior while in another skilled nursing facility. The nurse note dated April 24, 2023 at 3:41 p.m. revealed that the resident continues to have episodes of increased agitation in which the resident refuses to take medications and continue to not be able to redirect the resident. A nurse note dated April 24, 2023 at 6:35 p.m. revealed that the resident was transported to the hospital via 911 related to increased agitation. An interview was conducted on January 24, 2025 with a certified nursing assistant (CNA/staff #13), who stated that there is supposed to be at least one staff present when the residents are smoking to ensure the safety of the residents, which includes supervising the residents to ensure that they are not harming each other. She stated that if a resident was agitated and heading toward another resident, she would redirect the resident and if the resident hits another resident, it is abuse. An interview was conducted on January 24, 2025 at 3:11 p.m. with a licensed practical nurse (LPN/staff #21), who stated that staff should be able to recognize if there is a change in a resident's body language and know if a resident is becoming agitated. He stated that he and other staff have been trained on deescalating techniques and if a resident hits another resident, it is abuse. An interview was conducted with the Director of Nursing (DON/staff #1) on January 24, 2025 at 3:44 p.m. Staff #1 stated that it is her expectation that staff read cues when supervising the residents and if a resident has a diagnosis, the staff should be monitoring the behaviors. She also stated that all of the staff have received training on abuse and when a resident hits another resident, she considers it abuse. The facility policy, Abuse: Prevention of and Prohibition Against states that it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#20) and (#40) were free from abuse from other residents (resident #75). The deficient practice could result in further incidents of resident to resident abuse. Findings include: Regarding resident #20 and resident #75 -Resident #20 was admitted to the facility on [DATE], with diagnoses that included hemiplegia, urinary tract infection, gastroesophageal reflux disease, anxiety, and bipolar disorder. Review of the Discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that the resident had no cognitive impairment. A behavioral care-plan initiated September 24, 2024 revealed that the resident was at risk for impaired cognitive function related to hemiplegia and hemiparesis following cerebral infarction, with a noted intervention of monitor, document, and report to provider any changes in cognitive function, decision making ability, difficulty understanding others, and mental status. -Resident #75 was admitted to the facility on [DATE], with diagnoses that included post traumatic stress disorder, anxiety, attention deficit hyperactivity disorder, substance abuse, insomnia, and depression. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A behavioral care-plan initiated September 26, 2024 revealed the resident was at risk for trauma related to history of trauma, and post-traumatic stress disorder, which a goal of no emotional, physical, or psychological problems by the review date of December 18, 2024 and noted interventions of anticipate and meet the residents needs and resident can be triggered by loud noises so provide a calm and quiet environment. A review of the clinical record progress notes for resident #20 dated September 30, 2024 at 12:46 a.m. revealed that the nurse knocked on resident #20's door, and upon opening resident #20 and resident #75 were raising their voices at each other. Resident #20 was out of bed moving her wheelchair and ambulating, at the same asking for her cellphone back from resident #75. Both residents continued raising their voice at each other, and resident #75 suddenly raised her voice and threatened resident #20 over the cell phone disagreement and threw the cell phone on the floor. An interview was conducted with a Certified Nursing Assistant (CNA/staff #55) on October 10, 2024 at 2:20 p.m. The CNA reported that resident #75 has had altercations with several residents. The CNA stated that resident #75 had psyche issues and would accuse residents of stealing her things like clothes and other belongings, even though the items were donated by the facility to resident #75. The CNA concluded that resident #75 was the instigator in the incident with resident #20. Regarding resident #40 and resident #75 -Resident #40 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure, pneumonia, heart disease, congestive heart failure, insomnia, and depression. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A review of the clinical record progress notes for resident #40 dated October 3, 2024 at 10:00 a.m. revealed that resident #40 and resident #75 were engaged in a verbal exchange in the hallway. It was then observed that resident #75 raised her leg and made contact with resident #40 in the abdomen. It concludes that the residents were separated and resident #40 wished to continue to discharge as planned. An interview was conducted with a Certified Nursing Assistant (CNA/staff #91) on October 10, 2024 at 1:34 p.m. The CNA stated that resident #75 was alert and oriented, however she was also very behavioral. The CNA stated that she heard the resident's arguing from another room, darted out into the hallway where she witnessed resident #75 kick resident #40 in the chest. The CNA concluded that this was the first time she has seen resident #75 get physical but also stated that she had been verbally aggressive before. An interview was conducted with a Licensed Practical Nurse (LPN/staff #110) on October 10, 2024 at 2:50 p.m. The LPN stated that resident #75 was alert and oriented but was a textbook, druggie type of patient, and noted that she would yell out at staff and other residents. The LPN stated that resident #75 was put in a room by herself because she would cause problems any time she had a roommate. The LPN stated that resident #75 would make paranoid statements; and that, the staff would simply redirect her as best as they could. An interview with the Director of Nursing (DON/staff #15) was conducted on September 10, 2024 at 3:16 p.m. The DON stated that resident #75 had not been at the facility long; and that, she admitted on psychiatric medications. The DON stated that the resident on arrival was asking for dosage increases on her medications that were not appropriate. The DON stated that the first incident with resident #20 raised concerns, but she thought it was an isolated incident, and that they were separated immediately. The DON then stated that the second incident involving resident #40 and resident #75 confirmed the residents were arguing in the hall, and resident #75 raised her up and made physical contact between the two. The DON concluded that after the incident they put resident #75 on 1 to 1 with staff, and eventually had her petitioned to go to a psyche facility. The DON concluded that her expectation is that residents are separated when an incident occurs and reported appropriately. A review of facility policy titled 'Abuse: Prevention of and prohibition against' revised October of 2024 revealed that it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident's property, and exploitation. It further revealed that willful as used in this definition of abuse, means the individuals must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on staff interviews, review of records and review of policies and procedures, the facility failed to ensure that medical records were documented accurately and in accordance with accepted professional standards and practices for one resident (#12) regarding vital signs and blood glucose monitoring. The deficient practice could result in inaccurate records being documented for additional residents. Findings include: Resident #12 was readmitted on [DATE] with diagnoses that included osteomyelitis of vertebra, sacral and sacrococcygeal regions, pressure ulcers of left buttock (stage 4), left hip (stage 4), right hip (stage 4), type 2 diabetes mellitus, and depression. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] included that Resident #12 had intact cognition, required setup or clean up assistant for eating, and was incontinent of bowel/bladder. Review of June 2024 Medication Administration Records (MAR), revealed Resident #12 was administered insulin glargine (Lantus) on June 25, 2024 and June 26, 2024, with no record of Resident #12's blood sugar results. Review of June 2024 POC (point of care) Certified Nursing Assistant (CNA) Task documentation, revealed no evidence of vital signs performed on the evening shifts June 25, 2024 and June 27, 2024. Regarding Vital Sign Documentation: An interview was conducted on July 2, 2024 at 2:45 PM with CNA (staff #1), who stated that she was assigned to care for Resident #12 on the evening shift (2:00 PM - 10:00 PM) on June 28, 2024. The CNA stated that she completes documentation for all residents at the end of her shift, but did not complete documentation for Resident #12 that day. An interview was conducted on July 3, 2024 at 10:15 AM with a Licensed Practical Nurse (LPN/staff #2), who stated that CNA's are responsible for charting resident vitals in the medical record. An interview was conducted on July 3, 2024 at 12:20, with an LPN (staff #5) who stated the facility policy is for CNA's to complete vial signs twice a day, on the day and evening shifts, prior to the nurses' shift. The LPN stated that this is done to ensure that nurses can start medication pass immediately at the start of their shifts. An interview was conducted on July 3, 2024 at 11:53 AM, with CNA (staff #4), who stated that the 2-10 PM shift CNA's are required to complete vitals at 2:00 PM, and to document the results in the medical record. The CNA reviewed Resident #12's medical record and stated that there was no evidence that vitals during the 2:00 PM - 10:00 PM shifts on June 25, 2024 and June 27, 2024 had been conducted. The CNA further stated that this did not meet the facility requirements for documentation of resident's vitals. An interview was conducted on July 3, 2024 at 1:45 PM with the Director of Nursing (DON/staff #6), who stated that vitals should be conducted twice daily, and expected vitals to be conducted each nursing shift. The DON reviewed the medical record for Resident #12, and stated that there was no evidence that vitals had been obtained on June 25, 2024 and June 27, 2024 on the evening shift. The DON further stated that this did not meet her expectations and did not follow the facility policy. The DON stated the risk could include the potential to miss an acute change. Review of the facility policy titled, Documentation and Charting, included it is the policy of the facility to provide documentation of the resident's care, treatment, response to the care, signs, symptoms, as well as progress of the resident's care. Regarding Blood Sugar Monitoring: An interview was conducted on July 3, 2024 at 10:15 AM, with a Licensed Practical Nurse (LPN/staff #2), who stated that orders for medications/treatments come from the referring hospital, that would include blood sugar monitoring for resident's with diagnoses of type 2 diabetes mellitus. The LPN stated that the facility policy is to check blood sugar levels prior to administering insulin, any time insulin is ordered. The LPN also stated that the facility process for insulin administration included completing a blood glucose test prior to administrating insulin, and documenting the results in the medical record. The LPN stated that the risk of not monitoring blood sugars prior to administration of insulin could result in the resident's blood sugar bottoming-out, which could cause death. The LPN further stated that the standard of care for resident's with diabetes and insulin orders would be to check blood sugars twice a day and regularly monitor glucose levels. An interview was conducted on July 3, 2024 at 11:07 AM, with an LPN (staff #3), who stated that the facility policy is to monitor blood glucose levels as ordered, and the standard of care is to check blood glucose levels prior to administering insulin. The LPN reviewed the medical record and stated that Resident #12 received insulin on June 25, 2024 and June 26, 2024, but she found no evidence that a blood glucose test had been performed. The LPN also stated that Resident #12's blood glucose had not been monitored since June 12, 2024. The LPN further stated that the admission nurse should have called the provider for orders to monitor blood glucose levels, because Resident #12 had an order for insulin glargine (Lantus). An interview was conducted on July 3, 2024 at 1:45 PM with the Director of Nursing (DON/staff #6), who stated that blood glucose monitoring depends on the hospital orders and the patient. The DON further stated that insulin glargine (Lantus) is not held for low blood glucose levels, because it does not have immediate effects. The DON stated the standard of care for insulin administration would be to monitor for signs/symptoms of hypoglycemia, in lieu of physician orders for glucose monitoring. Review of the facility policy titled, Insulin Injections, revealed insulin injections and blood glucose monitoring will only be done following physician's orders. Lantus (insulin glargine injection) administration instructions included not to take Lantus during episodes of low blood sugar, test blood sugar levels while using insulin, such as Lantus. Individualize dosage based on metabolic needs, blood glucose monitoring, glycemic control, type or diabetes, and prior insulin use.

Based on observations, staff interviews, facility documents, and resident records, the facility failed to ensure 3 residents received medications in a timely manner. The sample size was 3. Findings include: 1) Resident #7 admitted to the facility on [DATE] with diagnoses that Osteomyelitis, Atherosclerotic Heart Disease, Anxiety Disorder, and Depression. According to the Minimum Data Set assessment completed on 12/29/2023, the Brief Interview for Mental Status revealed a score of 15 with suggested he was cognitively intact. He has an order dated 1/22/2024 for Ceftaroline Fosamil Intravenous Solution 600 MG (milligrams) intravenously two times a day for an infection of prosthetic knee joint. Review of his Medication Administration Report for January 2024, does not show any missed doses. His Ceftaroline IV medication is scheduled for 8:00 AM and 8:00 PM, with a leeway of 1 hour before and after. This means nursing staff is permitted to administer his medication between 7:00 AM to 9:00 AM, or 7:00 PM to 9:00 PM. However, on 1/2/2024, his 8:00 PM Cerftaroline dose was administered at 11:50 PM. On 1/4/2024 his 8:00 PM Cerftaroline dose was administered at 1:24 AM on 1/5/2024. On 1/5/2024 his 8:00 AM dose was administered at 10:24 AM and his 8:00 PM dose was administered at 10:19 PM. On 1/6/2024 his 8:00 PM dose was administered at 1:03 AM on 1/7/2024. On 1/7/24 his 8:00 AM dose was administered at 10:07 AM and his 8:00 PM dose was administered at 2:37 AM on 1/8/2024. In his care plan imitated on 12/22/2023, he has goals for his left knee infection to be free from complications with the intervention to administer antibiotic as per medical doctor orders. In a electronic Medication Administration Record (eMAR) note dated 1/1/2024 07:48 AM, it states his Ceftaroline Fosamil Intravenous Solution Reconstituted 600 MG is on order. A progress note dated 1/6/2024 2:25 PM revealed Nursing discussed concerns with resident regarding medication administration and times. Resident was informed about off site pharmacy and the facilities' need to wait for delivery when he first admitted to the facility. Medication administration discussed with resident which shows that, while some doses were given late, all doses have been documented as administered. Resident verbalizes understanding and voiced no further concerns. A subsequent eMAR note time stamped 1/12/2024 10:58 AM documents Ceftaroline Fosamil Intravenous Solution Reconstituted 600 MG unavailable. Pharmacy notified, MD notified. Hold. 2) Resident #9 was admitted on [DATE] with diagnoses that included Staphylococcal Arthritis, Left Knee Osteoarthritis, Tachycardia, and Cervical Disc Disorder With Myelopathy. Residnet # 9 had an order dated 1/11/2024 for 1000 mg of Vancomycin HCl Intravenous Solution every 12 hours for bone and joint infection until 01/20/2024. He also had an order dated 1/15/2024 for 2 grams of Ceftriaxone Sodium Solution Reconstituted every 24 hours for infection related to tachycardia. A review of his January MAR revealed a 7 was entered in place of administration of his Vancomycin on 1/8/2024, 1/9/2024 and 1/13/2024, as well as on 1/15/2024 for his Ceftriaxone. The chart code key indicates that a 7 means Other/See Nurse Notes. His Vancomycin medication is scheduled every 12 hours for 8:00 AM am and 8:00 PM, with 1 hour grace window before and after. This means nursing staff is permitted to administer his medication between 7:00 AM to 9:00 AM, or 7:00 PM to 9:00 PM. On 1/13/2024, his 8:00 AM dose of Vancomycin was administered at 10:18 AM and his 8:00 PM dose was administered at 10:00 PM. Resident #9's care plan initiated on 1/8/2024 revealed goal to be free of complications related to left knee infection with intervention to administer antibiotics as per orders. Corresponding eMAR notes for Vancomycin administration on 1/8/2024 10:19 PM reveal awaiting arrival from pharmacy. On 1/9/2024 at 1:07 PM: Followed up with pharmacy, medication will be delivered on 2:00 PM run, resident and MD aware, on 1/9/2024 at 8:00 PM, New order. Not yet in from pharmacy. On 1/13/2024 at 10:00 PM they took a vanco trough, with a progress note on 1/14/2024 at 4:34 PM stating Vancomycin was to be held and another trough taken due to previous trough being 36.7. Regarding Ceftriaxone, an eMAR note dated 1/15/2024 at 10:30 PM stated awaiting from pharmacy. 3) Resident #12 was admitted on [DATE] with diagnoses that included Cerebral Infarction, Hemiplegia And Hemiparesis, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, and Bipolar Disorder. According to a Brief Interview for Mental Status completed on 1/11/2024 by the interdisciplinary team, he score a 14 which indicates cognitive intactness. He had an order dated 1/4/2024 for 2 grams of Ceftriaxone Sodium Solution Reconstituted every 24 hours for Bacteremia. A review of his January Medication Administration Record (MAR) revealed a 7 was entered in place of administration of his Ceftriaxone on 1/4/2024, and a 10 on 1/5/2024. The chart code key indicates that a 7 means Other/See Nurse Notes and a 10 means hospitalized . There was no missed charting. His Ceftriaxone medication is scheduled at 2:00 PM every 24 hours, with an 1 hour grace window before and after. This means nursing staff is permitted to administer his medication between 1:00 PM and 3:00 PM. On 1/13/2024, his dose of Ceftriaxone was administered at 4:08 PM. On 1/10/2024, his dose was administered at 5:11 PM, and on 1/4/2024, it was administered at 4:08 PM. His care plan did not reflect any goals or interventions for antibiotics. An eMAR note for 1/4/2024 at 4:08 PM stated awaiting medications; patient just admitted to facility. During an interview conducted on 1/16/2024 at 1:17 PM with Resident #9, he stated he does not get his antibiotics on time. During an interview at 1:30 PM with Resident #12, he stated his medications are often late and he never gets his antibiotic on time. He states he will be told by the nurse that the pharmacy has not delivered it yet, or that there is a lot going on and they have a lot of patients. In an interview with a Licensed Practical Nurse (LPN/Staff #34) conducted on 1/16/2024 at 12:10 PM, she stated scheduled medications can be administered on hour before or one hour after the scheduled time, or they are considered late. She stated if antibiotics are given hours later it does not make them less effective. When asked why Resident #7's Ceftriaxone was not available on 12/23/2023, 12/26/2023, 1/1/2024 and 1/12/2024, she stated it was because the pharmacy only send so much IV medications and they will have to call to have more sent out. At 11:25 AM a chart review was completed with LPN (Staff #4) for resident #7 which revealed late administration on multiple occasions. She stated that even being given late doses, his condition would not worsen. She confirmed that he was given medications outside of parameters as it was supposed to be given within the hour before and hour after. During an interview on 1/16/2024 at 11:30 AM with Pharmerica, the Pharmacist Technician Supervisor, (Staff #78) stated they fill a 2 day supply which is 4 doses each time. He stated they track the medication and it will be sent out automatically. He stated they do not show any days where the pharmacy missed sending refills. He stated due to the stability of the medication, they can only send 2 days at a time. The Director of Nursing (DON/Staff #7, and the Clinical Resource Nurse, (Staff #20) were interviewed at 12:57 PM on 1/6/2024. The DON stated her expectation for administration of medications is that it should be within an hour of the scheduled time. This is for consistency and to make sure they do not get medications too close together. Regarding if it affects the effectiveness of the antibiotic, she stated they have a therapeutic level so not as much, but that it should still be passed on in report. Regarding the Ceftriaxone being so late so often, Staff #20 stated it is a a high cost medication and the half life of medication means they can only deliver 2 days at time. The pharmacy does have a morning and evening run, but she was unable to answer why there is such a discrepancy in times of administration. After reviewing the medication administration record for Residents #12, #9, and #7, she stated she would be doing an inservice on it now as she was not able to account for the wide time ranges. In the facility policy entitled Medication Administration- Administration of Drugs last updated on 6/2023, it details that the seven rights of medication administration are as follows in order to ensure safety and accuracy of administration . Right Time - Medications are administered within prescribed time frames.

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents. Findings include: A review of the personnel file for the Activities Director (staff #33) revealed staff #33 was hired on July 11, 2022. Further review of staff #33's personnel file revealed she completed the Arizona State Board of Nursing approved Nurse Aide Training Program on December 16, 2022. Additionally, an undated receipt indicated that she completed and submitted a CNA (Certified Nursing Assistant) application which has not yet been approved. Additional review of staff # 33's personnel file revealed a receipt for Activities Professional Course enrollment dated July 10, 2023. A job description for Activities Supervisor signed by staff #33 on August 24, 2023 indicated the essential duties and responsibilities of the position was to plan, develop, organize, implement, evaluate, and direct the activities programs of the facility. Under qualifications, the education and/or experience indicated that the member must be a qualified therapeutic recreation specialist or an activities professional who is licensed by this state and is eligible for recertification a s recreation specialist or as an activities professional or must behave, as a minimum two years' experience in a social or recreational program within the last five years, one of which was a full-time in a patient activities program in a health care setting. Under certificates and licenses portion, it indicated that the member be licensed or registered, in the State in which practicing or completed a training course approved by the State. An interview was conducted with staff #33 on October 19,2023 at 11:02 a.m., staff #33 stated she does not have her certification as a qualified therapeutic specialist or as an activities professional but is currently enrolled in a program. Staff #33 stated she is the only facility staff in charge of activities and there is no corporate oversight for activities that she has to report to. Furthermore, she stated that she is strictly in charge of activities. The facility policy titled Verification of Licenses revised April 2004 indicated that it is the policy of the company to verify that all employees in positions which require licensure or certification, have a current license or other authorization to practice in the state in which they work. The facility policy titled Employment Applications revised January 2022 noted that the facility requires applicants for employment to complete an employment application and that it used to obtain information regarding the applicant's identification and qualifications for employment.

Based on clinical record reviews, staff interviews and facility policies and procedures, the facility failed to ensure two residents (#116 and #121) were provided with showers or bathing. The sample size was 4. The deficient practice could result in residents' hygiene needs not being met. Findings include: The facility's bathing schedule revealed that showers are provided twice a week and residents receive showers based on their room numbers. The facility's skin observation- shower sheet included instruction to complete all bath or shower days. There was a section for comments and staff signatures. -Resident #116 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged on [DATE]. The ADL (activities of daily living) care plan dated January 25, 2022 included the resident having an ADL self-care performance deficit related to limited mobility, obesity, weakness, and bilateral lower leg swelling. The goal was to maintain the current level of function in ADLs. Interventions included extensive staff participation with toilet use, transfers, bed mobility; and limited extensive staff participation with personal hygiene and oral care. The daily skilled note dated March 17, 2022 included the resident was alert, oriented x 3 (person, place, and time), was independent with bed mobility, and required extensive assistance with one-person physical assistance with transfer and toilet use. The psychiatric note dated March 22, 2022 included staff reported that overall the resident had been compliant with treatment and care. Review of the CNA (Certified Nursing Assistant) documentation from March 1 through 31, 2021 revealed the bathing tasks were coded as NA (not applicable) and 8 indicating the activity itself did not occur from March 1 through March 31. The clinical record revealed no other documentation of showers provided to the resident. There was also no documentation of the reason/s why showers were not provided; and that, the resident refused showers. There was no evidence found that the resident was provided with showers from March 1 through 31, 2021. -Resident #121 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADL care plan dated July 10, 2020 included the resident had ADL self-care performance deficit related to limited mobility from rib fracture. The goal was that the resident will safely perform ADLs. Interventions included encouraging the resident to discuss feelings about self-care deficit, one staff participation to reposition and turn in bed, and to encourage participation to the fullest extent possible with each interaction. Review of the CNA documentation from May 1 through 31, 2021 revealed the resident had a sponge bath on May 11 and a full bath only on May 25 (one out of 31 days). The documentation also coded NA (not applicable) and 8 indicating the activity itself did not occur on May 4, 7, 11, 14, 18 and 28, 2021; and the rest of the boxes were either marked as X or were left blank. The clinical record revealed no other documentation of showers provided to the resident. There was also no documentation of reason/s why showers were not provided; and that, the resident refused showers. There was no evidence found that the resident was provided with showers from May 1 through 31, 2021. During an interview with a CNA (staff #96) conducted on September 8, 2022 at 9:07 a.m., she stated that residents are scheduled for showers; and that the schedules are kept in the shower binder and/or posted at the nurse station. The CNA said that if a resident refuses showers, she will return a little later during the shift and ask the resident again; and, as long as she is still on shift, she will keep asking or at least ask the resident's preference for shower schedule. She said that if the resident still refuses, she will get the nurse as a witness that the resident refused; and, the resident has to sign the shower sheet. The CNA stated that if the resident preferred a sponge bath or bed bath, she will provide it as well and document it in the shower sheet. Further, she stated she could not recall any incident or a particular resident who refused to be showered or was not provided with showers for an entire month. In an interview with a Licensed Practical Nurse (LPN/staff #35) conducted on September 9, 2022 at 9:24 a.m., she stated the schedule for showers is located at the nurses' station and residents received showers according to this schedule. She stated that when showers are provided or when a resident refuses showers, the CNA will document it in the shower sheet and the nurses have to sign on the sheet. She said that way, the nurses will know when a resident refused a shower. An interview with the Director of Nursing (DON/staff #113) was conducted on September 9, 2022 at 11:00 a.m. The DON stated that residents receive showers according to their schedule which is located in a binder at the nurses' station. She stated that when a resident refuses, the staff will attempt to offer the shower throughout the shift; and if the resident still refuses the resident and the nurse will sign the shower sheet form. She stated that sometimes, they hold off signing the shower sheet related to resident refusal until the next shift because the resident may allow them to provide showers later during the day. The DON further said that if the resident still refuses, then it will be documented as refusal. Further, the DON stated there were no shower sheets found for residents #116 and #121. The facility policy on Services to Carry Out Showers and Bed Bath revealed that it is their policy that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care. It also included showers and bed baths will be provided to residents in accordance with the resident's shower schedule provided; and that, showers and bed baths will be documented in the medical record.

Based on clinical record review, facility documentation, resident and staff interviews, and policies and procedures, the facility failed to ensure bathing or showers were consistently provided to one resident (#31). The sample size was 4. The deficient practice could result in hygiene needs not being met. Findings include: Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Staff Assessment for Mental Status that the resident was independent of cognitive skills for daily decision making. The assessment indicated the resident required extensive assistance of one person with personal hygiene, and required physical help in part of bathing with a one-person physical assistance. Review of the Care Plan initiated on November 4, 2021 revealed a focus for activities of daily living self-care performance deficit related to impaired mobility. Interventions included extensive assistance with bathing twice a week and PRN (as needed). Review of the facility shower schedule revealed that resident #31 was scheduled to receive showers on Friday and Tuesday evenings. Review of the shower books on units one and two revealed a shower (form) that included an area to document: if a shower/bath or bed bath was provided, a body diagram to document any new skin areas observed, fingernails clean, toenails clean, nails clipped, need clipping, signature, date and the resident name and room number. Review of the shower books revealed no evidence of shower forms for resident #31. Review of the Bathing task for November 2021 revealed evidence that no showers were provided or refused: -November 4 through November 10, 2021, 6 days -November 14 through November 29, 2021, 15 days Review of bathing task dated July 2022, revealed no evidence that showers were provided or refused: -July 1 through July 14, 2022, 14 days, -July 18 through July 25, 2022, 7 days. No shower sheets were provided by the facility for July 2022. Review of the clinical record bathing tasks dated August 14, 2022 through September 7, 2022 revealed no evidence of a shower being provided or refused between August 16, 2022 and August 22, 2022, 7 days. Shower sheets for November through December 2021 were requested, and July through September 2022. The facility provided shower sheets for two days in August, no others were provided. An interview was conducted on September 7, 2022 at 1:25 PM with a Licensed Practical Nurse (LPN/staff #35), who stated the facility policy is to offer showers or baths twice a week following a schedule. She also stated that Certified Nursing Assistants will document on a shower sheet, and in the clinical record if the shower/bath was completed or refused. She reviewed the medical record and stated that there was no evidence that the resident received or refused a shower between August 15 and August 25, 2022. She also reviewed the shower book and was not able to locate the notebook. The LPN stated that the risk of not receiving consistent showers could result in new skin issues not being identified, and uncleanliness. An interview was conducted on September 8, 2022 at 8:38 AM with a Certified Nursing Assistant (CNA/staff #93), who stated that showers are offered twice a week. He also stated that they document if the shower was given or refused in the clinical record and on a shower sheet twice a week. He further stated that the shower forms are kept in a notebook, but he has only looked in it a couple of times. An interview was conducted on September 8, 2022 at 9:23 AM with a CNA (staff #56), who stated that the facility process is to offer showers two times a week, and they are documented in the clinical record and on a shower sheet. She also stated that it is the CNAs that complete documentation on the shower sheets. The CNA further stated that they document if the resident would refuse a shower in the clinical record and on the shower sheet. The CNA stated that they document that they refuse in both places and that a NA would be documented when it is not their shower day. An interview was conducted on September 8, 2022 at 9:51 AM with resident #31, who stated that she is now receiving showers twice a week. An interview was conducted on September 9, 2022 at 10:23 AM with the Director of Nursing (DON/staff #113), who stated the facility policy is to offer showers twice a week, following a shower schedule. She also stated that they are documented in the clinical record or on a shower sheet. The DON reviewed the shower sheets dated November 2021 and stated that there was no evidence the resident was provided showers for 21 days during the month. She also stated that there were 21 days in July 2022 that there was no evidence the resident was provided or refused showers. Staff #113 further stated that this does not meet her expectation, and could result in odors, rashes or skin changes. Review of the facility policy titled, Showers/Bed baths, revealed showers and bed baths will be provided to residents in accordance with the resident's shower schedule provided. Shower and bed baths will be documented in the medical record/POC. Review of the facility policy titled, Services to carry out, ADL, revealed bathing will be offered at least twice weekly, and PRN per resident request.

Based on clinical record reviews, staff interviews, and facility policies and procedures, the facility failed to ensure care and services related to pressure ulcers were consistently provided to two residents (#124 and #125). The sample size was 3. The deficient practice could result in residents not receiving appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: -Resident #124 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan dated December 16, 2021 included the resident having pressure ulcer development related to limited mobility, weakness, full thickness wounds. Interventions included administering treatments as ordered and monitoring for effectiveness, following facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The weekly skin assessment dated [DATE] revealed the resident had surgical incisions to the right hip, right and left knee that were all well approximated with staples; and had a full thickness open wound to the lateral and medial left lower leg. The skin care plan dated December 17, 2021 included the resident had actual impairment to skin integrity related to multiple fractures and left lower extremity full thickness open wounds; and that, the resident had potential impairment to skin integrity related to decreased mobility. Interventions stated to follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record revealed weekly skin evaluations were completed after December 17, 2021. The weekly skin evaluations dated January 23, 2022 revealed the resident was back from the hospital. A skin assessment was completed and noted discolored purple area to the right heel. Further, it revealed that treatment was provided as ordered. The weekly skin pressure ulcer dated January 23, 2022 revealed an initial evaluation of a SDTI (suspected deep tissue injury) to the right heel described as a purple area, measuring 2.0 cm (centimeters) x 1.5 cm, with defined wound edges, normal surrounding tissue and had no exudate and odor. According to the assessment, the onset date was January 23, 2022. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The weekly skin pressure ulcer dated January 30 and February 6, 2022 revealed the resident had SDTI to the right heel. The wound team administration record for January 2022 revealed the [MEDICATION(S)] treatment was administered to the right heel as ordered. The wound physician note dated February 11, 2022 included that on February 4, 2022, a new DTI (deep tissue injury) was picked up per nursing on return from the ED (emergency department) for evaluation of wounds; and had been using skin prep. Wound assessment included an unstageable pressure injury to the heel obscured full thickness skin and tissue loss and had a status of not healed. The note included dry/scaly peri-wound, measurements of 2 cm x 2.6 cm x 0.01 cm, with no discharge noted and 1-25% epithelialization and 51-75% eschar. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the note did not indicate whether the pressure injury was to the right or left heel. The weekly skin pressure ulcer dated February 13, 2022 included an unstageable pressure ulcer to the left heel with 100% black/brown eschar tissue, measuring 2.0 cm x 2.6 cm, defined wound edges, normal surrounding tissue and no exudate or odor. According to the documentation, the onset date for this wound was January 23, 2022. However, review of the clinical record revealed no evidence that the unstageable pressure ulcer was assessed and monitored until February 13, 2022. Further, there was no evidence found that treatment was provided to the left heel since January 23, 2022. The discharge MDS (Minimum Data Set) assessment dated [DATE] coded that the resident had no pressure ulcer/injury and had no unhealed pressure ulcer/injury. On September 8, 2022 at 2:55 p.m., documentation of any assessment and treatment done to the unstageable pressure ulcer to the left heel was requested from the Director of Nursing (DON/staff #113). The DON provided a handwritten note that read there was no treatment to the left heel; and that there was no wound to the left heel. -Resident #125 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The weekly skin evaluation dated February 6, 2021 revealed pressure wounds noted on the sacrum and bilateral buttocks; treatment was provided as ordered; and no other issues noted at this time. The weekly pressure ulcer dated February 6, 2021 included an unstageable pressure ulcer to the sacrum. The weekly skin evaluation note dated March 13, 2021 included the wound to the sacrum; and that there were no other areas of concern noted. Succeeding documentation in the clinical record revealed the pressure ulcer to the sacrum was assessed, monitored and provided treatment as ordered. The care plan dated April 11, 2021 included the resident had potential impairment to skin integrity related to weakness; and, had stage 3 pressure ulcer to the sacrum related to weakness and impaired mobility. Interventions stated to follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Braden Scale dated April 11, 2021 revealed a score of 17 indicating the resident was at low risk for pressure ulcer. The weekly evaluation dated April 11, 2021 included the resident had a sacrum open wound and no other areas of concern noted. The weekly pressure ulcer dated April 11, 2021 revealed a stage 3 pressure ulcer to the sacrum described as an open area with [CONDITION(S)] to peri-wound. The weekly pressure ulcer dated April 18, 2021 revealed a stage 3 pressure ulcer to the left toe, measuring 1.5 cm x 0.5 cm x 0.1 cm, with scant serous exudate, pink wound bed, no odor, had defined wound edges and normal surrounding tissue. It also included the left toe continued with an open area, with treatment as ordered, and that the onset date for this wound was February 6, 2021. The clinical record revealed no evidence that the stage 3 pressure ulcer to the left toe was assessed and monitored until April 18, 2021. There was also no evidence found that a treatment was provided to the left toe from February 6, 2021 through April 18, 2021. Further review of the clinical record revealed the resident was discharged from the facility on April 19, 2021. During an interview with the DON (staff #3) conducted on September 8, 2022 at 10:48 a.m., the DON stated the facility has 3 wound nurse available 7 days a week; and that, the wound nurse assesses the wound on a weekly basis and documents in the electronic record. She stated that on admission, the nurse would assess the wound and the wound nurse would conduct an assessment the next day to ensure the assessment of the admitting nurse was correct. The DON also said that the floor nurses provide treatment and conduct an assessment on a weekly basis as well; however, the floor nurses cannot stage the wound but can only describe what they see. An interview was conducted on September 8, 2022 at 11:17 a.m. with a Licensed Practical Nurse (LPN/staff #88) who stated that upon admission, the resident is thoroughly assessed from head to toe by the nurse. He stated that only an RN (Registered Nurse) can do an assessment of the wound but any nurse can document what they see; that is a nurse can document size and the surrounding tissue. The LPN also stated that when a Certified Nursing Assistant (CNA) reports a wound, he would document the wound as he sees it and will call the provider for treatment if needed. In an interview with another LPN (staff #35) conducted on September 9, 2022 at 9:24 a.m., the LPN stated that a floor nurse can assess or document what is seen but cannot stage or say the type of wound. She said the wound nurse comes in on a daily basis; and, the wound doctor comes too but she does not how frequent. She said that treatment is provided on a daily basis and/or according to the treatment order. The LPN further stated that when she receives a report that a resident has a wound, she would assess, describe and document the wound and will notify the provider and the wound nurse In another interview conducted with the DON on September 9, 2022 at 11:00 a.m., she stated that any nurse that has confirmed training on wounds can assess the wound; however, she said the floor nurses are not allowed to do staging and identifying the type of wound. The DON said that when a resident is admitted , the floor nurse can describe the wound as they see it; then the wound nurse will assess the wound the following day. Regarding the pressure ulcer/injury of residents #124 and #125, the DON stated that they were data errors; and the nurses are expected to document in the progress note a clarification of the data error such as location of the wound. The facility policy on Wound Management included that it is their policy that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection and prevent new avoidable sores from developing. It also included that the nurse is responsible for assessing and evaluating the resident's condition on admission and readmission. It is expected that once a wound has been identified, assessed and documented, nursing shall administer treatment to each affected area as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, resident and staff interviews, and review of policy and procedures, the facility failed to ensure routine medications were consistently available for two residents (#34 and #67). The sample size was 5. The deficient practice could result in necessary medications not being available and not administered to residents as ordered by the physician. Findings include: -Resident #34 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)] of vertebra, major depressive disorder, anxiety disorder, nicotine dependence and other psychoactive substance use. A physician order dated July 29, 2022 included May hold medication until received from pharmacy. Regarding [MEDICATION(S)] The physician's order dated July 31, 2022 included for [MEDICATION(S)] ([MEDICATION(S)]) 150 mg (milligrams) three tablets by mouth one time a day for bowel care, may hold for loose stools. The order was discontinued September 8, 2022. Review of the August 2022 Medication Administration Record (MAR) revealed the resident did not receive [MEDICATION(S)] every day except on August 5, 18 and 20, 2022. The MAR was marked as '2', a code that meant Hold/See Nurse Notes, on August 25, 26 and 31, 2022 and marked as '7', a code that meant Other/See Nurse Notes, the other days. The corresponding nurse notes revealed the following: -awaiting pharmacy delivery on August 1, 2, 3, 8, 9 and 28, 2022 - UA on August 4 and 11, 2022 -Medication on order on August 6, 12, 13, 16, 25, 26 and 30, 2022 -Medication unavailable on August 14, 21 and 27, 2022 -Pending pharmacy refill on August 19, 2022 The corresponding nurse note for August 7, 2022 stated medication unavailable. NP notified and will call back with possible alternative medication order. However, further review of the progress note did not reveal the NP (Nurse Practitioner) called back with an alternative medication order and did not reveal follow up with the NP. The order was not discontinued or changed. The corresponding nurse note for August 10, 15, 17, 22, 23, 24, 29 and 31, 2022 revealed no documented reason on why the medication was not administered. Review of the September 2022 MAR revealed the resident did not receive [MEDICATION(S)] from September 1 through September 7, 2022. The MAR was marked as '2' on September 2, 5, 6 and 7, 2022 and marked as '7' on September 1, 3 and 4, 2022. The corresponding nurse notes revealed the following notes: -On order on September 1, 2022 -waiting for insurance to cover cost this medication/not given on September 2, 2022 -Medication unavailable on September 3, 2022 The corresponding nurse note for September 4, 2022 stated the medication was unavailable and the pharmacy was notified. Per the pharmacy the facility was notified of the cost of medication but the pharmacy never heard anything back. The note also stated will follow up with DON (Director of Nursing). The corresponding nurse note for September 5, 6, and 7, 2022 revealed no documented reason why the medication was not administered. Review of the progress notes did not reveal evidence the medication was administered or that the provider was notified from August 1 through 6, 2022, and August 8 through September 7, 2022. The progress note dated September 8, 2022 stated an order was received from the NP to discontinue [MEDICATION(S)]. Regarding [MEDICATION(S)] The physician's order dated August 7, 2022 included [MEDICATION(S)] 145 mcg (micrograms) one capsule by mouth one time a day for bowel care. The order was discontinued on September 8, 2022. Review of the August 2022 MAR revealed the resident did not receive [MEDICATION(S)] on August 8 through August 17, August 19, and August 23 through August 31, 2022. The MAR was marked as '2' on August 25, 26 and 31, 2022 and marked as '7' the other days. The corresponding nurse notes revealed the following: -Medication unavailable on August 8, 14 and 27, 2022 -awaiting pharmacy delivery on August 9 and 28, 2022 - UA on August 11, 2022 -Medication on order on August 12, 13, 16, 25, 26 and 30, 2022 -Pending pharmacy refill on August 19, 2022 The corresponding nurse note for August 10, 15, 17, 23, 24, 29 and 31, 2022 revealed no documented reason why the medication was not administered. Review of September 2022 MAR revealed the resident did not receive [MEDICATION(S)] from September 1 through September 7, 2022. The MAR was marked as '2' on September 2, 5, 6 and 7, 2022 and marked as '7' on September 1, 3 and 4, 2022. The corresponding nurse notes revealed the following notes: -On order on September 1, 2022 -waiting for insurance to cover cost for this medication/ not given on September 2, 2022 -Medication unavailable on September 3, 2022 The corresponding nurse note for September 4, 2022 stated Medication unavailable, pharmacy notified and reported meds will be delivered this evening. The corresponding nurse note for September 5, 6, and 7, 2022 revealed no documented reason why the medication was not administered The nursing progress note dated September 8, 2022 stated the pharmacy was called several times to follow upon the [MEDICATION(S)] medication. Prior authorization was not completed by the pharmacy. The physician was called to see if the medication could be replaced. The resident does not want an alternative medication. Waiting for the pharmacy and the physician to update. Will continue to follow-up. The progress note dated September 8, 2022 stated orders were received from the NP to discontinue [MEDICATION(S)]. Review of the progress notes did not reveal evidence the medication was administered or that the provider was notified before September 8, 2022. An interview was conducted with the resident #34 on September 8, 2022 at 2:02 pm. The resident stated that she feels constipated most of the time and goes between constipation and diarrhea. An interview was conducted with the Licensed Practical Nurse (LPN/staff #88) on September 8, 2022 at 2:08 pm. He stated that when a medication is unavailable, the process is to reorder the medication, contact the provider and go from there. He stated when a medication is unavailable, he will document it on the MAR and provide the reason the medication was not administered. The LPN stated if a medication is not administered, the nurse has to document something in the nursing note stating why the medication was not administered. The LPN also stated he would notify the oncoming shift if the medication was still unavailable. An interview was conducted with an LPN (staff #35) on September 8, 2022 at 2:43 pm. She stated that when medication is unavailable, the process is to contact the pharmacy, then contact the doctor and also check the e-kit. She stated if the medication is still not available at the end of the shift then the nurse should check with the pharmacy, let the doctor know and communicate with the resident. The LPN stated the nurses then have to enter a progress note stating what they did including the notification to the doctor. She stated if the medication is not being sent due to the resident's insurance then the process is to let the doctor know and maybe get the medication changed to what the pharmacy recommends. She stated if a medication is not administered, there should be a notification to the doctor and there should be documentation in the progress note. The LPN stated it is very important for the resident to receive the medication they have been ordered as the residents are there to get better and missing the ordered medication can cause more problems with their health. A phone interview was conducted with the Pharmacy Technician (staff #114) on September 8, 2022 at 3:10 pm. She stated that resident's [MEDICATION(S)] medication was never delivered and stated both of the medication, [MEDICATION(S)] and [MEDICATION(S)] were not sent out because of insurance issues. A phone interview was conducted with another Pharmacy Technician (staff #110) on September 8, 2022 at 3:15 pm. She stated that the medication [MEDICATION(S)] is leaving at 6:00 pm for delivery that day. She stated [MEDICATION(S)] and [MEDICATION(S)] were not delivered as both the medications were not covered by the resident's insurance and the pharmacy was waiting for authorization from the facility to bill the facility. She stated when the insurance does not cover certain medications, the pharmacy sends out an email to the facility to notify the facility that the insurance will not cover the medication and if the facility will cover the bill or not. An interview was conducted with the Director of Nursing (DON/ staff #113) on September 8, 2022 at 3:37 pm. She stated that the facility has a standing order to hold the medication until the medication becomes available from the pharmacy. She stated when medication is unavailable, her expectation is for the nurses to contact the pharmacy to check the status of the medication order and to see whether there is an insurance issue that is causing delay in delivery. She stated the pharmacy might make the nurses think the medication is coming. The DON stated when the medication is not delivered, the nurses are to follow the hold order. She stated if the unavailable medication is a critical medication then her expectation is for the nurses to contact the doctor and receive orders from the doctor for any alternative medication. She stated if the pharmacy stated there is an insurance issue or they are waiting for prior authorization, her expectation is for the nurses to follow up with the pharmacy, contact the physician and document it in the progress notes. She stated if the medication is for bowel care, her expectation is to assess the resident to make sure the resident is not constipated. She stated when the medication is continuously unavailable the nurses should be calling the provider. The DON stated [MEDICATION(S)] and [MEDICATION(S)] are specialty medications and if they are not available, nurses have to review the hospital record to see if the resident was taking the medication and contact the provider. She stated she remembered a nurse asking her about the missing medication earlier last month, and she asked the nurse to reach out to the provider. The DON stated if the nurse did not receive an order for alternate medications and the medications were not delivered from the pharmacy, then her expectation is for the nurses to let the provider know so that the provider can address it. She stated when the insurance does not cover certain medications, an email is sent to the facility by the pharmacy and is handled by a staff at the facility. -Resident #67 was admitted to the facility on [DATE] at 7:15 p.m. with diagnoses of intracranial abscess and [CONDITION(S)] and periapical abscess with sinus. The physician order summary dated July 15, 2022 included an order for [MEDICATION(S)]-[MEDICATION(S)] solution reconstituted 3 grams (2-1), use 3 grams intravenously four times a day for wound care for 18 days. The order was revised on July 16, 2022 at 7:04 a.m. to be given every six hours. The original and revised order were transcribed onto the medication administration record (MAR) for July to be administered at the following scheduled times: 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m., and was then changed to 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m., respectively. Upon further review, the MAR revealed the resident missed the scheduled dose at 8:00 p.m. on July 15, 2022. Review of a medication administration note at 3:02 a.m. stated New admit as of July 15, 2022 pending delivery of intravenous antibiotic . There was no evidence the physician was notified the antibiotic was not available and the resident missed a dose. Also, the pharmacy was not contacted at this time to get a status on the delivery of the antibiotic. Review of the medication administration note dated July 16, 2022 at 12:04 p.m. revealed the order for antibiotics was refaxed to the pharmacy. Review of a progress note dated July 16, 2022 at 12:32 p.m. revealed that two hours prior, at 10:00 a.m., the pharmacy was contacted to inquire about the antibiotic order. The progress note revealed the pharmacy staff stated the order in question cannot be seen on the chart and that the order had to be refaxed to be processed. (At which time the resident had already missed the second dose of antibiotic.) The progress notes further revealed the hospital was contacted in an attempt to obtain the medication; however, the charge nurse stated the medication can only be provided if the resident was readmitted to the hospital. The progress notes further noted that the estimated time of arrival for the antibiotic was unknown and this information was relayed to the resident's mother, the Director of Nursing (DON) and the physician. The resident's mother decided to have the resident transferred back to the hospital with the acknowledgement of the physician. A telephone interview was conducted on September 8, 2022 at 3:30 p.m. with a pharmacy technician (staff #110), who stated the antibiotic order was not received until 5:00 p.m. on July 16, 2022 and they were instructed to hold the medication because the resident was discharged . An interview was conducted on September 9, 2022 at 9:03 a.m. with an LPN (staff #35). She stated once the report has been received from the hospital, the resident and family are educated and consents are signed, the medication orders go directly into the resident's chart and are automatically sent to the pharmacy. She stated if medications have not arrived and the resident has missed a dose, she would notify the physician and contact the pharmacy to get an update status. She stated if the order was not received by the pharmacy, she would fax the order. An interview was conducted on September 9, 2022 at 9:51 a.m. with the DON (staff #113), who stated that once the referral packet is received from admission, orders are entered in the resident's chart, and the pharmacy receives those orders right away. She further stated that the arrival time of medications are dependent on a few factors, the date of submission because there is a cutoff time for when medications are ordered to receive them at a certain time (cutoff time is unknown to the DON at this time), the type of medication, the availability of the medication (back order), and insurance authorization. After reviewing the medication order for resident (#67), the DON stated she remembered the resident vividly. She stated that the intravenous medication in question was a specialty medication and the order had to be faxed. The DON stated that faxes are not recorded, there was no record that the medication was faxed when the resident arrived at the facility. The DON stated it was acceptable that the medication did not arrive until the following day and that the resident missed two doses because of when the order was submitted and because it was a weekend. She further added that the resident went to hospital because the resident's mother may have been a nurse and was upset that the resident missed two doses of the antibiotics even after it was explained to her the process of ordering antibiotics. The facility policy titled, Medication Administration: Administration of Drugs reviewed September 2022 stated the policy of the facility is that the medications shall be administered as prescribed by the attending physician. The policy stated if a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. The policy further stated that if a medication is unavailable and is not administered at the scheduled time, the documentation will be reflected in the clinical record, and physician notification and other information regarding the unavailable medication will be documented accordingly.

Based on clinical record reviews, staff interviews, and facility policy, the facility failed to ensure three residents (#6, #31, #34) received medications as ordered by the physician. The sample size was 5. The deficient practice could result in unnecessary medication administration. Findings include: -Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Acetaminophen Tablet 325 milligrams (MG) 2 tablets by mouth every 6 hours as needed for pain 1-4, discontinued August 4, 2022. -[MEDICATION(S)] Concentrate 100 MG/5 milliliters (ml) 0.5 ml by mouth every 4 hours as needed for pain 5-10, discontinued August 4, 2022. Review of the July 2022 Medication Administration Record (MAR) revealed [MEDICATION(S)] was administered for pain level of 1 on July 9, 2022, pain level of 0 on July 14, 15, 17, 30, 31, 2022, pain level of 3 on July 15, 2022, pain level of 2 at 12:32 PM on July 17, 2022, and for pain level of 2 on July 31, 2022. Review of the MAR for August 2022 revealed [MEDICATION(S)] was administered for a pain level of 0 on August 3, 2022. An interview was conducted on September 9, 2022 at 8:38 AM with the Director of Nursing (DON/staff #113), who stated the facility policy is to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON then reviewed the clinical record regarding July 2022 medication administration. She stated that [MEDICATION(S)] had not been administered according to physician orders. The DON stated that this did not meet the facility expectation, and the medication had not been administered following physician orders. She also stated that [MEDICATION(S)] had not been administered following the ordered parameters for pain management in July 2022. She further stated it was administered outside of parameters, and this did not meet facility expectations. She stated the risk could result in receiving pain medication unnecessarily. -Resident #31 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 5 mg by mouth every 4 hours as needed for pain 5-10/10 dated January 15, 2022. -[MEDICATION(S)] Tablet 12.5 mg by mouth two times a day for hypertension, to hold if systolic blood pressure (SBP) is <100 or pulse <60 dated March 3, 2022. -[MEDICATION(S)] 10 mg by mouth every 6 hours as needed for pain 4-10/10 dated June 11, 2022. -[MEDICATION(S)] 10 mg by mouth every 6 hours as needed for pain 4-10/10 dated June 15, 2022. -[MEDICATION(S)] 10 mg by mouth every 6 hours as needed for pain 4-10/10 dated June 23, 2022. -[MEDICATION(S)] 15 mg by mouth every 6 hours as needed for pain 5-10/10 dated July 12, 2022. -[MEDICATION(S)] 15 mg by mouth every 6 hours as needed for pain 1-10/10 dated July 7, 2022. -[MEDICATION(S)] 15 mg by mouth every 6 hours as needed for pain 6-10/10 dated August 22, 2022. Review of the June 2022 MAR revealed the following: -[MEDICATION(S)] was administered for an SBP of 94 on June 3, 2022. -[MEDICATION(S)] was administered for a pain level of 0 on June 2, 2022. -[MEDICATION(S)] was administered for a pain level of 0 on June 12, 2022. Review of the July 2022 MAR revealed the following: -[MEDICATION(S)] was administered for a pain level of 0 on July 2 and 3, 2022. -[MEDICATION(S)] was administered for a pain level of 1 on July 17, 2022. -[MEDICATION(S)] was administered for a pain level of 0 on July 24, 2022. Review of the August 2022 MAR revealed [MEDICATION(S)] was administered for: -a pain level of 5 on August 23, 24, 25, 26, 27, 28, 29, 2022. -a pain level of 4 on August 25, 27, 2022. -a pain level of 0 on August 29, 2022. -a pain level of 2 on August 30, 2022. Further review of progress notes revealed no evidence that the physician had been notified, or why the medications were administered outside of parameters. An interview was conducted on September 9, 2022 at 8:56 AM with the DON (staff #113), who stated that [MEDICATION(S)] had been administered outside of parameters in August 2022. She also stated that there was no evidence that the physician had been notified, or why [MEDICATION(S)] was administered. The DON reviewed the July 2022 MAR and stated that [MEDICATION(S)] had been administered outside of pain parameters. Staff #113 reviewed the June 2022 MAR and stated that [MEDICATION(S)] had been administered outside of the SBP parameters on June 3, 2022. She further stated that [MEDICATION(S)] had been administered for a pain level of 0, which did not follow physician ordered parameters. Staff #113 stated that she did not see any evidence that the physician had been notified or why the medications were administered outside of parameters. The DON stated that this did not meet her expectations and that the medications had been administered unnecessarily. An interview was conducted on September 9, 2022 at 10:01 AM with a Registered Nurse (RN/staff #35), who stated that the facility policy is to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #34 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated July 31, 2022 revealed the resident had acute/chronic pain related to impaired mobility, generalized weakness, and chronic history of pressure injury. The goal was the resident will voice a level of comfort. The intervention included anticipating the need for pain relief and responding immediately to any complaint of pain and following the pain scale to medicate as ordered. The MAR for July 2022 revealed the medication was administered for a pain level 0 on July 31, 2022. The MAR for August 2022 revealed the medication was administered for a pain level 0 on August 7 & 27, 2022. Review of the MAR for September 2022 revealed the medication was administered for a pain level 0 on September 3, 2022. Review of the progress notes revealed no evidence why the medication was administered outside of the ordered parameters. An interview was conducted with a Licensed Practical Nurse (LPN/staff #60) on September 7, 2022 at 9:54 a.m. She said when administering pain medication, she would assess the resident's pain utilizing the pain scale level 1-10, verify the order, and verify when the medication was given last. She stated she then records on the progress note when it was administered and what the verbalized pain level was, if the resident is able to communicate. The LPN also stated that in the event the resident does not have pain, the medication is held. An interview was conducted with the DON (staff #113) on September 7, 2022 at 10:11 a.m. She stated that her expectation with regards to administering pain medication is that the LPN would check valid orders, verify that the medication as needed falls within the parameter. The DON stated that it is an expectation that the nurse assess the pain level and that the assessed pain level falls within range. Upon review of the MAR, she stated that pain medication can be administered if the pain level is zero if it is given as prophylactic for wound care; however, review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Administration of Drug policy revealed medications must be administered in accordance with the written orders of the attending physician and that medications are administered according to appropriate indication.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that risks and benefits of a [CONDITION(S)] medication were explained to one resident (#34) prior to receiving the medication. The sample size was 5 residents. The deficient practice could result in residents and/or their representatives not being informed of the risks and benefits of [CONDITION(S)] medications. Findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated on July 31, 2022, revealed that the resident is prescribed antidepressant medication related to depression as evidenced by statements of sadness. Interventions included educating the resident, family/caregivers about risks, benefits and the side effects of the medication and giving antidepressant medications ordered by physician. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was discontinued on August 3, 2022. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident received antidepressant medication every day during the 7-day lookback period of the assessment. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a consent for [CONDITION(S)] medication [MEDICATION(S)] signed by the resident on August 12, 2022 which was 12 days after the medication was ordered. Review of progress notes revealed no documentation that the resident was informed of the risks and benefits of the medication [MEDICATION(S)] before August 12, 2022. An interview was conducted with a Licensed Practical Nurse (LPN/staff #88) on September 8, 2022 at 2:08 pm. He stated that when a resident has a new order for [CONDITION(S)] medication, a medication consent needs to be signed before medication administration. He stated obtaining [CONDITION(S)] medication consent is a part of the intake process during admission and is done by the nurses. The LPN stated the resident is educated on what [CONDITION(S)] medication is ordered and its adverse reaction. The LPN stated obtaining a consent for [CONDITION(S)] medication is important as it is the resident's right and law to know why they are on the medication. An interview was conducted with an LPN (staff #35) on September 8, 2022 at 2:43 pm. She stated that when a resident has a new order for [CONDITION(S)] medication, the resident should have a [CONDITION(S)] medication consent signed. The LPN stated the consent includes diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the resident then can refuse or agree to the treatment, and the resident and the nurse has to sign the consent form. She stated [MEDICATION(S)] is an antidepressant and the resident would need a consent for the medication before its administration. An interview was conducted with the Director of Nursing (DON/staff #113) on September 8, 2022 at 3:37 pm. She stated that her expectation from the staff is for them to obtain [CONDITION(S)] medication consent when a resident is ordered a [CONDITION(S)] medication. She stated the consent should state the name of the [CONDITION(S)] medication and the side effects. The DON stated the consent form is signed by the resident if the resident is able to sign, and the nurse. She stated a consent is important so that the resident is aware of the [CONDITION(S)] medication ordered. The DON stated [MEDICATION(S)] is a [CONDITION(S)] medication. She stated the facility audited [CONDITION(S)] medication consents, found that the resident was missing a consent for [MEDICATION(S)] and a consent was obtained after the audit. The facility's policy titled [CONDITION(S)] medication, revised November 2021, revealed the use of psychoactive medication must first be explained to the resident, family member, or legal representative. The policy further stated a consent is to be obtained either from the resident or responsible party if the resident is unable to give consent. The policy stated a verbal consent may be obtained if no responsible person is available and the person obtaining the consent is to sign the consent once obtained. The policy stated to explain the potential negative outcomes of psychoactive medication.

Based on clinical record review, staff interviews and facility policies and procedures, the facility failed to ensure the physician was notified of one resident's (#126) low blood pressure. The sample size was 1. The deficient practice could result in delayed treatment. Findings include: Resident #126 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The late entry physician admission progress note dated [DATE] revealed the resident presented with significant [CONDITION(S)] and was very debilitated. The assessment included moderate protein calorie malnutrition, hypertension and CAD (coronary artery disease). A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was transcribed onto the MAR (medication administration record) for [DATE] and included the medication was administered as ordered. An encounter note dated [DATE] included the resident was alert and oriented, was recently hospitalized for [CONDITION(S)] and had assessments of CAD and hypertension. The care plan dated [DATE] revealed the resident had hypertension. The goal was that the resident will remain free from signs and symptoms of hypertension. Interventions stated to give anti-hypertensive medications as ordered, monitor for side effects such as [CONDITION(S)] and increased heart rate or [CONDITION(S)], monitor for effectiveness of the medications and avoid taking the BP (blood pressure) reading after physical activity or emotional distress. The BP readings from [DATE] through 30, 2021 revealed warnings for readings that exceeded parameters on the following dates: -[DATE] and 29 - diastolic low of 60 exceeded; and, -[DATE] and 28 - systolic high of 139 exceeded The pulse rate for this period revealed a lowest pulse of 61 and highest pulse of 86. The weights and vitals summary included the following BP readings for [DATE] -At 6:35 a.m., the BP was ,d+[DATE] with a warning of systolic high of 139 exceeded; and, -At 4:01 p.m., the BP reading was ,d+[DATE]. Included was a warning that read diastolic low of 60 exceeded and systolic low of 90 exceeded. The pulse rate was documented as 128 with a warning of high of 100 exceeded. A late entry physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . However, per the documentation, the BP was ,d+[DATE] and pulse was 66 on [DATE] at 6:35 a.m.; and, it did not include that the resident had a BP of ,d+[DATE] and pulse rate of 128 on [DATE] at 4:01 p.m. There was no indication in the documentation the provider was aware of the low BP and high pulse rate taken approximately an hour after the provider wrote the note. The weights and vitals summary revealed that on [DATE] at 7:07 a.m., the BP was ,d+[DATE] mmHg with a warning that diastolic low of 60 exceeded and systolic low of 90 exceeded; and pulse rate of 129 with a warning that the high of 100 exceeded. The daily skilled note dated [DATE] revealed a BP reading of ,d+[DATE] and a pulse of 129 taken on [DATE] at 7:07 a.m. Per the documentation, the resident was alert and oriented, with the heart rate and rhythm within baseline and had no cardiovascular changes observed. The note did not include whether or not the physician was notified of the low BP and high pulse rate. The weekly skilled review note dated [DATE] included a primary medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The plan was to continue nursing for monitoring blood sugars and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The order for [MEDICATION(S)] was transcribed onto the MAR for [DATE]. Despite the documentation for a low BP and high pulse rate on [DATE] at 7:07 a.m., the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence found in the clinical record that the physician was notified of the resident's BP and pulse rate reading on [DATE]. The MAR for [DATE] included [MEDICATION(S)] was administered as ordered on [DATE] at 8:00 a.m. The weights and vitals summary revealed that on [DATE] at 3:08 p.m., the BP was ,d+[DATE] with a warning that diastolic low of 60 exceeded and systolic low of 90 exceeded; and pulse rate of 66 bpm. There were no BP and pulse rate readings prior to 3:08 p.m. A nursing note dated [DATE] at 4:10 p.m., included the resident was disoriented, was at baseline alert x 2 and was unable to understand the situation of this building being put into COVID outbreak status. A late entry daily skilled note dated [DATE] included BP reading of ,d+[DATE] and a pulse of 66 taken on [DATE] at 3:08 p.m. It also included the resident was alert and oriented x ,d+[DATE], was confused and needed to be redirected at times. Cardiovascular assessment included the heart rate and rhythm was within baseline, peripheral pulses present and no cardiovascular changes observed. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the documentation, BP was ,d+[DATE] and pulse was 66 taken on [DATE] at 3:08 p.m. The note further included that all other reviews of systems were negative unless stated otherwise in H&P. Physical examination included the resident had no distress and had coarse breath sounds. Assessments included [CONDITION(S)], moderate protein calorie malnutrition, hypertension and CAD. The plan stated to continue physical therapy, bowel care protocol, medications and supportive care. The documentation did not include any interventions ordered or implemented to address the resident's low BP. The clinical record revealed no evidence that the resident's BP was rechecked, monitored and assessed after 3:08 p.m. on [DATE]. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated [DATE] at 7:15 a.m. revealed that at 6:05 a.m. staff went into the resident's room to administer medications but the resident reported that she was not ready and for staff to come back. Per the documentation, at 6:25 a.m., staff entered the resident's room and found the resident with no pulse, no heart and no respiration. It included a code was called, CPR (cardiopulmonary resuscitation) was initiated and 911 was called. The note also included that at around 6:30 a.m. the fire department arrived and gave the time of death at 6:35 a.m. The eMAR (electronic MAR) note dated [DATE] at 9:35 a.m. included the resident was deceased . An interview was conducted on [DATE] at 9:07 a.m. with a Certified Nursing Assistant (CNA/staff #96) who stated she takes and records residents vital signs. The CNA stated that if the resident's BP reading is higher than set parameters or is extremely high, she will recheck it and then report the readings to the nurse. Further, the CNA stated that if the BP is low or extremely low, she will go get the nurse right away. During an interview with a Licensed Practical Nurse (LPN/staff #88) conducted on [DATE] at 11:17 a.m., the LPN stated that if he receives a report that BP readings for a resident is way too low, for example ,d+[DATE] or ,d+[DATE], he would call 911, call the physician and continue to monitor the resident while waiting for 911 to arrive. He stated he would also check the orders and will not give any antihypertensive medications at that time. In an interview with another LPN (staff #35) conducted on [DATE] at 9:24 p.m., she stated that a BP of 70ish/45 is low and if she receives a report about this reading, she would assess the resident for signs and symptoms, would notify the physician, DON (Director of Nursing) and family, would closely monitor the resident and would wait for orders. Staff #35 stated she will not necessarily call 911 because there are some residents who have BP running low but it is normal for that resident. She stated that if the resident has a low BP and is asymptomatic then she would not probably call 911. The LPN stated however, if the resident is manifesting symptoms, she would call 911. She further stated that stated either way, a symptomatic or asymptomatic resident with low BP, she would notify the physician, and the DON, assess/monitor the resident, wait for and implement orders when received. An interview was conducted on [DATE] at 10:15 a.m. with the DON (staff #113) who stated that if the BP was low and the physician was already aware that it was low, she would not necessarily call and notify the physician again of a low BP on the following day. Regarding resident 126, the DON provided copies of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . She pointed out that on [DATE], the progress note indicated a BP reading of ,d+[DATE]; and that the note indicated the physician reviewed the resident's BP. When asked whether or not the resident was seen by the physician and whether or not the physician was notified on [DATE] when the BP was ,d+[DATE], the DON stated there was no documentation found in the clinical record. The facility policy on Reporting Change of Condition included that it is their policy that all changes in resident condition will be communicated to the physician and documented. The facility policy on Documentation and Charting revealed that it is their policy to provide a complete account of the resident's care, treatment, response to care, signs, symptoms, etc., as well as the progress of the resident's care; and, guidance to the physician in prescribing appropriate medications and treatments. The facility policy on Quality of Care included it is their policy that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care.

Based on closed clinical record reviews, staff interviews, and facility policy review, the facility failed to ensure that two residents (#s 286 and 161) had sufficient fluid intake to maintain proper hydration. Both residents sustained actual harm as a result. Findings include: -Resident #286 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician progress notes [REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE], revealed in Section G that the resident required extensive assistance with eating/activities of daily living (ADLs). Review of the clinical record revealed a Medical Nutrition Therapy assessment dated [DATE], which included the resident's estimated fluid needs were more than 1947 milliliters (ml) per day. The assessment identified that the resident had swallowing difficulties related to dysphasia and required nectar thickened liquids. Also, documented was that the resident had experienced a weight loss of 10 percent over the past month, due to dysphasia. According to the Interdisciplinary Care Plan for nutrition dated August 24, 2012, the resident had increased nutrient needs due to recent weight loss, swallowing difficulty related to [MEDICAL CONDITION] and required nectar thickened liquids, and had poor oral intake. The goals were to gain one to two pounds per month, tolerate mechanically altered diet and to have no signs or symptoms of dehydration through the next review. Care plan interventions included to encourage fluids, thickened liquids per orders, and to monitor and document oral intake. A physician progress notes [REDACTED]. Review of the Fluid Intake entries for the resident from August 18 through 25, 2012, revealed that the fluid amounts did not reach greater than 1200 ml per day. A physician progress notes [REDACTED]. A physician progress notes [REDACTED]. However, further review of the clinical record revealed there were no corresponding nursing notes/assessment documentation related to this episode. Review of the Fluid Intake entries for August 26 through August 31, include the following fluid amounts consumed per day: August 26 240 ml August 27 1,200 ml August 28 400 ml August 29 900 ml August 30 1,200 ml August 31 240 ml Per the documentation, the resident's estimated fluid needs of 1,947 were never reached. A nursing note dated August 30 at 4:14 p.m., now documented stat lab results showed the resident had a potassium of 6.6 (normal range (3.5-5.2 mmol/L) creatinine 7.01 (normal range 0.60-1.50 mg/dL) and BUN (blood urea nitrogen)was 134 (normal range 8-25 mg/dL). The note included the physician was notified and there were new orders for IV fluids. There was no further nursing assessment documentation of the resident's condition at this time. Review of the physician's progress note dated August 30, 2012, revealed the resident has acute [MEDICAL CONDITION], anorexia, [MEDICAL CONDITION], and severe dehydration. A nursing note dated August 30, 2012 at 10:40 p.m., included a Foley catheter was placed. There was no clinical record documentation of the amount of urine obtained at this time. A nursing note dated August 31, 2012 at 11:53 a.m., documented resident's oxygen saturations were in the 80's and oxygen was given and increased to 91%. The physician was notified and a stat chest X-ray and SVN (small volume nebulizer) treatments were ordered. A nursing note dated August 31, 2012 at 6:14 p.m., revealed the resident had 100 cc of urine output from the catheter this morning, abdomen was distended and tender to touch, removed catheter and attempted to put in new one with no success. Physician at bedside. Labs came in with worsening [MEDICATION NAME] and potassium elevated and orders received to send the resident to the hospital for treatment. Further review of the clinical record revealed there was no documentation the resident's urine output was being monitored each shift from the time it was inserted on August 30 at 10:40 p.m., until August 31 at 6:14 p.m., for a period of over 19 hrs. Review of the hospital emergency room admission assessment records dated August 31, 2012, revealed the resident was admitted to the ICU with profound metabolic acidosis, acute [MEDICAL CONDITION], a urinary tract infection [MEDICAL CONDITION] with bandemia, likely GI related. Part of the plan was to aggressively hydrate the resident. An interview was conducted with the director of nursing (DON) on March 7, 2013. The DON stated that residents who are at risk for dehydration are closely monitored. She also stated that she does not know how this resident got so dehydrated. An interview was conducted with the medical director/resident's physician on March 7, 2013. The medical director stated that this resident should have been more closely monitored, because he was a total care resident. He also stated that the resident got worse very quickly and that he tried to treat his dehydration in the facility before sending him to the hospital. -Resident #161 was admitted to the facility September 23, 2012, with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was alert with confusion, was able to express some needs to staff and was able to feed self with set up and required the assistance of one for bed mobility, transfers and toileting. Review of the Nutritional Therapy Assessment conducted on September 28, 2012, documented an admission weight of 140.6 pounds (lbs), which placed the resident on the low range of his ideal body weight of 138 to 169 lbs and that the resident had reported a 25 pound (lbs) weight loss over the last six months. Per this assessment, fluid intake recommendations for this resident were greater than 1971 ml per day. physician's orders [REDACTED]. Diff) toxin found in his diarrhea stools. Physicians order noted on October 15, 2012, included for intravenous fluids of normal saline at 80 ml/hour every shift for two liters of fluid over two days, for [MEDICAL CONDITION]. A nurse's note dated October 21, 2012, included the resident continues with diarrhea and for the physician to be made aware. On October 22, 2012, the resident was again started on [MEDICATION NAME] 500 mg by mouth for 10 days for treatment of [REDACTED]. A physician's orders [REDACTED]. On October 23, 2012, another stool sample was sent and was positive for [DIAGNOSES REDACTED]. A dietary note dated October 24, 2012, documented the resident's intake had greatly declined from admission and was now averaging 54% of meals, and had a 7.6 lb weight loss. MD notified and to order appetite stimulant. Continue to encourage oral intake and will continue to monitor oral intake to assess need for further intervention. A nurse's note dated October 27, 2012, included the resident was confused and unable to verbalize needs. A urine sample was obtained by straight catherization and obtained 1500 ml of dark brown colored urine. An order was received to place an indwelling urinary catheter due to retention and a UA/C&S was sent to the lab. Review of the laboratory results for October 28, 2012, revealed positive results for a urine infection which identified staphylococcus aureus and [MEDICAL CONDITION] resistant (MRSA) present in the urine. The resident was started [MEDICATION NAME] mg by mouth two times a day. A nurse's note dated October 28, 2012, documented the resident had a catheter with dark brown urine and had two loose stools. Later that night the notes included the physician was notified of the resident's small amount of fluid and food intake throughout the day and would request a diet change. It was also noted the resident had fallen five times this day. Review of the certified nursing assistants (CNA) charting for fluid intake and meal consumption from October 15 through 30, revealed the recommended amount of fluids (1971 ml per day) was never reached. In addition, meal intake percentages consumed over the last eight days was less than 26-50% of meals on five out of 22 meals and consumed no more than 0-25% for 13 out of 22 meals documented. A nurse's note dated October 30, 2012, included the resident had mottling to bilateral lower extremities and that the physician was notified and the resident was sent to the hospital. Additional clinical record documentation included the resident was sent to the emergency roiagnom on [DATE], for respiratory distress due to low oxygen saturation (between 77-88 percent). Review of the hospital documentation revealed that upon admission the resident did not appear to be in any respiratory distress, however, due to the mottling of extremities it was difficult to obtain oxygen saturation, but once warmed was between 96-98% on room air. Initial labs included a BUN of 100 and a creatinine of 3.71. The resident was found to be hypotensive with blood pressures in the 90's over 50's and [MEDICAL CONDITION] pulses of 115. [DIAGNOSES REDACTED]. In an interview with a licensed practical nurse (LPN) conducted on March 6, 2013, she stated she does not review the intake of fluids or the meals that the CNA's document unless a CNA tells her that a resident is not eating or drinking enough. She stated she thought the CNA coordinator reviews that information. An interview was conducted with the CNA coordinator on March 6, 2013. She stated that she does not review the charting to look for problem or concerns with resident's intakes and that the dietician and DON would review it. Interviews were conducted on March 7, 2013, with two LPNs that cared for the resident when he was in the facility and stated the resident was confused a great deal of the time prior to leaving, exhibited by pulling off the dressings for his pressure sores, scratching and increasing the size of his wounds and pulling out or pulling on his indwelling catheter. An interview was conducted with the DON on March 8, 2013. She stated that she does not review all of the CNA documentation, but knows that the dietician reviews the intakes to conduct her assessments. She went on to add that all of the floor nurses have the capability to review what the CNA's document, even though it does not go into the electronic charting. In an interview with the registered dietician conducted on March 8, 2013, she stated when she did his initial assessment she placed his calorie and fluid intake on the high side based on his recent weight loss and nutritional needs to heal the pressure sore. She stated she does look at the CNA's documentation to do her work for the necessary look back periods for Medicare documentation. When questioned if the CNA's are aware of the desired fluid intake for each resident she stated she did not know, but it was in the paper chart. She did point out that they had identified two times earlier that the resident needed IV fluids during his stay. Review of the facility's policy on Hydration revealed that "...It is the policy of this facility to encourage fluid intake to maintain the resident's hydration in compliance with physician orders...To ensure that each resident is encouraged to consume adequate fluids in order to maintain proper hydration for optimum functioning of various body systems...Residents needing assistance will be assisted by facility staff..."