Every finding on record at Diamondback Healthcare Center

Based on clinical record review, observations, staff interviews, and review of policy and procedures, the facility failed to ensure proper infection prevention and control practices were implemented related to contact precautions for one resident of 5 residents (#117) and the facility failed to ensure that community infection control surveillance mapping was documented. The deficient practice could result in transmission of infection in the facility.Findings include: -Regarding Contact Precautions: Resident #117 was admitted to the facility on [DATE] with diagnoses that include enterocolitis due to clostridium difficile (C. Difficile), not specified as recurrent, urinary tract infection, site not specified, and other psychoactive substance abuse.Review of the comprehensive care plan dated February 3, 2026 revealed a focus for C. Difficile with interventions that included to use contact precautions such as: gowns and gloves during high-contact care activities, wear gowns and masks when changing contaminated linens, and use as much disposable equipment as possible. Review of a physician order with a start date of February 3, 2026, revealed single room contact precautions for C. Difficile (diagnosed), all cares, therapies and activities in room every shift until February 12, 2026.An observation was conducted on February 4, 2026 at 12:36 p.m. of Resident #117's room. Outside the room was a yellow signage which indicated the room was on contact precautions and required personal protective equipment (PPE), such as gowns and gloves, before entering the room. Additionally, a three-tiered isolation cart was positioned outside of Resident #117's room which contained disposable gowns, gloves, face masks, and sanitizing wipes. An observation was conducted on February 4, 2026 at 12:36 p.m. of a Certified Nursing Assistant (CNA/Staff #129) exiting Resident #117's room, a contact isolation room, without performing hand hygiene after delivering a meal tray. Upon exiting, the CNA was observed to grab another meal tray from the food cart then pushed the same tray back in the cart. There was no evidence that the meal tray the CNA touched and pushed back into the tray cart was discarded. Additionally, staff was observed to continue passing meal trays from the same food cart. Review of a Coaching and Feedback Form provided by the Administrator (Staff #62) revealed that the CNA (Staff #129) entered a contact isolation room without donning PPE and the course of action for this concern included providing education on proper PPE, isolation signage, and policies.An interview was conducted on February 4, 2026 at 12:43 p.m. with the CNA (Staff #129) who confirmed exiting the room of a resident that was on contact precautions without performing hand hygiene. The CNA stated that when a resident is on contact precautions, staff must don gowns and gloves when entering the room and doff gowns and gloves before exiting, provide disposable meal trays, perform hand hygiene, and disinfect any reusable items. The CNA stated that the signage and PPE outside of the room indicated what isolation precautions a resident requires. The CNA stated that the risks of not following contact precautions may result in the spread of the infection to staff and other residents. An interview was conducted on February 4, 2026 at 1:07 p.m. with a Licensed Practical Nurse (LPN/Staff #179), who stated that for a resident on contact precautions, staff need to use proper PPE which includes, mask, gowns, and gloves when entering the room. Staff #179 stated that the risks of not wearing the required PPE included spreading of the infection. An interview was conducted on February 4, 2026 at 1:26 p.m. with the Administrator (Staff #62), the Infection Preventionist (IP/Staff #140), with CNA (Staff #129) in attendance. The Administrator stated that due to an incident, involving CNA (Staff #129) not wearing contact isolation PPE when entering Resident #117's room to deliver a meal tray, and not performing hand hygiene upon exiting that the CNA would be placed on leave to minimize the potential spread of infection. The administrator stated that new scrubs were provided to the CNA (staff #129). The Administrator further stated that Resident #117 had C. Difficile which is highly contagious and is the reason why contact isolation precautions were required.The Administrator and Infection Preventionist stated that contact precautions must be followed even when delivering meal trays, and explained that there are serious risks if these isolation precautions are not followed. During the same interview as above, the CNA (staff #129), relayed stated that she knows it's a big deal and she has no idea why she didn't put on PPE, and that she has never worked on that unit.Review of the policy titled, Infection Prevention and Control Program (IPCP), last reviewed/revised on January 1, 2025 revealed, the facility maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Further review of the IPCP revealed hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures and all staff shall use personal protective equipment (PPE) according to established facility policy governing the use of PPE.

Based on observations, staff interviews, and policy review, the facility failed to ensure that food is labeled and dated after opening in accordance with professional food safety standards. The deficient practice may result in practices of food storage that may not be in accordance with professional food safety standards. Findings include:An observation of the kitchen was conducted on January 4, 2026, at 8:40 AM with the facility's Dietary Manager (DM/Staff #152). The following food items were discovered without labels indicating what date they had been opened: Two liquid egg cartons did not have an opened date label.One bag of chicken tenders in the freezer without opened date label.One bag of tilapia in the freezer had no opened date label. One bag of hot dog buns had no opened date label.The dietary manager proceeded to remove these items from the refrigerator and freezer and disposed of the food with no open date labels.An interview was conducted on January 5, 2026, at 10:40 AM with the DM/Staff #152, who stated that the food should be labeled with the date that it is opened, and the expiration date. Staff #152 stated that if food had no opened date or expiration date label, the kitchen staff should dispose of it immediately because eating from open, undated food could pose a risk to the residents.An interview was conducted on January 5, 2026, at 1:43 PM with the registered dietitian (Staff #206) who stated that the expectation was that all food products are properly labeled and dated upon delivery and storage, as well as thereafter, once items have been opened. Staff #206 stated that the risk included not knowing when the food was received, stored, or opened. A review of the policy titled, Food Safety Requirements (dated 2014), revealed that food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety. The policy further noted that all foods will be labeled, dated, and monitored refrigerated food, including, but not limited to leftovers, so that it is used by its use-by date.

Based on observation, interview, and record review, the facility failed to accurately document that a medication was discontinued and rationale thereof for one (#28) of three sampled residents. The deficient practice could result in negatively impacting continuity of care documentation. Findings include:Review of Resident #28's hospital records prior to admission revealed that she was admitted to the hospital on [DATE]. Upon discharge from the hospital, the medication list indicated no medication changes, and included olanzapine 2.5 mg by mouth once daily.Resident #28 was admitted to the facility on [DATE], with diagnoses including: urinary tract infection, resistance to multiple antibiotics, noninfective gastroenteritis and colitis, cerebral palsy, muscle weakness, abnormalities of gait and mobility, and depression.Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS further revealed that Resident #28 had exhibited no verbal or physical behavioral symptoms directed toward others during the assessment period.Review of physician orders revealed an order initiated on November 6, 2025, for olanzapine oral tablet, 2.5 mg by mouth once daily, with an indefinite end date.Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) revealed that olanzapine 2.5 mg was administered to Resident #28 on November 6, 7, 8, 9, 10, and 11, 2025. The MAR documented that olanzapine was discontinued on November 11, 2025, at 11:41 a.m.Further review of the MAR/TAR revealed an order for behavioral monitoring related to the use of the antipsychotic medication olanzapine, initiated on November 5, 2025, at 6:00 p.m. This monitoring order remained active and continued through Resident #28's discharge on [DATE], despite the discontinuation of olanzapine on November 11, 2025. No behavioral symptoms were documented during this period.Review of a physician history and physical progress note dated November 5, 2025, indicated that Resident #28 was recommended to continue olanzapine and benztropine for psychosis.On November 11, 2025, a psychiatry progress note was entered into the clinical record for Resident #28 and signed by the physician assistant (PA/Staff #224). The note documented that this was the initial psychiatric visit and stated that, from a psychiatric standpoint, no medication changes were recommended. The note did not document the discontinuation of olanzapine, despite the medication being discontinued later that same day. The note further directed staff to refer to the MAR for non-pharmacologic interventions.On November 11, 2025, a discontinue order for olanzapine was entered into the clinical record, noted as a telephone order given by PA/Staff #224 and entered by LPN/Staff #170. Review of the MAR confirmed that olanzapine was not administered after November 11, 2025; however, the associated behavioral monitoring order remained active.On November 13, 2025, a nurse practitioner progress note documented that Resident #28 would continue olanzapine and benztropine for psychosis.On November 17, 2025, a subsequent nurse practitioner progress note again documented that Resident #28 would continue olanzapine and benztropine for psychosis.Census records revealed that Resident #28 was discharged from the facility on November 19, 2025. Review of discharge records revealed that Resident #28 was discharged without a prescription for olanzapine.On January 29, 2026, at 11:09 a.m., an interview was conducted with LPN/Staff #170, who stated that physician orders are frequently entered into the electronic medical record by nurses and may be received via telephone, text message, or in person.On January 29, 2026, at 2:48 p.m., an interview was conducted with the nursing unit manager/LPN (Staff #211). Staff #211 stated that when an antipsychotic medication is discontinued, a black box warning alerts the user. Upon review of the clinical record, Staff #211 identified that although olanzapine was discontinued on November 11, 2025, provider documentation indicated that no medication changes were made. Staff #211 further stated that no changes were made to alert charting or behavioral monitoring following the discontinuation of olanzapine.On January 29, 2026, at 3:38 p.m., a telephone interview was conducted with the facility pharmacy consultant (Staff #228). Staff #228 stated that newly admitted residents are reviewed for diagnoses, behaviors, and medications. Staff #228 further stated that olanzapine 2.5 mg is commonly prescribed during hospitalizations for short-term behavioral control and that discontinuation typically does not require continued monitoring when the medication is no longer prescribed.On January 29, 2026, at 4:09 p.m., a telephone interview was conducted with PA/Staff #224. Staff #224 stated that he evaluated Resident #28 on November 11, 2025, at approximately 10:00-11:00 a.m. and subsequently discontinued olanzapine at 11:41 a.m. Upon review of his progress note, Staff #224 acknowledged that documentation of the discontinuation of olanzapine was omitted.Review of the facility policy titled Nursing Documentation, implemented October 1, 2025, revealed that nursing documentation is intended to accurately communicate changes in a resident's condition, treatment, and orders.Review of the facility policy titled Provision of Physician Ordered Services, implemented January 1, 2025, revealed that documentation of physician consultations and orders must be maintained accurately in the resident's clinical record.

Based on closed record review, staff interviews, review of facility process and policy, and the State Operations Manual the facility failed to ensure that all transfer/discharge notifications were made for two residents (#17 and #22). The deficient practice could lead to notifications and pertinent information regarding the discharge/transfer not being provided.Findings include:Regarding Resident #17 -Resident #17 was admitted to the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, fracture of the left femur, pulmonary hypertension, heart failure, and pneumonia. Review of the Ombudsman notification provided by the facility revealed no corresponding notification pertaining to the hospital transfer on September 5, 2024. The notification information provided was dated August 29, 2024 which was for a planned discharge. Review of the resident's face sheet revealed that the husband was listed as the responsible party while the daughter was listed as the emergency contact. The face sheet also listed the contact numbers for both the responsible party and the emergency contact. Additionally, the face sheet indicated that the resident was discharged to the hospital on September 5, 2024.A Physician Visit note dated September 5, 2024 revealed that the resident had a rapid decline in mental status and was sent to the hospital due to unresponsiveness. Review of the Order Summary Report did not reveal any order for the resident to be sent to the hospital. A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the reason for the assessment as discharge assessment-return anticipated. The MDS indicated that the resident was sent to the hospital. Review of the clinical record revealed no documentation of a transfer notice being provided to the resident or resident representative consisting of the required information. Regarding Resident #22 -Resident #22 was originally admitted to the facility on [DATE] with diagnoses of ventilator associated pneumonia, sepsis, respiratory failure with hypercapnia, type II neurofibromatosis, respirator dependence, visual loss, and pleural effusion. Review of the resident's face sheet revealed that the resident's mother was listed as her emergency contact. A contact number was listed for the mother was listed on the face sheet. An eINTERACT Transfer form dated June 24, 2025 revealed that the resident was transferred to the hospital due to hypotension. A Nursing Note dated June 24, 2025 documented that resident's blood pressure was 84/65. The POA (Power of Attorney) was at bedside and provider was notified. Per the note 911 was called for transport to emergency room per physician's orders. Review of the Order Summary Report revealed a physician's order dated June 24, 2025 which directed for resident to be transferred to the ER (emergency room) for hypotension. A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the reason for the assessment as discharge assessment-return anticipated. The MDS indicated that the resident was sent to the hospital on June 24, 2025. The assessment documented that the resident has severe cognitive impairment. Review of the clinical record revealed no documentation of a transfer notice being provided to the resident or resident representative consisting of the required information. An interview with a Social Worker (SW/staff #61) was conducted on January 29, 2026 at 3:13 p.m. Staff #61 stated that Social Services/Case Management is not involved with transfer/discharge notifications. Per Staff #61, it is Medical Records that oversees transfer/discharge notifications. An interview with the Medical Records Director (Med Rec Dir/staff #56) was conducted on January 29, 2026 at 3:17 p.m. Staff #56 stated that she just started tracking transfer/discharge notification around October 2025. She indicated that a form for transfer/discharge was created October 2025. This was also around the time that she took over ombudsman notification. Staff #56 said that the facility's liaison (staff #120) visits the residents transferred to the hospital and provides them the transfer/discharge notification. Otherwise, it is mailed out. However, she noted that she is not involved in the bed hold briefing as it is done during admission. Staff #56 noted that she is unsure of how mailed out notification is tracked. Completed transfer/discharge notifications are normally scanned into the residents' clinical records. However, the form can only be uploaded if provided to her. If she does receive the completed transfer/discharge form then it cannot be uploaded. Staff #56 said that transfer/discharge notification is important so that the resident/resident representative has information regarding the transfer/discharge, and their appeals rights. Per the Medical Records Director, the ombudsman is the resident's advocate and therefore should be aware of the resident's status. The resident needs the ombudsman's info because that is their advocate. Staff #56 said that it is important that they are able to provide documentation regarding the transfer/discharge notification since it shows that they are taking care of their residents and document the information that was provided to them. Without that documentation there is no paper trail of what information was passed on. A copy of the facility's transfer/discharge notification form was reviewed with Staff #56. It was noted that the information for the appeals was wrong. Additionally, the information for the ombudsman was also incorrect. Staff #56 stated that she is unsure of where that information was obtained. A review of residents #17 and #22 was conducted with staff #56. Staff #56 confirmed that there was not transfer/discharge notification in either residents' record. During an interview with the Admissions Coordinator/Clinical Liaison (staff #120) conducted on January 29, 2026 at 4:50 p.m., staff #120 stated that he visits the hospital where the residents were transferred to provide a means of contact between the facility and the residents. Staff #120 stated that he does not provide any transfer/discharge form or packet to the resident or resident representative during the visit. Additionally, he stated that he is unfamiliar with the form. Staff #120 said that it is important for the residents to be provided a transfer/discharge notification since most residents have never been in this circumstance before and would need information regarding resources and their rights. It is good to have that information that way they would want to come back. The impact of residents/resident representative not receiving that information is that they would not want to come back, might get the perception that they cannot come back, and lack information that they might need. An interview with the Administrator (staff #107) was conducted on January 29, 2026 at 6:02 p.m. The Administrator stated that a transfer notice is provided to the resident/resident representative 3-days prior to discharge. The Administrator said that there is a transfer/discharge notification for each level and each one has a checklist. The responsible party is called if not in the building during a change in condition. Per the Administrator, it is important that the transfer/discharge notification is provided since it is required per regulation, policy, continuity of care, and so that the resident/resident representative knows their rights and actions to take. The potential impact of not providing a transfer/discharge notification to the resident/resident representative is that resident might not receive the care needed and not know how to exercise their rights. The facility's transfer/discharge notification form was reviewed with the Administrator and she noted that it did not look like the one she approved and was unaware her team was utilizing the form. The Administrator stated that she is unaware of where the contact information for the appeals was obtained. The Administrator was informed that contact information for the appeals portion was erroneous. Review of the facility policy titled Discharge/Transfer of a Resident implemented January 1, 2025 stated that for unplanned discharge such as emergent transfer to an acute care setting, the facility will review the bed hold policy with the POA within 24 hours of transfer. Further review of the facility's policy for discharge/transfer did not reveal that it addressed transfer/discharge notification to resident/resident representative. Additionally, the policy did not indicate what the required information are that is to be provided to the resident/resident representative. Per the State Operations Manual Appendix PP, revision 232, the facility must notify in writing the resident and the resident's representative of the transfer/discharge which includes the following items: The reason for the transfer or discharge;The effective date of the transfer or discharge;The location to which the resident is transferred or discharged A statement of the resident's appeal rights including the name, address and telephone number of the entity which receives the request, and information on how to obtain an appeal form and assistance I completing the form and submitting the appeal hearing requestThe name, address and telephone number of the Office of the State Long-Term Care OmbudsmanThe contact information for the agency responsible for the protection and advocacy of individual with developmental disabilities (if applicable)The contact information for the agency responsible for the protection and advocacy of individual with mental disorder (if applicable)

Based on clinical record review, staff interviews, observation, and policy review, the facility failed to ensure resident-identifiable information was maintained confidentially and protected from public view for one Resident (#29). This deficient practice resulted in the exposure of protected health information (PHI) to an unauthorized individual and could result in a violation of residents' rights to privacy and confidentiality. Findings include:An observation conducted on January 29, 2026, at 10:45 a.m. revealed an unattended computer workstation with resident records actively displayed on the monitor. No facility staff were present or monitoring the workstation at the time of the observation. The information displayed on the computer screen included personal and identifiable dietary information for Resident #29.At 10:46 a.m., a non-employee was observed walking down the hallway and passing directly by the computer monitor displaying Resident #29's personal information, with no attempt made by staff to shield or secure the information.At 10:47 a.m., the Director of Nursing (DON/Staff #85) approached the unattended workstation and immediately logged off the computer.An interview conducted on January 29, 2026, at 10:47 a.m. with Staff #85 who confirmed that the unattended computer contained private resident information. Staff #85 acknowledged that leaving resident information visible on an unattended workstation could constitute a violation of the Health Insurance Portability and Accountability Act (HIPAA) and failed to meet facility expectations for protecting resident confidentiality.On January 29, 2026, at 11:54 a.m., Staff #85 provided documentation of staff training titled, PHI (Protected Health Information), Close Screens - Do Not Leave Information Exposed, Confidentiality, Policy Review, HIPAA, and Resident and Family Notification. The documentation indicated that 31 staff members had signed, acknowledging their understanding of the confidentiality requirements.A review of the facility policy titled Resident Rights, revised January 1, 2025, revealed that residents have the right to secure and confidential personal and medical records and that the facility is responsible for safeguarding resident information from unauthorized access or disclosure.

Based on clinical record review, interviews and review of facility policy and procedure, the facility failed to ensure medications were administered within the physician ordered parameters for Resident #09. The deficient practice may result in medications being administered outside physician ordered parameters.Findings Include:Resident # 09 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia, hypotension, dependence on respirator (ventilator) status, and bradycardia. A review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident had a Staff Assessment for Mental Status (SAMS) score of 3, indicated the resident cognition was severely impaired.Review of the medical records revealed medication orders with start date of May 07, 2024:Carvedilol Oral Tablet 3.125 milligram; Give 2 tablet enterally two times a day for hypertension (HTN); Hold if systolic blood pressure (SBP) is less that 110; Hold if heart rate (HR) is less than 60Clonidine HCL Oral Tablet 0.2 milligram; Give 1 tablet enterally two times a day for hypertension (HTN); Hold if systolic blood pressure (SBP) is less that 110; Hold if heart rate (HR) is less than 60Hydralazine HCL Oral Tablet 100 milligram; Give 1 tablet enterally three times a day for hypertension (HTN); Hold if systolic blood pressure (SBP) is less that 110; Hold if heart rate (HR) is less than 60Review of the medical records revealed medication orders with start date of May 08, 2024:Amlodipine Besylate Oral Tablet 10 milligram; Give 1 tablet enterally one time a day for hypertension (HTN); Hold if systolic blood pressure (SBP) is less that 110; Hold if heart rate (HR) is less than 60.Doxazosin Mesylate Oral Tablet 4 milligram; Give 1 tablet enterally one time a day for hypertension (HTN); Hold if systolic blood pressure (SBP) is less that 110; Hold if heart rate (HR) is less than 60.A review of the Nurse Practitioner progress note dated May 15, 2024, revealed that the resident's representative expressed concern regarding bradycardia.A review of the social services progress note, dated May 17, 2025, revealed that the provider was contacted to discuss the resident's heart rate and cardiac medications with the resident's representative; and that, representative felt heart rate was too low.A review of a physician progress note dated May 19, 2024 revealed that the resident continued with Bradycardia.Review of MAR dated May 2024, revealed that on May 19, 2025 resident was noted to have a change of condition for Bradycardia due to having a pulse of 36.A review of the hospital discharge form dated May 19, 2024 revealed the resident had a blood pressure of 133/60, a regular pulse rate of 36 beats per minute, and a general impairment of vegetative state.A review of the May 2024 Medication Administration Record (MAR), revealed Amlodipine Besylate 10 milligram was to be taken daily, and to hold if the Systolic Blood Pressure (SBP) is less than 110, and the heart rate/ beats per minute(bpm) is less than 60. Despite the order, the resident was administered the Amlodipine 10 mg outside of parameters on the following dates:May 10, 2024 administered at 54 bpmMay 11, 2024 administered at 54 bpmMay 13, 2024 administered at 54 bpmMay 14, 2024 administered at 57 bpmMay 18, 2024 administered at 52 bpmA review of the 2024 MAR, revealed two tablets of Carvedilol 3.125 milligram was to be given for HTN, with parameters to hold if the SBP was less than 110, and heart rate less than 60, twice a day. The resident was administered two tablets of Carvedilol 3.125 mg out of parameter on the following dates:May 10, 2025 administered at 54 bpm am shiftMay 11, 2025 administered at 54 bpm am shiftMay 13, 2024 administered at 54 bpm both shiftsMay 14, 2024 administered at 57 bpm am shiftMay 15, 2025 administered at 50 bpm evening shiftMay 18, 2024 administered at 52 bpm am shiftA review of the May 2024, revealed two tablets of Carvedilol 3.125 was held the evening shift of May 18, 2025 per physician request and the morning shift of May 19, 2025 at 44 bpm.A review of the May 2024 MAR, revealed Clonidine HCL .2 mg was to be given daily for HTN, with parameters to hold if SBP was less than 110, and heart rate less than 60. The resident was administered Clonidine HCL .2 mg out of parameter on the following dates:May 9, 2025 administered at 53 pm shiftMay 10, 2024 administered at 54 bpm am shiftMay 11, 2024 administered at 54 bpm am shiftMay 12, 2024 administered at 50 bpm pm shiftMay 13, 2024 administered at 54 bpm am shift and 50 bpm night shiftMay 14, 2024 administered at 57 bpm am shiftMay 15, 2024 administered at 50 bpm, night shiftMay 18, 2024 administered at 52 bpm am shiftA review of the May 2024 MAR, revealed Doxazosin Mesylate 4 mg was to be given daily for HTN, with parameters to hold if SBP was less than 110, and heart rate less than 60. The resident was administered Doxazosin Mesylate 4 mg out of parameter on the following dates:May 10, 2024 administered at 54 bpmMay 11, 2024 administered at 54 bpmMay 13, 2024 administered at 54 bpmMay 14, 2024 administered at 57 bpmMay 18, 2024 administered at 52 bpmA review of the May 2024, MAR, revealed Hydralazine HCL 100 mg was to be given three times a day for HTN, with parameters to hold if the SBP was less than 110, and the heart rate less than 60. The resident was administered Hydralazine HCL 100 mg out of parameter on the following dates:May 9, 2024 53 bpm night shiftMay 10, 2024 54 bpm noon shiftMay 11, 2024 58 bpm noon shift and 48 bpm night shiftMay 13, 2024 54 bpm noon shift and 50 bpm night shiftMay 14, 2024 58 bpm am shiftMay 15, 2024 50 bpm night shiftMay 18, 2024 52 bpm am shiftAn interview was conducted on December 5, 2025, at 2:26 p.m. with Certified Nursing Assistant (CNA) Staff #01 who stated that a normal pulse ranges are 60-100 beats per minute (bpm) and that staff are instructed to notify the nurse if a resident's pulse falls below 60 bpm. Staff #01 explained that a low pulse may cause a resident to experience headaches, dizziness with position changes, lethargy, or communication difficulties, and that in such cases, the nurse is promptly notified.An interview was conducted on December 5, 2024, at 2:53 p.m. with Licensed Practical Nurse (LPN) Staff #77 who stated that medication orders with parameters are to be followed as written. Staff #77 stated that if a resident's heart rate becomes too low, the resident could code. The nurse explained that a low heart rate may cause a resident to become lethargic or unresponsive and could result in a code event. Staff #77 also identified carvedilol as a medication class known to decrease heart rate. Staff #77 reviewed the electronic medical orders for the resident's Amlodipine, Carvedilol, Clonidine, Doxazosin and Hydralazine and confirmed that these parameters indicated that if the resident's blood pressure was below 110 mmHg or if the pulse rate was less than 60 beats per minute -- medications were not to be administered. Staff #77 further reviewed Resident #09's Medication Administration Record (MAR) for May 2024 and identified dates on which these medications were administered when the resident's pulse rate was below 60 bpm. Staff #77 stated that on those days, the medications should have been held to avoid putting the resident at risk for complications.An interview was conducted on December 5, 2025 at 3:17 p.m. with the Director of Nursing (DON/Staff #100). The DON stated the facility's expectation is for the nursing staff to follow the provider orders when administering medications. Staff # 100 stated that bradycardia can be a dangerous issue because it can stop the heart. Staff # 100 stated that episodes of bradycardia had to be reported to the provider, who can look for a pattern, and also decide if a cardiology consult is needed for further interventions. Staff # 100 stated that the resident's recent bradycardic episodes qualify as a change of condition, and that interventions are to be added to the care plan, the provider notified, as well as the family.Review of the Medication Administration policy, dated January 1, 2025, directs the staff to review the medication record for prescribed medications and review the 5 rights: right patient, right time, right medications, right route, and right dose.

Based on documentation, observations, staff interviews and the facility policy and procedures, the facility failed to report an injury of unknown origin and complete a 5-day written investigation in accordance to their Abuse Policy's required timeframe for one resident (#2). The sample size was three. The deficient practice may result in residents being abused or receiving the appropriate treatment and care untimely. Findings include: Resident #2 was admitted on [DATE] with diagnoses of anoxic brain damage, respiratory failure, pleural effusion, epilepsy, gangrene and necrosis of lung. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 which meant the resident did not have the BIMS assessment completed. The MDS assessment revealed that the resident was always incontinent of bladder and bowel. A review of the care plan revealed that the resident had a communication problem: rarely/never understood and rarely/never understands related to severe cognitive loss due to anoxic brain damage history, with an intervention to anticipate and meet needs, discuss with resident/family concerns or feelings regarding communication difficulty, ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position and wheels locked, avoid isolation. Resident #2 has potential impairment to skin integrity related to Activities of Daily Living (ADL) deficiencies, always incontinent of bowel and bladder, respiratory failure, epilepsy, anoxic brain damage, cognitive loss. The goal included that the resident will maintain or develop clean and intact skin by the review date. Interventions included to use a draw sheet or lifting device to move resident and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. A review of a skin assessment dated [DATE] revealed Resident #2 had no skin issues documented on the form. A review of the progress notes revealed that on November 18, 2024 the resident's spouse informed the nurse that there was a bruise on the resident's left dorsal foot below the 2nd toe. The spouse requested an X-ray. The nurse notified the hospice nurse and an order was received. Another progress note revealed that on November 19, 2024 the X-ray results were received from the hospice nurse that the resident's left foot had a fracture. The hospice nurse came to evaluate the resident and notify the spouse of the fracture. The spouse requested to send resident #2 to the emergency room to be evaluated and treated. Resident #2 was transported to the hospital. A review of a nursing skin assessment dated [DATE] revealed Resident #2 had bruising to the left foot near toes with known fracture. An interview was conducted with Certified Nursing Assistant (CNA/ staff #4) on January 7, 2025 at 11:00 a.m. who revealed that they did not care for resident #2 when the bruise was discovered. Staff #4 stated that any unusual marks are reported to the nurse. An observation was made on January 7, 2025 at 11:03 a.m. of resident #2's feet. Staff #8 (Wound Nurse) lifted the sheet and blanket off of Resident #2's feet while the resident was lying in bed. The resident was positioned slightly onto their right side. No padded side rails noted. The resident's left foot did not have any discoloration indicating a bruise. The toes did not appear straight or flat. They were bent at the joints. The left foot was resting on pillow that was between the right and left foot. An interview was conducted with Licensed Practical Nurse (LPN/ staff #5) on January 7, 2025 at 11:12 a.m. Staff #5 stated that when any unusual marks are reported, they go observe the mark, notify the Director of Nursing (DON), Assistant Director of Nursing (ADON), the doctor, family members, perform any orders received from the doctor, document in the chart, progress notes and the skin assessment tool. Staff #5 stated that the staff remembered the mark on resident #2. Staff #5 said that when the staff went to look at the area, the spouse was at the bedside and pointed it out. Staff #5 then called the doctor, notified hospice of what was observed. Then the staff stated the spouse requested an X-ray. Staff #5 stated an order for X-ray was then received but the spouse wanted the resident to be send out to the hospital instead of having the X-ray come out to the facility. Staff #5 stated the hospice nurse came and placed a soft boot on the toe to protect it in the meantime. Staff #5 stated the bruise was not on the toe but below, nickel sized, color was purplish blue in color. Staff #5 stated the resident winced in pain when the area was touched. Staff #5 stated the resident does not move on own and needs to be turned and repositioned every 2 hours. An interview was conducted with DON (staff #3) and Administrator (staff #6) on January 7, 2025 at 11:24 a.m. Staff #3 stated that when a resident has a bruise, area is assessed to see what is going on, an X-rays order is received and the nurse assesses and takes the next step. When asked what is your process for injuries of unknown origin is, Staff #3 stated an investigation is done and if needed to report it will be reported as well. When asked regarding what could happen if injuries are not reported and Staff #3 stated a wide variety can happen, absolutely nothing could heal, things could get worse, an open wound could get infected, depends on the type of injury. Staff #3 stated the facility did not report the incident as they did not think it was a reportable incident, understanding the patient's condition and Director of Operations (staff #9) said there was no open mark. Then staff #3 stated that in hindsight 5050 the incident should have been reported. Staff stated the family would massage the resident's feet and there were family dynamics. It was stated that the Hospice Nurse Practioner said that there was no suspected abuse. The staff stated as a provider this is very common, the way the fracture shows on Xrays and believed it was self-inflicted. An interview was conducted with staff #6 on January 7, 2025 at 12:48 p.m. who stated that no 5 day reports or list of reportables were available. Staff #6 stated that their first day was January 1 and gave it 24 hours when it was noticed that the shared files were gone (regarding the list of reportables and 5 day reports); and that, the shared files were wiped from the system. The policy Abuse Prevention, Identification, Investigation, and Reporting Policy was reviewed. The policy states: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Regulatory Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Section VII. Reporting/Response, Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on documentation, observations, staff interviews and the facility policy and procedures, the facility failed to report an injury of unknown origin within required timeframe for one resident (#2). The sample size was three. The deficient practice may result in residents being abused or receiving the appropriate treatment and care untimely. Findings include: Resident #2 was admitted on [DATE] with diagnoses of anoxic brain damage, respiratory failure, pleural effusion, epilepsy, gangrene and necrosis of lung. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 99 which meant the resident did not have the BIMS assessment completed. The MDS assessment revealed that the resident was always incontinent of bladder and bowel. A review of the care plan revealed that the resident had a communication problem: rarely/never understood and rarely/never understands related to severe cognitive loss due to anoxic brain damage history, with an intervention to anticipate and meet needs, discuss with resident/family concerns or feelings regarding communication difficulty, ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position and wheels locked, avoid isolation. Resident #2 has potential impairment to skin integrity related to Activities of Daily Living (ADL) deficiencies, always incontinent of bowel and bladder, respiratory failure, epilepsy, anoxic brain damage, cognitive loss. The goal included that the resident will maintain or develop clean and intact skin by the review date. Interventions included to use a draw sheet or lifting device to move resident and use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. A review of a skin assessment dated [DATE] revealed Resident #2 had no skin issues documented on the form. A review of the progress notes revealed that on November 18, 2024 the resident's spouse informed the nurse that there was a bruise on the resident's left dorsal foot below the 2nd toe. The spouse requested an X-ray. The nurse notified the hospice nurse and an order was received. Another progress note revealed that on November 19, 2024 the X-ray results were received from the hospice nurse that the resident's left foot had a fracture. The hospice nurse came to evaluate the resident and notify the spouse of the fracture. The spouse requested to send resident #2 to the emergency room to be evaluated and treated. Resident #2 was transported to the hospital. A review of a nursing skin assessment dated [DATE] revealed Resident #2 had bruising to the left foot near toes with known fracture. An interview was conducted with Certified Nursing Assistant (CNA/ staff #4) on January 7, 2025 at 11:00 a.m. who revealed that they did not care for resident #2 when the bruise was discovered. Staff #4 stated that any unusual marks are reported to the nurse. An observation was made on January 7, 2025 at 11:03 a.m. of resident #2's feet. Staff #8 (Wound Nurse) lifted the sheet and blanket off of Resident #2's feet while the resident was lying in bed. The resident was positioned slightly onto their right side. No padded side rails noted. The resident's left foot did not have any discoloration indicating a bruise. The toes did not appear straight or flat. They were bent at the joints. The left foot was resting on pillow that was between the right and left foot. An interview was conducted with Licensed Practical Nurse (LPN/ staff #5) on January 7, 2025 at 11:12 a.m. Staff #5 stated that when any unusual marks are reported, they go observe the mark, notify the Director of Nursing (DON), Assistant Director of Nursing (ADON), the doctor, family members, perform any orders received from the doctor, document in the chart, progress notes and the skin assessment tool. Staff #5 stated that the staff remembered the mark on resident #2. Staff #5 said that when the staff went to look at the area, the spouse was at the bedside and pointed it out. Staff #5 then called the doctor, notified hospice of what was observed. Then the staff stated the spouse requested an X-ray. Staff #5 stated an order for X-ray was then received but the spouse wanted the resident to be send out to the hospital instead of having the X-ray come out to the facility. Staff #5 stated the hospice nurse came and placed a soft boot on the toe to protect it in the meantime. Staff #5 stated the bruise was not on the toe but below, nickel sized, color was purplish blue in color. Staff #5 stated the resident winced in pain when the area was touched. Staff #5 stated the resident does not move on own and needs to be turned and repositioned every 2 hours. An interview was conducted with DON (staff #3) and Administrator (staff #6) on January 7, 2025 at 11:24 a.m. Staff #3 stated that when a resident has a bruise, area is assessed to see what is going on, an X-rays order is received and the nurse assesses and takes the next step. When asked what is your process for injuries of unknown origin is, Staff #3 stated an investigation is done and if needed to report it will be reported as well. When asked regarding what could happen if injuries are not reported and Staff #3 stated a wide variety can happen, absolutely nothing could heal, things could get worse, an open wound could get infected, depends on the type of injury. Staff #3 stated the facility did not report the incident as they did not think it was a reportable incident, understanding the patient's condition and Director of Operations (staff #9) said there was no open mark. Then staff #3 stated that in hindsight 5050 the incident should have been reported. Staff stated the family would massage the resident's feet and there were family dynamics. It was stated that the Hospice Nurse Practioner said that there was no suspected abuse. The staff stated as a provider this is very common, the way the fracture shows on Xrays and believed it was self-inflicted. An interview was conducted with staff #6 on January 7, 2025 at 12:48 p.m. who stated that no 5 day reports or list of reportables were available. Staff #6 stated that their first day was January 1 and gave it 24 hours when it was noticed that the shared files were gone (regarding the list of reportables and 5 day reports); and that, the shared files were wiped from the system. The policy Abuse Prevention, Identification, Investigation, and Reporting Policy was reviewed. The policy states: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Regulatory Definitions: Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Section VII. Reporting/Response, Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview, review of facility documentation, and review of facility policy, the facility failed to ensure that care and services were provided according to professional standards for one of one sampled resident (#42). The deficient practice could result in care not being provided to accepted standards of practice, leading to harm to a resident. -Findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses that included traumatic hemorrhage of cerebrum, Alzheimer's disease, dysphagia, and protein-calorie malnutrition. The admission minimum data set (MDS) assessment dated [DATE] revealed that the resident's brief interview for mental status (BIMS) score was 03, which indicated resident was severely cognitively impaired. Moreover, revealed the resident required substantial assistance for bed mobility and was totally dependent on staff for transfers from bed to chair. The assessment also indicated the resident had one unstageable unhealed pressure wound. An Admission Evaluation dated September 30, 2024, revealed moisture associated skin damage (MASD) to the resident's sacrum. Additionally a section indicated, Wound team to complete skin assessment. Review of medical records revealed no evidence of measurements. A physician order dated October 01, 2024, for wound care to coccyx pressure injury, to cleanse with cleansing wipes, pat dry, apply triad, leave open to air, every day shift and as needed with peri care. A Skin Check dated October 01, 2024 revealed that the assessment was marked, Skin warm & dry, skin color WNL (within normal limits), turgor normal. The resident was not assessed/ no information for risk of developing pressure ulcers/injuries. Further, the resident was not assessed/ no information for the presence of one or more unhealed pressure ulcers. An Initial Weekly Wound Evaluation dated October 01, 2024, revealed resident #42 had an unstageable pressure wound on the coccyx extending to buttocks, present upon admission. The wound was measured as follows: 7 cm by 5.5 cm, and unable to determine depth of wound. The wound was described as maroon discoloration with normal skin surrounding. A care plan revised October 01, 2024 revealed that Resident #42 was at risk for impaired skin integrity, with a goal that the resident will maintain clean and intact skin, and interventions to Identify / document potential causative factors and eliminate / resolve where possible and to Keep skin clean and dry. A review of the certified nursing assistant (CNA) task log for October 2024 revealed that the resident had Loose / Diarrhea bowel movement on the following dates and times: 10/03/2024: 14:30 10/04/2024: 4:49 17:29 22:38 10/05/2024: 17:29 10/06/2024: 15:05 19:59 10/07/2024: 17:29 10/08/2024: 17:29 21:18 21:19 10/09/2024: 17:09 23:18 23:18 10/10/2024: 5:28 9:43 21:00 10/11/2024: 17:29 10/12/2024: 17:29 20:25 10/13/2024: 2:58 14:40 10/14/2024: 20:05 10/15/2024: 5:16 12:49 10/16/2024: 8:53 10/17/2024: 13:42 22:55 10/18/2024: 12:30 10/19/2024: 17:00 10/20/2024: 12:16 10/21/2024: 10:55 10/22/2024: 14:58 10/23/2024: 5:19 9:07 10/24/2024: 5:19 10/25/2024: 17:13 A Skin Check dated October 08, 2024 revealed that the assessment was marked Skin warm & dry, skin color WNL (within normal limits), turgor normal. The resident was marked as having no external devices (cast, prosthetic, brace). No evidence of any other markings was on the form. A Weekly Wound Evaluation dated October 10, 2024, revealed that the coccyx wound present on admission had increased in size to 8 cm x 7.5 cm, and that the maroon discoloration had begun to denude (open) with red/pink tissue present in open areas. The note revealed that the size of wound increased due to patient having repeated loose stools. Further, the note indicated that the, tube feeding orders were changed and patient is on Imodium for loose stools. A physician order dated October 10, 2024, indicated for Imodium 2 mg oral tablet, to give one tablet via NG (nasogastric) tube, every 6 hours as needed for loose stools. A review of the Weekly Wound and Nutrition Interdisciplinary Team (IDT) meeting minutes for the week dated October 10, 202 through October 16, 2024 revealed that Resident #42's unstageable coccyx wound, described as a pressure injury, had increased in size. The increase in wound size was, due to patient having repeated loose stools. A Nurse Practitioner Visit note dated October 11, 2024 revealed the nurse reported Resident #42 was having diarrhea, and, will offer PRN (as needed medication). Review of the Medication Administration Record (MAR) for October 2024 revealed that the resident was administered Imodium one time, on October 21, 2024 at 9:56 AM. However, from the time the Imodium was ordered, until the first time it was given, the resident had daily episodes of loose stool, totaling 16 episodes. A Skin Check dated October 13, 2024 revealed that the assessment was marked Skin warm & dry, skin color WNL (within normal limits), turgor normal. The resident was marked as having no external devices (cast, prosthetic, brace). The note indicated under the section Skin Issues excoriation to coccyx and buttocks, resident only had one episode of loose stool on 10/12 and none for today. However, the CNA task log revealed 2 episodes of loose stools on October 12, 2024. An additional Nurse Practitioner Visit note dated October 14, 2024, revealed that no additional diarrhea was reported for Resident #42, despite the CNA task log indicating that the resident had 6 episodes of loose stool / diarrhea from October 11 to October 14, 2024. A Skin Check dated October 15, 2024 revealed that the assessment was marked Skin warm & dry, skin color WNL (within normal limits), turgor normal. The resident was marked as having no external devices (cast, prosthetic, brace). No evidence of any other markings was on the form. A Weekly Wound Evaluation dated October 19, 2024, revealed the coccyx wound had no evidence of measurements recorded on the evaluation. The note indicated that the, maroon discoloration is fading and the, open denuded areas are improving and the, wound edges are intact. Also, the wound bed had red granulation tissue present. The note further indicated that, loose stools due to tube feed have began to decrease in amount. A review of the Weekly Wound and Nutrition Interdisciplinary Team (IDT) meeting minutes for the week dated October 16, 202 through October 22, 2024 revealed that the unstageable coccyx wound, described as a pressure injury, had increased in size. The wound size was noted as 2 cm x 1.5 cm x .1 cm. The wound was described as 50% granulation tissue and 50% slough. An additional order dated October 20, 2024, indicated for wound care to coccyx pressure injury, to cleanse with wound cleaner, pat dry, apply medihoney followed by calcium alginate, and cover with dry dressing, every day shift and as needed if soiled or dislodged. A Skin Check dated October 22, 2024 revealed that the assessment was marked Skin warm & dry, skin color WNL (within normal limits), turgor normal. The resident was marked as having no external devices (cast, prosthetic, brace). No evidence of any other markings was on the form. A Surgical Note dated October 24, 2024, by the wound physician, revealed that the provider was asked to see this patient for my opinion on how to manage the wound found on the left buttock. The note indicated that the cause of the wound was, moisture associated skin damage. Further, the note indicated that the resident underwent a debridement of the wound with a surgical excision of devitalized tissue. The size of the wound pre-operatively was 3.0 cm x 5.0 cm and unable to determine depth of the wound, and the post-operative size of the wound was 3.0 cm x 5.0 cm x 0.1 cm. A physician order dated October 25, 2024, indicated for wound care to moisture associated skin damage (MASD) on the left buttock, to cleanse with wound cleaner, pat dry, apply medihoney followed by calcium alginate, and cover with dry dressing, every day shift and as needed if soiled or dislodged. An observation was conducted on October 28, 2024 at 10:47 AM of the resident sitting up in a wheelchair in her room, and her daughter seated beside her. The resident was unable to communicate. A wound care observation was conducted on October 30, 2024 at 11:21 AM, of the resident receiving a treatment consisting of medihoney alginate and a foam dry dressing for the left buttock, provided by a wound nurse / licensed practical nurse (Staff #63). The wound was located on the resident's left buttock, to the left of the bony prominence of the coccyx. The skin over the coccyx appeared healed. The open area of the left buttock wound had a dry, non-serosanguinous wound bed, and irregular borders. An interview was conducted on October 28, 2024 at 10:47 AM, with the resident's daughter. The daughter stated that while at the facility, her mother, ended up with a bedsore that she didn't have before. She stated that her mother had a lot of diarrhea that caused the wound. On October 29 2024 at 10:12 AM, an interview was conducted with a CNA (Staff #74) who stated that the resident has a pressure wound on her bottom, and that it usually has a dressing on it. She stated that the resident is dependent on staff for all care. An interview was conducted on October 29, 2024 at 10:15 AM, with a CNA (Staff #292). The CNA stated that she normally works on the unit with Resident #42, that she first started working with the resident about two weeks ago, and that the resident had loose stools every time, and needed to be changed approximately every two hours. She stated that the resident had a small wound on her bottom, that they put barrier cream and a dressing on it. She also stated that the dressings would get soiled, the CNA staff would remove the dressings when changing the resident, and let the nurse know so that the nurse could replace the dressing in between the times that the CNA staff changed the resident. An interview was conducted on October 29, 2021 at 10:21 AM, with a wound nurse / licensed practical nurse (LPN / Staff #73) who stated that when Resident #42 first admitted to the facility, that the resident had an unstageable wound that was dark around the coccyx. The unstageable wound then resolved, and moisture associated skin damage (MASD), showed up on her left buttock. She stated that there were no open areas of the wound when the resident first admitted , and that the MASD open area on the left buttock was first noticed on October 19, 2024. She stated that the resident was first referred to the wound physician for evaluation on October 24, 2024. An additional interview with another wound nurse / LPN (Staff #63) was conducted on October 30, 2024 at 11:21 AM. The LPN said he was familiar with the resident as he had been taking care of the wound since the first week. He stated that at the time of the resident's admission, there were no open wound areas on the resident's bottom, that there was just maroon discoloration. The LPN stated that the resident was having loose stools multiple times an hour where the new areas of wound had opened on the left buttock. When asked to clarify what exactly caused the open areas of the wound, the LPN stated that, if the stool was better managed, so it wasn't loose and watery, then she would not have the denuded areas. He stated that when the loose stools were noted, that the resident was started on Imodium to address the loose stools. When the MAR for October 2024 was reviewed together with the LPN, the LPN stated that the Imodium for loose stool had only been given once, on October 21, 2024. On October 230, 2024 at 1:30 PM, an interview was conducted with the registered dietician (RD / Staff #260) who stated that she was part of the weekly IDT review for Resident #43. The RD stated that she was, looped into her care almost immediately after admission; and that, the resident has, had loose stools ever since she's been here. She further stated that, anytime anyone is on tube feed, everyone always looks at tube feeding as the cause of loose stools, but half the time it is, half the time it isn't. The RD stated that, it's hard to say whether the type of tube feed was contributing to the resident's loose stools; and that, she had switched the type of tube feed on October 07, 2024, however the resident continued to have loose stool. The RD stated that during the weekly IDT meeting on the week of October 10 - 16th, 2024, that she remembered it was brought up in the meeting that the wound was deteriorating and a causative factor was the resident's repeated loose stool. The RD stated that an attempt had been made to switch the resident's diet to puree food to replace the tube feed on October 14, 2024, however the tube feed had to be restarted three days later due to concerns of poor intake by the resident. An interview was conducted on October 31, 2024 at 9:41 AM with an LPN (Staff #152). The LPN stated that she normally works on Resident #42's hallway and provides care for her. The LPN stated that if a resident had loose stool for some time that they would administer medication as ordered, and if no medication was ordered, that she would call the physician and get some. She stated that if the resident had a PRN (a needed) medication ordered for loose stool, that she would then give it. The LPN stated that she could not think of any non-pharmacological options to address loose stool. The LPN stated she was familiar with Resident #42 and had only given her Imodium once to address loose stool on October 21, 2024 when the resident's daughter had asked for it. She stated that she had never witnessed Resident #42 having loose stool before, and that neither the CNA staff nor the resident's family had made her aware of any loose stool prior to October 21, 2024. She also stated that the wound nurses had not communicated with her that Resident #42 was having loose stool. On October 31, 2024 at 9:48 AM, an interview was conducted with the resident's other daughter. The daughter stated that her mother could not control her bowel and that she needed to be changed approximately every 1-2 hours, because she was having loose stool and diarrhea. She stated that her mother had been having ongoing diarrhea that did not stop until within the last week. The daughter stated that she had left for vacation on October 18, 2024, and up to that point, her mother had back to back diarrhea the whole time, and that she started to be more vocal about the diarrhea to facility staff. An interview was conducted on October 31, 2024 at 10:17 AM, with the Director of Nursing, (DON / Staff #10). The DON stated that the facility's process if a resident has ongoing loose stool or diarrhea is to address it, we talk with the patient, talk with the staff, we look into non-pharmacological interventions, then whatever the doctor's orders are. He further stated that we would not let it continue, we address it. The DON further clarified that non-pharmacological options for loose stool could be adjusting the type of tube feed, patient education, and holding medications that might cause diarrhea. If all the options are exercised and the resident is still having diarrhea, then we address it with the doctor. The DON stated that if a resident is experiencing loose stool or diarrhea, that the nurse would assess to see if it truly was diarrhea. He stated it would not meet his expectation if a nurse did not go to the resident to assess the loose stool daily. He stated the nurse should investigate and assess and resolve the issue. The DON confirmed that in the case of Resident #42's ongoing diarrhea, the CNAs were documenting continued loose stools and the Imodium was not administered that could have helped resolve the loose stool issue. The DON stated that the importance of effective communication between the CNAs and nurses is huge, and if everybody is not on same page, then medication may be missed or there might be a possibility of all people on the care team not being able to resolve something in a timely manner. Review of the facility's policy titled, Change in Resident Condition, revised July 04, 2024, revealed that a licensed nurse will accurately document, in the Daily Nurses Notes, information relevant to changes in the resident's medical condition. Documentation is to include assessment of the resident's medical status, subsequent monitoring of interventions and their effectiveness, and communication to all involved parties. Review of the facility's policy titled, Incontinence Care, revised July 04, 2024, revealed that Nursing Assistants will check the resident at least very two hours and assist with toileting as needed. The unit nurse and charge nurse will monitor and oversee incontinence care. The facility's policy titled, Abuse Prevention, Identification, Investigation, and Reporting, revised July 04, 2024, revealed that staff will ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately.

Based on personnel record reviews, facility documentation, staff interviews and policy review, the facility failed to ensure staffs had competencies or skills needed to provide care for 8 residents on ventilator and tracheostomy. The facility census was 75. The deficient practice could result in patients with ventilator and tracheostomy (Vent/ Trach) not receiving care that they need. Findings include: Review of the Vent/Trach Census revealed eight (8) residents identified with a tracheotomy, ventilator or both a tracheotomy and ventilator. Review of the facility staff schedule dated August 11, 2024 revealed the following staff scheduled for the 6:00pm to 6:00 am shift for the facility: - For A Wing (Ventilator/ Tracheostomy unit) : LPN (Licensed Practical Nurse)/Staff #201 LPN/Staff #38 LPN/Staff #157 (requested off) - For C Wing: LPN/Staff #116 LPN/Staff #34 - 2nd Floor Nurse: LPN/Staff #67 The staff schedule did not reveal that a Respiratory Therapist (RT) was scheduled for 6pm to 6am schedule. One RT staff (#68) was only scheduled for 6:00a.m-6:30p.m. Review of the personnel record for LPN/staff #38, revealed a hire date of March 22, 2023. Further review of the personnel record revealed no documented experience providing care for ventilator and tracheotomy patients. The SA complaint tracking system included that a report was submitted on August 12, 2024 that the staffing did not staff respiratory therapist and instead utilized an LPN who did not care for the patients properly. The report stated that when the daytime RT arrived, she was in shock at the state of the trach and vent patients. The report further stated that none of the patients with trach and vents received the required trach care, vent checks, or suctioning as the staffing refused to staff respiratory therapists in a airway wing (unit) causing risk to every patients on trachs and/or vents. Further review of the facility schedule provided on site on August 14, 2024 by Director of Operations (DO/ Staff#119) revealed a Registered Nurse (RN/Staff#106) was scheduled Mondays, Tuesdays, Fridays and Saturdays 6:00p.m to 4: 00a.m for the week of August 12 thru August 18, 2024. Further review of the staff schedule for the week of August 12 thru August 18 2024 revealed no RT scheduled after 6:30 p.m. for August 17 and August 18, 2024. Additional review of the schedule revealed one RN/Staff #134 scheduled Saturday, August 17, 2024 for the 6:00a.m.-6:30p.m. shift on the vent/trach unit A. This review revealed no RN and/ or RT scheduled after 4: 00 a.m on Sunday, August 18, 2024. The facility will be solely staffed with LPN's and CNA's for this time frame. An interview was conducted on August 14, 2024 at 12:27 p.m. with Respiratory Therapist (RT/Staff #48) who stated when they returned to work following the weekend of August 10-11, 2024 they stated it was a real shit show. Staff #48 stated residents who were on vents had not been placed back on their vents and there were cuff issues. Staff #48 stated they were willing to stay and assist, but were told to leave because they were over their hours. Staff #48 stated they had concerns, because there had been a call off and the facility was trying to find a respiratory therapist or an RN at the last minute, but no one showed and that left LPN/Staff #201 in charge of vent/trach unit. Staff #48 stated they were very concerned knowing that LPN#201 was the only one who was able to suction and provide trach care only. Staff #48 stated there were a lot a resident's to care for, especially for someone with limited education and experience with trach and vent residents. They stated that there was potential for a serious emergency situation. An interview was conducted on August 14, 2024 at 12:42 p.m. with an LPN/Staff #118. Staff #118 stated they are able to provide trach care as needed. They stated they were provided trach care training and has been a nurse for [AGE] years. Staff #118 stated they were provided the trach training by the prior Respiratory Manager when they first signed on and also received annual skills training. An interview was conducted on August 15, 2024 at approximately 10a.m with a RT (Staff # 68). Staff # 68 stated he is responsible for taking care of complicated vent and trach patients and management of their respiratory needs. Staff #68 stated the facility has three full time day shift respiratory therapists, one full time for night shift and one PRN (as needed). Staff # 68 stated LPN's are with their scope of practice when providing basic care, such as suctioning, but that airway clearance is generally a shared responsibility with training. He further stated that he did not believe any LPN should provide any vent/trach care, especially with decannulations or accidental dislodgements. Staff #68 stated he finds the risks working with vent and trach residents stressful and he is trained to manage that airway. He stated an LPN and even an RN are not specifically trained to manage an airway and would consider it a high risk to not have an RT or an RN for any shift, with only an LPN on a high-risk unit. An interview was conducted with the Director of Nursing (DON/staff #70) on August 15, 2024 at approximately 11a.m., He stated respiratory therapists are scheduled 12-hour shifts- Sunday thru Saturdays - 7 days per week. He stated there can be fluctuations with this and would depend if there was a call off. He stated he would then replace with a PRN therapist or with registry staff. If no one available he would need to rely on the facility's qualified LPN or RN personnel. Staff # 70 stated the LPN's responsibilities on the vent/trach unit are to pass medications, care for peg tubes, help monitor some of the vent/trach machines, some suctioning as needed and assist the RT. Staff #70 stated the nursing staff did receive a training check off from the prior RT manager and from training from prior experience. Staff #70 stated the LPN's are not able to assess a trach or vent resident, but are able to assist the RT and in an emergency situation LPN's would have to do what they need to do to get that taken care of, by bagging and sending the resident to the emergency room . He stated it is not within the LPN's scope of practice to assess vent settings or independently implement nursing actions based on their observations, but are able to respond to alarms if there is an RN or RT in the facility to assist. Staff # 70 stated he was aware there were no Respiratory therapists or an RN were staffed on the date in question, but they are doing there best and trying to make changes and that there is a bigger picture with what the facility is trying to accomplish. An interview was conducted on August 15, 2024 at 12:42 p.m. with an LPN/Staff #81 at 9:23 a.m. Staff #81 stated she does not feel comfortable with ventilation settings, alarms, or emergent situation with vent residents. She stated it is not in her scope of practice. Staff # 81 stated she paired up with the respiratory therapist and will change dressings and suction the trach residents only as needed. An email was received from Director of Operations (DO/ Staff #119) on August 22, 2024, 10:29 AM who emailed the stating that the night shift supervisor on the dates in question was RN/Staff#106, who was overseeing the Licensed Practical Nurse acting as an RT. The email stated that the Staff#106 has an active RN license in the state of Arizona. Email had an attachment with identical staff schedule, similar to the one provided on site August 14, 2024 by DON/Staff #70 with the addition of RN/Staff #106. Review of the Arizona State Board of Nursing opinion: ventilator care by LPN's approved date: 5/93 revised date: 3/03, 03/07, 1/11, 1/15, 3/18. originating committee: Scope of Practice Committee states the following; - It is NOT within the scope of practice of a licensed practical nurse (LPN) to independently implement nursing actions based on conclusions of assessments drawn from his/her observations. e.g. perform ventilator adjustments. - It is within the LPN scope of practice to provide care to a ventilator dependent patient under the supervision and delegation of a registered nurse (RN), as specified in R4-19-101 - LPNs may assist with ventilator care in all settings by providing basic care, making observations, and by recording and reporting such observations. III.RATIONALE - An LPN may manage aspects of routine ventilator care in a ventilator-dependent patient. Acts which involve patient diagnosis or prescription of nursing interventions to implement a strategy of care, such as changing ventilator settings in response to laboratory results or change in patient condition, are NOT within the LPN scope of practice. Review of the facility policy title Tracheostomy Care states the facility will ensure that resident's who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences. 5. The facility will ensure staff responsible for providing tracheostomy care including suctioning are trained and competent according to professional standards of practice. Review of the facility policy titled Mechanical Ventilation with use of Oxygen Concentrator states the purpose is to establish a standardized procedure for using ventilators with oxygen concentrators in order to ensure patient safety, optimal respiratory support, and effective emergency response. Responsibilities included: -Respiratory Therapists: Responsible for setting up and monitoring the ventilator and concentrator, adjusting as necessary, and ensuring emergency readiness. -Nurses- Assist with patient assessment, monitoring, and documentation, and ensure effective communication within the care team. -Leadership- Ensure staff are trained on the protocol and policy, provide necessary resources, and oversee compliance with the policy

Based on observation, staff interviews, and review of policy and procedure, the facility failed to ensure that controlled medications were secured in a separately locked, permanently affixed compartment. This deficient practice could result in controlled medication accessible to unauthorized personnel. Findings include: On April 4, 2023 at 9:25 a.m., an observation of the medication storage room A was conducted with a licensed practical nurse (LPN/staff #70). A refrigerator was inside the medication room was not locked and had no locking mechanism visible. Inside the refrigerator was a locked box/container which the LPN said was a container for storage of controlled medications. Also, inside the refrigerator was a box of medication that contained a bottle of unopened lorazepam (antianxiety) oral concentrate belonging to a resident. The bottle of lorazepam was not inside the locked box/container found in the refrigerator. On April 4, 2023 at 10:00 a.m., the survey team was provided with access cards that allowed access to the use of the elevators. This access card was also allowed access to the medication storage rooms. In an interview with a certified nursing assistant (CNA/staff #10) conducted on April 5, 2023 at 10:22 a.m., the CNA stated that the nurses and housekeeping are the only staff with access to the medication rooms; and that, the CNAs do not have access to the medication room. Further, the CNA stated that nobody but the nurses should be in the medication rooms because drugs are stored there. An interview with another LPN (staff #88) was conducted on April 5, 2023 at 10:45 a.m. The LPN stated that only authorized staff have access to the medication room; and, authorized staff include only the director of nursing (DON) and the nurses. The LPN stated that the refrigerator in the medication storage rooms are for storing medications requiring refrigeration; and that, controlled substances are kept in the lock box contained inside the refrigerator. Further, the LPN said that medications not properly secured could result in diversion, or, that someone could get their hands on the wrong things like controlled medications. During an interview with the DSON (staff #16) conducted on April 5, 2023 at 1:00 p.m., the DON stated that there are no codes available to access the medication storage rooms; and that, the RNs (registered nurses), LPNs and RTs (respiratory therapists) were the only ones with access to the medication storage rooms. The DON stated that only the nurses have access to the keys required to open the lockbox; and that, the vendor cards do not allow access to the medication storage rooms. The DON further stated that a pharmacy representative even had to be escorted into that room when they are present in the facility. Further, the DON said that his expectation was that controlled medications in the refrigerator are stored in the lockbox found inside the refrigerator in the medication room. A review of facility policy on Controlled Medication, revised on March 3, 2022 revealed that all controlled medication will be stored under a double lock system. This document included that each medication cart has a locked box area for all narcotics.