Every finding on record at Havasu Nursing Center

Based on closed record review, staff interviews, and review of facility policy, the facility failed to ensure that transfer/discharge notifications were made for three sampled residents (#2), (#4) and (#6) to the representative of the Office of the State Long-Term Care Ombudsman. The deficient practice can result in further notifications of resident transfer/discharge not being provided to the Ombudsman.Findings include:-Resident #2 was admitted to the facility June 9, 2025 and discharged [DATE] with diagnoses that included encounter for other orthopedic aftercare, other specified degenerative diseases of basal ganglia, nontraumatic intracranial hemorrhage, unspecified, need for assistance with personal care.A discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had an unplanned discharge home with hospice. A Brief Interview for Mental Status (BIMS) was conducted revealing a score of 07, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors and that the resident required partial to moderate assistance with activities of daily living. Review of the Order Summary Report did not reveal an order for the resident to be discharged home with hospice services.However, review of the resident's Census List indicated that the resident discharged on June 13, 2025. A progress note dated June 13, 2025 documented that the, residents family advised that transport was coming to pick up resident to take home. Family advised resident is now a patient of hospice. AMA form was explained to family, and family was educated about taking patient AMA. See chart for signed AMA form. Resident left at approx. 1141 via wheelchair.-Resident #4 was admitted to the facility July 10, 2025 and discharged (AMA) July 11, 2025 with diagnosis including aftercare following joint replacement surgery, chronic obstructive pulmonary disease, unspecified, need for assistance with personal care. Review of the MDS assessment dated [DATE] revealed BIMS for resident #4 was unavailable for review. Further review revealed no indicators for behaviors, required supervision to moderate assistance with ADL's with a recent hip and knee replacement. Review of the care plan conference summary dated July 11, 2025 documented Resident concerned about staying at the facility due to husband's pancreatic cancer, Parkinson's and chemo fog. Resident insisted on going home to be with her husband and agreed to sign the AMA paperwork-Resident left the facility before signing the AMA document.A progress note dated July 11, 2025 documented resident left AMA.-Resident #6 was admitted to the facility July 18, 2025 and discharged AMA August 14, 2025 with diagnosis including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acute kidney failure, unspecified, unspecified abnormalities of gait and mobility, unsteadiness on feet. Review of the care plan date-initiated June 24, 2025 revealed a focus for discharge planning. Interventions included determine resident/representative goals for discharge.Review of the MDS assessment dated [DATE] revealed a BIMS of 15, indicating resident's cognition intact. There were no indicators for mood or behaviors and requires substantial to maximum assistance with ADL's.A progress note dated August 15, 2025 documented resident left the facility AMA and that the provider was made aware. Review of an Against Medical Advice Discharge Form dated August 14, 2025 was signed by resident #6 and Licensed Practical Nurse (Staff/LPN #62).A written request was submitted to the facility on September 4, 2025 at 1:47 pm requesting Ombudsman notification for June, July and August 2025.An interview was conducted on September 4, 2025 at 4:00 pm with the Administrator (Staff #23) and Director of Nursing (DON/Staff #19). It was stated when there is a resident who discharges from the facility AMA the facility will try to find out the need for discharge, ensure the resident is safe and provide notification of the AMA to all responsible parties. It was stated social services was responsible for notifying the ombudsman of all resident discharges, including those residents who discharge AMA. It was stated social services quit without notice, leaving administration to divide social service responsibilities among staff. Staff #23 stated he was responsible for notifying the state ombudsman and there was no documentation to provided that the state ombudsman was notified of AMA discharges. Review of the facility policy titled Discharging a Resident Without a Physician's Approval Revision date: March 2025 states a physician's or providers order is obtained for discharges, unless a resident or representative request the discharge against medical advice.Review of the facility policy titled Transfer or Discharge states Once admitted to the facility, residents have the right to remain in the facility. Transfers and discharges must meet specific criteria and require resident/representative notification, orientation, and documentation in the medical record.

Based on observation, clinical record review, interview, and review of policy and procedures the facility failed to ensure Enhanced Barrier Protection (EBP) was in place for seven residents (#2, #19, #20, #343, #36, #195, #94) according to professional standards. This deficient practice could result in the increased risk of pathogen transmission. Findings include: -Resident #2 was admitted to the facility on [DATE] with diagnoses that include Pyothorax without fistula and a breakdown (mechanical) of nephrostomy catheter among others. The MDS revealed the resident's BIMS score of 14 and also urinary incontinence and indwelling catheter care. The clinical record revealed a doctor's order for a nephrostomy tube output three times a day. -Resident #36 was admitted on [DATE] with diagnosis including acute respiratory failure with hypoxia with a peripherally inserted central catheter (PICC line LUE location). -Resident #19 was admitted on [DATE] with diagnosis of chronic obstructive pulmonary disease. This resident has a Physician order for Foley catheter care on January 1, 2025. There is no order for EBP measures, however, there was a Physician order to use the facility skin and wound protocol if indicated. -Resident #195 was admitted on [DATE] with primary diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. The resident has a G- tube site cleansing order and a daily tracheostomy care ordered by the Physician on April 05, 2025. -Resident #343 was admitted on [DATE] with a primary diagnosis of unspecified severe protein-calorie malnutrition. This resident also has a Foley catheter care and maintenance order by the Physician on April 9, 2025. -Resident #94 was admitted on [DATE] with a primary diagnosis of pneumonia with plans to use long term use of antibiotics. The resident has a PICC line on her right upper extremity (RUE) with a weekly dressing order from the Physician on March 29, 2025. -Resident #20 was admitted on [DATE] with a primary diagnosis of urinary tract infection. The resident is currently wearing a Foley catheter with a catheter care order placed on February 20, 2025. However, the Care Plan failed to reflect on Physician's order for EBP protocol and interventions for the seven residents (#2, #19, #20, #343, #36, #195, #94). There is also no evidence of any interdisciplinary communications to provide this vital universal precaution measure to protect the spread of infections within the facility; including signage outside resident's room visibly posted. An observation was conducted on April 10, 2025 at 2:00 p.m. It was observed that there was no signage identifying the residents' need for EBP. In addition, each of the residents that qualified for EBP did not have personal protective equipment readily accessible for staff use. Documentation failed to mention that any of the identified residents refused care plan regarding infection control. An interview with a CNA staff #32 conducted on April 10, 2025 regarding the EBP protocols, the staff #32 stated that she understood that they have to follow procedures such as hand sanitizing prior donning the gloves, and proper doffing of gloves after tending to the residents. The staff #32 also stated that they follow this procedure if there is EBP signage outside the residents' room. However, another CNA staff #19 stated CNAs receive notice from the LPNs/RNs regarding following the EBP protocols. An interview with the Director of Nursing who is also the Infection Preventionist staff #27 conducted on April 10, 2025 at 1:37 p.m revealed that the facility's current understanding of EBP protocol only involved the residents with a history of active multidrug-resistant organisms (MDRO). The staff #27 confirmed that there are no current residents that fit those profile requirements at the facility. When asked about the EBP federal guidelines, the staff #27 stated that, I just got some new literature, and believes that it is a dignity issue having to put the signage outside the residents with no active MDRO. However, when asked about the risks of not following the BP guidance, the staff #27 stated, are obviously the spread of infections. DON reiterated, that up until now, they were up to my expectations. For example, the staff #27 stated that the resident #195 did not have EBP signage but moving forward there will be EBP signage outside this resident's room. A facility EBP policy titled, Enhanced Barrier Precautions dated to 2024 revealed that enhanced barrier protection be initiated for residents with: (i) wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling/ implanted medical devices (e.g., central lines, ports, urinary catheters, feeding tubes, tracheostomy/ ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO; and that, EBP precautions should be used for the duration of the affected resident/s' stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.

Based on clinical record review, staff and family interviews, and facility documents and policy, the facility failed to ensure a resident's privacy was maintained during medication administration for one resident (resident #27). This deficient practice could result in further violations of resident privacy. Findings include: An observation was made on April 9, 2025 at 07:51 a.m. Licensed Practical Nurse (LPN) Staff #23 prepared medications for Resident #27. Staff #23 stepped away from the medication cart and went into Resident #27's room and gave the medications, however the computer screen was not closed or locked, displaying Resident #27's name, date of birth and medications. Staff #23 came back to screen and utilized the computer then turned around and went back into Resident #27's room again. The screen still had resident #27's name up with the screen unlocked. At 7:58 a.m. Staff #23 came back to the cart and was shown the screen and asked what could happen if the computer was left unlocked and unattended? Staff #23 stated somebody could come and mess with it. An interview was conducted on April 10, 2025 at 10:49 a.m. with Director of Nursing (DON) Staff #27 and revealed that the process for the medication pass and screen access is to either minimize or close the screen from any resident information display. Staff #27 state that if the screen was already left unlocked someone could see something that is HIPPAA (Health Insurance Portability and Accountability Act) protected. Asked how important is it to lock the screens and Staff #27 stated that it is absolutely important, everybody knows how important it is to protect the information. A review of the Resident Rights policy (revised February 2021), revealed that the Policy Statement reads: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: section t. Privacy and confidentiality. A review of the HIPAA Training Program policy (revision date April 2007) revealed that under the Policy Interpretation and Implementation part 1. To ensure the confidentiality of out resident's protected health information (PHI) and facility information, a HIPAA and data security training program will be provided for all employees and business associates who have access to protected health and facility information.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that the care plan was revised after each fall for one (#94) of four sampled residents. The deficient practice could result in resident not getting the individualized care that they need. Findings include: Resident #94 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, muscle weakness, unsteady on feet, abnormality of gait and mobility. An admission fall risk evaluation dated March 27, 2025 revealed that the resident had a history of 1-2 falls in the last 3 months. Further review of fall risk evaluation revealed that the resident was alert and oriented x 3. A care plan initiated on March 28, 2025 revealed that the resident had the high risk for falls. Interventions included to anticipate needs; ensure call light is within reach when in room; to participate in activities that promote exercise, physical activity for strengthening and improved mobility and ensure use of non-skid socks when ambulating or mobilizing in wheelchair. Further review of care plan revealed that the resident needed assistance with activity of daily living (ADL) tasks. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident is cognitively intact. Further review of the MDS dated [DATE], revealed that the resident had two falls in the last six months prior to admission. A progress note dated April 7, 2025 revealed that the resident was observed by staff sitting on floor next to her bed. According to the note the resident stated that she lost her balance, slid to floor and denied any head injuries. Doctor and family were notified. However, there was no evidence in the clinical record that the care plan had been revised regarding the fall on April 7, 2025; and that, a fall incident report had been initiated. A progress note dated April 8, 2025 revealed that Resident #94 was observed by the nurse lying on the floor in her room in front of the bathroom door. The note indicated that the resident had green/purple bruising on her right ankle/foot. The progress further revealed that the resident had a pain level of eight out of ten and was sent to emergency room (ER) for evaluation and treatment. A progress note dated April 8, 2025 at 2:59 p.m. by Licensed Practical Nurse (LPN/ staff # 13) regarding post fall revealed that the resident had an acute facture of the right 4th rib with 1-2-millimeter (mm) displacement with mild swelling around rib and the doctor and family were notified. A fall incident report dated April 8, 2025, revealed that the resident sustained a fall with contributing factors listed as wet floor, weakness/fainted, ambulating without assistance. The fall incident report revealed resident mental status as oriented to place. No other information was provided in this report. Further, review of the care plan revealed no evidence that the care plan had been revised regarding the fall on April 8, 2025. A review of the Medical Center, discharge instructions diagnosis dated April 8, 2025 revealed an unspecified injury of the head, fracture of one rib, on right side. A final report of computed tomography (CT) chest without contrast dated April 8, 2025 at 5:21 a.m. revealed an acute facture in the right 4th rib with 1-2 mm displacement and mild soft tissue swelling around the right 4th rib. Occupational Therapy Treatment Encounter Notes dated April 8, 2025 revealed that the resident appeared to have increased confusion and impaired safety awareness, educated resident and nursing staff on the resident change in status. The note also relayed that the resident was no longer cleared to ambulate in room/to bathroom without staff present, that therapy is recommending that the patient use a wheelchair for mobility, and call for staff to be present for all transfers. An interview was conducted with the Resident #94 on April 8, 2025, at 1:49 p.m., who stated that she had a fall two days prior and one was this morning. The resident declined further interview at that time. During an interview with a Certified Nursing Assistant (CNA/ staff # 9) conducted on April 9, 2025 at 9:31 a.m., the CNA stated that the resident recently had an unwitnessed fall. The CNA further stated that after the fall, interventions were initiated that included frequent monitoring, calling staff during transfer, and educating resident to use call light. The CNA then stated that CNAs do not document monitoring and supervision of resident in the clinical record, but notify nursing. An interview was conducted with a LPN (staff #6) on April 9, 2025 at 1:16 p.m., who stated that Resident #94 had a decline in mental status including hallucinations and talking to herself. The LPN reviewed the resident's clinical record and stated that the resident was admitted to the facility three weeks ago and had unwitnessed falls on April 7, 2025, and April 8, 2025. The LPN further stated that the fall on April 8, 2025 resulted in a bruise on the resident's right foot and head, and during that incident, the resident's vital signs were monitored, 911 was called, family/provider were notified, and the resident was sent to the ER. The director of nursing then reviewed the Resident #94 hospital records included chest CT that revealed a rib fractured. The LPN then stated that interventions were initiated after the resident's two falls that included frequent monitoring, education on call light, and self-transfer, but the interventions were not updated on the care plan. During an interview with the Director of Nursing (DON/ staff #27) conducted on April 9, 2025 at 1:44 p.m., the DON stated that during admission, residents were evaluated for fall risk, vitals, elopement, skin assessment, and initial care plan would be developed. The DON reviewed the clinical record and stated that the resident had falls on April 7 and April 8, 2025, she further stated that there were no notes regarding updated fall interventions in the clinical record, however updated interventions include use of a wheelchair and assistance with activity of daily living for toileting and transfer. The DON then stated that the facility fall policy would include assess with the appropriate care plan intervention. She then said that the facility did not follow their policy; and, the risk of not having the care plan updated after each fall could result in staff not having full information regarding the resident's medical conditions. Review of the facility's policy titled Care Plan, Comprehensive Person-Centered, revised on March 2022, revealed that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the undated facility policy titled Fall revealed that falls can often be an indicator of an impending decline. Each fall must be followed up with and updated in the plan of care with new interventions.

Based on observations, clinical record review, staff interviews and policies and procedures, the facility failed to ensure that a centered care plan with interventions was developed for one resident (#15) with oxygen orders. The deficient practice could result in a care plan that is not person centered. Findings include: Resident #15 was admitted on [DATE], with diagnosis included hemiplegia and hemiparesis, Type 2 diabetes mellitus, hypothyroidism, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief interview Mental Status (BIMS) of 08 which indicated the resident was cognitively impaired. Review of Initial Care plan dated September 20, 2022 revealed no focus area for oxygen. A review of the documented physician order revealed oxygen at 2 liter via nasal cannula to keep oxygen levels at 90 or above with start date of March 24, 2025. Review of a health status provider note dated March 30, 2025 revealed a verbalized understanding and discussed patient decline and use of oxygen as patient is needing the oxygen to keep oxygen saturations above 90%. A physician order dated April 10, 2025 revealed that resident #15 was on continuous supplemental oxygen at 2 liter per minute, via nasal cannula to maintain oxygen saturation above 90%. However, review of the compressive care plan revealed no focused area for oxygen. An interview was conducted on April 09, 2025 at 08:48AM with Certified Nurse Assistant (CNA/staff #18), who stated that staff know who is on oxygen through the nursing reports or when the resident is admitted . Staff #18 stated that the nursing report will provide information regarding how many liters as well as which machine is used for a resident. Staff #18 stated that she was aware of resident #15 being on oxygen. Staff #18 stated that the CNA, Registered nurse, social workers, and resident coordinators help in creating the care plans for the residents. The oxygen should be care planned for the resident; and that, the risks is that their oxygen saturation can drop. An interview was conducted on April 09, 2025 at 10:24AM with Licensed Practical Nurse (LPN/Staff #23), who described the facility process for oxygen administration who stated that it was importantant that oxygen is properly connected and resident is getting adequate amounts of oxygen liter. Staff #23 stated that resident #15 had been declining and was on oxygen at 2 liters and her oxygen saturations are monitored throughout the day. Staff #23 stated that the oxygen is care planned, but was unable to locate it on care plan. She confirmed that it should have been care planned. Staff #23 stated the MDS coordinator does the care planning; but that, all staff assigned to the resident are responsible for it. An interview was conducted on April 09, 2025 at 10:38AM with Minimum Data Set (MDS) Coordinator (Staff #43), who confirmed that she participates in the care planning and reviews doctors ' orders then creates care plans. Staff #43 stated that if doctor had oxygen order she would add it to the care plan and nurse will do it as well. Staff #43 stated that she had been into resident #15 room, but could nott recall if the resident was on oxygen. She reviewed residents #15 order and confirmed that she did not care plan for oxygen. MDS coordinator stated that if oxygen is not care planned the resident will be at risk of respiratory failure. An interview was conducted on April 10, 2025 at 01:08PM with Director of Nursing (DON/staff #27), who stated that the facility expectation is to have oxygen care planned so that nurses can implement orders. Staff #27 stated that risks when oxygen administration are not care planned is that oxygen will not be delivered effectively such as possibly not getting tubing changed when it supposed to be. Further, staff #27 stated that staff members would not know if the resident needs oxygen and how much is needed. A review of policy titled Oxygen Administration revealed that review of the resident ' s care plan to asses for any special needs of the resident. A review of policy titled care plan revealed that care plan should focus on the course of action needed to attain or maintain highest practicable level of well-being, based on communication about reliable, consistent and understood by all team members.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the appropriate services for mental or psychological difficulty was provided for one resident (#6). The deficient practice could lead to the resident not receiving the behavioral healthcare services needed. Findings include: Resident #6 was admitted to the facility on [DATE] with diagnosis of depressive episodes, type 2 diabetes, and hypertension. Review of the nursing note dated 6/22/2023 identified that the resident was talking in a loud voice and being argumentative with a Certified Nursing Assistant (CNA) in the dining room. A care conference note dated on 5/31/2023 at 10:45 AM revealed that resident #6 is smearing his stool on the curtain, the resident's bed, and himself. The care conference note revealed that resident #6 is declining to allow staff to assist in cleaning him up; this is a long-standing behavior that increases at times. A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. Review of a care conference conducted on 11/21/2023 at 10:30 AM revealed that resident #6 was told multiple times to make sure his body is covered up while laying in bed or close the curtain. The care conference stated that resident #6 likes to lay in bed without clothes on at times. Review of the encounter note titled BHS Psych - Follow up on 01/17/2024 at 9:30 AM indicated the resident was being seen for a psychiatric reassessment for previous major depressive disorder (MDD). The encounter note indicated that the resident mood is 8 and symptoms of depression were denied during the psych visit. However, upon revealing the encounter note, it did not show that the resident behaviors of yelling and being argumentative with staff was addressed. In addition, the encounter note also did not address the resident behaviors of playing with his own feces and smearing it on his bed, curtain, and body. An interview was conducted on 01/31/2024 at 9:35 AM with a Licensed Practical Nurse (LPN/Staff #52) stated this resident has a wide variety of certain behaviors. He does not really participate in activities, lacks social skills, and has inappropriate behaviors with other residents and staff at times. Staff #52 also stated we would catch the resident playing with his feces and urine a couple times a week. Staff #52 states the resident would not utilize his call lights when he needs help and would smear his feces in his body, curtains, and bed. When asked if resident #6 was referred for an updated Preadmission Screening and Resident Review (PASRR) Level II, staff #52 stated she is not aware of it and it is not within her scope of practice to refer for a PASRR Level II. An interview was conducted with the Director of Nursing/Staff #69 on 01/31/24 at 12:15 PM revealed relayed that resident #6's PASRR was not filled out completely as it did not address the resident Scatolia behaviors and certain areas that asked if the resident has issues with the adaptation of change, interpersonal symptoms, and concentration/related tasks symptoms. Staff #69 stated the resident behaviors of playing with his own feces were already notified to the Psych provider. However, upon reviewing the psych provider notes dated 8/8/23, 11/15/23, 1/1/24, and 1/21/24, did not indicate the resident Scatolia behaviors were informed or reviewed by the psych provider. Review of the facility policy, Behavior Monitoring under the Abuse Prevention program reviewed and revised on 09/2021 stated the facility will provide appropriate treatment and services to a resident who displays mental or psychological adjustment difficulty, in order to correct the assessed problem or provide care that is appropriate to that problem. The goal will be to assist the resident to reach and maintain his or her highest level of mental health and psychosocial functioning. For a resident who is exhibiting difficulties in the area, the staff should assure that there is an assessment of the residents' .when indicated, a psychological or psychiatric evaluation to assess, diagnose, and treat the condition should be completed.

Based on review of the clinical record, facility documentation, staff interviews, and policy, the facility failed to ensure residents property is not misappropriated. Findings include: On March 31, 2023 the facility became aware that the residents Petty Cash box was missing $110.00. It appeared that the money went missing between April 1, 2023, and April 14, 2023. An interview was conducted on January 30, 2024, at 12:20 PM with the Administrator (Staff #38) in regard to the incident. Staff #38 was asked who had access to the resident cash account to which he replied the only individuals that had access to the money were the Office Manager (Staff #63), Accounts Receivable (Staff #32), and the Receptionist at the time (Staff #100). Staff #38 was asked if a facility investigation had been conducted in regard to the matter; Staff #38 stated that an internal investigation was conducted into the incident, which included going over the account logs and interviewing the staff with access to the funds. Staff #38 stated that at no time were any individuals who had access to the petty cash box placed on leave pending the investigation, nor was there any additional audit conducted to ensure that other money was not missing. After interviews with staff, the only conclusion that was made was that the money went missing with no account as to where or why. Staff #38 stated that On April 19, 2023, Staff #100 was interviewed; until this date, Staff #100 worked April 3, 2023, through April 6, 2023, and then was out sick from April 7, 2023, through April 14, 2023. During the interview, an admission of improper accounting regarding the incident was made by Staff#100, and her employment was immediately terminated. When asked if the incident had been reported to the applicable agencies as per the facility policy and state and federal regulations, Staff #38 stated, No. When asked why this had not been reported, Staff #38 stated that he chose to report it only to his regional operations consultant. Staff #38 was additionally asked if he was familiar with the facility policy in regards to reporting incidents in the facility as well as the state and federal regulations, to which he replied, Yes. An interview was conducted on January 30, 2024, at 12:50 PM with Staff #63 in regard to the incident. When asked, Staff #63 stated that she did recall the incident and that money was missing from the resident cash fund. She stated that the only individuals who have access to this fund at the time besides her where Staff #32 and Staff #100. She stated that while she had access to the funds, handling them was not a normal task of hers and she only did it when the other staff members were unavailable. She stated that she was interviewed by Staff #38 in regards to the incident but was never put on leave pending the disposition of the investigation. To her recollection the money was never found. An interview was conducted on January 30, 2024, at 12:50 PM with Staff #63 in regard to the incident. She stated that she was the one that discovered the missing funds, it was after she had attempted to reconcile the residents petty cash fund that she found that it was missing $110.00. Staff #63 stated that the process of petty cash is that the facility keeps $300.00 in cash and that the residents who need cash can get it from the petty cash fund and then the funds are taken or reconciled from the residents account. She stated that she was interviewed by Staff #38 in regards to the incident but was never put on leave pending the disposition of the investigation. Staff #63 stated that during the investigation and through a process of elimination it was determined that could not have been anyone other than Staff#100, and when interviewed about the incident she did not at anytime deny that she had taken the money. Per the facilities policy titled Abuse Prevention Program revised September 2021 it defines Misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent used of a resident's belongings or money without the resident's consent. The policy states that if an incident occurs, or there is any allegation that an incident might have occurred, of abuse, neglect, mistreatment, or misappropriation of resident property, the administrator, or designee will investigate. Furthermore, while the investigation is being conducted, accused individuals or those suspected of being responsible for abuse, neglect, mistreatment, or misappropriation of resident property and are employees of the facility will be placed on suspension pending the results of the investigation. The policy further states that when an alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. The local police or sheriff is to be notified when items of a $25.00 or greater value are taken from a resident by an identified staff person.

Based on review of the clinical record, facility documentation, staff interviews, and policy, the facility failed to ensure residents property is not misappropriated. Findings include: On March 31, 2023 the facility became aware that the resident's Petty Cash box was missing $110.00. It appeared that the money went missing between April 1, 2023, and April 14, 2023. An interview was conducted on January 30, 2024, at 12:20 PM with the Administrator (Staff #38) in regard to the incident. Staff #38 was asked who had access to the resident cash account to which he replied the only individuals that had access to the money were the Office Manager (Staff #63), Accounts Receivable (Staff #32), and the Receptionist at the time (Staff #100). Staff #38 was asked if a facility investigation had been conducted in regard to the matter; Staff #38 stated that an internal investigation was conducted into the incident, which included going over the account logs and interviewing the staff with access to the funds. Staff #38 stated that at no time were any individuals who had access to the petty cash box placed on leave pending the investigation, nor was there any additional audit conducted to ensure that other money was not missing. After interviews with staff, the only conclusion that was made was that the money went missing with no account as to where or why. Staff #38 stated that On April 19, 2023, Staff #100 was interviewed; until this date, Staff #100 worked April 3, 2023, through April 6, 2023, and then was out sick from April 7, 2023, through April 14, 2023. During the interview, an admission of improper accounting regarding the incident was made by Staff#100, and her employment was immediately terminated. When asked if the incident had been reported to the applicable agencies as per the facility policy and state and federal regulations, Staff #38 stated, No. When asked why this had not been reported, Staff #38 stated that he chose to report it only to his regional operations consultant. Staff #38 was additionally asked if he was familiar with the facility policy in regards to reporting incidents in the facility as well as the state and federal regulations, to which he replied, Yes. An interview was conducted on January 30, 2024, at 12:50 PM with Staff #63 in regard to the incident. When asked, Staff #63 stated that she did recall the incident and that money was missing from the resident cash fund. She stated that the only individuals who have access to this fund at the time besides her were Staff #32 and Staff #100. She stated that while she had access to the funds, handling them was not a normal task of hers and she only did it when the other staff members were unavailable. She stated that she was interviewed by Staff #38 in regards to the incident but was never put on leave pending the disposition of the investigation. To her recollection the money was never found. An interview was conducted on January 30, 2024, at 12:50 PM with Staff #63 in regard to the incident. She stated that she was the one that discovered the missing funds, it was after she had attempted to reconcile the residents petty cash fund that she found that it was missing $110.00. Staff #63 stated that the process of petty cash is that the facility keeps $300.00 in cash and that the residents who need cash can get it from the petty cash fund and then the funds are taken or reconciled from the residents account. She stated that she was interviewed by Staff #38 in regards to the incident but was never put on leave pending the disposition of the investigation. Staff #63 stated that during the investigation and through a process of elimination it was determined that it could not have been anyone other than Staff#100, and when interviewed about the incident she did not at anytime deny that she had taken the money. Per the facilities policy titled Abuse Prevention Program revised September 2021 it defines Misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent used of a resident's belongings or money without the resident's consent. The policy states that if an incident occurs, or there is any allegation that an incident might have occurred, of abuse, neglect, mistreatment, or misappropriation of resident property, the administrator, or designee will investigate. Furthermore, while the investigation is being conducted, accused individuals or those suspected of being responsible for abuse, neglect, mistreatment, or misappropriation of resident property and are employees of the facility will be placed on suspension pending the results of the investigation. The policy further states that when an alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. The local police or sheriff is to be notified when items of a $25.00 or greater value are taken from a resident by an identified staff person.

Based on review of the clinical record, facility documentation, staff interviews, and policy, the facility failed to ensure residents property is not misappropriated. Findings include: On March 31, 2023 the facility became aware that the residents Petty Cash box was missing $110.00. It appeared that the money went missing between April 1, 2023, and April 14, 2023. An interview was conducted on January 30, 2024, at 12:20 pm with the Administrator (Staff #38) in regard to the incident. Staff #38 was asked who had access to the resident cash account to which he replied the only individuals that had access to the money were the Office Manager (Staff #63), Accounts Receivable (Staff #32), and the Receptionist at the time (Staff #100). Staff #38 was asked if a facility investigation had been conducted in regard to the matter; Staff #38 stated that an internal investigation was conducted into the incident, which included going over the account logs and interviewing the staff with access to the funds. Staff #38 stated that at no time were any individuals who had access to the petty cash box placed on leave pending the investigation, nor was there any additional audit conducted to ensure that other money was not missing. After interviews with staff, the only conclusion that was made was that the money went missing with no account as to where or why. Staff #38 stated that On April 19, 2023, Staff #100 was interviewed; until this date, Staff #100 worked April 3, 2023, through April 6, 2023, and then was out sick from April 7, 2023, through April 14, 2023. During the interview, an admission of improper accounting regarding the incident was made by Staff#100, and her employment was immediately terminated. When asked if the incident had been reported to the applicable agencies as per the facility policy and state and federal regulations, Staff #38 stated, No. When asked why this had not been reported, Staff #38 stated that he chose to report it only to his regional operations consultant. Staff #38 was additionally asked if he was familiar with the facility policy in regards to reporting incidents in the facility as well as the state and federal regulations, to which he replied, Yes. An interview was conducted on January 30, 2024, at 12:50 pm with Staff #63 in regard to the incident. When asked, Staff #63 stated that she did recall the incident and that money was missing from the resident cash fund. She stated that the only individuals who have access to this fund at the time besides her where Staff #32 and Staff #100. She stated that while she had acess to the funds, handling them was not a normal task of hers and she only did it when the other staff members were unavailable. She stated that she was interviewed by Staff #38 in regards to the incident but was never put on leave pending the disposition of the investigation. To her recollection the money was never found. An interview was conducted on January 30, 2024, at 12:50 pm with Staff #63 in regard to the incident. She stated that she was the one that discovered the missing funds, it was after she had attempted to reconcile the residents petty cash fund that she found that it was missing $110.00. Staff #63 stated that the process of petty cash is that the facility keeps $300.00 in cash and that the residents who need cash can get it from the petty cash fund and then the funds are taken or reconciled from the residents account. She stated that she was interviewed by Staff #38 in regards to the incident but was never put on leave pending the disposition of the investigation. Staff #63 stated that during the investigation and through a process of elimination it was determined that could not have been anyone other than Staff#100, and when interviewed about the incident did not at anytime deny that she had taken the money. Per the facilities policy titled Abuse Prevention Program revised September 2021 it defines Misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent used of a resident's belongings or money without the resident's consent. The policy states that if an incident occurs, or there is any allegation that an incident might have occurred, of abuse, neglect, mistreatment, or misappropriation of resident property, the administrator, or designee will investigate. Furthermore, while the investigation is being conducted, accused individuals or those suspected of being responsible for abuse, neglect, mistreatment, or misappropriation of resident property and are employees of the facility will be placed on suspension pending the results of the investigation. The policy further states that when an alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately. The local police or sheriff is to be notified when items of a $25.00 or greater value are taken from a resident by an identified staff person.

Based on clinical record review, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that one resident (#23) was free from abuse by failing to address complaints of pain during wound treatment. The deficient practice could result in resident having psychological trauma wound treatment. Findings include: Resident #23 was admitted on [DATE] with diagnoses of peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and chronic venous hypertension with ulcer of right and left lower extremities. The pain care plan dated September 5, 2022 revealed a goal that the resident's pain will be diminished and/or will be at an acceptable level. Interventions included to provide non-pharmacological interventions for pain; turn and reposition, rest and relaxation, watching TV, etc.; to administer medications as ordered; to monitor side effects and effectiveness of pain medications and consult with physician as needed. Review of the physician order recap for November 2022 revealed the following orders for: -Oxycodone (opioid) 10-325 mg (milligrams) give one tablet every 4 hours PRN (as needed) for moderate pain 6-10; and, -Ibuprofen (non-steroidal anti-inflammatory analgesic) 800 mg, give one tablet by mouth three times a day for pain. A progress note dated November 7, 2022 revealed that an incident happened at 1:00 a.m. Per the documentation, resident was medicated for pain at 11:30 p.m. and was later found in the bathroom in her wheelchair, had urinated in the trash can was soaking wet to include the bandages to the leg wounds. The documentation included that the bandages were changed to both legs; and that, the resident cried and screamed throughout the entire treatment. The note also included that the resident wanted a pain pill and was informed that it was too soon; and that, the resident had to wait until 2:30 a.m. Per the documentation, the resident was very angry but seemed to understand; however, 10 minutes later the resident was found on the floor in the bedroom sitting up and had removed all of the bandages and dressings to her legs. The note included that when the resident was asked what had happened, the resident replied that she did it because she wanted a pain pill right now. According to the documentation, the nurse educated the resident that she would still have to wait and would have to have the treatment to her legs done again. There was no evidence found in the clinical record that the facility managed the resident's complaints of pain during the dressing change on November 7, 2022. A review of the vital signs grid revealed that on November 6, 2022 at 4:24 a.m. the resident's verbal pain level was 6; and that, the resident was not re-evaluated until November 6, 2022 at 12:05 p.m. and the verbal pain level at that time was 8. The (Medication Administration Record) for November 2022 revealed oxycodone was administered as ordered on November 6, 2022 at 11:31 p.m. and on November 7, 2022 at 8:51 a.m. and at 4:19 p.m. However, the scheduled ibuprofen was not documented as administered on November 6 and 7. There was no evidence found in the clinical record why the scheduled ibuprofen was not administered as ordered. An interview with the medical doctor (staff #64) was conducted on March 16, 2023 at 12:09 p.m. Staff #64 stated that if there was an order for wound care once a day and the order was not time specific, the expectation was for the would care to be done that day. Staff #64 said that if a resident has pain related to wound care then a scheduled pain medication can be ordered to complete wound care. The medical doctor also said that if pain during wound care was not a common event, a PRN (as needed) medication can be offered; and, if there was no PRN medication available, his expectation was for the nurse/facility to call the provider and obtain an order for breakthrough pain management. Regarding resident #23, the medical doctor said that he could not recall facility calling him regarding the resident's pain during wound care that happened on the night shift. Staff #64 stated that if a resident was experiencing pain during any wound care treatments, the expectation was for the nurse/facility to administer PRN/scheduled pain medications as ordered, and to obtain an order for pain management if there is no order available. An interview was conducted with a licensed practical nurse (LPN/staff #12) on March 16, 2023 at 11:55 a.m. Staff #12 stated that if there was an order for once a day dressing changes/wound care then the treatment will be provided anytime that day unless a specific time was ordered. The LPN said that if a resident was having pain during a wound care the expectation was for staff to either administer scheduled/PRN pain medication, delay the wound care (if appropriate) closer to the scheduled/PRN medication time available or notify the provider and obtain an order for breakthrough pain management. Further, the LPN said that if a resident develops pain during the treatment, she would stop the dressing change, cover the wounds as appropriate and notify the provider. An interview was conducted with registered nurse (RN/staff #59) on March 16, 2023 at 12:05 p.m. The RN said that wound care is completed per the physician's order and typically are not time specific. Staff #59 stated the expectation was that the nursing staff address pain prior to wound care, administer any scheduled/PRN medications as ordered. The RN stated that if there was no scheduled/PRN pain medication available prior to wound care, it was reasonable for the nursing staff to delay the treatment (if appropriate) until closer to the time a pain medication would be available. She also stated that if a resident was experiencing pain during the treatment, the nurse should end the treatment. Further, the RN said the expectation was for nursing staff to exhaust all options to address pain prior to initiating wound care of a resident that has signs/symptoms of pain or verbalizes pain. The RN also said that residents have the right to refuse wound care. The facility wound and skin care protocols revealed that the assessment and documentation will always assess pain/pain control; and that, the goal of pain management in the pressure injury patient is to eliminate the cause of the pain, to provide analgesia or both. The protocol also included to assess all patients for pain related to the pressure injury or its treatment. Caregivers should not assume that because a patient cannot express or respond to pain that it does not exist. Manage pain by eliminating or controlling the source when possible (wound coverings, support surfaces, repositioning). Try to prevent or relieve pain associated with or made worse during dressing changes and debridement. Assess and care plan pain management (i.e., analgesia 30-45 minutes prior to dressing change) when appropriate. Contact physician/provider when additional pain management needed.

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure the necessary treatment and services were provided for wound care for one sampled resident (#18). The deficient practice could result in skin [CONDITION(S)]/wounds worsening. Findings include: Resident #18 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed an open area on the temple was identified on March 10, 2022 and a forehead lesion was identified on April 4, 2022. Review of the physician's orders revealed: -Cleanse the open areas to the right forehead/temple with normal saline every day, dated March 18, 2022. -Cleanse the wounds to the head with a wound cleanser and pat dry. Apply Silvagel to the wounds and cover with a calcium alginate and island dressing every day, dated May 9, 2022. Review of a care plan initiated on March 22, 2022 revealed the resident had alteration in skin integrity related to open areas to the right forehead/temple. Interventions included a mattress, treatment to the right forehead/temple as ordered, assisting with turning and repositioning. Review of wound skin status report revealed: -May 11, 2022 Forehead lesion assessment/measurements -May 11, 2022 Right temple puncture assessment measurements Review of the clinical record revealed wound assessments for the forehead lesion and right temple puncture dated May 3, 2022, May 11, 2022, and July 13, 2022. Further clinical record review revealed no evidence of any other wound assessments for the forehead or temple [CONDITION(S)]. Review of a Wound Healing Progress report revealed measurements for the forehead lesion and right temple puncture dated April 4, 2022, April 19, 2022, May 11, 2022, and July 13, 2022. Further review of the Wound Healing Progress report revealed no other measurements for the forehead and temple [CONDITION(S)]. Review of the 2022 Treatment Administration Records (TARs) for May, June, July and August revealed the open areas to the right forehead/temple dressings were completed as ordered. Review of a quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) of 13 which indicated intact cognition. The assessment also revealed the resident had open skin ulcers that were not ulcers, rashes or cuts. Further review of the medical record revealed no evidence that wound assessments had been completed during September 2022 and October 2022. Review of the TAR dated September 2022 and October 2022 revealed 9 days that there was no evidence the head wound dressings were completed as ordered, on 9/4, 9/6, 9/11, 9/13, 9/15, 9/19, 9/30/2022, 10/1, and 10/18. Further review of the TAR nursing notes revealed no evidence of the reason that the dressings were not completed on nine days during September 2022 and October 2022. An interview was conducted on October 26, 2022 at 12:06 PM with a Registered Nurse (RN/staff #47), who stated the resident does receive wound care to the right forehead and temple. She reviewed the medical record and stated that she did not see any evidence of wound measurements for the forehead and temple wounds. An interview was conducted on October 26, 2022 at 12:12 PM with the MDS Coordinator (staff #88), who stated there were no wound measurement/assessments documented in the clinical record or in the paper chart. An interview was conducted on October 26, 2022 at 12:30 PM with the Administrator (staff #64), who stated that the wound care nurse left two weeks ago, and since then the unit nurses were responsible for wound assessment and care. An interview was conducted on October 27, 2022 at 9:42 AM with a Certified Nursing Assistant (CNA/staff #116), who stated that the resident was admitted with open areas on the forehead, and that nurses complete the dressing changes. An interview was conducted on October 27, 2022 at 10:35 AM with a Licensed Practical Nurse (LPN/staff #49), who stated that the resident was admitted to the facility with a chronic head wound. She stated that nursing applies the dressing, but does not assess/measure the wounds regularly. She also stated that there was no one else that she was aware of that does assessments and measurements. The LPN further stated the wound dressing is documented in the TAR. She reviewed the medical record and stated that in September there were 7 days, and in October there were 2 days that an N was marked on the TAR, which means no. She further stated that if a resident refuses treatment it is marked as refused on the TAR ad there should be a nursing note. She stated that the facility policy is to follow physician orders as written. An interview was conducted on October 27, 2022 at 11:15 AM with the Director of Nursing (DON/staff #130), who stated that the TAR is signed when the dressing is completed. She also stated that an N on the TAR means not done, and there would be a checkmark if it was completed. She further stated that if an N is documented in the TAR, there should be documentation in the TAR nursing notes. The DON reviewed the clinical record and stated there was no evidence the dressings to the head wounds had been completed as ordered in September 2022 and October 2022 for 9 days. She further stated that the facility policy is to follow physician orders as written. The DON stated the risk of the dressings not being completed as ordered could result in an infection, and the wound becoming worse. Review of the facility policy titled, Wound and Skin Care Protocols and Procedures, revealed the DON is responsible for reviewing weekly wound report and monitoring progress/decline of any wound and assuring compliance with current standards of wound care practice. Review of the facility policy titled, Wound Care, revealed that the following information should be recorded in the resident's medical record: -type of wound care given -date/time the wound care was given. -all assessment date (wound bed color, size, drainage) obtained when inspecting the wound. -if the resident refused the treatment and the reason why. To notify the supervisor if the resident refuses.

Based on observation, clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#13) was assessed to self-administer medications. The sample size was 14. The deficient practice could result in residents not receiving medications as ordered by the physician. Findings include: Resident #13 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation conducted on October 27, 2022 at 8:56 AM, a clear medication cup was observed on resident #13's sink countertop. The cup contained three medications. The resident was in bed asleep. Review of the clinical record revealed no evidence of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan revealed no evidence of self-administration care planning. Continued review of the clinical record revealed the following medications were to be administered at 6:00 AM: -[MEDICATION(S)] ([CONDITION(S)]) 125 mg (milligram) one tablet by mouth daily -[MEDICATION(S)] (hypertension) 100 mg one tablet by mouth three times a day. -[MEDICATION(S)] HCL (hypertension) 0.1mg one tablet by mouth three times a day. An interview was conducted with a Licensed Practical Nurse (LPN/staff #49) on October 27, 2022 at 8:58 AM. The LPN stated that she had left [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] in a medication cup on the sink countertop for the resident to take after the resident was done in the bathroom. She stated that the facility policy for medication administration was to stay in the room and ensure the resident consumes all medications. The LPN stated that the facility does not complete assessments for resident self-administration. She also stated that it is the facility policy to administer all medications according to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that she did not follow the facility policy and left the medications unattended. She stated that the risk could include someone else taking the medication, or the medication being taken too closely together. After the interview the nurse removed the medication cup from the resident's room and discarded them. An interview was conducted on October 27, 2022 at 11:00 AM with the Director of Nursing (DON/staff #130), who stated that the medication administration policy states that staff are not to leave medications at the bedside. She also stated that when a resident refuses medication, the nurse should put the medications in a cup and re-attempt later, but not to leave medications in the room. The DON stated that the risk of not administering blood pressure medication as ordered could result in a hypertensive crisis, especially for a [CONDITION(S)] resident. The facility's policy titled, Administering Medications, stated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with the prescriber orders, including any required time frame. Medications are administered within one hour of their prescribed time, unless otherwise specified. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. If a drug is refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#34) receiving [CONDITION(S)] medication was monitored for behaviors and side effects. The sample size was 5. The deficient practice could cause resident behaviors and side effects to not be addressed. Findings include: Resident #34 was admitted on [DATE] with diagnoses that included chronic venous hypertension with ulcer of the lower extremity, [CONDITION(S)] and major depressive disorder. Review of physician orders revealed an order dated September 6, 2022 for [MEDICATION(S)] 150 milligrams (mg) by mouth daily for depression/[CONDITION(S)], [MEDICATION(S)] 25 mg by mouth daily for depression, and September 12, 2022 for [MEDICATION(S)] 300 mg by mouth twice daily for [CONDITION(S)]. The care plan initiated on September 28, 2022 revealed the resident had depression and the goal was the signs and symptoms of depression will be managed with current interventions. Interventions including administering [MEDICATION(S)] and [MEDICATION(S)] as ordered and monitoring for side effects. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident scored a 9 on the brief interview for mental status (BIMS) indicating moderate impaired cognition. The MDS assessment also revealed the resident was administered antidepressant medications for 7 days of the 7 days lookback period. Review of the medication administration record (MAR) revealed no evidence that behavior or side effect monitoring was being done for the [CONDITION(S)] medications. An interview with the Director of Nursing (DON/staff #130) was conducted on October 27, 2022 at 12:32 PM. The DON stated that both behavior monitoring and side effect monitoring are to be completed for any resident using [CONDITION(S)] medications. She stated a resident that is not being monitored for either behaviors or side effects of [CONDITION(S)] medications do not meet her expectations. The DON stated expectations include that all residents are monitored for both behaviors and side effects, and this information is expected to be documented in the resident's chart. Review of the facility policy Behavioral Assessment, Intervention and Monitoring (3/2019) revealed that when medications are prescribed for behavioral symptoms documentation will include monitoring for efficacy and adverse consequences.

Based on staff interviews and the Center for Medicare and Medicaid Services (CMS) requirements, the facility failed to designate a qualified Infection Preventionist (IP) on an ongoing basis by failing to ensure that the acting IP had completed the Infection Preventionist certification. The deficient practice could lead to an unqualified staff acting as the IP and improper infection prevention practices within the facility. Findings include: An interview was conducted with the acting IP/director of nursing (DON/staff #130) on October 28, 2022 at 8:35 AM. Staff #130 presented the IP certificate in her name dated October 28, 2022. She stated that the prior IP left the facility about 3 months ago and there has been no certified IP in the building. She stated that she did just take the test and print the certificate and she was aware that it did not meet the regulation to have no one as a certified IP in the building. An interview was conducted on October 28, 2022 at 8:39 AM with the Administrator (staff # 64). He stated that he understood that the facility had been without a certified IP for three months and that is a concern as it does not meet the current regulations. Review of the CMS updated guidance for Nursing Home Resident Health and Safety fact sheet dated June 29, 2022 revealed facilities are required to have a part time Infection Preventionist (IP) that must work in the facility and is required to have specialized IP training.

Based on clinical record review, staff interviews and facility policy, the facility failed to ensure one sampled resident (#34) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in residents not receiving specialized services that they need. Findings include: Resident #34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Level 1 PASARR (pre-admission screening and resident review) dated August 12, 2022 revealed the resident met the criteria for a 30-day convalescent care. The attending physician had certified, prior to admission, that the resident would require less than 30 calendar days of nursing facility services. The PASARR also revealed the nursing facility must update the Level 1 at such time that it appears the resident's stay will exceed 30 day. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated on September 28, 2022 revealed the resident had depression and the goal was the signs and symptoms of depression will be managed with current interventions. Interventions including administering [MEDICATION(S)] and [MEDICATION(S)] as ordered. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident scored a 9 on the brief interview for mental status (BIMS) indicating moderate impaired cognition. The MDS assessment further revealed the resident displayed hallucinations/[CONDITION(S)] and was depressed. Continued review of the clinical record did not reveal evidence the Level 1 was updated or that the resident was referred for a Level 2 PASARR. An interview was conducted on October 27, 2022 at 12:13 PM with the Director of Social Services (staff #79). She stated that a PASARR is part of the resident's clinical record and that the Level 1 PASARR generally comes with the residents when they are admitted to the facility. She stated that she reviews the document and if there was any question about the need for a referral for a Level 2 PASARR, she refers to the DON (Director of Nursing). She stated the DON determines the need for a Level 2 referral based on the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #79 further stated that on the PASARR form, in order for a resident to meet the 30-day convalescent care criteria, the resident's stay must be less than 30 days in duration. She stated that although this option was selected on the Level 1 PASARR for resident #34, the resident has been at the facility for longer than 30 days. Staff #79 stated this indicated the need for a reassessment of the resident's Level 1 PASARR. On October 27, 2022 at 12:23 PM, an interview was conducted with the DON (staff #130). She stated that she handles all PASARR Level 2 requests. The DON stated that she has never requested a Level 2 assessment in her [AGE] years as a DON. She stated that she believes that someone comes into the facility to do the Level 2 assessments but was not sure who handles the assessment. She further stated that resident #34 had a mental illness diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the fact that a Level 2 assessment was not done for this resident does not meet her expectation and is not acceptable. Review of the facility's Behavioral Assessment, Intervention and Monitoring Behaviors Policy (3/2019) revealed the facility would provide behavioral health services as needed to maintain the highest practicable wellbeing in accordance with the resident plan of care. All residents will receive a Level 1 PASARR screen prior to admission and if indicated that the resident meets the criteria for a mental disorder the resident will be referred to the state PASARR representative for a Level 2 screening. The Level 2 evaluation will be used when conducting the resident assessment and developing the care plan.

Based on clinical record review, staff interviews, observation, and policy review, the facility failed to ensure pressure ulcer measurements were consistently done for one resident (#147). The sample size was 2. The deficient practice could result in pressure ulcers not being measured. Findings include: Resident #147 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] and hypertension. Review of the admission skin assessment dated [DATE] revealed the resident had a pressure ulcer to the coccyx. Review of a pressure ulcer care plan dated 10/12/22 revealed that the resident had a pressure ulcer. The goal was for the ulcer to heal and not become infected. Interventions included use of a wound vac, repositioning, specialty mattress and monitoring for changes. A physician's order dated 10/13/22 stated: Stage IV pressure ulcer - Wound vac- 75 MMHG continuous pressure - change every Mon- Wed- Fri. Review of the Treatment Administration Record (TAR) for October 2022 revealed the wound vac to the pressure ulcer was changed as ordered. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired. The MDS assessment also revealed the resident had a one stage 2 and one stage 4 pressure ulcer that were present upon admission. Review of the clinical record did not reveal any evidence the wound was measured except for on the initial assessment. An interview was conducted with the Director of Nursing (DON/staff #130) on 10/27/22 at 12:21 PM. The DON stated that the wound nurse had left the facility and so the wounds were now being taken care of by the nurses. She stated that she realized a few weeks ago that measurements were not being done. The DON stated that this is a QAPI issue and is now being addressed. She added that it is her responsibility to ensure wound measurements are being done and they are not. The DON stated this could result in wounds worsening and not being treated correctly. During an observation of a dressing change done with the Licensed Practical Nurse (LPN/staff#11) on 10/27/22 at 12:59 PM, the wound was observed to be measured by the LPN. An interview was conducted with the LPN (staff #11) on 10/27/22 at 1:20 PM. The nurse stated that the dressings on the resident's coccyx has a wound vac and is changed every Monday, Wednesday and Friday. He stated that the resident tolerates it well. He stated that he documents the dressing change but does not measure the wound or document it. The LPN admitted that the wound nurse used to do this. Review of the facility policy titled Wound Care Protocols (revised 6/2021) stated the Director of Nursing will be responsible for reviewing weekly wound reports and monitoring progress/decline of any wound and assuring compliance with current standards of wound care practice.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one of seven sampled residents (#21) was free from an unnecessary medication, by failing to ensure the order for an as-needed (PRN) [CONDITION(S)] medication included the duration for the prn order. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #21 was readmitted on [DATE] with diagnosis that included [CONDITION(S)], other specified depressive episodes, anxiety disorder, [CONDITION(S)] disorder, [CONDITION(S)], acquired absence of left leg above knee, acquired absence of right leg above knee and chronic pain syndrome. Review of the physician's orders revealed an order dated March 4, 2021 for Lorazepam ([MEDICATION(S)]/anxiolytic) tablet 1 milligram (mg) by mouth every 4 hours PRN. However, the order did not include a stop date or duration for the PRN Lorazepam use. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] included the Brief Interview for Mental Status (BIMS) score was 3 indicating the resident's cognition was severely impaired. The MDS assessment also included the resident was receiving antianxiety medications. The comprehensive care plan dated March 31, 2021 revealed the resident required the use of anti-anxiety medications to manage and alleviate feelings of anxiousness. Interventions included to administer [MEDICATION(S)] as ordered. Review of the Medication Administration Record (MAR) for March 2021 revealed resident #21 received PRN lorazepam on March 16, 17, 18, 19, 21, 23, 24, 27, 28, 29, and 30, 2021. The MAR for April 2021 included the resident was administered PRN lorazepam daily except for on April 19, 20, and 23, 2021. A review of the MAR for May 2021 revealed the resident received PRN lorazepam on May 1, 2, 4, 5, and 6, 2021. Further review of the clinical record did not reveal any documentation from the provider regarding the rationale for the ongoing use and/or the duration for the PRN Lorazepam. An interview was conducted with a Registered Nurse (RN/staff #59) on May 5, 2021 at 1:20 p.m. The RN stated that PRN [CONDITION(S)] medications are ordered for 14 days and after 14 days the medication use is reassessed. She stated that if the resident has been using the medication daily, the nurses will notify the physician and the physician usually will change the PRN order to scheduled. The RN further stated that if the resident still required the PRN medication, the nurses would notify the physician and the physician would reassess the resident. An interview was conducted with the Assistant Director of Nursing (ADON/staff #70) on May 6, 2021 at 11:09 a.m. Staff #70 stated that when a resident is on a [CONDITION(S)] medication, pharmacy reviews the medication for gradual dose reduction (GDR). She stated that the physician assesses for continue use of the medication and will decide whether to continue the order or discontinue it. The ADON stated she does not know if the medication lorazepam should have a stop date. An interview was conducted with the Director of Nursing (DON/staff #51) on May 6, 2021 at 12:35 p.m. The DON stated PRN [CONDITION(S)] medications should be reassessed every 14 days for continue use. After reviewing the resident's order for [MEDICATION(S)], the DON stated it was probably better if the PRN [CONDITION(S)] medication order had a stop date. The DON stated the order should have been clarified with the physician. The DON stated that if there is no stop date for PRN [CONDITION(S)] medications, the residents are never reevaluated for its necessity. The DON stated it is important to reevaluate so that residents are not given unnecessary medications. In an interview conducted with the Pharmacist (staff #11) on May 6, 2021 at 12:51 p.m., he stated a PRN [CONDITION(S)] medication is reevaluated every 14 days. The Pharmacist stated a recommendation is sent to the physician and that the physician would give direction whether to continue the medication, change the medication to scheduled, discontinue the medication, etc. The facility's policy titled Antipsychotic Medications Use revised on December 2016 stated residents will not receive PRN doses of [CONDITION(S)] medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. The policy further stated that the need to continue PRN orders for [CONDITION(S)] medications beyond 14 days required that the practitioner document the rationale for extended order. The policy further stated the duration of the PRN order will be indicated in the order.

Based on clinical record reviews, resident and staff interviews, and review of the Facility Assessment, the facility failed to ensure that there was sufficient staffing to meet the needs of multiple residents (#4, #10, #11, #16, #53, and #57). The deficient practice could result in nursing care and services not being provided. The census was 54. Findings include: During the initial phase of the survey, 5 residents identified concerns of not having enough staff: -Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5-day Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. The assessment also included the resident was receiving pain medication as needed and that on a scale of 1 to 10, the resident had a pain level of 8. Resident #4 reported that he had to wait for his call-light to be answered for 45 minutes on May 4, 2021. The resident stated that he generally has to wait for approximately 45 minutes to receive pain medication. The resident also stated that he tries to request pain medication early to try and control the pain. -Resident #11 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] included a BIMS score of 15 indicating the resident was cognitively intact. The assessment included the resident's pain level was a 10 and that the resident received pain mediation as needed. Resident #11 reported that he pushed his call-light five times on May 3, 2021 to request pain medication. The resident stated each time the call-light was turned off and no one ever came to help him. The resident stated that sometimes he has to wait a long time and that he does not think there is enough staff. -Resident #16 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] included a BIMS score of 15 indicating the resident was cognitively intact. The assessment also included the resident needed extensive assistance with toileting. Resident #16 stated that it takes over an hour for staff to come and help her to the toilet. The resident said the facility is shorthanded and that staffing is worst on the weekends. -Resident #53 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS assessment dated [DATE] included a BIMS score of 13 indicating the resident was cognitively intact. The assessment included the resident was always incontinent of bowel and bladder and needed setup help for eating and/or drinking. Resident #53 said she had to wait for two hours for a glass of water. The resident stated that one to two days ago, she had to wait for almost an hour to have her brief changed and it really pissed her off. -Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission MDS assessment dated [DATE] included a BIMS score of 10 indicating the resident had mildly impaired cognition. The assessment included the resident required extensive assistance with bed mobility, transfers, and toileting. Resident #57 said that she has to wait a long time for staff to answer the call-light. The resident stated that she had already pushed the call-light three times and was still waiting for staff to come and help her use the toilet. The call-light was observed to be on during this time. -Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The fall risk care plan dated September 9, 2020 included the intervention to encourage the resident to utilize the call-light for assistance. The quarterly MDS assessment dated [DATE] included a BIMS score of 11 indicating the resident was cognitively intact. The MDS assessment also included the resident required limited assistance with toileting. The care plan for activities of daily living dated February 19, 2021 included interventions for limited assistance with bed mobility, transfers, walking, active locomotion, toileting and hygiene. An interview was conducted on May 5, 2021 at 10:01 a.m. with resident #10. The resident stated that he had to wait an hour on Monday, May 3, 2021 for a staff to assist him with transferring and walking to the toilet during the swing shift. The resident stated that he needs help because he is unstable. The resident said that he reported the concern to the Resident Care Coordinator/Certified Nursing Assistant (CNA/staff #57) and she told him the facility was short on help and that they were working on finding more staff. The Facility Assessment updated February 2, 2021, stated 2 Registered Nurses (RN) or Licensed Practical Nurses (LPN) are required during the night shift along with a 15:1, resident to CNA ratio, during the night shift. Review of the Daily Staff Posting dated May 2, 2021 revealed the census was 55 during the nightshift, 10:00 p.m. to 6:00 a.m. The posting included 2 LPNs and 3 CNAs were scheduled to work. Review of the Time Cards for May 2, 2021 revealed: (CNA/staff #75) worked from 2:00 p.m. to 2:00 a.m. (CNA/staff #52) worked from 2:15 p.m. to 2:00 a.m. (CNA/staff #58) worked from 1:45 a.m. to 10:15 a.m. (CNA/staff #77) worked from 5:45 a.m. to 2:30 p.m. (LPN/staff #29) worked from 12:00 a.m. to 6:45 a.m. (RN/staff #67) worked from 5:30 a.m. to 2:30 p.m. (LPN/staff #66) worked from 1:45 p.m. to 10:45 p.m. (LPN/staff #39) worked from 2:00 p.m. to 11:15 p.m. (LPN/staff #83) worked from 2:15 p.m. to 11:15 p.m. (LPN/staff #37) worked from 9:45 p.m. to 6:30 a.m. Further review the Time Cards revealed one (LPN/staff #37) and two CNAs (staff #52 and #75) worked on May 2, 2021 from 11:15 p.m. to 12:00 a.m. The Time Cards also revealed there were two LPNs (staff #29 and #37) and one CNA (staff #58) working from 2:00 a.m. to 5:30 a.m. During an interview conducted on May 5, 2021 at 9:43 a.m. with the Administrator (staff #36), the Administrator stated the Director of Nursing (DON) is responsible for scheduling the number of nurses needed for a shift. Staff #36 also stated that a CNA (staff #57) is responsible for scheduling the CNAs that are needed for a shift. The Administration further stated that he reviews the Daily Staff Posting each morning to determine if there are enough staff scheduled to provide care. On May 6, 2021 at 9:31 a.m., an interview was conducted with the Resident Care Coordinator/CNA (staff #57). She stated that she is responsible for scheduling the CNAs for the facility. Staff #57 stated that she works a lot of overtime because the facility is short staffed. She stated that she was aware that residents are complaining about the wait time. Staff #57 stated that it is her expectation that call lights are answered within 15 minutes. She said three CNAs are required for the overnight shift (10:00 p.m. to 6:00 a.m.). She stated that she worked by herself from 10 p.m. to 6 a.m. on Long Term Care side (Halls 100 and 200) more than once, while one CNA worked on the Medicare side (Halls 300 and 400). Staff #57 stated it was reported it to the Administrator who said they were trying to hire more staff. An interview was conducted with the DON (staff #51) on May 6, 2021 at 11:08 a.m. The DON stated if a CNA calls off work, they try to have another staff come in and work. The DON stated the number of CNAs needed is based on the census. The DON further stated they try to shoot for the ratio 16:1 for Long Term Care side and 13:1 for the Medicare side. The DON stated that if there are not enough staff, there could be poor outcome in resident care. The Facility Assessment Tool updated February 2, 2021 stated the general staffing plan is to ensure that sufficient staff are available to meet the needs of the residents at any given time. This takes into consideration the fluctuation in the census and acuity levels that impact staffing needs.

Based on observations, resident and staff interviews, facility documents, policy review, and the Centers for Disease Control (CDC) guidance, the facility failed to ensure infection control standards were followed regarding hand hygiene during an observation of wound care. The deficient practice could result in the spread of infection. Finding include: A Licensed Practical Nurse (LPN/staff #60) was observed to provide wound care to a resident on May 5, 2021 at 12:02 p.m. The LPN retrieved a bedside table from the hall, cleaned it with sanitizing wipes and placed the wound care supplies on the table. The LPN then sanitized her hands and donned clean gloves. She then entered the resident's room with the clean supplies. The wound was observed to be without a dressing. The LPN changed gloves and irrigated the wound with normal saline and packed the wound with [MEDICATION(S)], ¼ inch. The LPN then changed gloves and opened the package of xeroform. The LPN changed gloves and applied the xeroform. Staff #60 then changed gloves and opened the gauze and abdominal pad (ABD pad) packaging. She applied the ABD pad and covered it with gauze and secured the gauze with tape. The LPN then wrote her initials and date on the gauze. The LPN discarded the wrappers and supplies in the trash, doffed her gloves and washed her hands in the resident's sink before exiting the room. The LPN then cleaned the bedside table and the top of the wound cart at the resident's room doorway. Both the table and wound cart were placed in the hall outside of the resident room. The LPN was not observed to perform hand hygiene between any of the glove changes during the wound care. On May 6, 2021 at 09:39 a.m., an interview was conducted with the LPN (staff #60), who stated she was the designated wound care certified nurse. She stated that the process for wound care included gathering supplies from the treatment cart and placing them on a clean surface, performing hand hygiene, donning gloves, and opening all needed supplies on the treatment cart. The LPN stated she would then discard any trash, remove and discard the gloves, apply new gloves and remove the dirty dressing from the wound. Staff #60 stated the nurse was then expected to cleanse the wound per order, remove and discard those gloves, don new gloves and apply and secure the new dressing as ordered. She stated the new dressing would be dated and initialed. The LPN stated that after discarding the trash, the nurse should remove the gloves, wash their hands at the sink, and exit the resident room. She stated that all nurses were always to change gloves between dirty to clean areas on a resident. The LPN stated that she should perform hand hygiene each time the gloves were changed. She stated that normally she would have brought in hand sanitizer with her. The LPN stated that hand hygiene should have been performed at every glove change during the wound care observed on May 5, 2021. On May 6, 2021 at 9:59 a.m., an interview was conducted with the Director of Nursing (DON/staff #51). The DON stated that the wound care nurse should wash her hands upon entering the resident's room, set up supplies, perform hand hygiene, don gloves, remove the old dressing, doff gloves, perform hand hygiene, and don new gloves. The DON stated that her expectation is that gloves be changed and hand hygiene be performed if the gloves are visibly soiled or if the nurse was going from one wound to another wound on the resident. The DON further stated that she had learned that hand hygiene was not always required between glove changes; only when gloves are soiled or when providing care to another wound on the resident. The DON also stated that she was not aware of the current CDC guidance stating hand hygiene should be performed between glove changes. The facility's policy titled Dressing Clean revealed that hand hygiene is to be performed at the onset of the wound care, when changing gloves and after removing and discarding an existing dressing. The facility's policy titled Handwashing/Hand Hygiene revised August 2019 revealed that all personnel shall follow the handwashing/hand hygiene procedures to prevent the spread of infections to other personnel, residents and visitors. The facility considers hand hygiene the primary means to prevent the spread of infections. The policy stated to use an alcohol-based hand rub containing at least 62% alcohol or alternatively, soap and water for situations that included before handling clean or soiled dressings, gauze pads, etc.; after handling used dressings; and after removing gloves. The CDC guidance titled Hand Hygiene in Healthcare Settings revealed that gloves are not a substitute for hand hygiene. If a task required gloves, hand hygiene should be performed prior to donning gloves and before touching the patient or the patient environment. Hand hygiene should be performed immediately after removing gloves. The guidance further revealed that gloves are to be changed and hand hygiene performed during patient care if gloves become damaged, visibly soiled with blood or body fluids, following a task, moving from a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs.

Based on observations, staff interviews, and policy review, the facility failed to ensure that expired medications were discarded and not available for use. The deficient practice could result in resident receiving expired medications. The census was 54. Findings include: An observation was conducted of the 400-unit medication room on 05/06/2021 at 1:23 PM with a Licensed Practical Nurse (LPN/staff #83). Observed in the medication refrigerator was an open box of [MEDICATION(S)] (opioid analgesic) suppositories with an expiration date of 03/31/2019 and an open box of [MEDICATION(S)] suppositories with an expiration date of 11/2018. Following this observation, an interview was conducted with the LPN (staff #83). The LPN stated that all nursing staff are responsible for checking the items in the medication room including the refrigerator for expired items. The LPN stated that both boxes of suppositories were expired, and should have been removed and discarded. In an interview conducted with another LPN (staff #68) on 05/06/21 at 1:51 PM, the LPN stated that it is the nurses' responsibility to check the items in the medication room refrigerator for expiration dates. Staff #68 further stated that when she is ordering items for the medication room, she checks the items in the refrigerator for expiration dates. The LPN stated that the facility expectation is that there would be no expired items in the medication refrigerators. The LPN said the risk for not removing expired items is that the medication may not be effective or could cause a reaction if administered to a resident. An interview was conducted on 05/06/21 at 2:08 PM with the Director of Nursing (DON/staff #51). The DON stated that the nurses are expected to check for expired items in the medication refrigerator as they remove the medication. The DON stated that the expectation is that there would not be expired items in the medication refrigerator. Staff #51 stated the risk would be that the expired medication could be administered to the resident, and it may not be effective. The DON confirmed that those medications should not have been in medication refrigerator. The DON also stated that the medications should have been removed during the monthly defrosting of the refrigerator. The facility's policy titled Storage of Medications included the following: Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on clinical record review, resident and staff interviews, facility documents and policies and procedures, the facility failed to provide the necessary care and services to prevent neglect, by failing to ensure one resident (#9) was adequately supervised while outside and as a result, sustained prolonged sun exposure resulting in hospitalization . Findings include: Resident #9 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment dated (MONTH) 12, (YEAR) revealed the resident had a BIMS (Brief Interview for Mental Status) score of 9, which indicated moderate cognitive impairment. The MDS included the resident used a wheelchair for locomotion on and off the unit and required supervision (oversight, encouragement or cueing). A care plan for cognitive loss related to impaired memory and forgetfulness was updated on (MONTH) 14, (YEAR). An intervention was the resident needed reminders to call for assistance. A care plan updated on (MONTH) 14, (YEAR) for the potential for falls related to weakness and impaired mobility, included to continue frequent checks, remind the resident to call for assistance and that the resident can be impulsive. According to a care plan for alteration in fluid intake updated on (MONTH) 25, (YEAR) included that resident #9 had two plus [MEDICAL CONDITION] in both legs. Interventions included to assure adequate fluid intake. An additional intervention initiated on (MONTH) 26, (YEAR) included to monitor the resident for side effects of diuretic use, including electrolyte imbalance and dehydration. A nurses note dated (MONTH) 1, (YEAR) at 5:00 p.m. revealed the resident had been found outside by a nurse on the patio, his color was flushed, skin dry, and he was unresponsive to verbal commands. Vital signs were as follows: temperature was 103.3, pulse was 107 and blood pressure was 96/69. Cooling measures were initiated and 911 was called, and the resident was transported to the hospital. A hospital physician's history and physical report dated (MONTH) 1, (YEAR) included that resident #9 had a history of [REDACTED]. The resident was found outside of the nursing facility after a period estimated to be a couple of hours. The resident had significant sunburns noted to the back of his neck, the anterior aspect of his upper chest, his arms, the medial aspect of his torso, and the anterior aspect of both thighs. The resident complained of generalized pain and weakness throughout his body. In the emergency department the resident was given a liter of chilled saline. The report further included the resident had heat exposure, heat stress and acute kidney injury, secondary to heat exposure and dehydration. A hospital discharge note dated (MONTH) 2, (YEAR) revealed the following discharge Diagnoses: [REDACTED]. A nurses note dated (MONTH) 2, (YEAR) included the resident returned to the facility. Review of the incident report revealed that on (MONTH) 1, (YEAR) at 5 p.m., the resident was found outside in the courtyard. The resident had memory impairment and impaired decision making ability, and self propelled his wheelchair in and out of courtyards frequently without difficulty. The report included the resident was sunburned, his face and neck were flushed and there was a fluid filled blister on the back of his neck. Cool compresses were applied. The resident was unresponsive to verbal commands and 911 was called. The type of incident documented was heat exposure/sunburn. Review of the facility's investigation report revealed that on (MONTH) 1, (YEAR) at approximately 4:30 p.m., resident #9 was found to be asleep outside in an interior courtyard. The resident was brought inside by a LPN (licensed practical nurse/staff #71). The resident was found to be lethargic and was not responding to verbal stimuli. The resident had a red face, neck and hands with blisters forming on his neck. Cool towels were placed over the resident's head, neck and arms and cool water was provided to the resident to drink. The resident was sent to the emergency department and was treated for [REDACTED]. The report included that the courtyard is visible from inside of the facility. Per the report, the day shift (6a-2p) CNA reported that the resident was in bed at shift change that afternoon, and the 2p-10p CNA reported that she saw the resident in the television room around 3:00 p.m., and in the hallway around 3:15 p.m. The report further included that staff did not visualize the resident again until he was found asleep in the courtyard at 4:30 p.m. Further review of the investigation report revealed a witness statement signed by staff #71. In the statement, staff #71 stated that the resident was last seen by staff at 3:00 p.m., and was found in the courtyard at 5:00 p.m. (which differs from the time documented in the investigation report at 4:30 p.m.). Review of the dispatch Pre-Hospital Care Report dated (MONTH) 1, (YEAR), revealed the call was received at 5:24 p.m., paramedics were on scene at 5:27 p.m., and the resident was transported to the hospital at 5:40 p.m. During an interview with resident #9 conducted on (MONTH) 4, 2019 at 12:10 p.m., he stated that last (MONTH) (he did not remember the exact date), he had fallen asleep while he was outside in the courtyard, but did not remember how long. The resident stated that he woke up when staff were carrying him inside and that he got burned pretty bad. An observation of the facility's non-smoking courtyard where the resident had been found revealed the courtyard had glass doors on two opposing sides. One set of glass doors lead into the main hallway and the other set of glass doors lead into the television room. The television room had multiple windows, so the courtyard was visible from this room and from the main hallway. In addition, the courtyard was surrounded by multiple resident rooms with windows that faced the courtyard. An Internet source (Time and Date.com) was reviewed on (MONTH) 5, 2019 at 2:36 p.m., and revealed the weather on (MONTH) 1, (YEAR) from 2:56 p.m. until 4:56 p.m. was sunny, with a temperature of 105 degrees F. An interview was conducted on (MONTH) 5, 2019, with the Director of Nursing (DON/staff #19). The DON stated that on (MONTH) 1, (YEAR), resident #9 was found sleeping out on the non-smoking courtyard. The DON said the resident was independently mobile with his wheelchair and was able to let himself in and out of the courtyard independently. The DON said at the time of the incident, staff were checking the courtyard hourly, but was done informally and was not documented, and no specific staff was assigned to check the courtyard. The DON also stated that the resident's assigned CNA (certified nursing assistant) should have known that he had gone out to the courtyard. An interview was conducted on (MONTH) 5, 2019 at 2:56 p.m., with a random CNA (staff #40). Staff #40 stated that in (MONTH) (YEAR), the facility air conditioning system maintained cool temperatures in the facility, and resident #9 was known by staff to go outside on the courtyard several times a day to warm up. Staff #40 said they were aware that resident #9 went outside frequently and they monitored him while in the courtyard. The CNA stated that staff would bring the resident inside after 10-15 minutes to prevent the resident from overheating. The CNA also stated that water was not maintained in the courtyard for residents to drink. An interview was conducted on (MONTH) 6, 2019 at 9:38 a.m., with a LPN (staff #71). Staff #71 stated she was walking down the hallway and noticed that resident #9 was out on the non-smoking courtyard asleep in his wheelchair, and his legs were stretched out in front of him and his head was tucked down onto his chest. She said she went out and attempted to wake the resident up, but he was non-responsive. Staff #71 said she immediately wheeled the resident to the nurses station and with additional staff assistance, placed cold towels around the residents neck. She said the resident had reddened skin on his face and neck and 911 was called. Staff #71 stated that staff monitored the courtyard by looking out onto the courtyard as they went by, but there was no structured program for monitoring the courtyard, there was no specific staff assigned to monitor the courtyard, and the monitoring was not documented. Staff #71 said resident #9 was able to use his wheelchair independently to go in and out of the courtyard, and he frequently went outside and napped in the sun, and this was common knowledge among the staff. She added that she was not his assigned nurse on (MONTH) 1, (YEAR) and did not know how long the resident had been outside when she found him. A policy and procedure titled, Resident Hydration and Prevention of Dehydration included This facility will endeavor to provide adequate hydration and to prevent and treat dehydration. An intervention included that nursing will assess for signs and symptoms of dehydration during daily care. Review of a policy and procedure titled, Safety and Supervision of Residents which was current on (MONTH) 1, (YEAR) revealed the following: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy included Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include: Outdoor safety (outings, courtyards, etc). Hourly courtyard checks. A policy and procedure titled, Abuse Prevention Program included the objective of the policy was zero tolerance of abuse and neglect by employees. Neglect was defined as the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy included that resident's have the right to be free of abuse and neglect.

Based on closed clinical record review, staff interviews, and review of facility documentation, the facility failed to ensure that one resident (#183) received appropriate supervision to prevent an accident, and sustained second degree burns. Findings include: Resident #183 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Comprehensive Care Plan dated March 1, 2012, revealed the resident had a deficit in bed mobility related to paralysis, and had one sided weakness, deconditioning, limb immobilization and spasm of extremities. Approaches included to monitor for changes in level of consciousness, support paralyzed extremities in bed/chair, assure assistance in activities of daily living (ADL)'s and limited to extensive assistance with one person physical assist in some ADL's and transfers. The Minimum Data Set (MDS) discharge assessment dated [DATE], documented under Section G that the resident required supervision with eating and drinking. Review of the Nurse's Notes dated April 4, 2012, revealed the resident started to slur words when speaking with frequent repetition of statements and questions, was unable to sit up in her wheel chair, was unable to stand up in the bathroom, and was unable to clean herself up in the restroom. The note included the physician was notified of the change in condition and an order was obtained to send the resident to the emergency room for an evaluation for a decreased level of consciousness. The resident left the facility at 12:50 p.m. Further review of the Nurse's Notes dated April 4, 2012, revealed that the resident returned to the facility at 6:15 p.m. from the hospital after being diagnosed with [REDACTED]. The notes documented the resident was served dinner and spilled hot coffee on her lap and that ointment was applied to the burned areas on her upper thighs. Review of the Nursing Home Communication Form dated April 4, 2012, revealed that the resident spilled a hot cup of coffee into her lap and a cool compress and ointment were applied to the burns. Documentation included that blisters were apparent on her upper thighs. Nurse's Notes dated April 5, 2012, included that the resident continued to show signs and symptoms of altered mental status and was unable to sit up in the wheel chair, had difficulty holding pills and food in her mouth and did not have the ability to hold a glass and proceeded to spill liquids onto herself. Per the note, the resident was unable to grasp a cigarette and dropped it multiple times on the last attempt to go smoke. The notes also documented that smoking was not allowed for this resident currently because of inability to do so safely. Review of the Wound Care Center history and physical dated April 10, 2012, revealed that the resident spilled very hot coffee on her inner thighs four days ago and suffered deep partial thickness burns on the inner thighs bilaterally. The resident is complaining of pain in that area. Treatment consisted of daily dressing changes with Silvadene to all three wounds and Santyl will be applied to the yellow eschar on the two wounds on the left leg on a daily basis, with follow up at the wound clinic next week. Review of the Wound Care Center operative report dated April 10, 2012, the wound physician determined that sharp excisional debridement into the necrotic subcutaneous tissue was required to promote healing. The Wound Care Center progress notes dated April 24, 2012, documented the resident had deep partial thickness burns of the bilateral upper extremities. The wound measurements were as follows: wound #1 left proximal thigh 3.4 by 15 by 0.2 cm.; wound #2 left distal thigh 1.5 by 9 by 0.2 cm.; wound #3 right thigh 2.0 by 16 by 0.2 cm. An interview was conducted on March 20, 2013 with a certified nursing assistant (CNA). The CNA stated that he had just brought the resident back from the hospital for a decreased level of consciousness and assisted her back to her room. The resident then asked for a cup of coffee, which he got for her and left the room. An interview was conducted on March 20, 2013, with the director of nursing (DON). The DON stated that this resident spilled hot coffee on herself and that the certified nursing assistant (CNA) was counseled about giving a resident hot coffee who had a decreased level of consciousness.

Based on clinical record reviews, observations, staff interviews, and review of facility policy and documentation, the facility failed to ensure that one resident (#62) at high risk for falls and who had recurrent falls, received appropriate care and interventions, that resulted in falls with fracture, hematoma, and laceration requiring sutures. Findings include: Resident #62 was admitted on [DATE], and had current [DIAGNOSES REDACTED]. Observations conducted during the survey revealed the resident had a large hematoma on her forehead with multiple bruising noted around both of her eyes, and a sutured laceration noted to the bridge of her nose. Clinical record review revealed a fall risk assessment dated [DATE], that included the resident was assessed a higher fall risk with a score of "22." Denoted on this assessment was that a score of 1 to 3 was a lower risk, 4 to 6 was a moderate risk, and greater than 7 was a higher risk. The reverse side of this fall risk assessment form included ares to document interventions but it was blank. The quarterly Minimum Data Set (MDS) was also completed on June 2, and reflected intact memory and decision making, but also included that the resident exhibited repetitive physical movements, was resistant to care, was non-ambulatory, and required extensive staff assistance with transfers and bed mobility. The resident had no history of falls. The nursing note dated July 23, 2010, included a late entry from July 22, that reflected the resident sustained [REDACTED]. The resident also sustained falls on July 28 and August 24, 2010. Per the facility investigative documentation, the resident had been assisted to the floor during transfers on both occasions. The facility's report for the July 28 incident documented the resident did not utilize a height adjustable bed. There was no nursing note completed on July 28, regarding the fall, and no care plan developed. The facility's report for the August 24 incident revealed that while the resident was being assisted to bed she had to be assisted to the floor. There were no apparent injuries. Again, there was no care plan for falls developed, nor interventions established. The nursing note dated September 1, 2010, included that the resident required increased assistance with transfers secondary to pain in her left upper extremity and that she was unable to tend to her activities of daily living without assistance from the staff. The quarterly MDS, with an assessment reference date of September 2, 2010, included that the resident could make independent decisions that were reasonable, but had periods of altered perception and lethargy with mental function that varied over the course of the day. The resident's functional status had not changed since the previous MDS. Also documented was that the resident did not have a fall in the past 31 to 180 days. The MDS was coded inaccurately as intercepted falls, or assisting the resident to the ground, are considered falls per MDS 2.0 coding instructions. The resident's fall risk assessment was updated again on September 5, 2010, and the resident was assessed to be at even higher risk, from 22 to 28 on the risk scale. The 6 point increase in her fall risk was related to the resident having 1 to 2 falls in the last 90 days. An occupational therapy (OT) plan for rehabilitation was initiated on September 8, 2010. Documented was that due to chronic pain, the resident was at functional risk. Documented was that the resident had sustained recent falls, had weakness, and was to be transferred via mechanical lift. Short term goals were established to improve the resident's balance and lessen pain. While the OT goals addressed functional status and pain, there were no specific interventions regarding fall prevention. Additional clinical record review revealed no evidence that a care plan, including appropriate interventions, had been developed to address the resident's increased fall risk and that identified appropriate interventions. A nurse's note dated September 25, 2010, included that the resident's family member wanted the resident sent to the emergency room related to her confusion. Later that same day, at 7:12 p.m., the resident was documented to self transfer and sustain a fall. The facility's investigative report of the fall, dated September 25, included only that the resident's adjustable height bed was down and that the resident had been sent to the emergency room with a laceration on her nose. No additional information was documented including any other devices utilized such as alarms, any floor mats in place to protect against falls, and whether the low bed contributed to the resident's potential to fall when she had been previously documented to stand unpredictably. In addition, no documentation was included regarding any increased supervision provided after the resident's family member had expressed concerns regarding the resident's confusion. Review of hospital documentation dated September 25, 2010, included the resident had sustained a left nasal bone fracture. Nursing notes dated September 26, 2010, included the resident required 5 to 6 sutures to close the laceration to her nose. The nursing note dated September 27, 2010, included that the resident's family member had called to discuss the frequency of the staff checking on the resident. Also documented was that the resident was attempting to get out of be unassisted. Again, clinical record revealed no care plan to coordinate and evaluate the resident's fall risk had been implemented. The nursing note dated September 28, 2010, included that the resident was near the nurse's station for 1 to 1 observation when she fell and sustained a "baseball size" hematoma to the middle of her forehead, and reopened the laceration to the bridge of the nose. Documented was that the resident stood up from her wheelchair and fell forward, landing face down. Staff were unable to reach the resident in time to prevent or intercept the fall. Further documented was that the resident was admitted to the hospital. The facility investigative report for this fall, dated September 28, was incomplete and included no documentation regarding any interventions in place at the time of the resident's fall. The report did reflect that an ice pack was applied to the resident's forehead. Again, the care plan did not reflect the ongoing falls or the need to specialized interventions. On October 4, 2010, a fall reduction meeting was convened regarding the resident. Review of these meeting minutes revealed no specific non-pharmacological recommendations, no evaluation of appropriate supervision, nor any appropriate devices to be utilized to ensure the resident's safety. An interview was conducted with the director of nursing (DON) who stated that the resident has bilateral floor mats next to her bed and that the resident has been "told" on numerous occasions to call for assistance when she wanted to get up. There was no documentation regarding the effectiveness and the safety of utilizing floor mats for this resident. The DON also stated that he witnessed the resident fall on September 28, 2010 by the nurse's station. He stated two staff members tried to break her fall but were unable to reach the resident in time. The DON was unable to verbalize why there were no documented interventions or care planned interventions for falls implemented in the chart. An interview was then conducted with the MDS Coordinator, and she stated that it was her responsibilty to implement and update care plans for the residents but acknowledged that she had not implemented a care plan for falls on this resident. A review of facility policy entitled "Falls and Fall Risk, Managing" included based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.