Every finding on record at Haven Health Green Valley, LLC

Based on the clinical record review, observations, interviews, facility documentation, and policy, the facility failed to ensure that infection control practices for Enhanced Barrier Precautions (EBP) were followed for one resident (Resident #11). This deficient practice can result in contamination and the spread of infection. The universe is 15, and the sample is one resident. Findings include: Resident #11 was admitted to the facility on [DATE], with conditions that included type 2 diabetes mellitus, Hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, pressure ulcer of the sacral region, stage 4, urinary tract infection, and a Foley catheter.The quarterly Minimum Data Set (MDS) accepted on May 15, 2026, revealed that the resident had a Brief Interview Mental Status (BIMS) score of 15, indicating intact cognition. An observation was conducted on June 02, 2026, at 1:06 p.m. and at 2:27 p.m. Resident #11 did not have a numerical 6 on the door frame, which indicates Enhanced Barrier Precaution signage. There was no PPE observed outside of the room. An observation conducted on June 04, 2026, at 12:04 p.m., a numerical 6 was placed on the door frame, which was previously absent. Review of orders dated June 3, 2026, revealed to cleanse stage 4 pressure injury to the coccyx and right buttock with wound cleanser. An order dated May 20, 2026, directed that the catheter be changed every 30 days and replaced with a new one to prevent infections. An order dated May 1, 2026, indicated enhanced barrier precautions due to a Foley wound and MDRO (Multidrug-Resistant Organisms). An order dated April 22, 2026, reveals to check the wound vac for proper placement, functioning, and that the wound vac is upright. An order dated April 22, 2026, states to change the Foley catheter as needed for leaking, soiling, blockage, or as ordered by the provider. Review of progress notes dated June 01, 2026, revealed stage 4 pressure ulcer/injury- full thickness skin and tissue loss, Exudate type serosanguineous: mixture of serous and sanguineous fluid, typically pale, red, and watery. Odor after cleansing. Review of the progress note dated May 25, 2026, revealed that a Foley catheter is in place. A progress note on May 24, 2026, revealed the patient continues on antibiotics, Ciprofloxacin HCL tablet 250 MG, to give one tablet by mouth two times a day for a UTI related to urinary tract infection.Review of the care plan indicated the resident was on enhanced barrier precautions for MDRO, colonized c. auris, and wound. Interventions included having a patient identifier on the door frame. An interview conducted on June 04, 2026, at 11:31 AM with infection preventionist (IP) staff #118 stated that EBP signage is appropriate for a room with a resident with an indwelling catheter, central line, wounds, or MDRO. Staff #118 stated that the number 6 is the identifier for EBP rooms, so that staff know to take enhanced barrier precautions. When it is not placed in front of the room, the risks imposed are that MDROs can spread around the building. Staff #118 stated that bacteria can travel up the Foley to Enhanced Barrier Precautions to protect residents from getting infected. On June 05, 2026, at 9:51 a.m. Staff #118 stated there was no EBP signage in front of Resident #11's room because of a recent room change. However, staff #118 stated residents are on EBP due to having a Foley catheter, a wound, and active Candida auris infection it is important that staff wear gloves and gown for all high contact areas.An interview was conducted on June 05, 2026, with a wound nurse, Staff #49, who stated that EBP signage is a way of communicating to protect the residents from many kinds of bacteria. It is used for residents who have chronic wounds and any medical devices, such as Foley catheters and IVs. Staff #49 stated that resident #11 should be on EBP, and not having the sign in front of the resident's door may impose increased risk of infection and miscommunication due to staff not being aware of the use of EBP. An interview was conducted with a Certified Nursing Assistant (CNA/ Staff #137) on June 05, 2026, at 10:09 AM. Staff #137 stated that the number 6 on the door frame is how she knows the resident is on enhanced barrier precautions. Staff # 137 stated that if there is no EBP signage, she does not put on PPE (Personal Protective Equipment). The CNA stated that not having EBP signage in front of appropriate rooms can increase the risk of infection spreading. An interview conducted on June 05, 2026, at 10:22 a.m. with Director of Nursing (DON, staff#17), Staff #17 stated that EBP signage is replaced with the numerical 6 sign. Staff #17 stated it is important to wear PPE when a resident has an open wound, Foley, or MDRO. The DON stated that not wearing PPE when required can cause the spread of infections; therefore, staff are educated on enhanced barrier precautions in quick huddle updates and during rounds. The facility's policy titled Infection control enhanced barrier precautions (EBPs) dated January 1, 2024, states Enhanced barrier precautions (EBPs) are utilized to prevent the spread of mutli-drug resistant organisms ( MDROs) to residents. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator etc.); and Wound care for chronic wounds, (not shorter lasting wounds). Examples of chronic wounds include, but are not limited to, Pressure Ulcers (greater than stage 2), Diabetic Ulcers, Unhealed Surgical Wounds, and Venous Stasis Ulcers. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. The use of EBPs does not impose limitations on group activities or room restrictions for residents. Signs are posted on the door or wall outside the resident's room indicating the type of precautions and PPE required. PPE is available in the facility for EBP precautions. Residents, families, and visitors are notified of the implementation of EBPs throughout the facility.

Based on clinical record review, interviews, and review of the facility's policy and procedures, the facility failed to ensure a significant change in condition assessment was completed for Resident #120. The universe was 19. The deficient practice could result in residents not receiving the necessary care and services to maintain the highest and practicable wellbeing.Findings include:Resident #120 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, dementia, and adjustment disorder.An admission Minimum Data Set (MDS), dated [DATE] revealed Resident #120 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated she had moderate cognitive impairment. The same MDS also indicated she was not receiving hospice services.An entry in the clinical record titled, Psych Follow Up, dated [DATE] at 7:00 A.M. noted that Resident #120 was experiencing an increase in behavioral changes such as increased aggression, anger, and yelling with staff. It also noted that staff had reported that the resident exhibiting excessive daytime sleeping. The note further indicated that the resident also had a functional decline and now required feeding assistance and was unable to assist staff with her transfers.An encounter note, dated [DATE] at 8:31 P.M., was created by the Nurse Practitioner (NP/Staff #8). The note indicated that Staff #8 saw Resident #120 on [DATE]. It also noted that it was reported to Staff #8 that the resident was very sleepy for long periods of time and then during other times, she would be up and yelling. It also stated that the resident has had a significant decline over the last several months.A progress note, dated [DATE] at 6:24 P.M., indicated Resident #120's family member was contacted regarding her change of condition and that the resident's physician recommended a Hospice consult.Review of the Order Summary revealed a physician's order dated [DATE] indicated Resident #120 required an evaluation for hospice services.A second physician's order, dated [DATE], stated that Resident #120 required hospice services due to major depressive disorder.A Psychotropic Medication Review note, dated [DATE] at 10:39 A.M. noted that Resident #120 has had an increase in behaviors and refused to eat and participate in self-care. It further noted that the resident had transitioned to hospice and medication management will be directed by hospice services. A secondary review of Resident #120's MDS revealed there was no update to the MDS to reflect her change in condition. Review of Resident #120's Care Plan revealed no documentation regarding Hospice care. An interview was conducted on [DATE] at 8:53 A.M. with Registered Nurse (RN/Staff #31), who described a change in condition for a resident as a change in their mental or physical status. She provided an example of a resident going from a one person assist to a two or three person assist. Staff #31 stated that she would consider a resident transitioning to hospice services a change in their condition. She further stated that when a change in their condition takes place, the resident's care plan should be updated as well as their MDS assessments. Staff #31 shared that the MDS nurse (Staff #0) was one of the people responsible for updating the MDS. Staff #31 stated that she recalled Resident #120 and that she had declined quickly and required hospice services. Upon reviewing Resident #120's clinical chart, Staff #31 stated that there was no update to the MDS assessment or the care plan and it should have been done when she went on hospice. Staff #31 further stated that if there is a change in condition for a resident and their MDS and/or care plan is not updated, the resident would be at risk for not getting the care and/or services they need. An interview was conducted on [DATE] at 9:09 A.M. with Licensed Practical Nurse MDS (LPN/Staff #0). Staff #0 explained that if a resident has a significant weight change, a change in their skin condition, ability to provide their own self-care, or a change in their cognitive abilities, they had experienced a change in their condition. She further explained that if a resident was transitioning to hospice services, they would also be experiencing a change in their condition. Staff #0 stated that a change in a resident's condition would trigger an update to the resident's MDS assessment to reflect the change in their condition. Then once the MDS assessment is updated, the care plan is updated to reflect the changes. Staff #0 shared that she remembered Resident #120 and that she had a rapid decline in her condition. Staff #0 reviewed Resident #120's clinical chart and stated that Resident #120 was put on hospice services and there was a physician's order dated [DATE]. She added that Resident #120 had passed away on [DATE] and that she had passed away before the MDS was required to be updated. Staff #0 explained that when there is a change in the resident's condition, the MDS has to be updated within 14 days and that Resident #120 had passed away before the 14 day deadline. When asked when the 14 day deadline from the hospice order date was, Staff #0 stated it was [DATE]. She then acknowledged that the MDS update should have been completed by [DATE]. Staff #0 reviewed the clinical chart a second time and stated that she didn't update the care plan to include hospice services because the MDS was not updated. Staff #0 stated that she was aware that if the MDS and care plan is not updated when the resident has a change in their condition it means that services and cares were not being provided, from a legal standpoint. An interview was conducted on [DATE] at 9:42 A.M. with the Director of Nursing (DON/Staff #17). Staff #17 stated Resident #120 had a hospice order put in on [DATE] due to her change in condition and that the MDS was not completed because she deceased in the facility on [DATE]. She further stated that the regulations indicate that the MDS must be updated after a certain amount of days after the change in the resident's condition; however, she was not able to recall the exact number of days it needed to be updated. Staff #17 then requested to retrieve the policy from another office. Upon returning, Staff #17 stated that the facility's policy did not identify a timeframe for the MDS update but the regulations stated it must be done within 14 days. When asked when was the 14 day deadline for the MDS update to be completed, she stated that was on [DATE] and that the resident had passed away on [DATE]. Staff #17 then acknowledged that the update to the MDS was not done within 14 days which did not meet her expectations. Staff #17 explained that if the update to the MDS is not completed, then there would be a risk of not following an accurate plan of care for the residents. She further explained that in this situation, there was no risk to Resident #120 because they had identified the change in the resident's condition and had started her with hospice services. They just did not update the MDS which did not bring harm to the resident. On [DATE] at 10:26 A.M., Staff #17 approached surveyor and shared that the significant change MDS for Resident #120 had a created date of [DATE] but it was never completed due to the resident passing away. Staff #17 provided surveyor with a print out of a list of MDS in Resident #120's clinical chart. The list indicated that the [DATE] significant change MDS was incomplete. Staff #17 stated that the facility has 14 days to schedule the significant change MDS and then another 14 days to complete it and since the resident had passed away the MDS was not completed. Review of the facility's policy and procedure titled, Assessments and Care Planning, with an effective date on [DATE], indicated that OBRA (Omnibus Budget Reconciliation Act) required assessments are federally mandated and must be completed. It also noted that when a resident experiences a significant change in their status, an assessment must be completed. The policy also refers to the RAI (Resident Assessment Instrument) User's Manual (Chapter 2) regarding the timing and submission of assessments. A review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, version 1.20.1 updated [DATE] with an effective date of [DATE] was conducted The RAI User's Manual indicated that OBRA-required comprehensive assessments are to be completed when there is a significant change in the resident's health status. It further indicates that a Significant Change in Status Assessment (SCSA) must be completed within 14 days of the significant change in the resident's status occurred. The RAI User's Manual also defines a completed assessment as to the date that all information needed has been collected and recorded for a particular assessment type and staff have signed and dated that the assessment is complete.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that floor tiles, laminate flooring, shower drain, and door frame in common areas were safe for residents ambulating and showering. The deficient practice could result in residents falling and/or being injured. Findings include: On May 21, 2024 at 4:23 p.m., a walk through of the facility was conducted and the following environmental issues were observed: -one rectangular panel of the laminate flooring in Hall 100, between rooms #127 and #128, was broken and approximately half an inch was missing from one of the corners of the laminate. -the laminate panel in the doorway of room [ROOM NUMBER] was observed to have approximately 16.5 inches in length broken and missing. -six tiles in Hall 100 were cracked and/or broken. -the transition strip between the laminate flooring and the tile flooring on Hall 100 by room [ROOM NUMBER] was cracked in multiple areas. -in the hallway, near room [ROOM NUMBER] a piece of the flooring, circular in shape, was compressed, so that the floor was uneven and there was cracked and broken laminate around the circumference of the circle. -one rectangular laminate floor panel located near room [ROOM NUMBER] on Hall 100 was not secured to the floor. -there was no transition strip between the tile and the laminate flooring toward the end of Hall 100 by room [ROOM NUMBER]. -the drain in the bathroom shower on Hall 100 was approximately two inches in diameter and there was a square silver drain cover only partially covering the round open hole and the drain cover was not attached to the floor. -the doorframe of the bathroom on Hall 100 had areas were paint was missing and a brown rust color was observed. -upon entering the secured unit on Hall 100, one rectangular laminate floor panel was broken with approximately 3 inches by 1 inch of the panel missing. -in the hallway of the secured unit on Hall 100, a circular shape, approximately three inches in diameter, was compressed, so that the floor was uneven. -by the left door to the main dining room, the Azelea room, there were two eighteen by eighteen inch tiles broken and cracked. -by the right door to the main dining room, the Azelea room, the tile was not flush/even with the surrounding tiles, creating a dip of approximately one centimeter where residents would enter the dining room. -there was no transition strip between the tile and the laminate flooring near room [ROOM NUMBER] on Hall 200. An interview was conducted on May 22, 2024 at 8:37 a.m. with the Maintenance Manager (staff #430), who stated that anyone can put in a request for a repair and he prioritizes repairs based on resident safety, how it impacts the residents' stay, and anything to do with safety, should be repaired immediately. He stated that safety risks included falls and could include rust if the resident came into contact with the rust. He stated that he inspects the facility daily, and that he has laminate flooring, transition strips, and paint in stock. He stated that drain covers should be screwed down to make sure that the drain is covered. He also, stated that he has a company credit card and can purchase supplies when needed to make repairs. During the interview, a walk through the facility was conducted, so staff #430 could observe the above issues. He acknowledged that the uneven and broken flooring could be a fall risk for the residents and he had noticed the circular compressions in the floor sometime in the last six months. It was observed that he had begun fixing some of the tiles on Hall 100 by filling the broken and cracked areas with resin. He stated that he had removed the transition strip and would be replacing it before the end of the day. At approximately 9:21 a.m., the Environmental Engineer (staff #611) joined the interview. Staff #611 stated that he thought the circular compressions in the floor were a result of the drain below the flooring and the unevenness of the floor could be fixed. Staff #611 viewed the brown rust color on the bathroom doorframe on Hall 100 and stated that it was rust and could cause an infection to residents. He also acknowledged residents could be injured because the drain cover was bit secured to the shower floor. An interview was conducted on May 23, 2024 at 11:06 a.m. with the Administrator (staff #605), who stated that he supervises the maintenance department and was updated about the floors. He has been trying to fix the floor in the residents' rooms as needed and thinks some of the flooring in the facility is a potential risk for safety. It is expectation that staff put in requests for repairs and the repairs are done daily/weekly. The facility policy, Resident Safety: Safety and Supervision of Residents dated January 1, 2024 states that the facility strives to make the environment as free from accident hazards as possible. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. The Maintenance Manager job description states that the Maintenance Manager must have knowledge of all areas facility maintenance and is responsible for the maintenance of the physical environment, including offices, common areas, and resident rooms.

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents. Findings Include: A review of the personnel file for the role of activity manager (staff #432) was conducted on May 21, 2024. However, review of file did not reveal evidence that staff #432 possessed the qualifications required for the role of activities director. An interview was conducted on May 21, 2024 at 1:12 P.M. with staff #498, human resource manager. Staff #498 stated that the role of activity manager had no additional qualifications needed beyond the scope of qualifications that staff #432 had. She stated that the facility did not require licensure or registration for the activity manager. An interview was conducted on May 21, 2024 at 2:14 P.M. with staff #605 , administrator. Staff #605 stated that he was aware that the current activities director was not licensed or registered, but stated that staff #432 was in the process and getting ready to test soon. He further stated that the facility already had a performance improvement plan in place and that the Occupational Therapist, staff #536 was currently supervising the activities director since January 2024 until her licensing/ registration has been completed. An interview was conducted on May 22, 2024 at 8:03 A.M. with staff #432, activity manager. Staff #432 stated that she was the activity manager and that she had 4 additional staff members assisting in the activities department. She stated that she had initially started with the facility by working in the kitchen for 3 years and then had worked as an activity assistant for 2 years and further stated that she had been in the role of activity manager for 7 years. Staff #432 stated that she was certified at one point, but had lost the certification 2 years ago. She stated that she had been working on recertification and was scheduled to test on May 24, 2024. She stated that she had maintained her continuing education requirements in spite of not being certified. Additionally, staff #432 stated that she had maintained her active membership with the Arizona state professional's organization for activity directors. She stated that her current activity calendars were being reviewed by the therapy department, but could not recall when this process had started. She stated that there 2 therapist providing oversight, one was staff #533 and she was unable to recall the name or appearance of the other therapist, who was later identified as staff #536. She stated that staff #533 would review her calendar and at times make recommendations as they pertain to tasks involving therapy. An interview was conducted on May 22, 2024 at 8:22 A.M. with staff #533, PTA (Physical Therapy Assistant). Staff #533 stated that there is coordination between activities and therapy regarding outdoor activities and getting in or out of activities. He stated that he was not the supervisor for staff #432. He stated that he likes to look at the ideas the activity department brings forward and reviews them for safety. However, he stated that he only reviews the calendar and nothing else. He stated that he started reviewing the calendars in October of 2023. He further stated that the other staff member providing additional oversight was staff #536. An interview was conducted on May 22, 2024 at 8:28 A.M. with staff #536, OT (occupational therapist). Staff #536 stated that he had been checking on how the activities program is run and was involved in coordinating the program with the current activity's director. He stated that he was meeting with the activity manager approximately every two weeks, since the day he started with the facility back in April of 2024. An interview was conducted on May 22, 2024 at 10:03 A.M. with staff #605 (administrator). Staff #605 stated that he was uncertain when the activity manager licensure/ certification had lapsed. He stated that it was an identified deficiency when a home office audit was conducted at the beginning of the year. He further stated that he was unsure of the exact date when the OT started providing the oversight for the activity manager. Staff #605 further stated that his expectation is that staff who require licensure and or registration should never have it lapse. He stated that the risk for not having a licensed and or registered activity manager could include the scheduling of activities that might be inappropriate for the residents. A review of the facility policy entitled Hiring and Rehiring Employees dated January 1, 2024 revealed that the company policy is to hire qualified applicants. The policy further states that in order to qualify for a position, the facility looks at eligibility, qualifications, skills, attitude, dependability, cooperation and other legitimate business considerations. A review of the policy entitled Administrative Policies: Licensure, certification and registration of personnel dated January 1, 2024 revealed that personnel who require a license, certification or registration to perform their duties must present verification of the aforementioned to the human resources director/ designee prior to or upon employment.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#41). The deficient practice could result in residents not receiving care and services for oral/dental conditions. Findings include: Resident # 41 was initially admitted to the facility on [DATE] with diagnoses that included hemiplegia, hemiparesis, dysphagia, atherosclerotic heart disease, hypertensive heart disease, chronic diastolic heart failure, and chronic obstructive pulmonary disease. A dental note dated September 8, 2022 revealed that a consultation visit was completed. The findings/recommendations was ext (extraction) of #26 (lateral incisor), 27 (cuspid), and 28 (first bicuspid). The next schedule appointment was marked as October 5, 2022. However, further review of dental referral notes did not reveal any documentation of that visit or if that visit occurred. A care plan initiated on February 28, 2023 revealed that the resident is at risk for acute oral/dental health problems related to missing and/or cavity prone teeth. Interventions included coordinate arrangements for dental care, transportation as needed/as ordered. Review of dental noted dated January 2, 2024 indicated that an initial exam was conducted and found that resident had broken teeth. During the exam it was discovered that resident had a worn FUD (full upper denture) for over 3 years and never had lower dentures. It was noted that FUD fit loosely and needs adhesive for retention. The note indicated that recommended treatment included surgical exts (extraction) #26 (lateral incisor), 27 (cuspid), 28 (first bicuspid), and 29 (second bicuspid); and FUD/FLD (full lower denture). Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. The MDS also documented that the resident had obvious or like cavity or broken natural teeth. An interview with the Unit Secretary (staff #424) was conducted on May 23, 2024 at 9:19 a.m. Staff #424 stated that nurse or providers informs her which residents need dental services. For new residents they sent the face sheet to the dental provider, for long term care residents, if they do not know if Medicare covers, they call the dental office to ask if they cover and if the dentist is contracted. One of the dental providers comes in and provides dental services and the other will send a list and they let her know which residents needs to be seen. Staff #424 noted that the process for scheduling is usually via email contact initiated by her. For example, if a resident has an appointment today, she annotates it then the day after, she calls and checks if the resident has a follow-up appointment. Regarding resident #41, her name was not on list prior to the dental provider coming in today. Looking at the chart, staff #424 stated that she does not see anything else in reference to resident #41 seeing dental services other than the initial visit in January 2, 2024 and the one prior to that was with another dental provider back in September 8, 2022. The Unit Secretary stated that she would need to ask Medical Records to see if there are any other appointment dates. Review of an email thread between the Unit Secretary (staff #424) and the Dental Office Manager (staff #620) dated May 23, 2024 revealed that resident #41 does not have any current scheduled appointment. Staff #620 indicated that they will be scheduling resident #41 in two to three weeks. During an interview with the MDS Coordinator/Care Coordinator (staff #415) conducted on May 23, 2024 at 10:10 a.m., staff #415 stated that during assessment if oral/dental issues is noticed, the resident is sent for dental services and dietary gets involved to adjust based on needs. Speech also does an eval when resident is first admitted and if they see something pertinent then dental services is also set up. The MDS and Care Coordinator stated Social Services is notified and they relay to them if resident has obvious cavity, broken teeth, pain or trouble swallowing. Usually Social Services will set up the appointment. Staff #415 stated that every 3 months there is a quarterly assessment and they note if there are changes. If a big issue is noticed with oral/dental then let Social Services know. Staff #415 noted that they also ask CNAs if there are any changes and if residents are eating okay. An interview was with resident #41 was conducted on May 23, 2024 at 10:49 a.m. Resident #41 pointed at her remaining teeth and stated that she has pain in the areas she is pointing to. She said that she does have dentures but they are temporary ones. Resident #41 said she has 3 teeth left in the lower. They looked decayed and needs attention/extracted. During an interview with the Director of Nursing (DON/staff #417) conducted on May 23, 2024 at 12:47 p.m., staff #417 stated that residents are seen by the dentist per facility protocol, family approval of cost, transportation, and if any pain or dental issues are noted, and per dentist recommendation. The DON noted that family can refuse cost. The facility tries to see if there is anything through insurance for additional coverage, donated funds, share of cost money to get payment plan for dentist. Family and Social Services is contacted if they need assistance getting dental care/paying for dental care. The DON stated that dental notes are faxed and scanned into the resident's records. Staff #417 said that she believes routine dental care is yearly but in the public setting, they try to go every six months but she does not know what the frequency is that residents needs to be seen. The DON indicated that if a resident needs follow-up services, receptionist will keep a list of needed follow-up and Social Services is involved in coordination and care conferences which the family attends. Dental issues are expected to be brought up during care conferences. She stated that she expects for provider to be notified and an order sent to the Social Services and scheduler to work on getting the resident a dental appointment. There should be a follow-up dentist note. She stated that for the annual there is no tracking system but there is if it is about a follow-up appointment. During the dental exam, dental issues would be addressed. An order is generated for dental. There is a batch order which allows to schedule without needing doctor's orders but if the resident has pain then the provider has to be notified. Staff #417 said that the impact of resident not getting dental services is potential weight loss, infection, and pain. Review of the facility policy titled Personal Care: Dental Services effective January 1, 2024, indicated that routine and emergency dental services are available to meet the resident's oral health in accordance with the resident's assessment and plan of care. Additionally, it noted that social services representatives will assist residents with appointments and transportation arrange

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#50, and #3) to be free from abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken. Findings include: Regarding incident involving residents #50 and 191: -Resident #50 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia, auditory hallucinations, visual hallucinations, anxiety disorder, and disorientation. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's cognitive skills for daily decision making is severely impaired. The MDS also indicated that the resident was negative for indicators of psychosis, behavioral symptoms, and wandering during the assessment period. However, the MDS noted that the resident exhibited rejection of care which occurred 1-3 days during the assessment period. An incident note dated October 6, 2023 documented that according to a CNA (certified nursing assistant), this resident yelled at another resident to be quiet. The other resident then approached this resident, told her nobody tells me what to do and slapped her on the left cheek. The note documented that no visible injuries were noted. The note also indicated that the sheriff's department was contacted and informed family, and indicated that resident would be taken to the hospital. A behavior care plan revised on January 24, 2024 revealed that the resident #50 had behavior problems related to the effects of Alzheimer's dementia as evidenced by poor awareness of needed personal care, combativeness, and verbal outburst during personal care. Interventions included to anticipate and meet needs, assist to minimize disruptive behaviors, if issues arise, remove from situation. A care plan revised April 26, 2024 indicated that the resident #50 had impaired cognitive function related to Alzheimer's dementia with impaired thought processes, difficulty making decisions, short term memory loss that is not anticipated to improve. Interventions included supervision/assistance with all decision making, and keep routine consistent. -Resident #191 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses that included dementia, malignant neoplasm of cerebral meninges, major depressive disorder, and anxiety disorder. A behavior note dated October 5, 2023 indicated documented that the resident was out of the room wandering the halls. The note stated that the resident had been tearful most of the afternoon and upset that her family had dropped her off. Resident was observed to be quickly agitated with loud sounds or voices but was easily redirected. Resident was noted as compliant with medication and care. A behavior note dated October 6, 2023 documented that a CNA (certified nursing assistant) reported that the resident was pacing, going in to another residents' room and yelling at CNA. The CNA indicated that the resident from room [ROOM NUMBER]-1 called out for the resident to be quiet. Resident #191 then went in to room [ROOM NUMBER]-1 yelled at resident to not tell her what to do then slapped her on the face on the left cheek. The note documented that the CNA assisted resident #191 out of the room at which time the resident continued pacing. The note also documented that 911 was called and that the state agency was notified via after hours number. Additionally, the note indicated that the DON (Director of Nursing) and POA (power of attorney), spouse were notified. An additional behavior note also dated October 6, 2023 documented that resident wandered into other residents' rooms. Resident was noted to become easily angered with other residents when asked to leave their rooms or stop standing behind their chairs at meal times. Another behavior note dated October 7, 2023 stated that CNA reported that resident #191 threw a blanket at her roommate and was yelling, calling her names, telling her to get out of her room. The note also documented that resident #191 grabbed roommates' belongings. Roommate was transferred to another room. Review of the facility's final investigation report dated October 9, 2023 indicated that resident #191 was admitted to the behavioral unit on October 4, 2023. The report indicated that on her second night in the facility, resident #191 was pacing the halls and making noise. She had to be redirected by staff a couple of times. Resident #191 was entering other residents' rooms and yelling at the CNA (certified nursing assistant. The report noted that early Friday morning on October 6, 2023, at approximately 5:50 a.m., she was up wandering the hall being loud. Resident #50 was bothered by this noise and shouted from her bed BE QUIET in Spanish. Resident #191 did not like this, so she entered resident #50's room and yelled at her don't tell me what to do and slapped her on her left cheek. According to the report when the CNA observed resident #191 enter the room, she immediately followed and went in and redirected resident #191 back to the room. However, the CNA was not able to get to resident #191 before the slap occurred. The report indicated that the CNA did witness the event. The report noted that both residents were assessed and no injury was sustained by either resident. Further review of the facility's final investigation report revealed interviews of both residents, other residents, and staff members. Neither one of the residents involved could recall the incident. Additional residents interviewed indicated they felt safe at the facility. The CNA (staff #486) interview stated that she tried to redirect and kept resident away from the perpetrator. Staff #486 indicated that following the incident, resident #50 (alleged victim) had shown more emotions and aggression. Additionally, staff #486 noted that resident #191 (alleged perpetrator) and resident #50 (alleged victim) did not recall the event and ignored each other. Review of the admission Minimum Data Set (MDS) assessment for resident #191 dated October 10, 2023 revealed that the resident's cognitive skills for daily decision making was severely impaired. The MDS also noted that the resident exhibited hallucinations for indicators of psychosis. The assessment indicated that the resident exhibited physical and verbal behavior symptoms directed toward others which occurred 4-6 days during the assessment period. The resident also exhibited other behavioral symptoms not directed towards others 4-6 days during the assessment period. The MDS assessment revealed that the resident's identified behavioral symptoms placed the resident and others at significant risk for physical injury. The assessment also indicated that the behavioral symptoms significantly interfered with the resident's care. The behavioral symptoms significantly intruded or the privacy or activity of others and significantly disrupted the care or living environment. A care plan initiated on October 17, 2024 indicated that the resident #191 required special care unit related to continued impaired thought process, and unawareness of own safety needs. Interventions included observe for changes in behavior. A behavioral care plan initiated on October 18, 2023 indicated that the resident #191 had a behavior problem related to impaired cognitive function, impaired safety awareness, physical behaviors, verbal behavior, wandering/exit seeking. Interventions included to anticipate needs, identify behavior triggers, and if issues arise, remove from the situation, intervene as necessary to protect the rights and safety of others. A cognition care plan initiated on October 23, 2023 revealed that the resident #191 has impaired cognitive function/dementia or impaired thought processes related to dementia with behaviors, and diagnoses of brain cancer. During an interview with a Certified Nursing Assistant (CNA/staff #463) conducted on May 23, 2024 at 10:37 a.m., staff #463 noted that she was not familiar with resident #191. However, she stated that she was a little familiar with resident #50. She said that the first few days after resident #50 was admitted , she screamed a lot. However, she stated that she had no knowledge about the altercation between the two residents. An interview was conducted with a Licensed Practical Nurse (LPN/staff #479) on May 23, 2024 at 10:55 a.m. Staff #479 stated that resident #191 had behaviors, was confused a lot, and wandered. The LPN also noted that resident #50 was funny and did not have behaviors. Staff #479 stated that she was not aware of any incidents between these two residents. An interview was conducted with the Social Services Manager (staff #459) on May 23, 2024 at 11:53 a.m. Staff #459 stated that she does not remember which resident slapped who in the incident between residents #50, and #191. Regarding incident involving residents #3 and #190: - Resident # 3 (alleged victim) was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included nonrheumatic aortic stenosis, paroxysmal atrial fibrillation, essential hypertension, type 2 diabetes mellitus, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident #3 was cognitively intact. The MDS also indicated that the resident was negative for indicators of psychosis, behavioral symptoms, rejection of care, and wandering during the assessment period. Review of the care plan did not indicate care planning for behaviors or involvement in any resident-to-resident altercation. A communication note dated June 19, 2023 documented that resident#3 sustained no injury when slapped in the face by former roommate. The note stated that no redness, swelling, or bruising noted. According to the note resident denied pain. The note documented that resident was upset over incident but is stable. The note also indicated that resident understood to keep distance from the other resident going forward. Review of an incident noted dated June 19, 2023 indicated that resident#3 reported being slapped in the face during conversation with another resident. According to the note the resident#3 had gone into the other resident's room to have a conversation regarding allegations of being a liar. The note documented that the other resident became agitated and attempted to leave the room then slapped resident across the face when she did not get out of the way fast enough. A Social Services progress note dated June 19, 2023 stated that it was a late entry from June 14, 2023. The note documented that resident came into office and wanted to discuss issues she was having with roommate. She came in on the 14th but social services was not available. The note indicated that the writer did go to the resident's room and was told resident preferred to discus the next day. Resident came in and discussed issue she was having with roommate. According to the note, resident#3 noted that roommate was calling her a liar and spreading rumors to others. Another incident note dated June 19, 2023 documented that resident #3 was calm without further signs and symptoms of anxiety regarding the resident to resident incident. The note indicated that resident appeared relaxed and went to the dining room for meal and socialization with others. Furthermore, the note stated that there was no complaint of residual pain form incident with the resident stating that I always have some pain but not from this, I'm fine really. A Social Services progress note dated June 20, 2023 indicated another late entry. The note documented that resident#3 is doing well and continued to dine in the dining room for lunch and dinner. The note indicated that the resident still had some sentiment regarding the other resident calling her a liar. The note stated that resident is not approaching the other resident and is being cordial. Resident was requested to discuss with family and friends but not with residents. A nurse practitioner encounter note dated June 21, 2023 documented that resident had a recent altercation with previous roommate. Resident#3 indicated that she was slapped on the face. The indicated that resident had no pain related to the incident. -Resident #190 was admitted to the facility on [DATE] with diagnoses that included hypertensive chronic kidney disease, type 2 diabetes mellitus, dementia, anxiety disorder, and depression. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident #190 was independent for cognitive skills for daily decision making. Additionally, the MDS indicated that the resident was negative for indicators of psychosis, behavioral symptoms, rejection of care, and wandering during the assessment period. Review of the resident's #190 care plan did not reveal any plan of care related to behavior, mood and or resident to resident altercations at the time of the incident. A therapy note dated June 15, 2023 indicated that the resident#190 scored 11/30 on the SLUMS (St. Louis University Mental Status Examination) which indicated that she had moderate cognitive deficits. The note documented that despite maximum education and encouragement on cognitive therapy, resident declined cognition therapy. The note stated that resident was agreeable to dysphagia treatment. According to the note, the resident complained that she was having great difficulties with quality of life with her current roommate. The note stated that the resident prefers to have a quieter environment and is interested in a room change if possible. A Social Services progress note dated June 19, 2023 indicated a late entry documentation. According to the note the resident#190 was still shook up after the incident. The noted indicated that the resident's account of event changed from the initial explanation to the nurse. The note stated that the resident seemed calmer and noted that she would choose another table to eat at for meals. The resident indicated that she would eat lunch in her room that day. The note stated that it was discussed that it was okay for her to call her close friends and discuss the incident versus speaking with other residents to prevent anxiety. The note indicated that the resident agreed. An incident note dated June 19, 2023 documented that resident#190 had resident to resident altercation in her room. The note stated that resident became agitated and attempted to leave room. According to the note, the resident#190 reported that she attempted to get pass the other resident #3 and that she bumped into something with her arm. The note indicated that resident#190 was noted with 2 skin tears, one to left forearm and one to top of left hand with underlying bruising. The note documented that during the conversation with the resident, she was able to demonstrate the proximity of the altercation, possibly injuring her arm and bruising her leg on the foot board of her bed. The note stated that vital signs were stable after incident with slight anxiety regarding the incident. Another incident note dated June 19, 2023 document that resident#190 remained calm but somewhat anxious regarding the incident. The note indicate that the resident stated I never meant to hit anyone, I'm not like that. The note stated that resident denied pain to left arm and that there was no further sign or symptoms of acute bleeding from skin tears. A nurse practitioner note dated June 21, 2023 documented that a report was received indicating that resident#190 had an altercation with her roommate with some physical aggression. The note stated that no injuries were reported. Review of the facility's investigation report dated June 23, 2023 revealed that a resident to resident altercation occurred between residents #3 and 190 on June 19, 2023. According to the report resident #190 was lying in her bed sleeping when she was woken up by resident #3 talking to her in a loud and upset voice. The report noted that resident #3 told resident #190 I want to straighten things out. Resident #190 stated that she did not want to talk to resident #3 so she got out of the bed and attempted to leave the room. However, the report noted that resident #3's wheelchair was blocking resident #190's path. The report stated that resident #190 struggled to get around resident #3's wheelchair and slapped resident #3 on the face and made her way around the wheelchair. The report indicated that resident #3 shared room that the week prior, while the two were still roommates, she heard resident #190 say something derogatory about her. This made resident #3 upset and she confronted resident #190 about it. The report stated that resident #190 responded to the accusation stating you're a liar. The report indicated that in between the time of the incident on June 15 and the incident on June 19, resident #3 agreed to a room change. The investigation report noted that resident #3 stated that she had wheeled herself to resident #190's room to return a book she had borrowed and to confront her and set things straight. According to resident #3, while she was talking to resident #190 about the issue, resident #190 got out of the bed and attempted to leave the room. However, since resident #3's wheelchair was blocking the way, resident #190 slapped resident #3 in the face and scooted around her wheelchair. After resident #190 left the room, resident #3 followed resident #190 out of the room and informed a nurse that resident #190 had slapped her. Further review of the facility investigation report revealed a staff interview with a Care Coordinator (staff #438), who stated that residents were separated and social services involved following the incident. Staff #438 indicated that prior to the altercation the residents involved were passive aggressive towards each other. After the incident, the residents appeared anxious. Additionally, staff #438 noted that the alleged perpetrator and victim exhibited behavior of accusations and confrontations that provoked each other. Additionally, the facility investigation revealed that in an interview with the Resident Relations Assistant (staff #459), she noted that prior to the altercation, the residents involved were not friendly with each other. Following the incident, the residents stayed away from each other. During an interview with a Certified Nursing Assistant (CNA/staff #463) conducted on May 23, 2024 at 10:37 a.m., staff #463 stated that resident #3 was a nice lady but did not remember much, she liked to walk around the facility and could get lost but was easily redirected. The CNA stated that resident #190 was sweet but had memory problems. Staff #463 stated that she did not hear about the two residents having an altercation. The CNA said that they identify a resident is at risk for resident to resident altercation when they start making hostile statements and they get a mean/hostile look on their face. Staff #463 noted that when a resident to resident altercation occurs, they separate the residents and report the incident to the nurse, document what happened, and inform other CNAs. The CNA noted that when a resident to resident altercation occurs, the impact on the resident is that it is stressful for the resident that was abused and it causes a change in the resident's schedule. Staff #463 noted that it is important for them to identify those residents at risk for resident to resident altercation to ensure that they do not put those residents with other residents that are also the same in order to prevent incidents. An interview was conducted with a Licensed Practical Nurse (LPN/staff #479) on May 23, 2024 at 10:55 a.m. Staff #479 stated that she heard about the incident between residents #3 and #190 but was not sure about the details. The LPN noted that they were roommates at one point. Staff #479 stated that they identify residents as at risk for resident to resident altercation based on their behaviors. When a resident to resident altercation occurs, the residents are separated, the DON (Director of Nursing, administrator provider, family, and police are notified, assessments are completed and behaviors documented. Staff #479 noted that the impact on residents when a resident to resident altercation occurs is that the residents can have increased anxiety, they exhibit withdrawal/sadness/negativity/loss of appetite. The LPN stated that it is important to identify those at risk for resident to resident altercation since they are at higher risk for confrontation and therefore have to be watched so that behaviors can be communicated and incident prevented. An interview was conducted with the Social Services Manager (staff #459) on May 23, 2024 at 11:53 a.m. Staff #459 noted that residents #3 and #190 were roommates. She indicated that what she recalled about the incident between the two residents was that resident #190 was saying stuff/spreading rumors in the dining room area and resident #3 heard it and addressed it. Staff #459 said that resident #3 went to resident #190's room by her bed and blocked resident #190. Resident #190 slapped resident #3 resulting in a red mark on her face. Resident #190 hurt herself on the dresser as she was attempting to leave the room. Staff #459 noted that her role during abuse allegations is that she gathers preliminary information and provides it to the Executive Director (E.D.) so that he would know how to proceed. She noted that in instances of abuse, they interview 5 employees and 5 residents. The employees selected for interview are those that worked during the timeframe of the alleged incident and whoever would be knowledgeable about the incident. The residents selected for interview are those that were in the area or were witness to the incident. During an interview with the Director of Nursing (DON/staff #417) conducted on May 23, 2024 at 12:48 p.m., she stated that that her expectation is that staff reports incidents of resident to resident altercations and place interventions in order to prevent further incidents. Staff #417 stated that following a resident to resident altercation, the incident should be reported to the DON and administrator and ensure the safety of both residents and the entire unit. Review of the facility policy titled Abuse Policy version 0622, revealed that the facility strives to prevent the abuse of all their residents. The policy also noted that the resident suspected of being abused will be monitored and placed on alert charting.

Based on documentation, staff interviews, and the facility policy and procedure, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level I for one resident (#24), and failed to submit the PASRR Level II to the state agency. The deficient practice could result in residents not receiving additional services that are needed. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included schizophrenia unspecified, bipolar disorder, and Parkinsonism. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 11 indicating the resident had a moderate cognitive impairment. Review of the PASRR Level I dated June 6, 2023 did not reveal any serious mental illnesses, anti-psychotic medication, or assessment for substantial functional limitations. Due to the form not being completed, it was not submitted to the state agency for a PASRR Level II. Review of the care plan dated June 12, 2023 revealed that the resident uses anti-psychotic medications (Haldol) related to a diagnosis of schizophrenia as evidenced by episodes of verbal agitation and physical aggression. Interventions included to administer medications as ordered and monitor for side effects and/or toxic symptoms. Review of the care plan dated June 27, 2023 revealed that the resident has episodes of impaired cognitive function or impaired thought processes related to schizophrenia-bipolar disorder as evidenced by short term memory loss, and episodes of miscommunication related to hearing impairment. Interventions included to provide the resident with necessary cues, stop and return if the resident is agitated and to engage the resident in simple, structured activities that avoid overly demanding tasks. An interview was conducted on May 21, 2024 at 8:28 a.m. with the Resident Relations Manager (staff #473), who stated that she checks the PASRR Level I and it is updated after 30 days as per the regulation. She reviewed the clinical record and stated that the resident was admitted to long-term care, so the PASRR Level I should have been updated. She also acknowledged that the resident had a diagnoses of schizophrenia and a bipolar disorder, so the PASRR Level II should have been submitted to the state agency. She reviewed documentation with medical records and stated that she did not have a completed PASRR Level I for the resident. An interview was completed on May 22, 2024 at 2:40 p.m. with the Director of Nursing (DON/staff #417), who stated that it is her expectation that the PASRR is reviewed by staff #473 if the resident is going to stay more than 30 days. If the resident has an appropriate diagnoses, staff #473 should submit the PASRR Level I to the state agency. the PASRR Level two agrees that the purpose is to determine that the facility meets the needs of the resident and if additional services are needed. The facility policy, Pre-Admission Screening and Resident Review (PASRR) states that our facility will strive to verify that a Level I PASRR Screening has been conducted, in order to identify serious mental Illness (Ml) and/or an intellectual disability (ID) prior to initial admission of Individuals to the facility. If the resident is positive for potential Ml or ID, a Level II PASRR referral must be submitted. It Is the responsibility of the facility to make referrals for a Level II PASRR, or in some cases, to ensure the referral Is made by the Arizona Long-Term Care (ALTCs) case manager, if a Level II PASRR Is determined to be necessary.

Based on observation, interviews and policy review, the facility failed to ensure that physician's orders was followed regarding one resident's (#31) AV (arteriovenous) fistula. The deficient practice could result in the resident's AV fistula failing. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, hypertensive chronic kidney disease, Parkinsonism, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, and dependence on renal dialysis. Review of the order summary report revealed a physician order dated June 5, 2018 which indicated No Blood pressure or venipuncture to AV fistula site every shift for left arm. A care plan initiated on June 28, 2018 and revised on March 2, 2023 indicated that resident needs dialysis related to end stage renal failure. The goal was that the resident would not have signs and symptoms of complications from dialysis. Interventions included: Do not draw blood or take B/P (blood pressure) in left arm with graft, and check and change dressing daily at access site. However, review of the resident's blood pressure (BP) log over the last six months revealed that it was taken on the left arm on the following dates: - December 11, 2023 - December 18, 2023 - January 1, 2024 - May 13, 2024 Further review of the BP log revealed numerous occasions since the resident was admitted in which her BP was taken on the left arm. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS assessment also noted that the resident receives hemodialysis treatment. The assessment also indicated that the resident is dependent to renal dialysis. An interview with a Certified Nursing Assistant (CNA/staff #510) was conducted on May 22, 2024 at 4:19 p.m. Staff #510 stated that for residents on dialysis, you use the opposite arm to take BP. The CNA said that you do not take the BP on the arm with the fistula. Staff #510 noted that the nurse normally informs CNAs not to take the BP on the same arm as the fistula site. During an interview with a Licensed Practical Nurse (LPN/staff #513) conducted on May 22, 2024 at 4:32 p.m., staff #513 stated that you cannot take vitals on the same site as the fistula. The LPN noted that you want to check for bruit and thrill on the fistula site and do a skin assessment. An observation was conducted on May 23, 2024 at 9:49 a.m. During the observation the CNA (staff #462) accomplished hand hygiene, wiped/disinfected the vitals machine then took resident #31's vitals. Staff #462 explained that the reason she was using resident #31's right arm is due to her having a fistula on the left arm. An interview with the Director of Nursing (DON/staff #417) was conducted on May 23, 2024 at 9:49 a.m. Staff #417 stated that her expectation is that staff will take bp on the arm with the fistula before and after dialysis. The DON noted that she expects for staff to follow physician's orders when caring/treating residents. Staff #417 said that not following physician's orders with regards to not taking bp on the arm with the fistula could damage the fistula. The DON indicated that pre-dialysis vitals are inputted on Point of Care (POC) and includes temperature, pulse, bp, and weight. Staff #417 stated that staff do not have to document which arm they take the bp on since they do not take it on the fistula side. The DON noted that they run with consistent staff and it is communicated to CNAs not to take bp on side with the fistula. In the case of resident #31 if her fistula is on the left then bp should be taken on the right arm. Staff #417 stated that she does not know how the nurse knows that the bp is being taken on the appropriate arm. The facility policy titled End-Stage Renal Disease, Care of a Resident with revised September 2010, stated that residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The policy noted that staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, the care of grafts and fistulas. Furthermore, the policy noted that the resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the facility policy titled Documentation: Charting and Documentation in effect on January 1, 2024, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. Additionally, the policy noted that documentation in the medical record will be objective, complete, and accurate.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#75 , #241) were assessed, monitored and had orders for self-administration of medications and that one resident (#23) was monitored with appropriate level of supervision. The deficient practice could result in residents being injured. Findings include Resident #23 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, hypertensive chronic kidney disease, anxiety disorder, and a major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the the care plan dated September 12, 2023 revealed a behavior care plan related to dementia as evidenced by impaired safety awareness, physical behaviors, resistive to care, verbal behaviors, and wandering/exit seeking. Interventions included to administer medications as ordered, anticipate and meet the resident's needs, and encourage as much participation/interaction as possible during care activities. A behavior progress note dated September 16, 2023 revealed that a resident was restless, wandering/pacing the halls, and exit seeking. The resident was also noted hoarding objects in pockets and was difficult to redirect. A behavior progress note dated September 28, 2023 revealed that the resident was noted wandering into another resident's room this afternoon. The other resident became agitated and insisted that the resident leave. Staff was able to redirect both residents. Staff reported that the resident continues hoarding everyday objects in her purse, closet, and dresser drawers including dirty pull-ups. A progress note dated October 7, 2023 revealed that resident #23 was transferred to another room due to not getting along with her roommate. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A progress note dated October 18, 2023 at 11:47 a.m. revealed that resident #23 continues to wander into other residents' rooms and take their belongings back to her room. Resident #23 took another resident's shoes and put them in her closet, upsetting the resident who looked for her shoes all morning. A progress note dated October 30, 2023 revealed that resident #23 wanders in and out of other residents' rooms and can become agitated and combative with redirection. -Resident #47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbance, adjustment disorder, and major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 6 indicating the resident had a severe cognitive impairment. Review of the the care plan dated February 14, 2023 revealed a behavior care plan related to related to impaired cognition as evidenced by verbal aggression toward staff, rejecting needed care, yelling at staff, and obsessing over particular items. A progress note dated October 11, 2023 revealed that the resident gets easily irritated with other residents and staff, yells out and is often impulsive. A behavior health service provider is present in the facility and advised. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A physician's note dated October 23, 2023 included that resident #47 recently had an altercation with another resident. Both residents were yelling at each other and arguing about clothes. Resident #47 reported that she was slapped by the other resident. The incident was unwitnessed and there were no signs of injuries reported by nursing staff. Review of the facility's five-day written investigation dated October 20, 2023 revealed that on October 16, 2023 at approximately 7:20 p.m., the CNAs in the behavioral unit heard two roommates arguing with each other. They responded to the disturbance and found the residents yelling at each other and arguing over clothes. Resident #23 was topless and going through her roommate's (#47's) closet. The two resident's were close to each other pulling on each other's clothes. The resident's were separated immediately. Resident #47 stated that resident #23 slapped her, but there was witness to the slapping allegation. Both residents' were assessed, and no injuries were found, nor were there any complaints of pain. Review of the facility's five-day written investigation dated October 20, 2023 also included staff interviews: -a licensed practical nurse (LPN/staff #468), who stated that since the incident, resident #47 acts more defensive when anyone gets near her stuff. He also stated that resident #23 wanders into residents' rooms and grabs stuff. -(CNA/staff #425) stated that resident #23 goes into other residents' rooms and gets into their belongings. -(CNA/staff #407) stated that resident #47 gets upset when people bother her belongings. An interview was conducted on May 22, 2024 at 1:49 p.m. with (CNA/staff #425), who stated that resident #23 has a history of going into everybody's rooms and taking things. Resident #23 was going through resident #47's stuff and they got into it. Staff #425 stated that a resident has a right to privacy and she has to always redirect resident's when they are entering another resident's space and resident #47 is possessive of her boundaries and stuff. An interview was conducted on May 22, 2024 at 1:58 p.m. with the Resident Relations Assistant (staff #459), who stated that resident #23 was digging through resident #47's closet and was trying to take it away. She stated that resident#23 has a history of taking other residents' things and staff have reported that resident #23 takes other peoples clothes; staff are supposed to redirect her to another area or activity. Staff #459 stated that a resident has a right to his/her own things, and this includes his/her own personal space. An interview was conducted on May 22, 2024 at 2:29 p.m. with the Director of Nursing (DON/staff #417), who stated that staff are trained on resident rights, which includes the right to privacy. She stated that if one resident has history of taking other peoples' things, it is her expectation that staff redirect the resident when it occurs. This is her plan to protect the other resident's right to privacy, and when monitoring residents who wander, staff should try to keep the resident in a safe environment, and report it to the nurse, so the nurse can assess the resident. 47911 Regarding Resident #241: Resident #241 was admitted on [DATE] with diagnosis including atherosclerotic heart disease of the native coronary artery, chronic atrial fibrillation, essential hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea, hypertensive heart disease with heart failure, pleural effusion, cardiomegaly, atelectasis, cirrhosis of the liver, hypo-osmolarity and hyponatremia, fracture of T7-T8 vertebra, wedge compression fracture of the second lumbar vertebra, diverticulosis, abdominal aortic aneurysm, obstructive and reflux uropathy, type II diabetes, major depressive disorder-recurrent, constipation, and muscle spasms. The admission MDS (minimum data set) was noted to be in progress. A review of the physician orders, revealed no evidence of an order for Orajel or an order for self-administration of medication. A review of the electronic medical record revealed no evidence of an assessment for self-administration of medications. A review of the care plan for resident #241 revealed no evidence of medication self-administration. A review of the progress notes revealed no evidence that the resident had been assessed for self-administration of medication. An observation was conducted on May 20, 2024 at 10:37 A.M. A tube of Orajel was observed at bedside for resident #241. The resident's spouse, who was present at the time of observation, stated that the resident has gum pain and that she had brought the medication from home. She further stated that nursing staff were aware of the medication and had seen it when it was brought in. An observation was conducted on May 20, 2024 at 1:40 P.M. It was observed that Orajel was still on the resident's bedside table in plain view. An observation was conducted on May 21, 2024 at 7:40 A.M. It was observed that Orajel was still on the resident's bedside table. Regarding Resident #75: Resident #75 was admitted on [DATE] with diagnosis including traumatic subdural hemorrhage , traumatic subarachnoid hemorrhage, traumatic hemorrhage of cerebrum, acute transverse myelitis in demyelinating disease of the central nervous system, ataxic gait, hypertension, hyperlipidemia, fibromyalgia, peripheral vascular disease, chronic pain syndrome, urinary incontinence, retention of urine, peripheral vascular angioplasty with implants and grafts, atrial fibrillation, convulsions, seasonal allergic rhinitis, lack of coordination, cognitive communication deficit, weakness, unsteadiness, abnormalities of gait and mobility, mild protein-calorie malnutrition, neuromuscular dysfunction, and displaced bimalleolar fracture of the right lower leg. A review of the MDS dated [DATE] revealed a BIMS (brief interview of mental status) score of 12, suggesting mild cognitive impairment. A review of the physician orders revealed no evidence of an order for Voltaren, Flonase or for self-administration of medication. A review of the care plan for resident #75 revealed no evidence noting self-administration of medication. A review of the progress notes revealed no evidence that the resident had been assessed for self-administration of medication. An observation was conducted on May 20, 2024 at 10:22 A.M. It was observed that Flonase 50mcg and Voltaren 2.32% were on the resident's bedside table. An observation was conducted on May 20, 2024 at 1:41 P.M. It was observed that both medications were still located on the resident's bedside table. An observation was conducted on May 21, 2024 at 7:41 A.M. It was observed that Voltaren was still on the resident's bedside table; however, Flonase was no longer visible. An interview was conducted on May 21, 2024 at 7:48 A.M. with staff #452, CNA (certified nursing assistant). Staff #452 stated a medication is anything what nurses give to patients, including: oral, inhalants, eye drops, intravenous or any over the counter medications. Any medications given to a resident have to be prescribed by the doctor and need to include the amount and frequency of the medication. Staff #452 stated that residents can't have a medication at bedside unless it's prescribed. She stated that the risk of having medications that are not prescribed at bedside can include overdose. An interview was conducted on May21, 2024 at 7:55 A.M. with staff #508, RN (registered nurse). Staff #508 stated medications can include pretty much anything, including creams, ointments, vitamins, and eye drops. Staff # stated that medications are not allowed at bedside unless prescribed and assessed for safety. Staff #508 stated that she checks for medications in resident rooms every day. Staff #508 stated that risk of unauthorized medications at bedside could include other residents accidentally picking up the medication and using it. An interview was conducted on May 21, 2024 at 8:03 A.M. with staff #417, DON (director of nursing). Staff #417 stated that residents are not able to have medications at bedside unless they have been assessed and a physician order for the medication is in place. Staff #417 stated that if medications are brought in by the residents or family, they are removed by nursing staff for safe keeping in a secure place and labeled with the resident's name. Staff #417 stated that the expectation is residents are assessed for ability and safety to self-administer medications and that orders are in place for any medications at bedside. Staff #417 stated that the risk could include duplication of medication and or other confused patients could wander into the room and take-off with it. The facility policy entitled Medications: Self-Administration of Medications dated January 1, 2024 revealed that as part of the evaluation comprehensive assessment, the interdisciplinary team assesses each resident's cognitive and physical abilities to determine whether self-administration of medications is safe and clinically appropriate for the resident. The policy further stated that if a resident is deemed safe and appropriate to self-administer medications, it is documented in the medical record and care plan; however, no evidence of documented assessment was evident in the care plan or the medical record as a whole. The facility policy, Resident Safety: Safety and Supervision of Residents dated January 1, 2024 states that the facility's individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that code status was accurate and consistent in the medical record for one resident, #242. The deficient practice could result in resident not receiving care consistent with their signed advance directive. Findings include: Resident #242 was admitted on [DATE] with diagnosis including hypotension, hypertension, presence of a cardiac pacemaker, major depressive disorder-recurrent, obstructive and reflux uropathy, diverticulitis of large intestine and edema. A review of the MDS (minimum data set) revealed that the admission MDS was still noted to be in progress. A review of the physician orders dated May 15, 2024, revealed that the resident was a full-code, meaning that cardiopulmonary resuscitation and other resuscitation procedures should be used to keep the resident alive. A review of the care plan, dated May 16, 2024, revealed that the resident's advanced directives were in effect. Further stating that the resident's wishes should be carried out in accordance with her advanced directives and to ensure that her wishes are recorded correctly in her chart and follow physician orders. The primary landing page in the resident's electronic health record, at the top of the page, noted the resident to be a full-code. Further review of the electronic health record for resident #242 revealed that the resident had signed for DNR (do not resuscitate) on May 15, 2024. An interview was conducted on May 21, 2024 at 7:48 A.M. with staff #452, CNA (certified nursing assistant). Staff #452 stated that staff are able to locate a resident's code status in the electronic health record. She stated that the code status can be found on the top of the landing page in the electronic health record. Staff #452 pulled up the record for resident #242 and when asked, stated that resident #242 was noted to be a full-code. She stated that the expectation is that information in the record is accurate, and if for some reason it isn't, then it could be a problem for the facility as they would be going against the resident's wishes. An interview was conducted on May 21, 2024 at 7:55 A.M. with staff #508, RN (registered nurse). Staff #508 stated that the advanced directives are generally done by the admitting nurse. She stated that the nurse would review everything on the form with the resident to ensure that the resident understands what they are selecting and signing. Staff #508 stated that if the DNR option was selected, then the resident would sign the orange DNR form, which is then uploaded into the resident's electronic medical record. She stated that if it was necessary to obtain the code a specific resident, staff would first look in the electronic record to determine the code status. She stated that the DNR form is also available in hard copy on the unit, but it's generally a lot quicker to look in the electronic record. Staff #508 pulled up the electronic health record for resident #242 and stated that this resident is a full code. When staff #508 was asked to pull up the actual DNR document, she stated that the resident should actually be a DNR. An interview was conducted on May 21, 2024 at 8:03 A.M. with staff #417, DON (director of nursing). Staff #417 stated that staff will try to get the advanced directives completed on admission, but if the resident is unable to make the decision, then staff will attempt to reach the authorized representative and the resident will be a full code, until the advanced directive or DNR form can be signed. Staff #417 stated that there is a binder on each nurses station where the paper DNR's are housed, additionally the advanced directive/ DNR is noted in the electronic health record at the top of the page. She stated, to ensure the accuracy of the records regarding advanced directives/ DNR's, medical records perform an audit process. Staff #417 pulled up the electronic health record for resident #242 and stated that the resident was a full-code, based on the record and physician orders; however, when asked to review the actually documentation that the resident had signed, she stated that the resident had a DNR in place. Staff #417 stated that her expectation is that the form, orders and entry in the electronic health records match, which she stated they did not for resident #242. She stated that the risk is, if a resident 'coded', staff would likely look in the electronic health record first to initiate the code and if that information is incorrect, then the resident's wishes would not be followed. Staff #417 stated that she would immediately have the orders changed. A review of the facility policy entitled Advanced Directives revised April 2013 revealed that advanced directives will be respected in accordance with state law and facility policy. The policy further indicated that the plan of care for each resident will be consistent with the resident's treatment preferences and or advanced directives.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#47) had the right to privacy. The deficient practice could result in residents being denied their rights and impact psychosocial well-being. Findings include: Resident #47 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbance, adjustment disorder, and major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 6 indicating the resident had a severe cognitive impairment. Review of the care plan dated February 14, 2023 revealed a behavior care plan related to impaired cognition as evidenced by verbal aggression toward staff, rejecting needed care, yelling at staff, and obsessing over particular items. A progress note dated October 11, 2023 revealed that the resident gets easily irritated with other residents and staff, yells out and is often impulsive. A behavior health service provider is present in the facility and advised. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A physician's note dated October 23, 2023 included that resident #47 recently had an altercation with another resident. Both residents were yelling at each other and arguing about clothes. Resident #47 reported that she was slapped by the other resident. The incident was unwitnessed and there were no signs of injuries reported by nursing staff. -Resident #23 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, hypertensive chronic kidney disease, anxiety disorder, and a major depressive disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the the care plan dated September 12, 2023 revealed a behavior care plan related to dementia as evidenced by impaired safety awareness, physical behaviors, resistive to care, verbal behaviors, and wandering/exit seeking. Interventions included to administer medications as ordered, anticipate and meet the resident's needs, and encourage as much participation/interaction as possible during care activities. A behavior progress note dated September 16, 2023 revealed that a resident was restless, wandering/pacing the halls, and exit seeking. The resident was also noted hoarding objects in pockets and was difficult to redirect. A behavior progress note dated September 28, 2023 revealed that the resident was noted wandering into another resident's room this afternoon. The other resident became agitated and insisted that the resident leave. Staff was able to redirect both residents. Staff reported that the resident continues hoarding everyday objects in her purse, closet, and dresser drawers including dirty pull-ups. A progress note dated October 7, 2023 revealed that resident #23 was transferred to another room due to not getting along with her roommate. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A progress note dated October 18, 2023 at 11:47 a.m. revealed that resident #23 continues to wander into other residents' rooms and take their belongings back to her room. Resident #23 took another resident's shoes and put them in her closet, upsetting the resident who looked for her shoes all morning. A progress note dated October 30, 2023 revealed that resident #23 wanders in and out of other residents' rooms and can become agitated and combative with redirection. Review of the facility's five-day written investigation dated October 20, 2023 revealed that on October 16, 2023 at approximately 7:20 p.m., the CNAs in the behavioral unit heard two roommates arguing with each other. They responded to the disturbance and found the residents yelling at each other and arguing over clothes. Resident #23 was topless and going through her roommate's (#47's) closet. The two resident's were close to each other pulling on each other's clothes. The resident's were separated immediately. Resident #47 stated that resident #23 slapped her, but there was witness to the slapping allegation. Both residents' were assessed, and no injuries were found, nor were there any complaints of pain. Review of the facility's five-day written investigation dated October 20, 2023 also included staff interviews: -a licensed practical nurse (LPN/staff #468), who stated that since the incident, resident #47 acts more defensive when anyone gets near her stuff. He also stated that resident #23 wanders into residents' rooms and grabs stuff. -(CNA/staff #425) stated that resident #23 goes into other residents' rooms and gets into their belongings. -(CNA/staff #407) stated that resident #47 gets upset when people bother her belongings. An interview was conducted on May 22, 2024 at 1:49 p.m. with (CNA/staff #425), who stated that resident #23 has a history of going into everybody's rooms and taking things. Resident #23 was going through resident #47's stuff and they got into it. The residents were pulling on the clothing back and forth. Staff #425 stated that a resident has a right to privacy and she has to always redirect resident's when they are entering another resident's space and resident #47 is possessive of her boundaries and stuff. An interview was conducted on May 22, 2024 at 1:58 p.m. with the Resident Relations Assistant (staff #459), who stated that resident #23 was digging through resident #47's closet and was trying to take it away. She stated that resident#23 has a history of taking other residents' things and staff have reported that resident #23 takes other peoples clothes; staff are supposed to redirect her to another area or activity. Staff #459 stated that a resident has a right to his/her own things, and this includes his/her own personal space. An interview was conducted on May 22, 2024 at 2:29 p.m. with the Director of Nursing (DON/staff #417), who stated that staff are trained on resident rights, which includes the right to privacy. She stated that if one resident has history of taking other peoples' things, it is her expectation that staff redirect the resident when it occurs. This is her plan to protect the other resident's right to privacy, and when monitoring residents who wander, staff should try to keep the resident in a safe environment, and report it to the nurse, so the nurse can assess the resident. The facility policy, Resident Rights dated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality.

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#17) was free from sexual abuse from another resident (resident #51). The deficient practice could result in further incidents of resident to resident abuse. Findings Include: -Resident #17 (Alleged victim) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia, depression, anxiety, chronic kidney disease, and type 2 diabetes. A behavioral care plan with a start date of August 29, 2023 revealed resident #17 has impaired cognitive function, impaired decision-making related to Alzheimer's dementia with noted interventions of resident needing approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, instructions, and to keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident has major cognitive impairment. -Resident #51 (Alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, anxiety, hypertension, type-2 diabetes, and hyperlipidemia. A behavioral care plan with a start date of January 5, 2023 revealed resident #51 was at risk for behavior problems related to end stage dementia, as evidenced by verbal aggression towards staff and groping female residents without their consent, with noted interventions of identifying behavioral triggers, and keep the resident at arm's length from other female residents. Review of the facilities Reportable Event Record revealed that on the afternoon of April 1, 2024, resident #17 was seated in a day room where the resident's watch TV when a Certified nursing assistant (CNA/staff #119) entered and observed resident #51 with his hand down resident #17's shirt, appearing to be touching her breast. The CNA (CNA/staff #119) removed resident's #51 hand from resident #17's shirt, which made resident #51 upset and visibly agitated towards the CNA (CNA/staff #119). An interview was conducted with a CNA (CNA/staff #119) on April 9, 2024, at 11:06 a.m., Staff #117 stated that on the day of the incident they were working as a med tech and was passing medications when they observed resident #51 rubbing the shoulders of resident #17, and had his hand in her shirt. The CNA further stated that the resident can be physical too, and likes to grab at staff members also. In an interview conducted with the Director of Nursing (DON/staff #200) on April 9, 2024 at 2:30 p.m. The DON stated that resident #51 has lots of behaviors, verbally sexually suggestive among others. The DON also stated that the care plan states not to allow the resident within arms reach of female residents. The DON also stated that her expectation is that the staff separate the resident's immediately which they did and report it to management. Review of the facility's policy titled 'Resident rights/dignity: Abuse, Neglect, exploitation or misappropriation dated 2022 revealed the objective of the facility is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse.

Based on personnel file review, staff interviews, and facility policy, the facility failed to ensure that two of two sampled Certified Nursing Assistants (CNA/staff #100 and #91) were able to demonstrate competencies and skills necessary to provide care for residents. The census was 80. The deficient practice could result in inadequate care for residents. Findings include: Review of a personnel file for a CNA (staff #100) revealed a hire date of 05/14/03, for hourly employment. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies for 2022. Review of a personnel file for CNA/staff #91 revealed a hire date of 08/12/20, for hourly employment. The personnel record contained no evidence of a comprehensive evaluation for nursing skills and competencies for 2022. On 01/11/23 at 12:52 p.m. an interview was conducted with the Staffing Coordinator (staff #1). She stated that staff are evaluated for skills upon hire. She stated that she was not sure how often CNAs are re-evaluated. She stated that Human Resources sends reports to department heads and that the department heads were responsible to ensure that staff completes training and is up to date. An interview was conducted on 01/11/23 at 3:30 p.m. with the Clinical Resource Nurse (staff #117) and the Human Resource Director (staff #61). They stated that there had been no skills training for staff in 2022. On 01/12/23 at 1:05 p.m. a follow-up interview was conducted with the Human Resource Director (staff #61). She stated that skills evaluations and training was missed in 2022 due to the impending transition [acquisition] by the new owners. She stated that staff competencies should be evaluated yearly and as needed. An interview was conducted on 01/13/23 at 10:08 a.m. with the Director of Nursing (DON/staff #41). She stated that CNAs should receive skills training annually. She stated that the training was scheduled, but canceled. She stated that skills training was important to ensure staff competency to meet the needs of the residents. The Employment Requirements/Verification of Skills policy, revised 1/18, included that an employee shall possess the specific skills and knowledge necessary to provide residents residing in the facility with the type of care and services necessary to support and respect each resident ' s individuality, choices, strengths and abilities.

Based on review of the clinical record , staff interviews and review of the facility policy, the facility failed to ensure the pharmacist identified adequate monitoring for the use of medications in the pharmacy review for 5 residents (#32,#14,#37, #41 and #25). The deficient practice could allow for medication side effects and adverse consequences to go unadressed. Findings include: Regarding Resident #14- Resident #14 was admitted [DATE] with diagnoses to include the primary diagnosis of Covid 19 and other diagnoses of schizoaffective disorder bipolar type, bipolar II disorder, generalized anxiety disorder, major depressive disorder and dementia with other behavior disturbance. In the care plan initiated March 14, 2019, a focus area revealed that the resident had a behavior problem and interventions included to administer medications as ordered and to monitor for effectiveness and side effects. The care plan further revealed that the resident received antidepressant medication and psychotropic medication and side effects and medication effectiveness were to be monitored and documented every shift. The minimum data set ( MDS) dated [DATE] revealed that the resident scored a 5 on the brief interview for mental status (BIMS) indicating severe cognitive impairment. Review of the active orders revealed the following: - 12/22/2022 Olanzapine 5 mg.( milligrams) 1.5 tablets at bedtime for schizoaffective disorder. -12/19/2022 Divalproex Sodium delayed release 125 mg- give 250 mg by mouth two times a day for schizoaffective disorder and mood stability - 12/02/ 2022 Sertraline HCL 100 mg tablet in the morning for depression -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found. No evidence of pharmacy recommendations monitoring were found in the clinical record. Review of the December 2022 and January 2023 medication administration record (MAR) and treatment administration record (TAR) revealed that the medications were given as ordered. No evidence of monitoring for effectiveness or side effects were found. - Regarding Resident #31 Resident #31 was admitted [DATE] with diagnoses to include recurrent depressive disorder and chronic pain syndrome. Review of the residents care plan initiated on May 9, 2022 revealed the the resident had a behavior problem as evidenced by verbal aggression. An intervention for this issue was to monitor for behaviors and attempt to determine the underlying cause. This information was to be documented. The care plan further revealed that the resident was prescribed anti depressant medication and the interventions included that changes in mood and behavior were to be documented. The resident also received an anti anxiety medication that included an intervention of monitoring of side effects and effectiveness. The resident scored a 6 revealing severe cognitive impairment on the brief interview for mental status(BIMS) on the Quarterly minimum data set (MDS) dated [DATE]. 2022. Review of the active orders revealed the following: - 10/5/2022 Mirtazipine Tablet 15 mg(milligrams) at bedtime for depression - 4/5/2022 Cymbalta 30 mg in the morning for depression, 8/15/2022 60 mg at bedtime for chronic pain - 5/2/2022 Lorazapam 0.5 mg every 2 hours as needed for agitation -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found. No evidence was found of pharmacy recommendations for monitoring of side effects or effectiveness in the clinical record. Review of the November, December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed the the medications were given as ordered. No evidence of monitoring for effectiveness and side effects were found. - Regarding Resident #37 Resident#37 was admitted [DATE] with diagnoses to include recurrent major depressive disorder and primary insomnia. Review of the residents care plan initiated on March 22, 2021 revealed that the resident used an antidepressant medication related to insomnia and depression. The listed interventions included monitor and document side effects and effectiveness every shift. The quarterly Minimum Data Set, dated dated dated [DATE] revealed that the resident scored 15 on the brief interview for mental status ( BIMS) indicating that the resident was cognitively intact. Review of the active orders revealed : - 12/29/2022 Remeron 7.5 mg. ( milligrams) by mouth at bedtime for depression. -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found Review of the October, November, December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed the the medications were given as ordered. No evidence of monitoring for effectiveness or side effects were found. An interview was conducted with the facility medical director( staff #120) on January 13, 2023 at 11:21 am. He stated that he had been medical director for many years and had worked closely with staff. He stated that it was most important to monitor a resident when the resident first starts a new medication. He stated that as far as psychotropic's, things have changed over time. At this time, residents are monitored but residents were monitored more frequently previously. Staff #120 stated that if a resident is stable on a psychotropic medication it may be less critical to monitor every shift than to monitor someone displaying behaviors. Resident's psychotropic's are addressed and reviewed in the quarterly QAPI meetings. He stated that the staff were expected at convey any changes to him as well as what he observes himself during his visits. He stated that residents needs do change as they age and he was available for assessments as needed and he also works with attending physicians and pharmacists as needed. Staff #120 stated if there is a regulation requirement to document the monitoring, those changes can be made, as the facility makes an attempt to do things correctly and to meet the regulations. At 11:53 AM on January 13, 2023 an interview was conducted with pharmacist ( staff #118), Head pharmacist ( staff #119) and the director of nursing (DON / staff #41) -Staff #118 stated that as far as side effects or behavior monitoring the staff mainly rely on the the resident self reports They do also look at the residents clinical record and will look at the resident as a whole person. Staff # 119 stated that per regulations, monitoring is not required to be on a set schedule. He further stated that it was not a requirement to monitor for behaviors on a resident that receives an anti-depressant. Staff #119 stated that they, as pharmacists do not make recommendations to nursing. 46563 Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure five out of five residents (#32, #41, #14, #37, and #25) receiving psychotropic medications received consistent monitoring for behaviors and side effects. The facility census was 80. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: Resident #41 admitted to the facility on [DATE] with diagnoses including COVID 19, Alzheimer's disease with late onset, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 06 on the Brief Interview for Mental Status (BIMS) assessment, indicating lack of cognition. A review physician order: Lexapro tablet 10 mg, give 1 tablet by mouth for depression ordered on 10/13/21 Lorazepam tablet 0.5mg, give 2 tablets by mouth every 4 hours as needed for anxiety for the duration of hospice. Ordered on 10/7/22. Olanzapine tablet 5mg, give 1 tablet by mouth in the evening for dementia with behaviors. Ordered on 9/7/22. Quetiapine furmarate tablet 50mg, give 1 tablet by mouth two times a say for dementia with behaviors/agitation. Ordered on 11/9/22. Trazadone HCI tablet 50mg, give 0.5 tablet by mouth two times a day for anxiety, agitation, insomnia. Ordered on 12/23/21. A review of care plan initiated on 2/14/22 revealed the following: focus: risk for signs and symptoms of adverse behaviors such as yelling out, crying, agitation, restlessness, exit seeking, and hallucinations associated with diagnosis of dementia. Goal: will demonstrate acceptance of needed help without aggressive outburst. Intervention: administer medications as ordered. Monitor and document for side effects and effectiveness. A review of care plan initiated 10/29/19 revealed the following: focus: is at risk for signs and symptoms of adverse effects of medication due to antidepressant use. Goal: will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions: administer antidepressant medications as ordered by physician. Monitor and document side effects and effectiveness q-shift. Monitor/document/report PRN adverse reactions to antidepressant therapy. A review of care plan initiated on 1/14/22 revealed the following: focus: risk for sign and symptoms of adverse effects of medication due to use of psychotropic medications for management of dementia and depression. Goal: will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Resident will reduce the uses of psychotropic medication. Intervention: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift. Consult with pharmacy MD to consider dosage reduction when clinically appropriate at least quarterly. Monitor, document, report prn any adverse reactions of psychotropic medications. Review of the October, November, and December 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as well as adverse reactions. On 01/11/23 at 8:41 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #6). She stated that adverse side effects and behaviors will show up on the electronic MAR (eMAR). She stated that would also document in the resident ' s progress notes. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that behavior monitoring should pop up on either the MAR or the Treatment Administration Record (TAR). She stated that she would want it to pop up so that she would be able to monitor whether or not the behaviors were new or unusual, and/or whether the medication was working. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that the risks of not monitoring behaviors would include that the resident may receive unnecessary medication. An interview was conducted on 01/11/23 at 1:10 p.m. with the Director of Nursing (DON/staff #41). She stated that monitoring for psychotropic medications would include adverse side effects, AIMS and behaviors. She reviewed the resident ' s record and stated that there was no side effect monitoring. She stated that behaviors are documented under the Certified Nursing Assistant (CNA) tasks. She stated that the CNA ' s monitored the resident for behaviors including grabbing, hitting, kicking and pushing. Resident #25 admitted to the facility on [DATE] with diagnoses including hyperlipidemia, hypothyroidism, and lower back pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS) assessment, indicating appropriate cognition. Physician orders: Escitalopram oxalate tablet 10mg, give 1 tablet by mouth in the morning for anxiety/agitation. Ordered on 3/18/22. Lorazepam tablet 0.5mg, give 1 tablet by mouth every 6 hours as needed for agitation for duration of hospice. Ordered on 10/7/22. Lorazepam 1 tablet 1mg, give 1 tablet by mouth at bedtime for anxiety. Ordered on 11/12/22. Quetiapine fumarate tablet 50mg, give 1 tablet by mouth three times a day for behaviors. Ordered on 3/18/22. A review of care plan initiated on 4/8/22: focus: uses psychotropic medications due to dementia with hallucinations. Goal: will remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Interventions: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift. Review behaviors and interventions and alternate therapies attempted and their effectiveness. Monitor, document, and report PRN any adverse reactions of psychotropic medications. Review of the October, November, and December 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as well as adverse reactions.

Based on clinical record review, resident and staff interviews, and policy, the facility failed to ensure that one resident (#54) was assisted in obtaining routine dental care. The sample size was 20. The deficient practice could result in residents ' dental needs not being met. Findings include: Resident #54 admitted to the facility 07/06/21 with diagnoses that included Alzheimer ' s disease with late onset, dementia in other diseases classified elsewhere, without behavioral, psychotic, or mood disturbance and major depressive disorder, recurrent, in remission. Review of the Admission Nursing Review dated 07/06/21 revealed the resident had no missing, broken, obvious or likely cavity or broken natural teeth. An activities of daily living self-care performance deficit care plan dated 08/03/21 related to dementia with behaviors had a goal to maintain current level of function. Interventions included supervision/limited assistance with personal hygiene and oral care. A physician ' s order dated 12/09/21 included acetaminophen (analgesic) 500 milligrams (mg). Give 500 mg every 6 hours as needed for pain of 1-5 on a pain scale; give 1000 mg for pain of 6-10. However, additional review of the physician ' s orders did not indicate that a referral for routine dental care had been ordered and/or was being performed. Review of the September 2022 Medication Administration Record (MAR) revealed acetaminophen was administered per orders for pain levels ranging from 4 to 7. However, a review of electronic MAR (eMAR) notes did not indicate the location of her pain. Further review of the pain scales revealed a general pain level of 0. A physician ' s order dated 10/13/22 included acetaminophen 325 mg. Give 2 tablets two times a day for generalized pain. Review of the October 2022 MAR revealed acetaminophen was administered in accordance with physician ' s orders. The pain scales indicated that the resident ' s pain was generally 0. Review of the as needed (PRN) administration of acetaminophen included pain levels of 3-6. A Pain Evaluation was conducted on 11/08/22 at 1:23 p.m. According to the evaluation, the resident was able to interview and that she reported rarely experiencing pain over the past 5 days. The November 2022 MAR included twice daily administration of acetaminophen per physician ' s orders. The pain scales revealed a general pain level of 0. PRN acetaminophen was administered on 11/24/22 for a pain level of 7. The December 2022 MAR revealed acetaminophen was administered twice daily for generalized pain. Pain scales included a general pain level of 0, and PRN acetaminophen was not administered. On 01/09/23 at 11:01 a.m. an interview was conducted with the resident ' s representative. The representative expressed concern regarding the resident ' s dental issues, including missing caps in front, and the need for her to see a dentist. A physician progress note dated 01/09/23 at 1:12 p.m. included that upon the visit, the resident reported feeling so so. The note indicated that the resident appeared calm and pleasant, and that she was observed to have poor dentition. On 01/11/23 at 8:06 a.m. an observation of the resident was conducted. The resident was noted to have black/brown broken remnants and missing teeth. She was observed to display a nearly continuous sucking motion with her mouth when not speaking. At 8:06 a.m. on 01/11/23 an interview was conducted with the resident with a Spanish-speaking interpreter/Certified Nursing Assistant (CNA/staff #82). Staff #82 stated that the resident was very hard of hearing and that she read lips. She stated that she communicates with the resident by coming close to her face so the resident can see her lips and by speaking loudly. The resident stated her teeth hurt a lot. On 01/12/23 at 11:37 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #97). She stated that the resident shows her where her pain is. She stated that she will ask the resident what her pain level is and the resident usually states 3 or 4. She stated that otherwise, she will observe the resident ' s appearance. She stated that she asks how bad the pain is, but that the resident does not always provide a number. She stated that the resident primarily complains of pain in her ear. She stated that acetaminophen has been ordered for scheduled administration. She stated that administration of the medication is preventative. She stated that she visually assesses the resident ' s pain using the Pain Assessment in Advanced Dementia Scale (PAINAD) and that she does not always ask her what her pain level is. At 11:43 a.m. on 01/12/23 with the assistance of an interpreter, the resident was asked what her pain level was. The resident stated that on a scale of 1-10, her pain was a 10. She stated that sometimes some of her teeth hurt, other times they all hurt. She stated that her pain was great. She stated that she would like to see a dentist so that she can feel better. An interview was conducted on 01/12/23 at 1:58 p.m. with the Director of Nursing (DON/staff #41). She stated that the resident did not complain of pain. She stated that the resident did not indicate that her teeth hurt. She stated that the resident is able to communicate when she has pain. She stated that the resident did not complain of tooth pain. On 01/13/23 at 8:59 a.m. an interview was conducted with the Director of Social Services (staff #54). She stated that the unit secretary schedules appointments. She stated that if mobile specialists were coming into the facility, and the nurse makes her aware, she will make sure the resident gets an appointment. She stated that ultimately, she was responsible to ensure that residents are getting annual hearing, dental and vision appointments. She stated that if an emergent situation were to arise, she would also arrange an appointment as needed. She stated that if the residents were not getting their appointments it would be because either she had not set one up or the resident had refused. She stated that the lack of dental services had been an error on her part. The Dental Services policy, revised December 2016, included that routine and emergency dental services are available to meet the resident ' s oral health services in accordance with the resident ' s assessment and plan of care. Routine and 24-hour emergency dental services are provided to residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident ' s personal dentist, referral to community dentists and referral to other healthcare organizations that provide dental services. Social services representatives will assist residents with their appointments, transportation agreements, and for reimbursement of dental services under the state plan, if eligible. All dental services provided are recorded in the resident ' s medical record.

Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure five out of five residents (#32, #41, #14, #37, and #25) receiving psychotropic medications received consistent monitoring for behaviors and side effects. The facility census was 80. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: -Resident #32 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and post traumatic seizures. An Abnormal Involuntary Movement Scale (AIMS) dated 11/17/22 revealed a score of Not Applicable (NA). The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The resident reported no feelings of depression, and he displayed no symptoms of psychosis or behaviors. A physician ' s order dated 11/30/22 revealed quetiapine fumarate (antipsychotic) 25 mg (milligrams): give one tablet at bedtime for traumatic brain injury (TBI). No specific target behaviors related to TBI were identified in the order. Review of the November 30 through December 6, 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. A psychotropic medication care plan dated 12/06/22 related to TBI had a goal for the resident to be/remain free from psychotropic drug-related complications. Interventions included to administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as evidenced by decreased episodes of target behaviors had been completed. Another physician ' s order dated 12/12/22 included fluoxetine HCl (antidepressant) 20mg: give one capsule by mouth in the morning for depression. Review of the December 2022 MAR revealed the resident received psychotropic medications in accordance with the physician ' s orders. However, review of the clinical record did not indicate monitoring for side effects or effectiveness of the medication as evidenced by decreased episodes of target behaviors had been completed. On 01/11/23 at 8:41 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #6). She stated that adverse side effects and behaviors will show up on the electronic MAR (eMAR). She stated that would also document in the resident ' s progress notes. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that behavior monitoring should pop up on either the MAR or the Treatment Administration Record (TAR). She stated that she would want it to pop up so that she would be able to monitor whether or not the behaviors were new or unusual, and/or whether the medication was working. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that the risks of not monitoring behaviors would include that the resident may receive unnecessary medication. She reviewed the resident ' s record and stated that adverse side effects were not being monitored. She stated that the risks of not monitoring for adverse side effects might include falls, risks to self or others, or that nursing may not be aware of adverse effects. An interview was conducted on 01/11/23 at 1:10 p.m. with the Director of Nursing (DON/staff #41). She stated that monitoring for psychotropic medications would include adverse side effects, AIMS and behaviors. She reviewed the resident ' s record and stated that there was no side effect monitoring. She stated that behaviors are documented under the Certified Nursing Assistant (CNA) tasks. She stated that the CNA ' s monitored the resident for behaviors including grabbing, hitting, kicking and pushing. She stated that the resident was receiving an antipsychotic for TBI. She stated that the provider had documented that the resident was receiving the antipsychotic for insomnia related to the TBI in one of her notes. She stated that the resident was not being monitored for insomnia/hours of sleep. She stated that the resident was receiving fluoxetine for depression, but that they had never monitored for depression. 42998 - Regarding Resident # 14- Resident #14 was admitted [DATE] with diagnoses to include the primary diagnosis of Covid 19 and other diagnoses of schizoaffective disorder bipolar type, bipolar II disorder, generalized anxiety disorder, major depressive disorder and dementia with other behavior disturbance. In the care plan initiated March 14, 2019, a focus area revealed that the resident had a behavior problem and interventions included to administer medications as ordered and to monitor for effectiveness and side effects. The care plan further revealed that the resident received antidepressant medication and psychotropic medication and side effects and medication effectiveness were to be monitored and documented every shift. The minimum data set ( MDS) dated [DATE] revealed that the resident scored a 5 on the brief interview for mental status (BIMS) indicating severe cognitive impairment. Review of the active orders revealed the following: - 12/22/2022 Olanzapine 5 mg.( milligrams) 1.5 tablets at bedtime for schizoaffective disorder. -12/19/2022 Divalproex Sodium delayed release 125 mg- give 250 mg by mouth two times a day for schizoaffective disorder and mood stability - 12/02/ 2022 Sertraline HCL 100 mg tablet in the morning for depression -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found. Review of the December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed that the medications were given as ordered. No evidence of monitoring for effectiveness or side effects were found. - Regarding Resident #31 Resident #31 was admitted [DATE] with diagnoses to include recurrent depressive disorder and chronic pain syndrome. Review of the residents care plan initiated on May 9, 2022 revealed the the resident had a behavior problem as evidenced by verbal aggression. An intervention for this issue was to monitor for behaviors and attempt to determine the underlying cause. This information was to be documented. The care plan further revealed that the resident was prescribed anti depressant medication and the interventions included that changes in mood and behavior were to be documented. The resident also received an anti anxiety medication that included an intervention of monitoring of side effects and effectiveness. The resident scored a 6 revealing severe cognitive impairment on the brief interview for mental status(BIMS) on the Quarterly minimum data set (MDS) dated [DATE]. 2022. Review of the active orders revealed the following: - 10/5/2022 Mirtazipine Tablet 15 mg(milligrams) at bedtime for depression - 4/5/2022 Cymbalta 30 mg in the morning for depression, 8/15/2022 60 mg at bedtime for chronic pain - 5/2/2022 Lorazapam 0.5 mg every 2 hours as needed for agitation -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found. Review of the November, December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed the the medications were given as ordered. No evidence of monitoring for effectiveness and side effects were found. - Regarding Resident #37 Resident#37 was admitted [DATE] with diagnoses to include recurrent major depressive disorder and primary insomnia. Review of the residents care plan initiated on March 22, 2021 revealed that the resident used an antidepressant medication related to insomnia and depression. The listed interventions included monitor and document side effects and effectiveness every shift. The quarterly Minimum Data Set, dated dated dated [DATE] revealed that the resident scored 15 on the brief interview for mental status ( BIMS) indicating that the resident was cognitively intact. Review of the active orders revealed : - 12/29/2022 Remeron 7.5 mg. ( milligrams) by mouth at bedtime for depression. -No evidence of orders for monitoring for side effects or effectiveness of these drugs were found Review of the October, November, December 2022 and January 2023 medication administration record ( MAR) and treatment administration record (TAR) revealed the the medications were given as ordered. No evidence of monitoring for effectiveness or side effects were found. An interview was conducted with certified nursing assistant ( CNA/ staff #94) on January 11, 2023 at 2:03 pm. She stated that the CNAs will chart in the CNA charting and make the nurses aware of any behavior concerns so it can de documented in a progress note. She stated that all the residents in the secured unit are monitored for behaviors related to their diagnoses but the monitoring is not related to medications. An interview with the director of nursing (DON/ staff #41) was conducted on January 11, 2023 at 2:10 pm. She stated that the facility does not monitor and has never monitored routine psychotropic's. She stated that the physicians do their own monitoring. 46563 Based on clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure five out of five residents (#32, #41, #14, #37, and #25) receiving psychotropic medications received consistent monitoring for behaviors and side effects. The facility census was 80. The deficient practice could result in unnecessary medication use and adverse side effects. Findings include: Resident #41 admitted to the facility on [DATE] with diagnoses including COVID 19, Alzheimer's disease with late onset, and dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 06 on the Brief Interview for Mental Status (BIMS) assessment, indicating lack of cognition. A review physician order: Lexapro tablet 10 mg, give 1 tablet by mouth for depression ordered on 10/13/21 Lorazepam tablet 0.5mg, give 2 tablets by mouth every 4 hours as needed for anxiety for the duration of hospice. Ordered on 10/7/22. Olanzapine tablet 5mg, give 1 tablet by mouth in the evening for dementia with behaviors. Ordered on 9/7/22. Quetiapine furmarate tablet 50mg, give 1 tablet by mouth two times a say for dementia with behaviors/agitation. Ordered on 11/9/22. Trazadone HCI tablet 50mg, give 0.5 tablet by mouth two times a day for anxiety, agitation, insomnia. Ordered on 12/23/21. A review of care plan initiated on 2/14/22 revealed the following: focus: risk for signs and symptoms of adverse behaviors such as yelling out, crying, agitation, restlessness, exit seeking, and hallucinations associated with diagnosis of dementia. Goal: will demonstrate acceptance of needed help without aggressive outburst. Intervention: administer medications as ordered. Monitor and document for side effects and effectiveness. A review of care plan initiated 10/29/19 revealed the following: focus: is at risk for signs and symptoms of adverse effects of medication due to antidepressant use. Goal: will be free from discomfort or adverse reactions related to antidepressant therapy. Interventions: administer antidepressant medications as ordered by physician. Monitor and document side effects and effectiveness q-shift. Monitor/document/report PRN adverse reactions to antidepressant therapy. A review of care plan initiated on 1/14/22 revealed the following: focus: risk for sign and symptoms of adverse effects of medication due to use of psychotropic medications for management of dementia and depression. Goal: will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Resident will reduce the uses of psychotropic medication. Intervention: Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift. Consult with pharmacy MD to consider dosage reduction when clinically appropriate at least quarterly. Monitor, document, report prn any adverse reactions of psychotropic medications. Review of the October, November, and December 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as well as adverse reactions. On 01/11/23 at 8:41 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #6). She stated that adverse side effects and behaviors will show up on the electronic MAR (eMAR). She stated that would also document in the resident ' s progress notes. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that behavior monitoring should pop up on either the MAR or the Treatment Administration Record (TAR). She stated that she would want it to pop up so that she would be able to monitor whether or not the behaviors were new or unusual, and/or whether the medication was working. She reviewed the resident ' s orders and stated that she did not see behavior monitoring. She stated that the risks of not monitoring behaviors would include that the resident may receive unnecessary medication. An interview was conducted on 01/11/23 at 1:10 p.m. with the Director of Nursing (DON/staff #41). She stated that monitoring for psychotropic medications would include adverse side effects, AIMS and behaviors. She reviewed the resident ' s record and stated that there was no side effect monitoring. She stated that behaviors are documented under the Certified Nursing Assistant (CNA) tasks. She stated that the CNA ' s monitored the resident for behaviors including grabbing, hitting, kicking and pushing. Resident #25 admitted to the facility on [DATE] with diagnoses including hyperlipidemia, hypothyroidism, and lower back pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS) assessment, indicating appropriate cognition. Physician orders: Escitalopram oxalate tablet 10mg, give 1 tablet by mouth in the morning for anxiety/agitation. Ordered on 3/18/22. Lorazepam tablet 0.5mg, give 1 tablet by mouth every 6 hours as needed for agitation for duration of hospice. Ordered on 10/7/22. Lorazepam 1 tablet 1mg, give 1 tablet by mouth at bedtime for anxiety. Ordered on 11/12/22. Quetiapine fumarate tablet 50mg, give 1 tablet by mouth three times a day for behaviors. Ordered on 3/18/22. A review of care plan initiated on 4/8/22: focus: uses psychotropic medications due to dementia with hallucinations. Goal: will remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment. Interventions: administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness q-shift. Review behaviors and interventions and alternate therapies attempted and their effectiveness. Monitor, document, and report PRN any adverse reactions of psychotropic medications. Review of the October, November, and December 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. However, the clinical record did not include evidence of monitoring for side effects or effectiveness of the medication as well as adverse reactions.

Based on observations, staff interviews, and policy review, the facility failed to ensure their system of medication records is complete to enable accurate reconciliation and accounting for all controlled medications. The deficient practice could result in misappropriation of residents' medications. Findings Include: -Prior to medication pass observation conducted on January 11, 2023 at 8:26 a.m. with a licensed nurse (LPN/ staff #47), she was observed handed medication cards wrapped in the reconciliation sheets to the assistant director of nursing (ADON/staff #109). Staff #109 walked away with medication cards in her hands to another unit. Following this observation, an interview was conducted with staff #47 on January 11, 2023 at 8:50 a.m. Staff #47 stated the medications that was given to staff #109 are narcotic medications of the residents that have been discharged or have their orders discontinued. Staff #47 stated that staff # 109 or the director of nursing (DON/ staff #41) picks up the discontinued controlled medications once a week or whenever they have a chance. Staff #47 stated she did not know where the discontinued narcotic drugs are stored, or where it goes. An interview was conducted on January 11, 2023 at 9:00 a.m. with the DON (staff #41). The DON stated the process for the discontinued narcotic drugs included placing the narcotic drugs in a double locked safe in her office. During the narcotic medication destruction, the medications were placed in the red sharps container, then a bottle of Metamucil and water is added. She stated the red sharp container is placed in the red bag, then in the biohazard container. A second interview was conducted on January 11. 2023 at 10:58 a.m. with staff #41. She stated the process when narcotic medications are discontinued included the licensed nurse handing her the medications. Staff #41 stated she does not sign any document that she received the discontinued medications, and that she did not have a process, the nurses just hands it to her and she takes it. Further, staff #41 stated how she ensure the discontinued narcotic medications taken from the cart was given to her is that she trusts her staff and that she has been doing this job for a long time. Staff #41 stated she does not sign for the discontinued narcotic drugs given to her, and that she trusts her staff. On January 11, 2023 at 11:24 a.m., a joint review of the individual resident's-controlled substance record was conducted with the Federal Surveyor. The record review revealed that 14 of 65 sampled documents were incomplete. An interview was conducted on January 12, 2023 at 7:34 a.m. with staff #47. She stated the process when narcotic drugs are delivered from the pharmacy included an electronic signature and a paper signature that serves as the courier's receipts. She stated the narcotic medications is placed in the narcotic cart, then the new narcotic is added in the narcotic proof of use count sheet, indicated with a plus sign. She stated if a narcotic medication is discontinued, she would remove the medication card and individual narcotic sheet and give it to the ADON (staff #109) for destruction. She stated the narcotic proof of use sheet is marked with a minus sign indicating the card was removed. She stated she cannot determine by looking at the record with a minus mark, whether the resident went home with the medications, or was given to the ADON for destruction because there was no signature who took the narcotics. Staff #47 reviewed the form and stated the form was incomplete. She stated it could put her nursing license in jeopardy because she has no way of knowing by looking at the record who took the narcotics. She reviewed the form and said the columns marked destroyed or transferred were left blanks therefore the form was incomplete. Review of the facility form, Narcotic Proof of Use Count Sheet, dated December 13 through 31, 2022 revealed eight narcotic cards were removed from the narcotic cart. Further record review revealed that on January 1 through 5, 2023, three narcotic cards were removed from the narcotic cart. However, there was no signature to determine who took the discontinued narcotic medications, and the columns on the form indicating the drug disposition (completed, destruction, transferred) were left blanks. An interview was conducted with a registered nurse consultant (RN/staff #117) on January 12, 2023 at 2:11 p.m. Staff #117 reviewed the sampled form, Narcotic Proof of Use Count Sheet. After staff #117 completed the record review, she stated the chain of custody has insufficient details regarding the drug disposition. Review of the facility policy, Disposal of Medications, dated 2007, stated discontinued medications and/or medications left in the in the nursing care center after a resident's discharge, which do not qualify for return to the pharmacy, are identified and removed from current medication supply in a timely manner for disposition. The policy stated medications included in the Drug Enforcement Administration (DEA) classification as controlled substances (or those classified as such by state regulation) are subject to special handling, storage, and record keeping in the nursing care center in accordance with federal and state laws. The policy included that if a controlled medication is unused, refused, by the resident or not given for any reason, it cannot be returned to the container; it is destroyed, and a controlled medication disposition log or equivalent form, shall be used for documentation and shall be retained as per Federal privacy and state regulations. The policy stated the log shall contain signature of the required witnesses (two licensed nurses employed by the nursing care center).

Based on record review, staff interviews, policy review and CMS regulations, the facility failed to ensure that one resident (#56) received a timely Advanced Beneficiary Notification, within 48-hours, for termination of part A Medicare services. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, Major Depressive Disorder-recurrent / moderate, and Primary insomnia. Review of the MDS (Minimum Data Set) for resident #56, dated December 4, 2022, revealed a BIMS (Brief Interview of Mental Status) score of 01, indicating severe cognitive impairment. Record review of the nursing progress notes revealed that resident #56 remained in the facility on private pay after termination of Medicare Part A services. On January 10, 2023 at 2:01 pm a form, SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review, was provided by the facility. The form included Part A services last covered day was on December 7, 2022. Per the document, the notice was signed via verbal signature on December 8, 2022 by the Director of Social Services. Further record review revealed no evidence that resident #56 received Advanced Beneficiary Notification or Notice of Medicare Non-Coverage timely. Review of the nursing progress notes from December 2022 through January 2023 did not reveal information regarding Advanced Beneficiary Notification or Notice of Medicare Non-Coverage. Further record review revealed no documentation that an Advanced Beneficiary Notification or Notice of Medicare Non-Coverage had been discussed or signed. An in-person interview was conducted on January 11, 2023 at 9:00 am, with staff # 54 DOSS (Director of Social Services). She stated that the process for the Advanced Beneficiary Notification, included resident notification 2 to 3 days prior to end of services. Staff would document in notes, if they are unable to reach the representative. An in-person follow-up interview was conducted with staff # 54 (Director of Social Services) on January 11, 2023 at 11:32 am. She stated, with a telephonic ABN, social service staff can sign on behalf of the representative, without a witnessed signature. She stated, the untimely Advanced Beneficiary Notice for resident # 56 was an oversight. An in-person interview was conducted on January 11, 2023 at 12:30 pm with the administrator, staff # 65 (Administrator). He stated that the Advanced Beneficiary Notice and the Notice of Medicare Non-Coverage are reviewed with residents and or representatives, 48-hours prior to end of skilled services. The stated identified risk is non-payment for the resident's stay. He stated, notes regarding notification review and signature is not required, per the facility guidelines but is best practices. A review of the facility policy that was revised in 2022, revealed that 2 days prior to end of skilled services, the facility will issue a Notice of Medicare Non-Coverage. The policy states that an Advanced Beneficiary Notice will be issued when a Medicare Part A stay will end and that the facility is expected to maintain compliance with Medicare Beneficiary Notices per CMS (Centers for Medicare and Medicaid Services) guidelines. Further record review revealed no documentation that an Advanced Beneficiary Notification or Notice of Medicare Non-Coverage had been discussed or signed. An in-person interview was conducted on January 11, 2023 at 9:00 am, with staff # 54 DOSS (Director of Social Services). She stated that the process for the Advanced Beneficiary Notification, included resident notification 2 to 3 days prior to end of services. Staff would document in notes, if they are unable to reach the representative. An in-person follow-up interview was conducted with staff # 54 (Director of Social Services) on January 11, 2023 at 11:32 am. She stated, with a telephonic ABN, social service staff can sign on behalf of the representative, without a witnessed signature. She stated, the untimely Advanced Beneficiary Notice for resident # 56 was an oversight. An in-person interview was conducted on January 11, 2023 at 12:30 pm with the administrator, staff # 65 (Administrator). He stated that the Advanced Beneficiary Notice and the Notice of Medicare Non-Coverage are reviewed with residents and or representatives, 48-hours prior to end of skilled services. The stated identified risk is non-payment for the resident's stay. He stated, notes regarding notification review and signature is not required, per the facility guidelines but is best practices. A review of the facility policy that was revised in 2022, revealed that 2 days prior to end of skilled services, the facility will issue a Notice of Medicare Non-Coverage. The policy states that an Advanced Beneficiary Notice will be issued when a Medicare Part A stay will end and that the facility is expected to maintain compliance with Medicare Beneficiary Notices per CMS (Centers for Medicare and Medicaid Services) guidelines.

Based on clinical record review, staff interviews, and policy and procedure, the facility failed to ensure an advanced directive was accurate for one resident (#54). The sample size was 20. The deficient practice could result in residents ' wishes not being honored. Findings include: Resident #54 admitted to the facility [DATE] with diagnoses that included Alzheimer ' s disease with late onset, dementia in other diseases classified elsewhere, without behavioral, psychotic, or mood disturbance and major depressive disorder, recurrent, in remission. An admission progress note dated [DATE] at 3:27 p.m. included that the resident had been admitted via medical transport. An Advanced Directive Statement dated [DATE] revealed the resident ' s directive included cardiopulmonary resuscitation measures (CPR), artificial hydration, hospitalization , antibiotic therapy, and pain medication. The resident signed the directive herself on [DATE]. A facility representative witnessed the directive on the same date. A Prehospital Medical Care Directive dated [DATE] revealed a Do Not Resuscitate (DNR) status. The document was noted with the resident ' s electronic signature which was time stamped at 4:33 p.m. The document was signed by a Licensed Practical Nurse (LPN/staff #59) at 4:32 p.m. and witnessed by an LPN (staff #32.) The witness statement acknowledged that the signer was present when the directive was signed (or marked) and that the resident/responsible party appeared to be of sound mind and free from duress. The electronic signature was time stamped at 4:32 p.m. A physician ' s order dated [DATE] included for DNR status. The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 5 on the Brief Interview for Mental Status, indicating severe cognitive impairment. An interview was conducted on [DATE] at 11:37 a.m. with an LPN (staff #97). She stated that the admitting nurse provides education regarding an advance directive. She reviewed both advanced directives and stated that if the resident were to code, she would consider her a DNR. She stated that the provider had ordered a DNR. On [DATE] at 1:58 p.m. an interview was conducted with the Director of Nursing (DON/staff #41) and a Clinical Resource representative (staff #117). Staff #41 stated that an advance directive was completed upon admission. She stated that no nursing documentation would be expected when education was provided to the resident and/or their representative. She stated that they just attempt to get a declaration. She stated that if the resident is not alert and oriented, the responsible party would be contacted and the request would be made. She stated that was her expectation. She reviewed the advance directive signed by the resident and stated that the document would be honored, that it was a viable document. The DNR designation was reviewed and she stated that if the resident ' s advance directive election had changed, there should be documentation to indicate that was the case. She stated that once a discrepancy was identified, she would expect the nurse to reach out to the family/representative and ask them to clarify. Staff #117 stated that it did not meet the expectation for a nurse to have made the code designation. The Advanced Healthcare Directives Policy, revised ,d+[DATE], included that it is the policy of the facility to recognize the right of individuals to control decisions related to his/her medical care. This includes the right to consent, to refuse or to alter treatment plans and formulate advanced directives. Advanced directives executed in accordance with the applicable state law will be honored by the facility. At the time of admission, the Admissions Director/designee must determine whether a resident has executed an advanced directive or has given other instructions to indicate what care he/she desires in case of subsequent incapacity. The admitting nurse is responsible for documenting in the resident ' s medical record the discussion and any advanced directive that the resident executes, including the Arizona Prehospital Medical Care Directive (orange sheet). If a resident is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advanced directive, the facility may give the information to the resident ' s representative in accordance with state law. As long as an individual is competent and able to communicate, he/she will make their own decisions.

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#32) and/or their representative was informed of the risks and benefits of psychotropic medications prior to administration. The sample size was 20. The deficient practice could result in residents and/or their representatives not being fully informed of the risks, benefits and alternatives to proposed treatment. Findings include: -Resident #32 admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease and post traumatic seizures. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The resident reported no feelings of depression, and he displayed no symptoms of psychosis or behaviors. A physician ' s order dated 11/30/22 revealed quetiapine fumarate (antipsychotic) 25 mg (milligrams): give one tablet at bedtime for traumatic brain injury (TBI). Review of the November 30, 2022 Medication Administration Record (MAR) revealed the medication was administered in accordance with the physician ' s order. The December 1 through 6, 2022 MAR revealed the resident received antipsychotic medication per orders. A psychotropic medication care plan dated 12/06/22 related to (traumatic brain injury) TBI had a goal for the resident to be/remain free from psychotropic drug-related complications. Interventions included to administer psychotropic medications as ordered by the physician. Monitor for side effects and effectiveness every shift. However, an informed consent relating to the risks and benefits of quetiapine fumarate was not identified in the resident's clinical record until 12/07/22. Another physician's order dated 12/12/22 included fluoxetine HCl (antidepressant) 20mg: give one capsule by mouth in the morning for depression. Review of the December 13 through 31, 2022 MAR revealed the resident received the antidepressant in accordance with the physician ' s orders. However, an informed consent relating to the risks and benefits of fluoxetine HCl was not identified in the resident's clinical record until 01/04/23. On 01/11/23 at 8:41 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #6). She stated that once an order is obtained for psychotropic medication, nursing will explain the risks and benefits of the medication, alternatives to drug therapy and non-pharmacologic interventions. She stated that if the resident was alert and oriented x4, she would obtain the consent from the resident. If they can give verbal consent, she will complete an e-signed consent for them. She stated that the consent would be added to the resident's medical record instantaneously. She stated that the e-consent does not require two witnesses for a verbal consent from the resident. An interview was conducted on 01/11/23 at 1:10 p.m. with the Director of Nursing (DON/staff #41). She stated that the provider will explain the risks and benefits of psychotropic medications to the resident prior to administration of the medication. She stated that nursing staff would be responsible for education and obtaining the consent after that. The Psychotropic Medication Use Policy, revised 11/28/16, included the facility should comply with the psychopharmacologic dosage guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other applicable law relating to the use of psychopharmacologic medications including gradual dose reductions. Facility staff should inform the resident and/or representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations.

Based on observations, clinical record review, staff interviews, facility documentation, and policy review, the facility failed to provide the necessary treatment and services to promote healing for one resident (#6) with pressure ulcers. Findings include: Resident #6 was admitted on (MONTH) 1, (YEAR), with [DIAGNOSES REDACTED]. Regarding the coccyx (sacrum) pressure ulcer: Review of the admission nursing assessment dated (MONTH) 1, (YEAR) revealed the resident had an open ulcer to the coccyx. However, the documentation did not include any measurements, any description of the wound bed and surrounding skin, or if any drainage or odor was present. The assessment also did not include the stage of the ulcer, or if this wound was the unstageable pressure ulcer to the sacrum or a different wound. The admission nursing note dated (MONTH) 2, (YEAR) included that the coccyx area was red with an 8 x 10 cm area of open tissue. There is no documentation of an unstageable pressure ulcer to the sacrum. The skin care plan dated (MONTH) 2, (YEAR) included a potential for skin breakdown/pressure ulcers related to decreased mobility. The care plan included the resident had an unstageable pressure ulcer to the sacrum. Interventions included following the skin protocol, pressure reducing mattress and turning and repositioning as needed. An NP (nurse practitioner) note dated (MONTH) 2, (YEAR) included the resident had skin breakdown to the coccyx, secondary to friction spasms and pressure. The note included the resident had spastic [MEDICAL CONDITION]. The note did not include that the resident had an unstageable pressure ulcer to the sacrum, nor any description of the coccyx area. Review of the admission physician's orders [REDACTED]. A nursing progress note dated (MONTH) 4, (YEAR) revealed the resident had redness to the coccyx area. A physician's orders [REDACTED]. However, this order was not transcribed onto the TAR (Treatment Administration Record) for February, as a result there was no documentation that the treatment was done on (MONTH) 4, as ordered. Further review revealed that this order was discontinued on (MONTH) 5, (YEAR). A nursing progress note dated (MONTH) 5, (YEAR) revealed the resident had an unstageable decubitus ulcer to the coccyx, with interventions that included turning/repositioning and use of an alternating mattress. A physician's orders [REDACTED]. According to the Skin/Wound Note dated (MONTH) 5, (YEAR), the resident was admitted with an unstageable pressure injury to the sacrum, which measured 5 cm x 5 cm, and the wound bed had 80% slough with 20% pink tissue, and had blanchable redness in the periwound. This was the first documentation of a description of the wound bed and measurements. The note also included that the wound was cleansed with wound cleanser and that Puracol was applied. Review of the Weekly Skin and Pain Assessment note dated (MONTH) 6, (YEAR), revealed an unstageable ulcer to the coccyx and that treatment continued. The documentation did not include any measurements of the coccyx pressure ulcer, a description of the wound bed or surrounding skin, if there was any tunneling or undermining, or if there was any drainage or odor present. A nursing progress note dated (MONTH) 7, (YEAR) revealed an unstageable pressure ulcer to the coccyx, which had 75% slough. Per the note, an [MEDICATION NAME] dressing was in place and to continue treatment. An NP note dated (MONTH) 9, (YEAR) included that the coccyx was examined and the pressure ulcer was noted to be small. The Weekly Skin and Pain Assessment note dated (MONTH) 13, (YEAR) included there was blanchable redness to the coccyx. There was no mention of an unstageable pressure ulcer to the sacrum. The NP note dated (MONTH) 16, (YEAR) revealed skin breakdown to the coccyx. No further description was included. Per the Skin/Wound note dated (MONTH) 16, (YEAR), the resident had an unstageable pressure injury to the sacrum, which measured 5 x 4.8 cm, had 80% slough and 20% pink tissue to the wound bed, and blanchable redness to the peri-wound. Per the documentation, the wound was cleansed with wound cleanser and Puracol was applied. The note did not include if any tunneling, undermining, drainage or odor were present. This wound was measured 11 days after the previous assessment (on (MONTH) 5). A nursing progress note dated (MONTH) 19, (YEAR) revealed the treatment of [REDACTED]. The Weekly Skin and Pain Assessment note dated (MONTH) 20, (YEAR) revealed the coccyx wound had 80% yellow slough and treatments continued. The assessment did not include the stage of the pressure ulcer, any wound measurements, a description of the surrounding skin, or if any tunneling, undermining, drainage or odor were present. The nursing progress note dated (MONTH) 21, (YEAR) revealed the pressure ulcer to the coccyx continued to receive treatment of [REDACTED]. The Skin/Wound note dated (MONTH) 23, (YEAR) revealed the resident had an unstageable pressure injury to the sacrum which measured 4.6 cm x 4.5 cm, with 50% slough and 50% pink tissue, and blanchable redness to the peri-wound. Per the documentation, the wound was cleansed with wound cleanser and Puracol was applied. A nursing progress note dated (MONTH) 27, (YEAR) included redness to the coccyx area. Review of the Skin/Wound note dated (MONTH) 27, (YEAR) revealed the resident had a pressure ulcer to the coccyx, which was covered with slough and that a treatment was in place. The note did not include the stage of the pressure ulcer, any wound measurements, a description of the surrounding skin, or if any tunneling, undermining, drainage or odor were present. A nursing progress note dated (MONTH) 28, (YEAR) included the resident had a pressure ulcer to the coccyx and that treatments continued. Despite documentation that treatments with Puracol and [MEDICATION NAME] continued to the coccyx, the physician's orders [REDACTED]. Therefore, there was no consistent documentation that the physician ordered treatment was provided as ordered from (MONTH) 5 through 28, (YEAR). The Weekly Skin & Pain Assessment note dated (MONTH) 2, (YEAR) included an unstageable pressure ulcer to the sacrum, which measured 4.5 cm x 4.5 cm. A physician's orders [REDACTED]. This order was transcribed onto the TAR for (MONTH) (YEAR) and was first administered on (MONTH) 3. The Skin/Wound note dated (MONTH) 2, (YEAR) revealed the resident had an unstageable pressure injury to sacrum which measured 4.6 cm x 4.5 cm, with 50% slough and 50% pink tissue, and blanchable redness to the peri-wound. Per the documentation, the wound was cleansed with wound cleanser and applied with Puracol. A physician's orders [REDACTED]. A nursing progress note dated (MONTH) 9, (YEAR) included an unstageable pressure injury to the sacrum, which measured 4.2 cm x 4 cm, with 50% slough and 50% pink tissue on the wound bed, and blanchable redness to the peri-wound. However, the Weekly Skin & Pain Assessment note dated (MONTH) 9, (YEAR) revealed the resident had an unstageable pressure injury to the sacrum which measured 4.6 cm x 4.5 cm. The Weekly Skin and Pain Assessment note dated (MONTH) 10, (YEAR) included the resident had an open area to the coccyx. This assessment did not include the type of the wound, any measurement, description of the wound bed, surrounding skin, presence/absence of tunneling, drainage or odor. According to a NP note dated (MONTH) 16, (YEAR), the resident had a stage II pressure ulcer to the coccyx, which measured 2 cm x 2 cm. A physician's orders [REDACTED]. The Skin/Wound note dated (MONTH) 20, (YEAR) included an unstageable pressure injury to the sacrum which measured 3.5 cm x 3.5 cm, with 80% slough and 20% pink tissue on wound bed and blanchable redness to the peri-wound. A pressure ulcer care plan dated (MONTH) 22, (YEAR) included the resident had multiple pressure injuries and was at risk for further pressure injury development. Interventions included the following: -Administer treatments as ordered -Assess/record/monitor wound healing every week -Assess and document status of wound perimeter, wound bed, healing progress, and report improvements and declines to the physician -Weekly treatment documentation to include measurement of each area of skin breakdown to include the width, length, depth, type of tissue and exudate. The Weekly Skin & Pain Assessment note dated (MONTH) 24, (YEAR) revealed the sacrum as the site of the skin condition. However, the documentation also described the skin condition as an open area to the coccyx. The documentation did not include any measurements, description of the wound bed, surrounding skin, or the presence/absence of tunneling, drainage or odor. A physician's progress note dated (MONTH) 4, (YEAR) included no skin breakdown. However, the assessment documentation included a pressure ulcer to the sacral region with unspecified stage. The Skin/Wound note dated (MONTH) 5, (YEAR) included the resident had an unstageable pressure injury to the sacrum which measured 3.2 cm x 2.8 cm, with 80% slough and 20% pink tissue on the wound bed, and with blanchable redness to the peri-wound. Per the documentation, the wound was cleansed with wound cleanser and an alginate dressing. The Skin/Wound note dated (MONTH) 11, (YEAR) included the unstageable pressure injury to the sacrum had 100% slough, a pinpoint opening, and blanchable redness to the periwound. The note also included the slough was debrided by the wound physician and that the wound now measured 2 cm x 3 cm x 2 cm with 3 cm undermining from 10 o'clock to one o'clock. The wound was classified as a stage IV pressure injury. The note included the wound was cleansed with wound cleanser, [MEDICATION NAME] (antibiotic) was crushed and sprinkled onto the wound base, alginate was applied, and the wound was covered with [MEDICATION NAME]. A physician's note dated (MONTH) 11, (YEAR) revealed the resident had a stage IV pressure ulcer in the coccygeal lower spinal area and that the stage IV pressure ulcer to the sacrococcygeal area had non-viable tissue fat and deeper subcutaneous tissues, with lots of odor after removal of necrotic tissue. The note included the depth was 1 1/2 cm but did not include any other measurements. Review of a physician's orders [REDACTED]. The Weekly Skin and Pain assessment note dated (MONTH) 14, (YEAR), included the resident had wound injuries to the coccyx. The Weekly Skin and Pain assessment note dated (MONTH) 21, (YEAR), revealed the coccyx wound had a foul odor. The Weekly Skin and Pain assessment note dated (MONTH) 28, (YEAR), revealed the coccyx wound had tunneling and copious drainage. The Weekly Skin and Pain Assessment note dated (MONTH) 5, (YEAR), included the coccyx wound had tunneling and was under treatment. Further review of the Weekly Skin and Pain Assessment notes dated (MONTH) 14, 21, 28 and (MONTH) 5, (YEAR), revealed the notes did not include the wound type, any measurements, any description of the wound bed or surrounding skin, or if there was any tunneling, undermining, drainage or odor. Review of the TAR revealed the alginate dressing treatment to the coccyx was provided as ordered from (MONTH) 1, (YEAR) through (MONTH) 7, (YEAR). The Skin/Wound notes dated (MONTH) 19, 27 and (MONTH) 2, (YEAR), revealed the sacrum Stage IV pressure ulcer had undermining from 10 o'clock to one o'clock and that the treatment was provided as ordered. Regarding the right and left ischial tuberosity pressure ulcers: The Skin/Wound note dated (MONTH) 21, (YEAR), revealed the wound to the right ischial tuberosity was assessed by the wound physician as SDTI (suspected deep tissue injury) and measured 4.0 cm x 4.5 cm. The note also included interventions to replace the ischial step with the coccyx cutout pressure cushion with a roho wheelchair cushion. A physician's note dated (MONTH) 21, (YEAR), revealed the right ischial area was a deep tissue pressure injury and that the left ischium wound was blanchable. The note included that these 2 new wounds are not from lying down but are from the resident spending time in his wheelchair. Also included in the note was that the resident continued to be challenged nutritionally so a better turning schedule or weight redistribution must be put in place. The Weekly Skin & Pain Assessment note dated (MONTH) 24, (YEAR), did not include the right ischial tuberosity SDTI. Review of the Skin/Wound note dated (MONTH) 29, (YEAR), revealed the right ischial tuberosity SDTI measured 4.3 cm x 4.5 cm and had a dark purple wound bed. The note did not include the left ischial tuberosity wound. Review of the clinical record revealed no evidence that treatment was initiated and provided to these newly identified wounds from (MONTH) 21, (YEAR) through (MONTH) 4, (YEAR). A physician's note dated (MONTH) 4, (YEAR), revealed the resident continued to have issues with bilateral ischial pressure injuries. The Skin/Wound note dated (MONTH) 5, (YEAR), revealed the right ischial tuberosity wound was now classified as unstageable and measured 5 cm x 4.5 cm, with 80 % slough and dark purple edges. The note also included a deep tissue injury to the left ischial tuberosity which measured 4.0 cm x 3.0 cm, with dark purple wound bed and blanchable redness to the periwound. However, the note did not include whether the wounds had tunneling, drainage, or odor. A physician's orders [REDACTED]. Review of the TAR dated (MONTH) (YEAR), revealed the treatment was provided as ordered. A physician note dated (MONTH) 11, (YEAR), included the unstageable pressure ulcer to the left ischial area. The Weekly Skin & Pain Assessment note dated (MONTH) 14, (YEAR), included the wound injuries to the left and right ischial tuberosity areas, but did not include the wound classification, measurements, wound bed and surrounding skin descriptions, or whether there was tunneling, drainage, or odor. Review of the physician's note dated (MONTH) 25, (YEAR), revealed the unstageable pressure ulcer to the right and left ischial tuberosity were the same as the right and left buttocks pressure ulcers. This was the first documentation found in the clinical record that the wounds were the same. Regarding the buttocks wounds: The Weekly Skin & Pain assessment dated (MONTH) 7, (YEAR), revealed an opened area to the left buttock and the right gluteal fold. Review of the clinical record revealed no evidence these wounds were assessed, monitored or provided treatments from (MONTH) 7 through (MONTH) 24, (YEAR). The physician note dated (MONTH) 25, (YEAR), revealed the first documentation that the unstageable pressure ulcer to the right and left buttocks were the same as the right and left ischial tuberosity pressure ulcers. Regarding the left ankle: The Weekly Skin & Pain Assessment note dated (MONTH) 10, (YEAR), revealed an unstageable pressure sore to the left outer ankle. However, the note did not include measurements, a description of the wound bed and the surrounding skin, or whether there was drainage, tunneling, or odor. Review of the physician's note dated (MONTH) 16, (YEAR), did not include an unstageable pressure ulcer to the left ankle. Further review of the clinical record revealed no evidence that the physician was notified about the left ankle wound or that an order for [REDACTED].>Additional review of the clinical record revealed no evidence that the left ankle wound was assessed from (MONTH) 10, (YEAR) through (MONTH) 20, (YEAR). The Weekly Skin & Pain Assessment note dated (MONTH) 21, (YEAR), revealed the wound to the left inner ankle (which was different from what was previously identified) was red and nonblanchable. The note did not include measurements, a description of the wound bed and surrounding skin, or whether there was drainage, tunneling, or odor. The physician's note dated (MONTH) 25, (YEAR), included documentation regarding other wounds but did not include any documentation related to the left ankle wound. Review of the Weekly Skin & Pain Assessment note dated (MONTH) 27, (YEAR), revealed a discolored left inner ankle area (which was different from what was previously identified) with black eschar and red non-blanchable areas. The Skin/Wound note dated (MONTH) 2, (YEAR), did not include documentation regarding the left ankle wound. The physician's note dated (MONTH) 2, (YEAR), did not include documentation regarding the left ankle wound. A Weekly Skin & Pain Assessment note dated (MONTH) 5, (YEAR), revealed the left inner ankle area had black eschar and open areas and that treatment was being provided. However, there was no evidence found in the clinical record that treatment was provided to the left inner ankle wound from (MONTH) 10, (YEAR) through (MONTH) 7, (YEAR). Further review of the clinical record did not reveal any evidence that the physician was notified of the left inner ankle wound or that an order was obtained for treatment. Review of a physician's note dated (MONTH) 9, (YEAR), revealed documentation regarding vascular wounds but did not include documentation regarding the left ankle wound. During interviews conducted on (MONTH) 9, (YEAR) at 9:17 a.m. with a licensed practical nurse (LPN/staff #38), registered nurse (RN/wound nurse staff #72), and the wound specialist/physician (staff #164), staff #38 stated that the resident was admitted with some of the wounds and that the resident had been consistently non-compliant with positioning. Staff #164 stated the wounds on the left foot were vascular wounds and that the consulting vascular surgeon recommended amputation but the resident declined. Staff #164 further stated that the wounds to the left foot were identified as vascular because there was no blood supply to the areas and even though the areas could be pressure points, the wounds were not considered pressure ulcers. At this time, the wound nurse (staff #72) stated the wounds to the left foot had been documented as pressure ulcers. Staff #164 stated the wounds are vascular related and not pressure related due to the lack of blood flow and vascular problems. Staff #164 later stated the wound on the back side of the ischium is clearly a stage IV pressure ulcer and the wounds to the right and left ischium are unstageable pressure ulcers. During a wound observation conducted (MONTH) 9, (YEAR) at 10:05 a.m. with the wound nurse (staff #72) the following wounds were observed: -Back side of the ischium/sacrum - Staff #72 stated the resident was admitted with this wound. She stated it was a stage IV pressure ulcer measuring 2 cm x 2 cm x 1.5 cm with 3.3 cm undermining from 11 o'clock to 1 o'clock, no odor, clean wound bed, and blanchable periwound. -Left Ischial Area -Staff #72 stated that it was an unstageable pressure ulcer acquired at the facility maybe 2-3 months ago. She stated that the wound measurements were 2 cm x 2.8 cm, there was 100% slough, and the area around the periwound was blanchable with slight redness. -Right Ischial Area- Staff #72 stated that it was an unstageable pressure ulcer that measured 6 cm x 6 cm with tunneling at 2.1. She stated there was thick adhering slough to 90% of the wound and that the periwound was blanchable with slight odor. An interview was conducted with an RN (staff #130) on (MONTH) 10, (YEAR) at 2:19 p.m. She stated that for a resident admitted with a pressure ulcer she will document a description of the wound in the nursing progress notes including any drainage and measurements but that she cannot stage the wound. She stated that she would apply padded foam dressing if there is no treatment order and will notify the physician and the wound nurse and that they will assess the pressure ulcer right away or the next day. She stated that she would implement interventions like offloading, a mattress, and Prafo boot. She stated a weekly assessment is conducted and documented every week but will not include the measurement of the wound because the wound nurse does the measurements. Staff #130 also stated the wound nurse documents on a separate progress note and ensures that all pressure ulcers are identified and documented in the clinical record. During an interview conducted on (MONTH) 10, (YEAR) at 3:27 p.m. with the RN/wound nurse (staff #72) she stated the nurses report to her any wound that they have identified and that she will assess the wound the same day. She stated that she will document the wound including the stage and measurement in the progress note, initiate treatment, and notify the provider. She stated pressure injuries are measured weekly. She also stated the nurses can describe the wound and measure the wound but that they cannot stage the wound. The wound nurse stated that when there is a discrepancy regarding the location of a pressure ulcer wound, she will clarify the accurate location with the nurse. Staff #72 stated that resident #6 has the following pressure injuries: Stage IV pressure ulcer to the sacrum, unstageable pressure ulcer to the right ischial, and an unstageable pressure ulcer to the left ischial. She stated that the resident did not have any wounds on the buttocks but that the ischial areas can be identified as buttocks wound by the floor nurses because of the location. She further stated that she discovered the resident had a wound to the left ankle during the treatment observation on (MONTH) 8, (YEAR) and that the wound specialist has classified the wound as vascular. Another interview was conducted with staff #72 on (MONTH) 11, (YEAR) at 9:01 a.m. She stated that she documented a sacral wound and the NP documented a coccyx wound, and that could be why the nurses are documenting coccyx. The wound nurse stated the treatment to the unstageable right ischial pressure ulcer was not initiated until (MONTH) 5, (YEAR). She stated this was because the wound was an unopened SDTI when it was identified on (MONTH) 21, (YEAR). The wound nurse had no answer as to why treatment was initiated to an unopened SDTI to the left ischium on (MONTH) 5, (YEAR), the day that wound was identified. She also stated that the documentation indicated the treatment was provided to the coccyx but that there was no documentation that treatment was provided to the sacrum until (MONTH) 13, (YEAR). An interview was conducted with the Director of Nursing (DON/staff #139) on (MONTH) 11, (YEAR) at 10:39 a.m. He stated that when a certified nurse assistant (CNA) discovers an area on a resident's skin, the CNA is expected to notify the nurse who is expected to evaluate the area and initiate treatment to protect the wound. He stated the nurse is expected to notify the physician and the wound nurse. The DON stated the wound nurse will assess the wound, classify the wound, and initiate treatment in conjunction with the physician. He stated if there are discrepancies with the identification, location, or treatment of [REDACTED]. The DON stated the wound nurse provides him a weekly report of all the wounds in the facility. The facility's policy regarding Skin/Wound Care Protocol included that a skin care program will be maintained to assess all residents for their risk for skin breakdown and/or the development of pressure ulcers and to promote and/or maintain skin integrity. The goal is to maintain skin integrity and provide guidelines for skin care. It also included that pressure ulcers shall be staged in accordance with the National Pressure Ulcer Advisory Panel Pressure Ulcer Staging Definitions.