Every finding on record at Haven of Flagstaff

Based on observations, interviews, clinical record reviews, facility documentation, and facility policies, the facility failed to ensure that medications were not diverted for two residents (#13 and #15). This deficient practice could result in Controlled Substance being diverted and not being available to residents as prescribed.Findings Include: -Regarding Resident #15:Resident #15 was admitted to the facility on [DATE], with diagnoses of hyperlipidemia, Gastro-Esophageal Reflux Disease (GERD), and heart failure.A care plan initiated on November 13, 2025, revealed a focus area for the Resident #15 to be on Opiate medications related to post-surgical. The care also revealed a goal to be free of adverse reactions related to opiate medication and an intervention to administer medication as needed. A review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #15 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. The MDS further revealed that in Section N, the resident is taking opioids. A Physician's Order dated November 24, 2025, revealed an order for Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (a Controlled Substance/ an Opioid), give 1 tablet by mouth every 4 hours as needed for pain 6-10. The physician's order revealed that the order was discontinued on November 29, 2025.A Medication Administration Record (MAR) for November 2025 for Hydrocodone-Acetaminophen Oral Tablet 10-325 revealed that the medication was not administered on November 27, 2025 and only administered once on November 29, 2025.An Individual Control Drug Record dated November 2025 for Hydrocodone Acetaminophen Oral Tablet 10-325 revealed that Registered Nurse (RN/staff #54) identified that she had administered for the following dates:November 25, 2025November 26, 2025November 28, 2025November 29, 2025 However, the individual Control Record dated November 2025 for Hydrocodone Acetaminophen Oral Tablet 10-325 revealed that from November 29, 2025, through November 30, 2025, it had been signed out by a staff member 5 different times.-Regarding Resident #13:Resident #13 was admitted to the facility on [DATE], with diagnoses of cellulitis, sepsis, and type 2 diabetes. A care plan initiated on November 01, 2025, revealed a focus area for the resident to be on opioid medication related to abscess pain and post-surgical. A Physician's Order dated November 03, 2025, revealed an order for Oxycodone HCL Oral Tablet 5 MG (Oxycodone HCL) MG. A review of the comprehensive MDS assessment dated [DATE], reveals that Resident #13 had a BIMS score of 15, which indicated the resident is cognitively intact. The MDS then further revealed that in Section N, the resident is taking opioids.A Medication Administration Record for November 2025 for Oxycodone HCL Oral Tablet 5 MG revealed that the medication was not administered for the following dates: November 9, 2025 - November 12, 2025 November 14, 2025 - November 29, 2025However, on the Individual Control Drug Record dated November 2025 for Oxycodone HCL Oral Tablet 5 MG revealed that the medication was signed off 17 times by staff member/s, but the MAR revealed that it was only given 3 times. The record further revealed that (Staff # 54) identified that she had given the medication on November 08, 2025.Furthermore, A Job Description: Registered Nurse (RN) sheet had revealed that it had been signed on November 24, 2025, by Staff # 54. A 5-day report for an incident that occurred on November 30, 2025, revealed that Narcotic logs, Medication Administration Records, and Destruction Logs verified for the possibility of diversion of narcotics from Staff # 54. The 5-day report further revealed that a staff member had reported to the Director of Nursing (DON/Staff #75) that Registered Nurse (RN/Staff#54) had potential irregularities involving two controlled-substance accountability sheets, and an audit was initiated. The 5-day audit had also revealed that Resident #13's Medication Administration Record did not correspond with the narcotic sign-out sheet, and there were visible signs of alteration to the sheet. The 5-day further revealed that there were overwritten entries and inconsistent documentation patterns in the Resident #13 narcotic sheet. The 5 days then revealed that for Resident # 15, Hydrocodone-Acetaminophen Oral Tablet 10-325 MG was discontinued, but was continuously signed off on the narcotic sheet. The five-day further revealed that Staff #54 was asked to highlight the Individual Control Drug Record sheets for mediations she administered, but it was not reflected in the MAR. The 5-day period then revealed that the DON informed staff # 54 that the discrepancies were indicative of a potential controlled-substance diversion, and staff #54 denied the allegation and left the facility. A Termination Detail sheet dated December 02, 2025, revealed that Staff #54 was terminated for dishonesty/Fraud. The termination sheet further revealed a note for Drug Diversion. Was found to be stealing drugs after 2 days of shift work. Horrible employee. NOT REHIREABLE. A Final Universal Background check dated December 02, 2025, had revealed that Staff #54 had a misdemeanor dated September 22, 2020, for Driving Under the Influence/Drug Metabolite. The Universal Background check further revealed that she has an active warrant dated November 15, 2023. An interview was conducted on December 22, 2025, at 11:26 AM with Administrator (Admin/Staff#8), who stated that they had received approval to do onboarding for Staff #54, even though her background check was pending. She then stated that there was a second background check conducted that was received on December 02, 2025, which was flagged because (Staff #54) had a warrant. Another interview was conducted on December 22, 2025, at 11:42 AM with Staff #8, who stated that (RN/Staff #54) was hired on November 24, 2025, and only worked at the facility for 6 days. She then stated that Staff# 54 was in training with other staff for the following dates in November 2025: 25, 26, 27. She then stated that Staff #54 worked individually for November 2025, following the dates: 29, 30. She further stated that when nurses are in training, they don't have access to the medication cart. She then stated that Resident #13 MAR for November 2025 and the narcotic sheet do not correspond. She further stated that Resident #14, Hydrocodone medication, was signed off on the individual control drug record after being discontinued. She then stated that Staff #54 was suspended on December 01, 2025. An interview was conducted on December 22, 2025, at 12:06 PM with a Licensed Practical Nurse (LPN/Staff #100), who stated that a day shift nurse and a night shift nurse will count the narcotic tablet in the bubble wrap and verify it in the narcotic book. She then stated that if there are any discrepancies within this process, the Director of Nursing (DON/Staff #75) will be notified. She then stated that she will review the physician's orders for the pain and narcotic medication that the resident requests. She then stated that the physician's orders will determine which medication will be administered based on the resident's pain level. She further stated that if she were to give a resident narcotic medication, she would take it out of the bubble wrap and then sign off on the narcotic book. She further stated she will document on the MAR and then administer the medication. A second attempt was made on December 22, 2025, at 12:59 to (RN/Staff #23) unable to get in contact. An attempt was made on December 22, 2025, at 1:20 PM to (RN/Staff # 54), unable to get in contact.An email dated December 02, 2025, at 1:44 PM, sent by the Administrator (Staff #80) to state agencies revealed that five tablets of Hydrocodone Acetaminophen were punched after the discharge date , November 29, 2025, and were not reflected on the MAR.An attempt was made on December 22, 2025, at 2:21 PM to contact (Resident # 15), unable to get in contact.Unable to contact Resident #13 because there was no contact info on the clinical record. A further interview was conducted on December 22, 2025, at 2:43 PM with (Staff # 80), who stated that she had received a call at midnight from the (DON/Staff #75), who mentioned to her that Registered Nurse (RN/Staff # 23) said that the narcotic sheet did not look right. She further stated that the DON believes that there was drug diversion for Residents # 13 and #15. She also stated that with the video footage she has reviewed, she has not seen Staff #54 taking medication. She further stated that she spoke to Residents #13 and #15 regarding missing medication; they said that they had received their medication. She then stated that December 01, 2025 the DON had asked (RN/Staff #54) to arrive before her shift to discuss drug diversion, but (Staff #80) was not present for that discussion. The Administrator then stated that there was a discrepancy on the MAR and the individual control drug record. She further stated that they had notified local law enforcement, state agencies, and the provider. She then stated that on the second background check, Staff #54 had a warrant for Driving Under the Influence (DUI). The administrator then stated that Staff #54 technically could be hired under the rules of hiring. She then further stated that, based on her personal policy, she would not have hired her. An interview was conducted on December 22, 2025, at 03:01 PM with the DON, who stated that (RN/Staff #23) had called her on November 30, 2025, and was told that Staff # 54 was sleeping at the nursing station, and asked Staff #54 to be awakened. She also received a second call that Staff #54 was sleeping, so this prompted her to go to the facility. The DON then stated that when she had arrived at the facility, she saw Staff #54 at the nursing station charting. She then stated that Staff #54 told her that she was completing her charting and was tired. She further stated that Staff #54 and she left the facility at the same time. She then stated that when she arrived home, Staff # 23 had called her and told her that Resident #13's Individual Control Drug Sheet did not look right. She further stated that she had asked Staff #23 to take a picture of the narcotic sheet for Resident #13 and sent it to her. She also stated that when reviewing the narcotic sheet, it looked tampered with, and the administrator was notified about this. She also stated that (RN/Staff #72) called her and told her that the Individual Control Drug Record sheet for Resident #13 looks weird because the Resident #13 gets his oxycodone every 6 hours, and she was the last to administer that medication. She then stated that when (Staff # 54) came to work at 6:00 am, the narcotic count was 19 for the Oxycodone Tablet 5 MG, and when (RN/Staff # 54) left, the count went to 11 or 10. DON then stated that at the most, Resident # 13 could only receive two Oxycodone during Staff #54's shift. DON also stated that Staff# 54 claims she had administered the oxycodone eight different times, and none were signed off on the MAR for November 2025. She also stated that on December 01, 2025, she had asked (RN/Staff #54) to explain the medication administration time and who she had given medication to. She then stated that once (Staff #54) began highlighting the Individual control Drug Record for Oxycodone tablet 5 MG administered on a date Staff #54 did not work, she told Staff #54 about her suspicion of drug diversion. She then stated that Staff #54 was asked to do a urine sample, to which she reacted by saying that, since she is allergic to opioids, she could not take it and gather all her belongings. An Interview was conducted on December 22, 2025, at 3:31 PM with Unit Manager # 33, who stated it appears that on the Individual Control Drug Record the Hydrocodone Acetaminophen Oral Tablet 10-325 MG was signed off 5 times after it has been discontinued .A further interview was conducted on December 22, 2025, at 3:53 PM with the DON, who stated that the Individual Control Drug Record was tampered with and that it did not consult with the MAR, and then there was drug diversion. She further stated that there was no harm to the Resident #13 because he never asked for medication. She then stated that for Resident # 15, there is no harm because she did not receive medication from (Staff #54). She also stated that it's the nurse's practice to administer medication orders by the physicians with the parameters and to document it accurately in the MAR and the Narcotic sheet. A policy titled Medications: Controlled Substances revealed that not surrendered to anyone, including the resident's provider, except for the following: a. For a resident on pass or therapeutic leave; b. To a resident or responsible party upon discharge from the facility; or c. To the DEA or other law enforcement officials functioning in a professional capacity in exchange for a receipt documenting the transaction.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident (#10) was free from a preventable accident that resulted in serious injury. The deficient practice could lead to further instances of accidents resulting in injuries to residents. Findings include: Resident #10 was admitted on [DATE], with diagnoses that included acute kidney failure, cardiac murmur, repeated falls, difficulty in walking, and age-related osteoporosis. A quarterly minimum data set (MDS) assessment dated [DATE], revealed that the resident had a brief interview for mental status (BIMS) score of 4, indicating the resident had severe cognitive impairment. A physician order dated March 22, 2025, indicated for a right ankle boot for possible calcaneal stress fracture, and to repeat right ankle x-ray the week of April 7, 2025. A care plan dated April 16, 2025, revealed that the resident had or was at risk for having functional mobility deficits or functional mobility limitations, with an intervention that the resident required a hoyer lift for transfers. There was no evidence of a care plan for transfers prior to this date. An Incident (Risk Management) Report dated March 20, 2025, revealed that an incident occurred in the common bathroom, the resident then reported right ankle pain. The resident speaks mostly Navajo, and that a translator asked the resident what had happened. The resident stated that her right foot was hurt during a transfer. The right ankle was swollen, warm, and painful to the touch. The resident was sent to the hospital for an x-ray. Additionally, spoke with the CNA about safe transfers, slowing down, listening to residents, and removing the foot pedals of the wheelchair during transfers. A Change of Condition Summary note dated March 20, 2025, revealed that the nurse was informed by another nurse that the resident was having difficulty with transfers. The resident reported right ankle pain. This nurse assessed the resident, and the right foot was swollen and painful to the touch. The resident was sent out to the hospital for an x-ray. A Physician Progress Note dated March 22, 2025, revealed that the provider was asked to see the resident after her right ankle was recently caught up in the wheelchair during a transfer. The resident was assessed for traumatic right ankle pain. The x-ray of the right ankle revealed a possible stress fracture of the calcaneus. Recommended was an ACE wrap, a walking boot, and a follow-up x-ray the week of April 7th. An additional Incident Report, dated April 12, 2025, revealed that a CNA (Staff #30) and a med tech (Staff #46) notified the nurse that Resident #10 sustained an injury while being transferred by one-person assistance from the wheelchair to the bed. The CNA who transferred the resident stated that an audible pop or crack occurred during the transfer and that the resident reported severe pain to the left lower extremity. A witness statement by Staff #30, dated April 13, 2025, revealed on April 12, at 7:30 PM, Staff #30 transferred Resident #10 from wheelchair to bed. The resident's left foot bent to the left from the CNA's right leg and made a popping sound. Additionally, it was a 2 second transfer. The nurse was notified and assessed the resident. Another witness statement by Staff #46, dated April 12, 2025, revealed the CNA came out of the room stating that while transferring Resident #10, he heard a pop / crack noise. Staff #46 entered the room, and Resident #10 cried out and stated in Navajo that it really hurts. The nurse was notified, and the resident went to the hospital. A progress note dated April 12, 2025, revealed at 7:35 PM, this writer was approached by a med tech and certified nursing assistant (CNA) stating that Resident #10 was possibly injured during a wheelchair to bed transfer. Upon assessment, the resident was found lying on the bed, and complaining of severe pain to the left lower extremity and swelling was noted. The provider and the Assistant Director of Nursing (ADON) were notified, and instructed to send the resident to the ED for evaluation. The resident was sent to the hospital. At approximately 11:00 PM, this writer received a call from the hospital nurse and was informed that the resident sustained tibia and fibula fractures. Per the hospital nurse, the extremity has been splinted and the resident is scheduled for surgery in the morning on April 13, 2025. A supplemental training in-service, dated April 15, 2025, revealed that Staff #30 signed that he had completed transfer training and was confident with this skill. If Staff #30 would like more training, to seek out the Director of Rehab, the Director of Nursing, or anyone on the clinical leadership team. Additionally, the in-service statement revealed it is important to take time, remove or add any equipment on the mobility device, follow patient care plan, use a gait belt, 2-person assist, or hoyer if indicated. A History and Physical note from the hospital dated April 13, 2025, revealed the resident was transferred from the facility, and staff state they were transferring the resident from chair to bed and her left leg got caught on something and they heard a pop. Left lower leg hematoma was noted. Orthopedics has been consulted, and plans are for the operating room in the morning. X-ray of the left leg revealed spiral nondisplaced fractures of the midshaft and fibula and distal shaft of the tibia. A telephonic interview was conducted with a med tech (CMA / Staff #46) on April 29, 2025, at 10:04 AM, Staff #46 stated she was outside the resident's door in the hallway, passing medication. She stated she heard Resident #10 crying. Staff #46 was then informed by Staff #30 that he had heard a crack / pop when transferring the resident. Staff #46 stated that the resident is Navajo-speaking, so Staff #46 talked to the resident, who stated her leg hurt. A telephone call was placed to Staff #30 on April 29, 2025, at 10:05 AM, for an interview. A voicemail was left for a return call. A second call was made at 11:57 AM with no answer. The staff did not return the phone call. A telephonic interview was conducted on April 29, 2025, at 10:12 AM, with a CNA (Staff #91) who stated that she was aware of the incident with Resident #10, and that she was told by Staff #30 that he was transferring Resident #10 when the resident's foot caught on his foot. An interview was conducted with another CNA (Staff #8) on April 29, 2025, at 10:14 AM. Staff #8 stated that she was aware of the first incident with Resident #10 on March 20, 2025, because the resident stated to her that she was going to the bathroom and that two staff were assisting her and the footrest of the wheelchair hit her on the ankle area. Staff #8 stated that the resident got a boot for the ankle about a week later. After the first incident, Staff #8 stated that the Director of Rehab (DOR) provided training to the CNAs on safe transfers and ensuring the footrests were removed from the wheelchair to make sure that did not happen again. Staff #8 stated she was aware of the second incident with Resident #10 on April 12, 2025, as she was in the building on the day of the incident. Staff #8 stated that Staff #30 explained the event to herself and a nurse; and that, Staff #30 stated that he was transferring the resident, and then the resident's foot got stuck on his foot and he heard something and then went to get the nurse. Staff #8 stated that after the second incident, staff were instructed to use the hoyer lift for transferring Resident #10. A telephonic interview was conducted April 29, 2025, at 10:47 AM, with the resident's family and emergency contact. The family stated that approximately two weeks before the incident, where the resident's left leg was fractured, there was an incident where her right foot was injured when staff took her to the bathroom. After the first incident in the bathroom, the family stated that they had requested that two staff members be present when transferring Resident #10. Regarding the left leg injury, the family stated that a male staff member was transferring the resident, her leg got caught, and the staff, kept yanking on her, and her leg fractured in two places. The family stated that they were told by Resident #10 that she was yelling out for the male staff to slow down and stop, but he kept going. The family stated that Resident #10 stated that Staff #30 is always in a hurry, and that he does not speak Navajo. An interview was conducted on April 29, 2025, at 11:07 AM, with the Director of Rehab (DOR / Staff #120) who stated that Resident #10 had not received a therapy referral after the first transfer training incident on March 20, 2025. The DOR stated he has been doing transfer training with the staff, which started after the second incident on April 12, 2025. Staff #120 stated that for a squat pivot type of transfer, which is the type of transfer that was done with Resident #10, there should have been two people assisting, because of the high risk of the transfer. Staff #120 stated that the resident's injury was discussed as a clinical team and that the Director of Nursing (DON / Staff #2) and stated that the Resident #10 had been declining overall and should have been switched over to a hoyer lift transfer to increase safety. An interview was conducted with Resident #10 on April 29, 2025, at 11:45 AM, with a Navajo translator present. The resident stated that her leg hurt and that she remembered an incident where a man transferred her to bed and her leg popped. An interview was conducted with a CNA (Staff #70) on April 29, 2025, at 12:00 PM, who stated that on April 12, 2025, she was coming in for shift. She had received report that one of the CNAs was transferring the resident and that he heard her make a noise, then as he continued, he realized her leg was hurt. Staff #70 stated that she talked to Staff #30 who told her that the resident's leg got caught around the CNA's leg during the transfer. After the incident, Staff #70 stated that the facility instructed staff to only use the hoyer lift to transfer the resident and that the resident would require 2-person care moving forward. An interview was conducted with a registered nurse (RN/ Staff #27) on April 29, 2025, at 12:20 PM who stated that she was familiar with the incident with Resident #10 on April 12, 2025; and that, she assessed the resident approximately 5 minutes after the incident. She stated that she had observed the resident to have redness and swelling in the leg, as well as pain, and that normally, the resident does not complain of pain. Staff #27 stated that Staff #30 stated that somehow the resident's leg got wrapped up between one of the CNA's legs and he heard a pop. A telephonic interview was conducted with the DON (Staff #2) on April 29, 2025, at 1:54 PM. The DON stated that accident risks and hazards are identified by the facility completing a person-centered care plan, updating the residents' care plans as needed, and communicating to the CNAs. The DON stated that staff are trained to remove footrests from the wheelchair before transferring residents because there is a risk of accidentally injuring a resident's leg if caught in the foot rests during transfers. Regarding Resident #10's first incident on March 20, 2025, the DON stated that the CNA was transferring the resident and the foot rests were still on the wheelchair, the resident's foot got caught between the chair, and the foot rest and there was some bruising on the resident's ankle. The DON stated that there was no update to the resident's plan of care at that time. The CNA was educated to remove the footrests before assisting with a transfer. During the second incident on April 12, 2025, the DON stated that the CNA, Staff #30, was transferring the resident, the resident's feet did not move, and the CNA set her down and he heard a pop. The DON stated that no staff informed her that the resident's leg got caught during the transfer. The DON stated that the resident had tibia and fibula fractures in her leg. After the incident, the resident is to only have hoyer lift transfers. Review of the facility policy titled Resident Safety: Accidents and Incidents - Investigating and Reporting, dated January 1, 2024, revealed all accidents or incidents involving residents shall be investigated and reported to the administrator. Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. Review of the facility policy titled Positioning/Moving: Safe Lifting and Movement of Residents, dated January 1, 2024, revealed in order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Manual lifting of residents will be eliminated when feasible. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one of five sampled resident (#136) were safe to self-administer medication. The deficient practice could result in a medication overdose. Findings Include: Resident #136 was admitted on [DATE] with diagnosis of dysphasia, chronic obstructive pulmonary disease, bipolar disorder, depression, anxiety and pressure ulcer. The Admission Assessment Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A Care Plan dated March 07, 2025 revealed no indication of a focus for medication self-administration. Review of the clinical record revealed no evidence of a medication self-administration order. Review of the clinical record revealed no evidence of a medication self-administration assessment. During an initial observation of resident #136's room was conducted on March 11, 2025 at 12:01 p.m., there were two medications observed lying on the resident's bed in a grey plastic basket. The medications included: -Two blister packets containing a total of 14 throat lozenges -One 100-gram (g) tube of voltaren arthritis pain relieving cream An interview was conducted on March 11, 2025 at approximately 12:01 p.m. with resident #136, who stated that she applies arthritis pain cream to her left forefinger once a day and also takes tablets for dry mouth once a day. An interview was conducted on March 11, 2025 at 12:01 p.m. with a Registered Nurse (RN/staff #157) who entered the resident's room and stated that she observed two medications that included lozenges and voltaren cream in the gray basket lying on the resident's bed. The RN then stated that a physician order should be written that allows resident to self-administer medications, and that an assessment would be conducted to assess if the resident is safe for medication. If the facility assesses that the resident is safe to self-administer medications, the resident would be able to administer the medication. The RN was then observed to remove the medications from the resident's room and stated to the resident that she will ensure the resident receives the medications. Further review of physician orders revealed two new order dated March 11, 2025 for administration of the following medications: -Dry Mouth Drops Mouth/Throat Lozenge (Artificial Saliva), give 1 tablet by mouth as needed for dry mouth with active date of March 11, 2025 at 2:30 p.m. and administered by: CLINICIAN -Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)), apply to Bilateral hands topically as needed for arthritis pain with active date of March 11, 2025 at 2:30 p.m. and administered by: CLINICIAN The orders had been placed into the clinical record after notification from the surveyors on March 11, 2025 at 12:01 p.m. to the RN (staff #157) An interview was conducted on March 13, 2025 at 09:44 a.m. with Resident #136, who stated that she had been in the facility about two weeks, and she brought the voltaren arthritis pain cream and lozenges from her home. She then stated that she had been taking both medications once a day after coming to the facility for almost a week before it was taken away by one of the nurses on Tuesday March 11, 2025. An interview was conducted on March 13, 2025 at 09:56 a.m. with a Registered Nurse (RN/staff # 400) who stated that the physician will access to determine resident cognitive status, ability to name the medication and determine whether the resident is safe to self-administration medication. The RN then reviewed the resident physician's order and stated that the resident is on diclofenac for arthritis and lozenges for dry mouth and that there were no check boxes for medication self-administration or unsupervised medication self-administration. The RN further stated that the risk of a resident self-administering medications without a physician order or self-administration assessment could result in a choking hazard, self-harm and adverse reactions. An interview was conducted on March 13, 2025 at 10:25 a.m. with the Director of Nursing (DON/staff # 180) who stated that when residents request to self-administer medications, the nurse will conduct a medication self-administration assessment, notify the physician for a medication self-administration order. The DON reviewed the physician orders and stated that there was no evidence of a medication self-administration order for voltaren and dry mouth lozenges. The DON further stated that as soon as this was brought to her attention, an order was written for both medications. DON also stated that if a resident or family member would bring medications into the facility, staff will then ask them to hand it over to the facility, and the nurse will contact the provider for a physician order. The DON further stated that the risk of a resident self-administering medications without a physician's order or medication self-administration assessment could result in the medications being administered incorrectly. A review of a policy titled, Resident Rights - Self-Administration of Medication, January 1, 2024, revealed that Residents have the right to self -administration medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 5 sampled residents (Resident # 284) was free from abuse by another resident (#183). The deficient practice could result in other residents being abused. Findings include: -Regarding Resident #183 Resident #183 was admitted to the facility on [DATE]. 2024 with diagnoses of dementia, muscle weakness, and history of falling. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 2 indicating severe cognitive impairment. The assessment did not indicate any behaviors. A comprehensive care plan dated January 18, 2024, revealed that Resident #183 had communication problems due to dementia, and impaired cognitive function due to dementia. There was no evidence of a focus on interventions related to behaviors in the care plan. An alert charting progress note dated January 26, 2024, revealed that the resident was adjusting well to her new room, however there was no evidence in the note regarding the reason for the changes of the new room. A change of condition summary dated February 29, 2024, revealed that Resident #183 continued to look for her keys and roamed into other patients' rooms and attempted to access medication/wound carts. On March 7, 2024 a medication administration note indicated that the resident was combative with staff. A daily skilled evaluation note dated March 7, 2024, revealed physical behaviors (hitting, wandering, etc.). Patient placed on alert charting for physical behaviors toward other residents, patient continues to wander in other patients' rooms. Further review of the care plan revealed no evidence of revision related to behaviors despite the February 26, 2024, incident with resident #284. On March 15, 2024 a change of condition summary revealed that the patient had some aggression when trying to redirect her when she is doing something she should not be doing. -Regarding Resident #284 Resident #284 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, visual hallucinations, and urinary tract infection. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. The assessment did not reveal any evidence regarding behaviors. A comprehensive care plan dated January 31, 2024, revealed that Resident #284 had impaired cognitive function or impaired thought processes due to encephalopathy. A weekly skin/wound assessment dated [DATE], revealed that the resident was assessed after she alleged that her roommate (Resident # 183) hit her on the left upper chest, no redness, bruising, or open areas were noted. Review of a facility investigation report, which was not dated, revealed that on February 26, 2024 a Certified Nursing Assistant (CNA/staff #161) walked into the room of Residents #284 and #183. Upon entering the CNA found Resident #284 upset, while Resident #183 was standing by Resident #284's bed. The CNA removed Resident #183 from the room and went back to attend to Resident #284. The report revealed that Resident #284 told the CNA that Resident #183 said something rude in Navajo and hit her in the chest. The investigation revealed that Resident #183 was moved, on the day of the incident, to a private room on the other side of the unit The facility unsubstantiated the allegation. An interview was conducted with CNA (Staff #161) on March 13, 2025 at 10:32 a.m., who stated that when she walked into the residents' room on February 26, 2024, Resident #284 was yelling something in Navajo at Resident #183. She further stated that Resident #183 was standing over Resident #284 with her fist raised, shaking her fist at Resident #284. The CNA reported that she immediately removed Resident #183 from the room. The CNA further stated that when she returned to the room, Resident #284 told her that Resident #183 struck her with her fist. The CNA said she reported the incident to the nurse on duty but could not remember who that was, and to the Executive Director (ED/Staff #64). The CNA stated that Resident #183 had been physical with staff in the past, and would have outbursts with any little thing setting her off. The CNA also reported that she would always have another CNA in the room with her when providing brief changes for Resident #183, because the resident would become physical. During an interview conducted with the Executive Director (ED/Staff #64) on March 13, 2025 at 11:43 a.m., she stated that Staff #116 reported that residents #284 and #183 were in an altercation and resident #284 was claiming to have been struck by Resident #183. She stated that she immediately started an investigation, and as a result of the investigation, the residents were placed into separate halls. The ED also stated that Resident #183 was relocated to a private room while Resident #284 had discharged home on March 29, 2024. A Policy and Procedure titled, Abuse Policy, stated the objective of the facility is to provide a safe haven for the residents through preventative measures that protect every resident's right to freedom of abuse. The policy also includes a definition of abuse as intimidation with resulting physical harm, pain, or mental anguish. The policy goes on to state that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to implement their abuse policy involving an allegation of abuse with two residents (#284 and #183) to law enforcement. The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated. Findings include: -Regarding Resident #183 Resident #183 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and history of falling. A comprehensive care plan dated January 18, 2024 revealed that Resident #183 had communication problems due to dementia. The care plan also revealed that she had impaired cognitive function due to dementia. -Regarding Resident #284 Resident #284 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, visual hallucinations, and urinary tract infection. Review of the facility's investigation report revealed that on February 26, 2024, Resident #284 told a Certified Nursing Assistant (CNA/Staff #161) that Resident #183 said something rude in Navajo and hit her in the chest. The facility interviewed staff and residents as part of the investigation. The investigation revealed that the state agency, ombudsman, family, and provider were notified. However, further review of the facility's investigation revealed no evidence that the allegation of abuse was reported to law enforcement. An interview was conducted with, CNA (Staff #161) on March 13, 2025 at 10:32 a.m., who stated that Resident #284 had told her that Resident #183 had struck her with her fist. The CNA said she reported the incident to the nurse on duty and the Executive Director (ED/Staff #64). During an interview conducted with the Executive Director (ED/Staff #64) on March 13, 2025 at 11:43 a.m., she stated that Staff #116 reported that residents #284 and #183 were in an altercation and Resident #284 was claiming to be struck by Resident #183. She stated that she immediately started an investigation, and reported to Arizona Department of Health Services, Adult Protective Services, and Ombudsman within the appropriate time frame. The ED also stated that she did not notify law enforcement of the abuse allegation, and was unable to explain why law enforcement were not notified. A Policy and Procedure titled, Abuse Policy, revealed that if abuse is witnessed or suspected the ED and witness who is reporting will notify: Adult Protective Services, Ombudsman, State Survey Agency, Law enforcement when applicable, and Facility Director of Nursing (DON). Suspected abuse will be reported in accordance with the timeframes and standards required by Centers for Medicare and Medicaid Services (CMS).

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure an allegation of resident (#183) to resident (#284) abuse was reported to all applicable state agencies. The deficient practice could result in further allegations of abuse not being reported. Findings include: -Regarding Resident #183 Resident #183 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and history of falling. A comprehensive care plan dated January 18, 2024 revealed that Resident #183 had communication problems due to dementia. The care plan also revealed that she had impaired cognitive function due to dementia. -Regarding Resident #284 Resident #284 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, visual hallucinations, and urinary tract infection. Review of the facility's investigation report revealed that on February 26, 2024, Residents #284 and #183 were found to be in in an altercation, with an allegation of abuse from Resident #284. The report also revealed that the state agency, ombudsman, family, and provider were notified. However, the allegation of abuse was not reported to law enforcement. Continued review of the facility's investigative report revealed the incident was not reported to Law enforcement. An interview was conducted with a Certified Nursing Assistant (CNA/Staff #161) on March 13, 2025 at 10:32 a.m., who stated Resident #284 had told her that Resident #183 struck her with her fist. The CNA stated that she reported the incident to the nurse on duty and the Executive Director (ED/Staff #64). An interview was conducted with the Executive Director (ED/Staff #64) on March 13, 2025 at 11:43 a.m., who stated that Staff #116 reported that residents #284 and #183 were in an altercation and resident #284 was claiming to be struck by #183. The ED stated that she immediately started an investigation, and reported to Arizona Department of Health Services, Adult Protective Services, and, the Ombudsman within the appropriate time frame. When asked if she reported to law enforcement, she said no that she did not have a note in the report that they were notified. The ED was unable to explain why law enforcement was not notified. A Policy and Procedure titled, Abuse Policy, stated if abuse is witnessed or suspected the ED and witness who is reporting will notify: Adult Protective Services, Ombudsman, State Survey Agency, Law enforcement when applicable, and Facility Director of Nursing (DON). Suspected abuse will be reported in accordance with the timeframes and standards required by Centers for Medicare and Medicaid Services (CMS).

Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated, when stored for residents' use. The deficient practice could increase the risk of foodborne illness. Findings include: -Regarding food labeling, dating and storage An initial kitchen observation was conducted on March 11, 2025 at 11:10 a.m. with the Dietary Manager (DM/staff #43). During the observation, the following items were found in the refrigerator not labelled and dated: -An apple juice in a clear pitcher with the lid -An orange juice in a clear pitcher with the lid -Cranberry juices in clear pitchers with lid -Roasted potatoes stored in a stainless-steel container and covered with the plastic wrap An interview was conducted on March 13, 2025 at 11:08 a.m. with the Dietary Manager (DM/staff #43). The DM stated that unlabeled prepared food have the potential risk for foodborne illness. Additionally, during the interview with the DM (staff #43) conducted on March 11, 2025 at 11:10 a.m., staff #43 explained that the unlabeled apple juice, orange juice, cranberry juice, and roasted potatoes where prepared this morning for the lunch. The DM stated that beverages, and roasted potatoes will be served today. Staff #43 said that all dietary staff were responsible for labeling, and dating food and drink items. During the initial kitchen observation on March 11, 2025 at 11:35 a.m., the [NAME] (staff #8) was seen discarding the unlabeled roasted potatoes into the kitchen dumpster. An interview with the [NAME] (staff #8) was conducted on March 11, 2025 at 11:35 am. Staff #8 stated that the roasted potatoes were prepared on March 10, 2025 and that it was not labeled. The Cook further stated, that's the reason why the roasted potatoes were being discarded. During an interview with the Director of Nursing (DON/ staff #180) on March 13, 2025 at 11:46 a.m., staff #180 stated that the food items in refrigerator should be labelled and dated. The DON further stated that the kitchen staff should not be storing unlabeled and undated beverages and food items due to potential risk of foodborne illness. Review of the facility policy titled Food Storage and Date Marking, 2018 revealed TCS (temperature control for safety) foods should be covered, labeled and dated if stored and not for immediate use. All foods will be checked to assure that foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable), or discarded, at the end of the day. Use by dates for TCS foods are 7 days or less of prep date.

Based on clinical record review, staff interviews, and policy review, the facility failed to maintain medical records that are complete and accurate in accordance with professional standards for 2 of 15 sampled residents (# 183, 284). The deficient practice could result in records that do not accurately and completely reflect the care and services provided to residents. Findings Include: -Regarding Resident #183 Resident #183 was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and history of falling. A comprehensive care plan dated January 18, 2024 revealed that Resident #183 had communication problems due to dementia. The care plan also revealed that she had impaired cognitive function due to dementia. A late entry change of condition summary note dated February 26, 2024 at 11:44 p.m., revealed that the resident was adjusting well to a new room. However, there was no evidence in the progress note regarding what the change of condition was or why the change of room was necessary. A change of condition summary dated February 29, 2024 revealed that Resident #183 continued to look for her keys and was roaming into other patients' rooms and attempted to open medication/wound carts. On March 7, 2024 a medication administration note indicated that the resident was combative to the staff. A daily skilled evaluation note dated March 7, 2024, revealed physical behaviors (hitting, wandering, etc.) The note indicated that the patient was placed on alert charting for physical behaviors toward other residents, and that the patient continues to wander in other patients' rooms. On March 15, 2024 a change of condition summary note revealed that the resident has some aggression when trying to redirect when she is doing something she should not be doing. Further review of the clinical record from January 9, 2024 to March 15, 2024, revealed no evidence that the provider was notified regarding resident's behaviors. Review of progress notes from February 26, 2024 to March 15, 2024 revealed no evidence of the allegation of abuse from Resident # 284, that Resident # 183 hit her, or that the provider and family had been notified. -Regarding Resident #284 Resident #284 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, visual hallucinations, and urinary tract infection. A change of condition summary, late entry note, dated February 26, 2024 at 11:46 p.m., revealed that resident shows no signs or symptoms of pain or discomfort or any abnormal behavior. Review of progress notes revealed no evidence that Resident #284 had reported an allegation of abuse regarding her roommate, Resident #183, or that the provider had been notified. A request was made for all documentation in the clinical record regarding the incident between Resident #183 and Resident #284. The facility provided a social services note dated February 27, 2024 at 4:02pm, which stated that social services talked with Resident #284's representative regarding the altercation between Resident #284 and her Roommate #183. Review of the facility's investigation report revealed that on February 26, 2024, Resident #284 told the Certified Nursing Assistant (CNA/staff #161) that Resident #183 said something rude in Navajo and hit her in the chest. An interview was conducted with a CNA (Staff #161) on March 13, 2025 at 10:32 a.m., she stated that, Resident #284 told her that Resident #183 struck her with her fist. The CNA said she reported the incident to the nurse on duty, and the Executive Director (ED/Staff #64). The CNA stated that Resident #183 had been physical with staff in the past. She also stated that Resident #183 would have outbursts, and any little thing would set her off. The CNA further reported that she would always have another CNA in the room with her when changing Resident #183's brief because Resident #183 would become physical. An interview was conducted with a Licensed Practical Nurse (LPN/Staff #34) on March 13, 2025 at 10:42 a.m. who stated that if there is a resident-to-resident altercation she would separate the residents and make sure they are safe, then she would contact the ED immediately. She also said that she would put a progress note into the clinical record, and in the risk management system. An interview was conducted with an LPN (Staff #47) on March 13, 2025 at 10:50 a.m., who stated that resident-to-resident altercations occur she would contact the ED and the nurse on call to assess any injuries. She also stated that she would document a change of condition progress notes in the clinical record and in risk management. An interview was conducted with the Director of Nursing (DON/Staff #63) on March 13, 2025 at 11:25 a.m., who stated that she expected nurses to document any reports of resident-to-resident altercations in progress notes, and complete a risk management incident report. She also stated that Social Services usually will follow up, and also complete a progress note in the clinical record. An interview was conducted on March 13, 2025 at 11:43 a.m., with the ED (Staff #64), who stated that she expected reports of allegations of abuse to be documented in progress notes that included what happened and who they contacted. She stated that she would also expect that the altercation would be documented in the risk management system. She further stated she expected that the resident-to-resident abuse allegation would be documented in the aggressor's chart. The ED reviewed both residents' progress notes and stated there was no evidence in either of the residents' clinical records regarding the incident. She further stated that possibly no nurse was involved and the report came directly from the CNA to the ED. The ED stated that CNAs do not chart in the clinical record. The ED stated the importance of having allegations documented in the clinical record because it alerts all shifts. Review of the policy titled, Documentation: Documenting and Charting, revealed any changes in the resident's medical, functional, or psychosocial condition, shall be documented in the resident's medical record.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#1 and #2) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Regarding resident #1 Resident #1 was admitted on [DATE] with diagnosis including displaced intertrochanteric fracture of the right femur, low back pain, unsteadiness on feet, hypertension, unspecified glaucoma, major depressive disorder-recurrent, insomnia, type 2 diabetes with neuropathy, muscle wasting and atrophy, abnormalities of gait and mobility, osteoporosis, repeated falls and urinary tract infection. A review of the admission MDS (minimum data set) dated January 6, 2021 revealed a BIMS (brief interview of mental status) score of 00, indicating severe cognitive impairment. -Regarding resident #2 Resident #2 was admitted on [DATE] with diagnosis including unspecified fracture of right femur, repeated falls, unspecified dementia, type 2 diabetes, monoplegia of upper limb, facial weakness, other cerebral infarction due to occlusion or stenosis. A review of the progress notes revealed an entry, that on January 28, 2021 an altercation took place between resident #1 and #2. It was noted that both residents were sitting in their wheelchairs prior to the altercation. It was further noted that a PTA (physical therapy assistant) was maneuvering resident #2 around the dining table and upon passing resident #1, resident #2 starting hitting resident #1 with her left upper extremity. It was noted that resident #2 kept hitting resident #1 and then resident #1 starting hitting back in self-defense. Staff (PTA) alerted other staff to the incident and the residents were separated. It was noted that the residents were assessed for injuries and none were present. The progress notes further revealed that an LPN (Licensed Practical Nurse/ staff #22) notified the previous ADON (Assistant Director of Nursing) and he called the Arizona State Board of Nursing, leaving a voicemail regarding the incident and that case managers and family members were notified. However, there is no documented evidence that the incident was reported to the state survey agency. An interview was conducted on October 22, 2023 at 2:15 P.M. with CNA (certified nursing assistant/ Staff #18). Staff #18 stated that abuse could be mental, financial, verbal, neglect or physical. She stated that the facility has annual training but also provides monthly training refreshers. Staff #18 stated that if abuse is observed between residents, the first thing that is done is to physically separate the residents and ensure their safety. Residents may need to be moved to another room, if they were sharing a room. She further stated that once residents are safe, notifications and an incident report would occur and that these are time sensitive and would need to happen right away. Stated that she had received training on abuse and behavioral health. A telephonic interview was conducted on October 22, 2023 at 2:50 P.M. with an LPN (Staff #22). Staff # 22 stated that she had recollection of the incident, but given that it was in 2021, no longer recalled the specifics of what had occurred. An interview was conducted on October 23, 2024 at 1:40 P.M. with staff #115 (LPN). Staff #115 stated that if an altercation occurred between residents, they are immediately separated and she and other staff would check to make sure they are safe and not injured. If additional assistance was needed, staff know to call for help. Once residents are safe, the director of nursing is notified and the facility proceeds with notifications of family, physician, case manager as well as filling a complaint report. She stated that she believed that the notification window was a 2-hour time span for incidents of abuse. Staff #115 further stated that the facility conducts training regarding abuse at least annually, but usually more frequently. An interview was conducted on October 23, 2024 at 8:30 A.M. with staff #28 , DON (director of nursing). Staff #28 stated that the expectation is that resident to resident abuse does not occur; however with certain diagnosis behaviors [NAME] always predictable. She further stated that when an incident does occur, the facility is required to report incidents on a timely basis and follow-up with a thorough investigation. She stated that the risk of resident to resident abuse could result in injury to a resident. A review of the facility policy entitled Abuse, with a copywrite date of 2022, version 0622 revealed that abuse is not condoned in Haven Health facilities.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to submit a 5-day written investigation summary regarding physical altercation between 2 residents (#1 and #2). The deficient practice could result in allegations of abuse not being investigated. Findings include: -Regarding resident #1 Resident #1 was admitted on [DATE] with diagnosis including displaced intertrochanteric fracture of the right femur, low back pain, unsteadiness on feet, hypertension, unspecified glaucoma, major depressive disorder-recurrent, insomnia, type 2 diabetes with neuropathy, muscle wasting and atrophy, abnormalities of gait and mobility, osteoporosis, repeated falls and urinary tract infection. A review of the admission MDS (minimum data set) dated January 6, 2021 revealed a BIMS (brief interview of mental status) score of 00, indicating severe cognitive impairment. -Regarding resident #2 Resident #2 was admitted on [DATE] with diagnosis including unspecified fracture of right femur, repeated falls, unspecified dementia, type 2 diabetes, monoplegia of upper limb, facial weakness, other cerebral infarction due to occlusion or stenosis. A review of the progress notes revealed an entry, that on January 28, 2021 an altercation took place between resident #1 and #2. It was noted that both residents were sitting in their wheelchairs prior to the altercation. It was further noted that a PTA (physical therapy assistant) was maneuvering resident #2 around the dining table and upon passing resident #1, resident #2 starting hitting resident #1 with her left upper extremity. It was noted that resident #2 kept hitting resident #1 and then resident #1 starting hitting back in self-defense. Staff (PTA) alerted other staff to the incident and the residents were separated. It was noted that the residents were assessed for injuries and none were present. The progress notes further revealed that an LPN staff#22 notified the previous ADON and he called the Arizona State Board of Nursing, leaving a voicemail regarding the incident and that case managers and family members were notified; however, there is no documented evidence that the incident was reported to the state survey agency. Given that the incident occured in 2021, several of the staff members who witnessed the incident are no longer with the facility An interview was conducted on October 22, 2023 at 2:15 P.M. with staff #18 CNA (certified nursing assistant). Staff #18 stated that abuse could be mental, financial, verbal, neglect or physical. She stated that the facility has annual training but also provides monthly training refreshers. Staff # stated that if abuse is observed between residents, the first thing that is done is to physically separate the residents and ensure their safety. Residents may need to be moved to another room, if they were sharing a room. She further stated that once residents are safe, notifications and an incident report would occur and that these are time sensitive and would need to happen right away. A telephonic interview was conducted on October 22, 2023 at 2:50 P.M. with staff #22, LPN (licensed practical nurse). Staff # 22 stated that she had recollection of the incident, but given that it was in 2021, no longer recalled the specifics of what had occurred. An interview was conducted on October 23, 2024 at 1:40 P.M. with staff #115 LPN (licensed pratical nurse). Staff #115 stated that if an altercation occurred between residents, they are immediately separated and she and other staff would check to make sure they are safe and not injured. If additional assistance was needed, staff know to call for help. Once residents are safe, the director of nursing is notified and the facility proceeds with notifications of family, physician, case manager as well as filling a complaint report. She stated that she believed that the notification window was a 2-hour time span for incidents of abuse. Staff #115 further stated that the facility conducts training regarding abuse at least annually, but usually more frequently. She stated that the risk for not reporting timely or conducting an investigation, could impact finding out what actually happened and requirements regarding timely reporting. An interview was conducted on October 23, 2024 at 8:30 A.M. with staff #28 DON (director of nursing). Staff #28 stated that the facility is required to report incidents on a timely basis and follow-up with a thorough investigation. She stated that the facility was unable to locate the 5-day investigation of the incident regarding resident #1 and resident #2 and that these records might be in storage. She stated that she was fairly certain that a 5-day investigative report would have been completed and that she would look in the facilities storage facility for the investigative report. She stated that if the 5-day investigation was not completed then the risk would include not knowing what actually transpired and not meeting timely reporting guidelines. On October 25, 2024 at 5:35 P.M. an email was received from the Executive Director, staff #42. The email noted that the facility was unable to find the 5-day investigative report regarding this incident. There was no evidence that the 5-day investigative summary had been submitted to the state survey agency. A review of the facility policy entitled Abuse with a copywrite date of 2022 version 0622 noted that the executive director will begin an investigation immediately and complete the incident investigation within 5-working days utilizing an abuse investigation packet. It was further noted that this summary is then sent to the state survey agency;

Based on observation, interview, and record review the facility failed to ensure that one resident (#3) received care for pressure ulcers consistent with professional standards when observed wound care assessments were not completed on a weekly basis. This had the potential for pressure ulcers for resident #3 to worsen. Findings include: Resident #3 was admitted on [DATE] with diagnosis including venous insufficiency (chronic-peripheral), pressure ulcer of the left heel (unstageable), pressure ulcer of the right heel (unstageable), acute posthemorragic anemia and cellulitis of the left lower limb. A review of the discharge MDS (minimum data set) dated March 10, 2021 revealed no BIMS (brief interview of mental status) score. A review of the physician orders revealed orders for daily wound care to both right/ left heels and posterior right/ left calf. Orders were further observed for physical and occupational therapy. An order dated March 10, 2021 was also observed for a consult for heel debridement. A review of the care plan revealed that the resident had a DTI (deep tissue injury) to bilateral heels and had the potential for further pressure ulcer development due to decreased mobility. The noted intervention included to access, record and monitor wound healing weekly and as necessary. It further noted that length, depth and width would be measured when possible and that all assessments would be documented. The care plan further revealed that the resident had limited mobility due to right hand and bilateral lower extremity contractures. The intervention included referral to physical and occupational therapy as well as monitoring and documentation of contractures forming or worsening. The electronic health record for the resident revealed a time span greater than 7-days for pressure ulcer documentation and assessment for the following assessments: January 25, 2021, February 4, 2021 and February 27, 2021. An interview was conducted on October 22, 2024 with staff #115, LPN (licensed practical nurse). Staff #115 stated that that skin assessments are conducted weekly and documented in the electronic health record. She stated that the risk for not completing the assessment or not completing it timely would include not knowing what is going on with the resident in relationship to wound care or the wound worsening. An interview was conducted on October 23, 2024 at 10:30 A.M. with staff #72 (ADON-assistant director of nursing and wound care nurse). Staff #72 stated that upon admission, residents with wounds are placed on weekly wound care rounds with the physician or nurse practitioner. She stated that assessments are conducted weekly but sometimes more often contingent on what is going on with the pressure ulcer. Staff #72 stated that the risk for not having assessments completed weekly would be contingent on the resident's comorbidities. She stated the facility now has a program in place called PUP (pressure ulcer prevention) and that this has been very helpful in reducing the number of facility acquired pressure ulcers. An interview was conducted on October 23, 2024 at 10:40 A.M. with staff #28 DON (director of nursing). Staff #28 stated that the expectation is that pressure ulcer and skin assessments be completed weekly, as per policy. She stated that wound care and more specifically pressure ulcers were current QAPI (quality assurance and performance improvement) measures for the facility. Staff #28 reviewed the residents electronic health record and confirmed that the assessments were not consistent on a week to week basis for resident #3. She stated that the risk for not conducting weekly assessments timely could include a worsening of the pressure ulcer or wound. Facility evidence, to include a performance improvement plan for the improvement of pressure ulcer and wound management in 2022 revealed that the facility was actively pursuing a reduction of incidences and severity of pressure ulcers and wounds, seeking to minimize the risk of infection to ensure consistent and proactive care for residents. The plan detailed appointment of a wound coordinator to oversee and monitor outcomes, discussion of high-risk residents in interdisciplinary meetings, a review of trends during quality assurance and performance improvement meetings, and development of a standardized protocols in measuring and documenting wound size, depth and condition. The plan further outlined proactive interventions, infection control measures, goals and outcomes as well as evaluation of the plan by data analysis and to further delineate areas for continuous improvement. The plan further included in-service documentation. Data collection was observed from March 2022 through May 2022. Analysis of the data revealed that there were facility acquired wounds and some wounds were noted to have gotten worse, with improvement of wounds noted upon replacement of the wound nurse and integration of the PUP (pressure ulcer prevention) program. Subsequent data for June, July and August of 2022 revealed a significant amount of healing with completion of weekly wound reports noted to be at 100% for the 3-month interval. A review of the facility policy entitled Skin/Wound Management: Pressure Injury Risk Assessment with an effective date of January 1, 2024 revealed that the resident is to be assessed at admission and that the risk assessment is to be completed weekly thereafter; however, facility documentation did not reveal evidence of consistent weekly assessments. Given the integration of the aforementioned performance improvement plan in 2022, this citation is noted to be for past non-compliance.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#71) was free from abuse of another. The deficient practice could result on resident being physically and psychosocially harmed by other residents. Findings include: Resident #71 was admitted on [DATE] with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness. The minimum data set (MDS) assessment dated [DATE] include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact. The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents. -Resident #46 was admitted on [DATE] with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism. The MDS assessment dated [DATE] revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment. A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off. Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night. A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive. A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents. A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound. A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on the nurse. In an interview conducted with a certified nursing assistant (CNA/staff #3) on December 14, 2023 at 2:21 p.m., the CNA stated that abuse can be verbal, emotional, physical, sexual, and financial. She stated that if a resident slaps another resident, it was abuse; and that, she would separate the residents and report the incident to the nurse. An interview was conducted on December 14, 2023 at 2:36 p.m. with a registered nurse (RN/staff #8), who stated that she has received training on abuse and if a resident slaps another resident, it was abuse. During an interview with the Executive Director (ED/staff #1) conducted on December 14, 2023 at 2:47 p.m., the ED stated that abuse can be verbal, physical, sexual, seclusion, mental, neglect, and financial; and that, it was abuse, if a resident slaps another resident. The facility's Abuse Policy stated that the facility strives to prevent the abuse of all their residents. The facility recognizes that care is provided for residents with the diagnosis of dementia and other mental illnesses whose behaviors are not always predictable. The facility further recognizes that due to the proximity of residents to one another and an individual's freedom of choice, that situations may arise where it is not possible to completely prevent all incidents of abuse.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to provide evidence that the an allegation of abuse for one resident (#71) was thoroughly investigated and results of the investigation was reported to the State Agency within 5 working days of the incident. The deficient practice could result on further abuse of residents and appropriate actions not taken. Findings include: Resident #71 was admitted on [DATE] with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness. The minimum data set (MDS) assessment dated [DATE] include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact. The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents. -Resident #46 was admitted on [DATE] with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism. The MDS assessment dated [DATE] revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment. A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off. Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night. A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive. A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents. A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound. A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on the nurse. Despite documentation of resident #46 slapping or swatting resident #71, there was no evidence found in facility documentation that this incident was reported and thoroughly investigated by the facility. In an interview conducted with a certified nursing assistant (CNA/staff #3) on December 14, 2023 at 2:21 p.m., the CNA stated that abuse can be verbal, emotional, physical, sexual, and financial. She stated that if a resident slaps another resident, it was abuse; and that, she would separate the residents and report the incident to the nurse. During an interview with the Executive Director (ED/staff #1) conducted on December 14, 2023 at 2:47 p.m., the ED stated that abuse can be verbal, physical, sexual, seclusion, mental, neglect, and financial; and that, it was abuse, if a resident slaps another resident. The ED further stated that when there is an allegation of abuse, the staff and residents should be interviewed and an investigation should be completed within 5 days and submitted to the state agency. However, the ED stated that she does not have a 5-day investigation for incident between residents #46 and #71. The facility's Abuse Policy stated that the facility strives to prevent the abuse of all their residents. The ED will begin investigation immediately and complete within 5 working days using the Abuse Investigation Packet. A minimum of three residents will be interviewed in order to determine if there is a trend. interviews may also include Alleged Perpetrator, witnesses and staff members as applicable. When the investigation is complete, the ED will submit a summary to the state survey agency.

Based on personnel record review, staff interview, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in not providing activities that meet the physical and psychosocial needs of the residents. Findings include: Review of the personnel file for the Activity Manager (staff #95) revealed staff #95 was hired on July 30, 2021 as a CNA (Certified Nursing Assistant) and promoted to the Activity Manager on June 10, 2023. Continued review of the file did not reveal documentation that staff #95 met the qualifications for the Activity Manager. Review of the 2016 Employee Job Description for Haven Health Group, version 0916 revealed the Activity Manager works under the direction of the Executive Director and is an active member of the Interdisciplinary Care Team. The Activity Manager directs the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion of the activity's component of the comprehensive assessment along with the comprehensive care plan goals and approaches. The Activity Manager oversees the direction of an activity program, which includes scheduling of activities; both individual and groups, and the implementation of such programs. The Activity Manager directs the monitoring of the residents' responses as-well as the evaluation of responses to the programs to determine if the activities meet the assessed needs. The minimum requirements are: background check, fingerprint clearance card, TB clearance, employee screening post hire and must be able to speak and understand English. However, the job description did not include the requirements for an Activity Manager. During an interview conducted on 10/05/23 at 8:37 AM staff #95 stated that she has been with the facility for two years and has become the Activities Manager about four months ago further stating that she does not have the activities Manager certification but that she will be taking the class soon. During the interview staff #95 stated that she works five days a week, Monday through Friday, does not have an activity assistant and does not have coverage for activities over the weekend. An Interview was conducted on 10/05/23 at 9:30AM with the Executive Director (ED, staff #58) the job description for Activity Manager was reviewed along with the resume for the Activities Manager (staff #95). Staff #58 agreed that the job description did not include minimum requirements, such as education/certification or experience, and staff #95's resume revealed no education/certification. Staff #58 agreed that staff #95 did not meet the requirements needed for the position as Activity Manager as per CMS regulation.

Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure that a resident (#39) had been assessed to self adminster medications. The deficient practice could result in resident not receiving medications needed to maintain or improve their physical health. Findings included: The resident (#39) was admitted to the facility on [DATE] with diagnoses that include: orthostatic hypotension, hypo-osmolality and hyponatremia, other specified diseases of blood and blood-forming organs, and acute kidney failure, unspecified. A review of the physician's orders revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ Give 3 tablet by mouth two times a day for hypokalemia until 10/15/2023. Review of the MDS (minimum data set) dated September 17, 2023 revealed a BIMS (brief interview of mental status) score of 14 indicating cognitive intactness. On October 02, 2023 at approximately 2:18 PM during the initial screening process a small clear cup containing what appeared to be a tablet of medication that had been broken in half was observed on the bedside table of resident (# 39). The Director of Nursing (DON, staff# 23) entered to room and observed the medication. The DON asked the resident if he would like to have the medication crushed and put into some applesauce. The resident advised the DON that he had tried that once and will never eat applesauce again. A suggestion of crushing the medication and placing it in some pudding was made and the resident stated that he would give that a try. The DON then removed the cup containing the medication from the room. The DON returned a short time later with some chocolate pudding and mixed in the medication that had been crushed after the DON left the residents room. The DON then proceeded to spoon some pudding out and give it to the resident. October 3, 2023 at approximately 10:25 AM an interview was conducted with DON (staff # 23). The DON was asked to explain the steps she took regarding the medication. The DON stated that upon entering the resident's room she saw the pills at beside. The DON stated that she took the medication directly to the nurse, Licensed Practical Nurse (LPN # 97), verified the drug and then crushed them. Brought medication back to the resident's room, mixed it with the pudding and administered to the resident. The DON states that their policy states that they do not leave medications at bedside. Protocol would be to conduct evaluation to determine self-administration. On October 4, 2023 at 1:20 PM an interview was conducted with LPN (staff #97). The LPN was asked to take the surveyor through the morning med pass with resident (#39). She advised that she is aware of this resident from previous admissions to the facility and that he has low potassium levels and had been prescribed potassium tablets. She further stated that the resident had told her that he was having trouble swallowing medications. She added that the resident took one pill and had difficulty swallowing it. She then stated that she offered the resident to crush the medications and put them in applesauce and the resident stated that he tried that once and will never eat applesauce again. The resident was offered to have the medications crushed and put into pudding and he declined this as well. She stated that the resident refused to have his medications crushed. She added she advised the resident of the importance of taking his medications and that the resident stated that he wanted to take them on his own time frame. The LPN stated that she cut the tablet in two to make swallowing easier for the resident and against her better judgement she left the medication at the resident's bedside as he stated that he would take it. Review of facility policy- Administering Medications-Policy Statement- Medications shall be administered in a safe and timely manner, and as prescribed. (2001 MED-PASS, Inc. (Revised December 2012)). Review of facility policy on Self-Administration of Medications: Policy Statement- Residents have a right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. (2001 MED-PASS, Inc. (Revised December 2016)) The evaluation for self-administration was conducted after the fact in this situation.

Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure that alleged violations involving abuse were reported within required timeframe for one resident (#13). This resulted in the allegation of abuse not being investigated. Findings Include: Resident #13 admitted to the facility on [DATE] with diagnoses that included sepsis, scoliosis, osteoporosis, acute kidney failure, and acute respiratory failure. In her current care plan there is a goal with appropriate interventions related to her limited physical mobility related to contracture. In a 30 day look back period Resident #13 needed extensive assistance from staff when transferring (moving from bed to wheelchair and vice versa for example) with one occasion of full staff performance September 22, 2023 at 4:00 PM. During an interview conducted on October 2, 2023 at 01:56 PM, Resident #13 said she had dignity concerns, and stated that a Certified Nursing Assistant (CNA) had put her in her wheelchair despite her saying no. She was not able to recall the CNAs name, but stated that she had had to crawl back to bed. She could not recall the exact date, but stated it had been a few weeks, but her daughter and medical power of attorney would know more. During an interview on October 5, 2023 with Resident #13's daughter at 9:35 AM, she stated that the incident had happened several weeks ago and she considered it abuse. She stated she had spoken to the nurse on duty as well as the front desk about the incident due to her mother calling her frequently about the incident and seeming to be in distress. The daughter stated she completed a grievance form and submitted it to staff. The daughter stated she followed up with the same staff, Staff #42, several days later because she had not heard any updates. She stated she was told because the incident was considered abuse which needed to be reported immediately after the incident, it had been reported to the administrator and that is who would follow up with her. She was told the administrator and resident relations manager were aware of the situation and it was being handled. During an interview at 10:45 AM on October 5, 2023 with Staff #42, staff stated that she had spoken with Resident #13's daughter regarding and incident of a CNA being rough with her. She stated she asked the daughter if she had put in a grievance form, assisted her with completing one, and placing it in the submission box outside social services. Several days later the daughter followed up with her and stated she had not heard anything from the management team by way of an update on her mothers alleged abuse. Staff #42 touched bases with Staff #8 again who stated that the administrator was working on it as an abuse case. Staff #42 stated Staff #8 told her they would follow up with the resident's daughter. Staff #42 further stated she did not recall the exact date, but this started the week of September 18th. She has not spoken with the daughter nor management regarding the incident since. During an interview with the administrator (staff #58) on Octobder 5, 2023 at 10:25 AM, she stated she did not speak directly to resident #13 or her daughter about abuse concerns. She stated grievances go to resident relations/social services, and if it is abuse, then it is handed over to her. Grievances are submitted in a drop box outside of her and resident relations manager's offices. Staff #58 stated the policy for reporting and investigating abuse is to within a 2-hour window of learning of the incident and begin immediate investigation. Any involved staff will be immediately suspended. During an interview on October 5, 2023 at 10:29 AM with Staff #8, she stated that if anyone reports a grievance, the process is to get details, complete grievance form, and then bring it to either Staff #58 or whichever department is implicated. Even if a person does not specifically state they want to file a grievance, she treats all complaints as such and will follow grievance procedure. Regarding Resident #13, she stated that a staff member told her approximately 2 weeks ago that the daughter wanted to speak with her. When she went to talk to her, she stated that the daughter was visiting with Resident #13 and never stopped by to talk to Staff #8 afterwards. She has not had any reports of abuse or grievances directly from Resident #13. During a follow up joint interview with the administrator (staff #58) and resident relations manager (#8), they mentioned the submission box was broken and in the process of being replaced during the time period of the allegation. However, when the box was broken there was a temporary sleeve there and it is checked every morning. A review of the facility grievance binder did not show the form alleging abuse submitted by Staff #42 and resident's daughter. A review of facility self-reports did not show submission of any abuse allegations for Resident #13 in the allegation time period. Surveyor reported allegation of abuse to the administrator during the survey and the facility completed self-report within 2 hours. The actual allegation of abuse related to this tag was not substantiated.

Based on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that a PASRR Level 2 referral was completed for one resident (#30). The deficient practice could lead to residents not receiving needed care and services. Findings include: Resident #30 was admitted to the facility on [DATE] with diagnosis of Dementia, Unspecified severity with mood disturbance and Major Depressive Disorder, single episode, severe with psychotic features. The resident had a PASRR Level 1 and 2 at that time. A review of the resident record revealed that resident #30 readmitted to the facility with a new diagnosis of Schizoaffective Disorder, unspecified. Further review of the clinical record revealed a completed level 1 PASRR dated February 2, 2021. The level 1 PASRR revealed that the resident had serious mental illness and a level 2 PASRR should be completed. No evidence of any further PASRR documentation was found in the resident clinical record. The facility has planned the level II PASRR dated December 22, 2020 with a revision on December 30, 2022 but not for the PASRR level II referral from February 2, 2021. The resident has a diagnosis of schizoaffective disorder, unspecified dated November 21, 2022 with no PASRR related for this diagnosis. The resident has a diagnosis of Major Depressive Disorder, single episode, severe dated October 30, 2020. A review of the August 10, 2023 quarterly minimum data set (MDS) was conducted. Section C revealed that the resident was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 10. Section N revealed that the resident is receiving an antipsychotic and antidepressant and that antipsychotics were received on a routine basis. A progress note from the Nurse Practitioner dated August 8, 2023 revealed that the following problems were reviewed:Major Depressive Disorder, Single Episode, Severe with Psychotic Features and Schizoaffective Disorder. An interview was conducted with a Registered Nurse (RN) (staff #23) and the Minimum Data Set (MDS) Coordinator, (staff #40) on October 3, 2023 at 3:18 PM. Staff #23 accessed the resident's medical record on PCC (point click care) and was not able to provide the PASRR level II for the resident. An interview was conducted with the Administrator, staff #58 on October 4, 2023 at 12:55 PM. Staff #58 stated that the facility does not have any documentation for the PASRR level II. Review of the facility policy Pre- Admission Screening and Resident Review (PASRR 2020, Version 0920) revealed that the facility was responsible to make referrals for a Level II PASRR. The policy further revealed that an updated PASRR Level I screening must be conducted for each resident in the facility who had a serious mental illness not less than annually.

Based on clinical record review, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I was updated appropriately for one resident (#47). The deficient practice could result in specialized services not being identified and provided to residents. Findings include: Resident #47 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, psychoactive substance dependence,, and chronic obstructive pulmonary disease with acute exacerbation. A Level I PASRR screening completed on August 11, 2023 included the attending physician had certified, prior to admission, that the resident would require less than 30 calendar days of nursing facility services and that the nursing facility must update the Level I at such a time it appeared the resident's stay would exceed 30 days. However, review of the clinical record did not indicate an updated PASRR had been completed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. On October 4, 2023 at 08:30 AM, an interview was conducted with the Resident Relations (staff #8), she stated that the admission department will obtain a PASRR from the transferring facility and that she doesn't obtain or complete the PASRR for admission as she is still new to her role with the facility. Staff #8 stated that if the resident is admitted longer than 30 days then she will update the PASRR and that her assistant will complete an audit for any residents who would need an updated PASRR pass 30 days. An interview was conducted on October 4, 2023 with [NAME] President of Clinical Operations (staff #84). She stated that she and staff #8 went through the resident's chart and reviewed the Level I PASRR completed on August 11, 2023. However, per staff #84, there is no updated Level I PASRR for the resident after the 30 days convalescent care. On October 4, 2023 at 09:06 AM an interview was conducted with the Director of Nursing (staff #23), who stated that Admissions will obtain the PASRR and if the resident has a new diagnosis of serious mental illness (SMI) or disability then a Level II PASRR will be sent to the state agency for the screening process. Staff #23 stated that from here on out they will invite social services in their Gradual Dose Reduction / Psychotropic medication regimen review as part of the plan of corrections in order to catch any new diagnoses that would prompt for a Level II PASRR or an updated Level I PASRR. Review of the facility policy titled, Pre-Admission Screening and Resident Review (PASRR), revealed that the facility will strive to verify that a Level I PASRR Screening has been conducted, in order to identify Serious Mental Illness (MI) and/or an Intellectual Disability (ID) prior to initial admission of individuals to the facility. PASRR Level 1 Screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for MI or ID. If the resident is positive for a potential MI or ID, a Level II Screening referral must be submitted.

Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure rehabilitation services were provided for one resident (#16) as ordered by the physician. The deficient practice could result in resident not receiving rehabilitation services needed to maintain or improve their physical health. Findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses including non-insulin dependent diabetes mellitus, coronary artery disease, and left below knee amputation. Review of record of Provider Progress Notes dated December 5, 2022 for resident #16 revealed Patient has great difficulty walking and standing, requires wheelchair, difficult to leave assisted living for appointments so seen in assisted living today. Denies other pedal or ankle concerns at this time. Denies recent falls or trauma. Feeling well, denies nausea/vomiting/diarrhea/ Review of record of Provider Progress Notes dated June 22, 2023 for resident #16 revealed Patient has great difficulty walking and standing, requires wheelchair, difficult to leave assisted living for appointments, so seen in assisted living today. Denies other pedal or ankle concerns at this time . Review of the resident #16 Care Plan Detail Review dated July 31, 2023 for impaired functional mobility revealed an intervention refer to therapy as necessary. For at risk for falls related to gait and balance problems revealed an intervention for physical therapy to evaluate and treat as ordered or as needed and physical therapy to evaluate for transfer training. For Activity of Daily Living Self Care Performance Deficit related to activity intolerance, impaired balance, and limited mobility revealed an intervention for physical therapy/occupational therapy evaluation and treatment as per physician orders. Review of Minimum Data Set (MDS) Section G- Functional Status dated August 21, 2023 revealed that resident #16 required extensive assistance with one-person assist with bed mobility, transfer, locomotion on unit, locomotion off unit, toilet use, and personal hygiene. Review of a physician order dated September 14, 2023 revealed an order for physical therapy evaluation and treat, occupational therapy evaluation and treat, speech evaluation and treat, and rehab potential - fair was created by Staff #17. A review of record revealed no documentation that physical therapy, occupational therapy, and speech therapy evaluation and treatment was started for resident #16. An interview was conducted with resident #16 on October 2, 2023 at 1:40 PM who stated should be receiving therapy for leg amputation. An interview was conducted on October 3, 2023 at 2:25 PM, with a Physical Therapy Assistant (PTA/Staff #102) stated resident received physical therapy 6 months ago, then restorative therapy took over for safe mobility and fall prevention. An interview was conducted on October 4, 2023 at 8:25 AM, with a Certified Nursing Assistant (CNA/staff #75) stated resident #16 had a left leg amputation, and with turning, changing brief, getting resident out of bed and transfer require two-person assist. Staff #75 also stated resident #16 follows command like rolling in bed while staff is performing care. Staff #75 stated resident #16 is still working with rehab therapy. Staff #75 stated resident said, was going to therapy, still wants to do therapy, and wants to walk again. Staff #75 does not know what day and time they take resident to therapy. Staff #75 stated she does not do restorative therapy. An interview was conducted with resident #16 on October 4, 2023 at 11:11 AM, who stated she has been in the facility for a year and a half, received therapy a while ago, and wanted to continue therapy. She stated the therapy department informed her that they had run out of funds. She stated her last therapy on her leg was last year. She also stated she had throat issues last year but never completed therapy. Resident stated she was supposed to learn how to walk but she is still in a wheelchair. An interview was conducted on October 5, 2023 at 11:04 AM with the Director of Nursing (DON/Staff #23). Staff #23 stated a Licensed Practical Nurse (LPN) or a Registered Nurse (RN) are authorized to take orders and write in the medical record, also therapist are given access to take orders. Medical Record transcribes orders into PCC (Point Click Care). Medical Record creates the order into PCC and orders are confirmed and activated by an authorized licensed individual. An interview was conducted on October 5, 2023 at 11:43 AM, Physical Therapist (PT/Staff #101) stated resident #16 received therapy services. Staff 101 was unable to recall dates resident #16 received the therapy services. Staff 101 stated therapy services are stopped if resident stop making progress, or if resident reach maximum potential, or resident met set goals. For instance, if resident is a minimal assist to stand, or the resident level is not improving, then the resident is taken off the therapy list. Staff 101 stated that quarterly screenings of residents are performed by talking to certified nursing assistant or nursing. If there is a decline from prior discharge from therapy services, then the resident is reengaged for another physical therapy evaluation. There is weekly meeting to discuss recommendation for discharge or for continue therapy based on resident plan of care and progress in resident plan of care. An interview was conducted with resident #16 on October 5, 2023 at 2:37 PM during a Resident Council meeting who stated she just saw therapy and evaluated her leg. The facility's policy on Medication and Treatment Orders, revised July 2016 included, Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record.

Based on observations, staff interviews, manufacturer manual, and policy reviews, the facility failed to ensure the dishwasher sanitation was monitored, kitchenware was clean and dry, and that the electrical cord and outlets above the tray line were clean. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding dishwasher sanitation During the initial kitchen observation conducted on August 15, 2022 at 10:03 a.m., a staff member was observed testing the chemical dishwasher machine. The test indicated that the sanitizer level was low. It should be between 50-100 parts per million (ppm). The dishwasher (staff #97) adjusted the bucket tubing and tested the chemicals twice before it yielded the appropriate result. He said they will get a technician to service the dishwasher machine. A second observation of the kitchen was conducted on August 17, 2022 at 8:50 a.m. During this observation, the dishwasher chemical resulted in a reading between 25-50 ppm. Staff #97 ran the machine again then tested a second time and the result was 50 ppm. A third observation specific to the chemical dishwasher was conducted on August 17, 2022 at 12:39 p.m. The dishwasher staff was instructed by the dietary consultant (staff #124) to prime the machine manually four times prior to running a load. The chemical test resulted in a reading of 50 ppm. On August 17, 2022 at 12:58 p.m., another dishwasher chemical test was observed. The result was 25 ppm. Another observation of the dishwasher chemical test was done on August 17, 2022 at 1:04 p.m. The chemical test was still at 25 ppm. The water temperature was 120 degrees Fahrenheit. On August 17, 2022 at 1:21 p.m., the facility stated that the technician was on his way to fix/calibrate the issue. On August 18, 2022 at 8:59 a.m., the dishwasher chemical test was observed. The test resulted in 100 ppm. The facility titled Cleaning Dishes/Dish Machine policy (2018) stated that prior to use, personnel should verify proper temperatures and machine function. Review of the installation and operation manual for the dishwasher dated December 5, 2007 stated chlorine titration should be between 50 and 100 ppm. Regarding clean and dry kitchenware During an observation of the kitchen conducted on August 17, 2022 at 8:40 a.m., a metal bowl which was pretty dented with a torn edge was stored with the clean stack. Additionally, a small rectangular metal container which was greasy and wet was stored on the ready to use shelf. Continued check of the items on that shelf revealed two large rectangular metal containers that were wet and a little greasy. An interview with the acting kitchen manager (staff #12) was conducted on August 18, 2022 at 9:27 a.m. He stated that the dietary aide assists the dishwasher in putting away dishes. Staff #12 stated both are responsible for visually inspecting the items are clean and free of debris prior to storing them for use. The facility policy regarding cleaning dishes/dish machine (2018) revealed kitchen staff should visually inspect all items for cleanliness during the unloading process. If the items are not clean then they should be re-washed. Items should be inspected for cleanliness and dryness. All flatware, serving dishes, and cookware will be cleaned, rinsed, and sanitized after each use. Regarding the electrical cords/outlets over directly above the tray line An observation was conducted of the kitchen on August 17, 2022 at 10:49 a.m. Two electrical cords with outlets were observed hanging down from the ceiling directly above the tray line. Both cords/outlets were very dusty. The outlet was coated in dust and grime. The cord was lined with dust from top to bottom. In an interview conducted on August 17, 2022 at 11:45 a.m., the acting kitchen manager (staff #152) stated dusting and deep cleaning occurs twice a month. He said that although there is not a cleaning log, there is a checklist on a laminated sheet that they use to ensure that the kitchen is being cleaned. The facility policy (2018) pertaining to general sanitation of the kitchen stated that food and nutrition services staff will maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.