Every finding on record at Haven of Lake Havasu

Based on interviews, observations, clinical record review, and review of facility policy and procedure, the facility failed to provide adequate supervision to prevent an accident for one (#97) of three sampled residents reviewed for accidents and supervision, resulting in an injury requiring hospital evaluation and treatment. The deficient practice could result in residents sustaining injuries due to inadequate supervision.Findings Include:Resident #97 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following nontraumatic subarachnoid hemorrhage affecting left non-dominant side, dysphagia following nontraumatic subarachnoid hemorrhage, morbid (severe) obesity, anxiety disorder, muscle weakness, unspecified abnormalities of gait and mobility, and cognitive communication deficit.A Wander Elopement Risk Evaluation dated May 20, 2026, revealed an assessed score of 5. The following risk factors were identified for wandering and elopement: resident exhibited or expressed fear and/or anxiety, admission to the facility within the last month, 1-2 major mental health diagnoses, taking anti-anxiety/hypnotic medication, and mobility with a walker or wheelchair.A Care Plan initiated on May 20, 2026 revealed that the resident was at risk for falls or had an actual fall. Interventions included anticipating her needs.An admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating that she was cognitively intact. The MDS further indicated Resident #97 had fluctuating disorganized thinking and fluctuating inattention.A focused care plan initiated on June 3, 2026 revealed that she had impaired cognitive function/dementia or impaired thought processes regarding hemiplegia and hemiparesis following subarachnoid hemorrhage. Interventions included monitoring, documenting, and reporting to the medical doctor any changes in cognitive function, specifically changes in decision-making ability, memory, recall, general awareness, ability to express herself, ability to understand others, level of consciousness, and mental status.Another focused care plan initiated on June 3, 2026 revealed that the resident had delirium or an acute episode of confusion regarding inattention and disorganized thinking. Interventions included reorienting her to person, place, time, and situation when appropriate.A progress note dated July 12, 2026, at 1:51 a.m. revealed Resident #97 was found on the floor in front of the toilet. Resident #97 stated she had been holding onto the bars in the bathroom when her left leg became weak and she sat on the floor. Resident #97 was assisted back to bed and a brief was applied. Resident #97 was instructed to use her call light when bathroom assistance was needed.A fall risk evaluation dated July 12, 2026, revealed a fall risk score of 7 and indicated no other falls had been reported in the previous 90 days and no cognitive or behavioral symptoms. Resident #97's balance was noted to be unsteady but able to stabilize without physical assistance. The evaluation also identified moderate vision impairment and 1-2 health condition risk factors. A progress note dated July 15, 2026, at 2:21 a.m. revealed Resident #97 was observed outside sitting on the ground in the parking lot. The resident was unable to explain why she was outside and stated she was trying to get back to her room. A large protruding bump was noted on the left side of her eyebrow with bruising to the left elbow. The note further revealed Resident #97 was sent to the emergency room at approximately 2:10 a.m.Hospital physician documentation dated July 15, 2026, revealed Resident #97 was brought to the emergency department by paramedics after falling from her wheelchair after striking a parked vehicle. The documentation indicated Resident #97 stated she had been cooped up in the nursing home, was tired of being cooped up, and had left the facility. Resident #97 reported that she was in a wheelchair in the middle of the night, left the nursing home, struck a parked vehicle, and fell from the wheelchair. The resident was able to recount the events and denied loss of consciousness. A CT scan revealed no evidence of acute hemorrhage. Resident #97 was discharged from the emergency department at 4:36 a.m.A Physiatry progress note dated July 15, 2026, at 10:32 a.m. revealed Resident #97 had been hospitalized following recurrent falls, dizziness, weakness, confusion, and left-sided neglect secondary to a right frontal intraparenchymal hemorrhage with associated subarachnoid hemorrhage. The note documented bruising to the left forehead/brow.A restraint device evaluation dated July 15, 2026, at 5:51 p.m. revealed a Wander Guard device was applied to Resident #97.A Health Status progress note dated July 16, 2026, at 3:46 a.m. indicated Resident #97 was on fall precautions and a Wander Guard had been placed on her right wrist.An interdisciplinary team fall review progress note dated July 16, 2026, at 12:01 p.m. revealed Resident #97 sustained a minor head contusion following a fall. The note documented that the resident had been observed outside sitting on the ground in the parking lot, was unable to explain why she was outside, stated she was trying to get back to her room, and had a large protruding bump on the left side of her eyebrow with bruising to her left elbow.On August 11, 2026, at 11:31 a.m, a telephone interview was conducted with Licensed Practical Nurse (LPN/Staff #11). The LPN stated Resident #97 had appeared normal earlier in the shift and routinely went to the cafeteria to obtain snacks or sat in the hallway. The LPN stated she observed Resident #97 going toward the kitchen and subsequently became concerned when the resident did not return. The LPN looked outside and initially did not see Resident #97, then looked again and observed the resident near the corner of the driveway. The LPN estimated Resident #97 had been outside for approximately five minutes. The LPN stated the resident was on the ground with her wheelchair off the curb and had a goose egg on her forehead. The LPN stated Resident #97 appeared confused and repeatedly stated she did not know what had happened. The LPN reported the incident to the DON and physician, and the physician directed that Resident #97 be transferred to the hospital. The LPN stated Resident #97 had not previously wandered or exhibited this behavior and that she was not receiving special monitoring for wandering. The LPN further stated the facility had an alarm system, but the doors were not alarmed, and she did not recall an alarm activating.On August 11, 2026, at 12:14 p.m., an interview was conducted with the Director of Nursing (DON/Staff #77). The DON stated the facility completed a Wander/Elopement Risk Evaluation upon admission and that a score of 5 was considered low risk. The DON stated Resident #97 was not considered at risk for wandering or elopement prior to the incident and had routinely gone outside during the day to obtain a doorbell and would return inside. The DON stated there were no restrictions on Resident #97 going outside at night because she was alert and oriented and had not previously demonstrated wandering or exit-seeking behavior.The DON stated interventions for residents identified as being at risk for elopement could include increased monitoring and use of a Wander Guard, depending on the resident's assessed risk. The DON stated Wander Guards were generally used for residents considered high risk. The DON stated intervention decisions were based on the individual resident's mobility, wheelchair use, BIMS score, mentation, and whether the resident was alert and oriented. The DON identified nursing staff and the DON as responsible for ensuring interventions were implemented.Regarding Resident #97's incident, the DON stated staff notified her after hearing the front door and that Resident #97 was assessed and subsequently sent to the hospital. The DON stated Resident #97 was scheduled to be discharged the following day and that she had not identified a change in condition related to the incident prior to the resident leaving the facility. The DON stated she had not reviewed camera footage because the available footage only went back approximately three days.The DON stated that staff were expected to know when Resident #97 entered the kitchen and were expected to recognize when she had not returned. The DON stated staff did not know where Resident #97 was after she left the kitchen. The DON stated Resident #97 independently wheeled herself from the kitchen to the parking lot. The DON stated the exterior doors were locked from the outside beginning at approximately 10:00 p.m., but could be opened from inside the facility. The DON stated all staff were responsible for knowing the resident's whereabouts. The DON estimated Resident #97 was unaccounted for approximately five minutes. The DON stated that when a resident is believed to be missing, staff are expected to search for the resident in accordance with the facility's elopement policy.The DON stated that following the incident, a Wander Guard was placed on Resident #97 on July 15, 2026, by nursing staff. The DON stated no additional Wander/Elopement Risk Evaluation was completed before the Wander Guard was applied and that the Wander Guard assessment was used in connection with the intervention. The DON stated staff were informed of the Wander Guard placement and that the intervention was added to the resident's care plan.When asked whether the supervision and monitoring provided to Resident #97 on July 15, 2026, was consistent with the resident's assessed needs and the facility's expectations, the DON stated it was. The DON stated Resident #97 routinely obtained a doorbell from staff and went outside without difficulty and that there had been no prior concerns with her going outside. The DON stated the resident was alert and oriented and that allowing her to go outside during the overnight hours met the facility's expectations.The DON further stated that following a fall, the facility implemented fall precautions, including three days of neurological checks, use of the call light, and a call, don't fall sign. The DON stated there had been no previous concern regarding Resident #97 going outside independently. The DON stated Resident #97 had experienced weakness in her legs when in the bathroom but had previously been able to independently use her wheelchair.The facility's Elopement Policy, revised December 2007, revealed that when an employee discovers that a resident is missing from the facility, the employee is to determine whether the resident is out on an authorized leave or pass. The policy further required staff to follow the facility's established response process for a resident who is missing from the facility.The facility's Falls/Fall Risk Policy, effective January 1, 2014, revealed that staff and the practitioner were responsible for reviewing each resident's risk factors for falling and documenting the findings in the medical record. Examples of identified fall risk factors included dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system.

Based on clinical record reviews, staff and resident interviews, review of facility documentation, and review of policy and procedures, the facility failed to protect the rights of two residents (#1 and #2) to be free from physical abuse by another resident. The sample size was 4. The deficient practice could result in the resident being in an unsafe environment. Findings Include: -Regarding Resident #1 Resident #1 was admitted on [DATE] with a diagnoses that included attention and concentration deficit, dysphagia, acute respiratory failure, muscle weakness, abnormalities of gait and mobility, and symbolic dysfunctions. A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 05, indicating severe cognitive impairment. A care plan initiated on February 4, 2025, had a focused area for the Resident #1 having behavioral problems related to taking others' belongings without permission and eating other people's food. It was further documented that he had inappropriate contact with other residents' belongings and pulling on clothing, given food to other residents without permission, refusing medication and care, and initiating a physical altercation with another resident. Interventions updated on March 23, 2026, included one-on-one with staff and an (STAT) immediate psychiatric consult, completed on March 21, 2026. A Health Status Note dated March 21, 2026, at 05:56 PM documented that Resident #2 reported Resident #1 punched him multiple times in the face and twisted his arm. Resident #1 was located in the dining room and denied the allegation. The note documented Resident #1 was placed on one-on-one care, and a STAT psychiatric consult was completed, with new orders obtained and carried out. It was further noted that a full skin check was completed, and the Resident #1 was placed on the alert charting. It was documented that the family was notified. A review of the physician order dated March 21, 2026, for alert charting for every shift for three days related to a resident-to-resident altercation. revealed that Resident #1 was checked for 3 days every shift due to a resident-to-resident altercation. Multiple telephone call attempts were made to Resident #1 and Resident #1's spouse on April 20, 2026 and both were unreachable. -Regarding Resident #2 Resident #2 was admitted on [DATE], with diagnoses that included palliative care, chronic obstructive pulmonary disease, chronic respiratory failure, chronic atrial fibrillation, asthma, adjustment disorder, insomnia, and cellulitis of the left finger. A quarterly MDS dated [DATE], revealed a BIMS score of 14, indicating the resident was cognitively intact. A care plan was initiated on January 06, 2023, with a focused area of behavior problems related to verbal and physical behaviors. It was further documented that verbal altercation with another resident, using profanity directed toward another resident, had occurred. It was noted that the resident and roommate are antagonizing and irritating one another with sarcastic comments. It was further noted that there was a verbal dispute with another resident and that he then struck resident in the head. The care plan noted that Resident #2 also had a history of spitting water on staff members, kicking legs towards the staff during attempts with brief check/change, as well as cursing at the staff. It was documented that the Resident would refuse a brief check and/or change. A weekly skin check and Wound assessment dated [DATE], revealed that Resident #2 had discoloration of the ring finger of the left hand. There was no evidence of other skin-related conditions or injuries. A health status note dated March 21, 2026, at 5:28 PM revealed that Resident #2 approached the nurses' station with a hematoma to the left eye and a large skin tear to the right forearm, as well as minor cuts to the nose, lip, and right hand, and bruising to the left hand. Resident #2 stated that Resident #1 entered his room and had punched him multiple times in the face, then grabbed his arm and twisted it. It was documented that another staff member approached at his time and dressed the wound while the writer called the administrator and looked for Resident #1. It was noted that resident #1 was located in the dining room. The note revealed that a staff member was assigned to sit one-on-one with Resident #1. The nurse practitioner (NP) was notified with an order to send Resident #2 to the emergency room (ER) for evaluation and the family was notified. A weekly skin check and wound assessment dated [DATE], revealed that Resident #2 had minor skin tear on the back of the right hand, bruise on the back of the left hand, hematoma to left eye, minor scab to left side of bridge of the nose, scab to mid bottom lip, right big toe was black, and that he a had skin tear on right outer forearm with steri-strips in place. A review of the physician order for alert charting for every shift for three days related to a resident-to-resident altercation dated March 21, 2026, revealed that Resident #2 was checked for 3 days every shift due to a resident-to-resident altercation. A review of the five-day investigative reports submitted on March 26, 2026, revealed that the Administrator (staff #6) reviewed the camera footage from March 21, 2026, which revealed Resident #1 went into Resident #2's room and came out within less than a minute, and it was confirmed that a physical altercation occurred in Resident #2's room. A request to review the Camera Footage for March 21, 2026, at 12:53 PM was made, but staff #6 stated that camera footage was not available as it was deleted after 72 hrs. An interview was conducted on April 20, 2026, at 1:19 PM with a Licensed Practical Nurse (LPN/ Staff #1), who stated she worked on March 21, 2026. Staff #1 stated that Resident #2 came to her at the nurses' station with a black eye and skin tear to his eye, and stated that Resident #1 came to his room and punched him and twisted his arm. The LPN stated that she immediately called for help, and another Nurse (Staff #2) helped her. She stated that Resident #1 was located in the dining area. She stated that he was interviewed, but did not remember the incident. The LPN further stated that she did not witness any verbal altercation between these two residents before the event. An interview was conducted on April 20, 2026, at 1:37 PM with a Licensed Practical Nurse (LPN/Staff #7), who stated that she did not remember the exact date, but when she was coming from her lunch break, Staff #1 asked her to check on Resident #1 to see if he was okay due to Resident #2 reporting that Resident #1 had hit him. She stated that she was not there to witness the incident, but Resident #2 stated that Resident #1 had punched him in the face multiple times, grabbed his wrist, twisted his arm, and that he felt a pop in his wrist, and Resident #1 then left the room. The LPN stated that before the incident, she did not observe that either of the residents had any verbal altercation. She also stated that when she saw Resident #2 he had a swollen eye and face and a bruise on his right forearm with laceration, and she applied a bandage to that area. The LPN stated that earlier in the day, Resident #2 did not have any injuries. She stated that after she assessed Resident #2, she notified the charge nurse, administrator, and police. She stated that after the notification, Resident #2 was sent to the emergency room for further evaluation. An interview was conducted on April 20, 2026, at 1:59 PM with Resident #2, who stated that Resident #1 twisted his arm and hit him in the face. Resident #2 stated that he received a black eye and that he broke his glasses, which caused him pain. He stated that he was unaware of why Resident #1 hit him, and he did not talk to him before this incident. Resident #2 further stated that he felt safe since Resident #1 had gone home. An interview was conducted on April 20, 2026, at 2:53 PM with DON (staff #5), who stated that Resident #2 sustained a black eye and skin tears as a result of the resident to resident altercation. Staff #5 stated the Administrator watched the video it was confirmed that Resident #1 went into Resident #2's room. She stated that this physical abuse occurred, and it did not meet her or the facility's expectations. An interview was conducted on April 20, 2026, at 3:06 PM, with the Administrator (Staff #6), who stated that Resident #1 went into Resident #2's room and hit Resident #2's face and then exited the room. He stated that he reviewed the Camera footage, and it was revealed that Resident #1 went to Resident #2, and a physical altercation occurred. The Administrator stated that these two residents did not have any previous altercations. He stated that a resident-to-resident altercation happened, which did not meet his or the facility's expectations. A Policy titled Abuse policy with a revision date of April 2022, revealed that the objective is to provide a safe haven for the residents through preventative measures that protect every resident's right to freedom from abuse.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure two residents (#36 and #40) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse. Findings include: -Regarding Resident #36: Resident #36 was initially admitted to the facility on [DATE] and has a reentry date of May 15, 2023 with a diagnosis that includes Coronary Artery Disease (CAD), Hemiplegia or Hemiparesis, Seizure Disorder or Epilepsy, and Schizophrenia. Review of care plan dated May 15, 2023 revealed resident have an impaired visual function related to blindness of right eye and refuses to wear glasses. The interventions initiated on May 15, 2023 included staff to place any items directly in front of resident. Review of another care plan dated May 15, 2023 revealed resident have impaired cognitive function/dementia or impaired thought processes related to impaired decision making. The interventions included resident need supervision/assistance with all decision making; require approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, written lists, and instructions; monitor/document /report to medical doctor any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status and review medications and record possible causes of cognitive deficit. Review of another care plan initiated in May 15, 2023 revealed resident have mood problem related to adjustment disorder, paranoid schizophrenia. The interventions initiated on May 15, 2023 included to administer medications as ordered, monitor/document for side effects and effectiveness; behavioral health consults as needed; monitor/record/report to medical doctor as needed risk for harming others such as increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons. Review of another care plan dated May 15, 2023 revealed resident have behaviors related to difficulty interacting with others related to schizophrenia. The goal is that resident will not harm self or others through the review date. The interventions initiated on May 15, 2023 included to administer medications as ordered, monitor/document for side effects and effectiveness, and allow resident to make decisions about own plan of care. Review of Minimum Data Set (MDS) dated [DATE] revealed a quarterly Brief Interview for Mental Status (BIMS) score of 14.0 indicating cognitively intact and behavioral symptoms were not exhibited. Review of facility document titled, Incidents By Incident Type, revealed Resident #36 had a Physical Aggression Initiated Incident on September 16, 2023 at 6:58 am. Review of the State Agency complaint tracking system dated September 16, 2023 revealed that the facility submitted through online complaint form involving resident #36 and resident #40 incident. -Regarding Resident #40: Resident #40 was admitted to the facility on [DATE] and has a reentry date of May 4, 2022 with a diagnosis of Hypertension, Diabetes Mellitus (DM), Hemiplegia or Hemiparesis, Anxiety Disorder, and Depression. Review of care plan initiated on February 12, 2021 revealed resident have impaired cognitive function/dementia or impaired thought processes related to neurological symptoms cerebrovascular accident. The interventions initiated on February 12, 2021 included administer medications as ordered, monitor/document /report to medical doctor any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, or mental status. Review of care plan initiated on September 24, 2021 revealed resident have a behavior problem related to physical behaviors, struck another resident in the back of the head, slapped nurse's hand when trying to give medications, upset about pain medication, called staff idiots, kicked carts and Hoyer lift, threw trash on the floor. The goal initiated on September 23, 2021 included resident will have no evidence of behavior problems by review date. The interventions initiated on September 24, 2021 included to anticipate and meet resident's needs. Review of MDS dated [DATE] revealed a BIMS score 0f 99.0 indicating resident was unable to complete the interview, and behavioral symptoms such as verbal directed towards others and physical symptoms not directed toward others occurred. Review of facility document titled, Incidents By Incident Type, revealed Resident #40 had a Verbal Aggression Initiated Incident on September 16, 2023 at 6:58 am. Review of the State Agency complaint tracking system dated September 16, 2023 revealed that the facility submitted through online complaint form involving resident #36 and resident #40 incident. Review of records revealed the care plan interventions for resident #40 were revised on October 23, 2024 that included assist resident to develop more appropriate methods of coping and interacting by not touching others inappropriately, and encourage resident to express feelings appropriately. Review of records revealed Resident #40 was discharged on February 4, 2025. An interview was conducted on March 31, 2025 at 3:39 pm with a licensed practical nurse (LPN)/Staff #104. Staff #104 stated that she works day shift, her responsibilities included getting report from the night shift which includes residents' updates, new orders, and anything that might had happened during the night. Staff #104 stated that she put eyes in every room so everyone is accounted for. Then, she starts medication pass, or starts her assessment. Regarding resident to resident altercations, Staff #104 stated that she had a resident to resident altercation that she remembered. It involved somebody running into somebody, both residents were confused, and the residents run into each other's wheelchair, then the resident slapped each other's arm or pushed their wheelchair away. Staff #104 stated that she remembered a woman and a male resident, the male resident run into the woman resident with his wheelchair. Staff stated that she remembered resident #40. Staff #104 stated that there was music playing and she remember resident #40 was trying to get through and resident #36 was in the way. Staff #104 stated that resident #40 uses his foot to kick resident #36. Staff #104 stated that the male resident is no longer in the facility, passed away. Staff #104 stated that she does not remember exactly but somebody got hit, then they separated them, and then she did an interview to find out each resident's side of the story. Staff stated that she was working when the incident happened, she completed an incident report, she notified the family and the doctor, and she assessed both of the residents. Staff stated that there was a slap or a kick but she did not remember who did what but there was a physical contact. Resident #40 would kick because that was his thing and Resident #36 would slap, and there has been incident before where resident #36 doing the slap. Staff #104 stated that when an altercation between residents happens, she will notify the administrator, doctor, family, and the director of nursing (DON). Their abuse coordinator is the administrator. In addition, staff #104 stated that when she completes an incident report, it will automatically send to the progress notes because she completes an incident report in their Point Click Care (PCC) for risk management. Regarding her abuse training, she gets in-services, she had some done in the computer, and also done in -house where they go over the training. Her abuse training is done every year. Attempted to conduct an interview on April 1, 2025 at 1:20 pm with Resident #36. Resident #36 was in her room, lying in bed, watching television, the lunch tray at the bedside, and resident just looked at the surveyor. Review of facility's policy titled, Abuse Policy, version 0622 revealed Haven Health facilities strive to prevent the abuse of all their residents. Review of facility's policy titled, Resident Rights/Dignity: Resident Rights, in effect on January 1, 2024 revealed (1) federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#9, #228) were adequately supervised in order to prevent accidental falls; and, failed to ensure items in the environment that could be utilized unsafely were stored away from one resident (#31). The deficient practice resulted in two residents being physically harmed. Findings include: -Resident #9 was admitted on [DATE]. Resident was discharged to hospital March 8, 2023 and was readmitted on [DATE] with diagnoses that included age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with routine healing, Alzheimer's disease, unspecified dementia, unspecified severity, with other behavioral disturbance, and need for assistance with personal care. A review of the MDS (minimum data set) dated January 19, 2023 revealed a BIMS (brief interview of mental status) score of 01, indicating that the resident had severe cognitive impairment. Further review of the MDS revealed that the resident required extensive assistance with bed mobility, transfers total dependence with two staff assist and eating, supervision with one person assist. Review of the Admission Fall Risk Evaluation dated January 18, 2023 revealed resident #9 assessed as a high risk with a score of 20.0. Further review of the assessment revealed resident had a history of falls. A review of the resident's care plan revealed a focused note that the resident was at risk for falls related to confusion and unawareness of safety needs. Further review of the care plan revealed staff was to follow facility fall protocol. The focus and interventions were initiated on January 18, 2023 and cancelled March 10, 2023. A review of the physician's orders revealed an order for fall mats every shift for falls, rolling out of bed, patient safety with an order date of April 23, 2022 and a start date of April 24, 2022. The order was discontinued without any new orders for fall mats. A review of the progress notes revealed that on March 8, 2023 at 6:45 P.M. resident #9 sustained a fall on March 8, 2023 at 6:45 PM with major injury femur fracture. Documentation revealed the events surrounding this fall: Resident was last noted to be sitting in an upright position in bed. She had her tray with food (dinner) in front of her when the NA left the room. Approximately 15 minutes after the NA left the room it was reported that the resident had an unwitnessed fall out of bed. Resident denied head strike, however complained of hip pain and knee pain on the left side. The immediate interventions placed post-fall were Physical assessment completed including range of motion, neuro check, and vital signs. Resident complained of left hip and knee pain. EMS called to send resident out to ER for further evaluation. Family member, MD, DON, and ED notified. This fall was discussed as an Interdisciplinary Team (IDT) and the following new interventions were placed as a result of this discussion: Call light within reach, floor mats down on the floor, Vital signs obtained, physical assessment completed, EMS contacted and transferred resident to the hospital for further evaluation. Medical records revealed an investigation of the fall was completed by the IDT with the following results: Resident is a known fall risk who has fallen on several occasions in the past. She is also known to be impulsive at times, which has led to previous falls. The resident was sitting up in bed, eating. The NA was last noted to be in the room approximately 15 min prior to the fall assisting her with her meal. The resident complained of left knee and hip pain, EMS was called to send the resident out for further evaluation. At 1145am the facility received documentation from the hospital. A review of the emergency department physician note dated March 8, 2023 at 8:07 P.M. revealed resident #9, presenting to the emergency department today after a ground level fall complaining of bilateral knee pain, left arm pain and right-hand pain. She states that she was trying to transfer from her bed to a recliner when she stood up and put weight on her knee she felt them buccal she could not catch herself and fell forward hitting both of her knees straight down onto the floor. A review of the hospital progress notes date of service March 11, 2023 revealed resident #9 presented after a ground level fall. The progress note states resident was trying to transfer from her bed to her recliner and had a mechanical fall. No reports of head trauma. Workup in the ER was significant for a posterior lateral left femoral spiral fracture. Following consultation resident was determined too high risk for procedure and non-operative management was recommended. The report states resident has a history of dementia, alert and oriented only to self and not decisional. A review of the facility 5-day investigation revealed that resident # 9 had been sent to the hospital post fall and returned to the facility. It was noted that the resident did not have surgery for the incurred posterior lateral left femoral spiral fracture. The report further revealed that the facility conducted an IDT Fall Review March 9, 2023 implementing new interventions that included; call light within reach, floor mats down on the floor. Furthermore, the report indicated that resident #9 is a known fall risk who has fallen on several occasions in the past and is known to be impulsive at times, which led to previous falls. The report also states the care plan was updated and fall risk assessment completed. A review of the facility internal fall incident report dated March 8, 2023 revealed a nursing description of resident #9 observed on floor on top of mats, on her back, Resident complained of knee pain, the resident description reveals resident stated she fell out of her bed; and that, both knees hurt. An interview was conducted on February 14, 2025 at 11:04 A.M. with Licensed Practical Nurse (LPN/Staff #48) who stated that resident #9 is a fall risk and current preventative measures are: the Falling Leaf program and is provided with a Geri-Chair for positioning, floor mat and bed against the wall. Staff #48 stated that the resident is prescribed a psychotropic which placed her at an increased risk for falls. Staff #48 stated that a leaf is placed on the resident's door indicating the resident is a fall risk for staff. Staff #48 stated the nurses access the resident's care plan for the residents fall risk measures and these measures are shared with facility's staff. An interview was conducted on February 14, 2025 at 11:28 A.M. with Certified Nursing Assistant (CNA/staff # 460) who stated she was familiar with resident #9 and recalled the resident falling and sustaining a femur fracture. Staff #460 stated that resident #9 had fallen a couple of times prior to the fall with the fracture. Staff #460 recalled going into the resident's room and finding the resident on the floor, dinner tray pushed away and complaints of pain on both knees. Staff #460 stated that the resident was a set-up assist with meals and preferred to eat in bed. Staff #460 stated resident was found on her back at the end of the resident's bed, with the resident's head away from the bed and the resident's feet at the end of the bed. Staff #460 stated the resident's Geri-Chair was against the wall by the door approximately three feet away. Staff #460 stated resident #9 was a fall risk at the time with a lowered bed. Staff #460 stated there was no fall mat beneath the resident's bed. Staff #460 stated the resident was not consistent with the use of her call light due to her confusion and would forget that the call light was there. An interview was conducted on February 14, 2025 at 12:43 P.M with Director of Nursing (DON/Staff #388) who stated residents are assessed for falls upon admission, quarterly, and after any fall. Staff #388 stated the facility's fall risk protocol had different levels including from the resident assessment, to determining what interventions are needed for the resident. Staff #388 stated that the current fall risk protocol for the resident is ensuring the call light is within reach, non-skid socks, educate and encourage the resident, and fall risk protocols to be in place. Staff should familiarize with the care plan for the interventions for each resident. An interview was conducted on February 14, 2025 at 01:05 P.M. with [NAME] President of Clinical Operations (VP/Staff #438) who reviewed the residents care plan on the electronic medical records. Following the review, stated that the facility did have a previous extensive fall care plan prior to the residents discharge for two days. The discharge resolved the previous care plan and when the resident was readmitted the facility failed to put the care plan back in place for resident #9. Staff #438 further stated, maybe if the care plan was in place for falls, she may not have had an injury. -Resident #31 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care, unspecified sequelae of cerebral infarction, and nontraumatic intracerebral hemorrhage in hemisphere, unspecified. A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated resident was cognitively intact. MDS revealed impairment on one side for the resident's upper and lower extremities, dependent with showers and bathing and requires substantial/maximal assistance with personal hygiene. A review of the care plan date initiated April 18, 2024 revealed a focus for impaired thought processes related to short term memory loss. Interventions included consistent routines. An observation was made on February 11, 2025 at 2:11p.m of resident #31's room which revealed on the counter was 100ml of normal saline and container of 75 large bleach PDI-Sani Cloths. An interview was conducted on February 11, 2025 at 2:14p.m with Certified Medication Assistant (CMA/Staff #120). Staff #120 stated the identified items should not be at the residents bedside, that the bleach wipes are used to wipe down counters for residents diagnosed with Clostridium Difficile Colitis (C-Diff). Staff #120 stated resident #31 did not and has not been diagnosed with C-Diff and does not know why the items would be in his room. Staff #120 stated the risks of having them in the room is the resident could mistake them for wipes and the skin would become affected and tingly from the bleach content and if the saline is ingested could cause an allergic reaction or possible death. An interview was conducted on February 13, 2025 at 12:53 P.M with Director of Nursing (DON/Staff #388) Staff #388 who stated the bleach cloths and the normal saline should not be at a residents bedside. Staff #388 stated the bleach cloth are used for resident with C-Diff and the risks are the residents could get sick; and that, the saline solution could make soeones stomach hurt. 51239 -Resident #228 was admitted on [DATE] with diagnosis including hemiplegia, hemiparesis, displaced intertrochanteric fracture of left femur, and history of falling. A care plan initiated on November 04, 2022, revealed a fall risk focus with a goal to be free from falls through the review date. Interventions included to ensure the call light was within reach and encourage the resident to use the call light for assistance as needed. Further review of the care plan revealed that four interventions were initiated on November 08, 2022 which included: anticipate and meet needs, educate resident/family/caregivers about safety reminders and what do if a fall occurs, follow facility fall protocol, PT (physical therapy)/OT (occupational therapy/ST (speech therapy) evaluate and treat as ordered or PRN (as needed). The care plan revealed a fall risk intervention that was initiated on November 14, 2022 included to follow the falling leaf program. A fall risk evaluation completed on November 07, 2022, revealed that Resident #288 had 1-2 falls within six months and is a moderate fall risk. A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. Additionally, MDS revealed resident had the need for substantial/maximal assistance. A physician order dated November 14, 2022, was initiated to transfer the resident to the emergency room for evaluation of fall with left hip pain. An occupational therapy (OT) treatment encounter note dated November 14, 2022, revealed that socks and shoes were removed and that the resident required maximum assistance. The note also included that the resident was left unsupervised when calling maintenance to fix a bed, and that the resident was later found lying on the floor. A nursing progress note dated November 14, 2022 at 2:50pm, revealed that a Registered Nurse (RN) called the hospital for report and the hospital confirmed that an x-ray indicated that the resident sustained a left intertrochanteric displaced fracture; and that, the Director of Nursing (DON), Executive Director (ED), Physician, and Spouse were notified. A fall incident report dated November 14, 2022 revealed that the resident was calling for help and was found on the floor in supine position in front of a chair in her room. The immediate action taken was to notify administration, the provider, and the resident's spouse. The incident report included that a gait belt was in place but the resident was not wearing shoes or non-skid socks at the time of the fall. The report indicated the resident complained of left hip pain, sustained a skin tear to the left elbow during a fall out of a chair. The report also revealed that the resident stated, some blonde put me in that chair and I fell out. The incident report revealed predisposing factors that included improper footwear. A fall risk evaluation dated November 14, 2022, revealed that the resident had 1-2 falls within the last 6 months and was a moderate risk for falls. The evaluation included a gait analysis the indicated the resident is unable to independently come to a standing position. An x-ray report results dated November 14, 2022 2:13 PM, revealed a minimally displaced left trochanteric Femur fracture. A late entry Interdisciplinary Team (IDT) Fall review progress note dated November 15, 2022, revealed that the resident fell on [DATE] at 10:10 AM with major injury of a left intertrochanter fracture. The progress note indicated that a Nurse was alerted to the room because the resident was calling out for help, and that the resident was noted to be lying on the floor in a supine position in front of a chair. The progress note revealed that the resident was noted with a gait belt in place, without non-skid socks or shoes, and the call light was in reach. The IDT note revealed that the resident complained of pain and had shearing to the left elbow. The progress notes further revealed that the resident was transferred to the hospital for further evaluation. Review of the hospital report dated November 22, 2022, revealed that that the resident had a minimal displaced pelvis with intertrochanteric fracture of the left proximal femur, per x-ray results. A facility investigation report dated November 21, 2022, revealed that the resident fell out of a chair in her room and sustained a left intertrochanter displaced fracture. The facility investigation report also revealed that non-skid socks, and shoes were taken off of the resident before the fall occurred. The report included interviews of 5 staff members, and (#434, #432, #436, #435, #75), who confirmed that the resident was not wearing the non-skid socks at the time of the fall. The report relayed that an OT was interviewed and during the resident's time in the chair the OT had checked on the resident and the bed's safety. The report further revealed that it was unknown if the resident tried to ambulate or slipped out of the chair. However, the resident was found on the floor without shoes or socks. The report included that the Director of Rehabilitation transferred the resident using a gait belt to a side chair because she was anticipating the resident's bed to be fixed by maintenance, and that the resident had refused to use a wheelchair, with the call light in reach. The report concluded that there was no evidence of neglect or abuse with regards to the incident. However, the report included that the resident was found on the floor without shoes or socks. An interview was conducted on February 12, 2025 at 02:47 PM with Certified Nursing Assistant (CNA/Staff #440), who stated that when a fall occurs the nurse is radioed to assess the resident, and the CNA will stay with the resident until a nurse arrives to the room. She also stated that the nurse will inform the CNA if the resident is ok to transfer after the assessment has been conducted. The CNA further stated that residents are transferred using either a gait belt or a hoyer lift depending on the resident. Staff #440 stated that preventative measures for residents that are moderate risk for falls included floor safety mats at the bedside, safety wedges in bed, and a chair cushion that prevents from the resident from sliding out of the chair, call light in place, and no clutter in room. She stated that the resident cannot be transferred barefoot and should be wearing non-skid socks. An interview was conducted on February 13, 2025 at 08:07 AM with a RN (staff #400), who stated when a fall occurs the resident is assessed, they make sure the resident is safe, notify the DON, charge Nurse and then document the incident. She also stated that fall prevention measures include having the bed on the floor, using a sitter, or having a family member with the resident, falling leaf program, leaving the call light in reach, using socks with grippers, and not leaving the resident alone. The RN further stated that residents who sustain a fall will be placed on the falling leaf program, and that the resident should not be barefooted or transferred without non-skid socks. An interview was conducted on February 13, 2025 at 08:20 AM with DON (staff #388), who stated the resident should not be barefoot, that they cannot force residents to wear shoes, but the encourage/educate them as to why they should not be barefooted. She also stated that the risk of residents that are a fall risk not be wearing non-skid socks could result in slipping and falling. The RN relayed that she would want the resident to wear non-skid socks. An interview was conducted on February 14, 2025 at 11:14 AM with Housekeeping (Staff #75), who stated that when she witnesses a resident laying on the floor she would call the CNA or a Nurse, and stay with the resident until the nurse or CNA arrives. She also stated that housekeeping staff are not allowed to touch or move the resident. The housekeeper stated that she did not remember the resident or the fall incident. An interview was conducted on February 14, 2025 at 12:28 PM with the Director of Rehabilitation (staff #435), who stated that she has not worked at the facility for the past 2 years. She further stated that she did not remember the resident or the incident, and has no access to the facility records at this time. On February 14, 2025, three attempts were made to contact two previous staff members (#434 and #432) who were at the facility on the day the resident fell , however neither staff member answered their phone and no call back was received. Review of the facility orientation training, Clinical Orientation Day 1: Resident Safety, revealed that regarding fall prevention included the use of the falling leaf program that identified high fall risk resident with a green arm band and green leaf of tree magnet on the door frame, and is also identified in both the Kardex and care plan. The training also included the use of proper fitting clothes and shoes correct use of positioning, devices, wheel chairs. Review of a facility policy titled, Resident Safety: Safety and Supervision of Residents, revealed that employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. The resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks that shall include communicating specific interventions to all relevant staff, carrying out interventions, ensuring interventions are implemented and documenting interventions. Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently. Resident supervision is a core component of their approach to safety. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our facility-oriented approach to safety addresses risks for groups of residents. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/ accident data; and a facility-wide commitment to safety at all levels of the organization.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure advance directives were completed and maintained for one resident (#31). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care, unspecified sequelae of cerebral infarction, nontraumatic intracerebral hemorrhage in hemisphere, unspecified. A physician's order dated December 23, 2024 was written for DO NOT RESUSITATE -DNR without hold or end date; A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated resident was cognitively intact. Review of the Care Plan revaled a focus for advanced directives date initiated November 17, 2022 with a goal that the residents wishes and directions will be carried out in accordance with his advanced directives on an ongoing basis through the next review date. Interventions included: Carry out my wishes according to my advanced directives, Ensure my wishes are recorded correctly in my chart, and follow physicians order. This care plan intervention was intitated on November 17, 2022. An observation was made on February 11, 2025 at 5:01 pm of the resident medical chart, revealing an undated Pre-Hospital Do Not Resuscitate (DNR) form, no physician or patient signature. An interview was conducted on February 13, 2025 at 11:24 a.m. with Resident Relations Manager (Staff #145) who stated that her responsibilities included discharge planning, resident grievances, and attending family conferences. Staff #145 stated that the orange colored Pre-hospital DNR form and the advance directive are designated forms for residents who have made their choices for DNR. Staff #145 stated that the documents need to be signed and dated by the physician, resident or designated power of attorney. Staff #145 reviewed the orange Pre-Hospital DNR form uploaded in resident #31's medical chart. Following review of the DNR document, staff #145 stated on the date line, there is only the month; no date or year, further missing resident signature and the physician information is not filled out, signed, or dated. Staff #145 stated the risks of having an incomplete DNR form places the resident at risk of being provided with treatment that the resident did not want and may result in legal issues. Staff #145 stated a new DNR form should be uploaded into the resident's medical chart. An interview was conducted on February 13, 2025 at 12:43 p.m. with the Director of Nursing (DON/Staff# 388), who confirmed that residents advance directives documentation are uploaded. The DON reviewed the residents DNR advance directives in the medical chart stating there are new forms in the a binder that should have been uploaded into the residents records, however after further review of the DNR documents the forms were incomplete. DON stated that the risks for the resident are that they may be provided with the wrong care. Review of the facility policy titled, Residents 'Rights- Advance Directives' revealed, Advance Directives will be respected in accordance with state law and facility policy; The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive; The resident's attending provider will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes.

Based on observation, clinical record review, staff interviews, and facility policy and procedures, failed to ensure a care plan was developed with interventions implemented related to fall risks for one resident (# 9); and, failed to ensure a care plan was developed with interventions implemented related to self-administration of medications for one resident (#25). The deficient practice could result in residents needs not being met according to their assessed needs. Findings include: -Resident #9 was admitted on [DATE]. Resident was discharged to hospital March 8, 2023 and was readmitted on [DATE] with diagnoses that included age-related osteoporosis with current pathological fracture, left femur, subsequent encounter for fracture with routine healing, Alzheimer's disease, unspecified dementia, unspecified severity, with other behavioral disturbance, and need for assistance with personal care. A review of the MDS (minimum data set) dated January 19, 2023 revealed a BIMS (brief interview of mental status) score of 01, indicating that the resident had severe cognitive impairment. Further review of the MDS revealed that the resident required extensive assistance with bed mobility, transfers total dependence with two staff assist and eating, supervision with one person assist. Review of the Admission Fall Risk Evaluation dated January 18, 2023 revealed resident #9 assessed as a high risk with a score of 20.0. Further review of the assessment revealed resident had a history of falls. A review of the resident's care plan revealed a focused note that the resident was at risk for falls related to confusion and unawareness of safety needs. Further review of the care plan revealed staff was to follow facility fall protocol. The focus and interventions were initiated on January 18, 2023 and cancelled March 10, 2023. A review of the physician's orders revealed an order for fall mats every shift for falls, rolling out of bed, patient safety with an order date of April 23, 2022 and a start date of April 24, 2022. The order was discontinued without any new orders for fall mats. A review of the progress notes revealed that on March 8, 2023 at 6:45 P.M. resident #9 sustained a fall on March 8, 2023 at 6:45 PM with major injury femur fracture. Documentation revealed the events surrounding this fall: Resident was last noted to be sitting in an upright position in bed. She had her tray with food (dinner) in front of her when the NA left the room. Approximately 15 minutes after the NA left the room it was reported that the resident had an unwitnessed fall out of bed. Resident denied head strike, however complained of hip pain and knee pain on the left side. The immediate interventions placed post-fall were Physical assessment completed including range of motion, neuro check, and vital signs. Resident complained of left hip and knee pain. EMS called to send resident out to ER for further evaluation. Family member, MD, DON, and ED notified. This fall was discussed as an Interdisciplinary Team (IDT) and the following new interventions were placed as a result of this discussion: Call light within reach, floor mats down on the floor, Vital signs obtained, physical assessment completed, EMS contacted and transferred resident to the hospital for further evaluation. Medical records revealed an investigation of the fall was completed by the IDT with the following results: Resident is a known fall risk who has fallen on several occasions in the past. She is also known to be impulsive at times, which has led to previous falls. The resident was sitting up in bed, eating. The NA was last noted to be in the room approximately 15 min prior to the fall assisting her with her meal. The resident complained of left knee and hip pain, EMS was called to send the resident out for further evaluation. At 1145am the facility received documentation from the hospital. A review of the emergency department physician note dated March 8, 2023 at 8:07 P.M. revealed resident #9, presenting to the emergency department today after a ground level fall complaining of bilateral knee pain, left arm pain and right-hand pain. She states that she was trying to transfer from her bed to a recliner when she stood up and put weight on her knee she felt them buccal she could not catch herself and fell forward hitting both of her knees straight down onto the floor. A review of the hospital progress notes date of service March 11, 2023 revealed resident #9 presented after a ground level fall. The progress note states resident was trying to transfer from her bed to her recliner and had a mechanical fall. No reports of head trauma. Workup in the ER was significant for a posterior lateral left femoral spiral fracture. Following consultation resident was determined too high risk for procedure and non-operative management was recommended. The report states resident has a history of dementia, alert and oriented only to self and not decisional. A review of the facility 5-day investigation revealed that resident # 9 had been sent to the hospital post fall and returned to the facility. It was noted that the resident did not have surgery for the incurred posterior lateral left femoral spiral fracture. The report further revealed that the facility conducted an IDT Fall Review March 9, 2023 implementing new interventions that included; call light within reach, floor mats down on the floor. Furthermore, the report indicated that resident #9 is a known fall risk who has fallen on several occasions in the past and is known to be impulsive at times, which led to previous falls. The report also states the care plan was updated and fall risk assessment completed. A review of the facility internal fall incident report dated March 8, 2023 revealed a nursing description of resident #9 observed on floor on top of mats, on her back, Resident complained of knee pain, the resident description reveals resident stated she fell out of her bed; and that, both knees hurt. An interview was conducted on February 14, 2025 at 11:04 A.M. with Licensed Practical Nurse (LPN/Staff #48) who stated that resident #9 is a fall risk and current preventative measures are: the Falling Leaf program and is provided with a Geri-Chair for positioning, floor mat and bed against the wall. Staff #48 stated that the resident is prescribed a psychotropic which placed her at an increased risk for falls. Staff #48 stated that a leaf is placed on the resident's door indicating the resident is a fall risk for staff. Staff #48 stated the nurses access the resident's care plan for the residents fall risk measures and these measures are shared with facility's staff. An interview was conducted on February 14, 2025 at 11:28 A.M. with Certified Nursing Assistant (CNA/staff # 460) who stated she was familiar with resident #9 and recalled the resident falling and sustaining a femur fracture. Staff #460 stated that resident #9 had fallen a couple of times prior to the fall with the fracture. Staff #460 recalled going into the resident's room and finding the resident on the floor, dinner tray pushed away and complaints of pain on both knees. Staff #460 stated that the resident was a set-up assist with meals and preferred to eat in bed. Staff #460 stated resident was found on her back at the end of the resident's bed, with the resident's head away from the bed and the resident's feet at the end of the bed. Staff #460 stated the resident's Geri-Chair was against the wall by the door approximately three feet away. Staff #460 stated resident #9 was a fall risk at the time with a lowered bed. Staff #460 stated there was no fall mat beneath the resident's bed. Staff #460 stated the resident was not consistent with the use of her call light due to her confusion and would forget that the call light was there. An interview was conducted on February 14, 2025 at 12:43 P.M with Director of Nursing (DON/Staff #388) who stated residents are assessed for falls upon admission, quarterly, and after any fall. Staff #388 stated the facility's fall risk protocol had different levels including from the resident assessment, to determining what interventions are needed for the resident. Staff #388 stated that the current fall risk protocol for the resident is ensuring the call light is within reach, non-skid socks, educate and encourage the resident, and fall risk protocols to be in place. Staff should familiarize with the care plan for the interventions for each resident. An interview was conducted on February 14, 2025 at 01:05 P.M. with [NAME] President of Clinical Operations (VP/Staff #438) who reviewed the residents care plan on the electronic medical records. Following the review, stated that the facility did have a previous extensive fall care plan prior to the residents discharge for two days. The discharge resolved the previous care plan and when the resident was readmitted the facility failed to put the care plan back in place for resident #9. Staff #438 further stated, maybe if the care plan was in place for falls, she may not have had an injury. 50116 -Resident #25 was admitted to the facility on [DATE], with diagnoses that include acute and chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure. The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview Mental Status (BIMS) 15 which indicated the resident was cognitively intact. A review of the documented Self Medication Evaluation revealed, that a self-administration evaluation was conducted on January 7, 2025 at 4:00 pm. The resident #25 wanted to self-administer medications. A review of physician orders included the self-administering of medications: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 Micrograms/ACT (Fluticasone-Umeclidinium-Vilanterol) 1 inhalation, inhale orally one time a day unsupervised self-administration Rinse mouth after use Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril one time a day for allergies unsupervised self-administration. Artificial Tears Ophthalmic Solution 1-0.3 % (Propylene Glycol-Glycerin) Instill 1 drop in both eyes four times a day for dry eyes unsupervised self-administration. Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for Shortness of Breath unsupervised self-administration Rinse mouth after use. A review of the resident's care plan revealed that a focus area regarding self-administration of medications, goals and interventions was not included. Moreover, a review of the progress notes did reveal any notes from the IDT regarding self-administration of medications related to resident #25. An interview was conducted on February 13, 2025 at 1:41 pm with Director of Nursing staff #388, who stated that there is a process, and a policy in place regarding self administering medications. Staff #388 stated that an assessment is done by the nurse quarterly, and then discussed with the interdisciplinary team (IDT). The IDT will make notes, but then care plans are initiated. When the nurse makes the assessment, the doctor signs off on the order. The order will say Self administer on the Medication Administration Record (MAR). In the policy Medications: Self-Administration of Medications: Policy Interpretation and Implementation section 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. Review of the facility policy titled, Falls/Fall Risk: Fall Risk Assessment revealed the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for fall and establish a resident centered falls prevention plan based on relevant assessment information.

Based on record review, resident and staff interviews and observations, the facility failed to ensure proper nail care for one resident (#31) was performed. This deficient practice could result in resident grooming and hygiene needs not being met. Findings include: Resident #31 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care, unspecified sequelae of cerebral infarction, nontraumatic intracerebral hemorrhage in hemisphere, unspecified A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated cognition intact. Further review of the MDS revealed impairment on one side for the resident's upper and lower extremities, dependent with showers and bathing and required substantial/maximal assistance with personal hygiene. A review of the care plan revealed a focus for ADL self care perfomance indicating resident #31 had a deficit related to decreased mobility date initiated May 6, 2022. Interventions included resident require total assist to wash, rinse and dry with showers and bathing; requires substantial/maximum assist with combing hair, washing/drying face and hands. Resident #31 was observed on February 11, 2025 at 1:57 p.m. with long fingernails, and brown debris underneath them. Resident #31 stated he had been told staff were unable to have his showers or be shaved due to short staffing. Resident #31 was also observed to have a strong body odor. Resident #31 stated, I need a shave resident was observed with ungroomed beard growth and further stated, my hands are dirty from scratching. Resident was observed in bed with a soiled hospital gown. On February 13, 2025 at 10:51 a.m., a second observation and attempted interview were conducted with resident #31. The resident's fingernails remained long, with brown debris beneath them. Resident was unable to be interviewed as he was sleeping. On February 13, 2025 at 10:52 a.m., an interview was conducted with Certified Nursing Assistant (CNA)/staff (#490) who stated resident #31 was supposed to have his showers every evening on Tuesdays and Fridays. Staff #490 stated that when providing showers, the residents are provided with clean hygiene, trim facial hair and sometimes their hair if requested, oral care, nail care if not a diabetic and skin checks, which are documented on the resident's shower sheets. Staff #490 conducted an observation of resident #31 fingernails and stated the residents nails are dirty with a brown substance beneath them and are too long. Staff #490 stated the residents nail care should have been completed during his showers, if not diagnosed as a diabetic. An interview with DON/staff (#388) on February 13, 2025 at approximately 12:00 p.m. DON stated that her expectations were that residents are provided their baths or showers; and that, they are thoroughly cleaned which would include oral care, shaving for males, hair washed and nail care. The DON stated if a resident refuses their shower or bath it is expected that that the resident is encouraged or offered an alternate time to bathe. The DON stated that the risks of not providing nail care increases the residents risk for infections Review of the facility's policy titled, 'Personal Care: Activities of Daily Living (ADL) Supporting' revealed, residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care.

Based on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for two resident. (#25, #283). The facility census was 85 and the sample was 3 residents. The deficient practice could result in harm to the residents, staff and/or visitors who have access to medications. Findings include: -Resident #25 was admitted to the facility on [DATE], with diagnoses that include acute and chronic respiratory failure with hypoxia, chronic respiratory failure with hypercapnia, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure. The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview Mental Status (BIMS) 15 which indicated the resident was cognitively intact. Resident #25's care plan did not address resident as able to self-administer medications. A medication pass observation was conducted on February 13, 2025 at 0738 am with staff member Licensed Practical Nurse (LPN) #225. Two boxes were given to look at for medication distribution. The boxes had labels with the resident #25's name and medication but no medication was in the box. Staff # stated that the medications were in the resident room and had an order for them to be in the room. Orders for the following medications include: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 micrograms/ACT (Fluticasone-Umeclidinium-Vilanterol) 1 inhalation inhale orally one time a day related to unsupervised self-administration Rinse mouth after use. Fluticasone Propionate Suspension 50 MCG/ACT 1 spray in each nostril one time a day for allergies unsupervised self-administration. Artificial Tears Ophthalmic Solution 1-0.3 % (Propylene Glycol-Glycerin) Instill 1 drop in both eyes four times a day for dry eyes unsupervised self-administration. Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) micrograms/ACT (Albuterol Sulfate) 2 puff inhale orally every 6 hours as needed for Shortness of Breath unsupervised self-administration Rinse mouth after use. Upon entering Resident #25's room on February 13, 2025 at 0750 am, a tan colored metal box was seen on the bed. The resident unlocked the box and pulled out the Trelegy Ellipta Inhalation Aerosol Powder Breath Activated and used the inhaler. Staff #225 then instructed resident #25 to use the Flonase. Resident #25 stated it was in the dresser and pulled open the drawer and retrieved the Flonase and used as directed. Resident #25 then used the Artificial Tears Ophthalmic Solution that was sitting on the bedside table. A red colored inhaler was seen on the bedside. An interview was conducted on February 13, 2025 at 0756 am with staff LPN #225 and revealed that if medications are left at the bedside and not locked up it could lead to harm. An interview was conducted on February 13, 2025 at 0141 pm with Director of Nursing staff #388 revealed that residents can have medications at the bedside if they have orders for self-administering; but that, residents have a lock box they keep the medications. Staff #388 stated that the expectations are that they are to be locked with the key and staff are notified when administered so it can be put on the medication administration record. If medications are left at bedside anybody could get them. An interview was conducted on February 14, 2025 at 11:22 AM with Certified Nursing Assistant/Restorative Nursing Assistant staff member #300 revealed that if medications are found at the beside of a resident, the nurse would be notified right away and does not know of any residents that have medications at the bedside. -Resident #283 was admitted on [DATE] with diagnoses that included acute osteomyelitis left ankle and foot, left fibula fracture, and nicotine dependence. An 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. A care plan initiated on February 04 2025, revealed no evidence of a focus regarding self-administration of medications. A physician order dated February 04, 2025 revealed the following: Latanoprost Solution 0.005% instill 1 drop in both eyes' bedtime for Glaucoma Further review of physician orders revealed no evidence of an order regarding medications self-administration, or for administration of systane dry relief eye drops. Progress notes dated February 4, 2025 through February 13, 2025 revealed no evidence of a medication self-administration assessment During an observation conducted on February 11, 2025 at 1:26PM, a small eye drop bottles half full of a clear liquid was sitting on the resident's bedside table. The resident stated that the bottle contained eye drops and was his personal medication. An interview was conducted on February 11, 2025 at 01:31PM with a Licensed Practical Nurse (LPN/Staff #9), who observed that the eyedrops were on the resident's bedside table, and that she was not aware of the resident having the personal eye drops placed at the bedside, but was aware of prescribed eyedrops. Staff #9 stated that the eye drops were Systane Sterile 10mL (1/3 FL oz) dry relief eye drops, and they should not have been unattended on the bedside table. Staff #9 stated that the risk of medication being left at the bedside could result another person ingesting the medication. An interview was conducted on February 13, 2025 at 01:43PM with Director of Nursing (DON/Staff #388), who stated that a resident can self-administrator the medication if there are orders put in place by the doctor. She also stated that medication can be left at the bedside if approved by the physician after the assessment. She also stated the residents are made aware of the expectation of how to safely administer the medication and are given a lock box with a key. The DON stated that the resident lets us know when they self-administer so that it can be documented in the MAR. She stated that medication should not be left on bedside or outside of the lockbox. Review of the policy, 'Medications: Self-Administration of Medications' revealed that self-administered medications are stored in a safe and secure place, which is not accessible by other residents. Review of facility policy titled, 'Medications: Administering Medications' revealed that only persons licensed or permitted by this state to prepare, administer and document the administration of the medication may do so. Medications are administered in accordance with prescriber order, including time frame.

Based on observations, interviews, and review of policy, the facility failed to ensure food was stored in accordance with appropriate guidelines. The facility census was 85. The deficient practice could increase the risk for foodborne illness. Findings include: On February 11, 2025 at 12:20 PM an observation of the kitchen was conducted with the Dietary Manager (DM/Staff#280). During a review of the freezer, one box of breadsticks observed in the box with box lid and plastic packaging open, exposed to air in freezer with observable frost. Further inspection of the freezer revealed one box of bread dinner rolls in an opened plastic packaging open and exposed to freezer air. Dietary manager (DM/Staff #280) stated that dietary staff were supposed to tie the bag after opening it to ensure the packages remain closed. Staff #280 threw away the items. The walk-through of the food storage pantry revealed one 10 pound opened box of graham cracker crumbs exposed to air; one 10 pound box of bacon bits open and exposed to air; 90 oz dry storage container with no lid with bread crumbs on bottom of dry storage container; at the bottom of the storage container were two packages of crushed rice krispies treats and a small plastic knife. Staff #280 stated the breadcrumbs had fallen from the top shelf into the container. There was also one box of 1000 plastic spoons left opened in box uncovered, exposed to dust and air. The observation of the refrigerator revealed eight small fruit plates covered with plastic wrap with no dates, three 5 ounce cottage cheese with no dates; one chef salad with no date; half cut cucumber wrapped in plastic with no date; and one 16 ounce opened package of carrots with no open or use by date. A follow-up visit was conducted on 02/13/25 at 08:29 a.m., with the Dietary Manager (DM/Staff#280). An observation was made of running water over a 2.5 pound package of ham slices. Staff #280 stated this was the process used for defrosting frozen meat and that the water is run over the food product between 2-4 hours with a water temperature at 40 degrees or less. The water temperature was tested by Staff #280 with the facility thermometer at 73.4 degrees. Staff #280 stated the risk of defrosting ham slices at the temperature recorded is the building of bacteria and illness to the residents. An interview was conducted on 02/13/25 at 08:42 a.m. with the Dietary Manager (DM/Staff#280). Staff #280 stated she has eleven employees and the expectation is that the facility keeps no leftover food and that it is tossed. Any food that is cooked can be saved and stored for three days and any foods that are opened, the expectation is that staff place an open date and a use by date. Staff #280 stated that the risks are staff not knowing the age of the foods opened, cross-contamination of open foods and food-borne illness to the residents. Review of the undated facility policy titled, 'Food Storage and Date Marking' revealed sufficient storage are provided to keep food safe , wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared and transported at appropriate temperatures and by methods designated to prevent contamination or cross contamination. Refrigerated Food Storage: foods should be covered, labeled and dated if stored. Frozen Foods: Safe Thawing: Frozen meat, poultry, and fish should be defrosted in a refrigerator and should be used within seven (7) days of thawing.

Based on observation, staff interviews, and policy and procedures, the facility failed to ensure that refuse was disposed of appropriately. The deficient practice could result in an unsanitary condition and the harborage of pests and insects. Findings include: During a kitchen inspection conducted on February 13, 2025, at 8:50 a.m. with Dietary Manager (staff # 280) and Maintenance Manager (staff # 470), observation revealed the designated kitchen garbage receptacle had one of the two lids missing, leaving trash and food items exposed to the elements, animals and insects. Staff # 280 stated half of the lid had been missing for three weeks; and that, she failed to inform the maintenance department of the issue. Staff #280 stated that the garbage receptacle should have two lids and remain closed at all times. Maintenance Manager (staff # 470) stated he was unaware of the issue with the dumpster lids, but would notify the city to have it replaced. Staff # 280 and #470 stated the risks associated with not having a closed lid on the trash dumpster is, it draws pests and animals. Review of the facility policy titled, 'Policy and Procedure Manual: Waste Disposal' revealed, containers will be emptied as often as necessary throughout the day and at the end of each day. Trash bags will be sealed prior to removing them from the facility. Trash will be sealed prior to removing them from the facility. Trash will be deposited into a sealed container outside the premises.

Based on clinical record review, interviews, review of policies, the facility failed to ensure resident # 1 did not sustain repeated fall accident and injury. This may result in residents sustaining injuries due to repeated falls. Findings include: Resident #1 was admitted on [DATE], with diagnoses of anemia, chronic pain due to trauma, depression, essential hypertension, nondisplaced fracture of base of neck of left femur, and repeated falls. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating resident #1 had moderate cognitive impairment. The baseline care plan included that the resident was at risk for falls or have had an actual fall. The goal was to be free of falls through the review date. Interventions included: anticipate and meet my needs, be sure my call light is within reach and encourage me to use it for assistance as needed, follow facility fall protocol. One intervention was added on February 10, 2023, which included: educate me/family/caregivers about safety reminders and what to do if a fall occurs. Added interventions were started on February 22, 2023 which included: Follow Falling Leaf Program, frequently round on me for safety, I have a Call don't fall as a reminder, and tilt in space wheelchair. The care plan had fall minor injury with dates of February 09, 2023, February 22, 2023, and March 18, 2023. Review of the progress note dated March 18, 2023 at 12:00 Late entry: Late documentation on fall. Resident had fall. Report that resident was attempting to get out of bed and did not lock WC. Resident is confused and does not follow direction. Resident has been reminded on multiple occasions daily about asking for assistance and using call light. Resident was already back in bed, less than dime size scrape to right elbow. Denies pain and hitting head. Lights were on, floor dry and free of debris. Review of progress notes in the electronic health record (EHR) dated on March 20, 2023 at 12:06 Late entry: Resident returned from hospital, radial fracture right. Review of the xray report dated March 19, 2023 11:43, fractures through the distal radius and ulnar styloid. Review of progress notes in the EHR dated on February 23, 2023 Late entry: IDT Review of Fall. The resident fell on [DATE] at 6:30 p.m. The resident had minor injuries of abrasions to bilateral elbows. There is no documentation of the fall on February 22, 2023 in the nursing notes. An interview was conducted on December 03, 2024 at 9:38 a.m. with staff member #1 Certified Nursing Assistant, (CNA) who was employed with the facility at the time of the fall but does not remember the resident or the fall. Staff #1 stated that interventions to prevent falls include mats, bolsters, some wheelchairs have the metal so they can not tip back, low beds and make sure they are not up high. An interview was conducted on December 03, 2024 at 9:42 a.m. with staff member #2 Licensed Practical Nurse (LPN). Staff #2 stated that residents are assessed for falls on admission and they review the past three months to see if they have fallen. Something is placed on the outside of the door to indicate that the person is a fall risk. Some have bracelets. Staff #2 was not working when resident #1 fell . An interview was conducted on December 03, 2024 at 9:50 a.m. with Director of Nursing (DON) Staff member #3 and sitting in with was Clinical Resource Staff member #4. When asked what would be the plan if a resident was being admitted with a fall prior to arrival. The response by staff #3, typically standard interventions, might put them on the falling leaf program that they are a fall risk. When asked regarding what could happen if repeated falls, Staff #4 answered that depending on the fall, look at the root cause and analysis, what contributed to the fall and put those that are geared to that and update the care plan. A fall screen was conducted on March 23, 2023. The screening indicated that the resident's last fall was on March 18. Noting that the resident #1 has decreased safety awareness and cognitive deficits. Review of the Falls/Falls Risk policy was reviewed. Monitoring Subsequent falls and fall risk has 4 key points. Including having the staff and or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls.

Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure one resident (#135) was free from self-harm following an encounter of self-reported suicidal ideation. The deficient practice could result in further neglect, harm or possible death of residents. Findings include: Resident #135 was admitted to the facility on [DATE], with diagnoses that included major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status was conducted which revealed a BIMS score of 14, indicating resident's cognition was intact. Further review of the MDS section D for mood assessment revealed a severity score of 23. The score indicated resident was feeling down, depressed or hopeless. Additionally, trouble falling or staying asleep or sleeping too much, feeling tired or having little energy; Poor appetite, feeling bad about herself or that she is a failure or have let the family down; having trouble concentrating on things. These thoughts and feelings occurred nearly every day. Resident had thoughts that she would be better off dead or of hurting herself in some way. These thoughts occurred one day. Review of the psychiatric provider follow-up assessment progress note dated September 24, 2024 with time of 12:45 PM revealed that the resident reported that she, is not doing well and also reported, tired of living and weaker than ever. Further review of the psychiatric note revealed, suicidal ideations including resident reporting she, is ready to go and was having suicidal ideations with a plan to overdose on pills, if I could. Resident also reported a poor appetite with a lot of sleeping. This encounter was signed and dated by the psychiatric provider following the consultation. Review of the care plan and progress notes revealed no evidence that the facility acted upon the psychiatric follow-up assessment progress note dated September 24, 2024. The care-plan initiated on August 26, 2024 revealed that the resident had a mood problem related to depression. The goal was resident will have improved mood state, and no sign or symptoms of depression through the review date. Interventions included -- observe/monitor/record/report to medical doctor as needed risk for harm to self or others: suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions or writing a note), intentionally harmed or tried to harm self, sense of hopelessness or helplessness; possession of weapons or objects that could be used as weapons. Physician orders dated September 27, 2024, revealed an order for Sertraline tablet 25 milligrams Give 1 tablet by mouth one time a day for depression related to major depressive disorder, recurrent, unspecified. Review of the behavioral tracking for anxiety and depression in the medication administration record for October 1-8, 2024 revealed no identified changes in mood had been documented for resident #135. Medical record review revealed progress note dated October 8, 2024 at 05:15 AM resident was transferred via ambulance; responsible party notified; physician notified; DON notified; executive director notified; details of occurence leading to hospital transfer include: suicide ideation meausres taken to stabilize resident prior to determination to transfer: 1:1 sitter head to toe assessment; wound on left wrist cleaned resident is alert and oriented. Review of the Hospital records dated October 8, 2024 revealed, patient has lacerations on her left wrist in an attempt to stop being a burden to her family. Pt was trying to kill herself. The hospital record revealed a note from Emergency Medical Services (EMS) stating, when triaging this patient, the patient mentioned that she did have a plan for suicide and that if she went home, her plan was to take pills. Further review of the hospital record revealed a Columbia Suicide Severity Rating Assessment was conducted revealing a high-risk score recommending a psychiatric consult and patient safety precautions. Questions regarding this assessment include: have you wished you were dead or wish you could go to sleep and not wake up? Past month YES. In the pas month have you had actual thoughts of killing yourself? YES. In the past month have you been thinking about how you might do this? YES. In the past month have you had these thoughts and had some intention of acting on them? YES. In the past month have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? YES. In the past 3 months have you ever done anything, started to do anything, or prepared to do anything to end your life? Yes. An interview with a Licensed Practical Nurse (LPN/staff #65) was conducted on October 17, 2024 at 4:31 p.m. The LPN indicated that for residents with suicidal ideations that it is important information for staff to have as it gives them a better picture of the residents needs and what to look out for. Staff #65 noted that the risk of a care plan not addressing specific issues such as suicidal ideations can affect the residents care if the care plan is not updated; and that, would not give nurses a clear picture of the current needs for the resident. An interview was conducted with Certified Nursing Assistant (CNA/Staff #30) on October 17, 2024 at 5:04 p.m. Staff #30 stated she worked the night shift 3-4 days per week and was assigned resident #135 when she attempted to self-harm. Staff #30 stated she provided care or observed the resident every two hours. Staff #30 stated she went into the resident's room at approximately 5am to check for incontinence. She stated she woke the resident, using her flashlight and did not notice her arms at the time, but noticed dried blood on the resident's gown and fingers and thought she may have had a bloody nose. She stated she asked the resident where the blood had come from and the resident stated she had tried cutting herself with a knife from dinner because she felt she was a bother to her family and they were better off without her. Staff #30 stated the resident had not made any comments of self-harm or had been informed in report that this was of a concern. She stated that the resident was very calm regarding the matter of the incident. Staff #30 stated if this was a concern it would have been in the resident's care plan or given in report to monitor her for any ideas of hurting herself and immediately tell the nurse if a resident should voice any thoughts of self-harm. An interview was conducted with both the Director of Nursing (DON/staff #12) on October 17, 2024 at 5:46 p.m. The DON indicated that the residents care plan was not updated because the facility was unaware of the psych progress notes until the resident discharged to the hospital while gathering documents for the hospital. The DON stated if the facility were made aware of the resident's suicidal ideations, interventions would have been provided for the resident such as increased rounding, monitoring and changes to the care plan for staff. The DON stated, we don't read every single note and the psych provider did not share the information or concerns with the facility and should have. The DON stated they are in the process of revising their process regarding their communication with providers and reviewing any follow-up progress notes. Review of the facility policy titled, Abuse Policy dated 2022 (version 0622) revealed, faility strives to prevent the abuse of all their residents. By definition, abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, mental abuse. Review of the facility policy titled, Behavior/mood/cognition: behavioral assessment, intervention and monitoring dated January 01, 2024 revealed, the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The interdisciplinary team (IDT) will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any mondifiable factors that may have contributed to the resident's change in condition, including: emotion, psychiatric and/or psychological stressors (for example): depression; loneliness. The IDT will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure discharge planning included developing a discharge care plan for one sampled resident (#80). The deficient practice resulted in an ineffective transition to post-discharge care, and increases the risk factors leading to preventable readmission. Findings include: Resident #8 was admitted on [DATE] with diagnoses that included rhabdomyolysis, pressure-induced deep tissue damage of the sacral region, unstageable pressure ulcer of left buttock, and unstageable pressure ulcer of right buttock. An Admission Evaluation -Nursing assessment dated [DATE] revealed the resident's expectation at admission was to be discharged to the community. Review of the comprehensive care plan dated June 28, 2024, revealed an appropriate pre-discharge plan will be established by coordinating discharge plans with the Interdisciplinary Team (IDT), and helping to provide services according to care plan in an effort to enhance optimum well-being. This care plan included that a pressure ulcer was noted on admission. A physician's order dated July 5, 2024 included cleanse dissipated blister to mid lower back with NS pat dry apply Medi honey, apply calcium alginate and cover with dry dressing daily until healed every day shift A physician's order dated July 19, 2024 included cleanse unstageable to left buttock with wound cleanser pat dry apply collagen apply calcium alginate cover with dry dressing daily until healed every day shift related to PRESSURE ULCER OF LEFT BUTTOCK, UNSTAGEABLE. A physician's order dated June 29, 2024 included Apply [NAME] all-body powder to abdominal folds for moisture control. The Admission Assessment Minimum Data Set (MDS) assessment dated [DATE] included that this resident was not cognitively impaired and that this resident required substantial/maximal assist for lower body dressing, rolling right to left, sitting to lying and chair to bed transfers, and was dependent for toilet hygiene. A health status progress note dated August 1, 2024 revealed that Resident and son voiced concern regarding insurance and discharge, both were very noticeably unset, writer left a message for social worker and writer went to find speak with DON and she was not available, writer went to administrator and she went to resident room and spoke with family and gave them options and information that they were thankful for, both were both noticeably feeling better and writer witnessed son making phone calls. A daily skilled evaluation progress note dated August 2, 2024 revealed that wound care was provided and that the resident visibly upset and tearful during assessment due to possible discharge home tomorrow, she states she is not ready to go home and worries about her condition as she cannot dress her wounds by herself. Comfort and encouragement provided by RN Wound treatments being done daily and PRN due to area of dressings. Wounds are improving but still open in multiple areas. A Discharge summary dated August 2, 2024 included 8/2/2024 that the resident was discharged to a private home/apartment with home health services to be provided. A Discharge and Transfer assessment dated [DATE] included that the resident was being discharged to the community and that the facility IDT and/or managed care initiated the discharge. This document included that [NAME] would be providing the home health and that Preferred Home Care was providing a wheelchair. This document included to: cleanse unstageable to left buttock with wound cleanser pat dry apply collagen apply calcium alginate cover with dry dressing daily until healed, cleanse dissipated blister to mid lower back with NS pat dry apply Media honey, apply calcium alginate and cover with dry dressing daily until healed and Apply [NAME] all-body powder to abdominal folds for moisture control. This document also included that this resident requires substantial/maximal assistance with toileting hygiene. The Discharge return not anticipated Minimum Data Set (MDS) assessment dated [DATE] included that this was a planned discharge. However, an interview was conducted on August 19, 2024 at 2:53 with a staff member at [NAME] Home Health Agency, who stated that they did get the referral for this resident but that they did not provide services because they are not serviced by this resident's insurance. A complaint received on August 12, 2024 included that a patient was sent home with unstageable pressure ulcer, no medications, and no one to do wound change at home. This allegation included that the resident had severe yeast infection under both breast as she had not been being washed properly, that this resident was never taken to wound care center for proper treatment of wound and that the resident's family was refusing to do wound care and patient was taping napkins to the buttock. This complaint alleged that this was an inappropriate discharge. An interview was conducted on August 19, 2024 at 3:02 P.M. with resident #8 who said that the facility was to set up home health, had one person come out and they found out did not work with insurance without a primary doctor, then she had to get to primary doctor, and that tomorrow she was going to a wound care center. She said that the day after discharge that she went to the hospital because the wounds opened up, they referred us to wound care to see if I still require attendance. I had to go to the emergency to get my wounds cared for. She said that the facility did not train her family member on her care as her family members would never change her dressings. An interview was conducted on August 19, 2024 at 3:02 P.M. with resident #8's family member who said that they were not trained in wound care. This family member said that the facility filed for home health care but that it took over a week because they kept filing with people who did not accept her insurance. He said that the home health took a week to get there and do a wound dressing then told resident #8 she need a referral from a primary or an action plan form wound care or maybe both before they could continue with services. This family member said that this home health worker said that the wound was a lot worse than she was told and that it looked like haven hadn't taken care of it at all. This family member stated that he had called the facility multiple times trying to figure out the home health and that the resident never got the wheelchair from Preferred, because Preferred never got any paperwork for her. An interview was conducted on August 20, 2024 at 10:45 A.M. with the Resident relations manager (staff #27) who said that she talked about discharges with residents as soon as they arrive, and that weekly they have an Interdisciplinary team meeting and discuss who will be discharged in the next 7 days and when they discharge what services they will need, then get them a NOMNC (Notice of Medicare Non Coverage) and explain right to appeal, then set up home health. This staff said most people who discharge is through [NAME] but that it takes time to get and that there is 1 company for durable medical equipment available in the area and they put a hinder on discharge. This staff said that they let residents go home with our wheelchairs. This staff said that if they cannot get them services because insurance is not covering the required services, we give them orders for outpatient care or sometimes have to let them know that insurance does not cover service in the area. This staff said that for this resident, she got a NOMNC, and appealed and then lost the appeal and that the resident was discharged on a Saturday. She said that the staff ordered her a wheelchair but that she did not know if she got the the wheelchair. She said that wound care was set up through [NAME] and that the staff had received a notification that home health not covered insurance. She said that the staff only had 2 days to set up services. She said that she next sent the referral to Family Home Care. She said that this resident discharged on Saturday, that she was told that on Sunday the family called and they said that home health was not going to come on Sunday and help was needed with wound care and that the charge nurse told the family member to go to emergency room . This staff confirmed that they do not routinely check to see if residents have durable medical equipment once they have discharged . An interview was conducted on August 20, 2024 at 12:08 P.M. with the Director of Nursing (DON/staff #65) who said that if a resident has an order, the resident should receive the order the same day, and going forward they should receive the treatment as ordered. This staff said that a resident can be discharged if they are able to go home safely, if they are at their baseline, family, if they have support and equipment they need when they get home. A policy titled Admissions/Transfers/Discharges: Transfer or Discharge- Preparing a Resident for discharge date d January 1, 2024 revealed Nursing services is responsible for obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment.

Based on record review, interviews and facility documentation and policy, the facility failed to ensure one resident (#1) was free from abuse from a staff member. The deficient practice could lead to further abuse of residents. Findings include: Resident #1 was admitted to the facility on [DATE] with a diagnosis of acute and chronic respiratory failure with hypoxia and hypercapnia, wedge compression fracture of first lumbar vertebra, history of falls, and low back pain. Review of the most recent MDS (Minimum Data Set) dated April 16, 2024 revealed a BIMS (Brief Interview for Mental Status) score of 06, which indicated severe cognitive impairment. The facility reportable event record/ report stated that on January 6, 2024 it was reported to the administrator that registry aide (staff #5) was being unkind. The report stated after resident #1 refused shower and in attempt to give bed bath, staff #8 witnessed staff #5, with a wet cloth on her hand spun around, causing water to splash all over resident's #1 face. The report further stated the resident #1 told staff #5 that she got water all over her, to which staff #5 replied she meant to do that as the resident was getting bed bath. The report stated staff #8 cleaned resident #1 and remained by bedside throughout the remainder of bed bath without further incident. Staff #8 then reported it to the charge nurse and charge nurse reported it to the administrator. The report stated staff #5 was sent home immediately. An interview was conducted on June 11, 2024 at 09:55 AM with Staff #8, CNA (Certified Nursing Assistant) to recall the events that took place on January 6, 2024. Staff #8 stated that Staff #5, CNA, went into Resident #1's room to give her a shower. Staff #5 wanted to put Resident #1 in the hoyer lift to get her into the shower, but Resident #1 stated that she hurt too much and did not want to get into the shower. Staff #8 stated that Staff #5 said That's gross, you need to take a shower to the resident #1. She stated resident#1 then requested bed bath. Staff #8 stated she told Staff #5 that it was resident's right to refuse a shower so a bed bath can be provided. Staff #8 stated when a bed bath is given, a basin with warm water, a washcloth and soap is used. Staff #8 stated that Staff #5 put the washcloth in the basin of water and put soap on it, then staff #5 did not wring the washcloth out, held and moved the washcloth over Resident #1 face, dripping water all over the resident's face. Resident #1 stated hey, you soaked me to which Staff #5 stated I meant to do that. Staff #8 stated she tried to smooth the situation by saying that staff #5 did not mean to do that and she was sorry. She stated she cleaned the water off the resident's face and that both staff members finished the bed bath. Staff #5 left the room with the dirty linens and Staff #8 stated that Resident #1 said to her I am so happy you were a witness to that, I don't trust her and I want it reported, to which Staff #8 replied she will be reporting it immediately. Staff #8 stated that she notified the charge nurse and she remembers Staff #5 being escorted out of the building around suppertime. An interview was conducted on June 11, 2024 at 10:30 AM with the DON (Director of Nursing/ Staff #10). When asked if she remembered the events of of January 6, 2024 between Resident #1 and Staff #5, she stated she did not remember but she remembered Staff #5 was escorted out of the building and the facility notifed staff #5's recruiter. She stated the facility canceled staff#5's contract. When asked if the facility reported to the Licensing Board and Staff #10 replied no. An interview was conducted on June 11, 2024 at 10:37 AM with LPN (Licensed Practical Nurse/ Staff #7). She stated that on the morning of January 6, 2024, she discovered Staff #5 did not put a resident's nasal cannula back on, causing the resident oxygen saturations to drop to 89%. Staff #7 stated she told the charge nurse (Staff #2) of what had happened and Staff #2 spoke with Staff #5 and educated her on what to do when a resident is on oxygen. An interview was conducted on June 11, 2024 at 10:56 AM with the Administrator (Staff # 4). Staff #4 stated she did not substantiate this incident because when she interviewed Staff #5, she stated that it was an accident and apologized for it. She also stated she knew she had eye witness statements that the incident did occur but she said she could not be sure. Review of the facilities policy on Abuse, dated 2022, statesif the abuser is an employee, they will undergo immediate termination and licensure reporting as applicable.

Based on documention, staff interviews, and the facility policy and procedures, the facility failed to provide supervision as directed by the nursing board for one staff (#33). The deficient practice could result in residents being physically and/or emotionally harmed. Findings include: Review of staff #33's RN license revealed that it was issued on May 1, 2018 probationary status with the state of Arizona. The date action was taken was on July 23, 2021. Review of the, Arizona State of Board of Nursing Consent Agreement and Order Number 1805081, dated July 23, 2021 revealed that staff #33's license is hereby revoked; however; the revocation is stayed for as long as respondent remains in compliance with this order. During the stay of the revocation, respondent's nursing license is placed on probation for a minimum 36 months with terms and conditions. If respondent is non-compliant with any of the terms of the order the stay of the revocation shall be lifted and respondent's license shall be automatically revoked for a minimum period of five years. The respondent shall practice as a registered nurse, only under the direct supervision of a registered nurse in good standing with the Board, for the first 18 months. Direct supervision is defined as having a registered nurse present on the same unit with the respondent whenever respondent is practicing as a registered nurse. Thereafter and until completion of probation, respondent shall practice only under the on-site supervision of a registered nurse in good standing with the Board. On-site supervision is defined as having a registered nurse in present in the building while the respondent is on duty. Staff #33 was hired on October 11, 2022 as a registered nurse (RN). Review of the time card revealed that (RN/staff #33) worked on July 22, 2023 from 5:42 a.m. until 6:57 p.m. -Staff #44 was hired on January 21, 2022 as a registered nurse. Review of staff #44's RN license revealed that it was issued on December 6, 2022 unencumbered with the state of Arizona. Review of the time card revealed that (RN/staff #44) worked on July 22, 2023 from 5:43 a.m. to 3:54 p.m. Review of the daily staff posting dated July 22, 2023, revealed that 1 registered nurse (RN) was scheduled to work the day shift, 6:00 a.m. to 6:00 p.m. and 1 treatment nurse was scheduled to work the day shift, 6:00 am to 6:00 p.m., but only worked for 10 hours. Review of the staff schedule dated July 22, 2023 revealed that 1 (RN/staff #33) was scheduled to work the day shift, 6:00 a.m to 6:00 p.m. and 1 (RN/staff #44) was scheduled to work for 10 hours during the day shift. An interview was conducted on July 26, 2023 at 9:01 a.m. with the Director of Nursing (DON/staff #30), Human Resources (HR/staff #12), and resource staff (staff #76). During the interview, the daily staff posting dated July 22, 2023 was reviewed, which revealed that 2 registered nurses were scheduled to work the day shift, 6:00 a.m. to 6:00 p.m. and 1 treatment nurse/RN only worked for 10 hours. Review of the staff schedule dated July 22, 2023 revealed that 1 (RN/staff #33) was scheduled to work the day shift, and 1 (RN/staff #44) was scheduled to work for 10 hours during the day shift. Review of the time card for (RN/staff #33) revealed that she worked on July 22, 2023 from 5:42 a.m. until 6:57 p.m., and (RN/staff #44) worked on July 22, 2023 from 5:43 a.m. to 3:54 p.m. Staff #12 stated that (RN/staff #44) was supposed to supervise (RN/staff #33) and (RN/staff #44) left just under 10 hours. (DON/staff #30) stated that a licensed practical nurse cannot supervise (RN/staff #33). An interview was conducted on July 27, 2023 at 8:55 a.m. with the resource staff (staff #76). She stated that (RN/staff #33) is still on probation and agreed that staff was supposed to be supervised for the entire shift on July 22, 2023. The facility's policy, Abuse, Abuse Prevention and New Employees, dated 2017 states that all employees of facility will be screened in accordance with Human Resources Policies. Employees receive education on the Elder Justice Act as well as contact and reporting information as addressed in the Haven Health New Employee Orientation Packet.

Based on clinical review, staff interviews, and facility policy and procedures, the facility failed to ensure that medication administration for one resident (#18) met professional standards of practice, failed to ensure physicians orders for one resident (#8) were complete and failed to notify the physician of a change in condition (#65). The deficient practice could result in residents not receiving care that meets professional standards. Findings include: -Resident #18 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus with diabetic neuropathy, chronic systolic heart failure, and morbid obesity. The care plan for Diabetes Mellitus dated August 29, 2022 included the intervention to give diabetes medication as ordered by the doctor. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of the order summary revealed an order dated July 13, 2023, Humalog KwikPen Solution Peninjector 100 unit/ml (Insulin Lispro (1 Unit Dial)) Inject as per sliding scale: if 70 - 130 = 0; 131 - 180 = 2 units; 181 - 240 = 4 units; 241 - 300 = 6 units; 301 - 350 = 8 units; 351 - 401 = 10 units. Notify hospice if blood sugar (BS) 400> and if <65 subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with diabetic neuropathy. Review of the medication administration record (MAR) dated July 2023 revealed: -July 15, 2023 at 6:00 a.m. BS was 62. -July 20, 2023 at 6:00 a.m. BS was 53. -July 23, 2023 at 6:00 a.m. BS was 63. A progress note revealed: -July 15, 2023 at 12:58 p.m. resident appeared confused at the start of shift. BS , low reading of 62. BS increased with orange juice and meal. After meal BS noted at 110. Resident appeared more alert. Resident refused morning medications, including insulin. Resident educated on the need for medications. -July 20, 2023 at 5:09 a.m., Humalog KwikPen Solution Peninjector 100 unit/ml (Insulin Lispro (1 Unit Dial)) Inject as per sliding scale: if 70 - 130 = 0; 131 - 180 = 2 units; 181 - 240 = 4 units; 241 - 300 = 6 units; 301 - 350 = 8 units; 351 - 401 = 10 units. Notify hospice if BS 400> and if <65 subcutaneously before meals and at bedtime related to Type 2 Diabetes Mellitus with diabetic neuropathy. Orange juice was given with a snack. -July 23, 2023 at 4:55 a.m., resident had blood sugar of 63. She is still alert and verbally responsive. 6 ounces of juice given and will re-check in 15 minutes. Note: there was no documentation that the physician was notified when the resident refused her insulin, or when the BS was <65. An interview was conducted on July 26, 2023 at 2:52 p.m. with the Director of Nursing (DON/staff #30), who stated that a physician's script is needed to administer a medication and is an if order says to notify hospice when BS is less than 65 that would mean to notify the hospice physician to get further instructions. Staff #30 reviewed the MAR and the progress notes and stated: -on July 15, 2023, BS was 62, and juice was given and BS was retaken at 110, but the physician was not notified. -on July 20, 2023, BS was 53, and juice was given. There was no documentation that the BS was taken again or that the physician was notified. -on July 23, 2023, BS was 63, and juice was given. BS was retaken, but there was no documentation that the physician was notified. Staff #30 stated that there is a standing order for juice and if there is no change to notify the physician. She stated that there is no risk if the BS is not taken a second time after juice, shake or nutritional snack. The facility's policy Administering Medications dated December 2012 states that medications must be administered in accordance with the orders, including any required time frame. 43863 -Resident #65 was admitted on [DATE] with diagnoses that included urinary tract infection, pseudomonas, hypertensive heart and chronic kidney disease with heart failure, and type 2 diabetes mellitus. Review if the clinical record revealed no evidence that the physician was notified of a residents change in condition that included weight change, edema and shortness of breath prior to the resident's death in the facility. Review of a Nursing Admission Evaluation dated May 18, 2023, revealed that the resident expected to be discharged to the community, 3+ edema of right lower extremity present. Review of physician orders revealed the following order: -Daily weights: if greater than 2 lb gain in 24 hours notify Medical Doctor (MD) every day shift for congestive heart failure (CHF) weight monitoring, dated May 18, 2023. Review of a care plan initiated on May 19, 2023 revealed the following areas of focus: -Coronary artery disease related to atherosclerosis, with interventions that included to report to Medical Doctor (MD) shortness of breath, and weight as ordered. -Hypertension, with interventions that included monitor for increased heart rate (tachycardia), monitor and document any edema, and to notify MD -Altered cardiovascular status related to arrhythmia, hypertension with interventions that included monitor/document/report to MD changes in edema and changes in weight. Review of the May 2023 Medication Administration Record (MAR) revealed the following weights: -May 19, 2023 - 213 -May 20, 2023 - 207 -May 21, 2023 - 207 -May 23, 2023 - 212 Review of the May 2023 blood pressure results included: -May 19, 2023, 10:46 PM: 116/70 (millimeter of mercury) -May 20, 2023, 07:18 AM: 108/53 mmHg -May 21, 2023, 1:08 AM: 116/65 mmHg -May 21, 2023, 10:18 AM: 95/28 mmHg May 21, 2023, 10:42 PM: 105/59 mmHg -May 22, 2023, 08:00 AM 100/62 mmHg -May 22, 2023, 09:58 PM: 98/64 mmHg -May 23, 2023, 09:35 AM: 94/52 mmHg -May 24, 2023, 01:40 AM: 104/62 mmHg Further review of the clinical record revealed no evidence that the physician was notified regarding the weight gain of 5 pounds (lbs) between May 21, 2023 and May 23, 2023. Review of a Daily Skilled Evaluations revealed the following: - Dated May 20,2023 revealed 1+ edema to right lower extremity present and light red tint to urine in tubing and dark yellow output to gravity. -Dated May 21, 2023 revealed edema 1+ to right lower extremity, foley catheter with abnormal catheter findings, dark urine noted that is expected due to kidney failure and fluid restriction of 32 ounces (oz) daily. -Dated May 22, 2023 revealed edema present +2 of right lower extremity, foley catheter with dark urine noted, and denies shortness of breath. -Dated May 23, 2023 revealed and increase in right lower edema to 3+, and shortness of breath with exertion, and dark urine. Review of a Health Status Note dated May 23, 2023, revealed the resident stated that he has had shortness of breath while lying flat in the past seven days. Review of a Discharge Summary dated May 24, 2023, revealed circumstances surrounding death: A CNA (certified nursing assistant) called a nurse to the resident's room, noted resident unresponsive, with no audible pulse, blood pressure, or respirations. Family notified, physician notified. Review of the clinical record revealed no evidence that the provider was notified regarding the change in right lower extremity edema, shortness of breath or color of urine prior to the residents unexpected death in the facility. Review of the Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], that revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The assessment also revealed no indicating that the resident did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. An interview was conducted with the Director of Nursing (DON/staff #30) on July 26, 2023 at 8:19 AM, revealed that the facility policy regarding unexpected death included notifying family, provider, emergency department and funeral home of choice. Stated that there is an investigation would be conducted and that they would notify the state. Further interview was conducted on July 26, 2023 at 11:31 AM with the DON (staff #30), who stated that staff should notify the provider for any changes of condition including tachycardia, shortness of breath, She stated that these would be things that the MD should have been notified, if not present upon admission. She further stated that they did not have a coroner report regarding resident #65's death as it was not an unusual occurrence. She also stated that they did not do event reporting, a significant change assessment. An interview was conducted on July 26, 2023 at 11:41 with a unit Manager (staff #32). Staff #32 was also the previous DON at the time resident #35 was admitted to the facility. She stated that when a resident has change of condition the nurse should notify the provider, and document in the progress notes. The Unit Manager (staff #32) stated that the facility expectation is to follow physician orders as written, including orders regarding weight changes of 2 pounds (lbs.). She stated that she remembers the resident that he was admitted to the facility related to falls and chronic kidney disease. She further stated that the resident was on dialysis and may have weight changes. She reviewed the clinical record and stated that the resident had gained more than 2 lbs and that the provider should have been notified, and documented in the clinical record. She stated also stated that the resident was admitted with dark colored urine, but the physician should have been notified regarding the edema and tachycardia given the resident's diagnoses of congestive heart failure. An interview was conducted on July 26, 2023 at 1:34 PM with a Licensed Vocational Nurse (LVN/staff #106), who stated that the physician should be notified regarding any type of status change, and the notification should be documented in a progress note. He further stated that this would include weight changes in a resident with a resident receiving dialysis. He stated the risk in not notifying the provider regarding weight changes for resident's receiving dialysis could result in fluid overload, that included shortness of death and pulmonary edema. Review of the facility policy titled, Change in a Resident's Condition or Status, revealed that the facility shall promptly notify the resident, the attending physician, and representative of changes in the resident's medical condition and/or status. The nurse will notify the resident's physician when there is specific instruction to notify the physician of changes in the resident's condition. The nurse will record in the resident's medical record information relative to changes in the resident's medical condition or status. 48814 -Resident #8 was admitted on admitted on [DATE] with diagnosis include Muscle weakness unspecified abnormalities of Gait and Mobility, need assistance with personal care and paraplegia Review of resident's care plan, initiated on August 27,2020, revealed no document under interventions regarding RNA for continued UE/LE stretching to prevent further contractures Review of the Order details dated August, 28, 2020, stated that Resident was placed on RNA for continued UE/LE stretching to prevent further contractures. However, order detail failed to ensure script for frequency and time duration for Restorative Nursing Program (RNA) for the Resident Review of the admission Minimum Data Set (MDS) dated [DATE], that included a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognitively intact. It further revealed that the resident is receiving RNA for range of motion both passive and active for at least 15min for 4 days in 7 calendar day. During an initial interview conducted with resident #8 on July 24th, 2023, who stated that he supposed to have RNA every week, Mon-Fri for 30 minutes, but does not always get it due to short staffing. It happens 1-2 times per week only and can led to contracted arms and legs. An Interview was conducted on July 26, 2023 at 11:55 am with a Director of Rehab/Physical Therapist, who stated that the resident is on order for RNA skilled Physical therapist (PT) and Occupational therapist (OT) evaluation only and placed on RNA for upper and lower extremity for stretching to prevent contractures. She doesn't know if the script is supposed to have the amount of time/frequency for RNA. She further stated that she was unable to provide the discharge summaries of PT and OT because it's under Reliant Rehab company before and new therapy company TMC started from June 1st of 2023. She also stated that she is unaware that if the script is supposed to have the amount of time/frequency for RNA. She further stated that RNA is monitor by staff #26 who is the lead for RNA and a nurse. An Interview was conducted on July 27, 2023 at 11:41pm with a CAN/RNA, (staff# 26), who stated that she gets an order for RNA from Physical Therapist. She also showed an order script dated 8/28/2020 which stated that Resident was placed on RNA for continued UE/LE stretching to prevent further contractures. However, order detail failed to ensure script for frequency and time duration for Restorative Nursing Program (RNA) for the Resident. She further stated that PT or MDS determines the length of each session and she doesn't remember who told her to do RNA for 15 minutes per session, and for 5 days a week. She also stated then whenever resident doesn't have RNA then his fingers go into his palms and legs start to spasm. An Interview was conducted on July 27, 2023 at 12:45pm with an MDS Coordinator, staff# 52 who stated that she would meet with the RNA and Interdisciplinary team (IDT) to discuss and then determine whether to change, continue, or stop the program and there is no set time for RNA session that she was aware of, so she sets the time based on the Resident's ability. She is not aware of needing a script to provide RNA. She also stated that Exercises were determined by the prior therapy contractor, Reliant. The only thing in writing from prior therapy was the order, Therapy makes the recommendation and request an order from the physician. Another MDS Coordinator, staff # 71 presented with staff #52 in stated that when we do the period reviews, we are reviewing how the resident is doing and if they are still appropriate for the program. She further stated that they also discuss during the care conference and would discuss concerns. Care conferences are done quarterly and lookback for information, refusals, and stated that the previous reliant was also doing quarterly reviews on the residents. Working on making more standardized the process RNA as it was run by therapy before. An Interview was conducted on July 27, 2023 at 1:00pm with a Director of Nursing, staff# 30, who stated that facility require a script for RNA with time and frequency. She also reviewed the order for RNA and noted that the time and frequency was missing and stated that a nurse can determine the time and frequency. She further requested the therapy discharge summary from previous therapy company and she believes that the facility has to have access to the records for 5 years. Review of the facility's policy titled, Restorative Nursing Program (RNA), included that the resident has the right to be treated with consideration, respect, and with dignity and individuality.

Based on clinical record, staff interviews, and the facility policy and procedures, the facility failed to assist one resident (#60) with repositioning. The deficient practice could result in a skin breakdown. Findings include: Resident #60 was admitted to the facility on [DATE] with diagnoses that included generalized muscle, pathological fracture with routine healing, low back pain, and anxiety disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. It also included that the resident required a one-person extensive assist with bed mobility and used a wheelchair for ambulation. The care plan dated June 8, 2023 revealed that the resident has or is at risk for an activity daily living (ADL) self-care performance deficit. Interventions included that the resident requires one-person assistance with bed mobility. Review of the task sheet documentation for bed mobility/repositioning dated June 2023 revealed: -June 9, 2023, the resident did not reposition during the night shift. -June 14, 2023, the resident did not reposition during the night shift. -June 16, 2023, the resident did not reposition during the night shift. -June 19, 2023, the resident did not reposition during the night shift. -June 21, 203, the resident did not reposition during the night shift. -June 23, 2023, the resident did not reposition during the day shift. Review of the task sheet documentation for bed mobility/repositioning dated July 2023 revealed: -July 2, 2023, the resident repositioned himself independently with no physical help from staff during the day shift. -July 3, 2023, the resident repositioned independently during the day shift and did not reposition during the night shift. -July 4, 2023, the resident repositioned independently during the day shift and independently during the night shift. -July 7, 2023, the resident did not reposition during the night shift. -July 12, 2023, the resident did not reposition during the night shift. -July 18, 2023, the resident did not reposition during the day shift. During an interview conducted on July 24, 2023 at 11:57 a.m. with the resident, he stated that he had some sores on his back. An interview was conducted on July 25, 2023 at 3:05 p.m. with the MDS Coordinator (staff #52), who stated that she assessed the resident by reviewing the certified nursing assistants' (CNAs) documentation, nursing documentation, and therapy notes to complete the MDS. She also used the information taken and observed when she has contact with the resident. Staff #52 reviewed the MDS dated [DATE] and stated that the resident required an extensive one-person assist with bed mobility. Then, she reviewed the MDS dated [DATE] and stated that the resident had a change and required a two-person extensive assist with bed mobility and the resident went on hospice on July 27, 2023. She stated that the resident would not be able or willing to reposition himself in bed, the CNAs were responsible for assisting the resident with repositioning, and if repositioning did not occur there was a risk to skin breakdown and pulmonary issues. An interview was conducted on July 25, 2023 at 3:18 p.m. with a licensed vocational nurse (LVN/staff #106), who stated that the CNAs are supposed to reposition residents every two hours if the residents need assistance. He stated that resident #60 requires assistance and there is a risk to the resident if he is not being repositioned, such as skin breakdown and shearing. He stated that he may provide assistance with repositioning, but would not document that the assistance was provided. An interview was conducted on July 26, 2023 at 12:23 p.m. with the resource registered nurse (RN/staff #105). Staff #105 stated that the (ADLs) section in the MDS describes the level of performance and level of assistance needed by the resident to complete the ADL and then the ADL assistane that is required goes into a care plan. Staff #105 stated that ADL care is provided by CNAs and nurses and the CNAs would document the ADL care was provided for the resident under the tasks section of the clinical record. She stated that if the resident required extensive assistance with bed mobility/repositioning, staff would assist the resident every 2 to 3 hours. She stated that there should be documenation each shift to show if and how assistance was provided and if the CNA did not document that repositioning occurred on the task sheet then it did not occur. She also stated that there is a risk of skin breakdown occurring for a resident who requires extensive assistance. The facility's policy, Repositioning, dated May 2013 states that the purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. Review the resident's care plan to evaluate for any special needs of the resident.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide an ongoing program of activities designated to meet the needs of one resident (#18). The deficient practice could impact the psychosocial needs of the residents. Findings include: Resident #18 was admitted to the facility on [DATE] with diagnoses that included chronic systolic heart failure, morbid obesity, anxiety, and a major depressive disorder. Note: task sheets for Bingo, family/friend visits, ice-cream socials, manicures/health and beauty, movies/TV, music, and room visits from April to June, 2023 were requested and the facility had no documentation. Review of the quarterly activities data collection dated May 4, 2023 revealed that the resident likes to watch TV/movies, and manicures. It also revealed that the resident doesn't like group activities. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident is a totally dependent and requires a two-person assist with transfers and is requires a one-person extensive assist to dress and complete hygiene tasks. Review of the task sheets dated July 2023 regarding activities revealed no documentation for: -happy hour -family visits -ice cream socials -movies -room visits -one to one visits Review of the activity report dated July 2023 revealed that the resident participated in Bingo on July 6 and 18, 2023. There were no other activities documented for July 2023. During the initial interview conducted on July 24, 2023 at 2:39 a.m., resident #18 stated that she is not able to walk and move, she is a vegetable, and has not been outside and the staff don't give her activities. On July 24, 2023 at 12:00 p.m. and at 2:39 p.m., resident #18 was observed in her room sleeping. An interview was conducted on July 27, 2023 at 12:09 p.m. with the activity manager (staff #57), who stated that she usually documents the activities attended on the task sheet. Staff #57 reviewed the task sheets dated July 2023 and stated that the resident did not participate in Bingo or have a manicure in the last 30 days. She stated that when staff document not applicable on the task sheet, it means that the resident didn't want to attend the activity or was asleep and she doesn't report to the nurse staff if a resident is refusing to participate in activities. An interview was conducted on July 27, 2023 at 1:13 p.m. with the Executive Director (ED/staff #107), who stated that she supervises the activity manager. She stated that one to two activities are planned a day and some residents like one-to-one activities, such as getting their nails done. and a lot of the residents like to play Bingo. She stated that if a resident is not doing activities, staff should document the refusal. She also stated that it is okay for a resident to stay in his/her room and participate in activities if this is the resident's baseline. The facility policy, Documentation Activities, dated January 2011 states that the Activity Director/Coordinator is responsible for maintaining appropriate departmental documentation. Recordkeeping is a vital part of the activity programs including attendance records. The facility policy, Resident Rights, 2018 states that the facility promotes and protects the rights of residents including the right of access to individuals, services, community members, and activities inside and outside the facility.

Review of the employee file, staff interviews, and the policy and procedures revealed that the facility failed to ensure staff #57 had the educational requirements and experience for the position of Activity Manager. The deficient practice could result in activity assessments and the implementation of an appropriate activity program not being met for residents. Findings include: Staff #57 was hired on May 23, 2023 as the Activity Manager. Review of staff #57's resume revealed that staff #57's level of education was a high school diploma. There was no documentation of work experience or certification in recreational activities. Review of the job description revealed that the Activity Manager reports to the Executive Director, and directs the development, implementation, supervision, and ongoing evaluation of the activities program. Tasks and responsibilities include to actively monitor the residents' responses and evaluate these responses to the programs in order to determine if the activities meet the assessed needs of the resident. It also included the scheduling and supervision of the activity assistants and volunteers. The job description did not include educational/certification requirements or job-related experience. Review of the NAPT, Activity Director Training Course syllabus revealed an eight-week training program/75 hours. On July 27, 2023, staff #57 provided documentation of training. Review of staff #57's Activities Director's Network Certificate of Completions revealed that staff #57 had completed 10.5 hours of training out of the total 75 hours. The documentation was not dated. During an interview conducted on July 27, 2023 at 8:30 a.m. with Human Resource (HR/staff #12), she stated that staff worked in dietary prior to becoming the Activity Manager. She reviewed the job description for Activity Manager and stated that certification and/or prior experience is not required. During an interview conducted on July 27, 2023 at 1:13 p.m. with the Executive Director (ED/staff #107), she stated that she supervises the Activity Manager, and per regulation the Activity Manager needs certification or a therapy degree. The facility's policy Staff Development Program dated 2013 states that licensed and certified staff are required to maintain licensure and certifications according to their respective positions, in accordance with any state and federal requirements, rules, and regulations.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#46) was provided pain management services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for residents. The census was 58, the sample was 16 residents. Findings include: Resident #46 was admitted on [DATE] with diagnoses that included hemiparesis and hemiplegia, fracture of left femur, protein calorie malnutrition, COPD, major depressive disorder, chronic pain ddue to trauma, and need for assistance with personal care. A quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment included that the resident had constant pain in the last 5 days and received scheduled pain medication and as needed (PRN). An active care plan revealed the following areas of focus: - Risk for pain related to acute and chronic pain and is on an opioid analgesic to treat pan per physician order -Alteration in musculoskeletal status related to left ankle pain and muscle spasms with interventions that included to give analgesics as ordered, initiated February 1, 2023. -On Opiate medication related to pain with interventions that included to administer medication as ordered, non-medication intervention for pain prior to administration of PRN medication (reposition, relaxation, heat/cold application, muscle stimulation), initiated July 10, 2023. A review of the physician's orders revealed an order for: -Ibuprofen Oral Tablet 200 mg (milligram), Give 2 by mouth every 8 hours as needed for pain level 4-10 2 tablets = total dose 400 mg. -Tramadol HCL Tablet 50 mg, give 1 tablet by mouth every 6 hours as needed for pain 7-10. -Tylenol Extra Strength Tablet 500 mg, give 2 tablets by mouth every 6 hours as needed for pain 1-3 not to exceed 3 gr (grams)/24 hours. Review of a Medication Administration Record (MAR) dated July 2023 revealed that Ibuprofen oral tablet 200mg tablet, give 2 by mouth every 8 hours as needed for pain 4-10 was not administered as ordered on the following dates: -July 15, 2023 was administered for a pain level of 3 -July 16, 2023 was administered for a pain level of 4 -July 17, 2023 was administered for a pain level of 3 -July 18, 2023 was administered for a pain level of 3 -July 21, 2023 was administered for a pain level of 2 -July 22, 2023 was administered for a pain level of 1 -July 24, 2023 was administered for a pain level of 3 -July 25, 2023 was administered for a pain level of 1 Further review of the July MAR revealed that Tramadol 50 mg, give 1 tablet by mouth every 12 hours as needed for pain 7-10 was not administered as ordered on July 9, 2023. The record revealed evidence that tramadol had been administered for a pan level of 1 and there was no evidence in the clinical record that the provider had been notified. Further review of the clinical record revealed no evidence that the provider had been notified, or why the medication was administered outside of ordered parameters. An interview was conducted on July 26, 2023 at 1:34 Pm with a Licensed Vocational Nurse (LVN/staff #106), who stated that the facility expectation is to follow physician order as written, including parameters for pain medications. He further stated that he would have expected that the physician would have been notified, and documented in the clinical record. He reviewed the clinical record and stated that the ibuprofen had been administered outside of parameters multiple times in July, and that there was no evidence in the progress notes that the provider had been notified. He further stated that Tramadol had been administered outside of parameters on one occasion. He stated that the risk of not following physician orders as written could result in the medication not being effective. He also stated that the risk of not notifying the provider when a pain medication is administered outside of parameters could result in the provider not being aware of the pain medications effectiveness. An interview was conducted on July 6, 2023 at 3:31 with the Director of Nursing (DON/staff #30) who stated that it was the facility policy to follow physician orders as written, including parameters for pain medications. She also stated that if a medication is administered outside of parameters the provider should be notified for a new order including parameters, and be documented in the clinical record. She reviewed the clinical record and stated that the ibuprofen and tramadol had clearly not been administered within the ordered parameters, and that there was no evidence that the physician had been notified. The DON further stated that the risk of not administering pain medications as ordered could result in the resident's pan not being controlled. She also stated that the risk of not notifying the provider when a pain medication is administered outside of parameters could result in the risk of the pain continuing or getting worse. Review of the facility policy titled, Administering Medications, revealed that medications must be administered in accordance with the orders, including any required time frame. Review of the facility policy titled, Administering Pain Medications, revealed that it is the facility policy to administer pain medications as ordered, and report other information in accordance with facility policy and professional standards of practice.

Based on clinical record review, resident and staff interview, facility documentation and facility policy and procedures, the facility failed to ensure that one resident (#30) was free from neglect, as evidenced by failing to transfer the resident with the use of a gait belt resulting in a fall with injury. Findings include: Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident required two plus persons extensive physical assist with transfers. A review of the Impaired Activity of Daily Living/Mobility care plan dated October 14, 2011, revealed an approach of "extensive assist for bed mobility, transfers, dressing and toileting." The Nursing Monthly Summary dated November 27, 2011, documented the resident was assessed to require extensive assist of two or more staff for transfers. Review of a Resident Incident Report dated December 6, 2011 at 7:00 p.m., revealed the resident was lowered to a sitting position on the floor by two student nursing assistants. A review of the Departmental Notes dated December 6, 2011 at 11:43 p.m., revealed no documentation that the resident had fallen. According to the Reportable Event Record/Report, the resident had complained of pain and was sent 911 to the emergency room . The report further revealed that two student nursing aids were suspended until the investigation was completed and an inservice was provided regarding Proper Transfer Techniques for Residents. A review of the hospital Discharge Instructions dated December 7, 2012, revealed "Elbow Fracture, Simple Humerus (Upper Arm) Fracture, Treated with Immobilization Arm Sling..." Review of the the facility's investigation dated December 8, 2011, revealed that on the evening of December 6, 2011, two student nursing assistants attempted to transfer the resident from the bed to a shower chair. The investigation also revealed that "During the SNA's (student nursing assistants) transfer of the resident, no gait belt was placed around the resident to assist with the transfer from the bed to the shower chair. During the 2 person transfer, the resident's unaffected (R) right leg buckled and gave out. The SNA was loosing (sic) grip of the resident and the 2nd aide on the resident's weak effected left side proceeded to attempt to prevent the resident from slipping to the floor." The report further included that during this time the resident's "left arm was hyperextended over the armrest of the shower chair. The shower chair was removed from the area and the aide supporting the resident's left side grasped the resident under both arms to hold the resident and support him from touching the floor." A review of the Resident Incident Follow-up dated December 8, 2011, revealed the 24 hour follow-up documentation included "condition is stable, however remains in a soft cast to left arm. resident (sic) fractured left arm and shoulder." An interview was conducted at 9:20 p.m. on October 16, 2012, with the female student nursing assistant involved in the resident's transfer and fall on December 6, 2011 (she is currently a CNA working in the facility). She stated the fall occurred the first time she and the other male student nursing assistant were left unaccompanied by the CNA assigned to work with them. She further stated that she and the male SNA had discussed whether to use the gait belt to transfer the resident, but decided not to because the resident was wearing a hospital gown and they felt that the gait belt would cause a skin tear or an abrasion on the resident's bare back. She reported that she heard the resident's arm 'pop' twice as he was going down to the ground and that she informed several staff (a certified nursing assistant and nurses) that she heard the pop and was concerned about the resident's arm. During an interview conducted on October 16, 2012, the Director of Nursing stated that during the two person transfer with the resident, a gait belt should have been used. During an interview conducted at 7:55 am. on October 17, 2012, the resident stated that on December 6, 2011, the staff had dropped him. During an interview conducted at 10:00 a.m. on October 17, 2012, a registered nurse/student nursing assistant trainer stated that the student nursing assistants had been trained to use a gait belt when transferring a resident prior to being allowed to provide care to residents. During an interview conducted at 10:20 a.m. on October 17, 2012, a certified nursing assistant stated that she was working with the two student nursing assistants on the evening of December 6, 2011. She stated that she left the SNAs to go assist another CNA in providing care to another resident and told the SNAs to take the resident into the room and wait for her. During an interview conducted on October 17, 2012, the administrator was asked for evidence that the failure to use a gait belt during the transfer was addressed in the facility's Quality Improvement Committee program. The administrator failed to provide documented evidence of the development of an action plan and monitoring to ensure that the issue was resolved. The facility policy documented that "...It is the policy of our facility to maintain a work and living environment that is professional and free from...neglect...'Neglect' means failure to provide goods and services necessary to avoid physical harm..."