Every finding on record at Haven of Phoenix

Based on a review of records, observation, interviews, policies and procedures, the facility failed to ensure that two residents (#122 and #163) were not abused by another resident (#121 and #60) out of 11 sampled residents. The Universe was 99. The deficient practice could lead to physical and psychosocial harm to residents.Regarding the altercation between Resident #121 and Resident #122-Regarding #121, (Alleged Perpetrator) Resident #121 was re-admitted to the facility on [DATE], with diagnoses that included encephalopathy, anxiety, and bipolar disorder.A Physical Aggression incident report dated April 27, 2026, at 5:35 p.m., revealed that a Nurse was notified of an incident involving Resident #121 (alleged perpetrator) and #122 (alleged victim), who shared a room. The note included that the nurse entered the room and observed Resident #121 screaming it's my walker, and physically hitting Resident #122 in the right upper extremity. The note indicated that the residents were separated, and Resident #121 was removed from the room and reoriented to calm down. The note also included that Resident #122 was taken to a designated smoking area, the provider was notified, and an order was received to transfer Resident #121 to the hospital for further evaluation and care, and no injuries were noted at the time of the incident.A hospital transfer discharge summary progress note dated April 27, 2026 at 7:06 p.m., revealed that the resident became aggressive towards his roommate and staff, agitated, hard to reorient. Staff tried to reorient to facility, therapeutic communication and nursing sitter.A health status note dated April 27, 2026 at 8:40 p.m., revealed that the resident was transferred to the hospital related to AMS (altered mental status): agitation, restlessness and behaviors. The note indicated that the resident left the facility via ambulance.A review of the quarterly MDS (Minimum Data Set) assessment dated [DATE],revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 02, whichindicated severe cognitive impairment.A care plan for behavioral-problems related to physical behaviors was initiated on April 28, 2026, which revealed that Resident # 121 exhibited behavioral disturbances related to confusion, and episodes of physical aggression including yelling, hitting, striking staff and others.- Regarding #122, (Alleged victim)Resident #122 was re-admitted to the facility on [DATE], with diagnoses that included sepsis, type 2 diabetes, and cellulitis.An admission MDS (Minimum Data Set) assessment dated [DATE], revealed that Resident #122 had a BIMS (Brief Interview for Mental Status) score of 14, which indicated intact cognition. The assessment included that no behaviors were exhibited during the assessment period.A progress note dated April 28, 2026, at 10:58 a.m. revealed that patient was evaluated for involvement in a physical altercation.A shower body check program dated April 28, 2026, revealed that the Resident #122 had no breakdowns, open areas or areas of concerns.A facility report dated April 28, 2026, revealed that Resident #121 struck the left hand and was pulling on the walker of Resident #122, confusing his personal belongings with those of Resident #122. Resident #121 then struck Resident #122 on the chest, and then Resident #121 pushed Resident #121's hand off of the walker, in an attempt to protect himself, causing a skin tear. The report revealed that staff were present in the hallway and responded immediately, and there were no prior behaviors indicating imminent risk. The report also included that the alleged victim, Resident #122 reported mild chest discomfort, but no acute distress, with no bruising or redness noted. The report also revealed that Resident #121 was identified as initiating the altercation. The report indicated there was no evidence identified to suggest intentional harm, and the incident appeared to have occurred in the context of new admission adjustment and cognitive impairment.An interview was conducted on May 4, 2026, at 8:04 a.m. with a Licensed Practical Nurse (LPN, staff #83), who stated that the types of abuse include verbal, physical, and financial. The LPN further stated that the incident would be reported to the Abuse Coordinator and the Director of Nursing immediately. The LPN stated that the incident between Resident #121 and Resident #122 happened on April 27, 2026, in the evening around 5:30 p.m. to 6 p.m. Per the LPN, a screaming sound was heard coming from the room of Residents #121 and #122. The LPN stated that upon entering the room Resident #121 was anxious, pulling on a walker, screaming it's mine and punching Resident #122. The LPN also stated that both residents were immediately separated and skin assessments were performed with no injury observed for Resident #122, and that Resident #121 was observed to have a skin tear on his left arm. The LPN further stated that the provider was notified and Resident #121 was sent to the hospital. The LPN further stated that he would consider the altercation between Resident #121 and #122 as a physical abuse as Resident #122 physically assaulted by Resident #121.An interview was conducted on May 04, 2026, at 12:29 p.m. with the Resident #122, who stated that he recalled the incident with Resident #121 stating that Resident #121 was his roommate and the incident happened in the evening on the day that Resident #121 was admitted . Resident #122 stated that Resident #121 was using his walker while going to the bathroom, then started pulling Resident #122 and punched him 7 times on right wrist. Resident #122 then stated that he was about to hit Resident #121 with his right hand, when LPN (staff #83) intervened and pulled Resident #121 away. Resident #122 stated that Resident #121 started screaming and stated he did not want to stay in here. Resident #122 further stated that both residents were separated, and assessed by the LPN. Resident #122 also relayed that his right shoulder was hurting and that he would consider the incident as adult abuse because Resident #121 started hitting him and other staff members.An interview was conducted on May 4, 2026, at 2:51 p.m., with a Certified Nursing Assistant (CNA, staff # 24), who stated that the types of abuse include verbal, physical, and financial. The CNA stated that the facility process for a resident-to-resident altercation included separating both residents, notifying the abuse coordinator immediately, and assessing both residents for injuries. The CNA stated that he recalled the incident between Resident #121 and Resident #122. The CAN stated that Resident #121 was confused and using his and Resident #122's walkers to go to the restroom because Resident #121 believed that both walkers were his. The CNA also stated that Resident #122 then called for help and the CNA intervened and explained to Resident #121 which walker was his and then the CNA left the resident's room. The CNA stated that a few minutes later he and another CNA (staff #21) observed Resident #121 and Resident #122 yelling and fighting over a walker, saying threating words to each other, and that both residents got hurt. The CNA stated that the residents were separated and Resident #121 had skin tear on back of his hand. The CNA further stated that he would consider the altercation between Resident #121 and #122 as physical abuse because both residents were physically fighting over the walker and making threats for further violence.An interview was conducted on May 5, 2026, at 1:50 p.m., with the Interim Director of Nursing (DON/Staff #125), who stated that abuse could be verbal, physical, sexual or financial. The DON further stated that any incidents of abuse should be reported to the Abuse Coordinator immediately. The DON then stated that Resident #121 was new to the environment and the incident between Resident #121 and #122 occurred on the day Resident #121 was admitted to the facility. The DON also stated that Resident #121 was trying to take the walker of Resident #122 because he was confused. The DON stated that there were no injuries to either residents and she would not consider the altercation between Resident #121 and #122 as abuse.Regarding the altercation between Resident #60 and Resident #163- Regarding #60 (alleged perpetrator)Resident #60 was initially admitted to the facility on [DATE], with diagnoses that included type 2 diabetes, vascular dementia, unspecified mood, and anxiety.The clinical record dated May 4, 2020 through February 15, 2023, revealed the following behaviors: denial of medication administration and placement of left-hand brace, uncooperative with therapy.A review of an annual MDS (Minimum Data Set) assessment dated [DATE], revealed that a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition.A behavior progress note, dated February 16, 2023, revealed that the resident had an altercation with another resident and the police were notified.An incident note dated February 16, 2023, revealed that Resident #60 was witnessed by staff hitting Resident #163 with his fists in the north hall. Per note, Resident #60 ran into Resident #163 by his power wheelchair from the back, then hit him on his right knee and face. Resident #60 was assessed with no injuries, and was placed on observation, the police were notified and investigated the incident.A Shower Body Check Program form dated January 17, 2023, revealed no bruises/skin tears were present.A care planned focus for behavioral problem related physical altercation towards other residents, dated February 17, 2023, revealed interventions that included to identify behavior triggers, and refer to psychiatric provider as ordered A weekly skin assessment dated [DATE], revealed no new or ongoing skin injury.- Regarding #163 (alleged victim)Resident #163 was re-admitted to the facility on [DATE], with diagnoses that included type 2 diabetes, adjustment disorder, and mood (affective) disorder.A care plan dated April 8, 2021, revealed that Resident #163 had behavior problems related to socially and sexually inappropriate, and refusal of care.A review of a quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 13, which indicated intact cognition. The assessment included that no behaviors were present during the assessment period.A behavior progress note dated February 16, 2023, revealed that the resident had a physical altercation with another resident.A Incident progress note dated February 16, 2023, revealed that staff witnessed Resident #60 hit Resident #163. The note relayed that the residents were assessed with no injuries or bruises.Further review of care plan dated February 17, 2023, revealed that Resident #163 had a behavior problem related to impaired safety awareness. Interventions included that the resident will verbalize understanding of need to control verbal behaviors through the review date, and to identify behavior triggers.A weekly skin assessment dated [DATE], revealed no new or ongoing skin injury.An interview was conducted on May 4, 2026, at 1:40 pm, with an LPN (staff # 58), who stated that the different abuse can be verbal, physical, financial or misappropriation of property. The LPN stated that the facility process regarding resident-to-resident altercations included separating both residents, notifying the Abuse Coordinator immediately, and assessing both residents for injuries. The LPN then stated that she was not working at the facility when the incident occurred between Resident #60 and Resident #163. The LPN further stated that in general it would be considered abuse if one resident hits other resident because one resident was physically harming the other resident.An interview was conducted on May 5, 2026, at 1:50 p.m., with the Interim Director of Nursing (DON/Staff #125), who stated that abuse can be verbal, physical, sexual and financial. The DON further stated that any incidents of abuse should be reported to the abuse coordinator immediately. The DON then reviewed the clinical record for Resident #60 and Resident #163 and stated that she had not witnessed the incident but one resident hitting another resident would be considered physical abuse.Review of the facility policy titled, Resident Rights, dated January 1, 2024, revealed that preventing, recognizing and reporting resident abuseReview of the facility policy titled, Abuse Policy, date 2022, revealed that facilities strive to prevent the abuse of all their residents.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that medications were administered as ordered for two of five sampled residents (Resident #32 and #56). The deficient practice could result in resident's pain not being controlled.Regarding Resident #32: Resident #32 was readmitted to the facility on [DATE], with a diagnosis that included schizoaffective disorder, bipolar type; bipolar disorder; major depressive disorder; and anxiety disorder. A care plan focus dated February 24, 2025, revealed Resident #32 had polyneuropathy pain. Interventions included that the staff were to anticipate his need for pain relief and respond as soon as possible. A physician's order dated October 8, 2025, revealed Resident #32 is to take one 325 mg tablet of oxycodone-acetaminophen every 5 hours as needed for pain levels of 6 to 10. A quarterly minimum data set (MDS) assessment dated [DATE], revealed that Resident #32 had a BIMS (brief interview of mental status) score of 15, indicating that Resident #32 was cognitively intact. The assessment also revealed that Resident #32 received a scheduled pain medication regimen and received pain medications as needed. The assessment revealed that Resident #32 experienced pain occasionally over the last 5 days. A review of the medication administration record (MAR) for April 2026 revealed that the order of one 325 mg tablet of oxycodone-acetaminophen every 5 hours as needed for pain levels of 6 to 10 had been administered out of parameters on:- April 9, 2026, with an administration of the medication with a pain level of 5- April 19, 2026, with an administration of the medication with a pain level of 2- April 21, 2026, with an administration of the medication with a pain level of 4- April 28, 2026, with an administration of the medication with a pain level of 2- April 29, 2026, with an administration of the medication with a pain level of 5 An interview was conducted on May 5, 2026, at 10:39 AM, with a licensed practical nurse (LPN/Staff #38). Staff #38 stated that when administering medications, staff are expected to confirm the medication, review the vitals, and then review the right medication, right route, right dose, and the right resident for accuracy. Staff #38 stated it was important to give medication as ordered due to the risk of administering medications out of ordered parameters. Staff #38 also stated that she would confirm the order before administering it and would notify the provider if the resident refused to take the medication or requested a change to it. An interview was conducted on May 5, 2026, at 11:34 AM, with a certified nursing assistant (CNA/Staff #16). Staff #16 stated that what she would look for when a resident is in pain would be to see any physical signs, such as wincing, crying, increased anxiety, and not acting at their baseline. Staff #16 also stated that should she observe a resident in pain, she would ask the resident for their pain level and report the pain to the nurse immediately so that their pain level can be addressed appropriately. An interview was conducted on May 5, 2026, at 12:06 PM, with an LPN (Staff #14). Staff #14 stated that when administering pain medications, she would ask a resident their pain level and the location of the pain. Staff #14 stated that she would then check the ordered medications available to the resident per the resident's stated pain level. If the ordered pain medication specified a pain level range within the physician's orders, such as 6 to 10, she would administer the medication. Staff #14 also stated that she would reach out to the physician to confirm if a medication could be given out of parameters, and what other medications could be administered. Staff #14 also stated that orders, changes, or updates received from the physician would need to be documented in the resident's electronic health record. An interview was conducted on May 6, 2026, at 9:54 AM, with the interim director of nursing (DON/Staff #125). Staff #125 stated that when administering pain medications, staff are expected to ask a resident their pain level and the location of the pain. Staff #125 stated that staff are expected to administer the ordered medications per the resident's stated pain level. Staff #125 reviewed the orders and the April MAR of Resident #32. Staff #125 stated that oxycodone-acetaminophen every 5 hours as needed for pain levels of 6 to 10 had been administered out of parameters on April 9, 2026; April 19, 2026; April 21, 2026; April 28, 2026; and April 29, 2026. Staff #125 stated that the physician's orders were not followed on the listed days and that the risk of medications being administered out of parameters could be a lowered blood pressure, respiration, and overall abnormal vital signs. -Regarding Resident #56: Resident #56 was admitted to the facility on [DATE], with diagnosis that included dysphagia, gastro-esophageal reflux disease without esophagitis, hypertension, and anxiety. A quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also revealed that the resident received a scheduled pain medication regimen and received pain medications as needed. A physician's order dated July 24, 2025, revealed Resident #56 is to take one 5 milligram tablet of oxycodone-HCl every 6 hours as needed for pain scale 4-6 related to low back pain. A care planned focus dated November 18, 2024, revealed that the resident was at risk for pain related to generalized discomfort with interventions that included to administer analgesia medication as per orders. A Medication Administration Record (MAR) for April 2026 revealed that the order of one 5 mg tablet of oxycodone-HCl every 6 hours as needed for pain levels of 4 to 6 had been administered out of parameters on: - April 3, 2026, with an administration of the medication with a pain level of 7 - April 8, 2026, with an administration of the medication with a pain level of 7 - April 11, 2026, with an administration of the medication with a pain level of 7 - April 18, 2026, with an administration of the medication with a pain level of 8 - April 20, 2026, with an administration of the medication with a pain level of 7 - April 22, 2026 with an administration of the medication with a pain level of 8 - April 25, 2026 with an administration of the medication with a pain level of 7 - April 26, 2026 with an administration of the medication with a pain level of 8 - April 29, 2026 with an administration of the medication with a pain level of 7 An interview was conducted on May 5, 2026, at 10:04 AM, with a Licensed Practical Nurse (LPN/Staff # 65), who stated that when administering medications, staff are expected to confirm the medication, review the vitals, and the resident's pain level. The LPN further stated that according to the pain scale: 10 means most pain and 0 means no pain. The LPN reviewed the resident's clinical record and stated that Resident #56 had an order of Oxycodone HCl tablet 5 milligrams, to give 1 tablet by mouth every 6 hours as needed for mild pain of 4-6. The LPN then reviewed the MAR for the month of April 2026, and stated that the pain level documented in MAR referred to the resident's pain before the medication was administered to the resident. The LPN further stated that the clinical record revealed that Oxycodone had been administered for pain levels of 7 and 8, which was outside of the ordered pain level of 4 to 6. The LPN also stated that risk of not following physician ordered parameters for pain medication, could result in not controlling resident's pain. An interview was conducted on May 5, 2026, at 10:39 AM, with a LPN (Staff #58), who stated that when administering medications, staff are expected to confirm the medication, review the vitals, and then review the right medication, right route, right dose, and the right resident for accuracy. The LPN reviewed Resident #56's clinical record and stated that the resident had an order of Oxycodone HCl tablet 5 milligrams, to give 1 tablet by mouth every 6 hours as needed for mild pain 4-6. The LPN then reviewed the MAR for the month of April 2026, and stated that the pain level documented in the MAR referred to the resident's pain before the medication was administered to the resident. The LPN further stated that Oxycodone was administered for pan levels of 7 and 8 which was outside of the physician ordered parameters of 4-6. The LPN also stated that risk of not administering pain medication as ordered couls result in the resident's pain not being controlled. An interview was conducted on May 5, 2026, at 1:22 PM, with the interim Director of Nursing (DON/Staff #125, who stated that when administering medications, staff are expected to confirm the medication, review the vitals, and then review the right order, right dose, and the right resident for accuracy. The DON reviewed the resident's physician orders and the April 2026 MAR . The DON stated that oxycodone-acetaminophen every 5 hours as needed for pain levels of 4 to 6 had been administered out of the physician ordered parameters on 9 occasions during April 2026. The DON also stated that the risk of medications being administered outside of the physician ordered parameters could result in resident's not receiving effective pain-relieving medication. A policy titled, Medications: Administering Medications, in effect on January 1, 2024, revealed that medications are to be administered in accordance with the prescriber's orders, including any required time frame.

Based on observation, review of the clinical records, staff interviews, review of the Blood Glucose Monitoring System User's Guide, and review of the facility's policy and procedure, the facility failed to ensure that staff conducted proper hand sanitizing during a meal service and infection control procedures were performed after a point of care testing for blood sugar check, for one resident (#164) to help prevent a transmission of infections according to acceptable clinical standards of practice. The census was 99. The deficient practice could result in the spread of infectious diseases to other residents and could place the residents at risk for infection.Findings include: -Regarding Following Hand Hygiene: An observation of residents in the dining room was conducted on April 4, 2026 at 7:38 AM. There were a total of five Residents having breakfast and one staff member (#37) a Certified Nursing Assistant (CNA) assisting the residents. Each of the Residents were sitting at their own table. Residents had their breakfast, a cup of coffee and a glass of juice. A resident finished breakfast and left the dining room. Staff #37 removed the resident's plate, silverware and glasses from the table, walked to the garbage can, scraped the plate and placed it on the dirty tray cart. Staff #37 did not perform hand hygiene; however, he went to the tray cart and pulled a new breakfast tray for a resident, placed the dish in front of the resident along with the silverware, sat beside the resident, picked up the fork and placed eggs on it and fed it to the resident. Another resident in the dining area finished breakfast and left the dining room and staff #37 walked to the table, cleared the dishes, walked to the garbage can, scraped the dishes and then placed the dirty dishes onto the dirty tray cart. Another resident in the dining area then asked staff #37 for a refill of coffee. Staff #37 did not perform hand hygiene and took a coffee pot to the resident and filled the coffee cup. Staff #37 then placed his fingers on the top of the coffee mug and gave it back to the resident. An interview was conducted with staff #37 on May 4, 2026, at 7:38 AM. The CNA stated he did not perform hand hygiene during the dining service and the risk was cross contamination and spreading disease. An interview was conducted on May 5, 2026, at 1:02 PM with the Assistant Food Director, staff #97. He stated his expectation during dining service was that staff sanitize their hands between assisting residents. He stated the risks could potentially be foodborne illness, and spreading germs between residents. An interview was conducted on May 5, 2026, at 1:45, with the acting DON. She stated it did not meet expectation for staff to not perform hand hygiene between residents. Based on the observation, she stated we need to do some education. - Regarding Resident #164: Resident #164 was readmitted to the facility on [DATE] with diagnoses that included enterocolitis due to clostridium difficile (C-diff), infection and inflammation reaction due to indwelling urethral catheter, and methicillin resistant staphylococcus aureus infection (MRSA). A review of the Residents active physician's orders revealed that the Resident was placed on Enhanced Barrier Precautions related to wounds, indwelling catheter to drain urine from her bladder, and a peripherally inserted central catheter for intravenous access; and the Resident was also placed on contact isolation precaution for C-diff. A review of the Resident's care plan initiated on 04/21/2026, revealed that the Resident had C-diff. The interventions included contact isolation precaution by putting on personal protective equipment (PPE) such as gowns and masks when changing contaminated linens; placing soiled linens in bags marked biohazard; bagging linens and closing the bag tightly before taking it to the laundry; disinfecting all equipment used before it leaves the room; educating the resident, family and staff regarding preventive measures to contain the infection; place the resident in a private room with contact isolation precautions; and using as much disposable equipment as possible or use of dedicated equipment such as thermometer and blood pressure cuff. A review of the infection progress note dated 04/22/2026, revealed that the reason for the consultation included C. difficile Infection (CDI) and the Resident was on prophylaxis. Per the document, the Resident developed CDI during a hospitalization in the setting of prolonged, broad-spectrum antimicrobial therapy, and the treatment was transitioned to oral vancomycin prophylaxis through 04/30/2026 given continuation of antibiotics. It was further documented that the Resident denied diarrhea or loose stools. On 05/05/2026, at 7:33 AM, a medication administration observation was conducted with a Registered Nurse (RN/Staff #65) for Resident #164. The RN stated that the Resident was placed on contact isolation precaution for C-diff. On 05/05/2026, the outside of the Resident's room was observed to have a contact isolation precaution signage and a PPE cart. On 05/05/2026, at 7:35 AM, the RN (Staff #65) took a glucometer device from her medication cart, then put on a disposable gown and gloves, and entered the room of Resident #164. The room was observed to have a stethoscope and a blood pressure cuff inside an open square container placed on top of an empty bed; and a glucometer placed on top of a drawer located inside the Resident's room by the doorway. On 05/05/2026, at 7:37 AM, while in Resident #164's room, the RN (Staff #65) wiped one of the Resident's fingers with an alcohol swab to check the Resident's blood sugar, while the glucometer was placed on top of the Resident's bedside table. After the RN pricked the Resident's finger, she applied the blood on the test strip that was inserted in the glucometer to obtain the blood sugar result, and the RN informed the Resident that her blood sugar was 143. The RN removed her disposable gown and gloves and then placed it in a covered trash bin located inside the Resident's room and then washed her hands. On 05/05/2026, at 7:41 AM the RN (Staff #65) exited the Resident's room carrying with her the glucometer. The RN then placed the glucometer on top of a tissue paper, which was located on top of the medication cart. The RN stated that she used a tissue paper with hand sanitizer to wipe down the glucometer. She also said that she wiped the glucometer dry with another tissue paper. It was further observed that she placed the glucometer inside the top drawer of the medication cart. Further, the RN stated that for any isolation precaution, she would put on a gown and gloves; and before exiting the Resident's room, she would take off her gown and gloves, place it inside the trash bin located inside the Resident's room. The RN also stated that regarding a glucometer for a Resident with a contact isolation precaution, that each Resident should have a glucometer device inside the room. She said that she brought in a glucometer inside Resident #164's room because she did not want to risk going in the Resident's room and then finding out that there was no glucometer. She said that there should be a glucometer in the Resident's room but instead, used the glucometer from her medication cart. An interview was conducted on 05/05/2026, at 7:55 AM with the acting Director of Nursing/Assistant Director of Nursing (DON/ADON/Staff #125). The acting DON/ADON stated that she came over because -she was trying to find out why Staff #65 was withdrawing insulin from an insulin pen. She said that she was educating Staff #65 not to withdraw insulin from the insulin pen. The acting DON/ADON stated that the process and expectation for a resident on isolation is she will get back to me on that. She said that infection control is preventing the spread of infection by handwashing, using gloves, sanitizing if appropriate, and gowning up when appropriate. She stated that for a resident placed on contact isolation due to C-diff, she expects the staff to gown up and use gloves, and leave devices such as a vital sign machine, glucometer and supplies inside the Resident's room. She said that regarding the glucometer sanitizing, she would use a disinfectant wipe, and would not use a hand sanitizer to disinfect the glucometer because it does not kill the germs. The acting DON/ADON stated that she would remove the glucometer from the medication cart that was used to check Resident #164 's blood sugar and had been improperly disinfected. She stated that she had educated Staff #65. On 05/05/2026, at 8:01 AM, the acting DON/ADON removed the glucometer utilized for Resident #164 from the medication cart. On 05/05/2026, at 8:09 AM, a request was made for the facility's policies on transmission-based precaution and point of care testing; the facility's manufacturer's manual for their glucometer point of care testing device; and Staff #65's employee record. A review of the facility policy titled, D035 - Infection Control: Isolation – Initiating Transmission – Based Precautions, with an effective date of 01/01/2024, revealed that transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. When transmission-based precautions are implemented, the infection preventionist (or designee) ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment; ensures that protective equipment and supplies needed to maintain precautions during care are in the resident's room; and ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner are placed in or near the resident's room. The transmission-based precautions remain in effect until the attending physician or infection preventionist discontinues them, which occurs after criteria for discontinuation are met. A review of the facility policy titled, Infection Control: Infection Control Guidelines for All Nursing Procedures, version 011526, revealed that the Transmission-Based Precautions will be used whenever measures are more stringent than Standard Precautions are needed to prevent the spread of infection. When there is likely exposure to spores (i.e., C. difficile or Bacillus anthracis) (Note: Alcohol-based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30-60 seconds with soap and water or 2% chlorhexidine gluconate.) Review of the Blood Glucose Monitoring System User's Guide provided by the Executive Director (Staff #200) revealed that cleaning is the removal of dust and dirt from the meter and lancing device surface so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing are destroyed on the meter and the lancing device surface. Further, the manual guide revealed that the following products are validated for disinfecting the meter and lancing device: Medline micro kill bleach germicidal bleach wipes EPA registration 37549-1. The manual also revealed that to disinfect the meter, clean the meter with one of the validated disinfecting wipes. The facility's policy for Infection Control: Handwashing/Hand Hygiene dated January 1, 2024, stated All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors, to include before and after assisting a resident with meals.

Based on the review of the clinical records, staff interviews, and from the Arizona Health Care Cost Containment System, the Pre-admission Screening and Resident Review (PASRR), the facility failed to ensure the PASARR (pre-admission screening and resident review) was updated appropriately and accurately submitted, when applicable, for one resident (#32). The census was 99. The deficient practice could result in residents' medically related social and emotional needs not being met. The census was 99.Findings include:Resident #32 was readmitted to the facility on [DATE], with the diagnoses that included Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, and Anxiety Disorder. A review of the Minimum Data Set (MDS) 5-day assessment dated [DATE], revealed that the Resident's Brief Interview for Mental Status (BIMS) was not assessed. The Quarterly MDS assessment dated [DATE], revealed a BIMS score of 15.0, indicating that the Resident was cognitively intact. The assessment also revealed that no behavioral symptoms exhibited, and rejection of care behavior occurred daily. Further, the assessment revealed that the Resident had active psychiatric or mood disorder diagnoses which included Anxiety Disorder, Depression, Bipolar Disorder, and Schizophrenia. The MDFS further noted that the Resident used antianxiety and antidepressant medications. A review of records revealed that the Resident's PASARR was completed on 2/25/2025. The document revealed that Bipolar Disorder (Manic Depression) and Schizoaffective Disorder were selected as serious mental illness (SMI), and Anxiety Disorder and Depression were selected as mental disorders (MD). However, there was no document found in the Resident's medical record that a level 2 referral for determination was submitted to the appropriate state agency program. The Resident's care plan initiated on 5/01/2026, revealed per document that the Resident had a diagnosis of major depressive disorder, Anxiety disorder and Schizoaffective disorder which placed the Resident at risk for behavioral symptoms and the need for ongoing psychiatric oversight. The interventions included to ensure all specialized mental health services are provided or arrange as required, document frequent triggers and respond to interventional for all behavioral episode each shift, and report any changes to the provider. An interview was conducted on 5/05/2026, at 12:23 PM with the Resident Relations Manager (Staff #32). Staff #32 said that she started at the facility 3 weeks ago. She said that regarding the PASARRs, the PASARRs are filled out when admitted to the facility, and if the Resident stayed in the facility for 30 days, she would complete a Level 1 and Level 2 PASARR. She also stated that she would submit the PASARR to the Arizona Health Care Cost Containment System (AHCCCS) website by using her own provided AHCCCS log in identification. A follow up interview was conducted on 05/06/2026, at 9:17 AM with Resident Relations Manager (Staff #32). Staff #32 stated that regarding Resident #32's PASARR, the most recent PASARR was on 2/27/2025, which included a SMI diagnosis of bipolar disorder, schizoaffective disorder, anxiety disorder, and depression. She said that the Resident stayed in the facility for over 30 days. She also said that she was not able to find an email document that would indicate that a referral was sent to AHCCCS. Further, she stated that if she submits a PASARR to AHCCCS, she would use her AHCCCS identification number to login to the AHCCCS website. Then, after submitting the PASARR to AHCCCS, she would receive an email response back from AHCCCS. Staff #32 also stated that, when she started working at the facility, she did an audit for the Residents with SMI. She initiated their care plan. She said that she did not get far in regards to double checking if the residents meet the level 2. On 05/06/2026, at 1:07 PM, the Executive Director (Staff #200) provided a document electronically titled PASRR Documentation of past noncompliance. The document revealed an attachment for their PIP (performance improvement project) on PASRRs. Per the document, they identified and corrected the issue prior to survey completion. Per the document, systems are in placed to prevent recurrence and compliance achieved. Per the document, a Quality Team Tracking Form with a date of 1/28-4/28, the problem area included was PASRR, and the quality team was led by Staff #32. Further review of the Quality Team Tracking Form document revealed the following identified problems: -30-day convalescent not done nor completed;-admission PASRR not obtained within 72 hours;-PASRR level 2 not submitted or identified; and-failure to verify and maintain documentation of PASRR level 2 determination. However, a review of Resident #32's PASARR revealed that there was no document found in the medical record or facility document that would indicate that a referral for level 2 determination was submitted to AHCCCS. According to the Arizona Health Care Cost Containment System, the Pre-admission Screening and Resident Review (PASRR) Level I is a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified Nursing Facility in order to determine whether an individual might have a mental illness or intellectual disability. A Level I Screening must be completed before an individual can be admitted into a Medicaid- certified nursing facility and can be completed in a hospital, emergency room, doctor's office or in any community setting. The PASRR Level II is a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate. The determination is the outcome of the Level II evaluation which ensures that Nursing Facility placement is, or continues to be, appropriate, and that services provided to individuals with a MI, ID, or related condition meet the individual's needs, including the need for specialized services. Level II evaluations for individuals with ID are performed by the Department of Economic Security (DES) and evaluations for individuals with MI are coordinated by AHCCCS and performed by a designated entity. For individuals requiring admission to a nursing facility for a convalescent period, or respite care (not to exceed 30 consecutive days), do not require a PASRR Level II Evaluation. If it is later determined that the admission will last longer than 30 consecutive days, a new PASRR Level I Screening must be completed as soon as possible or within 40 calendar days of the admission date to the nursing facility.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that pain management was provided to one resident (#137) consistent with professional standards of practice, and the resident's comprehensive person-centered care plan. The deficient practice could place the resident's health at risk by not adequately treating the resident's pain.Findings include:Resident #137 was admitted to the facility on [DATE], with diagnoses that included aftercare following a joint replacement surgery and fibromyalgia.The assessment for Brief Interview for Mental Status (BIMS) dated 05/03/2026, revealed a score of 12.0, indicating that the Resident was moderately impaired.A review of the physician's pain medication orders revealed an order for Hydrocodone-Acetaminophen oral tablet 5-325 MG (milligram) give 1 tablet by mouth every 4 hours as needed for pain level of 4-6 and give 2 tablets by mouth every 4 hours as needed for pain level of 7-10; and Ibuprofen oral tablet 200 MG give 3 tablets by mouth every 4 hours as needed for pain level of 1-3.A review of the care plan dated 05/02/2026, revealed that the Resident was on an opiate medication. The goal included for the Resident to be free from discomfort or adverse reactions related to the medication use. The intervention included for the staff to administer the medication as ordered.The May 2026 Medication Administration Record (MAR) review revealed a transcribed order dated 05/01/2026 for Hydrocodone-Acetaminophen oral tablet 5-325 MG give 1 tablet by mouth every 4 hours as needed for pain level of 4-6, Hydrocodone-Acetaminophen oral tablet 5-325 MG give 2 tablets by mouth every 4 hours as needed for pain level of 7-10, and Ibuprofen oral tablet 200 MG give 3 tablets by mouth every 4 hours as needed for pain level of 1-3.Further review of the May 2026 MAR revealed that on:-05/2/2026, at 2:28 AM, the Resident's pain level was documented at 7, and per the documentation, the Resident was administered Hydrocodone-Acetaminophen oral tablet 5-325 MG 1 tablet, despite an order to give Hydrocodone-Acetaminophen oral tablet 5-325 MG, give 2 tablets by mouth every 4 hours as needed for pain level of 7-10;-05/2/2026, at 6:32 AM, the Resident's pain level was documented at 7, and per the documentation, the Resident was administered Hydrocodone-Acetaminophen oral tablet 5-325 MG 1 tablet, despite an order to give Hydrocodone-Acetaminophen oral tablet 5-325 MG, give 2 tablets by mouth every 4 hours as needed for pain level of 7-10;-05/2/2026, at 12:01 PM, the Resident's pain level was documented at 7, and per the documentation, the Resident was administered Ibuprofen oral tablet 200 MG give 3 tablet by mouth every 4hours as needed for pain level of 1-3, despite an order to give Hydrocodone-Acetaminophen oral tablet 5-325 MG, give 2 tablets by mouth every 4 hours as needed for pain level of 7-10;-05/2/2026, at 9:50 PM, the Resident's pain level was documented at 8, and per the documentation, the Resident was administered Hydrocodone-Acetaminophen oral tablet 5-325 MG 1 tablet, despite an order to give Hydrocodone-Acetaminophen oral tablet 5-325 MG, give 2 tablets by mouth every 4 hours as needed for pain level of 7-10;-05/3/2026, at 2:00 AM, the Resident's pain level was documented at 8, and per the documentation, the Resident was administered Hydrocodone-Acetaminophen oral tablet 5-325 MG 1 tablet, despite an order to give Hydrocodone-Acetaminophen oral tablet 5-325 MG, give 2 tablets by mouth every 4 hours as needed for pain level of 7-10;-05/3/2026, at 4:44 AM, the Resident's pain level was documented at 6, and per the documentation, the Resident was administered Ibuprofen oral tablet 200 MG give 3 tablets by mouth every 4hours as needed for pain level of 1-3, despite an order to give Hydrocodone-Acetaminophen oral tablet 5-325 MG, give 1 tablet by mouth every 4 hours as needed for pain level of 4-6;On 05/03/2026, at 10:47 AM, Resident #137 stated that her experience so far in the facility was not so good. The Resident stated that she just had a hip surgery. She said that she was screaming in pain. She used her call light every 4 hours to ask for pain medication but the staff comes to her late. She stated that she felt ignored.An interview was conducted on 05/05/2026, at 12:06 PM with Licensed Practical Nurse (LPN/Staff #14). Staff #14 stated that regarding pain medication administration, she would ask the resident what their pain level was and where the pain was located, she would check what type of pain medication was prescribed, and then she would administer the pain medication as ordered for the resident. She stated that regarding pain medications with parameters, she said that if a parameter order was 6-10 pain level, but the resident reported a pain level of less than 5, she would tell the resident that she would give them a different pain medication for the level of pain they were having. She stated that she would also ask the doctor if it was okay to give the pain medication outside the ordered pain level parameter. She also stated that most of the time, her residents would insist on receiving the medication which was more than what was ordered for the level of pain that the resident reported. Further, she stated that she would chart in the medical record and on the MAR that she contacted the doctor regarding the Resident's request for more or less pain medication. She said that she would follow the pain parameter orders, but she would document if the resident only requested 1 pain pill for a pain level of 9 when the order asked to give 2 pain pills. She said that it's whatever the resident wants.An interview was conducted on 5/5/2026, at 11:34 AM with a Certified Nursing Assistant (CNA/Staff #16). Staff #16 stated that when her resident is in pain, she said that the resident would be crying, anxious, not acting themselves, and she would ask the Resident about their pain level. She said that she would notify the nurse about the Resident's conditionAn interview was conducted won 05/05/2026, at 12:53 PM with the acting Director of Nursing/Assistant Director of Nursing (acting DON/ADON/Staff #125). She stated that the process and her expectation regarding medication administration is to follow the 5 rights, which are, right resident, right medication, right dose, right route, and to make sure that the resident remains safe. She also said that regarding physician's order, she expects the nursing staff to reach out to the provider if they have any questions regarding an order, to clarify the order, and that the physician order should be followed because if the order is not followed, the risk could put the resident at harm. She also stated that regarding pain medication orders, she expects her nursing staff to follow the order, ask the resident what their pain level is, and then determine if the medication is available to manage their pain. She stated that regarding the hydrocodone order with pain parameter, she said that if the resident's pain level was 5, then she expects the staff to give 1 tablet for pain level 4-6, and if the pain level was 7-10, she expects the staff to give the resident 2 tablets of hydrocodone for a pain level between 7-10; as ordered because it would relieve the pain. She would also expect the staff to reach out to the provider if the resident did not want to receive the 2 tablets at the pain level within the specified parameter. Further, she stated that she expects the nurse to document and reach out to the provider and informed them that the resident's pain level was 9 and that the resident just wanted to take 1 tablet for pain relief. She said that if a nurse gave 2 pills of hydrocodone for a pain level of 4, and the order was 1 pill, the staff should reach out to the provider and let the provider know that 2 tabs given for pain level of 4, if the order was not followed. In addition, she would assess the resident including taking their vital signs as it would lower their vital signs. She said that If this was the case, the staff did not follow the physician's order.The acting DON/ADON stated that if Resident #137 received 1 tablet of her ordered pain medication of Hydrocodone-Acetaminophen oral tablet 5-325 MG for a reported pain of 10 on 05/04/2026, at 8:35 AM and on 05/04/2026 at 11:56 AM, per progress note the resident requested to relieve a generalized pain level 8, she said that the pain was relieved from a 10 to 8; the staff did not follow the physician's order, the resident should have received 2 tablets of Hydrocodone-Acetaminophen oral tablet 5-325 MG. She said that the risk was that the resident did not have her pain relieved with just one tablet. She also stated that the pain scale tells staff how to properly medicate the resident and the pain scale of 10 would be severe pain and a 0 would be no pain.A policy titled Medications: Administering Medications, in effect on 01/01 2024, revealed that medications are to be administered in accordance with the prescriber's orders, including any required time frame.A review of the facility policy titled Pain Management: Pain Assessment and Management, in effect on 01/01 2024, revealed the purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and to address the underlying causes of pain. It further noted that the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.

Based on observation, staff interviews, and policy documentation, the facility failed to ensure that the daily nurse staffing information posted included all data requirements. The deficient practice could result in residents and visitors not being informed of accurate and current staffing information. Findings include:An observation on May 3, 2026, at 6:59 AM, of the staff postings for May 3, 2026, included the number of certified nursing assistants (CNAs), the number of restorative nursing assistants (RNAs), the number of registered nurses (RNs), the number of licensed practical nurses (LPNs), and the number of medication technicians, categorized by shift. There was no evidence of an area where the actual hours worked by staff could be completed. A review of randomly chosen days of staff postings compared with the staff assignment sheets revealed that none of the staff postings matched the actual number of staffs that worked.Review of the Daily Staffing reports revealed the following missing data requirements.- May 23, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- May 24, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- May 25, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- May 26, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- May 27, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- August 29, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- August 30, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- August 31, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- September 1, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- September 2, 2025, revealed no evidence of the calculation of actual hours reflected on the staff posting.- January 16, 2026, revealed no evidence of the calculation of actual hours reflected on the staff posting.- January 17, 2026, revealed no evidence of the calculation of actual hours reflected on the staff posting.- January 18, 2026, revealed no evidence of the calculation of actual hours reflected on the staff posting.- January 19, 2026, revealed no evidence of the calculation of actual hours reflected on the staff posting.- January 20, 2026, revealed no evidence of the calculation of actual hours reflected on the staff posting.An interview was conducted on May 5, 2026, at 1:33 PM with the Staffing Coordinator (Staff #4). Staff #4 stated that the current staff postings included the number of CNAs, the number of RNAs, the number of RNs, the number of LPNs, and the number of medication technicians. Staff #4 also stated that the data requirements included the date and the resident census for the day, as well as the projected hours. Staff #4 had also stated that any evidence of actual hours would not be located on the staff postings and is stored on an internal database. Staff #4 also stated that once she creates the schedule, she will provide a printed copy to the receptionist the day before, and the receptionist is expected to place the posting in an easily accessible area the next day. Staff #4 stated that no changes or additions are made to the staff postings, and the receptionist will place the old staff postings into a binder for proper storage. Staff #4 stated that she had been unsure if the data required for staff postings included the evidence of the actual hours that the staff had worked for the day.An interview was conducted on May 5, 2026, at 1:50 PM with the interim director of nursing (DON/Staff #125), who stated that she had been unsure what data requirements were to be included on the staff postings and had been unsure what the risk of missing information on the staff posting could present. Staff #125 stated that she would ask the executive director (ED/Staff #200) for clarity on tasks and questions she had been unsure of.A policy request was made to the ED (Staff #200) on May 5, 2026, at 2:31 PM, to request the staff posting policies and procedural guidelines. On May 5, 2026, at approximately 3:30 PM, an interview was conducted with Staff #200. The ED stated that there had been no policy or procedure in place regarding the staff posting data requirements. Staff #200 stated that the current staff postings included the number of CNAs, the number of RNAs, the number of RNs, the number of LPNs, and the number of medication technicians. Staff #200 further stated that she had been unaware that the staff postings were to include the actual hours worked by the staff due to the tracking on an internal database. Staff #200 stated that she had been unsure what the risk would be should staff postings have missing information, such as the actual hours that the staff had worked for the day.

Based on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for one (#56) of 29 sampled residents. The deficient practice could result in harm to the residents, and/or visitors who have access to medications.Findings include:Resident #56 was admitted to the facility on [DATE], with diagnoses that included dysphagia, gastro-esophageal reflux disease without esophagitis, hypertension, and anxiety.An admission evaluation record dated November 18, 2026, revealed that the resident did not desire to self-administer drugs.A quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition.There was no evidence in the progress notes of an interdisciplinary team (IDT) meeting related to medication self-administration.During an initial observation of Resident #56's room on May 03, 2026, at 08.47 a.m., a bottle of Soursop [NAME] supplement for gut health was observed on the resident's bed side table.An interview was conducted on May 03, 2026, at 8:47 a.m., with Resident #56, who stated that Soursop [NAME] is not a medication and is a supplement. Resident #56 further stated that he ordered the Soursop [NAME] supplement and administered it by himself.An interview was conducted on May 3, 2026 at 11: 44 a.m., with a Licensed Practical Nurse (LPN, staff # 58) who stated that she observed a bottle of Soursop [NAME] supplement for gut health on the Resident #56's bed side table, and that it was not supposed to be left unattended at the bedside. The LPN was then observed to remove the medication from the resident's room and placed it in the medication cart. The LPN then reviewed Resident #56's clinical record and stated that there was no evidence of an order for Soursop [NAME] supplement for gut health. The LPN further stated that residents who wanted to self -administer medication will be assessed, and the IDT (Interdisciplinary Team) will notify the provider for an order for self-administration of medications. The LPN also stated that the resident's care plan would be updated. The LPN further stated that the risks of leaving medications unattended at the bedside could result in residents taking medications that they may be allergic to or may interact with other medications.A physician order dated May 3, 2026, at 11:52 a.m., was written for Soursop [NAME], to give 30 milligrams (ml) after breakfast daily, one time a day for supplement, Administered by clinician only.An interview was conducted on May 4, 2026 at 8:21 a.m., with a LPN (staff # 83) who stated that the facility process for residents who wanted to self-administer medication included: notifying the provider, conducting an IDT assessment regarding medication dosage, storage and how to safely administer medication, and the care plan would be updated. The LPN then reviewed Resident #56's clinical records and stated that there was no document found in the clinical record regarding self-administration of medication. The LPN further stated that Resident #56 had an order dated May 3, 2026, at 11:52 a.m., for Soursop [NAME], to give 30 milligrams (ml) after breakfast daily, one time a day for supplement, administered by clinician only. The LPN further stated that the risks of leaving medications unattended at the bedside could result in resident may be overdose.An interview was conducted on May 5, 2026 at 1:22 p.m. with the interim Director of Nursing (DON/Staff# 125) who stated that facility process for resident self-administration of medications would be that the residents were assessed by the IDT team regarding medication dosage, storage and how to safely administer medication. After, the resident was assessed for self -administration of medication, the IDT team will notify the doctor and get an order for self-administration. The DON then reviewed the Resident #56's clinical records and stated that Resident #56 had an order dated May 3, 2026, at 11:52 a.m., was written: Soursop [NAME], to give 30 milligrams (ml) after breakfast daily, one time a day for supplement. However, the order does not indicate that the Soursop [NAME] medication should be store in Resident #56 room or self-administered by Resident #56 but administered by clinician only. The DON further stated that the risks of leaving medications unattended at the bedside could result in resident may take medications incorrectly or another resident could go into the room and take the medication.Review of the policy titled, Medication labeling and storage, revised date January 1, 2024 revealed that the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Review of the policy titled, Self-Administration of Medications, reviewed date January 1, 2024, revealed that Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.

Based on documentation, staff and resident interviews, and review of the facility policy and procedures, the facility failed to ensure the safety of one resident (#5) by not properly securing the resident and failing to maintain a safe speed during transport. The deficient practice could result in residents being physically injured.Findings include:Resident #5 was admitted to the facility on [DATE], and discharged on December 28, 2023, with a diagnosis including infection and inflammatory reaction due to internal left knee prosthesis, subsequent encounter, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end-stage renal disease, and dependence on renal dialysis.Review of the Care Plan, date-initiated December 18, 2023, revealed a focus for fall risk related to generalized weakness. Interventions included anticipating and meeting the residents' needs and following the facility's fall protocol. Further review of the care plan identified a focus for anticoagulant therapy. Interventions include having Vitamin K on hand for emergencies. Review of the Medicare-5 Day Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The assessment revealed no indicator for mood or behaviors, the use of a wheelchair for mobility, and was receiving hemodialysis. An Incident Note dated December 28, 2023, included that at 1500, the transporter notified the Nurse that the Rails of the Van lift hit the back of the resident's head. As the resident moved forward, the rails also hit both shoulders and both Knees. The resident had a little lump on the back of her head, complained of pain in both shoulders; no other injuries were noted, vital signs were within normal limits and pain medication was administered. The note included that all other parties were notified and the provider ordered to send the patient to the emergency department for a computed tomography scan of the head.Review of the facility investigation with discovery date of December 28, 2023, revealed the following narrative: On 12/28/023, our van driver, staff #9, was transporting Resident #5 from dialysis to the facility. The van was at a stoplight, the light turned green, and the driver sped up to get on the expressway. As he accelerated to enter the expressway, the driver overheard the resident make a startled verbalization. The driver looked back and observed the resident tipped back in her wheelchair and resting upon the wheelchair lift. The driver then proceeded to safely pull over and was able to get her back upright in the wheelchair, secured her in place, and returned to the facility. Upon return to the facility, nursing did an assessment of the patient and decided it was best to send the patient out to the hospital for further evaluation. On December 29, 2023, the hospital findings include a fractured vertebra. The driver has been suspended pending further investigation. The facility vans and wheelchair equipment have been checked, and all are in proper functioning order. Facility performed education with the drivers on proper driving techniques and use of straps to secure the wheelchair and the resident in place.Continued review of the facility investigation included corrective actions that revealed on December 28, 2023, it was reported that the van driver (staff # 9) failed to ensure the safety of a resident during a transport, resulting in a negative impact for the resident. Staff #9 was immediately placed on administrative leave without pay pending a full investigation. As part of the investigation, Staff #9 was questioned. When asked about this incident by the ED (Executive Director/staff #,10), Staff #9 stated that he was at the stoplight getting on to the expressway, and when the light turned green, he sped up, causing the resident to tilt back because she wasn't strapped down which resulted in her hitting the back of her head and lower neck. Staff #9 reported he wasn't sure what had happened to the strap and admitted that Resident #5 must not have been strapped down properly. Further review of the facility investigation revealed that Staff #9 was terminated effective immediately. A Discharge and Transfer assessment dated [DATE], revealed that the resident had an accident in Haven's transport van while boarding from the hemodialysis center and struck her head against the lift bar. Resident #5 sustained a scalp hematoma and complained of bilateral shoulder, knee, and cervical pain. Provider was notified and ordered to send the patient to the emergency department for further evaluation. A head-to-toe assessment was completed, revealing a right upper chest hemodialysis catheter without signs or symptoms of infection, global skin ecchymosis, and a back-scalp hematoma.Review of the Maintenance Device Review of the transport van dated December 29, 2023, revealed all belts, harnesses, and lift gate were in working order and functioning properly.Review of the employee file for Staff #9 revealed no prior incidents, and was provided with safety training and a clear motor vehicle report on January 22, 2020.An interview was conducted on December 16, 2025, at 1:13 PM with Medical Records Director (Staff #12). Staff #12 stated she is the supervisor for the drivers and that the drivers are required to have good driving records because they are placed on the facility's insurance plan and have to pass a background check and meet facility expectations. Staff #12 stated that the driving staff receive training before they can transport any resident. Staff #12 stated the drivers ride along with another driver, receive training on how to receive reports from the hospitals, how to strap residents in the van, conduct security checks by checking the seat belts, brakes on the resident's wheelchairs, and the four straps that need to be tightened to secure the resident in the van. The expectation is that this is completed every time. Staff #12 stated she could not recall the details of the incident involving driver #9, but that he had been terminated. Staff #12 stated that the expectation is if there is an incident involving transportation, to be called immediately and receive the directive on how to proceed.An interview was conducted on December 16, 2025, at 2:20 PM with Facility Driver (staff #14). Staff #14 stated she has been a driver for the facility for 5 years. Staff #14 stated she received training on how to strap the residents down, driving, where to pick up and drop off when taking the residents to their appointments, double-checking hooks on the floor (4), and the seat belt. Staff #14 stated that the hooks latch onto the wheelchair, and then there is a knob that needs to be tightened to secure the wheelchair. Staff #14 stated that when transporting residents, they are to keep a safe distance from the vehicle and maintain visual contact with the resident from the rearview mirror. Staff #14 stated she could recall the incident involving staff #9 and resident #5. Staff #14 stated that staff #9 did not do the double check for the hooks on the floor and did not hook the back hooks to the wheelchair, and did not strap the resident's seat belt, causing the resident to have an injury. Staff #14 stated she was informed the resident had an injury and hit the back of her head when staff #9 pulled off. Staff #14 stated, I think he may have hooked the back but not the front, because resident #5 fell backwards. Staff #14 stated that Staff #9 had no prior concerns with his driving or concerns from any of the residents. Staff #14 stated Staff #9 was fired and that resident #9's family wanted to sue the facility.An interview was conducted on December 16, 2025, at 3:46 PM with resident #16. Resident #16 stated they feel safe when being transported in the van and have never felt any movement of the wheelchair.Review of the facility policy titled Resident Safety: Safety and Supervision of Residents revealed that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision, and assistance to prevent accidents are facility-wide priorities.

Based on personnel file review, staff interviews, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. This deficient practice could have resulted in the activities provided not meeting the assessed needs of the residents. Findings Include: A review of the personnel file for the role of activity manager (AD/Staff #111) was conducted on May 21, 2024. However, the review did not reveal evidence that staff #111 possessed the qualifications required for the role of activities director. An interview was conducted on January 23, 2025, at 9:38 A.M. with staff #111, Activities Director. Staff #111 stated that she had been working at the facility as an Activities Director for several years. She stated that as an activities manager, she visited the residents, providing them with menus that included the activities of the day as well as the food menu. She also stated that she oversaw the smoke break. An interview was conducted on January 23, 2025, at 9:43 A.M. with staff #41, Human Resources. She was asked to retrieve staff #111's record to determine if they had an activities certificate. She stated that she did not see the certification/license. The staff later provided a document which mentioned that Staff #111's certificate was not present. An interview was conducted on January 23, 2025, at 2:35 P.M. with staff #6, Administrator. Staff #6 stated that his expectation of all staff members was to be licensed and to complete the required training and education. He stated that this should be the same for the activities director as well. He further stated that #111's license was lapsed, but not for very long. He stated that there was no risk to the residents as #111 had been working at the facility for [AGE] years. He stated that he could not find the old copy of the certificate as the facility underwent construction in 2018. A review of the facility policy entitled Hiring and Rehiring Employees, dated January 1, 2024, revealed that the company policy was to hire qualified applicants. The policy further stated that in order to qualify for a position, the facility considered eligibility, qualifications, skills, attitude, dependability, cooperation, and other legitimate business considerations.

Based on clinical record review, facility documents, staff interviews, and policies and procedures, the facility failed to ensure that one resident (#395) was free from neglect, by failing to ensure the resident was administered care and services to meet his needs. The deficient practice could result in residents not being provided the necessary services. Findings include: Resident #395 was admitted to the facility on [DATE] with diagnosis that included osteomyelitis, sepsis, methicillin resistant staphylococcus aureus infection, pressure ulcer of sacral region stage 4, quadriplegia, extended spectrum beta lactamase resistance, urinary tract infection, protein calorie malnutrition, and major depressive disorder. A care plan initiated on [DATE] revealed that the resident had bowel incontinence related to inability to control bowels. Interventions indicated included check resident every two hours and assist with toileting as needed. A laboratory result dated [DATE] indicated that Coranavirus was not detected. Review of a care plan initiate on [DATE] revealed that the resident is at risk for nutritional problems. The goal stated that resident will consume more that 75% of meals. Interventions included indicated to assist with meals as needed and monitor/document intakes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. Additionally, the MDS indicated that the resident was negative for psychosis, behavioral symptoms, wandering and rejection of care. Additionally, the admission MDS assessment dated [DATE] revealed that the resident required extensive 2-person physical assistance for toilet use. The MDS also documented that the resident required extensive 1-person assist for bed mobility, dressing, and personal hygiene. The assessment indicated that for range of motion, the resident has lower extremity impairment on both sides and uses a wheelchair as a mobility device. Further review of the admission MDS assessment dated [DATE] documented that the resident did not have a prognosis that would lead to less than 6-months of life expectancy. A care plan initiated on [DATE] revealed that the resident was Coronavirus positive. Interventions indicated included administer oxygen per orders, obtain/monitor labs are ordered, and report results to provider and follow-up as needed. The Vitals Summary for Blood Pressure (BP) revealed that the last one taken was on [DATE] at 4:59 p.m. with the reading documented as ,d+[DATE]. Additionally, the Vitals Summary for Pulse registered the following out of range readings on the following dates: - [DATE] (7:14 a.m.): 53 beats per minute (bpm) - [DATE] (4:01 p.m.): 54 bpm - [DATE] (1:59 p.m.): 52 bpm - [DATE] (1:59 p.m.): 50 bpm - [DATE] (10:06 p.m.): 55 bpm - [DATE] (7:30 a.m.): 109 bpm - [DATE] (3:54 p.m.): 57 bpm - [DATE] (4:59 p.m.): 56 bpm - [DATE] (2:41 a.m.): 54 bpm Further review of the Vitals Summary for Pulse revealed that the last reading documented was on [DATE] at 7:32 a.m. which indicated a pulse rate of 66 bpm. Review of the order summary revealed a physician order dated [DATE] which prescribed oxygen at ,d+[DATE] liters per minute as needed to keep saturation above 90%. The order indicated oxygen therapy every shift. However, review of the [DATE] MAR (Medication Administration Record) revealed that during the following dates/shifts the log was left blank/not documented regarding oxygen therapy: - [DATE]: 10 p.m.-6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 2 p.m. - 10 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. Additionally, review of the O2 (oxygen) summary revealed the following readings on the following dates: - [DATE] at 3:56 p.m. - 87% (oxygen via nasal cannula) - [DATE] at 3:42 p.m. - 75 % (oxygen via nasal cannula) - [DATE] at 12:59 a.m. - 88 % (oxygen via nasal cannula) Review of the [DATE] CNA (Certified Nursing Assistant) task log for Assist and encourage to turn and reposition revealed that the log was left blank/not documented on the following dates/shift: - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m.; 6 a.m. - 2 p.m.; 2 p.m. - 10 p.m. The [DATE] CNA task log for Bowel and Bladder Continence revealed that the log was left blank/not documented on the following dates/shift: - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m.; 6 a.m. - 2 p.m. - [DATE]: 2 p.m. - 10 p.m.; 6 a.m. - 2 p.m. Review of the [DATE] CNA task log for Toilet Use revealed that the log was left blank/not documented on the following dates/shift: - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m.; 2 p.m. - 10 p.m.; 6 a.m. - 2 p.m. The [DATE] CNA task log for Transferring revealed that the log was left blank/undocumented for the following dates/shift: - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m. - [DATE]: 6 a.m. - 2 p.m. - [DATE]: 10 p.m. - 6 a.m.; 2 p.m. - 10 p.m.; 6 a.m. - 2 p.m. Review of the [DATE] CNA task log for Eating revealed that the log was left blank/undocumented for the following dates/times: - [DATE]: 8 a.m. and 12 p.m. - [DATE]: 8 a.m. and 12 p.m. - [DATE]: 8 a.m. and 12 p.m. - [DATE]: 8 a.m. and 12 p.m. - [DATE]: 8 a.m.; 12 p.m.; 5 p.m. Review of the resident's electronic health record revealed a physician's order dated [DATE] directed for Stat (Statim meaning immediately) chest x-ray related to hypoxia. However, further review of the resident's electronic health record did not reveal any documentation regarding the result of the chest x-ray or that the provider received and reviewed the requested chest x-ray. A nurse practitioner note dated [DATE] timestamped 11: 59 a.m. indicated a late entry note which documented that the resident was Coronavirus positive. The note stated that resident later in the evening had hypoxia and later found unresponsive. The note further documented that EMS (emergency medical services) was called and resident was unable to be resuscitated and proclaimed as deceased . However, multiple eMAR (electronic Medication Administration Record) notes dated/timestamped after the NP note from [DATE] indicated that resident was receiving medications and refused medications. An eMAR note dated [DATE] timestamped 7:17 a.m. documented that the resident had expired. A health status note date [DATE] timestamped 7:55 a.m. documented that at approximately 5:00 a.m., the resident was found in bed unresponsive. The note stated that upon assessment the resident had no pulse and that cardiopulmonary resuscitation was initiated while 911 was called. The note indicated that paramedics assessed the resident and called time of death at 5:13 a.m. A subsequent health status note dated [DATE] timestamped 9:24 a.m. documented that the resident's remains was picked up by the cremation company. Review of the Human Remains Release Form dated [DATE] confirmed that the resident's date and time of death as [DATE] at 5: 13 a.m. A request for a copy of resident #395's health record was submitted on [DATE] at 3:52 p.m., which included a request for labs and diagnostics. An email from the facility dated [DATE] timestamped 8:05 a.m. regarding the record request for resident #395 stated that the facility do not have lab/diagnostics, assessments for continence, assessments for change of condition, facility investigation and POA (power of attorney). An interview with a Certified Nursing Assistant (CNA/staff #115) was conducted on [DATE] at 3:12 p.m. Staff #115 stated that ADLs (activity of daily living) were documented on the resident's electronic health record. According to the CNA there are different options used to code based on assistance given, resident refusal or not applicable. There are also spots for how many briefs were changed. Staff #115 stated that everything is coded. According to the CNA, if an item is left blank it either was not provided or the staff did not chart them. Staff #115 stated that there could be a small possibility that care was not provided. The CNA indicated that the expectation is that care provided is documented. Staff #115 said that during the Coronavirus (COVID) outbreak, the facility did not have any problem providing ADL care. The staff helped each other out and residents were rounded on every ,d+[DATE] hours. The CNA noted that ADL care provided to the residents included brushing teeth, brushing hair, dressing, assisting with transfers, brief changes, shower as scheduled. Staff #115 stated that residents were repositioned every 2 hours. During COVID, there could have been a little longer wait time. However, they tried their best to mitigate and have really good response time in the units. The CNA indicated that if there were patches of items undocumented, then they cannot verify if care was provided. Staff #115 stated that it is not appropriate if care is not provided. The CNA said that the impact on the resident is for example, sores can get worst, resident can have more skin breakdown, and it will look like neglect. Staff #115 noted that the importance of providing the care, treatment, and services to residents is to ensure that the residents' needs are met. The CNA further stated that during COVID, it was more essential to get residents' needs met since people were scared. Resident #395's CNA task logs were reviewed with staff #115 on [DATE] at approximately 3:12 p.m. Staff #115 (CNA) verified that some tasks to include eating and turn reposition had patches of missing data. The CNA commented that for meals and any tasks it should be coded if resident refused. When it is left blank, it looks like the tasks were not done. A Registered Nurse (RN/staff #38) was interviewed on [DATE] at 3:44 p.m. Staff #38 stated that the CNAs are expected to take vitals, keep an eye on resident, answer call lights promptly, and provide care to residents. Additionally, The RN noted that they expect that residents are provided hydration. Furthermore, staff #38 noted that they expect that documentation is done. The RN expressed that documentation has always been a problem as some staff do not understand the concept of documentation. Staff #38 reiterated that documentation is important. For nursing/CNA if not documented then it did not happen. The RN said that care should be provided and documented. If not documented then it can look like the task was not done. For example, for turning and repositioning if it is not documented as being done and the resident ends up with a bed sore then it looks like the staff did not do what they were supposed to do. Staff #38 indicated that during COVID there was a shutdown and residents' psychosocial was impacted and therefore it was important for staff to be there for the residents. The residents who did not have family needed the staff the most. If needs were not met it would greatly impact the residents. The RN noted that it is not appropriate to have a lack of documentation since it is hard to justify that care was given. Staff #38 noted that there is a potential that care was not given. This is not good for the resident and especially not good outcome for the resident. Care is important since the resident is dependent on staff and attention is needed since during COVID it was just the residents and the staff. Resident #395's CNA task logs were reviewed with staff #38 (RN) on [DATE] at approximately 3:44 p.m. Staff #38 confirmed that some tasks were left blank/not charted. According to the RN, items not charted could either mean it was not done or not documented. Normally, if the resident is not there, then the item will be coded with a X. Staff #38 noted that it is not acceptable that there are blanks. The expectation is that chart as N/A or coded appropriately. For the meals for example, the blanks could be not charted or not given but should have been coded. An interview with the Director of Nursing (DON/staff #8) was conducted on [DATE] at 4:05 p.m. Staff #8 stated that during COVID the expectation was not lowered. They separated people in isolation and still had same nursing staff with sufficiency. The standard was actually higher and there was more staff depending on the volume of residents. The DON said that the expectation for documentation is that staff document. Staff #8 said that they have to reflect via documentation that care was provided. There was a lot of paperwork. The DON noted that if documentation is missing in an evidence- based practice, it did not occur. However, staff #8 said that it is debatable if deserved care did not occur. The DON indicated that impact on the resident depends. Staff #8 stated that it would reflect on the resident's progress. In the case of turn and reposition, it will impact the resident adversely if care is not delivered. Resident #395's CNA task logs were reviewed with staff #8 (DON) on [DATE] at approximately 4:05 p.m. The DON confirmed that there are blank areas on the log. Staff #8 said that they do not know why there are blanks. The DON noted that X should be coded if resident was not in the facility. For the turn and reposition, it is not appropriate that there is lapse in documentation. Staff #8 stated that this log is important for pressure ulcer since this can provide answer to what is going on. The bowel and bladder lack of documentation is also inappropriate. For the eating portion, the lack of documentation is also inappropriate as they cannot confirm that the resident ate. The DON stated that based on documentation there is a possibility that the resident was not getting the care. Staff #8 reiterated that it is not appropriate to not reflect what was done for the resident. The DON noted that there is a possibility that resident will deteriorate and impact the health. Staff #8 agreed that based on documentation there could have been neglect. Review of the facility policy titled Abuse Prevention Program revised [DATE] indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The facility policy titled Resident Rights revised [DATE] stated that resident have the right to be free from abuse, neglect, misappropriation of property, and exploitation. Review of the facility policy titled Charting and Documentation revised [DATE] stated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's physical, functional or psychological condition shall be documented in the resident's medical record. The policy noted that the medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. The policy directed that documentation in the medical record will be objective, complete, and accurate. Furthermore, the policy directed that the following information is to be documented in the resident's medical record: - objective observations - medications administered - treatments or services performed - changes in the resident's condition - events, incidents or accidents involving the resident

Based on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one of 21 sampled residents (#82) had a referral for a Level II PASRR (pre-admission screening and resident review).The deficient practice could result in the resident not receiving specialized services needed. Findings include: Resident #82 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, anxiety disorder, post- traumatic stress disorder, and depression. Review of the clinical record revealed a Level I pre-admission screening and resident review (PASSR) dated November 27, 2024. Upon review of the document, the box indicating that a referral for Level II determination for mental illness (MI) only was selected. There was also boxes that were selected indicating that the resident had major depression, anxiety disorder, and post-traumatic stress disorder (PTSD). The form was signed and dated. Additional review of the clinical record revealed no evidence that a referral for a Level II PASRR was completed by the facility. Review of the care plan initiated November 27, 2024, revealed the resident used antidepressant medication related to depression and interventions included to administer antidepressant medications ordered by physician, monitor and document side effects and effectiveness. A minimum data set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) summary score of 15, indicating intact cognition. Further review of the care plan initiated December 3, 2024 revealed the resident used antianxiety medications related to anxiety disorder with interventions that included administration of antianxiety medications ordered by physician, monitor and document side effects and effectiveness. An interview was conducted with the social services director (staff #31) on January 23, 2025 at 11:38 AM, who stated that the social services director and the Assistant Director of Nursing (ADON/ staff #38) were responsible for making the referral to the appropriate authority when needed. During the interview, staff #31 reviewed resident's #82's Level I PASRR and confirmed that a referral for a Level II PASRR was indicated on the form. After reviewing the clinical record during the interview, staff #31 stated that she did not see a Level II PASRR referral completed by the facility. She further stated that the risk of not completing a referral for a Level II PASRR could result in the not receiving the appropriate services for his level of care. She also stated that it did not meet facility expectations to not complete a Level II PASSR. An interview was conducted with the Director of Nursing (DON/ staff #8) on January 23, 2025 at 2:07 PM, who stated that social services was responsible for making the referral to the appropriate authority when needed. During the interview the DON reviewed resident's #82's Level I PASRR and confirmed that the form indicated the resident be referred for a Level II PASRR. The DON also stated that it did not look like a referral was completed but he was not sure. The DON further stated that it did not meet facility expectations that the resident was not referred for a Level II PASRR. Review of the facility policy, Pre-admission Screening and Resident Review (PASRR) version 0920, revealed that if the resident is positive for potential MI or intellectual disability (ID), a Level II PASRR referral must be submitted. The policy also indicated that it is the responsibility of the facility to make referrals for a Level II PASRR if it is determined to be necessary.

Based on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that care was provided according to professional standards and that the resident's basic needs are being met for one resident (#42). The deficient practice could result in residents not being provided the care needed to maintain or improve health. Resident #42 was admitted to the facility on [DATE], with diagnoses that included spinal stenosis, cystitis, major depressive disorder, and multiple myeloma not having achieved remission. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) assessment score of 15, indicating intact cognition. Section I revealed the resident had an active diagnosis of diabetes mellitus. A physician order dated June 18, 2021, indicated for Humalog Solution 100 unit/ml (Insulin Lispro), to inject as per sliding scale, subcutaneously before meals and at bedtime for diabetes mellitus: If blood sugar 200-250 = 2; 251-300 = 4; 301-350 = 6; 351-400 = 8; 401-450 = 10; 451-500 = 12, and for 12 units to call the medical doctor Review of the Medication Administration Record (MAR) for December 2024 and January 2025, revealed the resident had the following blood sugar (BS) readings and was administered Humalog Solution (Insulin Lispro): -December 1, at 20:00: BS = 483, 12 units administered -December 4, at 20:00: BS = 477, 12 units administered -December 15, at 17:00: BS = 500, 12 units administered -December 22, at 17:00: BS = 500, 12 units administered -January 5, at 20:00: BS= 451, 12 units administered An interview was conducted with a Registered Nurse / Unit Manager (RN / Staff #114) on January 23, 2025, at 12:33 PM. The RN stated that if a physician's order indicted to call the physician for a high blood sugar reading, that the expectation would be for the nurse to call the physician in order to get any updated orders, which could be to give the resident an extra dose of insulin or to send the resident to the hospital. The nurse stated that a nurse would then document the outcome of the phone call with the physician in the progress notes. The nurse stated that the importance of notifying the physician if a resident's blood sugar was high would be to make the physician aware of the resident's condition. An interview was conducted with an RN and Assistant Director of Nursing (ADON / Staff #38) on January 23, 2025, at 12:49 PM. The ADON stated that if a resident's blood sugar was high, and the physician's order indicated to call the physician, that the facility's staff have to follow the doctor's order. The ADON stated that the purpose of the order to call the physician with a high blood sugar reading may depend on several factors: the physician may want to give an extra dose of insulin, or the high blood sugar may be a sign of infection, or the nurse could communicate to the provider if the blood sugar was related to an event such as the resident having a big meal. The ADON stated that the nurses document the phone call to the physician and the outcome of the phone call either in a progress note, or on the eMAR, which then auto-populates to the progress notes. The ADON stated that either way, the nurses' documentation would be in the progress notes. At this time, Resident #42's clinical record was reviewed together. The ADON stated that there's no notes in regard to documentation of communication to a physician or the outcome of communication on the dates when the resident's blood sugar was greater than 450. The ADON stated that this would not meet the facility's expectation, and that there will be education happening on this, and that the facility would want the nurses to show that they called the physician and the outcome of the phone call. An interview was conducted on January 24, 2025, at 10:10 AM, with the Director of Nursing (DON / Staff #8), who stated that the importance of communicating with the physician if a resident has high blood sugar is to prevent complications: acidosis and diabetic coma, risk of infection, and decreased wound healing. The DON stated that it is the facility's expectation that nurses follow physician orders and call the provider when indicated. Review of the facility policy titled Charting and Documentation, revised July 2017, revealed all services provided to the resident or any changes in the resident's medical or physical condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation will include care-specific details including notification of physician, if indicted. Review of the facility policy titled Medications: Administering Medications, effective January 1, 2024, revealed medications are administered in a safe and timely manner, and as prescribed.

Based on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that care was provided according to professional standards and that the resident's basic needs are being met for one resident (#10). The deficient practice could result in residents not being provided the care needed to maintain or improve health. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included acute chronic heart failure, pleural effusion, urinary tract infection, cellulitis of left lower limb, severe sepsis without septic shock, hypoxemia, and hypokalemia. The order summary revealed an order dated: -[DATE] for oxygen as needed (PRN) at ,d+[DATE] liters per a minute to keep oxygen saturation above 90% every 8 hours as needed for oxygen therapy. -[DATE] for oxygen at ,d+[DATE] liters per minute as needed to keep saturation above 90% every shift for oxygen therapy. -[DATE] vital signs per facility protocol -[DATE] for full code CPR Review of the care plan dated [DATE] did not reveal a plan for oxygen therapy. Review of the clinical record for vitals revealed documentation for: -oxygen saturation 77% on [DATE] at 7:45 a.m. -temperature 94 degrees on [DATE] at 7:45 a.m. -respiration 18 breaths a minute on [DATE] at 7:45 a.m. -blood pressure ,d+[DATE] on [DATE] at 9:44 p.m. -pulse 82 bpm on [DATE] at 9:44 p.m. Review of the treatment administration record dated [DATE] revealed oxygen as needed (PRN) at ,d+[DATE] liters per minute to keep saturation above 90% every 8 hours as needed for oxygen therapy dated [DATE] was not administered. A physician's note dated [DATE] revealed that the patient is currently awake and resting, not in distress, and no chest pain or palpitation. Vital signs with afebrile: pulse 100, respirate 18, blood pressure ,d+[DATE]. Lungs clear to Osco bilaterally with decreased air entry at the bases. Review of the progress notes did notes did not reveal any documentation of vitals, including oxygen saturation being assessed, or oxygen therapy being administered by staff. A progress note dated [DATE] revealed that the resident was found unresponsive at 5:30 a.m. Cardiopulmonary resuscitation (CPR) was initiated followed by a 911 emergency call. The emergency medical team (EMT) arrived at the facility at 5:38 a.m. The resident was pronounced dead at 5:55 a.m. by the EMT after all efforts to resuscitate the resident failed. The family on record was notified at 6:00 a.m. The medical doctor was notified at 6:05 a.m. and the facility Director of Nursing was equally notified. Review of the Public Requests Form for the City of Phoenix Fire Departement (FD) revealed the date of service, 911 response, was [DATE]. The 911 call was received at 5:38 a.m., and the FD was on scene at 5:44 a.m. Staff initially waited 15 minutes while doing CPR to call 911. Upon arrival, the resident was found supine in bed, while staff was standing behind the resident's head, performing inaccurate CPR (compressions). Staff was bagging the resident with the bag-valve- mask (BVM) inaccurately, with no oropharyngeal airway (OPA) in the resident. The FD took the resident's blood sugar level (BS) and it was LO (hypoglycemic) and administered dextrose 50% via intraosseous (IO). The BS level was rechecked after two minutes and the glucometer reading was 21.The facility staff was asked why he waited 15 minutes to call 911 and did not answer. Once the FD took over, the staff left the resident's room without giving a full report and did not return. An interview was conducted on [DATE] at 11:44 a.m. with a certified nursing assistant (CPR/staff #16), who stated that she knows how to check vitals, which includes blood pressure, pulse, temperature, and oxygen saturation, but she doesn't check vitals because the overnight shift doesn't check vitals. She stated that the CNAs check vitals once during the day shift and once during the evening shift, and the evening shift would give her a status report during shift change if there was a concern regarding a resident's vitals. She stated that if there was a concern, she would check the resident's vitals during the night. She stated that vitals are documented on a piece of paper and given to the nurse and the CNA also documents the results in the electronic record. She stated that she checks the residents every two hours throughout the night and on [DATE], she began her shift at 10:30 p.m. and completed her rounds. She checked the residents again at: 12:30 a.m., 2:30 a.m., and 4:30 a.m. She stated that she found the resident unresponsive at 4:30 a.m. She stated that the resident was not breathing and did not have a pulse, and while she was checking the resident's vitals, she radioed to (LPN/staff #2) that she needed a nurse stat and then stood by the side of the bed and began compressions. She stated that she did not count the compressions and did not provide breaths as she did not have a mouth piece. She stated that (LPN/staff #2) was in the hallway with (LPN/staff #11) immediately after she had called on the radio and staff #2 had called 911. (LPN/staff #11) came into the room and checked the resident's vitals, while she continued with compressions. Then, (LPN/staff #11) took over the compressions, while she stood at the upper right hand corner of the bed to provide breaths via the (BVM). She stated that she was not able to get behind the resident because the resident was short, and then, she stated that she was not able to get behind the resident because the bed was against the wall. She stated that the bed is on wheels and she didn't know if (LPN/staff #11) had tried to move the bed away from the wall, but stated that when she was trained to do CPR, she was trained to position herself behind the resident when using the BVM and to place the mask around the mouth creating a seal to make sure the air doesn't get out. She stated that (LPN/staff #11) did 5 or 6 compressions and told her to press the BVM bag one time. She stated that staff #11 instructed her to press the bag one or two times after every 5 to 6 compressions and when she pushed the bag, the resident's cheeks were puffing up and out, so she knew the air was going into the resident. This continued until the EMTs arrived and she could not remember what time they arrived. (LPN/staff #2) came into the room when the EMTs arrived and the EMTs asked how long the resident had been like this and she told them that she came into the room at 4:30 a.m. She stated that one of the EMTs asked (LPN/staff #2) why it took him so long to call 911 and he didn't answer. Then, (CNA/staff #16) stated that she doesn't know what time (LPN/staff #2) called 911. She stated that the EMTs were angry because no one would open the front door when they arrived. She stated that there was a male staff from the kitchen sitting by the front door and he took his time answering. She thinks the male staff may be a little slow. She stated that she was the only CNA in the resident's room during the entire incident. An interview was conducted on [DATE] at 2:25 p.m. with the Assistant Director of Nursing (ADON/staff #29), who stated that (LPN/staff #2) was responsible for completing the transfer form for the resident and would have called 911 from the nurse's station, but should have returned to the resident's room when he was done. She doesn't know why he didn't return to the resident's room to help. An interview was conducted on [DATE] at 8:41 a.m. with the dietary aide (staff #41). The Director of Nursing (DON/staff #50) was present. Staff #41 stated that he works from 6:00 a.m. to 2:30 p.m., but comes to work early because he doesn't have a car and has to get a ride to work. He stated that he gets dropped off at work about 4:30 a.m. and enters the building through the side door to the right of the main entrance. He stated that he usually goes to the employee lounge to eat breakfast and when it is 5:45 a.m. he walks up to the reception desk and waits until about 5:55 a.m. to clock in for work. On the day of the incident, he stated that he was waiting to clock in and there were two men with a stretcher at the door. He let them in because a stretcher usually means that someone needs help. An interview was conducted on [DATE] at 9:55 a.m. with a licensed practical nurse (LPN/staff #11), who stated that he was at his medication cart between rooms #147 and #150, when (LPN/staff #2) came over to tell him that there was an emergency in room [ROOM NUMBER]. He stated that he was not sure of the time. Staff #11 stated that he was not using a radio because the battery was dead. (LPN/staff #11) went with (LPN/staff #2) to room [ROOM NUMBER] where (CNA/staff #16) was performing compressions on the resident. He stated that there was a board under the resident and the crash cart was present. (LPN/staff #11) stated that he assessed the resident and instructed the (CNA/staff #16) to take the resident's vitals, while he was preparing the BVM bag. Then, he did the compressions and (CNA/staff #16) pumped the BVM bag. Staff #11 stated that he counted and completed 21 compressions to 2 breaths, and then decreased the compression to breath ratio to 15 compressions to 2 breaths because there was white foamy saliva coming out of the resident's mouth. He stated that (CNA/staff #16) tilted the resident's head and swept the mouth and he suctioned the mouth area. Then, (CNA/staff #7) entered the room and she took over the compressions because he had to help (CNA/staff #16) to tilt the resident's head correctly to use the BVM. He stated that normally staff should be positioned behind the head of the resident and (CNA/staff #16) was at the side of the resident. He pushed the bed away from the wall, so he could get behind resident's head and took over the BVM and CPR continued at a ratio of 1 compression to 2 breaths. He stated that (LPN/staff #2) came back and provided the last compression before the EMTs arrived. During a second interview conducted on [DATE] at 10:34 a.m. with the (ADON/staff #29), she stated that staff come running when they know that there is a code blue and they know there is a code blue because they hear the message on the radio. An interview was conducted on [DATE] at 10:45 a.m. with (CNA/staff #7), who stated that there are radios available to communicate with staff, but she doesn't use one because it is noisy and bothers the residents. She saw the certified medication assistant (CMA/staff #35), who told her that a resident was not waking up. She stated that (LPN/staff #2) was at the nurse's station and told her that a resident was not waking up. She stated that she the other nurse (LPN/staff #11) was doing compressions and she stepped in to help because he was so tired. She couldn't remember how many compressions she did because it all happened so fast. While she provided compressions, another CNA was standing next to the resident providing breaths via the BVM. She then stated that she thinks she did about 30 compressions and couldn't remember how breaths were done between compressions. She stated that she was trained to stand next to the resident, place the BVM over the resident's face and squeeze the bag. She stated that there were no other steps prior to placing the BVM on the resident's face and squeezing the bag. An interview was conducted on [DATE]:44 a.m. with the licensed practical nurse (LPN/staff #2), who stated that he was administering medications near rooms #136 and #137 when (CNA/staff #16) came out into the hallway to get him. Staff #16 was completing her last rounds and told him to come and check the resident now. He stated that he assessed the resident who was unresponsive. He did not detect a pulse and the chest was not rising. He went back to the cart to get his radio which was lying on the top of the cart and called for help. He stated that all staff are required to carry a radio. He stated that (LPN/staff #11) was near and all three went to the resident's room. He stated that the other nurse started compressions and the CNA did the BVM. An interview conducted on [DATE] at 2:54 p.m. with a certified medication assistant (CMA/staff #35), who stated that she was passing medications around 5:00 a.m. when staff told her that there was a code blue with one of the residents. She stated that she did not hear a code blue over the radio because her radio was charging. She stated that she went to the resident's room and the nurse asked her to start doing CPR; she and the nurse took turns providing compressions and rescue breathing via the BVM. She stated that rescue breathing was performed by standing at the side of the bed, tilting the resident's head, placing the BVM on the resident's face, but doesn't remember if the resident's cheeks were filling with air. She stated that during the emergency, she did not see any certified nursing assistants (CNAs) in the resident's room. She stated that the other nurse, a licensed practical nurse (LPN/staff #2) was at the nurse's station printing paperwork and when she went to the nurse's station, (LPN/staff #2) told her to take the paperwork and wait by the reception area for the EMTs. She went to reception area at the front of the building and there was male staff sitting there. When the EMTs arrived, at approximately 5:30 to 5:40 a.m., she let them in the building. An interview was conducted on [DATE] at 2:13 p.m. with the (DON/staff #50), who stated that all nurses and CNAs have to be CPR certified. The staff have access to radios, but are not required to use them. He stated that if a resident is unresponsive, the staff must notify at least one other staff by radio or by yelling out in the hall to call 911 and to help with CPR. The CNA can check the vitals and go get help if needed, but the nurse must be there to assess the resident and to see if CPR is required. One nurse should stay there to provide CPR and to supervise the CNA, who should be providing ventilation via the BVM bag. It is expectation that CPR is provided at a ratio of 100 compressions to 2 breaths and should be done immediately after the resident is assessed and unresponsive. He stated that a second nurse should be calling 911 and completing the transfer paperwork. He also stated that when ventilation is provided via BVM, the mask should be placed over the mouth and nose, and the staff should tilt the head. There should be no symptoms, such as the cheeks blowing up. If the cheeks do not fill up, there is no obstruction and the air should go directly to the lungs. He stated that it usually takes the EMTs about 15 minutes, sometimes 20 minutes to arrive. The facility policy, Emergency/First Aid: Emergency Procedure - Cardiopulmonary Resuscitation states that if an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or there are obvious signs of irreversible death (e.g., rigor mortis). The facility ' s procedure for administering CPR shall incorporate the steps covered in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or facility BLS training material. After 30 chest compressions provide 2 breaths via ambu bag or manually (with CPR shield).

Based on documentation, staff interviews and the facility policy and procedures, the facility failed to report an allegation of abuse to the state survey agency and failed to complete and submit a 5-day written investigation timely. The deficient practice could result in residents not being protected and being abused. Findings include: Resident #17 was admitted to the facility on [DATE] with diagnoses that included hypertension, schizophrenia, multiple sclerosis, and anxiety. The care plan dated April 21, 2022 revealed that the resident had an impaired cognitive function. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion and requires approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, written lists, and instructions. Resident #8 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis, unspecified dementia with mood disturbance, anxiety, and major depressive disorder. The care plan dated September 1, 2023 revealed that the resident had a impaired cognitive function/dementia or impaired thought processes related to neurological symptoms. Interventions included to keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion and use task segmentation to support short-term memory deficits. Present just one thought, idea, question or direction at a time. Review of facility documentation dated July 26, 2024 revealed that at 1:20 p.m. it was reported to the Assistant Director of Nursing (ADON/staff #151) that resident #17 told a certified medication technician (CMA/staff #27) that she was touched in the crotch area by another resident. The (ADON/staff #151) interviewed resident #17 and the resident stated that a man with glasses, a dark mustache, and a pot belly touched her in the crotch and in the hole. Resident #17 went down the hall with the ADON, and the case manager (staff #83) and identified resident #8 as the alleged perpetrator. The online report regarding the above allegation of sexual abuse was submitted to the state agency August 16, 2024 at 12:39 p.m. During an interview conducted on August 16, 2024 at approximately 11:20 am with the Administrator in Training (AIT/staff #150), he stated that about a month ago, resident #17 made an allegation about resident #8 touching her privates. Resident #17 stated that resident #8 touched her crotch area and scratched her when they were sitting in the dining room. He also stated that it was not possible for resident #8 to touch her crotch because she is a larger woman and the area could not be reached while she was sitting down. He stated that the facility did not report the allegation of sexual abuse to the state agency and no one completed a 5-day written investigation. He stated that the facility conducted there own investigation and called the regional nurse about the matter. The consensus was that resident #17 was in one of her delusional phases and it did not happen. He stated that resident #17 also said that resident #8 tried to poison her 5 years ago by putting poop in her mouth. Staff #150 stated that he didn't know what the regulations says about reporting an allegation of sexual abuse and the [NAME] President of Clinical Operations and former Administrator, made the decision to not report the allegation to the state agency. An interview was conducted August 20, 2024 at 2:24 p.m. with the Director of Nursing (DON/staff #35), who stated that allegations of sexual abuse must be reported to the state survey agency within two hours of the facility becoming aware of the allegation. The facility policy, Abuse Policy states that If abuse is witnessed or suspected, reporting and investigation will take place in this manner: -Executive Director (ED) will be notified. -ED and witness who is reporting will notify the following entities: -Adult Protective Services -Ombudsman -State Survey Agency -Law enforcement when applicable -Facility Director of Nursing (DON)

Based on record review, staff interviews, and the facility policy and procedures, the facility failed to ensure residents (#26, #25, and #3) were provided with the appropriate level of supervision. The deficient practice could result in the personal space of residents not being respected. Findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, chronic obstructive pulmonary disease, and hypertensive chronic kidney disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. The care plan dated July 23, 2024 revealed an impaired cognitive function/dementia or impaired thought process related to sexual advances towards staff. Interventions included to monitor/document/report to the 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. A nurse practioner note dated August 7, 2024 revealed that the resident has dementia issues and some history of being aggression with peers. The resident has been stable for months. Per a progress note dated July 16, 2024 at 7:04 p.m. Note Text: Writer went in to give residents medication. Resident held writer hand and writer ask if he needed anything. Resident made sexual advances to writer stating come closer and give me a kiss. Writer told resident that was not appropriate and walked out of room. Review of a progress note dated August 9, 2024 revealed that at 11:30 a.m. the resident alleged that a female resident struck him on the chest in the hallway, where staff immediately separated them and took them to safe areas. The resident stated that the female resident was blocking the pathway in front of him, when he alarmed her to move, she turned back and hit him on the chest. Upon assessment, the resident sustained no injuries, and bruises and or skin tears were not noted. The Administrator, medical doctor, social worker, and family member were informed immediately. Review of the 5-day written investigation dated August 15, 2024 revealed that the hallway was congested due to a medication cart located on one side of the hallway and an empty wheelchair on the other side of the hallway. Resident #26 was in his wheelchair behind resident #5 and was trying to get around resident #5. The Maintenance Director (staff #60) moved the empty wheelchair, so resident #26 could pass and when he passed by resident #5, she reached out and made contact with the back of resident #26's chest. Staff #60 moved resident #26 down the hallway. Resident #26 was assessed by the Director of Nursing (DON) and no injuries were noted. Review of the progress notes did not reveal documentation regarding the incident that occurred on August 19, 2024 where resident #26 touched resident #3 on the side/stomach area while seated next to each other in the dining room. -Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included radiculopathy in the lumbar region, unspecified mood affective disorder, irritability and anger, low back pain, and chronic post-traumatic stress disorder. Review of the care plan dated June 12, 2023 revealed that the resident is on an opiate medication related to chronic pain syndrome. Interventions included to review for pain medication efficacy. The (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact. The care plan dated August 9, 2024 revealed that the resident has a behavioral problem related to physical behaviors. At times the resident may have behaviors, reaching out to residents/getting residents attention in congested areas as I may become inpatient. Intervention included to anticipate the resident's needs and to identify behavior triggers. A progress note dated August 9, 2024 revealed that resident #5 struck another patient in the chest. Both patients were separated from the situation immediately to a safe environment. Upon assessment, the resident sustained no injuries. The medical doctor, Administrator and family were notified. The care plan was updated. An interview was conducted on August 16, 2024 at approximately 10:15 a.m. with the Maintenance Director (staff #60), who stated that there was an empty wheelchair on one side of the hall and a medication cart on the other. Resident #26 was in his wheelchair behind resident #5, who was also in her wheelchair. Resident #5 looked behind her and told resident #26 to move it. Staff #60 moved the empty wheelchair and resident #26 went around resident #5. Resident #5 tried to fight with resident #26 and the backside of her left hand touched resident #26's midsection of his body, but her movement was weak because she has pain in her arm. Staff #60 reported the incident to the Administrator. An interview was conducted on August 16, 2024 at 10:30 a.m. with resident #26, who stated that he asked resident #5 if he could get by with his wheelchair and she told him to wait. He stated that he said, What do you mean wait. When he went by her, she swung at him and hit his chest with the back of her hand. He stated that it hurt and it scared him because he has a pacemaker. He stated that resident #5 doesn't like him and that about a year ago, resident #5 tried to run into the back of his wheelchair. He stated that he asked resident #5 why she is doing this to him, bullying him, but she didn't answer. An interview was conducted on August 16, 2024 at 10:36 a.m. with Resident #5, who stated that resident #26 hit her wheelchair from behind two times and now her neck hurts. She stated that she asked resident #26, what was his problem and she swung to hit him, but hit the wheelchair. She stated that resident #26 is a big baby and she wants him to stay away from her. She stated that he is always following her around, stares at her, and tries to look under her dress. Resident #5 was not able to give any details as to how, when, or where the resident tried to look under her dress and stated that she feels safe at the facility. An interview was conducted on August 16, 2024 at approximately 11:00 a.m. with a certified medication assistant (CMA/staff #27), who stated that resident #5 likes to mumble that she hates people and wants to hit them. She has a history of saying that she hates resident #26, but has never told her why she hates him. Staff #27 stated that she has reported that resident #5 hates resident #26 to a registered nurse/unit manager (RN/staff #120) and (RN/staff #53) over a year ago, before resident #5 was transferred to her current room. She stated that resident #26 does have a history of putting his hands on staff, hugs and gives a little squeeze afterwards, and one nurse said that he tried to kiss her. During an interview with the Administrator in Training (AIT/staff #150) conducted on August 16, 2024 at approximately 11:20 a.m., he stated that resident #26 told him that he was coming out of his room and told resident #5 to stop, so he could get out of his room, but she kept going. When he caught up with her, she reached out with the back of her hand and made contact with his chest. He stated that resident #5 stated that resident #26 bumped into the back of her wheelchair a little bit, and (staff #60) moved the extra wheelchair in the hallway out of the way to make more room, so resident #26 could pass by. She stated that she reached out to resident #26 to tell him not to bump her wheelchair anymore. Staff #150 stated that if resident #5 was saying that she hated resident #26, it probably should have been reported to the Administrator and he would have made sure that staff kept an eye on the residents and verbal abuse can't be tolerated. An interview was conducted on August 16, 2024 at approximately 12:00 p.m. with the Director of therapy, who stated that resident #5 doesn't have the physical ability to extend her arms fully outwards and would not be able to hold her hands up if the slightest bit of pressure was applied. He stated that the resident didn't have the physical strength to hurt resident #26. -Resident #3 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, major depression, and anxiety. The Minimum Data Set, dated dated dated [DATE] included a brief interview for mental status score of 8 indicating the resident has a moderate cognitive impairment. Review of the progress notes did not reveal documentation regarding the incident that occurred on August 19, 2024 where resident #26 touched resident #3 on the side/stomach area while seated next to each other in the dining room. Review of the facility internal investigation dated August 16, 2024 revealed that on August 19, 2024 at 5:55 p.m. resident #26 approached resident #3 in the dining room and began tickling her. Resident #3 was heard saying, no and a certified nursing assistant (CNA) rushed to separate the two residents. Resident #3 was assessed and no injuries were observed. Resident #26 was educated about inappropriate behavior. During an interview with the Administrator in Training (AIT/staff #150) conducted on August 16, 2024 at approximately 11:20 a.m., he stated that resident #26 has a history of being touchy with the staff. An interview was conducted on August 20, 2024 at approximately 11:00 a.m. with resident #3, the Business Office Manager (staff #91). Resident #3 stated that she was in the kitchen/dining room area and resident #26 was sitting next to her. Resident #26 grabbed her on her right side with one hand and she said, stop it, stop it, stop it and resident #26 continued doing it. Resident #3 stated that a nurse came into the dining room and told resident #26 to leave her alone, but resident #26 said, no, she is mine and then he went away. She stated that she thinks that resident #26 was trying to hold on to her, he was tickling her. Resident #3 stated that she felt safe, but sobbed during the interview. Staff #91 stated that during a meeting a meeting with the DON and the Administrator, resident #26 was identified as the male resident who had touched resident #3. An interview was conducted on August 20, 2024 at 12:50 p.m. with the Staffing Manager/Resident Relations Assistant (staff #32), who stated that (CNA/staff #110) was present when resident #26 touched resident #3. An interview was conducted on August 20, 2024 at 1:03 p.m. with (CNA/staff #110), who stated that she was in the dining room assisting a resident with eating. She stated that resident #26 and resident #3 were sitting at the same table. CNA #110 asked resident #26 if he wanted a tray and he said, no, she doesn't want me. CNA #110 stated that she turned back to the resident she was assisting when she heard resident #3 say, no and saw resident #26 pull his hand out from resident #3's side/stomach area. CNA #110 stated that she asked resident #3 if she had a problem and the resident said, no. She stated that later she and the medication technician asked resident #3 what resident #26 had done to her and the resident demonstrated on the medication technician's side how resident #26 had tickled her. An interview was conducted on August 20, 2024 at 1: 41 p.m. with a licensed practical nurse (LPN/staff #106), who stated that resident #3 told the (CNA/staff #110) that resident #26 kept tickling her on the stomach and she kept telling him/shouted at him, no and he kept laughing. Staff #110 assessed resident #3 and did not observe any injuries, but resident #3 told staff #110 that she did not like resident #26 putting his hands on her. Staff #106 stated that she interviewed resident #26 and he said that it did not happen, and she educated him about keeping his hands to himself. Staff #106 stated that resident #26 should not be touching resident #3 and reported the incident to the Administrator.

The facility failed to ensure food was properly stored, prepared, handled and served according to professional standards. Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value. Findings include: During the initial tour of the kitchen conducted on September 5, 2023 at 8:26 AM, with the Food Service Manager (#38), the following observations were made in the large walk-in refrigerator and freezer and the dry storage: -Two boiled eggs in a container with in by date of September 5, with no use by date or year. -a package of bacon bits with a date of August 25, 2023 and no use by date. -10 ham slices in dated September 4 with no use by date or year. -a four-pound bus tub of kale opened and exposed to air with ice chips on top of the kale. Per staff (#38) this was done to keep the kale fresh, but should have been stored in its original packaging or wrapped in plastic. -a package of Delimex beef carne de res taquitos open exposed to air belonging to resident (#68). Per staff (#38) residents food should not be kept unopened in the facility freezer. -an open 48 fl oz container of salted caramel ice cream belonging to resident (#68). Per staff (#38) residents' food should not be kept unopened in the facility freezer. - a 48 fl oz container of Blue-Ribbon Chocolate and Vanilla ice cream belonging to resident (#65). Per staff (#38) residents' food should not be kept unopened in the facility freezer. -one 160 oz open package of [NAME] elbow macaroni with no open date and improperly sealed with contents spilled out into a gray tub. No open or use by date - one package of ziti macaroni open with contents spilled out of packaging into a gray tub. No open or use by date. -two 25 lb Imperial instant food thickener with no open or use by date on either of the boxes- Per staff #38 staff are to label with an opened and use by date. -one 9 lb bag of Instant Puree bread mix with an open date of July 5, 2022. Spillage of contents inside the box from opened plastic with dust particles. Staff #38 stated that the purpose of covering/sealing food is to maintain freshness, prevent contamination from other food particles, prevent freezer burn, and maintain the quality of the food. An interview was conducted on September 8, 2023 09:10 AM with the Food Service Manager (#38), who stated that he tries to ensure that his staff labels and dates all foods in the freezer, refrigerator and dry storage. The staff are also responsible in ensuring no damage of food that has come in from the food service distributors, discarding any open, not dated and over dated food products. Staff #38 stated he tries to prevent any leftover food and if there is, it is distributed to the staff. If the staff do not want it, he has directed his staff to discard it. Staff #38 stated the risks associated with improper storage is risk for contamination of open, unsealed food or the risk of attracting insects or rodents. Staff #38 stated an in-service was conducted with his staff regarding labeling, dating and proper storage. The facility's policy titled, preventing Foodborne Illness-Food Handling states that food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure resident do not sustain preventable accidents including falls resulting in major injury. Failure to ensure this resulted increased morbidity and mortality. Findings include: Resident #157 was admitted with diagnoses of dementia, need for assistance with personal care, and cognitive communication deficit. A Quarterly Minimum Data Set (MDS) dated [DATE] included that a Brief Interview for Mental Status (BIMS) score of 5 which indicates that the resident was severely cognitively impaired. This document included that this person required 2+ person extensive physical assistance with transfers. A care plan dated 6/14/22 included that the resident has an Activities of Daily Living (ADL) self care performance deficit related to diagnoses of COPD, Dementia and weakness. This document included that the resident required staff participation in transfers. A health status note dated 2/27/23 included that patient slid out of bed while a Certified Nursing Assistant (CNA) was changing her brief and that there was no injury. However, a health status note dated 2/28/23 included that the patient verbalized pain to bilateral lower extremities and hip and that the provider ordered an X-ray. Review of the clinical record did not find that this resident was in a bariatric bed or that a second person was assisting with the resident's care. Hospital records dated 2/28/23 included that Emergency Medical Services (EMS) reported that the resident was being cleaned and they basically dropped her. This document included that the resident had an acute displaced and impacted intertrochanteric fracture of the right femoral neck. An attempt was made 9/7/23 at 11:47 a.m. to contact CNA #102, however the phone number provided was not able to receive calls at that time. An interview was conducted on 9/7/23 at 12:10 p.m. with a Licensed Practical Nurse (LPN/staff #100) who said that she remembered this patient slid out of bed while the CNA was changing her. An interview was conducted on 9/7/2023 at 1:20 p.m. with a CNA (staff #2) who said that when a patient is big, she gets another person to assist her when performing care for a resident in bed such as a bed bath or personal hygiene. She said that she gets another person so she can watch to prevent falls. An interview was conducted on 9/8/23 at 9:30 a.m. with the Administrator (staff #88) who said that staff involved in this fall were LPN /staff #100 and CNA/#102. He said that they had no way to contact the CNA (staff #102) because her phone is turned off. An interview was conducted on 9/9/2023 at 10:09 a.m. with a CNA (staff# 48) who said residents who are larger are changed with two people. She said that when they turn they are sometimes larger than bed and that she would not want the resident to fall. She said that she always takes all safety precautions. This staff said that she remembered this incident and said that the problem is with the CNA in that incident is that she did not ask for help. She said that the CNA's always get help with large residents. An interview conducted on 9/8/23 at 11:32 a.m. with the Director of Nursing (DON/staff #20) who said that safety comes first and that it is very important to consider. He said that staff must have a good reading about the patients' size and some you can assist alone, some you cannot. He said that staff should use the proper bed, and that they are investigating tall beds. He said that that resident he would need a bariatric bed for bed mobility. He said staff are required to make the determine if a second person is required because they have the background and schooling and should be able to implement it. He said that this resident had an abrupt decline and that sometimes she would assist the staff but she declined. He said that the CNA did not get a second person. He said that the next day, I changed the bed for her, I changed her care plan, but that when she left us she did not come back. A policy titled Activities of Daily Living (ADLs), Supporting, revised 3/2018, revealed that a resident's ability to perform ADLs will be measured using clinical tools, including the MDS and that functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD). A policy titled Abuse, dated 2022, included that 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.

Based on observations, staff interviews, facility recipes, and policy review, the facility failed to ensure the nutritive value of puree food. The deficient practice could result in residents receiving food with altered nutritive value. Findings include: During an observation conducted on September 6, 2023 at 11:42 AM in the kitchen, the cook (staff #15) was observed preparing puree food for two residents. Staff (#15) placed several large spoons of chicken and broccoli into a blender, added hot chicken broth, and blended the mixture. Staff (#15) proceeded to place the broccoli and chicken mixture into a steam pan to serve without tasting. Staff (#15) stated the chicken broccoli mixture was ready to serve. Staff (#15) was asked how did he know that the texture was at the right consistency and texture for a pureed diet. Staff (#15) stated he had been doing this work for a long time and could tell by its appearance. A request was made to taste the chicken broccoli mixture and was also tasted by Food Service Director (staff #38). the chicken broccoli mixture was noted to be gritty, with a very thick consistency. Staff (#38) asked that staff (#15) add more broth to the puree mixture and blend it further. This time the puree had a fairly smooth texture. Staff (#15) then poured the pureed chicken broccoli mixture back into the into a steam table pan. Staff (#15) proceeded to add three large spoonful's of rice to the blender for two pureed servings. This was done without first washing the blender container used from the pureed chicken broccoli mixture. After finishing with the puree rice, staff #38 was informed of the error. Staff #38 stated the risks associated with not washing the container before proceeding to puree another food item, is the potential for cross contamination and mixing of foods for someone who may have food allergies. Staff #15 was asked to toss the rice, wash the blender container and restart the process. The rice was pureed to the right consistency and texture. Food Service Director (staff #38) then took over and proceeded to puree eggrolls for two residents. Staff #38 added four eggrolls to the blender container and added unmeasured amounts of chicken stock. The eggroll mixture when tasted, found the mixture tasted overwhelmingly of chicken base and was salty. Staff #38 continued to add unmeasured amounts of water and chicken stock to the eggroll mixture, changing the flavor profile and having the mixture become a liquid consistency. Staff #38 proceeded to add a thickener, to thicken the watery mixture. The eggroll mixture once thickened, was tasted. The eggroll mixture had a salty taste and the eggroll flavor was faint. Staff #38 stated although the puree was still salty and had a strong flavor of chicken base, the flavor of eggrolls could be noted. The mixture was added to the steam table pan for serving to the residents. An interview was conducted on September 8, 2023 09:10 AM with the Food Service Manager (staff #38), who stated that when making puree food, it is best practice to not water everything down with water. Staff (#38) stated he had become frustrated with the Nutrition Alliance consultant whom he felt had made the observation process difficult, for both he and his staff. Staff (#38) stated he was not using this as an excuse for the errors made, but had asked that the consultant be removed from his kitchen. Staff (#38) stated the recipes are listed in the cookbooks, and it is his expectation that cooks follow the cookbook or ask for help if they are stuck. He stated stock for the next day's meals are pulled the night before and checked the morning of to ensure that all is ready for preparation of meals. He stated if staff do not know the recipe, the staff should have a cookbook in front of them which they can open up and check for the recipe. He stated the cook and himself are supposed to test the puree food or another staff member should taste the puree food to ensure good flavor and consistency. Staff #38 stated using exact portions is also important to ensure nutritive value. Staff #38 indicated that staff # 15 was nervous and most likely felt overwhelmed by the process. A review of the facility policy titled, Preventing Foodborne Illness-Food Handling, revealed that Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. 3. All employees who handle. Prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in those practices prior to working with food or serving food to residents. 9. All food service equipment and utensils will be sanitized according to current guidelines and manufactures recommendations

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food brought by visitors and family was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value. Findings include: During the initial tour of the kitchen conducted on September 5, 2023 at 8:26 AM, with the Food Service Manager (#38), the following observations were made in the large walk-in refrigerator and freezer. -a package of Delimex beef carne de res taquitos open exposed to air belonging to resident (#68). Per staff (#38) residents food should not be kept unopened in the facility freezer. -an open 48 fl oz container of salted caramel ice cream belonging to resident (#68). Per staff (#38) residents' food should not be kept unopened in the facility freezer. - a open 48 fl oz container of Blue-Ribbon Chocolate and Vanilla ice cream belonging to resident (#65). Per staff (#38) residents' food should not be kept unopened in the facility freezer. An interview was conducted on September 8, 2023 09:10 AM with the Food Service Manager (#38), who stated all food brought in by family for the residents should be labeled with the resident's name, room number dated when brought in. Staff #38 stated foods brought for the residents should not be stored in the kitchen refrigerators or freezers and are to be kept on in the refrigerators on their units. Per staff #38 nursing staff are responsible for discarding any outdated foods for the residents. Staff #38 stated the risks associated with the storage of residents food items in the commercial freezers and refrigerators are possible cross contamination of improperly cooked foods, improper hygiene from families and unsafe cooling of the residents food. A review of the facility policy titled, Foods Brought by Family/Visitors states food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and homelike environment with the nutritional and safety needs of residents.

Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that infection control standards were maintained regarding hand hygiene and donning gloves by an LPN (Licensed Practical Nurse/staff #74) during medication administration. The deficient practice could result in the spread of infection to residents. Findings include: An observation during medication administration conducted on September 7, 2023 from 9:20 a.m. to 9:45 a.m. with an LPN (staff #74), the following was observed: -Staff #74 was observed administering medications which were handled with their bare hands. The LPN was observed popping pills out of the blister pack into her bare ungloved hand. Each resident was observed being administered the medication after it had been handled by staff #74. This occurred three times during the observation. -Staff #74 provided medications to multiple residents without sanitizing their hands between residents, after touching the residents and various objects in the resident's rooms, such as tray tables and bedding. During an interview conducted on September 8, 2023 at 10:57 a.m. with the LPN (staff #74), The LPN stated that they did not realize they were grabbing medications with their bare hands. Staff #74 further stated they should have used gloves or not touched the pills with their bare hands. During an interview conducted on September 8, 2023 at 11:05 a.m. with the DON (Director of Nursing/staff #20) Stated that it was wrong to handle the medications with an ungloved hand and that it was an infection control issue. They further stated that they have great respect for the infection control process and that their expectation is that they follow current infection control practices. A facility policy and procedure titled Medication Administrations included staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation procedures, etc.) for the administration of medications, as applicable.

Based on observations, staff interviews, facility documentation, review of facility policies and procedures, and documentation from the Centers for Disease Control (CDC), the facility failed to maintain an effective infection control program, which provided a safe and sanitary environment, in order to help prevent the development and transmission of disease and infection. As a result, the Condition of Immediate Jeopardy (IJ) was identifed. The facility also failed to ensure that one resident's urinal (#38) was properly labeled. Findings include: On April 3, 2014 at 1:25 p.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator was informed of the facility's failure to implement infection control precautions for one resident (#170) on contact isolation. Multiple observations were conducted of resident #170, who had a [DIAGNOSES REDACTED]. Facility staff were aware of the resident being out of his room and did not ensure the resident was consistently following contact precautions to protect other residents. In addition, staff were observed to not consistently follow contact precautions when going in and out of resident rooms that were on contact precautions. The Administrator presented an immediate plan of correction, which was accepted at 3:05 p.m. on April 3, 2014. This plan included infection control measures the facility was going to implement, in order to protect all residents and provide a safe and sanitary environment. Multiple observations were conducted of the facility implementing their plan of correction, which included the cleaning of contact surfaces throughout the building with appropriate disinfectant, staff in-services regarding infection control and contact precautions for[DIAGNOSES REDACTED], and observations of staff implementing the correct contact precautions. The Condition of IJ was abated on April 4, 2014 at 10:00 a.m., due to the corrective measures taken by the facility. -On April 1, 2014, a registered nurse (RN) was observed entering resident #152's room, with medications. Outside of this room was an isolation cart. The nurse was not observed to don gloves, nor a gown. At this time, the nurse's clothing was observed to touch the resident's footboard and privacy curtain. After the resident took the medications, the RN entered the resident's bathroom and washed his hands. Upon exiting the resident's room, an interview was conducted with this nurse. The RN stated that the resident was in isolation, due to[DIAGNOSES REDACTED]. The nurse stated that gown and gloves were to be worn when providing direct care to the resident. When it was pointed out that it was observed that his clothing was touching resident equipment, the nurse stated that he should have worn a gown and gloves, prior to entering the resident's room. During this observation, it was also noted that the resident's family member was in the room, sitting on the resident's chair next to the bed. The visitor did not have an isolation gown or gloves on and was observed to freely leave and enter the resident's room, without staff intervention. -Resident # 170 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set assessment dated [DATE], revealed that the resident was always continent of bowel. Review of a nursing note dated March 31, 2014 at 9:23 p.m., revealed the resident had multiple episodes of diarrhea during the shift, as well as a temperature of 101.1 degrees. The note included that a stool sample was sent to test for [DIAGNOSES REDACTED]. A lab result dated March 31, 2014, included the resident was positive for[DIAGNOSES REDACTED]. Nursing notes dated April 1 and 2, 2014, continued to reflect the resident had loose stools. A physician's telephone order dated April 2, 2014, included for [MEDICATION NAME] (antibiotic) 500 milligrams (mg) by mouth every eight hours for ten days and for the resident to be on contact isolation, due to[DIAGNOSES REDACTED]. During random observations conducted on April 2, 2014, resident #170 was observed multiple times wheeling himself from his room to the smoking area. During these observations, the resident was not wearing a gown, nor was he wearing gloves. Multiple observations of resident #170 were conducted on April 3, 2014. At 10:45 a.m., the resident was in his wheelchair going towards Station 1. The resident was observed to not be wearing a gown, nor gloves. At 11:00 a.m., resident #170 was observed in his wheelchair at Station 1, speaking with a certified nursing assistant (CNA). The resident was not observed to be wearing an isolation gown and gloves. At 11:39 a.m., the resident was observed near Station 1. The resident was accompanied by a staff member in the hallway using a walker. At this time, the resident and the staff member were both noted to be wearing isolation gowns and gloves. An interview was conducted with the Director of Nursing (DON) who was in the hallway as the resident passed. The DON identified the staff member to be part of therapy. She stated that when the resident worked with therapy and was out of his room, staff were informed that they and the resident would need to don gloves and isolation gowns. She explained that the resident was on contact precautions for[DIAGNOSES REDACTED]. Shortly thereafter, at 12:04 p.m. on April 3, the resident was observed outside of his room in a wheelchair with gloves on his hands, however, the resident did not have a gown on. During an interview with a RN at 12:08 p.m., the RN stated that the resident is independent with his activities of daily living and was continent of bowel and bladder. He added that staff have informed the resident to try and stay inside his room, but if he has to come out, the resident was to avoid touching others. The RN admitted that he was not sure what precautions the resident was to be using when he left his room or whether the resident was educated regarding handwashing. In an interview with a CNA on April 3 at 12:18 p.m., the CNA stated that the resident was continent of bowel and bladder and required no assistance. The CNA also stated that she was not aware if the resident had loose stool as of this day. With regards to the resident being on isolation precautions, the CNA explained that as far as she was aware, the resident was to wear gown and gloves when out of his room. The CNA stated that the resident would go in and out of the room, as he wanted. After this interview, the CNA returned from talking with a nurse and clarified that the resident was only to wear gloves when he came out of the room and that he obtains the gloves from the box on top of the isolation cart, located just outside of his room. When asked if the resident was a smoker, the CNA stated that he would go out to smoke independently, without any personal protective equipment (PPE). During an observation on April 3, 2014 at 1:58 p.m., the resident was seen outside of his room without a gown, and was reaching into the box of gloves on the isolation cart. Staff were also observed to remove gloves for patient care from this same box used by the resident. At 2:25 p.m., the Administrator stated that the medical director was in the building and recommended that a resident should be kept in contact isolation for[DIAGNOSES REDACTED] up to three days following the completion of antibiotic therapy. Administrative staff also stated that the resident was non-compliant with contact precautions and was a smoker. Review of the facility policy on Isolation Precautions-Contact Precautions, reflected that this type of precaution was to be used for residents with known or suspected to be infected or colonized with microorganisms transmitted by direct contact or indirect contact. Explanation on the use of PPE included wearing gown and gloves when entering the resident's room and removing them before leaving the room, as well as performing appropriate hand hygiene. Review of the 2007 Centers for Disease Control and Prevention (CDC) guidelines regarding[DIAGNOSES REDACTED] revealed that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands who have touched a contaminated surface or item. For the prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, it stated to use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines also stated to use gloves and gowns when entering patients room and during care and for all interactions that may involve contact with the patient or potentially contaminated areas in the patients environment. It further documented that before exiting the patient room, discard PPE (personal protective equipment) to contain pathogens. In addition, the CDC guidelines included that[DIAGNOSES REDACTED] infected patients continue to shed organisms for a number of days following the cessation of diarrhea. The guidelines also stated to implement an environmental and disinfection strategy to ensure the adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. -Review of the facility's February 2014 Infection Control Report revealed that there were 14 new facility acquired infections corresponding to an 18.7% infection control rate for nosocomial infections. There were three current[DIAGNOSES REDACTED] cases, two rolling over from the previous month and one new[DIAGNOSES REDACTED] infection noted to be of "indeterminate origin." Review of the March 2014 Infection Control Reports revealed 11 cases of[DIAGNOSES REDACTED], with cases noted to be clustered at or around room [ROOM NUMBER] and #113. A majority of the reports did not specify whether the infection was nosocomial or community acquired in origin. An Infection Report dated April 1, included resident #170's name with the infection category of gastrointestinal and related [DIAGNOSES REDACTED]." -Resident #38 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On April 4, 2014 at 9:00 a.m., an observation was made of resident #38's shared restroom. A urinal was observed to be stored behind the toilet. The urinal was not covered or labeled with a resident identifier. The Administrator was interviewed on April 4, 2014 at 9:02 a.m., who stated that the urinal should be labeled to identify which resident it belonged too. A CNA was interviewed on April 4, 2014 at 10:00 a.m. She stated that resident #38 shared his restroom with two other residents. The nurse unit manager was also interviewed on April 4, 2014 at 10:30 a.m. He stated that the urinals should be labeled.

Based on clinical record reviews, staff interviews, and review of facility policy and procedure, the facility failed to provide one resident (#168) with sufficient fluid intake to maintain proper hydration and health, and failed to ensure that one resident's (#35) fluid restriction was maintained as ordered. Findings include: -Resident #168 was admitted on [DATE] at 6:45 p.m., with [DIAGNOSES REDACTED]. Review of the admission orders [REDACTED]. The orders for the TPN from the discharging hospital revealed a flow rate of 90 milliliters per hour (ml/hr) over 24 hours, with a volume of 2,160 ml. A nursing admission note dated February 8, 2014 at 12:34 a.m., reflected the resident was admitted with "very extensive open abdominal wound...and high output fistula with [MEDICAL CONDITION]." The note further documented that several attempts were made to fax orders and that "pharmacy contacted, attempts still been made." The TPN order was sent to the pharmacy with a time stamp of February 8, 2014 at 2:06 a.m. A nursing progress note dated February 8 at 7:35 a.m., revealed that the resident was on a clear liquid diet and [MEDICATION NAME] and [MEDICAL CONDITION] drains were draining moderate amounts of bile. A facility pharmacy form titled, TPN/PPN Order reflected the order for the TPN. In addition, nursing staff were to add the multivitamin [MEDICATION NAME] Adult, three times weekly on Monday, Wednesday, and Friday, prior to hanging the TPN. Included in these orders was also an order [REDACTED]. A nursing note dated February 8 at 4:10 p.m., included the physician was in to assess the resident and the resident had a large abdominal wound with "[MEDICAL CONDITION]/[MEDICATION NAME] incision sites noted with two drain bags 400 cc (cubic centimeters) of green bile color drainage..." Furthermore, it was documented that the order for the TPN was faxed to the pharmacy and that the resident was on a clear liquid diet and tolerating well. The note also included the resident had a poor appetite. Review of a nursing note dated February 8 at 8:07 p.m., reflected the resident had multiple abdominal fistulas and was status [REDACTED]. The note further revealed that there were two drainage bags that were patent and intact to the wound area and were also draining large amounts. Further review of the clinical record including the February 2014 Medication Administration Records (MAR) revealed that there was no documentation that the TPN or the IV fluids had been started since admission through February 8. There was also no documentation of any consistent intake and output (I&O) monitoring that was done. Nursing notes dated February 9 at 7:46 a.m., documented that the resident was on a clear liquid diet and that the drains were draining moderate amounts of bile. A nursing note dated February 9 at 11:31 a.m., revealed that the TPN was to be delivered on the 10:00 a.m. round and that a call was placed to the pharmacy, as to why the TPN had not yet been delivered. The note included the orders were faxed on Friday ([DATE]), however changes were made on Saturday ([DATE]), regarding the TPN formula. Per this note, the physician was in to assess the resident and ordered to continue with the TPN, as ordered. The note further revealed that the resident had two drains located to the mid abdomen that were draining greenish bile, as well as an open fistula to the right abdomen. The output of drainage was 350 ml. The TPN was initiated on February 9, 2014, however, there were conflicting times as to when it was started. According to the February 2014 MAR, the time of administration for the TPN was 3:00 p.m. According to the Shipment Summary provided by the facility and pharmacy, the TPN was delivered on February 9 at 5:40 p.m. Prior to the TPN being administered, there was no documentation of any I&O monitoring that was consistently done or that the IV fluids had ever been initiated, despite the delay in obtaining the TPN solution. An Initial Nutritional Risk Review and assessment dated [DATE], revealed the resident's oral food intake was less than 50% of estimated needs and the assessed oral fluid intake was less than 1000 ml per day, as evidenced by less than 50% of meal intakes. Per this assessment, the resident scored 16, which indicated at high risk. In addition, the resident was assessed for dehydration risk. Taking into factors that the resident consumed less than 1000 ml/day based on meal intake and total dependence on TPN, the resident was identified to be at moderate risk for dehydration. The assessed hydration need for the resident was 2,905 ml per day. Narrative documentation revealed that the resident was on a clear liquid diet with TPN and that clear liquids were inadequate to meet needs. Despite this, a care plan addressing the resident's dehydration risk was not developed. A nursing note dated February 10 at 11:00 p.m., included the TPN with multivitamin was being administered. Furthermore, the resident's abdominal fistula drainage device and [MEDICAL CONDITION] bag were drained four times this shift and that the CNAs (Certified Nursing Assistant) were notified to empty the fistula and [MEDICAL CONDITION] drainage every 2 hours to prevent overfill and leakage. The resident was also assessed to have tenderness and pain to her abdominal fistula and had nausea and vomiting. On February 10, fluid I&O monitoring was initiated. The total amount of intake for the day was 600 ml. laboratory results dated [DATE] included a critically high blood urea nitrogen (BUN) level of 88 mg/dl (normal range is 7-25 milligrams per deciliter) and a critically low sodium level of 119 mEq/L (normal range is 136-145 millEquivalent per deciliter). The resident was seen by the physician on February 10, however, the progress note did not reflect the above critical lab levels. Review of the clinical record did not reveal any documentation that the physician was notified regarding the critical lab levels. A physician's orders [REDACTED]. A physician progress notes [REDACTED]. A nursing note dated February 11 at 3:32 p.m., documented the resident was on a free water restriction, due to [MEDICAL CONDITION]. The resident was also documented to have been treated for [REDACTED]. Review of the February 2014 MAR indicated [REDACTED]. Review of the I&O record revealed the resident's total fluid intake for February 11, was 720 ml and there was no documented output. Lab results dated February 12, reflected a critical high BUN of 113, and a low sodium level of 119. Nursing notes dated February 12 at 12:28 p.m., revealed the critical lab results were called into the physician at 6:52 a.m., and no orders were received. The note continued that "Upon seeing the patient, (the physician) ordered patient to be sent to hospital." Review of the hospital history and physical dated February 12, 2014, revealed that in the emergency department, the resident was hypotensive with blood pressure in the 60s/40s and received three liters of normal saline, with mild improvement to 70s/50s. The resident was assessed to have yellow-green drainage, with foul odor coming from her right lower quadrant [MEDICAL CONDITION] and yellow drainage from a closed incision to the left upper quadrant of her abdomen. In addition, the resident was noted to have hypoactive bowel sounds. The hospital documentation included that the admitting [DIAGNOSES REDACTED]. An interview was conducted with the resident's physician on April 2, 2014 at 10:58 a.m. After review of his progress notes, the physician stated that the resident was a medically complex case and recalled that the resident had an abdominal fistula due to complications from an anastomosis of the intestines, which led to copious amounts of fluid loss along with electrolytes. The physician stated that the resident had become more acidic metabolically and required to be sent out to the hospital. The physician further stated that he did not recall if he had received a call from nursing staff regarding a delay with the TPN. He did state that he was aware that the facility had not received it the day of admission. He stated that if it was an issue, he would have started the resident on IV fluids until the TPN arrived, which would have been sufficient for the resident to maintain nutrition. In an interview on April 2, 2014, a registered nurse (RN) stated that if the TPN had not yet arrived for a newly admitted resident, then the physician would be contacted for IV fluids, which he explained was available in the facility's emergency kit. He added that this would then be charted/documented in the resident's MAR. In an interview on April 2 at 1:10 p.m., the nurse unit manager stated that new orders for TPN can take up to 24 hours to receive, as it does not come directly from their pharmacy, but goes through a third party pharmacy that takes care of just IV fluids. The unit manager further explained that the resident had no order for intake and output, thus nursing staff only documented intake. After reviewing the resident's chart, the nurse manager could not locate any documentation that IV fluids were started, due to the delay with the TPN. During an interview with the wound care nurse (LPN) on April 2, 2014 at 1:39 p.m., the LPN stated that the resident had a large fistula in the middle of her abdomen that continuously drained liquid stool. She described that when the resident was first admitted , the floor nurse had a difficult time dealing with the amount of drainage coming from this site and required a [MEDICAL CONDITION] type drainage bag, which had to be changed about every 10 minutes. She further stated that the day after the resident was admitted , she assessed the resident and determined that due to the large amounts of drainage, the resident required a Foley bag which they attached to allow for more drainage. She explained that within a matter of a few minutes the bag filled with about 700 ml of liquid stool. She stated it still required draining the Foley bag every 10 to 15 minutes. An interview with the Director of Nursing (DON) was conducted on April 2, 2014 at 2:39 p.m. The DON stated that for a patient admitted with TPN orders, the urgency of receiving the TPN can vary depending on if the resident was strictly on TPN therapy or not. She explained that if the resident was on strict TPN therapy, then it should be expected that the TPN was received within 24 hours. In general, she added that if the order could not be filled, then the physician would be called and the resident would be started on IV fluids. The DON further explained that since the resident was taking things orally the immediacy to receive the TPN was not as urgent. She stated that the I&O documentation was all that was documented of the resident's intake and output, which started on February 10. The DON could not explain why I&O monitoring was started three days after the resident's admission on February 10. -Resident #35 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] twice a week. Review of the clinical record revealed physician's orders [REDACTED]. Review of the Intake and Output Roster from January through April 2014, revealed that there were over 20 days each month, that the documentation showed the resident's daily fluid intake was over 1000 cc per day. An interview was conducted with a CNA on April 2, 2014. The CNA was aware that the resident was on a fluid restriction. The CNA stated that resident #35 always eats in his room and they are to chart his fluid intake in the chart and monitor the fluid he drinks out of the water pitcher at the bedside. An interview was conducted on April 2, 2014, with the unit manager who was unaware that the resident was going over the restricted amount of fluid. Review of the facility's intake and output policy revealed that residents with the following conditions and [DIAGNOSES REDACTED]. According to a policy regarding Conditions Requiring Intake and Output, all residents upon admission will be placed on I&O for intake only for 72 hours and for nursing staff to record I&O. Review of the facility's Hydration Program policy revealed that a high risk resident included residents that were dependent on staff for provision of fluid intake. The At Risk Team responsibilities included assessing lab values, the resident's ability to obtain fluids, and the resident's fluid preferences. In addition, the policy reflected that if the resident required additional fluids during the day to meet daily requirements, the team would be responsible for determining the distribution of those fluids. The "at risk resident" was to also be noted on the resident's care plan to alert the nurse and staff of the need to offer additional fluids when administering medications or performing care.