Every finding on record at Haven of Show Low

Based on the clinical record review, staff interviews and facility policy and procedure, the facility failed to ensure that a level 1 PASRR (Preadmission Screening and Resident Review) was updated as required after 30 days of admission for 1 out of 14 sampled residents (Resident #28). The deficient practice could result in specialized services not being received and provided to the residents. The universe was 54.Findings include:Resident #28 was admitted on [DATE] with diagnoses that include: major depressive disorder, mild cognitive impairment of uncertain or unknown etiology, anxiety disorder, unspecified psychosis not due to a substance or known physiological condition and multiple sclerosis.Resident #28's PASRR form dated May 13, 2026 had a check mark where it asked question if the admission meet criteria for 30-day Convalescent Care. The form noted in italics that the NF (Nursing Facility) must update the Level I at such time that it appears the individual's stay will exceed 30 daysFurther review of the resident's clinical record did not reveal updated Level I PASRR after resident #28's admission exceeded 30 days.Resident #28's care plan created on May 14, 2026, revealed a focus area for use of antidepressant medication, and interventions included to monitor/document side effects and effectiveness of antidepressants given. Another focus area included was for the use of anti-anxiety medications with interventions that included to give anti-anxiety medications ordered by physician.An interview was conducted on July 28, 2026 at 11:36 a.m. with Resident Relations Manager (RRM, Staff #51) and revealed that residents are usually admitted to the facility with a PASRR prior to arrival. A new PASSR will be completed if a 30 day PASRR was done or if there is a significant change in health. If a PASRR was not done at admission then marketing and admissions staff (Staff #42) will complete the PASRR. A 30 day PASRR will be completed after the 30 days by Staff #51. To keep track of the 30 day PASRR stays, Staff #51 keeps a spreadsheet with the admission dates of the residents that are there with a 30 day PASRR. He will then follow up and complete a new PASRR before the 30 days are up. Staff #51 further revealed that it is mandated that a new PASRR is done, because you need to make sure that mental health and behaviors are taken care of. If they are not done, the resident may not get the care they need or moved to a higher level of care. After reviewing resident #28's PASRR dated May 13, 2026, staff #51 stated that the required update to the Level I PASRR after 30 days of admission had been missed and was overdue. Staff #51 acknowledged that the Level I PASRR should have been updated and stated that he would complete the required update because it is mandated by the state.During an interview with Admissions Staff (Staff #42) on July 28, 2026 at 1:32 p.m., Staff #42 revealed that it is part of her responsibility to make sure the PASRR is completed prior to arrival from the hospital or where ever the admission is coming from. If a PASRR is not done, Staff #42 knew how to complete one and will complete the PASRR from the AHCCCS (Arizona Health Care Cost Containment System) portal. Staff #42 stated she used the information from the patient's chart to create the PASRR. Staff #42 concluded the interview by stating that Resident Relations will do the 30 day PASRR and that they will keep track of the PASRR forms that are needed on a spreadsheet. Staff #42 also stated that they are mentioned in the morning meetings, that a 30 day PASRR is due.An interview with conducted on July 28, 2026 at 1:36 p.m. with executive director (ED, Staff #47). Staff #47 revealed that the expectation regarding PASRRs are that they are completed timely as possible. PASRRs are discussed in the stand up meetings each day. Staff #47 stated further that the risk is if PASRRs are not completed, patient care is not in compliance.A review of the policy titled Pre-admission Screening and Resident Review (PASRR) version 0624, revealed that for individuals with a convalescent period, or respite care (not to exceed 30 days), if it is determined that the stay will be 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 observations, staff interviews, and a review of facility policies, the facility failed to ensure that expired medications were properly discarded and not available for use. These deficient practices could result in residents receiving expired medications, and could result in resident injury, medication overdose, or contradictions. The facility census was 54.Findings Include:An observation of the medication room was conducted on July 28, 2026, at 10:41 a.m. with Licensed Practical Nurse (LPN, Staff #44). The following expired medications were identified: four 500 mL bags of IV Vancomycin 1500 mg/NS that expired on July 12, 2026; one 500 mL bag of IV Vancomycin 1500 mg/NS that expired on July 16, 2026; seven 50 mL bags of IV Vancomycin 300 mg/NS that expired on July 21, 2026; and one 50 mL bag of IV Vancomycin 300 mg/NS that expired on July 19, 2026.During the observation, an interview was conducted with Staff #44. Staff #44 stated that all nurses were responsible for checking and disposing of expired medications and that expired medications were either returned to the pharmacy or disposed of according to facility policy. Staff #44 stated that the presence of expired medications fell below her expectations and that administering expired medications could have resulted in unpredictable patient reactions because the safety and effectiveness of the medications could no longer be guaranteed. Staff #44 further stated that expired medications might not have provided the intended therapeutic effect.An interview was conducted with the Director of Nursing, Staff #68, on July 28, 2026, at 11:05 a.m. Staff #68 stated that medications should have been checked frequently, ideally every 15 days, and that expired medications should have been removed appropriately. Staff #68 stated that there was no designated person responsible for medication storage because all nursing staff shared that responsibility. Staff #68 further stated that medication storage rooms and medication carts should have been checked at least every 15 days. After reviewing the expired medications, Staff #68 confirmed that they should have been removed from the medication room. Staff #68 stated that the presence of expired medications fell below her expectations and explained that administering expired medications might not have provided the intended therapeutic effect and could have resulted in serious harm, including death.An interview was conducted with Registered Nurse (RN/ Staff #66) on July 28, 2026, at 3:16 p.m. Staff #66 stated that administering expired medications could have resulted in serious harm to a resident, including potentially life-threatening consequences. Staff #66 explained that medications had expiration dates for a reason and that administering expired antibiotics could have had the worst possible outcome, including death. Staff #66 stated that all nursing staff shared responsibility for removing expired medications from the medication storage room and that expired medications, including IV solutions, should have been checked daily. Staff #66 further stated that retaining expired IV solutions in the medication refrigerator was not acceptable and acknowledged that the expired IV solutions should have been removed. When asked how the IV fluids that expired on July 14, 2026, had remained in the refrigerator and were not discarded despite the shared responsibility of all nursing staff, Staff #66 responded that there was no good reason they had remained in the refrigerator.The facility's policy titled Storage and Expiration Dating of Medications and Biologicals, revised on January 1, 2024, included the following: If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

Based on interviews, review of clinical record, and facility policy, the facility failed to protect the resident's (#2) right to be free from physical abuse by another resident (#4). The deficient practice could result in physical and psychosocial harm.-Regarding Resident #2 (alleged victim): Resident #2 was re-admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, chronic obstructive pulmonary disease, epilepsy, cerebral aneurysm, depression, sarcopenia, and anxiety disorder.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #2 had a brief interview for mental status (BIMS) score of 12, indicating moderately impaired cognition.A nursing note dated October 26, 2025, revealed Resident #2 was in their wheelchair in the center of the hallway blocking the pathway, when another resident (Resident #4) was wandering in the same direction. Resident #2 stopped to receive medications. The aggressive resident (#4) grabbed Resident #2's wheelchair by the handles and attempted to push Resident #2 forward. Resident #2 yelled loudly for the other resident to stop, at which time the other resident did stop, and then proceeded to hit Resident #2 with an open palm to the top of Resident #2's head with medium force. Resident #2 called for the hitting resident to stop, and a certified nursing assistant (CNA) was able to remove the other resident after one hit to the top of Resident #2's head. The note also revealed that the nurse (Staff #19) witnessed the entire interaction.-Regarding Resident #4 (alleged perpetrator):Resident #4 was admitted [DATE], with diagnoses that included cystitis, fetal alcohol syndrome, problem related to social environment, unspecified dementia, depression, alcohol abuse, and unspecified symptoms and signs involving cognitive functions and awareness.A quarterly MDS assessment dated [DATE], revealed a BIMS assessment was not completed for Resident #4 due to the resident being rarely or never understood.A care plan dated May 7, 2025 revealed Resident #4 had a behavior problem of wandering. Interventions included to anticipate and meet the resident's needs and to assist the resident to develop more appropriate methods of coping and interacting.An Alert Charting note dated October 6, 2025, revealed Resident #4 was found outside the building laying on the ground in the parking lot.A Behavior note dated October 22, 2025, revealed Resident #4 was walking down the hallway carrying a brief and a package of wipes. When the nurse approached to attempt to take away the items, Resident #4 threw the items on the floor. The note revealed that the nurse reached down to pick up the items, and Resident #4 slapped the nurse on the nurse's right shoulder, and that the incident was reported to the Director of Nursing (DON).An Alert Charting note dated October 26, 2025, revealed that another resident (#2) was in their wheelchair in the center of the hallway blocking the pathway, and Resident #4 was wandering in the same direction, when the other resident in the wheelchair stopped to receive medications. Resident #4 grabbed the other resident's wheelchair by the handles and attempted to push the resident forward. The resident in the wheelchair yelled loudly for Resident #4 to stop, at which time Resident #4 did stop and then proceeded to hit the other resident (#2) with an open palm to the top of her head with medium force. The resident in the wheelchair called for Resident #4 to stop, and a CNA was able to remove Resident #4 after one hit to the top of the resident's head. The note also revealed that the nurse (Staff #19) witnessed the entire interaction.An interview was conducted on October 27, 2025, at 1:39 P.M., with Resident #2, who stated that she had an incident with a male resident several days ago. Resident #2 stated that she was going to see the nurse in the hallway, and that the male resident came up behind her and started pushing her wheelchair. Resident #2 stated that she told the male resident to stop, and that the male resident started hitting her on the top of her head. Then, she stated that the nurse (Staff #19) witnessed the incident, and called for another staff to separate the two residents, and that after the incident, staff kept the two residents separated. Resident #2 stated that during the incident, she did experience pain, and afterward she was worried because she has aneurysms, which could have caused her harm.A telephonic interview was conducted with a Licensed Practical Nurse (LPN / Staff #19) on October 27, 2025, at 2:16 P.M. Staff #19 stated that he witnessed the incident, and that he was passing medications with his medication cart in the middle of the hallway because the hallway was full of materials due to the floor renovation work. Staff #19 stated that Resident #2 wheeled up to the side of his medication cart in her wheelchair and Resident #4 was wandering behind Resident #2. Staff #19 stated that Resident #4 grabbed the handles of Resident #2's wheelchair and began to push it forward, at which point Resident #2 yelled out loudly because it scared her. Staff #19 stated that then, Resident #4 popped her (Resident #2) on the top of the head. Staff #19 stated that the pop was that Resident #4 raised his open hand approximately one foot above Resident #2's head and then brought his hand downward onto her head. Staff #19 stated that it was not a tap, but it also was not full force either, and that he would describe the hit as medium force. Staff #19 stated that Resident #2 did not voice any pain at the time of the incident but that she complained of a headache about 2 hours later, and then Staff #19 gave her pain medications. Staff #19 stated that Resident #2 called the police regarding the incident, and that the facility's phone system was not functioning at the time, so Staff #19 was unable to make any notifications until approximately 4:00 P.M. Staff #19 stated that after the incident, the facility staff ensured that the residents were kept separated.An interview was conducted with a Certified Medication Assistant (CMA / Staff #31) on October 27, 2025, at 2:27 P.M. Staff #31 stated that she did not witness the incident on October 26, 2025, but that she has witnessed similar situations with Resident #2, because he does not realize what he is doing or understand personal space. Staff #31 stated that after the incident, staff were supervising Resident #2 one on one. Staff #31 stated that the CNA who separated the residents during the incident was Staff #76.A telephonic interview was attempted on October 27, 2025, at 2:33 P.M. with Staff #76. The staff was unable to be reached by phone for interview.An interview was conducted on October 28, 2025, at 9:38 A.M. with a Registered Nurse (RN / Staff #22), who stated that there are different types of abuse, including verbal abuse, physical abuse, and neglect, and that if staff were to see or hear an allegation of abuse, that staff should intervene to separate the resident from abuse, and ensure the resident is safe, then report the incident to the Administrator.An interview was conducted with the Director of Nursing (DON / Staff #40) on October 28, 2025, at approximately 10:00 A.M. The DON stated that if staff see or hear anything that could be abuse, staff are to separate residents from the abuse, perform a head to toe assessment of the resident, assess the resident's physical and mental wellbeing, and report the incident to the DON or the Administrator. Regarding the incident between Resident #2 and Resident #4 on October 26, 2025, the DON stated that she received a call from Staff #19 that there was an incident between the two residents, where Resident #4 was confused and trying to get through the hallway and placed his hands on the back of Resident #2's wheelchair. The DON stated that Resident #2 then yelled at Resident #4. The DON stated that then, Resident #4's hand contacted Resident #2's head. When asked if this incident was determined to be physical abuse, the DON declined to directly state if it was abuse, but did state that it would depend on if the act was intentional. The DON stated that if a resident was intentionally trying to hurt the other resident then that would be considered abuse.An interview was conducted with the Administrator (Staff #50) on October 28, 2025, at 10:15 A.M. Staff #50 stated that abuse is generally an intentional harm or action against another resident. If staff were to see or hear an allegation of abuse, Staff #50 stated that he would expect them to report it to the Administrator or DON immediately. Staff #50 stated that if an act of physical abuse were to happen in front of floor staff, that he would expect staff to separate the residents and make sure they are safe, assess the residents, and then report the incident. Staff #50 stated that regarding the incident of Resident #2 and Resident #4 on October 26, 2025, that Staff #50 was notified by the DON, who was notified by Staff #19. Staff #50 stated that he was informed that Resident #2 was in the hallway and Resident #4 came up behind her wheelchair and pushed her wheelchair, and that Resident #2 did not like that and told him to stop. Then, Staff #50 stated that Resident #4 went like this (Staff #50 raised his hand then gestured moving downward with his open hand), on top of Resident #2's head. Staff #50 stated he had an interview with Resident #2 who stated that Resident #4 popped me on top of the head, and an interview with Staff #19, who stated that Resident #2 was bopped on the head by Resident #4. Staff #50 stated that the contact did happen; that Resident #4 did contact Resident #2's head.Review of the facility policy titled Resident Rights/Dignity: Resident Rights, dated January 1, 2024, revealed that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to a dignified existence, be treated with respect, kindness, and dignity, and be free from abuse, neglect, misappropriation of property, and exploitation.Review of the facility policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated January 1, 2024, revealed all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management.

Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#18) was provided care and services, according to professional standards and physician orders, to prevent a new pressure ulcer and prevent worsening of existing pressure ulcers. The deficient practice could lead to physical harm of residents developing new or worsening wounds. -Findings Include: Resident #18 was initially admitted to the facility September 25, 2019, with diagnoses that included hyperlipidemia, chronic kidney disease, diastolic heart failure, neuromuscular dysfunction of bladder, ulcer of anus and rectum, and localized edema. A quarterly minimum data set (MDS) assessment dated [DATE], revealed the Resident #18 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. Section GG revealed the resident was dependent on staff for bed mobility of sit to lying, and required substantial/maximum assistance with rolling in bed. Additionally, the resident had a diagnosis of paraplegia. A care plan dated May 24, 2021, revealed the resident was at risk for skin impairment, and had pressure ulcers on bilateral gluteal folds and sacrum, and a rectal fistula. Interventions included to assess/record/monitor wound healing weekly and as necessary. Measure length, width, and depth where possible, assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the physician. If the resident refuses treatment, confer with the resident, interdisciplinary team (IDT), and family to determine the cause and try alternative methods to gain compliance. Document alternative methods. There was no evidence of a care plan update for a facility-acquired pressure ulcer on the resident's scrotum. A physician order dated August 28, 2024, and discontinued September 4, 2024, indicated to cleanse left ischium with Dakins, pat dry, apply calcium alginate, cover with ABD pad, and secure with tape, change daily and as needed, and notify provider of any concerns, two times a day every Mon, Wed, Fri, and Sun. A duplicate order indicated for two times a day every Tue, Thu, and Sat, and was also discontinued September 4, 2024. There was no evidence of wound care orders or treatment for the left ischium wound from September 4, 2024 until November 1, 2024. A physician order dated August 28, 2024, and discontinued November 1, 2024, indicated for wound care: cleanse sacral ulcer with WCS, pat dry, sprinkle collagen powder to wound bed, apply Maxorb Ag, cover with ABD pad and secure with tape, two times a day every Mon, Wed, Fri, and Sun. An additional duplicate order dated August 29, 2024, indicated for two times a day every Tue, Thu, and Sat. A physician order dated August 28, 2024, and discontinued November 1, 2024, indicated for wound care: cleanse right ischium with Dakins, apply Maxorb Ag and ABD pad, change two times a day every Mon, Wed, Fri, and Sun. A duplicate order indicated for two times a day every Tue, Thu, and Sat. A physician order dated October 25, 2024, indicated to clean wound with normal saline, pat dry, pack wound with 1/4 inch put ABD wrap with kerlix every night shift for wound care. There was no evidence of which wound the treatment was indicated for. A Pressure Ulcer Documentation assessment dated [DATE], revealed the resident had three pressure ulcers: -Right gluteal fold pressure ulcer, present on admission, Stage 4, measured as 3.2 x 0.8 x 1.2 cm, no tunneling -Left gluteal fold pressure ulcer, present on admission, Stage 4, measured as 2.2 x 2.3 x 0.7 cm, no tunneling -Sacral pressure ulcer, present on admission, Stage 4, measured as 2.0 x 2.3 x 0.6 cm, no tunneling Wound Care Visit Discharge Instructions dated September 3, 2024, revealed the resident had wounds on the right and left ischium, sacrum, and peri-anus. Discharge instructions included: -Right and Left Ischium: cleanse wound with wound cleaner, change ABD pad dressing 3 times per day and as needed -Midline Sacrum: cleanse wound with wound cleaner, change ABD pad and Maxorb Ag dressing 3 times per day and as needed -Peri-anus: cleanse wound with wound cleaner, change ABD pad dressing 3 times per day and as needed A Weekly Skin Check and Wound assessment dated [DATE], revealed the resident had right and left gluteal fold pressure ulcers, and a sacral pressure ulcer. There was no evidence of measurements or further details of the wounds. A Pressure Ulcer Documentation assessment dated [DATE], revealed the resident had four pressure ulcers: -Right gluteal fold pressure ulcer, present on admission, Stage 4, measured as 1.9 x 0.7 x 0.4 cm -Left gluteal fold pressure ulcer, present on admission, Stage 4, measured as 2.5 x 0.5 x 1.5 cm, tunneling noted with a depth of 1.6 cm -Coccyx pressure ulcer, present on admission, Stage 4, measured as 2.6 x 3.1 x 2.1 cm, tunneling from 12:00 to 3:00 noted with a depth of 2.1 cm -Scrotum, present on admission, Stage 4, measured as 2.7 x 1.6 x 0.5 cm A Pressure Ulcer Documentation assessment dated [DATE], revealed the resident had four pressure ulcers: -Right gluteal fold pressure ulcer, present on admission, Stage 4, measured as 2.5 x 3.1 x 1.4 cm -Left gluteal fold pressure ulcer, present on admission, Stage 4, measured as 2.5 x 0.5 x 1.5 cm -Coccyx pressure ulcer, present on admission, Stage 4, measured as 2.3 x 3.0 x 2.1 cm -Scrotum, facility-acquired with an onset date of September 23, 2024, Stage 4, measured as 2.7 x 1.6 x 0.5 cm There was no evidence of documentaion on the presence of tunneling on any of the wounds. The clinical record was reviewed and there was no evidence of notification to the physician of the new facility-acquired scrotum wound, or any treatment orders. Additionally, there was no evidence of any weekly wound assessments, including measurements or descriptions of the pressure wounds, between September 26 - October 14, 2024. A Pressure Ulcer Documentation assessment dated [DATE], revealed the following: -Coccyx pressure ulcer, present on admission, Stage 4, measured as 2.3 x 3.0 x 0.5 cm -Right gluteal fold pressure ulcer, with the measurement left blank and no descriptors -Pressure Ulcer #3: no evidence of location or any measurement or descriptors A Weekly Skin Check and Wound assessment dated [DATE], revealed the resident had right and left gluteal fold pressure ulcers, a coccyx pressure ulcer, and a medial testicular pressure ulcer. There was no evidence of measurements or further details of the pressure ulcers. Review of the MAR for September 2024 revealed there was no right ischium and sacral wound care treatment completed either shift on September 11, 13, and 15, and the clinical record revealed there was no evidence of the resident refusing the missed wound care treatments. A Medication Administration Note dated September 23, 2024, revealed the resident did not want to lay down to have wounds measured at the time. There was no evidence that alternatives were coordinated with the resident. The MAR for October 2024 and the clinical record were reviewed, and the resident missed sacral and/or right ischium wound care treatments for the following reasons, with no evidence of coordination of alternatives per the care plan: -October 9: refused -October 10; resident was up in chair, and at dialysis -October 12: at dialysis -October 14: had visitors -October 15: refused, and at dialysis -October 19: up in chair for dinner -October 22: at dialysis -October 23: refused -October 27: refused -October 28: refused -October 29: up in wheelchair A Discharge Summary note dated November 5, 2024, revealed the resident was transferred to the hospital via ambulance for difficulty breathing. A physician progress note from the hospital admission dated November 12, 2024, revealed the resident was treated for sepsis present on admission secondary to sacral wound, pneumonia, and urinary tract infection. Additionally, sacral decubitus wound with a wound culture positive for Proteus mirabilis. The resident was treated with antibiotics. An interview was conducted with a Registered Nurse, (RN / Stff #50) on April 16, 2025, at 1:09 pm, who stated if a treatment is ordered every shift, then it should be completed at some time during the shift, for day shift and night shift. Staff #50 stated that she was familiar with Resident #6, and that he had pressure wounds on the buttocks and sacral area. Staff #50 reviewed the clinical record and stated that the resident had orders for weekly skin and wound assessments. Staff #50 also reviewed the gap in weekly assessments from September 26 - October 14, 2024, and stated that the impact on a resident of missing the weekly assssments could be worsening wounds, missing new wounds or onset of infection. On April 16, 2025, at 1:35 PM, an interview was conducted with an RN / unit manager (Staff #96), who stated if a treatment is ordered every shift and as needed, then the treatment should be done anytime during that shift as well as any additional times that are needed. Staff #96 stated that if a treatment was not completed as ordered, then the resident's condition could worsen. Additionally, Staff #96 stated that if a resident was ordered weekly skin checks, then the nurse should complete the assessment and document in the weekly skin assessment. Also, if a resident was not assessed weeekly as ordered, then the wound could worsen or become infected and lead to delayed care. Staff #96 stated she was familiar with Resident #6 and that he had wounds on the hips and coccyx. The clinical record was reviewed and Staff #96 stated that there's a week missing in there for the weekly skin assessments between September and October 2024. Additionally, the missing sacral wound care treatments from September 2024 were reviewed in the record, and Staff #96 stated that there was no documentation that the treatments were done on September 11, 13, and 15. An interview was conducted with the Director of Nursing (DON / Staff #48) on April 16, 2025, at 2:52 PM. The DON stated that if a treatment is ordered every shift then it should be completed during that shift. If a resident was at a dialysis appointment, or was in a wheelchair and did not wanted to be treated at that particular time, then the nurse should communicate with the resident to find an alternate time to provide the treatment, or if it was at the end of the shift to communicate to the next shift that the treatment was not done so that the next nurse could address it. The DON stated that she was aware that Resident #6 had pressure ulcers to the coccyx and right and left buttocks, and that she was notified that the resident had bleeding from the scrotum but when assessed, did not see a pressure ulcer on the scrotum. The clinical record was reviewed and the DON stated that she could not see any evidence of notifiction to the provider for the documented new onset of the scrotal pressure ulcer. The missing weekly wound assessments for September-October 2024 and the missing wound care treatments were reviewed together and the DON stated this would not meet her expectation and that the facility had already been taking steps to correct the issue. An interview was conducted with the [NAME] President of Clinical Operations (Staff #4) on April 16, 2025, at 3:17 PM. Staff #4 stated that for residents with pressure ulcers, at least once a week, the wound size and descriptors should be documented. Staff #4 stated that the oucome for Resident #6 was that although the resident had a guarded condition and several comorbidities, that there were some missed wound treatments and a newly acquired pressure ulcer. Staff #4 stated that within the past several months, it was identified by the facility that there were issues in the wound care of Resident #6 and that corrective steps were taken such as partnering with a new wound provider. Review of the facility policy titled Assessments/Care Planning: Care Plans, Comprehensive Person-Centered, dated January 1, 2024, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility policy titled Assessments/Care Planning: Change in a Resident's Condition or Status, dated Janaury 1, 2024, revealed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical condition, need to alter the resident's medical treatment significantly, refusal of treatment two (2) or more consecutive times, and/or specific instruction to notify the physician of changes in the resident's condition. Review of the facility policy titled Assessments/Care Planning: Resident Examination and Assessment, dated January 1, 2024, revealed the purpose of this policy is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. The assessment process shall be systematic, comprehensive and multidisciplinary based on the individual resident's needs, acuity and priorities in accordance with physician orders. Orders are to be completed in accordance with physician orders determined at a resident's time of admission or throughout the resident stay. A change in order for assessment is based upon the resident's acuity at the time of the order. Notify the supervisor if the resident refuses the examination. Notify the physician of any abnormalities, including but not limited to wounds or rashes on the resident's skin.

Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#6) was prevented from an accident of bleach ingestion. The deficient practice could lead to physical harm of residents, including serious illness and death. -Findings Include: Resident #6 was initially admitted to the facility May 1, 2021, with diagnoses that included Parkinson's disease, anxiety disorder, hypertension, obesity, and abscess of liver. An admission minimum data set (MDS) assessment dated [DATE], revealed the Resident #6 had a Brief Interview for Mental Status (BIMS) score that was dashed, indicating the assessment was not completed with the resident. There was no evidence of a care plan to address impaired cognition until July 12, 2023. A care plan was initiated this date for an alteration in neurological status due to metabolic encephalopathy/disease process, with interventions to cue and redirect as needed and give medications as ordered. A Daily Skilled Evaluation dated April 16, 2023, revealed Resident #6 wanders halls and occasionally attempts to go out the front door, and the resident is monitored while up in wheelchair. Daily Skilled Evaluations revealed the following: -March 10, 2023: the resident is oriented x 3. -March 11, 2023: the resident is oriented x 2. -March 15, 2023: the resident is oriented x 2. -March 17, 2023: All cares provided in resident's room due to COVID-19 isolation status, and the resident is oriented x 2. -March 18, 2023: the resident is oriented x 2. A Medication Administration Note dated May 18, 2023, revealed the resident is up all during the night and going into other resident's rooms. When trying to redirect him, the resident is grabbing the side rails and door frames, and is trying to go outside and setting off the alarm. The resident is trying to hit staff when being redirected. A provider Encounter Note dated May 20, 2023, revealed the resident is seen on May 21, 2023, for bleach ingestion. The resident is noted to have ingested bleach, and had put water in a container that had some bleach wipes in it and then drank that. Nursing staff had the resident drink about 750 cc of water. The resident appears asymptomatic. Nursing staff to push as much free water as possible, and continue to monitor. A facility Reportable Event Report dated May 22, 2023, revealed the administrator (Staff #26) was contacted by the nurse on duty for an incident on May 21, 2023, of potential bleach ingestion by Resident #6. During the investigation, the resident's BIMS score was re-assessed at 5, indicating severe cognitive impairment. Per the resident's roommate, the resident had filled a bleach wipe container with water, potentially ingesting the water after filling it. The resident was interviewed and gestured to a different water cup indicating he had mistaken the bleach container for his water cup, which was also located in the resident's room. Upon review of the incident, it was determined that the cleaning wipes were present in the resident's room. The staff were instructed to round on all other resident rooms to ensure other wipes containers were not accessible to residents. On April 16, 2024, a formal request was made to the facility for the facility's policy on chemical storage. The administrator signed a statement at 12:40 PM that the facility does not have a policy for chemical storage, that the facility follows the policy titled Resident Safety: Safety and Supervision of Residents. An observation was conducted on April 16, 2025, at 8:09 AM. In room [ROOM NUMBER], where a resident was laying in bed, a cleaning wipe container was observed on the shelf that was within reach from wheelchair level. An interview was conducted at this time with a Certified Nursing Assistant (CNA / Staff #31), who retrieved the cleaning wipe container from the room. The label of the container was read together. The CNA stated that the label had a warning that the product was harmful to humans. The CNA stated that cleaning wipe containers are supposed to be taken back to the nurse's station because they could be a hazard to residents. An interview was conducted on April 16, 2024, at 1:09 PM, with a Registered Nurse (RN / Staff #50) who stated that nurses assess the cognitive status of residents by asking orientation questions and documenting how many questions the resident got correct, and that would be documented as oriented x 1, x 2, or x 3. Staff #50 stated that the facility protects residents from hazardous chemicals by ensuring medications are not left at bedside and that chemicals should be stored in utility closets or janitor closets. The nurse stated that she did not believe it safe to leave hazardous chemical substances within access of a confused resident. An interview was conducted on April 16, 2025, at 2:52 PM, with the Director of Nursing (DON / Staff #48), who stated that the facility assesses resident's cognitive status by conducting the BIMS assessment to get a baseline, and that nurses assess the resident's orientation status. The DON stated that the facility keeps residents safe from hazardous chemical exposure by locking medications and that chemicals should be kept away from residents' rooms. The DON also stated that if a resident were to have access to harmful chemicals, then the resident could obtain it and have risk to the resident, and that it would not meet her expectation. Review of the facility policy titled Resident Safety: Safety and Supervision of Residents, dated January 1, 2024, revealed 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. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/ accident data; and a facility-wide commitment to safety at all levels of the organization. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#56) received medical care treatments ordered by the physician. The deficient practice could result in residents not improving. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included enterocolitis due to Clostridium Difficile (Cdiff), urinary tract infection (UTI), neuromuscular dysfunction of the bladder, and Parkinson's Disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 11 indicated the resident was moderately cognitively impaired. It also included that the resident did not reject care during the look-back period. The care plan dated August 29, 2024 revealed that the resident had infections, Clostridium difficile and urinary tract infection. Interventions included contact/droplet precautions, and educating the resident and staff regarding preventative measures to contain infections. Use as much disposal equipment and dedicated equipment as possible. Non-disposable resident care equipment to be appropriately cleaned and disinfected per facility protocol. The care plan dated August 30, 2024 revealed that the resident had enhanced barrier precautions related to a central line/PICC, indwelling catheter. Interventions included to don and doff gown and gloves and to perform hand hygiene as per facility protocol. A care plan dated August 30, 2024 revealed that the resident is at risk for skin impairment due to decreased mobility and included the interventions to administer treatments as ordered and monitor for effectiveness. An oxygen therapy care plan dated August 30, 2024 revealed oxygen therapy related to ineffective gas exchange included an intervention to provide oxygen per physician order and to monitor for signs and symptoms of respiratory distress and report to the medical doctor. Review of the Order Summary revealed: -August 29, 2024, Vancomycin HCI oral capsule 125 mg give one capsule by mouth every 6 hours related to enterocolitis due to Clostridium Difficile for eight days. -August 29, 2024, Amoxicillin oral capsule 500 mg give one capsule by mouth every 8 hours related to UTI. Discontinued on September 10, 2024. -August 29, 2024, Foley catheter size 16 french, 10 cc balloon. Different size may be inserted if size ordered cannot be reinserted. Change Foley catheter as needed for leaking, soiling, blockage or as ordered by provider. Discontinued September 2, 2024. -August 29, 2024, Nystatin External Powder 100000 unit/gram (topical). Apply to affected areas topically every shift for skin care. Discontinued September 21, 2024. -August 29, 2024, Catheter care with soap and water or wipes every shift for other. Discontinued on September 21, 2024. -August 29, 2024, oxygen at 0-5 liters per minute as needed to keep saturation above 89% every shift for oxygen therapy. Discontinued September 21, 2024. -September 2, 2024, Change suprapubic catheter every month. Discontinued September 21, 2024. Review of the Treatment Administration Record (TAR) dated September 2024 revealed: -August 29, 2024, Catheter care with soap and water or wipes every shift for other. Discontinued on September 21, 2024. Treatment was not provided on September 2, 5, 6, 7, 8, 9, 11, and 12, 2024. -August 29, 2024, Nystatin External Powder 100000 unit/gram (topical). Apply to affected areas topically every shift for skin care. Discontinued September 21, 2024. Treatment was not provided on 2, 5, 6, 7, 8, 9, 11, and 12, 2024. -August 29, 2024, oxygen at 0-5 liters per minute as needed to keep saturation above 89% every shift for oxygen therapy. Discontinued September 21, 2024. Oxygen saturation was not checked on September 2, 6, 7, 8, 9, 11, 2024. An interview was conducted on September 27, 2024 at approximately 11:45 a.m. with a licensed practical nurse (LPN/staff #57), who stated that she had received training on medication and treatment administration. She stated that a physician's order is needed for treatments and when a treatment is done, it should be documented in the Treatment Administration Record (TAR). Staff #57 stated if there is no documentation the treatment was not done, and she would contact the Director of Nursing (DON) and the physician, and document the physician's instructions. She stated that she thinks it is the responsibility of the Director of Nursing to review the TAR to ensure that treatments were provided as ordered. She stated that missed documentation indicated that the resident's catheter was not cleaned and there is a risk of getting a skin infection and a UTI. She stated that she was not sure where the Nystatin powder was supposed to be administered and would need to contact the staff who did the order with the physician to verify, but thought that it was most likely applied to the lower abdominal and inner thigh area. She stated that there is a risk of spreading and can lead to cellulitis if the powder is not applied as ordered. An interview was conducted on September 27, 2024 at 12:14 p.m. with the (DON/staff #2), who stated that staff had received training on administering medications and treatments and a physician's order is required for both. She stated that an order to administer a medication or treatment requires the medication, dosage, frequency, and route and once done -- should be documented on the MAR/TAR. She stated that she is responsible for reviewing the MAR/TAR to ensure medication and treatments are administered. During the interview, she reviewed the MAR/TAR dated September 2024 and stated that the catheter was not cleaned multiple times, which created a risk of infection like a UTI. She also stated that the nurse is responsible for completing skin assessments before applying the Nystatin, but it is usually applied to the abdominal folds and under the breast area. She stated that the Nystatin was not applied multiple times and would expect the staff to document on a progress note if the area was worsening. She stated that the affected area spreading doesn't indicate the problem is worsening, however stated that if the treatment was not documented it was not done. The facility policy, Medications: Administering Medications states that medications are administered in a safe and timely manner, and as prescribed. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones, or documents in the electronic medical administration record. Topical medications used in treatments are recorded on the resident's treatment record (TAR).

Based on clinical record review and staff interviews, the facility failed to ensure care and services related to wound was provided one resident (#57). The deficient practice resulted in the wound becoming necrotic and resident's transfer to the hospitalization . Findings include: Resident #57 was admitted to the facility on [DATE] with a diagnoses of Atrial Fibrillation, acute kidney failure, type II diabetes mellitus, systemic inflammatory response syndrome and bilateral lower extremity amputations. The admission note dated June 21, 2024 included the resident was admitted from a short-term general hospital, was confused as to situation and place and had bilateral lower extremity amputations. Per the documentation, the resident had pain of 10/10 from foley catheter; and, interventions to alleviate pain was to secure cathether and good peri/catheter care. An encounter note dated June 23, 2024 included a history of present illness that at the hospital, the resident's urinalysis was negative but a Foley catheter was placed for unknown reasons. Assessment included benign prostatic hyperplasia (BPH) with lower urinary tract symptoms. Per the documentation, the resident was noted to have a Foley catheter; and that, the provider will order bladder training and then removal of Foley catheter. The daily skilled evaluation dated June 23, 2024 revealed that the resident was oriented x 3 and had catheter use. The progress note dated June 24, 2024 at 4:59 p.m. included that the resident had a Foley catheter in place and was complaining of discomfort to his penis. Per the documentation, the nurse removed the Foley catheter and the Nurse Practitioner (NP) was notified. Further, the documentation included that resident will be monitored for spontaneous urination. The physician order dated June 24, 2024 included may replace Foley if not urinating every shift for 3 days. The daily skilled evaluation dated June 24, 2024 7:59 p.m. revealed the resident had catheter. However, there was documentation of the reason for the continued use and reinsertion of the Foley catheter. An encounter note dated June 25, 2024 included the resident did not have suprapubic tenderness; and that, the resident had Foley catheter. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. The assessment included that the resident had short-term and long-term memory problem and had severely impaired cognitive skills for daily decision making. Further, the MDS coded that the resident had an indwelling catheter. The CAA (Care Area Assessment) summary revealed that indwelling catheter was triggered for care planning. However, the clinical record revealed no evidence that a care plan related to the use of a Foley catheter and implemented interventions. The weekly skin check note dated June 28, 2024 included that the penis had slough noted at the meatus. Per the documentation, the resident was uncircumcised; and, the foreskin needed to be pulled back to note area of inflammation from previous catheter insertion. It also included that treatment was applied. The shower sheets dated June 28, 2024 revealed no documentation of any issues identified on the resident's penis The care plan dated July 2, 2024 included the resident had bladder incontinence related to dementia, history of CVA (cerebrovascular accident) and impaired mobility. Goal was that the resident's risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI (urinary tract infection). Interventions included to use disposable briefs and to check and change as needed. The physician order dated July 3, 2024 included for Santyl ointment (topical wound treatment) 250 unit/gram, apply to penis meatus topically at bedtime for wound care for small amount of slough area of the meatus. The weekly skin check notes dated July 4, and 12, 2024 included that the penis had slough noted at the meatus. Per the documentation, the resident was uncircumcised; and, the foreskin needed to be pulled back to note area of inflammation from previous catheter insertion. It also included that treatment was applied. The shower sheet dated July 8, 2024 revealed no documentation of any issues identified on the resident's penis. The clinical record revealed no evidence that Foley catheter care was administered or provided to the resident. It also did not include a reason why Foley catheter care was not provided; and that, the physician was notified. The encounter note dated July 11, 2024 revealed the resident was seen for penile abscess; and that, there was significant amount of smegma noted. Per the documentation, it inflamed but did not appear to be infected. It also included that the resident had Foley catheter; and, smegma was noted on the tip of the penis. Further, the documentaton included that the resident will be referred to the wound clinic as he might need debridement. The shower sheet dated July 11, 2024 revealed no documentation of any issues identified on the resident's penis. The encounter note dated July 16, 2024 revealed that the skin was warm and dry; and smegma was noted on the tip of the penis. The encounter note dated July 18, 2024 included that Foley catheter was noted. Despite documentation that the provider recommended referral to wound clinic, the clinical record revealed no evidence that the resident was referred to the wound clinic from July 11 through July 21, 2024. The progress note dated July 22, 2024 revealed that the resident had an appointment set at the wound clinic for July 31, 2024. The weekly skin check notes dated July 19 and 28, 2024 included that the penis had slough noted at the meatus. The documentation did not include whether or not treatment was administered. The shower sheet dated July 29, 2024 revealed no documentation of any issues identified on the resident's penis. The Santyl order was transcribed onto the medication administration record (MAR) for July 2024 and was documented as administered. The discharge and transfer assessment dated [DATE] included that the resident was transfered to the hospital. Per the documentation, the resident went to the wound clinic for his appointment for his penile wound; and , the wound clinic sent the resident to the ER (emergency room ) straight from the clinic. The report of consultation note dated July 31, 2024 revealed that the resident had a penile ulcer at the tip of the penis; and that, there was need to retract the foreskin. Per the documentation, wound clinic performed wound culture and biopsy of the penile lesion. Further, the documentation included that the resident was sent to the ER for STAT urology consultation and possible I&D (incision & drainage) A phone interview with the wound clinic registered nurse (RN/staff #8) conducted on August 19, 2024 at 2:03 p.m., the RN stated that resident #57 was sent to the wound clinic for consultation of the penile wound. The RN said that on examination, the resident had quite a bit of necrosis at the tip of his penis which was usually seen in residents who were actively dying. The RN said that the wound clinic sent the resident out to the ER; and, if we are sending a resident out, then it was pretty bad. She stated that in the case of resident #57, the wound clinic biopsied the wound beneath the necrotic tissue at the tip of the penis. The RN said that the resident should have been seen and evaluated much sooner; and that, the facility could have done a culture and sensitivity test on resident #57. Further, the RN stated that the wound care provider documented that resident #57 may need removal of the penis and it was bad; but, she was not sure that happened. An interview was conducted on August 19, 2024 at 2:00 p.m. with the director of nursing (DON/staff #26) who stated that the facility did not have a wound care nurse for the past year. The DON said that a head to toe skin assessment was completed and reviewed by staff when a resident is admitted at the facility. The DON said the resident was then placed on weekly skin assessment schedule for issues. Regarding resident #57, the DON said that there was a definite problem here. The DON said that staff cannot have the same exact note every time staff were looking at a wound; and, she would have followed up with the resident after it was identified by staff. Further, the DON stated that it was problem that the provider recommended for the resident to see the wound clinic on July 11; but this was not even made until July 22, 2024. In a later interview with the DON conducted on August 19, 2024 at 3:05 p.m., the DON said that based on the clinical record, staff did everything they could. She also stated that review of the clinical record revealed the resident had slough in his penis and this was the same as necrosis. An interview on August 19, 2024 at 4:20 p.m. with a certified nursing assistant (CNA/staff #35) who stated he noticed that resident #57 had a penile issue; and he notified the administrator and charge nurse each time. He said that they told him that they knew about the issue and things were being done to correct it. He stated that the penile issue continued to look worse; and, when staff were cleaning the penis staff had to pull back the foreskin which did not come back easily. Further, he stated that some of the female nurses/staff were not comfortable pulling foreskin back and cleaning it like they should.

Based on observations, staff interview, and review of policy and procedures, the facility failed to discard food/liquid items by their use-by-dates, failed to ensure that food items were appropriately refrigerated, and failed to ensure appropriate hand hygiene during food preparation and during the serving line. The census was 48, sample was 12. Findings include: An observation of the unit norishment refrigerator/freezer was conducted on [DATE] at 9:33 a.m. revealed an unlabeled container that contained a purple colored liquid substance had an expiration date of [DATE]. Another observation was conducted on [DATE] at 11:32 a.m. The cook (staff #5) placed a gloved hand into a salad bag removing the salad mix from the bag, then placing it on the plate. With the same gloved hand, the cook then reached out into his shirt pocket, removed a marker and dated the salad bag, opened the refrigerator door, placed the resealed salad bag into refrigerator, then removed a bag of boiled eggs and a bag of tomatoes from the refrigerator. The cook then proceeded to slice the boiled eggs and tomatoes on a cutting board without changing his gloves and placed the sliced boiled eggs and tomatoes on salad plate and then handed the completed salad plate to dietary aide (staff #47). At this point, the cook removed his gloves and donned new gloves without washing his hands. The cook opened the refrigerator with the new donned gloved hands, removed the cottage cheese from the refrigerator, grabbed a plate and placed the plate on the same cutting board used to slice eggs and tomatoes. The cook then opened the cottage cheese container, scooped cottage cheese onto the plate, closed lid of the cottage cheese, and returned the cottage cheese container to the refrigerator wearing the same pair of gloves. An interview was [DATE] at 1:16 p.m.p.m. with the kitchen manager (staff #6) and dietary manager (staff #100). The kitchen manager stated that the unlabeled container of purple liquid was grape cool-aid and it had an expiration date of [DATE]. Further, the kitchen manager stated that the container should have been removed. Both the kitchen manager (staff #6) and dietary manager (staff #100) stated that the risk of the using food/liquid items after expiration date could make residents sick. During the breakfast observation conducted on [DATE] at 7:12 a.m., the serving line cook (#57) removed her gloves, did not wash hands and proceeded to adjusting clean stacks of hot plates and the stacks of hot plate covers without her bare hands. She then donned gloves on without washing her hands and adjusted sink faucet spout and then sliced bananas on cutting board using the same gloved hands. Without changing her gloves, she then scooped the food from the hot tray, placed the food onto the individual hot plates, removed the sliced bananas from the cutting board one hand-full at a time and placed the sliced bananas directly onto each individual plate during serving. An interview with the kitchen manager (staff #6) and dietary manager (staff #100) was conducted [DATE] at 10:21 a.m. The kitchen manager stated that the expectation was for staff to use gloves for hand protection and to keep food safe; and that, staff were to wash their hands between gloves changes. The kitchen manager also said that staff wear gloves at all times when touching the food; and, before staff enters the refrigerator, they were expected to remove their gloves, and then donn new set of gloves before touching food. The dietary manager (staff #100) stated that gloves should always be used when staff was touching ready to serve food. Both staff stated that staff not washing hands, not performing hand hygiene and changing gloves in between food handling were not acceptable and did not meet the facility expectations. The kitchen manager stated that the risk of improper hand hygiene could result in resident's becoming sick from cross contamination. Review of the facility policy on dietary Services: Refrigerators and Freezers revealed that the facility will ensure safe refrigerator maintenance, temperatures, and will observe food expiration guidelines. All food shall be appropriately dated to ensure proper rotation by expiration dates. Use-by-dates will be completed with expiration dates on all prepared food in refrigerators. Supervisor will be responsible for ensuring food items in pantry, refrigerators are not expired or past perish dates. The facility policy on Food Storage and Date Marking included that food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Date marking to indicate the date or day by which a ready-to-eat, potentially hazardous food should be consumed or discarded will be visible on the Time and Temperature Control for Safety (TCS) that is not for immediate use. All foods will be checked to assure that foods will be consumed by their use by dates, or frozen, or discarded, at the end of the day. The facility policy on General Food Preparation and Handling, revealed that TCS foods that stand four or more hours at room temperature must be discarded. Staff will handle utensils, cups, glasses, and dishes in such a way as to avoid touching surfaces that food or drink will come in contact with. Tongs or other serving utensils will be used to serve breads or other items to avoid bare hand contact with food.

Based on observation, staff interview, and policy review, the facility failed to ensure that medications were dated when opened; and, failed to ensure expired medications were discarded and not readily available for resident use. The deficient practice could result in medication errors, reduced drug effectiveness and adverse reactions. The facility census was 48. Findings include: A medication observation was conducted on August 5, 2024 at 11:19 a.m. There was a white pill in a medicine cup on the bedside table of a resident #145 that was left unattended. The resident stated the pill was his phosphorus binder that was taken prior to lunch; and that, he self-administers this medication on a daily basis. An observation of medication cart #1 was conducted with registered nurse (RN/staff #48) on August 6, 2024 at 7:05 a.m. There were opened bottles of Vitamin C and Vitamin B12 with no open dates. There was also an opened aspirin bottle with no open date and had expiration date of July 2024. The RN stated that she was not familiar with the facility's policy on non-dated opened medication bottles. She said that the correct procedure was to date bottle upon opening; and that, the nurses were responsible for checking for expired medication on medication carts. During an interview with licensed practical nurse (LPN/staff #13) conducted on August 6, 2024 at 8:02 a.m., the LPN stated that once a medication bottle is opened, the bottle had to be labeled with the open date. The LPN said that she was not sure as to how long opened medication bottle was kept after opening; and that, the nurses were responsible for checking for expired medication on medication carts. During an observation conducted on August 6, 2024 7:00 a.m. through 8:30 a.m., a bag of intravenous (IV) Ceftriaxone (antibiotic) 1gram (gr) /100 milliliters (ml) was found on top of medication cart #2. The licensed practical nurse (LPN/staff #13) left the medication cart unattended from 7:37 a.m. through 7:45 a.m. with the bag of IV Ceftriaxone on top of the medication cart. On August 6, 2024 at 8:11 a.m. an interview was conducted with LPN/staff #13 who stated that an unattended IV medication on top of the medication cart was allowed as long as the resident's name was not visible. The LPN admitted to leaving the IV medication unattended, with the patient name visible on several occasions. The LPN also stated that leaving oral medications unattended on top of the medication cart it would not meet the facility policy and the risk for doing so could include another resident taking the medication. An observation of medication cart #2 conducted with licensed practical nurse (LPN/staff #13) on August 6, 2024 at 8:35 a.m. The medication cart #2 contained the following opened medication bottles with no open date: -Magnesium Oxide 400 milligram(mg); -Geri-Kit 8.6 mg; -Gentle-Lax 5 mg; -Calcium Citrate 250 mg; -Acid Reducer 20 mg; and, -Omeprazole 20 mg; The medication cart also contained the following opened and expired bottles: -Cetirizine 10 mg with expiration date of ________________; and, -Iron tablets 65 mg with expiration date of June 23, 2024. An observation of medication storage room was conducted on August 6, 2024 approximately 3:10 p. m. There were 3 bottles of expired Nutricia Pro-Stat, Wild Cherry Punch with expiration date of March 22, 2024. An opened bottle of 8-Hour Arthritis Pain Relief had no open date. During an interview with the Director of Nursing (DON/Staff #105) conducted on August 6, 2024 at 4:30 p.m., the DON stated that new multi dose bottles should be dated on the bottle immediately upon opening, and the expiration date checked. The said that she was not sure about the 28-day time limit in policy; but, the facility follows the manufacturer guidelines for expiration dates. The DON stated that medication was bought in from the pharmacy and locked inside medication cart until time for it to be administered; and that, it was against the policy to leave IV medication unattended on top of a medication cart, regardless of whether identification label was visible or not. Further, the DON stated that it was acceptable to leave medication unattended, whether on top of cart, or by resident bedside; and that, expired medications should be removed and discarded immediately. The facility policy on Medication Labeling and Storage revealed that medications and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. The facility policy on Discarding Medications, effective January 1, 2024 stated that medication that cannot be returned to the dispensing pharmacy are disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste, and controlled substance.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) assessments Level I screening was completed as required for one sampled resident (#4). The deficient practice could result in resident not receiving specialized services needed. Findings include: Resident (#4) was admitted on [DATE] with diagnoses of major depressive disorder, unspecified mood (affective) disorder, bipolar disorder, post-traumatic stress disorder, and anxiety disorder. A review of the Level 1 PASRR screening dated November 8, 2022 revealed that the resident's admission met the criteria for 30-day convalescent care. The care plan dated November 9, 2022 included that the resident used antidepressant and anxiety medications related to depression and anxiety disorder. Intervention included to give antidepressant and anti-anxiety medications as ordered by the physician. The clinical record revealed that the resident remained at the facility for longer than 30-days from admission. Review of the care plan dated July 20, 2023 revealed resident used anti-psychotic medications related to bipolar disorder; and that, medications were administered to treat behaviors of hallucinations and agitation. Intervention included to administer medications as ordered. The clinical record revealed resident had the new diagnoses on the following dates: -Post-traumatic disorder on July 19, 2023; -Bipolar disorder current episode depressed severe with psychotic features on July 19, 2023; -Mood (affective) disorder on October 19, 2023; and, -Major Depressive disorder on March 21, 2024. The physician progress note dated June 2, 2024 included that the resident's mood had been stable and resident continued to receive psychiatric treatment. Assessment included recurrent major depression. The encounter follow-up note dated June 13, 2024 revealed the resident was alert and oriented x 3 and had a calm mood. Diagnosis included recurrent major depressive disorder, in partial remission. Plan was to continue oral antidepressant daily. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident had intact cognition. The encounter follow-up note dated July 23, 2024 included tat the resident was alert and oriented x3 and had a calm mood. Diagnosis included anxiety. Despite documentation of new mental disorder/illness diagnoses and documentation that resident remained longer than 30-days, there was no evidence found that a PASSR Level I screening was completed for the resident after November 8, 2022. An interview and review of the clinical record was conducted on August 6, 2024 at 11:39 a.m. with a social worker (staff #12) who stated that the last PASRR Level I screening completed for resident #4 was on November 8, 2022. In an interview conducted with the Director of Nursing (DON/staff #105) on August 6, 2024 at 12:07 p.m., the DON stated that the last PASSR evaluation complete for resident (#4) was on November 8, 2022. The DON (staff #105) also stated that there should have been another one completed because resident (#4) passed the 30-day stay; and that, the resident not having another PASSR screening after 30-day stay did not meet the facility expectations. In another interview with the DON (staff #105) conducted on August 8, 2024 at 10:47 a.m., the DON stated that specialized services could have been recommended for resident (#4); and without the PASRR being completed, the resident could not have received appropriate services for her diagnoses. Review of the facility policy on Pre-Admission Screening and Resident Review (PASRR), revealed the facility would verify that a Level 1 PASSR screening had been conducted; and that, if the resident was positive for potential mental illness or intellectual disability, a Level II PASSR referral must be submitted. It was the responsibility of the facility to make referrals for a Level II PASSR, or ensure the referral was made by the case manager. The policy also included that a request for Level II evaluation is not required for individuals requiring admission to the nursing facility for a convalescent period (not to exceed 30 consecutive days). 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 admitted to the nursing facility.

Based on clinical record review, interviews, and policy review, the facility failed to ensure one resident (#41) and/or representative participated and involved in the development of the care plan and in making decisions of his care. The deficient practice could result in residents needs not being met. Census was 48. Findings include: Resident #41 was admitted on [DATE] with diagnoses of chronic kidney disease stage 3, adult failure to thrive, tremor, chronic pain, depression and abnormalities of gait and mobility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 6 which indicated the resident had severe cognitive impairment. The baseline care plan signed by resident #41 and dated July 15, 2024 revealed the resident and/or representative consented to receive care. The goal was for that resident/representative will participate in planning my care and treatment according to the resident's goals and preferences. Interventions included for resident/representative will be informed of the type of care to be provided and risks and benefis of proposed treatments; and, thre resident/representative will participate in IDT (interdisciplinary team) care conference meetings. The care conference note dated July 2024 included that resident comprehensive care conference was conducted on July 23, 2024; and, was attended by resident relations, activities and dietary staff. The IDT (interdisciplinary team) care plan conference note dated August 7, 2024 revealed the IDT met with resident and his representative to discuss care plan and provide estimated length of stay. The resident/representative were listed as attendees. Per the documentation, the resident and representative were informed of the managed care plan, processes on concurrent review and NOMNC (Notice of Medicare Non-Coverage) issuance. However, this was struck out on August 7, 2024 at 5:02 pm because of incomplete documentation. Another IDT Care Plan Conference note dated August 7, 2024 at 5:03 p.m., revealed that on July 23, 2024, IDT met with the resident and his representative to discuss care plan and provide an estimated length of stay; and that, the resident/representative were informed of the managed care plan and processes on concurrent review. Per the documentation, the resident/representative were attendees to this care plan conference. Despite documentation that resident/resident representative (RR) attended the care paln conferences, during the interview with resident #41 and RR was conducted on August 5, 2024 at approximately 1:00 p.m., the resident and RR reported concerns about being at facility for over three weeks, and no provider or staff member has met with them about care planning. The RR stated that she was frustrated because she made several attempts to contact the resident relations manager (staff #12) over the past three weeks; and, had left numerous messages for staff #12. However, the representative said that staff #12 was unavailable and the RR did not receive any response at all. In another interview with the resident and RR conducted on August 6, 2024 at 12:30 p.m., both the resident and RR reported displeasure about not knowing what's going on. The resident stated that the he signed something regarding an IDT care conference held on July 15, 2024; but, he was not aware that he was supposed to be present his care conference. The resident stated that he never attended a group meeting with staff to discuss his care, and did not know that such a group even existed. He said that did not recall meeting in a conference room, or having a group of people by his bedside discussing his care; and that, he was dissatisfied dissatisfaction with the attending primary care provider who knew nothing about him and made decisions about his care; and, never spoke with him about his care. The resident further stated that the attending primary care provider came in his room, introduced himself, and then left the room and mentioned nothing about course of action. The RR denied attending the care conferences for the resident in July 2024. An interview was conducted on August 7, 2024 at 12:00 p.m. with the RR who was waiting in hallway to talk to the resident relations manager (staff #)12 about care resident #41 was supposed to receive. The RR stated that she did not have an appointment; and that, although she was frustrated, she was willing to keep showing up, and wait as long as needed to meet with someone about the resident's care. An interview with Director of Nursing (DON/staff #105) was conducted on August 7, 2024 at approximately 12:35 p.m. The DON stated that the resident/representative were invited to care conferences which were typically held in conference room of facility. The DON stated that care conferences can also be held at bedside; and that, the meeting was dependent on resident preference. Further, the DON said that meetings were held for resident eligibility and updates; and, residents were encouraged to join. In an interview with the resident relations manager (staff #12) conducted on August 7, 2024 12:40 p.m., staff #12 said that she had beenin the position since October of 2023; and that, her responsibilities included addressing grievances, holding care conferences, clinical and concurrent reviews, and order equipment. She stated that care conferences were conducted by the bedside within 72 hours of admission; and that, documentation of this meeting was no longer necessary because the resident's needs were being addressed. Staff #12 said that care conference meetings were usually attended by her, the resident, DON, dietary director and activities director. Regarding resident #41, she stated that the notation in the care conference note dated August 7, 2024 was an error and she will correct the entry in the system. Staff #12 said that the correct date for the care conference was July 23, 2024; and that, this meeting was held in the office with the activities director (staff #29). Further, staff #12 stated that the RR was in attendance via the telephone; and, notice of non-coverage, and private pay policy were discussed during this meeting. During an interview with the DON conducted on August 8, 2024 at approximately 2:00 p.m., the DON stated that care conferences were to be documented in the clinical record; so, the resident relations manager (staff #12) was misinformed. Reviewof the facility policy on Care Plans-Comprehensive with revision date of [DATE], revealed that the care plan should reflect the resident's expressed wishes regarding care and treatment goals. In the event a resident refuse to participate in the development of care plan, refusals are to be documented appropriately in clinical record.

Based on clinical record review, resident and staff interviews and review of facility policies and procedures, the facility failed to ensure two residents (#24 and #37) received notification prior to the room change. The deficient practice could result in resident's preferences not honored. Census was 48. Findings include: -Resident #24 was readmitted to the facility on [DATE] with diagnoses of alcoholic hepatic failure, unspecified dementia with other behavioral disturbance, epilepsy, anxiety disorder and abnormalities of gait and mobility. The census list revealed that the resident had a room change on June 22, 2023 and December 4, 2023. The clinical record revealed no evidence that the resident was notified of a room change on June 22, 2023. The Room and/or Roommate Change Notice dated December 4, 2023 revealed that the notice was to inform the resident in advance of a room change and the reason for the room change was due to other residents' welfare effective December 4, 2023. However, the documentation did not include any further explanation of this reason. The notice signed by a staff member and dated December 4, 2023. However, the documentation did not include any resident signature. The clinical record revealed no evidence that the resident was given advance notice regarding the room change on December 4, 2023. The Room And/or Roommate Change Notice dated February 9, 2024 revealed that the notice was to inform the resident in advance of a room change with effective date of February 9, 2024. However, the section on the reason for the discharge was left blank. It also included that the notice was provided to the resident. It also included that the notice was signed by a staff; but, was not signed by the resident or the resident's representative. The clinical record revealed no evidence that the resident was given advance notice regarding the room change on February 9, 2024. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had intact cognition. The census list revealed that the resident had room change on August 1, 2024. However, the clinical record revealed no evidence that a written notice regarding the roommate or room change was provided to the resident prior to August 1, 2024. An interview was conducted on August 8, 2024 at 7:55 a.m. with resident #24 who stated that she did not recall signing a room change/roommate change form or being informed of a room or roommate change. -Resident #37 was admitted on [DATE] with diagnoses of transient cerebral ischemic attack, right sided hemiplegia and hemiparesis following cerebral infarction and muscle weakness. The admission Minimum Data Set assessment dated [DATE] revealed a BIMS score of 15 indicating the resident was cognitively intact. Review of the census list revealed the resident had a room change and became on August 1, 2024 and became the roommate of resident #24. However, the clinical record revealed no evidence that the resident was given an advance notice regarding the room change on August 1, 2024. In an interview with resident #37 conducted on August 8, 2024 at 7:45 a.m. resident #37 stated that she refused the room change was refused, did not like the change and admitted to throwing a fit regarding the change. The resident further stated that she was very upset and unhappy that day of the room change, and was still upset about the room change. Further, resident #37 stated that she did not receive or sign any written notice regarding the room change. Resident #37 stated the staff came to see her when she was still in her previous room, informed her of the move and then was to new room soon after on the same day. During an interview with the administrator (staff #49) and the director of nursing (DON/staff #105) conducted on August 8, 2024 at approximately 11:45 a.m., both the administrator and DON stated that room assignments were influenced by factors such as resident preference and/or behavioral issues. The DON stated that residents were to be given written and advance notice about room or roommate changes. The DON stated that residents #37 and 24 did not a written Room and/or Roommate notice for the room or roommate change on August 1, 2024. Further, the DON stated that the room And/or Roommate Change Notice dated February 9, 2024 for resident #24 documentation was incomplete. The facility policy on Resident Rights-Room Change/ Roommate Assignment with an effective date of January 1, 2024 included that prior to changing a room or roommate assignment, residents are given advance written notice of such change. Advance written notice of a roommate change includes why the change is being made.

Based on clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure blood pressure medications were administered following physician ordered parameters for one sampled resident (#4). The deficient practice could result in elevated blood pressure and possible stroke for the resident. Findings include: Resident (#4) was admitted on [DATE] with diagnoses of hypotension, major depressive disorder, bipolar disorder, and post-traumatic stress disorder. Review of the care plan dated March 22, 2024 included the resident had hypertension related to lifestyle. Interventions included to obtain blood pressure readings as ordered, to take blood pressure readings under the same conditions each time. For example, resident was sitting, use right arm. A physician order dated March 29, revealed an order for Midodrine hydrochloride (anti-orthostatic hypotensive) tablet 5 mg (milligrams), give one tablet by mouth every 8 hours for low blood pressure, hold for SBP (systolic blood pressure) greater than 130. This order was transcribed onto the Medication Administration Record (MAR) for June 2024 and July 2024. Review of the MAR for June 2024 and July 2024 revealed that Midodrine was administered outside of ordered physician parameters on the following dates: -June 6, 2024 with a systolic blood pressure of 131; -June 7, 2024 with a systolic blood pressure of 131; -June 30, 2024 with a systolic blood pressure of 139; and, -July 3, 2024 with a systolic blood pressure of 138. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 15 indicating the resident had intact cognition. Review of the clinical record revealed no documentation of the reason why Midodrine was administered outside of physician ordered SBP parameters; and that, the physician was notified. An interview was conducted on August 7, 2024 at 9:50 a.m. with a Licensed Practical Nurse (LPN/Staff #13) who stated medication administration included staff reviewing the physician order; and, if there were parameters for blood pressure (BP), the resident's BP would be assessed prior to medication administration. She stated that if the resident's BP was within the physician ordered parameters the medication would be administered to the resident. She also stated that if the BP was outside of the physician ordered parameters, the medication would not be administered. During the interview, a review of the clinical record was conducted with the LPN who stated that Midodrine was administered to the resident outside the physician ordered parameters on June 6, June 7, and June 30, 2024. The LPN further stated that this did not follow the physician orders and could result in elevated blood pressure and possibly stroke. An interview with the Director of Nursing (DON/Staff #105) was conducted on August 8, 2024 at 10:47 a.m. The DON stated that her expectation was for the nurse to follow the physician order when administering medications; and that, a medication would not be administered outside of physician ordered parameters. She further stated if the medication was administered outside the physician ordered parameters, the expectation was that the provider would be notified. During the interview, a review of the clinical record was conducted by the DON who stated that the MAR for June and July 2024 showed that Midodrine had been administered outside of physician ordered parameters on June 6, June 7, June 30, and July 03, 2024. Further, the DON (staff #105) also stated that this did not meet the facility expectations and the resident could be at risk for elevated blood pressure, discomfort, and headache. The facility policy on Medications: Administering Oral Medications included to verify that there is a physician's medication order, and perform any pre-administration assessments prior to administering medications.

Based on observations, clinical record review, resident and staff interviews, and review of facility policy, the facility failed to ensure one resident (#145) was assessed to be safe for medication self-administration. The deficient practice could result in resident not taking or able to take the medication needed for treatment. The census was 48. Findings include: Resident #145 was admitted on [DATE] with diagnoses of clostridium difficile, enterocolitis, end stage renal disease (ESRD), ankylosing spondylitis, and atherosclerotic heart disease. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 indicating the resident had moderate cognitive impairment. A physician order dated August 6, 2024 for Sevelamer Carbonate (phosphate binder) 800 mg milligram) three times a day for ESRD with meals. There was no evidence found in the clinical record that self-administration was determined as clinically appropriate for resident #145. There was no evidence that the resident was assessed for self-administration. A medication observation was conducted on August 5, 2024 at 11:19 a.m. There was a white pill in a medicine cup on the bedside table of a resident #145 that was left unattended. The resident stated the pill was his phosphorus binder that was taken prior to lunch; and that, he self-administers this medication on a daily basis. An interview was conducted with resident #145 on August 5, 2024 at 11:42 a.m. The resident stated the name of the pill that was in the cup was hard to pronounce so he calls it his dialysis meal pill. Resident #145 said that the nurse usually keeps his dialysis meal pill on his bedside table, so he can remember to take it. He said that the registered nurse (RN/Staff #2) was the one who left white pill next to his breakfast tray this morning. Further, the resident stated that he self-administers his medication three times a day, all the time because all the nurses allow it; and, he would just reach over and takes the pill when it's time. During an interview with a Registered Nurse (RN/Staff #2) conducted on August 5, 2024 at 11:47 a.m., the RN stated that when administering medications, nurses follow the 7 rights: right person, right medication, right dose, right time, right route, right reason, and right documentation. The RN also stated that when giving resident medications, the policy was to wait at bedside until all medications were taken by the resident; and that, no medications were to be left at bedside due to the risks such as leaving the medication for someone else to take. Further, the RN said that there was no reason for medication to be left at bedside and it was against facility policy to leave medications unattended. The RN said that if a medication was found at the bedside, it was to be removed and reported to the Director of Nursing (DON). An interview with a licensed practical nurse (LPN/Staff #13) was conducted on August 6, 2024 at 8:07 a.m. The LPN stated that when giving medication, it was a policy to stay by the bedside until all medications were administered; and, if any medication was found by the bedside, it was to be collected and turned in to the DON. During an interview with the Director of Nursing (DON/staff #105) conducted on August 6, 2024, the DON stated that there was absolutely no reason for any medication to be placed at the bedside-unless they have an order to do otherwise. The DON said that there were too many risks involved, such as someone else taking the medication, and that practice was against facility policy. Further, the DON stated there was no self-administration determination found in the clinical record for Resident #145. A facility policy on Self-Administration with an effective date of January 1, 2024 included that residents have the right to self-administer medications if the interdisciplinary team (IDT) determined that it is clinically appropriate and safe for the resident to do so. If it is deemed safe and appropriate for the resident to self-administer medications, this is documented in the medical record, and the care plan. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the responsible party or proper disposal.

Based on record review, resident and staff interviews, and review of policies and procedure, the facility failed to ensure PICC (peripherally inserted central catheter) line dressing change was administered as ordered by the physician for one resident (#496). The deficient practice could result in complications such as infection. The census was 48. Findings include: Resident #496 was admitted to the facility on [DATE] with diagnoses of left knee staphylococcal arthritis, immunodeficiency, systemic lupus erythematosus, and muscle weakness. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. It also included that the resident was coded as having medically complex conditions and had full code-Cardiopulmonary Resuscitation (CPR) status. A physician order dated [DATE] included for Ceftriaxone Sodium (antibiotic) injection solution reconstituted 1 GM (Gram), use 1 gram IV (intravenously) every 24 hours for MRSA [methicillin-resistant Staphylococcus aureus (bacteria)] related to left knee staphylococcal arthritis until [DATE]. The active physician order summary revealed the following medications with order start date of [DATE]: -Change peripherally inserted central catheter (PICC) line dressing every 7 days and as needed using sterile technique. (order start date: [DATE]); -Change PICC line tubing every 24 hours for intermittent flow every day shift; -Flush PICC line with 10 ml (milliliters) of NS (normal saline) every shift and as needed and pre/post medication; -Monitor PICC line insertion site every shift for signs and symptoms of infection, redness, warmth, swelling and drainage every shift; and, -Discontinue IV/PICC line after completion of IV antibiotics and provider approval dated [DATE]. A physician order dated [DATE] included enhanced barrier precautions due to the IV and PICC line. The orders for the PICC line and IV Ceftriaxone were transcribed onto the Treatment Administration Record (TAR) for July and [DATE]. Review of the TAR from [DATE] through [DATE] revealed that PICC line dressing/tubing changes, flushing and monitoring were administered as ordered by the physician. Further review of the TAR revealed that PICC line dressing change was documented as administered on [DATE] and [DATE]. However, during an observation of a PICC line dressing change conducted on [DATE] at 7:10 a.m., the PICC line dressing was not initialed and did not have a date and time it was last changed. The PICC line was on the right upper arm of resident #496; and, both clamps above injection caps were unclamped. The white perforated adhesive surrounding the transparent film had a significant amount of grayish areas. An interview with resident #496 was conducted immediately following the observation. The resident stated that the PICC line was placed on him because he had a left knee staph (bacteria) infection. The resident stated that he tries not to get the dressing dirty because it was hardly changed; and that, the dressing was last changed at the facility close to time of his admission. Resident#496 said that he does not know how often the PICC line dressing should be changed; but, the dressing was not changed this week. He stated that the dressing became dirtier each day, but he figured that it was okay since the nurses always used it. In an interview with a licensed practical nurse (LPN/staff #13) conducted on [DATE] at 7:35 a.m., the LPN stated that the facility policy was to change PICC line dressing at least once a week or if soiled; and, the site was to be checked every shift for signs and symptoms of infection. The LPN said that checking of the PICC line site was to ensure dressing was intact, clean, and dry. Regarding resident #496, the LPN stated that PICC line is necessary for resident antibiotic therapy due to knee infection. During the interview, a review of the clinical record was conducted by the LPN who stated that the documentation in the TAR showed that dressing observations were checked off each shift which meant no issues were observed. An observation the resident's PICC line dressing was conducted with the LPN who stated the resident's PICC line dressing was dirty and needed to be replaced. The LPN also stated that she could not to see or locate date/initials/time on when the dressing was last changed per their policy. During an interview with the director of nursing (DON/staff #105) conducted on [DATE] at 7:50 a.m., the DON stated that PICC line care included the use of aseptic technique, frequency of PICC line care, and what staff were to monitor each shift which includes looking for redness, swelling, drainage, and overall integrity of dressing. The DON stated that staff were to replace the PICC line dressing if it appears loose or soiled per policy. A review of the clinical record was conducted by the DON during the interview. The DON stated that there was a physician order for dressing changes and monitoring; and, documentation in the MAR and TAR for resident #496 showed completion of site checks each shift. An observation the resident's PICC line dressing was conducted with the DON who assessed the resident's dressing and stated that the dressing was soiled and needed changing immediately. The DON also stated that she was unable to locate date, time, and initials on when the dressing was last changed; and, this practice was not according to their policy. The facility policy on Intravenous Therapy: Central Venous Catheter Care and Dressing Changes with an effective date [DATE], included that to perform site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (e.g., damp, loosened, or visibly soiled). Inspection of the skin and dressing included drainage as a complication sign. Sterile dressing procedure stated dressing should be labeled with initials, date and time.

Based on clinical record reviews, interviews, and policy review the facility failed to ensure recommended follow up dental appointments were scheduled for 1 of 14 sampled residents (#8). The deficient practice could result in delayed dental services and risk of infection for resident. Findings include: Resident (#8) was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus without complications, personal history of traumatic brain injury, and unspecified dementia. The care plan dated November 14, 2022 included that the resident had oral/dental health problems. Intervention included to coordinate arrangements for dental care, transportation, as needed/as ordered. The late entry monthly nursing summary dated August 5, 2023 included that the resident was oriented x 3. Oral/dental assessment included resident had broken natural teeth and likely had cavity. Review of the dental consultation report dated August 16, 2023 revealed that teeth #3, #4, and #5 were untreatable due to decay and were extracted. The consultation report also recommended that the resident should return for additional extractions. The alert charting note dated August 16, 2023 included that the resident went to a dental appointment and had 3 teeth extracted. Per the documentation, the recommendation was for the resident to return for more extractions. On the lower left corner of the report was a handwritten initial of a registered nurse that it was noted and dated August 16, 2023. Despite documentation of the dental consult recommendation, there was no evidence found that scheduled follow up appointments for resident (#8) was made after August 16, 2023. The encounter note dated May 25, 2024 included that the resident was alert and oriented x 0 The physician progress note dated June 2, 2024 included the resident had poor dentition noted. The monthly nursing summary dated June 28, 2024 revealed the resident was oriented x 2. oral/dental assessment included that the resident had likely cavity and had no difficulty with chewing or swallowing. An interview was conducted on August 6, 2024 at 11:25 a.m. with a registered nurse (RN/staff #48) who stated that if the progress note showed there was a need for a follow up dental appointment, the expectation was for staff to verify if the follow up was completed. During the interview, a review of the clinical record was conducted with the RN (Staff #48) who stated that the recommendation for a follow up dental appointment on August 16, 2023 was passed along to the night shift nurse; however, there was no evidence found in the clinical record that the follow-up dental appointment was done or completed. The RN further stated that there was no evidence that a dental appointment had been scheduled after August 16, 2023. A telephone interview was conducted on August 7, 2024 at 8:22 a.m. with the transportation manager (Staff #115) who stated that the process of scheduling follow-up appointments for skilled nursing residents included receiving the appointment card from the transportation drivers; and, she would then put the next appointment into a scheduling system. In another interview with the transportation manager conducted on August 7, 2024 at 10:31 a.m., the transportation manager stated that there were no follow up dental appointments scheduled for resident (#8) after August 16, 2023. Further, the transportation manager said that this did not meet facility expectations and that the resident would be at risk for infection. During an interview with the Director of Nursing (DON/staff #105) conducted on August 8, 2024 at 10:47 a.m., the DON stated that the process for scheduling follow up appointments included for the appointment card given to the transportation manager (staff #115) who would then schedule the appointment. The DON (staff #105) also stated that the transportation manager (staff #115) also reviews physician orders for any appointments and would schedule them. A review of the clinical record was conducted by the DON who stated that the electronic health record revealed no documentation of any follow up appointments scheduled for resident (#8) after August 16, 2023. Further, the DON (staff #105) stated that this did not meet facility standards and the resident would be at risk for discomfort, dental caries, and infection. Review of the facility's policy on Dental Services revealed that the facility would provide routine and emergency dental services through contracts or referrals to a local, community, or resident's personal dentist. The facility also had a contract with a dentist that comes to the facility on a monthly basis. The policy also indicated that nursing services are responsible for notifying social services of a resident's need for dental services. Social services personnel would be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary.

Based on observations, clinical records review, staff interviews, and review of facility documentation, policies and procedures, the facility failed to ensure adequate supervision when smoking was provided for one resident (#25). The deficient practice could result in resident having potential for accidents related to smoking. Findings include: -Resident #25 was admitted on [DATE] with diagnoses of cerebral infarction, monoplegia of upper limb following other nontraumatic intracranial hemorrhage affecting left dominant side, aphasia, adjustment disorder with mixed anxiety, and depressed mood. The care plan dated revised on January 11, 2024 revealed the resident wished to smoke, was designated as having impaired safety awareness, and needed supervision. The goal was that the resident will smoke safely at designated areas at scheduled times. Interventions included that the resident may utilize device to promote safe smoking practices, demonstrate safe technique for putting out matches or lighter and disposing of ash, will ask for smoking materials, and was oriented to smoking procedures and areas. The smoking evaluation dated April 9, 2024 included that the resident had cognitive loss, dexterity problem and needed supervision. Per the documentation, the resident can light his own cigarette and needed the facility to store his lighter and cigarette The care plan revised on April 9, 2024 revealed the resident had a behavioral problem related to refusing medications and may try to smoke and hide cigarettes in her room. Interventions included to anticipate and meet her needs and intervene as necessary to protect the rights and safety of others. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident had short-term and long-term memory problems, had a moderately impaired cognitive skill for daily decision making, and required cues/supervision. During an observation conducted on August 5, 2024 at 11:37 a.m., resident (#25) was in her room sitting in a wheelchair and had her lighter. The resident stated that she keeps her own cigarettes and lighter in her room; and that, she does not wear a smoking apron and does not require or have supervision when she was out smoking During a smoking observation on August 6, 2024 at 3:53 p.m. resident #25 was at the designated smoking location with other 2 female residents; and, resident #25 was not wearing a smoking apron. There was no staff member present at the designated smoking area with the residents. An interview with the three residents including resident #25 was conducted during the observation. All three residents stated that they were assessed for smoking by staff; and, they were permitted to keep their personal smoking paraphernalia such as cigarettes and lighters in their rooms. Further, the three residents including resident #25 stated that they were not required to wear smoking and were not required to be supervised when smoking. An interview was conducted on August 7, 2024 at 3:54 p.m. with Certified Nursing Assistant (CNA/staff #56) who stated that residents who were independent can smoke and can keep their cigarettes in their room; but, not their lighters. The CNA stated that the lighters were to be kept at the front desk and the resident had to ask for their lighter when going out to smoke. The CNA stated that the facility no longer had a posted smoking schedule. She stated that she receives resident care information from the nurse; and that, all of the residents in her assigned section were independent smokers. Regarding resident #25, she stated that resident #25 was in her assigned care section; and, that facility management was aware that resident #25 had cigarettes and lighters in her room. The CNA further stated that the resident was not willing to give her lighter and cigarettes to staff. An observation was conducted on August 7, 2024 at 4:04 p.m. resident #25 came out of her room with cigarettes and a lighter on her lap and self-propelled herself in her wheelchair passing the staff at the front desk and a nurse at the nursing cart. The resident then proceeded into the dining room and self-exited alone through the dining room door leading into the courtyard to the facility's designated smoking area. The resident retrieved a cigarette from her lap, placed and lit the cigarette in her mouth. At 4:19 p.m., resident #25 lit up another. There was no staff present in the designated smoking area with resident #25 until 4:28 p.m. when a staff member came to designated smoking area and assisted resident #25 back inside the facility. In an interview with nurse (staff #13) conducted on August 7, 2024 at 4:22 p.m., the nurse stated there was a smoking assessment completed upon resident's admission; but, she does not know if there was a follow-up assessment. She stated that residents were not supposed to have lighters with them; and that, the lighters were normally kept at the front desk. The nurse said that the residents were required to ask the receptionist for their lighter. She said that there was a smoking schedule posted in the past; but now, the residents can go out any time to the designated smoking area since they were all independent. A review of the clinical record was conducted by the nurse during the interview and the nurse stated that the smoking assessment for resident #25 was completed by MDS Coordinator (staff #51) on April 9, 2024. The nurse said that the assessment included that resident #25 was a smoker, needed supervision when smoking, and had to ask staff for smoking materials. The nurse said that the facility had to store the resident's lighter and cigarettes. Further, the nurse said that she had not seen resident #25 with a lighter; and that, she was not aware of the resident's care plan or smoker assessment. The nurse further stated without supervision resident (#25) could be a risk for catching on fire or burning herself. An interview was conducted on August 8, 2024 at 7:40 a.m. with the MDS Coordinator (staff #51) who stated that the floor nurse completes the smoking risk assessment upon admission of the resident; but, if the floor nurse does not complete this assessment, she completes the smoking risk assessment and she would then initiate a smoking care plan. She states she updates the smoking assessment and smoking care plans quarterly and if there was a significant change in condition. The MDS coordinator stated the residents who were not independent were not permitted to have unsupervised smoking, the residents must be in view of staff while smoking, and the resident's smoking paraphernalia such as their lighters were kept at the front desk. The MDS coordinator stated that independent residents were allowed to keep their lighters in their rooms. A review of the clinical record was conducted by the MDS coordinator during the interview and she stated that the resident's most recent smoking assessment indicated that resident #25 required supervision with smoking and the resident's lighter was stored either at the nurse station or at the front desk. The MDS coordinator said that the resident's most recent smoking risk assessment was correct. The MDS coordinator stated that she updates a list of resident smokers who were to be supervised to be kept at the front desk. Regarding resident #25, the MDS coordinator stated that resident #25 should be supervised while smoking for safety issues due to the risk of resident dropping cigarette in lap or improperly disposing of hot cigarette butts. During an interview with acting Director of Nursing (staff #105) conducted on August 8, 2024 8:15 a.m., the acting DON stated that upon admission, a new resident is asked whether they are a smoker or not. The acting DON said that the nurse or the MDS coordinator then completes the assessment and, care plan findings; and, would reassess the resident quarterly, or sooner if a significant change was identified. The acting DON also said that all the residents at the facility who smoke facility smokers had been identified as independent. The acting DON also said that if they had a resident that required supervision, the facility have set smoking schedule, the smoking activity of the residents were to be supervised by staff rotation in the designated resident smoking area of the patio, and, the resident's lighters would be kept at the front desk. The acting DON stated that there were no residents at the facility who required supervised smoking, so the residents were permitted to keep their own smoking supplies in their rooms. Further, the acting DON stated that management was responsible for the implementation of the smoking policy; and that, the expectation was for staff to follow the facility smoking policy and procedures. During the interview, a review of the clinical record was conducted with the acting DON who stated that the most recent smoking assessment for resident #25 was on April 9, 2024; and that resident (#25) needed supervision with smoking activities and was not to have cigarettes or a lighter kept in her room. The acting DON stated that the smoker care plan for this resident (#25) was not followed/implemented by staff. A revision of smoking evaluation was completed by the acting DON and dated August 8, 2024. The evaluation included that resident #25 no longer needed supervision when smoking and the resident does need the facility to store lighter and cigarettes. The care plan was revised on August 8, 2024 to include that the resident wished to smoke, was designated as a safe smoker, and was independent. Review of the facility policy on Resident Safety: Smoking Policy revealed that resident's ability to smoke safely is re-evaluated quarterly. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure two residents (#1 and #7) were provided the level of supervision needed to prevent elopement and prevent one resident (#62) from an accident with injury. The deficient practice could result in residents being physically and emotionally injured. Findings include: Regarding Resident #1: Resident #1 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, visual hallucinations, restlessness and agitation, and wandering in diseases classified elsewhere. A physician's note dated January 23, 2024 revealed that the resident's prognosis was poor. The patient continued to be quite confused and malaised and the physician did not think that the resident should ever be outside of 24/7 supervised care. It was also noted that the physician believed that a long-term care facility was best for him and that the resident may need to be considered for a locked behavioral unit. A progress note dated January 24, 2024 at 10:57 a.m. revealed that the resident left out of the back door and walked towards the hospital and that he was a flight risk. A progress note dated January 24, 2024 at 12:56 p.m. revealed that the resident made a second attempt to elope and the staff had to go outside after him. A care plan dated January 24, 2024 revealed that the resident had a behavior problem related to wandering/exit seeking and that the resident has dementia. Interventions included wearing a Wanderguard on the wrist at all times. A physician's progress note dated January 25, 2024 revealed that the resident continued to be a wander risk and will probably need to be considered for the locked cognitive impairment unit at the other nursing facility. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 3 indicating the resident had a severe cognitive impairment. A progress note dated February 2, 2024 revealed that resident made four attempts to leave the building today. A progress note dated February 5, 2024 at 3:14 p.m. revealed that the resident set the Wanderguard off at 1:45 p.m. and a certified nursing assistant (CNA) redirected the resident to the locked outdoor smoking area. It noted that the receptionist went to pick up the resident and let staff know the resident was not there. Further, the noted revealed that a registered nurse (RN/staff #200) asked the receptionist to drive around the area and look for the resident, while staff continued to search the facility property. Also, the note stated that the RN called the receptionist at 2:14 p.m. to see if the receptionist had located the resident and she had found the resident by some townhouses behind Home Depot. The noted stated that the resident was returned to the facility and assessed for injuries. A progress note dated February 6, 2024 revealed that the resident and the resident's daughter were made aware that the resident would be transferred to another facility due to being an elopement risk. The resident and family were agreeable to the plan of care as it was in the best interest for safety purposes. The five-day written investigation completed by the Administrator (staff #1) dated February 9, 2024 revealed interventions following the elopement included the installation of an alarm on the therapy door to prevent similar incidents from occurring in the future. An interview was conducted on June 25, 2024 at 10:08 a.m. with an RN (saff #200), who stated that residents were assessed for being a wandering risk when they are admitted to the facility. The RN stated that when residents were a high risk, the physician was notified, so they can get an order for a Wanderguard. The RN stated that the resident wore the Wanderguard on their wrist and there were sensors on the doors of the building, so an alarm would go off and the door locked when the resident got near the door. The RN stated that resident #1 eloped through the door in the therapy room because the door did not have a sensor on it and he was found at The Home Depot. The RN said that when a resident elopes, there was a risk of the resident being injured, such as getting hit by a car, or getting lost. -Regarding Resident #7: Resident #7 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, alcohol dependence with withdrawal, and dysphagia, oral phase. A progress note dated October 28, 2020 revealed that the resident was observed by housekeeping opening a window and exiting the facility. It noted that the housekeeper alerted the staff, who then exited through the side door to approach the resident and the resident ran across the street towards the hospital and threw rocks at the staff following him. The note reveavled that resident #7 was observed by hospital security and taken down to determine safety concerns and then the resident was taken to the emergency room . A physician's note dated October 30, 2020 revealed it was a late entry and that the resident continued to have difficulties with wandering and behaviors. It noted that staff caught the resident trying to climb out a window the other day and the resident continued to wander into other residents' rooms. A care plan dated October 30, 2020 revealed that the resident had the potential for elopement from the facility related to dementia. Interventions included to have a Wanderguard in place for safety, verify the resident's presence on the nursing unit or facility every hour, and when the resident verbalized leaving to distract resident with activities. A progress note dated October 31, 2020 at 5:40 a.m. revealed that the resident left against medical advise through a room window and that the resident had kicked out the screen. A progress note dated October 31, 2020 at 6:22 a.m. revealed that the resident was not in his room at bed check at 5:00 a.m. It noted that the resident was on Clostridioides difficile (C-Diff) isolation. It further noted that the staff were alerted and the facility was searched and found that the blinds in the window were lifted and the widow was closed, but the outside screen was off of the window. It also noted that the DON, Administrator and the police were called. A progress note dated October 31, 2020 at 12:28 p.m. revealed that the LPN talked to an officer and gave the officer the information to contact the family. A progress note dated November 1, 2020 at 11:17 a.m. revealed that a registered nurse (RN) contacted the resident's sister to inquire whether she had seen or heard from the resident and that the sister stated that she had not heard from the resident. A progress note dated November 2, 2020 at 8:15 a.m. revealed that (RN) spoke with the resident's sister to ask whether she had heard from or seen the resident. It stated that the sister stated that the police department picked the resident up in Pinetop and took him to the hospital. Review of the progress notes did not reveal that IDT meetings occurred to determine if new interventions needed to be put into place after each elopement occurred. The five-day written investigation dated November 11, 2020 revealed that at approximately 5:30 a.m. staff was making rounds and noticed that the resident was not in his room and that it was strange because the resident was on C-Diff isolation. The information revaled that the screen on the window was observed lying on the ground, but the window was closed. It was also noted that the resident was last seen in his room on October 31, 2020 at approximately 5:00 a.m. Further, the stated revealed that the resident was finally located by the police on October 31, 2020 at approximately 7:00 p.m. at a nearby establishment and was taken to a local hospital where he was admitted . An interview was conducted on June 25, 2024 at 11:48 a.m. with the Director or Nursing (DON/staff #2), who stated that the facility does admit residents who are a wandering risk and the residents' get a Wanderguard bracelet that sets off an alarm when the residents go by the door. The DON stated that she did not think they have the alarms on the windows. She stated that the door would be closed if a resident is on isolation for C-Diff and should be checked every hour if the resident was a wandering risk. The DON stated that fifteen minute checks were not feasible because staff had to provide care to other residents, and if a resident had gone out the window, the resident should be in a room closer to the nurse's station. The DON thought there should be an IDT meeting to discuss the event and see if more interventions needed to go into place. She stated that there were a risk of the resident being injured or lost. The facility policy, Behavior/Mood/Cognition: Wandering and Elopements dated January 1, 2024 revealed that the facility will identify residents who were at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The policy further stated that if identified as at risk for wandering, elopement, or other safety issues, the resident's care plan would include strategies and interventions to maintain the resident's safety. Regarding Resident #62 -Resident #62 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI), obesity, chronic kidney disease, and muscle weakness. The MDS dated [DATE] include a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of a progress note dated March 29, 2024 revealed that the resident was being transferred to her room in her wheelchair by a physical therapist (PT/staff #25) and her right arm made contact with the doorframe causing a skin tear to the upper right forearm. The arm was cleaned and dressed. The order summary revealed an order dated March 29, 2024 for skin tear to the right forearm, clean the wound, wash and apply dressing until healed. An interview was conducted on June 24, 2024 at 1:19 p.m. with a physical therapist (PT/staff #25), who stated that he did receive training on the use of wheelchairs from the facility. He stated that they are supposed to push a resident forward through the doorway and to make sure the elbows are in and not outside of the armrest. The PT said that the risk was that the resident could be injured and cause a skin tear. He acknowledged that he did push the resident through the bedroom doorway and she did hit her arm resulting in a skin tear. An interview was conducted on June 24, 2024 at 3:32 p.m. with (RN/staff #200), who stated that she did receive training on equipment including wheelchairs, and when staff push a resident through the door, staff should make sure that the resident's arms and legs are not poking out, so there is enough room to clear the doorframe. Otherwise, she said, there was a risk that the resident could get hurt, such as a skin tear. An interview was conducted on June 24, 2024 at 3:48 p.m. with the (DON/staff #2), who stated that staff are trained to use wheelchairs safely. She stated that staff should make sure the wheelchair can clear the doorframe, and that the residents legs are are not dragging on the floor and arms are not hanging over the sides of the wheelchair. She stated that if staff don't check these things, there is a risk of the resident being injured. An interview was conducted on June 25, 2024 at 7:18 a.m. with licensed practical nurse (LPN/staff #51), who stated that a skin tear occurred when the resident was being pushed through her bedroom doorway. She said she did not witness the incident, but she cleaned the skin tear. The LPN stated that the resident told her that the therapist did it when he pushed her through the door. The facility policy, Resident Safety: Safety and Supervision of Residents dated January 1, 2024 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. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a resident (#14) to resident (#33) altercation did not occur. The deficient practice could result in residents being emotionally and physically harmed. Findings include: Resident #14 was admitted to the facility on [DATE] with a diagnoses of unspecified dementia with other behavioral disturbance, Alzheimer's disease, and hallucinations. The behavior care plan dated September 26, 2023 revealed the resident has behavior problems related to impaired cognitive function and Alzheimer's disease. The resident has a history of hallucinations, wandering, and verbal aggression. Interventions included to intervene as necessary to protect the rights and safety of others, and if issues arise, remove from the situation and take the resident to an alternate location as needed. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 3 indicating the resident had a severe cognitive impairment. A weekly skin check dated January 4, 2024 revealed that the resident had no new or ongoing skin impairments. Review of the progress notes did not reveal documentation of the resident to resident abuse that occurred on January 5, 2024. A weekly skin check dated January 5, 2024 revealed that the resident had a skin tear approximately 0.5 cm on his right hand. A physician's note dated February 10, 2024 revealed that the resident has had some aggressive behaviors towards another resident recently. No physical altercations. The facility is aware and have moved them farther apart from each other. -Resident #33 was admitted on [DATE] with diagnoses that included Alzheimer's disease, unspecified dementia with other behavioral disturbance, and hallucinations. The incontinence care plan dated February 21, 2022 included the interventions to check the resident every two to three hours and assist with toileting as needed, ensure the resident has an unobstructed path to the bathroom. A communication care plan dated February 21, 2022 revealed that resident #33 speaks mostly [NAME] and is extremely hard of hearing. He has difficulty understanding others due to decreased cognition related to Alzheimer's disease. Interventions did not include using an interpreter for the resident's first language, [NAME]. A wandering risk evaluation dated March 28, 2023 revealed that the resident is a high risk for wandering, does not understand what is being said due to language or cognition, and had a recent change of roommates. The behavior care plan dated November 18, 2023 revealed that the resident's behavior problem is related to cognitive impairment and communication barriers. At times the resident may become impatient and frustrated. Interventions included to anticipate and meet the resident's needs, if issues arise, remove from the situation, and intervene as necessary to protect the rights and safety of others The MDS(minimum data set)dated November 30, 2023 included a staff assessment for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the progress notes did not reveal any documentation pertaining to the resident to resident altercation on January 5, 2024. Review of the room and/or roommate change notice dated January 6, 2024 was not completed; the reason for room transfer was not documented and the staff who completed the form, the Resident Relations Manager (staff #15), was not available for interview. The resource staff (staff #315) did not know the reason for the incomplete form and did not know how the form should be completed. Reasons noted on the form included: resident/family/responsible party request, medical reason, safety, other resident's welfare, bed availability/admission, and other reason. A nurse practitioner (NP) note dated January 10, 2024 revealed that the resident is verbal and can communicate with staff. Memory, complex attention, concentration and language all appear predominately intact. Patient is generally alert and oriented. Patient displays impaired thought production and problem solving. There are apparent severe deficits in one or more areas concerning memory, complex attention, concentration, word finding difficulties and orientation. Review of the 5-day investigation dated January 11, 2024 revealed that on January 5, at approximately 12:05 a.m. resident #14 was using the restroom when resident #33 also wanted to use the facilities, and attempted to move resident #14. This interaction resulted in resident #14 sustaining a skin tear approximately 0.5 cm in size on his right hand. Resident #14 told registered nurse (RN/staff #82) that he was using the shared bathroom when resident #33 entered and started pushing him out, leading to an altercation where resident #33 allegedly poked resident #14 with something sharp. (RN/staff #82) separated the residents and washed the skin tear on resident #14's hand, followed by the application of Betadine and a band-aide to the injury. (RN/staff 82) assured resident #14 that he would not have to share a bathroom with resident #33 again. Staff searched for a sharp instrument/weapon and did not find anything. However, there was no documentation to indicate that staff looked at resident #33's fingernails to determine if they were long, pointy, or jagged. The residents were not interviewed until January 8, 2024 and could not recall any details of the situation that occurred on January 5, 2024. Resident #33 was moved to the other side of the facility. Other residents were interviewed, and the feedback, coupled with the lack of evidence for any wider safety issues, indicated that the incident was isolated. An interview was conducted on June 25, 2024 at 2:15 p.m. with the Administrator (staff #1), and resource personnel (staff #115). Staff #1 stated that resident #14 told a registered nurse (RN/staff #82) that resident #33 pushed him and poked him with something. He stated that resident #14 had a skin tear on the hand. He stated that he believes that resident #33 is able to answer simple yes or no questions, but the resident's first language is [NAME] and resident #33 was not interviewed at the time of the incident because (RN/staff #82) doesn't speak [NAME]. He stated that resident #14 and #33 share a room and he was not sure if the (RN/staff #82) found resident #33 in the bathroom or in the bedroom, but believes resident #33 was found near his bed. He also stated that an interpreter was not provided when interviewing resident #33. The facility's policy, Abuse dated 2022 states that the facilities strive to prevent the abuse of all their residents. The facility recognizes that we care for residents with the diagnosis of dementia and other mental illnesses whose behaviors are not always predictable. The facility further recognizes that due to the proximity of our residents to one another and an individual's freedom of choice, that situations may arise where it is not possible to completely prevent all incidents of abuse.

Based on documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to report an allegation of abuse and complete a 5-day written investigation regarding one resident (#62) in the required timeframe. The deficient practice could result in residents being abused. Findings include: Resident #62 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI), obesity, chronic kidney disease, and muscle weakness. A progress note dated March 24, 2024 revealed that a certified nursing assistant (CNA) went into the resident's room this morning around 6:30 a.m. and asked the resident if she wanted drinks for breakfast and the resident said that she was tired of the people here overpowering her and hitting her. The CNA reported it to the nurse. The MDS(minimum data set) dated March 28, 2024 include a brief interview for mental status (BIMS)score of 15 indicating the resident was cognitively intact. Review of a five-day investigation dated April 5, 2024 revealed that during the investigation, the Administrator (staff #1) was reviewing progress notes and discovered an entry by (CNA/staff #16) dated March 24, 2024 at 4:43 p.m. that stated the CNA went into the resident's room around 6:30 a.m. and asked the resident is she wanted drinks for breakfast and the resident said she was tired of people overpowering her and hitting her. It also stated that the CNA reported it to the nurse. An interview was conducted on June 24, 2024 at 12:57 p.m. with (CNA/staff #16), who stated that she was provided training on abuse, and if a resident says that something happened, she is supposed to report it to the Administrator within two hours. She stated that if the alleged perpetrator is a staff, the staff is sent home until the investigation is finished to keep the residents' safe. She stated that resident #62 told her that staff was hitting her and she reported it to a licensed practical nurse (LPN/staff #51), who instructed her to put it in a progress note. She stated that she asked (LPN/staff #51) if they needed to call anyone and the nurse said no. Then, a couple of days later, she was called into the Administrator's office and he asked her about the resident's allegation, and she was written up a week later for not reporting it. An interview was conducted on June 24, 2024 at 3:32 p.m. with registered nurse (RN/staff #200), who stated that she received training on abuse and if a resident reports an allegation of abuse, she has two hours to report the allegation to the Administrator. She stated that if the allegation involves a staff member, the staff must leave the building while the investigation is being done. She stated that there is a risk of the abuse continuing if it is not reported. An interview was conducted on June 24, 2024 at approximately 4:45 p.m. with the Administrator (staff #1), who stated that if a resident makes an allegation, staff should contact him and the Director of Nursing (DON) immediately to report it. He stated that he has up to two hours to report an allegation of abuse to the state agency. He stated that while he was investigating another allegation, he was reviewing the progress notes for resident #62 and came across a progress note dated March 24, 2024 written by (CNA/staff #16) stating that the resident had said staff were hitting her. He interviewed the the licensed practical nurse (LPN/staff #51) and she told him that (CNA/staff #16) never reported the allegation to her. He stated that (CNA/staff #16) was ultimately responsible for reporting the allegation to him and he only became aware of the allegation of abuse on April 1, 2024. He was aware that the timeline for reporting the allegation of abuse and 5-day investigation were not met. The facility's policy, Abuse dated 2022 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 state survey agency. -ED will begin investigation Immediately and complete within 5 working days using the Abuse Investigation Pack minimum of three residents will be interviewed in order to determine if there is a trend. Interviews may also include the alleged perpetrator, witnesses and staff members as applicable. -Suspected abuse will be reported in accordance with timeframes and standards required by CMS.

Based on closed clinical record review, staff interviews, and policy review, the facility failed to ensure one (#180) of four sampled residents was provided care and services to prevent the development of pressure sores. The deficient practice could result in residents developing pressure sores. Findings include: Resident #180 was admitted to the facility on (MONTH) 27, 2019, with [DIAGNOSES REDACTED]. Review of the care plan initiated (MONTH) 27, 2019 revealed the resident had impairment to skin integrity related to the right hip surgical incision. The goal was that the resident would have no complications related to skin injury. Interventions included pressure relieving/reducing mattress, pillows, sheepskin padding etc. to protect the skin while in bed. The care plan did not include skin concerns to the heels. Review of the clinical record revealed a physician order [REDACTED]. A care plan initiated on (MONTH) 27, 2019 revealed the resident had activities of daily living self-care performance deficit related to activity intolerance. Interventions included the resident required the assistance of one staff for repositioning and turning in bed, and transfers. Review of the Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 27, 2019, revealed a score of 16, indicating the resident was at low risk for developing pressure sores. Review of a nursing wound progress note dated (MONTH) 28, 2019 revealed the resident's heels were blanching with bogginess. The note included the resident was encouraged and educated about frequent activity/repositioning while in bed and in the wheelchair. The note also included the resident was repositioned using a pillow and that heel boots were placed on the resident's feet. The note did not include any description or other assessment of the heels. Additional review of the care plan revealed the care plan was not revised to reflect the heels with bogginess nor was there an intervention for heel boots on the care plan. The Certified Nursing Assistant (CNA) documentation for turning, repositioning, floating the heels when in bed, and wearing heel protective boots consisted of a Yes to indicate it was completed but did not include if some or all of the interventions were completed and how often. Per the documentation on the form from (MONTH) 28 through (MONTH) 2, 2019, Yes was documented three times on (MONTH) 28 and (MONTH) 2, two times on (MONTH) 29 through 31, and one time on (MONTH) 1. Further review of the clinical record revealed no additional documentation to indicate preventative measures were consistently implemented from (MONTH) 28 through (MONTH) 2, 2019. Review of the Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 3, 2019, revealed a score of 18, indicating the resident was at low risk for developing pressure sores despite skin issues being identified to the resident's heels on (MONTH) 27, 2019. Review of the weekly skin check dated (MONTH) 3, 2019, now revealed the resident had pressure sores to the right and left heel and included a recommendation for foam booties to prevent further breakdown. The admission Minimum Data Set (MDS) assessment dated (MONTH) 3, 2019 revealed a score of 15 on the Brief Interview Mental Status which indicated the resident had intact cognition. The assessment included the resident had two unstageable pressure sores with suspected deep tissue injury (DTI) in evolution that were not present at the time of admission. The assessment also included a pressure reducing device was in place for the chair and bed but did not include a turning/repositioning program had been implemented. The assessment also revealed the resident required extensive assistance of two+ staff for bed mobility and transfers, and did not use a wheelchair as a mobility device. Review of the wound physician's note dated (MONTH) 3, 2019, revealed the resident had DTI to the mid-lateral right heel and to the medial left heel. The right heel measured 3.5 centimeters (cm) x 4.5 cm with an area of 12.37 square cm. The left heel measured 2 cm x 3 cm with an area of 4.712 square cm. The right and left heel wound bed had 76-100% [MEDICATION NAME] and the peri-wound skin did not exhibit signs or symptoms of infection. Apply skin prep to the right and left heel and cover with a dry protective dressing daily. Recommendations included floating the heels when in bed, offloading the wound, offloading mattress, and repositioning per facility protocol. Physician orders [REDACTED]. Review of the Pressure Ulcer Documentation and Assessment form dated (MONTH) 3, 2019, revealed the onset of the DTI to the mid-lateral right heel and to the medial left heel was on (MONTH) 3, 2019. The right DTI measured 3.5 cm x 4.5 cm. x 0 and the left DTI measured 3.2 cm x 3.3 cm x 0. Both heels were non-blanchable, deep red and purple in discoloration with epithelization with no drainage or induration noted. Skin prep was applied to the heels and the heels were covered with a dry protective dressing. Interventions included floating the heels while in bed and offloading the wound. The documentation also included the resident was encouraged and educated about frequent activity/repositioning while in the bed and wheelchair and that the resident was repositioned and heel boots were placed on the resident's feet. The care plan regarding skin integrity was revised on (MONTH) 4, 2019, to include the deep tissue injuries to the right and left heel. Further review of the clinical record revealed skin and wound assessments, and pressure sore treatments were provided. The discharge MDS assessment dated (MONTH) 3, 2019, revealed the resident was discharged to the hospital on (MONTH) 3, 2019 with two unstageable DTI sores. An interview was conducted on (MONTH) 6, 2019 at 12:23 p.m. with the wound nurse (staff #17), who said their policy states that residents are to be repositioned every two hours or more. Staff #17 stated that the CNAs are responsible for repositioning residents. She stated the CNAs document the repositioning in the data system every shift and that there is no place for the CNAs to document how often a resident was repositioned each shift. She said there have been times when there was only one CNA on the day shift and that the CNAs have told her that they did not have time to reposition residents every two hours. She also stated that the size and shape of the pressure sores on the resident's heels, is the type of pressure sores a resident gets when the resident uses a wheelchair. Review of the facility's wound management policy dated 2013, revealed the goal of their comprehensive wound management program is to promote the highest level of functioning and well-being of their residents and to minimize the number of residents that develop in-house acquired pressure sores. A thorough head to toe assessment of each resident's skin will be completed on admission and at least weekly thereafter. The skin check will be completed by the wound care team which consists of the wound care nurse and the wound care assistant. A pressure ulcer risk assessment (Braden) will be completed upon admission, the following 4 weeks and quarterly thereafter. Residents with a Braden score less than 12 will have interventions placed to prevent pressure sore development. Skin impairment care plan and goals will be initiated, updated, and reviewed as applicable by the Interdisciplinary team. This is to include all residents at risk as well as those with actual skin impairments.

Based on clinical record review, resident and staff interviews, facility documentation and policies and procedures, the facility failed to ensure the environment remained as free from accident hazards as is possible, by failing to ensure that one resident (#35) was transferred safely, resulting in a fall with injury. Findings include: Resident #35 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a nurse report sheet dated May 22, 2017 revealed the resident had bilateral lower extremity weakness and was a two person assist with transfers. The admission nursing assessment dated [DATE] indicated the resident required extensive assistance of two staff members with transfers. An interim care plan dated May 23, 2017 indicated that the resident was at risk for falls. The goal was to have no falls through the next review. One of the interventions included for staff to assist with transfers. The care plan did not indicate how many staff were required to assist with transfers, nor the resident's weight bearing status. Review of the physical therapy plan of care dated May 24, 2017 revealed the resident required total assistance (100% assistance) with sit to stand transfers and maximum assistance (76-99% assistance) with transfers from bed to chair. A fall risk evaluation dated May 25, 2017 identified that the resident was at moderate risk for falls. The assessment noted the resident required hands-on assistance to move from place to place. Review of the occupational therapy plan of care dated May 25, 2017 revealed the resident was dependent on staff for transfers and that the helper does all of the effort. The documentation further included that the resident does none of the effort to complete an activity and that two or more helpers are required to complete an activity. Review of a nursing note written at 12:40 p.m. on May 26, 2017, revealed the resident fell during a Certified Nursing Assistant (CNA) transfer. The resident denied pain or discomfort. A nursing note dated May 26, 2017 at 12:40 p.m., revealed the resident was complaining of pain in her upper arms and chest. The physician was notified and a chest X-ray was ordered. Review of the X-ray report revealed the resident had an acute (new) fracture of the anterlolateral segment of the left fourth rib. A late entry Inter-Disciplinary Team (IDT) fall review dated May 27, 2017 revealed the resident had an assisted fall, with a fracture of the left rib. The note indicated that the resident was now to be transferred by mechanical lift. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The resident was also assessed to require extensive assistance of two persons with transfers. A history and physical completed by the resident's physician dated May 29, 2017, indicated the resident had a history of [REDACTED]. The note included that the resident was informed by her neurosurgeon that she would likely not walk again. Review of the facility's investigation regarding the fall revealed the resident had been lowered to the floor by two CNA's (staff #25 and staff #31), who were attempting to transfer her from the wheelchair to the bed. The incident occurred around 12:40 p.m. on May 26, 2017. Around 4:30 p.m., the resident complained of bilateral arm and chest pain. An X-ray showed that the resident had sustained a single rib fracture. The investigation further included that staff #25 was approached by staff #31 to help transfer the resident from her wheelchair to the bed. The two CNAs positioned the resident's wheelchair beside the bed and then hooked their arms under the resident's armpits, grabbed her pants and lifted her up. The two CNAs attempted to transfer the resident to the bed, but her weight became unbearable. They attempted to put her back into her wheelchair, but were unsuccessful, and had to lower the resident to her knees. The CNAs then placed their arms under the resident's armpits, grabbed her pants and were able to get her into bed. According to the investigation, neither CNA had used a gait belt during the transfer. The report included that the resident was appropriate for a two person lift per therapy, however, the CNA's should have used a gait belt. An interview was conducted with resident #35 at 11:30 a.m. on June 27, 2017. She said that prior to coming to the facility, she had surgery and is now paralyzed from her chest area down. She stated that she was dropped by two CNAs, as they were in a hurry. She said that it was the first time she had received care from them. She stated that they did not use gait belts and that prior to this event, all of the staff have used gait belts. She said that the fall caused a rib fracture and that it caused a good amount of pain. She stated that she was trying to help them get her up, by using her arms. She said that one of the CNAs was very tiny and she did not think she was strong enough to lift a person. During an interview with a Certified Occupational Therapist Assistant (staff #96) at 11:55 a.m. on June 27, 2017, she stated that when a resident is admitted , the CNA's know how to transfer the resident based on what the nurses tell them and the nurses know based on their assessment. She said that the CNAs are educated on how to safely perform transfers. She said that therapy evaluations are done either on the same day of admission or within 24 hours. Staff #96 stated that as part of therapy's evaluation, there might be a recommendation for a Hoyer lift. She reviewed the therapy notes and indicated that while most of the notes indicated that the resident required total assistance, one of them indicated that the resident needed extensive assist. She said based off of this, an extensive two person assist without a Hoyer would have been appropriate. She said however, that gait belts should be used with all transfers. She said the CNAs should have them on at all times. She said that this resident is paralyzed and cannot provide much assistance, when being transferred. She stated that the CNA's should have used one hand on the gait belt and one under the shoulder to properly lift the resident. Staff #96 stated that the way that they moved the resident, could have contributed to her rib fracture in that the emphasis would have been more on her shoulders, which could cause extra movement and injury. An interview was conducted with a Licensed Practical Nurse (LPN/staff #3) at 12:55 p.m. on June 27, 2017. She said the standard practice for CNAs to have a gait belt on them and that they use them with all transfers. An interview was conducted with a CNA (staff #71) at 1:00 p.m. on June 27, 2017. She stated that she always uses a gait belt when transferring or ambulating a resident. She said that she does a lot of the training in the facility regarding gait belts and she always educates the CNAs to use gait belts with all transfers. She said that regarding this incident, the CNAs should have used a gait belt during the transfer. During an interview with a CNA (staff #43) at 1:30 p.m. on June 27, 2017, she stated that she uses a gait belt every time she performs a transfer with a resident. She said that the gait belt is part of her uniform and should be in her possession at all times. In an interview with a nurse consultant (staff #113) at 2:24 p.m. on June 27, 2017, she stated that the facility has a policy that mentions gait belts, but there is no specific policy regarding gait belt use. An interview was conducted on June 28, 2017 at at 8 a.m., with one of the CNAs (staff #25) involved in this incident. Staff #25 stated that it was the first time working with this resident. She said they put their arms underneath her armpits and while they were trying to get her to bed, her knees buckled and they realized that they were bearing all of her weight, so they assisted the resident to her knees. She stated that they were able to get the resident back up off of the ground and into the bed. Several attempts were made via telephone to interview CNA (staff #31), however, no returned call was received. In an interview with the Director of Nursing (DON/staff #5) at 8:30 a.m. on June 28, 2017, she stated the issue with this incident was that the two CNAs did not use gait belts when they should have. She said the resident was not a Hoyer lift at the time of the incident and so the CNAs were appropriate with the amount of assistance provided, however, they should have used gait belts for the safety of the resident and themselves. She said that the expectation is that staff have gait belts on their person at all times. She said that when a CNA is hired, they are given a gait belt and are taught to use gait belts with all transfers. The DON further stated that one of the CNAs (staff #31) was a small individual and likely was not strong enough to lift the resident, and this may have contributed to the issue. Another interview was conducted with staff #25 at 12:30 p.m. on June 28, 2017. She stated that during the incident, they did not use a gait belt and that neither of them had gait belts on them at the time of the incident. She said that she had not been given one and did not know how to obtain one. She stated that she was taught to always use gait belts during transfers. During an interview with the ADON (staff #52) at 12:35 p.m. on June 28, 2017, she stated that all CNAs receive training on gait belts and that part of the training also includes telling the staff that they need to use gait belts for all transfers. Review of the facility's policy regarding safe lifting and movement of residents revealed that in order to protect the safety and well-being of staff and residents and to promote quality care, the facility uses appropriate techniques and devices to lift and move residents. The policy included that resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and movement of residents. The policy noted that manual lifting of residents shall be eliminated when feasible. Also, nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' need for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan, which will include the resident's preferences for assistance, resident's mobility, and weight bearing ability. The policy further included that staff responsible for direct resident care will be trained in the use of manual lifting devices such as gait/transfer belts and mechanical lifting devices. A policy regarding safety and supervision of residents included 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. The policy included that employees shall be trained and in-serviced on potential accident hazards and try to prevent avoidable accidents. Also noted was that the facility will implement interventions to reduce accident risks and hazards, provide training, as necessary, and ensure that interventions are implemented.

Based on clinical record review, hospital record review, staff interviews, review of the National Pressure Ulcer Advisory Panel (NPUAP), review of facility documents, and review of policies and procedures, the facility failed to prevent the development of a pressure ulcer for one resident (#147). The facility failed to assess and monitor the resident's skin and as a result resident #147 sustained harm. The sample size was three. Findings include: Resident #147 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's clinical record revealed an Admission Nursing Evaluation dated May 20, 2010, which revealed the resident did not have any pressure ulcers upon admission. The evaluation also documented that the resident required limited assistance of one staff member for transfers. It was documented that the activity of "to walk" in room, to walk in the corridor, or on/off the unit did not occur. The resident's clinical record revealed a Braden Scale dated May 20, 2010, which revealed the resident's total score was a 17 and was considered a low risk for the development of a pressure ulcer. A review of the resident's clinical record revealed a physician's orders [REDACTED]." A care plan dated May 20, failed to address the physician's orders [REDACTED]. The resident's clinical record revealed a five day Minimum Data Set (MDS) assessment dated [DATE], which revealed the resident did not have any pressure or stasis ulcers on admission to the facility. There was no documentation in the resident's clinical record that the physician ordered skin assessments were done from May 20 until the resident was discharged from the facility on May 30, 2010. The resident's clinical record revealed Medicare Daily Skilled Charting dated May 30, 2010, documented "Sent to...ER (emergency room ) for evaluation...with several wounds on heel and top of foot." A further review of the resident's clinical record revealed an Emergency Transfer Form dated May 30, 2010, which documented "Present complaint and duration: Left leg pain, sore on left heel, blisters on left foot...Left heel scab is 3 inches long." A review of hospital documentation revealed a Wound Assessment Worksheet dated May 30, 2010. The worksheet documented that the resident was admitted to the hospital with [REDACTED]. The worksheet also revealed that the resident had six suspected deep tissue injury wounds to the top of his left foot which measured 7 cm x 4 cm, 3.5 cm x 1 cm, 3.5 cm x 1.5 cm, 1 cm x .5 cm, and (2) 1 cm. x 1 cm. The worksheet also documented that the resident had four suspected deep tissue injury wounds in various locations on his left foot: 3.5 cm x 1.5 cm medial (inner) ankle, 1.5 cm x 1.5 cm on the lateral side below the pinky toe, and (2) 1 cm x 1 cm lateral (outside) ankle. The resident's clinical record revealed a Physical Therapy Discharge Summary dated June 1, 2010 which documented "...Patient has made excellent progress...however he has developed a pressure ulcer on his left heel. Sent to acute care hospital which then transferred him to another hospital..." An interview was conducted with the director of nursing (DON) on August 4, 2011. The DON stated that the licensed nurse was responsible for completing the skin assessments. The DON stated that the physician's orders [REDACTED]. The DON further stated that another Braden Scale should have been completed one week after admission on May 27, 2010. A review of the facility's policy Prevention of Pressure Ulcers documented, "...The facility should have a system/procedure to assure assessments are timely and appropriate..." The NPUAP revised its definition of pressure ulcers, "...Pressure ulcers are usually located over bony prominences, such as the sacrum, coccyx, hips, and heels, and are staged according to the extent of observable tissue damage...Effective treatment depends on a thorough assessment of the developing wound. Meaningful ulcer requires a systemic and objective approach. Clinical assessment should include...ulcer history; including etiology, duration, and prior treatment...anatomic location...stage...size...sinus tracts...drainage...necrotic tissue...Perform a head to toe skin assessment at least daily, especially checking pressure points..."