Every finding on record at Haven of Yuma

Based on the clinical record, staff interviews, and the facility's policy and procedures, the facility failed to ensure that pain medications prescribed as needed (PRN) were administered within the pain scale. The deficient practice could result in residents being overmedicated or undermedicated, affecting overall pain management. Findings included: The resident (#118) was admitted to the facility on [DATE], with diagnoses that included morbid obesity, Type II diabetes, and end-stage renal failure. The minimum data set (MDS) dated [DATE], included a brief interview for a mental status score of 15, indicating the resident was cognitively intact. The care plan dated April 28, 2021, revealed that the resident had acute pain and takes (Tylenol: non-opioid and Oxycondone: opioid) analgesics for right hip pain. Interventions included to administer analgesia medication as per orders. Review of the order summary revealed:-dated May 30, 2021, Oxycodone HCI tablet 5 mg, give one tablet by mouth every 6 hours as needed for PRN pain 6-10 related to displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routing healing. End date was June 13, 2021.-dated June 14, 2021, Oxycodone HCI tablet 5 mg, give one tablet by mouth every 6 hours as needed for PRN pain 6-10 related to displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routing healing.-dated May 28, 2021, Tylenol tablet 325 mg, give two tablets by mouth every 4 hours as needed for a pain scale 1 to 10. Not to exceed 3g/day. Review of the Medication Administration Record (MAR) dated June 2021 revealed:Oxycodone HCI tablet 5 mg, give one tablet by mouth every 6 hours as needed for PRN pain 6-10 related to displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing was administered nineteen times without assessing the pain scale of the resident. An interview was conducted on July 21, 2021, at 11:04 a.m. with a licensed practical nurse (LPN/staff #101), who stated that a physician's order for a pain medication as needed (PRN) requires a pain scale on the script. She reviewed the order for Oxycodone, give 1 tab for pain level of 6 to 10 every 6 hours. She stated that it is important to document the pain level at the time the resident is being evaluated for pain to determine if the pain level is an appropriate level for the order. She stated that she didn't see a pain level recorded on the MAR dated June 2021. She stated that the risk of giving pain medication outside of pain parameters is low blood pressure, doesn't address the pain, and there is the possibility of overmedicating. When she sees an error, such as the pain scale not being assessed, she notifies the charge nurse and goes to evaluate the resident. An interview was conducted on July 21, 2025, at 11:27 a.m. with the Director of Nursing (DON/staff #49). He stated that an order for pain medication PRN should include a pain scale and non-medical intervention. The risk of administering a pain medication outside of the pain scale is potential overdose. He stated that the unit manager is responsible for monitoring the MAR to ensure that medications are being given correctly. He reviewed the MAR dated June 2021 and stated that the Oxycodone 5 mg every six hours PRN had a pain scale of 6 to 10. After further review of the MAR, he stated that the prior order for Oxycodone did not have a pain scale, and it was corrected on June 14, 2021. He stated that the pain level was not recorded on the MAR multiple times. He reviewed the progress notes and stated that the pain scale was not documented prior to administering the Oxycodone. The facility policy, Medication and Treatment Orders stated that orders for medications and treatments will be consistent with principles of safe and effective order writing.

Based on observation, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that medications were stored and residents were assessed for self-administration of medication for 1 resident, #47. The deficient practice could result in medications not being administered properly and medications not being stored safely. Findings include:Resident #47 was admitted to the facility on [DATE], with a diagnosis that included unspecified fracture of T9-T10 vertebra, subsequent encounter for fracture with routine healing, and muscle weakness (generalized).Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09, indicating severe cognitive impairment. Review of the MDS revealed no indicators for mood or behaviors. Further review of the MDS section N revealed the resident was prescribed antiplatelets.During the survey's initial pool on July 20, 2025, at 12:16 PM, in Resident #47's room observed on the bedside table were two 1.5-oz bottles of Equate Nasal Saline Spray. One bottle was sitting on the table in full view when entering the resident's room, and one unopened bottle was observed standing in an empty Kleenex box. The resident stated staff were aware that she had the medication.On July 20, 2025, at 12:19 PM, a Licensed Practical Nurse (LPN/Staff #132) came into the resident's room, identifying the two bottles of medication as Equate nasal saline sprays on resident #47's bedside table. Staff #132 stated the resident should not have them in her room and should not take medication that is not prescribed. She also informed the resident that she was not supposed to have them in her room. Staff #132 reviewed the physician's orders on her medication cart, stating the resident did not have an order for the nasal saline sprays identified on resident #47's bedside table. Staff #132 stated that the risks of having unprescribed medications at the bedside are that the resident can take more than needed, or another resident could have used the medication. Staff #132 further stated, there would also need to be an assessment to determine if they are cognitively capable of administering their own medications. Review of the care plan, date-initiated August 8, 2024, revealed a focus on impaired cognitive function/dementia or impaired thought processes. Interventions included engaging the resident in simple, structured activities that avoid overly demanding tasks. Further review of the care plan revealed an update to the care plan, date-initiated July 20, 2025, with a focus that the resident wishes to self-administer normal saline nasal spray. Interventions included resident would be provided education on how to properly administer (Normal Saline Nasal Spray) and would give a return demonstration of how to self-administer Normal Saline Nasal Spray.A review of the physician orders revealed no orders to self-administer for medications or nasal saline.A review of the progress notes revealed no self-administration of medication assessment documentationA review of resident #47's completed assessments revealed no assessments to determine the resident's capability for self-administration of medications or for nasal saline.An interview was conducted on July 22, 2025, at 2:12 PM with Registered Nurse (RN/Staff#81). Staff #81 stated that the process for resident self-administration is discussed with the Director of Nursing or the Nurse Manager. Staff #81 stated the provider would need to provide an order for self-administration and place it in the resident's file. Staff #81 stated the resident would also need an assessment to determine if they are cognitively capable of administering their own medications.An interview was conducted on July 22, 2025, at 2:25 PM with the Director of Nursing (DON/Staff#49), who stated his expectations for resident self-administration are to follow the facility policy, get and order, complete an assessment for self-administration, and place in the care plan. The DON reviewed the resident's physician orders and completed the assessment for self-administration. The DON stated from his review of the resident's record there were no orders or assessments for self-administration and that the care plan should not have been updated before obtaining a physician's order and completing an assessment. Review of the facility policy titled F021 - Medications: Self-Administration of Medications 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is re- assessed periodically based on changes in the resident's medical and/or decision-making status.

Based on facility documentation, observations, staff interviews, and policy review, the facility failed to ensure that food items located in the refrigerator, freezer, and dry storage were stored for resident safety. The deficient practice could result in unsafe food storage, placing residents at risk for foodborne illnesses.Findings include:During a walk-through in the kitchen conducted on July 20 at 10:47 a.m. with the Assistant Dietary Manager (staff #39), observations were made in the large refrigerator, freezer, and dry storage: Refrigerator:#400 pan of pinto beans open, exposed to air - tin foil was ripped, exposing the contents. Expiration date 7/17/25-7/24/25Freezer:30 lb. Bountiful Box of broccoli cuts open, exposed to air in freezer120 pack Garlic Toast-open plastic with open box lid exposed to air in freezer Imperial brand ground rosemary expired 3/21/2025 Imperial brand Lemon Pepper Seasoning- opened 6/20 -expiration date April 19, 2024 Imperial brand Dill Weed expiration date 1/13/2024 Imperial brand Toasted Sesame Oil expired 7/2/2025 50 lb. box Bountiful Harvest long grain rice open box lid, with opened plastic packaging inside the box, with rice spillage outside of the packaging inside the box.Dry Storage:Food droppings were seen beneath the wire shelving and along the perimeter of the wall. 10lb box of lasagna noodles, open box with broken noodle pieces outside of the packaging, open and exposed to air. 25lb Knorr's chicken bouillon open and exposed to air During a second observation of the kitchen conducted on July 21, 2025, at 2:32 p.m., with the Dietary Manager (staff #20), testings were completed of the sanitation buckets throughout the kitchen. Testing with the appropriate chemical strips conducted by Staff #20 revealed the following results;3-compartment sink chem strip - 100ppm- required results 200ppmMeal Prep Sanitation Bucket- 100ppm- required results 200ppmTray line Sanitation Bucket-100ppm- required results 200ppm A second chemical strip test and kitchen observation were conducted on July 23, 2025, at 10:07 a.m. with the Dietary Manager (Staff #20). The following tastings were recorded: 3-compartment sink- 200ppmMela Prep sanitation bucket- 200ppmTray line sanitation bucket- 200ppmjuice/coffee station sanitation bucket-100ppmDry storage food droppings remained beneath the wire racks initially observed on July 20 at 10:47 a.m. Oatmeal spillage was observed near the base of the wheel of the wire racks, and unidentified food splatter on the wall in back of the wire racks. An observation was conducted on July 22, 2025, at 11:35 a.m. of the tray line meal temperatures. The following temperatures were recorded by the Dietary Manager (Staff #20):Refrigerated pineapple chunks- 59 degreesRefrigerated mandarin oranges and pineapples - 56 degreesCrystal Light beverage - 52 degreesCrystal Light lemonade beverage - 56 degrees An observation was conducted on July 23, 2025, at 8:25 a.m. of the meal cart temperatures. The following temperatures were recorded by the Dietary Manager (Staff #20):whole milk -45 degreeshealth shake - 43 degrees An interview was conducted on July 23, 2025, at 10:22 a.m. with the Dietary Manager (Staff #20). Staff #20 stated his current process regarding kitchen inspections is that he and the Assistant Dietary Manager (staff #39) make rounds of the kitchen, and will be making more frequent rounds of the dry storage, and will be pulling out the wire racks with cleaning of the floors and walls. Staff #20 stated it is currently part of their cleaning schedules and complete wipe downs once a day. Staff #20 stated it is currently the cook's responsibility to ensure the wipe downs are completed per the cleaning schedule. Staff #20 stated the current process regarding the sanitation buckets are that the buckets are changed every two hours, but if the cleaning cloths are soiled the sanitation buckets should be changed more frequently, further stating his staff will now change the sanitation chemical solution every hour to ensure they are at 200 parts per million and will also be providing an in-service with his staff. Review of the facility policy titled Food Storage and Date Marking states, Sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry, and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. (Follow regulatory authority procedure for date marking).11. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled (if not easily identifiable) and dated if stored for over 24 hours. Leftover food is used within seven (7) days or discarded. NOTE: Preparation date is day one. (Also see policy on Use of Leftovers in this section.) Follow state regulations for more detail.

Based on observations, clinical record reviews, resident and staff interviews, and facility documentation, policy and procedures, the facility failed to ensure water temperatures were within the safe water temperature range. The deficient practice put the residents at increased risks for serious injury and harm such burn and scalding. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Findings include: On June 19, 2023 at 7:04 p.m., the Condition of IJ was identified. The Administrator (staff #143) and the Director of Nursing (DON/staff #70) were informed of the facility's failure to water temperatures were within the safe water temperature range. During the initial screening, hot- and cold-water sink/faucet had temperature exceeding 120 degrees Fahrenheit (F) were found in multiple resident rooms at different hall. Water temperature readings were conducted with the maintenance manager (staff #112) who tested the water temperature in multiple resident rooms using facility thermometer and stated that the water temperature readings exceeded 120 degrees F. Further, staff #112 tested the water temperature from the cold-water faucet which revealed a temperature reading of 130 degrees F; and that, after 3-5 minutes of running the water the water temperature for the cold-water faucet began to drop. The Administrator (staff #143) presented a POC (plan of correction) on June 19, 2023 at 8:26 p.m. The administrator was informed that the POC was not acceptable and failed to include the following: the in-service regarding high water temperature and for which staff will be in-serviced; projected completion date for the in-service; how to prevent the incident from reoccurring, since high water temperatures were prevalent starting in the afternoon; staff responsible for maintaining documentation of water temperature logs; actions/measures to take address high water temperature readings from the cold faucets; alternative sinks for residents to use if sinks are inoperable; explanation for selected sample size; and, the tool used to measure water temperatures. A revised POC was received June 19, 2023 at 9:49 p.m. The Administrator (staff #143) was informed that the POC failed to include a completion date for the in-service training for all staff. At 10:22 p.m., another POC was received and was accepted at 10:33 p.m. The accepted POC included the following: the north and south water heater were turned down to 100 degrees F; residents and staff were informed of scalding risk and were asked not to use sink in room; staff in the building were in-serviced on scalding risk prevention; water in residents' rooms sink were drained to reach desirable temperatures; caution signs were posted at every resident sink warning them of scalding risks; daily water temperature taken each shift for 5 days in 8 randomly selected rooms (two per hall); consultation with outside contractor to diagnose the cause the hot water temperature from the cold water sink; and, the maintenance director or designee was responsible for ensuring water temperatures are taken according POC. Multiple observations were conducted of the facility implementing their POC which included caution signs posted in the residents' rooms near the sink, in-service training, contractors and plumbers present in the facility, and staff measuring water temperatures in rooms. On June 22, 2023 at 5:37 p.m. the Condition of IJ was abated after the following: the facility provided documentation that more than 50% of their staff were in-serviced and daily water temperatures were obtained; cold water faucets were turned off in resident rooms and as a result a sample of resident rooms were identified to have water temperature below 120 degrees F; plumbing experts identified that the exposed copper piping in the attic was being heated by ambient air during the heat of the day causing the temperature spikes in the uninsulated copper cold water lines; and verification that the cold faucets were shut-off. In addition, the facility provided a plan for long term resolution to include the installation of attic vents/fans and soffit vents to dissipate heat in the attic by circulating air as well as on-going monitoring of water temperature until the long-term resolution had been implemented and found to be effective. -Resident #276 was admitted on [DATE] with diagnoses of acute kidney failure, repeated falls, and malignant neoplasm of unspecified kidney. An observation of resident (#276) room was conducted on June 19, 2023 at 2:07 p.m. and revealed that hot and cold-water faucet was hot to the touch. The water temperature from the hot water faucet was 120.3 degrees F. Resident #276 stated that both faucets tend to be hot. In another observation conducted on June 19, 2023 at 4:12 p.m., the water temperature was at 121.5 degrees F. During an observation with the maintenance manager (staff #112) conducted on June 19, 2023 at 4:34 p.m., staff #112 attempted to let the faucet water run before checking the temperature. Staff #112 placed the Fieldpiece (brand name) thermometer directly under the running water as soon as the faucet was turned on. He tested the temperature from the cold faucet (right side) and revealed 122 degrees F and after 3 minutes it dropped to 100.4 degrees F. He then tested the temperature for the hot water faucet and it revealed 118.4 degrees F. In an interview conducted with resident #276 on June 19, 2023 at 9:06 p.m., he stated the water should have been checked a couple of days ago; and that when he went to wash his hands and it made him jump back because the water was very hot. Resident #276 stated he thought he did something wrong and checked to make sure he turned on the right one and saw that cold-water faucet was hotter than the hot water. Further, the resident stated that if his hands were not so thick he would have burnt his hands. On June 21, 2023 at 10:01 a.m. the Administrator (staff #143) stated that the replacement of two separate 2 valves, the closure of four cold water valves, and the adjustments to the water heaters were expected to have completely resolved the issue. However; at 3:59 p.m. the cold faucet water temperature in resident #276's room was 128.2 degrees F. -Resident #277 was readmitted to the facility on [DATE] with diagnoses of hereditary and idiopathic neuropathy, acute kidney failure, and fracture of unspecified part of neck of left femur. Review of the MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 11 indicating the resident had a moderate cognitive impairment. An observation in the room of resident #277 was conducted on June 19, 2023 at 2:42 p.m. and revealed hot water temperature of 122.6 degrees F. -Resident #64 was admitted on [DATE] with diagnoses of alcoholic polyneuropathy, and peripheral vascular disease. The progress note dated May 25, 2023 revealed the resident was alert and oriented x 2. The MDS assessment dated [DATE] revealed a BIMS score of 14 indicating the resident was cognitively intact. An observation of the room of resident #64 was conducted on June 19, 2023 at 3:06 p.m. The water temperature from the hot water faucet was 124 degrees F. In another observation conducted on June 19, 2023 at 3:43 p.m. the resident was sitting in a wheelchair and was able to move around the room while in his wheelchair. An observation was conducted on June 21, 2023 at 3:45 p.m. and revealed that the cold-water faucet had a temperature of 124.5 degrees F and the hot water faucet had a temperature of 124.7 degrees F. -Resident # 274 was admitted on [DATE] with diagnoses of psychotic disturbance, mood disturbance, and anxiety, and dementia. A progress note dated June 15, 2023 at 5:31 p.m. revealed resident #274 used a walker for mobility. An interview was conducted on June 19, 2023 at 3:38 p.m. with resident #274 who stated both hot and cold-water faucet were always running hot water. He said that he mentioned it to a CNA (name unknown) who tested the water temperature by touch and told him it was okay; however, the resident stated that it was still hot. During the interview, the water temperature for the cold-water faucet was tested and revealed 125 degrees F. At 4:15 p.m., the cold-water faucet water temperature was again tested and revealed temperature at 125.7 degrees F. An observation was conducted with the maintenance director (staff #112) on June 19, 2023 at 4:44 p.m. He tested the cold faucet water temperature and revealed water temperature at 125.6 degrees F. After a minute, the water from the cold-water faucet dropped to 123.4 degrees F; and, at 4:46 p.m., water temperature dropped to 119 degrees F. Review of the MDS assessment dated [DATE] revealed a BIMS score of 14 indicating resident was cognitively intact. The assessment included the resident required no setup or physical help from staff with transfer i.e. how that resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. -Resident #56 was admitted on [DATE] with diagnoses of peripheral vascular disease, type 2 diabetes mellitus with diabetic chronic kidney disease, and unsteadiness on feet. Review of progress note dated May 29, 2023 revealed resident was oriented x 2. The MDS assessment dated [DATE] revealed a BIMS score of 14 indicating resident was cognitively intact. -Resident #374 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, muscle weakness, and cirrhosis of liver. Review of the MDS assessment dated [DATE] revealed a BIMS score of 10 indicating resident had moderate cognitive impairment. An observation of the room of resident #56 and #374 who were roommates was conducted on June 21, 2023 at 3:31 p.m. The cold water and the hot water faucet were tested . The cold-water faucet as at 126.5 degrees F; and, the hot water faucet was at 124.6 degrees F. -Resident #500 was admitted on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery, type 2 diabetes mellitus with hyperosmolarity, depression, and unsteadiness on feet. Review of the MDS assessment dated [DATE] revealed a BIMS score of 15 indicating resident was cognitively intact. The assessment included the resident required setup only for locomotion off unit i.e., how resident moves to and returns from off-unit locations. An observation was conducted on June 21, 2023 at 3:57 p.m. and revealed the cold-water faucet had a water temperature of 124.7 degrees F. Review of the facility's record for hot water temperatures from January through June 2023 revealed the following hot water temperature readings from multiple different resident and showers rooms on different dates with hot water temperatures that ranged from 120 to 160 degrees F. An interview was conducted on June 19, 2023 at 7:45 p.m. with a registered nurse (RN/staff #25) who stated she had worked in the facility for about eight years and she was aware of the issues with the water temperature in the residents' rooms. She said that when the outside temperature was over 100 degrees, the cold water was warm; however, if the water runs for a few minutes it will cool down. The RN stated she knew that at this time of year the water temperature can run warm and they let maintenance know and try and educate staff and residents. The RN said that a resident in the 400 hall had complained the other night about the water temperature; and that, she did not report the water temperature complaint to maintenance staff. She also said that she should have reported the complaint to the maintenance because a resident can get hurt if the water was too warm. During an interview with a certified medical assistant (CMA/staff #9) conducted on June 20, 2023 at 9:36 a.m., the CMA said that there were residents who complained to her about the water especially in the shower room. She stated that she had to let the water run in order for it to cool down. She said she had been working at the facility for two years and had found that the water temperature was a problem in the summer. The CMA stated that about a year ago there were a couple of residents who reported that they used the water which was too hot and their skin were reddened from the water being too hot, but returned to their color after a while. The CMA said that she informed the nurse who applied calamine lotion on the residents affected area. An interview was conducted on June 20, 2023 at 11:53 a.m. with resident #275 who stated that he washed his hands at the sink and realized the water was hot when he turned on the cold water. Resident #275 said that the longer the water ran the hotter it got. He also stated that the staff that gave showers told him that he needed to hurry to take a shower because the water gets hotter later in the day. Resident #275 said that during his shower yesterday (June 19, 2023) the water was very hot and the aide told him that they needed to hurry because the water was hot. He said he liked to take his time to shower but if he does, the water would burn his body. Further, resident #275 said the shower aide had to raise the shower handle high in the air so the water could cool off before the water touched his skin. During an interview with the Administrator (staff #143) conducted on June 23, 2023 at 9:55 a.m., the administrator stated that his expectation was for staff to notify him of any hazards in the building. The Administrator said in the past, hot water temperatures were recorded in TELS; and that, cold water temperatures were not. However, the administrator said that the system only alerted him when the task of measuring the temperature was completed but it did not alert him of high-water temperature readings or whether it was out of compliance. He stated that it was the responsibility of the maintenance manager to notify him of any issues. The Administrator stated that he never saw the water temperature readings until he printed the report from TELS; and, he was surprised and thought the readings could not have been accurate. He stated that he questioned that that there was no flag from TELS to look deeper. The administrator stated that prior to the survey, the process they had in place prior to the survey did not meet his expectation and the potential risk of having elevated water temperature was scalding and/or injury to the residents. 48488 -Resident #6 was admitted with a primary diagnosis of unspecified bundle branch block. Review of the clinical record revealed the resident had a BIMS score of 15 indicating the resident had intact cognition. Per the documentation in the clinical record, resident used a wheelchair for mobility. -Resident #48 was admitted with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris and long term us of anticoagulants. The clinical record revealed resident used a wheelchair for mobility and had a BIMS score of 15 indicating the resident was cognitively intact. An observation of the room of residents #6 and #48 who were roommates was conducted on June 19, 2023 at 3:29 p.m. The water from the cold-water faucet felt hot to the touch and had a temperature of 123 degrees F. -Resident #17 was admitted with diagnosis of cellulitis of buttock. The clinical record revealed resident used a wheelchair for mobility and had a BIMS score of 15 indicating the resident was cognitively intact. An observation was conducted on June 19, 2023 at 3:41 p.m. The cold-water faucet in resident #17's room had a water temperature of 134 degrees F. 47911 -Resident #1 was admitted on [DATE] with diagnoses of Parkinson's disease and rheumatoid arthritis. An MDS assessment dated [DATE] revealed a BIMS score of 4 indicating resident had severe cognitive impairment. An observation conducted on June 19, 2023 at 3:39 p.m. revealed that the hot water sink/faucet in the resident's room had a temperature of 120 degrees Fahrenheit. In another observation conducted on June 21, 2023 at 4:09 p.m. it revealed that the hot water sink/faucet in the resident's room had a water temperature of 122 degrees Fahrenheit; and, the cold-water sink/faucet had a temperature of 127 degrees Fahrenheit. -Resident #53 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis affecting the right dominant side, unspecified dementia, and muscle weakness. The MDS assessment dated [DATE] revealed a BIMS score of 0 indicating the resident had severe cognitive impairment. An observation conducted on June 19, 2023 at 3:42 p.m. revealed the hot water sink in the resident's room had a temperature of 127 degrees Fahrenheit. In a later observation conducted on June 19, 2023 at 4:49 p.m., the hot water sink revealed a temperature of 118.9 degrees Fahrenheit and the cold-water sink had a temperature of 136 degrees Fahrenheit. An observation on June 20, 2023 at 9:23 a.m. revealed a sink hot water temperature of 94.8 degrees Fahrenheit and a cold-water temperature of 86 degrees Fahrenheit. An observation on June 21, 2023 at 4:38 p.m. revealed a sink hot water temperature of 124 degrees Fahrenheit and a cold-water temperature of 128 degrees Fahrenheit. -Resident #424 was admitted on [DATE] with diagnoses of peripheral vascular disease, diabetes mellitus and muscle weakness. An MDS (minimum data set) dated April 30, 2023 revealed a BIMS (brief interview of mental status) score of 03, indicating severely impaired cognition. An observation on June 20, 2023 at 9:02 a.m. revealed a sink hot water temperature of 98.7 degrees Fahrenheit and a cold-water temperature of 87.2 degrees Fahrenheit. An observation on June 21, 2023 at 4:30 p.m. revealed a sink hot water temperature of 127 degrees Fahrenheit and a cold-water temperature of 122 degrees Fahrenheit -Resident #39 was admitted on [DATE] with diagnosis including type II diabetes mellitus with diabetic neuropathy, unspecified age-related cataract, unsteadiness on feet and a history of falling. An MDS assessment dated May, 27, 2023 revealed a BIMS score of 13, indicating the resident was cognitively intact. An observation on June 19, 2023 at 3:42 p.m. revealed the hot water sink in the resident's room had a water temperature of 127 degrees Fahrenheit. An observation on June 19, 2023 at 4:49 p.m. revealed the hot water sink had a water temperature of 118.9 degrees Fahrenheit and the cold-water sink had a temperature of 136 degrees Fahrenheit. An interview was conducted with an LPN (staff #107) on June 19, 2023 at 7:20 p.m. The LPN stated she had been working at the facility for about 4 years and generally works on the 200 unit. She stated that she had not noticed any issues with the water temperatures. The LPN using her hands she tested the temperature of both the hot- and cold-water sink/faucet in the resident's room. The LPN stated that she was surprised the cold water was running so warm. She stated that she initially thought the hot water lever was reversed with the cold; until she tested the hot water which she reported as running hot. She stated that the risk of both hot and cold water running hot, could include a resident 'burning' themselves. Another observation was conducted on June 21, 2023 at 4:38 p.m. and revealed that the hot water sink had a water temperature of 124 degrees Fahrenheit and the cold-water sink had a temperature of 128 degrees Fahrenheit. -Resident #13 was admitted on [DATE] with diagnoses of nontraumatic intracranial hemorrhage and hemiplegia affecting left nondominant side. An MDS assessment dated [DATE] revealed a BIMS score of 8 indicating resident had moderate cognitive impairment. In an observation conducted on June 21, 2023 at 4:21 p.m. the hot water sink had a temperature of 125 degrees Fahrenheit and the cold-water sink had a temperature of 119 degrees Fahrenheit -Resident #54 was admitted on [DATE] with diagnoses including hemiplegia and hemiparesis affecting right dominant side, muscle weakness and type II diabetes mellitus with diabetic neuropathy. An MDS assessment dated [DATE] revealed a BIMS score of 14, indicating that the resident was cognitively intact. An observation was conducted with a certified medical assistant (CNA/staff #110) on June 21, 2023 at 4:34 p.m. revealed the hot water sink had a temperature of 128 degrees Fahrenheit and a cold-water sink had temperature of 134 degrees Fahrenheit. The CNA viewed the temperature gauge and confirmed the values. In an interview conducted with maintenance manager (staff # 112) on June 19, 2023 at 4:28 p.m., the maintenance manager stated that water starts getting hotter in the summer and when this happens he stated he manually sets the hot water temperature to 120 degrees Fahrenheit. He stated that there are two 100-gallon water tanks that service the resident rooms, one for each side of the building; and there were 6 tankless water heaters that service the kitchen, laundry, showers and non-resident bathrooms. He stated that during the summer, residents are encouraged to shower early in the morning to avoid the high temperatures. Staff #112 further stated that he conducts audits by checking the water temperatures weekly, which he reported had been ranging from 124-138 degrees Fahrenheit. He stated that he also adjusts the hot water temperature when he receives a report via the TELS portal. however, he said that the cold water cannot be adjusted. The maintenance manager stated that he runs the water for about 5 minutes before checking the temperature and/or placing his hands under the sink/faucet in the resident room. He stated that he does not if resident know to run the water for about 5 minutes before using it. Further, the maintenance manager stated that he does not know what water temperature could scald/burn a resident; but, he could look the information up in TELS. In a subsequent interview with the maintenance manager conducted on June 21, 2023 at 1:02 p.m., he stated that he was responsible for the facility water supply; and that, he takes the water temperatures weekly and whenever there were complaints and then documents them in TELS. The maintenance manager stated that the computer-based TELS application only requires documentation of the hot water temperatures and not the cold-water temperatures; and that, the documentation he enters was available via reports in the corporate office. He stated that he did not specifically alert anyone else in the facility or corporate, as they have access to TELS and would be able to look at the reports. He stated that when he does not enter the hot water temperatures, it gets flagged and he receives a reminder notice. He stated the seasonal manual hot water temperature adjustments were not documented in TELS, but could be in the comments section. He stated that some of the water tanks had been converted to tankless about 3 to 6 months ago; and that, the reciprocating pump, which adjusts the rate of water coming into the system was replaced in February 2023. Staff #112 stated the risk of the cold-water temperature running hot in resident rooms could put a lot of residents at risk and could cause a resident to get burned. 41020 An interview with a registered nurse (RN/staff #86) was conducted on June 20, 2023 at 8:43 a.m. The RN stated that she enters resident rooms and washed her hands in the sink located in the room; however, she stated that she does not notice the water temperature. She stated that neither the CNAs or residents had complained about the water being too hot. The RN said that if the water was excessively hot she would expect the CNAs to notify her; and that, the risks to the residents would include burns. In an interview with certified nurse assistant (CNA/staff #91) conducted on June 20, 2023 at 8:50 a.m., the CNA stated that he had worked at the facility for 9 years. He stated that in the summertime, they had to let the water run for a few minutes because the water was too hot; and that, after a few minutes the water cools down. He stated he had noticed that the water was really hot in the summer, and that he had told the nurse about it. The CNA also stated that if a resident was in the shower by themselves and the water was too hot the risks to the resident would include being burned. He further stated that the resident could turn the cold water on which was even hotter than the hot water. In an interview conducted with the administrator (staff #143) conducted on June 20, 2023 at 10:30 a.m., the administrator that the issue regarding the water temperatures being too hot had not been identified until now. He stated that staff had been aware of water temperatures rising in the summer and that the city where their facility was located was hot. In another interview with the administrator (staff #143) conducted on June 21, 2023 at 11:49 a.m., the administrator (staff #143) stated the facility did not have cold water logs. In a later interview with staff #143 conducted on June 21, 2023 at 1:47 p.m., he said that he absolutely had no idea that there were any issues with the water temperatures; and, he had never been told by anyone that there were any concerns regarding water temperature. During an interview with a restorative nurse aide (RNA/staff #20) conducted on June 22, 2023 at 8:46 a.m. the RNA stated that the water was very nice in the morning; however, the water can get very, very hot at around 11:00 a.m. or 12:00 p.m. He stated that this was very common every summer season and that every year they update the staff about this. However, he stated that no one had told him that the water was too hot yet, but someone will soon. During an interview with the Director of Nursing (DON/staff #70) and a corporate compliance representative (staff #191) conducted on June 23, 2023 at 5:37 p.m., the DON stated he stated that his expectation was for nursing staff keep him informed at all times if hazards are identified. He stated that no staff had ever complained to him that there was ever an issue with the water temperatures; and that when he interviewed staff after the IJ had been identified, staff responded that it was expected that the water temperatures would be higher in the city that they are located at. The DON that moving forward, he expected his staff to notify him of hot water temperatures since now they had been trained regarding the risks related to high water temperature. The facility's job description for a maintenance manager included a responsibility to supervise adjustment of water temperature valves to maintain required temperatures. Review of the facility policy titled, Safety and Supervision of Residents, revealed that the facility strives to make the environment as free from accident hazards as possible. The policy also included that as part of the facility-oriented approach to safety, employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. The facility policy on Maintenance Service revealed that the functions of maintenance personnel include, but not limited to, maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines and maintaining the building in good repair and free from hazards. The policy also included that maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Review of the facility policy on Safety of Water Temperatures revealed that tap water in the facility shall be kept within a temperature range to prevent scalding of residents. The policy also that the water heaters that service resident rooms, bathrooms, tub/shower areas shall be set to temperatures of no more than 115 degrees F, or the maximum allowable temperature per state regulation; and, maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log. It also included that if at any time water temperatures feel excessive to touch i.e. hot enough to be painful or cause reddening of the skin after removal of the hand from the water, staff will report this finding to the immediate supervisor. Risk factors for scalding/burns that are more common in the elderly included decreased skin thickness, skin sensitivity, peripheral neuropathy, reduced reaction time, decreased cognition; the length of exposure to warm or hot water, the amount of skin exposed, and the resident's current condition affect whether or not exposure to certain temperatures will cause scalding or burn.

Based on staff interview, facility documentation, policy and procedure, the facility failed to ensure there was a registered nurse (RN) was on duty 8 consecutive hours or 7 days a week. The deficient practice could result in residents not provided with the needed advanced care activities. Findings include: The facility census on June 19, 2023 was 88. Review of the staff posting from May 1 through June 20, 2023 revealed that the section on the number of RN was blank for May 25, 30, 31, June 3, 7, 8, 10 and 14. The staff Sign-in Sheets from May 1, 2023 to June 20, 2023 revealed that there was no RN who signed in for Registered Nurse did not sign-in for May 25, 30, 31, June 3, 7, 8, 10 and 14. A review of the punch detail for RNs from May 1, 2023 to June 2, 2023 revealed with documented punch data for the following RN staff: #190, #86, #25, #33. According to the data, there were no hours recorded for any RN on May 30, 31, June 3, 7, 8 and 10. In an interview conducted with the staffing coordinator (staff #21) conducted on June 21, 2023 at approximately 3:15 p.m., the staffing coordinator said that she was responsible for the daily staffing; and that, staffing was based on the census, facility needs and the PPD which was the staffing ration per day. She also stated that she would also adjust staffing accordingly based on the staff level of competency. The staffing coordinator said that the facility had a system called Slack which staff use to call off request. She stated that when she receives the call off request, she would then remove the request from Slack and call directly each staff member who may be available to work. She stated that the staff were really nice and pick up shifts for each other. the staffing coordinator said that staffing for the weekends were the same as other days; and that, it was based on the census plus one extra staff for additional support a continuity of coverage. She stated that all nursing staff had a rotating schedule for the weekends and some staff had a weekend schedule due to school commitments. The staffing coordinator stated that staffing concerns go to the DSD (Director of Staff Development) or the DON (Director of Nursing) who would inform her so she could look at the PPD and adjust staffing accordingly. She further stated that once a schedule is created, she would post it in the employee hallway; and, it would also be posted for the month on the facility app. She said the DON does not review the schedule; however, the DON reviews and requests for time off from nurses. Further, the staffing coordinator said that the facility has RN schedules and she knows all of the facility nurses' title (LPN-licensed practical nurse or RNs); and that, she would schedule the nurses according to the coverage. Further, she stated that the DON was always in the building and would help fill in the nursing scheduled call-offs. An interview with the DON (staff #70) was conducted on June 22, 2023 at 8:56 a.m. with the vice president of clinical compliance. The DON stated that the staffing coordinator consider resident acuity on where to place new residents; and, staffing acuity was based on what the needs of the residents are. The DON said that the facility uses the PPD to accommodate for higher acuity and a margin of need; and that facility census was taken into consideration when staffing every day and every shift. The DON stated that the weekend staff were no different than the weekdays; and they try and rapidly fill call-offs. He stated that there were staffing concerns were brought to the staffing coordinator, social services and unit manager; and that, the concerns were different each. The DON stated that if needed, the facility will investigate the concern. The DON also stated that he provides oversight, ensuring that their policies were followed and the facility was within the acceptable staffing ration per PPD. The DON said that the facility provides staffing at all times and clinical staff to all residents; and, when creating a staffing schedule, they outline to provide a RN to provide 8 hours a day and utilize flexibility of their staff. Further, the DON stated that he provides leadership as the DON for the 8 hours; and that, leadership was oversight. The facility policy on Staffing included that the facility provides adequate staffing to meet needed care and services for their resident population. It also included that the facility maintains adequate staffing on each shift to ensure that residents' needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.

Based on clinical record review, staff interviews and procedure, the facility failed to ensure that the pre-admission screening and resident review (PASRR) was completed for one resident (#34). The deficient practice could lead to residents not receiving needed care and services. Findings include: Resident #34 was admitted on [DATE] with diagnoses of unspecified psychosis not due to a substance or known physiological condition, anxiety disorder, major depressive disorder-recurrent and schizoaffective disorder-bipolar type. The level I PASRR (preadmission screening and resident review) screening dated October 28, 2020 included the resident had a terminal illness with a life expectancy of less than months and no current risk to self or others and behaviors/symptoms were stable. According to the documentation, a PASRR level II evaluation was not required at that time; however, it also included that the NF (nursing facility) must update the Level I if the individual's medical state improves to the extent s/he could potentially benefit from a program of services to address his/her MI (mental illness) and /or ID (intellectual disability). Review of the active physician orders revealed the resident was prescribed with Depakote (antimanic) for unspecified psychosis, Sertraline (antidepressant) for major depressive disorder and Keppra (anticonvulsant) for epilepsy as well as ordered symptom and behavior tracking. The care plan with revision date of August 8, 2022 included the resident used anti-psychotic medication related to psychosis and schizoaffective disorder. A physician note dated January 9, 2023 included diagnoses of schizoaffective disorder, bipolar type, anxiety disorder and major depressive disorder. A significant change MDS (Minimum Data Set) assessment dated [DATE] revealed that hospice service was not coded. The IDT (interdisciplinary team) care plan conference dated February 8, 2023 revealed resident was discharged from hospice. A physician progress note dated June 10, 2023 revealed the resident was previously on hospice service and was no longer on hospice as of January 12, 2023. The dietary progress note dated June 18, 2023 included resident was no longer on hospice. Despite documentation that resident was discharged from hospice and not meeting the exclusion criteria of PASRR, there is no evidence of that new PASRR was completed for resident #34. An interview with the resident relations manager (staff #6) and the resident relations assistant (staff #7) was conducted on June 22, 2023 at 9:05 a.m. Staff #6 stated that she and her team were responsible for completing the PASRR once the resident was admitted at the facility. She stated that all residents have to have a level I PASRR, either before they arrive or have one completed on the day of admission. Staff #6 said that if a resident will stay beyond 30-days, a level II assessment PASRR would be completed. Staff #6 stated that the criteria that do not require a level II PASRR includes respite stay, Alzheimer's or dementia diagnosis and terminal illness with a 6-month life expectancy. Staff #6 stated that if someone was on hospice with a terminal diagnosis of less than 6-months and disenrolls from hospice, social services would be notified; and, another PASRR should be completed. During the interview, a review of the clinical record was conducted with staff #6 who a level I PASRR was completed for resident #34 on October 28, 2023 because the resident met the terminal illness criteria with less than 6 months for live. Staff #6 said that when the resident was discharged from hospice in January 12, 2023 another PASRR screening should have been conducted as the resident no longer met the criteria of having a terminal illness with less than 6 months to live. However, staff #6 said that the clinical record revealed no evidence that another PASRR screening was completed after the resident was discharged from hospice. Further, staff #6 said that the expectation was that a new PASSR screening should have been completed for resident #34 after discharge from hospice. She stated that the risk for not completing a new PASRR for a resident with diagnosis of mental illness include that the resident might not receive needed services. The facility policy on Pre-Admission Screening and Resident Review (PASRR) included that the facility will strive to verify that a Level I PASRR Screening has been conducted, in order to identify serious mental illness (SMI) and/or intellectual disability (ID) priori to initial admission of individuals to the facility. The policy also included that the facility will strive to submit an updated Level I Screening and Level II evaluation request to AHCCCS or DES (as applicable) within 14 calendar days after the facility determines through the MDS assessment that there has been a significant change in the resident's physical or mental condition which may indicate potential MI or ID.

Based on observations, staff interview, and policy review, the facility failed to ensure food items were labeled and dated when opened. The deficient practice could result in a potential for food borne illness. Findings include: In an observation of the dry storage area conducted on [DATE] at 11:33 a.m., the following food items were found opened but were not labeled and dated: -Small syrup containers; -Croutons stored in a plastic bag; and, -A half-filled bag of bread. However, these food items did not have use-by, best-by or expired-by date noted on the containers or product wrapping. An interview with Kitchen Manager (staff #59) conducted on [DATE] at 11:32 a.m. The kitchen manager stated that his expectation was that opened food items were labeled and dated. He stated that the risk for not labeling and dating foods include that the food could be spoiled and outdated food could be served to residents and potentially cause illness. The facility policy on Food Storage and Date Marking, included that all foods should be checked to assure that foods will be consumed by their use by dates or discarded.

Based on review of clinical records, staff interviews, and review of facility policies and procedures, the facility failed to ensure one resident (#1) with severe weight loss had weight monitored as ordered by a provider. The deficient practice could result in residents not receiving care and services to promote positive outcomes. The sample size was 3. Findings include: Resident #1 was admitted on [DATE] with diagnosis that included anxiety disorder, metabolic encephalopathy, chronic kidney disease, dehydration, unspecified dementia, confusional arousals and unspecified severe protein-calorie malnutrition. A care plan initiated on April 5, 2023 for nutritional problems included a goal that the resident would comply with the recommended diet and have no signs or symptoms of dehydration. The interventions for these goals included assisting with meals as needed and encouraging fluids. The physician orders revealed the following orders dated April 5, 2023: -weekly weights on admission and then follow facility protocol every day shift for weight monitoring for 1 administration (started April 6 and ended April 7, 2023) -Weights per Facility Protocol The admission weight on April 5, 2023 was 104.1 pounds. The weight on April 7, 2023 was 98.5 pounds which was a 5.38% loss from the admission weight. The Nutritional Data Collection and assessment dated [DATE] revealed that the resident had 5.4% weight loss but marked that the resident had no weight change under rate of unplanned weight gain/loss. The assessment further included intervention to monitor intakes and weights as ordered. Despite documentation of weight loss and recommendation to monitor weights, the clinical record revealed no documentation of weight taken from April 8 through April 20, 2023. The weight on April 21, 2023 was 80.0 pounds which was a 23.15% loss from the admission weight. During an interview conducted on April 27, 2023 at 1:10 pm with a Dietary Manager (staff #9) who stated that every Wednesday there was a meeting to address resident weights and that weight loss was also brought up in the daily meeting. Regarding resident #1, the dietary manager stated they were not aware of any dietary issues and they were monitoring the resident's fluids and supplements. However, staff #9 stated that they should have been doing weekly weights for resident#1. Further, Staff #9 stated that the resident did not set off any red flags for them as far as nutritional concerns or weight loss. During an interview with the Director of Nursing (DON/staff #1) conducted on April 27, 2023 at 2:31 pm, the DON stated that the resident#1 should have had a weight taken every week and stated they would have to find out why there was a missing week. During another interview with the DON and the Administrator (staff #40) conducted on April 27, 2023 at 3:50 pm, the Administrator and DON stated that resident #1 had more than 5% weight loss between the first and second weight which would have triggered weekly weights. A facility policy titled Nutrition Management Program (copy written 2013) included that the facility provides a comprehensive nutrition management program with goals to promote the highest level of functioning and well-being of our residents and to minimize the number of residents that develop unintended weight loss or accompanying comorbidities. It is the policy that all residents are weighted within 24 hours of admission and for the following four weeks or until stable. Residents that demonstrate a significant weight loss will be placed on weekly weights until weight is stabilized. All other residents will be weighed monthly. A physician may request that a resident is not weighed according to standard policy if the resident is on palliative care and a physician's order to hold weights is in place. Residents at risk for developing weight loss will be reviewed each week by clinical and dietary staff. The threshold for significant unexpected weight loss will be based on the following criteria: -1 month 5% weight loss is significant, greater than 5% is severe.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure a PASRR (Pre-admission Screening and Resident Review) was completed for 1 resident (#29) who remained in the facility for longer than 30 days. The sample size was 2. The deficient practice could result in specialized services not being provided for residents who need it. Findings include: Resident #29 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A PASRR Level 1 dated February 24, 2022 indicated that this resident met the criteria for 30-day convalescent care, that the resident did not have a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This assessment was not completed for Section B Mental Illness. A Care Plan dated February 24, 2022 included that this resident used Antipsychotic medications which were administered to treat the behaviors of self-injury. A Care Plan dated March 1, 2022 included that this resident expressed the desire for continued placement. An admission Minimum Data Set assessment dated [DATE] included that this resident had a Brief Interview for Mental Status score of 14, which indicated intact cognition. Review of the clinical record revealed no evidence that other PASRRs were completed/updated once the resident's stay exceeded 30 days. An interview was conducted on April 20, 2022 at 2:12 PM with the Social Services Director/Resident Relations (staff #14), who said that residents need to be admitted with a PASRR Level 1 completed. She said that if the resident has a mental illness then the facility would need to do a new one to refer to the state. She said that qualifying mental illnesses are diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that she will complete a new PASRR as soon as she knows the resident is going to stay, that it depends on when they know. This staff said that this resident has been hoping to go back to their apartment. This staff member reviewed the Care Plan and said that she did not know if the resident was going to stay. A follow up interview was conducted on April 21, 2022 at 12:16 PM with the Social Services Director/Resident Relations (staff #14), who said that if she was to do another PASRR on this resident, she would recommend an evaluation on the resident, because she believes the resident has a qualifying diagnosis. She said that she is not required to complete another PASRR for this resident because her understanding is that the PASRR timing is determined by the resident's decision of choosing residency in the facility. An interview was conducted on April 21, 2022 at 12:32 PM with the Acting Director of Nursing (ADON/staff #139), who said that her expectation is that the staff get a pre-admission PASRR and that if the sending facility does not send one, one is filled out on admission to determine a level 1 or 2 recommendation. She said that if the resident will be in the facility for more than 30 days, they get another PASRR completed within 40 days. She said that it does not meet her expectations that this resident is still in the facility and did not have a PASRR completed. A facility policy titled Pre-Admission Screening and Resident Review (PASRR) revealed that PASRR Level 1 screenings are used to determine whether the individual has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This document included that a request for Level 2 evaluation is not required for individuals requiring admission to a nursing facility for a convalescent period or respite care 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 1 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, documentation, staff interviews, and policy and procedures, the facility failed to ensure discharge planning included developing a discharge care plan that included ensuring that one sampled resident (#173) was discharged to a safe environment. The deficient practice could result in residents being transitioned without effective post care. Findings include: Resident #173 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The discharge care plan dated December 25, 2021 stated the resident's wish is to return/be discharged home. The interventions included evaluating the resident's motivation to return to the community and establishing a pre-discharge plan with the resident/family/caregiver and evaluating the progress and revising the plan. The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident was cognitively intact. An Occupational Discharge Summary dated January 16, 2022 stated that the discharge destination is this long-term facility. Assistance/support to be provided, a.m. assistance/caregiver available, p.m. assistance/caregiver available. Discharge reason stated the resident has reached the highest practical level achieved. Short-term and long-term goals included the resident will improve ability to complete toilet/commode transfers with supervision or touching assistance with ability to right self to achieve/maintain balance. Functional assessment included: -Toileting hygiene, resident needs supervision or touching assistance -Toilet transfers, resident needs supervision or touching assistance The Physical Therapy Discharge Summary dated January 17, 2022 revealed the reason for discharge is per physician or case manager and the resident's discharge is to this long-term care facility. Functional skills assessment: -Bed mobility, resident requires supervision or touching assistance -Transfers, resident requires supervision or touching assistance -Ambulation, walk 10 feet, resident requires supervision or touching assistance Discharge recommendations: further skilled physical therapy services. Review of the Order Summary revealed an order dated February 1, 2022 for home health skilled nursing for medication management and physical therapy. Resident is homebound. Review of the progress note for the IDT (Interdisciplinary Team) Care Plan Conference dated February 2, 2022, revealed that it was a discharge meeting, the resident has declined to pay share of cost, and planned discharge is for February 4, 2022. A healthcare agency to provide 20 hours a week of caregivers. The agency is to meet with the resident on February 3, 2022 to get paperwork signed to have the caregiver start on February 4, 2022. A progress note completed by the case manager (staff #142) dated February 2, 2022 revealed the case manager attended the resident's discharge planning meeting today. The resident, Resident Relations Assistant (staff #16), and home healthcare agency (staff #300) were present. The plan is for the resident to discharge home on Friday around 11:00 a.m. The home healthcare agency will be meeting with the resident tomorrow at noon at the facility to set up services, schedule and the intake process. The plan is for services to start on Friday, 20 hours per week approved. The case manager will send the authorization to the home health care agency. The case manager will be doing a change in placement next week to review the resident's needs and ongoing services. No other questions or concerns voiced at this time. The discharge MDS assessment dated [DATE] revealed the resident requires extensive assistance with bed mobility, transfers, dressing, and toileting. It also included that the resident requires supervision (oversight, encouragement or cueing) with eating. The discharge assessment dated [DATE] stated the resident was discharged to the community with home health care services to be provided. Review of a progress note by the Resident Relations Assistant (staff #16) dated February 4, 2022 stated the resident is discharging home alone on Friday, February 4, 2022 with no durable medical equipment, that the resident already has a four-wheeled walker and home health skilled nursing and caregivers. The facility will take the resident home. A progress note completed by the case manager (staff #142) dated February 4, 2022 revealed that the resident was discharged home today. Staff from the home healthcare agency went to see the resident to set up services. The resident declined services over the weekend. The resident agreed to start services on Monday. The case manager spoke with the resident and explained the importance of having services at home to help the resident with daily needs. The resident agreed to have a caregiver on Monday. The case manager sent authorization to the home healthcare agency to start attendant care services on Monday, February 7, 2022. A progress note completed by the case manager (staff #142) dated February 7, 2022 revealed that the case manager received a call from Adult Protective Services (APS) stating that the resident had an open APS case. The APS caseworker went to see the resident today and the home healthcare caregiver just got there at the same time. The APS case worker indicated that the resident was soiled upon their arrival. The case manager explained that services were authorized upon the resident's discharge from the nursing home on February 4, 2022, but the resident declined services for that day and the weekend also. An interview was conducted on April 19, 2022 at 3:33 p.m. with the Resident Relations Manager/Social Services (staff #14), who stated that there is an IDT meeting when a resident is going to be discharged to discuss what durable medical equipment and services are needed, and if it is a safe discharge. She reviewed the progress notes for resident #173 and stated the resident was transferred from the skilled nursing to long-term care (LTC) in the facility on January 27, 2022, but the resident decided to go home and discharged on [DATE] because the resident did not want to pay the share of cost for LTC. She stated that during the IDT meeting, it was determined that the resident would receive 20 hours per week for an in-home health care aid. A second interview was conducted on April 20, 2022 at 8:22 a.m. with the Resident Relations Manager/Social Services (staff #14), and the LTC case manager (staff #142) via phone. Staff #142 stated that there was an IDT meeting on February 2, 2022 and she attended via phone. She said that during the meeting, she offered to send the resident to assisted living, but the resident declined. During the meeting, she stated she authorized 20 hours of in-home care per week and a caregiver was scheduled to go to the resident's home on February 4, 2022, to complete the intake process. Staff #142 stated that she received a call from the caregiver telling her that the intake process was completed, but the resident did not want her to stay. She stated she spoke to the resident as well, and the resident refused in-home health care services for the weekend and she tried to convince the resident to let the caregiver stay. Staff #142 said that she submitted an Adult Protective Services (APS) report and found out that the resident already had an open case; the APS investigator arrived at the resident's home on Monday, February 7, 2022 at the same time as the caregiver and interviewed the caregiver. She stated then, the caregiver provided services for a couple of days and then decided to call an ambulance on Monday, February 14, 2022 because she found the resident in bed covered in feces that morning. She stated that on February 14, 2022, the resident was yelling at the caregiver to get out and she was transported to the hospital. On February 14, 2022, staff #142 authorized in-health caregiver services from 20 hours per week to 28 hours per a week. Staff #142 said that the resident required moderate assistance with mobility and assistance to get out of bed, and the resident lived alone. She stated that during the IDT meeting on February 2, 2022, the team discussed the fact that the resident needed assistance with getting up and ambulating, but was only approved for 20 hours per a week. Staff #142 said that she did not know how the resident was going to get up to use the toilet, answer the door, get food, or get out of the home in an emergency when the caregiver was not there. She stated that the IDT team agreed that the 20 hours was going to be okay, but the resident needed assistance for the more than 20 hours per week, and the team knew that there was no one in the home to assist the resident. After the interview ended, staff #14 stated that staff #142 did not say the resident required more than 20 hours per week of caregiver care. Staff #14 was asked to contact staff #142 for clarification. A second interview was conducted and staff #142 stated that during the IDT meeting on February 2, 2022, the team talked about the resident needing assistance to ambulate and transfer. Then, staff #14 asked staff #142, why did we discharge the resident if the resident was not able to transfer and ambulate and said, maybe we should have done an AMA (against medical advice) if it was not safe. Staff #142 stated that when they talked during the IDT meeting on February 2, 2022, they all discussed that it was okay to discharge the resident. Then, staff #14 said, the resident was very upset and they were trying to do the right thing. Staff #142 stated that the resident's sister was not at the meeting, and no one contacted the sister, and they do not know if the sister was going to help the resident. After staff #142 hung up, the interview continued with staff #14, who stated that the IDT meetings are not documented and she did not think that therapy staff were present. She said that she did not remember everything that was discussed at the meeting, but remembers many times the resident being self-limiting and explained that meant that therapy says you can get up and the resident says, she cannot get up, which can be for different reasons, such as pain. She stated that she was not able to provide the referral for home health services because they threw all the paperwork away just the other day, but she was sure that the resident was able to stand and move around because she believes she knew the resident. On April 4, 2020 at 10:06 a.m., an interview was conducted with staff #132, who identified himself as the Director of Rehabilitation. He stated that therapy makes recommendations for DME, home health needs, and provides the level of functions the resident is at, and the appropriate level of placement. He said he was not at the IDT meeting for the resident on February 2, 2022 because the resident was discharged from therapy on January 16, 2022 and therapy does not play a role if the resident discharges from LTC. He reviewed the discharge therapy evaluation for the resident and stated that the resident required supervision/standby with ambulation, rolling in bed, and transfers. He said standby/supervision is for safety because they do not feel quite comfortable with the resident doing it herself. He stated that the resident was self-limiting, had the ability to do things by herself, but required the supervision for safety and when the resident was discharged from skilled nursing, the plan was for the resident to transfer to an LTC setting where the resident would have supervision, and was chosen because the resident was not able to take of herself. He said no one discussed whether it was safe for the resident to discharge home with him. He also said that based on his experience, the resident self-limitations are why the resident needed supervision, and required a lot of encouragement to do things, and refused to do things. On April 20, 2022 at 11:18 a.m., an interview was conducted with the Assistant Director of Nursing (ADON/staff #19), who stated that when she discharges a resident, the Skilled Nursing Review team reviews and decides if discharges are safe, what services are needed, and therapy attends meetings for both skilled and LTC residents. The ADON stated standby supervision means you are within reach to assist the resident for safety reasons. She stated standby supervision is used to encourage the resident and provide cues to ensure the resident is doing the task correctly. An interview was conducted on April 21, 2022 at 8:55 a.m. with the Administrator (staff #143), Vice President of Clinical Operations (staff #139), and the Corporate Compliance Director (staff #141). Staff #143 stated that there is a team meeting when a resident is being discharged from LTC, and therapy is not included. He stated that when it is determined that a resident requires supervision, it is to minimize the outcome of an adverse event. He stated that resident #173 was a resident driven discharge and the resident did not want to pay for the share of cost for LTC. He said they wanted to make sure they put services in place to help the resident. He stated that if the resident goes AMA, they cannot put services in place because they need a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . He said it was not an ideal situation, the resident said she was going and they were trying to put services in place to create an environment that was as safe as possible. He stated 20 hours for home health care is the initial allotment that is given to start and they re-evaluate and give more hours if needed. Staff #139 defined limited supervision as standing by and hands off to make sure the resident is safe, and limited assistance is about guiding someone, but does not include any hands on. She said it is the Director of Nursing's responsibility to complete the clinical review, put eyes on the resident, look at the MDS assessment and how it is coded, and to review the Certified Nursing Assistants and nurse progress notes when a resident is being discharged from LTC to determine the level of care and services needed. She stated the resident needs a safe shelter, food, and a safe environment. Staff #141 stated that it is the facility's process to contact APS when a resident leaves AMA. The facility's policy, Transfer or Discharge Notice, dated 2019 stated in determining the transfer location for the resident, the decision to transfer to a particular location will be determined by the needs, choices and best interest of that resident.

Based on personnel file review, staff interviews, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. Findings include: A review of the personnel file for the Activity Manager (AM/staff #54) revealed she was hired on March 1, 2018. Further review of the file did not reveal any evidence staff #54 had the qualifications for the position. An interview was conducted on April 20, 2022 at 11:18 a.m. with the Assistant Director of Nursing (ADON/staff #19), who stated that the Activity Manager is required to be certified for the position, and staff #54 is not certified. On April 20, 2022 at 12:37 p.m., an interview was conducted with the Administrator (#143), who stated that he is responsible for overseeing the Activity Manager and was aware that staff #54 does not have an activities certification. He stated it was his understanding that staff #54 had signed up for a class, but it got canceled due to COVID. He stated that he did not know if a class is available at this time, and does not know if staff #54 is signed up to take the class at this time. He stated that he will be following up on this. Review of the job description for the AM dated 2016 revealed the AM directs the development, implementation, supervision, and ongoing evaluation of the activities program. The AM directs the monitoring of the residents' responses as well as the evaluation of responses to the programs to determine if the activities meet the assessed needs. The job description did not include the qualifications for the position. Staff #54 signed the job description on March 1, 2018.

Based on clinical record review, staff interviews, facility document, and policy review, the facility failed to ensure one resident (#28) received treatment and care in accordance with professional standards regarding hospice and skin concerns. The deficient practice could result in hospice residents not receiving care and skin issues not being addressed. Finding include: Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview of Mental Status (BIMS) score was 0, which indicated severe cognitive impairment. The MDS assessment stated the resident needed extensive assistance with bed mobility, transfer, dressing, and personal hygiene. Regarding coordinated care with hospice: Review of a care plan dated February 25, 2022, included the resident is in hospice for the terminal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The interventions included hospice service to follow their protocol, treatment as ordered to ensure comfort, and nutrition and hydration to maintain comfort. Further record review of the resident's care plan revealed no evidence of interdisciplinary care that included hospice interventions. Record review of the certified nursing assistant task dated March 23, 2022 through April 20, 2022 stated bathing was not applicable, except March 27, 2022 which indicated a shower was provided. An interview was conducted on April 21, 2022 at 10:09 a.m. with a certified nursing assistant (CNA/staff #66). The CNA accessed the resident task record and stated the bathing was not applicable because she thinks resident #28 shower is provided by hospice. She stated she did not know when hospice comes in because she works day shift, and she does not see hospice. She stated she would not know if hospice gives showers or not because she does not see them. An interview was conducted on April 21, 2022 at 10:18 a.m. with a licensed practical nurse (LPN/staff #36), who stated she has worked in the facility for [AGE] years and she is familiar with resident #28, a hospice resident. The LPN stated she has not seen resident #28 today because a certified medication assistant (CMA) administered the resident's medications. An interview was conducted on April 21, 2022 at 10:25 a.m. with a CNA (staff #42). The CNA stated she has worked in the facility for about [AGE] years and she is also the shower aide. She stated the hospice CNAs do their own shower, and they have their own documentation. Staff #42 stated she thinks there is a hospice binder in the front. An interview was conducted on April 21, 2022 at 11:59 a.m. with the registered nurse/hospice case manager (RN/staff #140). The RN stated she has been the case manager for resident #28 since February 23, 2022 and that she is familiar with the resident. The RN stated hospice maintains a separate record and care plan from the facility. The RN stated the electronic calendar that contains the scheduled visits for hospice CNAs or RNs is only accessible to the hospice staff. She stated hospice develops their own care plan. She stated the facility does not know when hospice is going to visit the resident unless hospice calls the facility. The RN also stated there is no communication binder or schedule that communicates to the facility about the hospice scheduled visits, or care provided. The RN stated all the electronic records regarding the resident's care are kept within the hospice documents. An interview was conducted on April 21, 2022 at 1:09 p.m. with social services (staff #16), who stated she has invited hospice to a care plan conference but hospice does not attend. She stated there is no schedule for a hospice visit, and she did know when hospice is visiting. Staff #16 also stated she only knows hospice is coming when they check in at the front lobby. She accessed the hospice care plan and stated there is no input from hospice on the care plan. On April 22, 2022 at 10:55 a.m., documents were requested for the hospice binder, IDT (Interdisciplinary Team) care plan that included hospice, hospice progress notes, and ADL (activities of daily living) charting. Following the document request, the RN/clinical compliance director (staff #141) stated the hospice progress notes were faxed to the facility and scanned in the resident's electronic record. She accessed the medical record which revealed ADL charting that showers were provided by the hospice CNA. Staff #141 also stated there is no hospice binder and that there is no interdisciplinary care plan that includes hospice. However, direct care staff on the floor did not have any knowledge of the scanned hospice progress notes, ADL charting/shower, or care provided or not provided by hospice. Review of the facility policy, Hospice Program, stated a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. Review of the hospice contract dated October 2, 2018, included Interdisciplinary Team (IDT) Care Conferences, which stated hospice IDT members must confer with the appropriate staff to develop a plan of care prior to the initiation of services. The IDT members shall inform the provider about the plan of care. Care conferences will be scheduled every two weeks thereafter to update changes in the resident's condition and in the plan of care. Regarding skin concern: An observation was conducted of the resident on April 19, 2022 at 10:50 a.m. Resident #28 was lying in bed and the resident's left wrist was observed to have a bruise/discoloration that was not finger-like in pattern. Following the observation, an interview was conducted with a CNA (staff #67) who stated she had seen the bruising on the left wrist and that the resident did not know how she got the bruise. Following this interview, an interview was conducted with another CNA (staff #24), who stated she had not seen the bruise on the resident's left wrist, and that it did look like bruising. An observation was conducted on April 21, 2022 at 9:20 a.m. The resident was lying in bed facing the window, the bed was against the wall, and the head of the bed was facing away from the door. The resident's left arm was uncovered, and the left wrist was observed to have a dark cherry discoloration extending to the medial left wrist. Resident #28 stated she could not say where the discoloration came from. Review of the weekly skin assessments dated March 31, April 7, and April 14, 2022 revealed a wound on the coccyx but did not include any other skin integrity issues. Further review of the clinical record revealed no evidence that the cherry red discoloration on the resident's left wrist had been identified. Review of the physician orders revealed no order for anticoagulant therapy. An interview was conducted on April 21, 2022 at 10:12 a.m. with a CNA (staff #43). The CNA stated the resident required total care for ADLs, and extensive assistance of one person for turning and repositioning. Staff #43 stated the resident had to be gently pushed because the resident can only move a little. The CNA stated she saw discoloration on the resident's bottom, she notified the charge nurse, and would chart the discoloration on the PCC (point click care). An interview was conducted on April 21, 2022 at 10:18 a.m. with a licensed practical nurse (LPN/staff #36), who stated she was familiar with resident #28. The LPN stated the resident needed total care, a hospice resident. The LPN stated the process of completing a weekly skin check included a head to toe assessment looking for bruises, skin tears, and skin discoloration. She also stated that if anything was found abnormal during the skin check, it would be documented, an incident report completed, and she would notify the physician/family. She stated the incident reports are kept in the PCC under risk management. The LPN stated if the Certified Medication Assistant or CNA reported anything unusual about the resident's skin, she would have completed an accident report so it could be investigated. An interview was conducted on April 21, 2022 at 10:42 a.m. with a RN/vice president of the clinical operations (staff #139). The RN stated the process for when a bruise is found included completing an incident report, alerting the wound nurse, and notifying the physician. She also stated if it is not a suspicious bruise, it will be noted on the weekly skin check, and if the resident requires total care and ends up with a bruise, it will be investigated. A phone interview was conducted on April 21, 2022 at 11:15 a.m. with the CNA (staff #67) who stated she saw the discoloration on the resident's left wrist. She stated after she saw the bruise she immediately reported it to the ADON (staff #19). An interview was conducted on April 21, 2022 at 11:22 a.m. with the RN/ADON (staff #19), who stated the bruise was reported to her by the CNA and she told an LPN (staff #71) to complete an incident report and notify the doctor. The ADON accessed the resident's record, then stated she did not see documentation that the bruise was investigated. An interview was conducted on April 21, 2022 at 11:59 a.m. with the hospice case manager (staff #140) who stated she visits the resident every Thursday. She stated during her visits, she completes a head to toe assessment, takes vital signs, and assesses the resident for infection and pain. Staff #140 stated she saw the resident on Thursday (April 14, 2021), and she did not see a bruise or discoloration on the resident's left wrist. Staff #140 stated she looked at the resident's left wrist, and it looks like there is a bruise on the left wrist and part of the inner wrist. Review of the facility's policy Wound Management Program revealed a thorough head to toe assessment of each resident's skin will be completed on admission and at least weekly thereafter.

Based on observations, clinical record review, staff interviews, and the facility's policy and procedure, the facility failed to ensure one resident (#46) with a pressure ulcer consistently received care and services consistent with professional standards of practice to promote the prevention of pressure ulcer development. The sample size was 2. The deficient practice could result in residents developing pressure ulcers. Finding include: Resident #46 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission skin assessment dated [DATE] stated the resident's heels were boggy, right heel with circular protruding callus, and that the heel off-loading boots were in place and ordered. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan focus dated March 18, 2022 stated the resident has a potential impairment to skin integrity related to mobility, and has boggy heels. The care plan interventions included pressure relieving/reducing mattress, pillows, sheepskin padding, etc., to protect skin while in bed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 which indicated the resident had severe cognitive impairment. The MDS assessment stated the resident needed extensive assistance with bed mobility, transfer, dressing, personal hygiene and toilet use. The MDS assessment included the resident has a pressure ulcer and is at risk for developing pressure ulcers, and is on a pressure reducing device for the bed and is receiving application of dressings to the feet. Review of Treatment Administration Record dated April 2022 revealed no evidence skin prep was applied to the resident's heels and that heel off-loading boots were in place while the resident was in bed on April 5 and 14, 2022 on the 12-hour day shift as the boxes were blank. An observation was conducted on April 18, 2022 at 12:21 PM, the resident was observed lying in bed wearing a hospital gown. The resident was partially covered with a white sheet from the waist line to just below the knees, with the lower legs and feet exposed. The heel off-loading boots were observed lying directly on the mattress and not on the resident. The resident stated she took the blanket off because it was too warm. A second observation was conducted on April 20, 2022 at 7:57 AM. The resident was observed in bed wearing a hospital gown with the head of the bed elevated to a high fowler's position having breakfast. The resident's feet were lying directly on the mattress, there were no off-loading boots to the bilateral heels. An interview was conducted on April 21, 2022 at 3:07 PM with a Registered Nurse (RN/staff #19). The RN stated if a physician ordered a heel floating device, it should be on as ordered. The RN also stated that not putting on the off-loading heel device can lead to the heels breaking down which can lead to infection. An interview was conducted with the acting Director of Nursing (staff #139), who stated her expectation is that if a physician ordered a device to float the heels, the staff should float heels. She also stated if the heels are not floated there could be skin breakdown to the resident's heels. Review of the facility's policy, Wound Management Program, revealed the facility provides a comprehensive wound management program with a goal to promote the highest level of functioning and wellbeing of their residents and to minimize the number of residents that develop in house acquired pressure ulcers. The policy also revealed identifying residents at risk for wounds included completing a thorough head to toe assessment of each resident's skin on admission and weekly thereafter. The policy stated those residents with current wounds will be assessed for off-loading devices and receive education on proper positioning and position change frequency.

Based on observations, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one resident (#275) was placed on contact isolation precautions and that the resident's wound was covered. The deficient practice could result in the spread of infection. Findings include: Resident #275 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a laboratory result with a specimen collection date of April 6, 2022 and a result date of April 8, 2022 stated an aerobic culture result of 2+ [CONDITION(S)]. The laboratory result included a corrected result that stated, previously reported as staphylococcus aureus on 4/7/2022, [CONDITION(S)] resistant staph aureus, patient may be an isolation risk. Review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The note also stated the resident was in bed, the wound site was with increased subcutaneous or intramuscular fluid collection, and that it was unsafe to drain at the bedside. The note included wound #3 abdomen-right lower quad (RLQ) dressing/recommendation daily-dry protective dressing. Review of the Health Status Notes dated April 15 and 16, 2022 revealed the JP (Jackson Pratt) drain came out, the resident was sent to the hospital and returned to the facility. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Infection Surveillance Report Note dated April 19, 2022 revealed symptoms were first observed April 9, 2022, that a wound culture was done at the hospital, the resident was receiving the antibiotic [MEDICATION(S)], and that there were no isolation precautions. An observation was conducted on April 18, 2022 at 12:21 p.m. The resident was observed lying flat in bed with eyes closed. A bedside table was on the left side of the bed with a meal tray still covered. The resident was covered with a white sheet up to the waist line, and on the sheet were two circular dark red spots near the resident's right hip, one the size of a quarter, and the other the size of a half dollar coin. A second observation of the resident was conducted on April 21, 2022 at 2:51 p.m. The resident was observed lying in bed wearing a dark maroon long sleeve shirt that was pulled up above the waist. The resident's right lower quadrant abdominal surgical incision was observed with no dressing, no JP drain, and the surgical incision line had crusted beige dried flakes along the suture lines. The white bed sheet touching the surgical wound had diffused specks of brownish spots. Following this observation an interview was conducted with the resident in Spanish. The resident stated the surgical incision was tender, painful 4/10 on a pain scale, and warm to touch. The resident stated it hurts when the wound touches the shirt and the bed cover. The resident stated the nurse was administering medicine for the wound. An interview was conducted on April 21, 2022 at 3:28 p.m. with a Licensed Practical Nurse (LPN/staff #90). She stated that when a resident has [CONDITION(S)] in the wound with no dressing or not contained, the resident should be on contact isolation. She stated the process for isolation included putting a Stop Sign outside the resident's door, and an isolation cart with all the PPE (Personal Protective Equipment) is placed outside the room. The LPN stated everyone who is entering the resident's room should wear PPE, especially the person who is doing the dressing changes. During the interview, the LPN reviewed the resident's clinical record and stated the resident was sent out to the emergency roiagnom on Friday (April 15, 2022) because the resident had pulled out the JP drain tube. She stated the resident returned to the facility without the JP drain. An interview was conducted on April 21, 2022 at 3:45 p.m. with the Infection Control Nurse (ICP/staff #19). The ICP accessed the medical record and stated the resident's wound culture result was positive for [CONDITION(S)] on April 6, 2022 at 12:22 p.m. The ICP stated the wound should have been covered and the resident should have been placed on contact isolation. The ICP stated she reviewed the clinical record and there was no documentation that the wound was colonized. An interview was conducted on April 21, 2022 at 4:07 p.m. with the acting Director of Nursing (staff #139). She accessed the resident's clinical record and stated the dressing should have been placed on the resident's surgical wound. She further stated that if there is [CONDITION(S)] in the wound, the facility follows the policy for contact precaution and isolation discontinuation policy. A facility policy titled, Isolation-Categories of Transmission-Based Precaution (TBP), stated standard precaution shall be used when caring for residents at all times regardless of their suspected or confirmed infectious disease. The policy included transmission-based precaution shall be used when caring for residents who are documented or suspected to have infectious disease that can be transmitted to others. The policy included that based on CDC (Centers for Disease Control and Prevention) definitions, the three types of TBP are airborne, droplet, and contact. Examples of infections requiring contact precautions, included infections with multi-drug resistant organisms. The policy stated to place the resident in a private room if possible, PPE, dedicated non-critical care equipment and signs to alert staff to the type of precaution the resident requires. The facility policy titled, Isolation-Discontinuing, stated that isolation precautions will be discontinued when it is determined that a resident no longer requires such precautions. The resident will remain on appropriate precautions until the attending physician or the Infection Control Preventionist (ICP) orders them discontinued. The policy also included the ICP has the authority to order and discontinue isolation precautions when necessary. The ICP shall consult the attending physician and/or medical director and infection control committee regarding such decisions.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure a baseline care plan was developed and implemented with interventions regarding the use of a Bilevel Positive Airway Pressure ([MEDICAL CONDITION]) and/or Continuous Positive Airway Pressure ([MEDICAL CONDITION]) machine for one resident (#14). The deficient practice may result in the resident not being provided the services and person-centered care necessary to meet his/her needs. Findings include: Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nursing progress note dated February 18, 2020 at 9:30 p.m. included the resident was admitted with a [DIAGNOSES REDACTED]. It also included the resident required a [MEDICAL CONDITION] with 2 liters of oxygen. The Admission plus Self Care and Mobility (GG) for Patient Driven Payment Model (PDPM) dated February 18, 2020 revealed the reason for admission was acute [MEDICAL CONDITION] and that the resident used a [MEDICAL CONDITION] machine. The altered respiratory status/difficulty breathing care plan initiated on February 18, 2020 related to the [DIAGNOSES REDACTED]. Interventions included administration of medications/puffers and oxygen as ordered. However, the care plan did not identify the need or use of a [MEDICAL CONDITION] machine and interventions to include checking and cleaning of the machine, humidifier, filter and tubing. Review of the oxygen saturation summary dated February 19, 2020 revealed the resident was on oxygen via nasal cannula and [MEDICAL CONDITION] machine. The Daily Skilled assessment dated [DATE] revealed the resident had [MEDICAL CONDITION] machine. A physician late entry progress note dated February 21, 2020 included the resident was not compliant with his [MEDICAL CONDITION] use for nocturnal [MEDICAL CONDITION]. A Daily Skilled assessment dated [DATE] revealed the [MEDICAL CONDITION] as the respiratory equipment for the resident. Review of the oxygen saturation summaries dated February 22 and 23, 2020 revealed the resident had oxygen via nasal cannula and [MEDICAL CONDITION]. A Daily Skilled assessment dated [DATE] at 3:23 p.m. revealed [MEDICAL CONDITION] as a respiratory equipment for the resident. Despite documentations the resident was using the [MEDICAL CONDITION]/[MEDICAL CONDITION] machine, there was no evidence the baseline care plan was developed with interventions to address the resident's need for the use of the [MEDICAL CONDITION]/[MEDICAL CONDITION] machine. On January 12, 2021 at 2:42 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #27) who stated that the admitting nurse writes the baseline care plan as part of the admission assessment. She said the MDS (Minimum Data Set) nurse writes the comprehensive care plan based on the documentation of the admitting nurse. Staff #27 further stated it is the responsibility of the admitting nurse to ensure the assessments and orders that include the use of [MEDICAL CONDITION]/[MEDICAL CONDITION] machine were complete and accurate because the baseline care plan is based on this information. An interview with another LPN (staff #20) was conducted on January 13, 2021 at 9:12 a.m. The LPN stated management staff that included the Director of Nursing (DON), Unit Manager and the MDS coordinator should ensure all orders including the use of [MEDICAL CONDITION]/[MEDICAL CONDITION] were identified and care planned with interventions in place. She stated when the use of [MEDICAL CONDITION]/[MEDICAL CONDITION] is not care planned and she was not told about it during her shift, she would not know whether to use the [MEDICAL CONDITION]/[MEDICAL CONDITION] machine on the resident or not. On January 13, 2020 at 9:23 a.m. an interview with the MDS coordinator (staff #8) was conducted Staff #8 stated the admitting nurse enters the physician orders [REDACTED]. She stated the nursing staff checks the entry but the admitting nurse is ultimately responsible in ensuring orders for the use of [MEDICAL CONDITION]/[MEDICAL CONDITION] machine are in place. Staff #8 further stated the resident's care plan and the interventions put in place would be based on the information collected on admission. An interview was conducted with the DON (staff #17) on January 13, 2021 at 9:43 a.m. The DON stated the base line care plan is created during the admission assessment; and, if the admitting nurse checked, identified or documented anything related to the use of [MEDICAL CONDITION]/[MEDICAL CONDITION] machine, a baseline care plan should be created with interventions to address this identified need. She stated a more comprehensive care plan would be created later. The DON stated she reviewed clinical record of resident #14 with the clinical resource nurse. The DON said the lack of a care plan on the use of the [MEDICAL CONDITION]/[MEDICAL CONDITION] machine for resident #14 did not meet her expectations. The facility policy titled, Care Plans, Comprehensive Person-Centered revealed a 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.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure there was a physician order [REDACTED]. Findings include: Resident #14 was admitted on [DATE] with [DIAGNOSES REDACTED]. -Regarding oxygen use: The Admission plus Self Care and Mobility (GG) for Patient Driven Payment Model (PDPM) dated February 18, 2020 revealed acute [MEDICAL CONDITION] as the reason for admission at the facility. The assessment included the resident was alert and oriented to person, place, time, and situation; had a regular respiratory rate and had an oxygen saturation level of 93%. The care plan on altered respiratory status/difficulty breathing dated February 18, 2020 included [DIAGNOSES REDACTED]. Interventions included to administer oxygen as ordered. The care plan did not include interventions related to the care such as checking for the flow of oxygen and cleaning of tubing. A health status note dated February 18, 2020 included the resident was admitted with a [DIAGNOSES REDACTED]. Per the documentation, the resident had clear lung sounds, had and even and unlabored respirations and required a [MEDICAL CONDITION] with 2 liters of oxygen with no shortness of breath noted. However, the clinical record revealed no evidence of a physician order [REDACTED]. The Oxygen Saturation Summary dated February 18, 2020 indicated the resident's oxygen saturation level was 92% with [MEDICAL CONDITION]. The documentation did not include the dose and frequency of oxygen administered to the resident. Review of a Daily Skilled assessment dated [DATE] revealed the resident was alert and oriented to person and place. The respiratory section that included use of respiratory equipment such as oxygen was not marked or answered. The Oxygen Saturation Summary revealed that on February 19, 2020 the resident had the following oxygen saturation readings of 88% and 94% with oxygen via nasal cannula. However, the summary did not include the dose and frequency of oxygen administered. The Daily Skilled assessment dated [DATE] revealed the resident was alert and oriented to person, place, time and situation, had a regular respiratory rate, rhonchi (similar to wheezing) and shortness of breath while lying flat. Respiratory equipment included use of oxygen. The Oxygen Saturation Summary dated February 20, 2020 revealed the oxygen saturation level was 92% with oxygen via nasal cannula. The documentation did not include the dose and frequency of oxygen administered. Despite documentation of use of oxygen from February 18 through 20, 2020, the clinical record revealed no evidence of a physician order [REDACTED]. A physician late entry progress note dated February 21, 2020 included a past medical history included [MEDICAL CONDITION] [MEDICAL CONDITION] hypertension and obstructive sleep apnea (OSA). The note included resident was alert and oriented x2, had an oxygen saturation of 96% at room air, and had a clear, even and unlabored respiration. Assessment included acute [MEDICAL CONDITION] with hypercapnia requiring intubation due to pneumonia, severe [MEDICAL CONDITION] hypertension, [MEDICAL CONDITION], OSA and noncompliance with [MEDICAL CONDITION]. The documentation did not include whether the resident used oxygen or not. The Oxygen Saturation Summary dated February 21, 2020 revealed oxygen saturation level of 96% with oxygen via nasal cannula. The documentation did not include the dose and frequency of oxygen administered. The Daily Skilled assessment dated [DATE] revealed the resident was alert and oriented to person, place, time and situation, had a regular respiratory rate and clear breath sounds. The use of oxygen was not marked or answered. The Oxygen Saturation Summary dated February 23, 2020 revealed the resident's oxygen saturation level was 90% with oxygen via nasal cannula. The documentation did not include the dose and frequency of oxygen administered. The Daily Skilled assessment dated [DATE] revealed the resident was alert and oriented to person, place, time, and situation, that he had a regular respiratory rate and clear breath sounds. Respiratory equipment included use of oxygen. The documentation did not include the dose and frequency of oxygen the resident received. Despite documentation of continued use of oxygen, the clinical record revealed no evidence an order was obtained and the physician was notified of the lack of an order for [REDACTED]. -Regarding use of [MEDICAL CONDITION]/[MEDICAL CONDITION] machine: The Admission plus Self Care and Mobility (GG) for Patient Driven Payment Model (PDPM) dated February 18, 2020 revealed acute [MEDICAL CONDITION] as the reason for admission at the facility. The assessment included the resident used a [MEDICAL CONDITION] machine. However, the assessment did not include the settings, duration and frequency for the use of [MEDICAL CONDITION] machine. The care plan on altered respiratory status/difficulty breathing dated February 18, 2020 included [DIAGNOSES REDACTED]. The care plan did not identify the need the use of a [MEDICAL CONDITION] machine and any interventions such as checking and cleaning of the machine, humidifier, filter or tubing. A health status note dated February 18, 2020 included that resident was admitted with a [DIAGNOSES REDACTED]. According to the documentation, the resident required a [MEDICAL CONDITION] with 2 liters of oxygen. The Oxygen Saturation Summary dated February 18, 2020 indicated the resident's oxygen saturation level was 92% with [MEDICAL CONDITION]. The Oxygen Saturation Summary revealed that on February 19, 2020 the resident had oxygen saturation reading of 92% using a [MEDICAL CONDITION] machine. The Daily Skilled assessment dated [DATE] revealed the resident was alert and oriented to person, place, time and situation, had a regular respiratory rate, rhonchi and shortness of breath while lying flat. Respiratory equipment included the use of [MEDICAL CONDITION]. The Oxygen Saturation Summary dated February 20, 2020 included an oxygen saturation of 96% using a [MEDICAL CONDITION]. Despite documentation of use of [MEDICAL CONDITION]/[MEDICAL CONDITION] machine from February 18 through 20, 2020, the clinical record revealed no evidence of a physician order [REDACTED]. The Daily Skilled assessment dated [DATE] revealed the resident was alert and oriented to person, place, time and situation, had a regular respiratory rate, rhonchi to the left upper lung field, non-[MEDICAL CONDITION] to bilateral lower extremities and shortness of breath while lying flat. Respiratory equipment included use of a [MEDICAL CONDITION] machine. A physician late entry progress note dated February 21, 2020 included a past medical history included [MEDICAL CONDITION] [MEDICAL CONDITION] hypertension and obstructive sleep apnea (OSA). The note included the resident had an oxygen saturation was 96% at room air. Assessment included acute [MEDICAL CONDITION] with hypercapnia requiring intubation due to pneumonia, [MEDICAL CONDITION], OSA and noncompliance with [MEDICAL CONDITION]. The Daily Skilled assessment dated [DATE] revealed the resident was alert and oriented to person, place, time, and situation, that he had a regular respiratory rate and clear breath sounds. Respiratory equipment included the use of a [MEDICAL CONDITION] machine. A Discharge assessment dated [DATE] revealed the resident was lying in bed, was lethargic and was hard to awaken. Per the documentation, the resident was difficult to wake up and the [MEDICAL CONDITION] was applied. The physician was notified and resident was transferred to the hospital. Despite documentation of continued use of [MEDICAL CONDITION]/[MEDICAL CONDITION] machine the clinical record revealed no evidence an order for [REDACTED]. On January 12, 2021 at 2:06 p.m. an interview was conducted with a Registered Nurse (RN/staff #30) who stated when a resident is admitted with an oxygen and [MEDICAL CONDITION]/[MEDICAL CONDITION] machine, the admitting nurse or the unit manager is responsible in ensuring there is a physician order [REDACTED]. An interview was conducted on January 12, 2021 at 2:42 p.m. with a Licensed Practical Nurse (LPN/staff #27) who stated the admitting nurse takes the report from the hospital before the resident arrives at the facility. She said the admitting nurse would review all the orders and transcribe them into the clinical record. Staff #27 stated that another nurse would verify all the orders are accurate and complete before they become active. In an interview with another LPN (staff #3) conducted on January 13, 2021 at 8:43 a.m., she stated a resident admitted with obstructive sleep apnea may have orders for oxygen and [MEDICAL CONDITION]/[MEDICAL CONDITION] use which would be transcribed in the clinical record. Staff #3 said any resident with breathing problems would be assessed once per shift and as needed. Staff #3 stated a resident who requires but has no orders for oxygen and/or [MEDICAL CONDITION]/[MEDICAL CONDITION] use may manifest signs and symptoms of too much carbon [MEDICATION NAME] in the system such as trouble/shortness of breathing, hyperventilation, low oxygen, drowsiness, disorientation and confusion. She stated the physician would be notified when these symptoms occur. On January 13, 2021 at 8:57 a.m. an interview was conducted with a Registered Nurse (RN/staff #22) who stated a resident with [DIAGNOSES REDACTED]. On January 13, 2020 at 9:23 a.m. an interview was conducted with the MDS coordinator (staff #8). She stated the admitting nurse enters the physician orders [REDACTED]. Staff #8 stated a second nurse verifies the data for accuracy. She also stated nursing staff checks the entry in the clinical record but the admitting nurse was ultimately responsible in ensuring there are orders for the use of an oxygen and/or [MEDICAL CONDITION]/[MEDICAL CONDITION]. Staff #8 said the nurse would call the provider and get an order for [REDACTED].#8 who stated the clinical record has documentation that resident #14 was using oxygen and [MEDICAL CONDITION] machine. However, the admission orders [REDACTED]. An interview was conducted with the Director of Nursing (DON/staff #17) on January 13, 2021 at 9:43 a.m. She stated the process for admission begins with the referral and discharge orders. She stated that upon admission, the discharge orders would be noted into the system, the physician would be notified and requests for any additional orders would be made. She said there were no orders for oxygen and [MEDICAL CONDITION]/[MEDICAL CONDITION] use and this did not meet her expectations. The facility policy on Oxygen Administration stated a purpose to provide guidelines for safe oxygen administration. The preparation included verification that there is a physician's orders [REDACTED]. The policy also revealed that after completing the oxygen set-up or adjustment, the following information should be recorded in the resident's medical record: -Rate of oxygen flow, route and rationale; -Frequency and duration of treatment; -All assessment data obtained before, during and after the procedure; -How the resident tolerated the procedure. The facility titled Medication and Treatment Orders included the orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy stated medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. This includes standing orders. Orders for medications must include: the name and strength of drug, quantity or specific duration of therapy, dosage and frequency of administration, route of administration, and reason or problem for which it is given. The policy titled [MEDICAL CONDITION]/[MEDICAL CONDITION] Support included purposes to provide the spontaneously breathing resident with continuous positive airway pressure with or without supplemental oxygen, to improve arterial oxygenation in residents with respiratory insufficiency, obstructive sleep apnea, or restrictive/obstructive lung disease, and to promote resident comfort and safety. The policy also included that only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a [MEDICAL CONDITION] mask, and to review the resident's medical record to determine his/her baseline oxygen saturation or arterial blood gasses, respiratory, circulatory, and gastrointestinal status. Further of the policy revealed the documentation in the resident's record should include: a general assessment (including vital signs, oxygen saturation, respiratory, circulatory, and gastrointestinal status) prior to procedure; the time [MEDICAL CONDITION] was started and the duration of the therapy; oxygen concentration and flow, if used; how the resident tolerated the procedure; and oxygen saturation during therapy.

Based on observations, facility documentation, staff interviews, review of the Centers for Disease Control (CDC) and the World Health Organization (WHO) recommendations and policies and procedures, the facility failed to ensure that infection control standards were implemented on the COVID negative section. These deficient practices could result in the spread of infections including COVID-19 to staff and residents. Findings include: Review of the facility's floor plan revealed that part of the 200 Hall was designated as the active COVID section and another part was designated as the recovered COVID transitional section.The 400 and 500 halls were designated as the COVID negative section. Review of the resident census revealed that between July 8, 2020 and July 22, 2020, 16 residents had been admitted or readmitted to the facility from July 10-21, 2020 and were housed on the COVID negative section, and were current residents at the time of the survey. Observations were conducted on July 22, 2020 at 9:15 a.m. on the COVID negative section, where the 16 residents resided. Observations revealed there were no signs or instructions on the outside of this unit that notified staff/visitors regarding the personal protective equipment (PPE) that was required for this unit. There was also no sign/instructions outside of these resident's room indicating the type of isolation precautions that were in place (i.e. droplet, contact, airborne). Further observations revealed that multiple staff entered these rooms with a gown on and then exited the rooms without changing their gowns, and then entered other resident rooms. An interview was conducted on July 22, 2020 at 9:20 a.m. with a Certified Nursing Assistant (CNA/staff #95) on the COVID negative section. He stated that he did not know why there were no instructions for what personal protective equipment (PPE) was required for this section or any instructions indicating the type of isolation (i.e. droplet, contact, airborne). In an interview on July 22, 2020 at 9:45 a.m. with a CNA (staff #191), she stated that full PPE was required at all times to work on the COVID negative section of the facility. An interview with the Infection Preventionist (staff #29) was conducted on July 22, 2020 at 12:00 p.m. Staff #29 stated that the active COVID section was for confirmed cases of COVID-19; the recovered COVID transitional section was for residents who have recovered from COVID-19 and are being monitored for transfer off that unit or suspected cases of COVID-19 that require further monitoring; and the 400 and 500 Hall was the designated COVID negative section. She said there are no confirmed COVID in the building. She stated that the facility does not isolate new resident admissions or re-admissions for 14 days, but does monitor them for seventy-two (72) hours up to seven (7) days after admission for signs and symptoms of COVID. When questioned regarding the CDC recommended practice of a 14 day isolation for all new admissions or re-admissions, staff #29 had no explanation. She further stated that full PPE is required to work on the COVID negative section and that every resident is treated as though they are suspected of COVID. An interview with the Administrator (staff #1) was conducted on July 22, 2020 at 3:00 p.m. He stated that full PPE is required to be on the COVID negative section of the facility. -Additional observations were conducted on July 22, 2020 at 9:30 a.m. on the COVID negative section. One resident on the unit was on isolation precautions for COVID and another resident was on isolation for [MEDICAL CONDITIONS]. There were hanging containers on the doors which contained PPE. However, there was no signage on the outside of the doors notifying staff/visitors to check with staff prior to entering, there were no instructions regarding the type of isolation that the residents were on and no instructions regarding additional PPE that was required. In an interview on July 22, 2020 at 9:35 a.m., a CNA (staff #191) stated that she did not know why there were no isolation signs placed outside the resident rooms. An interview was conducted on July 22, 2020 at 10:00 a.m. with a CNA (staff #79) on the COVID negative section, who stated that there was one resident who was suspected of COVID and another resident who had [MEDICAL CONDITION]. Staff #79 acknowledged that there was no signage on the outside of these rooms to inform staff/visitors to check with clinical staff prior to entering, there were no instructions regarding the type of isolation that the residents were on (i.e. droplet, contact, airborne precautions) and no instructions for additional PPE that was required. Staff #79 stated that this was a concern, as staff and visitors should know. During an interview with the Infection Preventionist (staff #29) on July 22, 2020 at 12:00 p.m., she stated that the facility process is to hang yellow PPE containers on the resident's room doors to indicate an isolation resident. Staff #29 agreed that there were no signs for staff/visitors to see clinical staff prior to entering, or any instructions indicating the type of isolation that these residents were on and what PPE was required for these residents. She stated that full PPE is required to work on the COVID negative section and that every resident is treated as though they are suspected of COVID. An interview with the Administrator (staff #1) was conducted on July 22, 2020 at 3:00 p.m. He stated that a yellow container with PPE is placed on the resident's door to indicate the resident is on isolation. He agreed that there was nothing to instruct staff/visitors to check with staff/visitors before entering, or instructions to indicate the type of isolation and the required PPE that was needed. The Administrator stated that full PPE is required to be in the COVID negative section of the facility. Review of the WHO recommendations titled, Infection Prevention and Control guidance for Long-Term Care Facilities in the context of COVID-19 dated March 21, 2020, revealed that if a resident is suspected to have, or is diagnosed with [REDACTED]. According to the CDC recommendations titled, Responding to Coronavirus (COVID-19) in Nursing Homes dated April 30, 2020, all recommended COVID-19 PPE should be worn during care of residents under observation. Newly admitted or readmitted residents should be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. The CDC recommendations for the Coronavirus Disease 2019 included that infection control procedures including administrative rules and engineering controls, environmental hygiene, correct work practices and appropriate use of PPE, are all necessary to prevent infections from spreading during healthcare delivery. All healthcare facilities must ensure that their personnel are correctly trained and capable of implementing infection control procedures, and that individual healthcare personnel should ensure they understand and adhere to infection control requirements. Review of the CDC recommendations titled, Preparing for COVID-19 in Nursing Homes dated July 16, 2020 revealed that consideration can be made to extend the use of isolation gowns (disposable or cloth) such that the same gown is worn by the same healthcare personnel when interacting with more than one patient known to be infected with the same infectious disease when these patients are housed in the same location (i.e., COVID-19 patients residing in an isolation cohort). This can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. A facility policy titled, Isolation-Categories of Transmission Based Precautions revealed the following for contact and droplet precautions: Regarding signs it stated that the facility will implement a system to alert staff to the type of precaution the resident requires. This facility utilizes the following system for identification of contact and droplet precautions: however, these sections were left blank. Review of a policy regarding [MEDICAL CONDITION] Outbreak, Infection Control Measures dated April 2, 2020 revealed if an outbreak of [DIAGNOSES REDACTED] CoV2 occurs within the facility, strict adherence to standard and transmission based precautions and other infection control measures will be implemented according to the most current CDC recommendations. A policy titled COVID-19 Policy and Procedure for Separation of LTC and New Residents dated April 17, 2020 revealed it is their policy to protect the health and well-being of our residents and staff during infectious disease outbreaks. The policy included that new residents will remain on the transition unit for a minimum of 14 days.

Based on clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to ensure that each residents drug regimen was free from unnecessary drugs, by failing to administer medications in accordance with physician's orders [REDACTED].#71 and #89). The deficient practice could result in residents receiving unnecessary medications. Findings include: -Resident #71 was admitted on (MONTH) 6, 2019, with [DIAGNOSES REDACTED]. The 14 day Minimum Data Set (MDS) assessment dated (MONTH) 20, 2019 revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. A hypertensive care plan dated (MONTH) 6, 2019 revealed a goal for the resident to remain free of complications related to hypertension through the review date. Interventions included to give antihypertensive medications as ordered, to monitor/record side effects such as orthostatic [MEDICAL CONDITION], increased heart rate, effectiveness and to report to the medical doctor as necessary. A physician's orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record (MAR) revealed that [MEDICATION NAME] 12.5 mg was administered on six occasions when the resident's SBP was below the order parameters as follows: September 10: PM shift for a blood pressure of 102/50 September 12: PM shift for a blood pressure of 88/49 September 13: PM shift for a blood pressure of 89/54 September 24: PM shift for a blood pressure of 100/58 September 26: PM shift for a blood pressure of 100/50 September 28: PM shift for a blood pressure of 102/49 Review of the (MONTH) 2019 MAR revealed that [MEDICATION NAME] 12.5 mg was administered on five occasions when the resident's SBP was below the order parameters as follows: October 1: PM shift for a blood pressure of 98/50 October 4: PM shift for a blood pressure of 100/59 October 5: AM and PM shifts for blood pressures of 92/41 and 99/51 October 6: AM shift for a blood pressure of 101/51 -Resident #89 was admitted on (MONTH) 18, 2019, with [DIAGNOSES REDACTED]. An altered cardiovascular status care plan dated (MONTH) 1, 2019 related to a [DIAGNOSES REDACTED]. Interventions included to assess the resident for chest pain every shift, enforce the need to call for assistance if pain starts, monitor/document/report to medical doctor as needed any signs or symptoms of [MEDICAL CONDITION], vital signs every shift and notify physician of any abnormal readings. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR revealed that [MEDICATION NAME] HCl 40 mg was administered on four occasions when the resident's pulse was below the order parameters as follows: September 20: AM shift for a pulse of 56 BPM September 23: AM shift for a pulse of 58 BPM September 24: PM shift for a pulse of 58 BPM September 26: AM shift for a pulse of 55 BPM Further review of the (MONTH) 2019 MAR revealed that [MEDICATION NAME] 25 mg was administered once when the resident's pulse was below the ordered parameters as follows: September 26: AM shift for a pulse of 55 BPM Review of the (MONTH) 2019 MAR revealed that [MEDICATION NAME] HCl 40 mg was administered on four occasions when the resident's pulse was below the order parameters as follows: October 2: PM shift for a pulse of 58 BPM October 5: AM shift for a pulse of 56 BPM, and a second dose on the same date for a pulse of 58 BPM On (MONTH) 8, 2019 at 1:19 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #68). She stated her process for administrating an antihypertensive medication included reviewing the resident's blood pressure and pulse to discern whether or not it would be appropriate to give the medication. She said if the blood pressure is too low, she would hold the medication and make a note on the MAR and in the resident's clinical record. On (MONTH) 9, 2019 at 9:14 a.m., an interview was conducted with the Director of Nursing (DON/staff #121). She stated her expectation for nurses who are administrating an antihypertensive medication would include to review the resident's blood pressure and pulse, and hold the medication if either was below the physician's orders [REDACTED]. The facility policy titled, Administering Medications stated that medications shall be administered in a safe and timely manner, and as prescribed. The policy also included that medications must be administered in accordance with the orders and that vitals signs must be checked/verified, prior to administering medications.

Based on clinical record reviews, staff interviews and policy review, the facility failed to ensure two of five sampled residents (#42 and #71) receiving PRN (as needed) psychoactive medications had 14 day stop dates or that the physician documented the rationale for its continued use. The deficient practice could result in resident's receiving medications that may not be necessary. Findings include: -Resident #42 was admitted to the facility on (MONTH) 3, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. This order did not include a fourteen day stop date. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 12, 2019 revealed the resident scored an 11 on the Brief Interview for Mental Status (BIMS), which indicated moderate cognitive impairment. The MDS included the resident was totally dependent with transfers and toileting and needed extensive assistance with bed mobility. In the Mood and Behavior sections, the resident was assessed to not have any mood or behavior concerns. According to the Medication Administration Record [REDACTED]. A pharmacy consultation report dated (MONTH) 13, 2019 included there is a PRN order for an anxiolytic, ([MEDICATION NAME] 5 mg every 24 hours as needed for anxiety) without a stop date. The recommendation was to discontinue the medication. The recommendation further included if the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy and the rationale for the extended time period. The rationale for the recommendation was that CMS (Center for Medicare and Medicaid Services) requires that PRN orders for non-antipsychotic [MEDICAL CONDITION] drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rationale for the extended time period and the duration for the PRN order. However, there was no physician's response to the recommendations and the report was not signed by the physician. A psychological evaluation (MONTH) 19, 2019 by a consultant Psychiatric Mental Health Nurse Practitioner revealed that [MEDICATION NAME] was not on the list of [MEDICAL CONDITION] medications. The evaluation included that staff report no new concerns, no behavioral disturbances and that overall the patient was doing well. Recommendations included to continue the current treatment plan, with no medication changes. Review of the MAR for (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] one time on (MONTH) 29. Further review of the clinical record revealed there were no orders for an end date for the as needed [MEDICATION NAME] for (MONTH) and (MONTH) 2019, and there was no documentation by the physician of the rationale for its continued use. A pharmacy consultation report dated (MONTH) 28, 2019 repeated the recommendation to discontinue the [MEDICATION NAME] 5 mg every 24 hours as needed related to an anxiety disorder. The recommendation further included if the medication cannot be discontinued at this time, current regulations require that the prescriber document the indication for use, the intended duration of therapy and the rationale for the extended time period. The physician agreed with the recommendation and to implement as written. The report was signed by the physician on (MONTH) 30, 2019. A psychological evaluation dated (MONTH) 31, 2019 by a consultant Psychiatric Mental Health Nurse Practitioner did not include [MEDICATION NAME] on the list of [MEDICAL CONDITION] medications. The evaluation included that staff report no new concerns and no behavioral disturbances. Recommendations included to continue the current treatment plan, with no medication changes. According to the (MONTH) 2019 MAR, [MEDICATION NAME] was not administered to the resident during the month. Review of the (MONTH) 2019 MAR indicated [REDACTED]. However, another physician's orders [REDACTED]. The order did not include a 14 day stop date or an end date. Further review of the clinical record revealed there was no documentation that the resident was experiencing any anxiety or of the rationale for restarting the [MEDICATION NAME] and the duration. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The (MONTH) 2019 MAR indicated [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. In an interview conducted on (MONTH) 10, 2019 at 10:10 a.m. with the Unit Manager (staff #66), she stated the Director of Nursing (DON) implements recommendations from the pharmacy that have been approved by the physician and sometimes the unit managers assist. She stated that sometimes the doctors will not allow us to discontinue the medication. She said that whenever she speaks with the physician she puts the interaction with the doctor into the computer. In an interview conducted on (MONTH) 10, 2019 at 10:28 a.m. with the DON (staff #121) and the Clinical Compliance Manager (staff #154), the DON stated that she receives recommendations from the pharmacy monthly and she puts them in the computer. She stated the unit managers do their portion if she has too many to do. The Clinical Compliance Manager stated that each [MEDICAL CONDITION] medication needs a 14 day limitation and a review by the physician at the end of that time and a rational to continue. -Resident #71 was admitted on (MONTH) 6, 2019, with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The order end date was listed as indefinite. Review of the clinical record revealed a [MEDICAL CONDITION] medication informed consent for [MEDICATION NAME] dated (MONTH) 7, 2019, which was signed by the resident. An antianxiety care plan included the resident received [MEDICATION NAME]. The goal was for the resident to be free from discomfort or adverse reactions related to antianxiety therapy through the review date. Interventions included to give antianxiety medications as ordered by the physician and to monitor/document side effects such as dry mouth, dry eyes, constipation, [MEDICAL CONDITION], depression, forgetfulness or suicidal ideation. A Nurse Practitioner (NP) progress note dated (MONTH) 16, 2019 included to change the [MEDICATION NAME] to 0.5 mg and continue to monitor. An order dated (MONTH) 16, 2019 inlcuded for [MEDICATION NAME] 0.25 mg, 2 tablets every 8 hours as needed for anxiety. The order end date was listed as indefinite. However, review of the clinical record revealed no documentation by the physician/prescriber of the rationale for it's continued use for an indefinite timeframe. The 14 day Minimum Data Set (MDS) assessment dated (MONTH) 20, 2019 revealed the resident scored 13 on the Brief Interview for Mental Status (BIMS) assessment, indicating she was cognitively intact. The assessment revealed the resident required extensive 2-person assistance with transfers and toileting, and that the resident received antianxiety medication for 7 out of 7 days of the lookback period. Review of the (MONTH) 2019 MAR indicated [REDACTED]. A physician's orders [REDACTED]. The order end date was listed as indefinite. However, review of the clinical record revealed no documentation by the physician/prescriber of the rationale for it's continued use for an indefinite timeframe. Review of the (MONTH) 2019 MAR indicated [REDACTED]. On (MONTH) 8, 2019 at 1:19 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #68). She stated that she gives the antianxiety medication as ordered by the physician. She said she had not noticed that the medication did not have a stop date. On (MONTH) 9, 2019 at 9:14 a.m., an interview was conducted with the DON. She stated her expectation for nurses regarding implementation of as needed [MEDICAL CONDITION] medication orders included obtaining a signed informed consent prior to administering the medication and ensuring their is clinical indication for it's use. She said she understood that as needed anxiolytic medications were to be prescribed for 14 days and if the provider decided to continue the medication, the expectation would be for the provider to document the rationale. She stated that the order should have an end date. A policy titled, [MEDICAL CONDITION] Medication Use included the facility should comply with the Psychopharmacological Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other applicable law relating to the use of psychopharmacological medications. The policy further included that as needed orders for [MEDICAL CONDITION] drugs should be limited to 14 days. If the physician or prescribing practitioner believes that it is appropriate for the as needed order to be extended beyond 14 days, he/she should document their rationale in the resident's medical record and indicate the duration of the as needed order.

Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure that during an altercation involving three residents (#17, #64 and #144), one resident (#64) was free from physical abuse by another resident (#144). The deficient practice could result in other residents being subjected to abuse. Findings include: -Resident #17 was admitted on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated (MONTH) 12, 2019 included the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated moderate cognitive impairment, and that the resident utilized a wheelchair. The MDS did not include that the resident had any mood or behavioral indicators. A care plan included that resident #17 had a communication problem related to difficulty expressing himself. An intervention was to be conscious of the resident's position when in groups, activities and the dining room to promote proper communication with others. -Resident #64 was admitted on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. A significant change MDS assessment dated (MONTH) 30, 2019 included the resident had a BIMS score of 13, which indicated intact cognition. Per the MDS, the resident had no mood or behavioral indicators. Review of a care plan for impaired hearing and ability to understand and be understood revealed multiple interventions including to be conscious of the resident's position when in groups, activities and the dining room to promote proper communication with others. A health status note dated (MONTH) 1, 2019 at 3:06 p.m. included that resident #64 had an altercation with another resident (#144) at noon, and had acquired a scratch to the face, just above the upper lip on the right side, and sustained a skin tear to the left forearm. The note included the sites were cleansed with normal saline, a dry dressing was applied to the upper lip, and that skin closures were applied to the skin tear on the left forearm. -Resident #144 was admitted on (MONTH) 16, (YEAR) and readmitted on (MONTH) 9, 2019, with [DIAGNOSES REDACTED]. An admission MDS assessment dated (MONTH) 16, 2019 included the resident had a BIMS score of 13, which indicated the resident was cognitively intact. The assessment also included that resident #144 used a wheelchair, had no functional limitation with range of motion and moved about the unit with supervision. The assessment included that the resident did not have any mood or behavioral indicators. A Social Service Admission assessment dated (MONTH) 11, 2019 included that resident #144 was oriented to situation, place, time and person. Review of an investigative report dated (MONTH) 8, 2019 revealed that on (MONTH) 1, 2019 at 12:30 p.m., resident #144 and resident #17 had a verbal disagreement in the dining room, which escalated to insults. The report included that resident #144 directed his wheelchair in an aggressive manner towards resident #17, and another resident (#64) intervened, and resident #144 scratched resident #64 on the face and arm. The resident's were separated and the police were called. The investigative report also included a statement by resident #144, who reported that a verbal altercation had occurred between himself and resident #17, and that during the altercation he was approached by another resident (#64). He reported that resident #64 slapped him and then he punched resident #64 in the face. Review of the clinical record revealed resident #144 did not have any previous aggressive behaviors towards other residents. The clinical record documentation further included that resident #144 was discharged to the community on (MONTH) 3, 2019. An interview was conducted on (MONTH) 8, 2019 at 1:00 p.m. with a CNA (Certified Nursing Assistant/staff #26), who stated that she was present in the dining room on (MONTH) 1, 2019 at noon. The CNA stated that resident #144 and #17 were arguing while trays were being served and suddenly she heard resident #64 shout out. She said that she turned and observed resident #144 punch resident #64 in the center of his face. The CNA stated that she immediately placed herself between resident #144 and #64 and that resident #64 tried repeatedly to reach around her to punch resident #144, but was unable to reach him. An interview was conducted on (MONTH) 9, 2019 at 10:57 p.m. with the Director of Nursing (DON/staff #155) and a Corporate Nursing Consultant (staff #154). The DON stated that if a resident is identified to be at high risk for aggressive or assaultive towards other residents, staff will observe the resident's behavior and if the resident does not cause any issues, they will assess the need for a higher level of care. The DON said if there is a situation that involves a resident behaving aggressively towards another resident, staff will separate the residents and investigate what happened. Review of the Abuse policy revealed that the facility strives to prevent the abuse of all their residents and 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. The policy included that abuse is the willful infliction of injury and includes verbal, physical and mental abuse and that potential abusers can be residents.

Based on observation, clinical record reviews, staff interviews, hospital records, and policy review, the facility failed to ensure that one resident (#35) received care and services to prevent the development of a pressure sore and failed to ensure one resident (#180) who was admitted with a pressure sore received the necessary treatment and services to promote healing and prevent infection. Findings include: -Resident #35 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Weekly Wound Progress Note dated October 31, 2014, revealed the resident had a facility acquired pressure ulcer on the left bunion, which was described as an open blister and measured 1.5 cm x 1.5 cm with no depth. The note further included the wound was from the left bunion area rubbing on sandals, and the resident was advised to wear shoes that don't rub. Review of the clinical record revealed there was no documentation that the resident was explained the risks of continuing to wear shoes that rubbed against the bunion area. physician's orders [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] in Section C., revealed a BIMS (Brief Mental Status) score of 14; indicating the resident was cognitively intact. The MDS also assessed the resident to be at risk for pressure ulcers, however, did not have any. A care plan dated November 7, 2014 for the potential of pressure sore development related to immobility, did not reflect the pressure ulcer to the left bunion area, nor any interventions addressing the concern that the resident was wearing shoes that rubbed against the area. Review of the Weekly Wound Progress Note dated November 12, 2014, revealed that the left bunion open blister had healed. Despite documentation that the wound had healed, clinical record documentation showed that the wound treatment continued to be provided from October 31 through November 20. According to a Prescriber Fax Notification Form dated November 20, 2014, the physician was notified that a blister was found on the resident's left foot that measured 1.5 cm x 1 cm. A physician's orders [REDACTED]. Review of the Weekly Wound Progress Note dated November 22, 2014, revealed the resident had an unstageable left bunion pressure ulcer that measured 3.0 cm x 3.5 cm. The note further included that the resident was noncompliant and continues to wear tight fitting closed shoes or sandals that fit snug over the bunion. The note included the left bunion now had "thick white eschar," the foot was reddened from mid foot down, and that the nurse will call the physician. A nurse's note dated November 22, 2014, documented that the left bunion was larger with "yellow" eschar and the resident is wearing hard rubber sandals, which apply pressure directly over area and that non skid socks were given. A Prescriber Fax Notification Form dated November 22, 2014, documented the resident had a left bunion open area that had initially healed and now had eschar, had increased redness, and increased drainage. Also noted was that the resident was noncompliant with wearing loose soft shoes/slippers. A physician's orders [REDACTED]. A care plan for infection of the left bunion wound dated November 22, 2014, included under risk factors that the resident was non compliant with wearing non skid socks. Interventions included the following: antibiotic as ordered, every shift charting and evaluation of symptoms and effectiveness of antibiotic, culture and sensitivity as ordered, and to encourage hydration and food intake. There were no interventions that were implemented to address the concern that the resident was non compliant with wearing the socks. A care plan for the left bunion wound dated November 22, 2014, included under precautions "soft slippers encouraged." Interventions included the following: assess needs and/or care plan interventions for prevention of further problems, assess area weekly, observe and report any signs of infection, and keep off affected area. Review of the Nurse's Notes dated November 24, 2014, revealed the resident's family member gave verbal consent to place the resident in non-skid socks and remove hard confining shoes and that the family member was to take home ill-fitting shoes. Review of the November 25, 2014 Weekly Wound Progress Note revealed that the left bunion unstageable pressure ulcer measured 3.0 cm x 3.5 cm and was covered with 100% thick "yellow eschar with copious drainage..." and had increased redness and swelling. The note also stated that the physician was notified, and an antibiotic and an antibiotic ointment were being provided. Review of the Weekly Wound Progress Note dated December 2, 2014, revealed the same measurements as above, and that the left bunion had "yellow eschar" and copious serous drainage. The note also included that the entire lower foot was reddened and swollen, and the resident was noncompliant and continues to attempt to wear shoes over dressing. The note further stated the family was notified and gave the facility permission to remove all shoes, but the resident keeps finding shoes or slippers to wear. The resident was advised not to wear anything that applies pressure due to infection and compromised circulation, which could cause her to lose her foot. The resident finally surrendered her shoes and was wearing non-skid socks. Review of the Weekly Wound Progress Note dated December 12, 2014, revealed the left bunion unstageable pressure ulcer measured 3.5 cm x 3.0 cm with no depth, the wound was covered with "yellow/tan eschar," and that a fissure was noted along the outer edge between one and three o'clock, which was 2 cm in length. The lower 1/4 of the foot remained reddened. Further review of the clinical record revealed there were no further wound assessments of the left foot bunion area from December 13, through 18. Review of a podiatrist report dated December 19, 2014, included that the 1st toe medial joint (bunion area) was infected and had a blacken area that was 2 cm in diameter. The treatment plan was to admit to the hospital. The resident was sent to the hospital for an infected pressure ulcer of the left bunion on December 19, 2014. Review of the re-admission orders [REDACTED]. The orders also included for a dressing change to the left foot as follows: cleanse with normal saline, apply WIC silver daily. Review of the Initial Wound Evaluation dated December 23, 2014, revealed the following interventions were in place: pressure reduction mattress, wheelchair cushion, and boot to left foot. However, there was no assessment of the wound that was documented which included a description of the wound bed, surrounding tissue, any drainage and measurements. A nursing note dated December 23, 2014, documented that the left foot had a special boot in place and that the left foot wound was tan in color, was moist and had no odor. No measurements were noted. Review of the Wound Culture Report dated December 25, 2014, revealed that the foot wound contained a rare gram positive cocci, and [MEDICAL CONDITION]. Review of a podiatrist wound care noted dated December 30, 2014, revealed the resident had a wound to the left medial great toe (area of bunion) with 100% black eschar. The note included that the wound was infected and the resident was receiving IV medication. Despite the resident having eschar to the left bunion area, a Braden Scale for predicting pressure sore risk dated December 30, 2014, assessed the resident to be at low risk. Review of the clinical record revealed no documented evidence that the pressure ulcer was assessed from December 31, 2014 through January 15, 2015. Review of the Weekly Wound Progress Note dated January 16, 2015, revealed that the left bunion was an unstageable pressure ulcer, which measured 2.75 cm x 2.5 cm x 0.2 cm depth, with tissue that was white and black. A care plan dated January 23, 2015, included the resident had a pressure ulcer to the left bunion. An intervention included for treatments per orders. Review of the Weekly Wound Progress Note dated January 23, 2015, revealed that the left bunion stage 4 pressure ulcer measured 3 cm x 2 cm with a depth of 0.2 cm. A physician's orders [REDACTED]. Review of the Weekly Wound Progress Note dated January 30, 2015, revealed the left bunion pressure ulcer measured 4.0 cm x 2.0 cm with a depth of 0.2 cm. Review of the Treatment Administration Record (TAR) for January 2015, revealed no documented evidence that the physician ordered treatment was done on January 31. Review of the February 2015 TAR revealed no documented evidence that the physician ordered treatment was done on February 1, 2015. A physician's orders [REDACTED]. Review of the Weekly Wound Progress Note dated February 6, 2015, revealed a left bunion stage 4 pressure ulcer which measured 3 cm x 2.5 cm with a depth of 0.2 cm, with a scant amount of drainage, slough, and "yellow/tan" wound bed. A physician's orders [REDACTED]. An observation of wound care was completed on February 12, 2015, with two registered nurses (RN) who had never seen the resident's wound on the left bunion, prior to today. During the removal of the old dressing, it was observed that the foam dressing was about the size of a nickel, however, the wound was much larger than the foam. In addition, part of the open wound that was not covered by the foam, had been covered by the clear adhesive dressing. The wound measured 3.0 cm x 2.3 cm with a depth of 0.2 cm. The wound bed had approximately 40% slough, with macerated borders and the top 1/3 of the foot was reddened. Following the pressure ulcer observation, an interview was conducted with the acting Director of Nursing (DON). The DON stated that the foam dressing should have covered the entire wound and not just the center part of the wound. An interview was conducted on February 12, 2015, with the unit manager. The unit manager stated that this resident was wearing tight fitting shoes that caused a blister on her left bunion that became infected and resulted in a stage 4 pressure ulcer. She stated this pressure ulcer has continued to get worse. She further stated that on November 24, the resident's shoes were removed from the resident's room, and non-skid socks were provided. An interview was conducted on February 12, 2015, with a licensed practical nurse (LPN). She stated that wound dressing changes should be documented on the TAR when they are done, and she does not know why this was not done for this resident on January 31 and February 1. -Resident #180 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of an admission nursing assessment dated [DATE], revealed a stage two pressure ulcer present to the resident's gluteal fold. A Braden Scale assessment for pressure sore risk dated May 19, 2014, reflected a score of 16, which indicated at risk. On the reverse side of this form, the interventions checked as in place included to turn and reposition every two hours in bed, dietary referral, and weekly skin review by nurse. Review of an Initial Wound Evaluation dated May 19, 2014, revealed a stage two pressure ulcer to the gluteal fold, which measured 2 cm x 1.5 cm with no depth. The wound edge was pink, however, the description of the wound bed was not documented. On the reverse side of this form, a pressure reduction mattress was circled as an intervention in place. Review of the closed clinical record revealed a Temporary Care Plan-Skin Problem dated May 20. A stage two pressure ulcer was noted to the upper gluteal fold. The approaches circled included treatment as ordered, assess area weekly and chart color, odor, amount of drainage, and size, keep off affected area, and turn and position every two hours. A physician ordered treatment dated May 20, 2014 included for [MEDICATION NAME] dressing (foam dressing) for a stage two pressure ulcer to the gluteal fold. Daily changes and monitoring were ordered until the wound healed. Review of a Daily Wound assessment dated [DATE] revealed the wound bed was pink, with no odor. Although the wound bed continued to be described as pink, with pink wound edges on May 21 and 22, both assessments reflected odor was present. On a weekly wound progress note dated May 22, it was also noted that a foul smell was present. Further review of the clinical record revealed there was no documentation that the physician was notified of the foul odor to the wound. Despite documentation of a stage two pressure ulcer that was present upon admission, a Nutritional assessment dated [DATE], documented the resident had no skin breakdown. A Nutrition care plan dated May 21, included for a nutritional "Supplement as ordered." The specific type of supplement was not documented. A Nurse Practitioner (NP) progress note dated May 21 and 22, 2014, also documented that the resident had no open areas. A physician's orders [REDACTED]. A Braden Scale assessment dated [DATE], identified the resident was at moderate risk for pressure sore development. On the reverse side of this form, the interventions checked as in place included dietary referral, inspect skin daily with care, and a weekly skin review by the nurse. Review of the May 2014 Medication Administration Record [REDACTED]. According to the Treatment Administration Record (TAR), the [MEDICATION NAME] dressing was performed daily from May 20 through 26, at which time a hand written note documented "Resolved." Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. The resident was also assessed to have one stage two unhealed pressure ulcer that was present on admission. The resident was assessed to be frequently incontinent of urine and always incontinent of bowel and had a pressure reducing device for the bed and was on a turning/repositioning program. Review of the MDS Care Area Assessment summary revealed the pressure ulcer was located on the gluteal fold and that the resident was at risk for pressure ulcer development due to weakness, extensive assist with bed mobility, and incontinence. The assessment also included the skin was observed daily and weekly, and frequent repositioning was encouraged. Further review of the TAR for May 2014, revealed that no wound care was provided on May 27. Another physician's orders [REDACTED]. The order also included for [MEDICATION NAME] (antibiotic) 100 milligrams twice daily for 14 days for the resident's wound. Review of the Temporary Care Plan-Skin Problem, revealed that the pressure ulcer was noted to have been resolved on May 28. However, according to the Initial Wound Evaluation dated May 29, the resident had a stage 2 pressure ulcer to the coccyx, which was present on admission. The wound measured 1.5 cm x 1.5 cm with no depth, the wound edges were defined and the wound bed was pink with no tunneling, and had minimum drainage, and no odor. The note included that the stage two pressure ulcer was slowly healing without complications. A list of pressure reduction interventions, such as pressure relief mattress, wheelchair cushion, were listed, however, none were checked as being in place. Despite this documentation, NP progress note dated May 29 and 30, reflected the resident had no open areas, with a plan to continue current management. A Braden Scale assessment dated [DATE], identified that the resident was at risk for pressure sore development. The interventions listed on the back of this form as in place included to lift, do not slide the resident, inspect skin daily with care, and weekly skin review by the nurse. Review of a Daily Wound Assessment for June 2, 2014, revealed the wound had "moist" drainage, and the wound bed was now described as "black" and the wound edges were jagged, with odor and pain present. There was no documentation that the physician was notified of the deterioration of the wound. Contradictory to the above assessment, a Weekly Wound Progress Note dated June 3, documented the stage two coccyx pressure ulcer was healing. The wound measured 1.5 inches in length x 1 inch wide x 0.25 inches deep. However, on this same assessment, the wound bed was also described as "tissue closed" with new tissue and edge was pink, with no drainage or odor. An NP progress note dated June 4, 2014 was the first NP note which referred to the resident as a having a wound. The note reflected that the resident had a stage two/three wound to his coccyx, which was described as beefy granulation tissue and had odorous drainage. The recommendation was to change the treatment to [MEDICATION NAME] AG (antimicrobial) and foam dressing every 24 hours. Review of a Medicare Daily Skilled Nursing Note dated June 5, revealed the first documented entry that the resident was repositioned every two hours by Certified Nursing Assistants (CNA), in order to keep the resident off of the coccyx area. A physician's orders [REDACTED]. Review of the June 2014 TAR, revealed the resident did not receive the [MEDICATION NAME] treatment on June 6. On the reverse side of this form, it was documented that the resident refused the dressing change. However, review of the clinical record did not reflect that another attempt was made to provide the wound care at a later time, nor that the resident was educated on the risks of refusing the treatment. Review of the Daily Wound assessment dated [DATE] revealed the wound had odor with serous, purulent exudate, and the wound bed was 90% slough and 10% granulation. The periwound was noted to have mild [MEDICAL CONDITION] and the surrounding tissue had mild maceration. Another physician's orders [REDACTED]. The order did not specify how frequent it was to be done. The order also included for a wound culture. Review of a Weekly Wound Progress Note dated June 10, revealed the coccyx wound measured 1.5 inches in length x 0.75 inches wide with no depth. The wound edge was noted to be jagged, the wound bed was described to have a white, opaque area in the center, and there was no drainage or odor. The periwound tissue was pink on the left edge and there was no documentation of the presence of tunneling and undermining. However, another Weekly Wound Progress Note also completed on June 10, documented the wound measured 1.25 inches in length x 1 inch wide x 0.25 cm deep. The wound edge was defined, with "N/A" (not applicable) documented for the description of the wound bed, tunneling and undermining. No drainage was documented, however, there was slight odor present. The note further documented that the wound continued to heal with no signs and symptoms of infection. An NP progress note dated June 11, 2014 documented the resident has a stage two pressure ulcer to the buttock and that it continues to improve slowly. A final wound culture report dated June 13, revealed the resident to had Escherichia coli (E. coli), which was confirmed to be a ESBL (Extended Spectrum Beta Lactamase)-producing strain, Proteus mirablilis, and Diptheroids. A form titled Weekly Wound Progress Note dated June 15, documented the size of the wound to be 1.5 inches in length x 1.25 inches wide x 0.25 inches in depth. The wound edge was noted to have white slough, and the wound bed was described to be white, with no tunneling and undermining. Per the note, there was a small amount of drainage with strong odor and white slough was located in the center and edges of the wound. Review of the TAR, reflected that [MEDICATION NAME] and [MEDICATION NAME] treatment was administered daily from June 9 through 15, 2014, with one entry circled as not completed on June 10, due to the resident being at [MEDICAL TREATMENT]. Further review of the Temporary Care Plan-Skin Problem which had been discontinued on May 28, was now restarted with a date of June 15. This was the first care plan since the wound was noted to have resolved on May 28. Per the care plan, the resident had a stage two pressure ulcer to the coccyx. The approaches included treatment as ordered, assess area weekly and chart color, odor, amount of drainage, and size, observe and report any signs of infection such as redness, keep off affected area, report any additional red areas to the licensed nurse immediately, and assess needs and/or care plan interventions for prevention of further problems. A 30 day MDS assessment dated [DATE] continued to reflect one unhealed stage 2 pressure ulcer. Review of a Daily Wound Assessment for June 16, revealed the wound bed was described to be brown and white, had normal periwound tissue, and had "saturated" drainage, with a strong odor present. A physician's orders [REDACTED]. The treatment was to be done twice a day. A Daily Wound Assessment for June 17, revealed no change in the wound form June 16. However, the Daily Wound Assessment for June 18, now documented the periwound tissue to be macerated. An NP progress note dated June 18, 2014 for follow-up on wound management, documented that the resident's coccyx was examined and extensive worsening of the wound was noted since the previous visit (June 11). The wound was being assessed now as a stage three-four, with tunneling and extensive slough. The note included that due to the aggressive change in the wound, it was recommended the treatment be changed to a wound vac to promote wound healing. The wound culture was reviewed with conclusion of contamination/colonization versus actual infection. The wound was assessed to have no [DIAGNOSES REDACTED] or purulent drainage. Further recommendations included against empiric antibiotics due to the white cell count being normal with no signs of systemic infection. Aside from the extensive slough mentioned in the note, the wound was assessed to have some necrotic tissue on the wound edges with "Questionable tunneling at 12:00." A physician's orders [REDACTED]. Another physician's orders [REDACTED]. The wound base was to be filled with black foam and covered with clear drape. Treatment was to be every Tuesday, Thursday, and Saturday. Review of the TAR, revealed the order for the treatment every Tuesday, Thursday, Saturday, with the first treatment beginning on June 19. However, the ordered suction of 125 mmHg for the wound vac was not transcribed onto the TAR. A NP progress note dated June 19, 2014 documented that the goal was to use the black foam of the wound Vac to help debride the necrotic tissue and encourage healing. Per this note, mechanical debridement was not advised initially due to the risk of extending any potential infection down further into the tissues. Negative pressure likely will be more successful in [MEDICATION NAME] the wound initially, and reduce any bioburden that is impeding healing. Further documentation revealed "concern for the rapidity of its extension, suspect this is secondary not only to his debility but also nutritional status...Appropriate nutritional interventions are in place. Prognosis given overall clinical picture is very guarded..." Despite the above documentation that nutritional interventions were in place, other than the Prostat supplement and the Renal vite for end stage [MEDICAL CONDITION], there were no further dietary interventions that were implemented. In addition, there was no clinical record documentation that the resident was re-evaluated by dietary for any additional dietary needs, due to having a pressure ulcer. Further review of the Daily Wound assessment dated [DATE], revealed the wound had moist drainage, wound bed was tan/brown, and the periwound was macerated and reddened with odor, and that the resident had pain. Continued review of the clinical record revealed that there were multiple days in May and June 2014, with no documentation that the wound was assessed daily, as per their policy. In addition, there was a lack of documentation that the resident was consistently turned and repositioned every two hours, as part of the plan of care. Review of a Discharge Summary form revealed the resident was discharged on [DATE] to another facility, with a coccyx wound. During an interview on February 11, 2015, with the Assistant Director of Nursing (ADON), the ADON explained that the admission nurse would stage a pressure ulcer, compete a Braden Scale assessment, as well as initiate a care plan. She stated that assessments of the wound included descriptions of the wound bed, measurements, and presence of odor and drainage. She stated that weekly wound assessments were to be completed. The ADON also stated that nursing staff were expected to inform the physician of any worsening or changes in the wound, so that wound care orders and treatments could be changed and instituted. In addition, the ADON stated that weekly meetings for Wounds and Nutrition were held and discussion of the weekly wound assessments complied by her, would be presented to the interdisciplinary team, which included the dietitian and recommendations and need for changes in resident care would be discussed. With regards to resident #180, the ADON stated, after review of the resident's clinical record, that she was not aware of any other assessments or summaries of the resident's wound, including administrative documentation, explaining that all information regarding this, should be in the resident's medical record. Interviews on February 11, 2015 were conducted with a Registered Nurse (RN), who explained with regards to assessments and documentation, the following assessments would be expected: 1. Initial Wound Evaluation Form-for new wounds or wounds on admission, this could include pressure ulcers and skin tears. 2. Daily Wound Assessment-form completed for pressure ulcers and for any wound (surgical wounds, skin tears, any open area) for the week, which would document information, such as drainage, wound bed description, and nursing progress notes. 3. Weekly Wound Progress Note-completed weekly for each wound (any open area) which could include not only pressure ulcers but skin tears. In addition, the nurse explained that temporary and permanent care plans include specific interventions for wound management carried out by nursing, such as repositioning every two hours, and that this should be documented on the TAR as either an FYI (for your information) or initialed by nursing staff, as being completed and that this should be reflected in the care plan. During an interview on February 12, at 12:34 p.m., the MDS Coordinator stated in reviewing CNA documentation for the months of May and June 2014, that there was no documentation of a two hour turning schedule noted. On February 12 at 2:20 p.m., the DON, after review of the closed record, stated that he could not locate a care plan between May 20 and June 15, explaining that the May 29, date that was crossed out was mistakenly written, and that the care plan did not reflect changes in the wound and treatments. In addition, the DON stated that there was no consistent documentation that the resident was being turned every 2 hours and there should have been. The DON also stated that he could find no documentation that the resident's physician was informed of the foul odor on May 22, explaining that notification to the physician should have been made since there may have been something else going on that they were not aware of with the wound. He explained that the wound was not noted to have ever healed, and was unsure why it was documented as so, when there were no corresponding assessments to support this. With regards to changes in wound care, the DON stated that nursing should have informed the physician of the wound worsening with the treatment in place. In general, he stated that if a wound remained stable with a treatment order, and was not getting better or worse, nursing would continue to monitor for 10-14 days and then inform the physician. However, if the wound became worse with the same treatment in place, a notification to the physician would be warranted sooner. In review of the clinical record documentation with the wound nurse regarding documentation of a stage two despite documentation of a black wound bed and presence of slough, the nurse stated that it should not have been staged as a two, as the description revealed tissue damage further below the dermis level. Review of a facility policy on Skin and Wound Management Program Overview, dated as revised on June 1, 2007, revealed that "The resident can expect prompt assessment and screening for risk factors. Appropriate interventions will be implemented to (1) minimize risk of avoidable skin breakdown; and (2) provide treatment of [REDACTED]. Interventions include but are not limited to resident/skin assessments, nutritional management, appropriate positioning and use of pressure relief devices, implementation of treatment modalities and managing or elimination of contributing factors such as moisture from incontinence." Further review of this policy revealed that "3. Qualified staff will assess all residents weekly, from "head to toe" to identify any new pressure ulcers or other types of skin breakdown. Results of these assessments will be documented in the resident's medical record by a licensed nurse. 4. When a break in skin integrity is identified, the licensed nurse will document a detailed assessment in the medical record including type (pressure ulcer, arterial ulcer...) size, stage, location, drainage, odor of area. Documentation will also contain treatment ordered obtained, as detailed personalized care plan and notification to the Interdisciplinary Skin/Wound Management Committee...10. Medical nutrition interventions will be recommended by a qualified dietitian and implemented in accordance with physician's orders [REDACTED]. A policy on Wound Documentation dated June 1, 2007, documented that the purpose is to document the assessment, intervention, evaluation and care planning process of the skin care/wound program within the facility..."Daily assessment must be documented by a licensed nurse after treatment had been completed. If the wound does not have a daily treatment per the plan of care and the dressing is intact, the status of the dressi

Based on closed clinical record review, family and staff interviews, hospital records, and policy review, the facility failed to ensure that one resident (#106) received adequate supervision to prevent an elopement and subsequent fall, with injury. Findings include: Resident #106 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed a Wandering/Elopement Risk Review Tool dated [DATE], revealed the resident scored a 17, which indicated the resident was at risk for elopement. Also documented was that the resident had previously attempted to leave, or had successfully left the environment and exhibited exit seeking behavior. Review of the Wandering/Elopement Risk Review Tool dated [DATE], revealed a score of eighteen, which indicated at risk. A comment included that the resident had eloped in the past. A physician's orders [REDACTED]. A Care Plan for Behavioral Symptoms/Wandering dated [DATE], revealed the resident wanders with efforts to leave the facility. A goal included that the resident will not wander from the facility in an unsafe manner. One of the interventions was the use of a WanderGuard. Review of the Informed Consent for the WanderGuard to prevent elopement was signed by the resident's family member on [DATE]. Despite documentation that the resident had eloped in the past, a Wandering/Elopement Risk Review Tool dated [DATE], revealed a score of five, indicating the resident was not at risk. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] in Section C., revealed a score of seven, which indicated the resident had severe cognitive impairment. In Section G. (functional status) the resident required supervision only and no physical help from staff with transfers, walking in room, walking in corridor, locomotion on unit, and locomotion off unit. Review of the Geriatric Assessment Tool Kit completed by physical therapy on [DATE], revealed a fall risk score of 24; at minimal risk (a score of greater than 23 is minimal risk). Review of the Treatment Administration Record (TAR) for [DATE], revealed "wanderguard for safety check daily for function." Staff had initialed daily that this was done. Review of the Nurse's Notes dated [DATE], revealed that the resident was found at the convenience store, which was next door to the facility. The resident had fallen in the parking lot and was bleeding from the lips and mouth. Emergency services were on site and the resident was taken to the emergency room by ambulance for an evaluation. According to the facility's investigative report, surveillance footage showed that the resident exited the building on [DATE] at 10:52 a.m., after a water delivery man opened the front door and exited the building. The report included that a staff member walked up after the resident crossed the door threshold, but did not notice the resident, as her WanderGuard did not alarm. The resident then wandered away from the facility and was located at 11:02 a.m., at a convenience store. The report also included that when the paramedics called the facility to notify them that a resident was found next door at the convenience store, the receptionist alerted staff, who ran to the store parking lot and the resident was already on a stretcher. Per the report, the EMT stated that the resident said that she wanted to leave, so she did. The report also noted that the resident's WanderGuard was on her left ankle, when she was found at the convenience store. Additional investigative documentation included that on [DATE], the WanderGuard was retrieved from the hospital and was still working. The report also included that per a manufacturer's representative, the WanderGuard radio signal can be unintentionally interrupted, when the bracelet is placed on the lower extremity. Review of the hospital records dated [DATE], revealed the resident was found face down in a parking lot and had trauma to her face, and had a large acute right subdural hematoma with 6.1 millimeter (mm) of midline shift, and significant edema presenting, with a change in mental status and left hemiparesis. Review of the hospital General Consult Note dated [DATE], revealed the resident was status [REDACTED]. The resident was intubated and transferred to the intensive care unit (ICU) for further monitoring and care. Further review of the hospital records revealed that on [DATE], the resident was transferred to a neurological hospital for continued care and on [DATE], was discharged to hospice for palliative care, as she had not awakened. An interview was conducted on February 10, 2015, with a family member of the resident. The family member stated that the resident had eloped two other times prior to the last time when she was injured. The family member stated that one time she was found in the parking lot, and another time on the sidewalk in front of the facility. The family member further stated that the resident expired a few days after being admitted to hospice. An interview was conducted with the social worker on February 11, 2015. The social worker stated that this resident was impaired cognitively, but was able to ambulate independently and sometimes used a wheelchair. An interview was conducted on February 11, 2015, with a licensed practical nurse (LPN). The LPN stated that this resident wore a WanderGuard on her ankle and the WanderGuard is checked by a designated certified nursing assistant (CNA) each shift using a hand held device. She also stated that she does not know why a resident's risk of elopement would change over a two month period. An interview was conducted on February 11, 2015, with the assistant director of nursing (ADON). The ADON stated that this resident had a WanderGuard on her ankle and no one knew at the time of the incident, that the WanderGuard worn on a lower extremity would not set off the alarm at the front door. She also stated that when the front door is held open, the alarm will not go off, as it is disengaged. An interview was conducted with the acting director of nursing (DON) on February 11, 2015. The DON stated that a vendor held the door open for this resident, which disengaged the WanderGuard alarm and the receptionist did not see the resident leave. An interview was conducted on February 12, 2015, with the unit manager. The unit manager stated that this resident had tried to exit several times and was found outside the building one or two times before. Review of the facility's policy on Resident Safety Program: Wandering and Elopement revealed "...The purpose is to provide a system for identification of residents at risk for unsafe wandering and elopement...Provide a proactive program of supervision and interventions to minimize risk of a resident elopement. The policy also included that the Wandering/Elopement Risk Review Form must be completed by a qualified healthcare professional for each resident in order to identify the level of risk which may lead to elopement or potentially serious injury to the resident.

Based on closed record review, hospital record review, review of the facility's policies and procedures and interviews with facility staff, the facility failed to ensure that one resident (#26) was free from a significant medication error. Findings include: Resident #26 was admitted to the facility on [DATE] and discharged to the hospital on April 5, 2012 with [DIAGNOSES REDACTED]. Upon admission the resident had documented via an advanced directive that should the need arise that she would wanted to be resuscitated (Full Code). Clinical record review revealed a physician's orders [REDACTED]. The "Yellow Scale " was to be administered to the resident prior to meals, based on the resident ' s blood sugar level. There was also a physician's orders [REDACTED]. sugar level before bed. The Humalog insulin sliding scale before meals with the Yellow Scale 70 - 100 = 3 units 101 - 125 = 5 units 126 - 150 = 7 units 151 - 175 = 9 units 176 - 200 = 10 units 201 - 225 = 11 units 226 - 250 = 13 units 251 - 275 = 14 units 276 - 300 = 15 units 301 - 325 = 16 units 326 - 400 = 17 units < 70 or > 400 Call MD Humalog Insulin Green Scale at HS (bedtime) <70 call MD 70 - 100 = 0 100 - 200 = 0 201 - 225 = 2 units 226 - 250 = 3 units 251 - 275 = 4 units 276 - 300 = 5 units 301 - 325 = 6 units 326 - 400 = 7 units 400 units Call MD A physician's telephone order was written on April 5, 2012 at 2425 (12:25 AM) for Glucogon 1 mg (milligram) SQ (subcutaneous) x 2 for low blood sugar. Review of the facility's Reportable Event Record/Report revealed that on April 4, 2012 at 8 PM the resident's blood sugar level was 235. At that time the resident was administered 13 units of Humalog insulin by staff member #2 (per the yellow Humalog insulin sliding scale) which was ordered to be used prior to meals. The resident should have only received three units of Humalog insulin, as ordered, (per the green Humalog insulin sliding scale), which was to be used before bedtime. Further review of the facility's report revealed that at 12:25 AM on April 5, 2012 the resident was found to be lethargic and had clammy skin. At that time the resident's blood sugar reading was, " Low." The resident was administered one dose of Glucogan by the LPN. At 12:45 AM the resident's blood sugar reading was 22 and a second dose of Glucogan was administered. AT 12:50 AM the resident's blood sugar was 37 and the resident remained lethargic and with a blood pressure that did not register. The emergency medical services (EMS) were called and arrived at the facility at 12:55 AM. The resident was taken to the hospital with an admitting [DIAGNOSES REDACTED]. Additional review of the facility's Reportable Event Record/Report records that during review of the event it was identified that the resident's dose of insulin was, "possibly erroneous." The resident had orders for sliding scale insulin before meals and at bedtime. The "Yellow" scale was ordered to be used before meals at 0600 (6:00 AM), 1100 (11:00 AM) and 1600 (4:00 PM) after blood sugar checks. The "Green" scale was ordered to be used at bedtime or 10:00 PM after a blood sugar check. The report documented that at 8 PM on April 4, 2012 the resident's blood sugar was 235. Staff member #2 administered 13 units of Humalog insulin. The staff member reported that she used the "Yellow" scale (which was to be used before meals not at bedtime). Based on the appropriate "Green" scale the resident should have only received three units of Humalog insulin at that time. A Nurse's note dated April 4, 2012 during 2-10 shift documented that, "VS (vital signs) B/P (blood pressure) unable to get... Res was up in w/c." The Emergency Transfer Form from the facility dated April 5, 2012 at 12:00 AM recorded that the reason for transfer to emergency department was, low BS (blood sugar). That at 2430 (12:30 AM) the resident was given two milligrams (mg) [MEDICATION NAME] sc (sub-cutaneous). At 2445 (12:45 AM) the resident's BS (blood sugar) was 37, that the resident was very lethargic and they were unable to get v/s (vital signs). A review of the hospital records revealed that in the emergency roiagnom on [DATE], the patient was unresponsive and found to have a blood sugar of 31." Laboratory studies performed at the hospital revealed that the resident's glucose was 39. She was also found to be hypotensive...and transferred to the intensive care unit. The recorded emergency room impression was that the resident had, "Insulin Reaction [DIAGNOSES REDACTED]." A separate discharge summary note records that, "The patient came in shock and was treated in the Intensive Care Unit." A physician's note from the hospital dated April 23, 2012 stated, "Discussion was done with the family with regards to Advance Directives. The patient was made Do Not Resuscitate/Do Not Intubate and subsequent discussions led to acceptance of hospice." An interview was conducted with the director of nursing (DON) on August 22, 2012, she reported that the staff member responsible for the drug error no longer worked at the facility and that she had already turned in her resignation prior to the incident. She stated that the staff member may not have known that the medication error occurred. She also reported it is typical to have multiple scales for insulin dosages like the yellow and green scale and that the dosage given to the resident matched the wrong scale that was to be given prior to meals not at bedtime. The DON stated that she had not reported the staff member's medication error to the State Board of Nursing. A review of the facility's policy on Medication Administration Variance Reporting section 2.0 Fundamental Information stated "...Types of Medication Administration Variances: a. Medication not administered as ordered...Wrong dose." The facility policy for Medication Administration General Guidelines section 7.1 stated, "Medications are administered as prescribed...Medication Administration #1...Medications are administered in accordance with written orders of the prescriber. #9 Verify medication is correct three (3) times before administering the medication."