Every finding on record at Heritage Court Post Acute of Scottsdale

Based on clinical record review, staff interviews, and facility policy, the facility failed to protect the rights of two out of the four sampled residents (Resident #18 and Resident #21) to be free from Physical abuse by another resident (Resident #11 and Resident #51). The deficient practice could result in the other residents being abused. Findings Include: -Regarding Resident #18 and Resident #11: Resident #18 was admitted to the facility on [DATE], with diagnosis of T Acute and Subacute Infective Endocarditis, Schizoaffective disorder, anxiety disorder, chronic viral hepatitis C, and other psychoactive substance abuse. Orders dated May 24, 2024, revealed orders for monitoring behavior every shift for anti-anxiety episodes, monitoring for side effects of antianxiety/anxiolytics, and monitoring side effects of pain medication. Orders dated May 28, 2024, revealed an order for Hydroxyzine HCL 10mg 2 tablets by mouth every 8 hours as needed for anxiety AEB restlessness for 10 days, and May 28, 2026 orders revealed an order for Suboxone sublingual film 4-1mg twice a day for substance abuse. An admission MDS (Minimum Data Set) assessment dated [DATE], revealed Resident #18 had a BIMs (Brief Interview for Mental Status) score of 15, which indicates no cognitive impairment. Resident #18 was assessed on the MDS to show no behaviors indicative of refusing care or resistant to staff directives. Orders dated June 2, 2026, revealed an order for change of condition for psychosocial well being. A Progress Note, dated June 2, 2024, revealed a change of condition for Resident #18 and stated the resident will be assessed for psychosocial wellbeing every shift for 3 days. Resident #18 was assessed June 2, 2024 at 20:50 to be resting quietly in bed, with no complaints. A care plan revised June 2, 2024 revealed a focus on psychosocial well-being related to a physical and a potential for a behavior problem related to physical altercation. -Resident #11 was admitted to the facility May 13, 2024, with a diagnosis of Acute Osteomyelitis of the right ankle and foot, Schizophrenia, and psychoactive substance abuse. Orders dated May 14, 2026 revealed Oxycodone HCL 10mg tablet every 4 hours as needed for pain 7-10. Orders dated May 17, 2024, revealed monitoring for behavior every shift for psychotic episodes, monitor side effects of anti-psychotics, monitor side effects of pain medication and Olanzapine 5mg tablet at bedtime for schizophrenia AEB auditory hallucinations. An admission MDS assessment dated [DATE], revealed Resident #11 had a BIMs score fo 13, which indicates that Resident #11 was not cognitively impaired. Resident #11 was assessed to have a mood severity score of 12, indicating moderate depression or clinically significant mood distress. Resident #11 was not assessed to have no behaviors indicative of refusing care or resistant to staff directives. Orders dated June 2, 2024, revealed change of condition for psychosocial well-being monitoring for 3 days. A Progress note dated June 2, 2024, revealed a change of condition for psychosocial well-being to be monitored for 3 days, no issues noted at assessment date June 2, 2024 at 15:35. A care plan revised June 2, 2024, revealed Resident #11 had a potential for a psychosocial well-being problem related to a physical altercation. Resident #11 was assigned 1:1 sitter and increased supervision. An interview was attempted with Resident #18 on June 2, 2026, although the phone number listed on Resident's chart was inactive. Resident #18 was discharged [DATE]. An interview was attempted with Resident #11 on June 2, 2026, upon calling Resident #11 a family member answered the phone and it was revealed that Resident #11 is currently residing in Arizona State Prison and unable to be interviewed. An interview was conducted June 3, 2026 at 9:06 AM with Staff #91, licensed practical nurse (LPN). Staff #91 stated that a lot of things could be described as abuse, such as verbal, physical and sexual. He stated that if he notices any signs of abuse or if a resident voices concerns regarding abuse, he goes directly to the Abuse Coordinator of the facility. Staff #91 stated that if he notices residents becoming more agitated or loud in the way they communicate with each other he usually separates the residents from each other, ensuring they remain safe, and contacts the Abuse Coordinator. Staff #91 currently works on the Skilled Unit hallway and cannot recall the names of Residents #18 or #11, as most residents stay on average 6-8 weeks or less. Staff #91 stated that the facility does a good job at making sure that residents who may be easier to agitate or are more sensitive are closely monitored and if needed room changes can be accommodated. Another interview was conducted on June 3, 2026 at 9:38 AM with Staff #92, certified nursing assistant (CNA). Staff #92 stated the process when witnessing a resident-to-resident altercation or if a resident were to voice concern about a resident-to-resident altercation she would report immediately to the Abuse Coordinator of the facility, the Nurse or Director of Nursing (DON). She stated that CNAs do not document anywhere in a Resident's chart, but that if needed to provide any documentation of what they witnessed the Abuse Coordinator would inform them. If she witnessed a resident-to-resident altercation, Staff #92 stated that she would separate the residents, call the assigned Nurse immediately. She did not recall any recent resident-to-resident altercations, nor did she recall Resident #18 or Resident #11. An interview with the previous administrator for the facility, Staff #109, was conducted June 3, 2026 at 1:30 PM. Staff #109 stated that during his time as an administrator he could not recall any allegations that were substantiated, although he has not been the administrator since 2024. Staff #109 stated that if an abuse allegation was made the facility would have conducted an internal investigation immediately. If the facility was investigating a resident-to-resident altercation, the facility would have separated the residents to ensure they were safe and conduct an investigation. He stated, again, that he does not recall the names of Residents #18 or #11. An interview was conducted with Staff #28, Director of Nursing (DON) was conducted June 5, 2026 at 1:24 PM. Staff #28 stated that forms of abuse are physically hitting, verbal, exploitation, misappropriation, and isolation. Staff #28 stated that if a resident-to-resident altercation occurs, her expectations are that staff would separate the residents and ensure their safety and inform her immediately. Staff #28 stated that an assessment would be conducted on both residents, skin checks, neuro, physical assessment and a psychology evaluation. Staff #28 stated that the investigation of the resident-to-resident altercation would include interviews with each resident to find the root cause of the altercation, interviews with staff, and an Interdisciplinary meeting with staff to evaluate future care plans for each resident. Staff #28 was asked regarding the resident-to-resident altercation between Resident #18 and Resident #11. Staff #28 stated that she does not recall the exact event but does remember having the two residents in the facility. Staff #28 recalled that this incident was considered to be an unanticipated and isolated event, and that she cannot recall any other occurrences of the same behavior from Resident #11 after the care plan 1:1 sitter. Staff #28 was asked what the risks are for resident-to-resident altercations, and she stated that the aggressor could act in a similar manner affecting other residents and that the victim could be attacked again or fear that they will be. Staff #28 stated that the risk of not investigating and care planning appropriately to the allegation could cause fear and harm to other residents. Review of the facility's five day interval investigation of the incident revealed resident #18 and resident #11 were both involved in a physical altercation. The report stated that resident #11 was observed by staff to have his hands on resident #18's neck. Staff #91 and staff #28 both interviewed resident #11, where it was revealed that resident #11 did grab resident #18's neck and shirt after claims resident #18 was making fun of resident #11. Skin assessments were completed on resident #18, 1:1 was put in place for resident #11, and psychological evaluations were ordered for each resident. The local police were notified and an investigation initiated immediately. The facility interviewed five residents regarding their safety and concerns with residents #11 and #18; there were no concerns reported. The facility interviewed five staff members regarding residents #11 and #18 and who they would contact regarding a resident-to-resident abuse, all interviewed staff stated no concerns with either resident and that they would report any abuse to the Abuse Coordinator. The facility verified this an isolated and unanticipated incident. - Regarding Resident # 21 and Resident # 51: Resident # 21 was re-admitted on [DATE], with diagnoses of Depression, Anxiety Disorder, and Hyperlipidemia. Orders dated August 31, 2023, revealed an order for a change of condition for Psychosocial well-being for every shift for 3 days. A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed resident #21 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated cognitive intactness. A Progress note dated August 31, 2023, at 23:32 pm revealed that Resident # 21 had a change of condition for psychological well-being. Resident # 51 was admitted to the facility on [DATE], with diagnoses of Anxiety, Bipolar Disorder, and Schizophrenia. A Quarterly MDS dated [DATE], revealed that the assessment for Mental Status in Section C Resident #51's cognitive skills for daily decision making were severely impaired. A Progress Note dated August 31, 2026, 23:27 revealed that Resident # 51 had a change of condition for psychological well-being. A facility investigation dated August 31, 2023, revealed that Resident #21 stated that he was retrieving his hat from the closet when Resident #51 scratched him on the face. Resident #21 then reported pushing Resident #51's hand away and returning to his closet, and then Resident #51 had grabbed and scratched his arm. Resident #21 stated that he was only pushing Resident # 51 away. The investigation then revealed that an attempt was made to interview Resident #21, but due to Resident #21's cognitive status, an interview was unable to be completed. The investigation also revealed that the facility had verified that this was an unanticipated incident. A Care plan dated on September 15, 2023, revealed Resident #51 had a focus plan for potential psychological well-being problems related to a resident-to-resident altercation. An attempt was made on June 3, 2026,10:18 AM to contact Resident #51was no longer residing at that facility. An interview was conducted via phone on June 04, 2026, at 10:14 am with Certified Nursing Assistant (CNA/Staff #40), who stated that to the best of his knowledge, something did happen between Resident #51 and Resident #21. He then stated that he can not recall who the aggressor was, but he did report to the Executive Director (ED) at the time. However, A review of the facility follow-up investigation completed on August 31, 2023, revealed that (CNA/Staff #40) stated that he had witnessed Resident #21 hit Resident #51 in the back of the head. The facility follow-up investigation revealed that Staff #40 had separated the residents and alerted the Director of Nursing at the time. An interview was conducted on June 04, 2026, at 1:35 pm with CNA(staff #23), who stated that when there is a resident-to-resident altercation, staff will: separate the resident, notify the nurse, and inform social services. Staff #23 then stated that social services will place the residents in different rooms to prevent further altercations. The CNA then stated that the different types of abuse are: mental, physical, and neglect. He also stated that hitting or striking is a form of abuse. He further stated that when abuse is not addressed, it can cause a mental health disorder. An interview was conducted on June 05, 2026, at 10:55 AM with a Licensed Practical Nurse (LPN/staff #54), who stated the DON does the onsite/in-person training, and they have online training as well. She then stated that the different types of abuse are: physical, mental, and verbal. She further stated that physical abuse is unwanted touching, grabbing someone too hard, or jerking someone's arm. She stated that verbal abuse would be profanity or anything that makes someone fearful or intimidated. She also stated that when there is a resident-to-resident physical abuse, they will separate the resident, make sure that the victim is safe, conduct a head-to-toe, and report it to the DON. She then stated that DON will report to local law enforcement and would let them know the next steps for them to take. She stated that if abuse is ongoing, the potential risk is that it could cause mental and physical harm to the alleged victim. An interview was conducted on June 05, 2026, at 1:26 p.m. with the Director of Nursing, who stated that staff receive monthly education on physical, emotional, and verbal abuse. Staff #28 stated that physical abuse includes hitting or resident-to-resident altercations, while verbal abuse includes speaking negatively or rudely to a resident. Staff #28 stated that when a resident altercation occurs, staff are expected to separate the residents, ensure resident safety, complete a skin and neurological assessment, and notify the administrator. She further stated that an investigation would include interviews with staff and residents to determine the root cause, and notifications would be made to the provider, Medical Director, local law enforcement, and state agencies. Upon Review of the 5-day follow-up the DON stated that the incident dated August 31, 2023, Resident #51 was retrieving his hat from the closet and Resident #51 had hit him in the back of the head. She then stated that the facility had verified the incident and that it was an isolated, unanticipated event and that it constituted abuse. She then stated that the potential risks would be that the resident would not feel safe. A policy Revised/Reviewed in November 2017 titled Freedom From Abuse, Neglect, Exploitation revealed that the resident has the right to be free from abuse.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to report allegations of abuse for one resident (#1). The deficient practice could result in allegations of abuse not being reported, not investigated, and residents not being protected from further abuse.Resident #1 was admitted on [DATE] with diagnosis included fracture of left femur, difficulty in walking, anxiety disorder, depression, anemia, and cerebral infarction.The Admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that resident is cognitively intact.Nursing note dated August 15, 2025 at 09:30AM revealed the patient informed, thinks she was gang raped by night staff. However, the incident was not reported to state agency.A physician's progress Nursing note dated August 15, 2025 at 06:57PM revealed that the resident was having delusions patient informed, thinks she was gang raped by night staff. However, the incident was not reported to state agency.On September 09, 2025 at 8:10AM, a request was made at entrance to provide a document from the facility including list of all self-reports and investigation in the last 90 days. However, the DON was unable to produce documents because there were no self-reports in the last 90 days. On September 09, 2025 at 9:20AM, a second request was made for any abuse allegation in last 3 month. Director of Nursing signed on September 09, 2025 at 9:39AM she stated that there are no self-reports in last 3 months.Later on, September 09, 2025 at 2:50PM the DON provided internal investigation for resident #1. However, there was no evidence they reported to state agency.An interview was conducted on September 09, 2025 at 11:25AM with the Certified Nursing Assistant (CNA/staff#95), who stated that that abuse can be multiple things such as mental, physical, verbal and emotional. She stated the facility process for abuse is to notify supervisor and there is number in the break room where they can report the abuse. Staff #95 also stated that abuse should reported immediately to the supervisor.An interview was conducted on September 09, 2025 at 11:38AM with the Certified Nursing Assistant (CNA/staff#27), who stated abuse is defined as hitting, sexual, verbal, and financial. She stated that the facility process for abuse is to make resident safe, reported to ADON or DON. Staff#27 stated that resident #1 told her that she had been tried to rape but she fought them off on August 15, 2025 when she did morning vitals for her. Staff #27 stated that she reported to ED right away. She also stated Administrator got the ADON talked to her about resident #1 allegations. The CAN confirmed that any abuse allegation should be reported right away. An interview was conducted on September 09, 2025 at 12:50PM with the Registered Nurse (RN/staff #84), who defined abuse as any harm such as injury to resident which can caused by anyone such as staff or family members. He stated that the facility process for abuse to notify admin or DON immediately. He also stated he has not heard or witness any abuse within the last month.An interview was conducted on September 09, 2025 at 12:58PM with a Licensed Practical Nurse (LPN/Staff #69), who defined abuse as something that is wrong, out of character, empathic and sympathetic for the patient. He stated there are multiple types abuse such as mental, physical, seclusion, verbal, neglect, financial, and sexual. Further he stated that the facility process for abuse is not to leave the resident alone to ensure their safety, stop the abuse immediately if witnessed, let the management know immediately. He stated that he has not heard or witness any within the last month.An interview was conducted on September 09, 2025 at 1:07PM with Assistance Director of Nursing (ADON/Staff #56), who stated that she was aware of resident #1's allegation and notified Administrator. She stated that she conducted investigation on resident #1, however did not document anything down. She further stated that it depends on the situation if the Department of Health Services (DHS) needs to know about abuse allegation and if there is sexual abuse the police are notified. Then she stated resident #1 abuse allegation should be reported to DHS for either good or bad outcome. Staff #56 stated that risk of not reporting abuse to DHS would be the facility getting tagged, facility being closed down, abuse goes on with resident #1 and she can get hurt. An interview was conducted on September 09, 2025 at 2:31PM with Director of Nursing (ADON/Staff #19), who stated that as part of the abuse coordination, her role when they receive abuse allegation she is to investigate, report to the state, police, aps, ombudsman, provider, and family. She stated we would report the abuse allegation within two hours. Then she stated that she was aware of the potential sexual allegation that was from August 15, 2025. She stated that based on their internal investigation, resident #1 did not said anything about sexual assault or allegation so they did not report to DHS. Further she stated that it truly depends on the when they are supposed notify the DHS, if she had said it to the staff member three men raped her and made allegation of sexual abuse, then she would have reported to the DHS. She stated the risk of not reporting sexual abuse allegation would be resident wellbeing and safety. Reviewed the policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment Revised date September 2024 revealed that under procedure guide that In response to allegations of abuse, neglect, exploitation, or mistreatment, the Facility will: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately but: Not later than two (2) hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury . Not later than twenty-four (24) hours if the events that cause the allegation does not involve abuse and does not result in serious bodily injury. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported to: The Administrator of the Facility, The State Survey Agency, Adult Protective Services (as appropriate).

Based on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure that one resident (#59) and/or their representative were informed of the risks and benefits of psychotropic medications prior to the administration of the medications. The sample size was 5. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and the potential adverse side effects of psychoactive medications. Findings include: Resident #59 was admitted on [DATE] with diagnoses that include type II diabetes, depression, anxiety, left leg amputation above the knee, thrombosis and embolism of thoracic aorta, insomnia, and chronic pain. Review of the order summary report revealed the following prescriptions for antidepressant medications: - Duloxetine HCI capsule delayed release particles 60 MG (milligrams), prescribed January 24,2025. The order directed to administer 1 capsule by mouth one time a day for depression. - Trazodone HCI tablet 50 MG, prescribed January 24,2025. The order indicated to administer 1 tablet by mouth at bedtime for depression. - Sertraline HCI tablet 50 MG, prescribed January 29.2025. The order indicated to administer 1 tablet by mouth daily for depression. A consent for treatment with psychotropic medications dated 1/24/2025 revealed a signed consent for the use of antidepressant medications duloxetine and trazodone. Review of resident #59 clinical record did not reveal a consent form for the use of Sertraline HCI tablet 50 MG. Furthermore, there was no evidence that the resident and/or the resident's representative had been informed of the risks and benefits of the antidepressant medication, Sertraline. A care plan revised on March 21,2025 revealed that the resident is on psychotropic medications related to depression. Interventions included to educate resident, family/caregivers about the risks, benefits, and the side effects of medication drugs being given. Review of the March and April 2025 MARs (Medication Administration Record), revealed that medications were administered as ordered and monitored as required. The clinical record revealed the resident was discharged from the facility on April 11,2025. An interview with a Licensed Practical Nurse (LPN/staff #3) was conducted on April 16, 2025 at 3:10 p.m. The LPN stated that psychotropic medications are ordered by a provider. According to staff #3 residents who are prescribed psychotropic medications are briefed/ educated by the LPN/RN (registered nurse) regarding the medication's benefits and any possible side effects. Staff #3 stated any consents are filed in the resident's chart as part of the admission packet and are sometimes in a drawer at the nurses' station. The LPN stated that behaviors are documented every shift in the progress note section and/or the MAR/TAR (Medication Administration Record/Treatment Administration Record) in the resident chart. Staff #3 stated that the provider should be notified with any adverse effects from psychotropic medication. Resident #59's clinical record was reviewed with staff #3 (LPN) on April 16, 2025 at approximately 3:10 p.m. Staff #3 verified that there were no consents for the psychotropic antidepressant, Sertraline. An interview was conducted with the Director of Nursing (DON/staff #22) on April 16, 2025 at 3:35 p.m. The DON stated that the facility process for psychotropic medication is that a provider prescribes that medication and a consent is reviewed with the resident/representative and signed prior to the administration. Staff #22 stated that the risk could be, giving wrong medication. Additionally, the resident may not be aware of the side effects. The DON stated that the facility policy is to obtain a consent for the resident prior to administering psychotropic medications. Resident #59's clinical record was reviewed with the DON on April 16,2025 at approximately 3:35 p.m. The DON confirmed that the resident received Sertraline the entire month of February 2025, the entire month of March 2025, and April 1-11 2025. Additionally, staff #22 verified that there were no progress notes that documented that the consent for Sertraline had been obtained. The facility policy titled, Psychoactive Medication, revised May 2024 indicated the facility staff must inform the resident and/or representative regarding the use of the psychoactive medication. The policy also stated that a consent mush be obtained from wither the resident or the representative if resident is unable to give consent.

Based on clinical record review, facility documentation, staff interviews and policy review, the facility failed to ensure that one of one sampled resident's (#427) environment was free of accident hazards regarding medicated cream left at the bedside. This deficient practice could result in an adverse event for the resident. Findings include: Resident #427 was admitted to the facility on [DATE] with diagnoses that included urinary tract infection, acute pyelonephritis, type 2 diabetes mellitus, hypertension, acquired absence of right leg below knee and acute kidney failure. A care plan initiated on April 10, 2025 revealed that the resident was at risk for impaired cognitive function/dementia or impaired thought processes. Interventions included to administer medications as ordered. Review of a care plan revised on April 11, 2025 revealed that the resident had a fungal rash on his bilateral (both sides) buttocks. Interventions included to administer treatments as ordered and monitor for effectiveness. An initial observation of resident #427 was conducted on April 15, 2025 at 10:00 AM. The resident was observed lying in his bed. During the observation, four medicine cups containing a pink cream, were observed on a nightstand next to the resident's bed. A subsequent observation was conducted on April 15, 2025 at 10:20 AM. The four medicine cups containing the pink cream remained on the resident's nightstand. Review of the order summary revealed an order dated April 11, 2025. The order prescribed anti-fungal cream for a fungal rash, to be administered on the resident's bilateral buttocks every shift. An interview with a Registered Nurse (RN/staff #105) was conducted on April 15, 2025 at 10:22 AM. The RN stated that the cups contained a medicated cream and should not be at the bedside. Staff #105 was observed to go into resident #427's room, remove the cups from the table, and threw them in the trash can. An additional interview was conducted with an RN (staff #7) on April 15, 2025 at 10:25 AM. The RN stated that medicated creams should never be left at the bedside. During an interview with a Licensed Practical Nurse (LPN/staff #44) conducted on April 17, 2025 at 11:00 AM, the LPN stated that the cream was an anti-fungal cream which contained 2% miconazole nitrate. An interview with the Director of Nursing (DON/staff #22) was conducted on April 16, 20215 at 12:20 PM. The DON stated medications should not be left at the bedside. She stated that the facility did not have a self-medication administration evaluation and that none of the residents should be self-administering their medications. The DON noted that the anti-fungal cream should not have been at the bedside. The DON indicated that the risk of having medications at the bedside could include inappropriate resident use, overuse of medications, and/or improper use of medications. A policy request for medication administered at the bedside was requested on April 17, 2025. The facility stated that they did not have a specific policy for medications administered at the bedside and to refer to the Medication Administration policy. A policy titled, Medication Administration, stated the nurse preparing the medication administers it and must remain with the resident until all of the medication is used.

Based on record review, facility documentation, staff and resident interviews and policy review, the facility failed to ensure two of three sampled residents (#426 and #427) with an indwelling catheter received a physician order for the catheter and catheter care. This deficient practice could lead to residents not receiving proper catheter care and the development of an infection. Findings include: Regarding Resident #426: -Resident #426 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of ribs, left side, malignant neoplasm of left breast, anemia and chronic obstructive pulmonary disease. Review of an admission Brief Interview for Mental Status (BIMS) assessment, dated April 12, 2025, revealed a BIMS score of 15, indicating that the resident was cognitively intact. During initial observations on April 15, 2025 at 10:00 AM, resident #426 was observed to have an indwelling catheter in place. A Hospital Visit Summary, dated April 10, 2025, indicated that the resident had a Foley catheter in place upon discharge from the hospital. A care plan, revised April 10, 2025, revealed that the resident had an indwelling catheter. Interventions indicated to provide catheter care every shift as needed, monitor/document, and report to physician signs and symptoms of UTI (urinary tract infection), urine frequency/output and change in behavior. Review of the Order Summary Report retrieved April 15, 2025, revealed no orders for an indwelling catheter or for indwelling catheter care. The April 2025 Treatment Administration Record (TAR) indicated no evidence of scheduled or completed catheter care. A provider order was written on April 16, 2025, to remove the indwelling catheter. An interview with resident #426 was conducted on April 15, 2025 at 9:58 AM. Resident #426 stated that she had the catheter in the hospital and was admitted to the facility with the catheter in place. An interview with a Registered Nurse (RN/staff #182) was conducted on April 16, 2025 at 10:00 AM. The RN stated that resident #426's catheter was ordered to be removed for a voiding trial. Resident #426's record was reviewed with the RN (staff #182) on April 16, 2025 at approximately 10:00 AM. The RN verified that there were no orders regarding the resident's indwelling catheter prior to the order to remove the catheter on April 16, 2025. Resident #426's clinical record was reviewed with the Director of Nursing (DON/staff #22) on April 16, 2025 at approximately 12:25 PM. The DON confirmed that there were no orders for catheter care from the time of the resident's admission to the facility on April 10, 2025 through April 16, 2025. Further, the DON (staff #22) stated that the risk of not having orders for the catheter and for catheter care is that the resident could develop an infection. Regarding Resident #427: -Resident #427 admitted to the facility on [DATE] with diagnoses that included urinary tract infection, acute pyelonephritis, type 2 diabetes mellitus, hypertension, acquired absence of right leg below knee and acute kidney failure. A care plan pertaining to resident #427's risk for infection related to indwelling catheter was revised on April 15, 2025. Interventions included to monitor for signs and symptoms of acute infection and to notify the physician. A care plan revised April 16, 2025, revealed that the resident had an indwelling catheter related to BPH (benign prostatic hyperplasia) with obstructive uropathy. Interventions included to change the catheter bag and tubing as ordered, and to provide catheter care every shift as needed. Review of an Order Summary Report retrieved April 15, 2025, revealed no orders for and indwelling catheter or for indwelling catheter care. Additionally, review of the April 2025 TAR revealed no evidence of catheter care. However, review of the Order Summary Report retrieved April 17, 2025 revealed physician's orders dated April 16, 2025, for the catheter care to be performed every shift. An interview with RN (staff #182) was conducted on April 16, 2025 at 10:00 AM. The RN stated that the medical record did not contain provider orders for resident #427 to have catheter care performed prior to April 16, 2025. The resident's clinical record was reviewed with the DON (staff #22) on April 16, 2025 at approximately 12:25 PM. Staff #22 confirmed that there were no orders for catheter care form the time of the resident's admission to the facility on April 10, 2025 through April 16, 2025. During an interview with the DON (staff #22) conducted on April 16, 2025 at 12:25, she stated that if a resident had an indwelling catheter, orders for catheter care should be prescribed. The DON stated that the risk of not having orders for the catheter or for catheter care is that the resident could develop an infection. A policy titled, Catheter Care Indwelling, stated it is the facility's policy that each resident with an indwelling catheter will receive catheter care daily and as needed for soiling. A policy titled, Physician Orders, stated that the facility is to accurately implement orders from providers and that treatments or related procedure orders are to be transcribed into the eTAR (electronic treatment administration record).

Based on record review, facility documentation, staff and resident interviews and policy review, the facility failed to ensure that two of two sampled residents (#426 and #427) received appropriate respiratory care per physician orders. This deficient practice could lead to respiratory issues. Findings include: Regarding Resident #426: -Resident #426 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of ribs, left side, malignant neoplasm of left breast, anemia and chronic obstructive pulmonary disease. Review of an admission assessment for Brief Interview for Mental Status (BIMS), dated April 12, 2025, revealed the resident had a BIMS score of 15, indicating the resident was cognitively intact. A care plan that was initiated April 10, 2025, revealed that the resident has COPD (Chronic Obstructive Pulmonary Disease). Interventions included to give oxygen therapy as ordered by the provider. A provider order dated April 10, 2025, prescribed oxygen at 2 LPM (liters per minute) via nc (nasal cannula) continuous. May titrate to 5 LPM to keep O2 (oxygen) sats (saturation) above 90%. The April 2025 Medication Administration Record (MAR) indicated nursing staff were to document every shift that the resident was receiving oxygen continuously and record how many liters of oxygen the resident was receiving, as well as the oxygen saturation level. Review of the Weights and Vitals log, for April 10, 2025 through April 17, 2025 revealed that the resident's oxygen saturations were between 91% and 99%. However, the values for April 11, 14, 15, 16 and 17, 2025 indicated the resident was on room air during the readings. A care plan initiated on April 15, 2025 indicated that the resident had oxygen therapy related to ineffective gas exchange. Interventions included to administer oxygen per physician's orders. However, during an observation conducted on April 15, 2025 at 11:05 AM, resident #426, was observed without a nasal cannula in place and was not administered oxygen as ordered. An additional observation was conducted on April 16, 2025 at 9:56 AM. Resident #426 was observed with the nasal cannula on. The oxygen concentrator indicated she was receiving 5 LPM of oxygen. An interview was conducted on April 16, 2025 at 10:05 AM, with a Registered Nurse (RN/staff #182). The RN stated that resident #426 had an order for continuous oxygen at 2 LPM that could be increased to 5 LPM if oxygen saturations were less than 90%. The RN stated that the resident's oxygen saturations were 92% that morning and she would expect the resident to be receiving 2 LPM of oxygen. An observation of Resident #426's oxygen concentrator was conducted with the RN (staff #182) on April 16, 2025 at 10:17 AM. The RN stated the concentrator was set to 5 LPM. She assessed the resident's oxygen saturation which was 93%. The RN stated she did not know why the concentrator was set to 5 LPM and she adjusted it to 2 LPM. During an interview with the Director of Nursing (DON/staff #22), conducted on April 16, 2025 at 12:25 PM, she stated that the resident's oxygen order meant that the resident should always be on at least 2 LPM of oxygen. The DON said that if the resident's oxygen saturation was less than 90%, the nurse could increase the liters per minute until the oxygen saturations reached 90%. The DON further stated that if the resident's oxygen saturations were 92%, the resident should be on 2 LPM of oxygen. The DON stated that if the resident was on 5 LPM of oxygen, it might have been because her oxygen saturations dropped at some point during the night and would need to be reassessed. The DON further stated that the risk of resident #426 not receiving oxygen per provider order could be shortness of breath and/or hypoxia (low levels of oxygen in the blood). A follow-up observation was conducted on April 17, 2025 at 8:33 AM. Resident #426 was observed without a nasal cannula in place and was not administered oxygen as ordered. Regarding Resident #427: - Resident #427 admitted to the facility on [DATE] with diagnoses that included urinary tract infection, acute pyelonephritis, type 2 diabetes mellitus, hypertension, acquired absence of right leg below knee and acute kidney failure. A provider order dated April 10, 2025 prescribed oxygen at 2 LPM via nc continuously. The order indicated the oxygen may be titrated to 5 LPM to keep O2 sats above 90%. The April 2025 Medication Administration Record (MAR) indicated nursing staff were to document every shift that the resident was receiving oxygen continuously and record how many liters of oxygen the resident was receiving, as well as the oxygen saturation level. A care plan initiated on April 15, 2025 revealed that the resident was on oxygen therapy for ineffective gas exchange. Interventions included to administer oxygen per physician's orders. However, an observation conducted on April 15, 2025 at 11:31 AM revealed resident #427 did not have a nasal cannula in place and was not administered oxygen. A follow-up observation was conducted on April 16, 2025 at 9:54 AM. Resident #427, was observed without a nasal cannula in place and was not administered oxygen as ordered. An interview with resident #427 was conducted on April 16, 2025 at 9:54 AM. The resident stated he usually only used his oxygen at night due to sleep apnea. During an interview with RN (staff #182) conducted on April 16, 2025 at 10:15 AM, she stated that resident #427 had orders for continuous oxygen at 2 LPM. The RN stated that the resident's oxygen could be increased to 5 LPM if oxygen saturations were less than 90%. Staff #182 confirmed that the resident was not receiving oxygen at the time of the interview. An interview with the DON (staff #22) was conducted on April 16, 2025 at 12:20 PM. She stated that resident #427 should have his oxygen on at all times, per provider's order. The DON further stated that despite the resident's oxygen saturations being above 90%, he should still have his oxygen at all times. The DON indicated that the risk of not following provider orders for oxygen for resident #427 could be shortness of breath and/or hypoxia. A policy titled, Oxygen Administration, stated oxygen therapy is administered by a licensed nurse as ordered by the physician. Furthermore, the policy noted that the purpose of oxygen therapy was to provide sufficient oxygen to the blood stream and tissues. A policy titled, Physician Orders, stated the facility is to accurately implement orders from providers and that medications/treatments are to be transcribed into the MAR/TAR. It further stated that biological orders much be recorded in the resident's medical record under orders. The policy indicated that the facility would accurately implement orders upon the orders of a person licensed and authorized to do so in accordance with the resident's plan of care.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that residents were treated with dignity and respect. The deficient practice could result in residents being psychosocially effected. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing and Hypertension. The brief interview for mental status dated February 5, 2025 included a score of 14 indicating the resident was cognitively intact. The care plan dated February 4, 2025 revealed that the resident has acute/chronic pain related to a ground level fall (GLF) with hip fracture, hypothyroidism, hypertension (HTN), and hypotension. Interventions include to administer analgesia medication as per orders. The order summary included: -February 5, 2025, left hip surgical dressing to stay in place until surgical follow up. -February 5, 2025, Lidocaine External Patch 4% (Lidocaine) apply to affected area one time per day for pain and remove per schedule. -February 6, 2025, patient to transfer to another LTC facility. Review of the medication administration record dated February 2025 revealed that Lidocaine External Patch 4% (Lidocaine) apply to affected area one time per day for pain and remove per schedule was applied by (LPN/staff #1) on February 5, 2025 at 8:00 p.m. A progress note dated February 6, 2025 revealed that the Social Services Manager (#7) followed up with the resident in regard to a reported grievance that occurred overnight. Staff #7 went over the steps of correction the facility was taking, and the resident was both agreeable and at ease with and felt much better. A progress note dated February 6, 2025 revealed that the resident requested a transfer to another facility. An interview was conducted on February 25, 2025 at 10:16 a.m. with resident #22, who stated that (LPN/staff #1) wanted to apply the Lidocaine patch, but she had not asked for a patch and it was supposed to be applied as per the order. She stated that (LPN/staff #1) was applying the patch in the upper area and she put her left hand on her lower back, where the glut starts, to show (LPN/staff #1) where the patch is supposed to go. She stated that she didn't remember if there hands touched, but the LPN grabbed her hand, bent her arm back, and twisted it and she told the LPN that she was hurting her. She stated that she told (LPN/staff #1) that she wanted to speak to someone in charge and the LPN told her that she was in charge and there was no one else here. She stated that the LPN got close to her face and said, you don't know how to act like an adult and I am going to teach you how to be an adult. She stated that her roommate didn't say anything and was afraid of (LPN/staff #1) because staff #1 was already mad at her roommate for doing something. She stated that sometime later, it may have been morning, a certified nursing assistant was helping her roommate, and the roommate was telling the CNA what happened. The CNA told them that there have been all kinds of staff and resident complaints about (LPN/staff #1). Then a charge nurse came to talk to her. An interview was conducted on February 25, 2025 at 11:20 a.m. with (LPN/staff #1), who stated that her shift was 6:00 p.m. to 6:00 a.m. and applied the Lidocaine patch as prescribed before 10:00 p.m. She was applying the patch to the left hip. Her voice became elevated and she stated that this was a complete waste of time. The resident asked if she could stand up because it is easier to put the patch on the left buttocks, back area, and partially the left hip. She stated that there was a dressing on the front part of the left leg that was flipped up and she tried to put it back down when the resident grabbed her right wrist and she told the resident not to grab her, she was just trying to help her. The resident let go and said that she wasn't supposed to touch it. Then she put the pain patch on. The resident asked to speak with a charge nurse and she told her that she would have to wait until morning. She stated the resident didn't like the way that she was speaking to her and she stated that her voice is normally high and she spoke to the resident the way she was speaking during the interview, which was agitated and impatient. An interview was conducted on February 25, 2025 at 12:11 p.m. with the Director of Nursing (DON/staff #10), who stated that there is not usually a supervisor available at night, so a resident would have to wait to talk to a supervisor the next morning. She stated that (LPN/staff #1) and resident #22 both claimed that they were grabbed by each other on February 5, 2025. She received a call from a Certified Nursing Assistant (CNA/staff #2) on February 6, 2025 at 5:55 a.m. stating that resident #22 reported that (LPN/staff #1) grabbed her arm and twisted it. She stated that (LPN/staff #1) was still in the facility when she arrived at approximately 6:15 a.m. Staff #10 stated that if the resident told (LPN/staff #1) that she wanted to speak to someone in charge, staff #1 should have contacted the DON or the nurse manager because allegations are to be reported right away. She stated that she interviewed (LPN/staff #1) and was told that she was applying the resident's pain patch and the resident grabbed her wrist. Staff #10 reviewed the MAR dated February 2025 and stated that (LPN/staff #1) did apply the pain patch to the resident at the incorrect time. Then, staff #10 stated that (LPN/staff #1) told her that the bandage covering the surgical wound on the resident's hip was coming off and she was trying to secure the bandage when the resident grabbed her wrist because she didn't want (LPN/staff #1) to touch the bandage. Staff #10 stated that she did not ask staff #1 if she had explained to the resident that she was trying to secure the bandage prior to touching the bandage, but protocol would dictate that the nurse explain what she if going to do, so as not to invade the resident's personal space. Staff #10 stated that (LPN/staff #1) stated that she told the resident not to touch her, she was just trying to help her and the resident told (LPN/staff #1) not to touch the surgical bandage because it was not supposed to come off. (LPN/staff #1) told staff #10 that the resident and her roommate were pushing their call-lights a lot. Staff #10 stated that if there was an allegation of hands being put on each other and/or voices being raised, she should have been called and there are a lot risks if (LPN/staff #1) didn't allow the resident to speak to a charge nurse. Staff #10 stated that the roommate was not interviewed because she had already discharged from the facility. An interview was conducted on February 25, 2025 at 1:52 p.m. with a certified nursing assistant (CNA/staff #2), who stated that resident #22's roommate (resident #33) said that she didn't want (LPN/staff #1) in her room because they were afraid of her. Resident #33 told her that (LPN/staff #1) screamed in her face because she kept putting the call-light on, she needed to go to the bathroom and had wet the bed from urine and water. Staff #2 stated that residents have complained about (LPN/staff #1) and she has reported her to another nurse. She stated that one time, she heard a male resident asking for pain medication and (LPN/staff #1) told him that she would give it to him when she was ready and if he wasn't a drug addict, he wouldn't have a problem. She said to (LPN/staff #1), isn't the medication scheduled? and staff #1 didn't answer her. (CNA/staff #1) stated that she reported the incident to (LPN/staff #24), who told her that she didn't want to get involved. An interview was conducted on February 25, 2025 at 2:14 p.m. with the Social Services Manager (staff/#7), who stated that she was instructed by the (DON/staff #10) to follow up on the incident involving resident #22. She stated that resident #22 made a complaint on February 6, 2025 about (LPN/staff #1) speaking to her with an elevated voice, in an aggressive manner, and was short with her. The resident reported that (LPN/staff #1) twisted her arm when she tried to show her where to apply the pain patch and it hurt, and when she told staff #1 that she wanted to speak with a charge nurse, staff #1 told her that there wasn't a charge nurse. Staff #7 stated that she didn't observe any injuries. Staff #7 also spoke to resident #22's roommate, resident #33, who stated that (LPN/staff #1) was rude, didn't speak in a nice tone, when she asked for toilet paper and that she was not nice to resident #22. Resident #33 heard the altercation between resident #22 and (LPN/staff #1), but did not see anything because the curtain was shut. Staff #7 stated that she did not ask resident #33 what she heard during the altercation and did not document the interview with either resident. An interview was conducted on February 25, 2025 at 4:22 p.m. with (LPN/staff #24), who stated that it is important to treat the residents with dignity and respect, this is their home. She stated that staff should speak in a respectful manner, which includes tone and if she receives a report that staff is being rude or inappropriate, she would pull staff away from the resident and report the incident to the Administrator. She stated that she has heard other staff say that (LPN/staff #1) is mean to the residents: yells at them, doesn't give pain meds, and doesn't answer call-lights. She did remember a (CNA/staff #2) telling her that a male resident asked for pain medication and that (LPN/staff #1) told him to wait until she was ready and she did not report it to anyone. She stated that she thinks that (LPN/staff #1) went on break and staff were looking for her and she would have given the pain medication before she went on break. She stated that she just tries to keep to herself. The facility was unable to provide the resident rights policy, but provided the rights that the residents have to abide by while in the facility.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a thorough investigation was completed for one resident (#22) alleging abuse. The deficient practice could result in residents being physically and psychosocial harmed. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing and Hypertension. The brief interview for mental status dated February 5, 2025 included a score of 14 indicating the resident was cognitively intact. The care plan dated February 4, 2025 revealed that the resident has acute/chronic pain related to a ground level fall (GLF) with hip fracture, hypothyroidism, hypertension (HTN), and hypotension. Interventions include to administer analgesia medication as per orders. The order summary included: -February 5, 2025, left hip surgical dressing to stay in place until surgical follow up. -February 5, 2025, Lidocaine External Patch 4% (Lidocaine) apply to affected area one time per day for pain and remove per schedule. -February 6, 2025, patient to transfer to another LTC facility. Review of the medication administration record dated February 2025 revealed that Lidocaine External Patch 4% (Lidocaine) apply to affected area one time per day for pain and remove per schedule was applied by (LPN/staff #1) on February 5, 2025 at 8:00 p.m. A progress note dated February 6, 2025 revealed that the Social Services Manager (#7) followed up with the resident in regard to a reported grievance that occurred overnight. Staff #7 went over the steps of correction the facility was taking, and the resident was both agreeable and at ease with and felt much better. A progress note dated February 6, 2025 revealed that the resident requested a transfer to another facility. Review of the facilities 5-day investigation revealed that an interview could not be conducted with resident #22's roommate, resident #33, due to discharging on February 6, 2025. It also revealed that five residents were interviewed, but none of the residents' rooms were near resident #22's room. Review of the resident census and the facility map revealed that there residents staying in the rooms near resident #22's room. An interview was conducted on February 25, 2025 at 10:16 a.m. with resident #22, who stated that (LPN/staff #1) wanted to apply the Lidocaine patch, but she had not asked for a patch and it was supposed to be applied as per the order. She stated that (LPN/staff #1) was applying the patch in the upper area and she put her left hand on her lower back, where the glute starts, to show (LPN/staff #1) where the patch is supposed to go. She stated that she didn't remember if there hands touched, but the LPN grabbed her hand, bent her arm back, and twisted it and she told the LPN that she was hurting her. She stated that she told (LPN/staff #1) that she wanted to speak to someone in charge and the LPN told her that she was in charge and there was no one else here. She stated that the LPN got close to her face and said, you don't know how to act like an adult and I am going to teach you how to be an adult. She stated that her roommate didn't say anything and was afraid of (LPN/staff #1) because staff #1 was already mad at her roommate for doing something. She stated that sometime later, it may have been morning, a certified nursing assistant was helping her roommate, and the roommate was telling the CNA what happened. The CNA told them that there have been all kinds of staff and resident complaints about (LPN/staff #1). Then a charge nurse came to talk to her. An interview was conducted on February 25, 2025 at 12:11 p.m. with the Director of Nursing (DON/staff #10), who stated that there is not usually a supervisor available at night, so a resident would have to wait to talk to a supervisor the next morning. She stated that (LPN/staff #1) and resident #22 both claimed that they were grabbed by each other on February 5, 2025. She received a call from a Certified Nursing Assistant (CNA/staff #2) on February 6, 2025 at 5:55 a.m. stating that resident #22 reported that (LPN/staff #1) grabbed her arm and twisted it. She stated that (LPN/staff #1) was still in the facility when she arrived at approximately 6:15 a.m. Staff #10 stated that if the resident told (LPN/staff #1) that she wanted to speak to someone in charge, staff #1 should have contacted the DON or the nurse manager because allegations are to be reported right away. Staff #10 stated that the roommate was not interviewed because she had already discharged from the facility. An interview was conducted on February 25, 2025 at 1:52 p.m. with a certified nursing assistant (CNA/staff #2), who stated that resident #22's roommate, (resident #33), said that she didn't want (LPN/staff #1) in her room because they were afraid of her. Resident #33 told her that (LPN/staff #1) screamed in her face because she kept putting the call-light on, she needed to go to the bathroom and had wet the bed from urine and water. Staff #2 stated that residents have complained about (LPN/staff #1) and she has reported her to another nurse. She stated that one time, she heard a male resident asking for pain medication and (LPN/staff #1) told him that she would give it to him when she was ready and if he wasn't a drug addict, he wouldn't have a problem. She said to (LPN/staff #1), isn't the medication scheduled? and staff #1 didn't answer her. (CNA/staff #1) stated that she reported the incident to (LPN/staff #24), who told her that she didn't want to get involved. An interview was conducted on February 25, 2025 at 2:14 p.m. with the Social Services Manager (staff/#7), who stated that she was instructed by the (DON/staff #10) to follow up on the incident involving resident #22. She stated that resident #22 made a complaint on February 6, 2025 about (LPN/staff #1) speaking to her with an elevated voice, in an aggressive manner, and was short with her. The resident reported that (LPN/staff #1) twisted her arm when she tried to show her where to apply the pain patch and it hurt, and when she told staff #1 that she wanted to speak with a charge nurse, staff #1 told her that there wasn't a charge nurse. Staff #7 stated that she didn't observe any injuries. Staff #7 also spoke to resident #22's roommate, resident #33, who stated that (LPN/staff #1) was rude, didn't speak in a nice tone, when she asked for toilet paper and that she was not nice to resident #22. Resident #33 heard the altercation between resident #22 and (LPN/staff #1), but did not see anything because the curtain was shut. Staff #7 stated that she did not ask resident #33 what she heard during the altercation and did not document the interview with either resident. An interview was conducted on February 25, 2025 at 4:22 p.m. with (LPN/staff #24), who stated that it is important to treat the residents with dignity and respect, this is their home. She stated that staff should speak in a respectful manner, which includes tone and if she receives a report that staff is being rude or inappropriate, she would pull staff away from the resident and report the incident to the Administrator. She stated that she has heard other staff say that (LPN/staff #1) is mean to the residents: yells at them, doesn't give pain medications, and doesn't answer call-lights. She did remember a (CNA/staff #2) telling her that a male resident asked for pain medication and that (LPN/staff #1) told him to wait until she was ready and she did not report it to anyone. She stated that she thinks that (LPN/staff #1) went on break and staff were looking for her and she would have given the pain medication before she went on break. She stated that she just tries to keep to herself. The facility policy, Freedom from Abuse, Neglect, and Exploitation states that all identified events are reported to the Administrator immediately. An investigation will include the following: an interview with the person(s) reporting the incident; an interview with the residents; interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; an interview with all staff members (on all shifts) who may have information regarding the alleged incident; interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#44) was administered medication as prescribed. The deficient practice could result in adverse effects of medications administered. Findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses the included vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 2 indicating the resident was severely impaired. It also included that the resident did not exhibit any physical or verbal behaviors during the look-back period. A care plan dated January 18, 2025 revealed that the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to new environment. Interventions included to administer medications as ordered. The order summary included: -January 18, 2025, Seroquel oral tablet 50 mg (Quetiapine Fumate) give one tablet by mouth one time a day for major depressive disorder (MDD) as evidenced by severe mood swings. -January 18, 2025, (AD) monitor behavior every shift for depression episodes as evidenced by verbalized sadness every shift for depression. Verbalized sadness refer to NPI. -January 18, 2025, (AD)-monitor for sided effects of anti-depressants: common side effects sedation, drowsiness, headache, decreased appetite. Less common side effects: dry mouth, blurred vision, urinary retention. Rare side effects: extra pyramidal side effects. Notify provider if present every shift. -January 20, 2025, (AP) monitor behavior every shift for psychotic episodes as evidenced by target behavior: severe mood swings every shift. -January 20, 2025, (AP)- monitor for side effects of antipsychotics - common side effects: drowsiness, dry mouth, blurred vision, constipation, translent nausea, weight gain, increase salna, sweating. Less common side effects: edema, postural hypotension, urinary retention, stiff or tight muscles, shakiness, serious blood disorders. Rare side effects: extra pyramidal, [NAME] dyskinesia, jaundice, allergic reaction, increased photosensitivity, allergic dermatitis. Notify provider if present every shift. -January 21, 2025, per provider discontinue Seroquel oral tablet 50 mg (Quetiapine Fumate) give one tablet by mouth one time a day for major depressive disorder (MDD) as evidenced by severe mood swings. -January 23, 2025, change of condition for: (D/C Seroquel) provider notified, resident/responsible party aware and agreeable to point of care, responsible party notified. Every shift for 3 days post follow-up for discontinued Seroquel. A care plan initiated January 19, 2025 and resolved January 23, 2025 revealed the use of psychotropic medications use related to major depressive disorder (MDD) as evidenced by severe mood swings. Interventions included to monitor medications as ordered. Monitor/document for side effects and effectiveness and to monitor/record occurrence of for target behavior symptoms severe mood swings and document. Review of the medication administration record dated January 2025 revealed that Seroquel oral tablet 50 mg (Quetiapine Fumate) give one tablet by mouth one time a day for major depressive disorder (MDD) as evidenced by severe mood swings was administered on the 19, 20, and 21, 2025. An interview was conducted on February 26 2025 at 11:55 a.m. with the Director of Nursing (DON/staff #10), who stated that the facility received a discharge summary from the hospital when the resident was admitted , which included medication orders. She stated that the orders didn't include Seroquel, which is an Antipsychotic prescribed for schizophrenia and bipolar disorder. She reviewed the clinical record and stated that the resident did not have a diagnoses for schizophrenia or bipolar disorder and had a diagnosis for dementia and was administered Seroquel on January 19, 20, and 21, 2025. She stated that the Assistant Director of Nursing (ADON/staff #43) reconciled the medications and entered an order for Seroquel by mistake. Staff #43 created the order for the physician's verification. She stated that the psych provider saw the resident on January 21, 2025 and mentioned to the resident's caregiver that the resident was taking Seroquel. The caregiver told the psych provider that the resident is not supposed to be on Seroquel and the family reported the concern to her and the Seroquel was discontinued on January 21, 2025. She stated that this was a medication error and the physician was notified; the physician ordered for the resident to be monitored for side effects for 72 hours. The personal caregiver and the family had reported that the resident appeared over-sedated and it was not the resident's normal baseline. She stated that one of the risks of Seroquel is over-sedation and an altered mental status and the resident did experience over-sedation, which is documented in the progress notes dated January 21, 2025. An interview was conducted on January 21, 2025 at 12:22 p.m. with the Assistant Director of Nursing (ADON/staff #43), who stated that the hospital summary included the orders. The nurse reviews the orders and then looks for a diagnosis to go with each order. Then the nurse contacts the physician to relay the orders and the physician reviews the orders to make everything is correct. She stated once there is an orders, she puts the orders in the electronic record and the nurses start administering the medications. She acknowledged that she requested an order for Seroquel instead of Sertraline and stated that there is a risk to administering antipsychotics when not needed because it increases changes in the brain, increases the neurological activity, and a resident may not be able to sleep. The facility policy, Physician Orders states that admission orders are reviewed with the physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure adequate supervision was provided to one resident (#1) to prevent elopement. The deficient practice could result in injury or harm to the resident. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis of encephalopathy, dementia, and alzheimer's Disease. A review of record titled LN-Elopement/Wandering Evaluation-V2 dated December 11, 2024 revealed a score of 10.0 indicating resident is high risk. A review of care plan initiated on December 11, 2024 revealed resident at risk for impaired cognitive function/dementia or impaired thought processes related to new environment. The interventions with a revision date of December 30, 2024 included to administer medication as ordered, identify self at each interaction, face when speaking and make eye contact, reduce any distractions- turn off TV, radio, close door etc., use simple, directive sentences, provide with necessary cues- stop and return if agitated, and keep routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion A review of care plan initiated on December 12, 2024 revealed Elopement risk/wanderer related to dementia. The goal included that safety will be maintained through the review date. The interventions with a revised date of December 16, 2024 included 1:1 supervision, document wandering behavior and attempted diversional interventions, identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate and provide structured activities: toileting, walking inside and outside, provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. A review of record titled POC Response History Task: Behavior Symptoms dated December 15, 2024 at 15:12 revealed a check mark for wandering. Review of record dated December 15, 2024 revealed At approximately 1915 it was noted that patient was no longer in her room. Staff conducted a room to room search and searched area around the building. Police were notified at approximately 1930 and a search was initiated. Police found the patient on the corner of [NAME] and [NAME] street and returned her to facility. A head to toe assessment was performed and no injuries were noted. Staff notified the provider and family member, care plan updated and one on one supervision was initiated. Review of MDS (Minimum Data Set) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3.0 indicating severely impaired cognition, resident has inattention and disorganized thinking behavior continuously present, does not fluctuate, has wandering behavior occured 1 to 3 days, and has an active diagnosis of Anemia, Hypertension, Alzheimer's Disease, and Non-Alzheimer's Dementia. Review of facility document, Sign In Sheet, for December 16, 2024 revealed a sitter/Staff #14 was assigned as sitter. An interview was conducted on December 31, 2024 at 2:27 pm with certified nursing assitant (CNA)/staff #9. Staff #9 stated that they work in the skilled unit part of the facility which is from rooms 401 through 416. An interview was conducted on December 31, 2024 at 2:31 pm with a licensed practical nurse (LPN)/staff #8. Staff #8 stated that she takes care of residents in their skilled unit who requires occupational and physical therapy services, who are on intravenous antibiotics, and who needs wound care. Their resident to nurse ratio is 20 to 23 residents per nurse and they have three CNAs today. Staff #8 stated that most of her residents in the skilled unit require assistance with ambulation, are aware and oriented. An interview was conducted on December 31, 2024 at 3:02 pm with hospitality aid/Staff #14. Staff #14 stated that she was assigned as a sitter for a resident on December 16 and does not remember the resident's name. Staff #14 stated that they watch the resident so resident does not leave. Staff #14 stated that while she was the resident's sitter, the resident had conversation with her regarding wanting to go back to their apartment and going somewhere. An interview was conducted on December 31, 2024 at 3:17 pm with a LPN/Staff #10. Staff #10 stated that she does not remember any resident who wandered outside their facility or disappeared, but stated that they had a resident with a sitter and the sitter who was assigned was from their human resource (HR)/Staff #16. Staff #10 stated that they use a sitter sometimes when resident had a fall, when a resident is abusive to others or a resident who wanders. Staff #10 stated that when a resident wanders, they have a code to use for missing resident which they announced to all their staff using their walky talky device to help search for the missing resident, and if the resident is not found by staff, they call 911 and their director of nursing (DON). An interview was conducted on December 31, 2024 at 3:29 pm with HR staff/Staff #16. Staff #16 stated that she was a sitter/one on one for a resident who eloped from the facility on December 15 and the resident returned on the same day accompanied by their activities director/Staff #19. Staff #16 stated that the resident needed constant surveillance/one on one. Staff #16 stated that she was not aware on how the elopement happened. A phone interview was conducted on December 31, 2024 with LPN/Staff #13. Staff #13 stated that she was working on December 15, 2024 which was a Sunday. Staff #13 stated that she was the nurse for resident #1. Staff #13 stated that she was in the middle of passing medication and resident #1 was wandering around. Staff #13 stated that she saw resident by the exit area around sevenish and then one CNA informed her that their resident is missing. They searched for resident #1. Staff #13 stated that a resident stated that they saw a lady who went out of the front door. Staff #13 stated that they notified resident's family, then a staff member found resident in the street, they called the police, and then resident was returned back in the facility. Furthermore, Staff #13 stated that a staff nurse let the resident out when resident push the button to unlock the door to open. Staff #13 stated that resident may have been gone for a whole hour. Furthermore, staff #13 stated that after the elopement incident, they no longer use the tablet to open and close the door. Staff #13 explained that before the elopement incident, they were using a camera with a ring tablet to see who is it such as a delivery or an ambulance. And now, staff #13 stated that they will physically open the door for each person who enters the facility after 6:00 pm. An interview was conducted on December 31, 2024 at 4:13 pm with the DON/Staff #11. The DON stated that for a resident with dementia, if they do not wander, they treat them as normal resident, but with resident at higher risk and active, they put more eyes on them. The DON stated that resident #1 did not trigger elopement so they did not place them on a one on one until after the elopement occurred. The DON stated that they were made aware of the elopement incident with resident #1 when she received a call from the nurse, their staff looked around their surroundings to search for the resident, and one of their nurse stayed in the facility and called the police. The DON stated that the police found the resident, and their activity director went out to verify that the person with the police is their resident and then they brought resident #1 back to their facility. The DON stated that resident left their building when one of their nurses thought the resident was a family member because the resident was dressed in normal clothes. The staff did not know that the person they opened the door for was one of their residents until the staff was told by the CNA looking for the resident that she might have let a resident out. The DON stated that the incident was brought up during their QA (quality assurance) meeting. The DON stated they did not have any elopement incident in the past except this incident and that there is no camera or video to view regarding the elopement incident. Review of facility's policy titled Elopement last revised on May 2024 revealed that it is the policy of this facility to ensure that the facility provides a safe and secure atmosphere for all residents in the facility. To ensure that residents at risk for elopement are properly monitored (1) Residents identified to be high risk for elopment will have an appropriate plan of care developed to address the risk.

Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure one was resident (31) was not physically abused by another resident (#154). Findings include: Resident #31 was admitted on [DATE] with diagnoses that included disorder of the autonomic nervous system, unspecified, anxiety disorder, unspecified, dysphagia, unspecified, gastrostomy status, hypersomality and hypernatremia, acquired absence of right great toe, peripheral vascular disease, unspecified, paroxysmal atrial fibrillation, primary open-angle glaucoma, bilateral, indeterminate stage. In a Minimum Data Set (MDS) quarterly assessment completed on October 31, 2023 Resident #31 scored a 99 on a Brief Interview for Mental Status, indicating the resident was unable to complete the interview to determine the individual's attention, orientation and ability to register and recall new information. Resident did not display any behaviors such as aggression or wandering. Review of the physician's orders revealed the following, aa) monitor behavior every shift for anti-anxiety episodes as exhibited by target behavior: panic attacks, (aa)- monitor for side effects of anti-anxiety / anxiolytics: common s/e: sedation, drowsiness, ataxia, dizziness, nausea, confusion, nasal congestion. less common s/e: vomiting, skin rash, falls, agitation. rare s/e: hypotension, blurred vision, ataxia, mood swings. notify provider if present, bilateral mobility bars may aid in turning and repositioning patient, psych to eval and treat, weekly skin check (complete skin assessment/evaluation-prn/weekly uda), Keppra solution 100 mg/ml (levetiracetam), apixaban oral tablet 5 mg (apixaban) give 1 tablet via peg-tube two times a day for atrial fibrillation dissolve in 60 ml of water, give 5 ml enterally two times a day for seizures, hydroxyzine hcl oral tablet 25 mg (hydroxyzine hcl) give 25 mg enterally two times a day for anxiety as exhibited by panic attacks, melatonin oral tablet 5 mg (melatonin) give 1 tablet by mouth at bedtime for supplement. Review of the facility's investigation report dated October 21, 2022 10/21/2022, revealed that on October 21, 2022 a CNA was in the dining room and heard another resident state you can't do that, please stop. The CNA witnessed resident #170 hitting resident #31 shoulder. The CNA immediately separated the two residents and made sure they were safe. The CNA immediately reported the incident to the administrator. Further review of the investigation report revealed notifications were made to the appropriate persons and agencies, investigation was initiated and a plan of action was implemented to ensure the residents remained safe. Review of the care plan date initiated: December 8, 2022 and revision on August 312023 revealed the following: Focus: At risk for a communication problem related to subarachnoid hemorrhage; Intervention: Anticipate and meet needs. Assist with word finding as needed/appropriate. Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation. Monitor effectiveness of communication strategies and assistive devices; Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed. Use effective strategies touch, facial expression, eye contact, gestures, tone of voice, non-threatening posture, short direct phrases, speak slowly, speak in a calm, distinct manner, time to communicate, quiet setting for communicating with resident. Use touch, facial expression, tone and body language to enhance communication. Validate message by repeating aloud. Date initiated: December 8, and revision on August 31, 2023; Focus: Potential for a psychosocial well-being problem related to resident to resident altercation. Intervention: Consult with: Pastoral care, Social services, Psych services. Observe for side effects and adverse reaction to anti-anxiety medication: Drowsiness, lack of energy, Clumsiness, slow reflexes, Slurred speech, Confusion and disorientation, Depression, Dizziness, lightheadedness, Impaired thinking and judgment, Memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. unexpected side effects: mania, hostility and rage, aggressive or impulsive behavior, hallucinations. Provide opportunities for family to participate in care. When conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Intervention: Consult with Pastoral care, Social services, Psych services, Revision on 07/18/2023. Observe for side effects and adverse reaction to anti-anxiety medication, drowsiness, lack of energy, clumsiness, slow reflexes, slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgement, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. Unexpected side effects; mania, hostility or rage, aggressive or impulsive behavior, hallucinations. Provide opportunities for family to participate in care. When conflict arises, remove residents to a calm safe environment and allow to share/vent feelings. Review of the Grievance Facility Binder dated January 2022 through December 2022 revealed no formal grievances filed for resident (#31). Review of the resident council minutes revealed no concerns with resident-to-resident abuse or concerns with residents (#31) or (#170). Review of the shower sheets for resident #31 dated October 22, 2022 through October 30, 2022 revealed no skin issues, red marks, or bruising noted from resident to resident abuse. Review of the weekly skin assessments dated October 24, 2022 and October 31, 2022 revealed no new skin issues noted or reported for those weeks. On November 15, 2023 at 9:50 AM, an attempt was made to contact alleged victim representative. On November 16, 2023 at 8:21 AM, an attempt was made to contact alleged victim representative. Neither calls were successful. Resident #31 was not interviewable due to cognitive status. Alleged perpetrator, resident #170 was discharged from the facility September 5, 2023 with no further incidents with resident #31. 2. Resident #170 was admitted to the facility May 11, 2022 and discharged [DATE] with the following diagnosis, schizophrenia, unspecified, altered mental status, unspecified, personal history of traumatic brain injury, other seizures, bipolar disorder, unspecified, hypothyroidism, unspecified, essential (primary) hypertension, dysphagia, oropharyngeal phase, drug induced subacute dyskinesia, unspecified mental disorder due to known physiological condition, anxiety disorder due to known physiological condition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00. Review of Section E revealed resident had not exhibited any behaviors verbally or physically directed towards others, Review of Section G revealed resident required extensive assistance with bed mobility, transfers, and eating. Section G further revealed resident was total dependence for personal hygiene, toilet use, dressing and locomotion on and off the unit. Review of Section I revealed resident has an active diagnosis for anxiety disorder, Bipolar disorder, Schizophrenia, altered mental status, unspecified, personal history of traumatic brain injury, unspecified, mental disorder due to known physiological condition, drug induced subacute dyskinesia. Review of the Physicians Orders revealed the following, Lithium level and Depakote level in the morning for psych med management, bipolar for 1 Day, Benztropine Mesylate Tablet 0.5 MG Give 1 tablet by mouth one time a day for Parkinson's, Divalproex Sodium Tablet Delayed Release 500 MG Give 2 tablet by mouth at bedtime for Seizures, Divalproex Sodium Tablet Delayed Release 250 MG Give 1 tablet by mouth one time a day for Seizures, Lithium Carbonate ER Tablet Extended Release 450 MG Give 1 tablet by mouth at bedtime for Bipolar as evidenced by severe mood swings, Paliperidone Palmitate ER Suspension Prefilled Syringe 156 MG/ML Inject 156 mg intramuscularly one time only for Schizophrenia as evidenced by swatting at staff until 10/25/2022 09:00, ms)- mood stabilizers- monitor side effects of mood stabilizers: common s/e: nausea, diarrhea, abd cramping, sedation, headache, thirst, dry mouth, constipation, tremors. less common s/e: cardiac arrhythmia, weight gain, urinary frequency, confusion. rare s/e: rash, photosensitivity. notify provider if present. Review of the Care Plan dated May 11, 2022 revealed the following: Focus, Psychotropic medications use. Antipsychotic medication; Bipolar as evidenced by severe mood swings; Schizophrenia as evidenced by paranoia; Date Initiated: 05/12/2022, Revision on: 05/12/2022. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Revision on: 09/15/2023, Cancelled Date: 09/15/2023; NG 09/15/2023, canceled: antipsychotic-monitor for side effects of antipsychotics, common s/e: drowsiness, dry mouth, blurred vision, constipation, transient nausea, weight gain, increased saliva, sweating, less common side effects: edema, postural hypotension, urinary retention, stiff or tight muscles, shakiness, serious, blood disorders. rare side effects: extra pyramidal, tardive dyskinesia. Focus: Canceled: Potential to demonstrate verbally abusive behaviors related to Mental /Emotional illness, Poor impulse control, verbally abuse to other patients, verbally abuse to staff members, physically abuse to other patients. Date Initiated: 10/10/2022, Revision on: 09/15/2023, Canceled Date: 09/15/2023. Intervention: Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Revision on: 09/15/2023 Canceled Date: 09/15/2023. Canceled: Assess resident's coping skills and support system. Revision on: 09/15/2023 Canceled Date: 09/15/2023. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Revision on: 09/15/2023, Canceled Date: 09/15/2023. Canceled: Document observed behavior and attempted interventions. Revision on: 09/15/2023, Canceled Date: 09/15/2023. Evaluate for side effects of medications, Revision on: 09/15/2023, Canceled Date: 09/15/2023. Psychiatric/Psychoneurotic consult as indicated. Revision on: 09/15/2023, Canceled Date: 09/15/2023. Review of the facility five-day investigative report with incident date of October 21, 2022 revealed the facility implemented a Plan of Action as follows: 1. Resident #170 to follow-up with psych. 2. Residents #170 and #31 not to be seated at the same table. Unable to interview alleged perpetrator, resident #170 was discharged from the facility on September 5, 2023. Review of the Discharge Summary and Post Discharge Plan of Care effective date of September 5, 2023 revealed resident #170 was discharged to an assisted living facility, resident health had improved and no longer required the services of the facility. On November 17, 2023 interview and exit for complaints were exited with DON (staff #36), ADON, (staff #78) and Clinical Resource, (staff # 200). Staff #36 does not dispute the incident happening and feels the facility responded appropriately and believes it was an isolated incident, stating the facility ensured the residents were monitored and ensured their safety at all times. ensuring the residents remained safe from harm. Investigation Summary: Original complaint details an incident of resident to resident abuse. The incident in question is not disputed by the facility, however this incident appears isolated. Review of available data shows no other instances of altercations between these two residents. The facility staff were witness to the event and it was described as happening in an instant, with immediate staff intervention. Both residents were placed on monitoring which appears to have been followed, and the alleged perpetrator no longer has contact with the victim, as he was discharged from the facility on September 5, 2023. Review of the facility policy titled Abuse: Prevention of Prohibition Against states it is the policy of the facility that each resident has the right o be free from abuse, neglect, misappropriation of resident property, and expropriation. Facility staff are prohibited from taking, keeping, using or distributing photographs or video recordings of facility residents in any manner that would demean or humiliate a resident, regardless of whether the resident provided consent and regardless of the resident's cognitive status. This includes using any type of equipment (e.g., cameras, smart phones, or other electronic device) to take, keep, or distribute inappropriate photographs or recordings on social media. The facility ill provide oversight and monitoring to ensure that it's staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. This facility applies to all facility staff including, but not limited to employees, consultants, contractors, volunteers, students and other caregivers who provide care and services to residents on behalf of the facility.

Based on clinical record review, staff interviews, and policy review the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II was referred to the State designated authority for evaluation and determination and a PASRR Level I was completed for two residents (#170) and (#6). The universe is 54 and the sample size is 2. The deficient practice could result in specialized services not being identified and provided to residents. Findings include: Resident #170 was admitted to the facility on [DATE] and discharged [DATE] with diagnoses including schizophrenia, unspecified, altered mental status, unspecified, personal history of traumatic brain injury, other seizures, bipolar disorder, dysphagia, drug induced subacute dyskinesia, unspecified mental disorder due to known physiological condition, anxiety disorder due to known physiological condition. A Level I PASRR screening completed on June 11, 2022 included the attending physician had certified, prior to admission, that the resident would require less than 30 calendar days of nursing facility services and that the nursing facility must update the Level I at such a time it appeared the resident's stay would exceed 30 days. However, review of the clinical record did not indicate an updated PASRR had been completed. Further review of the PASRR Mental Illness (Section B), revealed the residents admitting primary diagnosis for schizophrenia; was checked no for not having the Serious Mental Illness. Review of the admission Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident interview was unsuccessful. Review of Section E revealed resident had not exhibited any behaviors verbally or physically directed towards others, Review of Section G revealed resident required extensive assistance with bed mobility, transfers, and eating. Section G further revealed resident was total dependence for personal hygiene, toilet use, dressing and locomotion on and off the unit. Review of Section I revealed resident has an active diagnosis for anxiety disorder, Bipolar disorder, Schizophrenia, altered mental status, unspecified, personal history of traumatic brain injury, unspecified mental disorder due to known physiological condition, drug induced subacute dyskinesia. On November 16, 2023 at 10:48 AM, an interview was conducted with the Social Services Supervisor (staff #71), she stated that the PASSR was completed prior to her hire with the facility. She stated the facility has noted some concerns with incomplete PASRR's and had completed an audit. Staff #71 reviewed the PASRR for resident #170 dated June 11, 2022, stating the PASRR had been filled out incorrectly and should have included the diagnosis for schizophrenia and submitted to the state agency for a Level II. Staff #71 stated current protocol is she will obtain a PASRR from the transferring facility and if the resident is admitted longer than 30 days then she will update the PASRR and submit to the state agency for further evaluation if needed. An interview was conducted on November 11, 2023 at 11:43 AM with the Director of Nursing (staff #36) and Clinical Resource (staff #200), who stated her expectations are that PASRR's are completed upon admission, 30-days, and annually. Staff #36 reviewed resident (#170) PASRR dated June 11, 2022 the PASRR was not completed correctly and the risks associated with this are if a resident has multiple diagnosis, mental disorders could mean the resident may not receive the appropriate care and services. She further stated the facility was aware there were concerns with PASRR's and had completed an audit by the Quality Improvement Team. 49325 Regarding resident #6 Findings include: Resident #6 was first admitted into the facility on [DATE]. Prior to admission, a PASRR Level II evaluation was completed on June 7, 2018 which revealed diagnoses of Post-Traumatic Stress Disorder (PTSD) and Borderline Personality Disorder. Care plan-initiated June 27, 2018 revealed, PASSR Level II upon admission appropriate for SNF with supportive services and will be able to verbalize/communicate required assistance post-discharge and the services required to meet needs before discharge. The Admission Minimum Data Set (MDS) assessment at the time of admission revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. Medical record review revealed that a new PASRR Level I was completed on September 13, 2022. Mental illness (Section B) of this new PASRR Level I revealed a diagnosis of Schizophrenia that was absent on the PASRR Level II evaluation from 2018. Referral determination (Section D) revealed that a referral for Level II determination for dual intellectual disability/mental illness was appropriate, however medical records revealed no referral for PASRR Level II evaluation and determination was done. Moreover, medical record review reveals a new PASRR Level I was started on January 16, 2023. The reasoning section for PASRR Level I was unfilled and the referral determination (Section D) was similarly unfilled upon review of document. However, per client uploaded files, under category section - admission, documentation reveals resident #6 had been admitted into the emergency room with date of service of January 12, 2023 at 5:20 PM. The Emergency Department (ED) provider notes under section titled, assessment and plan, reveal resident was brought for worsening paranoia and hallucinations. ED provider notes under section titled, plan, reveal mental status appeared markedly different than in 2018 -- upon consultation by psychiatrist who was familiar with resident #6. Review of MDS section c1310 e-signed on January 24, 2023 in leu of discharge, reveals resident #6 showed evidence of an acute change in mental status, as well as presenting with the following behaviors: inattention, disorganized thinking, and altered level of consciousness that come and go with changes in severity. During an interview with Social Services Director (staff #71) conducted on November 17, 2023 at 1:29 PM efforts were made to provide documentation regarding PASRR Level II referral, from September 13, 2022, which she was unable to do. Staff #71 stated that they would not get the appropriate services without a PASRR Level II evaluation and determination. Staff #71 reiterated that a new psychiatric diagnosis should be written at the time of diagnosis, and a resident should subsequently be referred for a PASRR Level II. Staff #71 also confirmed that the PASRR Level I from January 16, 2023 was incomplete. Staff #71 stated section D on PASRR Level I should always be completed. Staff #71 stated if a PASRR Level I is not completed residents cannot be assessed right because we do not know their appropriate levels. Staff #71 stated that a PASRR Level I was needed for re-admission from the hospital in the case of resident #6 otherwise would not be getting the appropriate services. An interview with the Director of Nursing (DON/Staff #36) was conducted on November 17, 2023 at 2:55 PM who stated a PASRR Level I should be completed if diagnosis of mental illness/intellectual disability arises as needed and annually. Regarding new admissions, staff #36 stated PASRR is obtained, if incorrect fixed after 30 days, and sent-in if needed for review. Staff #36 stated that the facility is not doing a good job of doing PASSAR, and are doing additional training on PASRR level II. The policy and procedure document titled, Resident Assessment - PASRR (revised May/2023) was reviewed and revealed, that the facility will ensure each resident is properly screened using the PASRR specified by the State. The facility will refer to the State's AHCCCS Pre-admission Screening and Resident Review (PASRR) policy.

Based on observations, clinical record review, interviews, and policy review, the facility failed to ensure one resident (#40) received the necessary services to maintain good grooming hygiene. This deficient practice could result in grooming needs not being met. A resident interview was conducted with resident (#40) on 11/14/23 at 10:24 AM. Resident (#40) stated he has not had a haircut since in the facility. Resident (#40) stated he dislikes the length of his hair and has requested a haircut multiple times throughout the year. Resident (#40) stated he informed the nursing staff of his request for a haircut, but was told that the facility does not offer those services. Resident (#40) stated there were a few CNA's who would cut the residents hair for them, but they are no longer work for the facility. Resident (#40) stated he has never received a haircut from a CNA, but was told thid was whom he may able to get a haircut from. Resident (#40) was admitted to the facility on [DATE] with diagnosis that includes, type 2 diabetes mellitus with diabetic neuropathy, unspecified, long term (current) use of insulin, acquired absence of left leg below knee, muscle weakness (generalized), depression, unspecified, partial traumatic amputation of right foot, level unspecified, subsequent encounter, depression, unspecified. A review of the September 21, 2023 quarterly minimum data set (MDS) was conducted. Section C revealed that the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) of 15. An interview was conducted with CNA (staff #48) 11/17/23 at 10:35 AM. CNA (staff #48) stated she has worked for the facility for almost a year. CNA (staff #48) stated her job responsibilities include assisting residents with their showers, nail clipping, skin assessments for any skin changes. CNA (staff #48) stated cutting residents' hair is part of their responsibilities as CNA's, but that she afraid to cut residents hair. She stated we have a CNA who provides haircuts for residents. She stated she is afraid to cut residents hair. Stated there is no barber or beauty shop on site. Stated she is unaware what services are provided for residents who are unable to go out or who have family that are able to assist getting them haircut services. An interview was conducted with Social Services Supervisor, (Staff #71) on November 17, 2023 at 10:42 AM. Staff #71 stated her department does not handle those services that they are responsibility of the activity department. (Staff #71) stated she had not received any requests from any residents requesting a haircut. (Staff #71) stated she is unaware of any services the facility provided for residents who are unable to get a haircut. An interview was conducted with Activities Director, (Staff #41) on November 17, 2023 at 11:09 AM. (Staff #41) stated she has been employed with the facility for 6 years. (Staff #41) stated not having a barber or hairstylist in house has been an issue, especially since Covid. She stated she has been trying to have volunteers come in to cut the residents hair for over a year, but has been unable to locate any. Staff #41 stated she realizes it is a problem and many residents do not have the funds or family to take them out for haircuts. She further stated she is unable to cut any of the resident's hair because a license to cut hair is required. An interview was conducted with Director of Nursing (DON, Staff #36) on November 17, 2023 at 02:55 PM. (DON,Staff #36) stated if a resident would like a haircut, they let a staff member know then social services will get someone in, have the resident taken to an appointment or have their family take them. She stated some residents have asked for assistance with cutting their own hair from CNA's who are willing will assist them. (DON,Staff #36) stated if a resident does not have the funds or family for a haircut the facility will cover the cost after social services checks if the resident has a trust, family or funds for the cost. Social services will inform the administrator who has the funds in a discretionary account. She further stated she was unsure if the resident would need to apply for these funds, as there has not been any recent resident requests. (DON,Staff #36) stated the facility have had beauty schools come into the facility to provide these services, but it has been over a year since they have. She stated the facility offers Angel Rounds to the residents and stated resident (#40) has never mentioned the need for a haircut during Angel Rounds. (DON, Staff #36) stated she was unable to provide any documentation of a resident who had been provided services through the facility's discretionary fund account for grooming services. A review of the facility policy titled Quality of Care ADL. Services to carry out states it is the policy of the facility that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psycho-social well-being of each resident in accordance with a written plan of care.

Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that infection control standards were maintained during medication pass. This deficient practice could result in the spread of infection to residents. Resident #4 was admitted to the facility on [DATE] with diagnoses that included paraplegia, scoliosis, neurogenic bladder, anxiety, anemia and depression. An observation during medication pass was conducted on November 15, 2023 at 8:43 a.m. with an RN (Registered Nurse) (RN/staff #8). The RN was observed administering medications to resident #4. However, no hand hygiene was observed and the RN was observed removing gloves from his pocket and using them during the medication pass. In an interview with the RN (RN/staff #8) conducted on November 16, 2023 at 10:18 a.m. The RN stated that as a nurse, you are not supposed to keep gloves in your pocket. The RN further stated that the reason is because of infection control, and that your pocket may not be clean. The RN also stated that you should be doing hand hygiene every time you come in contact with a resident. An interview was conducted on November 17, 2023 at 11:18 a.m. with the Director of Nursing (DON/staff #36). The DON stated that her expectation is for the staff to follow infection control guidelines including proper hand hygiene and wearing gloves. A review of the facility policy titled 'Infection prevention and control program' revised September of 2022 revealed that the goal is to recognize infection control practices while providing care. It further revealed that hand hygiene procedures will be followed by staff involved in direct resident contact.

Based on review of the clinical record, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one section (L) of a Minimum Data Set (MDS) assessment for one resident (#28) accurately reflected his oral/dental status. The sample was 19 residents. The deficient practice could result in residents not receiving care and services for oral/dental conditions. Findings include: Resident #28 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on February 21, 2022, did not include goals and interventions for the resident's dental condition. Review of the order summary report revealed that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The current and active order summary report revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Evaluation dated February 21, 2021 noted that resident #28 did not have carious or broken natural teeth. However, the Nutrition Admission Evaluation dated February 21, 2021 indicated that the resident had missing upper and lower teeth. The admission Minimum Data Set (MDS) dated [DATE], indicated that the resident did not have any oral/dental condition/issue. In contrast, the [NAME] Dental Services encounter dated March 15, 2022, noted that the resident would like dentures. Additionally, the form indicated that the resident needed a full mouth extraction with full upper and full lower dentures. The significant change in status MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. It also indicated that the resident did not have any dental problems/conditions. During an observation conducted on September 19, 2022 at 8:03 a.m. the resident was noticed to have jagged/broken teeth with occlusal surface which appeared to be black in color. During an interview conducted on September 22, 2022 at 1:31 p.m. with a Registered Nurse (RN)/MDS coordinator (staff #82), she stated that the MDS gathers information from CNA charting and therapy. Staff #82 said that she reviewed orders, progress notes and additional documents from hospital and assessments to verity it is current. She said that for dental, the information annotated on the MDS will also come from the care plan, the resident's initial admission record, and from the patient if they are alert and oriented. She stated that information from the miscellaneous tab of the resident's electronic record can also be used to populate the dental portion of the MDS. Review of resident #28's electronic clinical record, specifically the MDS and the [NAME] Dental Services form was conducted with staff #82 on September 22, 2022 at approximately 1:16 p.m. She noted that information from the [NAME] Dental Services form dated March 15, 2022 should have been reflected on the MDS. She stated that she was unsure of how that information should have been relayed to her. She also stated that that she was not clear on who was responsible for the dental portion of the MDS. During an interview conducted on September 22, 2022 at 3:04 pm with the Director of Nursing (DON/staff #92), the DON stated that the MDS coordinator is responsible for all sections of the MDS with the exception of section C, D, S and Q which is for Social Worker, Section F which is for the Activities Director, and Section K which is for Dietitian. She stated that she expects Social Services or the appropriate person to follow up on recommendations in order for the resident to get the care needed. Staff # 92 stated that when there is no documentation, there is no proof that care happened or was followed up and it creates a breakdown of communication. She said it is important for all staff to document assessments appropriately/accurately. A facility policy titled Resident Assessment reviewed January 2022, indicated that a RN must conduct or coordinate each assessment with the appropriate participation of health professionals. Furthermore, on assessment or correction request, the RN Assessment Coordinator is responsible for certifying overall completion once all individual assessors have completed and signed their portion of the MDS. Each individual who completed a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

Based on clinical record review, staff interviews, and facility policy, the facility failed to monitor one resident's (#4) weight per physician's orders. The sample size was 5. The deficient practice could result in resident not receiving the needed services for change of condition. Findings include: Resident #4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of active and current orders revealed a physician order dated June 6, 2022 which indicated weekly weights as ordered. Review of the weight summary log revealed the following: - June 2022: June 6 - 11: 203.2 lbs (taken June 7) June 12 - 18: 204.8 lbs (taken June 13) June 19 - 25: missing info/weight not taken June 26 - July 2: missing info/weight not taken - July 2022: July 3 - 9: 206.9 lbs (July 5) July 10 - 5: missing info/weight not taken July 17 - 23: missing info/weight not taken July 24 - 30: missing info/weight not taken - August 2022: July 31 - August 6: 205.2 lbs (August 4) August 7 - 13: missing info/weight not taken August 21 - 27: missing info/weight not taken August 28 - September 3: mission info/weight not taken - September 2022: September 4 - 10: missing info/weight not taken September 11 - 17: missing info/weight not taken September 18 - 24: 176.5 lbs (taken September 13); 178.2 lbs (taken September 15) Further review of the weight summary log revealed that on August 4, 2022, the resident weighed 205.2 pounds. On September 15, 2022, the resident weighed 178.2 pounds which is a -13.16% loss. A care plan focused on the resident's nutritional problem or potential nutritional problem revised on September 9, 2022 indicated interventions that included weekly weights for four weeks then monthly if stable. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating that the resident had moderate cognitive impairment. An interview was conducted on September 19, 2022 at 8:18 a.m. with the resident (#4). Resident #4 stated that his weight loss was both planned and unplanned by him. Planned in the sense that he wanted to lose weight to be healthier but not to the extent it has. He also stated that since the facility only provides three meals a day, it allowed him to lose weight when he is not eating more than those meals. During an interview with a Certified Nursing Assistant/Restorative Nursing Assistant (CNA/RNA/staff #35), she stated that the RNA's and another aide were responsible for taking residents weight. They worked together with the nutritionist to see what needs to be done. Staff #35 also stated that weights were documented on Point Click Care. RNA is responsible for notifying the nurse for weight fluctuation. When this occurs then the resident is weighed weekly or daily depending on the guide. The MDS Coordinator/registered nurse (RN/staff # 82) was interviewed on September 22, 2022 at 1:31 p.m. Staff #82 stated that CNAs takes and logs residents' weight. If there is an order, it populates on the Medication Administration Report (MAR). She noted that LTC residents are usually weighed monthly on the 1st day of the month. LTC residents with orders for weekly are tracked and should be documented on CNA tasks in the resident's electronic clinical record. Resident #4's electronic clinical record was reviewed with staff #82 at the time of the interview. Staff #82 noted that based on the physician's orders, the weight log was not being completed as prescribed by the physician. An interview was conducted on September 22, 2022 at 3:04 p.m. with the Director of Nursing (DON/staff #92) who stated that her expectation is that the CNA or nurse weigh the resident per physician's orders and document appropriately. Staff #92 stated that the RNA is in charge of getting weight as ordered. She also noted that the information should be logged into Point Click Care (PCC). A policy titled Weight revised September 2017, indicated that the facility aims to obtain an accurate weight as part of the resident's assessment. The Physician Orders policy reviewed August 2022, stated that the facility accurately implement orders in addition to medication orders (treatment, procedures ) only upon the written order of a licensed and authorized individual.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure routine medication was consistently available for one resident (#28). The sample size was 6. The deficient practice could result in necessary medications not available and not administered to residents as ordered by the physician. Findings include: Resident #28 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included malignant neoplasm of unspecified part of unspecified bronchus or lung, psychoactive substance abuse and major depressive disorder, single episode, severe with psychotic features. A physician's order dated August 4, 2022 included for [MEDICATION(S)] Tablet (Antipsychotic Medication) 5mg (Milligram), give 1 tablet by mouth one time a day for [CONDITION(S)] disorder as evidenced by severe mood swings. Review of significant change MDS (Minimum Data Set) assessment dated [DATE] revealed the resident scored 15 on BIMS (Brief Interview of Mental Status) which indicated resident cognition was intact. The MDS also revealed that resident received antipsychotic medications 3 out of 7 days and antidepressant 7 out of 7 days during 7 days look back period. Review of the comprehensive care plan revised on August 31, 2022 revealed [CONDITION(S)] medications use that included antipsychotic medication for [CONDITION(S)] as evidenced by severe mood swings. Intervention included to administer medications as ordered. Review of MAR (Medication Administration Record) for August 2022 revealed that resident did not receive [MEDICATION(S)] tablet from August 5 through August 9, 2022. The MAR was coded no '7' which referred to 'Other/ see nurse note'. The corresponding e-MAR (electronic MAR) notes stated the following: -On next pharmacy run. MD (Medical Director) aware on August 5, 2022 -Medication unavailable. On next pharmacy run. on August 6, 2022 -not available pharmacy pending on August 7 and 8, 2022 -medication not available on August 9, 2022 Review of the nursing progress notes for August 6 through August 9, 2022 did not reveal that the MD was notified and did not reveal that the medication was administered to the resident on those days. An interview was conducted with a Licensed Practical Nurse (LPN / staff #59) on September 22, 2022 at 1:51 pm. She stated that when a medication is unavailable, the process is to re-order the medication, call the pharmacy, put the medication on hold, notify the doctor and pass it on in the report with next shift. She stated everything should be documented in the nursing progress notes. She looked at the resident #28's August 2022 MAR and stated [MEDICATION(S)] is an important medication. She stated the medication should have been administered or the doctor should have been informed. She stated the medication is for [CONDITION(S)] disorder and if the resident missed doses of the medication, level of the medication in the resident's system will be out of normal which could result in the resident having worsening symptoms. An interview was conducted with the Director of Nursing (DON/ staff #92) on September 22, 2022 at 2:17 pm. She stated her expectation from the staff when a medication is unavailable is to contact the nurse manager or charge nurse, look to see if medication was available in e-kit (emergency kit), notify the provider and receive order to hold the medication or receive order to administer different medication. She stated her expectation is for the nurses to document in the progress note. She stated sometimes certain medication take longer to arrive from pharmacy if pharmacy needs prior approval. She stated in that case, the doctor should be notified and the medication order should be on hold. She stated [MEDICATION(S)] medication should be given everyday as ordered as not taking the medication could cause side effects in resident. The facility policy titled Medication Administration revised May 2022 included that the facility policy is, medication shall be administered as prescribed by the attending physician. The policy stated if a medication is unavailable, the nurse should document accordingly. The policy also stated that if a medication is withheld, refused, or given other than at the scheduled time, the documentation will be reflected in the clinical record. The facility policy titled Care and Treatment reviewed on July 2022 included that the facility policy is to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident.

Based on the observation, clinical record review, staff interviews and policy review, the facility failed to ensure that out of date medication was discarded for one resident (#26). The deficient practice could result in ineffective treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: Resident #26 was readmitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] = 0 units. Notify MD (Medical Director) if BS (Blood Sugar) below 60; ,d+[DATE]= 0 units; ,d+[DATE] = 2 units; ,d+[DATE] = 4 units; ,d+[DATE] = 6 units; ,d+[DATE] = 8 units; ,d+[DATE] = 10 units; 401+ = 12 units, notify MD if BS greater than 401, subcutaneously before meals for DM. Review of MAR (Medication Administration Record) for [DATE] through [DATE] revealed that resident received insulin [MEDICATION(S)] as ordered. During an observation conducted of the Station 3 cart on [DATE] at 7:41 AM with the Licensed Practical Nurse (LPN/ Staff #43), two boxes of resident's #26 medication- [MEDICATION(S)] solution was observed in the cart. One was labeled with open date of [DATE] which observed to have insulin left in the vial and another one was labeled with open date of [DATE]. During the medication administration observation with staff #43 on [DATE] at 7:41 AM, Staff #43 first observed drawing 4 units of [MEDICATION(S)] solution via syringe from the Insulin vial with open date of [DATE] but corrected after looking at the open date and discarded the insulin she drew. The staff then observed drawing 4 units of [MEDICATION(S)] solution via syringe from the vial with open date of [DATE]. Following the observation, an interview was conducted with the staff #43. She stated that the date on the vial of the [MEDICATION(S)] solution (Insulin [MEDICATION(S)]) was open date of the medication and stated the insulin vial expired after 30 days of opening the vial. She stated the vial with open date of [DATE] was expired and would discard the expired insulin vial so the nurses used the new one. During another interview with staff #43 on [DATE] at 8:15 AM, she stated that when a new insulin vial is opened, nurses have to put open date and expire date on the insulin vial. She stated the out of date insulin vial should be discarded and not used to avoid adverse reaction. During an interview with staff #43 on [DATE] at 1:57 PM, she stated that she discarded the expired insulin vial with open date [DATE] for resident #26. She stated if the insulin vial was opened on [DATE], the insulin expired on [DATE]. She stated she could not tell if the expired insulin was used for resident #26 from the date it expired dated [DATE] and new insulin vial was opened on [DATE] as she was not working those weeks. An interview was conducted with a Registered Nurse (RN/ staff #10) on [DATE] at 2:03 PM. She stated that when an insulin vial is opened, the vial should be labeled with open date. She stated the insulin vial will expire after 30 days after it is opened. She stated the expired insulin should not be used and should be discarded. An interview was conducted with the Director of Nursing (DON/ staff#92) on [DATE] at 2:19 PM. She stated her expectation is for the staff to label the Insulin vial with open date before its use and discard the insulin after 28 days. She stated the insulin should not be used after 28 days of opening as the solution will no longer be viable for use after 28 days. She stated after the resident #26's insulin [MEDICATION(S)] with open date [DATE] expired after 28 days, she did not know if the staff used the expired vial. She stated there might have been another vial that the nurses used and forgot to dispose the expired vial. Review of the [MEDICATION(S)] solution vials' package insert included instructions on storing of the medication. It revealed that after [MEDICATION(S)] vials have been opened (in-use), the vial that is being used should be thrown away after 28 days, even if it still has insulin left in it.

Based on review of the clinical record, staff interviews, and review of facility policies and procedures, the facility failed to ensure that dental needs were met for one of one sampled residents (#28) . The deficient practice could result in residents not receiving care and services for oral/dental conditions. Findings include: Resident #28 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on February 21, 2022 did not include goals and interventions for the resident's dental condition. Review of the order summary report revealed that a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The current and active order summary report revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Evaluation dated February 21, 2021 noted that resident #28 did not have carious or broken natural teeth. However, the Nutrition Admission Evaluation dated February 21, 2021 indicated that the resident had missing upper and lower teeth. The admission Minimum Data Set (MDS) dated [DATE], indicated that the resident did not have any oral/dental condition/issue. In contrast, the [NAME] Dental Services encounter dated March 15, 2022, noted that the resident would like dentures. Additionally, the form indicated that the resident needed a full mouth extraction with full upper and full lower dentures. The significant change in status MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. It also indicated that the resident did not have any dental problems/conditions. During an observation conducted on September 19, 2022 at 8:03 a.m. the resident was noticed to have jagged/broken teeth with occlusal surface which appeared to be black in color. During an interview conducted on September 22, 2022 at 11:11 am with a Certified Nursing Assistant (CNA/staff #35), staff #35 stated that resident #28 complained about his teeth hurting. However, he also told her that he had already informed a nurse regarding the problem so she did not follow up. An interview with the Social Worker (staff #72) was conducted on September 22, 2022 at 12:39 p.m. She said that once a week she talked to long term care (LTC) residents and asked if they were in pain or have concerns they need to get scheduled appointments for. She noted that when it came to this resident, she is unsure of why his condition was not followed up. She indicated that there was no progress note to detail what occurred following the dental visit. During an interview conducted on September 22, 2022 at 1:31 p.m. with a Registered Nurse (RN)/MDS coordinator (staff #82), she stated that the MDS gathers information from CNA charting and therapy. Staff #82 said that she reviewed orders, progress notes and additional documents from hospital and assessments to verity it is current. She said that for dental, the information annotated on the MDS will also come from the care plan, the resident's initial admission record, and from the patient if they are alert and oriented. She stated that information from the miscellaneous tab of the resident's electronic record can also be used to populate the dental portion of the MDS. During an interview conducted on September 22, 2022 at 3:04 pm with the Director of Nursing (DON/staff #92), the DON stated that the MDS coordinator is responsible for all sections of the MDS with the exception of section C, D, S and Q which is for Social Worker, Section F which is for the Activities Director, and Section K which is for Dietitian. She stated that she expects Social Services or the appropriate person to follow up on recommendations in order for the resident to get the care needed. Staff # 92 stated that when there is no documentation, there is no proof that care happened or was followed up and it creates a breakdown of communication. She said it is important for all staff to document assessments appropriately/accurately so that a resident's care and needs is recorded. A facility policy titled Dental Services reviewed November 28, 2017, indicated that it is the facility's policy that residents who require dental services on a routine or emergency basis have access to such services without barrier. Their guidelines for compliance noted that they will provide or obtain from an outside source, routine and emergency dental service for each resident. Assist resident as necessary or requested to make appointments for dental services or arrange for transportation to and from dental services location.

Based on clinical record review, family and staff interviews, and facility policies and procedures, the facility failed to provide documentation of two residents' (#1 and #2) assessments provided to a receiving provider. The sample size was four. The deficient practice could result in receiving facilities not having the necessary information for continuing care of residents. Findings include: -Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing note dated August 23, 2022 7:13 pm included that the wife asked to speak to the nurse and requested to send out the patient to the hospital. Patient stated, I want to go home. Wife stated, No, you are going to the hospital. three of your doctors are there. Transport arrived at 1515 to transport patient to the hospital. A hospital transfer form dated August 23, 2022 included that resident #1 was being transferred for failure to thrive and that the transfer was unplanned. The form included that other clinical notes were included. The form included that report was called in by a Licensed Practical Nurse (LPN/staff #33). Review of the form revealed no documentation of a name or title or location report was called to. Review of the clinical record revealed no documentation of what other clinical notes were included in the discharge from and the record had no documentation of what information was given to the receiving provider. -Resident #2 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A hospital transfer form dated June 8, 2022 included that resident #2 was being transferred for abnormal lab values and that the transfer was unplanned. The form included that report was called in by another Licensed Practical Nurse and that report was called to RN. Review of the form revealed no additional clinical information was included and the form had no documentation of a name or location report was called to. Review of the clinical record revealed no documentation of other clinical notes in the discharge from and the record had no documentation of what information was given to the receiving provider. During an interview conducted on September 7, 2022 at 11:00 am with a Licensed Practical Nurse (LPN/staff #33), staff #33 state that when a resident is being transferred to a hospital she calls for transport, prints out a face sheet, orders, recent labs, and any additional documentation that is needed. Staff #33 stated that all that information is given to the ambulance crew and that is who she gives report to. Staff #33 stated that she does not recall the name or title of the person she gave report to for resident #1. Staff #33 stated that she documents what is given to transport and what she tells them in the medical record under progress notes. Staff #33 stated that if it is not documented it is not done. Staff #33 stated she does not call the receiving facility to give them report. An interview was conducted on September 7, 2022 at 12:10 pm with the Director of Nursing (DON/staff #26). The DON stated all information reported to the receiving provider should be documented in the resident's records. The DON stated report should be given by the staff to the receiving facility. A facility policy titled Admission, Transfer and Discharge included that when the facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Information provided to the receiving provider must include a minimum of the following: -Contact information of the practitioner responsible for the care of the resident. -Resident representative information including contact information -Advance Directive information -All special instructions or precautions for ongoing care, as appropriate. -Comprehensive care plan goals; and -All other necessary information, including a copy of the resident's discharge summary, and any other documentation.

Based on observation, clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that care and treatments were provided to 1 of 3 sampled residents (#4) who developed an unstageable pressure ulcer, and by failing to provide care and treatments for two additional pressure ulcers which were present upon admission. There were five residents in the facility who were identified as having pressure ulcers. The deficient practice could result in delayed wound healing and/or deterioration of wounds. Findings include: Resident #4 admitted to the facility on (MONTH) 16, (YEAR) and readmitted to the facility on (MONTH) 29, 2019, with [DIAGNOSES REDACTED]. A nursing progress note dated (MONTH) 16, (YEAR) included the resident was admitted with a large stage 4 sacral ulcer and had a chronic indwelling urinary catheter in place. Regarding the right thigh pressure ulcers: Physician orders dated (MONTH) 16, (YEAR) included for an indwelling urinary catheter for a [DIAGNOSES REDACTED]. Review of the clinical record revealed no documentation that the resident was admitted with any pressure ulcers to the right thigh. An admission Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Per the MDS, the resident required extensive assistance with bed mobility, transfers and toileting, was always incontinent of bowel and had an indwelling urinary catheter. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) revealed that catheter care was not completed on the night shift on (MONTH) 17 and 25. Review of the clinical record revealed there was no weekly skin evaluation which was completed the week of (MONTH) 23-29, (YEAR). Another physician's order dated (MONTH) 6, 2019 included for an indwelling urinary catheter for [MEDICAL CONDITION]. The (MONTH) 2019 TAR revealed the order for catheter care, however, there was no documentation that catheter care was provided on (MONTH) 1, 8 or 13 (on the night shift) or (MONTH) 15 (on the day and night shift). Further review of the clinical record revealed no documentation that a weekly skin evaluation was completed from (MONTH) 13-18, 2019. The clinical record documentation showed that the resident was admitted to the hospital on (MONTH) 18, 2019 for altered mental status and readmitted on (MONTH) 29, 2019. Review of the re-admission physician's orders dated (MONTH) 29, 2019, revealed for an indwelling catheter for [MEDICAL CONDITION]/urine retention, a bariatric low air loss mattress for decubitus precautions and for weekly skin checks. Upon re-admission, there was no clinical record documentation that the resident had any pressure ulcers to the right thigh. A provider's progress note dated (MONTH) 5, 2019 included the resident had an indwelling urinary catheter for compromised skin condition. A weekly skin assessment dated (MONTH) 5, 2019 revealed there were no skin issues to the right thigh. A care plan initiated on (MONTH) 6, 2019 included the resident was at risk for further pressure ulcer development related to immobility, incontinence, diabetes mellitus and [MEDICAL CONDITION]. The care plan included for an indwelling catheter to promote wound healing with a goal that the resident will remain free from catheter related trauma. An intervention included to provide catheter care every shift and as needed. Further review of the pressure ulcer care plan revealed it was revised on (MONTH) 9, 2019 to include that the resident had a right inner thigh pressure ulcer, due to the indwelling urinary catheter. The care plan included the resident was at risk of her condition worsening due to non-adherence with plan of care, as the resident does not like pillows or other assistive devices separating her legs. The goal included there will be signs of improved healing through the next review date. Interventions included the following: administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing; measure length, width and depth where possible; assess and document status of wound perimeter, wound bed and healing progress; report improvements and declines to the medical doctor; catheter tubing re-routed to avoid inner thigh area; continue to educate and encourage resident on keeping padding in place to inner thighs; needs monitoring/reminding/assistance to turn/reposition; padding applied between legs to decrease pressure to the area; and weekly head to toe skin at risk assessment. Although the care plan identified that the resident was non compliant with keeping pillows or other assistive devices to keep her legs separated, there was no clinical record documentation of the resident's non compliance prior to (MONTH) 9. In addition, there was no clinical record documentation that a treatment order was obtained on (MONTH) 9 or 10, or that a thorough assessment of the right inner thigh pressure ulcer was conducted on (MONTH) 9, 10 or 11, 2019, which included any measurements, description of the wound bed and surrounding skin, staging of the pressure ulcer and if any drainage was present. A physician's progress noted dated (MONTH) 11, 2019 included the resident had new groin wounds, however, there was no description of the wounds. A physician's order for wound treatment was obtained on (MONTH) 11, 2019, two days after the pressure ulcer to the right thigh was identified. The order included to cleanse the right medial thigh pressure ulcer with normal saline, apply xeroform and cover with a dry sterile dressing every 24 hours. Review of the physician's progress note (MONTH) 12, 2019, revealed the resident had an ulceration on the right medial inner thigh (upper lid caused by the Foley catheter). There is mild thinning slough with scant serous drainage. No peri-wound inflammation. The note further included that the resident has a medical device associated ulceration to the right medial inner thigh. This note did not include any measurements. Review of a weekly pressure ulcer assessment dated (MONTH) 13, 2019 revealed the resident had a lower right inner thigh wound, with an onset date of (MONTH) 9. The wound was described as an unstageable pressure ulcer that measured 15.5 cm length by 1 cm, and the wound bed had slough with undefined wound edges with a small amount of serous exudate. This was the first documentation of any measurements to the right thigh pressure ulcer, since it was identified on (MONTH) 9. This same weekly pressure ulcer assessment dated (MONTH) 13, 2019 also included documentation that the resident now had a second pressure ulcer to the upper right inner thigh, which was a stage 2. The wound measured 18.5 cm length by 1 cm width with a pink wound bed and undefined edges and had a small amount of serous exudate. There was no physician ordered treatment for [REDACTED]. A wound care nurse practitioner progress note dated (MONTH) 21, 2019 revealed the resident had two ulcerations on the right medial inner thighs. The superior ulceration had minimal slough and the inferior ulceration had mild slough, with minimal granulation. No measurements were documented. The note indicated the wounds were medical device associated ulcerations. The note also included that a curette was used to remove slough from the right thigh. Review of the weekly pressure ulcer assessment dated (MONTH) 24, 2019 revealed the resident had an unstageable pressure ulcer to the right medial inner thigh, which measured 13.5 cm length by 1 cm width. The wound had a small amount of serous exudate and slough in the wound bed, with undefined wound edges. The note further included that the stage 2 pressure ulcer had healed. A nurse practitioner wound care note dated (MONTH) 26, 2019 revealed the medical device ulceration on the right medial inner thigh was improving and the superior ulceration has 100% re-[MEDICATION NAME] and the inferior ulceration has mild thin slough and mild granulation. A physician's order dated (MONTH) 27, 2019 included to cleanse the right medial thigh with wound cleanser, pat dry, apply [MEDICATION NAME], then apply a thin strip of xeroform and cover with a dry dressing for moisture associated skin damage. Review of the CNA documentation regarding assistance provided to the resident with bed mobility and turning and repositioning revealed no documentation of any assistance that was provided on (MONTH) 2, 6, 9, 18, 20, 23, 26, and 28, 2019 on the night shift. Regarding toileting assistance revealed no documentation that assistance was provided on (MONTH) 2, 9, 18, 20, 23, and 26, 2019 on the night shift. Regarding pressure ulcer devices in place revealed no documentation of any devices on (MONTH) 2, 6, 9, 18, 20, 23, 26 and 28, 2019 on the night shift. A physician's wound care progress note dated (MONTH) 5, 2019 revealed the right medial thigh ulceration was improving, with [MEDICATION NAME] of the edges and thin slough on the wound bed. Review of the weekly pressure ulcer assessment dated (MONTH) 6, 2019 revealed the resident had an unstageable pressure ulcer to the right medial thigh with an onset date of (MONTH) 9, 2019 which measured 13.2 length and width and 1 cm depth. The wound had a small amount of serosanguinous exudate with slough in the wound bed and defined edges. Only one thigh wound was documented. Review of the weekly pressure ulcer assessment dated (MONTH) 13, 2019 revealed the resident had an unstageable pressure ulcer to the right medial thigh, with an onset date of (MONTH) 9, 2019. The wound measured 9.5 cm length by 0.5 cm width by 0.2 cm depth with slough in the wound bed and undefined edges, and had a scant amount of serous exudate. Another physician's order dated (MONTH) 15, 2019 included for an indwelling catheter for wound management. Review of the CNA documentation regarding assistance provided to the resident with bed mobility revealed no documentation of any assistance that was provided on (MONTH) 2, 4, 9, 10, 13, 17, 19, 2019 on the night shift. Regarding assistance provided with turning and repositioning revealed no assistance was provided on (MONTH) 2, 4, 9, 10, 13, 17, 20, 2019 on the night shift. Regarding assistance with toilet use revealed no documentation of assistance provided on (MONTH) 2, 4, 9, 10, 13, 17, 19, 2019 on the night shift. Regarding documentation of pressure ulcer devices in place revealed no documentation on (MONTH) 2, 9, 10, 13, 17, 20, 2019 on the night shift. A Nurse Practitioner wound progress note dated (MONTH) 19, 2019 revealed the right thigh ulceration had resolved. A wound care observation of the resident was performed on (MONTH) 20, 2019 at 9:21 a.m., with the wound care certified Licensed Practical Nurse (LPN/staff #19). The resident was observed to be lying on her back in bed. There was a long thin strip of lightened skin noted to the inner right medial thigh, which was identified by the wound nurse as the newly healed pressure area that had been caused by the catheter tubing. The resident was not observed to have any open wounds to the right thigh. An interview was conducted with staff #19 on (MONTH) 20, 2019 at 10:06 a.m. He stated that the catheter caused the thigh wounds. He stated they assess residents for any items that could cause pressure injury, and that the catheter related wounds to the thigh could have been prevented by staff. Regarding the stage 4 sacral pressure ulcer: A nursing progress note dated (MONTH) 16, (YEAR) documented the resident was admitted with a large stage 4 sacral ulcer. Review of the Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 16, (YEAR), revealed the resident was at low risk, despite having a stage 4 pressure ulcer. A physician's order dated (MONTH) 16, (YEAR) included to cleanse the sacral pressure ulcer with wound cleanser, pat dry, apply 1/4 strength Dakin's soaked sterile gauze to the wound bed and cover with a dry dressing. Further review of the clinical record revealed no documentation that the stage 4 pressure ulcer was thoroughly assessed on (MONTH) 16 or 17, (YEAR), which included any measurements, a description of the wound bed and surrounding skin and if any drainage was present. Review of the (MONTH) (YEAR) TAR revealed no documentation that the physician ordered treatment was provided to the sacral wound on (MONTH) 17 (night shift). A physician's progress note dated (MONTH) 17, (YEAR) included the resident had a chronic indwelling urinary catheter for a stage 4 sacral wound. A weekly pressure ulcer assessment was completed on (MONTH) 18, (YEAR) and revealed that the resident had a very large stage 4 sacral pressure ulceration, which was present on admit. The wound was described as having exposed necrotic bone and heavy necrotic soft eschar to the wound bed, with slough and no significant granulation. The wound had heavy serous to brownish drainage with moderate odor on dressing removal and no peri-wound inflammation was present. The was the first assessment of the stage 4 sacral pressure ulcer, which was done two days after admission. The assessment also did not include any wound measurements. A physician's wound progress note dated (MONTH) 18, (YEAR) included the resident has a very large sacral ulceration, with exposed necrotic bone on the wound bed. There is heavy necrotic soft eschar on the wound bed with slough. No significant granulation. Heavy serous to brownish drainage with moderate odor on dressing removal. No periwound inflammation. The plan included to turn the resident per facility protocol, continue dressing the sacral ulceration and a nutrition consultation. No measurements were included. A care plan dated (MONTH) 18, (YEAR) identified a problem of actual impairment to skin integrity related to pressure injury to the sacrum. A goal was that the resident would be free of injury though the next review date. Approaches included to educate resident/family/caregivers on causative factors and measures to prevent skin injury; follow facility protocols for treatment of [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 23, (YEAR), revealed the resident was always incontinent of bowel and had an indwelling catheter. The MDS also included that the resident had a stage 4 pressure ulcer, which was present on admission. Review of the (MONTH) (YEAR) TAR revealed no documentation that the physician ordered treatment was provided to the sacral wound on (MONTH) 24 and 25 (day and night shifts) and on (MONTH) 29 (day shift). Review of the Braden Scale for Predicting Pressure Sore Risk dated (MONTH) 31, (YEAR) revealed the resident was at moderate risk. Review of the CNA documentation regarding assistance provided to the resident with bed mobility and toileting revealed no documentation of assistance provided on (MONTH) 20, 28, 29 or 31, (YEAR) on the night shift or on (MONTH) 30 on the day shift. Regarding assistance provided with turning and repositioning revealed no documentation of assistance provided on (MONTH) 16, 20, 28, 29 or 31, (YEAR) on the night shift or on (MONTH) 30 on the day shift. Regarding pressure ulcer devices in place revealed no documentation on (MONTH) 20, 28, 29 or 31, (YEAR) on the night shift and (MONTH) 30 on the day shift. Review of the (MONTH) 2019 TAR revealed no documentation that the physician ordered treatment to the sacral pressure ulcer was provided on the night shift on (MONTH) 1, 6 and 8. The next assessment of the sacral pressure ulcer was conducted nineteen days after the last assessment (which was done on (MONTH) 18). Per the weekly pressure ulcer assessment dated (MONTH) 7, 2019, the resident had a stage 4 pressure ulcer to the sacrum. The measurements were unclear as they were written as follows: 5.3.5 length and width, with a depth of 2.5 cm. The wound bed was described as beefy red, with attached wound edges and no exudate. This was the first documentation of any measurements of the stage 4 sacral pressure ulcer. A physician's order dated (MONTH) 9, 2019 included to cleanse the sacrum every day shift with wound cleanser, pat dry, apply Santyl ointment 250 units per gram to wound bed, apply [MEDICATION NAME] and cover with an island dressing. Physician orders dated (MONTH) 11, 2019 revealed to cleanse the sacrum with wound cleanser, pat dry, use skin prep to peri-wound, drape with tape, apply black foam to wound bed, apply wound vac at 125 millimeters of mercury (mmHg) continuous. Physician orders dated (MONTH) 12, 2019 included to discontinue the Santyl dressing once the wound vac was available. A weekly pressure ulcer assessment dated (MONTH) 14, 2019 revealed the resident had a very large sacral pressure ulcer stage 4, with exposed necrotic bone and heavy necrotic soft eschar on the wound bed with slough and no significant granulation. The assessment further noted heavy serous to brownish drainage with moderate odor on dressing removal and no peri-wound inflammation. The assessment did not include any wound measurements. A physician's order dated (MONTH) 15, 2019 revealed to cleanse the sacrum with wound cleanser, gently pack Dakin's 0.25% soaked Kerlix into wound bed and cover with an island dressing. Another treatment order dated (MONTH) 15, 2019 regarding the wound vac included to cleanse the sacrum with wound cleanser, pat dry, use skin prep to peri-wound, drape with tape, apply black foam to wound bed and apply wound vac at 125 millimeters of mercury (mmHg) continuous. Review of the (MONTH) 2019 TAR revealed no documentation that the sacral wound care was provided on (MONTH) 15. Review of the CNA documentation regarding assistance provided to the resident with bed mobility, toilet use and turning and repositioning revealed no documentation of assistance provided on (MONTH) 4, 5, 9, 12, 14, 2019 on the night shift and (MONTH) 17 on the day shift. Regarding pressure ulcer devices in place revealed no documentation on (MONTH) 4, 5, 9,12,14, 2019 on the night shift and (MONTH) 17 on the day shift. The clinical record documentation showed that the resident was admitted to the hospital on (MONTH) 18, and readmitted to the facility on (MONTH) 29, 2019. Review of the weekly pressure ulcer assessment dated (MONTH) 29, 2019 revealed the resident had a stage 4 pressure ulcer to the sacrum that was a deep beefy red full thickness wound and measured 9.5 cm in length by 11 cm in width by 5 cm in depth. The wound was described as now having 3 cm of undermining, moderate serosanguinous exudate with no odor and defined edges. This is the first documentation of clear measurements of the stage 4 sacral pressure ulcer. The physician orders dated (MONTH) 29, 2019 included to cleanse the sacral wound with wound cleanser or normal saline, apply wet to moist dressing with Dakin's and secure with tape every 12 hours until wound vac can be placed. A physician's order dated (MONTH) 29, 2019 included to cleanse the sacrum with wound cleanser, pat dry, apply no sting barrier skin prep to peri-wound skin, window frame wound with drape, apply black foam to sacral wounds, secure with additional drape, suction at continuous 125 mmHg. The order also included to change wound vac on Tuesday, Thursday, and Saturday, and as needed for malfunction or dislodgement and to monitor wound vac every shift for functioning and placement. Review of the provider's progress note dated (MONTH) 30, 2019 included the resident was admitted to the facility for rehabilitation and for wound care for a stage 4 decubitus ulcer of the sacral region and sacral osteo[DIAGNOSES REDACTED]. The note included that the sacral ulcer measured 7 cm by 6 cm by 5 cm and contained eschar/necrosis through to the muscle, tendon or bone. The note indicated to continue current dressing orders for wound care. Physician orders dated (MONTH) 2, 2019 included to cleanse the sacral wound with wound cleanser or normal saline, apply wet to moist dressing with Dakin's and secure with tape every 12 hours until wound vac can be placed started which was discontinued (MONTH) 6, 2019. A weekly pressure ulcer assessment dated (MONTH) 4, 2019 revealed the stage 4 pressure ulcer to the sacrum measured 9.5 cm length by 11 cm width, by 5 cm depth and 3 cm undermining. The wound bed was described as beefy red with no slough or eschar and has a moderate amount of serosanguinous exudate that now has a foul odor. A provider progress note dated (MONTH) 5, 2019 included the sacral ulcer measured 6 cm by 12.5 cm by 2.7 cm and contained eschar/necrosis through to the muscle, tendon or bone, and to continue current dressing orders. A care plan was initiated on (MONTH) 6, 2019 to reflect that the resident has a pressure ulcer to the sacrum and is at risk for further pressure ulcer development related to immobility, incontinence, diabetes mellitus and [MEDICAL CONDITION]. A goal included that the pressure ulcer will show signs of healing and remain free from infection. Interventions were as follows: administer treatments as ordered and monitor for effectiveness; assess/record/monitor wound healing, measure length, width and depth where possible; assess and document status of wound perimeter, wound bed and healing progress; report improvements and declines to the medical doctor; weekly head to toe skin at risk assessments and needs monitoring/reminding/assistance to turn and reposition. Review of the (MONTH) 2019 TAR revealed no documentation that wound vac monitoring was provided on (MONTH) 10. A physician's order dated (MONTH) 11, 2019 included to cleanse the sacrum wound with wound cleanser or normal saline, apply Dakin's 0.25% wet to moist dressing, cover with dressing and secure with tape every 12 hours. The next weekly pressure assessment was dated (MONTH) 13, 2019, which was nine day after the previous assessment (done on (MONTH) 4). The documentation revealed the stage 4 sacral pressure ulcer measured 7 cm length by 12 cm width by 4.5 cm depth, with 2.8 cm undermining. The wound bed was described as beefy red with a moderate amount of serosanguinous drainage, with no odor. The weekly pressure ulcer assessment dated (MONTH) 24, 2019 revealed the stage 4 sacral pressure ulcer measured 10 cm length by 7 cm width by 3.5 cm depth, with no undermining. The wound bed was described as beefy red with a moderate amount of serosanguinous drainage, with no odor. The next weekly pressure ulcer assessment was dated (MONTH) 6, 2019, which was 10 days after the previous assessment. The stage 4 sacral pressure ulcer measured 10 cm length by 6.8 cm width by 3.4 cm depth, with tunneling of 2.8 cm. The wound bed was described as having slough with a small amount of serosanguinous drainage, with no odor. Review of the weekly pressure ulcer assessment dated (MONTH) 13, 2019 revealed the stage 4 sacral pressure ulcer measured 9.2 cm length by 5.3 cm width by 3 cm depth and tunneling of 2.8 cm. The wound bed was described as beefy red with a moderate amount of serosanguinous drainage, with no odor and the wound edges are now rolling under. A wound observation of the resident was performed on (MONTH) 20, 2019 at 9:21 a.m. with a LPN/staff #19. The resident was observed lying on her back in bed. There was an intact dressing to the sacral area,with yellow, pinkish drainage to the dressing. Upon removal of the old dressing and packing, an odor was identified. The resident was observed to have a large deep oval pressure ulcer to the sacrum. The wound bed had a deep pink base with rolled edges and undermining was present. Staff #19 measured the wound and was 8.5 cm length 5.3 cm width by 2.5 cm deep, with tunneling of 2.3 cm between 10 to 1. The wound was identified by staff #19, as a stage 4 pressure wound which was present on admit. The weekly pressure ulcer assessment dated (MONTH) 20, 2019 revealed the stage 4 sacral pressure ulcer measured 8.5 cm length by 5.3 cm width by 2.5 cm depth and tunneling of 2.3 cm. The wound bed was described as normal for skin and had a moderate amount of serosanguinous drainage, with no odor and the wound edges are now undefined. Review of the CNA documentation regarding assistance provided to the resident with bed mobility revealed no documentation of assist provided on (MONTH) 2, 4, 9, 10, 13, 17, 19, 2019 on the night shift. Regarding assistance with turning and repositioning revealed no documentation of assistance provided on (MONTH) 2, 4, 9, 10, 13, 17, 20, 2019 on the night shift. Regarding assistance with toilet use revealed no documentation of assistance provided on (MONTH) 2, 4, 9, 10, 13, 17, 19, 2019 on the night shift. Regarding pressure ulcer devices in place revealed no documentation on (MONTH) 2, 9, 10, 13, 17, 20, 2019 on the night shift. Regarding the left heel deep tissue injury: According to the initial admission record dated (MONTH) 16, (YEAR), the resident was identified to have a superficial deep tissue injury (DTI) to the left heel. A physician's order dated (MONTH) 16, (YEAR) included to float heels as tolerated. Review of the (MONTH) (YEAR) TAR revealed no documentation that the heels were floated on (MONTH) 17, on the night shift. A physician's order was obtained on (MONTH) 17, (YEAR) to cleanse the left heel with wound cleanser, pat dry, apply [MEDICATION NAME], and cover with foam dressing. A care plan dated (MONTH) 18, (YEAR) identified a problem of actual impairment to skin integrity related to pressure injuries to the left and right heel. A goal included the resident would be free of injury though the review date. Approaches included to educate resident/family/caregivers on causative factors and measures to prevent skin injury; follow facility protocols for treatment of [REDACTED]. Review of the (MONTH) (YEAR) TAR revealed no documentation that the heel wound treatment was provided on (MONTH) 29. Review of the clinical record revealed no documentation that a weekly skin assessment was completed during the week of (MONTH) 23-29, (YEAR). A weekly skin evaluation dated (MONTH) 31, (YEAR) revealed the resident's bilateral heels were non blanchable. According to the (MONTH) 2019 TAR, there was no documentation that the resident's heels were floated on (MONTH) 1, 8 and 13 on the night shift and on (MONTH) 15 (day and night shift). A weekly skin evaluation dated (MONTH) 7, 2019 included the bilateral heels had healed. A wound care observation was performed on (MONTH) 20, 2019 at 9:21 a.m. The resident was not observed to have any wounds to the heels. An interview was conducted with a Certified Nursing Assistant (staff #42) on (MONTH) 20, 2019 at 1:59 p.m. She stated that residents would be at risk for pressure ulcers if staff were not cleansing residents well after incontinence, if left in a wet brief, and if a resident stayed in the same position too long. She stated that residents are repositioned every two hours and receive indwelling catheter care at least one time each eight hour shift by the CNA's. She stated that catheter tubing could cause pressure and staff could place a towel between the skin and catheter tubing and to make sure there is slack in the tubing between the stat Lock (indwelling urinary catheter stabilization device) and the insertion site. She stated that during catheter care, staff should lift the tubing when cleaning and visualize the skin beneath the tubing, and if she noticed any skin changes she would tell the nurse right away to come and assess the area. She stated that a resident should not develop a pressure ulcer under the indwelling urinary catheter tubing. Staff #42 said that she received in-services regarding residents with indwelling catheters and that staff were told to ensure that the skin was intact beneath the indwelling catheter tubing. She stated that during the training the wounds on resident #4's thighs were presented to the CNA's as pressure ulcers and were avoidable. An interview was conducted with a CNA (staff #3) on (MONTH) 20, 2019 at 2:23 p.m. She stated that pressure injuries could result from not positioning a resident often enough and improper placement of the catheter tubing. She stated the catheter tubing should be placed under the stat lock unless the resident refuses. She said that she would immediately report any changes to the skin to the nurse. She stated that resident #4 developed wounds from the indwelling catheter tubing, because the tubing was between her legs and her legs were pressing together which created pressure. She stated the CNA does catheter care every time the brief is changed. She stated that for staff to complete good catheter/peri-care, the resident would need to spread her legs, so staff can lift the catheter tubing to clean it and to look at the skin. She stated that she was told the wounds were pressure ulcers and were caused by the catheter tubing and the wounds should not have occurred. She also stated that residents receive repositioning every two hours. An interview was conducted with a CNA (staff #21) on (MONTH) 21, 2019 at 9:33 a.m. He stated that staff are expected to have 100% of their documentation completed by the end of the shift, and are to document after the care has been completed. He stated that there should not be any blanks in the documentation and if the care is not documented, then there is no proof that they did the care. He stated this resident is pretty compliant with her care. An interview was conducted with a LPN (staff #59) on (MONTH) 21, 2019 at 10:21 a.m. She stated that a resident is at risk for skin breakdown, if they are not repositioned often enough, if anything is sitting on the skin too long, if the resident does not have what they need for pressure relief and outside devices. She stated that an indwelling urinary catheter could cause a pressure injury, if the tubing is improperly placed (example: between areas of skin that are touching) or if a stat lock is improperly located. She stated that staff were told to be careful of the placement of the catheter tubing, and to be sure the stat lock position was being alternated. She stated that pressure wounds from medical devices/indwelling catheters would not be unavoidable. She stated that indwelling catheter care is completed each shift and that good care would include separating the resident's legs, lifting the tube and visualizing the peri area and under the tubing, as well as around the stat lock. She stated that any changes should be reported to the nurse as soon as the care is completed. She stated that she was aware of the pressure ulcer formation from the indwelling catheter tubing on resident #4 and that it was included in the shift to shift report. She stated the CNA's were made aware that the wounds were caused by pressure and were avoidable, and that the wounds could have been prevented with appropriate care and moving of the indwelling catheter tubing. She also stated there should not be blanks in the MARs/TARs and that a blank spot would mean the care was not given. She stated the risk of not doing wound care would be the wound could get worse or not show improvement. Staff #59 said if a resident's heels were not floated, the resident could get pressure ulcers in that area. At this time, she reviewed the holes in the TARs for resident #4 and stated that staff did not follow the expectation of the facility. Another interview was conducted with staff #19 on (MONTH) 21, 2019 at 12:05 p.m. He stated that the procedure followed by the facility for a new resident included assessing the resident's skin integrity. He stated the nurse does a skin assessment during the admission process to identify any skin integrity issues, including wounds. He

Based on observation, clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that safety measures and adequate supervision were provided to one resident (#2) who sustained a fall with injuries. The number of residents with falls was 6. The deficient practice could result in further falls with injuries. Findings include: Resident #2 was admitted to the facility on (MONTH) 30, (YEAR) and readmitted (MONTH) 9, 2019, with [DIAGNOSES REDACTED]. Review of a fall risk evaluation dated (MONTH) 30, (YEAR) revealed a fall risk score of 8, which indicated the resident was at medium risk for falls. The initial care plan with an effective date of (MONTH) 30, (YEAR) revealed the resident was at risk for falls. Interventions included keeping the bed in the lowest position and having a floor mat at the bedside. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 7, (YEAR) revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The assessment included the resident had [MEDICAL CONDITION] and required extensive assistance of two, with bed mobility and toilet use. The MDS also included the resident had no falls within the last 6 months or since admission. The comprehensive care plan dated (MONTH) 11, (YEAR) revealed the resident was at risk for falls with a goal to decrease the likelihood of falls. Interventions included keeping the bed in the lowest position and a floor mat at the bedside. The care plan also included the resident had ADL (activities of daily living) self care deficits related to [MEDICAL CONDITION]. Interventions included keeping the air activated call light within reach and that the resident required total assistance with transfers. Review of a fall risk evaluation dated (MONTH) 9, (YEAR) revealed a fall risk score of 9, which indicated the resident was at medium risk for falls. Review of a nursing progress note dated (MONTH) 24, 2019 at 7:17 a.m., revealed Heard a loud sound at the nursing station minutes after leaving resident's room/after repositioning lower legs back onto the resident lowered bed and medicating him. Resident found lying face down on the floor of his room in a pool of blood at his head . The note included the resident was assessed and observed to have a one and a half inch laceration under the left zygomatic arch, a half inch laceration to the left upper forehead and a slight amount of fresh blood from the left side of his mouth. Neurological assessments were initiated per their protocol. The note also included meticulous perineal care was given to the resident due to having a large formed bowel movement. The note did not include if a floor mat was in place at the time of the fall. The fall risk evaluation dated (MONTH) 24, (YEAR) revealed a fall risk score of 8. A nursing progress note dated (MONTH) 24, 2019 at 8:18 a.m. revealed 4 steri-strips were applied to the left zygomatic arch laceration and was reinforced with a heavy tight compression bandage, due to active bleeding. The note included the resident was transported to the hospital via ambulance. Review of the Nursing Home to Hospital Transfer form dated (MONTH) 24, 2019 revealed the resident was transported to the hospital, due to a fall and that the resident was having facial pain. Review of the hospital After Visit Summary dated (MONTH) 24, 2019, revealed the resident had a closed head injury and facial lacerations. The summary included a CT scan of the head/brain which revealed no evidence of an acute intracranial abnormality. The summary also included sutures were applied to the lacerations. A nursing progress note dated (MONTH) 24, 2019 at 11:45 a.m. revealed the resident returned to the facility via stretcher by medical transport. The note included the resident was observed to have an abrasion to the right shoulder and sutures to the left cheek bone. Review of the fall investigation report dated (MONTH) 24, 2019 revealed the fall occurred in the resident's room and that the resident stated that he moved his legs off the edge of the bed and fell . The report included the physician was notified and that orders were received to apply steri-strips to the left zygomatic arch and transfer the resident to the hospital. The report did not include documentation if the floor mat was in place at the time of the fall. Review of the Certified Nursing Assistant task documentation for fall prevention devices dated (MONTH) 2019 revealed documentation of a low bed, but did not include documentation that mats were to be on the floor, until after the resident fell . An interdisciplinary team fall committee progress note dated (MONTH) 25, 2019 revealed the fall was reviewed. The note included implementing a low bed with a floor mat to prevent further fall related injuries and that the resident agreed. During an interview conducted with residents on (MONTH) 20, 2019 at 10:13 a.m., they stated that the facility is understaffed and that residents are constantly crying out for help. One of the residents stated that they heard resident #2 calling for help and that he fell out of bed, and the next time they saw him he had stitches all over his face. An observation was conducted of the resident on (MONTH) 22, 2019 at 10:37 a.m. The resident was observed sleeping in the bed with a mat on the floor by the bed. An interview was conducted with resident #2 on (MONTH) 22, 2019 at 12:00 p.m. He stated that he woke up on the edge of the bed and that his call tube (air activated call light) was not next to him so he yelled for about 20 minutes and ended up falling off the edge of the bed. The resident stated that he hit a rolling table as he fell . He also stated that he received two wounds from the fall that required sutures. He stated that only two people were working the floor that day. The resident stated that there was never a mat on the floor beside his bed before he fell . During an interview conducted with a Certified Nursing Assistant (CNA/staff #55) on (MONTH) 22, 2019 at 10:40 a.m., the CNA stated that residents who are fall risks have their beds in the lowest position with the call light in reach, and with mats on the floor. She stated that resident #2 is a fall risk and now has a larger bed, with mats on the floor. An interview was conducted with a Registered Nurse (RN/staff #14) on (MONTH) 22, 2019 at 10:56 a.m. The RN stated that all residents are assessed for fall risk when they are admitted . She stated that for residents who are a fall risk, staff will ensure there is no clutter in the room, the call light is within reach, the bed is in the lowest position, and/or a floor mat is beside the bed. She stated that if the resident is care planned for a floor mat beside the bed, an order should be obtained and it should be on the Treatment Administration Record. The RN stated that resident #2 is at risk for falls and has had a fall. She stated if a floor mat is on his care plan, then there should have been a floor mat beside his bed. The RN also stated a resident's risk for injury is increased when fall interventions are not implemented, and if a floor mat was not in place the resident could hit their head on the floor. An interview was conducted with the Director of Nursing (DON/staff #72) on (MONTH) 22, 2019 at 12:29 p.m. The DON stated residents are assessed for fall risk on admission, quarterly, and as needed after a fall. She stated a fall care plan is initiated with interventions for residents that are assessed at risk for falls. The DON stated if the interventions included a low bed and a floor mat, her expectation is that staff implement the interventions. She also stated that if a floor mat is on the care plan, a physician's order should be obtained. Review of the facility policy titled, Fall Management System revealed each resident is provided with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. The policy included care plan interventions will be developed to prevent falls and will consider the particular elements of the assessment that put the resident at risk. The policy also included each resident is assisted in maintaining their highest practicable level of function, by providing the resident adequate supervision to prevent accidents.

Based on clinical record review, observation, staff and caregiver interviews, and policies, the facility failed to ensure that a physician's order was obtained and care and services were provided to one resident (#404) admitted with an indwelling urinary catheter. Findings include: Resident #404 was admitted on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. The Initial Admission Record dated (MONTH) 12, (YEAR) revealed the resident was alert and oriented to person but not to time and place. It also included the resident had an indwelling urinary catheter in place for a [DIAGNOSES REDACTED]. A Bowel and Bladder assessment dated (MONTH) 12, (YEAR) revealed that the resident was always incontinent of the bladder. It also included a score of 14 indicating that the resident was an unlikely candidate for bladder retraining. The initial care plan included that the resident had an indwelling urinary catheter; however, there were no interventions regarding the catheter care. The Physician's Admission Notes dated (MONTH) 13, (YEAR) revealed the resident had a past medical history of [REDACTED]. Review of a Daily Skilled Note dated (MONTH) 13, (YEAR) revealed the resident was alert and oriented x 2. The note also included that the indwelling urinary catheter was patent and draining to gravity and that catheter care was provided as needed. Review of the Physician's Order Summary dated (MONTH) (YEAR) revealed no evidence of a physician's order for the use of [REDACTED] Continued review of the clinical record revealed no evidence that the physician was notified to obtain an order for [REDACTED].>A nurse practitioner progress note dated (MONTH) 15, (YEAR) included the resident had a [DIAGNOSES REDACTED]. The plan included resident with Foley but more for facility ease of use. No Foley at home will discontinue and have facility follow for adequate output. Review of a nursing progress note dated (MONTH) 15, (YEAR) revealed the resident had penis swelling and pain to the area. A physician progress notes [REDACTED]. The progress note further revealed that upon examination there was bright red [DIAGNOSES REDACTED] at the head of the penis. The progress note also included the resident had a penile skin infection and [MEDICATION NAME] (antibiotic) would be ordered. A physician's order dated (MONTH) 15, (YEAR) included to discontinue the indwelling urinary catheter and to administer [MEDICATION NAME] 875/125 milligrams oral twice a day for 7 days for a skin infection. Review of the care plan updated on (MONTH) 16, (YEAR) revealed the resident had an infection of the penis and was being administered an antibiotic. However, it did not include that the indwelling urinary catheter was to have been discontinued. During an observation conducted on (MONTH) 16, (YEAR) at 9:50 a.m., the indwelling urinary catheter remained in place, despite the physician's order to discontinue the catheter on (MONTH) 15, (YEAR). A review of the Treatment Administration Record (TAR) dated (MONTH) (YEAR) revealed the indwelling urinary catheter was discontinued on (MONTH) 16, (YEAR) at 5:47 p.m. Further review of the clinical record including the TAR revealed no evidence that catheter care was consistently provided to the resident from (MONTH) 12 - 16, (YEAR). During an interview conducted on (MONTH) 18, (YEAR) at 9:45 a.m. with a licensed practical nurse (staff #79), staff #79 stated for new admissions, she conducts a comprehensive head to toe assessment and documents all her findings including an indwelling urinary catheter in the electronic record. Staff #79 also stated she will review the physician's orders to ensure there is an order for [REDACTED].#79 stated the order would also include the frequency for changing the catheter bag and catheter care and that the orders would be automatically transcribed onto the TAR. She also stated that catheter care is conducted by the certified nursing assistants and documented by the nurse in the electronic record (TAR). An interview was conducted on (MONTH) 18, (YEAR) at 10:07 a.m. with the Director of Nursing (staff #83) and the Corporate Resource Nurse (staff #84). Staff #83 stated that when a resident is admitted with an indwelling urinary catheter, the admitting nurse is expected to ensure there is an order for [REDACTED]. During an interview conducted on (MONTH) 18, (YEAR) at 11:48 a.m. with the resident's primary caregiver, she stated that the resident's indwelling urinary catheter was inserted at the hospital when the resident was too weak to get up and go to the bathroom. The caregiver further stated the indwelling urinary catheter was removed because the resident had an infection. In an interview with the Clinical Resource (staff #85) conducted on (MONTH) 18, (YEAR) at 11:57 a.m., staff #85 stated that per their policy, catheter care is conducted daily and as needed. During another interview conducted (MONTH) 18, (YEAR) at 12:25 p.m. with staff #83, he stated that it is his responsibility and the assistant director of nursing responsibility to review all orders and ensure there are orders for any indwelling urinary catheter and any treatment. He further stated there was no order for this resident's urinary catheter. Staff #83 also stated that orders are rarely missed because they utilize a New Admission Work Sheet and Chart Check form/checklist to ensure that there are orders to meet the resident's needs. The facility's policy Physician Orders included the facility will accurately implement orders in addition to medications orders, treatments, and procedures only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. The facility's policy Indwelling Catheter Care included that each resident with an indwelling catheter will receive catheter care daily and as needed.

Based on observations, staff interviews, and review of facility policies and procedures, and documentation from the Centers for Disease Control (CDC), the facility failed to maintain an effective infection control program to prevent the transmission of disease and infection. The facility also failed to ensure that one licensed staff member used proper hand washing technique during a treatment for one resident (#144), and failed to implement contact precaution measures. Findings include: On June 18, 2013 at 5:06 p.m., the condition of Immediate Jeopardy (IJ) was identified. The administrator and assistant director of nursing were informed of the facility's failure to implement infection control precautions for residents on contact isolation. Specifically, one Certified Nursing Assistant (CNA) was observed to be using the common (used for other residents) vital sign equipment on a resident with a clostridium difficile (c-diff) infection. The CNA failed to disinfect the vital signs equipment properly after it was used for the resident with[DIAGNOSES REDACTED]. The CNA, when interviewed, was aware of the facility policy on contact isolation and using different vital sign equipment for residents on contact isolation but did not follow the policy. The administrator presented the first immediate plan of correction at 6:11 p.m. on June 18, 2013; however, this plan was not accepted. At 6:46 p.m. on June 18, 2013, the administrator presented a second plan of correction. This plan included further clarification on the facility's cleaning procedures and measures that the facility was going to take in order to protect the residents. The second plan of correction was accepted on June 18, 2013 at 7:15 PM. The condition of IJ was abated on June 19, 2013 at 1:44 p.m., due to the corrective measures taken by the facility. -Resident #144 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] from the hospital. The resident was tested for[DIAGNOSES REDACTED] on June 10, 2013. The resident was positive for [DIAGNOSES REDACTED]. An observation was made of an isolation cart outside of resident #144's room on June 17, 2013 at 9:10 a.m. The top drawer of the isolation cart contained a disposable stethoscope, a disposable blood pressure cuff and a manual blood pressure cuff. A second observation of the same isolation cart on June 18, 2013 at 10:00 a.m. revealed the disposable items still remained outside of the resident's room in the top drawer of the isolation cart. Review of the vital sign flow sheet for resident #144 revealed eight sets of vitals had been taken since the confirmation of the[DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. An observation of resident care was made on June 18, 2013 at 3:01 p.m. A CNA was present in the resident's room. The CNA was wearing a contact isolation precaution gown and gloves. The CNA had the common vital sign machine that monitors blood pressure, temperature and oxygen saturation. The CNA was observed taking the resident's vitals with common equipment and not disposible equipment which would be used for people on isolation precautions. The CNA was observed taking the resident's blood pressure, temperature and blood oxygen concentration measurements with the non-disposable blood pressure cuff, temperature probe and pulse Ox attached to the vitals machine. While still wearing the isolation gown and same gloves the CNA was observed to take a sanitizing packet (Dispatch) out of the basket on the machine and sanitize the blood pressure cuff. He was not observed to clean the pulse ox, or the thermometer. The CNA then removed the gown and gloves and used the resident's rest-room to wash his hands. The CNA washed his hands, shut off the water, with his bare hands contaminating them, then obtained paper towels and dried his hands. An interview was conducted with the CNA immediately following the observation. He stated that the resident had[DIAGNOSES REDACTED] and was on contact precaution isolation. He stated that the disposable equipment in the top drawer of the isolation cart should have been placed in the resident's room, not removed from the room and should have been placed in an area that was obvious to the staff and easy for them to find when they entered the room. He stated the resident was able to use the restroom and he agreed the faucet should be turned off after he had dried his own hands using a dry towel to avoid re-contamination of his hands. Review of the Dispatch cleaner disinfectant wipe used revealed it kills[DIAGNOSES REDACTED] spores in five minutes. The cleaning wipe contained 0.65 percent sodium hypochlorite. Review of the manufacturers instructions for cleaning the vitals monitoring equipment revealed that diluted sodium hypochlorite ([MEDICATION NAME] agent) at one to ten ratio could be used to disinfect the equipment. However it stated the equipment should be shut off prior to doing so. The instructions further stated the oral probe could be decontaminated by cleaning with a cloth, sponge or cotton ball dampened with non-erosive cleaning solution such as sodium hypochlorite at a one to ten ratio. The Pulse Ox sensor could be cleaned with diluted sodium hypochlorite at one to ten ratio and the blood pressure cuff could be cleaned by hand washing the cuff in warm water with mild detergent and air drying after washing. The blood pressure cuff could be disinfected by using a diluted sodium hypochlorite in a one to ten solution. Further review of the facility infection monitoring logs from March 4, 2013 through June 17, 2013, revealed that of the 17 residents with[DIAGNOSES REDACTED] infections 13 of the infections were acquired at the facility. -Resident #58 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on March 4, 2013. -Resident #147 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on March 8, 2013. -Resident #96 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on March 11, 2013. -Resident #15 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on March 17, 2013. -Resident #44 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on March 19, 2013. -Resident #65 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on March 24, 2013. -Resident #138 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on March 26, 2013. -Resident #45 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on April 7, 2013. -Resident #165 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on May 1, 2013. -Resident #173 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on May 30, 2013. -Resident #32 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on June 4, 2013. -Resident #144 who was observed to have a CNA use non-portable equipment in her room was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on June 10, 2013. -Resident #30 was admitted to the facility on [DATE] and had a laboratory confirmed[DIAGNOSES REDACTED] test on June 12, 2013. An interview was conducted with the facility assistant director of nursing (ADON) and the facility administrator on June 18, 2013. The ADON stated he would expect their Nursing and CNA staff members to use the disposable equipment for residents who were on isolation precautions. They stated they would not expect equipment used for other residents to be taken into an isolation room and then used on other non-infected residents. An interview was conducted with the administrator, two corporate nurses and the ADON on June 19, 2013 at 10:55 a.m. The staff stated that CNA's are moved from hall to hall to avoid becoming stagnant with resident care. The administrative staff state that they meet with each staff member daily to see how they are doing and to do an observation of the staff member ensuring that they are not sick. They have sent staff home if they were sick. Staff are encouraged to stay home if they have a fever, nausea, diarrhea or any symptoms of the flu. The corporate nurse stated they have 18 facilities in the state of Arizona from which they can pull staff to replace any staff member who would call off from work. They have not been trending sick staff members with resident infections, the information is collected separately. The infection control nurse for the facility is the director of nursing (DON). The corporate nurse stated the DON position had four different nurses during the past 12 months. The corporate nurse stated the current DON is "Strong" and had been receiving training from the corporate nurse. The corporate nurse further stated that the increase in the percentage of infections recorded from last year to this year had been linked directly with the previous DON not utilizing the McGreers method of tracking and trending infections and many things that had been identified as infections included [REDACTED]. The Corporate nurse and ADON stated that they do frequent training with their staff regarding infection control. With[DIAGNOSES REDACTED] infections they consider the resident infectious and requiring isolation until 48 hours after the diarrhea had stopped. The corporate nurse stated that a hand washing audit had been done for the CNA that was observed not following proper infection control procedures, and that he failed the audit and was sent home on suspension until an investigation could be completed. Review of facility policy regarding Clostridium Difficile revealed it's purpose was "To prevent the transmission of Clostridium difficile in the long-term care facility...The Executive Director, Director of Nursing, Infection Control nurse and the infection Control Committee should be alerted to any case of [DIAGNOSES REDACTED]icile...Surveillance data must be maintained on cases of [DIAGNOSES REDACTED]icile infection. Continuing education on [DIAGNOSES REDACTED]icile may assist in limiting its spread...Gloves are worn to enter the room of a resident who has diarrhea caused by [DIAGNOSES REDACTED]icile. A gown is needed to enter the room of a resident who has diarrhea caused by [DIAGNOSES REDACTED]icile if substantial contact with the resident or environmental surfaces is anticipated. Gown and gloves are removed before leaving the resident's room and hands must be washed immediately following hand hygiene guidelines. Alcohol-based hand rubs do not kill spore-forming organisms...Items such as a stethoscope, sphygmomanometer, and...thermometer are dedicated to use on that resident only." The facility standard precautions policy stated..."Surface disinfection and reusable equipment...Resident care items and surfaces used for multiple residents are disinfected between uses. An approved disinfectant is used and allowed to dry before the next resident use." -Resident #107 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a physician's orders [REDACTED]. An observation of the treatment to the resident's left heel was made on June 19, 2013. The LPN (licensed practical nurse) was observed to use a hand sanitizer on his hands and don gloves. With his gloved hands, the LPN was observed to place his hands in his pocket to retrieve a skin prep. The LPN opened the skin prep and applied the skin prep to the resident's left heel with the same pair of gloves that he had placed in his pocket. An interview was conducted with the LPN on June 19, 2013. The LPN stated that he should have got the skin prep out of his pocket first and then put gloves on. The LPN stated that he put the gloves on in the "wrong sequence" but the resident was not on contact precautions. An interview was conducted with the ADON on June 20, 2013. When asked if the LPN should have used the same gloves to apply the skin prep that he used to retrieve the skin prep out of his pocket, the ADON stated "absolutely not." A review of the facility's policy Wound Care Procedure for Major Wounds documented "...Care must be taken to prevent contamination of the supplies and surfaces used in wound care..." -An observation was conducted during the initial tour on June 17, 2013. It was observed that two contact isolation rooms lacked disposal containers for potentially soiled gowns and gloves for these rooms. One of the rooms lacked a sign notifying visitors to check with the nurse before entering the room to ensure that the visitors were aware of the precautions to use. An interview with the registered nurse (RN) conducted on June 17, 2013, revealed that all isolation rooms are required to have signs posted and disposable containers within the room to prevent the spread of infection. CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, states, "...Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE,[DIAGNOSES REDACTED]icile, noroviruses and other intestinal tract pathogens; RSV)... "