Every finding on record at Heritage Health Care Center

Based on clinical record review, interviews, facility documentation, and policy review, the facility failed to ensure one of five sampled residents (Resident #36), was not administered pain medications outside provider-ordered parameters. This deficient practice places residents at risk for adverse drug reactions. The sample size was 5. The universe was 68. -Regarding Resident # 36 Resident # 36 was admitted to the facility on [DATE] with conditions that included Type 2 Diabetes Mellitus without complications, pressure ulcer of the right heel, and acute osteomyelitis of the right ankle and foot. Review of the quarterly Minimum Data Set, dated [DATE], revealed the resident had a Brief Interview Mental Status score of 15 indicating he was cognitively intact. The assessment indicated the resident received as needed (PRN) opioid therapy, and non-medication interventions for pain. The assessment failed to reflect the resident history of substance use disorder. An order for Acetaminophen 325 mg, dated October 20, 2025, instructed the staff to give two tablets every 6 hours as needed for a pain level 1-3; not to exceed 3 grams every 24 hours. A care plan initiated on October 20, 2025, identified the resident as being at risk for elopement and negative health outcomes related to continued substance use while in the facility. Interventions included administering medications as ordered and monitoring for side effects and potential drug interactions related to medication-assisted treatment (MAT). A care plan initiated on October 21, 2025, identified the resident as experiencing pain and discomfort related to a right heel wound. An intervention included evaluating the effectiveness of pain management interventions. Regarding Hydrocodone-Acetaminophen: An order for Hydrocodone-Acetaminophen (opioid) 5-325 mg (milligrams), dated November 8, 2025, instructed staff to give one tablet every four hours as needed for pain intensity 4-10 and to hold if the resident was drowsy. Review of the January 2026 Medication Administration Record (MAR) revealed Hydrocodone-Acetaminophen was given outside of the ordered parameter for a pain level of 1. Review of the February 2026 MAR revealed Hydrocodone-Acetaminophen revealed Hydrocodone-Acetaminophen was given outside of the ordered parameter on February 4, 2026 with a pain level of 0; and on February 7, 2026, with a pain level of 1. Regarding Acetaminophen: An order for Acetaminophen 325 mg, dated October 20, 2025, instructed staff to administer 2 tablets by mouth every 6 hours as needed for pain intensity 1-3, not to exceed 3 grams in 24 hours. Review of the January 2026 MAR revealed Acetaminophen was given outside of the ordered parameters on the following dates: January 6, 2026 with recorded pain level of 6January 9, 2026 with recorded pain level of 6January 10, 2026 with recorded pain level of 7January 19, 2026 with recorded pain level of 6January 20, 2026 with recorded pain level of 0January 21, 2026 with recorded pain level of 5January 25, 2026 with recorded pain level of 0January 26, 2026 with recorded pain level of 5 Review of the February 2026 MAR revealed Acetaminophen was given outside of the ordered parameters on the following dates:February 4, 2026 with a recorded pain level of 4.February 22, 2026 with a recorded pain level of 5. An interview was conducted on February 27, 2026 at 9:59 a.m. with Licensed Practical Nurse (LPN/Staff #95). The LPN stated that the administration outside of parameter with a resident with SUD can place the resident at higher risk for addiction and respiratory distress. The LPN revealed that medications are to be given according to provider order, and any concerns about the order should have been followed up with the provider. An interview was conducted on February 27, 2026, with the Director of Nursing (DON/Staff #15) in the presence of the Executive Director (ED/Staff#110) at 10:13 a.m. During the interview, the DON revealed having the opportunity to review the resident's January and February 2026 MARs, and had already emailed the compliance officer, a listing of the occurrences when Hydrocodone-Acetaminophen and Acetaminophen were administered outside of the ordered parameters. The DON stated she could not locate documentation in the resident's record authorizing administration outside of the provider's orders for the dates identified. The DON further stated that administering medications outside of ordered parameters for a resident with a history of SUD could place the resident at increased risk for adverse outcomes. The DON revealed that the nurse responsible has been coached and re-educated on the facility's policy of medication administration. The DON stated that the identified incidences of receiving medication outside of provider parameters without proper documentation failed to meet facility expectation. Review of the Administration of Medications policy, revised February 13, 2023, required the staff to note the resident's history and any parameters around drug administration. The policy in addition, referred to opioids as a high alert medication.

Based on clinical record review, interviews, facility documentation, and policy review, the facility failed to ensure that a valid advance directive and an updated medical directive were completed and readily accessible for two residents (Residents #5, #22). The deficient practice could result in residents receiving services that are not in accordance with their wishes, and they may be unaware of services that may or may not have been provided to the resident. The sample was 4. The universe was 68.Findings include:-Regarding Resident #5:Resident #5 was initially admitted on [DATE], and re-admitted on [DATE], with the diagnosis that included malignant neoplasm of prostate; acute kidney failure, unspecified; hypothyroidism, unspecified; neuralgia and neuritis, unspecified; primary open-angle glaucoma, bilateral, mild stage; benign prostatic hyperplasia with lower urinary tract symptoms; and muscle weaknessA POLST (Physician Orders for Life-Sustaining Treatment) form dated [DATE], revealed that Resident #5 selected to have no CPR (cardiopulmonary resuscitation) if they were to have no pulse or not breathing. The POLST also revealed that Resident #5 selected to have selective treatment with the goal to attempt restorative function while avoiding intensive care and resuscitation efforts. The form was signed by the resident's representative, and a facility staff member., A care plan goal with the initiation date of [DATE], revealed that Resident #5 had an advance directive POLST, and that the resident's advance directive would be honored.An order dated [DATE], revealed that Resident #5 had a full code status, indicating that if a resident's breathing or heart stops, medical staff will use all available life-saving measures to revive them. Despite the POLST form dated [DATE] requesting to avoid resuscitation efforts.A Prehospital Medical Care directive dated February 25, 2026, revealed in the event of cardiac or respiratory arrest the resident refused any resuscitation measures.An order dated February 26, 2026 was placed in the resident's clinical record that indicated Do Not resuscitate.On February 25, 2026, at 2:06 PM, a review of physical code status forms located in the nursing station was conducted with an RN (Staff #20) and an LPN (Staff #57) who stated that should a resident wish to request to have a DNR/DNI, the facility policy will require the signatures of a provider, a witness, the resident, or a representative of the resident on the prehospital medical care directive orange advance directive form. The RN also stated that should a representative provide verbal consent, this same prehospital medical care directive orange advance directive form will require a two-person signature as the witness to the verbal consent. Regarding Resident #5, The RN and LPN were not able to locate an advance directive in the electronic health records, as well as within the nursing stations' resident binder. The RN confirmed that a POLST dated [DATE], had been in the records of Resident #5 and stated that the resident was DNR; however, The RN could not locate a prehospital medical care directive orange advance directive form with the above-listed signatures or documentation that supported the order for full code, as it states within the resident's active orders, and would need to be confirmed with the ADON (assistant to the director of nursing). Regarding Resident #7, Staff #20 and #57 were not able to locate an advance directive in the electronic health records, as well as within the nursing stations' resident binder. Staff #20 confirmed that the lack of a POLST and a prehospital medical care directive orange advance directive form with the above-listed signatures or documentation that supported the order for DNR/DNI was not within their facility's expectations. Regarding Resident #22, Staff #20 and #57 were not able to locate an advance directive and a POLST in the electronic health records, as well as within the nursing stations' resident binder. Staff #20 confirmed that the lack of a POLST and a prehospital medical care directive orange advance directive form with the above-listed signatures or documentation for DNR/DNI was not within their facility's expectations.At 7:45 AM, on February 26, 2026, an interview with Resident #5 was conducted. Resident #5 stated he could not recall signing the said prehospital medical care directive orange advance directive form, nor could he recall a conversation with a staff member the day before regarding the prehospital medical care directive orange advance directive form and his wishes regarding life resuscitation interventions in the event of an emergency. At 8:28 AM, on February 26, 2026, the ADON (Staff #67) provided a newly updated prehospital medical care directive orange advance directive form for Resident #5 with a new signature provided by the resident and the social services director (Staff #14) as the witness, with the date of February 26, 2026. The healthcare provider and the original signature of the resident were still present on this form. A newly updated prehospital medical care directive orange advance directive form for Resident #7 was also received, with a new note that the resident's representative was reached out to with two witnesses confirming the verbal consent over the phone, and the social services director (Staff #14) as the witness, with the date of February 26, 2026. The healthcare provider's signature was still present on this form. Staff #67 also stated that the social services director was an acceptable witness for the prehospital medical care directive orange advance directive form.Regarding Resident #22:Resident #22 was admitted on [DATE], with the diagnosis that included personal history of traumatic brain injury; hypertension; gastro-esophageal reflux disease without esophagitis; tremor; long term use of anticoagulants; long term use of insulin; schizoaffective disorder, bipolar type; Guillain-Barre syndrome; generalized anxiety disorder; bipolar disorder, current episode depressed, mild or moderate severity; unspecified dementia, unspecified severity, with other behavioral disturbance; neoplasm of unspecified behavior of bone, soft tissue, and skin; protein-calorie malnutrition; dyspnea, unspecified; type 2 diabetes mellitus with diabetic polyneuropathy. Per the resident's face sheet, there is no evidence of additional information that states if Resident #22 had been in the facility on a date before [DATE].An order dated [DATE], revealed that Resident #22 had a DNR and no feeding tube status, indicating that if a resident's breathing or heart stops, medical staff will not complete CPR if the patient's breathing stops or if the patient's heart stops beating.An Advance Directive Statement Form, dated [DATE], revealed that should Resident #22 be unable to accept nutrition by mouth, they would not want nutrition to be administered via feeding tube; or unable to accept hydration by mouth, they would want hydration to be administered via intravenous line; or if a physician were to believe they were in pain, they would want to be given enough pain medications to eliminate apparent pain, even if the physician believes it posed a risk of depressing respiration and hastening their death; or in the event of cardiac arrest, they would not want CPR measures to be taken; or in the event their medical status changes or worsens to a terminal or irreversible condition, they would want to be transferred to the hospital; and if their heart stops functioning, they would not want defibrillation performed CPR to be initiated; and would want a blood transfusion if necessary and would not life support via mechanical ventilation.Resident #22's care plan revealed no evidence of a focus or interventions related to advance directives following admission on [DATE]. However, a revision to a care plan goal stating that the resident has an advance directive for CPR, do not shock, and DNI, was revised on [DATE], that stated that the resident's advance directives will be honored.A POLST form, dated February 25, 2026, revealed that the POLST form was voluntary, and was a medical order, no an advance directive. The form was marked as Yes, CPR, attempt resuscitation. Completion information on the form included that the resident's advance directive was reviewed to confirm no conflict with POLST orders, and that no advance directive exists. Despite the [DATE] Advance Directive Statement Form, that indicated in the event of cardiac arrest, they would not want CPR measures to be taken. There was no additional evidence regarding the discussion of an advance directive for Resident #22. An interview was conducted on February 25, 2026, at 10:47 AM, with an LPN (Staff #95) who stated a resident's code status could be found on the electronic chart of the resident, as well as located in the book located at each nursing station. Staff #95 also stated that should a resident's code status change, the expectation is to have that requested within the resident's electronic chart and physical book located at their nurses' station. Should an advanced directive be incorrect, the Staff #95 stated that staff could go against the wishes of the resident's rights.An interview was conducted on February 25, 2026, at 1:46 PM, with a CNA (Staff #43), who stated that in a time of emergency, she will ask a nurse for the code staff of a resident if they are unsure of a resident's code status. The CNA also stated that there is a list of code statuses for all residents on their unit in the back of the nurses' stations, or they would also look at the electronic health record. The CNA stated that reviewing and understanding what a resident's code status is important because it will be against the resident's medical care plan if staff do not follow it. The CNA also stated that should the forms and the list located in the nurses' station not match the resident's health records, they would proceed with a full code status procedure until the correct code status is confirmed, despite the possibility that a resident can get hurt and receive care against their wishes.On February 25, 2026, at 2:26 PM, an interview was conducted with the ADON (Staff #67), who stated that the advance directive process can be completed by any floor nurse, and once an advance directive has been documented and signed by all parties, it will then be provided to the health information manager/medical records director. The ADON also stated that should the documents be completed incorrectly, they are given to her to complete. The ADON also stated that should a resident request to be a DNR/DNI, the required documentation per state guidelines for that request would be to have accurately filled out and attached to the prehospital medical care directive orange advance directive form so that in the event of an emergency, those documents can be provided to an EMT. The ADON stated that if both the prehospital medical care directive orange advance directive form and POLST were incorrectly completed, and not readily accessible, treatment may be performed against a resident's wishes. On February 25, 2026, an interview was conducted with the Director of Nursing (DON/Staff #15), who stated that the facility adopted a new advanced directive process that requires a POLST form to be completed accurately and thoroughly, which should be completed on fuchsia paper, as well as a prehospital medical care directive orange advance directive form. The DON, stated that a complete and accurate advance directive should include a POLST with sections A, B, D, E, and F, which should be completed, with the expectation that the staff who is assisting with the completion of the form include their name and signature, as well as the completion date on the second page of the POLST. Should a resident want a DNR/DNI status, then a prehospital medical care directive orange advance directive form, with the signatures of a health care provider, the resident, or a representative of the resident, a witness or notary, not both, is required on this form. The DON stated that, should there be no advance directive in place, then staff is to follow through with a full code status. She also stated that should there be conflicting information, staff are expected to follow the most current form within the resident's records. Regarding Resident #5, The DON stated that due to the resident's most recent POLST form stating DNR, staff is expected to follow through with that wish, despite not having an orange advance directive form, and an active order stating full code. The DON further stated that the conflicting documentation within Resident #5's records was not within the facility's expectations. Regarding Resident #22, the DON stated that due to the resident's active order of DNI and do not shock status, a POLST and a prehospital medical care directive orange advance directive form should have been completed and within their records. The DON further stated that not having any documentation to support the active order of DNI and to not to shock, within Resident #22's records, was not within the facility's expectations.The prehospital medical care directive (DNR) document, last updated in [DATE], revealed that this document must be on paper with an orange background and that it should be displayed as visibly as possible for first responders. The document further revealed that the prehospital medical care directive was to be signed by the patient and their doctor, which informs EMTs or hospital emergency personnel not to resuscitate the patient, and not use equipment, drugs, or devices to restart the heart or breathing, and not intervene with necessary medical interventions to provide comfort care or to alleviate pain, and must be signed by the patient, in front of a witness or notary. The document also revealed that a health care provider and a witness or notary must also sign this form. Under Arizona law, a prehospital medical care directive or DNR must be on letter-sized paper or wallet-sized paper on an orange background to be valid.A policy titled 'Advance Directives and Advance Care Planning', last reviewed on [DATE], revealed that Residents have the right to self-determination regarding their medical care. The policy also revealed that the patient's advance directives should be implemented if necessary, assuming those wishes are legally valid and permissible by State law. The policy also states that each time a resident is admitted to the facility, quarterly, and when a change in condition is noted in the resident condition, the facility should review the advance directive and advance care planning information, and, that the social services director or designee should document this conversion in the medical record and assist as needed with updating the documents that need revision in accordance with state and federal requirements. The policy also revealed that social services ensures that a copy of the advance directive is obtained for the resident's medical record and verifies that there is an appropriate physician's order in the resident's medical record as well. The policy also revealed that the information is reviewed or updated, as appropriate, at least quarterly or more frequently if there is a significant change in the resident's medical condition, and that each quarter, the care plan team should also review with the patient to ensure that they are still in line with the wishes of the resident, and that should at any time a DNR order be revoked, that discussion would need to be documented in the resident's chart as such with the consent of the resident or the resident's representative.

Based on review of clinical records, staff interviews, facility documentation, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) guidance, and facility policy, the facility failed to ensure that physician insulin administration orders for notification of abnormal blood glucose results were followed for two of sampled residents (#4 and #36). This deficient practice placed residents at risk for delayed treatment or inadequate management of blood glucose levels. The universe was 68.Findings Include: -Regarding # 36 Resident # 36 was admitted to the facility on [DATE] with conditions that included Type 2 Diabetes Mellitus without complications, Stage 4 Chronic Kidney Disease (Severe), long-term (current) use of insulin, pressure ulcer of the right heel, and acute osteomyelitis of the right ankle and foot. An order dated October 20, 2025, directed the staff to notify the provider and administer 12 units of Humalog Solution 100 units/milliliters (ml), for glucose levels of 351 or greater. A Diabetes Mellitus care plan initiated October 21, 2025, instructed the staff to obtain blood sugar checks, and administer medications as ordered. However, the care plan did not reflect the sliding scale insulin orders, or the requirement to contact the provider when glucose exceeded 351. Review of a lab report, dated December 25, 2025, revealed the resident had a Hemoglobin A1C level of 7.8%. The report stated that the result exceeded the American Diabetes Association (ADA) guidelines recommended goal. The report also revealed the resident's average glucose was 177. Review of the December 2025 Medication Administration Record (MAR) revealed that blood glucose levels reached 351 mg/dL or greater, requiring 12 units of Humalog insulin per sliding scale orders; however, the clinical record did not document that the provider was contacted regarding these findings on the following dates: December 24, 2025 December 25, 2025 December 26, 2025 December 30, 2025 December 31, 2025 Review of the admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview Mental Status (BIMS) score of 15 indicating he was cognitively intact. The assessment also indicated the resident received insulin therapy on a daily basis. Review of the January 2026 Medication Administration Record revealed that blood glucose levels reached 351 mg/dL or greater, requiring 12 units of Humalog insulin per sliding scale orders; however, the clinical record did not document that the provider was contacted regarding these findings on the following dates: January 4, 2026 January 5, 2026 January 7, 2026 January 16, 2026 January 17, 2026 January 22, 2026 Review of the February 2026 Medication Administration Record revealed that blood glucose levels reached 351 mg/dL or greater, requiring 12 units of Humalog insulin per sliding scale orders; however, the clinical record did not document that the provider was contacted regarding these findings on the following dates: -February 2, 2026 -February 18, 2026 -February 19, 2026 -February 23, 2026 An interview was conducted on February 27, 2026, at 8:10 a.m. with the Activities Director, who is also a qualified Certified Nursing Assistant (CNA/Staff #82). Staff #82 stated that CNAs are responsible for performing blood sugar monitoring and are instructed to report values of 60 mg/dL or lower and 170 mg/dL or higher to the nurse. The CNA explained that when a resident's blood sugar becomes too high, the resident may exhibit symptoms such as feeling hot, clammy, flushed, and experiencing altered mental status. The CNA further stated that she believes the nurse reports elevated blood glucose findings to the provider so that appropriate interventions can be implemented to prevent potential complications, including shock. An interview was conducted on February 27, 2026, at 8:55 a.m. with the Registered Dietitian (RD/Staff #111). The RD stated that symptoms of hyperglycemia (elevated blood sugar) can include confusion, syncope, and heart palpitations. The RD emphasized that if a resident is on a sliding scale and the provider is to be contacted for blood glucose levels that reach a specified threshold, this protocol must be followed. Failure to notify the provider can worsen symptoms and increase the risk of complications associated with diabetes. An interview was conducted on February 27, 2026, at 9:59 a.m. with Licensed Practical Nurse (LPN/Staff #95). The LPN stated that signs and symptoms of hyperglycemia can include excessive sweating, malaise, and coma. The LPN further stated that when a sliding scale is ordered for a resident, and the instructions specify that the provider should be contacted for certain blood glucose levels, the provider must be contacted, as per facility expectation. The LPN explained that failure to notify the provider can place the resident at risk for hospitalization if blood glucose becomes too high and the resident becomes symptomatic. An interview was conducted on February 27, 2026, at 10:13 a.m. with the Director of Nursing (DON/Staff #15) in the presence of the Executive Director (ED/Staff #110). The DON stated that the resident's clinical record for December 2025 to February 2026, had been reviewed and a report listing occurrences where the provider was not notified for blood glucose levels ≥351 mg/dL had been emailed to the compliance officer. The DON confirmed that, according to provider orders, the provider should have been contacted in each instance, and the failure to do so did not meet facility expectations. The DON further stated that no documentation could be found showing that the provider had been contacted for these elevated readings for additional orders or instructions. The DON stated that some provider orders require notification only if the resident is symptomatic, however in this case, notification was required regardless of symptoms. The DON revealed that a failure to notify the provider, could result in the resident not receiving the best care for glucose control -Regarding Resident #4 Resident #4 was re-admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus, long term use of insulin, and acute kidney failure. A care plan revised on August 8, 2023, revealed that the Resident #4 has diabetes mellitus and the intervention included checking blood sugar as ordered. A physician order dated November 28, 2025 was written for Humalog solution 100 UNIT/ML (Insulin Lispro), to inject subcutaneously before meals and at bedtime for diabetes as per sliding scale: if 0 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 8 units; 351+ = 10 units and call medical director. A December 2025, Medication Administration Records (MAR) revealed no evidence that the physician was notified when the blood sugar (BS) was above 351 on following dates: -December 1, 2025, at 4:30 p.m., BS was 454 and at 8 p.m., BS was 359 -December 2, 2025, at 11:30 a.m., BS was 524, at 4:30 p.m., BS was 490, and at 8 p.m., BS was 390 -December 3, 2025, at 4:30 p.m., BS was 510, and at 8 p.m., BS was 382 -December 4, 2025, at 8 p.m., BS was 351 -December 5, 2025, at 6 a.m., BS was 431 A quarterly MDS (minimum data set) dated December 4, 2025, revealed that the staff assessed Resident #4 for mental status that revealed short and long-term memory loss. A physician order dated December 5, 2025 was written for Humalog solution 100 UNIT/ML (Insulin Lispro), to inject subcutaneously before meals and at bedtime for diabetes as per sliding scale: if 0 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 8 units; 351+ = 10 units and call medical director. A February 2026, Medication Administration Records (MAR) revealed an order of Humalog solution 100 UNIT/ML (Insulin Lispro), and an order start date of December 5, 2025, noting to inject insulin subcutaneously before meals for diabetes as per sliding scale: if 0 - 200 = 0 units; 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 8 units; 351+ = 10 units and call medical director. Further review of the MAR revealed no evidence that the physician was notified when the blood sugar (BS) was 449 on February 10, 2026, at 4:30 p.m. Progress notes reviewed from December, 2025, through January, 2026, revealed no evidence that the provider was notified when the blood sugar was above 351. An interview was conducted on February 27, 2026, at 8:15 a.m. with the licensed practical nurse (LPN, staff # 95) who stated that she worked in the facility for about a year conducting medication administration and providing insulin shots to residents. The LPN further stated that a resident's insulin order would have parameters on the chart indicating whether the resident was on low dose sliding scale, regular sliding scale or high dose. If a resident's sugar level was out of parameters then the provider would be notified and may give an order for an extra dose of insulin or may change the order. The LPN then reviewed the the blood sugar levels in the MAR for Resident #4 for the month of December 2025, and February 2026, and stated that the resident's blood sugar was really high for December 1 through December 5, 2025, and for February 10, 2026 and that the provider was not notified. The LPN also stated that the director of nursing (DON) reviews resident's charts for assessment or any changes. The LPN further revealed that the risk of not notifying the provider when a resident's blood sugar is too high, could lead to a potential for hospitalization. An interview was conducted on February 27, 2026, at 9:22 a.m., with the DON (staff # 15) who stated that nursing staff will take a resident's blood sugar and if the blood sugar was above the parameter, then nurses follow the order and notify the provider. The DON then reviewed the blood sugar levels for Resident #4 in the MAR for the month of December 2025, and February 2026, and stated that the blood sugar levels were really high for December 1 through December 5, 2025, and for February 10, 2026. The DON also reviewed the nursing notes and stated that the provider was not notified when blood sugar levels were high. The DON then stated that the risk of not notifying the provider and following the orders, included a risk for hyperglycemia. The DON also stated that she will educate her nurses and notify providers regarding change in insulin parameters. Review of the facility policy titled Administration of Medications, with a review date of September 9, 2025, revealed that every drug administered must have an order from the provider. The policy further revealed that it compares the order with the electronic medication administration record (eMAR) for accuracy. Per the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)guidance, persistent blood glucose readings above the ordered sliding scale should be communicated to the provider so the treatment plan, medications, or sliding scale orders can be reviewed and adjusted as needed to maintain safe, effective diabetes management The facility's Nursing Documentation policy, facility reviewed August 29, 2025, revealed the facility will ensure nursing documentation is consistent with professional standards of practice, the state nurse practice act, and any state laws governing the scope of nursing practice

Based on the interview, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure PASARR (Preadmission Screening and Resident Review) screening and referral were accurate, completed, and submitted per professional standards for 2 of 5 sampled residents (Residents #36, #2). The deficient practice could result in residents' medically related social and emotional needs not being met. The sample size was 5 and the census was 68.-Regarding Resident # 36 Resident # 36 was admitted to the facility on [DATE] with diagnoses that include long term (current) use of insulin, Type 2 Diabetes Mellitus without complications, Stage 4 (Severe) Chronic Kidney disease, and unspecified protein-calorie malnutrition. Review of the Pre-admission Screening and Resident Review (PASRR) Level 1 Screening tool, dated October 20, 2025, submitted by the referring hospital, revealed no evidence reflecting the resident's history of anxiety or substance use disorder. The clinical record also revealed no evidence to reflect a PASSR Level 1 screening, generated by the facility. A care plan initiated on October 20, 2025, identified the resident as being at risk for elopement and negative health outcomes related to continued substance use while in the facility. Interventions included administering medications as ordered and monitoring for side effects and potential drug interactions related to medication-assisted treatment (MAT). Review of the elopement risk evaluation, dated October 20, 2025, revealed the resident had a history of Substance Use Disorder. A mood or behavior care plan, dated October 21, 2025, revealed the resident was to take medications as ordered due to risk for change in mood or behavior due to medical condition. The clinical record revealed no evidence to reflect direct care planning for anxiety. Review of the admission MDS (Minimum Data Set) dated October 23, 2025, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated moderately impaired cognition. The assessment revealed no evidence reflecting the resident's history of anxiety, or use of antianxiety medications. An order was written for Hydroxyzine HCL (antianxiety) 10 mg, dated January 1, 2026, to be given 1 tablet as needed every 6 hours for anxiety. Review of the quarterly MDS, dated [DATE], revealed the resident had an active diagnosis of anxiety disorder, but did not take any anti-anxiety medications during the lookback period. An interview was conducted on February 27, 2026, at 8:10 a.m. with the Activities Director (Staff #82). The Activities Director stated that a correct PASSR helps staff develop appropriate interventions when a new resident is admitted . However, the Activities Director also indicated that even if the PASSR is not completely accurate, she believed she had the ability to figure out residents and their needs as they relate to the activities department. An interview was conducted on February 27, 2026, at 9:21 a.m. with the Social Services Director (Staff #14). The Social Services Director stated that PASRRs are used to ensure a resident is appropriate for admission to the facility and that the facility is able to provide the services the resident requires. The Social Services Director reported she is new to the PASRR portal and is currently working with the facility's Information Technology (IT) department to obtain access. The Director stated that ensuring the PASRR is accurate when received from the hospital is the expectation; however, she reported that she had been away when the new system was implemented. She stated that now that she has become aware of the issue, changes will be made to ensure the process is followed. The Director reviewed the resident's care plan and stated she was not aware the resident had a substance use disorder, as this diagnosis had not been identified or addressed in the care plan. The Director also reviewed the PASRR and revealed did not contain the resident's diagnosis of anxiety, which did not meet facility expectations. An interview was conducted on February 27, 2026, at 10:13 a.m. with the Director of Nursing (DON/staff #15) in the presence of the Executive Director (ED/Staff #111). The DON reviewed the resident's clinical record and stated that the resident's diagnosis of anxiety, the care plan, and the PASRR information did not match, indicating that expectations for accuracy had not been met. The Director of Nursing stated she would need to verify the substance use disorder diagnosis, as she suspected it may have been selected in error. The DON also stated that maintaining a correct and updated PASRR is expected, as it can impact the resident's care, and reported the facility is working to gain a better understanding of the PASRR process. Regarding Resident #2: Resident #2 was re-admitted on [DATE], with a diagnosis that included bipolar disorder, unspecified. A care plan goal initiated on August 21, 2024, revealed that Resident #2 use antipsychotic medications related to the diagnosis of bipolar disorder. A PASSAR form dated October 8, 2025, revealed no evidence of the diagnosis of bipolar disorder and no evidence of ordered antipsychotic medication. The PASARR form also revealed that three out of the five pages were completed for the PASARR review. An order dated November 13, 2025, was written for one tablet of Olanzapine (atypical antipsychotic medication) 5 MG one time a day for bipolar disorder, and exhibited behaviors of hallucinations, sitting self on the floor mat, then requesting assistance back into bed, frequently forgetting and asking to go to the dining room. A quarterly MDS assessment dated [DATE], revealed that the resident required a Staff Assessment for Mental Status to be conducted due to memory problems exhibited. The assessment also revealed that Resident #2 had the diagnosis of bipolar disorder, and had taken an antipsychotic during the last 7 days before the completion of the assessment. An interview was conducted on February 26, 2026, at 10:32 AM, with the SSD (Social Services Director/Staff #14). The SSD stated that should a mental illness, intellectual disability, or a related condition be identified, a PASARR level 2 would be requested before admission, especially if the resident is determined to stay longer than 30 days, and to be initiated before admission to the facility. The SSD also stated that should a concern arise after admission, it would be discussed with the interdisciplinary team. The SSD further stated that she had not needed to complete any additional PASARR level screenings since she took on the role in January 2025, and that it would be her responsibility to ensure that the process of submission and interventions is being monitored. Regarding Resident #2, the SSD stated that the diagnosis of bipolar disorder had been active at admission and that a PASARR level II should have been submitted. She further stated that there was no evidence in the resident's clinical record of a PASARR level II screening once it was determined that Resident #2 would have exceeded a stay of 30 days. The SSD also stated that an accurate and completed submission of a PASARR screening is important to ensure that, as a facility, staff understand the care a resident may need to be provided while at the facility. The SSD further stated that should a screening not be accurately completed and submitted for determination, the facility would fail to make sure a resident is in the right facility and receiving the appropriate placement and interventions. An interview with the DON (Staff #15) was conducted on February 26, 2026, at 11:53 AM. The DON stated that social services is responsible for ensuring that the PASARR is completed upon admission, and that the forms are typically obtained at the time of admission. The DON stated that discussions regarding PASARR completion generally occur when the auditor reviews the forms and brings any concerns to the team's attention. During the interview, the PASARR form was examined in detail, including the sections indicating that a new PASARR must be completed if a resident's stay is expected to exceed 30 days. The process for submitting the PASARR was also reviewed, including where the document must be sent and the required components of the submission. The DON also stated that staff were not previously aware of these requirements and advised that they would review this information with the SSD. The Arizona Health Care Cost Containment System (AHCCCS) Medical Policy Manual, regarding the PASARR level I screening tool, revealed that the nursing facility must update the level I at such time that it appears the individual's stay will exceed 30 days. A facility policy titled 'Pre-admission Screening and Resident Review (PASARR), last reviewed September 26, 2025, revealed that the facility will ensure that potential admissions are screened for possible serious mental disorders or intellectual disabilities and related conditions. The facility also revealed that a negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. The policy revealed that a positive Level 1 screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted before admission to a nursing facility. The policy also revealed that facilities should look to their state PASARR program requirements for specific procedures, PASARR contact information for the SMH/ID authorities, and the State Medicaid Agency. There is no evidence within the policy that addresses any updates to a level I at such a time that it appears that the individual's stay will exceed 30 days.

Based on observations, staff interviews, and policy review, the facility failed to ensure that food was stored in accordance with professional standards for food safety. The deficient practice has the potential to place residents at risk for consumption of expired or unsafe food. The census was 68.Findings include:On February 24, 2026, at 9:20 AM, an initial observation of the facility kitchen was conducted with the Food Services Director (Staff #44) and Dietary Manager & Director (Staff #111). At 9:21 AM, a walk-through of Refrigerator #1 revealed an original packaging of what the Food Services Director identified as grapes, with no evidence of a received date, opened date, or used-by date. At 9:26 AM, a walk-through of Freezer #1 revealed an original packaging that the Food Services Director identified as pepperoni, with a received date of September 5, 2025, with no evidence of an opened date, or a used-by date. A box containing an opened original packaging was identified by the Food Services Director as vegan burger patties, received on January 7, 2026, with no evidence of an open date or used-by date. In the same box was an opened original packaging identified as a cod fish patty by the Food Services Director, with no evidence of a received date, opened date, or use-by date. At 9:31 AM, a walk-through of the dry storage revealed the original box potatoes identified by the Food Services Director, with no evidence of a received date. The Food Services Director identified a box of bananas, with no evidence of a received date and an original bag of tortilla chips with no evidence of a received date, an opened date, or a used-by date.Following the initial observation on February 24, 2026, at 9:37 AM, an interview was conducted with The Food Services Director (Staff #44) and Dietary Manager & Director (Staff #111). The Food Services Director stated that items stored in the refrigerator, freezer, and dry storage, are expected to have a label displaying the received date, open date, and, as applicable, a used-by date, in accessible view to staff, per the facility policy. The Food Services Director further stated that should a food item be kept opened in its original packaging, staff are expected to place the food item in a sealable container or package with the received date, an opened date, and a used-by date, per facility policy. During the same interview conducted on February 24, 2026 at 9:37 AM the Dietary Manager & Director (Staff #111) stated that staff are expected to maintain the received date on the original box/packaging that contain fresh produce, and to check for wholesomeness on a daily basis, and are expected to discard food items when determined to do so. The Dietary Manager & Director stated that the risk of not maintaining the food labeling expectations within the facility policy could result in serving perished foods, foodborne illness outbreaks, and inconsistency with the longevity, quality, or safety of food items.A policy titled 'Food Safety', last reviewed May 1, 2025, revealed that food is stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth. The policy also revealed that pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid; and labeled with the name of the contents and date, when the item is transferred to the new container. The facility policy also revealed that a 'Use by Date' is noted on the label or product when applicable. The policy further documented that received food is labeled with the date received if not already indicated on the item, and, if multiple items are packaged in one box, each item will be individually dated with the receipt date. The policy also revealed that opened packages of food are resealed tightly to prevent contamination of the food item, and the ' use by date' will be used when applicable.

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to implement their policy regarding reporting allegations of abuse and neglect and to ensure that allegations of neglect were reported within a timely manner to the state agency for one of one sampled resident (Resident #32). The deficient practice could result in further instances of allegations of neglect not being reported and investigated promptly, and in accordance with professional standards. The universe was 68.Findings include:Resident #32 was admitted on [DATE], with the diagnosis that included type 2 diabetes mellitus; depression; retention of urine; benign prostatic hyperplasia without lower urinary tract symptoms; muscle spasm; and morbid obesity due to excess calories.A care plan initiated on February 23, 2024, revealed a focus for risk of change in mood or behavior due to medical condition. Interventions included medications as ordered, initiated February 24, 2024.The care plan for risk of change in mood and behavior was revised on February 13, 2025 to include that the resident makes statements of untruths related to receiving medications on time. A review of a quarterly MDS (Medicare Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 15 out of 15, which indicated intact cognition. The assessment also revealed that within the last 7 days before the assessment, Resident #32 felt down for two to six days; verbal behavioral symptoms and other behavioral symptoms not directed towards others occurred one to three days.On February 13, 2026, a behavior progress note revealed that the Resident told a medication technician, that he was being neglected and wanted to speak to a nurse right now. The progress note also revealed that the allegation was reported to the DON, who spoke to the resident and instructed staff to have 2 people in the room for care. however, there was no evidence that the allegation had been reported to the state agency.A care plan for risk of change in mood or behavior was revised on February 18, 2026 to include interventions for 2-person cares and medication pass.On February 20, 2026, a behavior progress note revealed that Resident #32 complained that he was not receiving his medications at night, and the resident stated that it is your fault. The nurse wrote that the ADON (assistant director of nursing) was notified that the resident accused staff of abusing and neglecting him. The nurse also relayed that the resident's medications were administered according to physician orders. Another behavior progress note dated February 20, 2026 revealed that cares in pairs was continuing.An interview was conducted on February 24, 2026, at 11:23 AM, with Resident #32, who stated that he felt that an LPN (licensed practical nurse/Staff # 32) had inflicted mental abuse on him, as evidenced by previous interactions that made Resident #32 feel less than a man. The resident also stated that he had increased anxiety when he was aware that the LPN would be on the upcoming shift, and that he had experienced anxiety attacks due to being scared of the LPN. Resident #32 further stated that he felt that he had been abused and neglected due to his race and did not understand why the staff would treat him that way. The resident stated that he had told the DON (director of nursing), but felt that the facility did not do anything about it. An interview was conducted on February 25, 2026, at 10:06 AM, with a CNA (certified nursing assistant/Staff #76) who stated that allegations of abuse and neglect, such as physically harming a resident, utilizing mean words towards a resident, taking the money of a resident, not listening to a resident's needs, and ignoring call lights and walking way to not provide care to a resident, such as closing the door; are examples of instances of abuse and neglect that are expected to be reported to their charge nurse The nurse is expected to report allegations shared by the aides to DON and up the chain of command. Regarding Resident #32, the CNA stated that the resident had reported alleged abuse and neglect to her, and had also reported the allegations to nurses; however, the CNA stated that the nurses told her that they were aware of the allegations and to let them handle the allegations, which she stated she did.An interview was conducted on February 25, 2026, at 10:47 AM, with an LPN (Staff #95) who stated allegations of abuse and neglect, such as pushing, kicking, hitting someone, intimidation, verbal abuse such as comments made to make residents feel demeaned such as mocking a resident for their beliefs, how they look, racist comments, or not taking care of someone and or withholding care from a resident, are instances of abuse and neglect that are to be reported to the state agency within a two hour timeframe. The LPN also stated that if a resident were to report an allegation of abuse and neglect, she would ensure the safety of the resident and then ensure that the ADON, DON, or the Administrator are made aware of the allegation so that an investigation can be conducted. Regarding Resident #32, the LPN stated that the resident had reported allegations of abuse and neglect regarding his water restrictions and not receiving his medications as ordered by a specific staff member. The LPN stated that she reported the allegations to the ADON, DON, and the Administrator; however, they did not communicate to her what the facility intended to do with the allegation. An interview was conducted on February 25, 2026, at 1:46 PM, with a CNA (Staff #43) who stated that allegations of abuse, such as hitting, mental abuse, emotional abuse, verbal abuse, expressions of anger, and mean words, that could result in a resident feeling scared, would be required to be reported to the nurses. The CNA stated that that she had reported the comments made by Resident #32 to the nurses on the shift, and had been met with responses that indicated that they are aware of the comments and that they have already spoken to Resident #32. The CNA stated that she was unsure what was done regarding the concerns. A phone call interview was attempted on February 26, 2026, at 10:09 AM with the alleged perpetrator (AP/Staff #32); however, it was unsuccessful, and a voicemail could not be left as there were no identifiers within the voicemail.An interview was conducted on February 26, 2026, at 1:15 PM, with the DON (Staff #15), who stated that all allegations of abuse and neglect, including verbal abuse, are expected to be reported to the abuse coordinator to determine next steps. Regarding the progress note from June 21, 2024, regarding the allegation of neglect, the DON stated that she was not notified of the allegation, indicating that the allegation had not been reported to the state agency and had not been reported per their facility policy and regulatory requirements. The DON also stated that should this allegation have been reported to her, it would have been reported to the state agency per the facility policy and regulatory requirements. The DON also stated that allegations of abuse and neglect are expected to be reported per facility policy for the safety of the residents, with the risk of the alleged abuse and neglect not being followed through on. Regarding the progress note on February 13, 2026, the DON stated that the allegation of neglect had been reported to her, and although a discussion may have occurred, she acknowledged that she did not complete documentation of any discussions she had with Resident #32. The DON requested the support of the ADON (Staff #67), Social Services (Staff #14), and the Administrator (Staff #110). The DON, ADON, and Social Services stated that there had been a conversation regarding the allegations; however, they confirmed that documentation of the conversation had not been completed and had not met the facility's expectations. The DON then further stated that the conversation included the determination that the allegation did not meet their understanding of what abuse and neglect were, and decided that it did not require further action, which included reporting it to the state agency, as stated per their facility policy and regulatory requirements. Social Services stated that the resident had exhibited behaviors of increased depression and anxiety, and stated that they did not make the correlation between the allegations of abuse and neglect and the resident's increased behaviors of anxiety and depression. Social Services further stated that following the most recent allegation of abuse and neglect made by Resident #32 during the annual re-certification, law enforcement shared with the facility that Resident #32 reported the comparison of his ex-wife resembling the alleged perpetrator, which Social Services stated may have been a potential trigger. It had also been discussed that there had been an attempt to interview the alleged perpetrator, but it had been unsuccessful. A phone interview was conducted on February 26, 2026, at 2:53 PM, with an LPN (Staff #32), who stated the allegations of abuse and neglect would require understanding of who has made the allegation, and stated that, depending on the person, she would only then report that information to the DON and indicating that she will report or not report allegations and will determine what is reported, depending on the rapport built with the resident. The LPN also stated that she could not recall that the Resident had disclosed any allegations of abuse or neglect to her or against her, and denied that any allegations of abuse and neglect against her had been untrue due to her character. The LPN did not state what actions or behaviors of abuse and neglect could look like.A policy titled 'Abuse - Identification of Types', last reviewed May 6, 2025, revealed that it is the policy of the facility to identify abuse, neglect, and exploitation of residents, and misappropriation of resident property. The policy also revealed that abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, painful or mental anguish, which included verbal abuse. The policy also revealed that the facility will apply the following definitions to identify abuse, neglect, and exploitation, and that facility staff should report any suspected abuse, neglect, or exploitation to the Executive Director or Director of Nursing.A policy titled 'Abuse - Reporting and Response - No Crime Suspected', last reviewed May 7, 2025, revealed that the facility will report alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, and report the results of all investigations to the proper authorities within prescribed timeframes. The policy also revealed that the facility will ensure that all staff are aware of reporting requirements and support an environment in which staff and others report all alleged violations of mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of the resident's property. The policy also revealed that alp associates are mandated to immediately report suspected abuse and/or neglect to their immediate supervisor and/or facility representative, and must be reported to the supervisor regardless of the time lapse since the incident occurred. The policy also revealed that all alleged violations, whether oral or in writing, must be reported to the facility and to other officials in accordance with State law through established procedures.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of two residents to be free from abuse (#10 and #20). The deficient practice could result in residents being at risk for abuse. -Regarding Resident #10: Resident #10 was admitted to the facility on [DATE] with a diagnosis that included type 2 diabetes mellitus, arthritis, and dementia. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4.0, which indicated severely impaired cognition. The assessment also revealed that the resident exhibited verbal and other behavioral symptoms directed towards others. A event progress note dated May 14, 2025 revealed a Certified Nursing Assistant (CNA)/med tech was walking by the room, staff heard a commotion, and witnessed Resident #10 and her roommate arguing over a plastic flower. The staff witnessed Resident #10 get slapped on the right side of her face by her roommate. Resident #10 then shoved her roommate's left shoulder. The note indicated that the Residents were separated and skin assessment was completed, with no injuries noted. The note also relayed that the Assistant Director of Nursing (ADON), Director of Nursing (DON), Administrator, and the provider were notified. The note also revealed that a room change was completed. A behavioral progress note, dated May 14, 2025, revealed that staff were unable to notify the resident's representative and case manager of the altercation with the resident's roommate. A care plan initiated on May 14, 2025 revealed that Resident #10 had the potential to be verbally aggressive related to dementia. Interventions initiated on May 14, 2025 included to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort level, body positioning, and pain; assess resident's understanding of the situation, allow time for the resident to express self and feelings towards the situation; and give the resident as many choices as possible about care and activities. On May 29, 2025 at 11:00 am, Resident #10 was observed lying in her bed, making non-discernable response when called by her name, but end up answering the surveyor's question which resident stated that she was fine. Regarding Resident #20: -Resident #20 was admitted to the facility on [DATE] with a diagnosis that included dementia, age related osteoporosis, and type 2 diabetes mellitus. An annual MDS assessment dated [DATE], revealed no recorded BIMS score. The assessment revealed that the resident had short term and long term memory problems, was rarely/never understood, and behavioral symptoms were not exhibited. A behavioral progress note, dated May 14, 2025, revealed that a Medication Technician stated that Resident #20 and her roommate were fighting over a plant, both claiming it was their plant, and staff separated both residents. The Medication Tech stated that they had hands on each other. Staff notified the social worker and the DON and Resident #20 was moved to another room. The note also indicated that the Resident's family and provider were notified of the room change. A care plan initiated on May 14, 2025, revealed that Resident #20 had a potential to be verbally aggressive related to dementia. Interventions initiated on May 14, 2025, included to assess and anticipate the resident's needs such as food, thirst. toileting needs, comfort level, body positioning, and pain; assess resident's understanding of the situation, allow time for the resident to express self and feelings towards the situation; and observe for behaviors every shift, and document observed behavior and attempted interventions. An observation was conducted on May 29, 2025 at 11:31 a.m. of Resident #20 sitting in the activity room. The resident was observed sitting in her wheelchair, smiling, propelling her wheelchair back and forth with her hands. An interview was conducted on May 29, 2025 at 11:04 a.m. with a Licensed Practical Nurse (LPN/Staff #5), who stated that she was familiar with the altercation incident. She stated that Staff #8 witnessed the incident and separated the residents (#10 and #20). The LPN further stated that the residents were fighting about a plastic flower, one resident got hit or slapped. The LPN further stated that the residents were separated and the DON and the administrator were notified. The LPN also stated that she assessed the residents to make sure that there were no physical injuries, and that she had not observed any signs of redness or bruising. The LPN stated that she interviewed the residents and both residents could not remember what had occurred. The LPN added that the resident altercation happened in the morning in the residents' room. She stated that Resident #10 had confusion, was able to wheel herself around in her wheelchair, and liked being in her own room. The LPN stated that Resident #20 was moved to another room. The LPN also stated that a physical altercation is a form of abuse, if there is a slap, push, punch, or being hit by another resident, she considered it as abuse, and she would notify the DON and administrator of the incident. The LPN stated that she received abuse training when she first started, during orientation, watched videos, and received abuse inservices. The LPN further stated that she was trained on abuse a week or so ago. An interview was conducted on May 29, 2025 at 11:17 a.m. with a Medication Technician (Staff #8), who stated that she was working on the day of the altercation between Resident #10 and Resident #20. She stated that she heard the residents arguing in room their shared room, and they were fighting over a vase of flowers. The Medication Technician stated that there was physical contact when Resident #20 swung her right hand to the left side of Resident #10's face. She further stated that Resident #10 wanted to swing back but she stepped in between, separating them. The Medication Technician stated that she took Resident #20 out of the room, and notified an LPN (Staff #5), DON and the administrator. She also stated the incident was a form of abuse because one resident hit another resident and abuse is physical contact between residents. The Medication Technician stated that abuse training, it is conducted yearly, and she had just recently competed it. An interview was conducted on May 29, 2025 at 11:46 am with the facility Administrator (Staff #3) and the DON (Staff #4) in the conference room. The DON stated that Resident #10 and Resident #20 were roommates, that there seemed to be no problem until a staff member heard a commotion in the residents' room, and when she walked walked in the residents were arguing over a fake flower. The Administrator stated that one resident (#20) slapped the other resident (#10), and Resident #10 resident responded by pushing Resident #20's shoulder. The DON stated that it is considered abuse if there is physical contact. Review of facility's policy titled, Abuse Prevention, last reviewed date of June 17, 2024 revealed it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Review of facility's policy titled, Resident Rights, last revised date of September 10, 2024 revealed the resident has the right to be free from abuse.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#5) was provided with adequate supervision to prevent a fall. The deficient practice could result in residents being harmed physically and psychologically. Findings include: Resident #5 was admitted to the facility on [DATE], with diagnoses that included, difficulty in walking, not elsewhere classified, other intervertebral disc degeneration, lumbar region without mention of lumbar back pain or lower extremity pain, other osteoporosis without current pathological fracture, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 09, indicating moderate cognitive impairment. The assessment revealed no indicator for mood or behaviors, frequent incontinence for bowel and bladder and non-Alzheimer's dementia. Further review of the MDS assessment revealed resident #5 had one fall since admission or prior assessment resulting in a major injury. A care plan dated February 7, 2025, revealed a focus for activities of daily living (ADL) assistance and therapy service, a self-care performance deficit related to impaired balance, limited mobility related to weakness, and at risk for falls, the resident has impaired cognitive ability /impaired thought processes related to BIMS score 09/15, resident has had an actual fall. Interventions included to assist with (ADLs) as needed and to have call light within reach, requires assistance by staff to move between surfaces for transfers, requires assistance by staff for toileting, administer medications as ordered, Therapy screen sent, added non-slip socks, or encourage resident to have shoes on when transferring or walking. A Care Management Note dated April 16, 2025 revealed resident #5 found sitting on the bathroom floor on his buttock facing the toilet. The resident reported to staff he was trying to go to the bathroom, and slid to the ground off the wheelchair. resident reported not hitting his head, no redness or bruising present. It was noted the resident's weakness has increased. A Care Management Note dated April 16, 2025 revealed resident #5 was found in the bathroom sitting on the floor in front of his wheelchair facing the toilet. The note reports the resident was taking his socks off and was not wearing non-slip socks. A Care Management Note dated April 17, 2025 revealed housekeeping informed staff that resident had fallen on his head and needed help. Staff went to resident #5 room finding the resident on hands and knees with the crown of his head on the floor. Resident #5 was observed rocking back and forth, saying I can't move my legs. Resident's wheelchair was behind him and was in the doorway of his room when found. A Note Text dated April 18, 2025 revealed a falls review for April 16, 2025. Resident stated to staff that his socks were slippery and sat down on his buttocks. New intervention of encouraging patient to wear non-slip socks have shoes on when transferring or ambulating. A Note Text dated April 24, 2025 revealed Pressure reducing mattress and cushion to wheelchair in place. New Roho placed in chair this week as old cushion appeared wearing out (3/18/25). Encouraging frequent repositioning. Review of the physician's orders dated April 25, 2025 revealed a Stat upright Magnetic Resonance Imaging (MRI) of thoracic spine without contrast. Diagnosis back pain with T7 and T8 compression fractures on computerized tomography scan (CT). Review of the fall risk assessment outcomes revealed fall risk scores ranging from 18-8 dated July 23, 2023 through March 1, 2025 with the last admission assessment completed April 17, 2025 with score of 16. Review of emergency department evaluation dated April 17, 2025 revealed resident #5 presented to the emergency department with chief complaint of fall injury. Resident reported having some mid back pain. Evaluation documents fall resulted after resident had fallen asleep in chair and fell out of it. The exam of the back and pelvis revealed tenderness to palpitation of the T-spine midline in the area of the T-7-T-10 with no traumatic step-offs. Findings of the of the thoracic spine CT revealed increasing T-7 compression fracture now moderate to severe with marked surrounding soft tissue swelling. Findings also noted interval development of some mild superior endplate fracture of the T-8 adjacent vertebral body with marked loss of disc space between T-7 and T-8 with associated soft tissue swelling noted in this region. Further review of the evaluation of the CT imaging revealed the resident does have what appears to be a new mild T-8 endplate compression fracture with no retropulsion. Review of a consultation note dated April 21, 2025 revealed the following notation He has been complaining of back pain. He has had an evaluation which has included imaging studies which have revealed osteoporosis and fractures of the T spine at T7-T8. He is felt to have a combination of potential etiologies. One of the Vertebral Fractures is related to osteoporosis and the other due to osteoporosis and possible aggravation from slipping out of his wheelchair and landing on his buttocks. He has been treated with differing medications with some improvement. It is hoped that he can get into a pain specialist that offers vertebroplasty. This is in the works that is to say it has been ordered. Review of the facility investigation dated April 22, 2025, revealed per the documentation resident #5 had complained of back pain April 7, 2025 that was not relieved with medication. Results of the x-rays revealed no acute distress. The provider ordered a CT on April 10, 2025 with results of a compression T-7 mild to moderate fracture of indeterminate age. Resident had a fall on April 16, 2025 in the bathroom trying to go by himself without calling for assist and fell from his wheelchair. On April 17, 2025 the report states the resident sustained another fall when he fell forward and slid out of his wheelchair. The report states the resident sleeps in his wheelchair. The facility determined through their interviews with the resident, staff and family no mention of mishandling by anyone at the facility. An interview was conducted May 1, 2025 at 1:03 p.m. with resident #5. Observations made on entering the resident's room. Call light was on at 12:59, staff responded at 1:02p.m. resident's bed was unmade with no bedding. Resident was observed with non-skid sock with his shoes on. Resident reported that he had fallen in the facility twice. resident reported he had fallen off the toilet and had hurt his back. Resident reported he had called for help by pushing my button before attempting to change his underwear. Resident #5 stated they took too long and didn't come to help me. The resident stated this has happened in the past stating staff take a long time to come and help me-sometimes one hour or more and I can't wait that long. An interview was conducted May 1, 2025 at 1:06 p.m. with Registered Nurse (RN/Staff #46). She stated she is the residents nurse and is aware of his care. Staff #55 stated resident #5 has a wound on his coccyx, complains of back pain is continent of bowel and bladder and a moderate assist of one. She stated residents are assessed for falls if they have fallen before, are weak and by how alert they are. She stated resident #5 is a fall risk and has had two falls, once on April 17, 2025 and April 18, 2025. Staff #46 stated the first fall is a result of not cooperating with using the call light, had no shoes on and had slid from the wheelchair to the floor in the bathroom. She stated the second fall happened when the resident had fallen asleep in his wheelchair and fell forward out of the wheelchair and was found by housekeeping. She stated when she was notified by housekeeping she went to the room and found the resident on his hands and knees stating he could not get up. Staff #46 stated she was assisted by a CNA with a gait belt to lift back into the wheelchair. Staff #46 stated the resident had not injuries with the fall on April 17, 2025, but did complain of increased back pain and head pain due to hitting his head from the second fall. Staff #46 stated the provider was notified, vital signs, neuro checks and was sent to the emergency room . Staff #46 stated new interventions were placed after the first fall that included frequent checks, use of the call light and encourage to sleep in his bed. After the second fall interventions included re-education with the family and resident regarding reinforce interventions with their father. Staff #46 stated staff have increased founding, frequent reminders to use the call light and reached out to the Director of Nursing (DON/ Staff # 25) and the Assistant Director of Nursing (ADON/Staff # 15) An interview was conducted May 1, 2025 at 1:29 p.m. with certified nursing assistant (CAN/Staff #55). Stated she is familiar with the resident's care and before his back issues was independent with his ADL's, but is now encouraged to use the call light and is now a one person assist with dressing and transfers to the toilet. Staff #55 stated she informed what fall interventions are needed for the residents from report from the nurse or the resident will wear a yellow arm band indicating they are a fall risk. There was no yellow arm band observed on the resident. Staff #55 stated she did not know why the resident did not have one. Staff #55 stated the resident is now a fall risk, stating she was not aware if the resident was a fall risk before his falls. Staff #55 stated she was unaware if resident #5 had sustained any injuries from his fall, but does have a pressure ulcer on his bottom and that his back was hurting. Staff #55 stated interventions in place prior to the falls were the use of non-skid socks and making sure call light in reach. She stated she was unaware of any new interventions post falls for resident #55. She stated the resident will refuse to use his call light and had an accident while in his wheelchair and was sitting in his feces, but did not know how long the resident had sat there since he did not call. An interview was conducted May 1, 2025 at 1:45 p.m. with Director of Nursing (DON/Staff #25) The DON stated prior to the fall resident #5 was set-up/independent- pull-up clothing and working with Restorative Nursing Assistant (RNA) 3xweek, post fall- off RNA, due to requiring requiring more of an extensive assist. She stated he is able to bear part of his weight, but does require assist with dressing and toileting. The DON stated staff are informed of a resident change of condition or level of care needed through report from shift to shift, the Kardex, education and continuity of care due to more changes to resident care and for new admissions and discharges. The DON stated residents are assessed for fall risk from a fall risk score and any changes mentally and physically, dementia or medical. She stated the resident was not a fall risk prior to his first fall. She stated the resident had fallen on April, 16 and April 17, 2025. She stated on April 16, 2025 that's when he went to the bathroom with socks on, his feet slipped and he sat down in the bathroom. She stated he was complaining of pain prior to the fall and had received the CT and X-ray prior to the first fall. The DON stated interventions in place prior to the first fall, were if he needed assist he would let us know and call light in reach. She stated interventions put into place after the first fall was a discussion of having regular socks and using non- skid socks. The facility implemented no skid socks after the second fall on April 17, 2025, conversation with staff and resident who would let us know to lay down him in the bed when he gets tired. She stated the resident has been agreeable has been agreeable to the interventions. Staff #25 stated it is her expectations that staff are informed of the resident's care plan, interventions and of any change of condition, that they ask their nurse, check the Kardex, or ask if they do not know. Review of the facility policy titled incident and Reportable Event Management The facility to the best of its ability strives to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. This does not include other types of harm, such as adverse outcomes that are a direct consequence of treatment or care that is provided in accordance with current professional standards of practice (e.g., drug side effects or reaction). 3. Implement interventions, including adequate supervision and assistive devices, consistent with a resident's needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and/or 4. Monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standards of practice.

Based on observations, clinical record review, staff interview, facility documentation and policy review, the facility failed to protect the rights of two residents (#7 and #9) to be free from physical abuse by another resident (#5). The deficient practice could result in further resident abuse. Findings include: Regarding residents #5 and #7: -Resident #5 was admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, with agitation, psychotic disorder with delusions due to known physiological condition, hallucinations, unspecified, generalized anxiety disorder. The care plan with revision date of January 17, 2025 included that resident had impaired cognitive function and at risk for change in mood or behaviors due to medical condition, recent BIMS (Brief Interview for Mental Status) score of 3 and dementia, and the use of antipsychotic medication; Seroquel related to diagnosis of psychotropic disorder with delusions and hallucinations, refusal of care, yelling at staff. Interventions included to administer meds as ordered; staff attempt to keep separate from other flagged residents; residents Quetiapine was increased after review of behaviors by MD who feels the gradual reduction rate was a fail with returned behaviors. On April 13, 2025 resident's roommate was moved to another room to separate at this time. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Further review of the MDS revealed a mood score of 05 indicating mild mood severity. There were no indicators for behaviors. Review of a progress event note dated April 1, 2025 at 6:42 am revealed resident#7 was seated in the TV area watching TV when resident #5 wheeled herself into the same area. Resident #5 started a verbal altercation with resident #5, totally unprovoked. The nurse heard the verbal altercation and stood to separate the two of them when resident #5 struck resident #7 on the back of the head. This incident was witnessed by staff. The note further states resident #7 was teary eyed, but okay Resident #5 though resident #7 had run over her in her wheelchair, but states this was not possible. Review of progress health status note dated March 31, 2025 revealed resident #5 behaviors were reviewed by the provider, who diagnosed resident #5 as having a failed Gradual Dose Reduction (GDR) with returned behaviors. -Resident #7 was admitted on [DATE] with diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, single episode, unspecified, depression, unspecified. The care plan dated April 3, 2025 included that resident #7 had impaired cognitive ability or impaired thought processes related to dementia, and at risk for change in mood or behaviors due to medical condition. Interventions included to cue, reorient and supervise as needed, supervision and assistance with all decision making, customary routines, and attempt to keep separate from other flagged residents, as flag on wheelchair is for visual effect. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood and other behavioral symptoms not directed towards others and indicators for wandering. The alert charting dated March 31, 2025 revealed that resident #7 involved in a physical and verbal altercation and was struck in the back of the head by resident #5. No injuries or residual effects noted. Incident was unprovoked and witnessed by the nurse. No complaints of pain/discomfort. Resting comfortably/quietly in bed with eyes closed. Resp even and unlabored. No distress noted. Call light within reach. Able to make her needs known. The nursing event note dated March 31, 2025 revealed nurse a verbal altercation between resident #5 and resident #7 initiated by resident #5. Resident #7 was sitting in the tv area watching tv. Resident #5 then wheeled herself into the same area. (LPN/Staff #18) stood up to separate the two of them when resident #5 struck resident #7 on the back of her head, this was totally unprovoked and witnessed by (CNA/Staff #28). The two of them were separated immediately. It states resident #5 falsely accused resident #7 of running over her in the wheelchair and that this was not possible. It further states resident #7 was teary eyed but stated she was okay. Both residents were separated immediately. Review of the facility investigation with discover date of March 31, 2025 included that both resident #5 and #7 were interviewed. The facility concluded the altercation between these two residents was an isolated event with resident #7 being startled and no injuries, with preventative measures put in place. Regarding residents #5 and #9: -Resident #9 was admitted to the facility January 1, 2025 with diagnosis of unspecified dementia, unspecified severity, with other behavioral disturbance, depression, unspecified, other abnormalities of gait and mobility. The Care Plan revealed resident #9 at risk for mood or behavior due to medical condition resident, has impaired cognitive ability /impaired thought processes related to dementia and has a communication problem related to BIMS 03/15 and dementia. Interventions included; Be conscious of resident position when in groups, activities, dining room to promote proper communication with others, face and speak clearly when communicating with resident, April 13, 2025 moved temporally to separate 2 residents. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood, display of verbal behavioral symptoms directed towards other and other behavioral symptoms not directed towards others. Review of the Event Note dated April 13, 2025 revealed (Staff/RN #32) was at the nurses station charting and heard a scream coming from resident #9 room the RN on shift went in to this resident's room as she was in the kitchen putting snacks away and then came out and informed RN #32 that resident #9 was saying that her roommate slapped her in the face as she was coming out of the bathroom (Staff/RN #32) went into the resident's room and asked what happened and resident #9 was holding the left side of her face (the cheek area) and the roommate (resident #5) states resident #9 hit her first across her chest by her heart so she hit her back. Resident #9 stated her roommate hit her first and denied hitting the roommate. Review of a Health Status Note dated April 14, 2025 revealed a status post note regarding a physical altercation with another resident, resident #9 was slapped on the left cheek area. Left cheek area with a red pinpoint mark & pinkish colored. Very teary eyed & upset. Emotional support offered. Unfamiliar to new environment, was ambulated into another room, redirected. Resting in bed respirations even and unlabored. No distress noted. Will continue to monitor. Review of the ongoing facility investigation facility report with discovery date of April 13, 2025 included resident and staff interviews were initiated. The initial report states at 9:25 p.m. resident #5 was coming out of the bathroom and resident #9 was sitting on the side of her bed with feet dangling when resident #5 slapped resident #9 across the face, with slight redness. Resident #5 stated resident #9 hit her first near her heart so she hit her back. Resident #9 denied hitting resident #5. Resident #9 was moved to another room. Leaving resident #5 by herself. An interview was conducted April 15, 2025 at 12:02 p.m. with (Staff/LPN #32). Staff #32 stated he has been with the facility since 2019 and is familiar with residents #5, #7 and #9. Staff #32 stated resident #5 had been fixated and upset about her the pending sale of her home. Staff #32 stated resident #5 is generally a pleasant lady, can be confrontational with staff and other residents- gets agitated with other residents who are verbal or loud. will tell them to shut up or if another resident should accidentally bump into her. Staff #2 stated he was told there was prior altercation with resident #7. Staff #32 stated resident #5 had been extremely upset after receiving mail informing her that her home was going to be sold and had been extremely agitated and frustrated. Staff #32 stated it might have been a cause for her lashing out. Staff #32 stated her medication has not been changed, but her order for Seroquel was reduced from 50mg to 25 mg prior to the first incident. After the first incident with resident #7 the doctor bumped it back up to 50mg, but resident #5 continued to be fixated about her home. Staff #32 stated resident #9 had been out with her daughter, leaving at 3:30 for dinner and came back at approximately 7:00 p.m. Staff #32 stated I gave her meds and resident #9 was lying in her bed, Resident #5 was also lying on her bed. Staff #32 stated he was sitting at the nurse's station charting and heard resident #9 yelling saying why did you do that to me? Staff #32 stated resident #9 was sitting on the side of her bed holding her face. Staff #32 stated resident told another registered nurse (Staff/RN #13) in Spanish that resident #5 had hit her on her face. Resident #9 was observed holding the left side of her face- resident #5 was observed sitting in her wheelchair near her bed. RN #13 asked resident #5 what happened. Resident #9 stated resident #5 came out of the bathroom and hit her. Resident #5 stated resident #9 had hit her first in the chest, and she had hit her back and now she wasn't happy because I got the best of her. Resident #9 denied hitting her. Resident #9 was observed with some redness on the left side of her face. Staff #32 stated a skin assessment was done immediately on resident #5 with no redness noted as well as the day following. Staff #32 stated the doctor made a change with resident #5 medications by increasing her Seroquel and a lab work. Staff #32 stated resident #9 has never hit anyone, is easily offended and will cry. Staff #32 stated both residents were immediately separated with resident #9 moved to another room that same day. An attempt was made on April 15, 2025 at 12:21 p.m. to interview witness, licensed practical nurse (Staff/LPN #18). Message was left for a return phone call. An attempt was made on April 15, 2025 at 12:24 p.m. to interview witness certified nursing assistant (Staff/CNA #28). Message was left for a return phone call. An attempt to interview was conducted April 15, 2025 at 3:22 p.m. with resident #7. Resident stated I don't remember, but I'm fine. The resident is cognitively impaired. An interview was conducted April 15, 2025 at 3:43 p.m. with resident #9, also present was the resident's daughter. Resident #9 was observed with a reddened area located on the left side of her upper cheek. Part of the cheek area were yellowish and green in color. Resident #9 stated not remembering what happened, but feels like she was kicked by a horse. Resident stated feeling safe. The daughter stated she was told by staff #32 that her mother's roommate had slapped her on the face. An attempt to interview was conducted April 15, 2025 at 3:54 p.m. with resident #5. Resident was seated in her wheelchair in her room. Resident stated I don't know what you're talking about. The resident is cognitively impaired. An interview was conducted April 15, 2025 at 4:04 p.m. with abuse coordinator (Staff/#71). Staff # 71 stated their responsibilities are reporting to the state and initiating the investigation and to the appropriate authorities. Staff #71 stated the facility must report all allegations to the state within two hours and submit a final report within five days. Staff #71 stated the facility substantiated the report regarding residents #5 and #7 and the report regarding residents #5 and #9 was still ongoing, but will probably substantiate. An interview was conducted April 15, 2025 at 4:26 p.m. with Director of Nursing (DON/Staff #92) who stated her expectations for reporting alleged abuse is that staff are to let their supervisors know and staff have been educated during in-services that the executive director is the abuse coordinator or they are to reach out to her. DON #92 stated resident #7 was assessed for injuries, there were none. Resident # 9 was assessed and noted redness on her left check. The DON stated resident #5 had no reported injuries for each incident. The DON stated there were no prior incidents or concerns between residents #5 and #7 or residents #5 and #9. Review of the facility policy titled Abuse - Prevention Issued October 4, 2022 and reviewed June 17, 2024 states It is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. Definition Abuse - is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are residents from abuse. necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on observations, staff interviews, and review of facility policies, the facility failed to ensure food in unit nourishment refrigerators was stored in accordance with professional standards for food service safety. The deficient practice could result in foodborne illnesses. Findings include: Regarding the East unit An observation of the East unit nourishment area was conducted on April 21, 2021 at 2:14 p.m. with the Kitchen manager (staff #37). The following were observed: -Refrigerator #1 was observed to have a temperature within the correct range and contained ham and cheese sandwiches, fruit (cut fruit and grapes), jello, pudding, and pitchers of juice. Review of the corresponding Record of Refrigeration Temperatures form for April 2021 revealed the refrigerator temperature was documented to be over 41 degrees Fahrenheit on 8 days. There was no documentation of comments or actions taken on the form. The form included the refrigeration temperature should not be greater than 41 degrees and to report to the supervisor when recorded temperatures are not adequate. -Refrigerator #2 was observed to have a temperature of 44 degrees Fahrenheit per the thermometer located in the refrigerator. The refrigerator contained med pass supplement, coffee, [MEDICATION(S)], Coke, and a moon pie at the time of observation. None of the items in the refrigerator at the time of observation required refrigeration. Later that day at 2:49 p.m., a second observation was conducted of refrigerator #2. The temperature of refrigerator #2 was observed unchanged at 44 degrees Fahrenheit. Review of the corresponding Record of Refrigeration Temperatures form for April 2021 revealed the temperature was documented to be over 41 degrees Fahrenheit on 4 days. There was no documentation of comments or actions taken on the form. The form included the refrigeration temperature should not be greater than 41 degrees and to report to the supervisor when recorded temperatures are not adequate. Regarding the West Unit An observation of the West unit nourishment area was conducted on April 21, 2021 at 2:30 p.m. with the Kitchen manager (staff #37). The following were observed: -Refrigerator #1 was observed to have a temperature of 24 degrees Fahrenheit per the thermometer located in the refrigerator. The refrigerator contained three food items that had frozen: a personal resident salad, a personal resident container of fruit, and a facility prepared salad. Additionally, the refrigerator contained a container of prepared oatmeal, med pass supplement, boost supplement, yogurt, a fruit/yogurt parfait from an outside source, applesauce, prepared fruit, salad, and a plastic container with unidentified contents. On April 22, 2021 at 8:25 a.m., another observation was conducted of refrigerator #1. The refrigerator temperature was 48 degrees per the reading on the thermometer in the refrigerator. The refrigerator continued to contain food items that required refrigeration. -Refrigerator #2 was observed to have a temperature of 43 degrees Fahrenheit on the thermometer located in the refrigerator. The refrigerator contained pudding, pitchers of juices, ham and cheese sandwiches. At 2:56 p.m. on April 21, 2021, the temperature was observed to be 46 degrees Fahrenheit. The refrigerator continued to contain food items that required refrigeration. An interview was conducted on April 21, 2021 at 2:20 p.m. with the Kitchen manager (staff #37). She stated the nurses and Certified Nursing Assistants (CNAs) are the ones obtaining the temperature checks on the unit nourishment refrigerators. She stated that she did not know which shift was responsible. An interview was conducted on April 21, 2021 at 2:32 p.m. with a Registered Nurse (RN/staff #42). She stated that she used to work nights and that the night shift nurse does the temperature check on the unit nourishment refrigerators each day. She stated that if the temperature was over 41 degrees Fahrenheit, the nurse would do a second temperature check. She stated that if the temperature was still over 42 all of the food in the refrigerator is considered spoiled and the refrigerator should be shut down and maintenance notified to repair or replace the refrigerator. She stated that if food became frozen in the refrigerator, they would not keep the food. She stated that the facility would replace any resident personal food that was spoiled related to the refrigerator temperature. In an interview conducted on April 22, 2021 at 8:21 a.m. with the Licensed Practical Nurse (LPN/staff #56) who had initialed some of the temperatures on the East Unit refrigerator forms, the LPN stated that she works the night shift and is responsible for checking the two nourishment refrigerators on the East unit on the nights that she works. The LPN stated that she checks the refrigerator temperatures at the beginning of her shift which starts at 10:00 p.m. She stated that the temperature was supposed to be between 36 degrees Fahrenheit and 41 degrees Fahrenheit. The LPN stated that if the temperature was over/under that range she would recheck the temperature. She stated that if the temperature was still out of range at the re-check that she would make note on the monitoring form and let maintenance or central supply know. She stated that, sometimes, if the temperature was over the range she would write it on the form. The LPN stated that on some of the days there should be a note that she notified maintenance or that she could not find the thermometer. Staff #56 stated that if there were not notes on the form there would be no way to show that follow up was done. Staff #56 stated that the temperature written on the form was the temperature that she obtained when she came on shift. She stated that she did not recall notifying anyone of this month temperatures being outside of range and that she probably did not. She stated that if there was no documentation on the monitoring form then she did not notify anyone. The LPN stated that if the temperature was 42 degrees Fahrenheit or over, she would sometimes take the pudding out and go back and see how the temperature was. She stated that if the temperature stayed out of range she would remove the food. She further stated that if the temperature was over the range, she would feel inside to see if felt cool and if it felt cool she would check the temperature again the next night. The LPN stated that she removed the food from the refrigerator two nights ago because the temperature was high and she thought the door had been left open. She stated that it was important that food in the refrigerators stay at appropriate temperature range and that she was expected to follow up if it was not. An interview was conducted on April 22, 2021 at 8:47 a.m. with the Director of Nursing (DON/staff #77). She stated that the temperature of the unit nourishment refrigerators needs to be taken every 24 hours by the night shift. The DON stated that there were temperature log forms on the cabinet above the refrigerators to log the temperatures. Staff #77 stated the form has the temperature ranges for the refrigerators printed on it. She stated that if the temperature was above the printed range, staff would need to empty out the refrigerator and throw all the food away, adjust the dial, and wait 24 hours until the next temperature check to see if the temperature was in range. The DON said if the temperature was in range, then staff could put food back into the refrigerator. The DON stated that staff may need to get another thermometer or take the temperature of the actual items in the refrigerator if the temperature continued to be out of range. She stated that the action taken by the staff should be documented on the monitoring form. Staff #77 stated that it was important for food to remain below 41 degrees Fahrenheit so that the food would not spoil and possibly cause gastrointestinal distress to residents. The DON reviewed the East side temperature forms. She stated that for the times the temperature was above 41 degrees Fahrenheit, the staff should have recorded action notes and the refrigerator issue should have been passed on in report so that the refrigerator would not be used until the issue was resolved. The DON stated that if food became frozen in the refrigerator it could impact the taste/appearance of the food but would not be dangerous. She stated that the staff did not meet expectations for maintaining the refrigerators in the nourishment area as they did not document follow up on the form and report the issue as required. The DON stated that the refrigerator temperatures should not be over 41 degrees at any time. Review of a facility's policy regarding Nourishment Storage Areas revised January 1, 2007, revealed the policy of the facility is to ensure the areas where nourishments and snacks are stored for the resident outside of the Food and Nutrition Services department are maintained according to the local/state and federal regulations and facility guidelines. The facility designates which department is responsible for the cleanliness and sanitation of the areas where resident snacks and supplements are stored. The temperature of the refrigerators/freezers is monitored according to facility guidelines. Food is covered, labeled and dated appropriately. Food is rotated and/or discarded according to facility guidelines. Review of the facility's policy on Food Safety revised November 28, 2017, revealed food is stored and maintained in a clean, safe, and sanitary manner following federal, state, and local guidelines to minimize contamination and bacterial growth. Ambient temperatures in refrigerators/coolers are recommended to remain in a range between 34-38 degrees Fahrenheit but may not exceed 41 degrees Fahrenheit to significantly slow growth of microorganisms.

Based on observations, staff interviews, and review of facility policy and procedure, the facility failed to ensure infection control practices were followed regarding personal protective equipment (PPE) for one resident (#206) and oxygen tubing for one resident (#203). The deficient practice could result in the spread of infection. Findings include: Regarding PPE: Resident #206 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On April 19, 2021 at 11:35 am, an observation was made of resident #206's room. Outside of the door, attached to the wall above the room number, was a yellow piece of paper that read yellow room gown required. An additional posting was observed on the door to the room that identified the room as a quarantine room with droplet/contact precautions in addition to standard precautions. The posting instructed everyone, including visitors, doctors, and staff to clean their hands when entering and leaving the room, wear a mask, wear eye protection, and to gown and glove. A Certified Nursing Assistant (CNA/staff #96) was observed inside the resident's room. Staff #96 was wearing a mask, and face shield, but was not wearing a gown. An interview was conducted with staff #96 on April 22, 2021 at 1:00 pm. Staff #96 stated the isolation rooms are marked with a yellow sign and that staff are to don a gown and gloves before entering an isolation room. Staff #96 stated that she remembered that she was not wearing a gown in resident #206's room on April 19, 2021. She stated the resident was being transferred to the hospital and that she was focused on assisting the resident and did not wear a gown. An interview was conducted with a Licensed Practical Nurse (LPN/staff #57) on April 22, 2021 at 1:44 pm. The LPN stated staff should don all the necessary PPE before entering an isolation room, even in an emergency situation. On April 22, 2021 at 2:05 pm, an interview was conducted with the Director of Nursing (DON/staff #77) and the facility's Infection Preventionist (IP/staff #41). The DON stated all of the rooms with yellow signs were isolation rooms and that staff were supposed to wear a gown and gloves while in the room. The DON stated if there was a true emergency, that the resident's life was immediately at risk, she might not take the time to put on a gown before entering the resident's room. She further stated the situation with resident #206 on April 19, 2021 was not an emergency. The DON stated the CNA might have misinterpreted the situation and thought it was an emergency, but the CNA should have put on a gown before entering the resident's room. The facility's policy titled Personal Protective Equipment revised December 2020, stated the purpose is to reduce the risk of and prevent the spread of infection to patients, visitors, and staff. The policy included staff should don an isolation gown prior to entering a resident room on isolation precautions. The facility's policy titled Transmission Based Precautions and Isolation Procedures, revised May 2020, included staff should don appropriate PPE upon entry to the environment (e.g. room or cubicle) of a resident on transmission-based precautions. Regarding Oxygen Tubing: Resident #203 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On April 19, 2021 at 11:20 am, the resident was sitting in her wheelchair. The oxygen concentrator in the room was on and set at 2 liters per minute. The tubing attached to the concentrator, including the nasal cannula, was on the floor, laying in a pile under the resident's bedside table. Another observation was conducted on April 19, 2021 at 12:20 pm. The resident's oxygen tubing, including the nasal cannula, was observed in a pile on the floor. An interview was conducted on April 22, 2021 at 1:00 pm with a CNA (staff #96), who stated oxygen tubing should never be left on the floor. She stated when the tubing is not in use, it should be stored in a bag that is attached to the oxygen concentrator. Staff #96 stated it would be unsanitary to keep the tubing and nasal cannula on the floor. The CNA stated she would change the tubing and nasal cannula if she saw it laying on the floor. An interview was conducted with the DON (staff #77) and the facility IP (staff #41) on April 22, 2021 at 2:00 pm. The DON stated that oxygen tubing should not be left on the floor at any time. Staff #77 stated some residents will take off their nasal cannula and throw it or will keep it next to them on the bed to ease anxiety. The DON stated she expects that staff would replace any oxygen tubing and nasal cannula that were seen on the floor. Regarding the observations of resident #203's oxygen tubing, the DON said she would expect the staff to check a resident who is on oxygen and notice if the tubing and nasal cannula were on the floor. The facility's policy Oxygen Administration/Safety/Storage/Maintenance revised May 15, 2020, included oxygen and respiratory supplies should be stored in a bag labeled with the resident's name when not in use.

Based on clinical record review, observations, staff interviews, and policy review, the facility failed to ensure one resident (#204) was treated with dignity. The deficient practice could result in residents not being treated in a dignified manner. Findings include: Resident #204 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan initiated on April 6, 2021 revealed the resident had impaired cognitive ability and impaired thought processes related to dementia and confusion. The goals were that the resident will follow 1 to 2 step instructions, be consistently redirected, be directed to wear a face mask, and to stay in her room. Interventions included to allow extra time for the resident to respond to questions and instructions, to face and speak clearly when communicating with the resident, and to cue, reorient and supervise as needed. Continued review of the care plan initiated on April 6, 2021 revealed the resident was on isolation or quarantine. The goal was that the resident would have no indications of psychosocial well being problem while in quarantine/isolation. Interventions stated to encourage or facilitate alternative ways of communication with friends and family, provide opportunities to express feelings related to situational stressors, provide in room activities, and to provide psychosocial support when in the resident's room by conversing with the resident or asking if the resident have questions or try to reduce fear. Review of the five day Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status score of 3, which indicated the resident was severely cognitively impaired. On April 19, 2021 at 10:55 AM, resident #204 was observed exiting her room into the hall without wearing a mask. A yellow sign was observed outside the resident's door that indicated the resident was on contact and droplet precautions. The resident was in the hall walking towards the nurses' station. A Certified Nursing Assistant (CNA/staff #96) assisted the resident back to her room. Staff #96 was heard telling the resident there was a virus going around, and that the resident only had one more day on isolation and then she could come out of her room. The CNA asked the resident if she wanted to go to her room and have a phone call from her husband. The resident was crying and saying she does not want to go back in there. Staff #96 helped the resident back to her room and exited the room. Moments later the resident was observed coming out of her room again. Staff #96 called the resident by her name and told the resident she had to go back to her room. The CNA then met the resident in the hallway and helped the resident back to her room a second time. Shortly after being assisted back to her room, the resident exited her room, went into the hall and started walking towards the nurses' station. The resident stated she wanted chocolate. While in another resident's room, staff #96 said to the resident no you can't come out. The resident replied I don't want to stay in here. Staff #96 then stated go back to your room, you don't have a choice, you cannot come out here. The resident stated I just want celebrate with a little chocolate. Staff #96 then exited the other resident's room and met resident #204 in the hallway. The CNA assisted the resident back to her room. A Licensed Practical Nurse (LPN/staff #60) was present on the unit and another staff member was at the nurses' station during the observation. No staff was observed to provide the resident a mask, get the resident chocolate, or assist the resident with talking to her spouse on the phone. An interview was conducted on April 20, 2021 at 12:33 PM with a Registered Nurse (RN/staff #47). The RN stated the CNAs on the unit try to work with resident #204. Staff #47 said the CNAs try to redirect the resident because she is confused. The RN stated the resident likes to talk with her spouse on the phone. Staff #47 stated a personalized care plan had been developed for the resident that the staff can implement when providing care to the resident. On April 21, 2021 at 8:17 AM, an interview was conducted with an LPN (staff #104). The LPN stated the care for a resident with dementia is different, that they have different needs. She stated that resident #204 was refusing to stay in her room. The LPN said the resident was on isolation precautions because she was a new admission. Staff #104 said that due to the COVID-19 pandemic, the facility requires all new admissions to remain on precautions for 14 days. The LPN stated the resident has choices. The LPN also stated that there are appropriate interventions that can be implemented when a resident is confused. An interview was conducted on April 22, 2021 at 1:45 PM with the CNA (staff #96). The CNA stated it had been difficult trying to keep residents who are on isolation precautions in their rooms because some of the residents are confused. The CNA stated that if a resident persists with unsafe behavior, then more staff would be requested to assist. Staff #96 stated that she had been instructed to redirect resident #204 and have the resident call her husband. The CNA stated the resident's dignity was not honored when she told the resident she did not have a choice, she had to stay in her room. The CNA stated that she was frustrated with a nurse that was not helping her with the resident. She said staff #60 was mad at her because she was in another resident's room while resident #204 kept coming out of her room. The CNA stated it was very frustrating that other staff would not assist. On April 22, 2021 at 2:23 PM, an interview was conducted with the Director of Nursing (DON/staff #77). The DON stated that her expectation of staff in regards to residents with dementia and dignity, is that even if staff get frustrated, staff should stay calm, provide options, and continue to redirect the resident. The DON stated that if a staff member witnessed anyone speaking to a resident in a way that did not honor a resident's rights or dignity, that staff member should speak to the person and then report the incident to management. The DON stated that if a staff member stated to a resident no you can't come out or go back to your room, you don't have a choice, you cannot come out here absolutely does not meet her expectation of honoring a resident's dignity and rights. Review of the facility's policy titled Dignity reviewed May 19, 2020 revealed each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as honor and value their input.

Based on clinical record review, facility documentation, staff interviews, and policy and procedure, the facility failed to ensure resident #278 was free from abuse by resident #277. Findings include: -Resident #278 was admitted to the facility on (MONTH) 30, 2013, with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment for resident #278 dated (MONTH) 11, (YEAR), revealed the resident had short term and long term memory problems. The MDS assessment also included the resident had not exhibited any behaviors, hallucinations, or delusions. A nurse's note dated (MONTH) 6, (YEAR) revealed resident #278 was in his wheelchair outside his room when resident #277 came up behind him and pushed his wheelchair with force, pushing him into his room and causing his right thigh to hit the end of his bed. The note included resident #278 moaned when hitting the end of the bed. The note also included no abrasion, redness, or bruising was noted. The note further revealed resident #277 attempted to repeat his action but was stopped by a Certified Nursing Assistant (CNA). -Resident #277 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. Review of the care plan for resident #277 dated (MONTH) 22, (YEAR), revealed the resident had a history of [REDACTED]. Interventions included distracting and/or redirecting the resident, ensuring a calm, quiet environment, and initiating behavior monitoring as needed. Review of the quarterly MDS assessment for resident #277 dated (MONTH) 31, (YEAR), revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS assessment also revealed the resident had not exhibited any behaviors, hallucinations, or delusions. Review of a social services note dated (MONTH) 8, (YEAR), revealed resident #277 stated that he felt resident #278 was a witch doctor and that he pushed resident #278 away from him so that he could not put witchcraft on him. Review of the facility's investigation report dated (MONTH) 9, (YEAR), revealed that on (MONTH) 6, (YEAR) at approximately 7:00 p.m., staff witnessed resident #277 aggressively push resident #278 in his wheelchair into his room which caused his thigh to hit the bed. Resident #277 attempted to push resident #278 again, but nursing staff intervened and stopped him. Resident #277 told staff, He (resident #278) is a witch doctor. Resident #277 was sent to the hospital on (MONTH) 6, (YEAR), for an evaluation. Behavior monitoring was initiated for resident #277. Resident #278 was assessed to have no injuries and was moved to a room away from resident #277 and closer to the nurse's station. An interview was conducted on (MONTH) 26, 2019 at 11:04 a.m. with the Director of Nursing (DON/staff # 35). She stated that resident #277 thought resident #278 was an evil person. Staff #35 said the next day that she acknowledged the resident to resident incident occurred, but she believed it was unintentional. An interview was conducted on (MONTH) 26, 2019 at 1:56 p.m., with a Certified Nursing Assistant (CNA/staff #63). She stated that she witnessed resident #278 singing or humming and that resident #277 told him to go away. The CNA stated that she then witnessed resident #277 push resident #278 in his wheelchair really, really hard. She stated she told resident #277 to stop, and that he listened. She said that resident #278 was moved to a room farther away. Review of the facility's policy regarding abuse revealed each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation of any type by anyone, including other residents and that all residents will be protected from all types of abuse. The policy included abuse is the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish. The policy also included the facility will identify, correct and intervene in situations in which abuse is more likely to occur.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure that pain medication was administered to one resident (#22) as physician ordered. Findings include: Resident #22 was admitted on [DATE], with [DIAGNOSES REDACTED]. A pain care plan included the resident experienced pain related to [MEDICAL CONDITION], chronic knee pain, chronic left rotator cuff tear and headaches. An intervention included to administer scheduled and prn (as needed) pain medications. A physician's order dated January 27, 2017 included for [MEDICATION NAME] 50mg-325mg-40mg (a combination of [MEDICATION NAME]-aspirin-caffeine) by mouth every four hours prn for a headache. Further review of the physician's orders for February 2017 through October 2017 also included the order for [MEDICATION NAME] 50mg-325mg-40mg by mouth every four hours prn for a headache. According to the physician's progress notes from February through October 2017, the resident had been prescribed [MEDICATION NAME]. Review of the MARs (Medication Administration Records) from March through October 2017, revealed the order for [MEDICATION NAME] 50mg-325mg-40mg by mouth every four hours prn for a headache. Licensed staff had initialed on the MARs, when the medication was administered. However, review of the pain flow sheets from March through October 2017 revealed documentation that Fiorecet (a combination of [MEDICATION NAME]-[MEDICATION NAME]-caffeine) had been administered (instead of the physician ordered [MEDICATION NAME]). Specifically, the pain flow sheets included hand written entries by licensed staff that Fiorecet was administered as follows: Pain Flow Sheet for March 2017: Fiorecet was administered once. Pain Flow Sheet for April 2017: [MEDICATION NAME] was administered three times. Pain Flow Sheet for May 2017: [MEDICATION NAME] was administered eleven times. Pain Flow Sheet for June 2017: [MEDICATION NAME] was administered twenty times. Pain Flow Sheet for July 2017: [MEDICATION NAME] was administered twelve times. Pain Flow Sheet for August 2017: [MEDICATION NAME] was administered ten times. Pain Flow Sheet for September 2017: [MEDICATION NAME] was administered six times. Pain Flow Sheet for October 2017: [MEDICATION NAME] was administered nine times. Continued review of the clinical record revealed there was no physician's order to administer [MEDICATION NAME]. An observation of a medication packet which was in a medication cart was conducted on November 14, 2017 at 1:00 p.m., with a RN (registered nurse/staff #54). The medication packet had a pharmacy label on it, which included the following information: -Resident #22's name -Name of the medication: butalb-acetamin-caff 50mg-325mg-40mg tablet (equivalent to [MEDICATION NAME]), one tablet by mouth every four hours prn for headache. -The physician's name -Dispense date of August 26, 2017 -Quantity dispensed was 30 tablets -The number of remaining tablets in the packet was 16 During the observation, an interview was conducted with staff #54. She stated that she thought [MEDICATION NAME] and [MEDICATION NAME] were the same medication. Staff #54 then referred to a drug book and stated that the [MEDICATION NAME] and [MEDICATION NAME] were different medications. Immediately following, an interview was conducted with another RN (staff #43) on the same nursing unit. Staff #43 stated that she did not know if [MEDICATION NAME] and [MEDICATION NAME] were the same medication. Staff #43 also referred to a drug book and then stated that they were different medications. An interview was conducted on November 14, 2017 at 1:30 p.m., with the DON (Director of Nursing/staff #8). Staff #8 stated that she was not sure if [MEDICATION NAME] and [MEDICATION NAME] were the same medication. At this time with staff #8 present, the pharmacy provider was contacted. Per the pharmacist, [MEDICATION NAME] and [MEDICATION NAME] were two different medications. The pharmacist stated that [MEDICATION NAME] contained aspirin and [MEDICATION NAME] contained Tylenol. The pharmacist stated that according to the pharmacy computer records, an order for [REDACTED]. The pharmacist also stated that the [MEDICATION NAME] was dispensed an additional thirteen times after March 31, 2017. The pharmacist further stated that the physician's order for [MEDICATION NAME] was dispensed incorrectly by the pharmacy. Immediately following, an interview was conducted with a Corporate Nurse consultant (staff #128). She stated that licensed staff were suppose to compare the physician's order and the medication label, prior to administering each medication. On November 14, 2017 at 2:15 p.m., another interview was conducted with staff #43, who stated that licensed staff were suppose to follow the five rights for medication administration. On November 14, 2017 at 2:30 p.m., staff #8 stated that licensed staff were suppose to compare the physician's order with the pharmacy medication label, prior to the administration of any medication. A facility policy titled, Administration of Medication included All medications are administered safely and appropriately to help residents overcome illness, relieve/prevent symptoms, and help in diagnosis. The policy also included the following: 6. If there is any discrepancy between the MAR and the label, check physician orders before administering medication.

Based on observations, staff interviews, and review of facility documents, the facility failed to ensure safe hot water temperatures in multiple resident bathrooms. Findings include: An observation was conducted on November 14, 2016 at 1:23 p.m., in resident room #101. A visitor stated that the water in the bathroom was extremely hot and to be careful when testing the hot water. At this time, the hot water temperature in the bathroom sink was tested and was 121 degrees Fahrenheit (F). Following this, additional resident bathroom hot water temperatures were tested as follows: -room #106 the hot water temperature was 125 degrees F. -room #107 the hot water temperature was 123 degrees F. -room #307 the hot water temperature was 122 degrees F. -room #313 the hot water temperature was 123 degrees F. An interview was conducted at 2:00 p.m. on November 17, 2016, with the Maintenance Director (staff #14). He stated that on Monday (November 14) he had lowered the temperature of the hot water, as the temperatures were between 112 and 115 degrees F., and he wanted the temperatures to be around 110 degrees F. He stated that he tests the water temperatures weekly. Another interview was conducted with the Maintenance Director at 2:20 p.m. on November 17, 2016. Staff #14 stated that he uses a thermometer to tests the hot water temperatures in the resident bathrooms. When asked how he calibrates the thermometer to ensure the temperatures are accurate, he stated that he did not know how to calibrate the thermometer, but uses a second thermometer when testing the temperatures. Following this interview, the Dietary Manager (staff #126) calibrated the thermometer used by maintenance and the surveyor's thermometer, with staff #14 present. Afterwards, staff #14 entered room #308 and demonstrated how he checks the water temperature using his thermometer. Staff #14 placed the bottom of the thermometer probe into the plastic sleeve, which covered the dimple and the bottom two inches of the probe. He then placed the probe about two inches from the top, into the stream of hot water. The water temperature registered 114 degrees F. The water temperature was then tested using the surveyor's thermometer and was 120 degrees F. During an interview conducted at 3:02 p.m. on November 17, 2016, the Dietary Manager and Registered Dietitian stated that in order to obtain an accurate temperature using the thermometer, the probe has to be in the stream of the water from the dimple to the bottom of the probe. They also stated that if only the top part of the probe was placed into the the stream of water, the temperature reading on the thermometer would not be accurate. A review of the facility's instructions for water temperature testing provided by the Administrator revealed to Ensure patient room water temperatures are between 105 degrees and 115 degrees Fahrenheit (or as specified by state requirements).

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the MDS (Minimum Data Set) assessment was accurate for one resident (#28). Findings include: Resident #28 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A nutrition care plan included that the resident was on hospice starting on June 21, 2016, due to a [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed that the resident was on hospice from June 21, 2016 through October 2016. However, quarterly MDS assessments dated July 6, 2016 and October 6, 2016, did not identify that the resident was receiving hospice services. In an interview with the MDS coordinator (staff #17) on November 16, 2016 at 2:30 p.m., she stated that the MDS assessments were coded incorrectly and that hospice should have been checked for this resident. In another interview with staff #17 on November 17, 2016 at 1:11 p.m., she stated that to find the information she needs to code the MDS, she completes a resident or family interview, and staff interviews. She stated that she also reviews the care plan, physician orders, CNA (certified nursing assistant) documentation, and progress notes to obtain information regarding the resident's status. In an interview with the Director of Nursing (DON/staff #27) on November 18, 2016 at 9:06 a.m., she stated that her expectation is that hospice care should have been coded on the MDS for this resident. Review of a facility policy titled, Certification of Accuracy of the MDS revealed that it is the responsibility of the person filling out the MDS to that ensure the information is accurate to the best of their knowledge.

Based on clinical record review, staff interviews and review of facility policy, the facility failed to ensure that two prn (as needed) medications were clarified with the physician regarding the frequency of administration for one resident (#157). Findings include: Resident #157 was admitted on [DATE]. The resident discharged to the hospital on April 22, 2016. [DIAGNOSES REDACTED]. A review of the clinical record revealed admission orders [REDACTED] -[MEDICATION NAME] suppository: one rectally prn, if no results after eight hours give Fleets enema prn for a [DIAGNOSES REDACTED]. -Fleets enema: one rectally prn, if still no result after eight hours call physician. A review of the March and April 2016 MARs (Medication Administration Records) revealed the above orders. However, the clinical record did not include any documented evidence that the either order had been clarified regarding the frequency of administration of the prn medication. An interview was conducted on November 16, 2016 at 11:00 a.m., with the Assistant Director of Nursing (staff #122). She stated that the [MEDICATION NAME] suppository and Fleet enema orders should have been clarified to include to administer after three days of no bowel movements. An interview was conducted on November 17, 2016, with the Director of Nursing (staff #27), who stated that the bowel care orders were incomplete and should have been clarified with the physician regarding the frequency of administration. A facility policy (untitled) included the following: 2. PRN orders: PRN medication orders are only used when resident's healthcare provider provides orders and parameters for use. The parameters must include: Frequency of dose.

Based on clinical record review, staff interviews, and policy review, the facility failed to protect one resident from abuse (#74). Findings include: Resident #74 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was oriented to self and place, but was confused. The resident required total assistance with activities of daily living (ADL's). A nursing note by an RN dated August 18, 2018 at 4:39 p.m., documented a late entry from August 17, 2015. Per the note, a family member was pushing the resident to stand up and grab the hand railing. The resident was standing up holding onto the hand rail and the family member was telling her to move her right foot, and he was kicking it forward to move it. The resident stated that she couldn't, but he said she has too. The family member also pushed her wheelchair about 6 feet from her to the right, so she could not sit down if she got tired, or could not stand up any longer. The family member was very forceful and very persistent. The resident stated several times that she could not do it and he made her stand there. The family member finally got mad and grabbed the wheelchair and told the resident that she can stay here the rest of her life and that he didn't care. A social service note dated August 18, 2015 documented that a family member visits the resident daily and has been witnessed by staff raising his voice and making negative comments to the resident. He tells her that she is the reason they are stuck here and that she is not making any progress and is wasting his money. The note also included that on August 17, it was witnessed by staff that he was making her walk by kicking her feet, and telling her to walk further. A nursing note by a LPN dated August 19, 2015 at 12:02 p.m. documented a late entry for August 17, 2015 for the day shift. Per the note, the resident was alert with confusion and able to make some needs known. The note included that later in the afternoon, this nurse was informed that the resident's family member was in the back hall and was taking her chair from her, then putting it out in front of her and making her walk to it. When she would stop to rest, he kicked her feet to make her continue walking. This nurse went to see what was going on and witnessed this happening. This LPN then talked with the Assistant Director of Nursing (ADON) regarding what to do and was directed to contact Social Services. Went to social services and she said that she would take care of it. The note included that the LPN reported back to the ADON and informed her what social services had said. After that, the LPN went to the back hall and the family member had stopped these actions. Another social service note dated August 25, 2015 at 11:19 a.m., included the social service director sent a referral to APS (Adult Protective Services) and had contacted the police department regarding the incident that occurred on August 17, 2015. The note included that the police were going to meet with the family member and inform him that his behavior was considered domestic violence and would not be tolerated. An interview was conducted on September 2, 2015 at 12:17 p.m., with the RN who documented the late entry in the nursing notes for August 18. The RN stated that on Sunday August 16, 2015, she witnessed the resident's family member being verbally abusive to the resident, accusing her of wasting his money, telling her you need to walk to get out of here. (There was no documentation of this incident on August 16). The RN said she reported this incident to the nurse in charge of the resident. This RN also stated that on August 17 and 18, she witnessed the family member being very rude and verbally abusive to the resident saying, You need to walk and kicking her right foot to make her take steps. She said the resident replied I can't and the family member pushed her wheelchair away from her, so she had no choice but to walk. Further review of the clinical record revealed there was no documentation that any action was taken to protect the resident from the potential for further abuse, after the concern on August 16 regarding the allegation of verbal abuse. There was also no documentation of any corrective measures that were implemented after the incident on August 17, in order to protect the resident from further abuse. Corrective action was not taken until after the third incident, which occurred on August 18. An interview was conducted on September 2, 2015 at 1:49 p.m., with the Director of Social Services. She stated that there was some staff indecision on whether to call the incident on August 17, abuse. She stated that on August 18, another incident of alleged abuse was reported to social services, so direct care staff were informed to monitor and observe the resident when the family member was visiting, but he was not restricted. The director stated that on August 19, the suspected abuse was reported to Adult Protective Services and the Director of Nursing, and on August 20, the police and Administrator were notified. She said that the police conducted an investigation on [DATE], and the results were pending. She said the family member has not returned to the facility since law enforcement was notified. The Social Services Director further stated that the nurses were not documenting the incidents in their notes, because the nurses were not sure if it was actual abuse or not. She stated that when she was made aware of the family member's behavior continuing, she felt it had now crossed the line and she needed to act. She stated her focus was trying to provide a safe discharge environment for the resident and now realizes that they could have done more to protect the resident. The director could not explain why they did not act immediately to protect the resident, when she was first informed of the suspected abuse. She stated that this was the first time she had an allegation of family abuse and was worried about what the family member might do to the resident, after discharge from the facility. Review of the facility's abuse policy revealed that residents have the right to live in a safe environment. The policy included that if the accused individual is not an employee, the person will be denied unsupervised access to the resident or other residents pending the results of the investigation. Following identification of the alleged abuse, the resident(s) receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent recurrence.

Based on clinical record review, staff interviews and policy review, the facility failed to implement their abuse policy regarding allegations of abuse involving one resident (#74). Findings include: Review of the clinical record for resident #74 revealed documentation that on August 17, 2015, a family member was pushing resident #74 to stand up and grab the hand railing. The resident was standing up holding onto the hand rail and the family member was telling her to move her right foot, and was kicking it forward to make her walk. The resident stated that she couldn't, but the family member said she had too. The family member also pushed her wheelchair about 6 feet from her, so she could not sit down if she got tired, or could not stand up any longer. The family member was very forceful and very persistent. The resident stated several times that she could not do it and the family member made her stand there. The family member finally got mad and grabbed the wheelchair and told the resident that she can stay here the rest of her life and that he didn't care. An interview was conducted on September 2, 2015 at 12:17 p.m., with the RN who documented the late entry in the nursing notes for August 18. The RN stated that on Sunday August 16, 2015, she witnessed the resident's family member being verbally abusive to the resident, accusing her of wasting his money, telling her you need to walk to get out of here. (There was no documentation of this incident on August 16). The RN said she reported this incident to the nurse in charge of the resident. This RN also stated that on August 17 and 18, she witnessed the family member being very rude and verbally abusive to the resident saying, You need to walk and kicking her right foot to make her take steps. She said the resident replied I can't and the family member pushed her wheelchair away from her, so she had no choice but to walk. Despite the allegations of abuse, the facility did not implement their policy, as they failed to conduct a thorough investigation and did not implement measures to protect the resident from the potential for further abuse. In addition, the facility did not report the allegations of abuse to the the State agency. An interview was conducted on September 2, 2015 at 1:49 p.m., with the Director of Social Services. She stated that there was some staff indecision on whether to call the first incident abuse. She stated that on August 18, another incident of alleged abuse was reported to social services, and direct care staff were informed to monitor and observe the resident, when the family member was visiting, but he was not restricted. The director further stated that on August 19, the suspected abuse was reported to Adult Protective Services and the Director of Nursing and on August 20, the police and the Administrator were notified. She stated she did not report the suspected abuse to the State agency. In addition, the Social Services Director stated that the nurses were not documenting the incidents in their notes, because the nurses were not sure if it was actual abuse or not. She stated that when she was made aware of the family members aggressive behavior persisting, she felt it had now crossed the line and she needed to act. She stated her focus was trying to provide a safe discharge environment for the resident and now realizes that they could have done more to protect the resident could not offer any explanation why she did not act immediately to protect the resident when she was first informed of the suspected abuse. She admitted that this was the first time she had an allegation of family abuse and that they failed to implement all of the facility's abuse investigation steps. Review of the facility's abuse policy revealed that residents have the right to live in a safe environment. All reports of abuse will be promptly and thoroughly investigated and shall remain confidential. The policy included if the accused individual is not an employee, the person will be denied unsupervised access to the resident or other residents pending the results of the investigation. Following identification of alleged abuse, the resident(s) receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent recurrence. The policy further documented that Federal requirements mandate that facilities must ensure that all allegations of abuse are reported immediately to their state agencies.

Based on clinical record review, staff interviews, and policy review, the facility failed to conduct a thorough abuse investigation and protect one resident (#74) from the potential for further abuse and failed to report the allegation to the State agency. Findings include: A nursing note by an RN dated August 18, 2018 at 4:39 p.m., documented a late entry from August 17, 2015. Per the note, a family member was pushing resident (#74) to stand up and grab the hand railing. The resident was standing up holding onto the hand rail and the family member was telling her to move her right foot, and he was kicking it forward to move it. The resident stated that she couldn't, but he said she has too. The family member also pushed her wheelchair about 6 feet from her to the right, so she could not sit down if she got tired, or could not stand up any longer. The family member was very forceful and very persistent. The resident stated several times that she could not do it and he made her stand there. The family member finally got mad and grabbed the wheelchair and told the resident that she can stay here the rest of her life and that he didn't care. A social service note dated August 18, 2015 documented that a family member visits the resident daily and has been witnessed by staff raising his voice and making negative comments to the resident. He tells her that she is the reason they are stuck here and that she is not making any progress and is wasting his money. The note also included that on August 17, it was witnessed by staff that he was making her walk by kicking her feet, and telling her to walk further. A nursing note by a LPN dated August 19, 2015 at 12:02 p.m. documented a late entry for August 17, 2015 for the day shift. Per the note, the resident was alert with confusion and able to make some needs known. The note included that later in the afternoon, this nurse was informed that the resident's family member was in the back hall and was taking her chair from her, then putting it out in front of her and making her walk to it. When she would stop to rest, he kicked her feet to make her continue walking. This nurse went to see what was going on and witnessed this happening. This LPN then talked with the Assistant Director of Nursing (ADON) regarding what to do and was directed to contact Social Services. Went to social services and she said that she would take care of it. The note included that the LPN reported back to the ADON and informed her what social services had said. After that, the LPN went to the back hall and the family member had stopped these actions. Another social service note dated August 25, 2015 at 11:19 a.m., included the social service director sent a referral to APS (Adult Protective Services) and had contacted the police department regarding the incident that occurred on August 17, 2015. The note included that the police were going to meet with the family member and inform him that his behavior was considered domestic violence and would not be tolerated. An interview was conducted on September 2, 2015 at 12:17 p.m., with the RN who documented the late entry in the nursing notes for August 18. The RN stated that on Sunday August 16, 2015, she witnessed the resident's family member being verbally abusive to the resident, accusing her of wasting his money, telling her you need to walk to get out of here. (There was no documentation of this incident on August 16). The RN said she reported this incident to the nurse in charge of the resident. This RN also stated that on August 17 and 18, she witnessed the family member being very rude and verbally abusive to the resident saying, You need to walk and kicking her right foot to make her take steps. She said the resident replied I can't and the family member pushed her wheelchair away from her, so she had no choice but to walk. Further review of the clinical record revealed there was no documentation that any action was taken to protect the resident from the potential for further abuse, after the concern on August 16 regarding the allegation of verbal abuse. There was also no documentation of any corrective measures that were implemented after the incident on August 17, in order to protect the resident from further abuse. Corrective action was not taken until after the third incident, which occurred on August 18. In addition, other than the nursing notes and the social service notes, the facility was unable to provide any investigation involving the allegation of abuse and there was no documentation that it was reported to the State agency. An interview was conducted on September 2, 2015 at 1:49 p.m., with the Director of Social Services. She stated that there was some staff indecision on whether to call the incident on August 17, abuse. She stated that on August 18, another incident of alleged abuse was reported to social services, so direct care staff were informed to monitor and observe the resident when the family member was visiting, but he was not restricted. The director stated that on August 19, the suspected abuse was reported to Adult Protective Services and the Director of Nursing, and on August 20, the police and Administrator were notified. She said that the police conducted an investigation on [DATE], and the results were pending. She said the family member has not returned to the facility since law enforcement was notified. The Social Services Director further stated that the nurses were not documenting the incidents in their notes, because the nurses were not sure if it was actual abuse or not. She stated that when she was made aware of the family member's behavior continuing, she felt it had now crossed the line and she needed to act. She stated her focus was trying to provide a safe discharge environment for the resident and now realizes that they could have done more to protect the resident. The director could not explain why they did not act immediately to protect the resident, when she was first informed of the suspected abuse. She stated that this was the first time she had an allegation of family abuse and was worried about what the family member might do to the resident, after discharge from the facility. She also stated that she failed to implement all of the facility's abuse investigation steps. Review of the facility's abuse policy revealed that residents have the right to live in a safe environment. The policy included that if the accused individual is not an employee, the person will be denied unsupervised access to the resident or other residents pending the results of the investigation. Following identification of the alleged abuse, the resident(s) receive prompt medical attention as necessary and the resident(s) are protected during the course of the investigation to prevent recurrence. The policy further documented that Federal requirements mandate that facilities must ensure that all allegations of abuse are reported immediately to their state agencies.