Every finding on record at Horizon Post Acute and Rehabilitation Center

Based on a review of records, observation, interviews, and a review of facility policies and procedures, the facility failed to ensure that one of 3 sampled residents (Resident #12), property was not misappropriated. The Universe was 145. The deficient practice could lead to resident's property to be misplaced or lost.Findings include:Resident #12 was admitted to the facility on [DATE], and discharged on [DATE], with diagnosis that included unspecified severe protein calorie malnutrition. A review of the MDS (Minimum Data Set) assessment dated [DATE], revealed no indication of BIMS (Brief Interview for Mental Status) score for Resident #12 as resident was in the facility for one day only.A progress admission notes dated [DATE], at 3:15 p.m. revealed that the Resident #12 was admitted for hospice respite. Further review of progress note indicated no indications of Resident #12 missing items.An inventory list dated [DATE], revealed that Resident #12 came with two rings and a chain with a cross.A facility Reportable Event Record / Report submitted to the State Agency on [DATE], revealed that on [DATE], around 12:30 p.m. revealed that daughter of Resident #12 alleged to the Administrator (staff # 179) that at time of admission on [DATE], her mother was wearing 2 rings and a crucifix necklace. Per report, Resident #12 had passed that evening and upon seeing her at the mortuary, the jewelry was not present. Per report, the facility initiated the investigation and staff and residents were interviewed. Per report, the allegation was inconclusive.An interview was conducted on [DATE], at 9:38 a.m. with a Social Service Supervisor (staff #74) who stated that when she received any grievances regarding missing items then the facility had 72 hours to resolve it. Staff #74 stated during a phone call that Resident's #12's daughter stated that her mother had 2 rings and a necklace were missing. Staff #74 then reviewed Resident #12 inventory list from [DATE], and the list indicated Resident #12 came with 2 rings and a necklace with a cross. The social services supervisor stated that she had spoken with her staff member (#202) and learned that the resident's daughter was present during the time the inventory was recorded. Social service supervisor stated that she was told by staff #202 that after the inventory was completed the resident's daughter said she would take the jewelry with her.An interview was conducted on [DATE], at 10:31 a.m., with Social Service team member (Staff #202) who stated that she does inventory for new admissions and she makes an offer to residents to assist them to get their valuables in a safe location. Staff # 202 stated that she had done the inventory for resident #12 in the presence of the resident's daughter and the staff member asked the daughter if she would like to put the residents personal items (jewelry, clothing, and blanket) in a safe place or keep them with the resident. Staff member #202 stated that the resident's daughter stated she would like to take the jewelry with her. Staff #202 further stated that she did not see the daughter leave with the jewelry. Staff #202 stated that regarding Resident # 12's missing items, the staff member notified the administrator, asked nurses, and searched the residents room for these items. Staff #202 said that video was also reviewed.An interview was conducted on [DATE], at 10:51 a.m. with a Licensed Nursing Assistant (LNA, Staff # 184) who stated that she works Monday through Wednesday from 6 p.m. to 6 a.m., and provided care to residents including transfer, personal hygiene, and oral care. This LNA stated that she recalled Resident #12 was a hospice patient and was in the facility for one day and then passed away on the same day. The LNA stated that she noticed the resident was wearing a necklace with a cross during the care she provided to Resident #12 but did not recall the ring. LNA stated that resident passed around 10 a.m. and she immediately called the registered nurse (RN, #99) and the nurse called the mortuary. The LNA stated that before mortuary left the facility, the mortuary personnel took the ring and necklace off of the resident and notified LNA(staff #184 that the jewelry was placed on the bedside table. The LNA stated that she then put the necklace with the cross and a ring with lots of stones in a zip lock bag with the resident's name and gave it to the RN. During the interview, the LNA stated that the facility process regarding missing items would be to notify the Administrator (staff # 179) then search residents' room, and view video footage. The LNA then stated that she would consider the incident as misappropriation of property because someone took property from the resident.An interview was conducted on [DATE], at 10:55 a.m. with Resident's #12 's daughter who stated that her mother came to the facility on [DATE], wearing 2 gold rings with diamonds, and a gold necklace. Per daughter her mother (Resident #12) wanted to keep jewelry with her and wear it all the time. Per daughter, she was in the facility with her mother all day on [DATE], and left the facility around 10 p.m.An interview was conducted on [DATE], at 11:36 a.m. with a Registered Nurse (RN, staff #99), who stated that she works Wednesday and Thursday from 6 p.m. to 6 a.m. RN stated that she was aware of Resident #12. The RN recalled taking Resident#12's vitals and checking with her daughter inquiring if she needed anything. The RN recalled that she saw a ring on the right hand of Resident#12. The RN did not recall a necklace. The RN stated that after Resident #12 passed away that she notified the mortuary and the hospice. The RN stated that after the mortuary left, the LNA (staff #184) handed her a zip lock bag containing a ring and another piece of jewelry. The RN stated that she placed the bag on the computer on station two and then handed it over in the morning to the day Licensed Practical Nurse (staff #76). During this interview the RN stated misappropriation of property means unauthorized, intentional, and unlawful use or taking of someone else's assets, funds, or property for personal gain for an unintended purpose. The RN further stated that she would consider this incident as misappropriation because jewelry was not in the resident's possession.A review of the facility investigation revealed the LPN (staff #76) took the zip lock bag from the RN (Staff #99). The LPN noted the bag had a ring and necklace but did not recall if there were one or two rings. The LPN stated that she then placed it underneath the computer tray on station 2 with the intention of giving the bag to social services when they got in. She stated that she forgot to turn them into social services before she left.An interview was conducted on [DATE], at 1:54 p.m. with the Administrator (staff # 179) who stated that there are different types of abuse are verbal, physical, emotional, and financial. Per Staff #179, the facility process for any allegation of misappropriation of property would be that the staff report immediately to the Administrator and then the administrator reports the incident to the police, family, Arizona Department of Health services (AZDHS), Adult Protected Services (APS), and Ombudsman within 2 hours, and continue to do the investigation. The Administrator stated that Resident #12 came to the facility with the daughter on [DATE], and was on hospice. The administrator stated that Social Service staff #202 welcomed the Resident #12 and the family to complete the admission agreement and inventory list. The Administrator stated that the Resident #12's inventory list included 2 rings and a chain with cross. Social Service then offered to keep items locked up in a safe location and the resident's daughter stated she was going to take it with her. The Administrator stated that Resident #12 expired on the same day she was admitted and about a week later the family reported the jewelry missing and the administrator then filed a report to police, AZDHS, APS and started the investigation. The Administrator stated that the resident's daughter stated that she wanted to take the jewelry home but the resident wanted to wear her jewelry while at the facility. The Administrator stated that he called the hospice company and mortuary regarding the inquiry of jewelry and they stated that they did not have any jewelry. The Administrator then stated that he interviewed the LNA (staff #184) who stated that mortician handed her a ziplock bag containing a ring with 4 stones and a crucifix chain.Per the administrator the LNA then stated that she handed the ziplock bag to the night shift nurse (RN, staff # 99).The Administrator stated that the night shift RN (staff #99) placed the ziplock bag containing jewelry by her computer and reported it to the dayshift nurse. LPN (staff #76) stated that Resident #12 had inventory that the mortuary took off. The Administrator stated that the dayshift LPN(staff #76) forgot to hand it over to Social Service or locked it in her cart. The Administrator further stated that the video footage revealed that both nurses exchanged the ziplock bag near the nurse station and confirmed that the jewelry was in the facility possession but not sure if it was trashed or shredded. The Administrator further stated that he called the family and offered $2500.00 for the loss. The resident's daughter was appreciative but refused the offer and wanted to keep looking for the jewelry. The Administrator further stated that the outcome of the investigation was inconclusive because they were unable to determine misappropriation of property.Review of the facility titled Admission/Transfer/Discharge inventory of personal effects, revised on January, 2026, revealed that it is the policy of the facility to take reasonable steps to protect the personal property of the residents. The policy further revealed that when a resident is admitted to the facility, an inventory of the resident's personal effects shall be done by a staff member of the facility and that the inventory should include the recording of all personal clothing, valuable articles, etc. which are brought into the facility with the resident and retained by the resident. personal effects shall be recorded on the Inventory of Personal Effects form.

Based on staff interviews, review of clinical record, and review of policy and procedure, the facility failed to ensure a resident's (#2) rights were honored regarding emergent transfer to the hospital. The deficient practice could result in a resident being unable to make choices about their health, and could cause physical or psychosocial harm to a resident.-Findings include:Resident #2 was admitted on [DATE], with diagnoses that included type 2 diabetes mellitus, hypertensive heart disease, chronic kidney disease, peripheral vascular disease, pulmonary hypertension, anemia, and acquired absence of the left leg below the knee.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #2 had a brief interview for mental status (BIMS) assessment score of 13, indicating intact cognition.The clinical record revealed no evidence that Resident #2 had a medical power of attorney or any other court-appointed entity to make medical decisions on the resident's behalf.A care plan initiated July 30, 2025, revealed Resident #2 had hypertension, with interventions that included to monitor for side effects such as orthostatic hypotension and increased heart rate, and to obtain blood pressure readings.Another care plan initiated August 14, 2025, included Resident #2 had a potential fluid deficit, with a goal that the resident would be free from symptoms of dehydration, and with interventions that included to monitor vital signs as ordered and record, and to notify the medical provider of significant abnormalities.A Nurse Practitioner / Physician Assistant (NP / PA) progress note dated February 11, 2026, included that the resident had worsened renal function, pending labs that day. The note included that the resident needed nephrology follow-up, and that an order was placed.A physician's order dated February 11, 2026, included to make follow up appointment with nephrology as soon as possible due to worsened renal function.An NP / PA progress note dated February 12, 2026, included that Resident #2 was complaining of tiredness, and the note revealed this was secondary to suspected acute kidney injury uremia, acute on chronic kidney disease, stage III, with metabolic acidosis, and suspected pre-renal acute tubular necrosis dehydration. Again, the note included for the resident to follow up with nephrology ASAP (As Soon As Possible), and that this was discussed with administration and nursing.A physician's order dated February 12, 2026, with a start date of February 14, 2026, included a basic metabolic panel (BMP) laboratory order.A physician's order dated February 13, 2026, and with a start date of February 14, 2026, included for sodium bicarbonate oral tablet 640 mg to give 1 tablet by mouth three times a day for metabolic acidosis.The clinical record revealed no evidence of any nursing progress notes completed on February 14, 2026, and no evidence of a nursing assessment done for Resident #2 for a request from the resident to go to the hospital on February 14, 2026. Additionally, the record revealed no evidence of any of Resident #2's concerns or any interventions done regarding his concerns on February 14, 2026.Physician's orders dated February 14, 2026, included: -Place foley catheter for outlet obstruction versus neurogenic bladder -Set up urology appointment due to partial obstructive uropathy versus neurogenic bladderThe clinical record revealed no evidence that any vital sign assessments of blood pressure, oxygen saturation, pulse, respiration rate, or temperature were assessed and recorded on February 14, 2026 (the date that Resident #2 requested to go to the hospital).Review of the medication and treatment administration record (MAR / TAR) for February 2026 revealed the record was blank on February 14, for the physician's order to place the foley catheter. The record revealed that on February 15, the entry was coded 7 / other / see nurse notes for the order to place the foley catheter.An eMAR (electronic Medication Administration Record) note dated February 15, 2026, included in reference to the order to place foley catheter, that the resident was noted with decreased urinary output and signs / symptoms concerning for urinary outlet obstruction versus neurogenic bladder. The note revealed that a new order was received to place the foley catheter to evaluate for outlet obstruction versus neurogenic bladder. The note included that the resident refused to have the foley catheter inserted and instructed the nurse to contact his attorney. The note included that the physician was notified.Another physician's order dated February 15, 2026, included a BMP laboratory order in the morning for acute kidney injury (AKI).Despite the physician orders for laboratory tests, for the start of a medication (sodium bicarbonate) for metabolic acidosis, and the order for a new foley catheter, there was no evidence of a change of condition monitoring for February 14-15, 2026.Review of the clinical record revealed no active physician orders for February 14 or 15, 2026, specifying how often or when to assess vital signs of blood pressure, oxygen saturation, pulse, respiration rate, or temperature.Despite the physician order on February 11, 2026, to set up nephrology appointment as soon as possible, review of the clinical record on February 26, 2026, revealed no evidence that a nephrology appointment was set up.A Nursing note dated February 17, 2026, revealed that a nurse entered Resident #2's room to administer medications, and the resident appeared unresponsive and not breathing. The nurse immediately re-assessed the resident, and confirmed lack of vital signs, and do not resuscitate (DNR) status, and retrieved a second nurse to confirm, and the resident was pronounced deceased .An interview was conducted with a licensed nursing assistant (LNA / Staff #21) on February 26, 2026, at approximately 11:15 a.m., who stated that she was familiar with Resident #2, and that she had never experienced the resident having any behaviors, and that the resident did not seem like the type to overreact.An interview was conducted with a certified nursing assistant (CNA / Staff #9) on February 26, 2026, at 11:37 a.m., who stated that she was very familiar with Resident #2 and worked with him frequently, and that the resident was not behavioral, and that when she had worked with the resident, that he never seemed upset with staff or his care.An interview was conducted with a licensed practical nurse (LPN / Staff #34) on February 26, 2026, at 11:42 a.m. who stated that she was not the resident's assigned nurse, but that she recalled on Saturday, February 14, 2026, she had seen the resident, and observed he had a peripheral IV in his arm, and that the resident appeared pale compared to his normal appearance.A telephonic interview was conducted with a CNA (Staff #54) on February 26, 2026, at 12:27 p.m., who stated that she was familiar with Resident #2, and that she was one of his assigned CNAs in the days before his passing, and that she had noticed the resident was not presenting as usual. Staff #54 stated she noticed that the resident normally did not complain of pain when staff helped to turn and move him in the bed, and that during the days before he passed away, Resident #2 was complaining of pain when staff assisted the resident with rolling and turning over in the bed. Staff #54 stated that she was not sure if the floor nurse was aware of the resident's new complaint of pain, but that Staff #54 believed so.An interview was conducted with an LPN (Staff #70) on February 26, 2026, at 12:31 p.m., who stated that she was familiar with Resident #2, and that the resident had not been doing well for several days before his passing. Staff #70 stated that the resident had lab work drawn often in the days before his passing, and the resident's renal function had plummeted.A telephonic interview was conducted with an LPN (Staff #18) on February 26, 2026, at 1:04 p.m. who stated that she was familiar with Resident #2, and that the resident never really asked for much, so that when he did ask for something, Staff #18 knew it was serious.A telephonic interview was conducted with a friend of Resident #2 on February 26, 2026, at 1:20 p.m. who stated that he received a phone call from Resident #2 on February 14, 2026, at 10:34 a.m. The friend stated that Resident #2 was very upset and said that he was not feeling well, and stated he felt that the facility was not doing enough to address his issues, and that the resident had told the nurse that he wanted to go to the emergency room and the nurse would not allow him to go. The friend stated that Resident #2 said that the nurse told Resident #2 that he did not meet criteria, and that the facility would not send him to the hospital. The friend stated that he then talked to the resident's floor nurse (Staff #66) on the phone, and the friend informed Staff #66 that Resident #2 wanted to go to the hospital emergently via 911 call, and Staff #66 stated that Resident #2 did not meet criteria for a 911 call, and that the doctor would not authorize the transfer to the hospital. The friend then stated that he called 911 and was patched over to the fire department, and discussed Resident #2's request to go to the hospital with the fire department. The friend said that he was informed by the fire department that they could not just pick up Resident #2 out of the facility and take him to the hospital. The friend stated that this incident had an upsetting effect on Resident #2, and that the resident was so riled up, that Resident #2 had requested the friend to contact his attorney. At the conclusion of the interview, the friend was requested to review his phone call log on his phone to confirm the dates and times of the phone calls. The friend reviewed his phone call log and stated Resident #2 had called him on February 14, 2026, at 10:34 a.m., and that the friend had called 911 five minutes later at 10:39 a.m.A telephonic interview was conducted with an LPN (Staff #66), on February 26, 2026, at 1:33 p.m. who stated she was familiar with Resident #2, and had cared for the resident at times before the resident passed away. Staff #66 stated that she had never seen any behaviors from the resident. Staff #66 also stated that she recalled one incident recently when the resident stated that he wanted to go to the hospital and felt that nothing was being done to address his medical issues. Staff #66 stated that she told the resident that he had an IV and was on medication, and that he did not meet the criteria to be sent to the hospital. Staff #66 stated that shortly after that, a friend of Resident #2 called and spoke with Staff #66 on the phone, and said to Staff #66 that Resident #2 was unhappy and felt nothing was being done for his medical issues, and requested that the resident go out to the hospital via 911. Staff #66 stated that she informed the friend that we can't call 911 for this patient because he did not meet the criteria, but stated to the resident's friend that if Resident #2 or the friend wanted to call 911, then they could do so themselves. When asked what the criteria included, Staff #66 stated that there are two ways a resident is transferred to the hospital emergently via 911; the first way included that a medical provider would write a physician order to transfer the resident emergently to the hospital, and the second way included that the nurse would assess the resident, and if the resident were having a medical emergency, then the nurse would call 911 to have the resident sent to the hospital urgently. Regarding the incident with Resident #2, Staff #66 continued to explain that shortly after she had spoken with the resident's friend on the phone, she received a call from the fire department asking about the welfare of Resident #2. Staff #66 stated that she told the fire department that there was not a physician order to send the resident to the hospital, and that he did not meet criteria to send to the hospital, and the fire department then cancelled their response to the facility. Staff #66 stated that she then went back to check on the resident, and that the resident was upset about the situation, and also stated that the resident said at that time that he did not like the food, and that Staff #66 gave him some sandwiches, and that she did not hear any further complaints from the resident that day. After the incident, Staff #66 stated she relayed the resident's concern to the resident's provider.A telephonic interview was conducted on February 26, 2026, at 1:49 p.m. with a nurse practitioner (NP / Staff #3) who stated that she was one of Resident #2's medical providers and was familiar with the resident. Staff #3 stated that in the week before Resident #2 passed, she was seeing the resident more frequently, and that she was treating the resident for several conditions, including worsening kidney function, acute kidney injury, and dehydration, and was attempting to diagnose a possible urological issue. Staff #3 stated that she had received a message from the resident's floor nurse on February 14, 2026, that revealed that the resident had wanted to go to the hospital, and that the fire department was called by the resident's friend, and that the nurse spoke to the fire department and then the fire department cancelled the response to the facility. Staff #3 stated she then messaged back to the nurse why, to determine why the resident wanted to go to the hospital, and that the nurse relayed to Staff #3 that the reason the resident had wanted to go to the hospital was because he did not like the food that was served at the facility, and no other concerns were brought to the provider.An interview was conducted with a registered nurse (RN / Staff #15) on February 26, 2026, at 2:25 p.m., who stated that the facility did not have a list or set of criteria that a resident would have to meet in order to be sent out emergently to the hospital. Staff #15 stated that a nurse would complete a nursing assessment, and it would be up to nursing judgment to determine if the resident needed emergent transfer to the hospital, and that the medical provider would also be contacted to determine if the resident needed to be sent out. Staff #15 stated that if a resident requested to be sent out emergently to the hospital, then that is the resident's right to make that decision, and she would send the resident to the hospital via 911.An interview was conducted with an LPN (Staff #26) on February 26, 2026, at 2:29 p.m., who stated that there was not a list or set of criteria that a resident would have to meet in order to be sent to the hospital. Staff #26 stated that the situation would rely on nursing judgment, and if the resident was experiencing a change of condition, and the nurse and provider deemed transfer to the hospital necessary, then the resident would be sent to the hospital. Additionally, Staff #26 stated that if a resident requested to go to the hospital via 911, then she would assess the resident, determine why the resident wanted to go, and see if she could meet the resident's needs. Staff #26 said if the resident still wanted to go, then she would walk the resident through the process of calling 911. Additionally, Staff #26 stated that she did not think she was allowed to help a resident call 911.An interview was conducted with an LPN (Staff #39) on February 26, 2026, at 2:36 p.m., who stated that she is not allowed to decide whether a resident is sent to the hospital or not. Staff #39 stated that the decision to send a resident to the hospital has to go through upper management and the provider. Staff #39 stated she is not allowed to call 911 to send a resident to the hospital. Staff #39 stated she did not know if there would be any risk or impact on a resident who wanted to be sent urgently to the hospital and did not get their choice honored.An interview was conducted with the Assistant Director of Nursing (ADON / Staff #90) on February 26, 2026, at 3:25 p.m., who stated that there was not a list or set of criteria that a resident had to meet in order to qualify to be sent out to the hospital. The ADON stated that the decision to send a resident to the hospital is made by first assessing the resident, then contacting the doctor, and a decision is made whether the resident needs to be sent out to the hospital. The ADON stated that the nursing assessment would include observation of the resident, and assessment of vital signs, and any other specific assessments that would be needed to determine the status of the resident. The ADON stated that if the resident was adamant about going to the hospital, and the nursing assessment revealed that the resident needed to go, then the resident would be sent to the hospital. The ADON stated that the nursing assessment would be documented in the clinical record because it would be important for anybody who needed to review, including the provider. Regarding any impact it may have on a resident if the resident chose to go to the hospital, and did not have their choice honored, the ADON stated that she did not know what kind of impact it would have because typically, the facility staff would send the resident to the hospital. Additionally, the ADON stated that the resident always has a choice. Regarding Resident #2, the ADON stated that she was not aware of any situation where the resident requested to go to the hospital, nor was she aware of any situation where the fire department was contacted to send the resident to the hospital.A telephonic interview was conducted with the Director of Nursing (DON / Staff #2) on February 26, 2026, at 3:48 p.m., who stated that there was not a set of criteria that a resident would need to meet to be sent to the hospital. If a resident requested to go to the hospital, the nurse would assess what their concern was and talk to the provider. The DON stated that if the resident was adamant about going to the hospital, it would be the resident's right to make the choice to be sent to the hospital. The DON stated that if the resident were stable, she would not assume there would be a risk to the resident if the resident's choice to go to the hospital was not honored. The DON stated she familiar with Resident #2 and that the resident was in acute kidney injury and had received IV fluids during the week before he passed away. The DON stated she was not aware of any situation where the resident had requested to go to the hospital, and was also not aware of any situation where the fire department had been contacted regarding Resident #2's request to go to the hospital.A statement provided by facility dated February 26, 2026, revealed the facility did not have a policy regarding emergent hospital transfer.Review of the facility policy titled Resident Rights, dated May 2025, revealed it is the policy of this facility that all resident rights be followed per state and federal guidelines, as well as other regulatory agencies. The resident has the right:To be encouraged and assisted throughout his or her stay in the facility to exercise theseResident Rights as well as those which Residents are entitled as a U.S. citizen.To voice grievances regarding treatment or care or recommend changes in facility policies and services without fear of reprisal, restraint, interference, coercion ordiscrimination, and to have prompt efforts undertaken by the facility to resolve them.To choose a personal attending physician (and be informed how to contact him or her), [NAME] fully informed in advance about care and treatment, and, unless adjudicatedincompetent or otherwise found incapacitated under state law, participate in planningmedical treatment.Review of the facility policy titled Change of Condition Reporting, revised July 2015, revealed it is the policy of this facility that all changes in resident condition will be communicated to the physician and resident representative and documented. For a Life-Threatening Change:1. Licensed nurse will initiate appropriate first aid measures until emergency responsepersonnel arrive on the scene.2. Licensed nurse will inform the primary physician (alternate physician or MedicalDirector) of resident status as soon as possible once resident needs have been met andimmediacy of nursing care is completed.3. Licensed nurse will inform family/ resident representative of change of condition anddocument notification.4. All nursing actions, physician contacts, resident representative, and resident assessmentinformation will be documented in the nursing progress notes.For Acute Medical Change: 1. Any sudden or serious change in a resident's condition manifested by a marked change inphysical or mental behavior will be communicated to the physician with a request forphysician visit promptly and/or acute care evaluation. The licensed nurse will notify thephysician.2. If unable to contact attending physician or alternate physician timely, notify MedicalDirector for follow-up to change in resident condition.3. The resident representative will be notified that there has been a change in the resident'scondition and what steps are being taken.For Routine Medical Change: 1. Unusual signs and symptoms will be communicated to the physician promptly. Routinechanges are minor changes in physical and mental behavior, abnormal laboratory and xrayresults that are not life threatening.2. The nurse is responsible for notification of physician prior to end of assigned shift when asignificant change in resident's condition is noted.3. If unable to reach physician, all calls to physicians or exchanges requesting callbacks willbe documented on the nursing progress notes.4. If the physician has not returned the call by the end of the shift, the on-coming nurse willbe notified for follow-up.5. If unable to contact attending physician or alternate timely, notify Medical Director forresponse and follow-up to change in resident status.6. Document resident change of condition and response in nursing progress notes andupdate resident Care Plan, as indicated.7. All attempts to reach the physician and responsible party will be documented in thenursing progress notes. Documentation will include time and response.8. The nurse will notify the resident representative and document the notification.Review of the facility policy titled Vital Signs, Weight, and Height, revised May 2007, revealed the resident's vital signs shall be recorded as the physician's orders indicate, or as frequently as the resident's condition warrants. Vital signs shall be taken and recorded in accordance with the resident's condition and current treatment plan, and as prescribed by the attending physician. This may vary with certain factors such as residents on cardiac medications may warrant daily pulses, those on blood pressure medications may warrant daily or weekly blood pressures, residents involved in a possible head injury incident may warrant neuro-checks every 15 minutes for a period of time, etc.Review of federal regulation 42 CFR S 483.10 revealed the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. The resident has the right to be informed of, and participate in, his or her treatment, including: the right to participate in the development and implementation of his or her person-centered plan of care. The resident has the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice.

The facility failed to ensure residents do not abuse other residents.Based on observations, interviews, record review, the facility failed to protect the resident's right (#1) to be free from physical abuse by another resident (#2). The deficient practice could result in further abuse of residents and appropriate action not taken.Findings include:Regarding Resident #1 (alleged victim) :Resident #1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia, seizures, hypothyroidism, major depressive disorder, schizophrenia, anxiety disorder and muscle weakness.Review of Resident #1's quarterly minimum data set (MDS) assessment dated [DATE] revealed that the Brief Interview for Mental Status (BIMS) score was 15, indicating the resident is cognitively intact.Review of Resident #1's care plan revealed a focus for potential psychosocial well-being problem related to an altercation with another resident. The plan included to monitor for changes in mood/behavior, date initiated, October 21, 2025.-Regarding Resident #2:Resident #2 was admitted on [DATE] with diagnoses that included multiple sclerosis, major depressive disorder, and essential primary hypertension.Review of Resident #2's quarterly minimum data set (MDS) assessment dated [DATE] revealed that the brief interview for mental status (BIMS) score was 15, indicating the resident is cognitively intact.Review of Resident #2's care plan revealed a focus: potential to demonstrate verbally abusive behaviors related to ineffective coping skills, date initiated: 10/07/2023. Goal: Will verbalize understanding of need to control verbally abusive behavior through the review date. Target date: 12/30/2025. Another focus: Potential for a psychosocial well being problem related to incident with another resident PASRR level II referral submitted May 30, 2025. PASRR level II determination received June 5, 2025- Resident #2 does not meet criteria for PASRR level II and will remain PASRR level l. Date initiated May 19, 2025.A nursing progress note dated May 18, 2025 at 23:11 by licensed practical nurse (LPN)/Staff 9 stated that Staff #9 revealed Resident #2 was involved in an altercation with his roommate over noise in resident's room. Both parties were separated for individual safety.A nursing progress note dated October 21, 2025 at 19:11 by Director of Nursing Services (DON)/Staff #5 revealed Resident #1 had an incident with another resident. Both were immediately separated and assessed for injuries. Skin Concerns noted, treatment initiated, currently denies pain.A nursing progress notes dated October 21, 2025 19:35 by DON/ Staff #5 revealed that Resident #2 had an incident with another resident. Both were immediately separated and assessed for injuries. No skin concerns noted, currently denies pain. Change of condition initiated for mood/behavior changes. Police notified, resident arrested at this time related to domestic violence and taken to jail.A nursing progress note dated October 21, 2025 at 19:58 by DON Staff #5 revealed that the resident is on blood thinners and was offered to be sent to the emergency department, declines at this time.A Skin/Wound note dated October 22, 2025 at 13:06 by Licensed Practical Nurse (LPN)/Staff #6 revealed that Resident #1 had steri strips noted above left eye. Scratching and bruising to face, arms and chest.A telephonic interview was attempted on October 31, 2025 at 10:47 a.m. with certified nursing assistant (CNA)/ Staff #8. Staff #8 did not answer her phone, however a voice mail message was left to return the call. No call was returned by Staff #8.An interview was conducted on October 31, 2025 at 11:12 a.m. with (CNA) Staff #3 and revealed that she did not see the incident between Resident #1 and Resident #2, but stated when you see abuse that you report it to the abuse coordinator. Trainings are done when staff first start.An interview and observation was conducted on October 31, 2025 at 11:16 a.m. with Resident #1 revealed that Resident #2 started yelling, cussing and calling names and said something that he was going to f@&k me up and kill. He then came over and crashed into the over the bed table that was placed next to the curtain. Resident #1 did not want to hit him and Resident #2 started gouging his eyes. Resident #1 said some cuss words and told Resident #2 he could not hit. Then Resident #2 started punching Resident #1. Resident #1 then called Resident #2 a girl. Resident #2 then started punching Resident #1 with a black metal looking water cup (Resident #1 pointed to a bedside night stand where the black metal cup was at). Resident #1 pointed to his left side of face by his eye and eyebrow where white looking strips were placed, and stated Resident #2 scratched my face and ears. Resident #1 then pointed to his left shoulder and a dark colored bruise was noted on the ball of the shoulder, scratches on upper arm/shoulder, bruise to the antecubital area and more scratches to his lower arm. Resident #1 stated that he does have pain. The police came, pressed charges and took Resident #2 to jail. Resident #1 did not hit Resident #2 because Resident #2 was old.An interview was conducted on October 31, 2025 at 11:34 a.m. with assistant director of nursing (ADON) Staff #4 and revealed that she was working in the building when the incident happened, did not witness the event. Resident #2 had already left the room. Made sure the residents were safe, assessed the patients, notified DON Staff #5 and Administrator Staff #7, notified the police and started talking to everyone. Resident #2 did not go back into the room. Resident #2 did have a history of inappropriate behavior before, but Staff #4 does not remember the date. The police came right away.An interview was conducted on October 31, 2025 at 11:44 a.m. with director of nursing services (DON)/ Staff #5 and revealed that she was aware of the incident between Resident #1 and Resident #2. Injuries were noted and Resident #1 had a laceration, scratches, abrasions and redness at the neck. Resident #2 had injuries to his hands, resulting in a small abrasion to the second digit knuckle and the first digit knuckle was swollen to the right hand. There were no prior incidents between the two residents. That is one reason why the residents were paired up. They keep the room dark, wear headphones and have not had any issues between them. Staff #4 checks on him as part of her angel rounds. Resident #2 had a prior incident with another resident in May. At that time both residents were separated, separate stations and all the same parties notified. Resident #2 was being seen by psych and social services. Resident #2 was in his own room for a while, but we needed the room. Resident #1 was selected because he is polite, quiet and had no issues. The risk for residents abusing other residents is harm.Review of the facility's policy titled, Abuse: Prevention of and Prohibition Against, last revision date of October 2024 revealed Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion.Review of the facility's policy titled, Resident Rights with a reviewed date May 2025 revealed: The Resident has the right to be free from verbal, sexual, mental, or physical abuse, corporal punishment, involuntary seclusion and any physical or chemical restraint imposed for purposes of discipline or convenience or for other than treating medical symptoms.

The facility failed to ensure one resident was free from abuse from another resident,Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#100) was free from physical abuse from other residents (resident #200). The deficient practice could result in further incidents of resident to resident abuse.Findings include:-Resident #100 was admitted to the facility on [DATE], with diagnosis that Diabetes mellitus type 2, end stage renal disease, anemia, hyperlipidemia, heart disease and depression.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A behavioral care-plan initiated May 5, 2025 showed the resident had the potential to demonstrate verbally aggressive behaviors related to poor impulse control and agitation, with a goal of will have zero episodes of verbally aggressive or agitation behaviors and a noted intervention of when resident becomes verbally aggressive, intervene before agitation escalates.-Resident #200 was admitted to the facility on [DATE], with diagnosis that include dementia, rheumatoid arthritis, anemia, depression, heart failure, and peripheral vascular disease.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. A behavioral care-plan initiated September 9, 2021 revealed the resident has the potential to demonstrate physical behaviors related to physical aggression towards other residents, with goals noted as will not harm self or others, and noted interventions of analyze key times, places, circumstances, triggers, and what de-escalated behaviors and document those, assess and anticipate resident's needs, and document observed behavior and attempted interventions.Review of information received from the SA complaint tracking system revealed that on July 18, 2025, at 5:45 a.m. a complaint incident was received that revealed that resident #200 had punched resident #100 with a closed fist. The complaint also states that the administrator was aware and had told the staff to keep quiet about the situation. A review of progress notes for resident #100 dated June 30, 2025 at 12:13 p.m. revealed resident #100 was alert and oriented to person, place and time. Able to communicate well, and had appropriate affect.A review of progress notes for resident #100 dated July 16, 2025 at 3:36 p.m. revealed Resident #100 has been observed bumping into walls and objects while independently wheeling himself in his manual wheelchair. Resident has a dx of legally blind due to Diabetes. Resident has been educated on the risks of ambulating independently. Resident became irate, became verbally aggressive and called is brother [NAME] on the phone. While on speaker, [NAME] asked to be transferred to another facility, his brother agreed and asked this write to facilitate a transfer. Brother was also educated on the risks of resident ambulating independently in his wheelchair and he demanded he continue with the wheelchair.An interview was conducted with resident #100 on July 22, 2025 at 1:45 p.m. The resident stated that he was running down the hallway and bumped into resident #200. He then stated he was shocked and said who was that? and stated that resident #200 got verbally aggressive and punched me in my face. He continued that he was just rolling down the hallway in his wheelchair and that he bumped into resident #200 on accident. The resident further stated that resident #200 was totally abusive. The resident concluded that a charge nurse identified as staff #15 broke it up, and didn't know if anyone else saw it.An interview was conducted with resident #200 on July 22, 2025 at 2:00 p.m. The resident stated that resident #100 ran into him on purpose, from behind. Resident #200 stated that there was all kinds of room on the side in the hallway resident #100 could have used instead of running into him, and pointed to the other side of the hall. Resident #200 stated that he pushed resident #100 away, and that resident #100 came straight at him. Resident #200 stated that resident #100 was trying to hit him and he told him to stop, and that resident #200 was just an asshole and was looking for it. Resident #200 concluded that yes he felt abused and stated that he was just trying to protect himself, and noted that he had a scratch on his arm from the incident. A roughly 1.5 long scratch that appeared to be healing was noted on resident #200's right arm during this interview, however review of skin notes and other documentation reviewed revealed nothing in the clinical record related to the injury.An interview was conducted with a Certified Nursing Assistant (CNA/staff #10) on June 23 2025 at 9:56 a.m. The CNA stated that she has been there a year and 11 months. When asked about the incident between the residents she stated that the incident happened on Wednesday, and that she doesn't work Wednesdays. The CNA concluded that she did hear about the incident involving resident #100 and resident #200 but did not work that day.An interview was conducted with a Certified Nursing Assistant (CNA/staff #5) on June 23, 2025 at 10:08 a.m. The CNA stated that yes resident #100 and resident #200 had an altercation, but that she wasn't involved. The CNA further stated she was in another resident's room when the incident occurred and didn't see anything. She also stated that resident #100 had told her about the incident. The CNA stated that that's what he said referring to resident #100. The CNA stated that after the incident that a nurse took resident #100 down the hallway and took resident #200 to his room.An interview was conducted with a Licensed Practical Nurse (LPN/staff #15) on June 23, 2025 at 10:43 a.m. The LPN stated yeah I got between them, referencing resident #100 and resident #200. The LPN stated that there were arms flailing around, and that like resident #100 said he bumped into the back of resident #200. The LPN stated they were both yelling and flailing arms but stated she did not see the beginning of the altercation. The LPN stated further that from her understanding, both residents were assessed, but that it was just her asking are you ok and that nothing was documented in the record. The LPN stated that she can't speak for other staff, only to what she saw. The LPN concluded that after she reported the incident to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), and that was all, as the DON and ADON were the ones above her she stated she didn't do anything else.An interview with the Director of Nursing (DON/staff #50) was conducted on June 23, 2025 at 11:20 a.m. The DON stated that she was aware of an incident, and that what she was told was staff #15 heard some arguing, saw them kind of yelling, arms flying a bit, separated them, interviewed them, and stated she guesses resident #100 had bumped into resident #200's wheelchair, and they tried to push each other out of the way. She further stated that staff #15 had assessed both residents, and that usually a skin assessment would be done if they had been hitting each other or if there was a physical altercation. The DON stated that both residents told her they weren't injured, and would normally do a skin assessment if they were. During the interview the DON accessed the clinical record and confirmed that no assessments and no incident documentation was noted for either resident in the clinical record related to the altercation. The DON further stated that the incident wasn't reportable because it was in a community setting and that it wasn't reportable because no threat was made. The DON concluded that it was not reported to any state agency because neither resident stated they were hit.The DON provided camera footage of the hallway where the altercation occurred, and stated that video clearly shows nothing occurred. However, on review of the video, does not show either resident, but does show 6 staff members responding urgently to some kind of situation occurring around the corner out of view from the camera. One of the responding staff members was staff #5, clearly visible in the footage.An interview was conducted with a certified nursing assistant (CNA/staff #5) on June 23, 2025 at 11:37 a.m. During this interview the CNA was shown the footage provided by the DON and confirmed she was one of the responding staff in the video. However, no documentation related to the altercation between resident #100 and resident #200 was noted in the clinical record for either resident, from any author.An interview with the Director of Nursing (DON/staff #50) and Administrator (Admin/staff #75) was conducted on June 23, 2025 at 11:41 a.m. During the interview when asked about the incident the administrator stated they did not report the incident. The Administrator then asked the surveyor why he was not interviewed, as he was the one that conducted the interviews following the incident. The surveyor then asked the administrator why they interviewed the residents if no investigation was completed, and the administrator stated nothing further other than they didn't do an investigation or report it because it wasn't reportable, there wasn't any threats made so we didn't feel we needed to.A review of facility policy titled Abuse: Prevention of and the prohibition against revealed it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. It further reveals that abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and that willful as used in this definition means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

The facility failed to ensure a credible allegation of abuse was investigated.Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that their policy on abuse was followed. The deficient practice could result in more cases of resident to resident abuse not being investigated.Findings include:-Resident #100 was admitted to the facility on [DATE], with diagnosis that Diabetes mellitus type 2, end stage renal disease, anemia, hyperlipidemia, heart disease and depression.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A behavioral care-plan initiated May 5, 2025 showed the resident had the potential to demonstrate verbally aggressive behaviors related to poor impulse control and agitation, with a goal of will have zero episodes of verbally aggressive or agitation behaviors and a noted intervention of when resident becomes verbally aggressive, intervene before agitation escalates.-Resident #200 was admitted to the facility on [DATE], with diagnosis that include dementia, rheumatoid arthritis, anemia, depression, heart failure, and peripheral vascular disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. A behavioral care-plan initiated September 9, 2021 revealed the resident has the potential to demonstrate physical behaviors related to physical aggression towards other residents, with goals noted as will not harm self or others, and noted interventions of analyze key times, places, circumstances, triggers, and what de-escalated behaviors and document those, assess and anticipate resident's needs, and document observed behavior and attempted interventions.Review of information received from the SA complaint tracking system revealed that on July 18, 2025, at 5:45 a.m. a complaint incident was received that revealed that resident #200 had punched resident #100 with a closed fist. The complaint also states that the administrator was aware and had told the staff to keep quiet about the situation. A review of progress notes for resident #100 dated June 30, 2025 at 12:13 p.m. revealed resident #100 was alert and oriented to person, place and time. Able to communicate well, and had appropriate affect.A review of progress notes for resident #100 dated July 16, 2025 at 3:36 p.m. revealed Resident #100 has been observed bumping into walls and objects while independently wheeling himself in his manual wheelchair. Resident has a dx of legally blind due to Diabetes. Resident has been educated on the risks of ambulating independently. Resident became irate, became verbally aggressive and called is brother [NAME] on the phone. While on speaker, [NAME] asked to be transferred to another facility, his brother agreed and asked this write to facilitate a transfer. Brother was also educated on the risks of resident ambulating independently in his wheelchair and he demanded he continue with the wheelchair.An interview was conducted with resident #100 on July 22, 2025 at 1:45 p.m. The resident stated that he was running down the hallway and bumped into resident #200. He then stated he was shocked and said who was that? and stated that resident #200 got verbally aggressive and punched me in my face. He continued that he was just rolling down the hallway in his wheelchair and that he bumped into resident #200 on accident. The resident further stated that resident #200 was totally abusive. The resident concluded that a charge nurse identified as staff #15 broke it up, and didn't know if anyone else saw it.An interview was conducted with resident #200 on July 22, 2025 at 2:00 p.m. The resident stated that resident #100 ran into him on purpose, from behind. Resident #200 stated that there was all kinds of room on the side in the hallway resident #100 could have used instead of running into him, and pointed to the other side of the hall. Resident #200 stated that he pushed resident #100 away, and that resident #100 came straight at him. Resident #200 stated that resident #100 was trying to hit him and he told him to stop, and that resident #200 was just an asshole and was looking for it. Resident #200 concluded that yes he felt abused and stated that he was just trying to protect himself, and noted that he had a scratch on his arm from the incident. A roughly 1.5 long scratch that appeared to be healing was noted on resident #200's right arm during this interview, however review of skin notes and other documentation reviewed revealed nothing in the clinical record related to the injury.An interview was conducted with a Certified Nursing Assistant (CNA/staff #10) on June 23 2025 at 9:56 a.m. The CNA stated that she has been there a year and 11 months. When asked about the incident between the residents she stated that the incident happened on Wednesday, and that she doesn't work Wednesdays. The CNA concluded that she did hear about the incident involving resident #100 and resident #200 but did not work that day.An interview was conducted with a Certified Nursing Assistant (CNA/staff #5) on June 23, 2025 at 10:08 a.m. The CNA stated that yes resident #100 and resident #200 had an altercation, but that she wasn't involved. The CNA further stated she was in another resident's room when the incident occurred and didn't see anything. She also stated that resident #100 had told her about the incident. The CNA stated that that's what he said referring to resident #100. The CNA stated that after the incident that a nurse took resident #100 down the hallway and took resident #200 to his room.An interview was conducted with a Licensed Practical Nurse (LPN/staff #15) on June 23, 2025 at 10:43 a.m. The LPN stated yeah I got between them, referencing resident #100 and resident #200. The LPN stated that there were arms flailing around, and that like resident #100 said he bumped into the back of resident #200. The LPN stated they were both yelling and flailing arms but stated she did not see the beginning of the altercation. The LPN stated further that from her understanding, both residents were assessed, but that it was just her asking are you ok and that nothing was documented in the record. The LPN stated that she can't speak for other staff, only to what she saw. The LPN concluded that after she reported the incident to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), and that was all, as the DON and ADON were the ones above her she stated she didn't do anything else. An interview with the Director of Nursing (DON/staff #50) was conducted on June 23, 2025 at 11:20 a.m. The DON stated that she was aware of an incident, and that what she was told was staff #15 heard some arguing, saw them kind of yelling, arms flying a bit, separated them, interviewed them, and stated she guesses resident #100 had bumped into resident #200's wheelchair, and they tried to push each other out of the way. She further stated that staff #15 had assessed both residents, and that usually a skin assessment would be done if they had been hitting each other or if there was a physical altercation. The DON stated that both residents told her they weren't injured, and would normally do a skin assessment if they were. During the interview the DON accessed the clinical record and confirmed that no assessments and no incident documentation was noted for either resident in the clinical record related to the altercation. The DON further stated that the incident wasn't reportable because it was in a community setting and that it wasn't reportable because no threat was made. The DON concluded that it was not reported to any state agency because neither resident stated they were hit.The DON provided camera footage of the hallway where the altercation occurred, and stated that video clearly shows nothing occurred. However, on review of the video, does not show either resident, but does show 6 staff members responding urgently to some kind of situation occurring around the corner out of view from the camera. One of the responding staff members was staff #5, clearly visible in the footage.An interview was conducted with a certified nursing assistant (CNA/staff #5) on June 23, 2025 at 11:37 a.m. During this interview the CNA was shown the footage provided by the DON and confirmed she was one of the responding staff in the video. However, no documentation related to the altercation between resident #100 and resident #200 was noted in the clinical record for either resident, from any author.An interview with the Director of Nursing (DON/staff #50) and Administrator (Admin/staff #75) was conducted on June 23, 2025 at 11:41 a.m. During the interview when asked about the incident the administrator stated they did not report the incident. The Administrator then asked the surveyor why he was not interviewed, as he was the one that conducted the interviews following the incident. The surveyor then asked the administrator why they interviewed the residents if no investigation was completed, and the administrator stated nothing further other than they didn't do an investigation or report it because it wasn't reportable, there wasn't any threats made so we didn't feel we needed to.A review of facility policy titled ‘Abuse: Reporting alleged violations of abuse, neglect, exploitation and mistreatment' revealed that in response to allegations of abuse, neglect, exploitation or mistreatment, the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury. It further revealed that The facility shall conduct a prompt, thorough, and complete investigation in response to reportable allegations of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property.

The facility failed to ensure a credible incident of abuse was reported timely and accurately.Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that an incident of abuse was reported timely and accurately. The deficient practice could result in further incidents of resident to resident abuse.Findings include: -Resident #100 was admitted to the facility on [DATE], with diagnosis that Diabetes mellitus type 2, end stage renal disease, anemia, hyperlipidemia, heart disease and depression.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A behavioral care-plan initiated May 5, 2025 showed the resident had the potential to demonstrate verbally aggressive behaviors related to poor impulse control and agitation, with a goal of will have zero episodes of verbally aggressive or agitation behaviors and a noted intervention of when resident becomes verbally aggressive, intervene before agitation escalates.-Resident #200 was admitted to the facility on [DATE], with diagnosis that include dementia, rheumatoid arthritis, anemia, depression, heart failure, and peripheral vascular disease.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9 which indicated the resident had moderate cognitive impairment. A behavioral care-plan initiated September 9, 2021 revealed the resident has the potential to demonstrate physical behaviors related to physical aggression towards other residents, with goals noted as will not harm self or others, and noted interventions of analyze key times, places, circumstances, triggers, and what de-escalated behaviors and document those, assess and anticipate resident's needs, and document observed behavior and attempted interventions.Review of information received from the SA complaint tracking system revealed that on July 18, 2025, at 5:45 a.m. a complaint incident was received that revealed that resident #200 had punched resident #100 with a closed fist. The complaint also states that the administrator was aware and had told the staff to keep quiet about the situation. A review of progress notes for resident #100 dated June 30, 2025 at 12:13 p.m. revealed resident #100 was alert and oriented to person, place and time. Able to communicate well, and had appropriate affect.A review of progress notes for resident #100 dated July 16, 2025 at 3:36 p.m. revealed Resident #100 has been observed bumping into walls and objects while independently wheeling himself in his manual wheelchair. Resident has a dx of legally blind due to Diabetes. Resident has been educated on the risks of ambulating independently. Resident became irate, became verbally aggressive and called is brother [NAME] on the phone. While on speaker, [NAME] asked to be transferred to another facility, his brother agreed and asked this write to facilitate a transfer. Brother was also educated on the risks of resident ambulating independently in his wheelchair and he demanded he continue with the wheelchair.An interview was conducted with resident #100 on July 22, 2025 at 1:45 p.m. The resident stated that he was running down the hallway and bumped into resident #200. He then stated he was shocked and said who was that? and stated that resident #200 got verbally aggressive and punched me in my face. He continued that he was just rolling down the hallway in his wheelchair and that he bumped into resident #200 on accident. The resident further stated that resident #200 was totally abusive. The resident concluded that a charge nurse identified as staff #15 broke it up, and didn't know if anyone else saw it.An interview was conducted with resident #200 on July 22, 2025 at 2:00 p.m. The resident stated that resident #100 ran into him on purpose, from behind. Resident #200 stated that there was all kinds of room on the side in the hallway resident #100 could have used instead of running into him, and pointed to the other side of the hall. Resident #200 stated that he pushed resident #100 away, and that resident #100 came straight at him. Resident #200 stated that resident #100 was trying to hit him and he told him to stop, and that resident #200 was just an asshole and was looking for it. Resident #200 concluded that yes he felt abused and stated that he was just trying to protect himself, and noted that he had a scratch on his arm from the incident. A roughly 1.5 long scratch that appeared to be healing was noted on resident #200's right arm during this interview, however review of skin notes and other documentation reviewed revealed nothing in the clinical record related to the injury.An interview was conducted with a Certified Nursing Assistant (CNA/staff #10) on June 23 2025 at 9:56 a.m. The CNA stated that she has been there a year and 11 months. When asked about the incident between the residents she stated that the incident happened on Wednesday, and that she doesn't work Wednesdays. The CNA concluded that she did hear about the incident involving resident #100 and resident #200 but did not work that day.An interview was conducted with a Certified Nursing Assistant (CNA/staff #5) on June 23, 2025 at 10:08 a.m. The CNA stated that yes resident #100 and resident #200 had an altercation, but that she wasn't involved. The CNA further stated she was in another resident's room when the incident occurred and didn't see anything. She also stated that resident #100 had told her about the incident. The CNA stated that that's what he said referring to resident #100. The CNA stated that after the incident that a nurse took resident #100 down the hallway and took resident #200 to his room.An interview was conducted with a Licensed Practical Nurse (LPN/staff #15) on June 23, 2025 at 10:43 a.m. The LPN stated yeah I got between them, referencing resident #100 and resident #200. The LPN stated that there were arms flailing around, and that like resident #100 said he bumped into the back of resident #200. The LPN stated they were both yelling and flailing arms but stated she did not see the beginning of the altercation. The LPN stated further that from her understanding, both residents were assessed, but that it was just her asking are you ok and that nothing was documented in the record. The LPN stated that she can't speak for other staff, only to what she saw. The LPN concluded that after she reported the incident to the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), and that was all, as the DON and ADON were the ones above her she stated she didn't do anything else.An interview with the Director of Nursing (DON/staff #50) was conducted on June 23, 2025 at 11:20 a.m. The DON stated that she was aware of an incident, and that what she was told was staff #15 heard some arguing, saw them kind of yelling, arms flying a bit, separated them, interviewed them, and stated she guesses resident #100 had bumped into resident #200's wheelchair, and they tried to push each other out of the way. She further stated that staff #15 had assessed both residents, and that usually a skin assessment would be done if they had been hitting each other or if there was a physical altercation. The DON stated that both residents told her they weren't injured, and would normally do a skin assessment if they were. During the interview the DON accessed the clinical record and confirmed that no assessments and no incident documentation was noted for either resident in the clinical record related to the altercation. The DON further stated that the incident wasn't reportable because it was in a community setting and that it wasn't reportable because no threat was made. The DON concluded that it was not reported to any state agency because neither resident stated they were hit.The DON provided camera footage of the hallway where the altercation occurred, and stated that video clearly shows nothing occurred. However, on review of the video, does not show either resident, but does show 6 staff members responding urgently to some kind of situation occurring around the corner out of view from the camera. One of the responding staff members was staff #5, clearly visible in the footage.An interview was conducted with a certified nursing assistant (CNA/staff #5) on June 23, 2025 at 11:37 a.m. During this interview the CNA was shown the footage provided by the DON and confirmed she was one of the responding staff in the video. However, no documentation related to the altercation between resident #100 and resident #200 was noted in the clinical record for either resident, from any author.An interview with the Director of Nursing (DON/staff #50) and Administrator (Admin/staff #75) was conducted on June 23, 2025 at 11:41 a.m. During the interview when asked about the incident the administrator stated they did not report the incident. The Administrator then asked the surveyor why he was not interviewed, as he was the one that conducted the interviews following the incident. The surveyor then asked the administrator why they interviewed the residents if no investigation was completed, and the administrator stated nothing further other than they didn't do an investigation or report it because it wasn't reportable, there wasn't any threats made so we didn't feel we needed to.A review of facility policy titled ‘Abuse: Reporting alleged violations of abuse, neglect, exploitation, or mistreatment' revealed that the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property are reported to the administrator of the facility, the state survey agency, and adult protective services.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one resident (#22) to be free from abuse by another resident (#16). The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: -Resident #22 was admitted to the facility on [DATE] with diagnoses that included: Human Immunodeficiency Virus Disease, hemiplegia, bipolar disorder, generalized anxiety disorder, unspecified dementia, schizoaffective disorder, major depressive disorder, and general muscle weakness. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 9, indicating a moderate cognitive impairment. Further, the MDS revealed that resident #22 had impairments on one side in the upper and lower extremities and used the aid of a wheelchair for mobility. A nursing progress note dated May 18, 2025 at 11:10 p.m. revealed that resident #22 was involved in an altercation with his roommate (resident #16) over noise. Resident's left eye had an abrasion and was beginning to swell. The residents were separated, monitored, and resident #22's eye was treated. -Resident #16 was admitted to the facility on [DATE] with diagnoses including: multiple sclerosis, major depressive disorder, general muscle weakness, and adult failure to thrive. A quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, indicating that resident #16 was cognitively intact. Resident #16's psychiatric progress note dated October 9, 2023 revealed that he did not like his current roommate. Additional psychiatric progress notes dated: October 16, 2023, October 30, 2023, November 13, 2023, December 11, 2023, December 29, 2023, January 12, 2024, January 21, 2024, February 1, 2024, February 16, 2024, March 25, 2024, April 5, 2024, May 10, 2024, June 20, 2024, and July 29, 2024, revealed issues with sleep in regards to roommate and staff providing care. Resident #16's care plan revealed a focus of potential to demonstrate verbally abusive behaviors in regards to ineffective coping skills, initiated on October 7, 2023. Facility census records revealed that resident #22 and resident #16 began sharing room on July 19, 2023. An interview was conducted with resident #22 on June 4, 2025 at 11:58 a.m. Resident #22's eye was still visibly discolored and he stated that he was hit by his roommate late at night after words were exchanged. He stated that resident #16 was frequently verbally aggressive with staff, and resident #22 would tell his roommate to be kind. Resident #16 was interviewed on June 4, 2025 at 12:22 p.m., he stated that he was tired of his shit and insults and that on the night of the incident he told resident #22, Quit f***ing with me, or I will slap the sh** out of you. Soon afterwards he stated that he went to his roommate's bed and hit him one time in the eye with the back of his hand. An interview was conducted with the director of nursing (DON/staff #126) on June 4, 2025 at 1:42 p.m. DON #126 stated that if there are documented behavioral concerns between residents, then the roommates should be separated. When asked to review the psychiatry notes in resident #16's clinical record. DON #126, stated that her expectation would be to have the psych nurse communicated the on going issues so issues could have been addressed. A facility policy titled Abuse: Prevention of and Prohibition Against, revised 10/2023 states that the facility will act to protect and prevent abuse and neglect form occurring in the facility by: identifying, correcting and intervening in situation in which abuse, neglect, exploitation and/or misappropriation of resident's property is more likely to occur.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure the medication error rate was not 5% or greater, by failing to administer medications as ordered for three of four residents (#58, #25, #103). The deficient practice could result in adverse effects and further medication errors. Findings Include: Six medication administration errors were identified out of 38 opportunities during medication administration observation. The medication error rate was 15.79% -Regarding Resident #58 Resident #58 was admitted to the facility on [DATE] with diagnoses that included viral hepatitis, anxiety disorder, depression, and schizophrenia A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Provider orders revealed an order for Senna Plus 8.6/50 mg (milligrams), take 1 tablet by mouth in the morning. The medication was scheduled to be administered at 8:00 AM. A medication administration observation was conducted with a Licensed Practical Nurse (LPN/staff #138) on May 15, 2025 at 7:00 AM for Resident #58. The LPN (staff #138) was observed to take a bottle of Senna 8.6 mg out of the medication cart and place one tablet in the cup with the other medications. The resident was observed to swallow the Senna 8.6 mg. An interview was conducted with the LPN following the administration, regarding administering Senna instead of Senna Plus. The LPN acknowledged that she mistakenly administered the wrong type of Senna to the resident. -Regarding Resident #103 Resident #103 was admitted to the facility on [DATE], with diagnoses that included coronary artery disease, hypertension, Diabetes mellitus, thyroid disorder, and depression. An annual MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Provider orders for Resident #103 revealed the following orders to be administered at 8:00 AM: -Amlodipine 10 mg, give 1 tablet by mouth -Carvedilol 12.5 mg, give 1 tablet by mouth -Losartan Potassium 50 mg, give 1 tablet by mouth -Levetiracetam 1000 mg, give 1 tablet by mouth -Metformin 500 mg, give 1 tablet by mouth A medication administration observation was conducted with a Licensed Practical Nurse (LPN/staff #153) on May 15 at 9:25 AM for Resident #10. The LPN was observed administering the medications at 9:30 AM, with the resident observed swallowing the medications at 9:31 AM. An interview was conducted with the LPN (staff #153) following the administration. She acknowledged that the medications were administered late according to the provider order and facility policy. She stated medications are considered late if administered more than 1 hour after the scheduled time. The LPN stated she usually finished her 8:00 AM medication pass around 10:30 AM and that she typically administers medications to 27-30 residents. She stated she has brought her concerns regarding late medications to the attention of the Director of Nursing. -Regarding Resident #25 Resident #25 was re-admitted to the facility on [DATE] with diagnoses that included orthopedic aftercare, absence of left toes, and Type 2 Diabetes mellitus with hyperglycemia. A quarterly MDS assessment dated [DATE] revealed a BIMS score of 13, which indicated intact cognition. During a medication observation with another LPN (staff #153), who stated that she had 5 more residents to administer medications. The LPN (staff #153), was observed in a resident's room, administering insulin. Upon exiting the room, the LPN stated she was administering sliding scale insulin to Resident #25. Upon review of Resident #25's orders, an order for blood sugars to be assessed and Humalog sliding scale to be administered before meals. Resident #25's blood sugar was assessed after he had eaten breakfast and the insulin was administered late. An observation of the morning medication pass was conducted on May 16, 2025 at 9:30 AM. One LPN (staff #54) stated that she had 5 more residents to administer medications to at that time. She also stated she had expressed concern to the DON regarding not being able to get medications administered on time. It was observed at this time that the resident had already eaten breakfast. An interview was conducted with the Director of Nursing (DON/staff #109) on May 15, 2025 at 10:16 AM, who stated that medications are considered administered on time if they are administered one hour before to one hour after the scheduled time. She stated nurses have been instructed to communicate with their supervisor if they were not able to administer medications on time. She stated nurses have not communicated any issues to their supervisors. She acknowledged the late medications administered during the observed medication passes and stated the risk of late medications could be adverse effects of medications given too close together. An additional interview was conducted with LPN (staff #138) on May 15, 2025 at 1:02 PM. The LPN stated that she had informed the DON that nurses are not able to complete their medication passes within the one-hour time frame and that medications were therefore being administered late. An additional interview was conducted with the DON on May 16, 2025 at 10:25 AM. She acknowledged the medication errors and stated they are working on a process to address the issue. She stated the medication errors could lead to negative outcomes. A facility policy titled, Administration of Drugs, dated May 2025, revealed that medications shall be administered as prescribed by the attending physician. If a medication is given other than at the scheduled time, the documentation will be reflected in the clinical record.

-Resident #545 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included urinary tract infection, adult failure to thrive, gastrostomy status, chronic kidney disease stage 3, obstructive and reflux uropathy and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominate side. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #545 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. The MDS assessment further revealed that the resident had a Foley catheter and an intravenous catheter (IV). A Nursing Care Plan, dated May 10, 2025, indicated Resident #545 had an indwelling catheter, a Peripherally Placed Central Catheter (PICC) and a feeding tube. Physician orders, dated May 10, 2025, revealed the following: -Check for Foley catheter privacy bag every shift, -Catheter [Foley] care every shift -Check placement of G-tube (feeding tube) every shift, -Cleanse G-tube with warm soap and water or normal saline (NS), pat dry, every shift, -Jevity 1.5 at 80 milliliters per hour (ml/hr) via G-tube continuous via pump x 20 hours per day. Start at 12:00 PM and turn off at 8:00 AM and -PICC line flush with 10 ml NS and 5 ml heparin every shift. An initial observation of Resident #545 was conducted on May 13, 2025 at 12:05 PM. The resident was observed to have a Foley catheter in place. The Foley catheter drainage bag was observed directly on the floor under the resident's bed. A privacy bag was not observed covering the Foley catheter drainage bag and the emptying spout was observed directly touching the floor of the resident's room. An interview was conducted with a Licensed Practical Nurse (LPN/staff #57) on May 13, 2025 at 12:10 PM. The LPN admitted had observed the foley catheter bag sitting on the floor, under the resident's bed. She stated the bag should not be touching the floor and should be in a privacy bag. The LPN was observed to raise the resident's bed to a higher position. Upon raising the bed, it was discovered that the Foley catheter bag was not attached to the bed, but was sitting directly on the floor. The LPN picked up the Foley catheter bag, put a privacy bag over it and hung it from the bed railing. An observation was made of an LPN (staff #138) performing feeding tube and PICC management care on May 15, 2025 at 12:18 PM. The LPN was observed to don a gown outside of Resident #545's room, as the LPN entered the room she donned gloves. The LPN was not observed to sanitize her hands before donning the gloves. The LPN repositioned the resident in his bed, closed the door to his room and doffed her gloves. She then donned new gloves. The LPN did not sanitize her hands in between glove changes. The LPN was observed cleaning the two PICC line ports with an alcohol wipe. She was then observed to administer 10 cubic centimeters (cc) of NS into each port, followed by 5 cc of Heparin (an anticoagulant). The LPN placed an alcohol cap onto each port. She doffed her gloves, threw them into a garbage can and donned new gloves. The LPN did not sanitize her hands in between glove changes. The LPN was then observed to write the date on a bottle of Jevity (tube feeding formula) and hang it on an IV pole. She connected the tubing to the Jevity and to a bag of water that was hanging from the IV pole. The LPN programmed the pump to 80 cc/hr. At that time, the resident had requested a pain pill, so the LPN doffed her gloves and removed her gown. She left the room and came back with a pain pill, after donning a new gown and gloves. She did not sanitize her hands. The LPN was observed to check the placement of the feeding tube, checked for any residual and flushed the tube with 20 cc of water. She administered the crushed pain pill, mixed with water and then flushed again with 30 cc of water. The LPN then secured the feeding tube tubing to the port on the resident and began the feeding. She then removed her gown, doffed her gloves and threw them into the garbage can. She did not sanitize her hands. An interview was conducted with the LPN, following the procedure. She acknowledged that she should have sanitized her hands between donning and doffing gloves and when she removed gloves following the procedures. An interview was conducted with the Director of Nursing (DON/staff #109) on May 16, 2025 at 10:09 AM. The DON stated that the LPN (staff #138) should have sanitized her hands before she began the procedure, before and after donning/doffing gloves and at the end of the procedure. She stated the risk of not doing so could be cross contamination from one to another. Review of the facility policy titled, IPCP Standard and Transmission-Based Precautions (revised October 2022), revealed that Enhanced Barrier Protection (EBP), which referred to the use of gown and gloves during high-contact resident care activities, is indicated when contact precautions do not otherwise apply for residents with wounds and/or indwelling medical devices, regardless of MDRO colonization. The policy also defined wound care as an activity requiring the usage of PPE for residents on EBP. A policy titled, Infection Control/Procedure/Catheter care, reviewed July 2024, revealed that drainage bags were to be kept in privacy bags. It also explained that when performing catheter care, staff should wash hands, put gloves on, perform the task, remove gloves and wash hands. A policy titled, Tube feeding-Nasogastric or Gastrostomy, revised May 2025, revealed staff were to wash hands before performing cares with the feeding tube. Based on clinical record review, observation, and staff interviews, the facility failed to ensure appropriate infection control practices were implemented and followed for two residents (#64, #545). The deficient practice could result in a spread of preventable illness to residents and staff. Findings include: -Resident #64 was admitted to the facility on [DATE] with diagnoses that included dementia, reduced mobility, and aphasia. Review of the care plan revealed a focus, initiated May 28, 2020, which revealed that the resident had actual or potential for pressure injury development related to tube feeding and history of pressure injury over the right heel, left lateral ankle, right medial great metatarsal head, and sacrum/upper buttocks. The focus also revealed that on December 2, 2024, the resident had a pressure injury to the left plantar great metatarsal head. Interventions in place for this focus included the usage of Enhanced Barrier Precautions (EBP). Review of physician orders revealed an order, dated January 10, 2025, which instructed the usage of enhanced barrier precautions, related to enteral feeding and wound care. Review of the Minimum Data Set (MDS), dated [DATE], revealed that Resident #64 had one stage four pressure ulcer, which was present upon admission, and one unstageable pressure ulcer, which was not present upon admission. An observation of wound care was conducted on May 15, 2025 at 2:12PM for Resident #64's left platar great metatarsal head wound and the scar tissue on the resident's ankle. Observation in Resident #64's room during the wound care revealed signage for Enhanced Barrier Precautions (EBP) on the wall behind the resident's bed. The wound care was provided by a Registered Nurse (RN/Staff #11) and a Licensed Practical Nurse (LPN/Staff #105). Prior to interacting with the resident, both staff members performed hand hygiene and donned gloves. Both staff members failed to don gowns prior to beginning the wound care. During the wound care, the staff properly removed the soiled dressings and applied new dressing, but gowns were not utilized in any point during the wound care. An interview was conducted on May 15, 2025 at 2:23PM with the Registered Nurse (RN/Staff #11) who had provided the wound care, stated that gown and gloves would be required during wound care for residents with chronic wounds, who would usually be on contact precautions. She explained that if a resident had a lot of drainage in the wound, this would warrant the resident to be put onto contact precautions, which would then require the use of a gown and gloves. The RN stated that Resident #64 did not have a lot of drainage in her wound, so she did not need to use a gown and gloves during her wound care. Interview was conducted on May 16, 2025 at 12:32PM with the Director of Nursing (DON/Staff #109), who stated that staff should don gown and gloves any time they are providing direct care for residents with orders for Enhanced Barrier Precautions (EBP). The DON identified the purpose of EBP to be to decrease the risk for infection, especially for residents that may have chronic open wounds.

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one (Resident #28) of twenty-seven residents. The deficient practice could result in residents not receiving care consistent with the signed advanced directive. Findings include: Resident # 28 was admitted on [DATE] for surgical aftercare following surgery on skin and subcutaneous tissues. Additional diagnoses included local infection of the skin and subcutaneous tissue, open wound of lower back and pelvis without penetration into retroperitoneum, unspecified open wound of right buttock, unspecified open wound of left buttock, chronic kidney disease, stage 3, hypertensive chronic kidney disease or unspecified chronic kidney disease, unspecified atrial fibrillation, and orthostatic hypotension. A review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, suggesting that the resident had no cognitive impairment. A review of the resident dashboard, located in the electronic health record and verified by physician order review revealed a code status of cardiopulmonary resuscitation (CPR) as CPR/Full Code, however the resident's Advanced Care Directive form dated [DATE] indicated that resident preferance as do not resuscitate (DNR) status refusing resuscitation measures including but not limited to: CPR, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation and related emergency procedures. The form stipulated that if checked, the orange prehospital medical directives form must be completed. The attached orange pre-hospital directive indicated that in the event of cardiac or respiratory arrest, the resident refused any resuscitation measures including cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of advanced cardiac life support drugs and related emergency medical procedures. The facility Advance Health Care Directives form indicated the resident had elected DNR code status, however the baseline care plan revealed no entry notating the presence of specific treatment of healthcare choice, whether full-code or DNR. An interview with the resident (#28) was conducted on [DATE] at 09:07 AM who confirmed that she had elected DNR status. An interview was conducted on [DATE] at 08:40 AM with staff #152 Certified Nursing Assistant (CNA). The CNA stated that resident code status is identified using the code arrest book that is located in the nursing station. If a code arrest occurs and the resident is identified as a full code, the facility has a radio system that is used to call for help. If the code is successful, the resident is taken to the hospital. An interview was conducted on [DATE] at 10:07 AM with staff #151 social service supervisor. The social service supervisor revealed advanced directives are confirmed by the nurse during the admission process with the resident or their representative. The nurse confirms and adds the advance directive to the physician orders which are reviewed and signed by the provider. She stated that if a resident who was identified as a full code had a code on the unit, a code would be called using the facility radio system. Responding staff would begin cardiopulmonary resuscitation, using the automated external defibrillator (AED) available on the unit and 911 emergency response would be activated. She stated that if the code is successful, the resident would be transported to the hospital for further care. An interview was conducted on [DATE] at 08:35 AM with staff #101, registered nurse (RN). The RN stated that the staff check the code book at the nurses' station to verify resident code status in conjunction with the electronic health record dashboard to confirm code status. If the resident had elected DNR status, the prehospital directive (orange card) would be placed on the top of the record in the code book at the nurses' station for ease of verification. The RN obtained the book from the nurse's station and verified that resident #28 had both advanced directive and prehospital directives in the record indicating election of DNR status. The RN stated that if there was a noted a discrepancy between the information in the dashboard of the electronic health record and the book on the unit, the RN would report it through the chain of command to the Director of Nursing. The RN obtained the code book from the nursing station and verified that resident #28 had completed advanced directives that indicate DNR status which were in conflict with the notation of full code on the electronic health record dashboard. The RN identified the risk of this discrepancy as a possibility of resuscitating someone who did not want to be resuscitated. Staff #101 stated that this did not meet her expectation, as the code status in the electronic health record and the code arrest book in the nurse's station should all match what is ordered by the physician. An interview was conducted on [DATE] at 10:01 AM with staff #232, Nurse Practitioner (NP) who stated that the advanced directives are typically reviewed with the residents and or representatives if they do not have the capacity to make decisions. Staff #232 stated that he would explain the options and would refer to case management to complete the necessary forms. The NP stated that orders would be placed in the in the medical record if updates or changes were indicated. An interview was conducted on [DATE] at 10:48 AM with staff #109 Director of Nursing (DON), who reviewed the DNR process. She reported that nurses review the consent packet with residents and/or their representatives upon admission to the facility and advanced directives are included in the discussion. When resident's choice is confirmed, the resident or responsible party sign the required forms, the signature is witnessed by facility staff and the documents are scanned and placed in the Electronic Health Record. She stated that medical records staff review the documents and organize them into 'code books' that are located at each nursing station. The DON reported that the medical records department does a weekly review of these resources and if a resident changed their advanced directives, the 'code book' would be updated and new forms scanned into the medical record. The DON stated that corresponding physician orders are entered into the electronic health record. She stated that in the event of a resident emergency, staff confirm code status by accessing the advanced directives on the book at the nurses' station or review of the Kardex in the electronic health record whichever is closer. She stated that this did not meet her expectations and stated that the risk of discrepancy between the book and the electronic health record would be that a resident's elected DNR wishes would not be followed. The DON reviewed the resident's Kardex, electronic health record and 'code book' from the unit and confirmed that there was a discrepancy on the Kardex indicating that the patient had elected full-code status which conflicted with the signed Advanced Care Directive Form dated [DATE]. She confirmed the expectation that the code book and the clinical record match. She identified the discrepancy, that if there is an error, someone who opted not to be coded could be and their wishes may not be followed. The DON stated that she would confirm the resident's advanced directives and follow with a facility-wide audit to ensure accuracy. A review of the facility policy/procedure entitled Advance Directives in Section Care and Treatment reviewed [DATE], revealed that advance directives will be recognized and respected by the facility.

-Regarding Resident #37: Resident #37 was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE], with diagnoses that included, other psychotic disorder due to a substance or known physiological condition, chronic pain, depression and anxiety. A Pre-admission Screening and Resident Review (PASRR) Level I Screening dated September 12, 2024 completed prior to admission, revealed that it was left mostly blank. A care plan initiated on September 12, 2024 included the following focus: -Psychotropic medications use related to schizoaffective disorder -Ineffective coping related to substance abuse -Potential for a psychosocial well-being problem with interventions that included to consult with psych services and social services. -Potential for mood problem An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment also revealed diagnoses that included a psychotic disorder other than schizophrenia, anxiety disorder and depression. A PASRR Level I Screening dated October 14, 2024 revealed that Resident #37 had mental disorders to include anxiety and depression and had a substance related disorder. A level II screening was deemed necessary for mental illness only. A care plan focus of potential for mood problem revealed a PASRR level II was submitted on October 14, 2024. A PASRR Level II referral response was sent and a note, dated October 16, 2024, from the State PASRR Program-AHCCCS (Arizona Health Care Cost Containment System) relayed that the resident did not meet the criteria for a Level II PASRR evaluation. The letter stated that if their condition changed in the future to submit a new Level I screening tool if needed. A physician order dated February 17, 2024 included an order to administer Olanzapine (antipsychotic) 10 milligrams (mg) for schizoaffective disorder aeb (as evidenced by) striking out. A Review of a PASRR Level I Screening dated February 18, 2025, after the resident had been in the hospital revealed the Mental illness, symptoms and medication sections were left blank, despite the February 17, 2025 diagnosis of schizoaffective disorder. The box was marked that stated no referral necessary for any Level II . A psychologist provider progress note, dated March 6, 2025 revealed a diagnosis of schizoaffective disorder. A modified quarterly Minimum Data Set (MDS) assessment dated [DATE] included active diagnoses of schizophrenia, anxiety and depression. The assessment also included a Brief Interview of mental status (BIMS) score of 15, which indicated intact cognition. Review of the nursing care plan, initiated May 13, 2025, included that the resident was receiving psychotropic medications for schizoaffective disorder. Despite documentation that the resident had a new diagnosis of schizoaffective disorder, no evidence was found that the facility referred the resident to the appropriate state-designated mental health or intellectual disability authority for review or why the resident was not referred. During an interview conducted with the Social Services Assistant (SSA/staff #151) on May 15, 2025 at 8:56 AM, she stated the social services department reviews the face sheet upon admission and completes a PASRR prescreening. She also stated, after that a 30-day PASRR is conducted that included a review of medications, diagnoses and psychiatric notes. She stated that if there were diagnoses such as: anxiety, depression, schizophrenia, any mental diagnosis or psychoactive substance abuse, they would recommend a level II PASRR. The SSA (staff #151) further stated that if a resident had a previous declination of a level II by the State, but then went to the hospital or had a new diagnosis, they would need to be reassess with a Level I PASRR and go through the process again. The SSA stated she was not aware of the schizoaffective disorder diagnosis for Resident #37 and therefore she did not complete a 30-day review or send the referral for a Level II PASRR. An interview was conducted with the MDS Coordinator (staff #41) on May 15, 2025 at 11:02 AM. The MDS Director stated she received information regarding Resident #37's new diagnosis of schizoaffective disorder from a provider progress note dated March 6, 2025. She stated other management team members were aware of the new diagnosis and that a PASRR should have been completed. An interview was conducted with the Social Services Director (staff #45) on May 16, 2025 at 11:02 AM. The Social Services Director stated she and her assistant were not made aware of the new schizoaffective diagnosis in March 2025 for Resident #37. She relayed that Resident #37 should have had a new Level I PASRR completed and it should have been referred to the State for a Level II PASRR, and that this did not occur related to the new diagnosis of schizoaffective disorder. A policy titled, PASRR, reviewed May 2025, revealed that each resident would be properly screened using the PASRR specified by the State. Based on clinical record review and staff interviews, the facility failed to ensure two residents' PASARR screenings (#3, #37) were completed accurately and referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, mood affective disorder, and convulsions. Review of the Arizona Pre-admission Screening and Resident Review (PASSAR) level one screening tool, completed October 19, 2010, revealed that the resident met the criteria for a thirty-day convalescent care stay. At this time, no referral was deemed necessary for a level two PASARR evaluation. Review of Resident #3's diagnoses revealed that she was diagnosed with major depressive disorder, single episode, on February 15, 2014. Resident #3 was then diagnosed with mood disorder due to known physiological condition on August 7, 2019. She was diagnosed with anxiety disorder on July 20, 2021, and she was diagnosed with dementia on October 1, 2022. Record review revealed no evidence that a new PASARR was completed until August 12, 2019. Review of the PASARR level one screening tool, completed August 12, 2019, revealed that Resident #3 was documented to have no serious mental illnesses (SMI) and had no mental disorders or suspected mental disorders. The PASARR indicated that no referral was necessary for a level two PASARR evaluation. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #3 had active diagnoses which included anxiety disorder, depression, bipolar disorder, and mood affective disorder. Review of the physician orders revealed an order, dated May 8, 2025, revealed that Resident #3 was prescribed Mirtazapine 7.5mg for depression. Despite documentation that the resident had diagnoses of major depressive disorder, mood disorder, bipolar disorder, and anxiety disorder, no evidence was found that the facility referred the resident to the appropriate state-designated mental health or intellectual disability authority for review or why the resident was not referred. Interview was conducted on May 16, 2025 at 10:25AM with the Case Manager (Staff #45) and the Social Services Supervisor (Staff #151), who stated that the purpose of a PASARR is to ensure that residents are getting the psychiatric care needed. The staff members stated that in order to determine if Resident #3's 2019 PASARR was completed accurately, they would need to refer to the diagnoses and Medication Administration Record (MAR) from that time. However, the staff members stated that the PASARR completed for Resident #3 in 2019 was not reflective of Resident #3's active diagnoses, and a new one should have been completed. Interview was conducted on May 16, 2025 at 12:32PM with the Director of Nursing (DON/Staff #109), who stated that she would expect all residents to get a PASARR level one screening on admission to determine if a referral for level two services is necessary. She also stated that if a resident remained in the facility after thirty days, she would expect social services to complete a new PASARR. The DON reviewed the PASARRs completed for Resident #3 and agreed that she would expect Resident #3's diagnoses to have been reflected on the PASARR level one screening. The DON identified the purpose of completing an accurate PASARR would be to determine if the resident was safe in the facility or needed a higher level of care. She explained that if a resident was considered to have serious mental illness and required level two services, then the resident's psychiatric needs could not be met in the facility.

Based on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for one resident (#448). The deficient practice could result in harm to the residents, and/or visitors who have access to medications. Findings Include: Resident #448 was admitted on [DATE], diagnosis included displaced fracture of surgical neck of left Humorous, anemia, retention of urine, hypokalemia, chronic pain syndrome, alcohol abuse, and anxiety disorder. The Admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that resident was cognitively intact. Review of care plan revealed no evidence that Resident #448 was able to self-administer medication. Review of the physician's orders revealed no orders to self-administer medications. Review of the assessments revealed not assessed to self-administer medications. Review of progress note revealed no interdisciplinary meeting for self-administering medication. Further review of the Physicians orders revealed no orders for Omeprazole delayed release capsule, 20 mg acid reducer (proton pump inhibitor). An observation conducted on May 13, 2025 at 08:50 AM revealed Resident #448 was laying in her bed awake, table on the side of her bed which had water and purple medication bottle with a cap on her table. Resident #448 stated that this is her over the counter medication for heart burn. An interview was conducted on May 13, 2025 at 8:54 AM with Certified Nurse Assistance (CNA/staff #200), who identified this medication was Omeprazole 20mg acid reducer for heat burn and it is not supposed to be left on the bedside. She stated there are risk posed to have medication left the bedside where the resident can overdose and cause diarrhea because it is for acidity. CNA took the medication and called the nurse; additionally a doctor came into the room. An interview was conducted on May 13, 2025 at 08:56 AM with the Physician (staff #178), who stated that over the counter medication are not allowed to be on bedside. An interview was conducted on May 13, 2025 at 08:58 AM with the Licensed Practical Nurse (LPN/staff #145), who identified the medication was an over the counter medication Omeprazole 20 mg for acid reflux. She stated that she was not aware that resident #448 had this medication. She stated that medication was not allowed to be on beside. She stated there are risk of this medication left on beside such as resident can overdose, can cause dizziness, vomit, or have abdominal pain. An interview was conducted on May 16, 2025 at 12:18PM with Director of Nursing (DON/ Staff #109), who stated that no one is allowed to have any over the counter medication left on beside even if it is Omeprazole. She also stated strictly no medication can be allowed on beside. She stated that resident is not allowed to self-administer medication unless they have been assessed. She stated if they are assessed and able to self-administer - then the resident would be given knowledge on how safely administer medication and knowledge of the medication, then physician orders the medication, and it will be care planned. She stated that risk of having omeprazole or medication left on bedside the staff member would not know what medication the resident is taking or interaction with the medication that the facility was providing. Reviewed the policy titled Self-Administration of Medications Revised date May 2025 revealed that to participate in self-administration drugs, the interdisciplinary team will assess and periodically re-asses the resident based on change in the resident's status. If resident is a candidate for self-administration of medication, a physician's order for self-administration of medications or for specific medication. Review of policy titled Quality of Life revised April 2025 revealed avoid leaving in the resident's room any medication that might cause harm.

Based on review of clinical record review, staff interviews,facility policy and procedure, the facility failed to ensure incontinence care was provided for one resident (#3). The deficient practice could result in residents not receiving necessary care and services to maintain good grooming and personal hygiene Findings include: Resident #3 was admitted on [DATE] with diagnoses that included dysarthria following unspecified cerebrovascular disease, facial weakness, hemiplegia and hemiparesis, dysphagia following cerebral infarction, muscle weakness, anxiety disorder, and depression. A physician order dated February 10, 2022 included to apply barrier cream to buttocks every shift and as needed for incontinent episodes and preventative measures. The bowel/bladder incontinence care plan was initated on February 10, 2022 with a goal that the resident would remain free from skin breakdown due to incontinence and brief use. Interventions included using disposable briefs and changing them every shift and as needed, encourage fluids during the day to promote prompted voiding responses, establish voiding patterns, and check as required for incontinence. A care plan initiated on February 10, 2022 revealed the resident had the potential for pressure ulcer development related to decreased mobility. The goal was that the resident would have intact skin and be free of redness and blisters. Interventions included applying barrier cream as ordered, encourage fluid intake, assist to keep skin hydrated and daily body checks. The admission Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 12 indicating resident had a mild cognitive impairment. The assessment included the resident was frequently incontinent of urine and bowel, was not on a toileting program, required extensive physical assistance with bed mobility, transfers, toilet use and personal hygiene. Review of the medication administration record (MAR) for May 2022 revealed no documentation the barrier cream was applied to the buttocks on May 9 (night shift) and 11 (day shift). The documentation survey report for May 2022 revealed that the tasks on personal hygiene, bed mobility, bowel and bladder continence and toilet use were not marked as completed on May 3, 8, 14, 23, 28, and 29. The clinical record revealed no evidence that abovementioned tasks were provided to the resident on the dates not marked as completed in the report. During an interview conducted on December 20, 2022 at 3:34 p.m. with a certified nursing assistant (CNA/staff #21) who stated that resident #3 was incontinent, needed his brief changed between 3 and 5 times a shift and needed assistance with a lot of his care. The CNA stated the resident was receptive to care and never refused care from her. An interview with a registered nurse (RN/staff #69) was conducted on December 21, 2022 at 10:41 a.m. The RN stated that resident #3 was incontinent of bladder and bowel many times during the shift and was encouraged to help with his ADLs (activities of daily living); but, the resident was never out of bed for her. During an interview conducted with the Director of Nursing (DON/staff #73) on December 21, 2022 at 11:57 a.m., the DON stated the expectation was for staff to provide continence care, to round on the residents every couple of hours, provide toileting before bed and to document care in the clinical record. A facility policy titled Incontinent Care reviewed May 2022 included that it is the policy of this facility to remove urine and feces from skin, check for incontinent episodes and offer throughout the shifts based on resident needs, cleanse and lubricate skin. The procedure includes to document the care in the resident record.

Based on review of clinical record review, staff interviews, facility policy and procedure, the facility failed to ensure wound care and treatment was administered as ordered for one resident (#1). The deficient practice could result worsening of the wound. Findings include: Resident #1 was admitted on [DATE] with diagnoses of orthopedic aftercare following surgical amputation, acquired absence of left leg above knee, peripheral vascular disease and local infection of the skin and subcutaneous tissue. A care plan initated on November 11, 2022 revealed the resident had an actual impairment to skin integrity with potential for further impairment related to decreased mobility related to left AKA (above the knee amputation) surgical wound. The goal was that the resident would not have any complications related to the left AKA incision with wound vac. Interventions included to administer treatment per orders, observe effectiveness, identify/document potential causative factors and eliminate/resolve where possible, and follow facility protocols for treatment of injury. The provider order dated November 14, 2022 revealed an order for a NPWT (Negative Pressure Wound Therapy) to left AKA at 125 mmHg (millimeters of mercury) continuously; check proper settings and function; change canister as needed; patch leaks as needed with drape. If unable to maintain good seal or if [NAME] bleeding occurs, stop NPWT and remove dressing; loosely pack with damp gauze with 1/4 strength Dakin's solution and cover with dry dressing; and, notify physician and wound care team every shift. Another physician order dated November 15, 2022 included for NPWT to left AKA at 125 mmHg continuously; check proper settings and function; change canister as needed; patch leaks as needed with drape. If unable to maintain good seal or if [NAME] bleeding occurs, stop NPWT and remove foam dressing; clean with NS (normal saline) or wound cleanser, pat dry and cover with dry dressing and secure; and to notify physician and wound care team every shift for surgical site. The admission Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 14 indicating the resident had intact cognition. The assessment included that resident required extensive physical assistance with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. A provider note November 21, 2022 revealed that the left lower extremity had a significant edema (swelling) within the thigh and over the recent AKA (above the knee amputation) stump. The note included the wound vac was removed for examination and there was significant leakage through the adhesive and poor suction on the sponge dressing. Per the documentation, the skin around the distal thigh was macerated and there was thin serosanguineous drainage from the central and lateral aspect of the wound. Further, the note included the wound vac had not been functioning appropriately; and that, the provider spent a great deal of time cleaning and prepping the wound and reapplying the wound vac. The physician order dated November 21, 2022 included for doxycycline hyclate (antibiotic) Tablet 100 mg (milligram) give 1 tablet by mouth two times a day for left stump cellulitis for 5 days. A daily skilled note dated November 24, 2022 written by a licensed practical nurse (LPN/staff #13) included that the resident had a +4 pitting edema to the left AKA with serosanguineous weeping. The note included the wound vac had no suction and an attempt was made to replace the wound vac; however, the staff was unable to due to moisture. Per the note, dry dressing and gauze with calcium alginate for absorption was applied to the wound. The clinical record revealed no documentation that the physician or the wound team was notified that the wound vac was removed on November 24, 2022. A daily skilled note dated November 25, 2022 included the resident had a wound vac to the left AKA surgical wound and that, the resident responded to treatment. The documentation also included that the wound vac dressing was not holding pressure and had to be replaced. The clinical record revealed no documentation that the physician or the wound team was notified that the wound vac dressing was not holding pressure and had to be replaced on November 25, 2022. A nursing note dated November 26, 2022 at 10:57 a.m. revealed that the wound vac dressing was unable to maintain a good seal or adequate suction despite numerous attempts to seal the dressing. Per the note, the wound vac was stopped and the foam dressing was removed; and that, the incisin was cleansed with wound cleanser, patted dry and covered with dry dressing and absorbent pads and secured with tape. Further, the documentation included that a supervisor was notified. An eMAR (electronic medication administration record) note dated November 26, 2022 at 4:42 pm included that the left stump remained with the wound vac in place at 150 mm Hg. However, there was no evidence found in the clinical record that the order was changed for the wound vac suction setting from 125 mmHg to 150 mmHg. An eMAR note dated November 27, 2022 revealed the resident had a wet to dry dressing applied to the left AKA surgical incision. The MAR for November 2022 revealed the application of NPWT was not marked as administered on November 26 (day shift) and 27, 2022. There was no evidence found in the clinical record the physician or the wound team was notified of the wound vac not administered as ordered on November 26 (day shift) and 27, 2022. A nursing note dated November 28, 2022 revealed there was a dark tissue noted to left stump and the provider was on site and ordered to have the resident sent to the hospital ER via 911. Per the documentation, the family was notified of the transfer. A physician order dated November 28, 2022 included to send resident to the ER (emergency room ) for evaluation and treatment via 911. A progress note dated November 28, 2022 revealed that the provider received a call from an NP (nurse practitioner) and a subsequent photo of change in resident's surgical stump. The note included that it needed to be addressed immediately in a hospital; and that, the provider recommend to send the resident to the hospital. An interview was conducted on December 21, 2022 at 8:23 a.m. with the wound nurse (staff #15) who stated that wound vac's should be monitored every shift to ensure they have a seal and the suction was set to the proper level ordered. Staff #15 stated staff are trained to re-enforce the dressing or apply a new one if there was a leak in the wound vac. Staff #15 stated if they cannot get it to maintain good suction they should call the wound team or the provider. Regarding resident #1, the wound nurse said that the resident had a lot of drainage from his surgical wound and it would fill up the small canisters on the wound vac quickly. Staff #15 stated that as long as the canisters were changed regularly, the dressing would not become saturated and it would maintain a good seal; and that, the facility made sure to have back up canisters in the room and at the nursing station to avoid fluid back up into the dressing. Staff #15 said that the issue of excessive fluid was identified on the day of resident #1's admission and a more advanced dressing (dermatack) was used for the drape to stick better to the wounds surrounding tissue. Further, the wound nurse said that she was never called or notified when resident #1 had issues with his wound vac or when there were periods when the wound vac was not in place. During a phone interview with a licensed practical nurse (LPN/staff #13) conducted on December 21, 2022 at 10:04 a.m. the LPN stated that resident #1's wound vac was not draining; and, she had to redo the dressing because when she came on shift the wound vac was not in place. The LPN said she did not know how long the wound vac had been off the resident but the bed was saturated from the night shift. Staff #13 stated she could not get the wound vac to function properly; and, she was not given any information on how to use the wound vac or how to apply it to the resident. An interview was conducted on December 21, 2022 at 11:48 a.m. with another LPN (staff #71) who stated that the suction on a wound vac is set as ordered by the provider; and that, when leaving the room she ensures there are no beeps on the wound vac and that the suction is good. Regarding resident #1, the LPN stated that the resident had a lot of seeping; and that, the canisters on the vac needed changed every couple hours. Regarding her documentation of suction setting of 150 mmHg, staff #71 stated she does not know why she documented that the wound vac was set at 150 mmHg without a physician order. During an interview conducted with the Director of Nursing (DON/staff #73) on December 21, 2022 at 11:57 a.m., the DON stated the expectation was for staff to apply the wound vac properly and monitor that it is functioning during the shift. Regarding resident #1, the DON stated that the resident needed his wound vac to be reapplied constantly and staff made attempts to reinforce the dressing. The DON stated there were extra canisters available in the resident's room and at the nursing station because resident's canisters were filling so fast. Further, the DON stated the expectation was for staff to follow the provider orders for wound care; and that, any issues are communicated with the providers and documented in the clinical record. A facility policy titled Wound Management reviewed May 2022 included to monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure assistance in obtaining dental care and services was provided to one resident (#4). The deficient practice could result in residents not receiving dental care needed. Findings include: Resident #4 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, alcohol abuse, severe protein-calorie malnutrition and unspecified dementia. A physician order dated May 6, 2022 included that the resident may have dental care/service as needed. A nurse practitioner (NP) note dated May 9, 2022 included the resident had dental caries and pain when eating. According to the documentation, the resident had a dry mouth, was encouraged to push fluids and to receive oral care. Plan was to follow up with a dentist for poor dentation. Further, the note included that if the resident has fevers or persistent leukocytosis, dentation may be the source of infection. A physician progress note dated May 9, 2022 revealed the resident assessment and plan included to follow up with a dentist for poor dentation. However, review of the clinical record revealed no evidence that a dental order or appointment was made. Another NP note dated May 11, 2022 continued to include that the resident had dental and pain when eating. According to the documentation, the resident had a dry mouth, was encouraged to push fluids and to receive oral care. Plan was to follow up with a dentist for poor dentation. Further, the note included that if the resident has fevers or persistent leukocytosis, dentation may be the source of infection. A nutrition admission evaluation dated May 11, 2022 revealed the resident was on a regular mechanical soft texture, thin fluid consistency, and no supplements ordered. The assessment included the resident had her own upper and lower teeth with some missing on both upper and lower; required extensive assistance with dining in the resident's room; and, needed an altered diet related to chewing ability as evidenced by some missing teeth. Diagnosis included dementia and dehydration. The admission Minimum Data Set (MDS) assessment dated [DATE] included that resident #4 did not have any broken or loosely fitting dentures, no natural teeth or tooth fragments; and, had coughing or choking during meals and complaints of difficulty or pain when swallowing. An eMAR (electronic medication administration record) notes dated May 13 and 14, 2022 included the resident was medicated with Ultracet (analgesic/narcotic) 37.5-325 mg (milligram) for pain everywhere. An eMAR note dated May 29, 2022 revealed the resident was complaining of loosing a tooth on the right-side lower jaw; and that, the physician was notified. A care plan was initiated on May 30, 2022 for oral/dental health problems related to missing/loosing teeth. The goal was that the resident would comply with mouth care at least daily. Interventions included to coordinate arrangements for dental care, monitor/document/report to the physician as needed for signs and symptoms of oral/dental problems and provide mouth care. Despite being care planned, documentation of pain, complaints of losing and missing teeth and physician recommendation to follow-up with a dentist for poor dentation, there was no evidence found in the clinical record that a dental appointment or referral was set or made for resident #4. Further review of the clinical record revealed resident was discharged from the facility on May 31, 2022. A discharge note dated May 31, 2022 revealed the resident was discharged home; and that, all medications, scripts and discharge instructions were provided and reviewed with resident and family. Further, the note included the resident was instructed to follow up with PCP (primary care physician). However, the documentation did not include dental referral or appointment. An interview was conducted on December 20, 2022 at 12:33 pm with Social Services/Case Manager (staff #58) who stated that if a resident needed an urgent dental service related to pain or infection, the dental referral would be initiated within three days. Staff #58 stated there was no dental referral made for resident #4 because there was no specific order for a dental consult. A phone interview with an NP (staff #65) was conducted on December 21, 2022 at 9:51 a.m. The NP stated resident #4 was admitted with poor dentation and there was some concern for infection. Staff #65 stated there were orders for oral care; however, she does not remember the resident complaining of any pain or anything related to her teeth. Further, the NP said that she was never notified of any loosing teeth; and, at the time she felt outpatient dental care would be fine. During an interview with the Director of Nursing (DON/staff #73) conducted on December 21, 2022 at 11:57 a.m., the DON stated resident #4 had poor dentation but it was not an issue for her. The DON stated that if she was having tooth pain or an infection, a physician order would have been entered and the resident would have seen a dentist. Further, the DON stated that if the provider thought the resident could wait and follow up with a dentist after discharge they would have noted that as well in the clinical record. A facility policy titled Dental Services reviewed January 2022 included that it is their policy to ensure that residents who require dental services on a routine or emergency basis have access to such services without barrier. Emergency dental services include services needed to treat an episode of acute pain in teeth, gums, or palate and broken or otherwise damaged teeth or any other problem of the oral cavity that required immediate attention by a dentist. If a referral for dental services does not occur within three business days from the date of loss/damage, the facility will document what actions were taken to ensure the resident could eat, drink and communicate adequately while awaiting dental services.

Based on observation, clinical record review, staff interviews, and facility policy and procedure, the facility failed to ensure infection control measures were implemented as required for one resident #105, and failed to ensure one staff wore the face mask appropriately. The deficient practice could result in spread of infection to staff and residents. Findings include: Regarding the face mask On March 28, 2022 at 2:50 p.m., two female staff and one male staff (A) wearing their face masks were observed walking together from the reception area to the kitchen/dining room. At the end of the hallway just before the kitchen/dining room, another male staff (B) wearing a white shirt and tan pants was observed standing and holding a folded box carton. The male staff (B) then started talking to one of the female staff who was walking down the hallway. However, the male staff (B) was observed with his facemask positioned down his chin with his nose and mouth not covered the whole time he was talking with the female staff. An interview was conducted on March 31, 2022 at 1:11 p.m. with a unit secretary (staff #70), who stated that every person i.e. staff and visitors that enters the building must have their masks on at all times while inside the building. In an interview with a Licensed Practical Nurse (LPN/staff #28) conducted on March 31, 2022 at 1:18 p.m. The LPN stated that face masks must be worn at all times while inside the building, and that the mask should be worn to cover the nose and the mouth. She stated that when the mask is worn under the chin or one loop is not on the ears or the mask does not cover the nose, it is considered inappropriate use of the face mask. The LPN said the only time staff can remove the mask is when they are in the staff break room eating their food. During an interview with the Infection Preventionist (staff #99) conducted on March 31, 2022 at 2:28 p.m., she stated that a mask should be worn when any employee, vendor and/or visitor enter the facility, and that masks should be worn with both straps on, fitted to the face, and should cover the nose and the mouth. Regarding resident #105 Resident #105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident was cognitively intact. The assessment indicated that the resident had a diabetic foot ulcer that required ointments and dressings. A physician order dated March 4, 2022 stated wound culture to the left foot. Review of a wound culture result indicated it was collected from the resident's wound on the left lower extremity on March 4, 2022, and was reported to have moderate growth of staphylococcus aureus and carbapenem-resistant Enterobacteriaceae (CRE) [CONDITION(S)] pneumoniae on March 14, 2022. The Nurse Practitioner (NP/staff#147) event note dated March 15, 2022 stated the wound culture has resulted and is positive for moderate growth of E. faecalis sensitive to Penicillin and [MEDICATION(S)], moderate growth CRE [CONDITION(S)] pneumonia, moderate growth MSSA ([CONDITION(S)]-susceptible Staphylococcus aureus). Current antibiotic regimen with [MEDICATION(S)] and [MEDICATION(S)] adequate coverage for E. faecalis and MSSA. No options at facility for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident census for March 2022 revealed that resident #105 was in a semi private shared room with a resident on March 1, 2022 until March 19, 2022. Further review of the March 2022 census revealed that resident #105 was moved to a private room on March 19, 2022. A physician order dated March 21, 2022 stated change of condition for contact isolation for CRE in left foot and intravenous (IV) antibiotics for [CONDITION(S)] to left foot until April 16, 2022. An interview was conducted on March 31, 2022 at 1:44 PM with a Registered Nurse (RN/staff #18). The RN stated that there is a dashboard in the computer charting system that notifies the nursing staff of new lab results. She stated that it is the nurse's responsibility to review the lab result and notify the physician. The RN stated that lab result reports such as wound cultures are reported to the facility staff typically in the morning. The RN stated that if an abnormal lab result or wound culture was resulted and indicated an infectious disease, then the resident should be placed in isolation. The RN stated that if the physician did not give orders for isolation and she knew the resident had an infectious disease, then she would notify the Director of Nursing (DON). Staff #18 stated for a wound that is infectious, the resident should be placed into a private room as soon as possible. The RN stated that if the resident's wound culture result was reported on March 14, 2022, then the resident should have been placed in isolation right away because of the CRE in the wound. The nurse stated that she suspected that resident #105 was not compliant with the dressing on the left leg. She explained that the resident knows how to remove the boot because the resident instructs the nurses how to do it. The RN stated that when she further assessed the dressing that the dressing appeared to be ball up and looked like it was rearranged. The nurse stated that if it took the facility 5 days to place the resident on isolation precaution and move the resident to a private room, it would be too long as there is a potential risk for infection to spread to staff and other residents. An interview was conducted on March 31, 2022 at 2:30 PM with the RN Infection Preventionist (IP/staff #99). The IP stated that when a floor nurse receives lab results, they should review the results and notify the physician. She further explained that if the nurse does not understand the result or is unfamiliar with the lab or wound culture result, then they should ask the charge nurse or the IP. Staff #99 stated that she and the DON run reports twice a week to review labs. She stated that a part of her role as an Infection Preventionist is mapping infections and looking at orders and progress notes. The IP stated that if a wound culture is abnormal, the nurses should notify the provider and isolation precautions should start very soon after. She stated, four or five days later is too long for an infectious disease. The IP reviewed the resident #105's clinical record and stated that the resident was moved to a private room on March 19, 2022. Additionally, the IP stated while staff should use standard precaution with all wounds, there is a risk to spread infection to others in the facility. An interview was conducted on March 31, 2022 at 2:57 PM with the DON (staff#142). The DON stated that if an abnormal lab result or wound culture was resulted and received, then the nurse should notify the provider and the provider should provide new orders. The DON stated that if the provider orders a resident to be placed on isolation precautions, then the facility staff should get the room set up and transfer the resident to the private room as soon as they receive the physician order to do so. The DON stated that when she reviewed the census sheet for room changes on Monday March 21, 2022, it was revealed resident #105 had been moved from a semi private room on March 19, 2022 to a private room over a weekend. Further she stated she reviewed the NP note that was entered late and noticed that the resident should be placed on contact precautions. The DON stated she entered the physician's order on March 21, 2022. The DON stated that the standard of practice that occurred in this case does not meet her expectations. Another interview was conducted on April 1, at 8:20 AM with DON (staff#142). The DON stated that the resident was moved on March 19, 2022 because the nurse manager spoke with the infectious disease physician and the physician directed the nurse supervisor to move the resident and place the resident on contact precautions. The DON stated there was no physician's order entered into the resident's clinical record until March 21, 2022. The DON stated that she went back and spoke to the RN (staff #18) about the resident being non-compliant and picking at the dressing. The DON stated that staff #18 confirmed to the DON that yes, she thought the resident picked at the dressing. The DON stated that her expectation of the nurse is to document and notify the provider because there is further increased risk to spread infection. The DON stated that if the resident's wound culture result came in on March 14, 2022 and was determined as infectious, she expects the nurses to talk to the physician. Further, the DON stated that she would expect the Infection Preventionist to challenge why the resident was not on precautions once she reviewed the wound culture. The DON stated that not placing the resident on contact precautions was possibly missed because the resident was not on any antibiotics and that is usually where she and the IP catch new infections because they do not review every lab specifically. The DON stated that for the duration, the resident was not in isolation and had an infectious disease. She stated she did not believe there was an increased risk to staff or the resident's former roommate because they follow standard precautions and their policies and procedures. The DON stated that if it took 3 or 4 days for the resident to be placed into contact isolation, then no that does not meet her expectation for infection prevention of an infectious disease. The facility's policy titled Infection Prevention and Control Program with subject transmission-based precautions and isolation revised January 2022, stated it is the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. It is appropriate to individualize decisions regarding resident placement (shared or private), balancing infection risks with the need for more than one occupant in the room, the presence of risk factors that increase the likelihood of transmission, and the potential for adverse psychological impact on the infected or colonized resident. It is therefore appropriate to use the least restrictive approach possible that adequately protects the resident and others. Multidrug Resistant Organisms ([CONDITION(S)]) includes CRE. Prevention and control of [CONDITION(S)] included contact isolation. Room Placement will depend on the epidemiology of the specific microorganisms, the ability of the resident to assist in confining and containing the microorganisms and the temporal relationship of the known infected or colonized residents to newly identified cases. If Standard Precautions are applied universally to all residents, placing [CONDITION(S)] residents in private rooms or cohorting becomes a secondary infection control measure. Roommates exposed to a [CONDITION(S)] positive resident will not be subject to a surveillance culture unless evidence of active infection is present. The policy stated that however, residents exposed to [CONDITION(S)] positive roommates will be observed and monitored for 72 hours to rule out possible [CONDITION(S)] infection.

Based on clinical record review, staff interviews, facility documents, and policy review, the facility failed to ensure one resident (#425) and/or their representative were informed of the risks and benefits of a [CONDITION(S)] medication prior to receiving the medication. The sample size was 6. The deficient practice could result in residents and/or their representatives not being aware of the risks and benefits of psychoactive medications. Findings include: Resident #425 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was discharged from the facility on February 13, 2022. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on February 9, 2022. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, further review of the clinical record revealed no evidence the resident or the resident's representative were informed of the risks and benefits of receiving [MEDICATION(S)] prior to the medication being administered. An interview was conducted on March 30, 2022 at 1:50 PM with a Licensed Practical Nurse (LPN/staff #146). The LPN stated that if any resident is on a [CONDITION(S)] medication there has to be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that it is important to obtain a consent from the resident because it is the resident's right to be informed of the side effects and risks related to the drug class. Staff #146 stated that if the resident or representative refused to sign the consent, then the form would be signed as refused and the physician would be notified. An interview was conducted on March 30, 2022 at 2:06 PM with the Director of Nursing (DON/staff #142) The DON stated that when a resident has been ordered a [CONDITION(S)] medication, the expectation is that staff would ensure there is an appropriate diagnosis, review the risks and benefits of the medication with the resident or the representative, and obtain consent for the medication. The DON stated that it is important to obtain consent prior to the administration of a [CONDITION(S)] medication because a resident has a right to be informed and to know the risks and side effects, and to make an informed choice for their health or beliefs. The DON stated that [MEDICATION(S)] is an antidepressant [CONDITION(S)] medication and would require consent prior to administering the medication. The DON stated that after review of resident #425's clinical record, the facility was unable to provide evidence that the facility obtained informed consent for the administration of a [MEDICATION(S)] prior to the medication being administered 4 times. Further, the DON stated that the quality improvement team (QIT) had noticed that these consents for [CONDITION(S)] medications had been an issue with non-compliance and on February 17, 2022, a plan was implemented to correct the non-compliance. Review of the facility's quality improvement documentation for psychoactive medications revealed the facility had identified a problem with inconsistent documentation for psychoactive medications that included consents not being obtained timely when initiating psychoactive medications. The documentation included an in-service was provided on February 17 & 18, 2022, the content of the in-services, and audits conducted on February 17 & 23, 2022 and March 1, 9, 16, 24, and 29, 2022. The facility's policy titled [CONDITION(S)] Drug Use, revised November 2021, revealed informed consent is an educational process that must take place between the facility and the resident. Residents prescribed [CONDITION(S)] medications will be referred to the facility's [CONDITION(S)] Drug Review Committee and/or the Psychiatrist to ensure informed consent is obtained prior to medication use.

Based on observation, clinical record review, resident and staff interviews, and policy and procedures, the facility failed to ensure one resident (#34) had the right to self-determination by failing to honor the resident request to eat breakfast in the dining room. The sample size was 26. The deficient practice could result in residents being denied their right to make their own decisions. Findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the current care plan initiated on June 25, 2014 revealed the resident requires extensive assistance, dependence on staff for activities of daily living (ADL) due to [CONDITION(S)] and contractures to both upper extremities. The goal stated the resident's ADL needs will be met by staff. Interventions included assistive dining for all meals and for staff to anticipate and meet the resident's needs. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. It also included that the resident was not delusional and did not hallucinate. The assessment included the resident requiring extensive two-person assistance with bed mobility and transfers, extensive one-person assistance with dressing, and was totally dependent for eating. On March 30, 2022 at 7:55 a.m., resident #34's call-light above the resident's door was on. A male staff member was observed answering the call-light at 7:59 a.m. On March 30, 2022 at 8:07 a.m., meal trays were observed being served to resident #34 and resident #34's roommate in their room. On March 30, 2022 at 8:09 a.m., an interview was conducted with resident #34. Resident #34 stated that he had pushed the call-light earlier that morning, and told staff that he wanted to get up and go to breakfast. The resident stated the staff left the room and did not return. It was observed that resident #34 was still in bed, not dressed and the resident's food tray had been left on a mobile tray on the left side of the bed. Resident #34 said he needed help with eating. On March 30, 2022 at 8:19 a.m., a female staff member was observed entering the resident's room with a drink in her hand and shutting the door. The MDS nurse (staff #31) was interviewed on March 30, 2022 at 9:09 a.m. He stated that he was helping out on the 400 Hall this morning with answering call-lights and assisting with meal time. He said that he answered resident #34's call-light earlier that morning and the resident wanted help with getting dressed, and getting up in the wheelchair, so he could go to breakfast in the dining room. Staff #31 said that he announced over the radio that resident #34 wanted to get up, get dressed and go to breakfast, but that he does not know if the Certified Nursing Assistants (CNAs) responded. He stated that if a resident wants to get up, get dressed and go to breakfast, it is his/her freedom of choice to make these decisions. Staff #31 stated that he did not know if there was an impact on a resident who is not allowed to get up, get dressed, and eat with other residents in the dining room. On March 30, 2022 at 9:22 a.m., an interview was conducted with two CNAs (staff #64 and staff #68) in the resident's room. Staff #64 stated that the resident usually gets up, gets dressed, and goes to breakfast in the dining room. It was observed that both staff had radios and they stated that their radios had been on, but they did not hear a message this morning saying that resident #34 wanted to get dressed. Both staff members stated that the resident had eaten breakfast in his room and they had just finished helping the resident get dressed and get up. Resident #34 was observed sitting in the wheelchair. An interview was conducted on March 30, 2022 at 9:39 a.m. with the Director of Nursing (DON/staff #142), who stated that staff are expected to answer the call light as soon as possible. Staff #142 stated staff are supposed to address the resident's needs if possible and, if staff need help, staff is responsible for calling for help on the radio. She said the facility's process for staff members is to call for help and wait for a response from staff over the radio, and if there is no response, staff should seek out staff to assist. She also stated that staff #31 was helping with tray service and answering call-lights this morning. The DON stated that he does not remember staff #31 calling out over the radio for help with resident #34. She said as the DON, she does listen to the radio and would follow-up if no other staff responded. She said the residents have the right to make choices, such as getting dressed, getting up, and eating in the dining room. The DON stated resident #34 may feel ignored and that the resident usually does eat in the dining room. The facility's policy, Resident Rights, stated that as a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to be treated with respect and dignity including the right to reside and receive services in the facility with reasonable accommodation of your needs and preferences except when to do so would endanger your or other residents' health or safety. The policy also stated the resident has the right to self-determination through support of their choice, including the right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with their interests, assessments, plan of care, and make choices about aspects of their life in the facility that are significant to the resident.

Based on observations, clinical record review, resident and staff interviews, and policy and procedures, the facility failed to ensure Ted Hose were applied to one of two sampled residents (#113) as per the physician order. The deficient practice could impact the health and wellbeing of residents. Findings include: Resident #113 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. It also included that the resident did not refuse care during the lookback period. A Nurse Practitioner (NP) progress note dated March 28, 2022 stated that the NP discussed elevation and compression of edematous extremities with the resident's nurse. [CONDITION(S)] improved, resident with 1+pitting [CONDITION(S)] with some retraction to lower extremity. Review of the Treatment Administration Record (TAR) for March 2022 revealed no evidence the anti-embolism stockings/TED hose or equivalent were applied on March 30 and 31, 2022. Review of the progress notes for March 28 through March 31, 2022, did not reveal evidence the resident refused to wear the Ted hose. During the initial interview conducted with resident #113 on March 28, 2022 at 1:37 p.m., it was observed that the resident was not wearing a Ted hose on the bilateral left extremity while in bed. On March 29, 2022 at 10:22 a.m., the resident was observed not wearing Ted hose while in bed. On March 30, 2022 at 11:16 a.m., the resident was observed not wearing Ted hose while in bed. An interview was conducted on March 30, 2022 at 11:16 a.m. with a Licensed Practical Nurse (LPN/staff #48), who stated that Ted hose are normally put on by the nurse and if the resident refuses to wear the Ted hose, she would document the refusal in the progress note/MAR (Medication Administration Record). Then, she reviewed the MAR for March 2022 and the progress notes and stated that she could not find any documentation saying the resident refused to wear the Ted hose. On March 30, 2022 at 11:26 a.m., an interview was conducted with a Certified Nursing Assistant (CNA/staff #144), who stated that he knows the resident and has worked with the resident at least 6 times. The CNA stated that he has never seen the resident wearing Ted hose. Then, the CNA spoke to the resident and observed that the resident was not wearing the Ted hose. The resident told the CNA that he has not worn the Ted hose for at least a week and does not know if he is still supposed to be wearing them. The resident stated that he would wear the Ted hose if he is supposed to wear them. Staff #144 said he would follow-up on the Ted hose. On March 30, 2022 at 12:12 p.m., staff #144 stated he went to central supply and got a new Ted hose for the resident. An interview was conducted on March 30, 2022 at 12:13 p.m. with an LPN (staff #143). He reviewed the resident's TAR and said the resident was supposed to have Ted hose on, and observed that the Ted hose was not on. The LPN said that it is his understanding that the Ted hose should have been put on that morning, but the CNA did not know that the resident was supposed to wear the Ted Hose. The LPN stated that he would be making a note that the Ted Hose were not put on the resident and that new ones were retrieved by the CNA. The Director of Nursing (DON/staff #142) was interviewed on March 30, 2022 at 12:51 p.m. She said the nurses are supposed to put the Ted hose on the residents, and that an order is needed. Staff #142 stated the Ted hose are usually put on during the first medication round and the first round starts at 8:00 a.m. The DON stated it is her expectation that staff notify her or go to central supply to get the Ted hose if needed. She said, if a resident refuses to wear the Ted hose, staff should document the refusal on the MAR, notify the provider, and document in a progress note that the resident was educated on risks and benefits regarding the Ted hose. The DON stated that there is a risk of [CONDITION(S)] if Ted hose are not put on. The facility's policy, Anti-embolic Stocking (Elastic Stockings, Ted Hose), reviewed April 2021 stated it is the policy of the facility to provide support for lower extremities and to aid return circulation from lower extremities as needed. Observe the resident for signs and symptoms of circulatory problems, including color of toes, temperature, pain, and [CONDITION(S)]. Remove stockings as ordered or at least once every shift, unless contraindicated, to inspect the condition of skin. The facility's policy, Physician Orders, revised August 2021 stated it is the policy of this facility to accurately implement orders in addition to medication orders (treatment procedures) only upon the written order of a physician duly licensed and authorized to do so in accordance with the resident plan of care.

Based on observation, clinical record review, resident and staff interviews, and policy and procedures, the facility failed to ensure a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in residents receiving unnecessary oxygen treatment. Findings include: Resident #113 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The assessment also included the resident did not receive oxygen therapy while at the facility during the lookback period. A review of the Daily Skilled Note dated March 18, 2022 revealed under respiratory, oxygen via nasal cannula was administered while a resident and was set at 2 liters. Review of a Daily Skilled Note dated March 23, 2022 revealed the resident's oxygen saturation was 95% and the Method: was oxygen via nasal cannula. A Daily Skilled Note dated March 25, 2022 revealed the resident's oxygen saturation was 92% and that the Method: was oxygen via nasal cannula. A Daily Skilled Note dated March 29, 2022 at 9:37 a.m. stated the oxygen saturation was 96.0 % and Method: oxygen via nasal cannula. However, review of the clinical record did not reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On March 28, 2022 at 1:31 p.m., the resident was observed receiving oxygen via nasal cannula, while lying in bed. The oxygen concentrator was between 3-4 liters. The resident stated that he was not sure how many liters of oxygen was supposed to be administered. An interview was conducted on March 30, 2022 at 11:16 a.m. with a Licensed Practical Nurse (LPN/staff #48). She reviewed the resident's orders and stated that she did not see an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said, since the resident's oxygen level was at 96%, this was not an emergency situation and there should have been an order for [MEDICAL RECORD OR PHYSICIAN ORDER] On March 30, 2022 at 12:56 p.m., an interview was conducted with the Director of Nursing (DON/staff #142). She stated that an order is needed prior to administering oxygen to a resident. She said staff would administer oxygen if the resident was having desaturation, below 90% oxygen saturation, and would contact the physician. Then, she reviewed the progress note dated March 29, 2022 at 9:37 a.m. and stated that the note says the resident received oxygen via cannula and the oxygen saturation was 96%. She also said that the note should have included that the physician was contacted. The facility's policy, Oxygen Therapy, reviewed July 2021 stated it is the policy of this facility that oxygen therapy is administered by a licensed nurse as ordered by the physician or as a nursing measure and in an emergency measure until the order can be obtained.

Based on clinical record review, staff interview, and facility policy review, the facility failed to provide food in a form to meet one resident's (#213) needs. The sample size was one. Findings include: Resident #213 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Prior to admission, the resident had been in the hospital. According to the hospital consultation report dated March 7, 2012, the resident had left lower lobe pneumonia, most likely due to aspiration. The report further documented that the resident would need 24-hour rehabilitation nursing service, as well as speech therapy. Upon admission to the facility, the resident was being treated with antibiotics for pneumonia. Physician orders dated March 8, 2012, included that the resident was on a regular mechanical soft diet. Review of the interim care plans revealed no care plan had been developed to address the resident's dietary needs or aspiration risks. A review of the occupational therapy evaluation dated March 9, 2012, revealed the resident was able to feed self after set up utilizing regular utensils with minimal assistance. Review of the nursing notes dated March 10, 2012, revealed the following incident: At 12:30 PM the resident was in the dining room eating lunch assisted by the daughter. "Patient was eating a hot dog then patient noted having difficulty breathing at 12:45 PM. Restorative nursing assistant (RNA) began performing the [MEDICATION NAME] maneuver. Patient belched and began coughing. Patient was returned to room accompanied by daughter." The resident was returned to bed and noted to be cyanotic. The resident was able to speak at this time and told the nurse that he was all right. An oxygen saturation (O2 SAT) was obtained and read 7% room air. The resident was placed on an oxygen mask and his O2 SAT rose to 90% and then back down to 26% with wheezing noted. At 1:15 PM the resident was transferred to the hospital. A review of the hospital emergency room notes dated March 10, 2012, revealed the resident arrived at 1:50 PM. The following was documented: "[AGE] year old male with acute respiratory distress secondary to aspirating a hot dog. On my arrival to the room the patient had O2 SAT in the 50's-60's. I immediately opted to intubate. I did not see any large foreign body to remove however pieces of hot dog and hot dog bun were suctioned from and removed from the endotracheal tube post intubation." A review of the [MEDICAL CONDITION] consult notes dated March 10, 2012, revealed that the [MEDICATION NAME] found very thick and copious amount of secretions (remains of a hot dog was not documented). A review of the [MEDICATION NAME] consult report dated March 15, 2012, revealed the resident had been having difficulty with solid food for the last several years with recurrent aspiration pneumonia. The report further included the resident had been evaluated by dietary and a swallow evaluation deemed the resident was unsuitable to take anything by mouth, except a pureed diet. Recommendations included for a [MEDICAL CONDITION] tube placement. An interview conducted on October 18, 2012 at 11:00 AM with the licensed practical nurse (LPN) caring for the resident on that day revealed that she was not in the dining room when the choking occurred and was not knowledgeable regarding what form the hot dog was served. An interview with dietary staff conducted on October 18, 2012, revealed that if a resident was on a mechanical soft diet and requests a hot dog, it would be served in a chopped up form, not cut up. Staff explained the hot dog would be put through a machine that alters the texture to a mechanical soft consistency which is the size between a piece of corn and rice. An interview conducted on October 18, 2012, with the RNA who had performed the [MEDICATION NAME] maneuver on the resident and stated that he recalled that the resident had coughed up a piece of hot dog the size of a dime and that he thinks his daughter had been cutting up a hot dog for the resident to eat. The RNA stated that he had been concentrating on the resident and not what he was eating. A review of the facility policy regarding therapeutic diets, revealed that therapeutic diets were to be prepared and served according to written orders from the attending physician.

Based on observations, record reviews, policy and facility documentation reviews, and interviews, the facility failed to ensure that nine residents (#s 1, 2, 9, 13, 19, 20, 22, 24 and 28) with wound or skin conditions received necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. The concerns were identified to be present and ongoing throughout the past recertification survey. The expanded sample was 28. Findings include: -Resident #20 was admitted to the facility from an acute care hospital on January 21, 2009, with pertinent [DIAGNOSES REDACTED]. Despite the resident's high risk for wound complications and ongoing complaints of pain to the area, the left toe/foot area was not appropriately assessed or monitored, and therefore timely identification of wound deterioration did not occur. There was also a lack of follow-through with antibiotic therapy and no evidence that the resident was seen for follow-up by the surgeon, as ordered. On February 7, 2009, the resident had sudden onset of chest pain and severe anxiety which resulted in hospital transfer, at which time the resident's left foot was assessed and the condition required further amputation. The resident was admitted with hospital transfer information that revealed the resident had undergone a left toe amputation on January 20, the day prior to facility admission, for an ischemic left great toe with dry gangrene. An addendum to the hospital discharge summary included that the surgeon requested that [MEDICATION NAME] (antibiotic) 500 milligrams be administered the resident twice a day for 10 days. Documented on the addendum was that the facility was contacted on January 22, and the prescription was given to the nurse. The nursing admission assessment included that the resident had a left big toe amputation. There was no information on whether the surgical wound had sutures/staples, the incision line, the presence of drainage, the appearance of the foot, base of the toe and peri wound, or circulation/movement/sensation (CMS) assessments. The nursing narrative included that the resident's toe dressing was not changed (per resident request as it was done prior to being discharged from the hospital). Documented was that the wound would be measured upon the next dressing change. The admission orders [REDACTED]. The dressing was to be changed every day. admission orders [REDACTED]. The wound treatment was transcribed onto the treatment record; however, there was no evidence that the treatment was provided until January 23, two days after admission. There was no evidence that the wound was assessed, measured, or monitored. The care plan that identified the resident's risk for skin breakdown due to the surgical incision, amputation, and [DIAGNOSES REDACTED]. To meet this goal, an approach included to conduct weekly skin assessments and to notify the physician "of abnormal findings" as needed. The care plan that identified the resident's risk for infection (related to the amputation and surgical incision), included that staff were to "observe incision for s/s (signs/symptoms) of infection" and notify the physician of abnormal findings, as well as to follow-up with the surgeon "as ordered." There was also a care plan that identified the resident's alteration in comfort, due to pain related to the resident's toe amputation. The review of the nursing notes revealed the resident was alert and oriented, required assistance with functional activities, and was medicated at least daily with narcotic [MEDICATION NAME] for left foot pain. What the nursing narratives did not include were specific assessments of the resident's incision/wound area, surrounding skin condition, or CMS. The nursing notes dated January 24 and 25, included that the resident had [DIAGNOSES REDACTED]. This documentation was incorrect as the hospital information revealed ischemic toe with gangrene, that necessitated the need for amputation, not foot involvement. Therefore, the need for a comprehensive assessment of the resident's left foot/toe area was even greater in order to determine changes in condition. The nursing note dated January 29, included that the left foot treatment was done with no signs or symptoms of infection. However, there was no documented assessment of the wound or foot area. The review of the Pain Flow Sheets revealed that during the resident's 18 day stay, he was administered narcotic [MEDICATION NAME] 29 times. The reason documented for 28 times was for left foot/leg pain. There was no evidence that the resident was seen by the surgeon, ordered to be provided one week after admission, or that the [MEDICATION NAME] antibiotic was ever transcribed or administered. The nursing note dated February 7, 2009, included the sudden onset of left-sided chest pain, left arm numbness, and extreme anxiety. 911 was called and the resident was sent to the hospital. The emergency room (ER) report included that the resident had been having chronic left foot pain secondary to the toe amputation. The resident was nauseous, had fever and chills, and felt "achy" all over. The resident described his foot pain as "dull, deep-seated" which was moderate in intensity and exacerbated by movement. The ER assessment reflected that the resident had an "infected postoperative wound" to the left foot. Documented was that the wound had scant exudate with necrosis at the surgical site located at the stump area (base of the first toe). Also noted was a red streak from the wound up towards the resident's calf area. Infectious disease and vascular consultations revealed the presence of frank gangrene at the toe stump site, with [MEDICAL CONDITION] extending to the whole left foot and foul odor. Documented was "extensive discoloration and gangrenous changes," and myositis of the left foot with nonpalpable circulation. The resident subsequently underwent a left below knee amputation. During a family interview, it was reported that the resident had stitches to the incision area, and that family reported the presence of "black" substances at the site, that staff reported was dried blood. The family member stated the resident also had been experiencing chills and ongoing pain to the area, that were not reported to the physician. -Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial nursing data collection tool dated December 7 included the resident used an indwelling urinary catheter. Admission physician orders [REDACTED]. A pressure ulcer status form from the day of admission was started for a 4 centimeter (cm) tear to the penis. After the initial entry, there was no further documentation on the form. Also, no treatment for [REDACTED]. Review of the resident's December 15 care plan revealed identified problems with the use of an indwelling urinary catheter as well as skin breakdown, but did not include breakdown to the penis. A nurse practitioner (NP) note dated December 18 revealed the resident had been evaluated in the past for a suprapubic catheter, but had been deemed not a candidate due to scar tissue from abdominal surgeries. In addition, the note included the resident had chronic urethral meatus breakdown which was present prior to admission. Documentation from the resident's February 19, 2010 initial visit to a wound clinic (for evaluation of pressure ulcers located elsewhere) revealed no mention of the tear to the penis. Review of NP progress notes from February and March 2010 showed no mention of the tear on the resident's penis. Weekly skin integrity forms from April and May 2010 failed to include any documentation of breakdown to the penis. The May 2010 treatment record showed evidence that catheter care was being performed every shift. However, the clinical record failed to include any documentation as to the condition of the resident's penis. During an observation of catheter care on May 20, 2010, bleeding from the side of the resident's penis was observed. The direct care staff member stated the penis was "split." The split was measured at 4 cm long. In addition to that area, which was documented on admission as above, an open ulcer was observed, which measured 1.2 cm by 1.0 cm. Staff reported prior knowledge of the area, yet there was no documentation as such in the clinical record. The resident's nurse was then interviewed and said she had observed the bleeding open area the week prior when she had changed the catheter, and had notified the NP. According to the certified nursing assistant taking care of the resident, during an interview later in the day, the wound nurse had been present in the room two days earlier and had seen the split to the resident's penis. During an interview on May 20, the NP said she had seen the penis about two months prior, and in comparison it was now "dramatically different." She said the ulcer was caused by trauma from the catheter, and that she would need to order a suprapubic catheter procedure. Following that observation, the NP wrote orders for a suprapubic catheter to be placed secondary to a "worsening" split in the penile tissue, and for a treatment to the split of [MEDICATION NAME] daily. -Resident #22 resided in the facility from [DATE] until July 29, 2009. Pertinent [DIAGNOSES REDACTED]. The admission nursing assessment revealed the resident had cognitive deficits and was dependent upon staff for activities of daily living (ADLs). The resident was also admitted with a right arm peripheral intravenous (IV) line and with topical treatment to buttock and peri area excoriations. The nursing note dated July 18, 2009 at 10 a.m., included that the resident's right upper arm, lateral aspect, was red and "shiny," and was "weeping clear drainage." Documented was that a dressing was applied. There was no documented assessment regarding range of motion, pain, [MEDICAL CONDITION], or that the physician was notified. There was no order for the dressing and no evidence that the arm condition was monitored. The nursing note dated July 22, included that the resident's "L (left) arm swelling" was reduced throughout the day. There was no prior documentation about left arm swelling or clarification that this was a mistaken entry and the resident's right arm was swollen (in addition to being red, shiny, and weeping) as documented earlier. Per the Weekly Skin Integrity Data Collection entry dated July 23, 2009, the resident had an "old" area to the left upper arm. This weekly skin assessment form did not include any assessment of the resident's right arm area, nor any notations of buttock or peri and inner thigh area excoriations, that continued to be treated with zinc oxide. The IV line was discontinued on July 22. The review of the IV flow sheet revealed that a "0" was documented under the column for assessing the presence of phlebitis. Further review also revealed that a "0" had been documented on July 18, the same date the resident's right lateral arm was noted to be red "shiny" and weeping fluid. The physical therapy note dated July 28, included that the resident was noted to have swelling of the right anterior hand. There was no evidence that a further assessment was conducted. The occupational therapy note dated July 29, included that the resident complained of right wrist pain and that nursing was made aware. The nursing note dated July 29 at 6:15 a.m. included that the resident was complaining of pain to the right arm, from the wrist to elbow. Documented was that the resident's "arm to fingers" was swollen and painful to move. The physician's progress note, also completed on July 29, included that the resident's right elbow area was red, warm, swollen and tender. The physician ordered for the area to be x-rayed, and due to the abnormal x-ray findings, the resident was transferred to the ER. The hospital report included that the resident was originally admitted with new [DIAGNOSES REDACTED]. However, further tests showed an acute venous [MEDICAL CONDITION] within the right cephalic vein above the elbow. Staff were interviewed and unable to recall specifics regarding this resident's care due to the amount of time that had elapsed. However, staff reported that weekly skin assessments should reflect ongoing skin conditions and that physician notification was required for any skin issue that may require further interventions. -Resident #1 was admitted on [DATE], with pertinent [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The resident was assessed via the March 9, 2010 Minimum Data Set (MDS) assessment to be alert and oriented. The care plans, updated on March 9, indicated that the resident had chronic lower extremity [MEDICAL CONDITION] "with weeping" due to [MEDICAL CONDITION]. The goal for this care plan was for the resident to have "no more than one episode per week of weeping from bilateral lower extremities..." Approaches included to "observe for weeping and notify MD as needed." Another care plan, dated March 9, identified the resident's risk for skin breakdown due to incontinence, and "chronic weeping of bilateral lower legs. An approach to minimize the resident's risk for breakdown included to conduct weekly skin assessments and report the findings to the physician if needed. The review of the Weekly Skin Integrity Data Collection forms (weekly skin assessments) revealed an entry dated April 26, 2010, that the resident's bilateral lower legs were "scaly, red + swollen." Noted was that the areas were "old." The nursing note dated April 27 at 2 a.m., included that the resident's left foot was red from the mid-foot to the toe area, with warmth. Documented was that the physician was contacted and a course of antibiotics was ordered. The physician's progress note, dated April 28, included that the resident had chronic discoloration and texture changes to the lower extremities. Also documented was that the resident was currently on antibiotic therapy due to redness, warmth, and swelling to a small round lesion on the resident's left toe. Documented was that the lesion was due to an injury (the resident's toe got stubbed). Documented also was that there was a significant improvement in the toe, with the [MEDICAL CONDITION] down and no longer warm or red. The weekly skin assessment dated [DATE], did not address any specific skin condition and only included that the resident had lower extremity [MEDICAL CONDITION]. This was inaccurate when compared with the physician's orders [REDACTED]. The next weekly skin assessment was dated May 3, and included was that the resident's bilateral lower extremities were red and swollen, and that the condition was "old." There was also another skin assessment completed on May 5, and this included that the resident's bilateral lower extremities were "red + swollen." The weekly skin assessment dated [DATE], included that the resident's bilateral lower extremities were red and swollen, with "crust." Also documented was that treatment with Ace wraps was ongoing. There was no further documentation able to be located regarding the extent of the "crust" areas in order to determine if physician notification was warranted or if ongoing use of constrictive wraps were indicated. The treatment sheet entry dated May 16, at 2 a.m., included that the resident continued to have the Ace wraps applied, as she refused to let staff take them off at bedtime. The next skin assessment was completed on May 17, and this included that the resident's bilateral lower extremities were "red, hot, swollen c (with) crust scabs" and with "raised bumps." Per the nursing note entry of May 17 at 6 p.m., the resident's bilateral lower extremities were red, hot, swollen, and the skin was "transparent" with yellow crust areas and "bumps." Documented was that the physician was notified and new orders included the initiation of antibiotics, to obtain wound cultures, and to elevate the resident's legs. The resident's bilateral leg condition was observed on May 18, with the wound nurse in attendance. The resident's lower extremities were noted to be bright red in color, the skin tight, shiny and swollen, with multiple open areas, especially around the inner and posterior ankle area. The open areas were crusted with yellow exudate. There were also papule-type raised areas, approximately 1 centimeter in diameter each, noted primarily on the lower leg area. The resident was interviewed and stated that the leg areas were painful and itchy. The wound nurse was interviewed and stated that she would need to notify the physician for alternate treatment orders. The treatment orders dated May 18, included to cleanse the resident's lower legs with wound cleanser, to apply [MEDICATION NAME] to the open areas, and to cover the open areas with non-adherent dressings, and then wrap with Kerlix and change daily. The resident was interviewed again on May 19, and stated that she had not known "how bad" her legs were, as she could not easily visualize them from looking down from her wheelchair position, and that she routinely stayed up late into the night and therefore did not elevate her legs. Nursing staff were interviewed and confirmed that the resident was often non-compliant with going to bed and elevating her legs. Final review of the resident's care plan revealed that this chronic behavior was not included in the resident's plan of care. -Resident #19 resided in the facility from [DATE] until November 3, 2009. Pertinent [DIAGNOSES REDACTED]. The resident had been admitted from an acute care hospital and transfer hospital information included that the resident had undergone partial thickness debridement of wounds of the lower extremities. Documented was recent debridement of right lower extremity wounds, and a left "gangrenous-appearing" heel and possible osteo[DIAGNOSES REDACTED]. Included also was that the resident underwent [REDACTED]. Despite the resident's skin history, a comprehensive assessment of the resident's wounds was not conducted. The admission nursing assessment dated [DATE], included that the resident had dressings to the right and left legs, and that the resident "refused" to have them removed for assessment. Noted was a "scab" to the resident's left great toe and to the second toe and that each measured 1 cm in diameter. [MEDICAL CONDITION] was also noted to be present. The physician's progress note included the presence of lower extremity [MEDICAL CONDITION], status [REDACTED]." The physician's orders [REDACTED]. The treatment order included to cleanse the wounds and pat dry, then to cover with Xeroform gauze, another dressing, then to wrap with Kerlix. This treatment was to start on October 10. The form titled, Weekly Skin Integrity Data Collection, was reviewed and included an initial entry for October 11. Documented on this date was that the resident had bilateral leg [MEDICAL CONDITION]. Documented also was an old "open" area. There were no notations made on the corresponding body map, although the instructions were to indicate "new" sites. The directions on the form regarding open areas included to "proceed to appropriate skin condition record." A Non-Pressure Skin Condition Record, initiated on October 11, included the scabbed areas to the resident's first toe and third toe. Documented was that both areas measured 1 cm by 1 cm, and were brown. The MDS assessment dated [DATE], included that the resident had no cognitive impairments, required extensive assistance with functional activities, and had six stage 2 stasis ulcers. The care plan dated October 15, included the risk for further breakdown due to multiple open areas to the bilateral lower extremities, including toe areas. An approach to reduce the resident's risk and to promote wound healing included to perform weekly skin assessments and to notify the physician of abnormal findings. The October 18 and 25 weekly skin assessments also just included the presence of bilateral leg [MEDICAL CONDITION], and the assessment of November 1, included involvement of the feet as well. The Non-Pressure Skin Condition Record reflected that on October 18 and 25, the toe areas were still black, but each was documented to be a "healing scar." On November 1, the areas were assessed to each measure 0.5 in diameter and be brown. The appearance of the wound was documented with, "scar intact" for each. The review of the October treatment record revealed that the treatment order was transcribed, but there was no information as to how many wounds were being treated, as per the transcription, the treatment was to the "BLE" (bilateral lower extremities). Further review of the October treatment record revealed that the resident refused the dressing change on October 13, and there was no documentation that the wound treatments were provided on October 16, but that the resident received the treatments the remainder of the month. Despite the documentation that nurses were changing the resident's dressings consistently, there was no documentation that the wounds were assessed or being monitored. Again, there was no wound documentation that included specific location, measurements, wound bed, odor, drainage, peri wound, circulation or sensation, or evidence of ongoing monitoring of the areas. The resident was transferred to theER on [DATE], due to high fever and emesis. The hospital record was reviewed and revealed that the resident had "severe bilateral [MEDICAL CONDITION] wounds with foul-smelling odor from both legs." The bilateral leg wounds were noted to be fibrotic and necrotic, with multiple wounds on the lower extremities and a plantar ulcer with a graft jacket in place but with surface infection. The recommendation was for bilateral debridement of all necrotic and fibrotic tissues in the wounds and continued IV antibiotics. -Resident #24 was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. The nurse's note dated April 27, at 4 p.m., documented the resident was seen outside in front of the building lighting a cigarette while on oxygen therapy. The oxygen tubing caught fire burning the resident's nose and lip areas. The resident was assessed to have singed facial hair and mustache burns. Licensed staff further documented that the right side of the resident's face and nostrils were black in color. Documented was that the nurse washed the resident's nose and cleaned out with Q-tips, "...skin doesn't look severely burned." There was no thorough assessment of the extent of [MEDICAL CONDITION] size or color. Per documentation, the physician was called and he stated to "keep an eye" on the resident and if any change in condition, to send to the emergency room . Review of the physician's orders [REDACTED]. The next nurse's note was April 28, which documented that the resident had no complaints of pain or shortness of breath. No assessment of [MEDICAL CONDITION] documented. Review of the physician's orders [REDACTED]. At 2 p.m., on April 29, the nurse's note documented that the resident was confused, incoherent, and he had extremely labored breathing. The resident's nostrils were swollen, painful to touch, and there was a small amount of bleeding in the morning, however, there was no assessment of the resident's burns. The nurse documented the physician was notified and new orders were received and carried out. The next nurse's note was dated April 29, at 8 p.m. The nurse documented that an order was received to send the resident to the hospital emergency room and that the resident "probably" would be picked up by the ambulance. Another nurse's note was dated April 29, at 9 p.m., as a late entry for 7:30 p.m. In this note the nurse documented that the resident's facial area around the nose had brown eschar and that the resident had difficulty keeping his oxygen nasal cannula in place as it was uncomfortable. The physician subsequently came to assess the resident, and orders were issued to send to the ER for evaluation. The physician's progress note dated April 29, documented that "yesterday" the resident sustained [REDACTED].) The physician further documented the resident's face was brown along both nares which extended up his nasal cavity with [MEDICAL CONDITION]. There was scabbing and blistering to the left face and he had second [MEDICAL CONDITION] his mustache area. The physician documented the resident needed a burn evaluation. The physician wrote and order on April 29, to transport the resident to the emergency room for [MEDICAL CONDITION] to smoking with an oxygen tank. Documentation from the burn center dated April 29, 2009, revealed the resident was seen in the ER for flame [MEDICAL CONDITION] his nose and upper lip secondary to smoking while using oxygen via a nasal cannula. Burn triage and treatment included cleansing and [MEDICATION NAME] the wound to the tip of the nose and left cheek which had brown eschar. Scabbed areas on the lip were removed. Discharge instructions included applying [MEDICATION NAME] ointment with dressings to the tip of the nose and left cheek, and to apply [MEDICATION NAME] to the upper lip and inside the left nare. Review of the treatment administration records for April 2009, revealed the resident received no care or treatment for [REDACTED]. On April 30, licensed staff documented [MEDICAL CONDITION] his nose, lips, and cheek were treated. Review of the care plans revealed that a care plan was not initiated to address the resident'[MEDICAL CONDITION] May 5, nine days after the resident sustained [REDACTED]. The occupational note dated May 7, documented the resident has had impaired activity tolerance secondary to the "burn accident" [MEDICAL CONDITION] his nose and difficulty breathing. The facility reported this "incident" to the state survey agency, and also that it had not been reported timely. During the facility's investigation, nurse interviews were collected that indicated the resident's condition warranted more interventions then he was initially provided with. One nurse documented that the resident had to use his nasal cannula orally, as he nose was clogged and made it hard to receive air. This nurse then accompanied the resident to the physician visit, there the physician stated that the resident needed to be sent to the hospital for an evaluation as the physician had not known that the resident's condition was "this bad." Another nurse documented that on April 29, after she received report she went into the resident's room to assess him and she observed the resident [MEDICAL CONDITION] his face with swollen nostrils and blood dripping from them. The former assistant director of nursing (ADON) documented that on April 24, 2009, she observed the resident to have black soot around his mouth and nose and his oxygen tubing was burned in half. She documented that she removed the soot from the resident's face and no burned areas were "noted." This former ADON also documented that no red areas or inflamed areas were seen; however, his mustache and eyebrows were singed. The ADON documented that she called the on-call physician and the only orders received (based on her assessment of no burned areas and singed areas) was to observe the resident and to call with any changes. During an interview conducted on May 18, 2010, the interim DON stated that nurses did not document their ongoing assessments of the resident'[MEDICAL CONDITION] that they should have obtained physician orders [REDACTED]. The DON further stated that the previous administrative members were terminated as a result of this incident, and that in-services were provided regarding complete and accurate wound assessments, care plans, change of condition, and documentation. The review of the in-service documentation on wound care included only a handful of nurses, and the topic of what specifically was covered was not included. -Resident #28 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Braden Scale documented that the resident was at a high risk for the development of pressure sores. The nursing admission assessment dated [DATE], documented the resident had bruises to his right and left lower arms. No [MEDICAL CONDITION] was assessed. The weekly skin assessment dated [DATE], documented the resident had bilateral [MEDICAL CONDITION] of the feet; however, there was no assessment of the type or severity of the [MEDICAL CONDITION]. The physician's orders [REDACTED]. The physician's note dated May 14, documented that the resident requested to see the physician regarding a complaint of increased pedal [MEDICAL CONDITION]. The physician assessed the [MEDICAL CONDITION] as 2 plus pedal [MEDICAL CONDITION] bilaterally. The nurse's note dated May 15, documented that the resident was up in his chair most of the day watching television. Review of the nurse's notes revealed there was no documentation or assessments by nursing of the resident's pedal [MEDICAL CONDITION]. Review of the clinical record revealed no care plan that addressed the resident's [MEDICAL CONDITION]. The weekly skin assessment dated [DATE], documented the resident had multiple bruises, no [MEDICAL CONDITION], redness or open areas was assessed. During an observation conducted on May 18, at 12:15 p.m., the resident was observed with a Kerlix dressing wrapped around his right foot. Both feet had 3 plus non-[MEDICAL CONDITION]. When interviewed, the resident stated he hit his foot on something during the morning and sustained a skin tear. He stated that the nurse provided emergency care and covered the wound so he could go to therapy. The resident further stated that he has ongoing problems with swelling in his feet and was prescribed [MEDICATION NAME]. On May 18 at 12:30 p.m., the wound care nurse uncovered the resident's foot wound. The skin tear was clean and dry. She assessed the resident to have 3 plus pedal [MEDICAL CONDITION] and showed this surveyor that the resident had a small, red, non-blanchable and irregular area approximately 1 cm by 0.25 cm on the back of both heels. The wound care nurse was not previously aware of these reddened areas. She stated she was unsure what type of wound the red areas presented as, and would have the physician assess them. On May 19, the clinical record contained no evidence the physician was notified of the reddened heel areas or that he was informed of the 3+ pedal [MEDICAL CONDITION]. Furthermore, there was no documentation of the foot wounds or of the pedal [MEDICAL CONDITION] in the clinical record despite being assessed by the wound care nurse the previous day. On May 19, at 8:20 a.m., the staff nurse stated that she had not done any assessment of the resident's [MEDICAL CONDITION] following the need for [MEDICATION NAME], and also stated that the [MEDICAL CONDITION] should be documented and care planned. At 8:30 a.m., on May 19, the wound nurse was questioned regarding the pedal [MEDICAL CONDITION] and reddened areas on the residen