Every finding on record at Life Care Center of Sierra Vista

Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and facility's policy review, the facility failed to protect the rights of one resident (Resident #10) to be free from abuse by another resident (#25). This deficient practice could place residents at risk for resident-to-resident abuse and potential physical harm.Findings include: -Resident #25 (Perpetrator) was admitted to the facility on [DATE], with diagnoses that include pulmonary embolism, acute respiratory failure, heart failure, and hypertension. 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. The care-plan revealed the resident used antidepressant medication related to depression, with a goal of being free from adverse reactions and a noted goal to observe and report adverse reactions, and psyche follow up as indicated. -Resident #10 (Victim) was admitted to the facility on [DATE], with diagnoses that include heart failure, atrial fibrillation, aneurysms, insomnia, depression, and hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident had no cognitive impairment. The progress note dated June 6, 2026 at 2:14 p.m. revealed that during the morning medication pass, the writer heard resident #25 yelling and cussing toward a Certified Nursing Assistant (CNA) while threatening to kill his roommate (resident #10) because Resident #10's TV was too loud. The CNA connected headphones to Resident #10's TV and returned to work. The note further revealed that at 11:00 a.m., Resident #25 was again at the nursing station threatening to kill a CNA. Resident #25 then returned to his room and continued yelling. A housekeeper yelled for help to the nurse and the CNA. Upon entering the room, the nurse observed Resident #25 holding a detached wheelchair leg in his hand trying to go after resident #10. The CNA attempted to pull back resident #25's wheelchair and resident #25 slipped out of his chair. The note further documented that resident #10 pushed the wheelchair leg away from him and it hit resident #25 in the head, leading to a wound to his head that was bleeding, and a skin tear on his forearm from the fall. A review of skin assessments for resident #25 dated June 6, 2026 2:14 p.m. revealed resident #25 had a laceration to the head, evaluated by emergency services, and noted that resident #25 tried to hit another resident with the leg of his wheelchair, and upon trying to strike resident #10, resident #10 pushed the leg back striking resident #25 in the head. An interview with a Licensed Practical Nurse (LPN/ Staff #100) was conducted on June 25, 2026 at 1:39 p.m. Staff #100 stated that on the day of the incident resident #25 was stating he was going to kill his roommate over his TV volume. Staff #100 stated that staff fixed resident #10's Bluetooth for his TV to fix the issue but that 2 hours later resident #25 was found in his room attempted to strike resident #10 with a wheelchair leg. Staff #100 stated that a CNA attempted to remove resident #25 by pulling on his wheelchair, which resulted in resident #25 falling from the wheelchair while resident #10 simultaneously pushed the wheelchair leg away leading to it hitting resident #25 in the head. Staff #100 stated that she didn't think resident #10 had any injuries but that resident #25 had a skin tear on his leg, and a laceration on the top of his head. Staff #100 stated that police and emergency services were called and eventually resident #25 was taken to the local hospital by the crisis team. Staff #100 stated the incident constituted resident-to-resident abuse and described resident #25 as very aggressive. An interview was attempted with resident #10 on June 26, 2026 at 8:45 a.m.; however, the resident was unable to provide reliable information regarding the incident. An interview was conducted with the Director of Nursing (RN/staff #50) on June 26, 2026 at 9:33 a.m. The DON stated that resident #10 is a poor historian, and has transient confusion. She further stated that resident #10 had no injuries, and resident #25 had a wound to his head. She further stated that resident #25 had psyche issues, was suicidal, and was receiving psychiatric services through a community mental health provider. The DON stated that there were no behavioral interventions documented in the care plan. She stated that the lack of care plan documentation was an oversight, however that interventions were in place and verified the resident had been seen by psyche services. The DON stated that the incident as she was told stemmed from resident #25 attempting to hit resident #10 with a wheelchair foot rest. The DON stated that she told staff to stay between the two residents until emergency services arrived and that after the incident resident #25 was moved to a new room before being taken by the crisis team to the hospital. The DON concluded that it was unfortunate the event happened and that resident #25 did not return to the facility. A review of facility policy titled 'Abuse - Prevention reviewed April 1, 2026 revealed it is the policy of the facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to protect the resident's (#1) rights to be free from misappropriation from staff. This deficient practice could result in further incidents of staff to resident financial abuse. Findings include: -Resident #1 was admitted to the facility on [DATE], with diagnoses that include congestive heart failure, atrial fibrillation, ventricular tachycardia, thyrotoxicosis, and pulmonary embolism. Review of the admission 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 review of the State Agency (SA) complaint system revealed that on January 8, 2026 at 5:22 p.m. an incident was reported by the facility that a local police department officer arrived to the facility at 3:30 p.m. and informed the receptionist that he needed to speak with the Director of Nursing. The Executive Director and Assistant Director of Nursing spoke with officer in the Executive Director's office and the officer expressed concern about a resident who recently discharged , identified as Resident #1. Resident #1 had reported charges to her card on December 12th, 14th and 15th. The officer explained they have video footage of a woman wearing scrubs and asked if they could identify this individual. After evaluation, they identified the picture to look like a CNA employed by the facility, Staff #20. The facility provided officer with Staff #20's date of birth and work schedule. The facility also notified another local facility as she is an employee of theirs as well. The officer, Director of Nursing, Assistant Director of Nursing had spoken about next steps. The Director of Nursing and Executive Director attempted to call Staff #20 with no answer. They agreed to return to facility at 10:00 p.m. when employees next shift is to terminate and collaborate with local law enforcement on upcoming arrest and investigation. As stated by the officer, the individual will be arrested on class 1 misdemeanor charge on January 8, 2026. Resident #1 was discharged from the facility on December 30, 2025.An interview with a Certified Nursing Assistant (CNA/staff #30) was conducted on February 2, 2026 at 4:39 p.m. Staff #30 stated she was aware of the incident of the stolen card, and that it was used at Walmart. Staff #30 stated that it was staff #20 who stole it and that she was taken off the schedule following the incident. Staff #30 further stated she was shocked to hear about the allegation and that it's never ok to steal from a resident. Staff #30 stated that absolutely she would consider it abuse, it's financial abuse. Staff #30 concluded that this was the only incident of this type that has happened that she was aware of. An interview with a Licensed Practical Nurse (LPN/staff #40) was conducted on February 2, 2026 at 4:58 p.m. Staff #40 stated they recently had training related to money and credit cards from residents over the recent incident. Staff #40 stated they heard an employee took a resident's credit card and used it, but that they did have recent training on it and that it is never ok to do that. Staff #40 stated that abuse can be all kinds of things, physical, sexual, verbal, and financial. Staff #40 stated that yes stealing a credit card would be financial abuse, and that the abuse coordinator is the executive director Staff #50. An interview was conducted with the Executive Director (ED/staff #50) on February 3, 2026. Staff #50 stated that after resident #1 had discharged from the facility, she received a credit card statement in the mail and had $900 worth of charges on it for toys, whiskey, and anime all from a local department store. Staff #50 stated that the charges were in three separate trips over 2 days. Staff #50 stated that within hours the police had traced the receipt to their employee identified as staff #20, and had showed up to the facility to arrest her on potentially felony charges. Staff #50 stated she made 2 attempts to call staff #20 and couldn't get ahold of her. Staff #50 stated that the police met her at the facility at 10:00 p.m. that same day and had a meeting with staff #20, and with the police present and terminated staff #20's employment over the incident. Staff #50 stated that she spoke to the resident and that the credit card company had reimbursed the lost funds. Staff #50 concluded that of course this isn't the standard of their facility, and they substantiated the complaint in their report to the SA. A review of facility policy titled 'Abuse - Identification of types reviewed May 6, 2025 revealed it is the policy of the facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the resident's (#100) rights to be free from abuse by another resident (#200). This deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #100 (Perpetrator) was admitted to the facility on [DATE], with diagnosis that include Dementia, insomnia, anxiety, and malnutrition. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 01 which indicated the resident had severe cognitive impairment. A review of resident's #100 care-plan revealed the resident has impaired cognitive ability related to dementia, and needs simple 1 to 2 step instructions. -Resident #200 (Victim) was admitted to the facility on [DATE], with diagnoses that include Spinal stenosis, diabetes mellitus type 2, weakness, anxiety, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06 which indicated the resident had significant cognitive impairment. A review of progress notes for resident #100 dated November 28, 2025 at 9:11 p.m. revealed resident #200 was traveling on the same side of the hall moving towards the direction of Resident #100. Resident #200 was heard saying don't you hit me. As the writer got up to separate the residents, Resident #100 was visualized reaching up with his right hand and punched resident #200 in the face twice. The note further revealed that other staff members arrived to assist, resident #100 was placed on a 1:1 with a staff member, and that the administrator, doctor, and law enforcement were notified. The note concluded that resident #100 was sent to the local hospital for further evaluation. A review of provider progress notes for resident #200 dated November 28, 2025 at 9:54 p.m. revealed resident #200 was being seen for a physician acute visit because resident #200 was examined after she was punched in the face by resident #100. The note continued that there was no major damage except light bruising, and some increased pain to her right shoulder. The note concluded that the provider increased the resident's prednisone back to 5 milligrams (mg) daily for pain. A review of Social services notes for resident #100 dated November 29, 2025 at 10:03 a.m. revealed the social services director had spoken to the house supervisor at the emergency room where resident #100 was taken, and that the facility would be unable to take resident #100 back and that they are looking for placement. An interview was conducted with a Certified Nursing Assistant (CNA/staff #5) on December 5, 2025 at 10:54 a.m. The CNA stated that normally resident #100 is usually gentle, but sometimes he would get agitated and they would just redirect him. The CNA stated he didn't witness the altercation between resident's #100 and #200 but he heard about it, and that it was an altercation. The CNA also stated it was the first time he knew of that resident #100 got physical with another resident. The CNA concluded that there are several types of abuse, including physical, verbal, neglect, and that abuse is doing something others wouldn't want them to do. An interview was conducted with a Licensed Practical Nurse (LPN/staff #10) on December 8, 2025 at 2:00 p.m. The LPN stated that resident #100 does have episodes of being unpredictable, and said he was in the facility previously and some days was very cooperative, and other days was cussing and swinging at staff. The LPN stated he doesn't remember if any of those episodes happened with other residents, but that it wasn't uncommon for resident #100 to swing at staff. The LPN further stated that the provider luckily was in the building at the time of the incident and saw resident #200 at bedside. The LPN continued that resident #200 had a busted lip after the incident, as well as some redness, but no other injuries. An interview with resident #200 was conducted on December 8, 2025 at 2:13 p.m. Resident #200 stated that she sure did get hit, and pointed to the right side of her mouth. Resident #200 further stated that she saw resident #100 coming down the hall, and told him not to come down this way. Resident #200 stated that resident #100 said I go where I damn well please and that she told him I'm not trying to make you angry and then resident #100 got real close to her, and moved towards her again. Resident #200 stated that she told him to go home and he replied no godammit I go where I please, grabbed resident #200 by the hand, and stated I'm gonna stop you and then hit her in the face, twice. Resident #200 continued that it busted her lip and bled for a bit inside her mouth, and that she had trouble eating because of it. Resident #200 further stated that she does feel safe in the facility, and that staff responded to the incident very fast. Resident #200 concluded that yes, it was obvious abuse. An interview was conducted with the Director of Nursing (RN/staff #50) was conducted on December 8, 2025 at 2:24 p.m. The DON stated that she was notified about a resident to resident altercation. She stated that she was told resident #100 had punched resident #200 in the face, and in the mouth. She stated that resident #200 told her the same thing. The DON stated that right away the staff were told to notify the police and emergency services, and that resident #100 was put on a 1 to 1 immediately after it happened. The DON continued that resident #100 was taken to the local hospital because it was a behavioral change for him, and that she had notified the hospital they couldn't take resident #100 back due to his behaviors. The DON stated that staff were present but were out of reach at the time of the incident. The DON further stated that abuse is the willful intent to inflict harm, be it physical, verbal, sexual, neglect or isolation. The DON concluded that she considered it a resident to resident altercation, and if that is defined as abuse so be it, but that she didn't think it was willful. A review of facility policy titled 'Abuse - Prevention' revised May 6, 2025 revealed it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.

Based on a review of the clinical record, staff and resident interviews, and facility policy, the facility failed to ensure the resident's personal privacy and confidentiality of their medical records. The deficient practice could result in the exposure of personal/private medical information. Findings Include:An observation was conducted on September 09, 2025, at 4:18 AM, where medication Cart # 2 was left unattended with an unlocked computer displaying Residents' # 8,14,2,10,6,4, and 12 medical information. Licensed Practical Nurse (LPN/Staff #33) went to medication cart # 2 after coming out of a resident room. Resident # 8 was admitted to the facility on [DATE], with diagnoses of chronic kidney disease, dementia, and anxiety. Resident # 14 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, muscle weakness, and acute respiratory failure with hypoxia. Resident #2 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, muscle weakness, and heart failure.Resident # 10 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, type 2 diabetes, and hyperlipidemia.Resident # 6 was admitted to the facility on [DATE], with the diagnoses of type 2 diabetes, hyperlipidemia, and chronic obstructive pulmonary disease. Resident # 4 was admitted to the facility on [DATE], with diagnoses of borderline personality disorder, anxiety disorder, and depression. Resident # 12 was admitted to the facility on [DATE], with diagnoses of type 1 diabetes, anxiety disorder, and depression. An interview was conducted on September 09, 2025, at approximately 4:18 AM with (LPN/Staff # 33), who stated that the computer screen should be locked when going into a resident room. She also stated that she was giving medication to resident #6. She stated that the risk of this would be that anyone can click on a resident and see their medical history, date of birth , and medications. An interview was conducted on September 09, 2025, at 4:27 AM with a Certified Nursing Assistant (CNA/Staff # 61) at the nursing stations, who stated that staff received HIPAA training, which includes: names, medical history, phone numbers, and the reason for the resident being at the facility. She also stated that staff would need to log out of the computer, and not leave documentation that displays the resident files, their medical history, and medication. (CNA/Staff #53) came to the nursing station and mentioned that the risk is that the resident's information is exposed to anyone.An interview was conducted on September 09, 2025, at 11:44 AM with the Director of Nursing (DON/Staff #82), who stated that staff receive HIPAA training that covers the privacy protection of health information, and the expectation of confidentiality. She also states that the computer should be logged out or locked. She further stated that when computers are not locked or logged out, the risk could be a breach of protected health information. She also stated that this includes residents' names, date of birth , medical condition, and medications. Review of the facility's policy titled Social Services and Resident Rights, revised June 2022, indicated that The resident has a right to secure and confidential personal and medical records.

Based on observation, interviews, and review of facility policy and procedure, the facility failed to ensure medications including controlled substances were stored according to regulation and facility policy. The deficient practice could lead to residents gaining access to medications.Findings include:An observation was conducted on [DATE], at 4:10 A.M. of the facility hallway between the 100 and 300 hall units. There was an open doorway, with no restriction to walk between the two units. At the corner of the two units was a nurse's station, and behind the nurse's station was a medication cart that was not locked. A bottle labeled as iron tablets was on top of the medication cart. There were no staff observed in proximity to this nurse's station. During the observation, there were staff observed going in and out of resident rooms approximately 100 feet away on the 100 hall unit, and at times there were no staff observed on the 100 hall unit. The cart remained in surveyor observation during the entire period of time, and no nurse walked past the nurse's station until the surveyor requested a nurse (Staff #17) to come to the nurse's station for an observation of the medication cart and interview at 6:22 A.M. An interview was conducted with a Licensed Practical Nurse (LPN / Staff #17) on [DATE], at 6:22 A.M. Staff #17 observed the medication cart and stated that the medication cart was unlocked. The medication cart drawers were opened and the contents were observed together. Staff #17 stated that there were 3 loose pills in the top drawer of the medication cart and that he could not identify the pills. Staff #17 then disposed of the pills in the sharps container on the medication cart. Multiple bottles of medications were observed together in the medication cart, and Staff #17 stated that there was a bottle of ibuprofen 200 mg pills, acetaminophen 500 mg pills, and aspirin 325 mg pills. Additionally, in the cart was a bag of vancomycin 750 mg intravenous solution that Staff #17 stated that the resident it was labeled for had been discharged for a while, and a bottle of prednisolone acetate 1% eye drops labeled for another resident that Staff #17 stated was no longer in the facility. Regarding the locked drawer within the medication cart, Staff #17 stated that he did not have access to the key and that he alerted the Director of Nursing (DON) to come to the nurse's station to unlock the drawer to observe the contents of the locked drawer.An interview was conducted with the DON (Staff #82) on [DATE], at 7:02 A.M. while observing the medication cart together. The DON stated that the medication cart was unlocked and that there was a bottle of iron pills on top of the cart. The DON unlocked the separately locked drawer of the medication cart and one white pill was observed in the drawer. The DON identified the pill and stated that it was a 0.25 mg alprazolam pill, and that the type of medication was a benzodiazepine drug. The DON stated for that type of drug, the storage requirement is to have the medication double locked. The DON stated she was going to destroy the pill with a witness at that time.A follow-up interview was conducted with Staff #17 on [DATE], at 7:12 A.M. Staff #17 stated that the importance of locking medication carts is because the facility has many residents who wander and so that the residents do not take the wrong medications, and that it is part of the policy to keep the medication carts locked.An additional follow-up interview was conducted with the DON on [DATE], at 10:42 A.M. The DON stated that her expectation is for nurses to keep the medication carts locked if no staff are present at the carts. The DON stated that the importance of locked medication storage is because there is a risk of ingestion if residents were to gain access.Review of the facility policy titled Storage and Expiration Dating of Medications and Biologicals, revised [DATE], revealed that the facility should ensure medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, and refrigerators/freezers. The facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. The facility should store Schedule II-V Controlled Substances, in a separate compartment within the locked medication carts, and should have a different key or access device. The facility should ensure all controlled substances are stored in a manner that maintains their integrity and security. Additionally, the facility should ensure medications and biologicals for expired, discharged , or hospitalized residents are stored separately, away from use, until destroyed or returned to the provider.Review of the State Operations Manual, Appendix PP, issued [DATE], revealed that in accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. Additionally, the facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Based on observations, staff interviews, facility documentation, and a review of policies and procedures, the facility failed to ensure that food items in the freezer were properly labeled and dated. This deficient practice had the potential to result in food contamination, which could cause illness or food poisoning among residents.Findings Include:On September 7, 2025, at 10:15 a.m., during an initial walk-through visit with [NAME] #27, who was present on behalf of the kitchen manager (Staff #42), a partially full plastic bag of broccoli without a label or date, was observed sitting on a shelf inside the freezer.An interview was conducted immediately following the observation, on September 7, 2025, at 10:20 a.m., with [NAME] #27. The staff member confirmed the findings and acknowledged that all opened food items should be labeled with the date they were opened and stored in either a sealed container or a zipper bag. The kitchen staff also confirmed the understanding that using food items without proper labeling could place residents at risk for food poisoning and other food-borne illnesses.On September 8, 2025, at 2:00 p.m., an interview was conducted with the kitchen manager (Staff #42), who stated that all opened food items must be labeled with the date they were opened and stored in a sealed container or zip bag. He explained, When the foods are opened, and if they are not used completely, we wrap the leftovers and label them with the date they were opened and the date by which they should be used. He further stated, If it is broccoli, we wrap it up, label it, then put it in a container and store it on a first-in, first-out basis. He added that cooking with unlabeled food items posed a risk to residents' health and confirmed that the unlabeled bag of broccoli had been discarded.Staff #42 also stated that he regularly reminded kitchen staff on duty to double-check food storage areas for items that needed to be labeled and stored properly before the end of their shifts. He agreed that failure to follow these procedures could lead to serious health risks for residents and would violate the facility's standards.A review of the facility's policy titled Food Safety and Sanitation revised on April 23, 2023 and reviewed on May 1, 2025 revealed that pre-packaged food must be placed in a leak-proof, pest-proof, non-absorbent, National Sanitation Foundation (NSF)-sanitary container with a tight-fitting lid. The container must be labeled with the name of the contents and the date when the item was transferred. A Use By date is also noted on the label or product when applicable. The policy further specified that food items must be dated when placed on the shelves in the food storage room.

Based on clinical record, staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database the facility failed to implement their policy regarding conducting thorough investigation of abuse/neglect allegation, protecting residents from further abuse for one resident (#46), and reporting allegations of abuse. The deficient practice could result in abuse/neglect continuing and not being prevented. Findings include: Resident #46 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of fatty liver, hypertension, and protein-calorie malnutrition. Review of resident #46's progress note dated March 26, 2025 revealed that the facility contacted another state agency regarding suspicion of financial exploitation involving the resident's frequent visitor (resident friend #666). Review of the SA database did not reveal any documentation that a self-report was submitted by the facility regarding the allegation of exploitation. However, the SA database revealed that another state agency reported an allegation of exploitation. A written request for a copy of incident report and facility investigation pertaining to resident #46 was submitted to the facility on September 7, 2025 at 1:40 p.m. An email response was received from the Executive Director (ED/staff #411) on September 7, 2025 at 2:07 which stated that there are no incident or investigations found. An interview with a Licensed Practical Nurse (LPN/staff #24) was conducted on September 9, 2025 at 4:18 a.m. Staff #24 stated that it is important for residents to not feel abused and implement abuse policy to ensure that residents' issue is not ignored and not treated poorly. The LPN said that if residents are abused then it can impact them poorly--lead to depression, feel unseen, and not heard as human beings. Staff #24 is unfamiliar with the exploitation issue concerning resident #46 and was not aware of any visitor restrictions. During an interview with a Certified Nursing Assistant (CNA/staff #101) conducted on September 9 2025 at 5:04 a.m., staff #101 stated that any type of abuse is reported to supervisor immediately so that it does not cause mental, physical, and emotional repercussions to the resident. The impact if it is not reported is that the resident can become anxious. The CNA noted that resident #46 can be confused at times but can definitely relay information. Staff #101 noted that she is unaware of any issues of exploitation regarding resident #46. An interview with the Social Services Assistant (SS Asst/staff #32) and the Social Services Director (SS Dir/staff #93) was conducted on September 9, 2025 at 10:02 a.m. Staff #93 noted that they found out about the exploitation was due to non-payment of cost share. The SS Dir said that resident friend #666 visited resident #46 and there was an allegation of financial. exploitation. During the course of the investigation, resident friend #666 was restricted from vising resident #46 per the previous administrator. An interview with the Assistant Director of Nursing (ADON/staff #90) was conducted on September 9, 2025 at 11:04 a.m. Staff #90 stated that his expectation is that any allegation of abuse is reported immediately to ensure that residents are protected. The ADON noted that it is important that residents are not exploited because nobody wants to see somebody taken advantage of-specially the residents who are a vulnerable group. According to staff #90 he remembered that there was a concern that resident #46 was being exploited by resident friend #666 but there were no specific details. There was picture of the resident friend #666 posted at the reception desk informing staff to not allow him in the facility. Another state agency was contacted involved. The ADON noted that he was unsure if the facility would do an investigation since they cannot easily do one on someone not affiliated with the facility. However, he said that exploitation is considered as abuse and that the facility investigates all allegation of abuse. Staff #90 said that the facility should have probably investigated in collaboration with the other state agency. Review of the facility policy titled Abuse - Identification of Types reviewed May 6, 2025 stated that the facility staff should report any suspected abuse, neglect, or exploitation to the Executive Director or Director of Nursing. The facility policy titled Area of Focus: Incident and Reportable Event Management reviewed November 25, 2024 noted that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property are reported immediately, but no later than 2-hours after the allegation is made. The policy also noted that all alleged violations are thoroughly investigated to prevent further abuse, neglect, exploitation or mistreatment.

Based on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to report allegations of exploitation for one resident (#46) within the required timeframe. The deficient practice in abuse allegations not being reported and further abuse continuing. Findings include: Resident #46 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of fatty liver, hypertension, and protein-calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has intact long term and short-term memory. An Alert Note dated March 26, 2025 documented that the facility contacted another state agency for suspicion of financial exploitation involving resident's frequent visitor (resident friend #666). However, further review of the resident's clinical record did not reveal any indication that the allegation of financial exploitation was reported to The State Agency (SA). Furthermore, review of the SA database did not reveal any documentation that a self-report was submitted by the facility regarding the allegation of exploitation. A cognition care plan that was initiated on August 29, 2025 revealed that the resident has mild cognitive impairment. Interventions included to cue, orient, and supervise resident as needed. Review of resident #46's care plan did not indicate any risk for exploitation. A written request for a copy of the incident report and the facility investigation pertaining to resident #46 was submitted to the facility on September 7, 2025 at 1:40 p.m. An email response was received from the Executive Director (ED/staff #411) on September 7, 2025 at 2:07 which stated that there are no incident or investigation found. An interview with a Licensed Practical Nurse (LPN/staff #24) was conducted on September 9, 2025 at 4:18 a.m. Staff #24 stated that allegations of abuse have to be reported immediately. According to the LPN, it is important for residents to not feel abused and implement abuse policy to ensure that residents' issue is not ignored. Staff #24 said that if residents are abused then it can impact them poorly--lead to depression, feel unseen, and not heard as human beings. Staff #24 is unfamiliar with the exploitation issue concerning resident #46. During an interview with a Certified Nursing Assistant (CNA/staff #101) conducted on September 9 2025 at 5:04 a.m., staff #101 stated that any type of abuse is reported to supervisor immediately so that it does not cause mental, physical, and emotional repercussions to the resident. The CNA noted that the report has to be done within 2-hours of the allegation. The impact if it is not reported is that the resident can become anxious. Staff #101 noted that she is unaware of any issues of exploitation regarding resident #46. An interview with the Social Services Assistant (SS Asst/staff #32) and the Social Services Director (SS Dir/staff #93) was conducted on September 9, 2025 at 10:02 a.m. Staff #93 noted that they found out about the exploitation was due to non-payment of cost share. The SS Dir said that resident friend #666 visited resident #46 and there was an allegation of financial. exploitation. According to staff #93, the other state agency investigated the allegation of financial exploitation. During the course of the investigation, resident friend #666 was restricted from vising resident #46 per the previous administrator. An interview with the Assistant Director of Nursing (ADON/staff #90) was conducted on September 9, 2025 at 11:04 a.m. Staff #90 stated that his expectation is that any allegation of abuse is reported immediately to ensure that residents are protected. The ADON noted that it is important that residents are not exploited because nobody wants to see somebody taken advantage of-specially the residents who are a vulnerable group. According to staff #90 he remembered that there was a concern that resident #46 was being exploited by resident friend #666 but there were no specific details. There was picture of the resident friend #666 posted at the reception desk informing staff to not allow him in the facility. Another state agency was contacted and investigated the allegation. The facility policy titled Area of Focus: Incident and Reportable Event Management reviewed November 25, 2024 noted that alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property are reported immediately, but no later than 2-hours after the allegation is made. The policy also noted that all alleged violations are thoroughly investigated to prevent further abuse, neglect, exploitation or mistreatment. Review of the facility policy titled Abuse - Identification of Types reviewed May 6, 2025 stated that the facility staff should report any suspected abuse, neglect, or exploitation to the Executive Director or Director of Nursing.

Based on clinical records, review of facility documentation, review of the State Agency (SA) database, staff interviews, and review of policy and procedure the facility failed to ensure an allegation of exploitation (resident #46) was fully investigated. The deficient practice could result in allegations of abuse to include exploitation not being investigated and abuse/exploitation occurring in the facility. Findings include: Resident #46 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of fatty liver, hypertension, and protein-calorie malnutrition. A report submitted from another state agency was received by the State Agency (SA) on June 19, 2025 regarding an allegation of exploitation pertaining to resident #46. Review of the SA database revealed that the facility failed to submit a self-report regarding the allegation of exploitation. Further review of the SA database indicated that the facility failed to submit a thorough investigation regarding the allegation of exploitation. A written request for a copy of the incident report and the facility investigation pertaining to resident #46 was submitted to the facility on September 7, 2025 at 1:40 p.m. An email response was received from the Executive Director (ED/staff #411) on September 7, 2025 at 2:07 which stated that there are no incident or investigation found. An interview with a Licensed Practical Nurse (LPN/staff #24) was conducted on September 9, 2025 at 4:18 a.m. Staff #24 stated that it is important to investigate allegations of abuse to ensure the issue does not further escalate, ensure that the issue is not ignored, and have proof of what happened to document facts. The impact of not investigating allegations is that it can impact the resident (victim) poorly leading to depression and feeling like they are not seen/heard as human beings. Staff #24 is unfamiliar with the exploitation issue concerning resident #46. During an interview with a Certified Nursing Assistant (CNA/staff #101) conducted on September 9 2025 at 5:04 a.m., staff #101 stated that allegations of abuse/exploitation have to be investigated because residents are human beings and they have rights and those rights should not be violated. According to the CNA, the impact of not investigating allegations of abuse/exploitation is that the residents can end up depressed, the resident will be talking about the issue and each time there is a caregiver there can be hostility. An interview with the Social Services Assistant (SS Asst/staff #32) and the Social Services Director (SS Dir/staff #93) was conducted on September 9, 2025 at 10:02 a.m. Staff #93 noted that they found out about the exploitation due to non-payment of cost share. The SS Dir said that resident friend #666 visited resident #46 and there was an allegation of financial. exploitation. According to staff #93, the other state agency investigated the allegation of financial exploitation. During the course of the investigation, resident friend #666 was restricted from vising resident #46 per the previous administrator. An interview with the Assistant Director of Nursing (ADON/staff #90) was conducted on September 9, 2025 at 11:04 a.m. Staff #90 stated that his expectation is that any allegation of abuse is reported immediately to ensure that residents are protected and it can be investigated. According to the ADON he remembered that there was a concern that resident #46 was being exploited by resident friend #666 but there were no specific details. Staff #90 stated that exploitation is considered abuse and that all allegations of abuse is investigated by the facility. He noted that the allegation should have been investigated in collaboration with the other state agency. The facility policy titled Area of Focus: Incident and Reportable Event Management reviewed November 25, 2024 noted that all alleged violations are thoroughly investigated to prevent further abuse, neglect, exploitation or mistreatment.

Based on record review, staff interviews, review of facility documents and policy, the facility failed to ensure one resident (#43) was referred for Level II Pre-admission Screening and Resident Review (PASRR). The deficient practice could result in residents not receiving appropriate services to meet their needs.Findings Include:Resident #43 was initially admitted to the facility on [DATE] with diagnoses that included paraplegia, Paranoid Schizophrenia and Schizophrenia Disorder.A review of record dated September 25, 2023 revealed a Level 1 PASRR (Pre-admission Screening and Resident Review) was completed, but no referral for any Level II.The care plan initiated on October 5, 2023 revealed that Resident uses antipsychotic medications related to Schizophrenia as evidence by auditory hallucinations. A review of orders dated February 18, 2025 revealed Resident has an active order for risperidone oral tablet 0.5 MG (milligram) give 0.5 mg by mouth at bedtime for schizoaffective disorder auditory hallucinations.Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15.0, cognitively intact; has Schizophrenia; and resident uses antipsychotic medications.Another review of record dated August 1, 2025 revealed a Level I PASRR was completed, and a check mark was placed for a referral for Level II determination for mental illness only.An interview was conducted on September 9, 2025 at 9:44 AM with Staff #93/Social Service Director (SSD) and present during the interview was Staff #32/social service assistant in the social service office. The SSD stated that her responsibility involved completing the cognitive and emotional section of the MDS; discharge planning; care conferences with residents and family; trauma assessment; sends psych evaluation for suicidal ideation and depression; reach out to APS (Adult Protective services) and Ombudsman for any concern; and assist residents for ALTCS (Arizona Long Term Care Services) application. The SSD also stated that their new admitted residents come with PASRR document. She stated that she is involved with revising, renewing, and updating their residents' PASRRs every year. She stated that when she reviews a resident's PASRR, she looks at their diagnosis. And, if she feels that the resident qualifies for PASRR Level II based on mental illness or disability, she sends it out to be reviewed by the PASSR program at Arizona ACCHSS (Arizona Health care Cost Containment System). While the SSD was looking at Resident #43's electronic record, she stated that Resident #43 has schizophrenia, resident was not exhibiting behaviors, and there was no PASSR Level II referral because the resident had not received inpatient psych treatment within the past two years. The SSD stated that she could not find a document indicating that Resident #43 was referred for a Level II determination to the State- designated authority.Review of facility document titled, Level II Passar, dated September 9, 2025 at 10:36 AM revealed a communication was sent to AZ AHCCCS. GOV asking for any record of Level II PASSR ever being requested for Resident #43. Review of facility's policy titled, Pre-admission Screening and Resident Review (PASARR), with a review date of September 26, 2024 revealed a positive level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II.

Based on record review, staff interviews, review of facility documents and policy, the facility failed to ensure medications for one resident (#38) were administered as ordered by the physician. The deficient practice could place residents' safety at risk and could result in resident's not receiving the treatment that they need.Findings Include:Resident #38 was admitted to the facility on [DATE] with an active diagnoses that included Heart Failure, Hypertension, and Orthostatic Hypotension.A review of admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental status score of 12.0, moderately impaired.A review of physician's order dated August 22, 2025 revealed an order for Isosorbide Mononitrate ER (Extended Release) oral tablet 30 mg (milligram) give 0.5 tablet by mouth one time a day related to atherosclerotic heart disease. Hold for SBP (systolic blood pressure) less than 110 or HR (heart rate) less than 60.A review of Resident's blood pressure and pulse rate taken on September 8, 2025 at 6:14 AM revealed a blood pressure of 106 over 66 and a pulse rate of 80 beats per minute.On September 8, 2025 at 7:37AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN)/Staff #48. The medication, isosorbide ER 30 mg one tablet, was dispensed. At 7:43 AM, Staff #48 entered resident's room and administered the medication by mouth to Resident #38.A review of Resident's September 2025 Medication Administration Record (MAR) revealed that on September 8, 2025 at 8:00 AM schedule time, Isosorbide Mononitrate ER oral tablet 30 mg give 0.5 tablet by mouth one time a day related to atherosclerotic heart disease, and hold for systolic blood pressure (SBP) less than 110 or heart rate (HR) less than 60 was documented as administered. Despite an order to hold the medication for SBP less than 110, and the Resident's blood pressure was 106 over 66 which was outside the parameter, Staff #48 did not follow a physician's order to hold the medication for a SBP of less than 110.A review of progress note, Skilled Note, dated September 8, 2025 at 8:06 AM revealed Resident's vital signs were taken at 6:14 AM. The blood pressure was 106 over 66, pulse rate was 80, and respiration was 16.An interview was conducted on September 8, 2025 at 11:23 AM with a Certified Nursing Assistant (CNA)/Staff #84. Staff #84 stated that when she comes to work, the first thing she does was to get report from the previous shift for resident updates, and then she takes her residents' vital signs (VS). Once she had completed taking her residents' VS, she makes a copy of her VS sheet to give to her nurse so her nurse can see the blood pressures, pulse, respiration, temperature, and oxygen saturation.Another interview was conducted on September 8, 2025 at 12:44 PM with CNA/Staff #55. Staff #55 stated that when coming in to work, she gets report from the night shift staff, and then she immediately starts taking VS. She stated that she checks VS in the morning because some residents take blood pressure medications. She stated that after taking the residents' VS, she makes a copy of her VS sheet to give to the nurse by 6:30 AM, and then she can later enter her residents' VS in the electronic record before 10:00 AM. She stated that a low BP is anything lower than 100 over 50; a high BP is anything higher than 150 over 90. She stated that if a BP is low or high, she will report it immediately to the nurse.An interview was conducted on September 8, 2025 at 12:58 PM with an LPN/Staff #72 in the rehab nursing station. Staff #72 stated that when she comes to work, she gets report from the previous nurse, does narcotic inventory, looks at the dashboard in the electronic medical record to find any changes related to her resident, and she administers medications to her residents. Staff #72 stated that she starts her medication pass at 7:00 AM for the 8:00 medication time. She stated that she will start first with residents not requiring blood pressure parameters which gives her CNAs time to get their VS. Once she gets to the residents with VS parameters, she has their VS that she needed for her medication administration. Staff #72 cited examples of medications requiring VS parameters, which included a medication called isosorbide. In addition, she stated that the VS parameters usually is their facility standard, SBP less than 110 and pulse rate less than 60, which she will not give an antihypertensive medication. Furthermore, she stated that when administering antihypertensive medications, she will get the resident's BP and pulse rate because an antihypertensive medication can lower the BP, and the risk if the medication was given to the resident can cause lethargy, paleness of skin, and hypoxia. A follow up interview was conducted on September 8, 2025 at 1:13 PM with Staff #48. Staff #48 stated that before medication pass, the first thing she does was to look up for her residents' VS to identify any out of range VS such as a resident having a low or high BP, and to make sure the resident gets assessed. She stated that a low BP is below 110 and high BP is over 150. She stated that the CNAs starts taking the residents' VS at 6:00 AM. During the interview, Staff #48 looked at Resident #38's electronic record. She stated that she held Resident's Lisinopril medication this morning due to a BP of 106 over 66. She also stated that the Resident's isosorbide medication does not have a parameter because she had spoken with the doctor and was told that the isosorbide medication is just to hold for a pulse rate less than 60 and Resident #38's pulse was 80 this morning. Staff #48 read the isosorbide medication order and stated that the order stated to hold for SBP less than 110 or heart rate less than 60. Staff #48 stated that she can ask the provider to clarify the order and get an updated order. In addition, Staff #48 stated that isosorbide medication decreases the heart rate and generally will not drop the blood pressure.Despite Staff #48 stating that she had spoken with the doctor and she was told to hold the isosorbide medication for a pulse rate less than 60, a review of Resident's record revealed an active order for Isosorbide Mononitrate ER (Extended Release) oral tablet 30 mg (milligram) give 0.5 tablet by mouth one time a day related to atherosclerotic heart disease. Hold for SBP (systolic blood pressure) less than 110 or HR (heart rate) less than 60.An interview was conducted on September 9, 2025 at 11:22 AM with the Director of Nursing (DON)/Staff #82 in the administrator's office. The DON stated that on September 8, 2025, Resident #38's had an order transcribed on the MAR for isosorbide mononitrate ER oral tablet 30 mg give half tablet by mouth one time a day related to arteriosclerotic heart disease, hold SBP of less than 110 or HR less than 60 order, and in the medical record at 6:14 AM the Resident's BP was 106 over 66. The DON stated that if her staff was going off the BP of 106 over 66, the isosorbide medication should not be given. The DON further stated that if the instruction was to hold the medication, her expectation was for the nurse to take the resident's BP, and hold or give the medication depending on the BP parameters.Review of facility's policy titled, Physician Orders, reviewed date of February 27, 2025 revealed the facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines.Review of facility's policy titled, Administration of Medications, reviewed date of September 16, 2024 revealed the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.

Based on observation, record review, staff interviews, review of facility documents and policy, the facility failed to ensure hand hygiene was performed during medication administration observation and the facility failed to sanitize a glucometer after use. The deficient practice could place residents at risk for infections.Findings Include:Resident #26 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Urinary Tract Infection (UTI), and Diabetes Mellitus (DM).A review of orders revealed the following physician orders:- Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Milliliter) inject 10 unit subcutaneously one time a day related to Type 2 Diabetes Mellitus; and- Insulin Lispro Injection Solution 100 UNIT/ML inject 4 unit subcutaneously before meals related to Type 2 Diabetes Mellitus.On September 9, 2025 at 5:25 AM, a medication administration observation was conducted with Licensed Practical Nurse (LPN)/Staff #16. The following medications were dispensed: Lispro 4 units and Lantus 10 units via insulin pen for subcutaneous injection route. At 5:27 AM, Staff #16 stated that she needs to take Resident's blood sugar first. At 5:31 AM, Staff #16 entered Resident #26's room. At 5:33 AM, Staff #16 don new gloves and informed Resident that she will be taking his blood sugar. After resident agreed to having his blood sugar taken, Staff #16 wiped resident's finger with an alcohol swab, air dried, then proceeded in poking the finger with a lancet. Staff #16 read the Resident's blood sugar from the glucometer. She stated that the blood sugar was 305. At 5:37 AM, Staff #16 wiped the injection sites with alcohol swabs, and while Resident was lying on his left side, one subcutaneous injection was administered in the Resident's right lower abdomen and the other subcutaneous injection was administered in the Resident's right-side upper abdomen.On September 9, 2025 at 5:40 AM, Staff #16 left Resident #26's room. She removed her gloves, returned the insulin pens and the glucometer in the top drawer of the medication cart. She left her locked medication cart carrying with her Resident #26's water pitcher to get the Resident ice water. At 5:44 AM, Staff #16 entered Resident's room with the pitcher of ice water. After giving the Resident his pitcher of ice water, Staff #16 exited the room and used an alcohol-based hand sanitizer to perform hand hygiene.An interview was conducted on September 9, 2025 at 5:45 AM with Staff #16. She stated that there was only one glucometer for her to use inside her medication cart. She stated that traditionally, she would wipe the glucometer before and after use. She would normally use an alcohol wipe or a sanitizer called purple Sani wipe to clean the glucometer, but she does not have the purple Sani wipe at the moment because it is at the nurses' station. Staff #16 did not give an answer relating to the risk if a glucometer was not sanitized. Instead, Staff #16 stated that the glucometer does not touch the resident, she used gloves when using the glucometer, and the only thing that touched the resident during the procedure was the test strip. In addition, Staff #16 stated that when she brought the glucometer in the resident's room, it was with her because she cannot test the resident's blood sugar without it. She stated that the glucometer was placed near the sink area or on her hand. She stated that while she was assisting the resident with his water, she stated that she did not remember to where she placed the glucometer, maybe it might had been in her pocket or placed on the little table stand by the resident's bed.An interview was conducted on September 9, 2025 at 10:22 AM with LPN/Staff #48. Staff #48 stated that before and after using a glucometer to check her resident's blood sugar, she uses a Sani wipe to clean the glucometer and let it dry for three minutes. She sanitized the glucometer to make sure it is sterilized clean because if it is not sterilized, there is a risk of transferring blood or germs to other residents. In addition, Staff #48 stated that she performs hand hygiene every time she enters and exits a resident's room to protect and prevent the transfer of germs to other residents. In addition, Staff #48 stated that last week their facility had an in service on handwashing, and when she was hired, her orientation and training included a health care academy, hand hygiene and infection control.An interview was conducted on September 9, 2025 at 10:37 AM with the Infection Preventionist (IP)/Staff #74 and present during the interview was the Assistant Director of Nursing (ADON)/Staff #90. The IP sated that infection control goes with hand hygiene. She stated to hand sanitized in between, before, and after resident care. The ADON stated to hand sanitized before and after resident care, before entering a resident's room and upon exiting the room, before and after dispensing medication, and then after leaving the resident's room. The ADON stated that the risk without performing hand hygiene could result in transferring communicable diseases or microorganism, and could place the residents at risk for infection. Regarding a glucometer device, the ADON stated that it should be cleaned with a Sani wipe. The ADON stated that the facility's Sani wipe is prepacked Sani cloth bleach wipe. It is stocked in the medication cart either located on the top or bottom drawer. The ADON stated that it is important to sanitize the glucometer to prevent blood born illness and to prevent infection.An interview was conducted on September 9, 2025 at 11:22 AM with the Director of Nursing (DON)/Staff #82. The DON stated that the process and expectation about hand hygiene is to perform it when caring for resident prior and after caring, after going on break, and before serving meals. The DON stated that she would refer to the policy for hand hygiene. In addition, the DON stated that if hand hygiene was not followed, the risk is transmission of infection or illness. Her expectation is for staff to follow infection control and perform hand hygiene. Regarding the use of glucometers, the DON stated to follow the policy of cleaning between resident use and per instruction provided on disinfecting wipes for dry time to prevent infection or transmission of germs.Review of facility document titled, Assure Prism Blood Glucose Monitoring System Quality Assurance/Quality Control (QA/QC) Reference Manual, revealed that the meter should be cleaned and disinfected after use on each patient. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfection procedure. The disinfecting procedure is needed to prevent the transmission of blood borne pathogens. Blood glucose meters are at high risk of becoming contaminated with bloodborne pathogens such as Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV). Transmission of these viruses from resident to resident has been documented due to contaminated blood glucose devices. According to the Centers for Disease Control and Prevention, cleaning and disinfecting of meters between resident use can prevent the transmission of these viruses through indirect contact.A review of facility's policy titled, Blood glucose monitoring, long-term care, revealed that the Centers for Disease Control and Prevention recommends refraining from sharing blood glucose monitors among residents whenever possible. If one device must be used to monitor several residents, it must be cleaned and disinfected after every use following the manufacturer's instructions to prevent carryover of blood and infectious agents.A review of facility's policy titled, Hand Hygiene, reviewed date of July 7, 2025 revealed that associates perform hand hygiene before and after contact with resident; after contact with blood, body fluids, or visibly contaminated surfaces; after contact with objects and surfaces in the resident's environment; after removing personal protective equipment (e.g., gloves, gown); and before performing a procedure such as an aseptic task.

Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (#100). The deficient practice could result in not receiving medications that are physician ordered and necessary. Findings include: Resident #100 was admitted to the facility on [DATE] with diagnoses that include Sepsis, weakness, chronic obstructive pulmonary disorder, asthma, anemia, endocarditis, hypothyroidism, hyperlipidemia, and hypertension. A review of the 5-day MDS (Minimum Data Set) dated January 7, 2025 noted the resident had a BIMS of 15, indicating no cognitive impairment. The care plan dated January 7, 2025 revealed the resident has a stage 1 pressure injury, with interventions including administer medications as ordered. The care plan dated January 7, 2025 also revealed the resident is at-risk for rehospitalization, with a noted intervention of staff to provide timely communication to physician's regarding any change in resident's condition. Review of the physician's orders dated January 3, 2025 showed an order for Ceftriaxone injection solution 2GM (grams) with instructions to give 2 grams intravenously in the evening for infection for a duration of 12 days. Review of the physician's orders also showed an order for Heparin lock flush solution 10 units/ml (milliliters) for PICC line flush with instructions to use 5 ml intravenously [NAME] 12 hours, indicating the line was patent and ready for use. However, a review of the MAR (Medication administration record) revealed that for the resident's stay, from October 3, 2025 to October 9, 2025 the resident received only 1 administration of Ceftriaxone on October 8th, 2025. Further record review revealed no evidence that the physician or pharmacy were notified that the medication was not available. A review of progress notes dated January 4, 2025 at 7:54 p.m. revealed that the Ceftriaxone 2 gm was unavailable. A progress note dated January 5, 2025 at 9:47 p.m. revealed that the Ceftriaxone 2 gm was unavailable. A further review of progress notes revealed no additional notes on the status of the remaining administrations, including on January 7th 2025 where the documentation for the administration is blank, indicating that the medication was not given to the resident. Review of facility provided Omnicell items table list report dated March 14, 2025 included medications present in the facility for use. The list included 6 vials of Ceftriaxone 1 GM vial. However, while the list shows the medications were in the facility, they were not used in accordance with professional standards. A discharge progress note dated January 9, 2025 at 12:24 p.m. revealed the patient was noted to have a red non-raised rash to trunk and back, that the resident's skin color was grey and the patient complained of being cold and shivering. The note continued that the resident had a pulse of high pulse of 123, a low blood pressure of 88/55, and that they had contacted the on-call provider who gave instructions to send the resident to the hospital to be evaluated and treated. The note concluded that the emergency room staff had been given report to the resident's status indicating that the transfer was emergent. An interview conducted with a Licensed Practical Nurse (LPN/staff #30) on April 16, 2025 at 12:06 P.m., the LPN stated that new orders for IV antibiotics do not automatically go to the pharmacy and require the nurse to fax a set of orders to the pharmacy for them to be properly delivered. The nurse stated that for resident #100 that likely wasn't done and that's why the drugs were not available. An interview conducted with a Registered Nurse (RN/staff #40) on April 16, 2025 at 1:15 p.m., the RN stated that IV medications are ordered from the pharmacy when the nurses receive them, and have to be faxed over after they are received to be delivered correctly. The nurse further stated that the pharmacy will not deliver the drugs without faxing them unlike other medications. An interview was conducted on April 16, 2025 at 1:50 p.m. with the Director of nursing (DON/staff #50). During this interview the DON accessed the clinical record for resident #100. The DON confirmed the order for Ceftriaxone 2gm to administered once daily per the provider instructions, and stated the resident had only been given one dose for her entire stay in the facility. The DON stated that for IV medications the orders are put in the system, printed, and then faxed to the pharmacy who will then fill and send it. The DON stated that the resident was here for sepsis, and combined with the low BP and high pulse stated sounds like sepsis to me. The DON concluded that the medication not being given per provider instruction did not meet her expectations, and that resident #100 was transferred to the local hospital. A review of facility policy titled 'Administration of medications reviewed September 16, 2024 revealed The facility will ensure medications are administered safely and appropriately per physician's order to address residents' diagnoses and signs and symptoms.

Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in preventable injuries as a result of elopement. Findings include: -Resident #200 was admitted to the facility on [DATE] with diagnoses that included abdominal aortic aneurism, diabetes mellitus type 2, dementia, and hypertension. A 5-day Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. A care plan dated March 25, 2025 revealed resident #200 was at risk for elopement, with noted interventions of adding the resident to the elopement book for additional supervision, and encouraging the resident to participate in activities to divert from exit seeking behavior. An elopement assessment risk evaluation dated March 25, 2025 revealed staff had assessed the resident and found him to be an elopement risk and required additional supervision to divert from exit seeking behavior. A progress note dated March 27, 2025 at 1:33 p.m. revealed monitoring for exit seeking behavior, and noted 2 incidents of exit seeking behavior was observed. A progress note date March 28, 2025 at 10:49 a.m. revealed the patient had an elopement when he made his way from his room [ROOM NUMBER], ambulated to the front lobby and out the front door. Nobody attempted to stop the resident until the patient was outside and on the sidewalk. Multiple staff members made contact with the patient and helped to direct the patient back towards the front door of the facility. A CNA was next on scene to help escort resident #200 back inside the facility and to his room. The note concluded that resident #200 had been exit seeking all morning and is very impulsive. A progress note dated March 28, 2025 at 11:15 a.m. revealed that resident #200 had been observed wheeling around the facility and was last observed wheeling towards the main hallway in long term care. The note continues at 10:56 a.m. resident #200 had a repeated elopement out of the main hall west door. No alarms sounded from that door as it was unlocked on the inside. The gate facing north towards another business was also unlocked and ajar. The writer observed an empty wheelchair sitting halfway in the rocks outside. The writer continued that they made a quick visual sweep of any possible sightings before coming back inside the facility to alert staff that the resident had eloped again. Alerted the DON first at approximately 11:00 a.m. and code called overhead for elopement protocol. Multiple staff on foot checked immediate surroundings, facility sweep underway, and surrounding businesses checked by staff. The note concluded with a description of the resident's clothes and that the resident was ambulatory. An interview was conducted with a Licensed Practical Nurse (LPN staff/#30) on April 16, 2024 at 12:06 p.m. Staff #30 stated that resident #200 was identified as a flight risk from day 1. Staff #30 stated that he alerted the management the first day that resident #200 was too much of a wanderer and needed to get him out of the facility because he would get out. Staff #30 continued that his wandering behavior got worse as time went on, to include wandering into other peoples rooms, and that resident #200 required constant redirection. Staff #30 stated that after the second elopement he was placed on a 1:1 and given snacks and other things to help redirect him. Staff #30 stated that the first time resident #200 got out the front we heard on the intercom, rehab we need someone to the front two times, assuming it was a delivery because it wasn't called as an elopement. Staff #30 continued that while doing the medication pass, a CNA came and informed staff #30 that resident #200 had gotten out the front door. Staff #30 also stated that, all the managers were in a meeting and they had no idea, stating a manager even said later, That's what that page was for? indicating that it was not called an elopement on the overhead page. Staff #30 continued that the second incident resident #200 was in his wheelchair in the hallway, headed to therapy, got pulled aside for something else and when he returned to his cart was unable to find resident #200. Staff #30 stated that when they went out the back door, that the door was unlocked and the alarm was disabled, and the gate leading off the property outside that door was also ajar. Staff #30 stated they then called a code yellow and a sweep and search was initiated by several staff members. Staff #30 continued that resident #200 was found in a local grocery store by one of the CNA's, that they made multiple calls to surrounding businesses and the police. Staff #30 stated that while resident #200 was mobile, he had a 6.3cm triple A and the first question they had for the CNA was if the resident was alive, which he was. Staff #30 concluded that they were lucky and thankful it didn't rupture and after he returned to the facility they initiated a 1:1 for resident #200 until he left the facility, among other interventions. An interview was conducted with a Certified Nursing Assistant (CNA/staff #50) on April 16, at 1:34 p.m. The CNA stated that when resident #200 was reported missing, several of the staff went out and went around the grocery store parking lot looking for him. The CNA further stated that she got into her car and drove around looking for him in the area. They stated that when resident #200 got out he went out the back door and that one of the nurses found it unlocked. The CNA continued that when they were about to return to the facility, they decided to make a second sweep through the grocery store and that's when they located resident #200 inside. The CNA stated that resident #200 was found tired and wobbly, so they stated that one of the staff was left with him while she got a wheelchair and wheeled him back. The CNA concluded that when she got to the door resident #200 got out of the door was disarmed, green, and unlocked so that no alarm would go off. An interview was conducted with the Director of Nursing (DON staff/#50). The DON stated the day of the incident with resident #200 a nurse came to her office and stated resident #200 had gotten out. She stated that they both bolted up and headed out to find him. She stated that they had a strong suspicion because of the back gate being open, and the wheelchair being near the back door, and that it was a good clue the empty wheelchair that he got out that door. She further stated we made all our notifications to the police and others, and stated local PD was sending someone to help look for resident #200. The DON concluded that he was found nearby and was returned to the facility and placed on a 1:1 as they don't have a locked behavior unit, and that a performance improvement plan (PIP) was put in place to check doors and gates regularly as both were unlocked when the resident eloped. A review of facility policy titled 'Missing residents / Actual Elopement' revealed the facility must develop and implement preparedness policies and procedures based on the emergency plan, and that the policies and procedures must be reviewed and updated at least annually. It further revealed that elopement occurs when a resident leaves the premises or a safe area without authorization (ie,. An order for discharge) and or any necessary supervision. A situation where in which a resident with decision-making capacity leaves the facility intentionally generally not be considered an elopement, UNLESS the facility is unaware of the resident's departure and/or whereabouts.

Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (#100). The deficient practice could result in not receiving medications that are physician ordered and necessary. Findings include: Resident #100 was admitted to the facility on [DATE] with diagnoses that include Sepsis, weakness, chronic obstructive pulmonary disorder, asthma, anemia, endocarditis, hypothyroidism, hyperlipidemia, and hypertension. A review of the 5-day MDS (Minimum Data Set) dated January 7, 2025 noted the resident had a BIMS of 15, indicating no cognitive impairment. The care plan dated January 7, 2025 revealed the resident has a stage 1 pressure injury, with interventions including administer medications as ordered. Review of the physician's orders dated January 3, 2025 showed an order for Ceftriaxone injection solution 2GM (grams) with instructions to give 2 grams intravenously in the evening for infection for a duration of 12 days. However, a review of the MAR (Medication administration record) revealed that for the resident's stay, from October 3, 2025 to October 9, 2025 the resident received only 1 administration of Ceftriaxone on October 8th, 2025. A review of progress notes dated January 4, 2025 at 7:54 p.m. revealed that the Ceftriaxone 2 gm was unavailable. A progress note dated January 5, 2025 at 9:47 p.m. revealed that the Ceftriaxone 2 gm was unavailable. A further review of progress notes revealed no additional notes on the status of the remaining administrations, including on January 7, 2025 where the documentation for the administration is blank, indicating that the medication was not given to the resident. Review of facility provided Omnicell items table list report dated March 14, 2025 included medications present in the facility for use. The list included 6 vials of Ceftriaxone 1 GM vial. However, while the list shows the medications were in the facility, they were not used in accordance with professional standards. An interview conducted with a Licensed Practical Nurse (LPN/staff #30) on April 16, 2025 at 12:06 P.m., the LPN stated that new orders for IV antibiotics do not automatically go to the pharmacy and require the nurse to fax a set of orders to the pharmacy for them to be properly delivered. The nurse stated that for resident #100 that likely wasn't done and that's why the drugs were not available. An interview conducted with a Registered Nurse (RN/staff #40) on April 16, 2025 at 1:15 p.m., the RN stated that IV medications are ordered from the pharmacy when the nurses receive them, and have to be faxed over after they are received to be delivered correctly. The nurse further stated that the pharmacy will not deliver the drugs without faxing them unlike other medications. An interview was conducted on October 20, 2023 at 11:29 a.m. with the Director of nursing (DON/staff #50). During this interview the DON accessed the clinical record for resident #100. The DON confirmed the order for Ceftriaxone 2gm to administered once daily per the provider instructions, and stated the resident had only been given one dose for her entire stay in the facility. The DON stated that for IV medications the orders are put in the system, printed, and then faxed to the pharmacy who will then fill and send it. The DON concluded that the medication was actually in their Omnicell, and that it did not meet her expectations that the medication was not provided. A review of facility policy titled 'Administration of medications' reviewed September 16, 2024 revealed that the facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.

Based on clinical record review, interview, and a complaint submitted via the State Agency's (SA) online complaint portal, the facility failed to ensure that resident #1's Power of Attorney (POA) was notified of the resident's hospitalization . The deficient practice prevented the POA from being informed of the resident's care and change in condition. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included Dementia, malnutrition, and age-related cataract. Review of the quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) assessment was completed on February 16, 2024. The BIMS assessment revealed resident #1 scored a 06 which indicated the resident was severely cognitively impaired. The MDS also indicated resident #1 had no behavioral symptoms or falls since the prior quarterly assessment. A complaint was received, on February 14, 2025, via the SA complaint portal which indicated the resident was taken to the hospital due to a fall. The complaint indicated the POA was not notified of the hospitalization by the facility and did not find out about resident #1's fall until the hospital had contacted them. A review of resident #1's medical records did not reveal any documentation that the Power of Attorney or family member was notified of the resident's transport to the hospital. A review of progress notes revealed an entry dated March 18, 2024 at 5:30 AM which indicated the resident had woken up in the middle of the night due to complaining of shortness of breath but did not have a fever, cough, or sore throat. The note also indicated the physician ordered Zithromax (Z-pack) to be administered. The next progress note was entered on April 24, 2024 at 4:52 PM which indicated the resident was readmitted to the facility from the hospital and the resident had a right hip fracture. An interview was conducted on March 3, 2025 at 9:09 AM with Certified Nursing Assistant (CNA/Staff #13). Staff #13 explained that when a resident has a change in their condition they would notify the nurse on duty and the nurse would chart it in the resident's EHR. Staff added that CNAs only charted vitals and Activities of Daily Living (ADLs). When asked if a fall resulting in a resident being hospitalized would be considered a change in condition, staff #13 agreed that it was. When asked who would be notified of a resident's change in condition, staff #13 indicated that the nurse would let the resident's family and the doctor know. An interview was conducted on March 3, 2025 at 9:32 AM with Licensed Practical Nurse (LPN/Staff #57). Staff #57 explained that if a resident has a change in their condition, she would document it in a nurse's note in the progress note section (of the EHR) and she would notify the Director of Nursing (DON), the family if they had a Power of Attorney and the Doctor. Staff #57 also explained that if a resident had a fall which resulted in an injury, it would be considered a change in the resident's condition. Staff #57 added that she would document the notifications in a progress note in the resident's chart. Staff #57 indicated she was familiar with resident #1 and shared that she was working when resident #1 had a fall. She had heard the resident call out and saw that the resident was in the doorway of her room. She continued to explain that she assessed resident #1 and the resident was complaining of pain in the leg. Staff #57 also indicated that the doctor had told her to send the resident to the hospital for x-rays. When reviewing the resident's EHR with staff #57, staff #57 was not able to locate a progress note for the fall. Staff #57 was not able to explain why a progress note was not done, however she recalled that she notified the DON and the Doctor but didn't think resident #1 had any family members so no family notification was made. An interview was conducted on March 3, 2025 at 9:55 AM with LPN/Staff #26. Staff #26 explained that if a resident had a change in their condition which resulted in them needing to go to the hospital then she would document it in the resident's progress notes. She also indicated that she would inform the doctor, the resident's emergency contact, and the DON. Once the notifications were done, it would be documented in a progress note. Staff #26 shared that the risk of not notifying the emergency contact of the resident's change in condition and transfer would be the family not knowing what is going on with the resident. An interview was conducted with the DON/Staff #56 was conducted on March 3, 2025 at 10:13 AM. Staff #56 indicated that when a resident has a change in their condition, the nurses are to document the change in a progress note in the EHR. If there was a fall that was not their baseline and resulted in injuries, that would be a change in their condition. When staff #56 was asked to locate documentation in resident #1's EHR related to a change in her condition in April of 2024, staff was not able to locate anything related to a fall. When asked if the chart should tell her why resident #1 went to the hospital she stated, I would assume so. When staff #56 was referred to an attachment in the EHR that contained the hospital's discharge notes, staff #56 shared that the report indicated the resident had a witnessed fall and the resident had surgery on the hip per the surgical report. Staff #56 also shared that she looked up past incident reports and did not see anything related to resident #1's fall. Staff #56 was not able to determine if resident #1's family/POA was notified of the resident's hospitalization . She also shared that the risk of not notifying them would be a break in the change of communication or the family/POA might decide to visit the resident in the facility only to find out the resident was at the hospital instead and it might be hard on them. Review of the facility's policy titled, Changes in Resident's Condition or Status, revised on September 5, 2024 indicated the facility will notify the resident representative of changes in the resident's condition or status. This also included when there is an accident involving the resident which results in injury, and when there is a decision to transfer . the resident from the facility .

Based on clinical record review, interview, and a complaint submitted via the State Agency's (SA) online complaint portal, the facility failed to ensure that resident #1's electronic health record (EHR) contained accurate information about the resident's condition including changes in their condition. The deficient practice could prevent the resident from obtaining accurate services based on their medical condition. Findings include: Resident #1 was admitted on [DATE] with diagnoses that included Dementia, malnutrition, and age-related cataract. Review of the quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) assessment was completed on February 16, 2024. The BIMS assessment revealed resident #1 scored a 06 which indicated the resident was severely cognitively impaired. The MDS also indicated resident #1 had no behavioral symptoms or falls since the prior quarterly assessment. A complaint was received, on February 14, 2025, via the SA complaint portal which indicated the resident was taken to the hospital due to a fall. A review of resident #1's medical records did not reveal any documentation of a fall that took place in April 2024 which required the resident's transport to the hospital. A review of progress notes revealed an entry dated March 18, 2024 at 5:30 AM which indicated the resident had woken up in the middle of the night due to complaining of shortness of breath but did not have a fever, cough, or sore throat. The note also indicated the physician ordered Zithromax (Z-pack) to be administered. The next progress note was entered on April 24, 2024 at 4:52 PM which indicated the resident was readmitted to the facility from the hospital and the resident had a right hip fracture. An interview was conducted on March 3, 2025 at 9:09 AM with Certified Nursing Assistant (CNA/Staff #13). Staff #13 explained that when a resident has a change in their condition they would notify the nurse on duty and the nurse would chart it in the resident's EHR. Staff added that CNAs only charted vitals and Activities of Daily Living (ADLs). When asked if a fall resulting in a resident being hospitalized would be considered a change in condition, staff #13 agreed that it was. An interview was conducted on March 3, 2025 at 9:19 AM with CNA/Staff #20. Staff #20 shared that she was working the day that resident #1 had a fall. Staff #20 indicated that the fall had taken place in the doorway of resident #1's room and that it was not witnessed by staff. She also indicated that the physician was in the building at the time of the fall and he ordered the resident to be sent to the hospital. Staff #20 recalled that it had taken four or five staff members to assist the resident with getting off the floor. Staff also did not recall the exact date that the fall took place. When asked if a fall would be considered a change in the resident's condition and if it needed to be documented, staff #20 indicated that it would be a change in the resident's condition and the nurses would document it in the resident's chart. An interview was conducted on March 3, 2025 at 9:32 AM with Licensed Practical Nurse (LPN/Staff #57). Staff #57 explained that if a resident has a change in their condition, she would document it in a nurse's note in the progress note section (of the EHR) and she would notify the Director of Nursing (DON), the family if they had a Power of Attorney and the Doctor. Staff #57 also explained that if a resident had a fall which resulted in an injury, it would be considered a change in the resident's condition. Staff #57 added that she would document the notifications in a progress note in the resident's chart. Staff #57 indicated she was familiar with resident #1 and shared that she was working when resident #1 had a fall. She had heard the resident call out and saw that the resident was in the doorway of her room. She continued to explain that she assessed resident #1 and the resident was complaining of pain in the leg. Staff #57 also indicated that the doctor had told her to send the resident to the hospital for x-rays. When reviewing the resident's EHR with staff #57, staff #57 was not able to locate a progress note for the fall. Staff #57 was not able to explain why a progress note was not done. She indicated that she thought that she had completed the progress note. An interview was conducted with the DON/Staff #56 was conducted on March 3, 2025 at 10:13 AM. Staff #56 indicated that when a resident has a change in their condition, the nurses are to document the change in a progress note in the EHR. If there was a fall that was not their baseline and resulted in injuries, that would be a change in their condition. When staff #56 was asked to locate documentation in resident #1's EHR related to a change in her condition in April of 2024, staff was not able to locate anything related to a fall. When asked if the chart should tell her why resident #1 went to the hospital she stated, I would assume so. When staff #56 was referred to an attachment in the EHR that contained the hospital's discharge notes, staff #56 shared that the report indicated the resident had a witnessed fall and the resident had surgery on the hip per the surgical report. Staff #56 also shared that she looked up past incident reports and did not see anything related to resident #1's fall. Staff #56 shared that her expectation was for incidents to be documented in a timely and accurate fashion according to company policies and standards. Failure to do so would put them at risk of having an inaccurate representation of someone's care. Review of the facility's policy titled, Nursing Documentation, last revised on September 5, 2024 indicated that nursing documentation is to be consistent with professional standards of practice. The policy further stated that staff must document a resident's medical and non-medical status when any positive or negative condition change occurs . It also stated the medical record must contain an accurate representation of the actual experience of the resident.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to protect the rights of one resident (#2) from sexual abuse by a visitor. The deficient practice resulted in the resident being sexually abused. Findings include: Resident #2 was admitted on [DATE] with diagnoses of cognitive communication deficit, Parkinson's disease, and anxiety disorder. The care plan with revision date of September 9, 2024 revealed the resident had actual and potential psychosocial well-being problem related to cognitive impairment, family discord and past history of physical and sexual abuse. Interventions included supervised visits with a family member and during visits, resident #2 and the family member had to be either in a public area or must be able to be viewed by staff while in her room. A communication note dated September 23, 2024 included that the resident's family member/POA (power of attorney) asked to get a report of a sexual abuse allegations from September 9; and that, the family member wanted to know what was in the report as he felt that he was being accused of something. Per the documentation, the family member reported that the resident's allegations were done to get attention; and that, the resident was molested when she was 7 and when she was married was abused by her husband. The documentation also included that the family member reported that the day the resident made allegations that she had been raped (September 9) was the day that the family member was not feeling well and only made a short visit. It also included that the short visit did not leave time for a rape and it does for inappropriate touching. The documentation also included that the family member was notified that eyesight visitations will be continued until the facility was told otherwise. The late entry mood note dated September 25, 2024 revealed the resident was more emotional and was crying out more lately. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 03 which indicated the resident had severe cognitive impairment. The alert note dated October 1, 2024 included that at approximately 3:30 p.m., the resident reported that she was suicidal as she was crying in the hallway. The facility visitor sign in-sign out sheet for October 14, 2024 revealed that the family member/POA visited and was at the facility from 11:00 a.m. through 12:13 p.m. The clinical record revealed no evidence found that the family/POA was supervised during his visit with resident #2 on October 14, 2024 from 11:00 a.m. through 12:13 p.m. The clinical record also revealed no evidence that the care plan for supervised visits were discontinued for the family member/POA. The alert note dated October 14, 2024 revealed that at approximately 2:00 p.m., two certified nursing assistants (CNAs) reported that resident #2 had abnormal vaginal bleeding that was found during showers; and that both CNAs reported that it was a lot of bleeding. Per the documentation, when the nurse approached the resident in the hall, the resident reported that she did not do anything wrong. It also included that the resident was assessed and external examination showed no bleeding, swelling or bruising and there was no blood in the resident's brief. Further, the documentation included that directions were given to send the resident to the hospital for examination. The alert note dated October 14, 2024 included that at approximately 2:15 p.m., a CNA who was upset reported to the social service director that the CNA was helping other CNAs with showers and was giving resident #2 showers. Per the documentation, the CNA reported that when the CNA was washing the resident's vagina, there was a lot of blood on the wash cloth; and that she grabbed a new wash cloth, washed the area again and there was still significant amount of blood. The documentation included that when the CNA asked the resident if she was ok, the resident yelled out that the family member/POA did not do anything to her. Further, the documentation included that the resident was assessed, EMS (emergency medical services) was called and resident was transferred to the hospital. Another alert note dated October 14, 2024 revealed that at approximately 2:25 p.m., the nurse was informed by a CNA who provided showers to resident #2 that that CNA witnessed a significant amount of vaginal bleeding; and that, the CNA used two rags which were both bloody. The documentation included that when the resident became aware of this, the resident reported that the family member/POA did not do it. The documentation included that a noninvasive assessment was conducted and the resident's brief was examined and there was no apparent blood or visible physical trauma observed. Per the documentation, instruction was given to proceed with hospital transfer and notification of the family member/POA. The transfer to hospital summary note dated October 14, 2024 revealed that at approximately 2:30 p.m., a CNA observed the resident was having vaginal bleeding; and that, the resident was post-menopausal. Per the documentation, both the nurse and the CNA reported that bleeding was initially [NAME]-red with beginning of perineal care whilst in a shower after visit concluded. The documentation also included that when asked about the bleeding, the resident immediately responded that the family member (POA) did not do it. The note included that the resident was sent to the ER (emergency room ) with explicit instructions to perform vaginal inspection via speculum. A health status note dated October 14, 2024 included the resident left the facility for evaluation at the hospital ER. The communication note dated October 14, 2024 included that at approximately 2:45 p.m., the family/POA was notified that the resident was transferred to the hospital for evaluation related to abnormal groin bleeding. Per the documentation, the family/POA responded by asking whether the bleeding was in the resident's private area and then ended the call. The sexual assault medical examination report dated October 14, 2024 revealed that the resident was frail, suffered from Parkinson's disease and had a difficult time communicating. Per the documentation, resident reported that the family member/POA had assaulted her earlier in the day but was not certain of the time. It also included that the resident reported that she and the family member/POA went to the mall and the family member/POA assaulted her in the care. The documentation included that the resident reported that the family member/POA took her shorts off, held her legs, placed his finger into her vagina, put his penis into her vagina and put his mouth and hands on both her breasts. It also included that the resident reported that she was slapped on the left side of the face-neck with the hand; and that, the family member/POA had assaulted her when she was a child. Physical examination included injuries noted in the lower extremities, external genital area and the labia minora. Description of the injuries included 0.5 cm (centimeter) x 1.5 cm red bleeding 1 o'clock to 3 o'clock at the edge of the vaginal orifice and 1 cm linear scratch 12 o'clock approximately 2 cm anterior to the vaginal orifice. Examiner's diagnosis included sexual assault by history and examination. The hospital report dated October 14, 2024 revealed that the resident was seen at 5:00 p.m. for evaluation for sexual assault. Per the documentation, facility reported that there were prior reports of sexual assault that were unsubstantiated. It also included that the resident reported lower abdominal pain, denied vaginal bleeding/discharge; and that, she was allegedly sexually assaulted by a patient from the facility yesterday. The documentation also included that the resident reported there were 3 discrete episodes of sexual assault that included touching and penile penetration. Continued review of the hospital report revealed that the police department informed the hospital that the resident told the police that she had been sexually assaulted 3 times while at the facility. The event note dated October 15, 2024 revealed that the nurse received a report from the hospital ED that the assessment and bruises were consistent with abuse; and that, the resident would need to have additional photos done. The event note dated October 15, 2024 included the resident arrived back to the facility, was agitated, crying and moaning. Per the documentation, the resident stated Why did he do this to me?, Was I bad? How could he hurt me, why did he do this to me? It also included that the resident kept crying and moaning, was given medications, and attention was diverted to watching a movie with the nurse until the resident fell asleep. A communication note dated October 15, 2024 included that the family/POA was informed that he would not be allowed into the building pending investigation. The administration note dated October 15, 2024 revealed that resident was restless and upset. The email correspondence from the facility's executive director (ED/staff #13) addressed to the provider and dated October 15, 2024 included that the resident was sent to the ER for vaginal bleeding; and that, clinical inspection was done at the ER and findings were consistent with sexual abuse. The administration note dated October 16, 2024 revealed that resident was agitated and was crying. The administration note dated October 17, 2024 included that the resident was crying and was asking the question What did I do wrong? over and over. An interview was conducted on October 17, 2024 at 2:04 PM with CNA (staff #20) who was working the day of October 14, 2024. The CNA stated that she assisted another CNA (staff #10) in getting resident #2 in the shower and then proceeded to the nurses' station. The CNA said that staff #10 came out of the shower and told her that she was washing the resident's vagina and that resident had blood in the area. The CNA said that staff #10 showed her the rag she used and asked her if it was normal for resident #2 to have that much blood. The CNA said that she asked staff #10 if resident #2 had hemorrhoids and staff #10 replied with a no. She stated that she then went with staff #10 back into the showers and had used the flashlight on her phone to check resident #2. The CNA said that she did not see any scratches or hemorrhoids and at that point, she gave resident #2 a towel to dry off and asked the resident if she had gotten hurt. The CNA said that looked at her and replied that family member/POA did not do anything to her vagina. The CNA said that she then reported the incident to the ED (staff #13) and registered nurse (RN/staff #6). Further, the CNA said that earlier in the day of the incident, during lunch, resident #2 appeared to be uncomfortable. An interview was conducted on October 17, 2024 at 3:01 p.m. with another CNA (staff #22) who stated that she was familiar with resident #2 but was not working with her on October 14, 2024. Staff #22 stated that the family member/POA would visit resident #2 often; however, she does not know where these visits take place or if there were any safety precautions in place during these visits. In an interview with a licensed practical nurse (LPN/staff #14) conducted on October 18, 2024 at 9:08 a.m., the LPN stated he was working on October 14, 2024 and was familiar with resident #2. He said that resident #2 had one visitor on October 14, 2024 and it was the family member/POA; however, he said that he was not sure where the visit took place. The LPN stated that at one point, the family member/POA was at the nurses' station for approximately 15 minutes because resident #2 was being changed in her room; but, he lost sight of the family member/POA after that. He stated that during his shift the CNA (staff #10) reported that resident #2 had blood on her washcloth during a shower. The LPN said that he had reported the incident to the Assistant Director of Nursing (ADON/staff #4) and RN (staff #6). An interview was conducted with the CNA (staff #10) on October 18, 2024 at 9:18 a.m. The CNA said that she was scheduled to be on the rehab unit on October 14, 2024 but the long term care unit needed help so she was assisting residents with showers. The CNA said that resident #2 was her first shower of the day since she was up and around; and that, resident #2 does not do her own washing so staff was doing it for her. The CNA said that she was washing the resident's privates with soap and a washcloth when she noticed a good amount of blood and she was not sure where it was coming from. She reported that she was able to get another CNA (staff #20) to assist her in locating the source of the bleeding and both she and staff #20 saw the blood coming out of the resident's vagina. The CNA said that she and staff #200 reported the incident to the RN (staff #6) and the ED (#13). Regarding resident #2, the CNA said that the resident's agitation usually gets worse after her visits with the family member/POA. During an interview with the Director of Nursing (DON/staff #18) conducted on October 17, 2024 at 3:58 p.m., the DON said that she was somewhat familiar with resident #2 as she had just recently started working at the facility on October 2, 2024; and she was not working on October 14, 2024 which was the day of the incident. The DON said that the visits between resident #2 and the family member/POA were to take place within the staff's line of sight; and that, she only became aware of this on October 14, 2024 when the incident took place. The DON said that the visits of the family member/POA with resident #2 were put on hold pending the outcome of the abuse investigation; and that, if a staff sees the family member/POA on the premises, the staff were to inform her, the ADON or the ED immediately so they could intervene. Further, the DON said that allowing family member/POA to continue to have unsupervised visitation with resident #2 would have the risk of abuse to continue. In an interview conducted with the ED (staff #13) conducted on October 17, 2024 at 4:12 p.m., the ED stated that visits between resident #2 and the family member/POA were to take place either on the front porch, the front lobby, or the sitting area by the ice cream parlor. The ED said that she was working on October 14, 2024 and was approached by the RN (staff #6) and two CNAs (staffs #10 and #20). She said that she was told that the resident was being provided with showers by the CNA and there was blood on the washcloth when the CNA did the peri care. The ED stated that the two CNAs reported that they got on their knees with a flashlight, saw that there were no cuts but the bleeding appeared to be coming from the resident's vagina. The ED said that she instructed the RN (staff #6) and another nurse to do an exam to determine the cause of the bleeding. The ED further stated that the risk to the resident if someone, who was accused of sexually assaulting them continued to have unsupervised visits depended on whether the allegation was substantiated or unsubstantiated. The facility's policy on Abuse - Protection of Resident was last reviewed on July 18, 2023 revealed that the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. The policy also revealed that to ensure the protection of residents during an investigation included removal of access by the alleged perpetrator to the alleged victim and assurance that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents. The facility policy on Visitor Management reviewed on June 17, 2024 included that all associates are responsible for ensuring the safety and well-being of residents, associates and visitors. Reasonable clinical and safety restrictions include a facility's policies, procedures or practices that protect the health and security of all residents and staff; and, these may include, but are not limited to denying access or providing limited and supervised access to an individual if that individual is suspected of abusing, exploiting, coercing a resident until an investigation into the allegation has been completed or has found to be abusing, exploiting or coercing a resident.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure abuse policies and procedures were implemented to protect the rights of one resident (#2) from sexual abuse by a visitor. The deficient practice could result in appropriate action not taken and further abuse of the resident. Findings include: Resident #2 was admitted on [DATE] with diagnoses of cognitive communication deficit, Parkinson's disease, and anxiety disorder. The care plan with revision date of September 9, 2024 revealed the resident had actual and potential psychosocial well-being problem related to cognitive impairment, family discord and past history of physical and sexual abuse. Interventions included supervised visits with a family member and during visits, resident #2 and the family member had to be either in a public area or must be able to be viewed by staff while in her room. A communication note dated September 23, 2024 included that the resident's family member/POA (power of attorney) asked to get a report of a sexual abuse allegations from September 9; and that, the family member wanted to know what was in the report as he felt that he was being accused of something. Per the documentation, the family member reported that the resident's allegations were done to get attention; and that, the resident was molested when she was 7 and when she was married was abused by her husband. The documentation also included that the family member reported that the day the resident made allegations that she had been raped (September 9) was the day that the family member was not feeling well and only made a short visit. It also included that the short visit did not leave time for a rape and it does for inappropriate touching. The documentation also included that the family member was notified that eyesight visitations will be continued until the facility was told otherwise. The facility visitor sign-in/sign-out sheet for October 14, 2024 revealed that the family member/POA visited and was at the facility from 11:00 a.m. through 12:13 p.m. The clinical record revealed no evidence found that the family/POA was supervised during his visit with resident #2 on October 14, 2024 from 11:00 a.m. through 12:13 p.m. The clinical record also revealed no evidence that the care plan for supervised visits were discontinued for the family member/POA. There was no evidence found in the clinical record and facility documentation of a reason why the family member/POA was not supervised on October 14, 2024 from 11:00 a.m. through 12:13 p.m. The clinical record review revealed that on October 14, 2024, two certified nursing assistants (CNAs) reported that resident #2 had abnormal vaginal bleeding that was found during showers; and that both CNAs reported that it was a lot of bleeding. Per the documentation, when the nurse approached the resident in the hall, the resident reported that she did not do anything wrong. It also included that the resident was assessed and external examination showed no bleeding, swelling or bruising and there was no blood in the resident's brief. Further, the documentation included that directions were given to send the resident to the hospital for examination. The transfer to hospital summary note dated October 14, 2024 revealed that when asked about the bleeding, the resident immediately responded that the family member (POA) did not do it. The note included that the resident was sent to the ER (emergency room ) with explicit instructions to perform vaginal inspection via speculum. The sexual assault medical examination report dated October 14, 2024 revealed that the resident reported that the family member/POA had assaulted her earlier in the day but was not certain of the time; and that, she and the family member/POA went to the mall and the family member/POA assaulted her in the car. Physical examination included injuries noted in the lower extremities, external genital area and the labia minora. Examiner's diagnosis included sexual assault by history and examination. The event note dated October 15, 2024 revealed that the nurse received a report from the hospital ED that the assessment and bruises were consistent with abuse. The email correspondence from the facility's executive director (ED/staff #13) addressed to the provider and dated October 15, 2024 included that the resident was sent to the ER for vaginal bleeding; and that, clinical inspection was done at the ER and findings were consistent with sexual abuse. An interview was conducted on October 17, 2024 at 3:01 p.m. with another CNA (staff #22) who stated that she was familiar with resident #2 but was not working with her on October 14, 2024. Staff #22 stated that the family member/POA would visit resident #2 often; however, she does not know where these visits take place or if there were any safety precautions in place during these visits. In an interview with a licensed practical nurse (LPN/staff #14) conducted on October 18, 2024 at 9:08 a.m., the LPN stated he was working on October 14, 2024 and was familiar with resident #2. He said that resident #2 had one visitor on October 14, 2024 and it was the family member/POA; however, he said that he was not sure where the visit took place. The LPN stated that at one point, the family member/POA was at the nurses' station for approximately 15 minutes because resident #2 was being changed in her room; but, he lost sight of the family member/POA after that. During an interview with the Director of Nursing (DON/staff #18) conducted on October 17, 2024 at 3:58 p.m., the DON said that the visits between resident #2 and the family member/POA were to take place within the staff's line of sight; and that, she only became aware of this on October 14, 2024 when the incident took place. The DON said that the visits of the family member/POA with resident #2 were put on hold pending the outcome of the abuse investigation; and that, if a staff sees the family member/POA on the premises, the staff were to inform her, the ADON or the ED immediately so they could intervene. Further, the DON said that allowing family member/POA to continue to have unsupervised visitation with resident #2 would have the risk of abuse to continue. In an interview conducted with the ED (staff #13) conducted on October 17, 2024 at 4:12 p.m., the ED stated that visits between resident #2 and the family member/POA were to take place either on the front porch, the front lobby, or the sitting area by the ice cream parlor. The ED said that she was working on October 14, 2024 and was approached by the RN (staff #6) and two CNAs (staffs #10 and #20). She said that she was told that the resident was being provided with showers by the CNA and there was blood on the washcloth when the CNA did the peri care. The ED stated that the two CNAs reported that they got on their knees with a flashlight, saw that there were no cuts but the bleeding appeared to be coming from the resident's vagina. The ED said that she instructed the RN (staff #6) and another nurse to do an exam to determine the cause of the bleeding. The ED further stated that the risk to the resident if someone, who was accused of sexually assaulting them continued to have unsupervised visits depended on whether the allegation was substantiated or unsubstantiated. The facility's policy on Abuse - Protection of Resident was last reviewed on July 18, 2023 revealed that the facility will ensure that all residents are protected from physical and psychosocial harm during and after the investigation. The policy also revealed that to ensure the protection of residents during an investigation included removal of access by the alleged perpetrator to the alleged victim and assurance that ongoing safety and protection is provided for the alleged victim and, as appropriate, other residents. The facility policy on Visitor Management reviewed on June 17, 2024 included that all associates are responsible for ensuring the safety and well-being of residents, associates and visitors. Reasonable clinical and safety restrictions include a facility's policies, procedures or practices that protect the health and security of all residents and staff; and, these may include, but are not limited to denying access or providing limited and supervised access to an individual if that individual is suspected of abusing, exploiting, coercing a resident until an investigation into the allegation has been completed or has found to be abusing, exploiting or coercing a resident.

Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure medications were administered as ordered for one resident (#1). The deficient practice could result in resident not receiving treatment for their assessed needs. Findings include: Resident #1 was admitted on [DATE] with diagnoses of encephalopathy, muscle weakness, and a cognitive communication deficit. A review of the admission minimum Data Set (MDS) assessment, dated October 8, 2024, revealed the resident was not able to complete a Brief Interview for Mental Status (BIMS); and that, staff assessment revealed the resident had a severely impaired cognitive skills for daily decision making. The hospital discharge instructions dated October 8, 2024 included an order for Droxidopa (anti-Parkinson agent) 300 mg (milligrams) capsules every 8 hours for 30 days. Problem lists included brain disorder, chronic stroke and coagulopathy. The physician order dated October 4, 2024 included for Droxia (antimetabolite and used to treat certain cancer) oral capsule 300 mg three times a day for hypotension for 30 days. The physician order summary report revealed an order dated October 4, 2024 for Droxia (antimetabolite) oral capsule 300 mg three times a day for hypotension for 30 days. The start date of the order was October 5, 2024 and the end date were November 4, 2024. Continued review of the order summary report revealed that the reason for the discontinuation of the Droxia on October 7, 2024 was documented as entered in error. The order for Droxia was transcribed onto the October 2024 MAR (medication administration record) and had a discontinue date of October 7, 2024. Review of the October 2024 MAR documentation revealed that Droxia was administered to resident #1 six times between October 5, 2024 and October 7, 2024. There was no evidence found that the physician was notified of the error for Droxia. The clinical record revealed no evidence that Droxipoda was administered to resident #1 as ordered by the hospital. There was also no documentation found of why it was not administered; and that, the physician was notified. An interview with Licensed Practical Nurse (LPN/staff #8) was conducted on October 17, 2024 at 5:16 p.m. The LPN said that the process for entering medication orders involved obtaining the discharge order from the hospital via a computer order system then entering it into the electronic record. The LPN said that a second nurse will double check and reconcile the orders to ensure its accuracy; and, orders can also be entered into the electronic record at any time by any nurse. During the interview, a review of the clinical record was conducted with the LPN who stated that the hospital discharge order did not match orders entered in clinical record. An interview was conducted with the Director of Nursing (DON/staff #18) on October 17, 2024 at 4:25 p.m. The DON said that incoming residents come with discharge orders which goes through the facility's admissions department. The DON said that orders are then given to a nurse who transcribes them orders into the EHR (electronic health record). The DON stated that after the orders were transcribed, a second nurse then verifies the orders as the first nurse reads the discharge orders. A review of the clinical record was conducted with the DON who stated that the hospital order for Droxidopa did not match the order for Droxia in the EHR; and that, resident #1 was administered with Droxia 6 times before the medication was stopped. The DON further stated that this was an order transcription error and this did not meet her expectations. The facility's policy on Administration of Medications was last reviewed on August 24, 2023. The policy defines a medication error as the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1- The prescriber's order .

Based on clinical record review, staff interviews, review of facility documentation, facility policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure there was a physician order for a narcotic medication that was administered to one resident (#2). The deficient practice could result in residents receiving unnecessary medication. Findings include: Resident #2 was admitted on [DATE] with diagnoses of paroxysmal atrial fibrillation and Alzheimer's disease. A care plan dated [DATE] included that this resident was at risk for falls related to cognitive impairment and hypotension. A physician's order dated [DATE] included acetaminophen (analgesic) Tablet 325 milligrams, give 2 tablet by mouth every 4 hours as needed for temperature above 101 degrees, not to exceed 3 gram/24 hours. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. A review of the clinical record revealed no evidence of any physician order for morphine (opioid) for resident #2. Review of the MAR revealed no transcribed order for morphine for resident #2. A progress note dated [DATE] included the nurse writing the note was called into resident #2's room to assess the resident with night shift (NOC) nurse and that when a Certified Nursing Assistants (CNA) were changing resident #2, he took one last breath and then did not seem to be breathing. This note included that upon assessment of the resident, vitals were absent, no apical pulse auscultated, no pulses or respirations noted at time 6:45 P.M. Review of the intake information submitted by the facility to the SA complaint tracking system on [DATE] revealed that an allegation was made that the former Director of Nursing (DON) was informed by a Registered Nurse (RN/staff #59) that resident #2 was not doing well and seemed to be in pain on [DATE]. The information also included that staff #59 allegedly asked the former DON if they could get an order for comfort medications and the former DON responded, No, I have some morphine here and you can give him this. Per the documentation, the former DON then was said to pull a bottle of Morphine out of her locked cabinet, where she keeps discontinued Narcotics to be destroyed. The information also revealed that staff #59 stated that former DON drew up the morphine and handed it to the RN, and instructed the RN to go give the medication to resident #2. Further, the information revealed that the former DON admitted to giving the morphine orally to resident #2 at around 4:00 P.M. and at 6:45 P.M. the resident #2 was found deceased . The information noted that in review of medical records there were no physician order for morphine. The facility's 5-day investigative report submitted to the SA on [DATE] revealed a written statement by the former DON dated that she gave the RN (staff #59) the 0.25 of morphine from a bottle that had not yet been destroyed and that the former DON did not instruct the RN to check if there were orders in. The report also revealed that former DON wrote that she should not have given the medication to the the RN and that it was a mistake. Continued review of the facility's investigative report revealed a witness statement dated [DATE] written by staff #11 that sometime in April she was in the former DON's office when staff #59 (RN) walked in with concerns about a resident needing pain pills but did not feel comfortable with giving him the pill due to possible chocking since he was not doing well. The statement noted that the former DON pulled out a box of morphine and said she had that to give to the resident. Per the statement, the RN (staff #59) was very hesitant and looked at both the former DON and staff #11 and told staff #11 she better not say anything to anyone or else. Further, the statement revealed that the RN (staff #59) asked what does she tell the resident's family member since she was right next to him, the former DON stated to tell the family that it was liquid tylenol. Per the statement, the RN (staff #59) was very scared, walked out, and came back with a syringe that she washed. The statement noted that the former DON instructed the RN (staff #59) to throw it away because she had more. Per the statement, the former DON told the RN (staff #59) that she drew up, I think .5 something close to that. The facility investigation also included an email written by an RN (staff #59) dated [DATE] that stated she went to the former DON with her concern of patient condition and the former DON gave her 0.25 ml (milliliter) of morphine and left the room. The documentation included that the RN (staff #59) wrote that this was a mistake and not a common practice. Further review of the facility's investigative report revealed a letter by the Medical Director of the facility dated [DATE] that stated the physician (staff #3) was informed that resident #2 was given morphine on [DATE] and did not recall giving an order for the patient. The facility investigation report concluded the facility substantiated the allegation of misappropriation of a controlled substance and administering medication without a physician's order. Despite the lack of order for morphine; and documentation that the morphine was administered to the resident, there was no evidence that an order was requested from the physician. A phone interview with the the Registered Nurse (RN/staff #59) who administered the Morphine was attempted on [DATE] at 12:21 P.M. but was unsuccessful. The RN did not answer or returned the call. An interview was conducted on [DATE] at 2:43 P.M. with the physician (staff #3) who stated that resident #2 was a cardiac and memory patient; and, had diagnoses of atrial fibrillation and hypotension. The physician further stated that he did not prescribe morphine; and that, his records did not reflect that this resident was on hospice. In an interview conducted with the former DON (staff #36) on [DATE] at 2:48 P.M., the former DON stated that resident #2 received morphine on [DATE]; but, the resident had no physician orders for morphine. She said that she believed this resident was on hospice already because she had been speaking to the family about it. The former DON also stated that the RN (staff #59) came to her office that day and requested for comfort medications for resident #2. The former DON said that she then took a bottle that was not yet destroyed, had not been used and gave this to the RN (staff #59) to administer 0.25 ml dose to resident #2. Further, the former DON stated that the RN (staff #59) administered the morphine to resident #2. An interview was conducted on [DATE] at 3:24 P.M. with a former certified nursing assistant (CNA/staff #11) who stated that she did not remember the resident's name but on that day of the incident, a nurse walked in the former DON's office; and that, the nurse informed the former DON that a resident needed pain medications but that the resident will choke if she gave him the pain medication. The former CNA also said that the nurse told the former DON that there was no liquid Tylenol available. The former CNA said that the former DON pulled out a morphine box and told the nurse to just give the resident some of this and tell the resident's daughter that the nurse gave the resident liquid Tylenol. The former CNA said that the nurse just stood there so the former DON said that she would be drawing up the dose so if anything happens it will fall on the former DON. The former CNA said that the nurse looked at her and the DON told the nurse and the former CNA not to say anything. The former CNA stated that the dose that was prepared by the former DON was more than 0.25 milliliters (ml) of morphine and the nurse left and administered it to the resident. Further, the former CNA said that the nurse washed the syringe, brought it back and gave it to the former DON who told the nurse to dispose of it; and that, the former DON told the former CNA that resident #2 was going home the next day on hospice care. The former CNA further stated that when she found that resident #2 passed the DON told her again that she (referring to former CNA) better not say anything. An interview was conducted on [DATE] at 5:00 P.M. with a Licensed Practical Nurse (LPN/staff #10) who said that when administering medications, the LPN would check the right patient, the full name, the date of birth, and double check the physician's order and the medication provided by the pharmacy. She said that she cannot give a resident a medication that the resident did not have order for; and, when another nurse gave her a medication to administer because she did not perform the necessary checks. The LPN said that the physician have to be notified when a nurse give a medication that a resident does not have an order for. Further, the LPN said that the narcotic medication, morphine was not kept in stock at the facility; and that, morphine is ordered for each individual resident. During an interview was conducted with the Regional Director of Clinical Services (RDCS/staff #23) on [DATE] at 5:33 P.M., the RDCS said that the nurse (staff #59) went to the former DON's office and reported to the former DON (staff #36) that resident #2 was in pain; and that, the resident was going on hospice but was not yet in hospice at that time. The RDCS said that former DON (staff #36) then drew the morphine from the bottle and gave it to the nurse (staff #59) who then gave it to resident #2. The RDCS said that the former DON (staff #36) admitted to being wrong and should have called the doctor for orders prior to giving the morphine the nurse who administered it to the resident. The RDCS said that she did not know whose morphine bottle/medication the former DON used; but, the nurse (staff #59) who was present at the time of the incident reported that the morphine bottle was taken by the former DON from the file cabinet where the facility kept medications that needed to be disposed of. Further, the RDCS said that a search was made of the file cabinet and an open bottle of Morphine liquid was found; and that, the facility's 5-day investigation substantiated that resident #2 received morphine that was not prescribed to him. A policy titled Physician/Prescriber Authorization and Communication of Orders to Pharmacy revised [DATE] included the facility should not administer medications or biologicals except upon the order of a Physician/Prescriber lawfully authorized to prescribe for and treat human illnesses.

Based on observations, clinical record review, resident and staff interviews, documentation from the Centers for Disease Control (CDC) and policy review, the facility failed to maintain an effective infection control program, by failing to ensure that contact precautions were followed for one resident (#39) with active Clostridium Difficile (C-diff). As a result, the Condition of Immediate Jeopardy (IJ) was identified. Findings include: On September 3, 2015 at 11:32 a.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator was informed of the facility's failure to implement infection control procedures for resident #39, who was on contact precautions for[DIAGNOSES REDACTED]. Observations were conducted of one housekeeping staff member, who was going in and out of this resident's room, without donning a gown and gloves, and then entered three other resident's rooms, without washing her hands The Administrator and the Corporate nurse presented a plan of correction on September 3, 2015 at 12:43 p.m. The Administrator was informed that the plan of correction needed to include how they were to communicate to other disciplines regarding which precautions were to be used for various infections and what personal protective equipment (PPE) needed to be used. A revised plan of correction was presented and was accepted at 12:55 p.m. The plan included cleaning contact surfaces of the three resident rooms with an appropriate disinfectant; staff inservice's regarding contact precautions and PPE; and performing daily audits of infection control practices related to residents on contact precautions, specifically[DIAGNOSES REDACTED] over the next month, then monthly audits for an additional three months. Multiple observations were conducted of the facility implementing their plan of correction, which included cleaning the contact surfaces of the three resident rooms affected, staff in-services regarding infection control and contact precautions for[DIAGNOSES REDACTED], and observations of staff implementing contact precautions. The Condition of Immediate Jeopardy was abated on September 4, 2015 at 8:50 a.m. -Resident #39 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE], revealed the resident was cognitively intact and was frequently incontinent of bowel. The assessment also noted the resident had a [DIAGNOSES REDACTED]. A care plan dated August 13, 2015 included the resident had an active [DIAGNOSES REDACTED]. Review of the clinical record revealed a laboratory report dated August 23, 2015, which documented the resident was positive for[DIAGNOSES REDACTED] toxin. A physician's order dated August 24, 2015 included for [MEDICATION NAME] (antibiotic) 500 milligrams (mg) by mouth three times daily for fourteen days and [MEDICATION NAME] (antibiotic) 500 mg by mouth four times daily for fourteen days for[DIAGNOSES REDACTED]. According to the infection control log for August 2015, the resident was identified on August 10, 2015 to have a nosocomial infection of[DIAGNOSES REDACTED] and that the infection continued on August 24. Review of the bowel movement monitoring sheet from August 25 through 30, 2015, revealed the resident had at least two bowel movements each day. Nursing progress notes from August 25, 26, 27, and September 1 and 2, 2015, documented that the resident had loose stools, and continued to be on isolation precautions, due to[DIAGNOSES REDACTED]. On September 3, 2015 at 11:03 a.m., an isolation cart containing gowns, gloves, masks, and booties was observed outside of resident #39's room. There was also a housekeeping cart containing cleaning tools and solutions, which was outside of the resident's room. A facility housekeeping staff member was observed inside of resident #39's room and was not wearing a gown and gloves. The housekeeper was observed cleaning the floor with a mop. A certified nursing assistant (CNA) was observed standing outside the room and handed the housekeeper a glass of water for the resident. The housekeeper did not wash her hands before taking the glass of water from the CNA and gave the glass to the resident. The housekeeper was then observed to step out of the resident's room carrying the mop, without washing her hands. She then detached the mop cloth from the mop and placed it in a clear plastic bag and touched other cleaning equipment and solutions on the housekeeping cart. She was then observed to re-enter the resident's room without washing her hands and without donning a gown and gloves. After cleaning the resident's room, the housekeeper exited the room, without washing her hands. The housekeeper was then observed to enter three other resident's rooms. An interview with the housekeeping staff member was conducted on September 3, 2015 at 11:15 a.m. She stated that before she starts cleaning residents rooms, she will ask the nurse regarding the type of protection to use before entering. However, she said that she did not ask the nurse about resident #39's room before her shift, because it was busy, so she just proceeded to clean the resident's room. She said that she did not know that resident #39 had[DIAGNOSES REDACTED], but knew there was an isolation cart outside the resident's room. She further stated that she usually wears a gown, pair of gloves and a mask for[DIAGNOSES REDACTED]. She also stated that after she cleaned the room, she went in three other rooms. An interview was conducted with a licensed practical nurse (LPN) following the observation. She stated that resident #39 was placed on isolation precautions, because of[DIAGNOSES REDACTED] and was currently having symptoms. A later interview was conducted with this same LPN on September 3 at 12:18 p.m. The LPN stated that when a resident is placed on isolation precautions, she will inform the CNA and all the staff that will be assisting the resident for the shift. She stated that the resident's door has a sign that informs the staff as to what kind of personal protective equipment (PPE) to use before entering the room. She also said that when she is in the hall she checks staff when entering and exiting the resident's room and reiterates and re-educates on using PPE. An interview with resident #39 was conducted on September 3, 2015 at 1:55 p.m. The resident stated that she was being treated for [REDACTED]. She stated that she developed loose stools three days after her admission in the facility and was treated with antibiotics and had completed them. She said she then began having loose stools again and the stool was retested and was positive for[DIAGNOSES REDACTED]. She said that she still has 2-3 episodes per day. She also stated that she was informed by staff that she has[DIAGNOSES REDACTED] and this is the reason why everybody that comes in her room wears a gown and gloves. Review of the facility policy on Clostridium Difficile revealed that contact precautions are used for residents with[DIAGNOSES REDACTED]. The policy included to use gloves and gowns when entering the room of a resident who has[DIAGNOSES REDACTED] infection. The policy also included that gowns and gloves are removed before leaving the resident's room and hands must be washed immediately. Review of the 2007 CDC guidelines regarding[DIAGNOSES REDACTED] revealed that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands, who have touched a contaminated surface or item. For prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines included to use gloves and gowns when entering patients rooms and during care and for all interactions that may involve contact with patient or potentially contaminated areas in the patients environment. Also noted was that before exiting the patient rooms, discard PPE to contain pathogens. In addition, the CDC guidelines included that[DIAGNOSES REDACTED] infected patients continue to shed organisms for a number of days following the cessation of diarrhea. The guidelines stated to implement an environmental and disinfection strategy to ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently.

Based on a review of the clinical and hospital records, the facility's investigative documentation, staff interviews, and review of facility policy, the facility failed to ensure that one resident (#19) was provided adequate supervision to prevent harm. The sample size was three. Findings include: Resident #19 was originally admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed care plans to address the resident's vision, hearing, and short term memory deficits, fall risk, and her need for supervision to extensive assistance with activities of daily living, secondary to a [DIAGNOSES REDACTED]. In addition, a social isolation care plan was developed and included that the resident preferred to sit outside in the sun and would move herself into the sunlight when placed in the shade. However, the care plan did not include any interventions to ensure the resident's safety while outside, unsupervised. A nursing note dated April 21, 2012, included that the facility staff had escorted the resident outside to the courtyard and had placed her in the shade. Per the documentation, the resident enjoyed sunbathing and would frequently wheel herself into the direct sunlight. The nursing note also included later that same day, the resident was found outside in the courtyard, unresponsive in her wheelchair. The documentation included that the resident was foaming at the mouth, her heart rate was 60, her respiratory rate was six, her temperature was 101.7 degrees, and oxygen saturation level was 74 percent on room air. According to the documentation, oxygen was administered and cool rags and ice were applied, while awaiting emergency medical services response. The resident was then transferred to the hospital and admitted to intensive care. An Internet search revealed that the temperature in Sierra Vista on April 21, 2012, was forecasted to be 91 degress F (Fahrenheit). The hospital history and physical dated April 21, 2012, included that the resident arrived at the hospital, confused and with a temperature of 107. Per the documentation, the resident was assessed to have hyperthermia and heat stroke. The documentation also included that the resident was hydrated and admitted to intensive care unit with cool blankets. The hospital discharge documentation dated April 23, 2012, included that neurologically, the resident had not recovered and had been unresponsive, despite vigorously being cooled down. The documentation also included, "Her temperature at one time was 107 degrees F." According to the documentation, it was decided that the resident would receive palliative comfort care only. On April 24, 2012, the resident was readmitted to the facility, with [DIAGNOSES REDACTED]. The admission nursing note dated April 24, 2012, included that the resident was alert, and able to responded to questions appropriately. The documentation also included that the resident had multiple blisters on her head, chest, neck, shoulders, and legs. According to the note, the resident was placed on comfort care. Following re-admission to the facility, treatment orders were obtained for the blisters on the resident's bilateral lower extremities, right knee and thigh, face, chest, and left shoulder. A physician's orders [REDACTED]. The facility's reportable event report dated May 2, 2012, included that a significant event occurred on April 21, 2012 at 12:45 p.m., which resulted in resident injury. According to the documentation, the resident, who was alert and oriented, had requested at 11:15 a.m., that a staff member (#1) wheel her outside to sunbathe. Per the documentation, the staff #1 escorted the resident to the courtyard, and left her in the company of other staff members, residents, and family members. At approximately 12:45 p.m., a resident's family member reported to the nurse that the resident, "looked bad." At that time, the resident was found unconscious, with an elevated temperature. A Certified Nursing Assistant's (staff #1) written statement included that at 11:15 a.m., she escorted the resident outside to the courtyard and placed her under a shaded area. Per the documentation, she asked family members and two nurses who were present, to watch the resident for a while. Per her statement, she went back to work assisting other residents and then reported for dining room duty. At 12:45 p.m., the nursing station received a telephone call from family members that someone was still outside. The CNA's (Certified Nursing Assistant) statement further included that she then went outside and found the resident unresponsive, at which time she brought the resident inside the facility and yelled for the nurses to help. Per the documentation, the resident was warm to the touch and cool wet towels with ice were applied, while waiting for the paramedics to arrive. A Registered Nurse's (RN) (staff #2) written statement included that she had received a telephone call from the rehabilitation nurse, who stated that a family member had stated that the patient, "does not look good," in the courtyard. According to her statement, she advised the CNA to go get the resident from the courtyard. The CNA returned and stated that the resident needed a nurse. The documentation also included that the resident was unresponsive, foaming at the mouth, and that the weekend manager and nurse practitioner were notified. Another RN's (staff #3) written statement included that at approximately 1:00 p.m., she was called STAT (immediately) and reported to the courtyard. At this time, the resident was found unresponsive in her wheelchair. The resident's temperature was 101.7 degrees F and other staff members were putting ice on the resident. The written statement also included that the resident had been taken outside to sunbathe and had been outside for approximately 1 hour and 45 minutes. Per the documentation, paramedics were called and the resident was transferred to the hospital. Telephone interviews were conducted on March 27, 2013, with the two RNs (staff #2 and #3) on duty at the time of the above incident. However, an interview, with the CNA was unable to be conducted, due to her medical leave of absence. On March 27, 2013 at 3:15 p.m., an interview was conducted with staff #2. Staff #2 acknowledged that she was the RN assigned to the resident's nursing unit on April 21, 2012, and that she was able to recall the above stated incident. The RN stated that the CNA (staff #1) had escorted the resident outside to the courtyard and had placed her under a tree for shade. She stated that the resident was legally blind and was unable to propel herself in the wheelchair, but that the resident could move herself into the direct sun to sunbathe. According to the RN, the resident received her meals in her room, and it was at that time that the CNA realized the resident was still outside. The RN stated that the CNA then went outside and found the resident unresponsive, warm, and sitting in the sun. The RN further stated that the CNA had told her that she had gotten busy and had forgot that the resident was outside and it was the CNA's responsibility to check on the resident and escort her back into the building. Another interview was conducted on March 27, 2012 at 3:30 p.m., with the RN weekend manager (staff #3). The RN stated that she was on duty on April 21, 2012, and that she was able to recall the above incident. The RN stated that she heard an over-head alert and that she responded to the resident's room, where she found the resident unresponsive. The RN also stated that she thought that a family member of a resident had informed the staff that a resident, who was outside, did not look good. According to the RN, she was informed that the resident had been taken outside to the courtyard by staff #1 to sun bath, which the resident frequently did. According to the RN, the CNA had stated that she had gotten busy and had forgotten about the resident and that the CNA would have been responsible to check on the resident and bring her back inside the building. Although the resident's sun bathing activity was well known by the facility, neither the clinical record documentation, or the written and verbal staff 's statements, included any evidence that the resident had been monitored while outside on the courtyard or that procedures had been implemented to ensure the resident's safety to prevent harm while outside, unsupervised. A facility policy titled Incident Management included, "The facility identifies residents at risk for incidents and adequately plans care and implemented procedures designed to reduce risk and minimize the potential for occurrence." The policy also included, "Each resident receives adequate assistance and oversight as defined in an individualized plan of care that reduces the risks for incidents..." The policy also included the following: -Develop an organized method to define, monitor, and reduce risks associated with incidents and falls that can compromise a resident's lifestyle and quality of life. -Identifies residents who are at risk for incidents and implement care-planned procedures designed to reduce the risks of incidents. Although the facility provided a policy titled Weather Precautions, it was dated June 13, 2012, which was nearly two months after the above incident.