Every finding on record at Life Care Center of Tucson

Based on staff and resident interviews, review of facility documentation, clinical records and facility policy, the facility failed to ensure that one resident (Resident #15) out of one sampled resident was free from preventable accident by failing to ensure appropriate safety measures during a transfer. The universe was sixty. The deficient practice could place other residents at risk for preventable falls and serous injury.Findings include: Resident #15 was admitted to the facility on [DATE], with multiple diagnoses that included a historical fracture of the right shoulder girdle and need for assistance with personal care. The quarterly Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for mental Status (BIMS) score of 14 indicating intact cognition. Review of the MDS also revealed that the resident required substantial assistance with transfers from the bed to the chair. The care plan initiated on January 30, 2026 revealed a focus area related to a risk for falls, with intervention that included assistance with activities of daily living (ADLs) as needed. Further review of the care plan initiated on January 30, 2026 revealed a focus area related to ADLs with interventions to include that the resident required two-person dependent assistance with transfers. A health status note dated April 22, 2026 at 10:30 P.M., revealed that during a two-person-assisted transfer from the wheelchair to the bed, the resident fell because the bed brakes were unlocked. The fall resulted in the resident being sent to the hospital for a suspected shoulder fracture and pain. Review of emergency department documentation, dated April 22, 2026, revealed x-ray results that indicated a displaced spiral fracture of the proximal humeral shaft. Following the incident, a care-plan initiated on April 28, 2026 revealed a focus area related to alteration in musculoskeletal status related to chronic right humeral fracture, with interventions that included following provider orders for weight bearing status and following up with an orthopedic provider. A pre-surgery progress note dated May 5, 2026 revealed details regarding a scheduled surgery for the resident related to a right displaced humerus fracture. A physician order dated May 8, 2026 revealed an order for the resident to remain non-weight bearing on the right upper extremity following the right humerus fracture. An interview was conducted on July 8, 2026 at 1:09 P.M., with a Certified Nursing Assistant (CNA/ Staff #23). Staff #23 stated that a transfer of a resident included checking that the bed is locked prior to completing the transfer. An interview was conducted on July 8, 2026 at 2:47 P.M., with a CNA (Staff #110). Staff #110 stated that the process for transfers included using a gait belt for support, and ensuring all brakes on the bed and chair are locked. Staff #110 stated that the risks associated with not ensuring the brakes are locked include the resident falling. Staff #110 further stated that if the brakes are not locked, there is a chance for both the resident and staff member to fall. An interview was conducted on July 8, 2026 at 2:56 P.M., with Resident #15. Resident #15 stated when resident #15 was being assisted to transfer from her wheelchair to her bed, she fell as a result of the bed brakes not being locked. She recounted Staff #14 and Staff #102 assisted her, and stated that both staff members were standing too far away to assist her adequately. Resident#15 stated that staff would normally assist her by holding on to the seat of her pants in replace of using a gait belt to assist her to stand and transfer. Resident #15 recalled reaching towards the bed, and the bed rolling away from her so that she fell forward on her shoulder. Resident #15 stated she heard a pop in her shoulder and cried out in pain. Resident #15 stated that she felt the incident was both accidental and neglectful. She further stated that the fall could have been prevented. An interview was conducted on July 9, 2026 at 11:24 A.M., with a CNA (Staff #14). Staff #14 stated that she was one of the CNAs assisting Resident #15 to transfer. Staff #14 further stated she was present during the fall, and she had been informed that the resident required only supervision during transfers, despite the resident's care plan indicating she required two-person dependent assistance. Staff #14 further stated that she supervised the transfer from wheelchair to bed, and that the bed brake was unlocked. Staff #14 stated that the process for transfers included ensuring that all the brakes are locked prior to the transfer being completed. Staff #14 further stated that she did not check the brakes on the resident's bed because she assumed they would be locked. She further stated she should have checked the brakes. An interview was conducted on July 9, 2026 at 11:53 P.M., with a CNA (Staff #102). Staff #102 stated that she was also present during the fall. Staff #102 stated she was assisting Staff #14 to transfer Resident #15 to the bed. Staff #102 stated that the resident stood to transfer, reached for the bed, the bed rolled forward, and the resident fell forward. Staff #102 stated that she should have checked to ensure the brakes were locked, but had not. She further stated that both she and Staff #14 were at fault. An interview was conducted on July 9, 2026 at 1:32 P.M. with an Occupational Therapist (OT/Staff #121). Staff #121 stated that safety during transfers included using gait belts, and that it would be inappropriate for the wheels on beds or chairs to be unlocked during a transfer. Staff #121 further stated that therapy staff and CNAs are trained on appropriate transfers. A follow-up interview was conducted on July 9, 2026 at 2:27 P.M. with Staff #102. Staff #102 stated she had personal documentation of the incident. Review of the handwritten witness account from Staff #102 recounted that on April 22, 2026, the resident fell onto the bed, on her right arm, and the resident yelled out that she broke her arm. The witness account revealed the resident was sent to the hospital immediately following the incident. An interview was conducted on July 10, 2026 at 8:38 A.M., with a Licensed Practical Nurse (LPN/ Staff #67). Staff #67 stated that during a transfer, the bed and chair should be checked to ensure the brakes are locked. Staff #67 further stated that not checking that the brakes were locked on Resident #15's bed is not an accidental action. An interview was conducted on July 10, 2026 at 10:41 A.M., with the Director of Nursing (DON/ Staff #3). Staff #3 stated that the resident fell on her bed during a transfer and was sent to the hospital. Staff #3 stated that the resident was diagnosed with an acute fracture. Staff #3 further stated that the resident was referred to orthopedic services, and was deemed to need surgery. Staff #3 stated that the bed brakes were not locked during the transfer. Staff #3 stated that the process for transferring a resident included ensuring the resident is able to transfer, then checking that the chair and bed brakes are locked. A review of the staff file for Staff #14 revealed that the staff member completed an annual skills competency on April 23, 2026, including transfers. Staff #14 was marked as competent in this skill. A review of the staff file for Staff #102 revealed that the staff member completed an annual skills competency on April 24, 2026, including transfers. Staff #102 was marked as competent in this skill. Facility policy, titled Area Focus: Fall Management, reviewed December 3, 2025, revealed the purpose of the policy included ensuring each resident received adequate supervision to prevent accidents. Further review revealed this included that a comprehensive care plan would be developed and initiated to include a resident's fall risks. Facility policy, titled Activities of Daily Living (ADLs), reviewed September 10, 2024, revealed that staff should utilize appropriate safety measures to maintain resident safety related to any bed or chair mobility.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 1 of 3 sampled residents (Resident #1) was free from verbal abuse by a staff member. The deficient practice could result in other residents being abused.Findings Include:-Regarding Resident #1:Resident # 1 (alleged victim) was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with foot ulcers, absence of left foot, morbid obesity, and mood disorder. A comprehensive care plan initiated on August 25, 2025 revealed that the resident had an activity of daily living (ADL) self care performance deficit due to activity intolerance. The care plan further revealed interventions that included toilet use requiring maximum assistance and requiring 2-person dependent assist with transfers. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident is cognitively intact. The MDS also revealed that the resident required substantial assistance for toilet transfers. An Event Note dated March 27, 2026, documented that Resident # 1 was wheeling herself in her wheelchair in the hallway to the nurses' station to request assistance. The note indicated that Resident # 1 was requested a brief change. At that time, a Certified Nursing Assistant (CNA/Staff #169) seated at the nurses' station heard the resident, turned around and made an inappropriate comment. The note further documented that the resident began crying following the interaction.-Regarding Staff #169:Review of Staff #169's (alleged perpetrator) personal file revealed that she was employed as a CNA with a hire date of February 27, 2025.An Education Acknowledgement Form dated December 17, 2025 revealed that Staff #169 was trained on the use of Professional language. The acknowledgement form further revealed the summary of the training included that Staff # 169 should use professional language when reporting to co-workers and residents. Using profanity is prohibited at work. Review of the Acknowledgment for revealed that Staff #169 signed the form on December 17, 2025. Further review of Staff #169's personnel record revealed a certificate of completion of Annual General Requirements Curriculum on March 11, 2026. The certificate revealed that the curriculum topics included Abuse, Neglect, and Exploitation: Mandatory Reporting, Resident Rights, Respect in the Workplace, and The Elder Justice Act, Prevention of Abuse in Persons with Dementia: Mental Health & Psychosocial Needs of Residents; and Person-Centered Care. A Suspension Pending Investigation Form dated March 27, 2026 revealed that at approximately 6:45 a.m. it was reported that Resident # 1 was asking Staff # 169 for help. It was reported that Staff # 169 cussed and told Resident # 1 it was her fucking fault while turning away from Resident and going downstairs. The Suspension Form also revealed that Staff # 169 was placed on suspension pending investigation.The Suspension Pending Investigation Form further revealed a section to be completed after the investigation which was signed on March 29, 2026 by Director of Nursing (DON/Staff # 43). The section revealed that the facility unsubstantiated the allegation however Staff # 169 resigned via text. A Facility investigation report submitted April 1, 2026 revealed that Resident # 1 was interviewed and claimed she did not receive any patient care the morning of March 27, 2026 and had urinated over herself and put on her call light but Staff # 169 would not answer the light. The report also revealed that Resident #1 had told #169 she was going to notify someone regarding the lack of assistance and # 169 became angry stood up and told Resident # 1 it's your fucking fault. Resident # 1 sated Staff # 118 was present during the altercation. Resident # 1 stated that the statement made her cry and she did not feel safe with Staff # 169.The Facility investigation report submitted April 1, 2026 revealed a written statement dated March 27, 2026 from Staff #118. The statement revealed that Staff # 118 was doing morning checks and noticed at approximately 5:15am Resident # 1 kept asking for help and her call light was on and Staff # 169 was refusing to help. The statement revealed that Staff # 118 stayed as Resident # 1 came out of the room begging for Staff # 169 for help. Staff # 169 refused and according to the statement at one point Staff # 169 told Resident # 1 that it was resident's fucking fault. The statement revealed that Resident # 1 went back to her room crying and Staff # 118 went to comfort her. Staff # 118 report incident to his supervisor who instructed to call DON and Administrator. The Facility investigation report further revealed a written statement by Staff # 169 dated March 27, 2026 from Staff # 169. The statement revealed that Resident # 1 had turned on her call light at 4:00 am when Staff # 169 and another unnamed CNA was doing their last rounds and was not able to help at that time because no one was able to go with Staff # 169 and provide care to Resident # 1 due to the 2-person assist. The statement revealed that after 5:00 a.m. Resident # 1 came out of her room angry and said she should not have to wait so long. The statement revealed that Staff # 169 claimed she agreed with Resident #1 stood and and went downstairs to get another unnamed CNA to help assist Resident #1. In the statement Staff # 169 revealed she may have said the term fuck when she went downstairs but denied that it was directed at Resident # 1. An attempted interview with Resident #1 on April 23, 2026 at 8:15 am revealed that Resident # 1 had been sent to the emergency room the night before due to arm pain. Phone call to Resident # 1 was attempted at 10:06 a.m. but was unable to connect with Resident # 1. An interview was conducted with Staff # 38 on April 23, 2026 at 9:18 a.m. who stated that she saw Resident # 1 in the dining room and Resident # 1 told Staff # 38 that she had a rough morning because she needed help and Staff # 169 was rude. Staff # 38 stated Resident # 1 told her that Staff # 169 was rude to her and blamed her for not getting cares because of the cares in pairs. Staff # 38 revealed that she believed Resident # 1's mood to be fine and resident did not seem distraught over it or crying at that point. An interview was conducted with Staff # 118 on April 23, 2026 at 9:22 a.m. who stated that he got to Resident # 1's floor around 5:15 a.m. because they had conducted a fire drill earlier and he was getting everyone to sign the maintenance book., Staff # 118 stated when he got to the floor there were a lot of call lights on including the call light to Resident # 1. Staff # 118 stated that he saw Staff # 169 sitting at the nurses satiation on her phone watching what he thought was a movie. Staff # 118 stated that Resident # 1 came out of her room and asked Staff # 169 asking for help getting her brief changed. Staff # 118 stated that Staff # 169 kept refusing because she was the only one on the floor at the time and did not have another person to help because she is cares in pairs. Staff # 118 stated Staff # 169 stood up and told Resident # 1 it's your own fucking fault. Staff # 188 stated that Resident # 1 began to cry and went back into her room while Staff # 169 sat back down at the nurses station and returned to watching her phone. Staff # 118 then said Staff # 169 stopped watching her phone stood up and said I'm already expecting a call from (DON) tonight but I don't give a shit. Staff # 118 stated that he went to Resident # 1's room to comfort her and reported the incident to his supervisor who instructed him to report do DON and Administrator. Staff #118 stated that he never witnessed Staff # 169 get a second person to help Resident # 1.The interview with Staff # 118 and the written statement from Staff # 118 documented on March 27, 2026 were consistent. An interview with CNA, Staff #24, on April 23, 2026 at 9:38 a.m. revealed that Resident # 1 was in cares in pairs because the resident accused staff of not helping her. Staff # 24 revealed that Resident # 1 likes to press her call light a lot and it can be difficult due to the cares in pairs to get her help immediately and Resident # 1 is known to want care immediately at times. Staff # 24 revealed if you communicate with her what is going on including the delay then she will back off on the requesting because she is aware that she requires 2 people.A phone interview was attempted on April 23, 2026 at 10:03 a.m. to Staff #169. The attempt was unsuccessful and was not able to make contact with Staff # 169. An interview was conducted with DON (Staff # 43) on April 23, 2026 at 10:47 a.m. The DON revealed that on March 27, 2026 she received a text from Staff # 118 around 6:15 a.m. who stated that Staff # 169 was not helping Resident # 1 and swore at Resident # 1. The DON revealed that investigation was immediately conducted and Staff # 169 was put on suspension. The DON revealed that they determined the investigation to be inconclusive because of Resident # 1's history of false allegations and they felt Staff # 118 was inconsistent with his allegations. The DON also revealed that Staff # 169 had resigned during the investigation. The DON revealed that the concern of staff members verbally abusing Residents is the effect it has on a Resident's psychological well being.A Policy titled, Abuse Identification of Types, reviewed June 16, 2024, revealed that it is the policy of the facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property. The policy also revealed that mental abuse is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. The policy revealed examples of mental and verbal abuse include mocking, insulting, ridiculing and threatening residents including depriving a resident of care.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one of three sampled residents (#119) to be free from abuse by another resident (#103). The deficient practice could lead to ongoing abuse, leading to harm to other residents.-Findings include:Regarding Resident #119Resident #119 (alleged victim) was admitted to the facility on [DATE], with diagnoses including displaced fracture of the surgical neck of the right humerus, cognitive communication deficit, unsteadiness on feet, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, age-related cognitive, mood affective disorder, and insomnia.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS further revealed that Resident #119 had exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period.Review of Resident #119's care plan, which was initiated on October 11, 2025, revealed a risk for impaired cognitive ability and impaired thought processes regarding the diagnosis of dementia. Interventions included: cueing, orienting, and supervising Resident #119, as needed.Resident #103 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, unspecified dementia, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, restlessness and agitation, anxiety disorder, major depressive disorder, and insomnia.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had severe cognitive impairment. The MDS further revealed that Resident #103 had exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period.Review of Resident #103's care plan, which was initiated on November 14, 2023, revealed a risk for change in behavior due to the medical condition dementia with behaviors. Interventions included consulting with Resident #103 on references regarding customary routine. Another care plan risk initiated on May 13, 2025, revealed a risk for Resident #103 to be physically aggressive during the activities of daily living (ADL) care and showers. Interventions included monitoring for behaviors while in the dining area and Resident #103 touching/striking other residents or staff. -Regarding the December 12, 2025, incidentOn December 12, 2025, an event progress note was entered into the clinical record for Resident #119. It stated that Resident #119 was sitting in the hall surrounded by other residents. Resident #119 was heard yelling at another resident. Resident #103 was screaming as well and hitting Resident #119 with a stuffed animal across the chest. Resident #103 then began kicking resident #119 back. Residents were immediately separated and placed on 15-minute checks. The medical director was at the facility and was made aware. Skin checks were performed, and no redness was noted.Review of a skin assessment for Resident #119 on December 12, 2025, revealed that Resident #119's skin was intact with no redness or bruising. On December 12, 2025, an event progress note was entered into the clinical record for Resident #103. It stated that Resident #103 was sitting in the hallway surrounded by other residents. Resident #103 was heard yelling at another resident as well as hitting Resident #119 with a stuffed animal across the chest. Resident #119 then began kicking Resident #103 in the leg. Residents were immediately separated and placed on 15-minute checks. The medical director was at the facility and was made aware. Skin checks were performed, and no redness was noted.Review of a skin assessment for Resident #103 on December 12, 2025, revealed that Resident #103's skin was intact with no redness or bruising.Review of the facility's undated 5-day investigation report regarding the altercation that occurred on December 12, 2025, revealed that the facility verified the allegation the by evidence collected. Further review indicated that both residents were unable to recall the incident and residents #119 and #103 were referred to the psych provider. An interview was conducted with Assistant Director of Nursing (ADON/Staff #54) on January 5, 2026, at 11:27 a.m. Staff #54 stated that on December 12, 2025, at approximately 3:30 p.m. she heard screaming outside of her office. Staff #54 then witnessed Resident #103 hitting Resident #119 across the chest with a stuffed animal and Resident #119 kick Resident #103 in the leg. After separating the residents, Staff #54 then witnessed the residents crying. She assessed both residents for physical injuries and no injuries were noted. Staff #54 stated she could not recall any other resident to resident altercations involving Resident #119, but said Resident #103 did have at least one other altercation with another resident. Staff #54 stated that she was the only staff member to witness the incident and she would consider this incident to be abuse. An interview was conducted with the Facility Administrator and Abuse Coordinator (Staff # 131) on January 5, 2026, at 12:55 p.m. Staff #131 stated that physical abuse can occur and can be substantiated without physical injuries. Review of a facility policy titled, Abuse-Prevention, issued October 4, 2022, and reviewed May 6, 2025, revealed that the facility's procedure includes identification, assessment, and a care plan for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict. These include verbally and physically aggressive behaviors.

Based on observation, interview, and record review, the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for one of the 5 sampled residents. The deficient practice could result in injury to residents.Findings Include:Resident #119 was admitted to the facility on [DATE], with a diagnoses of Essential (primary) hypertension, hyperlipidemia, unspecified severe protein-calorie malnutrition, chronic kidney disease, stage 3, chronic obstructive pulmonary disease, anemia, nonrheumatic aortic (valve) stenosis, occlusion and stenosis of left carotid artery, nonrheumatic aortic (valve) insufficiency, dysphagia following cerebral infarction.An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 4, indicating moderate cognitive impairment. The elopement assessment was assessed as not a risk for the resident (#119).According to the progress notes dated August 25, 2025, it was revealed that the resident became confused at intervals and wandered out into the hall.As per the Elopement risk evaluation dated August 28, 2025, the resident is identified as at risk for elopement, and the following interventions were placed: Add the resident to the Elopement book (This will be at all the nursing stations and with the receptionist), encourage participation in activities to divert from exit-seeking behavior. The Elopement risk assessment further revealed that the interventions have been initiated, reviewed, or modified, and appropriate physician orders have been requested. obtained, family / responsible party/resident has been notified, and the care plan has been updated.The resident's picture, along with his room number and risk for elopement, was added to the yellow binder, which is referred to as the Elopement book. One of these books is also located at the reception area.Nursing progress note August 30, 2025, at 4:49 p.m. revealed that at 3:35 p.m. that resident #119 was missing. The patient was previously seen by this nurse about 30 minutes prior in the west hall, wearing a red shirt and blue pajama pants. Staff immediately began to conduct a facility room search. The area was searched around the building. 911 was notified, as well as the resident's sister. The DON and Administrator were also notified. A sheriff deputy found the resident at a nearby store. The resident was checked out by EMS and brought back to the building.An interview was conducted with the LPN # 36 on September 17, 2025, at 4:00 PM, which revealed that the residents are evaluated for elopement risk upon admission. Residents are assessed for elopement risk using the Yellow Book, which lists those prone to wandering; a copy is kept at the front desk. Staff review the book at the start of each shift and check on at-risk residents. If a resident shows exit-seeking behavior, staff intervene with redirection, initiate 15-minute checks for 72 hours, and notify the physician, psych team, and family. In the event of an elopement, the physician, family, and police are alerted. There are no Wander Guards in place; monitoring and 15-minute checks are the primary interventions. Residents with a BIMS score of 4 require close supervision, with hourly checks recommended due to poor cognition and safety awareness. Staff #35 further stated that she was aware of a recent elopement incident through messages, but she was not on duty that weekend. Of the four facility entrances, two are locked after 4 PM, and the others require a security code to exit.An interview was conducted with the CNA # 22 on September 17, 2025, at 4:41 PM revealed that the staff monitor residents assessed for elopement risk using a yellow binder and conduct 15-minute checks for those listed. The CNA # 22 further stated that she was present when the resident was admitted and stated that the resident # 119 understands conversations but has limited communication ability. He frequently walked around his room and occasionally entered others' rooms, requiring redirection-prompting the start of 15-minute checks. Initially, he wasn't considered at risk, but his status changed after a week following reassessment. I was informed that he exited the facility through the front door one weekend after 4 PM, reportedly assisted by the receptionist. I believe wander guards could help prevent such incidents.An interview was conducted with the Director of Nursing (DON / Staff # 100) on September 17, 2025, at 6:12 PM. It was revealed that Residents are assessed for elopement risk upon admission, and staff monitor for wandering during daily rounds. The Elopement Book, containing resident photos and demographics, is kept at all nurse stations and the front desk. The receptionist, on duty from 8:00 AM to 4:30 PM, monitors the front door. According to the AD's interview, the recent incident involved a resident exiting through the front door. Initially, the resident was not at risk, but following a significant condition change on August 28, 2025, an assessment identified him as high risk, and the care plan was updated. However, a subsequent assessment on September 2, 2025, overrode this update, and the change was not reflected in the conference care plan. The facility maintains a yellow binder for residents on elopement watch, along with a 15-minute check protocol. Staff #100 stated to remember the resident from his admission and stated the resident could understand but had limited communication and often wandered into other rooms, prompting redirection and 15-minute checks. Staff #100 stated the resident was later reassessed as a risk. Staff #100 stated that the resident left the faciity on a weekend, dressed and exited through the front door, reportedly opened by the receptionist after 4 PM. There are no Wander Guards or security cameras in place. Staff #100 acknowledged that the facility did not adequately protect the resident after his elopement risk was identified.A review of the facility policy titled Elopement, last revised on November 19, 2024, revealed that the resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision and assistance devices to prevent accidents.

BBased on clinical record review, interviews, the State Agency's (SA) complaint portal, and review of the facility's policies and procedures, the facility failed to ensure 4 out of 4 residents' (#47, #48, #52, and #53) medications were not misappropriated by nursing staff. The deficient practice resulted in the facility not keeping an accurate record of controlled substances. Findings include:Related to Resident #47-Resident #47 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of the right femur, generalized muscle weakness, stage 3 kidney disease and cognitive communication deficit.Review of the admission Minimum Data Set (MDS), dated [DATE], revealed Resident #47 had a Brief Interview for Mental Status (BIMS) and scored a 12 which indicated he had moderate cognitive impairment. The same MDS also indicated the resident was taking opioids as part of his medication regimen.The care plan, revised on May 24, 2024, revealed Resident #47 was on a PRN (Pro Re Nata or as needed) pain medication therapy related to multiple fractures, osteosarcoma and chondrosarcoma. Interventions included administering analgesic medications as ordered by the physician and to observe and monitor for possible side effects.A physician's order, dated April 23, 2024, indicated Resident #47 was to take Fentanyl patch 72-hour 75 MCG (micrograms)/HR (hour). Instructions stated to apply 1 patch, transdermally, every 72 hours for chronic pain and remove per schedule. The clinical record indicated this order was discontinued on April 29, 2024 due to a dosage increase.A new physician's order, dated April 29, 2024, indicated Resident #47 was to take Fentanyl patch 72-hour 100 MCG/hour. Instructions stated to apply 1 patch, transdermally, every 72 hours for chronic pain and remove per schedule.An entry, on Resident #47's Progress Note, dated May 4, 2024 at 5:58 P.M., was created by Registered Nurse (RN/Staff #61). The note indicated that Fentanyl patch was applied, changed and noted on the MAR.A second Progress Note entry was dated May 5, 2024 at 9:58 P.M. and was created by Staff #120. The entry noted that Fentanyl patch was applied and changed and noted on the MAR.An entry, on Resident #47's Progress Note, dated May 6, 2024 stated that the Nurse Practitioner (NP) and the resident's wife were notified about the missing Fentanyl patch, and the investigation is ongoing per DON (Director of Nursing). The entry was created by RN/Staff #51.Review of the May 2024 MAR revealed Staff #120 documented on May 4 at 7:28 AM that she had removed the Fentanyl Patch 100 mcg and at 7:29 A.M. she had applied a new patch. There was no documentation that reflected staff #61 had removed or applied the Fentanyl 100 mcg patch on May 4, 2024 as indicated on the Progress Note.Review of a complaint submitted to the SA complaint portal on May 10, 2024 at 8:08 A.M. indicated there was a possible drug diversion of Resident #47's Fentanyl by Staff #120. The facility's 5-day investigation included a controlled substance record for Fentanyl 75 mcg patch. The same record had an entry, dated May 4, recorded by Staff #120. The entry indicated at 7:00 A.M. a patch was taken and there was 1 patch remaining. There was a note written stating wrong pt (patient). The entry was signed by Staff #120 and the 2nd signature was illegible. The same 5-day investigation report indicated the 2nd signature was not able to be identified. The investigation report also included a Controlled Substance Record sheet for another resident who was in the facility at the time of this alleged incident. The record indicated the resident had an order for Fentanyl 75 mcg patch. However, the same record did not have documentation that the medication patch was given to the resident on May 4, 2024 or May 5, 2024.An interview was conducted on August 14, 2025 at 11:16 A.M. with Registered Nurse (RN/Staff #51), telephonically. Staff #51 shared that he had noticed a patch of Fentanyl 75 mcg missing and had reported it to his interim supervisor.An interview was conducted on August 14, 2025 at 12:00 P.M. with LPN/Staff #108. Staff #108 shared that when a resident is discharged and their narcotic medications are left at the facility, they continue the narcotic count and it is documented on the controlled substance count sheet. He continued to explain that the process is continued until the medication is destroyed by the ADON and the DON. He shared that he had never destroyed medications but he understood the process of destroying medications was needing to be done by two nurses.An interview was conducted on August 15, 2025 with LPN/Staff #97 at 11:17 A.M. Staff #97 explained the process for managing controlled substances as continuing to keep the medication in the lockbox until the DON and the ADON collect it. They then take it somewhere to destroy the medication. She shared that they still continue to include the medication in their narcotic count every shift until it is removed to keep track of how many medications they have on hand. She added that the risk of not doing so would be the medication being given to the wrong patient and the facility not keeping an accurate count of how many medications they have on hand. She also added that there was also a risk of medication being stolen.Related to Resident #48Resident #48 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes without complications, Alzheimer's Disease, and Osteoarthritis.A review of the Discharge MDS, dated [DATE] revealed Resident #48 had a BIMS of 02 which indicated she had severe cognitive impairment.The physician's orders, dated May 3, 2024, indicated the order for Ozempic 2 mg subcutaneous solution Pen-injector 8 mg/3ml (milliliter) was created by Staff #120 at 8:58 P.M. The entry on the order details indicated the order was prescriber written. The same order was discontinued by Staff #120 on May 6, 2024 and there was no reason given for the discontinuation.Review of the hospital discharge medication orders received by the facility did not reveal an order for Ozempic.The May 2024 MAR revealed that on May 3, 2024 Staff #120 documented Ozempic not being administered at 9:00 P.M. due to vitals outside of parameters of administration.A secondary review of the Ozempic order did not reveal parameters with the order.An interview was conducted on August 14, 2025 at 10:34 A.M. with Physician (Staff/#123). Staff #123 indicated that he was not a provider at the facility however, there were Physicians from his medical group who served the facility. He also indicated that Nurses are not permitted to put in orders without his approval.Review of the facility's 5-day investigation report, submitted to the SA, on May 10, 2024 at 10:52 A.M. indicated that on May 5, 2024 the DON was notified by a nurse that Resident #48's Ozempic was missing. During the investigation, it was discovered that a second resident, Resident #53, had medication orders put in, which was later determined to have not been authorized by the provider. The same report also included a written statement from Staff #120 where she indicated that she had put in an order for Ozempic to be refilled for the wrong resident. The same statement also indicated that Staff #120 had put in an order for Mounjaro to be refilled for the wrong resident as well.Related to Resident #53-Resident #53 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, type 2 diabetes without complications, and generalized muscle weakness.A physician's order for Mounjaro Subcutaneous Pen-Injector 2.5 MG/0.5ML, dated May 3, 2024, was created by Staff #120 at 8:59 P.M. The communication method, identified on the Order Audit Report, indicated that the prescriber wrote the order. The prescriber was identified as Staff #123 The same Order Audit Report indicated the order was discontinued on May 6, 2024 at 4:17 P.M. by Staff #120 and the discontinue reason listed was wrong patient.Review of the hospital discharge medication list received by the facility did not reveal an order for Mounjaro.Review of the May 2024 MAR for resident #53 had an entry for May 4, 2024. The entry was signed by Staff #120 and noted that the vitals (were) outside of parameters of administration.The facility submitted a complaint to the AZBON (Arizona Board of Nursing) on May 10, 2024 at 12:35 P.M. The complaint listed Staff #120 as the Nurse in question. The complaint to the AZBON listed the resident as Resident #53. Included in the complaint to the AZBON was the Proof of Delivery by Cheetah courier with a tracking number of 202391710. This indicated the Mounjaro was delivered to the facility on May 6, 2024 at 3:48 P.M.Related to Resident #52-Resident #52 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, pleural effusion, pneumonia, and acute respiratory failure.The care plan, initiated on March 26, 2023, indicated Resident #52 was admitted to Hospice services due to his terminal prognosis with the goal of his dignity and autonomy being maintained at the highest level. Interventions included observing the resident closely for signs of pain and to administer pain medications as ordered.Review of the physician's orders indicated Resident #52 was admitted to Hospice services on March 26, 2023. Additional review of the physician's order revealed an order for Morphine Sulfate Oral Solution 100 MG/5ML with instructions to give 0.25 ML by mouth every hour as needed for Hospice Pain management 4-10.Review of the October 2023 MAR revealed an entry on October 27, 2023 created by Staff #120. The entry had a code of 10 which indicated, Other/See Progress Notes. Review of the progress notes revealed no documentation on October 27, 2023 by Staff #120.A review of the 5-day investigation report, submitted to the SA on November 2, 2023 at 11:56 A.M. included a statement from LPN/Staff #124. The statement was written on November 2, 2023 and indicated that on October 26 Staff #124 took report and counted narcotics with off-going Staff #120 however, during this time the two bottles of liquid morphine was not counted. The same investigation report included a second statement from LPN/Staff #121 on October 28, 2023 at 12:02 P.M. The statement shared that Staff #121 received shift report from Staff #120 and while doing count, Staff #121 noticed both bottles of morphine for Resident #52 was off. Staff #121 indicated, in her written statement, that she brought it to the attention of Staff #120 and they both did a corrected count.A telephone interview was attempted on August 15, 2025 at 9:41 A.M. with Staff #121, however the phone number was not in service.The 5-day report, submitted to the SA, by the facility indicated Staff #120 was suspended on May 6, 2024 and terminated on May 10, 2024. The report also indicated the staff member was reported to the AZBON. An interview was conducted on August 14, 2025 at 12:00 P.M. with LPN/Staff #108. Staff #108 explained that residents who are taking controlled substances have their medications stored in the narcotic box which is located in each medication cart. He also explained that the medications are considered double locked because the narcotic box is locked and is stored within the locked medication box with only the on-duty nurse having the key to the cart and narcotic box. Staff #108 confirmed that liquid morphine is kept within the locked narcotic box inside of the medication cart. He explained that during shift change, both of the incoming and outgoing Nurses will either visually inspect or pour out the medication to get an accurate count of what is in the bottle. If the amount of medication does not match what is recorded on the count sheet, the Assistant Director of Nursing (ADON) or the Director of Nursing (DON) will be notified and they will review the issue and do an investigation. When asked about the process for ordering medications for residents, Staff #108 shared that the Doctor will put in orders or tell the Nurse to put in the orders for the residents and then the Nurse will fax the order to the pharmacy. He explained that nurses are not able to order medications without a physician's authorization. The risk to the residents would vary depending on the medication itself. He explained that the risks could be nothing all the way to a lethal overdose.An interview was conducted with LPN/Staff #97 on August 15, 2025 at 11:17 A.M. Staff #97 explained that controlled substances are stored in a lock box in the medication cart. The Nurse on duty is the only person with the key however, there was a master key in case a Nurse accidently gets locked out of the medication cart. Staff #97 indicated that the master key was held by nurse management. Staff #97 explained that Nurses are able to order medications by calling the Doctor or the Nurse Practitioner (NP) to consult with them. She indicated that the Doctor or NP has to approve the orders for medications and that Nurses are not able to order medications without a Physician's authorization.An interview was conducted with ADON/Staff #67 on August 15, 2025 at 12:31 P.M. Staff #67 shared that her expectations for tracking the controlled medications during shift overlap is for both the outgoing nurse and the incoming nurse do the medication count together and that count is then documented on the controlled sheet which is in front of the narcotic book. She also explained her expectations for ordering new medications. She shared that for all narcotic medications, the nurse needs to have a written order. For all other medications, orders are entered into the Electronic Health Record (EHR) and then it automatically is sent to the pharmacy. She shared that both Nurses and Physician's are able to put in the orders, however, she expected that if a Nurse puts in the order, they are to also document, in the EHR, the phone call with the Physician and that they verified the order with the Physician. Staff # 67 recalled the incident with Resident #48 and shared that her and the interim DON, at the time, noticed there were several medication orders coming in at night time which was not the norm. She recalled that the interim DON had spoken with the Physician to verify if he approved the medication order and the physician confirmed that he did not approve the medication order for Ozempic and Mounjaro. Staff #67 indicated that when Staff #120 did not document the phone orders on the progress note and putting in the orders without a Physician's approval, she was not meeting Staff #67's expectations. She also shared that the risk to the resident if they were administered the medications without the Physician's oversight, the resident could have a negative reaction to the medications. Regarding Resident #53's Mounjaro, Staff #67 was asked about the entry dated May 4, 2024 on the MAR. After reviewing the MAR, she stated that it was documented, by Staff #120, that the medication was not administered due to vitals being outside of parameters. Staff #67 shared that the medication did not have parameters so that (documentation) did not make sense. She also reviewed the October 2023 MAR for Resident #48 and shared that the documentation by Staff #120 was the same for Ozempic, vitals being outside of parameters as the reason for not giving Resident #48 the medication, did not make sense due to the medication not having parameters. Related to Resident #52, Staff #67 was asked to review of Morphine narcotic count sheet. She reviewed the records and shared that it looked like there were two separate bottles of morphine. It looked like Staff #120 opened the 2nd bottle before the 1st bottle of morphine was zeroed out. Somehow, we jumped from 29.75 ML to 23 or 25 ML on the narcotic count sheet. She shared that the jump in numbers told her there was some missing medication and it also told her that either someone was stealing the medication or they administered it and forgot to document the administration. However, due to the large amount that went missing, 4.25 ML or 6.25 ML, the chances that 17 to 25 doses of Morphine being administered and not documented was highly unlikely. Related to Resident #47, Staff #67 explained that the resident had an order for Fentanyl 75 mcg in April of 2024, however the dosage was increased to 100 mcg on May 1, 2024. Staff #67 confirmed that the Fentanyl patches would be tracked using the Narcotic Count Sheets. She also explained that the patch was replaced every 72 hours where the Nurse would remove the patch at 8:59 A.M. and then put on a new patch at 9:00 A.M. which was outside of Staff #120's scheduled working hours as her shift ended at 7:00 A.M. Review of a policy titled, Storage and Expiration Dating of Medications and Biologicals, indicated it last revised on August 1, 2024. The policy refers to controlled substances storage and explains that 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. It states that controlled medications must be counted with another designated staff member when there is an exchange of keys. It also noted that the facility should ensure all controlled substances are stored in a manner that maintains their integrity and security.Review of a second policy titled, Abuse, indicates the policy was last reviewed on May 6, 2025. The policy states that Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent. It also provides examples of misappropriation which included Missing prescription medications or diversion of a resident's medication(s), including but not limited to, controlled substances for staff use or personal gain.

Based on clinical record review, interviews, the State Agency's (SA) complaint portal, and review of the facility's policy and procedures, the facility failed to ensure a resident (#40) received medications according to physician's orders. The deficient practice could result in resident experiencing unnecessary pain.Findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses that included Dementia, fusion of the spine in the cervical region, and a fracture of the humerus in the right arm. The care plan, initiated on August 9, 2023, indicated Resident #40 was on pain medication therapy related to chronic pain syndrome. Interventions included administering analgesic medications as ordered by the physician and to observe for side effects and effectiveness of the medications.A physician's order, dated September 18, 2023, revealed an order for Dilaudid (Hydro-morphine HCI) Oral Tablet 2 MG (milligrams). The order indicated that .5 mg tablet was to be given every 4 hours as needed for pain 4-10.Review of the Narcotic Count Sheet for Hydro-morphine HCL 2 mg tablet starting October 9, 2023. The documentation revealed that Licensed Practical Nurse (LPN/Staff #120) logged out doses on the following days and times:- October 18 at 7:00 P.M. and 11:00 P.M.- October 19 at 7:00 P.M., and 11:00 P.M.- October 25 at 7:00 P.M. and 11:00 P.M. - October 26 at 3:00 A.M., 7:00 A.M., and 7:00 P.M.- October 27 at 11:00 P.M., 3:00 A.M., and 7:00 A.M.Review of the October 2023 Medication Administration Record (MAR), provided by the facility, indicated that Dilaudid Oral Tablet 2 MG was not administered on October 18, 19, 24, and 25 by Staff #120.Review of the staff schedule reveals that the night shift is from 6:00 P.M. to 6:00 A.M.Review of the facility's 5-day report submitted to the SA regarding Resident #40 revealed that Resident #40 was complaining of pain on October 27, 2023 at 10:15 A.M., however the nurse working that shift was unable to administer pain medication due to the narcotic count sheet indicating the medication was last given at 7:00 A.M. The same report revealed that the medication cart keys was handed to the day shift nurse at 6:40 A.M. which was prior to the 7:00 A.M. medication log out time indicated on the Narcotic Count Sheet. The same 5-day report included a statement from the day shift nurse, LPN/Staff #121. The statement revealed that Resident #40 was medicated with Dilaudid at 11:16 A.M.A telephone interview was attempted on August 15, 2025 at 9:41 A.M. with Staff #121, however the phone number was not in service.An interview was conducted with Staff #67 on August 15, 2025 at 12:31 P.M. Staff #67 shared that when a resident is discharged without their narcotic medications, the medication gets destroyed by a nurse manager. She indicated that the documentation of the destruction is documented via the pharmacy website when her and the ADON destroys it. When asked what happened with Resident #40's Dilaudid medication, Staff #67 explained that Staff #120 signed the medication out on the Controlled Substance Count sheet but did not document the administration on the MAR. She said it was reasonable that Staff #120 did administer the medication but did not document it or it was signed off on the sheet and not given to the resident and possibly stolen. When asked if it was reasonable for the documentation to take place in one area and not the other area 8 times by the same staff in a short time frame, Staff #67 indicated that it was not reasonable and there was a possibility that the medication was diverted. She shared that possible diversion would be a risk to residents because they would not be getting their pain medications and they would be in pain. She also shared that documenting medication administration on the Narcotic Count Sheet and not the MAR did not meet her expectations.Review of the policy titled, Administration of Medications, indicates the policy was last reviewed on September 16, 2024. The policy states that The facility will ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.Review of a second policy titled, Abuse, indicates the policy was last reviewed on May 6, 2025. The policy states that Misappropriation of resident property is the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's property or money without the resident's consent. It also provides examples of misappropriation which included Missing prescription medications or diversion of a resident's medication(s), including but not limited to, controlled substances for staff use or personal gain.

Based on observations, staff interviews, and policy, the facility failed to ensure multiple food items were stored at safe temperatures in accordance with professional standards. This deficient practice could result in placing residents at risk for food-borne illnesses. The facility census was 58. Findings include: During an initial observation of the kitchen, conducted at 8:25 a.m. on July 14, 2024 with staff #15. In the walk-in refrigerator, the thermometers both inside and out registered a temperature displaying 45 degrees Fahrenheit (F). Inside the refrigerator were various food items including milk, eggs, yogurt, meat, cheese, and dressings. Staff #15 stated the temperatures are recorded on the log twice daily, morning and evening. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 14, 2024 was recorded at 36F. The evening temperature was recorded at 40F. The log includes a critical limit (CL) for temperature at 40F on the high end, and revealed that in the event of a temperature not within the required range, to notify the Director of food services or maintenance immediately. During a kitchen observation conducted on July 15, 2024 at 10:12 a.m. of the same walk-in refrigerator, the external thermometer and internal thermometer registered a temperature displaying 42F. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 37F. The evening temperature was recorded at 40F. During a kitchen observation conducted on July 16, 2024 at 9:30 a.m. of the same walk-in refrigerator, the external thermometer registered a temperature displaying 50F. The internal thermometer registered a temperature displaying 44F. A second observation was made on July 16, 2024 at 11:50 a.m. The external thermometer again showed a temperature displaying 50F, and the internal thermometer displayed a temperature of 44F. Review of the monthly temperature log for July 2024 revealed the morning refrigerator temperature on July 15, 2024 was recorded at 38F. The evening temperature had not been recorded yet. An interview was conducted on July 16, 2024 at 12:35 p.m. with a cook (kitchen staff #40). The cook stated that most of the foods served for meals are stored in the walk-in refrigerator, including prep stuff for the next day, thawing meat, dairy and milk, as well as cottage cheese. The cook also stated that left overs are also stored in the same walk-in. The cook stated that temps in the walk-in need to be 39F or below, and that temperatures are recorded using the outside thermometer twice daily in the monthly log. An interview was conducted on July 16, 2024 at 12:44 p.m. with the Registered Dietician and Kitchen Manager (RD/kitchen staff #66). The RD stated that temperatures need to be under 40F in the walk-in or it puts the food at risk of causing food-borne illness such a botulism. The RD stated that all refrigerated items used in the facility are stored in that walk-in, including dairy, cheese, eggs and leftovers. The RD further stated that he was aware of a door being replaced on the freezer for a temperature issue, but was not sure about the walk-in. During this interview the RD removed two random containers of food product from the walk-in refrigerator and took the temperature of them. A single serving yogurt container, and a jar of Mayonnaise. The temperature of both items was measured by the RD at 45F. An interview was conducted with the Maintenance director (Facility/staff #32) on July 16, at 1:25 p.m. The Maintenance director stated that there was a mistake with what the temperature was set at in the walk-in refrigerator. He stated that the walk-in was accidently set to 40F by mistake when it was being worked on, roughly one month ago. He further stated that the outside thermometer on the walk-in was broken, and does not register temperatures correctly. However, the facility logs showed multiple entries for the month of July with temperatures ranging from 32F and 40F. An interview was conducted with the Executive director (ED/staff #110) on July 17, at 11:50 a.m. The ED stated they were aware of the food issue and it was being corrected. The ED further stated that her expectation is that food is stored safely, an that thermometers will be calibrated correctly going forward. Review of the facility policy titled 'Food Safety' revised April 26, 2023 and reviewed May 1, 2024 revealed that it is the policy of the facility to ensure food is stored and maintained in a clean, safe and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. It further revealed that the danger zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F allow the rapid growth of pathogenic microorganisms that can cause foodborne illness.

Based on record review and staff interview the facility failed to ensure the emergency and standby power systems were functioning properly. Failure to implement an emergency and standby power systems plan during an emergency could lead to harm of the patients and/or staff. Findings include: Based on record review and staff interview on July 17-18, 2024, the facility failed to ensure the emergency generator was adequate for the facility needs during an emergency. The facility has had a rental generator since March 2, 2020. On July 14, 2024 the facility experienced a power failure and the temporary generator failed to turn on leaving the facility totally without power. Medical equipment, the elevator and facility walk-in refrigerator and freezer were none functioning during the total outage. The following are staff interviews: Monday, July 15, 2024, at approximately 0941 hours an interview was conducted with staff # 32, Maintenance Director. Staff #32 stated that he was notified at 1815 hours on July 14, 2024, that the power was out. Staff #32 stated that he responded to the facility arriving at 1845 hours. Staff # 32 further stated that the facility was dark and the staff were panicking. Staff # 32 stated that he began troubleshooting and found that the main breaker for the facility had popped and that he reset it. Staff #32 further stated that it took approximately one hour to troubleshoot and that the generator was manually started between 1945 and 2000 hours. Staff # 32 stated that the chillers were not active as they drew too much voltage. Staff # 32 stated that When he arrived at the facility on July 15, 2024, he was unaware that the circular pumps were off. Staff # 32 stated that he later learned that staff #33 had bypassed the circular pumps because he had turned the alarm had been turned off. Staff# 32 stated that had the alarm been on he would have known there was an issue with the circular pumps. Staff #32 stated that at 0700 hours on July 15, 2024, they had to go through the facility and reset all of the AC units. Monday, July 15, 2024, at approximately 1010 hours an interview was conducted with staff # 69, RN unit nurse. Staff # 69 stated that the electricity went out between 1820 and 1830 hours on July 14, 2024. The residents that were on oxygen concentrators had to be switched to O2 tanks due to the electricity being out. Staff #69 stated that the alarm did not go off last night regarding the generator. Staff # 69 further stated that with the electricity being out he knew that the doors needed to be watched to prevent any elopement. Staff # 69 stated that if the resident rooms are hot they should begin moving residents immediately however, if the electricity is out the elevators would not work so they would not be able to move the residents. Staff # 69 stated that he was assuming the generator would kick in right away, but that it did not, and this is why they called maintenance. Monday, July 15, 2024, at approximately 1048 hours, Staff # 33 was interviewed. Stated that the power had gone out the previous night, July 14, 2024. Staff # 33 stated that he received a telephone call from Staff # 32, Maintenance Director sometime around 1810-1815 hours on July 14, 2024, and asked him to respond to the facility. Staff # 33 stated that he arrived at the facility around 1847 hours and saw that the facility was all dark. Staff # 33 stated that the generator had not kicked on right away and estimated that the generator got going between 1906 and 1910 hours. Staff # 33 further stated that when the power goes off, the gas shuts off for safety reasons and this turns the pumps off to include the chiller system. Staff # 33 stated that he and staff # 32 were in the boiler room around 0500 hours on July 15, 2024, and realized the air conditioning was not cooling. Staff #33 stated that he noticed the heat when he came in at 0500 hours on July 15, 2024, and noticed the kitchen was hot and rechecked the rooms. Stated that he noticed the rooms were hot but did not re-temp them at that time. Stated that he thought the residents should be moved to a place that was more comfortable. The west elevator was working last night when the lights came back. The north elevator was not working. Stated that no discussion of moving residents last night. Stated that residents could have been moved last night. Stated that some units were still functional, but because of auxiliary pump the residual water was allowing for a few units to work. Stated that he did not know at what temp residents should be moved. Stated that extension cords were running into the rooms. All red plugs are in the hallway. There are no red plugs in the rooms. Staff # 33 stated that there is no standard practice to handle a power outage. Stated that in all the time that he has been there, there have been no mock disaster drills. Stated that he had brought concerns up to staff #32 regarding what they would do, especially with the heavier residents. The findings were confirmed by staff #32 and #110 during the exit conference conducted on July 18, 2024. The first day the facility was on a temporary generator was March 2, 2020 per the rental contract the facility provided. The life safety code portion of this survey started July 17, 2024. 1598 days is the distance between the two dates. Which is 4 years, 4 months and 15 days.

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to implement and maintain an effective training program for annual training: abuse, resident rights, infection control, dementia training, and emergency preparedness for multiple staff (#50, #26, #43, #54, #38, #59, #32 and #110). The deficient practice could impact the safety, rights, and care provided to residents. Findings include: Review of the employee records for a registered nurse (RN/staff #50) revealed that abuse training was completed on June 15, 2022, completed resident rights on February 27, 2023, infection control training on June 15, 2022, and there was no documentation for emergency preparedness. -Review of the employee records for (RN/staff #26) revealed that abuse training was completed on October 6, 2022, resident rights completed on March 31, 2023, infection control completed on January 27, 2023, and emergency preparedness was competed on January 27, 2023. -Review of the employee record for Licensed practical nurse (LPN/staff #43) revealed that abuse training was completed March 9, 2022, resident rights completed on May 25, 2022, infection control completed May 31, 2022, and there was no documentation for emergency preparedness. -Review of the employee record for (LPN/staff #54) revealed that abuse training was completed on January 2, 2023, resident rights was completed on January 2, 2023, infection control was completed on February 20, 2023, dementia care January 3, 2023, and there was no documentation for emergency preparedness. -Review of the employee record for a Certified nursing assistant (CNA/staff #38) revealed that abuse training completed on October 18, 2022, resident rights October 18, 2022, infection control June 20, 2022, dementia training completed on October 18, 2022, and emergency preparedness was not attempted. -Review of the employee records for The Director of nursing (DON/staff #59) revealed that abuse training was completed on June 29, 2022, resident rights training was not attempted, infection control was not completed, emergency preparedness was not attempted. -Review of the employee records for the Maintenance Director (staff #32) revealed that abuse training, resident rights, infection prevention, and dementia care were not attempted. -Review of the employee records for Administrator (staff #110) revealed no documentation for abuse training, resident rights was not attempted, infection control was not attempted, and emergency preparedness not attempted. An interview was conducted on July 16, 2024 at 1:56 p.m. with the human resources accounting clerk (staff #73), who stated the corporate office usually sends an email when training needs to be done. She stated that all staff, including the Administrator, are required to complete emergency preparedness, resident rights, abuse, infection control, and dementia training annually and the training are due based on the the staff's date of hire. An interview was conducted on July 16, 2024 at 3:33 p.m. with (staff #110), who stated that all the staff are required to complete the training annually, but not all the staff had completed emergency preparedness. She stated that they have printed up most of the current training for the ten employees. An interview was conducted on July 17, 2024 at 11:19 a.m. with (DON/staff #59), who stated that she has a policy on required annual training for staff: infection control, abuse, resident rights, dementia, emergency preparedness. She stated that the training due date is based on the date of hire and everyone, including the Administrator, are supposed to complete the training. The facility policy, Yearly Required Training: states that a facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. Each associate will be provided the following core educational content annually through the learning management software that will be part of a curriculum titled Annual General Requirements Curriculum. Each associate will need to complete the courses individually by the due date provided in the course assignment page. Core education includes: infection prevention and control, emergency preparedness, resident rights, abuse, but did not include dementia care.

Based on observations, staff and resident interviews, and the facility's documentation and policies, the facility failed to ensure a safe and comfortable environment for residents: Findings include: Regarding safe environment: During the initial walk-through observation of the facility conducted on July 14, 2024 at 10:11 a.m., the following was observed: - Doorway frame missing in room [ROOM NUMBER], light brown paint is peeling, exposing the green pain underneath. It felt rough to the touch. - Corner handrail by room [ROOM NUMBER] was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact. - Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. - Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch. - Second floor nurse's station corner had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch. - Corner handrail on the second floor by the stairway had 4 screws sticking out. Additionally, the handrail had gouges and was sharp/rough to the touch In a follow-up wall-through conducted on July 17, 2024 at 8:53 a.m., the following was observed: - Numerous handrails on the second floor was rough with gouges that are rough/sharp to the touch. - Numerous doorframes on the second-floor hallway had paint peeling and has gouges that were sharp to the touch. This included shower doorframe. - Corner handrail by room [ROOM NUMBER] was rough with gouges and the edges felt sharp enough to scratch/tear skin during an unintended contact. - Corner rail by soiled utility on the second floor had a metal brace that was slightly sticking out. - Second floor nurse's station corner still had a nail sticking out on the bottom corner. That same bottom corner had gouges that were rough to the touch. - Below the handrail next to linen room on the second floor by room [ROOM NUMBER] had a metal brace on the wall corner that is slightly sticking out. That same corner has pieces of the wall corner with severe gouges that is rough/sharp to the touch. - Corner entry to wall to room [ROOM NUMBER] had a metal brace that was coming off the wall and the wall corner had severe gouges that was rough/sharp to the touch. - Inside entry wall right hand side in room [ROOM NUMBER] has long deep gouges on the lower wall above the baseboard. - Corner handrail on the second floor by the stairway no longer had the 4 screws sticking out. However, the handrail had gouges and was sharp/rough to the touch. An interview with a Registered Nurse (RN/staff #50) was conducted on July 17, 2024 at 8:29 a.m. Staff #50 stated the process for submitting work orders is that they can either use the book, the app, or call the emergency number for maintenance for whoever is on call. When asked about the overall status of the hallways/residents' living area, the RN noted that the place could use a lot of TLC (tender loving care). Staff #50 noted that to their knowledge maintenance had never asked staff or residents' input regarding what needs to be done. The RN indicated that like the staff, the residents have just come to accept the overall appearance/status of the facility. However, it would be nice to make the area more presentable, a little bit more modern. An interview with the Maintenance Director (staff #32) was conducted on July 17, 2024 at 9:34 a.m. Staff #32 noted that works orders are submitted by residents by informing the nurses and/or staff who in turn submit work orders via TELS system. The Maintenance Director noted that the turn around time for work orders depends on the required work. Usually the priority are those work orders related to call lights, O2 (oxygen) tanks or anything related to resident safety. For work orders tagged as priority, maintenance resolves them no more than 24-hours. Other work orders such as painting, normally takes 2-3 days to close out. Staff #32 stated that there are no current plans for updates to halls or rooms per corporate. The Maintenance Director indicated that they conduct walk-throughs on Mondays and take care of the issues. A walk-through with the Maintenance Director (staff #32) was conducted on July 17, 2024 at approximately 9:56 a.m. to look at the identified observations above. Below are staff #32's comments: - room [ROOM NUMBER]'s long deep gouges on the lower wall above the baseboard-noted that it is not very homelike - handrail by room [ROOM NUMBER] with a metal brace on the wall corner - indicated that it was not noticed before but is a concern since it is metal - shower doorframe on second floor - noted that it is a concern since there are metal components - room [ROOM NUMBER] - indicated that it is a concern since the metal brace came off as we were inspecting it - nail sticking out at nurse's station was no longer there, a photo from the entrance day and earlier in the morning sticking out was shown to staff #32 - he noted that it is a concern since someone could get hurt with it. A follow-up interview was conducted with the Maintenance Director (staff #32) on July 17, 2024 at approximately 10:15 a.m. Staff #32 stated that in their opinion, the facility is livable, but some of the identified harm during our walk-through puts it at 75% homelike. Whether they gets all the things fixed, it is a routine and it will get messed up again. The Maintenance Director said that it is hard to maintain but it is livable and that if residents were asked, the residents would say it is okay. Staff #32 said that during their walk-through, they identify what can damage residents and staff, prioritize it and fix it. However, if nobody says anything, and they are not aware, they it cannot be fixed. The Maintenance Director said that it is important for the facility to be safe and comfortable so residents and their families are happy and to make it better for the residents. An interview with the Administrator (staff #110) was conducted on July 17, 2024 at 1:09 p.m. Staff #110 stated that the expectation is that the living area for resident are clean, free of obstruction and without significant odors. The facility is to be clean and safe from hazards. Staff #110 stated that repairs should be maintained to have a homelike environment such as paint and upkeep. The Administrator stated that this is important since this is the home for people living here and they deserve a good quality of life. It has to be safe so that residents are not put at risk for accidents or injuries. Staff #110 stated that the impact if the facility is not homelike and safe is that residents might feel discomfort, might reduce the homelike environment feel until things were repaired, it could provide a risk for some type of injury i.e. if legs extend beyond the wheelchair there could be a risk of injury. Review of the open work order report generated on July 15, 2024 did not reveal any work order pertaining to any of the issues identified during the walk-through observations. Review of the facility policy titled Preventive Maintenance Program revised January 11, 2023 and reviewed January 22, 2024 indicated that the facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public. The facility policy titled Work Request System revised May 14, 2019 and reviewed January 15, 2024 indicated that the work order request system was designed to provide an established and effective means of requesting, coordinating, and completing maintenance of a corrective nature. A facility policy titled Resident Rights issued June 8, 2020 and reviewed September 25, 2023 indicated that resident has a right to safe, clean, comfortable, and homelike environment.

Based on observation, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate and comfortable temperature levels was provided to meet the needs of 14 residents (#4, #5, #8, #11, #20, #25, #34, #35, #41, #42, #43, #48, #56, and #167). The deficient practice could result in the resident's room not having a homelike and comfortable environment. The facility census was 58 and the sample was 14. Findings include: On the morning of July 15, 2024, between the hours of 6:45 a.m. to 7:00 a.m., surveyors experienced a notable difference in temperature perceived and felt when entering the facility. The temperature felt uncomfortably warm. During an interview with the Assistant Maintenance Technician (staff #33) conducted on July 15, 2024 at approximately 6:45 a.m., staff #33 mentioned that the generator did not kick in properly during the power outage yesterday evening. This resulted in the cooling tower (chiller) not activating to cool down the temperature in the facility. Staff #33 stated that the chiller is in the process of kicking in but will take approximately 4 hours to cool down the facility. An observation of the residents' areas was conducted on July 15, 2024 starting at approximately 7:15 a.m. There was no evidence that rooms were being tested for ambient temperature by the staff. This was despite the residents' areas being noticeably and feeling warm/uncomfortable. Regarding Resident #4: -Resident #4 was admitted to the facility on [DATE] with diagnoses that included fracture of the lower end of the right femur, pain in right knee, chronic kidney disease, and osteoarthritis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating that the resident was cognitively intact. The assessment also revealed that the resident was dependent for transfers. The MDS indicated that the resident uses a walker as a mobility device. During an interview conducted with the resident on July 15, 2024 at 8:23 a.m., the resident stated that last night they had no power and that she was uncomfortable. An observation was conducted of the resident's room on July 15, 2024 at 8:23 a.m. There was a notable warm temperature in the room. Regarding Resident #5: -Resident #5 was admitted to the facility on [DATE] with diagnoses that included pressure ulcer of sacral region, osteoporosis, hypertension, and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has modified independence pertaining to decisions regarding tasks of daily life. The assessment also indicated that the resident required substantial assistance for chair to bed transfers, and sit to stand activities. The MDS also noted that the resident uses a wheelchair as a mobility device. During an interview conducted on June 15, 2024 at 8:19 a.m., the resident responded Si when asked if it was warm in their room. An observation was conducted of the resident's room on June 15, 2024 at 8:19 a.m. The temperature registered 80.7? Fahrenheit. The room felt noticeably warm. During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:30 a.m., the temperature was taken with a thermometer and registered 76.6 Fahrenheit. Regarding Resident #8: - Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, angina pectoris, and peripheral vascular disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has modified independence when it came to decisions regarding tasks of daily life. The MDS also indicated that the resident is dependent on assistance with regards to most transfers. The MDS also noted that the resident uses a wheelchair for mobility. During an observation of the resident's room on July 15, 2024 at 8:17 a.m., the temperature taken with the thermometer registered 81.2? Fahrenheit. Physical inspection of the air conditioner (AC) thermostat located in the room revealed that the controls do not work regardless of the setting. The room felt uncomfortably warm. An interview with the resident was conducted on July 15, 2024 at 8:17 a.m. Resident #8 confirmed that it is hot in the room. During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:29 a.m., to check the temperature in the residents' area, resident #8's room temperature registered 81.1 degrees Fahrenheit. Regarding Resident #11: -Resident #11 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included paroxysmal atrial fibrillation, antherosclerotic heart disease, dementia, and paralytic syndrome. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS assessment also indicated that the resident is dependent on assistance for transfers. An observation of the resident's room was conducted on July 15, 2024 at 8:26 a.m. During the observation, the room felt hot. The temperature taken with a thermometer registered 81.1 Fahrenheit. During an interview with resident #11 conducted on July 15, 2024 at 8:26 a.m., the resident said that hell yeah, it's hot referring to his room. In a follow-up observation conducted on July 15, 2024 at 9:33 a.m., it was noted that the temperature in the room was finally comfortable. The temperature taken with the thermometer registered 76 Fahrenheit. Regarding Resident #20: -Resident #20 was initially admitted to the facility on [DATE] on readmitted on [DATE] with diagnoses that included quadriplegia, chronic obstructive pulmonary disease, heart failure, esophagitis, schizophrenia, and bipolar disorder. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The assessment noted that the resident is dependent on assistance for transfers. The MDS also indicated that the resident utilizes a wheelchair as a mobility device. An observation conducted on July 15, 2024 at 8:12 a.m. revealed that the room was uncomfortably hot. The temperature taken with a thermometer registered 83.5 Fahrenheit. In an interview with resident #20 conducted on July 15, 2024 at 8:12 a.m., the resident stated that they did not have AC (air conditioner) in their room since Friday. The resident said that on Friday, July 12, the AC was fixed just before supper. However, it stopped working through the night Friday into Saturday. The resident noted that maintenance looked at it yesterday and it was still not working. During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:29 a.m., the room was still felt uncomfortably hot. The temperature was taken with a thermometer and it registered at 82.4 Fahrenheit. Regarding Resident #25: -Resident #25 was admitted to the facility on [DATE] with diagnoses that included anemia, heart failure, diabetes, and depression. Review of the Significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that he is cognitively intact. The assessment also indicated that the resident is dependent on assistance for all transfers. The MDS noted that the resident uses a wheelchair as a mobility device. A CNA (Certified Nursing Assistant/staff #9) was observed entering resident #35's room on July 15, 2024 at 8:35 a.m. Resident #35 was heard asking the CNA to turn on his air conditioner (AC). Staff #9 informed the resident that they did not think that the AC was working. The CNA told resident #35 that the thermostat was set at 74 Fahrenheit and stated that the AC had not been working but that they would report it to the Maintenance Director. Staff #9 noted that that AC was also not working in room [ROOM NUMBER] this morning and that it they reported it to the Maintenance Director when he was up on the second floor. An interview with a CNA (Certified Nursing Assistant/staff #9) was conducted on July 15, 2024 at approximately 8:38 a.m. Staff #9 said that the process is that they would document in a book at the nurse's station when things are not working. The CNA noted that they are going to document the issue right now. During an interview with resident #25 conducted on July 15, 2024 at approximately 8:40 a.m., resident #35 stated that he was hot last night and told a CNA last night. The resident was informed by that CNA that the air was not working and that there was nothing she could do about it. The resident said that they were told there was a fan. However, they did not see one. Resident #25 stated that they did not sleep well because they were hot. They said that they woke up at 3:00 a.m. and it was still hot. The resident noted that they were offered water through the night and cold cloth. An observation of the resident's room was conducted on July 15, 2024 at 8:55 a.m. The temperature was taken using a thermometer and registered 82.4 Fahrenheit. The wall-mounted thermostat was set at 74 Fahrenheit and the reading of the actual room temperature was displayed 84 Fahrenheit. Regarding Resident #34: -Resident #34 was admitted to the facility on [DATE] with diagnoses that included dementia, hypertension, and type 2 diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. The MDS also indicated that the resident utilizes a walker as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:24 a.m. During the observation, the room was noticeably hot. A look at the wall mounted thermostat located in the room revealed the temperature to be 84 Fahrenheit. A thermometer was used to take the room temperature and it registered 83.0 Fahrenheit. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at on July 15, 2024 at 9:33 a.m., the temperature was taken using a thermometer and it registered 74.3 Fahrenheit. Regarding Resident #35: -Resident #35 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included systolic heart failure, dysphagia, Takotsubo syndrome, dementia, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident makes independent decision regarding tasks of daily life. The assessment indicated that the resident requires substantial/maximum assistance for most transfers. The MDS also noted that the resident utilizes a wheelchair as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:20 a.m. The room was observed to have the AC on. However, it was only blowing room temperature air. The temperature was taken using a thermometer and it registered 81.8 Fahrenheit. An interview with resident #35 conducted on July 15, 2024 at 8:20 a.m., the resident stated that the is very warm. During a walk-through inspection conducted with the Maintenance Director (staff #32) conducted on July 15, 2024 at 9:31 a.m., the temperature was taken with a thermometer and it registered 79.5 Fahrenheit. Regarding Resident #41: -Resident #41 was admitted to the facility on [DATE] with diagnoses that included acute embolism, atherosclerotic heart disease, hypertension, depression, and obstructive and reflux uropathy. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The MDS also indicated that the resident is dependent on assistance for transfers. The assessment also noted that the resident uses a wheelchair as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:20 a.m. During the observation, it was noted that the AC was on but was only blowing room temperature air. The temperature was taken using a thermometer and it registered 81.8 Fahrenheit. During an interview with resident #41 conducted on July 15, 2024 at 8:20 a.m., the resident stated that it was warm in the room. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at 9:31 a.m. During the inspection, the temperature was taken with a thermometer and it registered 79.5 Fahrenheit. Regarding Resident #42: -Resident #42 was admitted to the facility on [DATE] with diagnoses that included heart failure, hypertension, diabetes, paraplegia, and seizure disorder. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The MDS indicated that the resident requires partial/moderate assistance for some transfers. An observation of the resident's room was conducted on July 15, 2024 at 8:11 a.m. During the observation the resident's room felt uncomfortably warm. The temperature was taken using a thermometer and the inner wall by the resident's restroom registered 87.1 Fahrenheit while the wall by the window registered 83.3 Fahrenheit. Regarding Resident #43: -Resident #43 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes, chronic kidney disease, anxiety disorder, depression, and gastro-esophageal reflux disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The assessment indicated that the resident is dependent on assistance for all transfers. The MDS also noted that the resident uses a wheelchair as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:09 a.m. During the observation, the resident's room was noted to be pretty warm. The temperature was taken with a thermometer and it registered 82.6 Fahrenheit. An interview with resident #43 was conducted on July 15, 2024 at 8:19 a.m. Resident #43 stated that the during dinner last night, a storm hit town and a power outage ensued as they finished dinner. Due to the fire outage, the elevator was not functional, fire doors closed, and after awhile the emergency lights came on. However, the elevators remained non-functional. The resident noted that they were unable to get back to their room upstairs so they were instead placed in room downstairs until the power came back on. Resident #43 noted that the power came back on between 10:30 p.m. to midnight. The resident said that when they got upstairs, it was so hot and the doors were closed so it was really hot in their room. The resident noted stated that there was no air conditioning, no fan in the room and it was so uncomfortable due to the heat. When they woke up in the morning, it was really hot and uncomfortable. They noted that it was so hot in their room that even the CNA (Certified Nursing Assistant) was sweating and wiping herself with paper towels as she was helping them. The resident noted that they almost could not breathe because it was so hot. The resident explained that they came back downstairs to grab breakfast and to cool down. Resident #43 said that last night, what the staff did to assist with the heat was to give him cold water and just not put blankets on him. The resident explained that in their case, the room have to be kept at 73 Fahrenheit otherwise they are uncomfortable. Resident #43 noted that last night the heat is too bad and it was so bad that even with oxygen and the CPAP (continuous positive airway pressure) machine, they still could not breathe right. The resident mentioned that this was the longest that they had to go without AC. However, they mentioned that this happens every summer. Resident #43 noted that since the beginning of this summer, the air in the hallway has not worked and that was the reason why there was a fan on in the hallway even before the power outage. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at 9:38 a.m. The temperature was taken with a thermometer and it registered 81.0 Fahrenheit. Regarding Resident #48: -Resident #48 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included seizures, narcolepsy without cataplexy, dysphagia, aphasia, depression, meningitis, diabetes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident has severely impaired cognitive skills for daily decision making. The MDS also indicated that the resident is dependent on assistance for all transfers. An observation of the resident's room was conducted on July 15, 2024 at 8:17 a.m. During the observation, it was noted that the AC (air conditioner) in the resident's room was not working. Physical inspection of the thermostat was unremarkable. However, the controls do not work regardless of the setting. In an interview with resident #48 conducted on July 15, 2024 at 8:17 a.m., the resident noted that the AC does not work. Resident #48 confirmed that it is hot in the room. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at 9:29 a.m. During the inspection, the temperature was taken with a thermometer and registered 81.1 Fahrenheit. Regarding Resident #56: -Resident #56 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, epileptic seizures, gastric ulcer, bipolar disorder, and gastro-esophageal reflux disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident is cognitively intact. The MDS noted that the resident utilizes a wheelchair as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:24 a.m. The wall mounted thermostat displayed the room temperature at 84? Fahrenheit. The temperature was taken using a thermometer and registered 83.0 Fahrenheit. A walk-through inspection was conducted with the Maintenance Director (staff #32) on July 15, 2024 at 9:32 a.m. The temperature was taken using a thermometer and it registered 74.3 Fahrenheit. Regarding Resident #167: -Resident #167 was admitted to the facility on [DATE] with diagnoses that included pulmonary embolism, gastrointestinal hemorrhage, multiple sclerosis, polycystic ovarian syndrome, type 2 diabetes, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. The MDS noted that the resident utilizes a walker as a mobility device. An observation of the resident's room was conducted on July 15, 2024 at 8:10 a.m. The temperature was taken with a thermometer and registered 79 Fahrenheit. During an interview with the resident conducted on July 15, 2024 at 8:10 a.m., the resident stated that they did not have a functioning air conditioning the first week that they were here. The resident said that they told the facility but they did not fix the issue until last week Monday or Tuesday. Resident #167 noted that there was a power outage last night and it was very hot and humid. The resident noted that the power did not come back on until 11:30 p.m. The resident said that they woke up from the noise and looked at their watch and that was how they knew when the power came back on. The resident noted that the nurse had checked on them and opened the window for them. A follow-up interview was conducted with a CNA (Certified Nursing Assistant/staff #9) on July 15, 2024 at 9:22 a.m. The CNA noted that they are supposed to move the resident when it is hot and the air is not working. On July 15. 2024 at 9:22 a.m., it was observed that the staff were transferring residents from the second floor to the first floor. An interview with the Maintenance Director (staff #32) was conducted on July 15, 2024 at 9:41 a.m. Staff #32 stated that they were notified at 6:15 p.m. of the power outage. They then called the Assistant Maintenance Technician (staff #33) and got ready to go out to the facility. Staff #32 noted that they arrived at the facility at approximately 6:45 p.m. They noted that the facility was dark, and the staff was panicking. They both started troubleshooting, checked the electrical room, and checked the breakers. It appeared that the main breaker for the building was popped, so they kicked it on. They turned the generator on manually at around 7:40-8:00 p.m. Staff #32 noted that it took about an hour to troubleshoot. They did not get the chillers working again since it took too much voltage. However, there was enough power for oxygen, air mattress, CPAP (Continuous Positive Airway). The staff #32 noted that downstairs it was 75 degrees and upstairs it was 78 degrees. The Maintenance Director noted that chiller temperatures have to be 80 and 90 always a 10-degree difference. When they got arrived in the facility in the morning, they did not know that the circular pumps went off. They had to go though each unit at 7:00 a.m. to reset all the AC (air conditioner) units. The Maintenance Director said that staff #33 had bypassed the circular pumps because they turned the alarm and did not share this with staff #32. Had the alarm been on, they would have known there was an issue with the circular pumps. An interview with a Registered Nurse (RN/staff #69) was conducted on July 15, 2024 at 10:10 a.m. Staff #69 stated that the electricity went out last night around 6:15-6:20 p.m. The RN indicated that they checked and instructed staff that residents on O2 (oxygen) had to be put on the O2 tank. Staff #69 indicated that they are familiar with which residents are on O2. The RN stated that the first priority is to get the residents on O2 then checked each room to make sure that everyone was fine. They explained to residents that there was a storm and electricity is out and staff made sure that everyone had ice water. Staff #69 noted that by the time they notified maintenance, one of the nurses had already contacted the ED (Executive Director/staff #110) and the DON (Director of Nursing/#59). Maintenance arrive approximately 15-20 minutes later. The generator came on bout 15-20 minutes later. The RN noted that the O2 concentrators can be ran by the generator but no CPAP/BiPAP (Continuous Positive Airway/Bilevel Positive Airway Pressure) and they have to use the red plugs. The beds would not be working since it requires too much electricity. Staff #69 said that there were two residents that they had to put back on the air mattress after they were able to put everyone that needed on to be on O2. The RN indicated that vital-need equipment were not automatically plugged into the red outlets and that staff had to physically switch out the needed equipment to the red outlets and plug them in. Staff #69 said that one of the residents from the second floor got stuck downstairs until around 11:30 p.m., when the electricity came back. They made sure that the resident had water and that there was a CNA (Certified Nursing Assistant) assigned to that resident. They checked on that resident to make sure that the resident was okay. Staff #69 noted that the alarm did not go off last night regarding the generator. The generator did not kick in. The light went on and off and the doors shut. The RN went to each of the residents' room and informed them that they were there and that the electricity will comb back. Staff #69 said that by the time they left at around 8:30 p.m., it was not hot. However, when they returned on shift at around 7:10 a.m., it was hot. The NOC shift did not talk to them since they were assigned to the first floor. Therefore, they were not aware of anyone taking the temperature in the residents' rooms at night. Staff #69 said that if the resident's room is warm, they are supposed to move the resident to another location and report the issue to maintenance as soon as possible. However, since the facility had no electricity the elevator was not working, so they could not move the residents. The RN said that if you have to check the temperature then it is too late since it is too hot. Elderly people, they do not feel the change quick, you have to recognize if the climate is not okay. When there is an issue staff can call or use the TELS system to submit a work order. For the power outage, the phone call was appropriate response. They got the residents ice. They assumed that the generator would kick in. However, it did not kick in right away. During an interview with the Assistant Maintenance Technician (staff #33) conducted on July 15, 2024 at 10:48 a.m., staff #33 stated that they were called in when the power went out to get the generator started. They stated that the Maintenance Director called them at approximately 6:15-6:30 p.m. They arrived at the facility around 6:47 p.m. The Assistant Maintenance Technician noted that when they arrived at the facility, the building was dark and they had to get the generator key and got it going. The generator finally kicked in at about 7:06 p.m. Staff #33 noted that they do weekly test on the generator and run it weekly for 3 hours, take temperature readings, etc. to ensure that it is working. The Assistant Maintenance Technician said that last week, they came by and looked at the generator to see if they were going to disconnect it while they were going to do some work. Staff #33 said that there is no alarm system for the generator. However, for the boilers, when the gas runs low and runs out, an alarm goes off, and it shuts off the pumps to include the one for the chiller which they did not know. The alarm for the boiler went off and you have to go and switch off the alarm, and places on standby, causing the chiller and boiler to automatically shut off. Staff #33 stated that it takes 2-3 hours to get going for the chiller to actually start cooling and get the air conditioner working. The Assistant Maintenance Technician said that this morning, they realized that the AC was not cooling, this was around 5:00 a.m. Last night, they reset the AC before he left at 2:15 a.m. Staff #33 noted that they checked the temperatures in the rooms before leaving and it was averaging 73-78 Fahrenheit upstairs and 72 Fahrenheit downstairs. The Assistant Maintenance Technician stated that it takes time to cool off the rooms. The windows upstairs were open because the staff were trying to keep the residents cool. Staff #33 admitted that they did not document any of the room temperature taken last night. They also noted that each time the pumps go into standby mode, they had to go into each room and reset the AC. The Assistant Maintenance Technician said that when they arrived in the facility this morning and came into the kitchen, they noticed and felt that it was hot. They went upstairs to check the rooms but did not take the temperature. Staff #33 said that it was hot and the residents were sleeping. They commented that the residents could have been moved from the second floor to the first floor where it was cooler. They indicated that the process when it is hot in the facility is to use portable coolers, and noted that there are only 3 portable coolers and they are all being used upstairs. Staff #33 admitted that the elevator was not working in the [NAME] last night when the power outage ended. They stated that they would have moved the residents if it was hot. They noted that they were not sure what the temperature is when residents have to be moved. Staff #33 noted that they used extension cords for red plugs in the hallways since they were not in all rooms. They said that the only things plugged into the red outlet were oxygen and things needed for the resident's health and safety. Staff #33 said that there were no fans in the rooms. They admitted that they are supposed to try and make sure the residents are comfortable as much as possible with the limited resources and old system. They noted that climate control is for the residents' comfort. They indicated that they called the Maintenance Director (staff #32) at approximately 6:12 a.m. and was told that he was on his way and they will all figure it out. Staff #33 recalled that last year, when it last happened last summer, the facility brought all the residents downstairs to the dining rooms. Back then the electricity was out for 2 hours but it was long enough to feel the heat. Staff #33 stated that they saw the Maintenance Director around 7:00 a.m., and both of them went around the rooms. They both agreed that the rooms were hot but did not take temperatures of the residents' rooms. They noted it was hot based on ambient air. Staff #33 stated that it was around 8:00 a.m. when temperatures were taken and it averaged 83? Fahrenheit upstairs and 78 Fahrenheit downstairs. The Assistant Maintenance Technician indicated that they were concerned about the residents being in hot rooms since they are weak and have conditions. Staff #33 noted that neither the Administrator (staff #110) nor the DON (staff #59) asked them about temperatures. They indicated that they were with the Maintenance Director (staff #32) were outside working on the chiller when the DON approached the Maintenance Director to have a conversation but did not know what was discussed. Staff #33 noted that they are trained for fire but admitted there is not an emergency elevator or a plan on how to evacuate residents from the second floor that are not ambulatory. The Assistant Maintenance Technician admitted that they have not done disaster drills. It is a concern how to get residents out and there are a few who are very heavy set. It is the second time the electricity had gone out and they noted that they do not have a standard practice to follow. An interview with a Registered Nurse (RN/staff #50) was conducted on July 17, 2024 at 8:29 a.m. Staff #50 stated that when they arrived on shift the day after the power outage, the none of the residents complained. However, staff #50 said that the rooms felt hot to him. The RN stated that they had not experience a power outage that resulted in the facility being hot. Staff #50 noted that the protocol when a resident's room is hot is for them to move the resident to a cooler room. The RN said that there are guns (thermometer) on the cart that are used to check room temperature. However, it was unknown whether the temperature for the rooms were taken. An interview with the Administrator (staff #110) was conducted on July 17, 2024 at 1:09 p.m. Staff #110 stated that a comfortable environment for residents is part of homelike environment. Residents should have areas to rest, congregate, have a sense of peace, and lack of chaos. The Administrator stated that the impact on residence if the facility is not comfortable with regards to temperature is that it could influence sleep hygiene, quality of sleep, and rest. It could influence maintaining proper hydration. Could for disturbing for one's ability to rest comfortably.

Based on observation, a staff interview, and the facility policy and procedures, the facility failed to ensure that the daily staff posting included the correct information. Findings include: On July 14, 2024 at approximately 9:00 a.m. the daily staff posting was observed hanging on the wall just to the left of the reception desk. The information observed on the posting was: -July 12, 2024 -census 60 -number of each type of staff for each shift -the total hours scheduled for each type of staff for each shift -the actual hours worked was not completed During this time the Director of Nursing (DON/staff #59) approached and removed the daily staff posting dated July 12, 2024 and stated that she was just about to the change it. Review of the facility documentation revealed that the census was 58 on July 14, 2024. An interview was conducted on July 17, 2024 at 11:30 a.m. with the (DON/staff #59), who stated that the Central Supply Director/staffing coordinator (staff #95) is responsible for completing daily staff posting and works Monday through Friday. She stated that staff #95 prepares the daily staff postings for the weekend and the weekend receptionist is supposed to switch them out. She stated that the posting is for visitors and residents to see how many staff are available in the building. The facility policy, Facility Staffing Posting revised December 13, 2023 states that the facility needs to post nurse staffing information in a prominent place where it is accessible to residents and visitors. The data should be clear, readable, up to date and current. When listing the total number of staff and actual hours worked, the facility is required to reflect staff absences on each shift that occur due to callouts or illness. The nurse staffing data needs to be posted on a daily basis at the beginning of each shift. The required information that needs to be posted includes: I. Facility name 2. Current date 3. Resident census 4. Total number of staff and actual hours worked per shift for: a. Registered Nurses b. Licensed Nurses c. Certified Nurse Aides

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#6) received assistance with bathing. The deficient practice could result in poor hygiene and skin infections. Findings include: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included a anxiety, depression, unspecified protein-calorie malnutrition, and a personal history of venous thrombosis and embolism. The care plan for activities of daily living (ADLs) dated March 25, 2024 revealed that the resident has an ADL self-care performance deficit related to weakness and decreased mobility due to acute kidney failure (AKF), pressure ulcer (PU), seizures (s/z) and depressive disorder (d/o). Interventions included that the resident requires assistance by staff with bathing/showering as necessary. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident was cognitively intact. It also revealed that the resident was dependent on assistance with showers/bathing. Review of the shower/bathing task sheet revealed that the resident was schedule to bath on Monday and Thursday evenings. Review of the shower/bathing task sheet dated April 2024 revealed: -Thursday, April 4, 2024, bathing was completed. -Thursday, April 11, 2024, bathing was refused. -Thursday, April 25, 2024, activity did not occur. Review of the skin care alert form revealed the following directions: Complete this form [NAME]. While assisting the resident with self-care (bathing, toileting. dressing, Etc.), document the presence of any areas of concern or changes in skin, including: redness, bruising, surgical wounds, drainage. rashes, blisters, etc. Use side two to document detail and indicate current strategies to prevent pressure ulcer/injuries. Review of the skin care alert forms from April 2024 through June 2024 revealed one form dated April 15, 2024 with the documention of a bed bath being completed. Review of the shower/bathing task sheet dated May 2024 revealed: -Friday, May 3, 2024, activity did not occur. -Monday, May 6, 2024, bathing was completed. -Thursday, May 9, 2024, activity did not occur. -Monday, May 13, 2024, activity did not occur. -Monday, May 20, 2024, activity did not occur. -Thursday, May 23, 2024, activity did not occur. Review of the shower/bathing task sheet dated June 2024 revealed: -Friday, June 14, 2024, activity did not occur. -Monday, June 17, 2024, bathing was completed. -Thursday, June 20, 2024, bathing was completed. -Monday, June 24, 2024, bathing was completed. -Thursday, June 27, 2024, bathing was completed. Review of the shower task sheet dated July 2024 revealed bathing only one time during the week of July 4, 2024. No bathing was documented on the task sheet from July 5, 2024 through July 15, 2024 and no refusals were documented. During an interview conducted on July 16, 2024 at 12:23 p.m. with the Director of Nursing (DON/staff #59), she stated that skin care alert form is being used for the paper shower form and acknowleded that there is nothing on the form to indicate a shower, hair washing, or nail care was done. The form states that it can be used for shower, toileting, dressing, etc. She acknowledged that staff are not identifying which task is being done. During a second interview conducted on July 17, 2024 at 11:12 a.m. with the (DON/staff #59), she stated that there is a shower schedule for the residents and each resident is scheduled for showers twice a week. It is her expectation that if a resident is not showering, the certified nursing assistant (CNA) should offer a couple of times and report the refusal to the nurse. The nurse should talk to the resident. The nurse could document the refusal on the skin care alert form ask the resident to sign it. She stated that there is a risk of poor hygiene and skin breakdown if a resident is not bathing. The facility policy, Activities of Daily Living (ADLs) revised February 12, 2024 states that the resident will receive assistance as needed to complete activities of daily living (ADLs). Any change in the ability to perform ADLs will be reported to the nurse.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that initial and ongoing weights were conducted for one resident (Resident #36). The deficient practice could result in a change of condition not being assessed and monitored. Findings include: Resident #36 was admitted to the facility on [DATE] with diagnoses that included anoxic brain damage, Parkinson's disease and chronic respiratory disease. Review of the clinical record revealed that the resident weighed 187 pounds on February 9, 2024. Review of the nutritional assessment dated [DATE] revealed that the resident was malnourished. The care plan dated February 22, 2024 revealed that the resident was at risk for weight fluctuation related to dysphagia and anoxic brain injury. Interventions included eternal feeding as ordered and weight as per the facility policy. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status score of 2 indicating the resident had moderate cognitive impairment. The clinical record revealed that the resident weighed 168.6 pounds on June 4, 2024 and 167.4 pounds on July 2, 2024. An interview was conducted on July 17, 2024 at 10:07 a.m. with a Registered Dietician (staff #66), who stated that a nutritional assessment is done when residents are admitted and all residents are supposed to be weighed. He stated that resident #36 was not weighed when he was admitted to the facility and the weight documented in the clinical record was taken from the weight documented in the hospital transfer records. He also stated that the resident should have been weighed monthly as per the facility policy in order to assess and monitor weight loss, fluctuations, fluid shifts, and if a weight change has occurred, so the root cause can be determined. He stated that there is a risk of developing malnutrition and/or congestive heart failure (CHF) fluid retention not being recognized if weights are not being monitored. An interview conducted on July 17, 2024 at 11:15 a.m. with the Director of Nursing (DON/staff #59), who stated that the facility policy states that all residents are supposed to be weighed weekly for the first four weeks and then monthly. The reason for weighing the resident is to check for significant weight loss or gain. She stated that when the resident was admitted , the certified nursing assistant (CNA) should take the resident's initial weight and should not use the recorded weight from the hospital records because the weight may not be accurate. She stated that they just recently talked about weighing hospice patients, and all residents should be weighed. The facility addendum to the Lippincott procedure revised August 21, 2023 states that measuring a patient's weight is part of a routine admission to a health care facility. An accurate record of the patient's weight is essential for calculating dosages of drugs, fluid maintenance, anesthetics, and contrast agents; calculating tidal volume in patients requiring mechanical ventilation; assessing the patient's nutritional status; and determining the patient's height-weight ratio, body surface area, and body mass index (BMI). The facility policy, Weights and Heights reviewed August 23, 2023 states that all residents are weighed within 24 hours of admission and weekly for 4 weeks and as needed thereafter or more as determined by the RAR committee and/or physician order.

Based on record review and staff interviews, the facility failed to ensure that two residents (#222 and #223) and/or the resident's representative received an accurate and complete Advanced Beneficiary Notice (ABN) when Medicare services terminated. The deficient practice could result in residents not knowing of their potential liability for payment. Findings include: Resident #222 was admitted on [DATE] with diagnosis including urinary tract infection, difficulty walking, muscle weakness, arteritis, hypothyroidism, hyperlipidemia, repeated falls, neuromuscular dysfunction of the bladder, and protein-calorie malnutrition. A review of the admission MDS (minimum data set) dated January 7, 2024 revealed a BIMS (brief interview of mental status) score of 00, suggesting severe cognitive impairment. A review of the advanced beneficiary notification for resident #222 revealed the estimated cost for ongoing care effective on February 2, 2024 would be $345.00 a day. The form further revealed that both option 1 and option 3 had been selected in the area that indicated to check one box only. The directions on the form stated to select only one option. Option 1 noted that the care as listed above, outlining the $345.00 a day fee, was wanted, and option 3 noted that the resident does not want the care as listed above. Option 1 and option 3 are in conflict with one another. ____________________________ Resident #223 was admitted on [DATE] with diagnosis including knee pain, patella fracture, depression, glaucoma, irregular heartbeat, obesity, osteoarthritis, breast cancer and spinal stenosis. A review of the 5-day MDS (minimum data set) dated November 29, 2023 revealed a BIMS (brief interview of mental status) score of 15, suggesting that the resident was cognitively intact. A review of the advanced beneficiary form for resident #223 revealed that the estimated cost, to the resident, beginning December 05, 2024 would be $345.00 a day. The 'options-section' of the form denoting that only one box should be checked revealed that no boxes were checked, leaving ambiguity as to whether resident #223 was opting to continue or not continue with services past December 05, 2023. _____________________________ An interview was conducted on July 16, 2024 at 3:13 P.M. with staff #112 (Social Services Director). Staff #112 stated that she believed the advanced beneficiary notification (ABN) was always required for each resident when they are running out of Medicare days of service. Staff #112 stated that only one box should be checked for those sections explicitly stating check one box and that this section is required to be completed. Staff #112 reviewed the ABN for resident #223 and stated that a check-box should have been selected, but had not. Staff #112 reviewed the ABN for resident #222 and stated that only one box should have been checked not 2, as observed on the form. Staff #112 stated that the risk would include, that if the form was incorrectly completed, it would make the form invalid. Staff #112 stated that these forms were completed inaccurately and that she takes full responsibility for the errors. Staff #112 stated that going forward one person will be completing the form, another person will audit it for accuracy and it will be documented in point click care (PCC). An interview was conducted on July 16, 2024 at 3:27 P.M. with staff #110 (administrator). Staff #110 stated that her expectation is that the ABN is given timely and accurately. She stated that the ABN is completed by social services. Staff #110 reviewed the ABN documentation for resident #223 and resident #222 and stated that these should have been completed accurately, but the options section of the ABN was not accurately completed for either resident. Staff #110 stated that the risk could include reimbursement being impacted as well as an impact on resident rights. A review of the policy entitled Resident Rights with a review date of September 25, 2023 revealed that the resident has the right to request, refuse and or discontinue treatment.

Based on employee record review, staff interviews, and the facility policy and procedures, the facility failed to ensure that one staff (#110) was free of tuberculosis (TB) prior to working in the facility. The deficient practice could result in residents being infected with tuberculosis. Findings include: Staff # was hired as the Administrator (staff #110) for the facility on January 8, 2024, During an interview conducted on July 16, 2024 at 1:56 p.m. with the accounting clerk/human resources personnel (staff #73), she stated that (staff #110) did not provide a current TB test for herself. She stated that the Executive Director is probably supposed to have a TB test prior to working in the building. She stated that the reason for testing is to prevent the risk of TB spreading throughout the building. An interview conducted on July 17, 2024 at approximately 9:50 a.m. with the (staff #110), who stated that she did not have a tuberculosis test prior to working in the facility. She stated that she was tested yesterday, July 16, 2024, and the test results had not been read. An interview was conducted on July 17, 2024 at 11:19 a.m. with the Director of Nursing (DON. /staff #59), who stated that when a person is hired, he/she is required to show a test result for TB is negative prior to working in the facility. She stated that the administrator (staff #110) walks the floors of the building and should do daily. She doesn't interact directly with residents, but follows up with residents as needed. She stated that staff #110 can come into contact with residents when she is walking the halls. The facility policy, Tuberculosis - Testing and Screening revised June 28, 2024 states that the facility will evaluate each associate and volunteer for tuberculosis in accordance with current CDC guidelines, unless more stringent guidance is provided by local or state regulation. New associates or volunteers who have been made a conditional offer shall be screened for presence of infection through the following measures; pre-placement risk assessment and symptom evaluation and the facility should also perform skin test for M. Tuberculosis using the Mantoux TST skin test.

Based on resident and staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure a residents' care was not neglected. Neglected care could result in increased morbidity for residents. Findings include: Resident #48 was admitted on [DATE] with diagnoses of depression, anxiety disorder, generalized muscle weakness and difficulty in walking. A 5 day Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively intact and needed partial/moderate assistance with toileting hygiene. A care plan dated 5/16/23 included that this resident requires Activities of Daily Living (ADL) assistance and therapy services needed to maintain or attain highest level of function. Interventions include to assist with mobility and ADL's as needed. However, a complaint/Incident Investigation Report dated 2/1/24 included that a resident is stating that on Saturday, January 20, at approximately 9:00 PM, a Certified Nursing Assistant (CNA) came into the room to provider patient care, but was refusing to change her brief. The resident stated that the Aide was trying to force her to stand up and when patient expressed that she couldn't do it, the CNA threw the brief at the patient and told her to change it herself. A 5 day facility investigation included an interview with a Licensed Practical Nurse (LPN/#105) dated 1/26/24 at 7:07 AM, which included, Upon entering residents room, to administer evening medications, the resident was upset and kept asking me why does that CNA hate me. She was very loud and just kept repeating that she could not stand and that they don't believe me when I tell them I can not stand for long and they insist that I stand for them to change my brief. She just kept repeating that and that she had been in the hospital and was bleeding inside and that is why she is weak. I explained to her that no one hates her and that I would talk to them. She was still upset so I informed her that the CNA would be told not to come back in her room and that I would change her brief and assist her with whatever she needed. This 5 day facility investigation also included an interview that was conducted on 1/22/24 with the Director of Nursing (DON/staff #16) .(resident #48) stated that she had the call light on to ask to have her diaper changed because she was wet. (resident #48) stated that when the CNA did come in to provide care, the CNA kept demanding her to stand saying, You're able to stand. I've seen you stand before. Resident #48 said that she kept trying to tell the CNA that her legs were bothering her and she couldn't stand. She further stated that the CNA then threw a diaper at her and said to change herself before walking out of the room. After speaking with resident #48, I met with the roommate. The roommate states that she watched the CNA throw the brief at the patient. This writer asked if the CNA could have been trying to toss the brief onto the bed to gather their supplies in one area, and the roommate denied this as a possibility An interview was conducted on February 7, 2023 at 1:23 P.M. with resident #27 who said that about a month ago, her roommate (resident #11) was complaining about the aid not changing her. She said that the aid just handed a brief to her and said you can change herself. An interview was conducted on February 7, 2023 at 1:55 P.M. with a Certified Nursing Assistant (CNA/staff #55) who said that when checking if a resident needs a brief change, she would ask them if they need help and to check them every 2 hours to see if they need assistance with transferring or hygiene. She said that it is abuse if a resident asks for assistance with brief care and staff refuse. An interview was conducted on February 7, 2023 at 2:00 P.M. with a Registered Nurse (RN/staff #32) who said that if a resident asks for help, staff have to help them. This nurse said that refusing to help a resident is 100% abuse. An interview was conducted on February 7, 2023 at 2:09 P.M. with the Executive Director (staff #6) who said that our staff should be responding to residents' requests for help, and checking on them if they have a need for assistance. She said that staff should respond with promptness and assist residents according to their ability, need and care plan. She said that it is not her expectation that the staff would refuse to assist the resident as it would be neglect of care. A policy titled Abuse - Identification of Types dated 7/18/23 revealed that abuse includes the deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This policy included that in these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s).

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#4) was free from neglect by staff. The deficient practice could result in further incidents of neglect of the residents. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, diabetes, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. An anticoagulant care plan created on December 14, 2023 revealed that the resident was on anticoagulant therapy. The goal was to not experience uncontrolled bleeding through the next review period, with noted interventions that staff will observe and report adverse reactions of anticoagulant therapy such as lethargy, sudden changes in mental status, blurred vision, significant or sudden changes in vital signs, and bruising. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. A review of progress notes revealed that during direct care two staff members had identified a medium sized hematoma on the right side of the resident's forehead, and that no report was given to the writer from day shift of any incidents that had occurred that day. An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 PM. The LPN stated that at the beginning of the shift on the morning of December 25, 2023, it was reported that the resident had a hematoma on the right side of her face. The LPN also stated that nobody did neuros because nobody knew when it happened. An interview with a Certified Nursing Assistant (CNA/staff #13) was conducted on January 4, 2024 at 9:15 AM. The CNA stated that the resident was normally very pleasant but confused, and not aggressive. The CNA stated that during rounds at the end of the shift, approximately 6:00 p.m. on Saturday December 23, 2023 no bruising was seen on resident #4. An interview was conducted with a Registered Nurse (RN/staff #82) on January 4, 2024 at 9:55 AM. The RN stated that when she got the report of the hematoma, she notified the doctor and started a neurological assessment. The RN also stated that the resident was on three separate blood thinners. However, a review of the clinical record revealed no change of condition assessment and no neurological assessment. An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON further stated that no neurological assessment was done for this incident. The DON also stated that her expectation of her staff is to follow the facility policies and that there should have been no delay in treatment. A review of facility policy titled 'Preventing, Reporting, and Investigating Abuse' revised July 2022 revealed that Neglect is a failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an injury of unknown origin was reported to the Administrator, and state agency within 24 hours. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. Review of the facility's investigation report revealed that on December 24, at approximately 12:00 PM, the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior. Review of State agency documentation revealed the report for this incident was received by the agency on December 27, 2023 at 10:30 AM. An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 PM. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON further stated that the facility had 24 hours to report an injury of unknown origin. A review of facility policy titled 'Abuse - Protection of residents' reviewed July 18, 2023 revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source are reported immediately, or not later than 24 hours of the events that caused the allegation do not involve abuse to the Administrator and to other officials including the State survey agency in accordance with State law through established procedures.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident's representative (#4) was able to exercise her rights regarding decisions about the resident's care. This deficient practice could result in resident's or their representatives not being able to make their own healthcare decisions. Findings include: Resident #4 was admitted to the facility on [DATE], with diagnoses that include Dementia, anxiety, Diabetes mellitus type 2, chronic kidney disease stage 3, dysphagia, weakness, heart failure, and right lower extremity amputation. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1 which indicated the resident had significant cognitive impairment. Review of the facility's investigation report revealed that on December 24, at approximately 12:00 p.m. the Resident's daughter approached the nursing station expressing that there was a large bruiser to her mother's face that was not present during her visit the day prior. Review of progress notes revealed a nurse's note that detailed the daughter of the resident visiting on Sunday December 24, 2023 and had requested the nurse send the resident to the hospital related to the hematoma that was discovered. However, review of progress notes further revealed that on December 25, 2023 the daughter was again present at the facility and upset with the facility staff because the resident was still in the facility. A progress note dated December 25, 2023 at 1:18 p.m. detailed the staff called 911 and had the resident sent with emergency services to the hospital. The note further reveals the daughter followed the resident to the hospital. An interview was conducted with a Licensed Practical Nurse (LPN/staff #91) on January 3, 2024 at 4:00 p.m. The LPN stated that the daughter of the resident had requested her mother be sent to the hospital but for some reason the nurse didn't do it. The LPN further stated that she was the one who sent the resident to the hospital, and it was on December 25, 2023 after noon. An interview with the Director of Nursing (DON/staff #33) was conducted on January 4, 2024 at 12:30 p.m. The DON stated that there was a delay in communication among the staff and a delay in action with regards to this injury when it was discovered. The DON also stated that she can't speak to why they didn't send her out, and further stated that we have done in-services on whether the residents have rights to be sent out and how our opinions don't matter. The DON concluded that her expectation is that the staff would follow facility policy. A review of facility policy titled 'Area of Focus, Resident rights' Reviewed November 27, 2023 revealed that the facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

Based on clinical record review, staff interviews, physician interview, hospital documentation, and review of facility policy, the facility failed to provide care and services to prevent the development of multiple pressure ulcers for one resident (#344). Findings include: Resident #344 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed admission physician orders dated August 24, 2012, which included the resident's skin was to be assessed weekly. Review of the admission nursing assessment dated [DATE], revealed the resident had redness within the buttocks fold and hemorrhoids. A Braden scale for predicting pressure sore risk dated August 25, 2012, documented the resident was at high risk. A physician's order dated August 25, 2012, included for protective ointment to be applied to the buttocks/sacrum area every shift, due to redness. The interim care plan for skin integrity dated August 25, 2012, identified the resident had incontinence and had a stage 1 pressure ulcer. Interventions included for skin treatment daily, reposition every two hours, and for weekly skin checks. According to the weekly skin integrity data collection sheet dated September 1, 2012, the resident had redness on her buttocks. Review of the Minimum Data Set (MDS) assessment from September 5, 2012, documented that the resident did not have any pressure ulcers. The next skin assessment was completed 13 days later on September 14. Per the wound nurse's note (from September 17), she was requested by nursing to evaluate the redness on the resident's buttocks on September 14. The documentation included there was redness present in the sacral area and blanching was present. No measurement of the reddened area was documented. Review of the September 2012 Treatment Administration Record (TAR) revealed that the protective ointment was not applied on 20 different shifts. Further review of the clinical record revealed there were no further skin assessments that were completed after September 14 through October 14, 2012. Review of the October 2012 TAR revealed that between October 1 through 15, the protective ointment was not applied on eight shifts. A nurse's note dated October 15, 2012, documented the resident complained of a "sore bottom area." Hemorrhoids were noted, as well as open sores. Per the note, the wound nurse was notified and evaluated the resident and found six pressure sores. According to the pressure ulcer records dated October 15, 2012, six pressure ulcers were identified, three of which were unstageable. The assessments were as follows; a left superior rectum stage 2 measuring 1.0 by 0.7 centimeters (cm) with red granulated tissue, superior rectum stage 2 pressure ulcer measuring 1.0 by 1.0 cm with red granulated tissue, and right superior rectum stage 2 pressure ulcer measuring 1.7 by 1.3 cm with red granulated tissue, the left buttock measuring 1.5 by 1.5 cm with 40 percent slough, 40 percent necrotic tissue, and 20 percent red granulation, the right proximal buttock measuring 1.1 by 1.5 cm with 45 percent slough, 45 percent necrotic tissue, and 10 percent red granulation and the right distal buttock measuring 1.5 by 0.7 cm with 50 percent slough and 50 percent granulation. A physician's order dated October 15, 2012, included to apply extra protective cream every shift to the buttocks area and to not scrub off. There was also an order to place an indwelling urinary catheter for incontinence to allow healing. The indication for the order was "pressure sores." The resident's comprehensive care plan was updated on October 15, 2012, to reflect the presence of pressure ulcers. Interventions included for protective ointment to the buttocks/sacrum area every shift, assist to reposition, minimize pressure over bony prominences, provide incontinence care after episodes and for skin assessments weekly and as needed. Clinical record documentation revealed that the resident had loose stools on and off throughout her admission. The resident was tested for [MEDICAL CONDITION] several times and the tests were all negative. In addition, the documentation included the resident was receiving a regular diet with high protein foods and supplements, and that the resident's appetite was good or fair throughout her stay. A physician's order dated October 17, 2012, included to apply extra protective cream every shift and as needed (PRN) to rectal, bilateral ischial and bilateral buttock area. It was also documented that a foley was placed due to the new onset of pressure ulcers. A physician's progress note dated October 17, 2012, documented the resident had multiple stage 3 decubitus ulcers on her buttocks. According to the MDS assessment dated [DATE], the resident had three stage 2 pressure ulcers and three unstageable pressure ulcers. The resident was transferred to the hospital on October 17, 2012, for wound care to multiple pressure ulcers to the buttocks. According to the hospital documentation dated October 17, 2012, the resident had several decubitus ulcers around the perianal/gluteal area and that slough was present on several of them. During an interview conducted on October 2, 2013 at 1:30 p.m., a Licensed Practical Nurse (LPN) stated that there is a wound nurse who does the "major treatments." She stated that she applies the gels, ointments, and wraps. She reported that the nurses on the floor are responsible for performing the weekly skin checks. She stated that the weekly skin checks are documented on a form and in the treatment book. The LPN reported that residents receive showers two or three times a week and that once a week the nurse will perform a skin check, while a resident is in the shower room. During an interview conducted on October 3, 2013 at 8:23 a.m., a nursing unit manager stated that the wound nurse does an initial skin check on top of the one done by the resident's nurse upon admission. She stated that the nurses on the floor apply the ointments. She reported that if a resident has a stage 2 pressure ulcer or higher, the wound nurse would get involved. She stated that the nurses are responsible for completing the weekly skin checks. The unit manager reported that the skin checks are documented on the weekly skin check form and the nurses sign off on the TAR as well. An interview was conducted with the Director of Nursing (DON) on October 3, 2013 at 11:00 a.m. The DON stated that the reasons for the resident's pressure ulcers were her declining nutrition and loose stools. When asked why the weekly skin checks were not done, she was unable to give an explanation and stated that she was not the DON at that time. An interview was conducted with the Medical Director on October 3, 2013 at 12:30 p.m. He reported that the wounds should not have been documented as decubitus ulcers since they were not over a bony prominence and that they were caused by excoriation from [MEDICAL CONDITION]. A subsequent interview was conducted at 1:13 p.m. The Medical Director was asked if he assessed the resident's pressure ulcers at that time, which he replied "no." A review of the facility policy titled Post-admission Weekly Skin Assessments included, "On a weekly basis, a licensed professional searches for areas of skin that differ from surrounding tissue. The results of the skin assessment are documented on the Weekly Skin Integrity Data Collection form. The Weekly Pressure Ulcer Status Record are used for weekly assessment of existing wounds."

The facility failed to provide adequate supervision to prevent falls with injuries for two residents (#s 7 and 10), failed to ensure that one resident (#8) was transferred correctly and the shower care was secure, to prevent a fall. Resident #7 sustained actual harm. The sample size was three of nine. Findings include: -Resident #7 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed care plans dated November 16, 2011, that documented the resident with deficits with Activities of Daily Living (ADLs) and that staff would set-up items at sink level for grooming and hygiene and assist as needed. The care plans also documented that the resident had a potential for falls/injuries due to forgetfulness and dementia. The care plan further documented that staff would place frequently used items within easy reach, to avoid resident reaching for items. The resident's clinical record revealed a Fall Risk Evaluation dated November 16, 2011, that documented that the resident had been assessed as a high risk for falls. Further review revealed an admission Minimum Data Set (MDS) assessment dated [DATE], that documented the resident needed extensive one-staff assistance for dressing and personal hygiene. The MDS further documented that the resident used a wheelchair as her primary mobility device. A review of the clinical record revealed documentation in the nurse's notes from December 29, 2011, that the resident was found on the floor, in front of her wheel chair, and that the brakes were not applied. The nurse's note further documented that the Licensed Practical Nurse (LPN) had initiated teaching with the certified nursing assistant (CNA). The resident was assessed and sent to the hospital on December 29, 2011, for x-rays of the hip and head. The x-rays were negative for fractures. The nurse's note documented the resident had complained of rib pain on December 30, 2011, and the physician was notified and new orders were given for the resident to have x-rays of her rib areas. The x-rays revealed that the resident had an acute fracture of the left eighth rib. On April 24, 2012, a review of the facility's investigative documentation revealed that the resident had fallen from her wheel chair while at the sink performing morning grooming. The documentation revealed that the wheel chair was not locked and the resident fell , when reaching for a washcloth. An interview was conducted on April 24, 2012, with staff #1 who was assigned to provide cares to the resident during the morning of December 29, 2011. Staff #1 stated that he had positioned the resident in front of the sink so that she could wash her face and brush her teeth. Staff #1 stated that he always applied the brakes to the wheel chair. The staff member stated that on that morning, he forgot and the resident fell when she pushed herself away from the sink and reached for a washcloth. Staff #1 stated that the LPN on duty gave him instructions, after the fall, that the resident's wheel chair should be locked when the resident was at the sink. The CNA further stated that the application of the brakes on the wheel chair was a standard of practice to protect the resident from falls when at the sink. An interview was conducted on April 24, 2012, with the LPN who had provided teaching to staff #1 on December 29, 2011. The LPN stated that she had instructed staff #1 to make sure the brakes are applied to the resident's wheel chair when she is at the sink. The LPN stated it was a safety practice. During an interview with Staff Development staff on April 24, 2012, the Staff Development staff stated that CNA's were observed to ensure they were performing resident cares in a safe manner. The Staff Development staff further stated that CNAs would be expected to apply wheel chair brakes when cognitive impaired residents were at the sink performing or being assisted with grooming. Random interviews were conducted with CNA staff regarding application of wheel chair brakes during ADL cares and CNAs stated they would apply the wheel chair brakes if a resident was at the sink. A review of the facility policy for wheel chair use revealed documentation that wheel chairs were used to provide non-ambulatory residents with safety and comfort. The facility was unable to provide a policy regarding wheel chair positioning during ADL care, but current practice revealed an in-formal policy of applying wheel chair brakes when resident's were at the sink area performing ADL cares. -Resident #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an annual MDS assessment dated [DATE], that documented the resident as needing extensive one-person assistance with bathing activities and limited one-person assistance with transfers. The The MDS further documented that the resident had been assessed as not steady during surface to surface transfers and needed human assistance to stabilize balance. Further review of the clinical record revealed a Fall Risk Assessment June 18, 2011 and July 18, 2011, that documented the resident was a high fall risk and that the resident would not wait for assistance and had to be reminded to wait for assistance before transferring. A fall care plan dated May 12, and updated on June 18, and July 19, 2011, revealed that the resident had potential for falls/injuries due to a history of falls and impulsive behaviors. The care plan documented that the resident's environment should remain free of accident hazards. Continued review of the clinical record revealed that the resident fell on [DATE], while in the shower room. A review of the facility's investigative documentation dated July 27. 2011, revealed that the resident fell to the floor, without injury, due to the shower chair not being secure, the brakes did not hold, and the staff providing care was not using a gait belt in preparation for transferring the resident from the shower chair to her wheel chair. An interview was conducted on April 26, 2012, with staff #3, the staff showering the resident on July 26, 2011. Staff #3 stated that the resident attempted to stand up from the shower chair and the brakes were not working and the shower chair slipped away and the resident sat on the floor. Staff #3 stated she was getting ready to transfer the resident from the shower chair to her wheel chair. Staff #3 stated that she had checked the brakes prior to transferring the resident but could not remember if she had applied a gait belt to transfer the resident. Interviews were conducted with various direct care staff who stated that part of preparing a resident for bathing/showering staff are to check the shower chairs for any damage and check the brakes to ensure they are functioning. The staff further stated that faulty equipment is removed from the resident care area and reported to maintenance staff. An interview was conducted on April 26, 2012, with a maintenance staff who stated he remembered the incident on July 26, 2011, with resident #8. The maintenance staff stated that after the fall, he was notified and found the shower chair to be cracked and the brakes were not holding correctly. He stated the shower chair was discarded as un-repairable. The maintenance staff stated that random inspections were done of the shower rooms, but no documentation was provided to show evidence that shower chairs were inspected by anyone other than CNAs when showering residents. An interview was conducted on April 26, 2012, with the nurse who was the Director of Nursing (DON) at the time of the resident's fall. The DON stated that staff were to use gait belts, at all times, when transferring a resident, including in the shower rooms. A review of the policy for staff assistance when bathing a resident documented that staff are to make sure the wheels on the shower/bath chair are lock and the chair is steady to prevent the resident from falling. The facility policy on gait belt use documented that gait belts were to assist staff safely transfer residents. -Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a closed clinical record for resident #10 revealed the following: The physician admission orders [REDACTED]. Review of the admission fall risk evaluation revealed a total score of 24. A score of 10 or higher indicated that the resident was high risk for falls. The interim care plan, dated August 28, 2011, revealed she was a fall risk. The interventions to be used were the assistance of one person for ambulation and transfers. Chair and bed alarms were to be used and be audible to staff. Review of the Falls Reduction Checklist dated August 28, 2011, revealed that the resident was to have a "low bed with side mat." Review of the residents five day MDS assessment dated [DATE], documented the resident's functional status for eating was limited assistance with one person physical assist. The Care Area Assessment (CAA) triggered ADL function and the area was care planned. Review of the nursing notes of September 2, 2011, revealed that at 6:00 PM the resident was found on the floor, on the right side of her bed, on her left side, the bed alarm was sounding, and she was verbally responsive. She was assessed to have a bump to her right forehead, her nose was "gash" with blue coloring, bruising, they was a "gash" to her upper lip, and a skin tear to her left above the ace wrap to her left foot. The nursing progress notes further revealed that the resident had stated she had tried to reach her dinner tray and was not able to reach it, so she reached for a chair next to her bed and fell over the edge onto her face. The physician ordered her to the emergency room for CAT scan. Further review of the nursing notes from August 28 through September 2, 2011, revealed no documentation that the floor mats had been in place on each side of the bed. The review failed to revealed that if the bed was in the lowest position when the resident fell over the edge and no documented evidence that the floor mats had been in use at the time of the fall. Review of the facility incident report failed to document the position of the bed and failed to document that the mats were at the sides of the residents' bed when the resident fell over the edge of the bed landing on her face. An interview was conducted by telephone on April 26, 2011, at 1:45 PM, with the LPN, stated that she was the nurse who responded to the bed alarm and found the resident on the floor. However, she was not able to remember if the bed was in the lowest position, nor could she remember if the floor mats were in place. She further stated she did not know if the resident was reaching for a wheelchair or a regular chair next to her bed. However, she did state that the over the bed table was in place over the resident's bed and her dinner tray on the table. An interview was conducted on April 26, at 2:30 p.m., with the CNA who on September 2, 2011, had worked the 2 PM to 10:00 PM shift and cared for the resident. Staff stated that when she sets a resident up for meals in their room she always puts the head of the bed up 90 degrees, she raises the entire bed to provide room for the over the bed tray table to fit. She further stated that was the way she always set the residents up for meals in their rooms. The CNA further stated she encourages the resident to eat their meals in the dinning room to ensure the resident's safety, they require cueing and/or physical assistance of one person. When the resident required the assistance of one person physical assist the CNA staff were to remain with the resident to ensure assistance and safety. Review of the facilities Fall Management policy documented fall risk factors that have cognitive impairment, environmental factors such as bedroom hazards and life style factors such as needing assistance with ADL are significant fall risk factors.

Based on clinical record review, staff interviews, review of hospital records, and review of facility policies, the facility failed to provide the necessary care and treatment and as a result two residents (#s 22 and 23) developed pressure ulcers. Specifically the facility failed to adequately assess, monitor, document interventions, alter treatment, and implement policies and procedures for one resident (#22) and as a result this resident developed a Stage II pressure ulcer on her heal and a Stage IV decubitus ulcer on her coccyx. The sample size was 24. Findings include: The facility failed to adequately assess, provide preventative skin care, monitor for changes or improvement, or alter treatment for [REDACTED]. The resident was admitted to the hospital in which during her 16 day stay, she required surgical intervention four times for the debridement of the ulcer. Specific findings are as follows: -Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed that upon admission the nurse documented "reddened bottom" on the resident's admission assessment. No preventative skin treatments were documented as initiated. There was no documentation that the physician was notified and treatment was obtained. The pressure ulcer prevention checklist for this resident indicated that the interventions ordered, on the date of admission, were a nutritional assessment-dietary consult, weekly skin integrity assessment check form, and physical, occupational and speech therapies consults. The resident's interim care plan, dated January 31, 2009, the day of admission, revealed the resident was at risk for a break in skin integrity due to immobility and pain. Interventions indicated at the time were weekly skin checks. There was no documentation on the care plan that identified the reddened area or additional interventions to address the skin issue. Documentation on February 2, 2009, revealed the resident was seen by the wound nurse for a skin assessment. The documentation revealed the resident was continent, repositioned herself, and had a reddened area on her coccyx and buttocks with intact skin. There were no measurements of the area. There were no additional interventions added to address the reddened area. There was no documentation that the resident was educated on turning and repositioning to reduce further harm to this area. However on a weekly skin integrity data collection form also dated February 2, revealed a Stage II pressure area on coccyx. The form indicated this was a new condition. No wound description or measurements were taken of the wound. No pressure ulcer status record was initiated on this same date. There was no reason documented regarding the discrepancy made by the two nurses' assessments of the coccyx area on February 2. Again, no treatments were initiated for the area and there was no documentation that the physician was notified. Also on February 2, 2009, the nutrition data collection assessment form indicated the resident's skin was intact, and that the resident had a Braden score of 15, which identified that the resident was at risk for the development of pressure ulcers. On February 6, 2009, a preventative mattress/overlay for pressure reduction was ordered. The resident's 5-day Minimum Data Set (MDS) assessment, completed on February 7, 2009, revealed the resident had desensitized skin to pain or pressure, had no skin ulcers, and had no behaviors. On February 8, 2009, the clinical record documented that a certified nursing assistant (CNA) asked to have a nurse look at the resident's sacral area. There was no documented evidence in the clinical record regarding the condition of the resident's skin; instead, there were physician orders written for a wound care team evaluation, an air mattress, new wheelchair cushion, to prop a pillow to lower back to decrease pressure to sacral area, and turn the resident every two hours to keep pressure from lower back. There were still no orders for wound care. On February 9, 2009, the wound team documented that the resident's contributing factor to the development of the pressure ulcer was the resident's reluctance to move and reposition even though there was no prior documented evidence that demonstrated the resident was noncompliant with care. The pressure ulcer was described in the documentation as a 7 by 4 centimeters (cm) erythremic area ulcer to the coccyx. Documentation revealed the ulcer to be unstageable with 40 percent necrotic tissue that required debridement. treatment of [REDACTED]." Repositioning frequently was also ordered. The resident's comprehensive care plan, dated February 9, 2009, revealed the coccyx ulcer to be unstageable and measured 7 by 4 cm. The resident's admission MDS assessment dated [DATE], documented that the resident required the assistance of one for bed mobility, was able to make her own needs known to staff, and had no behavioral problems. The MDS documented that the resident's skin was desensitized to pain and pressure and was documented to have a Stage II and Stage IV pressure ulcers. Section V. of the Resident Assessment Protocol of the MDS triggered for pressure ulcers and directed the nursing staff to care plan accordingly. There was no evidence that the care plan was updated to reflect the identified concern of pressure ulcers. physician progress notes [REDACTED]. Nurses' notes, dated February 11, 2009, revealed the resident's coccyx wound was unchanged and the resident had also developed a blister on her right heel. There was no documentation of the size, color or appearance of the blister. The blister was swabbed with iodine and cover with ABD pad and wrapped with rolled gauze. There was no documentation that the physician was notified. No orders for treatment were written. The treatment of [REDACTED]. There was no indication where the treatment was to be used on the body. The resident's comprehensive care plan was updated on February 11, 2009, to reflect the right heel blister as a Stage II pressure ulcer. The care plan for pressure ulcers was revised with a list of interventions for the unstageable coccyx pressure ulcer on February 12, 2009. One if the interventions was "'report any decline in wound status to physician." The pressure ulcer care plan was not updated again during the resident's admission. A review of the treatment activity record (TAR) revealed the treatment for [REDACTED]. Further review of the TAR revealed, on February 11, the treatment to the coccyx ulcer was not signed off as completed for the 6 a.m. to 2 p.m. shift and was circled on the 10 p.m. to 6 a.m. shift on the same date. There was no documentation of why the treatment was not recorded as completed on either shift. On February 13, 2009, the wound team documented a 5 cm by 5 cm Stage II pressure ulcer on the resident's right heel. There was no documentation by the wound team concerning the status of the coccyx wound on February 13. There was no documentation of physician notification of the development of the blister or of the lack of improvement in the coccyx ulcer prior to the February 13. physician progress notes [REDACTED].?" coccyx ulcer only. February 12 physician progress notes [REDACTED]. Documentation throughout the nurses' notes and therapy documentation revealed the resident was alert and oriented and was very motivated to progress to independence in order to be discharged home. The nursing notes, dated February 13, documented the patient was alert and oriented, up in wheelchair and was "repositioning frequently and keeping track on notebook." Documentation on the facility's weekly pressure ulcer record, dated February 13, revealed the resident was discussed as "reluctant to reposition." There was no explanation of the discrepancy in charting the resident's willingness or ability to change positions. The resident's interim care plan was updated on February 13, to reflect the resident had a break in skin integrity. There was no documentation prior to February 13 in the care plan of the coccyx wound or heel breakdown that the resident experienced. Goals and interventions added on the 13th were not completed on the form. The form directs the nurse to circle of the interventions implemented of the following: pressure reduction mattress/overlay/speciality bed/seat cushion. None were circled. One goal checked for the resident was "Wound to heal from Stage ____ to Stage ____" within 21 days. The form was not completed in order to assist staff in recognizing expected healing or deterioration. Physician notes, dated February 14 and 15 2009, did not indicate the presence of the pressure ulcers. On February 16, the Pressure Ulcer Status Record revealed the coccyx wound measured 7 by 7 cm. The color was identified as black necrotic tissue. The response to treatment was identified as "deteriorated." The form had an area to enter the date the physician was notified. A line was drawn through the area with no date listed. The nurse practitioner ordered [MEDICATION NAME] 875 milligrams (mg) to be given every 12 hours for 10 days, for [MEDICATION NAME] decubitus/infection on February 16, 2009. Nurses' notes, dated February 17 at 2:00 p.m., revealed that the resident was alert and oriented and changed positions frequently. Physician notes dated February 17 revealed the nurse practitioner documented that the resident developed a Stage II pressure ulcer on the sacrum during her stay, due to her refusals to turn and stay off her back. The wound was described with eschar remaining, beefy red wound bed in spots. There was no documentation of the resident's heel blister. The physician progress notes [REDACTED]. A physician's order, dated February 20, 2009, ordered a First Step mattress for pressure relief for two unstageable ulcers, one on coccyx and one to right heel. Nurse's notes, dated February 21 at 5:15 p.m., revealed the dressing had been changed four times since morning. The wound was now draining foul smelling pus like drainage of approximately "a couple of teaspoons." Tunneling under the skin was noted to be approximately three inches up toward the resident's head, two to three inches on the left side of the coccyx, two inches upward and one inch sideways on the right side of the coccyx. The nurse also noted that large tissue sections looked as if they could sluff off. The physician was contacted and ordered a STAT surgical consult for the coccyx wound. At 1:45 a.m. on February 22, a nurse's note documented the resident had had a temperature of 100.7 at 12:30 a.m. and was medicated with 1000 mg of Tylenol but the temperature remained at 100.7 degrees 45 minutes later. The resident and the resident's medical power of attorney requested the resident be sent to the hospital. The documentation indicated the physician was called and ordered to have the resident transported to the hospital. A review of the treatment activity record (TAR) revealed the treatment for [REDACTED]. A review of the hospital records revealed the resident was seen in the emergency department, presented with a fever, and complaints of pain in her buttock from a worsening ulcer in the past two weeks, and pain on her right fool that increased with palpation of the blister. Upon examination, the sacral decubitus ulcer was identified as Stage IV, and measured approximately 10 cm by 7 cm with purulent material, surrounding redness, warmth to touch and seemed to track deep into the skin. The right heel was identified to have a Stage I pressure ulcer. The resident was admitted to the hospital. Upon admission, an in depth physical examination was completed along with a computerized tomography scan. The physicians identified a multi-organism infection of a Stage IV pressure ulcer, with tracking from the wound to the bone. Osteo[DIAGNOSES REDACTED], or infection of the bone was also diagnosed . Wound cultures were done which showed a mixed infection of aerobic bacteria well as anaerobic organisms. An infectious disease consult was obtained for the resident. The consulting physician concurred with surgical debridement of the wound as well as the [DIAGNOSES REDACTED]. The resident underwent [REDACTED]. The second debridement surgery, done on February 25, 2009, found the wound again measured approximately 12 cm by 12 cm, and remained full thickness with bone exposed. The third surgery for [REDACTED]. A wound vac to assist with healing was placed on during the surgery. On March 6, 2009, the resident was again taken to surgery for [REDACTED]. The physician documented that once the wound "superficialized," the resident may be a candidate for primary closure versus split-thickness skin graft. The resident was discharged on [DATE], after a 16 day hospitalization . An interview was conducted with a licensed professional nurse (LPN) on March 3, 2010. The LPN had worked on the unit, but did not remember the resident. The LPN stated that a Braden scale was completed on admission to the facility to evaluate each resident's risk for developing pressure ulcers. In addition the LPN stated that a full skin assessment was to be completed on each resident at the time of admission. Residents were then assigned, by room number, a day of the week for weekly skin checks. The residents were also to have a skin assessment completed by the wound care nurse within a few days of admission. An interview was conducted with the assistant director of nursing (ADON) on the unit on March 3, 2010. The ADON was not employed by the facility at the time of the resident's stay, but stated that the Braden scale was to be done on admission and also a head to toe skin assessment by the admitting nurse, to ensure the staff was aware of what the resident's skin condition was like at the time of admission. The ADON stated that if a resident was found, on admission, to have a skin issue such as redness, the nurse could write an order for [REDACTED]. The ADON stated that nurses could suggest treatment to the physician if the nurse so chooses. An interview was conducted with the director of nursing (DON) on March 4, 2010. The DON was not employed at the facility at the time of the resident's stay. The DON stated that she was unable to speak for the staff actions prior to four months ago, when she began her employment. The DON stated that if a resident had redness on the buttocks on admission, treatment should have been started immediately, as per the policy of the facility. If the wound progressed as fast as this resident's clinical record indicated, the DON stated that she would have contacted the physician concerning an order for [REDACTED]. After reviewing the resident's clinical record, the DON stated that there were no obvious documented reasons why the skin redness was not addressed. The DON stated that if the ulcer did not show signs of improvement after the first few days of treatment, or further disintegration, the physician should have been notified immediately. The DON stated the treatment should have been re-evaluated and possibly changed. The DON stated that she would have also discussed with the physician a wound clinic or specialist referral for the resident. The facility was unable to provide documentation of consistent turning and repositioning for the resident at any point in her stay. -Resident #23 was admitted to the facility on [DATE], and readmitted on [DATE]. The admission nursing assessment dated [DATE], revealed that the resident had a pressure sore to the right heel. Written next to right heel was "1" (inch)." Admission physician orders dated December 8, 2009, failed to include any wound care or treatment orders for the heel pressure ulcer. A physician's telephone order dated December 8, 2009, ordered an air mattress to the bed to prevent breakdown. On December 9, 2009, a physician telephone order for Replicare to the right heel every three days and heel cushions was received. A Venous Arterial/Stasis Ulcer Record dated December 10, 2009, was located in the clinical record. The location was right heel, it documented a Stage II that was 2.0 cm by 2.0 cm with 0.1 cm depth. This was documented as the "initial." The treatment to the right heel was changed on December 10, 2009, to Allevyn non-adhesive, wrap with Kerlix, and change every three days and as needed. The treatment record revealed the treatment was completed on December 12, 2009. A skin assessment was blocked off to be completed on the treatment record on December 14, 2009. However, this assessment was not completed. The resident was discharged to the hospital and returned back to the facility on [DATE]. The admission nursing assessment dated [DATE], revealed the resident had a pressure sore, but the form did not indicate the location. On the picture of the body, an "X" was marked on the right heel and right shin. Review of admission physician orders dated December 18, 200,9 revealed an order for [REDACTED]. Review of the treatment record for the month of December 2009 revealed the physician ordered treatment for [REDACTED]. The [MEDICATION NAME] was applied to the heel every three days, instead of the sacrum per the order, except the treatment was not initialed on December 24, 2009, when it was blocked off to be done. A weekly skin integrity data collection form dated December 25, 2009 had an X in the "other" box. documented next to that was 2 abdominal openings, right leg opening, and right heel opening. A weekly skin integrity data collection form dated December 28 had an "X" in the boxes for "other, redness, open area, and new." written in was right ulcer, abdominal wounds, old scabs, right buttock, right lower extremity skin tear. The body had "X's" and circles on the right heel, the abdomen, the peri area, the right foot, and the right buttock. A telephone physician's order dated December 30, 2009, ordered to discontinue the [MEDICATION NAME] to the sacrum wound and apply EPC (protective cream) to buttocks and coccyx every shift and as need. Also an air mattress for the bed was ordered and to float the resident's heels. A comprehensive care plan dated December 30, 2009 revealed a problem of stage II pressure ulcer to the right heel. Approaches included to float heels, air mattress to the bed, measure weekly, and administer treatment per physician orders. Review of the recapitulation of physician orders for January 2010 revealed a new order of SSD (silver sulfadene) cream to open blister on right buttocks, change twice daily and cover with [MEDICATION NAME] and tape. Written next to the order was December 30, 2009 as being the original date of the order. Review of January 2010 treatment record revealed no treatment of [REDACTED]. However, it was not completed on January 2 and 3, 2010 on the evening shift. A weekly skin integrity data collection form dated January 5, 2010 had x's on the body on the right heel "X's" with ulcer written next to it, on the buttock were three "X's", and there were "X's" on the abdomen, peri area, and right foot. None of the weekly skin integrity sheets had measurements or explanation of the wounds. A physician's telephone order was obtained on January 6, 2010, ordered to discontinue SSD cream to buttocks. Pressure Ulcer Status Records dated January 6, 2010, were located in the clinical record for the right buttock identified as a Stage II with measurements of 0.5 cm by 0.5 cm. Another form for the inner buttock documented the pressure wound as a Stage II with measurements of 0.2 cm by 0.5 cm. Another form for the left buttock documented the pressure wound as a Stage II with measurements of 0.5 cm by 1.0 cm. There were still no measurement for the right heel wound. The clinical record was inconsistent with orders, treatments, and measurements for the resident's right heel wound and sacrum wounds. An interview was conducted with administrative staff on March 5, 2010 at 8:30 a.m. She stated the treatment and measurements were inconsistent. She was unable to find any measurements for the heel wound and the sacrum wound until January 6, 2010, the day before the resident discharged . Review of facility policy documented, "Skin integrity assessments are performed weekly by nurses on all residents paying particular attention to all pressure points. The Weekly Skin Integrity Data Collection Form is used. Treatment is initiated immediately." "Summary Details of a Pressure Sore Prevention Program" was also provided by the facility. The summary revealed "1. do an assessment for risk of skin breakdown on admission and quarterly.-Medical Assessment -Braden Scale 2. Implement prevention protocol determined on the Pressure Ulcer Prevention Checklist 3. Include the resident on the Pressure Area High Risk Listing in the nursing station...5. Provide adequate skin cleansing, moisturizing and protection. 6. Avoid pressure with systematic turn and position schedule and pressure relieving or distribution devices for support surfaces...Alter treatment and intervention as required." Review of facility policy entitled "treatment of [REDACTED]."

Based on clinical record reviews, closed clinical record reviews, staff, physician, and pharmacist interviews, observations, review of facility investigations, review of hospital records, and a review of facility policies and procedures, the facility failed to provide assistive devices (foot pedals) for a wheelchair for one resident (#29) during transport which resulted in a fracture that required surgical intervention. The facility failed to provide adequate interventions, carry out fall interventions, and follow a plan of care to prevent falls for two residents (#s 10 and 18), failed to properly transfer two residents (#s 17 and 23) that required the use of a mechanical lift in which one resident (#23) sustained a skin tear. The facility also failed to secure one container of cleaning solution. The sample size was 24. Findings include: -Resident #29 was admitted to the facility on [DATE], and discharged to the hospital for an evaluation of a right distal femur fracture on August 14, 2009. The resident was readmitted to the facility on [DATE], after a surgical repair of the fracture that was completed at the hospital. Other [DIAGNOSES REDACTED]. Review of a comprehensive plan of care dated December 15, 2008, documented a problem of impaired mobility. Approaches or interventions included, "Evaluate the use of assistive devices for positioning. Assist with positioning, transfers, ambulation as necessary or as requested by resident. Allow resident opportunity to perform task themselves prior to offering assistance." Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had short-term memory problems and was moderately impaired for daily decision making. The resident also required cues and supervision and was assessed to be totally dependent on two people for transfers. Communication was assessed as sometimes being understood and usually understands others. Review of nurse's notes contained multiple Weekly Summaries. Review of the weekly summaries dated April 8 through August 12, 2009, revealed that the resident was aphasic and propelled his wheelchair independently. A nurse's note dated August 14 at 4:45 p.m. revealed the following, "Writer pushing resident in his W/C (wheelchair) to take him to his room for meds (medication) - resident c (with) legs straight out in front of him - resident hollers and writer noted R (right) leg up under the W/C - moved leg out from under W/C - resident c/o (complained of) pain R knee - call to (name of nurse practitioner) - new order for x-ray of R knee - call to (name of family member) to inform him of pain in R knee..." A physician's order was obtained on August 14 to x-ray the right knee. A telephone physician's order was given to transport the resident to the emergency room for a right distal femoral fracture. An x-ray report dated August 14 documented, "DISTAL FEMORAL METAPHYSEAL FRACTURE. status [REDACTED]. Review of a hospital history and physical dated August 15 revealed the presenting complaint as, "pain and swelling of the right knee." The report also documented that supracondylar corrective surgery was performed which was open reduction internal fixation (ORIF) of the right distal femur periprosthetic fracture. The report also included that an intramedullary rod was placed by the orthopedic surgeon. Also, the resident subsequently developed a fever of unknown origin postoperatively. Review of the facility's investigation dated August 18 revealed that the RN (registered nurse/staff #3) pushed the resident back to his room to do his fasting blood sugar when his leg dropped and he hollered. The RN was suspended due to "neglect to ensure that resident had leg rest in place on wheelchair." It also revealed that the facility conducted inservices for nursing and therapy staff on August 16 and 17, 2009, on adaptive equipment and assistive devices only and failed to address the need to allow residents to self propel who are able to or not to assist residents for the convenience of staff. The resident returned to the facility on [DATE]. [DIAGNOSES REDACTED]. An interview was conducted on March 4, 2009 at 1:00 p.m., with staff #3 whom had pushed the resident in the wheelchair on August 14, 2009. She stated that the resident normally self propelled his wheelchair with his feet and never had foot rests on his chair. The RN stated he did not require foot rests because he would not be able to propel himself independently if he had them. The RN stated that she recalled the event on August 14 and stated she was "in a hurry" to get her blood glucose checks completed and pass her medications so she could get back to the dining room. She stated that she had pushed the resident in his wheelchair everyday since she did not have the time for the resident to propel himself to his room. She stated he always had held his feet up in the air while she pushed him, even though he had right sided weakness. The RN stated on August 14, the resident was toward the back of the dining room and therefore she had to push him further and weave in and out of tables with him which was probably what caused his leg to drop. It was during this same interview, the RN was asked to explain why she had pushed the resident instead of allowing him to self propel per his normal. She reiterated that she pushed him back to his room "to get it done faster because she was trying to get meds and blood sugars done." She then stated that the incident was "not a matter of using equipment, just I was in a hurry." Then she finally stated that now when she observes staff pushing residents down the hall in a hurry without leg rests, she tells them to slow down. Another interview was conducted with an LPN (licensed practical nurse) on March 4, 2010. She stated that residents who self propel themselves in the wheelchair and used their feet do not have foot rests in their rooms. She stated that foot rests were available in central supply. An interview was conducted with the administrator on March 4, 2010 at 1:20 p.m. He stated foot rests were available in central supply. He stated staff knew where to go to get the foot rests. He further indicated that the incident had occurred with resident #29 due to a lack of knowledge of adaptive equipment, not necessarily staff convenience. -Resident #10 was admitted to the facility on [DATE], and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an annual MDS assessment dated [DATE], revealed the resident was independent with transfers and bed mobility. A care plan with an original date of April 9, 2009, revealed the resident had the potential for falls and interventions included to use a wheelchair for long distances, to remind resident to use brakes, encourage the resident to use assistive device when ambulating, ensure proper footwear, maintain environment free of clutter, place items within reach, and provide adequate lighting. This care plan was not updated on readmission, August 8, 2009, with new interventions after the Fall Risk assessment was completed. Review of a Fall Risk assessment dated [DATE], revealed the resident had a score of 24. The form indicated that a score of 10 or higher was "at risk" for falls. The directions at the top of the form included, "When resident's total score is 10 or more, interventions should promptly be put in place." On the back of the form were instructions to document interventions on the back of the form and on the resident's care plan. There were no interventions documented on the Fall Risk form per the instructions for August 9, 2009. A nurse's note dated August 11, 2009 at 10:30 a.m. revealed the resident was leaning forward in her wheelchair and fell out. The fall was witnessed and there was no injury. There was a new intervention added to the care plan for a therapy screen. This intervention was also added to the Fall Risk form, as well as an intervention for a tab alarm. The therapy screen was not located in the clinical record. A nurse's note dated August 17, 2009, documented that the resident continued to remove the tab alarm. On October 7, 2009 at 6:00 a.m., a nurse's note documented that the resident was found on the floor scooting with pants down and her wheelchair was found in the bathroom. The nurse's notes and investigation failed to include if the resident's tab alarm sounded when the fall occurred. The intervention documented on the Fall Risk was a urinalysis. The care plan was updated with interventions of urinalysis and therapy screen. The therapy screen was not located in the clinical record again. The urinalysis results were noted to be negative. Written on the care plan was to discontinue the tab alarm due to the resident removed it. However, this was undated and written above the October 7, 2009, interventions. There were no physician orders found in the clinical record for the tab alarm, the initiation or the discontinuation. There was no further documentation in the nurse's notes that included the resident either had a tab alarm or even removed the tab alarm from August 17 through October 7, 2009. On November 1, 2009 at 11:05 p.m., a nurse's note documented that the resident was found on the floor in the hallway with wheelchair tipped over. There was no documented injury and no mention of the tab alarm. The intervention on the Fall Risk form was a therapy screen, again. The care plan also had the intervention of therapy screen updated on November 2, 2009. A therapy screen was not found in the clinical record. The facility investigation for the November 1, 2009, incident included follow-up documentation dated November 16, 2009, for a "drop seat" for the wheelchair. A nurse's note dated November 15, 2009 at 11:20 a.m., revealed the resident had a witnessed fall without injury in the hallway. The note did not mention the tab alarm. There were no new interventions documented on the Fall Risk form. The nurses's notes documented that a urinalysis was collected. The care plan and Fall Risk were not updated with any interventions. The facility investigation for the November 15 incident documented an intervention of a urinalysis. This urinalysis was again negative. On November 17, 2009 at 10:55 p.m., a nurse's note documented the resident was found on the floor in her room in front of her closet and was incontinent. The nurse's note failed to mention the tab alarm, if it was on or if it sounded. The intervention documented on the Fall Risk form for November 17 was a tab alarm, which was previously discontinued on the care plan because the resident removed it. On November 17 the care plan was updated with a new intervention of low bed and tab alarm. The facility investigation for the November 17 revealed a follow up dated December 4, 2009, to discontinue the alarms due to resident removes and destroys it, "placed on frequent monitoring." A nurse's note date November 18, 2009 at 1:00 a.m. and 5:00 a.m., documented the bed alarm was in place and "bed low." On November 18, 2009 at 11:30 a.m., a nurse's note documented the resident was found in her room on the floor next to the bed and wheelchair. The note also documented the bed alarm sounded. The note included that no injuries were noted and a tab alarm was placed on the wheelchair and a landing strip was placed next to the resident's bed. The Fall Risk was updated with an intervention of a landing strip. The care plan was updated as well with the intervention of a landing strip. The facility investigation included interventions of landing strip, tab alarm to bed and wheelchair, and that a therapy screen was done. However, the therapy assessment was not located in the clinical record. A nurse's note on November 20, 2009, documented that the resident transferred self in and out of bed and takes off alarm. A note dated November 25, 2009 at 11:30 p.m. documented that the resident had another fall. She was found in her room on the floor with her right arm twisted backwards pinned against the wall behind her. The note documented the resident complained of pain and her right arm, shoulder, and elbow were "very weak" and slightly swollen. The note included that that "no w/c (wheelchair) alarm in place." It did not document if a bed alarm sounded, and did document "bed low," but failed to document if a low bed was in place per the previous intervention. The Fall Risk assessment and care plans included a new intervention of "sensor" alarm to bed and wheelchair. The facility investigation for the November 25, 2009, incident included interventions of an x-ray and tab alarm was changed to sensor alarm. It also included a therapy screen again. A physician's order was noted on November 26, 2009, for an x-ray to the resident's right elbow, shoulder, and humerus. The x-ray of the shoulder dated November 26, 2009, showed an impression of "POSSIBLE NON DISPLACED FRACTURE OF THE SCAPULA THE HUMERAL HEAD AND NECK APPEAR INTACT." A physician's order dated November 26, 2009, included a sling to the right should to be place on in the morning and off at bedtime. A nurse's note on November 26, 2009, documented that the resident removed tab and sensor alarms and needed verbal reminders to leave in place. A therapy screen dated November 26 was located in the clinical record. The results and recommendations included, "alarms, mat and call bell in place. Staff to continue to monitor safety." A nurse's note dated November 27 documented that the resident was found with the sensor alarm in pieces in the toilet and the resident was sitting on the toilet. An interdisciplinary note dated November 27 documented that alarms were to be removed from the wheelchair and "do frequent monitoring." A care plan intervention was added on November 27 for "frequent monitoring." There was no definition for "frequent." Visual Check Flow Sheets were located in the clinical record, the first one was completed on November 27, 2009. However, from 7:45 p.m. to 12:45 a.m. there was no evidence that the resident was checked. On November 28, 2009, there was no documented evidence on the flow sheet that the resident was check from midnight to 5:45 a.m. A November 30, 2009 nurse's note documented, "30 minute checks continue on resident..." December 1, 2009 at 3:30 a.m., a nurse's note documented that the bed sensor alarm was found on an empty bed in the room and a tab alarm was placed on the resident. The note documented the resident took off the tab alarm and threw it. A physician's order dated December 2, 2009 for an Xray follow up of the right shoulder. The results of the Xray were, "NO ACUTE FRACTURE NOTED." Multiple Visual Check Flow Sheets from December 2 through 22, 2009 were either missing or incomplete. There was multiple days with no evidence that "frequent" or 30 minute monitoring was conducted for the resident's safety. Review of a quarterly MDS assessment dated [DATE], assessed the resident to have moderately impaired decision making, communication was assessed as usually understood and always understands. Bed mobility and transfers were assessed to require limited assistance of one person. Accidents were documented as fell in the past 30 days, fell in the past 31-180 days, and other fracture in last 180 days. A nurse's note dated December 22, 2009 at 9:40 p.m. documented the resident was found on the floor in another resident's room with her left leg folded under her. There was no new intervention added on the Fall Risk, it documented "Resident has "landing strip" placed along side bed. Refuses sensor or tab alarms. Resident on every 30 minute checks." There were no new interventions or any updates to the fall care plan related to this fall. The facility investigation for the above incident included a recommendation again of a therapy screen. A therapy screen dated December 24, 2009 was located in the clinical record. The recommendation/result was, "...alarms are in place but she removes them. Continue to monitor resident. No other recommendations at this time. Nursing checking her at 30 minute intervals." Visual Check Flow Sheets for December 24, 25, 28, and 29, 2009, were incomplete and failed to document 30 minute checks. Checks for December 26 and 27 were not located in the clinical record. On December 30, 2009 at 1:00 a.m., the resident was found on the floor in her room leaned against her bed. The nurse's note documented that the bed alarm was sounding. It also documented that "30 minute visual checks continue." There was no new interventions added to the Fall Risk or the care plan for the above incident. The facility investigation form for the incident included a recommendation of another therapy screen. There was no evidence in the clinical record of the therapy screen for this incident. Visual Check Flow Sheets for January 1, 2, 3, 4, 7, and 8, 2010, were again not documented every 30 minutes and were incomplete. An interdisciplinary note dated January 8, 2010, documented that the resident had no further falls and interventions remain in place. The Fall Risk intervention was updated with, "Resident has landing strip next to bed, low bed, sensor alarm on bed, on 30 minute checks, refuses tab alarm, does not seek assistance..." And again, therapy screen. A low bed had been documented on interventions, however the nurse's notes did not indicate the resident had a low bed. The nurse's notes document, "bed low." Visual Check Flow Sheets for January 9, 10, and 11, 2010, were again not documented every 30 minutes and were incomplete. The resident was found on the floor again on January 13, 2010 at 12:30 p.m. between the beds in her room. The nurse's note documented the resident was attempted to go to the bathroom. Her left wrist was noted to be red and she complained of pain. An x-ray as performed of her hand and wrist, which was negative. The Fall Risk intervention was medication review and restorative nursing program. The care plan was also updated with an intervention of restorative nursing. A therapy screen was completed on January 13, 2010. The recommendations were, "Safety measures in place - no further recommendations at this time." The Visual Check Flow Sheet for documentation of 30 minute checks on January 13, 2010, was blank from 6:15 a.m. to 1:45 p.m. There was no evidence that the 30 minute checks were completed. The resident had the fall at 12:30 p.m. Again, Visual Check Flow Sheets for January 16, 17, 20, 21, 23, 24, 25, 26, 27, 28, 29, 30, 31, 2010 and February 1, 3, 4 and 5, 2010, were not documented every 30 minutes and were incomplete. On February 5, 2010 at 10:30 p.m., the resident was again found on the floor. She was found in her room next to the bed with urine on the floor per the nurse's note. The facility investigation included recommendation of a medication review and continue other interventions. There was no evidence that the medication review had been completed per the prior Fall Risk intervention on January 13, 2010. On February 8, 2010 the Fall Risk had a new intervention of medication review, the care plan was updated with the same intervention as well. A therapy screen dated February 8, 2010 documented recommendations of, "...resident on restorative program - nursing are reviewing resident's meds (medications)." The nurse's notes documented a witnessed fall on February 9, 2010 at 12:30 a.m., the resident fell forward out of her wheelchair. The Fall Risk was updated for a medication review to be completed and a urinalysis, which was negative. The Fall Risk had an intervention added on February 11, 2010, for the consultant pharmacist to do review (of medications) on next visit. Visual Check Flow Sheets for February 6 through 24, 2010, were again not documented every 30 minutes and were incomplete. Observations conducted throughout each day of the survey of the resident from March 2 through 5, 2010, revealed the resident did not have a low bed. The bed was observed in the lowest position, but was not a low bed. The resident was not observed to have an alarm on her wheelchair, a sensor alarm was observed on her bed. An interview was conducted with the Director of Nursing (DON) on March 3, 2010 at 10:30 a.m. She stated that falls were tracked in the interdisciplinary team meetings, but they did not talk about medications or restraints related to falls. She stated that the fall interventions have been "very cookie cutter" and the team has "tried working harder since January to think outside the box." She stated a toileting schedule had never been implemented for the resident, but "could be done." She stated she was unsure why the "intensive" medication review had not been done per the documented interventions, but the facility "could only do our part." She then stated the pharmacist would come do the medication review tomorrow. An interview was conducted with a LPN on March 3, 2010. She stated the resident's restlessness and frustration lead to her falls. She stated 90 percent of her restlessness related to her inability to communicate. She stated that the resident never had a low bed. She stated the 30 minute checks stopped "awhile" ago and was unsure exactly when. An interview was conducted with a certified nursing assistant (CNA) on March 3, 2010 at 1:30 p.m., she stated the resident used to have a toileting schedule but she did not presently have one. She stated most of her falls were at night or early morning when she tried to go to the bathroom. She stated that 30 minute checks had not been done "for awhile" on the resident. An interview was conducted with a LPN supervisor on March 3, 2010 at 2:00 p.m. She stated the resident sometimes needed assistance to transfer and was sometimes independent, she stated the resident was non compliant. She stated a toileting schedule has not ever been attempted for the resident. She stated she should still be on "frequent monitoring" and stated she was aware it was not being done all the time. An interview was conducted with an LPN on March 4, 2010 at 3:30 p.m., she stated the resident had not been on 30 minute checks since February 24, 2010. She was unsure why the checks had stopped. An interview was conducted with a Pharmacist on March 4, 2010. He stated that the facility first contacted the pharmacy on March 3, 2009, for an intensive medication review and it was done "offsite." He stated there were no results of the review. He stated he was currently conducting a medication review to rule out medications being a factor in the resident's falls. -Resident #18 was admitted to the facility February 4, 2010, with [DIAGNOSES REDACTED]. An interim care plan dated February 4, 2009, documented that the resident was considered a high fall risk due to recent falls and was non-compliant with safety instructions. The interventions identified documented that the resident required one to two staff members for ambulation. The care plan also documented to have a low bed and to have a bed alarm in place. A review of the resident's clinical record revealed in the nursing notes dated February 8, 2009, that the resident was found face down on the floor. The resident denied hitting his head. In this same entry the CNA stated that the resident was found earlier to have his bed in the highest position and the CNA lowered for the resident. The entry documented that the guardian of the resident was notified and the guardian stated that when she spoke with the resident earlier, the resident sounded "very out of it". The resident was sent to the ER due to an increase in confusion. There was no documented evidence in the clinical record that the resident's bed alarm was in place prior to this fall or if the resident's bed was in the lowest position. There was no documented evidence that neurological checks were initiated by licensed staff. On February 8, 2009, the facility completed a discharge summary that documented that the resident underwent [REDACTED]. The facility's incident follow up and recommendation form also did not have documented evidence that the resident's bed alarm was in place prior to this fall or if the resident's bed was in the lowest position. A review of the hospital's admission history and physical statement dated February 9, 2010, revealed the following information, a scan obtained in the emergency room showed acute or chronic subdural hematoma. The history and physical stated that the resident "...was brought to the emergency room from his nursing home as he was noted to have a change in his mental status. He had become aggressive which is not normal for him. He was found face down on the floor having party slipped out of the bed, hitting his head. As per his guardian, she claims that yesterday he was unresponsive and his eyes rolled up. Later on he slipped out of bed and was lying on the floor and his guardian requested that the patient be transfered to the emergency room ..." An interview with a LPN conducted on March 4, 2010, revealed that neurological checks were to be documented when a resident sustained [REDACTED]. An interview with the assistant director of nursing (ADON) revealed a 72 hour alert was initiated immediately when a resident falls. During that 72 hour period the nursing staff was to document on the Neurological Assessment Flow Sheet neurological assessment starting at fifteen minute intervals as well as the resident's vital signs. The DON was unable to find any documentation that the neurological assessment/72 hour alert had been initiated after the resident fell . A review of the facility policy regarding Neurological Assessment revealed the following, The Neurological Assessment Flow Sheet shall be initiated by a written physician's order for neurological checks or when indicated by a resident (e.g., head injury, post fall, neurological decompensation). -Resident #23 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A weekly care management review note dated December 22, 2009, documented that the resident was transferred with the use of a mechanical lift. Review of nurse's notes dated December 28, 2009, documented that the resident received a five centimeter skin tear to the side and back of the right calf while being transferred with a mechanical lift. The note also documented, "...being lowered c (with) Hoyer (brand of mechanical lift) leg rest from W/C could have scraped pts (patients) LE (lower extremity)." The note also documented that treatment orders were obtained from the nurse practitioner and steri-strips were applied. A facility investigation dated December 28, 2009 revealed that the resident was being transferred from the bed to the wheelchair with mechanical lift and two person assistance. It documented that the resident hit her leg on the wheelchair and sustained a skin tear to the right posterior lower extremity, steri strips and a pressure dressing were applied. The recommendations were to use three person assistance with the mechanical lift for the resident. Review of the initial MDS dated [DATE], assessment revealed the resident required two plus person assistance and was totally dependent for transfers and bed mobility. A care plan was initiated on December 30, 2009, for potential of pain due to "open areas." Approaches included to medicate the resident prior to doing treatment if able. An interview was conducted on March 4, 2010, with the physical therapist who transferred the resident with the mechanical lift. She stated that herself, a physical therapy assistant, and a CNA transferred the resident with the mechanical lift. She stated the resident dropped quickly into the wheelchair which caused her leg to hit the side of the wheelchair or leg rest and cause a skin tear. The facility had no evidence of retraining staff on mechanical lifts or any inservice related to the incident. The other staff members were not interviewed, the DON and the physical therapist could not recall who was present at the time of the transfer. -Resident #17 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's significant change MDS assessment dated [DATE], revealed the resident had short term memory problems, cognitive skills for daily decision-making were moderately impaired, was totally dependant on staff for transfers, and was unable to ambulate. A review of the resident's clinical record revealed a Care Plan dated December 16, 2009, which documented "Potential for injury d/t (due to) impaired mobility-poor control over posture" as a problem. An approach documented for the problem was "Assist with all transfers using Sabina or Hoyer (mechanical lift)." A further review of the resident's clinical record revealed Nurse's Notes dated February 21, 2010, which documented "CNA reported that while transferring resident from Sabina lift to wheelchair resident lifted her arm and slid from Sabina's sling to the floor. Resident stated she hit her head with the floor. Denied pain at this time." The resident's clinical record revealed Nurse's Notes dated February 23, 2010, which documented "Therapy to screen with Sabina to see if still appropriate for Sabina transfers." The resident's clinical record revealed a Therapy Screen Form for Falls dated February 24, 2010, which documented "Observed nursing properly adhering to sling protocol; resident stable in device no ability to slide through. Possible incorrect use of sling. Staff education completed." An interview was conducted with the occupational therapist who completed the Therapy Screen on March 4, 2010. The occupational therapist stated she observed one CNA transfer the resident in the Sabina lift but was not sure if it was the CNA who transferred the resident when she fell . An interview was conducted with the CNA who transferred the resident when she fell on [DATE]. The CNA stated that she was not observed by therapy for the proper use of the Sabina lift. The CNA further stated that when the resident fell , she lifted both arms and placed them between the bars and the sling and slid to the floor. The CNA stated the resident had done this before but she had not reported it to anyone. An interview was conducted with the long term care supervisor on March 4, 2010. The long term care supervisor stated that she was not sure if the CNA who was involved when the resident fell was involved in the therapy screen on February 24, 2010. An interview was conducted with the DON on March 4, 2010. The DON stated that she did not know if the CNA who was involved when the resident fell was re-inserviced on the proper use of the Sabina lift. An interview was conducted with the administrator on March 4, 2010. The administrator stated that the facility assessed the resident for the safe use of the Sabina lift. The administrator further stated that the facility did not feel that the CNA used the Sabina lift improperly and she had used it "over and over." A review of the facility's policy Incident Management documented, "The facility identifies residents at risk for incidents and adequately plans care and implements procedures designed to reduce incident risk and minimize the potential for occurrence." Issue regarding a chemical: -On March 3, 2010, one container of cleaning solution was observed in a non secured cabinet within a shower room accessible to residents. An interview with the environmental services director revealed that the cleaning solution is to be secured in a locked cabinet within the shower room and not accessible to residents. The Material Safety Data Sheet pertaining to the clean solution revealed the following information, "...Handlin