Every finding on record at Mirabella at Asu

Based on record review, staff interviews, observation and the facility policy and procedures, the facility failed to ensure that an adequate supervision and environmental safeguards were provided to prevent elopement for a resident (#105). The deficient practice placed the resident at risk for serious injury, exposure to traffic injury, abduction and death.Findings Include:Resident #105 was admitted to the facility on [DATE], and discharged on October 29, 2025 with diagnosis that included seizures, depression, anxiety, unspecified dementia without behavioral disturbance, and difficulty in walking.The progress note dated October 17, 2025 at 11:28 pm stated under Mood and Behavior that it was unknown if resident slept through the night and also stated that the resident wandered at night.Another progress note dated October 18, 2025 at 1:14 pm stated that the resident was impulsive and is wandering.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #105 had a Brief Interview for Mental Status (BIMS) score of 11, indicating intact cognition. Further, review of MDS revealed that Resident #105 did not exhibit any behavior.A care plan dated October 26, 2025, revealed that Resident #105 was at risk for wandering and elopement.A progress note dated October 26, 2025, revealed that around 3 a.m., resident was found exiting the facility. Per note, staff assessed the resident and returned resident to his floor by a wheelchair. Per note, no falls or injuries were noted and resident seemed very confused but pleasant. Per note, Resident #105 stated to staff that he had business to take care of when attempting to leave. Director of nursing (DON), medical director (MD), and family were notified and the resident room was changed closer to nurse station.An incident report dated October 26, 2025, revealed that Resident #105 exited the emergency exit by his room and was found wandering outside of the facility on the facility grounds. The report stated resident was alert and oriented X1, confused and looking for a store. Resident #105 was assessed and no injuries were observed.A wandering risk assessment dated [DATE], revealed that resident had a score of 10.0 and at a moderate risk for wandering.During record review, an elopement/wandering risk assessment dated [DATE] was provided by the facility. No elopement/wandering risk assessment completed prior to the incident was available for review.A facility reportable event record report submitted to the State Agency on October 26, 2025, at 9:30p.m., revealed that Resident #105 had no prior history of elopement or behavioral disturbance per medical record review and family report. The report further revealed that on October 26, 2025, at approximately 1:45 a.m., Resident #105 approached the nurse' station and stated that he wanted to go out to the store and to the bar. Staff provided redirection and assisted him back to bed. During routine care/safety rounds approximately 2:45 a.m., staff discovered that Resident #105 was not in his assigned room. A facility-wide search was initiated immediately. At approximately 3:10 a.m. Resident #105 was found outside the facility near the main entrance, walking toward a nearby convenience store. When approached, Resident #105 stated that he just wanted to go to the store to buy a couple of things and wanted to go to the bar. Two staff members safely redirected him and transported Resident #105 back to his room via a wheelchair. Resident was then assessed, placed on one-on-one observation, physician/family/administrator were notified. Resident#105 room was moved to the room closer to the nurses station. A skilled evaluation dated October 28, 2025, revealed that patient was moved to another room due to elopement risk and certified nursing assistant was assigned for 1 on 1 care.An interview was conducted on November 14, 2025, at 12:10 p.m. with a Certified Nursing Assistant (CNA, staff #15) who stated that on October 25, 2025 night shift, during her rounds, staff # 15 observed that Resident #105 was in his room during each of the following checks: - 8 p.m., 10 p.m., 12 a.m. Then at approximately 1:30 a.m., Resident #105 came to nurse station holding his wallet and stated that he was trying to find the main entrance to leave the building. Staff #15 then redirected Resident #105 to his room, assisted him to bed, and stated that he then he went back to sleep. At around 2 a.m., while conducting another round, she stated that CNA (staff#12) entered Resident #105's room and discovered that he was not there. Staff #12 then informed Staff #15 that Resident #105 was missing. Staff #15 stated that she then went to the other unit to request assistance. She stated that the Licensed Practical Nurse (LPN, staff #25) was not on the floor at that moment, so Staff #15 sought for help from CNA (Staff#40) from other unit. Since Resident #105 room was located near the stairwell, staff #15 immediately checked both flights of stairs and existed through the side door, calling out the name of Resident #105 name multiple times. Staff #15 then proceeded around to the front of facility, where Staff #15 encountered Staff #28. Staff #15 then described Resident #105 and staff #28 confirmed that he had just seen Resident #105 walking towards CVS in front of the Omni Hotel. Resident #105 was observed attempting to cross the street. Staff #15 then called out the name of Resident #105 name and quickly approached him. Upon contact, Resident #105 appeared confused and stated that he was going out for a beer because he had just gotten a divorce. Staff #15 stated that she informed Resident #105 that he was at facility and that staff #15 and staff #28 would assist him back to his room safely. Then with the help of staff #28, staff #15 obtained a wheelchair and escorted Resident #105 back upstairs. Staff #15 then notified LPN #25 in the hallway of the incident and explained what had occurred. She stated that Resident #105 remained calm and sat with staff #15 in the second-floor living area until the end of the shift. Staff #15 then stated that residents in facility did not have access to the elevator and needed a security code (FOB) to go in and out of elevator. Staff #15 then stated that there is also an emergencyexit through stairs which had a push bar to open the door and an alarm would turn on as the door was opened. CNA (staff #15) also stated that when someone tried to open the emergency exit door then an alarm would turn on. Staff #15 then stated that maintenance also notified all staff that if emergency exit door were not latched properly then the door would not shut properly. Staff #15 stated that this may have facilitated the elopement of Resident #105. Staff #15 also stated that risk associated with resident's elopement would be falls, getting hit by car, or the resident missing.An interview was conducted on November 14, 2025, at 12:15 p.m. with a Licensed Practical Nurse (LPN, staff #25) who stated that she was an agency staff. Staff #25 then stated that she did not recall the exact date but she recalled about the incident regarding Resident #105. Per staff #25, on October 26, 2025, she was not on the floor and was on a break when she got a call from facility that she needed to return to the facility. LPN then stated that in the main lobby in first floor she encountered Resident #105 in his wheelchair with staff #28. Staff #25 then directed resident to the second floor. Resident #105 was then assessed for injury, and was put on one on one with staff #15. LPN then stated that residents in the facility did not have access to elevator and can go in and out of the building with either CNA or nurse or family member. Staff #25 also stated that she did not have idea that there was another exit door down the hallway by the resident's room and how it worked. Staff #25 further stated that risk associated with resident elopement would be injury or hit by car.An interview was conducted on November 14, 2025 at 1:10 p.m., with the administrator (staff #30) who stated that interdisciplinary team (IDT) make determination which resident and when a resident can go in and out of the facility. Staff #30 then stated that the facility is skilled nursing and did not have a secured unit and if a resident wanted to go out then that's resident's right but the facility advises residents to check with nurses for their safety. Staff #30 then stated that residents did not have access to the elevator and needed a security code (FOB) to go in and out of elevator. Staff #30 further stated that facility does have emergency exit door which was not advice to use for regular access. Staff #30 also stated that there is a sign that stated Push until alarm sounds, and door will open in 15 second, Access to floors 1 and 2 only and when the emergency door opens then an alarm will sound. Staff #30 then stated that Resident #105 did not have any history of elopement in the past and after the incident happened, x-ray was done on Resident #105 for any injury, facture or dislocation of bone. Staff #30 also stated that after the elopement incident, all residents were assessed and no residents were identified at elopement risk. Staff #30 further stated that risk associated if resident elopes would be getting hurt or feeling dehydrated.An interview was conducted on November 14, 2025 at 1:43 p.m., with the director of facility services (staff #35) who stated that there are four stairway emergency exit door in building which lock from the outside and go from second floor to the loading dock on ground floor of south side of building. Staff #35 further stated that door has local alarm and alarm goes off from the moment alarm was touched and then hold the door for fifteen second before the door open. Staff #35 then stated that door alarm is pretty loud but if a staff is in resident room then it may not be heard. Staff #35 also stated that if a resident is able to come out of second floor emergency exit then there are no other alarms in either first or ground floor and resident can easily go out of the building by pushing the door bar.An observation was made on November 14, 2025 around 2pm with Staff #35 of emergency exit door(EED) located near the room where Resident #105 was initially before the elopement on October 26, 2025. During the observation, staff #35 pushed the push bar of EED and an alarm started beeping for approximately 15 seconds and then the door got unlocked without the requirement of FOB or card access. After the door opened, it was also observed that there was continuous flight of stairs which went from second floor to loading dock on ground floor of south side of building.Review of the facility's policy titled Elopement and Hazardous Wandering, reviewed on November 2025, revealed that all residents will be assessed for risk of elopement through the pre-admission and/or admission process. The facility will put measures in place to minimize the risk of elopement that are individualized to resident needs. When an elopement occurs, immediate efforts to locate the resident will be taken. All occurrences will be documented and all follow-up required by State and Federal regulations will occur.

Number of residents sampled: 9Number of residents cited: 2Based on clinical record reviews, staff interviews, and review of facility policy, the facility failed to ensure that a current copy of the advance directives were in the clinical record for 2 of 9 sampled residents (#31 and #4) residents. The deficient practice could result in resident wishes not respected and followed. -Resident #31 was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, Parkinson's disease, hypertensive chronic kidney disease, Stage 3 chronic kidney disease and depression.The portable medical order signed by resident #31 and dated [DATE] included that the resident had a code status of no CPR (cardiopulmonary resuscitation) and no artificial means of nutrition desired.The hospital discharge summary report dated [DATE] revealed the resident had an advance directive, had no preexisting DNR/DNI (Do Not Intubate) directives and a copy was not in the resident's chart.The clinical admission note dated [DATE] revealed the resident followed commands, was oriented to person and place, was experiencing signs of short-term memory loss and had mild cognitive impairment. The documentation also included that the resident had a pleasant mood, had no unwanted behaviors witnessed, had insomnia and did not wander at night.An alert charting dated [DATE] included that the resident was transferred from the hospital and was admitted at the facility for therapy s/p (status post) right femur fracture.A physician order dated [DATE] included for an advance directives of DNR.The alert charting dated [DATE] revealed the resident was alert and oriented to self and place and was noted to be confused at times through the night.The physiatry progress note dated [DATE] included the resident was alert and oriented x 1-2, forgetful and had a good mood. Assessment included deconditioning, gait instability, right femur fracture, cognitive impairment and ground level fall.The activities care plan dated [DATE] revealed the resident was alert and oriented. The encounter note dated [DATE] included that the resident's code status was DNR and no CPR.The face sheet of the the clinical record revealed that the resident had a code status of DNR (Do Not Resuscitate).However, further review of the clinical record revealed no evidence that a current copy of the Do Not Resuscitate (DNR) advance directive had been signed by the resident since her admission to the facility on [DATE].-Resident #4 was admitted on [DATE] with diagnoses of mechanical complications of other prosthetic devices, Parkinson's disease without dyskinesia and benign prostatic hyperplasia (BPH) without lower urinary tract symptoms.The alert charting dated [DATE] revealed the resident was alerted and oriented x 3. The clinical admission note dated [DATE] included that the resident was oriented to person and place, makes self understood and understands others. The orange Prehospital Medical Care Directive (Do Not Resuscitate) form dated [DATE], was signed by the resident's Power of Attorney (POA). However, the following required sections were left blank: Signature of the doctor or other healthcare provider and date; and, Signature of a witness and date. Further review of the form revealed that the name of the resident's POA was written in the section designated for the resident's name.The encounter note dated [DATE] revealed current code status of DNR; and that, there was a POLST (Physician Orders for Life-Sustaining Treatment) form or POLST-like form in the electronic medical record documenting resident preferences. An undated pink portable medical order form included no CPR, do not attempt to resuscitate and comfort-focused treatments were marked. This form was signed by the resident's POA (Power of Attorney). However, the required section on Health Care Provider was not signed and dated. During an interview conducted on [DATE], at 3:07 p.m., Certified Nurse Assistant (CNA/staff #48) stated that a resident's code status was typically documented in the clinical record and on the Kardex. She said that code status was also discussed during shift change when staff exchange information. The CNA stated that it would be difficult to remember every resident's code status without checking the clinical record. She stated that if she found a resident unresponsive and was unsure of their code status, she would call out for a nurse or ask someone to get the nurse immediately.In an interview with a Registered Nurse (RN/staff #47) on [DATE], at 4:07 p.m., the RN stated that advance directives must be obtained from the resident or their Power of Attorney (POA) upon admission, even if the resident had a previous admission with advance directives already on file. He said that it was important to obtain new directives at each admission, as the resident's wishes may have changed depending on their current medical condition. He also stated that advance directives must be signed by both the resident or POA and the provider; and, if either signature was missing, the form was considered incomplete and not valid.An interview conducted on [DATE], at 9:57 a.m., Licensed Practical Nurse (LPN/staff #11) who stated that upon a resident's admission, she obtains information about the resident's code status. She said that if the resident is a Do Not Resuscitate (DNR), a form must be signed by the resident or their representative and then submitted to the provider for signature. She further stated that until the provider signs the form, the resident was considered full code. The LPN also stated that residents' code statuses were discussed daily during staff huddles to ensure all staff are aware of each resident's current status.During an interview with the Director of Nursing (DON) on [DATE], at 10:24 a.m., she stated that upon a resident's admission, staff were expected to have the resident or their Power of Attorney (POA) sign an advance directives form to indicate whether the resident is a full code or Do Not Resuscitate (DNR). She stated that the provider must also sign the form; and, until both the resident/POA and the provider have signed the DNR form, the resident was considered full code. Regarding residents #4 and #31, the DON stated that she will review the clinical records and ensure that advance directives forms were signed and completed.In a later interview with the Director of Nursing (DON) on [DATE], at approximately 10:45 a.m., the DON stated that both the pink and orange advance directive forms for Resident #4 were signed by the resident's Power of Attorney (POA) but had not been signed by the provider. She also stated that she would obtain a current advance directive for Resident #31.Review of the facility policy on Advance Directives revised on [DATE] revealed that it is their policy to inform and educate residents and or responsible party of their right to make health care decisions on admission and periodically. During orientation, administrative staff will discuss the legal requirements necessary for residents to complete an Advance Directive. Upon admission, the social services director or facility designee will meet with the resident or the resident's legal representative (if resident is determined as unable to make relevant health care decisions). During this meeting, documents will be reviewed in accordance with the Resident's Rights Policy and Procedure. The social services director or designee will then ask the resident or the resident's legal representative whether the resident has completed an Advance Directive or POLST, and if not, whether the resident wishes to formulate an Advance Directive. If a resident has completed an updated Advance Directive or POLST, the Social Services Director or designee will document this in the Advance Directive section of the medical record and include a copy of the Advance Directive as well. In the absence of an Advanced Directive or POLST or in the absence of a physician order consistent with the resident's wishes, the facility will proceed with full code measures.

Based on clinical record review, staff interviews and review of facility policy and procedures, the facility failed to ensure that the attending physician documented acknowledgement of their monthly Medication Regimen Review recommendations for three of five sampled residents ( #8, #10 #15). The deficient practice could result in regulatory recommendations provided by a licensed pharmacy not being considered during treatment of the residents. Findings Include: - Regarding Resident #8 Resident # 8 was admitted on [DATE] with diagnoses to include repeated falls, acute embolism malnutrition, anxiety and depression. The residents MDS (Minimum Data Set) dated August, 2025 revealed a BIMS (Brief Interview for Mental Status of 12, indicating that the resident had moderate cognitive impairment. The resident's care plan initiated on July 24, 2025 revealed the resident was at risk for falls, high risk medications were in use and anticoagulants prescribed. On July 29, 2025 Amiodarone HCL 200 Milligram, 2 tablets two times daily via G -Tube was ordered. On July 29,2025 Apixaban Oral 5 Milligram,1 tablet two times daily via G-Tube was ordered. Review of the medication administration record for August revealed that the medication was administered as ordered. The medical record included the Consultant Pharmacist Medication Regimen Review (MRR) dated July 25, 2025. The recommendation was to review the resident's dose of Amiodarone as it was considered in the high range for the elderly. A review and clarification were requested. The MRR further revealed a concern regarding a significant interaction between Amiodarone and Apixaban. The document revealed that a dose adjustment or more frequent monitoring may be necessary. No evidence of a documented reply was found in the resident's clinical record. - Regarding Resident #10 Resident # 10 was admitted on [DATE] with diagnoses to include non-displaced fracture of the fifth metacarpal bone, left hand, falls, mood disorder and cerebral infarction. The residents MDS (Minimum Data Set) dated July 22, 2025 revealed a BIMS (Brief Interview for Mental Status of 14, indicating that the resident was cognitively intact. The resident's care plan initiated on January 13, 2025 revealed that the resident was prescribed high risk medications. On February 27, 2025 Buspirone 5 milligram by mouth two times daily was ordered. On February 19, 2025 Citalopram Hydrobromide 40 milligram one time daily was ordered. On February 27, 2025 Duloxetine HCL 30 milligram delayed release sprinkles one capsule in the morning was ordered. Review of the medication administration record for August revealed that the medication was administered as ordered. The medical record included the Consultant Pharmacist Medication Regimen Review dated July 17, 2025. The recommendation was to review the resident to determine if a gradual dose reduction for Buspirone, Citalopram and Duloxetine was appropriate, the document revealed a request for the provider to document his/her decision. No evidence of a documented reply was found in the resident's clinical record. -Regarding Resident #15 Resident #15 was admitted to the facility on [DATE] with diagnoses that included displaced fracture of lateral malleolus of left fibula, unspecified sequelae of cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of the admission MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 15, which indicated the resident was cognitively intact. High-Risk Drug Classes, Section N – Medications revealed, resident #15 was taking antidepressant and anticoagulant at the time of the assessment. Review of the electronic medical records (EMR) revealed the active psychotropic medication order: Fluoxetine Hydrochloride Oral Tablet 60 Milligram (Fluoxetine HCl) give 1 tablet by mouth one time a day for depression. Review of the Consultant Pharmacist's Medication Regimen Review (MRR) revealed documented recommendations for Resident #10 by the Pharmacist/Staff #100 reported July 17, 2025. Documentation recommendations included routings for medical doctor (Staff #100) which included: This residents stay is approaching or has reached the 30-day point. Please determine if a gradual dose reduction (GDR) or discontinuation of any of this resident's psychotropic medication fluoxetine can be attempted (unless contraindicated). Please, make any notes below. Thank you. Follow-through note written to physician. Despite documentation indicating, please, make any notes below; follow-through note written to physician no acknowledgement was documented for this recommendation by Medical Doctor/Staff #105. An interview was conducted on August 7, 2025 at 1:38 PM with Director of Nursing (DON/Staff #33) who stated that any recommendations that the Pharmacy sends she gives them to the provider for review. Staff #33 stated that usually the pharmacy reviews are done for either the new admissions or as needed. Staff #33 stated that the recommendations are printed once they are available in the pharmacy website; but that, she has to keep logging in to check for incoming recommendations. Staff #33 stated that the facility presently has one provider for all the residents. Staff #33 stated that the provider reviews the recommendation and staff carry out whatever the provider orders or recommends; and that, the notes are done on the recommendation when they are carried out. Staff #33 stated that there was a recent change in provider and were still adjusting with the way the pharmacy reviews are done because the providers were new. Staff #33 reviewed the EMR for any uploaded documented recommendation acknowledgements by the provider, however she did not find any documents at that time. A phone interview was conducted August 7, 2025 at 2:09 PM with Nurse Practitioner/Staff #110 alongside the DON. Staff #110 confirmed that she worked in collaboration with the attending Medical Doctor (Staff #105) at the facility. Staff #110 stated that the medical doctor and her had received a stack of pharmacy recommendation reports on August 4, 2025 and was not sure when she was supposed to be doing that. Staff #110 stated usually checks her bin and the medical doctor (Staff #105) and stated that the medical doctor nor she had done any monthly medication reviews prior to Monday (August 4, 2025). Staff #110 stated that the risks of not review recommendations depend on the recommendation and was unsure since she was only given the documents recently on Monday. Staff #110 confirmed that she had not reviewed any MRR for Resident #15. After the phone interview, Staff #33 reiterated that the risk of not reviewing the pharmacy recommendations would depend on the recommendations. Staff #33 stated that the facility expectations were that if the pharmacy makes recommendation the physician or provider should review them. Further review of pharmacy recommendations reports was conducted alongside the DON which revealed many provider notes were unavailable after the month of May 2025. Staff #33 stated that the facility had a large turn over in June 2025; and that, the provider changes happened so the providers were getting adjusted; and that, this was when the lag time occurred due to change of new provider. Staff #33 admitted that last week, I forgot to hand it to her. Another interview was conducted on August 7, 2025 at 4:25 p.m. with the Director of Nursing (DON)/Staff #33 who stated that she received an email from the provider today regarding the MRR; and that, the provider stated that they just reviewed the MRR today. The DON stated that this does not meet her expectations. The facility is currently working on coordinating better with Pharmacy and the Provider. The DON stated she would provide a copy of the email from the provider. Review of the facility policy titled, Medication Management: General (revised 2017) revealed, it is the policy that the residents' medications are managed in accordance with the state/federal regulations and facility standards; the consultant pharmacist will review each resident's medication regimen at least once a month; the pharmacy medication review recommendation will be acted upon in a timely manner.

Number of residents sampled: 16Number of residents cited: 0The facility failed to ensure that all food in the nourishment refrigerator was labeled according to facility policy. Findings include: During the initial observation of the nourishment refrigerator conducted on August 5, 2025 at 11:46 a.m., the following items were found to be stored with no resident name, room number and no open or received date.- 1 Yogurt Parfait- 1 cup containing an unidentified white liquid- 1 carton Protein drink- 1 pink thermos containing an unknown substanceAt the time of the observation certified nursing assistant (CNA) / staff #21 was asked to confirm that the names and dates were absent on these items. Staff #21 confirmed the information and stated the items would be discarded immediately.During the follow up observation of the nourishment refrigerator at 2:12p.m. on August 7, 2025 a tan grocery bag with unidentified food items was discovered. No labels or dates were visible on the bag or food items. When the bag was removed from the refrigerator Registered Nurse (RN) /staff # 47 stated that the bag was his lunch. He further stated that the refrigerator was for resident food and staff food should not be stored in that location.An interview with Nutritional Services Manager/ Staff #49 was conducted on August 7,2025 at 9:26 a.m. She stated that the residents were served snacks upon request. The snacks were stored in the kitchen and staff retrieve them as needed. She further stated that the nourishment refrigerator was the responsibility of the nursing staff.An interview with Licensed Practical Nurse (LPN)/ staff # 2 was conducted on August 7,2025 at 2:04 p.m. Staff # 2 stated that if a resident had food that he or she wishes to be stored in the refrigerator, nursing staff would put the resident name, room number and open date in a visible location and would place it in the nourishment refrigerator. All food must be labeled and discarded within 72 hours of the open date. An interview with the Director of Nursing (DON)/Staff #33 was conducted on August 7,2025 at 2:26 p.m. The DON stated that any food brought in or stored in the resident's nourishment refrigerator must dated and labeled with the resident's name and room number. She stated that this refrigerator was the responsibility of the nursing staff and they were to check for labeling, including name, room number, open and expiration dates. She further stated that this refrigerator was only to be used for resident food, and staff food should not be stored in this location. The DON stated that the findings did not meet her expectations and this practice could cause the residents to become ill from foodborne illness.The facility policy Dietary Services: Food brought into Facility by Family/Visitors (7/2025) revealed that the facility will ensure all items from an outside source will be covered, labeled with the resident's name and room number and dated. The food is to be easily distinguishable from facility food. The policy further revealed that outside food stored in the refrigerator must be discarded 3 days after the date brought in. All food or beverages not properly labelled must be discarded.

Number of residents sampled: 5Number of residents cited:Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure that signs were posted related to enhanced barrier precautions (EBP) for two residents (#12 and #31) of 5 sampled residents. The deficient practice could result in transmission of infections to staff and other residents. Findings include: -Resident #4 was admitted on [DATE] with diagnoses of mechanical complications of other prosthetic devices, Parkinson's disease without dyskinesia and benign prostatic hyperplasia (BPH) without lower urinary tract symptoms. The alert charting dated June 26, 2025 included that the resident was alert and oriented x 3 and had a foley catheter 16Fr in place which was draining well. The clinical admission note dated June 26, 2025 revealed the resident had an intact, patent catheter in place due to urinary retention. The physician order dated June 26, 2025 included to provide urinary catheter care every shift for preventative care/hygiene. The daily skilled note dated June 28, 2025 included resident had an indwelling urinary catheter/Foley catheter. An encounter note dated June 29, 2025 included indwelling catheter was in place with clear yellow urine. Diagnoses included BPH without lower urinary tract symptoms. Plan was to continue to monitor the indwelling urinary catheter. The order note dated June 29, 2025 revealed that the provider was notified regarding foley catheter being dislodged and was changed; and that, the resident had an appointment on July 7, 2025 for suprapubic catheter placement. The discharge instruction form dated July 7, 2025 revealed that the resident had a suprapubic catheter placement. A physician order dated July 7, 2025 included for the following:-Suprapubic catheter care output every shift; and,-Check leg bag and that bag is not changeable and can only be changed by urology. The daily skilled note dated July 8, 2025 included that the resident had an external urinary catheter and had suprapubic insertion with a leg bag. The physiatry progress notes dated July 21 and July 28, 2025 revealed that the resident had suprapubic catheter in place. The daily skilled note dated August 4, 2025 included the resident had an external urinary catheter. During observations conducted on August 4, 2025 at 9:10 a.m., there was a blue drape with pockets that contained PPE (Personal protective equipment) such as gloves and gowns which was hanging by the resident room door. There was no signs related to what type of precautions was posted. In an interview with a certified nurse assistant (CNA/staff #41) conducted on August 4, 2025 at 9:44 a.m., the CNA stated that resident #4 was on EBP (enhanced barrier precautions) because the resident had an indwelling catheter. She stated that a staff/visitor need to wear gown and gloves if they are entering the resident room and will be touching the resident or providing direct care. Multiple random observations was conducted on August 4 at 11:50 a.m., August 5 at 8:10 a.m. and 9:52 a.m., August 6 at 9:27 a.m. and August 7, 2025 at 11:09 a.m. revealed that resident #4 continued on EBP. However, there were no EBP signs posted/found. An observation of the room of resident #4 was conducted on August 7, 2025 at 12:05 p.m. with the registry nurse (staff #2) and the RN (staff #47) who both stated that there was no signs/posting found. The registry nurse (staff #2) stated that resident #4 was on EBP because of an indwelling catheter and there should be a sign regarding EBP posted with the blue drapes. The RN (staff #47) stated that there was no reason shy the resident's room did not have any signs on EBP posted. -Resident #31 was admitted on [DATE] with diagnosis of displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing. The skin check dated August 1, 2025 revealed that the resident had staples and surgical dressing on the front right trochanter. The physician order dated August 2, 2025 included for EBP every shift for wounds. An observation was conducted on August 4, 2025 at 8:10 a.m. The was a yellow drape with pockets that contained PPE was hanging on door to the room of resident #31. There was no signs posted regarding instructions and the type of precautions the resident had. In an interview conducted with a registered nurse (RN/Staff #10) on August 4, 2025 at 8:14 a.m., the RN stated that resident #31 was on EBP because of the surgical wound. She stated that PPE should be donned before entering the room if a staff/visitor would be touching the resident or provide direct care to the resident; and that, staff/visitor do not need to don PPE if they are just going to talk with resident #31. The nurse pointed to the yellow drape hanging on the door but did not notice the lack of signage/posting. An interview was conducted with a registry nurse (staff #2) on August 7, 2025 at 12:05 p.m. The registry nurse stated that the blue or yellow drapes containing PPE hanging over/on the resident room doors indicated that the residents were in some king of precautions. She stated that there should be signs posted at the door to inform visitors/staff or any individual who wish to enter the room; and that, this posting will tell the individual to go see the nurse who will then instruct the individual on what to put on before entering the resident room and any other instructions that the individual need to know to be inside the resident room. At 12:09 p.m., a registered nurse (RN/staff #47) joined the interview and confirmed what the registry nurse had stated regarding posting/signage. During an interview conducted with a CNA (staff #48 on August 7, 2025 at 3:07 p.m., the CNA stated that the color of the drape containing PPE hanging on the resident's room door tell staff what type of precautions the resident has. She stated that if the drape is colored blue, it indicated that the resident was on EBP for either presence of a foley catheter or a PICC (peripherally inserted central catheter) line; and if the drape is colored yellow, the resident was on contact precautions. An interview with a licensed practical nurse (LPN/staff #11) was conducted on August 8, 2025 at 9:57 a.m. The LPN stated that the blue and yellow drape with pockets and containing PPE that was hanging over a resident room door indicated that the resident was on some kind of precaution. She stated that if the resident had an indwelling catheter or PICC lines, the drape would be blue for EBP; and, if the resident was on contact precautions such as C-diff infections, the drape would be yellow. She stated that any individual (staff/visitor) who will be touching the resident such as staff providing direct care of visitors hugging the resident, would have to wear a gown and gloves on before entering the resident on EBP. The LPN said that each room that was on any type of precautions such as EBP should have signs posted as to what type the precautions the resident has and to don the required PPE before entering the resident room. Further, the LPN stated that there should always be a sign posted on the resident room door for residents on precautions; and, if there was not any signs posted, this meant that the facility may have ran out of available signs to post. During an interview with the Director of Nursing (DON) conducted on August 8, 2025 at 10:24 a.m., the DON stated that the facility knows type of infection the resident has prior to the resident being admitted at the facility. She stated that when the resident was admitted , staff will ensure that the right precautions was followed. She said that on a daily basis, the nurses including herself conduct daily rounds and check for availability of the PPE, ensuring that there is adequate PPE and ensuring that staff/visitor were following the precautions in place. The DON further stated that there should be signs posted as to the type of precautions and what PPE was to be used to enter the resident room on any type of precautions. Regarding resident #4, the DON stated that she was made aware that the room did not have signs posted yesterday. She stated that she and the nurses conducted rounds and she did not know why she and her staff missed resident #4 having no signs posted. The facility policy on Infection Control Precautions - Categories of Transmission Based Precautions revised on July 2025 revealed that standard precautions shall be used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-Based precautions are the second tier of basic infection control and are to be used in addition to standard precautions for patients who may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission. EBP are recommended for residents known to be colonized or infected with MDRO (multidrug resistant organism) as well as those (who meet criteria) at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). Standard precautions still apply while using EBP. A sign will be used to alert staff of the implementation of EBP or ESP (enhanced standard precautions), while respecting the resident's privacy. Place a sign at the doorway instructing visitors to report to the nurses' station before entering the room. The policy also included the use of CDC (Centers for Disease Control) sign and/or other measures to alert staff of the implementation of transmission-based precautions, while respecting the privacy of the resident. In the SNF (skilled nursing facility) setting, place a Contact precautions sign on the doorway of the resident. Duration of signage shall be for the duration of the illness.

Number of residents sampled: 5Number of residents cited: 1 Based on clinical record review, staff interviews and review of facility policy and procedures, the facility failed to ensure there was adequate indication for the use of an antipsychotic for one of 5 sampled residents (#31). The deficient practice could result in resident receiving an unnecessary antipsychotic medication. Findings include: Resident #31 was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of the right femur, Parkinson's disease without dyskinesia, hypertensive chronic kidney disease, stage 3 chronic kidney disease and depression.The hospital Discharge summary dated [DATE] revealed the resident had depressive disorder and insomnia. Medications included Quetiapine (antipsychotic) 50 mg (milligrams) by mouth at bedtime and Quetiapine 25 mg by mouth at bedtime as needed to be combined with 50 mg dose if no success with sleeping.Further review of hospital discharge documentation revealed no evidence that resident #31 had psychotic behaviors such as hallucination and delusions.The clinical admission note dated August 1, 2025 revealed the resident followed commands, was oriented to person and place, was experiencing signs of short-term memory loss and had mild cognitive impairment. The documentation also included that the resident had a pleasant mood, had no unwanted behaviors witnessed, had insomnia and did not wander at night.An alert charting dated August 1, 2025 included that the resident was admitted for therapy s/p (status post) right femur fracture.There was no evidence found in the clinical record that an evaluation was conducted to determine that the use of Quetiapine was justified.Despite the lack of documentation of adequate indication for the use of Quetiapine, the physician order dated August 1, 2025 included for Seroquel (brand name for Quetiapine) 25 mg give 2 tablets by mouth at bedtime for insomnia and give 1 tablet by mouth every 24 hours as needed for insomnia at bedtime, to be combined with 50 mg dose if resident had no success with sleeping. It also included Quetiapine 50 mg 1 tablet by mouth at bedtime for sleep and give 0.5 tablet by mouth every 24 hours as needed for sleep to combine with scheduled 50 mg to equal 75 mg.This order was transcribed onto the MAR (medication administration record) for August 2025 and revealed that the medication was administered to resident #31 starting August 2, 2025. The documentation in the MAR revealed that the number associated with side effects related to Quetiapine was monitored and documented. However, there was no evidence found in the clinical record that the risk and benefits for the use of Quetiapine was explained to the resident or resident representative prior to the administration of Quetiapine on August 2, 2025. There was also no evidence that the target behavior for which Quetiapine was prescribed for was monitored. The baseline care plan dated August 2, 2025 did not include that the resident was taking any psychotropic or anti-psychotic medications. Interventions included to administer medications as ordered and to monitor/document for side effects and effectiveness.The alert charting dated August 2, 2025 revealed the resident was alert and oriented to self and place and was noted to be confused at times through the night.The mini nutrition note dated August 2, 2025 included the resident had severe dementia or depression and had suffered psychological stress or acute disease in the past 3 months.The physiatry progress note dated August 4, 2025 included the resident was alert and oriented x 1-2, forgetful and had a good mood. Assessment included deconditioning, gait instability, right femur fracture, cognitive impairment and ground level fall.The activities care plan dated August 4, 2025 revealed the resident was alert and oriented, friendly and seemed to appear in good spirits.The encounter note dated August 5, 2025 revealed a medication list that included Seroquel 25 mg give 2 tablets by mouth at bedtime for insomnia and give 1 tablet by mouth every 24 hours as needed for insomnia at bedtime, to be combined with 50 mg dose if resident had no success with sleeping; and, Quetiapine 50 mg 1 tablet by mouth at bedtime for sleep and give 0.5 tablet by mouth every 24 hours as needed for sleep to combine with scheduled 50 mg to equal 75 mg. Per the documentation, the resident had dementia and had past medical history of depression, dementia and Parkinson's disease; and that, the resident was frail, was in good spirits, was confused and was oriented to self only. Psychiatric examination included no current evidence of anxiety or depression. Diagnoses included Parkinson's disease and dementia in other diseases classified elsewhere without behavioral/psychotic/mood disturbance and anxiety. Plan was to continue Quetiapine.A review of the clinical record showed no evidence that the resident had psychotic behaviors such as hallucinations, delusions, or disorganized thinking or speech. There was also no documentation showing that the target behavior of insomnia Quetiapine was prescribed to treat was monitored or recorded.In an interview with a registry nurse (staff #2) conducted on August 7, 2025 at 12:05 p.m., the registry nurse stated that when a resident is admitted with or prescribed with a psychotropic medications such as Seroquel, she would obtain a consent that explains the risk and benefits for the use of the medications from the resident or resident representation prior to administering the medication to the resident. She stated that she would enter the order in the electronic record; and that, the order for the psychotropic medication such as Seroquel should have a diagnosis and target behavior that the medication was prescribed for. She stated that when the resident or resident representative consents for the psychotropic medication, she would administer the medication as ordered by the physician and would monitor and document the behavior, side effects and effectiveness of the medication.During an interview with the Director of Nursing (DON) on August 7, 2025, at 3:00 p.m., the DON stated that a signed consent for the use of psychotropic medications must be obtained from the resident or their representative before the medication is administered. She added that this consent should be documented in the electronic record. Regarding Resident #31, the DON stated she would ensure that a consent form for the administration of Seroquel was signed; and that, a new consent must be obtained with each admission and that staff cannot rely on a consent form signed during a previous admission.In an interview conducted with a registered nurse (RN/staff #47) conducted on August 7, 2025, at 4:07 p.m., the RN stated that when a resident is admitted with or prescribed a psychotropic medication, he ensures that consent is obtained and signed by the resident or their Power of Attorney (POA). He said that if the resident or POA refuses or does not sign the consent form, the medication is not administered, and the provider is notified. The RN stated that if consent was given, he enters the order into the electronic clinical record and ensures that the target behavior and the indication for the medication were documented. He further stated that Seroquel was an antipsychotic typically used to treat psychosis but acknowledged that it had also been used to help residents with sleep.An interview with Licensed Practical Nurse (LPN/staff #11) was conducted on August 8, 2025, at 9:57 a.m. The LPN stated that when a resident is prescribed an antipsychotic medication such as Seroquel, she verifies the order with the provider, informs the resident of the risks and benefits, and obtains signed consent from the resident or their representative. She explained that if consent is not obtained or the form is not signed, the medication is not given, and the provider is notified. The LPN said that once consent was obtained, she enters the order into the electronic medical record and administers the medication as prescribed. She also said that the order should include the indication for use, and after administration, she monitors for the target behavior and any side effects. Further, the LPN stated that Seroquel was an antipsychotic typically used for residents with serious mental illness (SMI) or other mental health diagnoses; and that, there were no current residents in the facility that were receiving Seroquel.During an interview with the Director of Nursing (DON) on August 8, 2025, at 10:24 a.m., she stated that when a resident was prescribed a psychotropic medication such as Seroquel, staff were required to obtain consent from the resident or their Power of Attorney (POA). She stated that the medication order must include the dose, frequency, indication, target behaviors, and possible side effects. The DON said that Seroquel is an antipsychotic typically prescribed for residents exhibiting psychotic behaviors such as hallucinations or psychosis. While reviewing the clinical record of Resident #31 with the DON, she stated that Seroquel had been prescribed to help the resident sleep. The DON further stated that Seroquel was an antipsychotic and should not be used for sleep. She also said that Resident #31 does not display psychotic behaviors, and stated that if the resident was experiencing difficulty sleeping, an appropriate alternative such as Ambien, a sedative-hypnotic, could be used instead.Review of the facility policy on Psychotropic Medications included that resident's medications are managed in accordance with the state/federal regulations and facility standards. The purpose included to ensure that resident drug regimen is free from unnecessary drugs which was any drugs when used in excessive dose (including duplicate therapy), or excessive duration, or without adequate monitoring, or without adequate indications for its use, or in the presence of adverse consequences which indicate the dose should be reduced or discontinued, or any combination of the reasons above. Adequate indications for use was defined as documented rationale for administering a medication that is based upon an assessment of the resident's conditions and therapeutic goals, and after any other treatments have been deemed clinically contraindicated. This includes medication administered is consistent with manufacturer's recommendations and/or clinical practice guidelines, standards of practice, medication references, clinical studies or evidence-based reviews. Each medication will have a diagnosis, indication for use and therapeutic goal documented in the medical record. Residents may be admitted to the facility on psychotropic medications that were started in the hospital or the community without a clear document indication for why the medication was begun or should continue. The prescribing practitioner and IDT (interdisciplinary team) should determine if the medication is justified by conducting a comprehensive medical evaluation.

Based on observations, staff interviews, record review, and policy review, the facility failed to ensure that the medication error rate was not 5% or greater for two of three residents (#37, #10). The deficient practice could result in further medication administration error.Findings include:Two medication administration errors were identified out of thirty-five opportunities during medication administration observation. The medication error rate was 5.71%.-Regarding Resident #37Resident #37 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease without dyskinesia, essential hypertension, and unspecified dementia.A medication administration observation was conducted on August 6, 2025 at 8:56 PM with Licensed Practical Nurse (LPN/Staff #11). During medication administration for Resident #37, the LPN was observed placing one Docusate 100 milligram capsule into a medicine cup. Resident was administered the medication from the cup.Review of Medication Administration Records (MAR) physician orders for the Resident #37 revealed:Docusate Sodium Oral Capsule 50 milligram; give 1 capsule by mouth two times a day to soften stool. Start date August 2, 2025 and end date August 6, 2025.An interview was conducted on August 6, 2025 at 10:52 AM with Licensed Practical Nurse (LPN/Staff #11) who confirmed that she had administered to the Resident #37 Docusate 100 milligram capsule instead of 50 milligram capsules as ordered by the provider. Staff #11 stated she should have administered half of the dose instead as ordered by the provider.-Regarding Resident #10Resident #10 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, need for assistance with personal care, and history of falling.A medication administration observation was conducted on August 6, 2025 at 9:24 PM with Registered Nurse (RN/Staff #10). During medication administration for Resident #10, the RN was observed placing two Lactobacillus Rhamnosus GG oral - 200 milligram Inulin capsules into a medicine cup. Resident was administered the medication from the cup.Review of Medication Administration Records (MAR) physician orders for the Resident #10 revealed:Lactobacillus Rhamnosus (GG) Oral Capsule; give 2 capsules by mouth one time a day for prophylaxis. Start date February 1, 2025 and date August 6, 2025.An interview was conducted on August 6, 2025 at 9:40 AM with Registered Nurse (RN/Staff #10) who confirmed that the written order from the provider did not indicate any units for Lactobacillus Rhamnosus (GG). RN stated that, I don't know why that one (order) doesn't have the units, they usually have the units thus she would ask the doctor about that.An interview was conducted on August 6, 2025 at 11:32 AM with Director of Nursing (DON/Staff #33) who stated staff should follow the 5 R's when administering medications including right medication name, dose, strength, stop date, and parameters. Staff #33 stated that if any of these variables were missing that the staff should reach out to the doctor and clarify the order. Staff #33 reviewed the active order for the Resident #37 at 11:37 AM which indicated Docusate Sodium Oral Capsule 50 milligram; give 1 capsule by mouth two times a day to soften stool. Staff #33 stated that the way the order was documented, I would give 50 milligrams. Staff #33 reviewed the active orders for the Resident #10 at 11:41 AM who confirmed that she could not see the strength in the order for Lactobacillus Rhamnosus GG. Staff #33 stated that it was the facility's expectation that any order that is unclear would have to be clarified with the physician.Review of the alert charting progress note documented by Staff #10 on August 6, 2025 at 16:00 for Resident #10 revealed, patient had order for Lactobacillus Rhamnosus (GG) oral capsule with no unit of measure listed.Review of policy titled, Medication and Treatment Administration (revised [DATE]) revealed, it is the policy that administration standards for the delivery of medication and treatments will be adhered to by all staff responsible for providing these services; medications and treatments shall be administered as prescribed; the seven rights of medication administration shall be observed: right resident, right drug, right dose, right time, right route, right manufacturer.

Based on clinical record, facility documents, staff interviews and facility policy, the facility failed to ensure that an allegation of abuse was reported to the appropriate state agencies for 3 residents (#65, #164, and #167). Findings include: -Resident #65 was admitted on [DATE] with diagnoses of Aphasia following Cerebral Infarction, and need for assistance with personal care. A Minimum Data Set (MDS) dated [DATE] included that the staff had assessed the resident as severely impaired to make decisions regarding daily life and that the resident had a memory problem An interview was conducted on 11/29/23 at 10:58 a.m. with a social services worker (staff #1) who said that he had walked into the room to ask the resident's daughter some questions and that he saw the resident's private caregiver standing next to her. This staff said that the therapist walking into the room, and that he saw the caregiver lean in and yells in the resident's face that therapy was here and when she did not respond the caregivers' response was to shake her awake. This staff said that the gut reaction was it was forceful and after that another employee asked this staff about the caregiver because she wasn't following some rules. This staff said that it clicked then that this incident was probably abusive and that he asked management to tell him what he needed to do. This staff said that management said that he should report it to Adult Protective Services (APS) and that he did. However, no evidence was provided that this allegation was reported to all the required state agencies and that a thorough investigation was completed. -Resident #164 was admitted on [DATE] with diagnoses of dementia and altered mental status. A care plan included that this resident is a wanderer and that the resident is confused and disoriented An alert note dated 7/3/2023 included that Patient was witnessed entering into another patient room. When this nurse attempted to redirect the patient, he became aggressive and refused to leave the other patient's room. He approached the other patient in bed, and wanted to hold her hand, telling her he wanted to take her to a dance. A second staff member was called into the room to assist with redirecting this patient. After several attempted, he left the room. The patient laying in bed reports being frightened and feels unsafe. However, no evidence was provided that this allegation was reported to all the required state agencies and that a thorough investigation was completed. -Resident #167 was admitted on [DATE] with diagnoses of muscle weakness and cognitive communication deficit. An Admission MDS dated [DATE] included that this resident was severely cognitively impaired and required partial to moderate assistance with toileting hygiene and bathing. A progress note dated 10/19/23 included The following report was received by Adult Protective Services Central Intake Unit: [NAME] at ASU- At approx. 12:20 PM, CNA ., ran into my office to get me to come quickly to the room of (resident #167). She stated that the (family member)was in the bathroom yelling at (resident #167). I hurriedly left my office and on my way asked . medical records, to assist me in room. Yelling could be heard down the hallway as I got closer to the room. Upon entering, I opened the door to the bathroom and found the resident on the toilet and (family member) screaming aggressively at her and pointing fingers at her face saying that she needs to get up and walk and that is what you are here for. Advised . to leave the bathroom, however, I had to physically go in between her and (resident #167) and guide (this family member) out of the bathroom. She then came out of the bathroom into the hallway of the room, but continued yelling and flailing arms. Advised (family member) that it was not appropriate to yell at (resident #167) like that, that (she) is doing the best that she can and that she is weak and in pain. (Family member) continued yelling and refused to settle down. She was then told that she would need to leave the facility and go cool off. I escorted her to the South elevators and sent her to leave building. Advised concierge to not allow her back into the building until further notice. However, no evidence was provided that this allegation was reported to all the required state agencies and that a thorough investigation was completed. An interview was conducted on 11/29/23 at 12:08 PM with the Administrator (staff #2) who said that she was unable to find documentation that the resident #65's allegation was reported to the Health Department or other required agencies other than APS or that a 5 day investigation was completed. An interview was conducted on 11/29/23 at 1:30 PM with the Director of Nursing (DON/staff#4) who said that there is no 5-day or initial report for the incident with resident #165 for 7/3 consistent with the other two reports. He states they will add it to QAPI and that his expectation is that things are reported timely per facility policy. A policy titled Abuse and Incident Reporting revised 4/20 revealed that the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, are reported appropriately and timely in accordance with Federal and State requirements.

Based on observations, clinical record reviews, facility documentation, resident and staff interviews, and policies and procedures, the facility failed to ensure that three residents (#108, #159 and #6) received the necessary services to maintain good grooming and personal hygiene. The sample size was 3. The deficient practice could result in poor hygiene for residents. Findings include: -Resident #108 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Nursing Assistant Admission Checklist dated October 3, 2022, revealed the resident preferred showers to be provided at 9:00 AM. The signature lines were blank with no evidence of a nurse signature or date. Upon obtaining a copy of the form, the RN signature had been completed and dated October 3, 2022 by staff #200. Review of a care plan dated October 5, 2022 for functional status with goal personal hygiene revealed the resident required bathing assistance of one-person assistance and preferred a shower during the day. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08, which indicated the resident had moderate cognitive impairment. The assessment also revealed the resident required physical help with one-person physical assistance with bathing. Review of the October 1, 2022 through October 12, 2022 bathing task form revealed no evidence that showers had been provided. During an interview with the resident conducted on October 10, 2022 at 10:03 AM, the resident stated he had not had a shower since being admitted . An interview was conducted on October 12, 2022 at 9:23 AM with a Registered Nurse (RN/staff #200), who stated that on admission the CNAs will complete a nursing assistant admission checklist, that reviews the resident's preferences regarding type of shower/bath, time and how often they would like to receive showers/baths. She stated she reviews the form and places that information in the clinical record, in the task section. She further stated that the facility policy is to offer showers three times a week, per the resident preference. The RN also stated that she would expect that all residents on the unit would receive a shower at least one time a week. The RN also stated that it be documented in the medical record, if the resident received the shower or refused. She reviewed the nursing assistant admission checklist and stated that the resident preferred showers at 9:00AM. She reviewed the clinical record and stated that the Task for showers had not been documented/started. The RN stated that she would expect that the resident would have received showers and it would be documented in the shower tasks if it was provided or refused. She reviewed the bath task form in the clinical record and stated that there was no evidence that the resident had received showers/baths or refused. The RN further stated that the resident had been nine days without a shower and that it did not meet the facility policy. Staff #200 stated that the second page of the nursing assistant admission checklist had no signatures but that she signed in the RN signature line and dated it October 3, 2022, after the form had been requested. She stated that this did not follow the facility policy and she would report it to the Director of Nursing (DON). An interview was conducted on October 12, 2022 at 9:50 AM with the DON (staff #39), who stated that residents get to choose how often they would like to receive showers, and that CNAs complete an admission checklist for resident preferences that includes showers. She also stated that the shower preference would then be placed in the clinical record in shower/bath tasks. She further stated that the CNAs would document in the tasks section if the shower/bath was received or refused. The DON stated that she would expect that if a resident had been in the facility for nine days there would be documentation in the shower/bath task form that the resident had received or refused showers/bathing. She stated that occupational therapy often gives showers, and that the CNAs would also document showers in tasks if provided by occupational therapy. She reviewed the medical record and stated that there is no documentation that the resident received or refused showers since admission. An interview was conducted on October 12, 2022 at 9:59 AM with the Director of Therapy (staff #201), who stated that occupational therapy will provide showers for residents. He stated that they would document in the therapy notes that are uploaded into the clinical record. He reviewed the occupational therapy notes in the clinical record and stated that one shower was provided by occupational therapy on October 7, 2022. He also stated that was the only day that occupational therapy provided showers for the resident. He also reviewed physical therapy notes and stated that there was no evidence that the resident received a shower from physical therapy. He said that typically facility staff do not wait for therapy to provide showers because it may not be on the therapy plan for the day. An interview was conducted on October 12, 2022 at 1:05 PM with the Administrator (staff #60), who stated that CNAs review the resident tasks for the shower preferences. She also stated that she expected showers/baths to be provided with a minimum of two days between showers. She also stated that CNAs should document if a shower is provided or refused in the clinical records in the shower/bath task. The Administrator stated that her expectation is for CNAs to document in the clinical record if a shower was provided or refused. Staff #60 reviewed the medical record and stated that there is no documentation of a shower being provided or refused for this resident. Staff #60 stated that the preferences were not placed in the tasks form so the CNAs would not know that a shower was due. She further stated that the resident received one shower in eleven days, and that this is not appropriate. -Resident #159 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on October 4, 2022 for functional status with goal personal hygiene revealed tasks that bathing assistance required setup and showers were the preferred bathing method. Review of the shower task form for a look back of 30 days, revealed the resident refused one shower on October 8, 2022, but there was no evidence of other showers performed or refused. The admission MDS assessment dated [DATE] revealed a BIMS score of 15 which indicated intact cognition. Further review of the assessment revealed no evidence of rejection of care, and that personal hygiene required limited assistance with one-person assistance. Review of October 2022 physician orders revealed no evidence that the resident could not be provided showers. An interview was conducted on October 11, 2022 at 3:29 PM with a Certified Nursing Assistant (CNA/staff #14), who stated that residents can have showers daily if they want. She also stated that showers are documented every shift in tasks in the clinical record. The CNA reviewed the shower tasks for the resident and stated that the resident had just received a coronary artery bypass graft (CABG) and that they were waiting for orders to shower the resident. An interview was conducted on October 13, 2022 at 9:59 AM with the DON (staff #39), who reviewed the clinical record for resident #159 and stated the bath/shower form had been marked as not applicable on multiple days, which could indicate that the resident may not have been able to be showered related to the CABG. She further stated that the resident could have been provided a bed bath and that she did not see any evidence in the medical record that the resident received or refused a bed bath. She reviewed the care plan and stated there is evidence the resident requested to be given showers and required setup. The DON also stated there is no evidence in the care plan the resident could not have received a shower. She stated that if the resident could not take a shower it should be care planned as such, and that a bed bath should be documented and be added to the plan of care. The DON stated she saw no evidence of any orders that the resident could not have a shower. She stated that this did not meet the facility expectation and the resident had not received a shower/bed bath or bath since admission, for nine days. -Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS assessment dated [DATE] which revealed a BIMS score of 12 which indicated intact cognition. Further review of the assessment revealed no rejection of care, and the resident was dependent for showers. Review of the care plan initiated on September 18, 2022 revealed that the resident preferred showers and required one-person assistance on days Tuesday, Thursday, and Saturday. Review of occupational therapy (OT) notes revealed the resident received a shower with OT on the following dates: -September 20, 2022 -September 28, 2022. Review of shower task forms for a 30-day time from September 18, 2022 through October 12, 2022 revealed evidence that showers were provided: -September 22, 2022 -Nine days later there is evidence a shower was provided on October 1, 2022. -No further evidence of a shower/bath being provided or refused from October 2, 2022 through October 13, 2022. An interview was conducted on October 13, 2022 at 9:59 AM with the DON (staff #39), who reviewed the shower task forms in the clinical record and stated that there were eight days between September 22 and October 11, 2022 that there is no evidence that the resident received or refused showers. She further stated that there is no evidence in the clinical record that showers were performed or refused from October 2 through October 13, 2022, six days. The DON stated that this did not meet the facility expectations. The DON reviewed the care plan and stated that there is evidence the resident's preferred bath days were Tuesday, Thursday and Saturday during the day. Review of the facility policy titled, Basic Resident Services, revealed the following basic services will be provided to the resident, including personal assistance and care as needed including bathing. Review of the facility policy titled, Documentation Guidelines, revealed it is the policy of the company to ensure that all documentation is accurate, truthful, timely and in keeping with state and federal guidelines and standards of practice. Documentation provides evidence of results that care was provided.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure the advance directive process was complete for one resident (#158), by failing to obtain a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could lead to medical treatment inconsistent with the resident's wishes. The findings include: Resident #158 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon initial review of the resident's clinical record, including the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On October 12, 2022 at 9:15 a.m. a written request was made for a copy of the resident's (#158) advance directive. On October 12, 2022 at 11:04 a.m. in response to the request for the resident's advance directive, the director of nursing (DON/staff #39) provided a copy of an admission packet and a resident-signed prehospital medical care directive, as part of the life care planning packet. The admission packet revealed the following advance directive communication: the facility, Will honor any advance health care directive that complies with Arizona law. Resident acknowledges that, in his/her admission packet, he/she has received a copy of the Skilled Nursing Center's policy regarding advance health care directives, the policy has been explained to him/her, and he/she understands the policy. Resident also acknowledges he/she has been provided a copy of Arizona's Life Care Planning Packet at admission. According to the DON, the missing physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Based on the prehospital medical care directive, the resident had executed a medical care directive--DNR, upon admission; however, the facility did not communicate the resident's wishes to the resident's physician at the time of admission as evidenced by a lack of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on October 12, 2022 at 11:48 a.m. with the DON (staff #39), who stated a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Furthermore, the DON stated that the prehospital DNR sheet was completed with the resident on admission but the expectation was to have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy, Advance Directive revealed the following procedure, Upon admission to this facility, the Social Services Director or facility designee will meet with the resident. During this meeting, documents will be reviewed in accordance with the resident's rights policy and procedure. The Social Services Director or designee will then ask the resident whether the resident has completed an Advance Directive or Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the facility will provide, at the time of a resident's admission, written information concerning the resident's rights to make decisions concerning medical care, including the right to refuse medical or surgical treatment, and the right to formulate an advance directive. If the resident or legal representative has executed on or more advance directive (s), these documents are obtained, incorporated and consistently maintained in the same section of the resident health information record readily retrievable by any facility staff, and the facility will communicate the resident's wishes to the resident's direct care staff and physician. Furthermore, the policy included, In the absence of an Advance Directive or POLST or in the absence of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure one sampled resident's (#8) clinical record included the required information for transfer/discharge. The deficient practice could result in residents not having a safe and effective transition of care. Findings include: Resident #8 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a nursing Transfer to Hospital note dated August 15, 2022 at 2:41 PM revealed a radiology technician performed an arterial and venous ultrasound on the resident's right upper extremity as ordered. The radiology technician reported to the nurse that the resident's entire right arm was occluded. The note included the physician assistant and medical director were notified and an order was given to transfer the resident to the hospital. The note also revealed the resident agreed to the transfer and the bed hold form was provided. The resident left at 1:10 PM. A review of the front sheet revealed the resident's emergency contact was the resident's spouse. Review of the discharge minimum data set (MDS) assessment dated [DATE] revealed that the resident was sent to the acute care hospital with return not anticipated. A review of the SNF/NF to Hospital Transfer Form dated August 15, 2022 revealed no evidence that medications and the last time the medications were taken were reported to the receiving facility. The form did not include who called in the information or who the information was called to; the places for that documentation did not contain a name. The Report Called in by on the form had Pending hospital admission. The form did include the resident's emergency contact information. Continued review of the clinical record revealed no documentation that all the appropriate information was communicated to the receiving health care institution or that an order was written to send the resident to the hospital. An interview with the director of nursing (DON/staff #39) was conducted on October 12, 2022 at 7:58 AM. The DON stated that if a resident was to be sent to an acute care hospital, the nursing staff would call the resident's physician and obtain an order. The DON stated the order is to be entered into the clinical record. She stated the receiving facility would be contacted and discharge assessments would be completed and printed out and sent with the resident. The DON also stated the information is to be documented in the resident's progress notes to update the record. The DON further stated this does not meet her expectation of an appropriate discharge. She stated she was unsure of her expectation for appropriate documentation for discharge, that she would have to check the facility policy. An interview with the facility administrator (staff #90) was conducted on October 12, 2022 at 8:20 AM. She stated that her expectation is that nursing staff would document any discussion with the resident or representative regarding discharge and transport as well as discharge information. Review of the facility policy Discharge/Transfer (10/22) revealed that when a resident is discharged , the facility must ensure that the transfer or discharge is documented in the resident's medical record and the appropriate information is communicated to the receiving health care provider. Review of the facility policy Transfer (7/22) revealed that an emergency transfer of a resident to a hospital would be under the orders of the resident's physician. The family or responsible party would be notified as soon as possible with the notification documented in the resident's medical record. Review of the facility policy Clinical Record Documentation Guidelines (7/2022) revealed physician orders are entered and implemented in a timely manner.

Based on an observation, staff interviews, and review of policy and procedure, the facility failed to ensure a controlled medication was stored and reconciled in accordance with professional standards of practice. The deficient practice increases the risk for loss or potential diversion of controlled medications. Findings include: On August 23, 2021 at 10:14 a.m. an observation of a facility medication cart was conducted with a Registered Nurse (RN/staff #19). During the observation, two zip lock plastic bags were identified in the lower drawers of the cart. The two bags contained nine medications in the original prescription containers and five dosette boxes containing approximately 100 or more unidentified pills. Upon further review of the medications, one prescription bottle was noted to contain multiple [MEDICATION(S)]-acetaminophen (opioid [MEDICATION(S)]/non-opioid [MEDICATION(S)] combination) 5-325 milligrams (mg) tablets. An interview was conducted on August 23, 2021 at 10:26 a.m. with a RN (staff #19). She stated that the medications in the bags were one of the resident's home medications. She stated that the resident's family had refused to take them back home. She said she was instructed to keep the medications locked in the medication cart until the resident was discharged . She stated that she had not looked at the medications and that she did not know what exactly was in the bags. She stated that the risk of keeping home medications in the medication cart may include that someone might accidentally administer them. She stated that narcotics should be kept in a second locked box, and that they should be counted and accounted for each shift. She stated that she had no idea how many tablets were in the bottle when they were brought in and that she did not know how many tablets remained. On August 24, 2021 at 10:06 a.m., an interview was conducted with the Director of Nursing (DON/staff #61). She stated that controlled medications are locked into a secured narcotic drawer in the medication cart. She stated that they have a bound narcotic book that they get from the pharmacy, and in the front of the book there is a shift-to-shift count. She stated that narcotics will be counted at each shift and if a count is off, an investigation will take place. She stated that there is no specific policy regarding residents bringing medications from home. She stated that if a resident did bring in medications, she would instruct the nurses to secure them in the medication cart until someone could come to take them home. But, she stated she would prefer not to have them in the facility at all if the resident did not need them. She stated that if a resident did need the medication, the physician's order would specifically state that was the case. She stated that concerns related to having a resident's home supply of [MEDICATION(S)]-acetaminophen kept in a zip lock bag in the medication cart included the lack of counting/or having a verified number of tablets in the container and also that the medication was not locked in the secured narcotic drawer. She stated that she did not know how many tablets were in the container when the resident was admitted because no one really noticed that the [MEDICATION(S)] was in the bag. She stated that she understood that this was an issue, and that they had since sent the medications home with the resident's family. The facility's controlled drugs policy noted a policy statement that the company will provide control of narcotics, depressants, and stimulant drugs, which meet the requirements of State and Federal narcotic enforcement agencies, to ensure maximum safety for residents and nursing personnel. The procedure included that all controlled substances are kept locked at all times. The policy noted that the controlled substances are kept in a separate drawer or separate cabinet, which is locked at all times, with only the charge nurse or Certified Medication Aide (CMA), having the key. The nurse/CMA is to keep the key in her possession at all times when on duty. Controlled drugs are to be counted each shift by the nurse/CMA going off duty and the nurse/CMA coming on duty. The checklist is to be signed by each nurse/CMA counting the controlled substances.