Every finding on record at Mountain View Care Center

Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure one out of three sampled residents (#3) was provided necessary care when oxygen saturation was low. The deficient practice could result in delayed treatment of respiratory distress, respiratory failure, and death.Findings include:Resident #3 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse, emphysema, and chronic respiratory failure.A Physician's Order, dated June 8, 2026, indicated Resident #3 required Oxygen at 2 liters per minute (lpm). The order further indicated that the oxygen may be titrated to maintain oxygen saturations at 89% or greater.Resident #3's Care Plan was initiated on June 9, 2026 and noted that the goal was for the resident to not have signs or symptoms of poor oxygen absorption. Interventions included administering medications as ordered, monitoring side effects and effectiveness, provide oxygen per physician's orders, and to stay with the resident during episodes of respiratory distress.An admission Minimum Data Set (MDS), dated [DATE], revealed Resident #3 participated in a Brief Interview for Mental Status (BIMS) and scored a 10 which indicated he had moderate cognitive impairment. The same MDS also indicated Resident #3 used continuous oxygen therapy.A Physician Progress Note, dated June 23, 2026 at 4:21 P.M. revealed that a chest x-ray showed mild to moderate bilateral perihilar infiltrates. The same note indicated that the Physician added Augmentin (an antibiotic) 875 milligrams (mg) by mouth twice a day for the perihilar infiltrates.A second physician's order, dated June 23, 2026, indicated Resident #3 was to be monitored for a change in condition for pneumonia.The Care Plan was revised on June 24, 2026 to include a goal of resolving Resident #3's pneumonia without complications while he completes antibiotic therapy. Interventions included administering medications, monitoring for adverse reactions, notifying the physician if signs or symptoms does not resolve, and reporting pertinent lab results to the physician. An Oxygen Saturation summary revealed an entry, dated June 25, 2026 at 8:00 A.M., recorded by Licensed Practical Nurse (LPN/Staff #12). The entry indicated Resident #3's oxygen saturation was at 92% at 3 lpm.A Nursing Note, dated June 25, 2026 at 2:54 P.M., was created by Staff #12. The note indicated Resident #3 was alert and oriented to person and place. It further noted that the resident was receiving oxygen via a nasal cannula at 3 lpm and was tolerating respiratory treatments. The note further indicated that the resident's family members had visited at lunch.An additional Nursing Note, dated on June 25, 2026 at 3:02 P.M., was created by Staff #19. The note indicated Resident #3 was sent to the hospital via stretcher with the Power of Attorney (POA) and another family member present.There was no documentation explaining what, if any, interventions were attempted by staff members and why Resident #3 was sent to the hospital.The same Oxygen Saturation Summary revealed an entry, dated June 25, 2026 at 3:04 P.M., was recorded by LPN/Staff #19. The entry indicated Resident #3's oxygen saturation was 60% at 4 lpm.An e-Interact form for Resident #3, created by staff #19 revealed was transferred to the hospital on June 25, 2026 at 2:15 P.M. and his oxygen level was at 60% at 10:22 P.M. It was noted that the reason for the hospital transfer was due to his oxygen being at 60% while on 4 lpm via nasal cannula.An interview was conducted on August 5, 2026 at 12:25 P.M. with Staff #12. Staff #12 shared that she did not remember Resident #3. After reading a Nursing Note, that she created on June 25, 2026 on the Electronic Health Record (EHR), Staff #12 stated that she could not recall that day even though her note indicated the Resident had family members visiting him. She also shared that based on her note, it did not look like Resident #3 was experiencing an emergent issue that day. Staff #12 further shared that her shift ends at 2:30 P.M.An interview was conducted on August 5, 2026 at 2:20 P.M. with Staff #19. Staff #19 shared that he did not remember Resident #3. After reviewing Resident #3's EHR, Staff #19 read the note that he created on June 25, 2026. Staff #19 shared that he was not able to remember why Resident #3 was sent to the hospital. He further shared that when residents are sent to the hospital, he would document in the chart the reason. He also shared that after reading the above note that he wrote, he could see that he needs to write more information on there.A subsequent interview was conducted On August 5, 2026 at 2:54 P.M. with Staff #19. Staff #19 shared that when he started his shift there was a commotion with Resident #3's family members and the family was not pleased because the family was demanding a lot of stuff. He further shared that the family had said Resident #3's oxygen level was low and had wanted the resident to be sent to the hospital. Staff #19 shared that he then called the provider to get orders for the resident to be sent to the hospital and then called 911. Staff #19 shared that he observed Resident #3 having his oxygen on at 4 lpm but did not do anything else for the resident because a family member had taken control of the situation. Staff #19 also recalled observing Resident #3 gasping and shared that he did not increase the resident's oxygen to aid his breathing. Staff #19 further shared that the oxygen concentrators do go up to 6 lpm but he did not increase it. Staff #19 shared that during shift change he was not aware that Resident #3 was in distress as the information was not communicated to him from Staff #12.An interview was conducted on August 5, 2026 at 3:08 P.M. with the Assistant Director of Nursing (ADON/Staff #44). Staff #44 shared that oxygen saturations below 90% would be concerning for him. He would expect staff to do an assessment on the resident and check their lungs, provide supplemental oxygen, check the orders for any breathing treatments that could be provided, and to notify the provider of the situation for additional guidance. He further shared that the Nurse should document their assessment of the resident and what interventions they provided. After reviewing the EHR, Staff #3 shared that at 2:46 P.M. a Condition Follow-up note indicated Resident #3's oxygen saturation was at 92%. Then at 2:54 P.M. a Skilled Evaluation note indicated Resident #3's oxygen was 90% to 92% which was still good. Then at 3:02 P.M. a Nursing Note showed that Resident #3 was transferred to the hospital. Staff #44 shared that based on the documentation, he did not know why the resident was transferred to the hospital. Staff #44 also reviewed the e-Interact form and shared that Resident #3's oxygen saturation was 60%. Staff #44 was not able to describe what actions staff took when Resident #3's low oxygen levels was discovered by staff.A telephonic interview on August 13, 2026 at 11:24 A.M., with a Resident #3 family member. The family member shared she and the POA arrived to visit Resident #3 on June 25, 2026 at 12:30 P.M. She further shared that she had asked Staff #12 what the resident's most recent oxygen saturation was and the Nurse informed her it was 92%. The family member recalled that while Resident #3 was sitting up and eating lunch, she could hear crackles in his lungs. She further recalled that a Physical Therapist (PT) then met with the Resident after lunch around 1:15 P.M. to 1:30 P.M. and the PT used a pulse oximeter to measure his oxygen saturations and it was low. The family member stated that could hear gurgling when Resident #3 took breaths and alerted Staff #12 of the resident's low oxygen some time before 2:00 P.M. She also shared that after the PT had left the room, only a Certified Nursing Assistant (CNA) had gone into Resident #3's room to take his vitals and left. No other staff members entered Resident #3's room to check on him and administer assistance with oxygen until emergency services arrived. The family member further shared that an ambulance had arrived between 2:15 P.M. and 2:45 P.M.Review of the facility's policies and procedures titled Respiratory Care; Oxygen Administration revealed that it was last reviewed in July 2026. The policy stated that oxygen therapy is administered by licensed nurse as ordered by the physician. It further stated that it can also be administered as an emergency measure.Review of a second facility policy and procedure, titled Change of Condition Reporting, revealed that it was reviewed in July 2025. The policy and procedure revealed that for a Life Threatening Change a licensed nurse was to initiate appropriate first aid measures until emergency response personnel arrive on the scene. It further revealed that all nursing actions and resident assessment information were to be documented in the nursing progress notes.

Based on clinical record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure the medical record was complete and accurate for one of three sampled residents (#3) when there was a change in condition. The deficient practice could result in care team members not being adequately informed regarding the resident's status and could lead to adverse outcomes for the resident.Findings include:Resident #3 was admitted to the facility on [DATE] with diagnoses that included syncope and collapse, emphysema, and chronic respiratory failure.An admission Minimum Data Set, dated [DATE], revealed Resident #3 participated in a Brief Interview for Mental Status (BIMS) and scored a 10 which indicated he had moderate cognitive impairment. The same MDS also indicated Resident #3 used continuous oxygen therapy.A Physician's Order, dated June 8, 2026, indicated Resident #3 required Oxygen at 2 liters per minute (lpm). The order further indicated that the oxygen may be titrated to maintain oxygen saturations at 89% or greater.Resident #3's Care Plan was initiated on June 9, 2026 and noted that the goal was for the resident to not have signs or symptoms of poor oxygen absorption. Interventions included administering medications as ordered, monitoring side effects and effectiveness, provide oxygen per physician's orders, and to stay with the resident during episodes of respiratory distress.A Physician Progress Note, dated June 23, 2026 at 4:21 P.M. revealed that a chest x-ray showed mild to moderate bilateral perihilar infiltrates. The same note indicated that the Physician added Augmentin 875 milligrams (mg) by mouth twice a day for the perihilar infiltrates.A second physician's order, dated June 23, 2026, indicated Resident #3 was to be monitored for a change in condition for pneumonia.The Care Plan was revised on June 24, 2026 to include a goal of resolving Resident #3's pneumonia without complications while he completes antibiotic therapy. Interventions included administering medications, monitoring for adverse reactions, notifying the physician if signs or symptoms does not resolve, and reporting pertinent lab results to the physician.An Oxygen Saturation summary revealed an entry, dated June 25, 2026 at 8:00 A.M., recorded by Licensed Practical Nurse (LPN/Staff #12). The entry indicated Resident #3's oxygen saturation was at 92% at 3 lpm.A Nursing Note, dated June 25, 2026 at 2:54 P.M., was created by Staff #12. The note indicated Resident #3 was alert and oriented to person and place. It further noted that the resident was receiving oxygen via a nasal cannula at 3 lpm and was tolerating respiratory treatments. The note further indicated that the resident's family members had visited at lunch.An additional Nursing Note, dated on June 25, 2026 at 3:02 P.M., was created by Staff #19. The note indicated Resident #3 was sent to the hospital via stretcher with the Power of Attorney (POA) and another family member present. There was no documentation explaining what, if any, interventions were attempted by staff members and why Resident #3 was sent to the hospital.The same Oxygen Saturation Summary revealed an entry, dated June 25, 1026 at 3:04 P.M., was recorded by LPN/Staff #19. The entry indicated Resident #3's oxygen saturation was 60% at 4 lpm.An e-Interact form indicated Resident #3 was transferred to the hospital on June 25, 2026 at 2:15 P.M. and his oxygen level was at 60% at 10:22 P.M. It was noted that the reason for the hospital transfer was due to his oxygen being at 60% while on 4 lpm via nasal cannula.Review of the clinical record revealed no evidence that interventions were implemented when Resident #3's oxygen saturations were clinically low.An interview was conducted on August 5, 2026 at 12:25 P.M. with Staff #12. Staff #12 shared that she did not remember Resident #3. After reading a Nursing Note, that she created on June 25, 2026 on the Electronic Health Record (EHR), Staff #12 stated that she could not recall that day even though her note indicated the Resident had family members visiting him. She also shared that based on her note, it did not look like Resident #3 was experiencing an emergent issue that day. Staff #12 further shared that her shift ends at 2:30 P.M.An interview was conducted on August 5, 2026 at 2:20 P.M. with Staff #19. Staff #19 shared that he did not remember Resident #3. After reviewing Resident #3's EHR, Staff #19 read the note that he created on June 25, 2026. Staff #19 shared that he was not able to remember why Resident #3 was sent to the hospital. He further shared that when residents are sent to the hospital, he would document in the chart the reason. He also shared that after reading his note that he wrote, he could see that he needs to write more information on there. The interview then was concluded.On August 5, 2026 at 2:54 P.M., Staff #19 asked to speak with Surveyor as he had remembered more information regarding Resident #3. Staff #19 shared that when he started his shift there was a commotion with Resident #3's family members and the family was not pleased because they were demanding a lot of stuff. He further shared that the family had said Resident #3's oxygen level was low and had wanted the resident to be sent to the hospital. Staff #19 shared that he then called the provider to get orders for the resident to be sent to the hospital and then called 911. Staff #19 shared that he observed Resident #3 having his oxygen on at 4 lpm but did not do anything else for the resident because a family member had taken control of the situation. Staff #19 also recalled observing Resident #3 gasping and shared that he did not increase the resident's oxygen to aid his breathing. Staff #19 further shared that the oxygen concentrators do go up to 6 lpm but he did not increase it. Staff #19 shared that during shift change he was not aware that Resident #3 was in distress as the information was not communicated to him from Staff #12.An interview was conducted on August 5, 2026 at 3:08 P.M. with the Assistant Director of Nursing (ADON/Staff #44). Staff #44 shared that for a change in vitals that require hospitalization, he expects staff to document the vitals and notify the provider and to follow up with any pending orders. He further shared that the documentation in the progress notes should identify the condition and who they notified. Staff #44 shared that oxygen saturations below 90% would be concerning for him. He would expect staff to do an assessment on the resident and check their lungs, provide supplemental oxygen, check the orders for any breathing treatments that could be provided, and to notify the provider of the situation for additional guidance. He further shared that the Nurse should document their assessment of the resident and what interventions they provided. After reviewing the EHR, Staff #3 shared that at 2:46 P.M. a Condition Follow-up note indicated Resident #3's oxygen saturation was at 92%. Then at 2:54 P.M. a Skilled Evaluation note indicated Resident #3's oxygen was 90% to 92% which was still good. Then at 3:02 P.M. a Nursing Note showed that Resident #3 was transferred to the hospital. Staff #44 shared that based on the documentation, he did not know why the resident was transferred to the hospital. Staff #44 was not able to describe what actions staff took when Resident #3's low oxygen levels was discovered by staff and he stated that did not meet his expectations as they are to document their interventions. Staff #44 added that his biggest concern was that the lack of documentation puts the resident at risk because the facility wouldn't have a complete and accurate picture of the resident and would not be able to provide appropriate follow-up care. An interview was conducted, telephonically, on August 13, 2026 at 11:24 A.M., with a resident's family member. The family member shared that her and the POA had arrived to visit Resident #3 on June 25, 2026 at 12:30 P.M. She further shared that she had asked Staff #12 what the resident's most recent oxygen saturation was and the Nurse informed her it was 92%. The family member recalled that while Resident #3 was sitting up and eating lunch, she could hear crackles in his lungs. She further recalled that a Physical Therapist (PT) then met with the Resident after lunch around 1:15 P.M. to 1:30 P.M. and used a pulse oximeter to measure his oxygen saturations and it was low. The family member stated that she could hear gurgling when Resident #3 took breaths and alerted Staff #12 of the resident's low oxygen some time before 2:00 P.M. The family member further shared that an ambulance had arrived between 2:15 P.M. and 2:45 P.M.Review of the facility's policy and procedure, titled Change of Condition Reporting, revealed that it was reviewed in July 2025. The policy and procedure revealed that for a Life Threatening Change a licensed nurse was to initiate appropriate first aid measures until emergency response personnel arrive on the scene. It further revealed that all nursing actions and resident assessment information was to be documented in the nursing progress notes.Review of an additional policy and procedure, titled Documentation and Charting, revealed it was last revised in July of 2025. The policy stated that the facility will provide an account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care.

Based on resident and staff interviews, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need. Findings include: The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all four quarters in 2024. Per the report, submitted weekend staffing data was excessively low. The facility assessment with a last reviewed date of [DATE] revealed that the facility was licensed to provide care for 120 residents, had an average daily census of 95, had an average daily of 20 post-acute skilled residents, had an average of 45 admissions and discharges per month, had an average of 40 persons admitted on a weekday, had an average of 25 persons discharged on a weekday, had an average of 8 persons admitted on a weekend, and had an average of 5 persons discharged on a weekend. The majority of the residents are admitted from an acute care hospital for rehabilitation services. Most of the residents require the assist of one to two staff members for activities of daily living (ADL), while there are a few who require mechanical lift transfer. The majority can feed themselves after set-up or with supervision. The assistance with ADL averages included the following: - Bathing: 4 -independent, 76 -assist of 1 to 2 staff, 15 -dependent; - Dressing: 5 -independent, 75 -assist of 1 to 2 staff, 15 -dependent; - Transfer: 8 -independent, 82 -assist of 1 to 2 staff, 5 -dependent; - Toileting: 8 -independent, 72 -assist of 1 to 2 staff, 15 -dependent; - Eating: 75 -independent, 12 -assist of 1 to 2 staff, 8 -dependent; and - Mobility: 10 -independent, 30 -assistive device used to ambulate, 55 -in chair most of the time. Furthermore, the facility assessment's staffing plan considers both census numbers and acuity levels that impacts staffing needs, and staff accordingly. The facility hires and schedules staff for an average census, and the census average has been consistent at 95. The Nursing Services Staffing Plan for licensed Nurses (LN): RN (registered nurse), LPN (licensed Practical Nurse) and CNAs (certified nursing assistant) included the following: - Director of Nursing (DON): one full-time days; - Unit Manager-Acute Services: three, two during the week and one on the weekends; - Wound/treatment nurse: one-full-time days; - MDS Nurses: one full-time days; - CNA Staffing Coordinator: one full-time days and on call; - Restorative CNA: one full-time 5 days a week; - RNs/LPNs post-acute 6am-2pm: one each day (200) hallway; - RNs/LPNs post-acute 2pm-10pm: one each day (200) hallway; - RNs/LPNs long term care 6am-2pm: three each day (100, 300 and 400) hallways; - RNs/LPNs long term care 2pm-10pm: three each night for building (100, 300 and 400); - RNs/LPNs long term care 10pm-6am: two each day (100/200 and 300/400) hallways. After reviewing the facility assessment dated [DATE], the facility assessment did not include the number of CNAs each day for each hallway and for each shift in the staffing plan. Review of record revealed on February 3,2024, the census was 103 and on February 4, 2024, the census was 104. Review of the daily staffing assignment with staff initials for February 4, 2024 revealed the following information: Regarding day shift from 0600-1400 assignment: -one LPN with initials, one CNA with initials and one CNA with a c/o next to the name for the 100 hallway; -one LPN with initials, one CNA with initials and one CNA name with a line over it for the 200 hallway; -one RN without initials and two CNAs with initials for the 300 hallway; and -one LPN and two CNAs with initials for the 400 hallway. Regarding evening shift from 1400-2200 assignment: -one LPN with initials, one CNA with initials and one CNA with a c/o next to the name for the 100 hallway; - one LPN with initials, one CNA with initials and one CNA name with a line over it for the 200 hallway; -one RN without initials and three CNAs with initials for the 300 hallway; and -one LPN and two CNAs with initials for the 400 hallway. Regarding night shift 2200-0600 assignment: -one LPN without initials and two CNAs with initials for the 100/200 hallways; and -one LPN without initials, one CNA with initials and one CNA without initials for the 300/400 hallways. Review of facility record related to grievances for 2024 revealed a staffing issue complaint on February 19, 2024. An onsite survey was conducted by the Department. And, the allegation was unsubstantiated. Review of the daily staffing assignment with staff initials for [DATE] revealed the following information: Regarding day shift from 0600-1400 assignment: -one LPN with initials, one CNA without initials and one CNA with a c/o next to the name for the 100 hallway; -one LPN with initials, one CNA with initials and one CNA with a c/o next to the name for the 200 hallway; -one RN without initials, one CNA with initials and one CNA with a 200 next to the name for the 300 hallway; and -one LPN and two CNAs all three staffs assigned have initials next to their names for the 400 hallway. Regarding evening shift from 1400-2200 assignment: - one LPN with initials, one CNA without initials and one CNA with a c/o next to the name for the 100 hallway; - one LPN with initials, two CNAs with a c/o next to their name, and the other hand-written name of the CNA with initials has float all hall for the 200 hallway; - one RN without initials, one CNA with initials, another CNA without initials has 200 written next to the name for the 300 hallway; - one LPN and two CNAs with initials were on the schedule for the 400 hallway. Regarding night shift 2200-0600 assignment: - one RN without initials and one CNA with initials for the 100/200 hallways; and -one LPN without initials and two CNAs with initials for the 300/400 hallways. Review of record revealed on [DATE], the census was 99. Review of the daily staffing assignment with staff initials for [DATE] revealed the following information: Regarding day shift from 0600-1400 assignment: -one LPN with initials, one CNA without initials and one CNA with a c/o next to the name for the 100 hallway; -one LPN and one CNA with initials were scheduled for the 200 hallway; -one RN without initials and two CNAs with initials were scheduled for the 300 hallway; and -one LPN and two CNAs all three staffs assigned have initials next to their name for the 400 hallway. Regarding evening shift 1400-2200 assignment: - one LPN with initials, one CNA without initials and one CNA with a c/o next to the name for the 100 hallway; - one LPN with initials, one CNA with initials and one CNA with c/o next to their name for the 200 hallway; - one RN without initials and two CNA with initials scheduled for the 300 hallway; - one LPN and two CNAs with initials were on the schedule for the 400 hallway. Regarding night shift 2200-0600 assignment: - one LPN without initials and one CNA without initials for the 100/200 hallways; and -one LPN without initials, one CNA without initials and one CNAs with initials for the 300/400 hallways. Review of record revealed on [DATE], the census was 100. Review of the daily staffing assignment with staff initials for [DATE] revealed the following information: Regarding day shift from 0600-1400 assignment: -one LPN without initials, one CNA with initials and one CNA without initials for the 100 hallway; -one RN without initials and two CNAs with initials for the 200 hallway; -one LPN without initials, one CNA with initials and one CNA without initials for the 300 hallway; and -one LPN without initials, and two CNAs with initials for the 400 hallway. Regarding evening shift from 1400-2200 assignment: -one RN without initials and two CNAs with initials for the 100 hallway; -one LPN without initials and one CNA with initials scheduled for the 200 hallway; -one LPN without initials and two CNAs with initials for the 300 hallway; and -one RN without initials, one CNA without initials and one CNA with initials for the 400 hallway. Regarding night shift from 2200-0600 assignment: -one LPN without initials and two CNAs with initials for 100/200 hallways; and -one LPN without initials and two CNAs without initials for the 300/400 hallways. Review of the daily staffing assignment with initials for [DATE] revealed the following information: Regarding day shift from 0600-1400 assignment: -one LPN and two CNAs with initials for 100 hallway; - one LPN with initials, one CNA with initials and another CNA without initials and has till 7pm for the 200 hallway; - one LPN with initials, one CNA with initials and one CNA with a c/o next to the name for the 300 hallway; and -one LPN and two CNAs with initials for the 400 hallway. Regarding evening shift from 1400-2200 assignment: -one LPN with initials and two CNAs with initials for the 100 hallway; -one LPN with initials, one CNA with initials and one hand-written name of a CNA with initials and til 7pm for 200 hallway; -one LPN without initials and two CNAs with initials for the 300 hallway; and -one LPN and two CNAs with initials for the 400 hallway. Regarding night shift from 2200-0600 assignment: -one LPN without initials, one CNA without initials, and another CNA with initials with a hand-written split 300 for the 100/200 hallways; and -one LPN without initials, one CNA with a c/o next to the name and one CNA without initials for the 300/400 hallways. Review of record revealed on [DATE], the census was 94. Review of the daily staffing assignment with staff initials for [DATE] revealed the following information: Regarding day shift from 0600-1400 assignment: -one LPN without initials, one CNA with initials and one CNA without initials for the 100 hallway; -one LPN with initials, one CNA with initials, and one CNA with a hand-written name without initials for the 200 hallway; -one LPN without initials, one CNA with initials and one CNA with a hand-written name with initials for the 300 hallway; and -one LPN with initials and two CNAs with initials for the 400 hallway. Regarding evening shift from 1400-2200 assignment: -one LPN without initials, one CNA without initials and one CNA with initials for the 100 hallway; -one LPN with initials, one CNA with initials, and one CNA with a hand-written name without initials for the 200 hallway; - one LPN without initials, one CNA with initials, and one CNA with a hand-written name with initials for the 300 hallway; and - one LPN with initials and two CNAs with initials for the 400 hallway. Regarding night shift from 2200-0600 assignment: -one LPN without initials, one CNA without initials and one CNA with initials for the 100/200 hallways; and -one LPN without initials, one CNA without initials and one CNA without initials with a c/o next to the name for the 300/400 hallways. Review of record revealed on [DATE], the census was 94. Review of the daily staffing assignment with staff initials for [DATE] revealed the following information: Regarding day shift from 0600-1400 assignment: -one LPN without initials, one CNA without initials and one CNA with initials for the 100 hallway; -one LPN without initials, one CNA with initials and one CNA with initials and a hand written left early next to the name for the 200 hallway; -one RN without initials, one CNA with initials and one CNA with a c/o next to the name for the 300 hallway; and -one LPN without initials, one CNA with initials and one CNA with a c/o next to the name for the 400 hallway. Regarding evening shift from 1400-2200 assignment: -one LPN without initials and two CNAs with initials for the 100 hallway; -one LPN without initials and two CNAs without initials for the 200 hallway; -one RN without initials, one CNA with initials and one CNA with a c/o next to the name for the 300 hallway; and -one LPN without initials, one CNA with a c/o next to the name, one CNA with initials and a c/o next to the name and one hand-written CNA name without initials for the 400 hallway. Regarding night shift 2200-0600 assignment: -one RN without initials and one CNA with initials for the 100/200 hallways; and -one RN without initials and three CNAs with initials for the 300/400 hallways. Review of the daily staffing assignment with staff initials for [DATE] revealed the following information: Regarding day shift from 0600-1400 assignment: -one LPN with initials, one CNA with initials and one with a c/o next to the name for the 100 hallway; -one LPN without initials, one CNA without initials and one CNA with a c/o next to the name for the 200 hallway; -one RN without initials, one CNA with initials and one CNA with a c/o next to the name for the 300 hallway; and -one LPN and two CNAs with initials for the 400 hallway. Regarding evening shift 1400-2200 assignment: -one LPN with initials, one CNA with initials and one CNA with a c/o next to the name for the 100 hallway; -one LPN without initials, one CNA without initials and one CNA without initials and a hand written next to name to 300 for the 200 hallway; -one RN without initials, one CNA with initials, one CNA with a c/o next to the name, and a hand-written CNA name at 6 pm without initials for the 300 hallway; and -one LPN and one CNA with initials were on the schedule for the 400 hallway. Regarding night shift from 2200-0600 assignment: -one LPN without initials and one CNA with another CNA orientee (O) with initials next to the orientee name for 100/200 hallways; and -one RN with initials and two CNAs with initials for the 300/400 hallways. Review of record revealed on [DATE], the census was 95. During the survey's initial pool screening on [DATE] at 11:30 AM, one resident stated that the staffs are good and nice. The facility used to just be short on nights, now all shifts short. The call light waits times mostly 10 minutes, sometimes one to two hours or they do not come. The longer waits happens around shift change. An interview was conducted on [DATE] at 3:12 PM with LPN/Staff #105. Staff #105 stated that regarding scheduling, there is a book in the nurses' station which shows assignments for CNAs and nurses for each hallway. If any changes are made in the schedule, the nurse for the hallway will make the changes. He stated that when he arrives to work, he normally will write his initials on the schedule and that means that he is in the facility working on schedule. He stated that the facility has a scheduler who makes the schedule, Staff #85. The scheduler will change the schedule on who will be replacing the staff and who will not be coming to work. If the person did not come as scheduled, the scheduler will scratch off the name and replace it with another name. He stated that there are two CNAs and one nurse for each hallway on days and evening shifts and one nurse with one CNA for night shift for two hallways. Another interview was conducted on [DATE] at 7:46 AM LPN/Staff #106. Staff #106 stated that 100 and 300 hallways are the long-term care hallways, 200 hallway is the skilled hallway, and 400 is behavioral locked hallway. For long term care, skilled and behavioral hallways, each hallway is staffed with one nurse and two CNAs for the day and evening shifts and one nurse and one CNA for night shift. She stated that there is a schedule book where names of nurses and CNAs are scheduled for each hallway and shift. She stated that in the schedule book, she writes her initials next to her name to signify that she is at work. The staffing coordinator will let her know if a staff is not coming, and it will be crossed out as a call off. An interview was conducted on [DATE] at 8:20 AM with another resident. The resident stated that some weekends, the staff is shorthanded. He added that there was one occasion when he had to assist the staff in picking up room trays at the residents' rooms. The staff instructed him to stop because it is their responsibility, and it is not safe for him. An interview was conducted on [DATE] at 8:54 AM with another resident. The resident stated that sometimes, there is only one CAN and a nurse in the 100 hallway for at least 30 to 32 residents. On some weekends, only one nurse and one CNA are present in the 100 hallway. She mentioned asking one of the CNA staff why she has to work 16 hours if she doesn't want to, and the CNA staff replied that if she doesn't work 16 hours, she'll get fired. An interview was conducted on [DATE] at 2:55 PM with Staffing Coordinator/Staff #85. She stated that as the staffing coordinator, she makes sure that the building is fully staffed, she looks for coverage when someone calls off or else she will work the floor if she can't find coverage. She stated that she makes sure that the hall has one nurse and two CNAs on every hall for the first and second shift and two nurses and four CNAs at night. She stated that the schedule/assignment process is that the staff writes their initials next to their name on the schedule, if they don't initial she pulls the labor results/punch time. She stated that if no initials or punch time then she knows that they did not come to work. Regarding the Payroll-Based Journal (PBJ), she does not deal with this stuff. It is either the administrator or Human Resources that deals with PBJ. An interview was conducted on [DATE] at 3:04 PM with Human Resources (HR)/Staff #83. Staff #83 stated that her role includes onboarding staff, education, all their licensure is up to date and current. Regarding cardiopulmonary resuscitation (CPR), an instructor comes in their facility, is a private entity fireman, and instruct CPR for an entire class. Regarding PBJ, the staff clocks in and out, it generates report, she reviews nursing hours then calculate to how many RNs, LPNs, and CNAs, and every day hours are generated. Regarding staffing report showed low weekend staffing, she stated that the difference between the weekend is that they do not have nursing managers on the weekend which are the DON, assistant director of nursing (ADON), MDS coordinator, and wound care nurse who works Monday through Friday. She stated that they use a third-party service center, who takes their hours of work day and submits to the Centers for Medicare & Medicaid Services (CMS). She stated that when a clinical staff clocks in and out, that shows their work day, it generates report, and then their third party is responsible in generating the report to be submitted to CMS. An interview was conducted on [DATE] at 4:23 PM with the DON/Staff #50. The DON stated that staffing depends on acuity and census, there is one nurse for each hallway for days and evening shift, and on night shift there is one nurse for two hallways. Regarding CNAs, she stated that it depends on acuity and census, she stated that there is always one CNA per hallway during days and evening shifts and on the night shift, there are three CNAs and more as needed based on acuity and census. She stated that the staffing coordinator makes the scheduling. She stated that if residents come to her regarding grievance of waiting too long, she will look at staffing and speak with the staff on the schedule. An interview was conducted on [DATE] at 4:47 PM with the administrator/Staff #96 in his office. The administrator stated that HR reports all the staffing data to be reported to CMS. During the interview, the HR staff entered the office and stated that because there are no managers like DON, ADON, MDS coordinator, there hours will reflect on the weekdays but not on the weekends, there is less staff on the weekend because there is no DON, ADON, MDS coordinator, wound nurse because their hours are not reflected on the weekend. Additional interview was conducted on [DATE] at 7:14 AM with the DON in her office. The DON stated that regarding call outs, they have a nursing clinical rotation, so if a nurse calls out they have the DON, ADON, MDS coordinator to fill the hole, they have CNAs to pick up the holes, and the best way is to see in the punch details, since the schedule sometimes is not updated. If there is no replacement, she stated that they always have staff replaced for call outs which shows in the punch details. She stated that the c/o means call out. Furthermore, she stated that there is one CNA to fifteen residents, but can change and fluctuates. The acuity of their resident population changes based on the season. There is lower acuity between late spring, early fall and summer. Lower acuity resident requires less intense medical care, typically for their skilled resident such as requiring intravenous antibiotics and their long-term care resident are generally low acuity which requires less intense medical care, and some of their long-term residents have been here for months or years. She stated that their long-term care residents are mostly elderly who are incapable of caring for themselves in different capacities, and they require assistance and each have different needs. She stated that in hallway 100, there are 28 to 30 residents which requires 1 to 2 CNAs, locked hallway mostly with dementia anywhere from 20 to 28 residents, and normally depends on resident's needs.

Based on observation, resident and staff interviews, the facility failed to ensure that meals were served at an appetizing temperature for one resident (#46). The deficient practice could lead to nutritional issues and affect residents' quality of life. Resident #46 was admitted on [DATE], with diagnoses that included encounter for other orthopedic aftercare and type two diabetes mellitus with foot ulcer. The review of the resident's admission Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) summary score of 15, which confirms that the resident is cognitively intact. Review of the resident's orders revealed that the resident had an active order, as of December 05, 2023, for a NAS (No added salt) diet, regular texture, regular/thin consistency. An interview was conducted with the resident #46 on June 03, 2025, at 11:00 AM, who stated that the food delivered to him at lunch was lukewarm; it wasn't hot. He added that, for him, lukewarm food is considered cold. He expects his food to be hot when delivered, but the facility doesn't have enough staff to provide proper resident care or assist residents with their needs, including delivering room trays on time. Interview was conducted on May 3, 2025, at 12:15 PM with the Dietary Supervisor (Staff #4), who stated that after the food carts leave the kitchen, they are moved into the hall where typically two Certified Nursing Assistants (CNAs) will pass the trays. When asked if she noticed that it takes staff a long time to pass trays, the Dietary Supervisor stated she had noticed that the tray distribution could sometimes take a while. She stated that she had encouraged staff to work together to ensure food does not get cold. She also stated that she had brought up a suggestion at resident council, which proposed a different method to pass trays, which would help prevent food from getting cold. She stated that at this time, this suggestion had not been implemented. Interview was conducted on June 3, 2025 at 1:25PM with the Director of Nursing (DON/Staff #50), who stated that while every set of CNAs may distribute meal trays differently, she would expect food to be delivered at a safe temperature. Based on observations, staff interviews and policy review, the facility failed to ensure that prepared food were distributed to residents at a safe and appetizing temperature. The deficient practice could result in the potential of bacterial growth in susceptible conditions. Findings include: On June 2, 2025 at approximately 11:45AM, the tray line was observed, and the initial temperature of the chicken was 201 degrees F, the gravy was 165 degrees F, the spinach was 154 degrees F, and the stuffing was 159 degrees F. No cold components were included in the tray line for this observation due to no cold components on the menu for that day. During this tray line, meal service and tray distribution to one unit was observed. Observation conducted during tray distribution on June 2, 2025 at 12:30PM revealed that only two staff assisted in passing trays to the entire unit. One staff member passed the trays, while another staff member served drinks. The dining room area was served first, and then trays were passed to residents who chose to eat in their rooms. While passing, the staff passing the trays realized that one resident's tray was missing, and he left for the kitchen to retrieve a tray for this resident. During this time, the Dietary Supervisor (Staff #4), who had previously been observing with this surveyor, took over to ensure trays continued to be passed. Passing the lunch trays for this unit took approximately 25 minutes to complete. On June 2, 2025 at 12:55PM, a test tray was provided after all trays had been passed to the residents. The final temperatures of the food were obtained by the Dietary Supervisor (Staff #4), which revealed the chicken was tempted at 117 degrees F, spinach was tempted at 107.2 degrees F, and stuffing was tempted at 108 degrees F. The test tray was sampled by three surveyors on June 2, 2025 at approximately 1:00PM. Three of three surveyors described the spinach as cold. Two of three surveyors described the chicken and stuffing as lukewarm, while one of three surveyors described the chicken and stuffing as cold. An interview was conducted with the Resident #46 on June 03, 2025, at 11:00 AM, who stated that the food delivered to him at lunch was lukewarm; it wasn't hot. He added that, for him, lukewarm food is considered cold. He expects his food to be hot when delivered, but the facility doesn't have enough staff to provide proper resident care or assist residents with their needs, including delivering room trays on time. Interview was conducted on June 3, 2025 at 12:15PM with the Dietary Supervisor (Staff #4), who stated that after the food carts leave the kitchen, they are moved into the hall where typically two Certified Nursing Assistants (CNAs) will pass the trays. When asked if she noticed that it takes staff a long time to pass trays, the Dietary Supervisor stated she had noticed that the tray distribution could sometimes take a while. She stated that she had encouraged staff to work together to ensure food does not get cold. She also stated that she had brought up a suggestion at resident council, which proposed a different method to pass trays, which would help prevent food from getting cold. She stated that at this time, this suggestion had not been implemented. Follow-up interview was conducted on June 3, 2025 at 1:06PM with the Dietary Supervisor, who acknowledged that the lunch was served at a colder temperature than desired. She stated that the facility has considered investing in hot plates, which would help keep food warm, but that the budget has not allowed this purchase yet. Interview was conducted on June 3, 2025 at 1:25PM with the Director of Nursing (DON/Staff #50), who stated that while every set of CNAs may distribute meal trays differently, she would expect food to be delivered at a safe temperature. Review of the facility policy titled, Food Storage (dated 2014), revealed that food should be stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination.

Based on review of records, observation, interviews, and review of facility policy and procedure, the facility failed to ensure one resident (#31) was not abused by another resident (#37). The deficient practice could lead to physical and psychosocial harm to residents. Regarding the altercation between Resident #31 and Resident # 37. Resident #31 (alleged victim) was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and Dementia without behavioral disturbance. A review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 01 which indicated the resident is cognitively impaired. Review of the progress note dated June 1, 2025 at 1:08pm revealed at approximately 12:30 p.m resident was sitting in her wheelchair on the hallway when her roommate passed by and was witnessed by a state surveyor hitting the resident on the back of her head. The resident was evaluated for injury. No injuries discovered. The resident was moved to another room to ensure her safety. All parties notified. Review of the progress note dated June 1, 2025 at 1:08 p.m revealed that this RN(staff #50) was notified by unit staff that the resident had her hair pulled by another resident. The residents were immediately separated and resident #31 ' s family was called to be notified of the situation as well as to receive consent for room change. Full skin assessment completed by this RN and no ailments in skin noted and the provider was notified. Review of the skin evaluation dated June 02, 2025 revealed that resident # 31 had no new open areas or findings present and skin appears clean, dry and intact. Review of the progress note dated June 2, 2025 at 3:32 p.m revealed change of condition for room change/event every shift for 3 days. The note stated that Resident #31 is adjusting well to the new room and roommate. No new issues, concerns, or complaints noted at present time. Resident # 37 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy and dementia with other behavioral disturbance. A review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 13 which indicated the resident is cognitively intact. Review of physician progress note on June 2, 2025 at 7:14 a.m Stated that the provider was informed of an altercation occurring yesterday where the resident pulled another resident ' s hair. The resident was evaluated, labs ordered. Resident #37 does not recall an altercation happening. A psychologist consultation was ordered. Review of the progress note dated June 3, 2025 at 2:32 p.m revealed a change of condition for behavioral monitoring every shift for three days. DHS Surveyor observed on June 01, 2005 at 12:03 p.m resident #31 was in her wheelchair in the hallway as resident # 37 walks by and pulls the hair of resident # 31 who yells in distress then resident # 37 releases it and quickly walks away. Staff #30 CNA was in the same hallway when altercation occurred quickly looked up when resident # 31 screamed and walked over to resident #31. Staff # 30 asked resident #31 if she was ok. Resident # 31 nodded no and gesture a hair pull pointing at resident # 37. A phone interview was conducted on June 03, 2025 at 11:44 a.m with staff # 30 who stated she didn ' t see it happen but was standing in the hallway when she heard resident #31 yelling so she turned to look by then resident # 37 was already walking past resident # 31. When she asked resident #31 what happened resident #31 stated I am scared and pointed to resident # 37. Staff # 30 says resident #31 usually does not speak much, but this time she verbalized how she was feeling. Staff # 30 stated that resident #31 and resident #37 rooms are changed and are now no longer roommates after the altercation. Staff # 30 stated that resident # 37 was never physically abusive in the past but has been verbally abusive to a previous roommate. Staff # 25 LPN was with a resident in room [ROOM NUMBER] when she immediately came out of the room after hearing resident #31 yelling.Staff # 25 asked resident #31 what happened she gestured hair pull and pointed at resident # 37 who was standing at the end of the hall. Staff # 25 told resident #37 to keep her hands to herself, resident # 37 states she didn ' t do anything. DHS surveyor immediately interviewed Staff # 25, she stated she does not want to get them for every little thing because they are just roommates. Review of the facility ' s policy titled Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment revised December 2023 indicated that Each resident has the right to be free from abuse.Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Based on observations, clinical record review, interviews and policy and procedures, the facility failed to ensure one resident (#54) was free from chemical restraint, by failing to implement a provider's order for a gradual dose reduction of a psychotropic medication. The deficient practice could result in residents being administered psychotropic medications as chemical restraints and not to treat medical symptoms. Findings include: Resident #54 was admitted to the facility on [DATE] with a diagnosis that included Alzheimer's Disease, Type 2 Diabetes Mellitus, and Dementia. Review of care plan dated November 23, 2021 revealed psychotropic medications use related to dementia with psychosis AEB delusions. The interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, and consult with pharmacy, medical doctor to consider dosage reduction when clinically appropriate. Review of record revealed the following physician's orders: - On July 19, 2024 an order for Lexapro oral tablet give 10 mg by mouth one time a day for Depression AEB self-isolation; - On July 19, 2024 an order for Trazodone tablet 100 mg give one tablet by mouth at bedtime for Depression AEB inability to fall/stay asleep; - On August 3, 2024 an order for Quetiapine Fumarate tablet give 25 mg by mouth at bedtime for Dementia with Psychosis AEB Delusions; - On February 24, 2025 an order for Namenda oral tablet 5 mg (Memantine HCl) give 1 tablet by mouth one time a day for Dementia; - Monitor side effects every shift of anti-depressant medication: (sedation, drowsiness, headache, decreased appetite. Less common side effect: dry mouth, blurred vision, urinary retention. Rare side effect: extra pyramidal); and - Monitor side effects every shift of anti-psychotic medication (involuntary movements, drowsiness, dry mouth, blurred vision, constipation, temporary impotence, nasal stuffiness, weight gain, loss of appetite, sweating. Less common side effect: edema, extra pyramidal symptoms, postural hypotension, urinary retention, stiff or tight muscles, shakiness, restlessness. Rare side effects: tardive dyskinesia, jaundice, allergic reaction, increased photosensitivity, allergic dermatitis. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9.0, indicating moderately impaired; does not exhibit behavior symptoms; does not exhibit rejection of care; does not exhibit wandering; no psychosis, no delusions, and resident is receiving antipsychotic and antidepressant medications. Review of record, Medication Regimen Review (MRR), dated March 4, 2025 revealed a consultant pharmacist's recommendation for a trial dose reduction of the medication quetiapine from 25 mg to 12.5 mg every day. The resident's physician/prescriber agreed with the recommendation and clinical rationale on April 24, 2025. Review of medication administration record (MAR) for April, May, and June 2025 revealed resident was administered Quetiapine Fumarate 25 mg by mouth at bedtime for Dementia with Psychosis AEB Delusions, and resident was monitored for psychotic behavior episodes for delusions every shift. However, the April, May, and June 2025 medication administration record revealed that the medication Quetiapine 12.5 mg dose reduction was not implemented. An interview was conducted on June 3, 2025 at 4:07 pm with the Director of Nursing (DON)/Staff #50 and present during the interview was Clinical Resource/Staff #900. The DON stated that her Assistant Director of Nursing (ADON)/Staff #54 spears head the process regarding medication regimen review pharmacy consultation recommendations. The DON stated that the ADON gets all the recommendations from their consultant pharmacist and then the ADON will discussed it with the provider. The provider will decide if agrees with the consultant pharmacist's recommendation. If the provider agrees with the consultant pharmacist's recommendation, the DON stated that the resident's medical record will be updated. If the recommendation is to decrease the dosage of the medication, then the resident's medical record will be update. On June 3, 2025 at 4:12 pm, the ADON/Staff #54 arrived in the DON's office. An interview was conducted with the ADON, and present during the interview were the Director of Nursing (DON)/Staff #50 and Clinical Resource/Staff #900. The ADON stated that he will follow the provider's orders and follow the recommendation from the MRR. While the ADON was looking at Resident #54's March 4, 2025 MRR document, the ADON stated that the MRR recommendation dose reduction of quetiapine was from 25 mg to 12.5 mg , and was signed by the provider on April 24, 2025. On the other hand, while the DON was looking at Resident #54's June 2025 MAR, she stated that the current order for quetiapine medication is at 25 mg. The ADON stated that the provider wanted the medication dose updated. The DON stated that the quetiapine order was not updated in the June 2025 MAR. The DON stated that her expectation is that she will include the psychiatrist, talk to her staff and the provider. The DON stated that the process is to include the psychiatrist, and that she will follow up with the resident's provider immediately after today's date. The DON stated that the medication regimen review should have been immediately taken care of after it was caught. The survey exited on June 4, 2025 at 8:51 am. On June 4, 2025 at 1:26 pm, a document via email was received from the Director of Nursing regarding Resident #54's psychotropic medication gradual dose reduction (GDR). The document titled, Consent for Treatment: Use of Antipsychotic Medication, dated April 25, 2025 revealed a consent for medication quetiapine daily dose of 12.5 mg, signed and dated by the resident's representative on April 24, 2025, and has an additional hand written notes on the bottom of the page,Consent to maintain current treatment of 25 mg per day quetiapine. Provider aware. Review of facility's policy, Medication Regimen Review, with a last reviewed date of August 2023 revealed (A) MRR recommendations to physician: the report is provided by the pharmacist or facility to the responsible physician, facility's Medical Director and the Director of Nursing Services within seven working days of review. (6) In performing drug regimen review, the pharmacist utilizes federally mandated standards of care, in addition to other applicable standards. (7) Nursing will review pending pharmacy recommendation each month and report pending recommendations to the providers. Review of facility's policy, Psychoactive Medication, last revised date on May 2023 revealed (12) perform gradual dose reduction (GDR) as per regulatory guidelines to find an optimal dose or to determine whether continued use of the medication is benefiting the resident. Tapering may be indicated when the resident's clinical condition has improved or stabilized.

Based on clinical record reviews, facility documentation, staff interviews, policy and procedures, the facility failed to investigate, prevent, or correct an alleged violation of abuse for one resident #64. The allegation of verbal abuse was thoroughly investigated involving two residents (#64) and (#41). The deficient practice could result in abuse not being addressed and investigated. Findings include: -Resident #64 was admitted to the facility on [DATE] with diagnoses of morbid (severe) obesity due to excess calories, essential hypertension, Lymphedema, and hypothyroidism. -Resident #41 was admitted to the facility on [DATE] with diagnoses of bipolar disorder, pulmonary hypertension, arthrosclerotic heart disease of native coronary arteries without angina pectoris. On June 1, 2025 at 11:49 a.m the resident #64 stated I have a big problem, my roommate accused me of stealing her stuff from her table; also accused me of stealing her credit card. The resident #64 continued the nurses know about it, the social services knows about it! This morning resident #41 called me a fat fucking pig, and she prayed for me to die almost daily. The resident #64 further stated this room was supposed to be my home; I was here first. I do not feel comfortable with my roommate in the room. The resident #64 nodded when asked if she thought she was verbally abused by resident #41. Resident #64 also stated that she never let the Ombudsman know because the facility staff knew about it. However, when interviewing the other roommate, resident #41 on June 1, 2025 at 1:06 p.m the resident stated I do not like my roommate because she turns the light on the whole night, and I cannot sleep with the light on so my roommate reported me to the nurses all the time, and they moved me, but I don ' t like it, I want my bed next to the window. Review of both Nursing and Physician notes found no report of any verbal altercation between the two roommates #64 and #41. The Social Service notes stated this resident to resident altercation after the matter was brought to the Director of Nurse's (DON) attention on June 1, 2025. There was no report of incompatibility between the roommates prior to June 1, 2025 found on the record. The Social Service note on June 1, 2025 stated Spoke with patient #41 regarding roommate incompatibility. Offer a room change. The patient refused to move rooms. Offered to switch sides. The patient refused to switch sides. The patient denies making unkind comments toward the roommate. The patient agreed to be cordial with the roommate and involve Social Services Department (SSD) in future conflict. This followed by another Social Service note on June 2, 2025 that stated SSD followed up with resident #41 and roommate and reviewed agreement. Offered room change for both roommates and both refused, again. Reviewed preferences and both agreed to the specific distance of the divider curtain between them. Both agreed to be cordial and involve SSD in future conflict. The facility was unable to provide any evidence that a verbal abuse investigation had been completed regarding this altercation. There is no trail of investigation or plan of correction records found prior to June 1, 2025 regarding this resident to resident verbal altercation. During an interview with one of the CNA #63 conducted on June 3, 2025 at 9:15 a.m, the CNA #63 stated that the resident #64 always complained that resident #41 kept coming to search her belongings at her side. This created an exchange of words between the two residents cursing each other. The CNA #63 stated that she reported the matter to the nurses and both the nurses and the leaders always talked to both residents and offered solutions such as separating them to different rooms. However, according to the CNA #63, both residents do not want to change their rooms. An interview with LPN nurse staff #112 who works for the residents stated that this is an ongoing matter, at least for three months where the facility leaders tried to offer room change but both residents declined to move out of their current room. The nurse #112 stated that she never encountered any altercation between the roommates but the CNAs has brought the issues to her attention, however, there is no record that these verbal altercations have been reported on both the residents ' files. An interview with the Director of Nurse #50 on June 3, 2025 stated that resident #41 is declining intermittently, however the DON stated that the challenge is both residents refused to move out of the rooms because they are still well alert and the leaders considered their resident rights, they tried to monitor the residents by giving them the options mentioned earlier. An interview with the social worker #39 on June 3, 2025 at 9:22 a.m stated that she received the report of the roommate verbal altercation on June 1, 2025 following the report made by the surveyor on June 1, 2025. An interview with the administrator, staff #96 on June 3, 2025 at 9:46 a.m stated that he was not aware of this resident to resident altercation until the surveyors reported the matter to the DON and the staff on June 1, 2025. The facility conducted an investigation on this matter following the report made by the surveyors on June 1, 2025. Review of the Abuse and Neglect policy titled: Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, revealed verbal abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The procedure included that the facility in response to the alleged violations involving abuse will ensure to be reported to the (a) the administrator, (b) the state agency, and (3) Adult Protected Services (as appropriate). However, if the events that cause the allegation does not involve abuse and does not result in serious bodily injury should be reported to the facility leadership team no later than twenty-four (24) hours. Furthermore, after receipt of a report of possible abuse, neglect, mistreatment, or misappropriation of resident property, steps are immediately taken to protect the identified residents and the of all allegations are reported within five (5) working days of the incident to: (a) Administrator and (b) The State Survey Agency. The policy further included that the facility will have evidence that all alleged or suspected violations are thoroughly investigated.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a referral for a PASARR (Pre-admission Screening and Resident Review) level II determination was obtained timely for one resident (#57). This deficient practice could result in residents not receiving the appropriate level of services. Findings include: Resident #57 was admitted to the facility on [DATE], with diagnoses that included schizophrenia and depression. The PASARR level I screening dated May 17, 2024 and August 15, 2024, revealed the resident had a serious mental illness of schizophrenia, a mental disorder of depression, and that a PASSAR Level II referral was not necessary. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicates cognitively intact; resident's mood revealed symptoms of feeling down, depressed, or hopeless with frequency of several days; and the resident had an active diagnosis of schizophrenia and depression. Review of the care plan initiated on August 9, 2023, revealed the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to Schizophrenia, history of cerebrovascular accident (CVA) with Right Sided Weakness, Depression, and hypertension. A review of psychiatric progress notes dated February 25, 2025 revealed resident has a history of recurrent major depressive disorder, active schizophrenia, and delusional disorders. The resident continues to request for valium for nerve pain but will not be given to him by psych provider. Resident mood: depressed, anxious, calm, cooperative. A physician progress note dated April 16, 2025 revealed the resident stated that resident used to take Valium four times a day. The resident's psychiatrist does not want resident to be on Valium. Despite documentations that the resident had a diagnosis of schizophrenia and depression, a referral for a PASARR Level II determination was not obtained. An interview was conducted on June 3, 2025 at 10:56 am with a Case Manager/Staff #39 in the conference room. Staff #39 stated that her roles are she follows their skilled residents and assists with the long-term part with Staff #73. She stated that she coordinates with the insurance and initiates process for discharge. Regarding the PASARR process, she stated that it is done upon admission. If resident does not have one, she completes one. And, if a resident has a level one PASARR, then the resident won't need another one after 30 days. She stated that a PASARR Level two is done if the resident meets the criteria for each box: mental illness (MI) symptoms, psych treatment, psych meds, and developmental disability. She stated that regarding a resident with schizophrenia diagnosis as mental illness, she would find out if the resident meets the level 2 PASARR by looking at the resident's symptoms, psych treatment history, psych medication and diagnosis, then she will submit it to AHCCCS (Arizona Health Care Cost Containment System). The AHCCCS will review the PASARR, and if resident meets level 2 PASARR, she will receive a notification from AHCCCS if the resident meets the criteria. In addition, she stated that for a long-term care resident, the PASARR is done when resident has a status change. Staff #39 brought her laptop computer with her during the interview. While she was looking at Resident #57 electronic health record in PCC (Point Click Care), she stated that she sees a level one PASARR dated August 15, 2024, and resident has a SMI (serious mental illness). She stated that the resident did not meet the other criteria for level two PASARR because resident does not have symptoms, resident was evaluated by a psychiatrist on August 15, 2024, and the resident only met one criteria. She stated that the resident has to meet all criteria to be sent for PASARR level two referral. She restated that just by having a SMI will not qualify a referral for level two PASARR without having dementia. An interview was conducted on June 3, 2025 at 4:19 pm with the Director of Nursing (DON)/Staff #50 in her office, and present during the interview is the Clinical Resource/Staff #900. The DON stated that the social service does the PASARR and she will differ the interview to them. After the DON was informed that the surveyor had interviewed the case manager regarding PASARR, the DON stated that her understanding of PASARR is that there are other criteria to be met, and as far as her understanding, the resident did not meet the criteria with having a schizophrenia diagnosis alone. The survey exited on June 4, 2025 at 8:51 am. On June 5, 2025 at 7:53 pm, a document was received via email from the Clinical Resource/Staff #900. The document revealed the facility's compliance with the PASARR level two screening process. The document revealed A diagnosis of schizophrenia does not automatically trigger for a Level II PASARR evaluation. In accordance with the Social Security Act Title 42, CFR 483.102(b)(2), an individual must meet the criteria of having a Serious Mental Illness (SMI) to be referred for level II. An individual is considered to have a serious mental illness based on 3 things: diagnosis, level of impairment (serious limitations), and duration of illness (recent treatment). All three must be met to request a Level II evaluation. Review of facility's policy, PASRR, last reviewed on May 2022 revealed that the facility will refer to the state's AHCCCS Pre-admission Screening and Resident Review (PASRR) policy.

The facility failed to ensure appropriate infection control measures were implemented and followed for one resident (#56) with a feeding tube while administering tube feeding. The deficient practice could result in a spread of preventable illness to residents and staff. Findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included hereditary ataxias, protein-calorie malnutrition, and gastrostomy status. Review of Resident #56's care plan revealed a focus, initiated June 10, 2024, which indicated that Resident #56 required tube feeding related to dysphagia. Interventions in place for this focus included to use enhanced barrier precautions. Review of physician orders revealed an order, dated June 10, 2024, which indicated that Enhanced Barrier Precautions (EBP) were in place. The order indicated that Personal Protective Equipment (PPE) was required for high resident contact care activities, related to having a feeding tube. Review of the Minimum Data Set (MDS) dated [DATE] revealed that the resident had a feeding tube while a resident. The MDS revealed that the resident received 51% or more of her totally calories through tube feeding, and averaged 501cc per day or more of fluids by IV or tube feeding. Observation of a tube feeding for Resident #56 was conducted on June 2, 2025 at 1:28PM with a Registered Nurse (RN/Staff #18). Prior to beginning the tube feeding, the RN prepared his materials and conducted hand hygiene. The RN then donned gloves but no gown. The RN proceeded to flush the tube, administer the tube feeding per the orders, and flush again the system without issue. The entire tube feeding was conducted by the RN without the use of a gown. Interview was conducted on June 2, 2025 at 1:33PM with the RN who conducted the tube feeding. When asked if the RN had received training on Enhanced Barrier Precautions (EBP), the RN stated he was not familiar with what EBP was. The RN was then asked what types of isolation are implemented at the facility. The RN stated he knew he had a few residents on contact precautions and maybe an airborne precautions room, but he was unsure of other isolations being used. The RN stated that he might have received in-service training on EBP but he would have to verify this. Interview was conducted on June 3, 2025 at 1:25PM with the Director of Nursing (DON/Staff #50), who stated that she would expect EBP to be used for any residents with feeding tubes, PICC lines, wounds, or catheters to be placed on EBP. She also stated that a gown and gloves should be used any time staff is providing advanced care to a resident on EBP. Review of the facility policy titled, Infection Prevention and Control Program, revealed that under the infection control program, the facility will decide what measures/interventions should be applied in individual circumstances. Review of the facility policy titled, IPCP Standard and Transmission-Based Precautions, revealed that EBP required the use of gown and gloves during high-contact resident care activities for residents with wounds and/or indwelling medical devices (including feeding tubes).

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#57) was free from abuse from a visitor, five residents (#116, #59, #126, #112, and #134) were free from abuse from another resident and prevent an injury of unknown origin for one resident (#118). The deficient practice could result in residents being abused. Findings include: Regarding resident #116 and resident #117: -Resident #116 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, necrotizing enterocolitis, anxiety, anemia, gastroesophageal reflux disease, hypertension, dementia with behavior disturbance, fracture of left ulna, fracture of left radius, moderate protein-calorie malnutrition, cellulitis left upper limb, and major depressive disorder. A progress note dated [DATE] at 10:56 AM, that stated staff witnessed another resident (#117) place his hands on the resident's (#116) neck. No injuries were noted and no signs of pain. The care plan dated [DATE] revealed the resident wandered aimlessly and was disoriented to place with impaired safety awareness with an intervention to document wandering behavior and attempted diversional interventions. The Brief Interview for Mental Status (BIMS) score dated [DATE] was 0 indicating resident had severe cognitive impairment. The clinical record revealed that the resident was discharged to the hospital on [DATE]. -Resident #117 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, major depressive disorder, suicidal ideation's, diabetes mellitus, anxiety, insomnia, hyperlipidemia, and weakness. The BIMS score dated [DATE] was 13 indicating he was cognitively intact. Review of a progress note dated [DATE] at 10:56 AM, that stated the patient was witnessed physically putting his hands on another resident's (#116) neck. The two were immediately separated. The resident (#117) began making suicidal statements and throwing items at staff. The resident #117 was transported by emergency personnel to the emergency room . Review of resident #117's care plan did not reveal any behaviors displayed by the resident. The clinical record revealed the resident was discharged to the hospital on [DATE]. The facility's investigative documentation revealed that staff #9 witnessed resident #117 get up during an activity and put his hands around resident #116's neck. The two residents were immediately separated. No injuries were noted. Resident #117 was sent out to the emergency room due to his behaviors. During an interview conducted with a certified nursing assistant (CNA/staff #12) on [DATE] at 2:28 p.m., the CNA stated that residents were not allowed to wander into other resident's rooms; and, if a resident wander into another room, she will redirect them to go somewhere else. An interview was conducted on [DATE] at 2:45 p.m., with a Registered Nurse (RN/staff #65) who stated that residents were not allowed to wander into other resident's rooms. The RN said that she will redirect the resident from wandering into other resident's room by talking to the resident, changing their direction, or by offering them a snack. Regarding resident #57: -Resident #57 was admitted to the facility on [DATE], with diagnoses that included dementia, schizophrenia, dysphagia, hyperlipidemia, major depressive disorder, anxiety disorder, hypertension, and convulsions. Review of resident #57's clinical records revealed the resident had wandered into another resident's (#47) room on [DATE] at 1:52 PM. The other resident's visitor attempted to redirect the resident out of the room and accidentally scratched the resident's right shoulder/neck area. The visitor was educated to ask staff for assistance and was asked to leave the facility pending further investigation. No injury was noted other than a mark to the right shoulder. The care plan dated [DATE], revealed the resident was at risk for wandering and is disoriented to place with impaired safety awareness with an intervention to document wandering behavior and attempted diversional interventions. The facility's investigative documentation revealed a summary that stated resident #57 had wandered into another resident's room and when the other resident's visitor attempted to redirect the resident, the visitor scratched resident #57's right shoulder. Regarding injury of unknown source for resident #118 -Resident #118 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, muscle weakness, cognitive communication deficit, hypertension, epilepsy, syncope and collapse, adjustment disorder, anxiety disorder, depression, and adjustment insomnia. The resident discharged on [DATE] and deceased on [DATE]. The progress notes dated [DATE] at 5:00 PM, revealed the resident had bruising around her left eye. The resident stated that her cousin did it; however, it was documented that no family members had recently visited the resident. No probably cause of the bruising was identified. A care plan dated [DATE], revealed the resident was at risk for falls. Interventions included: avoid rearranging furniture, encourage resident to wear appropriate footwear when ambulating or wheeling in wheelchair; keep needed items within reach; maintain a clear pathway, free of obstacles; and physical therapy evaluation. A care plan dated [DATE], revealed the resident was at risk for wandering and disoriented to place with impaired safety awareness with an intervention to document wandering behavior and attempted diversion interventions. Review of the facility's investigative documentation revealed a summary that stated resident #118 had bruising under her left eye and that her cousin did it. There was no documentation of any falls. The patient was independent with ambulation and wandering behaviors. She was capable of picking things up off the floor so the injury was likely a result from her trying to pick something up from the floor and bumped her eye on a piece of furniture. During an interview conducted on [DATE] at 11:00 AM, the Administrator (staff #34) stated that they were unable to interview resident #118 due to her cognitive status to obtain more information. The administrator said that staff were not aware of any visitors; and that, there were no visitors identified on the visitor log as family members of the resident. The administrator said that the facility visitor logs at that time were temperature check logs for Covid and were not actual visitor logs. 21369 Regarding resident #59 and resident #109: -Resident #59 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dementia, psychosis, amnesic disorder and major depressive disorder. The MDS (Minimum Data Set) assessment dated [DATE] that revealed a BIMS score that the resident had been assessed with severe cognitive impairment. -Resident #109 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis due to cerebral infarction, acute kidney failure, depression, and epilepsy. An MDS assessment dated [DATE] a BIMS that the resident had been assessed with severe cognitive impairment. On [DATE], the facility reported to the State Agency (SA), that resident #109 was found in the room of resident #59 who was in bed; and that, a staff observed resident #109 hitting resident #59. A review of the facility's investigative documentation dated [DATE] that resident #109 stated he was hitting resident #59 because he thought resident #59 was in his bed and he was kicking him out. Resident #59 was assessed with swelling under his right eye. Regarding resident #127 and resident #126: -Resident #127 was admitted on [DATE] with diagnoses that included dementia with behavioral disturbances, acute respiratory failure, unspecified psychosis, anxiety disorder, and unspecified mood disorder. An MDS assessment dated [DATE] that revealed a BIMS assessed that documented the resident had severe cognitive impairment. -Resident #126 was admitted on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbances, stage 3 chronic kidney disease, and dysphagia. An MDS assessment dated [DATE] revealed a BIMS that the resident had been assessed with severe cognitive impairment. On [DATE], the facility reported to the SA that resident #127 had picked up a chair and repeatedly hit resident #126 with the chair. According to the facility documentation, resident #126 went out to the hospital for evaluation and treatment on [DATE]; and the resident had a closed laceration to the top of his head and bruising on his forearms. A review of the facility's investigative report dated [DATE] revealed documentation that staff were in the process of getting resident #126 into bed; and, the staff left resident #126 in a chair in his room while the staff left the room to get resident #125's wheelchair. When staff returned to the room, the staff witnessed resident #127 push resident #126 out of the chair and resident #126 went to the floor. Per the documentation, the staff witnessed resident #127 pick up a chair and began hitting resident #126 on his head; and that, the staff separated the residents. Further review of the investigative documentation revealed an interview with resident #127 who stated he thought resident #126 had stolen his stuff. Regarding resident #112 and resident #114: -Resident #112 was admitted on [DATE] with diagnoses that included paraplegia, unspecified convulsions, fibromyalgia, major depressive disorder, mood disorder, and post-traumatic stress disorder. An MDS assessment dated [DATE] included the resident had a BIMS score of 14 indicating the resident had intact cognition. On [DATE], the facility reported to the State Agency (SA) of an incident where resident #112 was witnessed to be slapped in the face by resident #114. A review of the facility's investigative documentation revealed statements from staff that stated they had witnessed resident #114 slap resident #112; and that, resident #112 reported that she had been slapped by resident #114. 48926 Regarding resident #135 and #134: -Resident #135 was admitted on [DATE] with diagnoses including type 2 diabetes mellitus, chronic kidney disease, dementia, cognitive communication deficit, and schizophrenia. The MDS assessment dated [DATE] revealed a BIMS score of 00, indicating resident had severe cognitive impairment. Further review of the MDS revealed the resident had exhibited verbal behaviors directed at others on one to three days of the seven-day assessment period. The comprehensive care plan revealed the resident received psychotropic medications for auditory hallucinations and angry outbursts. Intervention to provide a calm, quiet environment during episodes of yelling. -Resident #134 was admitted on [DATE] with diagnoses of dementia, anxiety, diabetes mellitus type 2, and aphasia. Review of the MDS assessment revealed the resident had exhibited verbal behaviors directed at others on one to three days of the seven-day assessment period; and, had a BIMS score of 00 indicating severe cognitive impairment. The comprehensive care plan included that the resident received an anti-anxiety medication for anxiety as evidenced by pacing. Intervention included to provide a calm, quiet environment when pacing. The nursing progress note dated [DATE] at 11:12 a.m. revealed resident #134 had been in a fight with resident #135 and received a scratch on the neck. Review of the facility report dated [DATE] revealed that the licensed practical nurse (LPN) had reported a resident to resident altercation involving residents #134 and #135; and that, resident #134 had a scratch on her arm and on her neck. Resident #135 was reported to have no visible injuries. The facility report concluded that a resident to resident altercation had occurred. Review of the facility policy titled Abuse: Prevention and Prohibition Against dated [DATE], revealed that each resident had the right to be free from abuse including injuries of unknown origin. The policy included the facility will take action to protect and prevent abuse and neglect from occurring within the facility by; identifying, correcting and intervening in situations in which abuse is more likely to occur; and identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as: Verbally aggressive behavior, physically aggressive behavior, and wandering into other's rooms/space. The policy further included that if an allegation of abuse is reported, discovered or suspected, the facility will protect all residents from physical and psychosocial harm during and after the investigation; including increase supervision of the alleged victim and residents. If the allegation of abuse involved another resident, the facility will separate the residents so that they do not interact with each other until circumstances of the reported incident can be determined and the facility would continue to assess, monitor and intervene as necessary to maximize resident health and safety.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure adequate supervision was provided to prevent resident from wandering into other resident's room for two residents (#57, #116); and, prevent one resident (#129) from elopement. The deficient practice could result avoidable harm to all residents due to lack of adequate supervision. Findings include: -Resident #57 was admitted on [DATE], with diagnoses that included dementia, schizophrenia, major depressive disorder and anxiety disorder. The progress notes dated September 29, 2023 revealed the resident was unable to communicate needs, was monitored for safety, ambulated independently on the hall and wandered in and out of rooms. The progress notes dated October 1, 2023 at 1:52 p.m., revealed the resident had wandered into another resident's room; and that, the visitor of the other resident attempted to redirect the resident out of the room. The care plan dated August 25, 2023 revealed the resident was at risk for wandering, was disoriented to place and had impaired safety awareness. Intervention included to document wandering behavior and attempted diversional interventions. Review of the facility's investigative documentation revealed that resident #57 had wandered into another resident's room; and that, the other resident's visitor attempted to redirect the resident. There was no evidence found in the clinical record and facility documentation that adequate supervision was provided to prevent resident #57 from wandering to other resident's room. -Resident #116 was admitted on [DATE] with diagnoses of metabolic encephalopathy, necrotizing enterocolitis, anxiety, dementia with behavior disturbance and major depressive disorder. The Brief Interview for Mental Status (BIMS) score dated June 15, 2022 was 0 indicating resident had severe cognitive impairment. The care plan dated August 18, 2021 revealed the resident wandered aimlessly, was disoriented to place, and had impaired safety awareness. Intervention included to document wandering behavior and attempted diversional interventions. A progress note dated July 22, 2022 included that the resident was alert and confused; and that, she was monitored for wandering and poor safety awareness. There was no evidence found in the clinical record and facility documentation that adequate supervision was provided to prevent resident #57 from wandering to other resident's room. A progress note dated July 23, 2022 at 11:09 a.m. revealed that the nurse heard a loud thud and found the resident lying on her back on the floor. Per the documentation, the resident was bleeding from her mouth and the back of her head; and, had a skin tear on her left arm. It also included that 911 was called and the resident was transported to the emergency room . A progress note dated July 26, 2022 at 1:35 p.m. included that the fall committee interdisciplinary team determined that the resident had wandered into another resident's room and startled the other resident who was sleeping. The other resident raised his arm when he was startled and resulted in resident #116 losing her balance and falling. Review of the facility's investigative documentation revealed that resident #116 had wandered into another resident's room. During an interview conducted with a certified nursing assistant (CNA/staff #12) on January 19, 2024 at 2:28 p.m., the CNA stated that residents were not allowed to wander into other resident's rooms; and, if a resident wander into another room, she will redirect them to go somewhere else. An interview was conducted on January 19, 2024 at 2:45 p.m., with a Registered Nurse (RN/staff #65) who stated that residents were not allowed to wander into other resident's rooms. The RN said that she will redirect the resident from wandering into other resident's room by talking to the resident, changing their direction, or by offering them a snack. In an interview with the lead CNA (staff #100) conducted on January 19, 2024 at 2:55 p.m., the lead CNA stated that residents were not allowed to wander in other resident's rooms; and that, she will redirect the resident, ask them to come with her or go over where she is, or get them a drink/snack. 21369 -Resident #129 was admitted on [DATE] with diagnoses of epilepsy, unspecified dementia, anxiety disorder, dysphagia, and fibromyalgia. The elopement/wandering assessment dated [DATE] included that the resident was a high risk for elopement/wandering. The care plan dated December 11, 2023 revealed that the resident was an elopement risk and a wanderer related to disorientation to place and impaired safety awareness; and that, the facility entrances/exits are secured (alarmed), but resident is able to move freely throughout the building. The care plan did not identify any other interventions. On December 13, 2023, the facility reported that on December 12, 2023 at approximately 1:30 p.m., staff were looking for the resident; and that, the resident was not in his room. According to the documentation, the resident was found outside the front of the building. Per the facility's investigative report dated December 21, 2023, staff reported last seeing the resident at the nurses' station, visiting with staff at approximately 1:15 p.m. The investigative report only documented that the resident was found outside in front of the building; and that, the resident reported that he was looking for his wife. An interview was conducted on January 16, 2023 at 2:30 p.m. with staff #57 who stated that when a resident was assessed as a high risk for elopement/wandering, the care plan interventions would be implemented as soon as possible but within 24 hours of the assessment. In an interview with staff #34 conducted on January 18, 2024 at 11:00 a.m., staff #34 stated that resident #129 left the building without staff knowledge; and that, there was no documentation of any alarms going off. Staff #34 further stated that the resident exited the building through the front door which was not alarmed. Review of the facility policy titled Abuse: Prevention and Prohibition Against dated October 2022, revealed that each resident had the right to be free from abuse including injuries of unknown origin. The policy included the facility will take action to protect and prevent abuse and neglect from occurring within the facility by; identifying, correcting and intervening in situations in which abuse is more likely to occur, to include validating that the facility has deployed the correct number of competent staff on each shift to meet the needs of the residents; and identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as: Verbally aggressive behavior, physically aggressive behavior, and wandering into other's rooms/space. The policy further included that if an allegation of abuse is reported, discovered or suspected, the facility will protect all residents from physical and psychosocial harm during and after the investigation; including increase supervision of the alleged victim and residents. If the allegation of abuse involved another resident, the facility will separate the residents so that they do not interact with each other until circumstances of the reported incident can be determined and the facility would continue to assess, monitor and intervene as necessary to maximize resident health and safety.

Based on clinical record review, staff interviews, facility documentation, and policies and procedures, the facility failed to complete a thorough investigation to rule out abuse regarding an injury of unknown origin for one resident (#118). The deficient practice could result in the injury of unknown origin not investigated and appropriate corrective actions not taken. Findings include: Resident #118 was admitted on [DATE], with diagnoses of metabolic encephalopathy, muscle weakness, cognitive communication deficit, hypertension, epilepsy, syncope and collapse, adjustment disorder, anxiety disorder, depression, and adjustment insomnia. The progress notes dated December 9, 2023 at 5:00 p.m., revealed the resident had bruising around her left eye; and that, the resident reported that her cousin did it. The clinical record revealed no documentation that the bruise was assessed to include description on color or size. There was no facility documentation found that family members recently visited the resident. Review of a care plan dated June 8, 2023, revealed the resident was at risk for falls. Interventions included to avoid rearranging furniture, encourage resident to wear appropriate footwear when ambulating or wheeling in wheelchair; keep needed items, watch, in reach; maintain a clear pathway, free of obstacles; and physical therapy evaluation. A care plan dated September 9, 2023, revealed the resident was at risk of wandering, was disoriented to place and had impaired safety awareness. Intervention included to document wandering behavior and attempted diversion interventions. The skin evaluation dated December 14, 2023 (approximately 5 days after the bruise was identified) included that the resident continues with bruised on eye. A physician progress note dated December 14, 2023 revealed that the resident reported her cousin slapped her in the face; and that, staff reported that the resident kept on saying the same thing. Review of the facility's investigative documentation revealed that resident #118 had bruising under her left eye; and that, her cousin did it. Per the documentation, there was no documentation of any falls; the resident was independent with ambulation, had wandering behaviors, was capable of picking things up off the floor; and that, the injury was likely a result from her trying to pick something up from the floor and bumped her eye on a piece of furniture. There was no evidence found that this incident was thoroughly investigated by the facility to include any interviews conducted. During an interview conducted on January 18, 2024 at 11:00 a.m., the Administrator (staff #34) stated that they were unable to interview resident #118 due to her cognitive status. The administrator said that staff were not aware of any visitors; and that, there were no visitors identified on the visitor log as family members of the resident. The administrator said the facility visitor logs at that time were temperature check logs for Covid and were not actual visitor logs. The administrator further stated that the family was not contacted during the investigation to determine if anyone had visited the resident. Review of the facility policy titled Abuse: Prevention of and Prohibition Against dated October 2022 revealed that the investigation would include interviews with person(s) reporting the incident, the resident(s) involved, any witnesses to the incident including the alleged perpetrator and staff member(s) on all shifts who may have information regarding the alleged incident.

Based on clinical record review, staff interviews and facility policy, the facility failed to ensure adequate supervision was provided and fall prevention measures recommended by the provider were implemented for 1 of 3 sampled residents (#8). The deficient practice could result in resident having injury from a preventable fall. Findings include: Resident #8 was admitted on [DATE] with diagnoses of malignant neoplasm of brain, cerebral edema, and anxiety disorder. A fall risk evaluation dated 7/26/2023 included a score of 15, which indicated the resident was a high risk for fall. It also included that the resident had a history of falls and had 1-2 falls in the past 3 months. The care plan dated 7/26/2023 revealed the resident was at risk for falls. Intervention included bed in lowest position. A care plan initiated 7/27/2023 included that the resident was an elopement risk/wanderer related to being disoriented to place; and that, he had impaired safety awareness. Interventions included to assess for fall risk. -Fall #1: A fall risk evaluation dated 7/30/2023 included a score of 2 indicating the resident was low risk for fall. It also included that the resident had no history of falls in the past 3 months. The nursing note dated 7/30/2023 revealed that the resident was found lying on his back with his head against the wall with the wheelchair next to the resident's left side. Per the documentation, the resident had previously been seen sitting in a wheelchair in the hallway and the resident refused to get out of his wheelchair. The documentation included that it was apparent that the resident attempted to get out of his wheelchair without locking the chair which resulted in the fall. Another nursing note dated 7/30/2023 revealed that the resident had several areas of bruising, skin tear and a laceration; and that, the injuries were consistent with the fall. Further, the documentation included that the resident was monitored by the CNAs (certified nurse assistants) and the floor nurse. A fall risk evaluation dated 7/31/2023 included a score of 9 indicating the resident was a medium risk for fall. It also included the resident had 1-2 falls in the past 3 months. A Nurse Practitioner/Physician's Assistant (NP/PA) progress note dated 7/31/23 included that the resident was alert and oriented x3, had falls, will get up and would walk ADLIB. Assessment included impaired mobility, weakness with recurrent falls. Per the documentation, a 1:1 sitter was recommended. However, review of the clinical record revealed no evidence that the resident was provided with a 1:1 sitter. -Fall #2: The fall committee IDT (interdisciplinary team) note dated 7/31/2023 included that on 7/31/2023 at around 6:00 a.m., the resident was found on the floor in supine position with his head against the wall. Per the documentation, the resident was alert and oriented x1, had poor impulse control, [NAME] poor safety awareness and was alone at the time of the incident. It also included that fall appeared consistent with resident trying to get out of wheelchair by himself. The documentation also included that the resident had light purplish discoloration on the left arm, right hand and coccyx and a small skin was found on left eyebrow and right elbow; and that, four hours after the incident, resident's right hand got swollen. X-ray was ordered and had negative results. Further, the documentation included that neuro checks were started and interventions i.e., labs ordered were implemented. -Fall #3 A nursing note dated 7/31/2023 included that the resident was ambulating without assistance and with an unsteady gait. Per the documentation, staff assisted the resident back to bed but resident would not sit still; and that, the resident was assisted to a wheelchair due to confusion and unsteady gait. The documentation included that resident continued to get up by himself; and that, at 11:00 the nurse heard a loud noise coming from the dining room. Per the documentation, the resident was found lying on the floor on his right side with the wheelchair next to the resident. The documentation also included that the resident sustained a skin tear to the left forearm. Further, the documentation included that neuro checks were started and interventions i.e., psych consult was implemented Another fall committee IDT note dated 7/31/2023 revealed that at around 11:00, the resident was found on the floor in supine position in the dining room. Per the documentation, the resident was alert and oriented x 1, had poor impulse control and poor safety awareness and was alone at the time of the incident. It also included that the resident was last seen in his wheelchair by staff. The documentation included that the fall appeared consistent with the resident trying to get out of the wheelchair by himself and fell . The documentation also included that the resident had bruises noted on his left arm, right hand and coccyx; and, had a small skin tear on his left eyebrow and right elbow. Another nursing note dated 7/31/2023 included that the resident developed a hematoma on his back related to his previous two falls. The documentation included that there was a hard mass lump which was tender to touch and was red/blue in color found in the back area. An Admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 7 which indicated the resident had severe cognitive impairment. The assessment included the resident needed partial assistance from another person to complete some activities. The weekly skilled review dated 8/2/2023 included that the resident had poor safety, poor balance, poor mobility and poor cognition. It also included that the resident had impulsivity and had a TUG (Timed Up and Go) test score of 22 indicating the resident was a high fall risk. The physician admission progress note dated 8/2/2023 revealed the resident continued to experience falls and his new baseline may need to be considered as non-ambulatory for safety; but that, therapy would determine that. Assessments included impaired mobility, weakness with recurrent falls. Plan was for a 1:1 sitter. A NP/PA progress noted dated 8/4/2023 included that the laboratory results and urinalysis were unremarkable. The documentation included that the provider continued to recommend a 1:1 sitter. -Fall #4 The nursing note dated 8/5/2023 revealed that the resident fell from his wheelchair in the dining room and sustained a laceration to his right eyebrow and a skin tear to his left lateral elbow. Per the documentation the NP ordered for the resident to be sent out to the ER (emergency room ) for possible sutures to the eyebrow. -Fall #5 The fall committee IDT note dated 8/7/2023 revealed that on 8/5/2023 at around 1:55 a.m., a CNA witnessed the resident stood up in his wheelchair and attempted to walk in the dining room; and that, the resident fell before the staff could intervene. Per the documentation, the resident sustained a laceration to the right eyebrow and a skin tear to his right elbow; and that, orders were received to send the resident to the ER due to resident potentially needing stitches to his laceration. Further the documentation included that the resident obtained stitches and a CT (computed-tomography) scan was don with no hemorrhage identified; and that, the resident was sent back to the facility within a few hours. -Fall #6 A nursing note dated 8/6/2023 included that the resident was found on the floor, sitting upright with his back against the wall. Per the documentation, the resident was alert and oriented to self only, confused and was unable to answer any questions. The documentation also included that staff informed the family who requested for the resident to be sent to the ED (emergency department); 911 was called and at 6:15 p.m., the resident was transferred to the hospital. The fall committee IDT note dated 8/7/2023 revealed that on 8/6/2023 at around 5:45 p.m. a CNA informed the nurse that the resident was found sitting upright on the floor in the dining room with his back against the wall next to his wheelchair. Per the documentation, the resident was unable to say what happened due to cognitive impairment; and that, it appeared that the resident attempted to get out of his wheelchair. The documentation included that the resident's family requested for the resident to be sent to the ED. The weekly clinical/IDT review note dated 8/11/2023 included that no further interventions required; and that, the resident had another fall and was transferred to the hospital for evaluation. Despite documentation of repeated falls, the care plan was not revised to include new interventions implemented. Despite documentation of a recommendation for 1:1 sitter, the clinical record revealed no evidence that this was provided to the resident. An interview was conducted on 8/24/2023 at 12:48 p.m. with a Licensed Practical Nurse (LPN/staff #31) who said that when a resident had a fall, she would assess for range of motion and wounds, check the resident's vitals and neuros. She said that floor staff do not make new interventions as this is done during the IDT team meeting. She stated that the floor staff can see and implement the new interventions as the clinical record was linked to the IDT notes. The LPN stated that if the physician makes a recommendation, it should be followed. Regarding resident #8, the LPN stated that the resident had a history of falls had a lot of confusion, forgetfulness and had an inability to follow commands. She said that when resident #8 first came at the facility, he was walking with a cane but was downgraded to needing a wheelchair. She stated that the resident would get up from the wheelchair by himself, was very quick on his feet and could get up at the snap of a finger. She said that she had never seen the staff not follow a provider recommendation before; however, staff do not do 1:1 to residents. In an interview with the Director of Nursing (DON/staff #15) conducted on 8/24/23 at 3:31 p.m., The DON stated that if a physician recommended a 1:1 sitter, the management would have a conversation with them and the conversation would have been documented in the progress notes. Regarding resident #8, he stated that he remembered the resident as being very impulsive. He said that the facility did not provide a full-time sitter for resident #8 but had provided temporary ones at times. He also said that the facility did not have charting on temporary 1:1 sitter. He said that the physician's recommendations of a 1:1 sitter resident #8 was not reviewed. A facility policy on Incidents and Accidents revised 7/2022 revealed that it is their policy to implement and maintain measures to avoid hazards and accidents.

Based on clinical record review, resident interview, staff interviews, and review of facility policies, the facility failed to ensure that three residents (#65, #211 and #11) received adequate supervision to prevent medication accidents. The deficient practice could result in the resident sustaining medication accident-related injuries. Findings include: -Resident #65 Resident #65 was admitted on [DATE] with diagnosis including metabolic encephalopathy, sepsis, polyneuropathy, peripheral vascular disease, non-pressure related chronic ulcer of the left lower leg and type II diabetes with other skin ulcer and skin complications. The MDS (minimum data set) dated March 1, 2023 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. A review of the care plan dated April 27, 2023 revealed no evidence of authorized medications at bedside for resident #65. A review of physician orders, for resident #65, on June 5, 2023 did not reveal evidence of an order for Voltaren 1% arthritis cream; however, Voltaren 1% arthritis cream was observed on 3 separate occasions on the bedside table of resident #65. A review of the electronic medical record revealed no evidence of an assessment for self-administration of medications for resident #65. A review of the MAR (medication administration record) revealed no evidence of self-administration monitoring for resident #65. An observation on June 5, 2023 at 10:45 a.m. revealed Voltaren 1% arthritis cream present on the bedside table of resident #65. A subsequent observation on June 6, 2023 at 10:31 a.m. revealed the presence of Voltaren 1% arthritis cream on the bedside table of resident #65. A final observation for resident #65, on June 7, 2023 at 7:45 a.m., revealed the resident eating breakfast and the Voltaren 1% arthritis cream was observed on the bedside table next to the breakfast tray. An interview was conducted on June 7, 2023 at 8:44 a.m. with a certified nursing assistant ( CNA/ staff #35.) The CNA stated that she had been working at the facility for 1.3 years. The CNA stated that, to her knowledge medications were not permitted at bedside, and that this includes all over the counter medications as well as creams. She stated that if medications were observed at bedside, she would remove the medication and inform the nurse. She stated that the risk of medications at bedside could include another resident using the medication and getting sick. An interview was conducted on June 7, 2023 with a licensed practical nurse( LPN/staff #67). The LPN stated that she had been working at the facility for 1.2 years. The LPN stated that medications included prescribed as well as over the counter medications. She stated that supplements and creams are considered medications. The LPN stated that medications were not allowed in the resident rooms unless there was an order for the medication to be self-administered, in conjunction with a self-administration assessment. She further stated that orders and assessments are found in the electronic health record (EHR). She stated that she would know if a resident was authorized to have medications at the bedside if the physician's order and assessment were present in the EHR She stated that if they were not, then the resident should not have medications in their room. The LPN stated that if an unauthorized medication was found in the resident's room, she would remove it and explain the reason to the resident. Confiscated medications are stored in the medication room, until a physician's order and assessment can be obtained. Once confiscated, the LPN stated, she would call the doctor and explain the situation. She stated that the risk factor for having medications at bedside can include other patients obtaining the medication and potentially being allergic to it. The LPN reviewed the electronic health record for resident #65 and stated that there was no evidence of a self-administration assessment, but indicated that she did locate a physician's order dated June 6, 2023 with a noted start date of June 7, 2023. An interview was conducted on June 7, 2023 with the director of nursing (DON/staff #15). He stated that he considered creams and supplements to be medications. Staff #15 further stated that medications were not to be at bedside unless there is an order and an assessment for the resident and medication. He stated that it was his expectation to have an order and assessment for any medication in the resident's room. The DON stated that risk factors of having unauthorized medications in a resident's room include not knowing what the resident is taking, or that the medication could be mixed with something else and or interact adversely with other prescribed medications. - Resident #211 Resident #211 was readmitted on [DATE] with diagnosis including lymphedema, non-pressure related ulcer on right lower leg, type II diabetes with diabetic polyneuropathy, and pain in right leg. A review of the MDS (minimum data set) dated May 23, 2023 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. A review of the physician orders, revealed an order for ammonium lactate external cream and Preparation H external cream, but revealed no evidence of an order for Cortisone-10 cream at bedside. A review of the care plan dated March 6, 2023 revealed that the resident is noted to have impairment to skin integrity. Interventions noted included good nutrition and hydration, floating heels, following facility injury treatment protocols, monitoring of skin injury, caution during transfers and bed mobility. The care plan revealed no evidence of authorized medications at bedside for resident #211. A review of the progress notes, revealed no evidence of authorized medications at bedside for resident #211. A review of the electronic health record revealed no evidence of a medication self-administration assessment for resident #211. An observation on June 5, 2023 at 1:29 p.m. revealed the presence of Cortisone-10 cream at bedside for resident #211. A subsequent observation on June 6, 2023 at 8:10 a.m. revealed the presence of Cortisone-10 on the resident's bedside table. On June 7, 2023, 2 plastic containers were observed on the resident's bedside table. An interview with resident #211 was conducted on June 7, 2023 at 7:45 a.m. with resident #211. The resident stated that she had taken the Cortisone-10 cream, mixed it with A & D ointments and stored the mixture in the previously observed containers. An interview was conducted on June 7, 2023 at 8:44 a.m. with CNA, staff #35. The CNA stated that she had been working at the facility for 1.3 years. The CNA stated that, to her knowledge medications were not permitted at bedside, and that this includes all over the counter medications as well as creams. She stated that if medications were observed at bedside, she would remove the medication and inform the nurse. She stated that the risk of medications at bedside could include another resident using the medication and getting sick. An interview was conducted on June 7, 2023 with LPN, staff #67. The LPN stated that she had been working at the facility for 1.2 years. The LPN stated that medications include prescribed as well as over the counter medications. She stated that supplements and creams are considered medications. The LPN stated that medications are not allowed in the resident rooms unless there was an order for the medication to be self-administered, in conjunction with a self-administration assessment. She further stated that orders and assessments are found in the electronic health record (EHR). She stated that she would know if a resident is authorized to have medications at bedside if the physician order and assessment were present in the EHR She stated that if they were not, then the resident should not have it in the room. The LPN stated that if an authorized medication is found in the resident's room, she would remove it and explain the reason to the resident. Confiscated medications are stored in the medication room, until a physician's order and assessment can be obtained. Once confiscated, the LPN stated, she would call the doctor and explain the situation. She stated that the risk factor for having medications at bedside can include other patients obtaining the medication and potentially being allergic to it. The LPN reviewed the electronic medical record for resident #211 and stated that there was an order for the medication, but not self-administration and there was no evidence that a self-administration assessment had been conducted. An interview was conducted on June 7, 2023 with the DON (director of nursing) staff #15. He stated that he considers creams and supplements to be medications. Staff #15 further stated that medications are not to be at bedside unless there is an order and an assessment for the resident. He stated that it is his expectation to have an order and assessment for any medication in the resident's room. The DON stated that risk factors of having unauthorized medications in a resident's room include not knowing what the resident is taking, or that the medication could be mixed with something else and or interact adversely with other prescribed medications. A facility policy titled Self-Administration of Medications with a revision date of May, 2022, revealed that if a resident would like to participate in medication self-administration, the interdisciplinary team (IDT) will assess and periodically re-evaluate the resident based on their current status. The policy further stated, that if a resident is a candidate for self-administration, that this will be indicated in the chart. Additionally, it is noted that nursing will be responsible for monitoring self-administration of medications in the eMAR (electronic medication administration record). However, IDT did not assess resident #211 for self-administration of medication, nor was there evidence in the resident's chart noting that resident #211 is a candidate for self-administration of medication. 47954 Based on closed clinical record review, staff interviews, and review of facility policies, the facility failed to ensure that one resident (#11) received adequate supervision to prevent medication accidents. The deficient practice could result in the resident sustaining medication accident-related injuries. Findings include: Resident #11 was admitted [DATE] with pertinent diagnosis that include a Chronic obstructive pulmonary disease, Depression, Hypertension, Hypothyroidism, and Weakness. Record review of a quarterly MDS (Minimum Data Set), dated January 16, 2023 noted a BIMS (Brief Interview for Mental Status) of 15, indicating that the resident has no cognitive impairment. On June 7, 2023, A bottle of pills labeled Neuriva was noted at the resident bedside. This inhaler was noted to be within arm's reach of the resident. A surveyor alerted staff to the observation and the nurse staff member removed the bottle from the resident's room. Review of the care plan revealed no care plan measures or interventions for self-administration. Review of physician orders noted no order for Neuriva or a similar medication. An interview was conducted on June 7, 2023 at 8:44 a.m. with a Certified Nursing Assistant (CNA/Staff #35). The CNA stated that if medications are not allowed at bedside. The CNA stated that if medications were found she would notify the nurse to remove the medications. The CNA further stated that another resident could get their hands on the medication and get sick as a result. An interview was conducted on June 7, 2023 at 9:45 a.m. with a Licensed Practical Nurse (LPN/staff #67) The LPN stated that medications are not allowed in the resident rooms unless there is an order where they can self-medicate. Assessments for self-medication would be in PCC. The nurse was asked to look up resident #11's profile for an order to self-medicate, and for an order for Neuriva, she stated no order or assessment was observed. An interview was conducted on June 7, 2023 at 10:09 a.m. with the DON / RN (Staff #15) The DON stated that medications are not supposed to be at bedside unless there is an order or UDA assessment. If both are not in place and medications are at bedside, The DON stated that that is not meeting his expectations. He further stated that the risk factor is that it is not known what the resident is taking, the medication could be mixed with something else and/or interact with other prescribed medications. A review of the facilities policy titled 'Self-Administration of medications' revised May 2022 revealed the facility will ensure that each resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) to determine of the resident is safe to self-administer medications. The policy further states that if a resident is a candidate for self-administration, that this will be indicated in the chart. Additionally, it states that nursing will be responsible for monitoring self-administration of medications in the eMAR (electronic medication administration record.) However, since resident #11 was not identified as appropriate for self-administration, and had no order for the medication, the resident was at risk for a medication related injury.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure a referral for a PASARR (Pre-Admission Screening and Resident Review) level II determination was obtained timely for one resident (#58). This deficient practice could result in residents not receiving the appropriate level of services. Findings include: -Resident #58 was admitted to the facility on [DATE] with diagnoses that included post- traumatic stress disorder (PTSD), major depressive disorder, anxiety disorder, and unspecified schizophrenia. The care plan initiated on August 16, 2022 revealed a problem that included at risk for re-traumatization related to history of trauma, domestic partner violence, post-traumatic stress disorder, and sexual abuse. The interventions included all care and services provided by the facility. The care plan did not address that the resident's Level I PASARR screening document indicated a referral for Level II determination for mental illness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5 which indicated the resident's cognition was severely impaired. The MDS also included a diagnoses of anxiety disorder, depression, schizophrenia, and post-traumatic stress disorder. Review of the PASARR level I screening document dated May 8, 2023, revealed that an exemption was selected due to the resident's expected stay in the nursing facility does not meet the criteria for 30-day convalescent care. The screening document included mental illness for schizophrenia, major depression, anxiety disorder, and PTSD ( post traumatic stress disorder). The screening documented symptoms of serious difficulty interacting with others, frequently isolated or avoided others or exhibited signs suggesting severe anxiety or fear of strangers, and a note indicating due to PTSD the resident can't have a roommate. Per the screening document, the resident exhibited self-injurious or self-mutilation, suicidal talk, history of suicide attempt or gestures, and excessive tearfulness. The referral determination (section D) documented yes on referral of Level II determination for dual ID (intellectual disability) and MI (mental illness). Review of the clinical record revealed that the resident remained in the facility for more than 30 days. However, record review revealed no evidence that a PASARR (Preadmission Screening and Resident Review) Level 2 was completed. An interview was conducted with the social services director (staff #41) on June 8, 2023 at 12:08 p.m. She stated all residents that were admitted to the facility were required to have a Level I PASARR prior to admission. She stated that typically she tried to do the review within the first 7 days after admission for compliance. She stated that when she completed the PASARR review, the assistants were then responsible for sending it to the state via email, contingent on the diagnosis. She stated that she had a list of potential diagnosis for the PASARR level II that included diagnoses such as depression, anxiety, schizophrenia, and PTSD. She stated the PASARR Level II submission is documented in the resident's electronic health record under social services. Staff #41 accessed/reviewed the record for resident #58 and stated the PASARR was completed on May 8, 2023. She stated based on the PASARR screening document, the resident meets the criteria for a Level II PASARR referral because the resident has multiple diagnoses of mental illness. Further, she stated that it was not submitted. She stated her assistant did not communicate to her that they were not able to reach the POA (power of attorney) for signature and this was an oversight on her part. She stated that it should have been submitted in September 2022 . She stated that the risk factors if Level II referral is not submitted timely included that the resident might not be appropriate in the facility and the resident might not get the psychological services and appropriate help needed. The facility 's policy regarding PASARR Resident Assessment revealed that the facility should ensure that each resident is properly screened using the PASARR specified by the State. The procedure indicated that the facility refers to the State' s AHCCCs (Arizona Health Care Cost Containment System) Pre-admission Screening and Resident Review (PASARR) policy. Review of a Arizona Healthcare Cost Containment System policy titled, Preadmission Screening and Resident Review (PASARR) revealed that all residents entering a Medicaid certified nursing facility must be screened for cognitive disability and or serious mental illness. The PASARR is a two-level screening process. The level 2 screening determines whether the resident can be appropriately treated in a nursing facility setting.

Based on review of facility documentation, staff interviews and review of policies and procedures, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week. Findings include: Review of the nursing unit assignment records for July 2022 revealed that on July 2 and 3, there was no RN who provided services for at least eight hours each day. Review of the daily nurse staffing posting records for July 2022 revealed that on July 2 and 3, there was no RN who provided services for at least eight hours each day. Review of the labor hours report for July 2022 revealed that on July 2 and 3, there was no RN who provided services for at least eight hours each day. An interview was conducted on June 8, 2023 at 9:55 a.m. with the staffing coordinator (staff #60). She stated that the facility schedules an RN to provide services for 8 hours per day. She stated that on July 2 and 3, 2022, the RN called off. During interviews conducted on June 8, 2023 at 12:45 p.m. with the administrator (staff #94), staff #94 stated that he was aware of the requirement that there must be an RN on duty for at least eight hours per day. He stated he was sure that there was an RN on duty on July 2 and 3, 2022 because he always has a weekend RN manager on call. He stated he will review the staffing records for the indicated dates. On June 8, 2023 at 12:52 p.m. staff #94 stated that there was an RN scheduled on July 3, 2022 but the RN called off and was replaced with LPN (licensed practical nurse). Staff #94 stated there was no RN scheduled for July 2, 2022. He stated it is his expectation that an RN is scheduled in the facility 8 hours every day. Review of the Facility Assessment with a revision dated September 2022 included a combination of RNs/LPNs on each shift. The Facility Assessment did not include the Federal requirement for RN staffing. The minimum requirement is at least one RN for 8 hours, 7 days a week.

Based on observations, staff interview, and policy review, the facility failed to ensure that food was stored in accordance with professional standards for food safety. This deficient practice could increase the risk of food [NAME] illnesses through lack of refrigeration. Findings include: During an initial kitchen observation conducted on June 6, 2023 at 8:05 a.m., a box containing small individual Kens dressing cups was observed on the shelf in the pantry. The packaging for each cup listed needs refrigeration on the top. An interview was conducted on June 7, 2023 at 10:14 a.m. with the Food Services Director (staff #117) The FSD stated that she did not see that the cups were supposed to be refrigerated and that she would put them in the refrigerator immediately. She further stated that the cups should have been stored in the refrigerator and not in the pantry or food prep area. An interview was conducted on June 8, 2023 at 1:50 p.m. with the Administrator (staff #94), The Administrator stated that his expectation was that food is stored safely according to facility policy. A review of facility policy titled Food Storage Revised April 6, 2023 stated that upon delivery, all food items should be inspected for safe transport and quality. The policy further states that food items should be stored, thawed, and prepared in accordance with good sanitary practice.

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#2) and/or her representative were informed of the risks and benefits of vaccinations, and gave consent, prior to their administration. The deficient practice could result in other residents receiving vaccinations without informed consent. Findings include: Resident #2 admitted on [DATE] with diagnoses of cerebral ischemia, chronic kidney disease, stage 3 and myasthenia gravis without exacerbation. The clinical record revealed the resident was admitted for respite care. Review of a Recipient Consent or Declination for COVID-19 Vaccination/Booster form dated February 21, 2023 revealed information regarding the risks and benefits of the vaccine. The documentation included a Yes response to consent to receive the COVID-19 vaccine or booster. The document included a written note that a verbal consent had been obtained from a provider (staff #150) and a nurse practitioner (NP/staff #157) on February 21, 2023 at 9:21 p.m.; and, was signed as witnessed by two licensed practical nurses (LPNs/staffs #13 and #115). The Influenza Immunizations Informed Consent form dated February 21, 2023 revealed the risks and benefits of the vaccine; and that, a verbal consent to give permission to administer the vaccine was obtained from the provider (staff #150) and an NP (staff #157) and was signed as witnessed by LPN/staff #13. The clinical record revealed no documentation the resident or resident representative was informed or the risk and benefits of the vaccines. Continued review of the clinical record revealed no documentation why the resident or representative was not able to sign the consents for the vaccines. The daily skilled note dated February 22, 2023 included the resident was alert and oriented x 4. The history and physical progress note dated February 23, 2023 included the resident was sitting in bed, was confused and hallucinating. Assessments included severe dementia with behaviors and cerebral ischemia. Review of a nursing progress notes dated February 23, 2023 revealed the resident received the COVID-19 and influenza vaccine with no immediate adverse side-effects noted; and that, the resident would be monitored for 72 hours. The discharge Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. An interview was conducted with an LPN (staff #89) on March 23, 2023 at 9:15 a.m. The LPN stated that prior to administering a vaccination, she would obtain a doctor's order and a consent; and let the resident know the risks and benefits of the vaccine(s). She stated that if the resident is their own responsible party, the resident may sign the consent themselves; otherwise the family must consent to the vaccine. The LPN said that a verbal consent from the family or representative was acceptable as well. She stated the purpose of the consent was to ensure that the resident/resident representative was fully informed of the risks and benefits of the vaccine(s); and that, the resident/resident representative have the right to accept or refuse it. In an interview with the Infection Preventionist (IP/staff #60) conducted on March 23, 2023 at 9:23 a.m., the IP stated she was responsible for the vaccination program in the facility; and, in the admissions packet there are consent forms for vaccinations. She stated the admitting nurse provides education and obtains the consent or declination; and, separate consents are required for each vaccine. The IP said that she had an outside contractor that come into the facility every 2 weeks to administer the vaccines; and they require an additional vaccine permission form. She stated she obtains the signed forms, collates the information and sends it to the contractor. Regarding resident #2, the two providers gave verbal permission for the resident to receive the COVID vaccine; and, the day before the vaccine was given she notified the resident's family who expressed no concerns. However, she stated that she did not document the conversation in the clinical record. She stated the resident #2 did not have a dementia diagnosis and had her family as her representative. The IP said that during the resident's admission, there had been a death in the resident's family and she did not want to bother the resident's representative. The IP said the resident had not been deemed incompetent; and that, the resident did not have a Power of Attorney (POA) listed. However, the resident's family she was the POA, but did not provide POA paperwork. She stated the resident's family was listed as her emergency contact; but she did not call her at the time of the vaccine administration because it was not an emergency. She stated that as long as residents can speak for themselves they can make their own decisions. Further, the IP said that it was not unusual for the providers to sign the consents because residents are sent over to the facility so late in the evening. The IP said that she did not review the resident's cognition prior to administering the vaccination; and that, the resident seemed so engaged with getting the vaccine, so lucid; however, maybe the resident was excited to get a lollipop. The IP stated that if she had to do it over, she would have said the resident was not able to receive the vaccine. During an interview with the Director of Nursing (DON/staff #82) conducted on March 23, 2023 at 1:02 p.m., the DON stated that his expectation was that if the resident was capable, and not deemed incompetent, the resident may sign the consent for themselves; and that, if they are cognitively impaired, the nursing staff would talk to the resident's representative. The DON said that in the event there was no known or knowledge of a family and/or representatives, then two provider signatures on the consent were appropriate. Regarding resident #2, the DON stated that he could not think of a reason why the nurse decided to do a two-provider consent at that moment; and, this did not meet his expectations. The facility policy on Resident Rights, revised on May 2021, included all resident rights be followed per state and federal guidelines as well as other [regulatory] agencies. The resident has the right to be fully informed in advance about care and treatment, and, unless adjudicated incompetent or otherwise found incapacitated under state law, participate in planning medical treatment.

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure there was a physician order for vaccinations prior to its administration for one resident (#2). The deficient practice result in administration of vaccination not indicated and/or ordered by the physician. Findings include: Resident #2 admitted on [DATE] with diagnoses of cerebral ischemia, chronic kidney disease, stage 3 and myasthenia gravis without exacerbation. The clinical record revealed the resident was admitted for respite care. Review of a Recipient Consent or Declination for COVID-19 Vaccination/Booster form dated February 21, 2023 revealed information regarding the risks and benefits of the vaccine. The documentation included a Yes response to consent to receive the COVID-19 vaccine or booster. The document included a written note that a verbal consent had been obtained from a provider (staff #150) and a nurse practitioner (NP/staff #157) on February 21, 2023 at 9:21 p.m.; and, was signed as witnessed by two licensed practical nurses (LPNs/staffs #13 and #115). The Influenza Immunizations Informed Consent form dated February 21, 2023 revealed the risks and benefits of the vaccine; and that, a verbal consent to give permission to administer the vaccine was obtained from the provider (staff #150) and an NP (staff #157) and was signed as witnessed by LPN/staff #13. The order summary report an order dated February 21, 2023 to administer pneumococcal vaccine per CDC guidelines if indicated and consented. The history and physical progress note dated February 23, 2023 included the resident was sitting in bed, was confused and hallucinating. Assessments included severe dementia with behaviors and cerebral ischemia. Review of a nursing progress notes dated February 23, 2023 revealed the resident received the COVID-19 and influenza vaccine with no immediate adverse side-effects noted; and that, the resident would be monitored for 72 hours. However, the clinical record revealed no evidence of a physician order for the COVID-19 and influenza vaccine administrations. An interview was conducted with an LPN (staff #89) on March 23, 2023 at 9:15 a.m. The LPN that prior to administering a vaccination, she would obtain a physician order; and that, it would not be appropriate to administer a vaccine without a physician order. Further, the LPN stated that a physician order for vaccination was required to meet the professional standard. In an interview with the Infection Preventionist (IP/staff #60) conducted on March 23, 2023 at 9:23 a.m., the IP stated that a physician order for the vaccine administration was included in the admission orders. The IP stated she received verbal confirmation from all the providers that residents may receive vaccinations; and that, vaccines are located in the batch orders that are triggered upon resident admission. She stated that all of those orders, including vaccinations, were part of the admission process; and that, that it would not be acceptable to administer a vaccination without a physician order. The IP said that she does not always document as well as she should. Regarding resident #2, she stated that she had been remiss in not confirming that there was a physician order for the COVID-19 and influenza vaccine administration. During an interview with the Director of Nursing (DON/staff #82) conducted on March 23, 2023 at 1:02 p.m., the DON stated that his expectation was that nursing staff would obtain a physician order for vaccines to be administered; and that, having no physician order for the COVID-19 and influenza vaccine administered to resident #2 did not meet his expectations. The facility's policy on Physician Orders revised in May 2021 revealed that it was their policy that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs. No drugs or biologicals shall be administered except upon the order of a person lawfully authorized to give such an order. Drugs and biological orders must be recorded in the resident's medical record under orders in Point Click Care (PCC).

Based on clinical record review, staff interviews, and review of policy, the facility failed to ensure one resident (#2) and/or her representative were informed of the risks and benefits of vaccinations prior to their administration. The deficient practice could result in other residents receiving vaccinations without informed consent. Findings include: Resident #2 admitted to the facility on [DATE] for respite care and had diagnoses of cerebral ischemia, chronic kidney disease, stage 3 and myasthenia gravis without exacerbation. The facesheet for the clinical record of resident #2 revealed that the resident had an emergency contact and resident representative. Review of a Recipient Consent or Declination for COVID-19 Vaccination/Booster dated February 21, 2023 revealed information regarding the risks and benefits of the vaccine. In the space provided, a check mark was placed in the box next to the Yes response, indicating consent to receiving the COVID-19 vaccine or booster. However, the consent revealed that a verbal consent had been obtained from a provider (staff #150) and a nurse practitioner (staff #157). In the space provided for the witness, the signatures of Licensed Practical Nurses (staff #57 and staff #117) were documented. An Influenza and the Pneumococcal Immunizations Informed Consent dated February 21, 2023 revealed sections where the risks and benefits of the vaccine were written. In the space provided to either give permission or not give permission for the vaccine, a check mark was placed in the box indicating permission had been granted. However, the consent revealed that a verbal consent had been obtained from the provider (staff #150) and a nurse practitioner (staff #157). The document was witnessed by LPN/staff #57. The care plan dated February 22, 2023 included resident was at risk for impaired cognitive function/dementia or impaired thought process related to hospice, respite, cerebral ischemia and senile degeneration of the brain. The physician history and physical note dated February 23, 2023 revealed that the resident was confused and hallucinating. Assessment included severe dementia. Review of a nursing progress notes dated February 23, 2023 at 1:02 p.m. revealed the resident received the COVID vaccine, influenza vaccine with no immediate adverse side-effects noted. The note included that the resident would be monitored for 72 hours. The eMAR (medication administration record) note dated February 23, 2023 revealed that and Prevnar (pneumococcal) 13 vaccine was administered to the resident. However, there was no evidence found in the clinical record that the resident representative was informed of the risks and benefits of the vaccinations prior to its administration. The discharge Minimum Data Set assessment dated [DATE] revealed the resident scored 00 on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The nursing note dated February 24, 2023 included that the resident was discharged to home with hospice care. An interview was conducted with a licensed practical nurse (LPN/staff #78) on March 23, 2023 at 9:15 a.m. The LPN stated that prior to administration of a vaccine, she would obtain a doctor's order; and, will obtain consent and let the resident know the risks and benefits of the vaccine(s). She stated that if they are their own responsible party they may sign it themselves, otherwise the family must consent. She stated that the purpose of the consent was to ensure that the resident/resident's family was fully informed of the risks and benefits of the vaccine(s) and that they have the right to accept or refuse it. Further, she stated that verbal consent was acceptable. In an interview with the Infection Preventionist (IP/staff #20) conducted on March 23, 2023 at 9:23 a.m., the IP stated that she was responsible for the vaccination program in the facility; and that, the admissions packet has consent forms for vaccinations. She stated the admitting nurse provides education and obtains the consent or declination upon resident's admission; and that, separate consents are required for each vaccine. The IP said that she has an outside contractor come into the facility every 2 weeks to administer the vaccines; and, they require an additional vaccine permission form. The IP said that she obtains the signed forms, collates the information and sends it to the contractor. Regarding resident #2, the IP said that two providers gave verbal permission for the resident to receive the COVID vaccine. She stated that she notified the resident's daughter-in-law the day before the vaccine was given and that she expressed no concerns. However, she stated that she did not document the conversation in the resident's clinical record. She stated that the family was the resident's representative. The IP said that there had been a death in the resident's family and she did not want to bother the resident's representative. The IP said that the resident did not have a diagnosis of dementia, did not have a Power of Attorney (POA) listed, and had not been deemed incompetent. She stated that the resident's representative told lived in the state and that the resident's representative said she was the POA, but did not provide POA paperwork. Further, the IP said that the resident's representative was listed as an emergency contact; however, the IP did not call the resident's representative when the vaccine was given because it was not an emergency. She stated that as long as residents can speak for themselves they can make their own decisions. The IP also said that it was not unusual for the providers to sign the consents because residents are sent over to the facility so late in the evening. She further stated that she did not review the resident's BIMS (brief interview for mental status) prior to administering the vaccination. She stated that the resident seemed so engaged with getting the vaccine, so lucid, but that maybe the resident was excited to get a lollipop. She stated that if she had to do it over, she would have said the resident was not able to receive the vaccine. During an interview conducted with the Director of Nursing (DON/staff #101) on March 23, 2023 at 1:02 p.m., the DON stated that his expectation was that if the resident is capable, and not deemed incompetent, the resident may sign the consent for themselves. He stated that if they are cognitively impaired, nursing will talk to the resident's representative. The DON said that the providers' signatures are appropriate in the event that there was no knowledge of family and/or representatives. The DON said that in this case, two providers may sign the consent. Regarding resident #2, the DON said that he could not give a reason why the nurse decided to do a two-doctor consent at that moment; and that, this did not meet his expectations. The Resident Rights policy revised in May 2021 included that it was their policy that all resident rights be followed per state and federal guidelines as well as other regulatory agencies. The resident has the right to be fully informed in advance about care and treatment, and, unless adjudicated incompetent or otherwise found incapacitated under state law, participate in planning medical treatment.

Based on observations, clinical record reviews, staff interviews, review of facility documentation and policies and procedures, the facility failed to ensure that multiple medications including medications for three residents (#14, #20 and #46) were stored at the proper temperatures, per manufacturer's recommendations and facility policy. As a result, the Condition of Immediate Jeopardy (IJ) was identified. The facility also failed to ensure that one narcotic box was secured. The deficient practice resulted in medications not being stored at the proper temperatures, resulting in the potential for medications to not be as effective and causing possible adverse consequences for residents. The deficient practice also resulted in medications not being stored in a manner to prevent loss or diversion. Findings include: On January 29, 2020 at 11:33 a.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator (staff #133) was informed of the facility's failure to ensure that medications stored in medication room refrigerators were stored per manufacturer's recommendations and per facility policy. The Administrator (staff #133) and Director of Nursing (DON/staff #132) presented a plan of correction on January 29, 2020 at 12:31 p.m. At 1:10 p.m., the Administrator (staff #133), a compliance RN (registered nurse/staff #136), a consultant RN (staff #137) and a consultant Administrator (staff #138) were informed that the plan of correction was unacceptable and needed to include additional information such as: the content and completion of staff inservice's; nurse education regarding medications stored per manufacturer's recommendations; the duration of the temperature checks; interventions to be implemented if temperatures are out of range; time frames for delivering replacement medications; who is responsible for completing the temperature logs and what audits will be done and who is responsible to complete the audits. A revised plan of correction was received on January 29, 2020 at 4:08 p.m. and included the additional components as mentioned above. The revised plan of correction was accepted at 4:21 p.m. on January 29, 2020. Multiple observations were conducted on January 29 and 30, 2020 of the facility implementing their plan of correction. New medication refrigerators were being maintained per manufacturer's recommendations. Staff interviewed were knowledgeable of the new medication refrigerator procedures and what corrective action was to be done if temperatures were found to be out of the recommended parameters. As a result, the Condition of Immediate Jeopardy was abated on January 30, 2020 at 2:17 p.m. -Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. -Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Give 2 mg intramuscularly for uncontrolled [MEDICAL CONDITION]. May repeat once. -Resident #20 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]., inject 1.8 milligrams subcutaneously one time a day for diabetes. An observation was conducted of the 400 hall medication room refrigerator on January 29, 2020 at 8:45 a.m., with the DON (staff #132). A temperature gauge inside of the refrigerator was observed to be 22 degrees Fahrenheit (F.) At this time, the [MEDICATION NAME] for resident #46 and #14 and a [MEDICATION NAME] pen for resident #20 were observed inside the refrigerator. The [MEDICATION NAME] was also stored inside of the refrigerator in an unlocked plastic box. Review of the Refrigerator/Freezer Temperature Log for January 2020 which was on the door of the refrigerator revealed that temperatures were to be checked once a day. Further review of the Temperature Log revealed the temperatures recorded were below 36 degrees F. on the following days: January 1, 3, 4, 5, 6, 9, 10, 11, 12, 14, 15, 16, 17, 19, 20, 21, 22, 23, 25, 26, 27. In addition, the temperatures were not checked on January 28 and 29. The Refrigerator/Freezer Temperature Log did not include what the required temperature range should be. During the observation, an interview was conducted with the DON who stated that the temperature of the refrigerator should be at 34-40 ish. An interview was conducted with a LPN (licensed practical nurse/staff #92) on January 29, 2020 at 8:55 a.m. Staff #92 stated that she was not sure what temperature the [MEDICATION NAME] and the [MEDICATION NAME] should be stored at. She also said that the box that the [MEDICATION NAME] was stored in should have been locked and that she usually ensures the narcotic box is locked when starting her shift, but she forgot to do that today. An interview was conducted with the facility's pharmacy consultant on January 29, 2020 at 9:10 a.m. The pharmacy consultant stated that the [MEDICATION NAME] and the [MEDICATION NAME] pen should be stored at 36-46 degrees F. Review of the manufacturer's instructions for the [MEDICATION NAME] pen documented Keep very cool: do not freeze. The manufacturer's instructions for the [MEDICATION NAME] documented Refrigerate 36 - 46 degrees Fahrenheit. An observation was conducted of the medication room refrigerator on the 200 hall on January 29, 2020 at 10:40 a.m. with a LPN (staff #67). The temperature gauge was at 29 degrees F. An immediate interview was conducted with staff #67 who stated that the temperature must have went down as it was just at 32 degrees F. Staff #67 stated if she noticed that the refrigerator temperature was too low, she would call the maintenance director and stand by the refrigerator until he came. Staff #67 stated that she would not complete a work order if she observed that a medication refrigerator was out of range. An interview was conducted with the maintenance director (staff #54) on January 29, 2020 at 2:00 p.m. Staff #54 stated that licensed nursing staff were responsible to ensure the temperature was within range in the medication refrigerators. Staff #54 stated that if licensed nursing staff observed that a temperature was not within range, they should let him know and place a maintenance order in TELS (a preventative maintenance program). Staff #54 stated that he did not recall ever being notified that medication refrigerators were not at the proper temperatures. An observation was conducted on January 29, 2020 at 2:55 p.m. of the 400 hall medication room refrigerator, with an LPN (staff #127) which was recently purchased by the facility. Although no medications were stored in this refrigerator, the temperature gauge was 30 degrees F. An immediate interview was conducted with a LPN (staff #127) on January 29, 2020 at 2:55 p.m. Staff #127 stated It's 30, sounds good to me. Staff #127 further stated that she thought the temperature of the medication refrigerator should be between 28 and 30 degrees F. Another interview was conducted with the DON on February 3, 2020 at 10:00 a.m. The DON said that licensed nursing staff should check the temperature of the medication refrigerators at the beginning of their shift and notify maintenance if it was not within the desired range. -During an observation conducted on January 29, 2020 at 8:19 a.m. with a LPN (staff #82), staff #82 entered the 200 unit medication storage room to obtain a medication ([MEDICATION NAME]), which she stated was stored in the refrigerator. She then stated that the temperature of the interior refrigerator was between 34 and 35 degrees, per the inside thermometer. Staff #82 then checked the [MEDICATION NAME] that she was going to administer and stated that the manufacturer's recommendation was for the [MEDICATION NAME] to be stored between 36 to 46 degrees, and the current temperature did not meet the specific temperature. Staff #82 then removed the refrigerator log which was attached to the outside of the refrigerator. After reviewing the log, staff #82 said the log for January 2020 contained many entries that she thought were not within the required range. She further stated that she was unsure of what the temperature range should be, however; also stated that some of the documented temperatures of 30 or 32 degrees seemed too low. Staff #82 stated the form did not indicate what the required temperature range needed to be for various medications. She also said that there were no guidelines for staff to follow if a temperature seemed too low or was out of range. Review of the Refrigerator/Freezer temperature logs for the 200 unit hallway refrigerator revealed sections to document the date, the refrigerator and freezer temperatures and staff initials. The temperature logs did not list what the proper refrigerator temperature range should be. Further review of the logs revealed the following: -March 2019: There were 13 out of 31 days with temperatures that were out of range as the temperatures were between 30-34 degrees. -April 2019: There were 20 out of 30 days with temperatures that were out of range as the temperatures were between 30-32 degrees. -May 2019: There were 7 out of 28 days with temperatures that were out of range as the temperatures were between 30-34 degrees. There were 3 days with no documentation of temperatures. -June 2019: There were 18 out of 28 days with temperatures that were out of range as the temperatures were between 30-32 degrees. There were 2 days with no documentation of temperatures. -July 2019: There were 16 out of 29 days with temperatures which were out of range as the temperatures were 32-34 degrees. There were 2 days with no documentation of temperatures. -August 2019: There were 23 of 27 days with temperatures that were out of range as the temperatures were 28-33 degrees. There were 4 days with no documentation of temperatures. -September 2019: There was 1 day with a temperature of 32 degrees. There was also one day with no documentation of a temperature. -October 2019: There were 22 out of 31 days with temperatures that were out of range as the temperatures were between 32-34 degrees. -November 2019: There were 20 out of 30 days with temperatures that were out of range as the temperatures were 32-34 degrees. There was one day with no documentation of a temperature. -December 2019: There were 21 out of 30 days with temperatures that were out of range as the temperatures were 30-32 degrees. There was one day with no documentation of a temperature. -January 2020: There were 19 out of 28 days with temperatures which were out of range as the temperatures were 30-32 degrees. -An observation of the refrigerator located in the medication room which was behind the nurse's station was conducted with a LPN (staff #67) on January 29, 2020 at 8:49 a.m. Inside of the refrigerator was a thermometer, with a temperature reading of 30 degrees F. The following medications were located inside the refrigerator: 18 vials of influenza vaccine, 4 vials of [MEDICATION NAME] stabilized solution, 5 vials of pneumococcal vaccine, one box of [MEDICATION NAME] (laxative) suppositories, 5 bags of IV (intravenous) [MEDICATION NAME] (antibiotic), 5 bags of IV [MEDICATION NAME] (antibiotic), a box of GRANIX injection (colony stimulating factor), a vial of [MEDICATION NAME] N human insulin and a vial of Humalog insulin. Review of the box of [MEDICATION NAME] solution revealed instructions to store the medication between 36 degrees and 46 degrees F. Review of the instruction packet found in the box of [MEDICATION NAME] N insulin revealed instructions to keep all unopened [MEDICATION NAME] N in the refrigerator between 36 degrees to 46 degrees F. and to not refrigerate an opened vial. The instruction packet found in the box of Humalog insulin included that unopened Humalog should be stored in a refrigerator between 36 degrees and 46 degrees F. The box of influenza vaccine revealed instructions to refrigerate and store the vaccine between 36 degrees and 46 degrees Fahrenheit. In the box of the [MEDICATION NAME] suppositories were instructions to store the medication at temperatures below 30 degrees F. During an interview with staff #67 conducted on January 29, 2020 at 1:28 p.m., she stated the pneumococcal vaccine, influenza vaccine, [MEDICATION NAME] solution and the [MEDICATION NAME] suppositories which were found in the refrigerator were all brand new and had never been used. She stated the bags of IV [MEDICATION NAME] were prescribed for a resident who is admitted at the facility and is currently receiving the antibiotic treatment. She stated the bags of IV [MEDICATION NAME] were prescribed for a resident who was discharged yesterday from the facility. Staff #67 further stated that she does not know when the medications were delivered and stored in the refrigerator. She said the pharmacy delivers medications and treatments at different times of the day. When the pharmacy delivers the medications, she said the delivery is segregated according to the nursing halls and the nurse in charge will be given the delivered medications prescribed for residents in that hall. She stated the nurse is responsible in receiving and storing the medications either in the medication cart/room or in the refrigerator if needed. Staff #67 stated the night shift nurses are responsible for checking the refrigerator temperatures which are done after midnight and should be documented on the temperature log located on the door of the refrigerators. She stated the refrigerator temperature is maintained and kept every month. Review of a policy regarding Medication Storage revealed it is the policy of the facility to store all drugs and biologicals under proper temperature controls. All medications requiring refrigeration or temperatures between 36-46 degrees F. are kept in a refrigerator, with a thermometer to allow temperature monitoring. A policy regarding Drug Storage included the following: It is the policy of this facility to ensure the proper and safe storage of drugs and biologicals. The policy included that proper temperature ranges should be maintained with acceptable guidelines. Review of the facility's policy regarding Medication Access and Storage dated August 2018 revealed .Schedule III and IV controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose .

Based on observations, clinical record reviews, interviews, review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines and policies and procedures, the facility failed to ensure that thorough wound assessments were completed, and/or the physician was notified of pressure ulcers when identified, and/or that treatment orders were obtained timely and/or that treatments were provided as ordered for four of five sampled residents (#245, #247, #248 and #89), with pressure ulcers. The deficient practice resulted in residents not receiving adequate care and treatment for [REDACTED]. Findings include: -Resident #245 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Braden Scale for Predicting Pressure Sore Risk dated January 11, 2020 included the resident scored a 13, which indicated moderate risk for developing pressure ulcers. Regarding the left heel: A care plan dated January 11, 2020 revealed the resident had actual impairment to skin integrity related to a fluid filled blister to the left heel. Interventions were to float heels, low air loss mattress for skin integrity, monitor and document the location, size and treatment of [REDACTED]. A shower skin assessment sheet dated January 13, 2020 included the resident had scabs to feet. However, there was no indication of a specific location of the scabs on the feet. A skin assessment shower sheet dated January 16, 2020 included Mark on the diagram all body marks that are old or new. Include scars, bruises, rash, cuts, pressure ulcers or other open areas. The sheet indicated an x over both heels, with no further description. A Braden Scale for Predicting Pressure Sore Risk dated January 18, 2020 included the resident scored a 15, which indicated low risk for developing pressure ulcers, despite having a blister to the left heel. Despite documentation that the resident had a blister to the left heel, there was no clinical record documentation that the physician was notified of the left heel blister, there was no documentation of any treatment that was provided and no documentation that a thorough assessment of the left heel was completed, which included measurements, a description of the heel/blister, if any drainage was present and the condition of the surrounding skin from admission on January 11 through 19, 2020. The first thorough assessment of the left heel was completed nine days after admission. According to the skin ulcer non-pressure weekly eva;uation (although the wound was on the heel) dated January 20, 2020, the following was documented: left heel wound measured 9.5 x 10.0 cm and was described as dark serous filled blister, with a scant amount of serous exudate, no odor, wound bed was black/brown (eschar), wound edges were attached and surrounding tissue was normal. The onset date was listed as January 20, 2020 and that this was the initial review (although there was documentation on the care plan that the resident had a fluid filled blister to the left heel on admission). The evaluation also noted that this wound was marked as other for type of skin ulcer/wound. Interventions included to apply [MEDICATION NAME] and wrap with Kerlix Monday, Wednesday, Friday and as needed until resolved. However, review of the clinical record revealed there was no physician's order to apply [MEDICATION NAME] and wrap with Kerlix from January 20 through 24, 2020. In addition, there was no clinical record documentation including on the Treatment Administration Record (TAR) of any treatments that were provided to the left heel from admission on January 11 through January 24, 2020. A wound care consult note was completed on January 24, 2020 by the wound care nurse practitioner (NP/staff #141). The skin assessment was as follows: left heel with a dark serous filled blister which measured 9.5 x 10.0 x 0.0 cm. The plan included the floor nurses will collaborate with the wound team for aggressive wound care and offloading of pressure points and assisting with turning as needed. The goal was to offload all pressure points by turning, using specialized mattress (low air loss/LAL), wheelchair cushions and/or foam heel protectors as needed, clearing dead tissue-if any, granulation and [MEDICATION NAME]. The resident's [DIAGNOSES REDACTED]. A physician's note dated January 25, 2020 included the resident had multiple pressure ulcers, however, no locations were documented. Despite the physician's note, there was no treatment order for the left heel pressure ulcer. A Braden Scale for Predicting Pressure Sore Risk dated January 25, 2020 included the resident scored a 15, which indicated low risk for developing pressure ulcers. A skin ulcer non-pressure weekly assessment dated [DATE] revealed the following: left heel measured 9.5 x 10.0 cm; dark fluid filled blister, other type of ulcer/wound; scant amount of serous exudate, no odor, wound bed black/brown (eschar), wound edges undefined, surrounding tissue normal, onset date January 20, 2020. Interventions included apply [MEDICATION NAME] and wrap with Kerlix Monday, Wednesday and Friday and as needed until resolved. Review of the physician's orders revealed an order date of January 27, 2020. The order included the following: Late entry for 1/20/2020 left heel serous filled blister, apply [MEDICATION NAME] and wrap with Kerlix Monday, Wednesday, Friday and as needed until resolved for skin maintenance. However, this late entry order was back dated seven days prior. Review of the January 2020 TAR revealed the order dated January 27, 2020 as a late entry for January 20, 2020 to apply [MEDICATION NAME] to left heel and wrap with Kerlix on Monday, Wednesday and Friday and as needed until resolved. However, there was no documentation that the treatment was done from January 20 through 28. A wound treatment observation was conducted on January 29, 2020 at 2:57 p.m., with the wound nurse (staff #35). The resident's left heel appeared to be covered with dark colored tissue. Per staff #35, the left heel measured 9.5 cm x 10.5 cm with 90% necrotic tissue, with an area of pink looking skin. The treatment was completed as ordered. In an interview with staff #35 on January 30, 2020 at 10:53 a.m., she stated that she did an assessment upon admission for resident #245, however, she stated the left heel area was identified on January 20, 2020. She said that a treatment would have been started upon finding the area on January 20. She then reviewed the TAR and acknowledged that the treatments were not documented until January 27. She stated she must have forgotten to put the treatment into the electronic charting system. A wound care consult note was completed on January 31, 2020, by the wound care NP (staff #141). The note included this was a follow up on multiple wounds. The note also included the left heel wound has more eschar, is stable and there is no drainage. The left heel measured 9.3 x 11.0 x 0.0 cm, dark serous filled blister with 60% dry eschar along edges and no drainage. An interview was conducted on January 31, 2020 at 12:53 p.m., with staff #141. He stated that the left heel wound was pressure related, based on the location. Regarding the coccyx: An Initial Admission Record dated January 11, 2020 included the resident had redness on the buttocks. The Admission Record did not include any further description of the redness to the buttocks. However, a care plan dated January 11, 2020 included the resident had actual impairment to skin integrity related to an unstageable wound to the coccyx. Interventions were for a low air loss mattress, monitor and document the location, size and treatment of [REDACTED]. Review of the clinical record revealed there was no thorough assessment of the buttocks area, which included measurements, a description of the wound bed, any drainage, any signs or symptoms of infection and the condition of the surrounding skin. There was also no documentation that the physician was notified of the redness/unstageable wound to the coccyx, nor was there a physician's order for any treatment on January 11 and 12, 2020. A shower skin assessment sheet dated January 13, 2020 included the resident had a patch over the left buttock. The first thorough assessment of the buttocks area was not conducted until January 13, 2020. Per the skin pressure ulcer weekly assessment dated [DATE], the resident had an unstageable pressure ulcer as follows: coccyx measured 4.5 x 5.5 cm unstageable (slough/eschar), black/brown eschar wound bed, scant amount of serosanguineous exudate, no odor, wound edges undefined and surrounding tissue was normal. The assessment included the pressure ulcer was present upon admission, with an unknown onset date, and that this was the initial evaluation. Interventions included cleanse coccyx with normal saline, pat dry, apply calcium alginate, cover with dry dressing on Monday, Wednesday and Friday and as needed until resolved. However, review of the clinical record revealed there was no physician's order to cleanse the coccyx with normal saline, apply calcium alginate and cover with a dry dressing on Monday, Wednesday and Friday. This treatment was also not on the January 2020 TAR, therefore; there was no documentation that this treatment was provided from January 11 through January 14. Another physician's order dated January 15, 2020 included to cleanse the coccyx pressure ulcer with normal saline, pat dry, apply calcium alginate and cover with a dry dressing on Monday, Wednesday and Friday, and as needed until resolved. Review of the January 2020 TAR revealed this order was included however, there was no documentation that this treatment was completed on January 20. A shower skin assessment sheet dated January 20, 2020 revealed there was a marked area to the buttocks which indicated wound bleeding. A skin pressure ulcer weekly assessment dated [DATE] revealed the following: coccyx pressure ulcer measured 4.5 x 5.8 cm, unstageable black/brown eschar to wound bed, scant amount of serosanguineous exudate, no odor, wound edges undefined and surrounding tissue was normal. The assessment included the pressure ulcer was present on admission with an unknown onset date. Interventions included to cleanse the coccyx pressure ulcer with normal saline, pat dry, apply calcium alginate, cover with dry dressing on Monday, Wednesday and Friday and as needed until resolved. Further review of the January 2020 TAR revealed the treatment to the coccyx was not done on January 22. A wound care consult note was completed on January 24, 2020, by the wound care NP (staff #141). The note included that the chief complaint was a sacral wound. The note stated that the resident's entire sacral area was either red or broken down. The skin assessment regarding the sacral wound was as follows: wound measured 12.0 x 19.0 x 2.0 cm, with 40% eschar, 30% pink, 30% intact skin, red-delayed blanching, small amount of serous drainage, no odor, and some purple discoloration surrounding. The plan included floor nurses will collaborate with the wound team for aggressive wound care and offloading of pressure points and assisting with turning as needed. The goal was to offload all pressure points by turning, using specialized mattress, wheelchair cushions and/or foam heel protectors as needed, clearing dead tissue-if any, granulation, and [MEDICATION NAME]. A [DIAGNOSES REDACTED]. Treatment: currently no dressing will stay in place due to incontinence-Zinc barrier cream mixed with [MEDICATION NAME]. A physician's note dated January 25, 2020 included the resident had multiple pressure ulcers. There was no specific mention of the pressure ulcer to the coccyx. A skin pressure ulcer weekly assessment dated [DATE] revealed the coccyx pressure ulcer measured 12.0 x 19.0 x 2.0 cm; was unstageable (slough/eschar), black/brown eschar wound bed, scant amount of serosanguineous exudate, no odor, wound edges undefined, and surrounding tissue was normal. Physician orders dated January 27, 2020 included to cleanse the coccyx pressure ulcer with normal saline, pat dry, apply copious amount of zinc oxide mixed with skin protectant every shift and as needed until resolved, one time a day for wound maintenance. A wound treatment observation was conducted on January 29, 2020 at 2:57 p.m., with the wound nurse (staff #35). The wound was observed to be irregular in shape with slough covering some of the wound bed, with wound edges appearing macerated. Per staff #35, the sacral wound measured 10.4 cm x 11.5 cm x 1.2 cm with 60% necrotic tissue in the wound bed, 40% slough and that the wound was unstageable. The treatment was completed as ordered. In an interview with staff #35 on January 30, 2020 at 10:53 a.m., she stated that she did an assessment upon admission for resident #245. She stated that she noted the cites that were found including the sacral area. She stated the wound NP follows this resident weekly and was brought in for this resident's treatment, because the wound on the coccyx was not getting better. A wound care consult note was completed on January 31, 2020 by the wound NP (staff #141). The note included this was a follow up on multiple wounds. The note included the resident's sacral area had improved, the moisture associated damaged area surrounding it has almost completely resolved with use of zinc/petroleum, the eschar covering the wound bed was soft, but there was more slough and there were no signs or symptoms of acute infection. Per the assessment, the sacral wound measured 9.0 x 8.0 x 0.8 cm with 20% pink, 80% yellow/slough loosening and separating from wound bed, small amount of serous drainage and no odor. An interview was conducted on January 31, 2020 at 12:53 p.m., with staff #141. He stated that resident #245, came in with the coccyx wound. Regarding the right heel: An Initial Admission Record dated January 11, 2020 included the resident had a blister to the right heel. A care plan dated January 11, 2020 revealed the resident had actual impairment to skin integrity related to deep tissue injury to the right heel. Interventions were to float heels, low air loss mattress, monitor and document the location, size and treatment of [REDACTED]. However, review of the clinical record revealed no documentation of a thorough assessment of the right heel, which included measurements of the area and a description of the color of the skin to the right heel, nor was there documentation that the physician was notified and that a treatment was put into place on January 11 or 12. A shower skin assessment sheet dated January 13, 2020 included the resident had scabs to feet. However, there was no further indication as to the specific location on the feet. A weekly skin evaluation dated January 13, 2020 revealed blood blister to right heel. A thorough assessment of the right heel was completed two days after admission. Review of the skin pressure ulcer weekly assessment dated [DATE] revealed the following: right heel measured 2.0 x 1.0, unstageable (slough/eschar) blood blister, no exudate, no odor, wound edges and surrounding tissue were normal. The documentation included that the pressure injury was present on admission with an unknown onset date and that it was the initial evaluation. Interventions included right heel blood blister, apply [MEDICATION NAME] and wrap with Kerlix on Monday, Wednesday and Friday and as needed until resolved. However, review of the clinical record and TAR revealed no physician's order for the [MEDICATION NAME] to be applied to the right heel until January 15, 2020. A physician's order dated January 15, 2020 included treatment for [REDACTED]. Further review of the TAR revealed the above wound treatment was done on January 15, however, there was no documentation that treatments were done from January 16 through 20. A skin pressure ulcer weekly assessment dated [DATE] revealed the right heel measured 2.0 x 1.0 cm; blood blister suspected deep tissue injury (SDTI); no exudate, no odor, wound bed normal, wound edges undefined and surrounding tissue was normal. The assessment included the SDTI was present on admission with an unknown onset date. Interventions were to apply [MEDICATION NAME] and wrap with Kerlix on Monday, Wednesday and Friday, and as needed until resolved. However, further review of the TAR revealed no documentation that the [MEDICATION NAME] treatment was completed from January 21 through January 24. A wound care consult note was completed on January 24, 2020 by the wound NP (staff #141). The note included there were two wounds present to the right heel as follows: right heel measured 4.5 x 3.0 x 0.0 cm, with red serous filled and the right heel plantar measured 2.5 x 2.5 x 0.0 cm, with 100% thin eschar-no fluctuance. The plan included floor nurses will collaborate with the wound team for aggressive wound care and offloading of pressure points and assisting with turning as needed. The goal included to offload all pressure points by turning, using specialized mattress, wheelchair cushions and/or foam heel protectors as needed, clearing dead tissue-if any, granulation and [MEDICATION NAME]. A physician's note dated January 25, 2020 included the resident had multiple pressure ulcers. However, there was no indication of where the pressure ulcers were located. A wound treatment observation was conducted on January 29, 2020 at 2:57 p.m., with wound nurse (staff #35). The wound was observed to cover the resident's right heel with dark colored tissue and measured 4 x 3.2. Staff #35 stated the wound had 100% necrotic tissue and started as a fluid filled blister. The treatment was completed as ordered. In an interview with staff #35 on January 30, 2020 at 10:53 a.m., she stated that she did an assessment upon admission for resident #245. She stated that she noted the cites that were found including the right heel. An interview was conducted on January 31, 2020 at 12:53 p.m., with the wound NP (staff #141). He stated resident #245 came in with the right heel wound. A wound care consult note was completed on January 31, 2020, by staff #141. The note included this was a follow up on multiple wounds. The note also included the right heel wound was stable. The skin assessment was as follows: right heel: 2.0 x 3.0 x 0.0, red serous filled, less fluid than last week and right heel plantar: 3.5 x 3.5 x 0.0 cm, 100% thin eschar-no fluctuance. In an interview with a LPN (staff #82) on January 30, 2020 at 10:00 a.m., she stated the floor nurse who admits a new resident to the facility completes the initial skin assessment, and if something of concern is noted, the area is documented and the wound nurse is notified. She stated the wound nurse does a complete assessment of the area of concern. She stated if an area of concern on the skin is identified by a Certified Nursing Assistant (CNA) during care, they are to report it to the nurse right away, who will look at it and then the nurse should contact the doctor to get an order, and that the wound nurse will also be notified. In another interview with staff #35 on January 30, 2020 at 10:53 a.m., she stated the wound NP follows this resident weekly. Regarding the days where the treatment was not documented as completed, she stated sometimes time gets away from her and she may forget to document that the treatment was done. She stated that she has a notebook where she jots down treatments that she does for the day and any new orders. However, review of this documentation did not provide what type of treatment was done or the location of the treatment. An interview was conducted on January 31, 2020 at 12:53 p.m., with staff #141. He stated that he does not work specifically for this building, but rounds once a week with the wound nurse (staff #35). He stated they follow her list of residents with wounds and go over any new concerns she has. He said that he is not contracted to work with all of the residents in the facility. He stated he typically lets staff #35 measure, so the measurements stay consistent, but he is also assessing everything such as, how debilitated they are, preventative measures in place and signs and symptoms of infection. He said that he only provides oversight to staff #35 when he is rounding with her. -Resident #89 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan (initiated September 2018) included the resident was at risk for impairment to skin integrity related to a history of moisture associated skin damage, had a potential for impairment to skin integrity related to incontinence of bladder and limited mobility. The care plan included the resident had a stage 2 pressure ulcer to the right buttock. An intervention was to provide treatment as ordered. Another care plan identified that the resident had a self care performance deficit with activities of daily living (ADLs) related to weakness, dementia, and impaired mobility. An intervention included the resident required staff participation to reposition and turn in bed. A skin pressure ulcer weekly assessment dated [DATE] included an open area to the right buttock, which was identified on October 1, 2019. The assessment included the wound was a stage 2 and measured 4 cm x 2 cm x 0.1 cm. The interventions were to cleanse buttocks and apply barrier cream every shift and as needed until healed, and reposition frequently. A physician's order dated October 2, 2019 included to cleanse buttocks and apply barrier cream every shift and as needed until healed. Review of the TAR for October 2019 revealed the wound treatment to the buttocks was not completed on eight occasions. Review of the TAR for November 2019 revealed the treatment was not completed on two occasions. Review of the TAR for December 2019 revealed the treatment was not completed on two occasions. A physician's order dated January 2, 2020 included to cleanse buttocks with saline, cover with sponge dressing daily x 10 days in the morning for wound healing until January 13, 2020. Review of the TAR for January 2020 revealed the above treatment was not completed on three occasions. A care plan dated January 6, 2020 included the resident had pressure ulcer development to the right buttocks related to history of ulcers and immobility. Interventions included to administer treatments as ordered, monitor for effectiveness and to follow facility policies and protocols for the prevention and treatment of [REDACTED]. A wound treatment observation was conducted on January 29, 2020 at 1:07 p.m., with wound nurse(staff #35). The resident was observed on a low air loss mattress in a low bed position. Staff #35 measured the wound on the right buttocks at 0.9 cm x 1.9 cm with a general depth of 0.1 cm. She stated there was moisture associated skin damage ongoing with a pink wound bed and slight serosanguineous drainage. She stated the wound was a stage 2 and assessments of the wound were completed weekly with measurements. In an interview with the wound nurse (staff #35) on January 30, 2020 at 10:24 a.m., she stated that upon admission she does a skin evaluation assessment. She stated she notes everything she sees on the assessment. She stated that she then opens a more specific pressure ulcer or non-pressure ulcer weekly assessment, so it will trigger every week in the system. She stated if a resident has a wound concern, then she will put the appropriate treatment in place with the wound NP who comes in weekly. She stated the wound NP rounds with her on residents he is following and sees any new residents who she has concerns about. She stated that she stages the wounds unless she has questions, then she would consult with the wound NP. She stated when she does her initial assessment, she assesses the resident by starting at the heels and works her way up. She stated if something comes up on a resident she is not already seeing, staff members let her know there is an area of concern. -Resident #247 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital history and physical note dated January 12, 2020 revealed the resident had no rashes or [MEDICAL CONDITION] to exposed areas of the skin. Regarding the mid back pressure ulcer: The initial admission record dated January 13, 2020 included the resident was alert and oriented to person, place and time. Per the assessment, the resident had pressure ulcer on the coccyx and right gluteal area, however, there was no documentation of a pressure ulcer to the back. The nursing admission note dated January 13, 2020 included that a head to toe assessment was done and there was no documentation of a pressure ulcer to the back. The skin care plan dated January 13, 2020 included the resident had potential/actual impairment to skin integrity and had a stage 3 pressure ulcer on the vertebrae. The goal was to have no complications related to skin injury type. Interventions included for monitoring/documenting location, size, treatment of [REDACTED]. A skin evaluation dated January 14, 2020 revealed the resident had a pressure ulcer to the mid back. However, the documentation did not include the stage, measurements, a description of the wound bed/edges and surrounding skin and if any drainage was present. Despite documentation that the resident had a stage 3 pressure ulcer, there was no clinical record documentation that a thorough assessment of the stage 3 pressure ulcer to the mid back was completed on January 13 or 14, 2020, nor any evidence that the physician was notified, or that treatment orders were obtained or wound treatments were provided on January 13 or 14. The weekly skin pressure ulcer note dated January 15, 2020 which was two days after admission and was not signed by the nurse revealed the resident had a stage 3 pressure ulcer to the mid vertebrae. Per the note, this assessment was the initial evaluation. The assessment included the pressure ulcer was present on admission, with an unknown onset date. The wound measured 1 cm x 2 cm x 1.5 cm, with a pink wound bed and undefined edges, and a small amount of serosanguinous exudate and surrounding skin was normal. The treatment documented was to cleanse the area with Dakin's solution, pat dry, pack with packing strip and cover with a dry dressing every Monday, Wednesday and Friday and as needed until resolved. However, there were no physician orders for the Dakins solution treatment and there was no documentation that this treatment was done on January 15 or 16. Review of a NP progress note dated January 15, 2020 revealed there were no open areas or pressure ulcers to the resident's back. According to a daily skilled note dated January 15, 2020, the resident was alert and oriented x 3 and overall skin description was clean and warm to touch, with no active symptoms. The note also included that the skin condition was not a new onset, however, the documentation did not describe what skin condition the resident had. The wound NP note dated January 17, 2020 included a chief complaint of mid-back wound. The history of present illness included the wound nurse reported wound on the back x 1 year, had received wound care by home health and denies being evaluated at a wound clinic. Assessment included open wound of back. The plan included aggressive wound care and offloading of pressure points, assistance with turning as needed. Goals included offloading of all pressure points by turning, using specialized mattresses, wheelchair cushions and clearing of dead tissue if any. The treatment included to apply Mupirocin (topical antibiotic) to 1/4 inch packing gauze three times a week and as needed. The documentation did not include the type of wound, the stage, any measurements or a description of the wound bed/edges/surrounding skin and if any drainage was present. The admission MDS assessment dated [DATE] revealed a BIMS score of 14, indicating the resident had intact cognition. Per the MDS, the resident required extensive assistance with two persons for bed mobility, transfers and toilet use. The MDS also included the resident was at risk of pressure ulcer development and had one unhealed stage 3 pressure ulcer. Despite documentation in the NP note (from January 17) to apply Mupirocin to the back, there was no physician's order for Mupirocin to be appled. In addition, there was no evidence that the Mupirocin was applied to the mid back pressure ulcer from January 17 through 20. A Braden Scale for Predicting Pressure Ulcer Risk dated January 20, 2020 revealed the resident was at high risk for pressure ulcer development. The weekly skin pressure ulcer note dated January 21, 2020 revealed the resident had a stage 3 pressure ulcer to the upper mid vertebrae which was present on admission, with an unknown onset date. Per the note, the pressure ulcer measured 1 cm x 2 cm x 1.5 cm, with a pink wound bed, undefined wound edges, had scant serosanguinous exudate, no odor and normal surrounding skin. The treatment included to cleanse the area with Dakin's solution, pat dry, pack with packing strip and cover with dry dressing Monday, Wednesday and Friday and as needed until resolved. However, was there no order for Dakins treatment and there was no documentation that the treatment was done from January 21-23, 2020. The nutrition IDT (interdisciplinary team) update note dated January 23, 2020 revealed the resident had increased protein needs related to multiple pressure ulcers. The wound NP note dated January 24, 2020 included a chief complaint of mid back wound. Per the note, the back wound was chronic. The low back open wound measured 1 cm x 2 cm x 2.7 cm, wound bed was 80% pink and 20% yellow slough, with a small amount of serous drainage. The plan was to continue [MEDICATION NAME] on 1/4 inch packing gauze 3x/week and as needed and cover. The primary goal was for infection control/prevention and granulation growth. However, there was no physician's order for the use of [REDACTED]. As a result, there was no evidence that this treatment was administered from January 24-27. The weekly skin pressure ulcer note dated January 28, 2020 included a stage 3 pressure ulcer to the upper mid vertebrae which was present on admission, with an unknown onset date. The wound measured 1 cm x 2 cm x 1.7 cm with a pink wound bed, scant serosanguinous exudate with no odor, undefined wound edges and normal surrounding skin. The treatment documented was to cleanse the area with Dakin's solution, pat dry, pack with packing strip and cover with a dry dressing on Monday, Wednesday and Friday and as needed until resolved. On January 28, 2020, a physician's order was obtained to cleanse the wound with Dakin's solution, quarter strength solution, pat dry, apply packing strip soaked in [MEDICATION NAME] wound gel and pack Monday, Wednesday and Friday and as needed until resolved for a [DIAGNOSES REDACTED]. A pressure ulcer

Based on observations, clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure that one resident (#4) was free from neglect which resulted in a severe sunburn, and failed to ensure that two residents (#'s 31 and 32) were free from resident to resident abuse. Findings include: -Resident #4 was readmitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 3, (YEAR) revealed the resident had severe cognitive impairment with skills for daily decision making and required extensive assistance for locomotion off the unit. A care plan included that the resident prefers to initiate activities of choice independently. A goal was to participate in his preferred leisure activities daily. Interventions included that it was somewhat important for the resident to go outside for fresh air when the weather was good, for staff to encourage the resident to go outside when weather was good and to assist outside for fresh air. A care plan for the potential to demonstrate verbally abusive behaviors related to ineffective coping skills included to give the resident as many choices as possible about care and activities. A Nursing Note dated (MONTH) 10, (YEAR) at 11:38 a.m. included that the Nurse practitioner was in to see the resident related to being found outside. Orders given to start IV (intravenous) fluids and [MEDICATION NAME] was administered for pain. Will continue to monitor. A Nursing Note dated (MONTH) 10, (YEAR) at 2:35 p.m. revealed Checked on patient related to being found outside this morning. Thighs were noted to be red and starting to get blisters. Nurse practitioner .called and orders were given to apply Aloe Vera Gel to thighs every shift and as needed and to finish the liter of fluids .Denies pain at this time but states that his legs hurt if you touch them . Another Nursing Note dated (MONTH) 10, (YEAR) at 3:00 p.m. revealed Resident was found outside the patio by CNA (certified nursing assistant), warm to touch, observed with altered cognition. Offered fluids as tolerated, cool compress applied. Nurse practitioner present, evaluated resident. Assisted to bed, kept comfortable and continue offering fluids, and cool compress. Observed slight redness lower abdomen and reddened area on both front of thighs and feet .Resident alert, oriented and able to verbalize needs at this time, but unaware of him being outside . An IDT (Interdisciplinary Team) Note dated (MONTH) 11, (YEAR) documented Investigation started to how long resident was outside. He frequently goes outside by himself. Will get policy for residents going outside. MD (medical doctor) in facility to see resident. A Skin Ulcer Non-Pressure Weekly note dated (MONTH) 11, (YEAR) documented .Top of head only very light pink and appears to be quickly resolving. Arms and hands light pink. Left great toe with intact pink blister. Left thigh is most affected area with redness along entire thigh and intact blister along anterior lateral thigh. Right thigh has redness, anterior thigh, shoulder redness intact . A Nursing Note dated (MONTH) 12, (YEAR) at 2:57 p.m. included .skin care rendered to reddened and superficial open areas . A nursing note dated (MONTH) 14, (YEAR) at 3:16 p.m. included the resident had a bath this morning and most of the closed blistered areas had opened to left thigh, superficial open areas noted, wound care nurse informed. A Skin Ulcer Non-Pressure Weekly note dated (MONTH) 18, (YEAR) documented .All areas resolved except for thighs and left knee. There are still areas covering thighs with redness and notable intact stable scabs over left thigh and left knee. All areas may remain open to air at this time . A Nursing Note dated (MONTH) 21, (YEAR) at 1:17 p.m. revealed Dr .in and updated resident's condition and concerns on skin alteration on his thigh, no new order received . A Skin Ulcer Non-Pressure Weekly note dated (MONTH) 21, (YEAR) revealed .Right thigh has disperse scabbing surrounded by redness that appear to be healing as expected. No drainage or signs and symptoms of infection. The scabbing on right thigh appears thin not involving deeper tissue. Left thigh with extensive scabbing/eschar dispersed over most of surface area of the anterior and lateral thigh. Left knee has eschar that has unknown depth of tissue involvement of approximately 10 x 3 centimeters surface area . Review of a physician progress notes [REDACTED].Earlier this month the patient went outside, quite atypically for him and sat in the sunshine during the day. He was later found, and with the polyester pants that he had on collecting the sunlight, he sustained sunburns from his knees to his hips on the dorsum of his thighs that are almost coalescent in places. While originally just [DIAGNOSES REDACTED] and blisters, as they have evolved some of these are undoubtedly full-thickness and covered with eschar. These are currently left uncovered and cleaned daily. He also has a one centimeter area on his medial aspect of his left great toe that occurred on the same day .I requested today that they be updated, having been asked to see the 'sunburn' for the first time today. Some of these wounds on this particular patient will take the better part of 6 months to heal .He unfortunately sustained significant solar injury to his thighs that will take time to heal . A Skin Ulcer Non-Pressure Weekly note dated (MONTH) 24, (YEAR) included .Right thigh has disperse scabs on anterior surface of skin. All scabs appear stable and surrounding redness has faded showing improvement from last assessment .There are several very small fluid filled blisters on medial surface of upper thigh. Left thigh has scabs over anterior and lateral surface of skin. The scabs/eschar are significant and remain thickened with unknown tissue involvement beneath particularly over patients left knee. No signs/symptoms of infection . A Nursing Note dated (MONTH) 25, (YEAR) at 11:36 a.m. revealed .the patient's wounds are showing improvement in the sense that the surrounding skin around the scabs are less pink and there continues to be no signs and symptoms of infection. Review of the facility's investigative report dated (MONTH) 28, (YEAR) revealed .to the best of our knowledge we are able to identify that (resident's name) was in his room at approximately 10:05 a.m. and (name of CNA) checked on (name of resident) in the courtyard at approximately 10:45 a.m. Thus, it is believed that (name of resident) was outside for approximately 30 to 40 minutes .Review of the weather temperatures on Monday (MONTH) 10, (YEAR) identify that at 6:00 a.m. the temperature was 90 degrees and at 12:00 p.m. temperatures were recorded at 99 degrees .Prior to this incident it was the custom and practice of CNA's performing rounds to check the courtyard as part of their rounds. However, there was no documentation evidencing the courtyard was checked . Review of a Skin Ulcer Non-Pressure Weekly note dated (MONTH) 2, (YEAR) revealed .Right and left thighs continue with dispersed intact scabs on anterior surface of skin. All scabs appear stable and surrounding tissue is pink intact scar tissue. Wounds are showing improvement . A physician's orders [REDACTED]. A physician's orders [REDACTED]. A nurse practitioner note dated (MONTH) 4, (YEAR) revealed the following: The resident had an episode in which he was self-propelling his wheelchair and was found after being stuck in a sun-exposed area of the courtyard for unknown period of time, but felt to be 25-45 minutes based on courtyard rounds. He was lethargic and very warm. His heavier clothes were removed and he was given ice water and cool towels, and as a precaution was given IV fluids of 500 milliliters .It was noted later that the pants he had on at the time had retained a significant amount of heat, causing blistering wounds to the anterior of both thighs. He has been followed by the wound care team very closely since then and his thighs appear to be healing very well. No apparent infections or concerns . A physician note dated (MONTH) 5, (YEAR) included I am seeing the patient in follow-up of [MEDICAL CONDITION] the bilateral legs from thighs to knees. These are narrowing to a strip of eschar on each side that are clearly improving. He is reporting no complaints of pain except when dressing changes are done he will simply ask that care be exercised .Since our last visit the patient has been doing considerably better. He fortunately seems to be not uncomfortable with his wounds. The scabs will start to clear fairly soon. [MEDICATION NAME] treatment is obviously being used .Full thickness burn of thigh . A physician's orders [REDACTED]. Change daily . Review of a Skin/Wound Note dated (MONTH) 23, (YEAR) revealed Right and left thighs continue with dispersed eschar on anterior surface of skin. Most eschar presents with lifting from wound bed. Eschar to left knee continues to be stable. Surrounding tissue is pink intact scar tissue. Wounds are showing improvement. Patient will complain of mild pain .pain subsides when treatment is done .Provider updated, continue current treatment of [REDACTED]. A Skin/Wound Note dated (MONTH) 30, (YEAR) included Eschar to left shoulder was unstable and was separated from wound bed, wound bed presents with pink [MEDICATION NAME] tissue. Surrounding tissue is intact scar tissue. Bilateral anterior thighs continue with stable eschar, surrounding tissue is showing pink intact scar tissue. Intact scar tissue present to areas of where eschar has separated from wound bed and sloughed off. No indication of infection . A Nursing Note dated (MONTH) 9, (YEAR) included .Treatments to bilateral thigh areas and left shoulder continue., per wound nurse .the scabbed area over the left knee has begun to lift, each site is free from signs and symptoms of infection and are showing positive progression . An interview was conducted with a LPN (licensed practical nurse/staff #59) on (MONTH) 14, (YEAR) at 9:05 a.m. Staff #59 stated that they did not know how long the resident was outside when he got sunburned. Staff #59 stated that staff used to check the courtyard maybe every two hours to ensure residents were safe, but did not document when this was done. Staff #59 further stated that since the incident, 30 minute checks of the courtyard are done and are documented. An interview was conducted on (MONTH) 14, (YEAR) at 9:15 a.m., with the CNA (certified nursing assistant/staff #20) who found the resident outside. Staff #20 stated that she had just returned from lunch when she looked out the window of another resident's room across the hall from resident #4, and she saw resident #4 outside. Staff #20 stated that the resident was unresponsive, so she quickly brought the resident back into the facility and called a nurse. Staff #20 stated that when she found the resident, the wheel of his wheelchair was off of the path in the courtyard, as the ground was unlevel and the resident's wheelchair was stuck. Staff #20 stated that she did not know how long the resident had been in the courtyard. Staff #20 stated that staff check the courtyard all the time, but do not document when it's done. Staff #20 stated that there was no set time when the courtyard was to be checked. During the interview with staff #20, it was observed that when the door was opened at the end of the hall near resident #4's room, the door alarmed. Observations further revealed that if the door was shut after someone exited the unit, the alarm automatically shut off. When asked who had the responsibility to respond when the alarm sounded in order to determine who exited the building, staff #20 stated that it was everyone's responsibility and those who hear the alarm. An interview was conducted with another CNA (staff #14) on (MONTH) 14, (YEAR) at 9:25 a.m. Staff #14 stated that it was everyone's responsibility to check the alarm at the end of the hall to determine who exited the unit, but there was no specific person who was assigned to this task. Staff #14 further stated that if she was busy, someone else would check the door. An interview was conducted with the Administrator (staff #121) on (MONTH) 14, (YEAR) at 11:15 a.m. Staff #121 stated that when the incident occurred, staff were checking the courtyard every 30 minutes to ensure resident safety, but it was not documented that it was done. Review of the facility's policy regarding Resident Safety revealed, It is the policy of this facility to create a safe environment for the resident .Make routine visits to check on the resident's condition and comfort . Review of the facility's Abuse policy revealed that it is the policy of this facility that each resident has the right to be free from neglect. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm and pain. -Resident #31 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 21, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS included that the resident exhibited verbal behaviors toward others on 1-3 days of the lookback period. -Resident #32 was admitted to the facility on (MONTH) 14, (YEAR), with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 21, (YEAR), revealed a BIMS score of 10, which indicated the resident had moderate cognitive impairment. The MDS included the resident exhibited physical and verbal behaviors toward others on 1-3 days of the lookback period. Review of the facility's investigative documentation revealed that on (MONTH) 25, (YEAR), resident #31 and resident #32 were witnessed yelling at each other. The report included that resident #32 had resident #31 by the arm near his left elbow and pinched him, and then resident #31 hit her on the bottom with a cane. Resident #31 sustained a skin tear to the left arm. An interview was conducted with resident #31 on (MONTH) 13, (YEAR) at 12:49 p.m. He stated that resident #32 scraped the skin off of his arm when she got mad at him. An interview was conducted with resident #32, however she was unable to recount the details of the incident. An interview was conducted with a CNA (staff #65) on (MONTH) 14, (YEAR) at 1:37 p.m. She stated that in the event of abuse, she would make sure the resident is removed from the situation and is safe. An interview was conducted with a LPN (staff # 25) on (MONTH) 14, (YEAR) at 1:51 p.m. She stated that in the case of abuse she would remove the resident and make sure they are okay, and then notify the Administrator immediately. An interview was conducted with a CNA (staff #114) on (MONTH) 15, (YEAR) at 10:02 a.m. She stated that resident #32 uses mean words and a mean tone with resident #31. She stated that resident #32 will get angry at resident #31. She stated that she checks on them every 15-30 minutes, but the checks are not at a scheduled time and she does not document the checks. An interview was conducted with a LPN (staff #31) on (MONTH) 15, (YEAR) at 10:14 a.m. She stated that she could recall the incident between resident #31 and resident #32 on (MONTH) 25, (YEAR), as she was the nurse on that hall at the time. She stated that she was at her medication cart and heard someone talking loudly. She stated that resident #31 and resident #32 were walking side by side and resident #32 grabbed resident #31 by the arm. She stated that she had the CNA (staff #119) wait with the residents until she could get there. She said that resident #32 told her that she was not trying to hurt resident #31 and that she grabbed his arm to get his attention because he was a little in front of her, and her nails got caught in his skin. She stated that resident #31 told her that he was startled and that is why he hit resident #32 on the bottom with the cane to get her to stop. She said that if she observed physical or verbal outbursts between residents, she would separate them and report the issue. She stated that staff keep a close eye on resident #31 and resident #32 and watch for any agitation or behaviors. An interview was conducted with the Administrator (staff #121) on (MONTH) 15, (YEAR) at 10:44 a.m. He stated that in the case of a resident to resident altercation, they first make sure the residents are safe by separating the residents, and then try and determine what triggered the event. He stated that these residents had behaviors before entering the facility. He said that they set up as many interventions as possible to minimize any abusive situation, as residents have the right to be free from abuse. An interview was conducted with a LPN (staff #79) on (MONTH) 15, (YEAR) at 12:06 p.m. He stated that it is well known that resident #32 scratches and pinches resident #31, and that they are constantly bickering. He stated that he has seen resident #32 scratch or pinch resident #31, at which point resident #31 yells out and then resident #32 has said I will get you with the cane next time. He stated that they need to look out for the residents and uphold resident rights and do all they can to protect the residents. An interview was conducted with a CNA (staff #119) on (MONTH) 15, (YEAR) at 3:05 p.m. She stated that she was working the hall during the event between resident #31 and resident #32. She stated that she witnessed resident #32 trying to pull resident #31 into their room by holding his right arm above the elbow. She said that she witnessed resident #31 get the cane and smacked resident #32, but she was too far away to stop him. She said that resident #31 told her that it caused a skin tear and it hurt him. Review of the Abuse policy revealed that each resident had the right to be free from abuse. The policy included the facility will take action to protect and prevent abuse and neglect from occurring within the facility by; identifying, correcting and intervening in situations in which abuse is more likely to occur; and identifying, assessing, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect such as: Verbally aggressive behavior and physically aggressive behavior. The policy further included that if an allegation of abuse is reported, discovered or suspected, the facility will protect all residents from physical and psychosocial harm during and after the investigation; including increase supervision of the alleged victim and residents. If the allegation of abuse involved another resident, the facility will separate the residents so that they do not interact with each other until circumstances of the reported incident can be determined and the facility would continue to assess, monitor and intervene as necessary to maximize resident health and safety.