Every finding on record at Oasis Pavilion Nursing & Rehabilitation Center

Based on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 2 of 4 residents sampled (#1, #2) to be free from verbal abuse between residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse.Findings include:Resident # 1, the alleged victim, was re-admitted to the facility on [DATE], with a diagnosis of noninfective gastroenteritis and colitis, unspecified protein deficiency, alcohol use, and dependence on renal dialysis.A comprehensive care plan initiated on April 30, 2025 revealed that Resident #1 had behavioral problems related to attention seeking. The care plan revealed that on June 22, 2025 Resident #1 stated that if someone is going to be physically aggressive or say derogatory remarks towards him he would defend himself. Interventions included not to use joking or kidding language when speaking with resident as this causes confusion or agitation.A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating he was cognitively intact. A comprehensive care plan revised on July 6, 2026 revealed that on July 5, 2026 Resident #1 had behaviors of being impulsive when someone is verbally aggressive with words. Interventions included allowing the resident to talk about his feelings and find a positive outcome. A Psychiatric progress note dated July 8, 2026, revealed that Resident #1 had described a recent incident involving interpersonal conflict with Resident #2 who was calling him names, which triggered frustration and a gesture toward Resident #2, though no physical aggression occurred. Resident # 2, the alleged perpetrator, was re-admitted to the facility on [DATE], with a diagnosis of encounter for palliative care, unspecified dementia severe without behavioral disturbance, and Parkinsonism.A comprehensive care plan initiated on July 1, 2026, revealed that Resident #2 had behavioral symptoms related to dementia and Parkinson's and can be impulsive at times. Interventions included keeping his environment calm and relaxed and monitoring and treating for constipation as needed.An admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating he was cognitively intact. A comprehensive care plan revised on July 6, 2026, revealed that on July 5, 2026 Resident #2 had attention seeking behavior related to calling his friends names when he is frustrated. Interventions initiated on July 6, 2026 included allowing resident to express his thoughts and feelings and find positive outcomes. A Psychiatric progress note dated July 9, 2026, revealed that two days prior to the visit, Resident #2 was involved in a verbal altercation with another resident, admitting he called Resident #1 a 'bitch' when frustrated.A facility report, undated, revealed that on July 5, 2026 at approximately 12:00 p.m. Resident #1 and Resident #2 were eating lunch in the main dining room with Resident #6 at the same table. The report documented that Resident #2 started calling Resident #1 derogatory names. Resident #2 did not stop calling Resident #1 names even though Resident #1 had asked him to stop calling him names. Resident #1 then approached Resident #2 when Resident #2 said another derogatory name and Resident #1 raised his hand up and made a motion to brush him on the shoulder and chest. The facility report concluded that no contact was made by Resident #1 to Resident #2 but did not make a conclusion regarding the verbal abuse allegations. In an interview conducted on July 21, 2026, at 12:02 p.m. with Resident #2 who stated that he called Resident #1 a bitch. Resident #2 was observed to become frustrated and asked the surveyor to leave.In an interview conducted on July 21, 2026, at 12:59 p.m. with a Dietary Aide (Staff #19) who reported that on July 5, 2026 he was working the dining room when he came out into the dining room Resident #2 was trying to get his attention. Staff #19 heard Resident #1 say 'come on say it louder to my face'. The Staff #19 stated that Resident #2 said 'Shut up bitch' really loud to Resident #1. The Staff #19 stated that Resident #1 came over and flung his arm at Resident #2's chest to back off Resident #1. The dietary aid stated that is when staff came in and separated the residents. Staff #19 stated at no time Resident #1 and Resident #2 were joking around and that they were angry with each other. Staff #19 stated that he thought this was verbal abuse by Resident #2 because he was not joking and calling Resident #1 derogatory names for no reason.In an interview conducted on July 21, 2026, at 1:26 p.m. with Resident #6 who stated that Resident #2 crossed a line and should have never called Resident #1 a bitch. Resident #6 stated he was seated with Resident #1 and Resident #2 when Resident #2 started calling Resident #1 a 'bitch' loudly in the dining room. Resident #6 stated he was shocked and angry that Resident #2 did this. Resident #6 stated that Resident #1 got very angry and told Resident #2 not to call him that. Resident #6 stated that Resident #2 began yelling other expletives, that he could not remember, at Resident #1 causing Resident #1 to go over to Resident #2. Resident #6 stated that Resident #1 held his position at Resident #2 with his fist wanting to hit him but then ended up pushing him back in the chest. Resident #6 stated it took a while before staff came in and separated the two residents.An interview was conducted with Director of Nursing (DON/Staff #67) on July 21, 2026 at 3:07 p.m. who stated that abuse can be physical, verbal, emotional, or financial. Staff #67 stated that examples of verbal abuse include derogatory statements made to other residents and racial slurs. Staff #67 stated that she was notified after the incident happened with Resident #1 and Resident #2 and it was alleged Resident #1 hit Resident #2. Staff #67 stated that through her investigation she found the two residents had grown up together and would sometimes joke around but Resident #1 had told her he did not hit Resident #2. Staff #67 stated that it was confirmed in her investigation that Resident #2 had a history of being impulsive and utilizing aggressive language which he did during the incident. A review of facility documentation revealed a policy and procedure titled Resident Abuse, Neglect, Misappropriation Policy reviewed & updated on April 16, 2026. The policy and procedure stated, that the facility will not condone abuse by anyone including other residents. The policy goes on to define verbal abuse as any use of oral, written or gestured language that includes disparaging and derogatory term to residents or their families, or within hearing distance, to describe resident, regardless of their age, ability to comprehend or disability.

Based on clinical record, staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database the facility failed to implement their policy regarding reporting allegations of abuse to appropriate agencies and conducting a thorough investigation of an abuse/neglect allegation for one resident (#1). The deficient practice could result in abuse/neglect continuing and not being prevented.Findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction unspecified, anemia unspecified, and malignant neoplasm of unspecified part of bronchus or lungs.Review of the Modification of Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact. The MDS also indicated that the resident exhibited verbal and other behaviors during the assessment period. Review of State Agency (SA) database revealed a complaint filed from the complainant on April 3, 2026 of the alleged abuse to Resident #1. Further review of the SA database revealed no self-reports from the facility regarding the abuse allegation for Resident # 1.An interview conducted with Complainant on April 7, 2026 at 9:16 a.m. revealed that she had contacted the facility on March 30, 2026, speaking to staff # 35 notifying her that there was an allegation of abuse made for Resident # 1. The complainant stated that Resident # 1 was allegedly being abused and someone was trying to kill him by putting a pillow over his face with something sour on it. An interview was conducted with Social Services Director (Staff # 35) on April 7, 2026 at 12:11 p.m. who stated that she along with the Director of Nursing (DON/Staff # 68) are responsible taking any complaints regarding abuse and neglect and initiating the reporting and investigation of all allegations. Staff # 35 further stated that she has 2 hours to notify the SA as well as Adult Protective Services (APS), and Ombudsman. She stated that per they policy she also has to notify the Administrator of all allegations of abuse and an investigation is conducted where they interview staff and residents and if specific staff are involved, they are placed on suspension. She stated that she was contacted by the complainant on March 30, 2027 regarding Resident # 1 being forced to drink green stuff and asking about abuse in the building. Staff # 35 stated she told the complainant that no abuse had taken place against Resident # 1. Staff # 35 revealed there were no notifications to SA, APS, or Ombudsman and the Administrator was not notified as she did not think there was abuse because there was nothing in the progress notes or medical record indicating abuse. An interview was conducted with DON (Staff #68) on April 7, 2026 at 12:50 p.m. who stated that per the policy and state regulations they have 2 hours to report to the SA all allegations of abuse and 5 days to investigate and report to the state agency the facility's findings. The DON revealed it is important to follow this policy to make sure all allegations are reported and properly investigated. The DON stated that Resident # 1 was here for a very short stay from March 16, 2026 until March 19, 2026 when family decided they wanted him transferred to the hospital for further testing. The DON reported that she was contacted by Staff # 35 asking her if there were any grievances or reports of abuse by Resident # 1 or family. DON revealed that she had not received any allegations of abuse by the family, resident, or Staff # 35. She further stated if she had they would have followed the policy, reported and conducted an investigation. An interview was conducted with Licensed Practical Nurse (LPN/Staff #128) on April 7, 2026 at 2:05 p.m. who stated she remembered Resident # 1 being transported to the hospital by request of the family. She stated that she recalled Resident #1 was very agitated as there were was a lot of traffic in his room because hospice had also visited him. Staff # 128 stated that if there is an allegation of abuse, they immediately bring it to Staff # 68 or Staff # 35. Staff # 128 also stated that once they are notified, they start the investigation and make all the required calls to SA and police and do their investigation. Staff # 128 stated she was unaware of any investigations regarding Resident # 1. An interview was conducted with the Administrator (Staff # 37) on April 7, 2026 at 2:19 p.m. who stated that if there is any allegations of abuse either Staff # 35, Staff # 68, or himself will timely report the allegation within two hours and do their investigation. The Administrator stated that it is important to follow their policy because they follow the state guidelines and we want to make sure we get a clear picture of the allegation. The Administrator stated that no one had brought to his attention an allegation of abuse regarding Resident # 1 until today. Staff # 37 revealed that it is his expectation that allegations are brought to his attention as they are made per the policy. The facility policy titled Resident Abuse, Neglect, Misappropriation Policy, reviewed and updated on January 2026, revealed that any incident or suspected incident of abuse or resident abuse or unwitnessed injuries that cannot be explained will be reported promptly to the appropriate agencies/individuals, Social Services Director, Abuse Officer, and Administrator. The policy also revealed that the facility will investigate all incidents, all staff involved in the incident will be interviewed and written summaries of events will be requested by all parties. The Social Services/ DON/designee are the facility designated abuse officer who are responsible for tracking, trending, and investigation of the involved parties. The Administrator will be alerted to every investigation within 24 hours of occurrence. The policy further revealed that all allegations of abuse will be reported immediately to the direct supervisor and or Social Services Director/DON/designee, reporting of the incident will include the following: reporting to state agencies, the Police Department, analysis of the occurrence and any corrective actions.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure an allegation of resident (#1) abuse was reported to all applicable state agencies. The deficient practice could result in further allegations of abuse not being reported and investigated by the appropriate state agencies. Findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction unspecified, anemia unspecified, and malignant neoplasm of unspecified part of bronchus or lungs.Review of the Modification of Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact. The MDS also indicated that the resident exhibited verbal and other behaviors during the assessment period. Review of State Agency (SA) database revealed a complaint filed from the complainant on April 3, 2026 of the alleged abuse to Resident #1. Further review of the SA database revealed no self-reports from the facility regarding the abuse allegation for Resident #1.An interview conducted with Complainant on April 7, 2026 at 9:16 a.m. revealed that she had contacted the facility on March 30, 2026, speaking to staff # 35 notifying her that there was an allegation of abuse made for Resident # 1. The complainant stated that Resident # 1 was allegedly being abused and someone was trying to kill him by putting a pillow over his face with something sour on it. An interview was conducted with Certified Nursing Assistant (CNA/Staff # 86) on April 7, 2026 at 11:50 a.m. who stated that if there is an allegation of abuse or he suspects abuse he immediately will report to his supervisor or abuse coordinator who is Staff #35. The CNA (Staff #86) stated that Staff # 35 would do notifications to the Administrator and police and other state agencies. An interview was conducted with Licensed Practical Nurse (LPN/Staff # 134) on April 7, 2026 at 12:03 p.m. who stated that if there was an allegation of abuse, she would report it to either Staff # 35 or the Director of Nursing (DON/Staff # 68). Staff # 134 stated that she would do any assessments that needed to be done while Staff # 35 and/or Staff # 68 would make all the notifications to the SA and a police and administrator. An interview was conducted with Social Services Director (Staff # 35) on April 7, 2026 at 12:11 p.m. who stated that she along with the Director of Nursing (DON/Staff # 68) are responsible taking any complaints regarding abuse and neglect and initiating the reporting and investigation of all allegations. Staff # 35 further stated that she has 2 hours to notify the SA as well as Adult Protective Services (APS), and Ombudsman. She stated that per their policy she also has to notify the Administrator of all allegations of abuse and an investigation is conducted where they interview staff and residents and if specific staff are involved, they are placed on suspension. She stated that she was contacted by the complainant on March 30, 2027 regarding Resident # 1 being forced to drink green stuff and asking about abuse in the building. Staff # 35 stated she told the complainant that no abuse had taken place against Resident # 1. Staff # 35 revealed there were no notifications to SA, APS, or Ombudsman and the Administrator was not notified as she did not think there was abuse because there was nothing in the progress notes or medical record indicating abuse. An interview was conducted with DON (Staff #68) on April 7, 2026 at 12:50 p.m. who stated that per the policy and state regulations they have 2 hours to report to the SA all allegations of abuse and 5 days to investigate and report to the state agency the facility's findings. The DON reported that she was contacted by Staff # 35 asking her if there were any grievances or reports of abuse by Resident # 1 or family. DON revealed that she had not received any allegations of abuse by the family, resident, or Staff # 35. She further stated if she had they would have followed the policy, reported and conducted an investigation. An interview was conducted with the Administrator (Staff # 37) on April 7, 2026 at 2:19 p.m. who stated that if there is any allegations of abuse either Staff # 35, Staff # 68, or himself will timely report the allegation to the SA, APS, and Ombudsman within two hours and do their investigation. The Administrator stated that no one had brought to his attention an allegation of abuse regarding Resident # 1 until today. Staff # 37 revealed that it is his expectation that allegations are brought to his attention as they are made per the policy. The facility policy titled Resident Abuse, Neglect, Misappropriation Policy, reviewed and updated on January 2026, revealed that any incident or suspected incident of abuse or resident abuse or unwitnessed injuries that cannot be explained will be reported promptly to the appropriate agencies/individuals, Social Services Director, Abuse Officer, and Administrator. The policy further revealed that all allegations of abuse will be reported immediately to the direct supervisor and or Social Services Director/DON/designee, reporting of the incident will include the following: reporting to state agencies, the Police Department, analysis of the occurrence and any corrective actions.

Based on clinical records, review of facility documentation, review of the State Agency (SA) database, staff interviews and review of policy and procedure facility failed to ensure an allegation of abuse (Resident #1) was fully investigated. The deficient practice could result in allegations of abuse not being thoroughly investigated and abuse occurring in the facility.Findings include:Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction unspecified, anemia unspecified, and malignant neoplasm of unspecified part of bronchus or lungs.Review of the Modification of Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident was cognitively intact. The MDS also indicated that the resident exhibited verbal and other behaviors during the assessment period. Review of State Agency (SA) database revealed a complaint filed from the complainant on April 3, 2026 of the alleged abuse to Resident #1. Further review of the SA database revealed no self-reports from the facility regarding the abuse allegation for Resident # 1 or a 5-day facility investigation report. An interview conducted with Complainant on April 7, 2026 at 9:16 a.m. revealed that she had contacted the facility on March 30, 2026, speaking to staff # 35 notifying her that there was an allegation of abuse made for Resident # 1. The complainant stated that Resident # 1 was allegedly being abused and someone was trying to kill him by putting a pillow over his face with something sour on it. An interview was conducted with Social Services Director (Staff # 35) on April 7, 2026 at 12:11 p.m. who stated that she along with the Director of Nursing (DON/Staff # 68) are responsible taking any complaints regarding abuse and neglect and initiating the reporting and investigation of all allegations an investigation is conducted where they interview staff and residents and if specific staff are involved, they are placed on suspension. She stated that she was contacted by the complainant on March 30, 2027 regarding Resident # 1 being forced to drink green stuff and asking about abuse in the building. Staff # 35 stated she told the complainant that no abuse had taken place against Resident # 1. Staff # 35 revealed that a facility investigation was not conducted because there was nothing in the progress notes or medical record indicating abuse. An interview was conducted with DON (Staff #68) on April 7, 2026 at 12:50 p.m. who stated that per the policy they have 5 days to investigate and report to the state agency the facility's findings. The DON reported that she was contacted by Staff # 35 asking her if there were any grievances or reports of abuse by Resident # 1 or family. DON revealed that she had not received any allegations of abuse by the family, resident, or Staff # 35. She further stated if she had been notified, they would have conducted an investigation. An interview was conducted with Licensed Practical Nurse (LPN/Staff #128) on April 7, 2026 at 2:05 p.m. who stated she remembered Resident # 1 being transported to the hospital by request of the family. She stated that she recalled Resident #1 was very agitated as there was a lot of traffic in his room because hospice had also visited him. Staff # 128 stated that if there is an allegation of abuse, they immediately bring it to Staff # 68 or Staff # 35. Staff # 128 also stated that once they are notified, they start their investigation and make all the required calls to SA and police and do their investigation. Staff # 128 stated she was unaware of any investigations regarding Resident # 1. An interview was conducted with the Administrator (Staff # 37) on April 7, 2026 at 2:19 p.m. who stated that if there are any allegations of abuse either Staff # 35, or Staff # 68 would conduct an investigation. The Administrator further stated that during the investigation staff # 68 and # 35 conduct interviews with residents that reside near the resident and interview staff that work with the resident. The Administrator stated that once the investigation is done, he reviews the investigation and sends it to the SA within 5 days of the initial report of the allegation. The Administrator stated that no one had brought to his attention an allegation of abuse regarding Resident # 1 until today. Staff # 37 stated that it is his expectation that allegations are brought to his attention as they are made and a proper investigation is conducted. The Administrator stated the risk of not doing an investigation is we don't get a clear picture of the allegation.The facility policy titled Resident Abuse, Neglect, Misappropriation Policy, reviewed and updated on January 2026, revealed that any incident or suspected incident of abuse or resident abuse or unwitnessed injuries that cannot be explained will be reported promptly to the appropriate agencies/individuals, Social Services Director, Abuse Officer, and Administrator. The policy also revealed that the facility will investigate all incidents, all staff involved in the incident will be interviewed and written summaries of events will be requested by all parties. The Social Services/ DON/designee are the facility designated abuse officer who are responsible for tracking, trending, and investigation of the involved parties.

Based on clinical record review, staff interviews and policy, the facility failed to ensure that medical records were accurately documented and/or completed for one of six sampled residents (#5) regarding urinary output. The deficient practice could result in resident ' s clinical records not being an accurate representation of their care/condition. Findings include: Resident #5 was admitted on [DATE] with diagnoses that included muscle weakness, difficulty in walking, other abnormalities of gait and mobility, encounter for change or removal of surgical wound dressing, and acute and chronic respiratory failure with hypoxia. Review of the resident ' s clinical record revealed an order on November 5, 2021 by the Primary Care Physician (PCP) for an indwelling catheter to straight drainage: 16FR 10CC DX: Urinary Retention. Further review of the clinical record revealed another order on November 5, 2021 by the PCP for routine catheter care every shift per facility protocol. According to the residents Minimum Data Set (MDS) dated [DATE] the resident had a Brief Interview for Mental Status (BIMS) summary score of 15 indicating he was cognitively intact. Further review of the MDS revealed the resident had an indwelling catheter in place as well as a Urinary Tract infection (in the last 30 days). According to a progress note dated November 26, 2021 at 11:59 stated that the resident was noticed to have low 02 stats and at 11:30 the resident began ' pursed lip breathing. ' , the physician was notified and gave the order to transport the resident to the hospital. Review of the resident #5 ' s clinical census revealed that the resident was not active after November 26, 2021 and reactive on December 2, 2021 indicating that the resident was admitted to the hospital after being transferred. Review of the Treatment Administration Record (TAR) for November 2021 revealed catheter outputs were documented on November 27 and 28th of 2021 when the resident was not in the facility. An interview was conducted with a Licensed Practical Nurse (LPN/Staff #59) on May 12, 2025 at 4:46p.m. The LPN stated that her role in catheter care is to ensure the integrity of the catheter and ensure there are no issues with infection. The LPN stated that she was not sure if nurses are to fill out the resident ' s outputs when they are out of the facility but they do receive the information at discharge. An interview was conducted with a Certified Nursing Assistant (CNA/Staff #21) on May 12, 2025 at 5:06 p.m. The CNA stated that her role in catheter care is to clean the residents catheter in addition to document the resident ' s output while they are in the facility. An interview was conducted with a Director of Nursing (DON/Staff #67) on May 12, 2025 at 5:13 p.m. The DON stated that if a resident is transferred to the hospital and is discharged from the facility, even for a short period of time, there should be no documentation regarding outputs from their catheter. The DON was asked to pull up resident #5 ' s chart and identified that during the time period of November 27th and 28th the resident was not in the facility. The DON further verified that there were documented 50cc outputs on both days on the resident ' s TAR. The DON stated she is not sure why that was done and stated that the risks of misdocumenting information would be incorrect information being in the resident ' s medical record. Review of a facility policy revised May 22, 2022 and reviewed April 20, 2025 titled, Urinary Catheter Care, states the facility is to maintain an accurate record of the resident ' s daily output, per facility policy and procedure.

Based on the clinical record, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#55) was assessed, monitored, and provided emergency response. The deficient practice could result in residents not receiving emergency treatment and could lead to physical and psychosocial harm. Findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included altered mental status, chronic obstructive pulmonary disease, malignant neoplasm of the brain, type II diabetes, hemiplegia and hemiparesis affecting the left dominant side, and slurred speech. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 11 indicating the resident had a moderate cognitive impairment. The order summary included the following orders: -December 11. 2024, oxygen (O2) per nasal cannula (NC) to keep saturation greater than 90%: Check SATs every shift and as needed (PRN) every shift for vitals. -January 19, 2025 at 1:40 p.m., send the patient to the hospital. The order was created by a licensed practical nurse (LPN/staff #12). -January 19, 2025 revised at 5:33 p.m., send patient out emergent per the medical doctor (MD). Patient educated of the bed hold policy and given written notice of transfer. The order was revised by the Director of Nursing (DON/staff #10) -The order was created on January 20, 2025 by the (DON/staff #10), 1:40 p.m., on January 19, 2025 order by the Medical Director to send patient out emergent for altered mental status (AMS) per MD. Patient educated of the bed hold policy and given written notice of transfer. Review of the vitals revealed that the resident's oxygen level was taken on January 19, 2025 at 8:51 a.m. and was 93% via nasal cannula. The hospital transfer form dated January 19, 2025 at 2:00 p.m. revealed that the resident was transferred to hospital for low oxygen saturation. The oxygen level recorded was taken on January 19, 2025 at 8:51 a.m. and was 93% via nasal cannula. The report was called in by a registered nurse (RN/staff #15) to the emergency room and the ambulance transportation company on January 19, 2025, but the time and type of transfer was not documented. A nurse practitioner note late entry on January 28, 2025. Effective date January 19, 2025, revealed that the NP received a report from nursing that the resident was exhibiting AMS, tachycardia, hypotensive and desating to the 80's. The charge nurse was aware. The family doesn't wish for the resident to be on hospice. The patient was sent out 911 for a higher level of care. The resident was observed and this was a change of condition. An interview was conducted on January 28, 2025 at 11:18 a.m. with the Director of Nursing (DON/staff #10), who stated that she was not at the facility when the resident was transferred to the hospital on January 19, 2025 in the afternoon. She reviewed the progress notes and acknowledged that there was no documentation regarding the resident's change of condition (COC), vitals, stating that the MD had been notified, or whether the MD had ordered the resident transfer to the hospital emergent or non-emergent. Then she reviewed the vitals and stated that the resident's oxygen level was last taken on January 19, 2025 at 8:51 a.m. and was 93% via nasal cannula, but she had no way of knowing the oxygen level on the afternoon of January 19, 2025 when the resident was transferred to the hospital. She stated that the resident's pulse rate was 130 on January 19, 2025 at 2:30 p.m. and a normal pulse is under 100, so the resident's transfer to the hospital should have been emergent and the MD should have been notified of the COC. She stated that she is responsible for auditing hospital orders and the first order did not specify if the transfer was non-emergent or emergent, so she created a second order with a question mark because she wanted to know if the resident was transferred emergent or non-emergent, and the reason for the transfer. Once she found out that the resident had an altered mental status, she changed the transfer order to emergent. Then staff #1 reviewed the hospital transfer form dated January 19, 2025 at 2:00 p.m. and stated that she didn't know if 2:00 p.m. was the time the nurse started the form, called for transport, or the time the resident was transferred. She stated that the reason for transfer on the form was an abnormal pulse oximeter, which meant that the resident's oxygen saturation level was low, but the form did not indicate whether the transfer was emergent or non-emergent. She also acknowledged that that the form did not indicate the time the resident was transferred. Staff #10 left the interview and when she returned, she stated that the Administrator had spoken to the NP who stated that she was at the facility on January 19, 2025 and ordered for the resident to be transferred 911 and would be entering a progress note in the clinical record. An interview was conducted on January 28, 2025 at 1:50 p.m. with a second Director of Nursing (DON/staff #1), who stated that she contacted (RN/staff #15) on January 19, 2025 and staff #15 told her that the Nurse Practitioner (NP) was at the facility and instructed staff #15 to transfer the resident to hospital non-emergent. She stated that she received a message from the charge nurse (LPN/staff #12), saying the resident was sent out for being lethargic and desating. She stated that the message didn't indicate whether the transfer was emergent or non-emergent and had made a note to follow up with staff #12 because she had questions about how the resident was sent out to the hospital, but it was the weekend and by the time she came back to work, the resident had already been admitted . She stated that an order is supposed to be placed in the clinical record and a progress note is completed documenting the the condition of the resident, vitals, why the resident was transferred to the hospital, including the type and time of the transfer, and the physician's instructions. An interview was conducted on January 28, 2025 at 2:05 p.m. with (RN/staff #15), who stated that the NP was at the facility. The charge nurse (LPN/staff #12) talked to the NP, was told to transfer the resident non-emergent, and he also completed the transfer paperwork for the resident. She stated that she took the resident's vitals, which should be in the clinical record and had no opinion as to whether the resident should be sent to the hospital emergent or non-emergent. An interview was conducted on January 28, 2025 at 2:10 p.m. with the charge nurse (LPN/staff #12), who stated that he remembered the resident, but doesn't remember anything about the transfer and doesn't remember if it was emergent or non-emergent. He stated that if he talked to the NP and sent the resident to the hospital, he would have completed a progress note. He stated that he wasn't assigned to the resident, but as a charge nurse may or would have helped. He stated that it was common sense, if the resident wasn't breathing, the resident would be an emergent transfer. The facility policy, Orientation for Transfer or Discharge (Emergent or Therapuetic Leave) states that for an emergency transfer or discharge to a hospital or other acute care institution, implement the following procedures: call 911 if the resident meets clinical/behavioral criteria per facility policy, or assist in obtaining transporation and notify the resident's attending physician.

Based on observation, clinical review, interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#22) was provided wound care and services in accordance with professional standards of practice. Findings include: Resident (#22) was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included metabolic encephalopathy, mild protein-calorie malnutrition, unspecified dementia, and chronic kidney disease. A care plan dated December 11, 2024 revealed that the resident was at risk for skin breakdown related to: -a pressure ulcer/deep tissue stage I, disease process and abnormal labs. -upon admission: left foot, a stage 2 closed blister, roof intact and not filled with fluid; there was no drainage and was resolved on December 24, 2024. -upon admission: sacrum/coccyx (superior), pressure ulcer stage I dark red non blanching. Skin was intact and peri wound appeared within normal limits (WNL). It was upgraded on December 24, 2024 to a pressure 3. Interventions included to address any incontinence care as needed, encourage and assist the resident in shifting of position every two hours while in bed and every one hour when up in chair, and wound care as ordered by the medical doctor. Review of the order summary revealed: -December 18, 2024, left heel (plantar): cleanse with normal saline (NS), pat dry. Apply betadine and let air dry, leave OTA. Monitor for worsening and report changes to provide. Every shift for wound care. -December 18, 2024, encourage use of low airloss mattress (LAL) for wound prevention/maintenance. -December 18, 2024, encourage/assist to apply barrier cream to buttocks, sacrum, and groin, every shift, and after episodes of incontinence or if shin concerns are present. Every shift for skin protection/care. -December 19, 2024, clean buttocks with NS and pat dry. Apply medihoney and a non stick dressing and secure in place. Monitor for signs and symptoms (S/S) of infection and report any concerns to the provider. Every day shift for wound care. -December 20 2024, encourage use of wedge and other support surfaces for positioning and offloading. -December 20, 2024, wound consult for evaluation and treatment for the sacrum. -December 20, 2024, wound consult for evaluation and treatment , bilat buttocks and left heel. -January 13, 2024, send patient out non emergent family requested related to wound per medical doctor. Patient educated on bed hold policy and given written notice of transfer. -January 11, 2025, wound coccyx: cleanse wound with wound cleaner and gentle pat dry with sterile gauze. Apply zinc oxide to the wound bed and leave open to air. Every day shift. Note: an order cleanse sacral wound with wound cleanser, apply hydrogel ointment to wound bed, primary dressing: calcium alginate, facility choice of available sterile, non adhesive, moisture preserving dressing, secondary dressing: facility choice of available secondary dressing to secure primary layer in place was not in the order summary. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident had two, stage I, pressure ulcers and one, stage II, pressure ulcer which was not present upon admission/entry or reentry. A physician's visit report dated December 24, 2024 revealed that the resident was being seen for a stage III sacral wound that was currently under treatment by wound care nursing at the time. The facility nursing staff has requested care and wound care consultation. Services will be rendered on their behalf due to the persistent complexities and resistance to healing of the the patient's wounds. -General notes: stage III sacral wound with noted eschar present and left heel with deep tissue injury (DTI). -Wound Assessment: wound #1 superior sacral is a stage 3 pressure injury pressure ulcer acquired on 12/24/2024 and has received a status of Not Healed. Initial wound encounter measurements are 11.66 cm length x 8.39 cm width x 0.2 cm depth, with an area of 97.827 sq cm and a volume of 19.565 cubic cm. Necrotic tendon, necrotic muscle and necrotic adipose are exposed. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. There is a Small amount of sanguineous drainage noted which has a Mild odor. The patient reports a wound pain of level 0/10. The wound margin is attached to wound base Wound bed has 1-25%, bright red, pink, firm, granulation, 1-25% adherent, yellow slough, 26-50% moist, black eschar. The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The temperature of the periwound skin is WNL. Periwound skin does not exhibit signs or symptoms of infection. -Procedures: wound #1 (Pressure Ulcer) is located on the superior sacral. A non-selective mechanical debridement was performed. Non-viable tissue was removed. The procedure was tolerated well with a pain level of 0 throughout and a pain level of 0 following the procedure. Post Debridement Measurements: 11.66 cm length x 8.39 cm width x 0.2 cm depth; with an area of 97.827 sq cm and a volume of 19.565 cubic cm. Post debridement stage noted as stage 3 pressure injury. -Wound orders superior sacral: follow-up in one week cleanse wound with wound cleanser apply hydrogel ointment to wound bed primary dressing: calcium alginate, facility choice of available sterile, non adhesive, moisture preserving dressing secondary dressing: facility choice of available secondary dressing to secure primary layer in place plan of care discussed with facility nursing staff Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) dated December 2024 did not reveal an order to cleanse sacral wound with wound cleanser, apply hydrogel ointment to wound bed, primary dressing: calcium alginate, facility choice of available sterile, non adhesive, moisture preserving dressing, and to use a secondary dressing: facility choice of available secondary dressing to secure primary layer in place was not in the order summary. An interview was conducted on January 27, 2025 with the wound nurse (LPN/staff #7). She reviewed A physician's visit report dated December 24, 2024 and stated that she was present when the wound provider evaluated the resident on December 24, 2024. She stated that during the visit, the sacral wound was open with slough and the provider upgraded the pressure ulcer from a stage I to a stage III. She also stated that during the visit on December 24, 2024, the provider ordered hydragel with calcium alginate to be applied daily and as needed, which was to be done by her and she would have documented the treatment was applied in the Treatment Administration Record (TAR). Staff #7 reviewed the resident's orders and stated that there was not an order for hydragel calcium alginate. Then, she reviewed the MAR and the TAR for December 2024 and stated that the treatment for hydragel calcium alginate was not on the MAR or the TAR, so there was no documentation of the treatment being done. Staff #7 stated that she must have forgotten to put the order for hydragel calcium alginate in, so it was not added to the MAR or TAR. She stated that there was a risk of the eschar not softening and the Medihoney should have been discontinued. An interview was conducted on January 27, 2024 at 1:05 p.m. with the Director of Nursing (DON/staff #1), who stated that treatments require a physician's order and when a nurse receives a verbal order, the order should be submitted and carried out as ordered. She stated that there is risk of the wound worsening if the ordered treatment is not done. She stated that it is the responsibility of the wound nurse to review the orders to ensure that nothing is forgotten. Review of the Wound Nurse General Job Description revealed that the wound nurse is responsible for rounding daily on residents with treatment orders to ensure the treatments are being completed and charted. The facility policy, Prevention and Treatment of Pressure Ulcers and Other Skin Issues states that any resident who has a pressure ulcer on admission has the appropriate treatment to promote healing and prevent any other pressure wounds.

Review of the clinical record, staff interviews, and the facility policy and procedures, revealed that the facility failed to document one resident's (#55) change of condition, that the physician was notified, the physician's instructions, and the type or time of the hospital transfer in the clinical record. Findings include: Resident #55 was admitted to the facility on [DATE] with diagnoses that included altered mental status, chronic obstructive pulmonary disease, malignant neoplasm of the brain, type II diabetes, hemiplegia and hemiparesis affecting the left dominant side, and slurred speech. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 11 indicating the resident had a moderate cognitive impairment. The order summary included the following orders: -December 11. 2024, oxygen (O2) per nasal cannula (NC) to keep saturation greater than 90%: Check SATs every shift and as needed (PRN) every shift for vitals. -January 19, 2025 at 1:40 p.m., send the patient to the hospital. The order was created by a licensed practical nurse (LPN/staff #12). -January 19, 2025 revised at 5:33 p.m., send patient out (non-emergent/emergent) for (?) per the medical doctor (MD). Patient educated of the bed hold policy and given written notice of transfer. The order was revised by the Director of Nursing (DON/staff #10) -The order was created on January 20, 2025 by the (DON/staff #10), 1:40 p.m., on January 19, 2025 order by the Medical Director to send patient out emergent for altered mental status (AMS) per MD. Patient educated of the bed hold policy and given written notice of transfer. Review of the vitals revealed that the resident's oxygen level was taken on January 19, 2025 at 8:51 a.m. and was 93% via nasal cannula. It did not reveal the oxygen saturation level when the resident had a change of condition in the afternoon on January 19, 2025. A nurse practitioner note late entry on January 28, 2025. Effective date January 19, 2025, revealed that the NP received a report from nursing that the resident was exhibiting AMS, tachycardia, hypotensive and desating to the 80's. The charge nurse was aware. The family doesn't wish for the resident to be on hospice. The patient was sent out 911 for a higher level of care. The resident was observed and this was a change of condition. An interview was conducted on January 28, 2025 at 11:18 a.m. with the Director of Nursing (DON/staff #10), who stated that she was not at the facility when the resident was transferred to the hospital on January 19, 2025 in the afternoon. She reviewed the progress notes and acknowledged that there was no documentation regarding the resident's change of condition (COC), vitals, stating that the MD had been notified, or whether the MD had ordered the resident transfer to the hospital emergent or non-emergent. Then she reviewed the vitals and stated that the resident's oxygen level was last taken on January 19, 2025 at 8:51 a.m. and was 93% via nasal cannula, but she had no way of knowing the oxygen level on the afternoon of January 19, 2025 when the resident was transferred to the hospital. She stated that the resident's pulse rate was 130 on January 19, 2025 at 2:30 p.m. and a normal pulse is under 100, so the resident's transfer to the hospital should have been emergent and the MD should have been notified of the COC. She stated that she is responsible for auditing hospital orders and the first order did not specify if the transfer was non-emergent or emergent, so she created a second order with a question mark because she wanted to know if the resident was transferred emergent or non-emergent, and the reason for the transfer. Once she found out that the resident had an altered mental status, she changed the transfer order to emergent. Then staff #1 reviewed the hospital transfer form dated January 19, 2025 at 2:00 p.m. and stated that she didn't know if 2:00 p.m. was the time the nurse started the form, called for transport, or the time the resident was transferred. She stated that the reason for transfer on the form was an abnormal pulse oximeter, which meant that the resident's oxygen saturation level was low, but the form did not indicate whether the transfer was emergent or non-emergent. She also acknowledged that that the form did not indicate the time the resident was transferred. Staff #10 left the interview and when she returned, she stated that the Administrator had spoken to the NP who stated that she was at the facility on January 19, 2025 and ordered for the resident to be transferred 911 and would be entering a progress note in the clinical record. An interview was conducted on January 28, 2025 at 1:50 p.m. with a second Director of Nursing (DON/staff #1), who stated that she contacted (RN/staff #15) on January 19, 2025 and staff #15 told her that the Nurse Practitioner (NP) was at the facility and instructed staff #15 to transfer the resident to hospital non-emergent. She stated that she received a message from the charge nurse (LPN/staff #12), saying the resident was sent out for being lethargic and desating. She stated that the message didn't indicate whether the transfer was emergent or non-emergent and had made a note to follow up with staff #12 because she had questions about how the resident was sent out to the hospital, but it was the weekend and by the time she came back to work, the resident had already been admitted . She stated that an order is supposed to be placed in the clinical record and a progress note is completed documenting the the condition of the resident, vitals, why the resident was transferred to the hospital, including the type and time of the transfer, and the physician's instructions. An interview was conducted on January 28, 2025 at 2:05 p.m. with (RN/staff #15), who stated that the NP was at the facility. The charge nurse (LPN/staff #12) talked to the NP, was told to transfer the resident non-emergent, and he also completed the transfer paperwork for the resident. She stated that she took the resident's vitals, which should be documented in the clinical record. An interview was conducted on January 28, 2025 at 2:10 p.m. with the charge nurse (LPN/staff #12), who stated that he remembered the resident, but doesn't remember anything about the transfer and doesn't remember if it was emergent or non-emergent. He stated that if he talked to the NP and sent the resident to the hospital, he would have completed a progress note. The facility policy, Change in a Resident's Condition or Status Policy states that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on clinical record review, staff interviews, review of facility documentation, and policy, the facility failed to ensure that the electronic health record for resident #1 was complete and accurately documented. The deficient practice could result in incomplete and/or inaccurate clinical records and potentially impact resident care. Findings include: Resident #1 was admitted on [DATE] with diagnosis including malignant neoplasm of the kidney, secondary malignant neoplasm of the brain, depression, prediabetes, cerebral edema, repeated falls, obesity and other abnormal findings on diagnostic imaging of the central nervous system. A review of the documentation from resident's hospital (Hospital B) prior to admission to the facility with an admitted on April 13, 2024 noted that the resident's family took her to a hospital (Hospital A) post fall, and were then recommended to take the resident to Hospital B. Documentation from Hospital B further revealed that the resident had known metastases to the lung and brain, as well as a noted history of imbalance and falls. Hospital records stated that the resident had reported dizziness, falls and trouble standing. The physical therapy documentation from Hospital B also revealed' fall risk as a documented precaution for resident #1. A review of the MDS (minimum data set) dated April 22, 2024 revealed that the resident had a BIMS (brief interview of mental status) score of 14, suggesting that the resident was cognitively intact. A review of the focus areas in the care plan for resident #1 revealed an identified accident potential due to a new environment and weakness. The care plan further notes that the resident was admitted to the hospital on March 29, 2024 after a ground level fall. The electronic health record for resident #1 revealed a new admission fall risk assessment on April 17, 2024 with a score of '0', indicating that the resident was noted to be a low risk for falls. Question #3 on the fall risk assessment, asked specifically about the history of falls within the last six months. The response to this question was noted that the resident had no fall history; however, the resident's admitting diagnosis, MDS and care plan included documentation that the resident had repeated falls. A further review of the progress notes in the electronic health record revealed that the resident had a fall on April 27, 2024 at 7:00 PM. The progress notes revealed that a CNA (certified nursing assistant) reported that resident #1 had a fall in the bathroom. An interview was conducted on April 7, 2024 at 10:25 AM with staff #151 (CNA). Staff #151 stated information regarding a resident's falls and or fall risk is shared during shift change, meetings and is documented in the electronic health record via the fall risk assessment and progress notes. An interview was conducted on April 7, 2024 at 10:35 AM with staff #161, (RN/registered nurse). Staff #161 stated that the fall risk assessment is completed by the admitting nurse. Staff #161 stated that when completing the fall risk assessment, the nurse would review the history of falls, would interview the resident and or family, review the history and physical from the hospital, and review therapy document, as applicable. An interview was conducted on April 7, 2024 at 11:31 AM with staff #76 (MDS nurse). Staff #76 stated that a resident's fall history can be obtained from the hospital history and physical. She stated that she would meet with the resident to further review their history of falls and if a fall risk is identified, it would be included in the care plan. She stated that all nurses are oriented to the care plan and the overall process for identifying a resident who is a fall risk. Staff #76 reviewed the resident's MDS and care plan and confirmed that notations regarding the potential fall risk had been documented for resident #1. Staff #76 stated that because she also reviews resident safety, she has a fall log where it was noted that the resident was identified as a fall risk and that it had been discussed with staff. Staff #76 stated that given that the resident's fall risk had been identified as a safety concern, the fall risk assessment should have identified resident #1 as a fall risk as well. Staff #76 stated that upon review of the admission fall risk assessment, the potential fall risk for resident #1 had not been identified. Staff #76 stated that the risk for having conflicting information in the electronic health record could include staff confusion and inaccurate documentation. An interview was conducted with staff #65 LPN (licensed practical nurse). Staff #65 stated that he was familiar with resident #1 and that she had fallen once on his shift. Staff #65 stated that he had conducted the admission fall risk assessment for resident #1. Staff #65 stated that he thinks about fall history in terms of the resident' history in the facility and not prior to entering the facility. He stated that is why he felt the fall risk assessment was accurately completed; however, staff #65 did state that the resident is currently a fall risk and that the risk of not identifying a resident as a fall risk when warranted could include additional falls. An interview was conducted with staff #147 (DON/Director of Nursing). Staff #147 stated that fall risk assessments, should be conducted accurately via resident / family interview and by reviewing hospital and or transferring facility documentation. She stated that the fall risk assessment captures current and historical information for the resident. She reviewed the resident record and the fall risk assessment and stated that resident #1 should have been identified as a fall risk. She stated that this did not meet her expectations. She further stated that when assessing the history of falls on the fall risk assessment, the nurse who conducted the assessment, may have misinterpreted the guidance. Staff #147 stated that the risk could include not putting the proper precautions in place for the resident. A review of the facility policy entitled Falls and Fall Risk Managing dated January 05, 2024 revealed that based on previous evaluations and data, staff will identify interventions related to the resident' specific risks and causes to try to prevent residents from falling.

Based on record review, interviews, and observation of current practice, the facility failed to ensure the right of one resident (#2) to be free from abuse from another resident (#1). The deficient practice could result in resident abusing and experiencing emotional and mental trauma from the abuse. Findings include: Regarding Resident #2 Resident #2 was admitted to the facility on [DATE] with diagnoses of hypertension, history of strokes, and a history of falls. The admission Minimum Data Set (MDS) assessment dated [DATE] a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment. The MDS also indicated resident #2 used a walker for mobility purposes as the resident had an impairment on the lower extremity on one side. Review of a progress note dated April 5, 2024 revealed a nurse heard someone yelling for help and upon entering the room the nurse found resident #2 sitting on the floor and her roommate was sitting in resident's bed looking through her belongings. The note indicated that resident #2 informed staff that the roommate (resident #1) had pulled her off the bed and pushed her to the floor. Further, the note revealed resident #2 reported being sore from the fall. A progress note revealed that on April 6, 2024 resident was complaining of pain in the left hip as a result of the fall. An x-ray was taken of the left hip and femur. A radiology report dated April 6, 2024 indicated a new fracture of the left femur. A Post Adverse Occurrence Observation note dated April 6, 2024 revealed resident #2 had no injuries as a result of the fall. The noted indicated that the resident had a sore to the left hip and that it was the same area where the resident had a previous hip fracture. An interview was conducted on April 25, 2024 at 9:14 AM with resident #2 regarding the incident on April 5, 2024. Resident #2 stated that resident #1 was pacing in their room and started accusing resident #2 of being in resident #1's bed. Resident #2 stated that resident #1 then pulled resident #2's left foot and I went to the floor. Resident #2 indicated they started calling out for help and staff helped her into her wheelchair. Resident #2 stated the incident happened on a Friday and then she had an x-ray. Regarding Resident #1 Resident #1 was admitted to the facility on [DATE] for palliative care. The discharge MDS assessment dated [DATE], indicated that resident #1's cognitive skills for daily decision making was severely impaired. There was no evidence regarding the alleged incident of resident #1's abuse of resident #2 on April 5, 2024. Review of the facility's 5-day investigative report revealed Licensed Practical Nurse (LPN/Staff #141) reported to the Director of Nursing (DON) that resident #2 was pulled to the floor of her room by resident #1. The report also indicated that both resident (#1 and #2) were roommates at the time of the incident. The report noted that resident #1 was admitted to the facility on e hour prior to the incident. An interview was conducted on April 25, 2024 at 9:20 AM with the Social Services Director (SSD/Staff 83). Staff #83 indicated they try to assess a potential resident to determine if they have behaviors before they are admitted into the facility. The SSD stated that this meant having conversations with a resident's case worker, staff at the previous facility or family members. An interview as conducted with the Admissions Coordinator (staff #15) on April 25, 2024 at 9:46 AM. Staff #15 indicated that they did not accept residents with behavior issues very often. However, when they do, roommates did not get along because of disagreements on room temperature or a roommate was being too loud. When asked what was done to determine if resident #1 needed interventions to be put into place to ensure the safety of herself and other residents prior to moving in, staff #15 indicated that she was not sure what was done to determined if resident #1 needed interventions in place to ensure her safety and the safety of others prior to admission. Another Admissions Coordinator (staff #62) stated that they had spoken with resident #1's case manager who stated that resident had no behaviors. An interview was conducted with the DON on April 25, 2024 at 10:00 AM. The DON indicated that prospective resident screening was done by the Admissions Coordinator and themselves. The DON stated they typically do not admit residents who have a dementia diagnoses with behaviors because they are not adequately trained to work with that population. Regarding the incident with residents #1 and resident #2, the DON stated that when she interviewed staff, they said they were surprised at her (resident #1) outburst because up to that point, she just needed redirection. The DON also stated that resident #2 initially reported having no pain but a few days later she had pain so she was sent to the hospital for x-rays. The DON added that there was a change in resident #2's x-ray attributed from the fall. A review of the policy titled, Resident Abuse and Neglect Policy, reviewed on January 9, 2023, defined physical abuse as hitting, slapping, pinching, kicking etc. The policy guidelines revealed, It is the responsibility of the facility to identify any resident whose personal history rends them at a risk for abusing residents, and development of intervention strategies to prevent occurrence, monitoring for changes that would trigger abusive behavior, and reassessment of the interventions on a regular basis.

Based on observations, clinical record review, resident and staff interviews and review of facility policy and procedure, the facility failed to ensure the right to personal privacy was respected and valued for two sampled residents (#6 and #79). The deficient practice could result in resident rights to privacy not honored. Findings include: -Resident (#6) was admitted to the facility February 1, 2024 with diagnoses of unspecified injury of the head, abnormalities of gait and mobility, generalized muscle weakness and need for assistance with personal care. The annual MDS (minimum data set) assessment dated [DATE] included a BIMS (brief interview for mental status) score of 15 indicating the resident had intact cognition. An initial interview was conducted with resident #6 on March 4, 2023 at 9:28 a.m. Resident #6 stated that staff were either not knocking when they enter the room or was knocking once and not waiting for a reply before entering. Resident #6 stated she had been embarrassed by staff not knocking or waiting for a response before entering, due to being undressed. An observation was conducted on March 5, 2024 at 2:20 p.m. Resident #6 turned on her call light for assistance. It should be noted that resident's door was closed. At 2:26 p.m., a certified nurse assistant (CNA/staff #9) entered the resident's room without knocking at the door prior to entry. The CNA did not wait for the resident's response and permission to enter; and, did not introduce herself. An interview was conducted on March 5, 2024 at 2:26 p.m. with the CNA (staff #9) who stated that the correct process when entering a resident's room was to knock and wait for the resident to ask them to enter. The CNA further stated she did not knock on the door prior to her entry to the resident's room; and she did not introduce herself to the resident. -Resident #79 was admitted on [DATE] with diagnoses of cardiorespiratory conditions, coronary artery disease and heart failure. The annual MDS assessment dated [DATE] included a BIMS score of 15 indicating the resident had intact cognition. An interview was conducted on March 5, 2024 at 2:28 p.m. with resident #79 who stated that staff just come into her room without knocking or waiting for her to tell them to come in. Resident #79 turned on her call light and at 2:34 p.m., a CNA (staff #45) knocked on the resident's door once and proceeded to enter without waiting for the resident's response and permission to enter the room. In an interview conducted with the CNA (staff #45) on March 5, 2024 at approximately 2:37 p.m., the CNA stated that when entering a resident room staff was to knock first, wait for a response before entering and introduce themselves. She stated that with non-verbal residents she will enter the room; however, she stated that resident #79 was verbal. The CNA further stated that she entered the resident's room without waiting for the resident's response that it was okay to go in the room. An interview was conducted on March 5, 2024 with assistant Director of Nursing (ADON/staff #72) who stated her expectation when staff enters a resident's room was for staff to knock, wait for the resident to respond or motion them to enter and to introduce themselves before initiating care. Review of the facility policy on Residents Rights included employees shall treat all residents with kindness, respect and dignity and has the right to personal privacy and confidentiality of his or her personal and medical records, personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups.

Based on observations, staff interviews, and facility policy and procedure reviews, the facility failed to meet professional standards of quality care by failing to ensure resident information and a list of resident names to unauthorized personnel were not exposed when the electronic record screen was unlocked and unattended. This failure to meet these professional standards can result in the potential for resident personal information available to be seen by unauthorized individuals. Findings include: During an observation of the medication cart conducted on March 6, 2024 at 7:50 a.m., there was an uncapped syringe and pill cup filled with an assortment of pills that were left unattended on a cart. The electronic health record (EHR) was open and uncovered, displaying a resident's picture and list of medications. The registered nurse (RN/staff #161) who was responsible for the medication cart and the EHR was found in alcove with another patient; and the pill cup, syringe, and EHR screen were out of the line of sight of the nurse. In another medication administration with the RN (staff #161) conducted, The RN walked away from the medication cart with an unlocked EHR that revealed a view to a list of residents' names. The RN was about to enter a resident's room for medication administration before she was stopped to lock the screen to the EHR. During an interview with the Assistant Director of Nursing (ADON/staff #72) on March 7, 2024, at 2:06 p.m., the ADON stated that nurses were expected to lock the medication carts and the facility's EHR when stepping away from the screen and medication cart. She also stated that this could lead to a resident grabbing medication or having access to personal health information. The facility policy on Resident Rights reviewed January 5, 2023 revealed that the unauthorized release, access or disclosure of resident information is prohibited. All release, access or disclosure f resident information must be in accordance with current laws governing privacy of information issues. Review of the facility policy Medication Administration reviewed in October of 2023 revealed that no medications will be left unattended at the bedside for any reason and that nurses must ensure that the medication cart is securely locked at all times when not in the nurse's view.

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the residents' (#1 and #63) rights to be free from abuse of another resident (#149 and #15). The deficient practice could result in further abuse of residents and appropriate action not take. Findings include: Regarding resident #1 and resident #149 -Resident #1 (alleged victim) was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure, Parkinson's disease with dyskinesia, major depressive disorder, chronic obstructive pulmonary disease, and rheumatoid arthritis. The activities of daily living (ADL) care plan initiated on November 28, 2022 included that the resident required assistance due to weakness, congestive heart failure, Parkinson's disease, and restless leg syndrome. Interventions included assist with ADLs as needed. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. The MDS also indicated that the resident had not exhibited psychosis, behavioral symptoms, wandering, or rejection of care during the assessment period. A nursing note dated August 14, 2023 revealed that the resident #1 reported that that resident #149 threw a remote control at her; and that, the remote control hit her in the upper right shin and a large purple bruise was left from the remote control. A physician order dated August 14, 2023 revealed to monitor bruising on right upper shin one time a day for swelling for 5 days. The incident report dated August 14, 2023 included that resident #1 reported that resident #149 threw a remote control at her; and that, the remote control hit her in the upper right shin. The documentation also included that resident #1 sustained a large purple bruise from the incident; and, the resident was immediately removed from activities and assessed by a nurse. Another physician order dated August 15, 2023 included to monitor bruising to the right lower extremity for worsening and signs and symptoms of infection one time a day for swelling for 14 days. A physician order dated August 15, 2023 included an order for a stat x-ray for right leg pain. A case management note dated August 15, 2023 revealed that the long-term care case manager was notified via email that resident had bruise to right shin; and that, radiographs were ordered and treatment was in place. Review of a nurse practitioner psychiatric note dated August 16, 2023 indicated that resident was alert and oriented X 3, was cooperative per staff, and insight and judgment were good. -Resident #149 (alleged perpetrator) was readmitted on [DATE] with diagnoses that included blindness in the right eye, diabetes mellitus type 2, and amputation at knee level of right lower leg. Review of the care plan initiated on July 10, 2023 included that the resident had behavioral symptoms for impulsive decision making related to feeling sorry for himself and attention seeking related to life choices and have outburst behaviors. Interventions included to allow to express feelings and thoughts, extra staff assistance when abusive or resistive, keep environment calm and relaxed, remove from others when behavior is unacceptable, redirect with diversion activities and one to one supervision. The admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating that the resident had intact cognition. The MDS also revealed that the resident did not exhibit psychosis, behavioral symptoms, rejection of care, and wandering at the time of the assessment period. Review of the facility's self-report dated August 14, 2023 included that residents #1 and #149 were in the activities room. Per the documentation, resident #1 was watching television (TV) and resident #149 changed the TV station; and that, resident #149 thought he heard resident #1 said why do they had to watch that Indian show. The documentation included that resident #149 became upset, picked up the remote and threw it, hitting resident #1 in the right lower extremity. Per the report, both residents were separated immediately. The facility's final investigation included a witness statement dated August 18, 2023 from resident #1 who stated that she was speaking to an activities assistant when resident #149 took control of the remote and changed the channel to something native. Per the documentation, resident #1 asked the activities assistant if the residents had to keep watching the channel; and that, resident #149 then started coming towards resident #1 and called resident #1 a racist. It also included that the activities assistant had to physically stop resident #149 from coming at resident #1 after he threw the remote at her. The facility investigation also included a witness statement from another resident dated August 18, 2023. Per the documentation, resident #149 came into the activities room and immediately changed the channel to head banging music and turned the volume up; and that, the activities assistant asked him to turn the volume down in respect of other residents. It also included that resident #149 responded that everyone was racist and began yelling expletives. Further, the statement included that resident #149 then threw the remote at and started approaching resident #1; and that, the activities assistant asked resident #149 to leave and took resident #1 to the nurse's station. Continued review of the facility investigation revealed a witness statement dated August 14, 2023 from the Social Services Director (SSD/staff #250) who reported that an activities assistant wheeled a tearful resident #1 to the nurse's station; and that, the activities assistant informed her that resident #149 threw a remote control at resident #1's leg leaving an already visible bruise. Per the documentation, resident #1 reported to the SSD that resident #149 hit her for no reason; and that, resident #1 asked the activities assistant if they had to watch Native shows. It also included that resident #149 became upset and called resident #1 a racist; and that, resident #149 yelled expletives at her prior to throwing the remote at her leg. Further, the documentation included that resident #149 admitted to the SSD that he threw the remote at the table and it hit resident #1; and that, resident #149 was leaving AMA (against medical advice). Review of the facility's final investigation report dated August 18, 2023 revealed that the facility concluded that the allegation of abuse was substantiated since resident #149 threw the remote, hitting resident #1 in the leg which resulted in a bruise; and that, resident #149 left the facility AMA. Regarding resident #63 and resident #15 -Resident #63 (alleged victim) was admitted on [DATE] with diagnoses of Parkinsonism and anxiety disorder. A skin integrity care plan initiated on May 17, 2023 included that the resident was at risk for skin breakdown related to disease process, impaired mobility, and incontinence. Interventions included to address any incontinence care as needed, dietary consult, encourage or assist in repositioning, and observe skin daily during routing care, and report changes. A care plan initiated on May 17, 2023 revealed that the resident was on medication for anxiety. The goal was resident will have optimal benefit of medication without side effects. Interventions included to monitor for side effects and report changes to the doctor. The admission MDS assessment dated [DATE] revealed a BIMS score of 14 indicating that the resident was cognitively intact. The MDS also included the resident did not exhibit psychosis, behavioral symptoms, rejection of care or wandering during the assessment period. Review of a care plan revised on June 7, 2023 revealed that the resident required assistance for ADLs (activities of daily living) related to weakness and unsteady balance. Interventions included to assist with ADLs as needed. A case management note dated July 26, 2023 included the resident reported that her old roommate (resident #15) ran into her with an electric wheelchair; and that, resident #63 reported that she was unsure if resident #15 ran into her on purpose. Per the documentation, resident #63 also reported that this had occurred on more than one occasion with the most recent event happening yesterday; and that, resident #63 was sitting on the edge of the bed eating dinner when resident #15 backed up in her wheelchair bumping into her and hitting her knees. A social service note dated July 26, 2023 revealed that the Social Services Director (SSD) received a report from the unit nurse that resident #63 was receiving threatening statements and actions from her roommate. According to the documentation, resident #63 was assessed and moved to another unit for safety. The nursing note dated July 26, 2023 included that skin assessment was done; and that, resident #63 had a small indentation with small bruise under her right knee and her right knee hurts. Further, the documentation included that there was no open skin and that a call was placed to the provider with new orders noted. Review of the facility report dated July 26, 2023 revealed that resident #63 reported that resident #15 had been mean to her and bumped into her knees with the motorized scooter. The report noted that residents were separated and placed on different units as part of the intervention implemented following the event. The incident report dated July 26, 2023 included that resident #63 was bumped by a wheelchair which resulted in a small bruise on her right knee. -Resident #15 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, major depressive disorder, and multiple sclerosis. A behavioral care plan initiated on February 7, 2023 revealed the resident had behavioral symptoms related to impulsive behavior. Interventions included to allow resident to express thoughts and feelings, extra staff assistance when abusive or resistive, and keep environment calm and relaxed. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating that the resident was cognitively intact. The MDS also included the resident was negative for psychosis, behavioral symptoms, wandering, and rejection of care. A nursing note dated July 26, 2023 revealed that the roommate (resident #63) reported that resident #15 had been mean, bumped into the roommate with the motorized scooter and told the roommate that she controlled the room. Per the documentation, the roommate (resident #63) stated that the resident told the roommate that no one would believe if the roommate told anyone about the incident. Further, the documentation included resident #15 bumped only one person with her chair; and that, resident #15 had used similar behaviors with previous roommates. Furthermore, the note included that resident #15 stated that she would like to be in her room by herself. Further review of the care plan did not include interventions to address resident's behavior to intimidate roommates or tendency to use wheelchair to bump into people. A social service note dated July 26, 2023 included that social services director (SSD) informed the resident's family/POA (Power of Attorney) regarding the altercation between the resident and her roommate; and that, the resident's family/POA expressed sympathy for the altercation and she would come in the facility to speak with the resident. Per the documentation, the resident's family/POA was informed that resident #15 will be moved to a different due to resident #15 being the aggressor in the incident. A case management note dated July 27, 2023 revealed resident #15 stated that she got along with her roommate (resident #63); and that, they never had an argument. It also included that resident #15 reported that she bumped into resident #63 on accident due to her not having enough room to maneuver the wheelchair; and that, she agreed to a room change for more space. Another Case Management note dated July 27, 2023 documented that resident #15 was transferred to another room in C-hallway with all her belongings. Review of the facility report revealed that on July 26, 2023, resident #63 reported to the nursing staff that resident #15 had been mean to her and bumped her knees with the motorized wheelchair. Per the documentation, resident #15 stated that she was trying to back up her motorized wheelchair and accidentally hit resident #63; and that, interventions post incident consisted of separating residents into different rooms on different halls. An interview with a certified nursing assistant (CNA/staff #166) was conducted on March 7, 2024 at 12:58 p.m. The CNA stated that staff use the care plan and the nurse guidance to identify residents with behaviors that increases their risk for resident to resident altercations. The CNA said that the interventions following a resident to resident altercation included deescalating the situation, separating and monitoring the residents. The CNA stated that staff were provided abuse training approximately twice a week via meetings, pamphlets, and as incidents occur; and that, staff reports instances/allegations of abuse to the Director of Nursing (DON) within 2 hours of the incident. An interview was conducted on March 7, 2024 at 1:09 p.m., with a Licensed Practical Nurse (LPN/staff #123) who stated that they are able to identify residents with behaviors that can potentially lead to resident to resident altercations by knowing the residents' baseline and observing behaviors. The LPN said that residents have behaviors and any little things that may trigger them; and that, they try to match up roommates as best possible and accommodate those changes and see if the situation was ideal. The LPN also said that they document on assessments/notes regarding psych and behavior; and, any issue that makes resident prone to resident to resident altercation was care planned. The LPN further stated that following a resident to resident altercation, the following interventions are put in place: separate residents, re-direct, removing residents them from the situation. The LPN also stated that staff were supposed to update the care plan following a resident to resident altercation; and, staff reports incidents/allegations of abuse to the DON as soon as possible. During an interview with the Assistant Director of Nursing (ADON/staff #58) conducted on March 7, 2024 at 1:38 p.m., the ADON said that her expectation was that abuse is stopped and the residents are separated and safe; and that, abuse is reported as soon as it is identified so that the facility can in turn report to the required outside agencies within 2 hours. Review of the facility policy titled Abuse and Neglect dated January 9, 2024 included that it is their responsibility to identify any resident whose personal history renders them at risk for abusing residents, and development of intervention strategies to prevent occurrence, monitoring for changes that would trigger abusive behavior, and reassessment of the intervention on a regular basis.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure that care plan was updated and revised as needed for one resident (#15). The deficient practice could result in resident not receiving appropriate treatment/services to meet their needs. Findings include: Resident #15 was admitted on [DATE] with diagnoses of anxiety disorder, major depressive disorder, and multiple sclerosis. Review of the quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating that the resident was cognitively intact. The MDS also included that the time of the assessment the resident was negative for psychosis, behavioral symptoms, wandering, and rejection of care. A nursing note dated July 26, 2023 revealed that the roommate (resident #63) reported that resident #15 had been mean, bumped into the roommate with the motorized scooter and told the roommate that she controlled the room. Per the documentation, the roommate (resident #63) stated that the resident told the roommate that no one would believe if the roommate told anyone about the incident. Further, the documentation included resident #15 bumped only one person with her chair; and that, resident #15 had used similar behaviors with previous roommates. Furthermore, the note included that resident #15 stated that she would like to be in her room by herself. Further review of the care plan was not updated to address the resident's behavior and did not include interventions to address resident's behavior to intimidate roommates or tendency to use wheelchair to bump into people. An interview with a Licensed Practical Nurse (LPN/staff #123) was conducted on March 7, 2024 at 1:09 p.m. The LPN said that care plan was supposed to be updated following a resident to resident altercation to mitigate further incidents. During an interview with the Assistant Director of Nursing (ADON/staff #58) conducted on March 7, 2024 at 1:38 p.m., The ADON stated that it is the expectation that the care plan is updated following a resident to resident altercation, an incident or new behavior in order to meet the resident's needs. During the interview a review of the clinical record for resident #15 was conducted with the ADON who stated that there was no care plan update or revision following the incident between residents #63 and #15. The ADON further stated that there should have been an update in interventions to assist the resident with behavior; and that, not updating the care plan could lead to resident to resident incident happening again. Furthermore, she noted that updating the care plan helps staff know what is going on with the resident in order to meet their needs. The facility policy titled Care Plans, Comprehensive Person-Centered dated October 2023 stated that assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. When possible, interventions address the underlying sources of the problem areas, not just the symptoms or triggers. Review of facility policy titled Abuse and Neglect dated January 9, 2024 stated that it is the responsibility of the facility to identify any resident whose personal history renders them at risk for abusing residents, and development of intervention strategies to prevent occurrence, monitoring for changes that would trigger abusive behavior, and reassessment of interventions on a regular basis.

Based on observation, resident and staff interviews, clinical record review and facility policy and procedures, the facility failed to ensure care and services related to an indwelling urinary catheter was provided to one resident (#47). The census was 96. The deficient practice could result in residents being at risk for urinary catheter complications and urinary tract infections. Findings include: Resident #47 was admitted on [DATE] with diagnosis of urinary tract infection (UTI), sepsis, unspecified organism and type 2 diabetes mellitus (DM) without complications. The care plan dated January 25, 2024 revealed the resident had altered elimination as exhibited by bowel incontinence and indwelling Foley catheter. The goal was that the resident will not develop a urinary tract infection related to Foley catheter use. Interventions included barrier cream incontinent care to prevent skin breakdown; catheter care per facility policy; assistance to the commode/toilet with morning care, before and after meals, with bedtime care, and as needed; assistance with urination/bowel movements; and, performing a thorough peri-care after each incontinent episode. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. The MDS assessment also revealed the resident had an indwelling urinary catheter, was dependent for toileting hygiene and required partial to moderate assistance for transfers. The physician order dated February 22, 2024 revealed the following orders: -Indwelling catheter to straight drainage, 16 fr 10 cc (cubic centimeter) for diagnosis of retention; -Catheter Care Q shift and prn; -Change catheter bag every night shift every Sunday for infection control; and -Change Foley Catheter monthly and prn for blockage or obstruction, every night shift every 4 weeks on Thursday for catheter Care. In an observation conducted on March 6, 2024 at approximately 8:54 a.m., resident #47 was observed being wheeled by a staff through the facility hallway with her catheter tubing exposed on her right leg, the catheter bag with urine was uncovered and was attached to the bottom cross bars of the resident's wheelchair. The uncovered catheter bag was dragging on the floor as the resident was being pushed in her wheelchair. An interview was conducted on March 6, 2024 at 8:59 a.m. with a Licensed Practical Nurse (LPN/Staff #163) who was observed pushing the resident in the hallway. The LPN was asked to observe the placement of the resident's catheter tubing and catheter bag. The LPN stated it was incorrect placement and should not touch the floor and should have a cover on the bag. She further stated the risks associated with the catheter bag dragging on the floor put the resident at risk for contamination and urinary tract infection (UTI). The LPN then proceeded to place the catheter bag correctly and covered the catheter tubing on the resident's lap. In an interview with resident #47 conducted on March 6, 2024 at 12:34 p.m., the resident stated that urinary catheter care was provided by staff once a day or when it itches. Resident #47 stated the catheter was placed when she was admitted to the hospital, but she does not recall why it was inserted. Resident #47 also said that she had a urinary tract infection and was receiving antibiotics for it. An observation conducted during the interview revealed that the resident's catheter bag was uncovered and was touching the floor while the resident was lying in bed. An interview was conducted on March 6, 2024 at 12:36 p.m. with a certified nursing assistant (CNA/staff #165) who stated that when providing peri care and if the resident was a female, staff will clean the tubing with wet wipes and wipe away from the vaginal area. She stated catheter care was provided every brief changes and care provided was documented in the resident's electronic record. The CNA further stated that the catheter bag was drained every shift and she will report any concerns or changes to the nurse. During the interview, an observation of resident #47 was conducted with the CNA who stated that the resident's catheter bag should not be touching the floor and should be placed below the resident's waist. The CNA said that the risks associated with the bag touching the floor and improper placement of the tubing could result in bacteria and germs that cause UTI. The CNA then proceeded to reposition the resident's indwelling catheter tubing and raised the resident's bed to prevent indwelling catheter tubing/bag from touching the floor. An interview with registered nurse (RN/staff #161) was conducted on March 6, 2024 at 12:52 p.m. The RN stated that depending on the type of indwelling catheter, the CNAs were trained to provide catheter care and in-service training were done regularly with staff. She stated preventative interventions had been implemented to minimize complications from urinary catheter for the resident with standing orders to change the bag, assess the flow and integrity of the urine and ensure the resident did not have discomfort or pain. The RN further stated that the correct placement of the indwelling catheter bag was below the patient for easy flow; there should be no bends in the catheter tubing; and, the catheter tubing should not be touching the floor. The RN said the risks associated with incorrect placement of indwelling catheter bag/tubing were contamination and increased chance of the resident getting an infection. During an interview conducted with Assistant Director of Nursing (ADON/staff #72) conducted on March 6, 2024 at 1:11 p.m., the ADON stated that indwelling urinary catheter care can be done by either the nurse or CNA. The DON said that the indwelling catheter should be cleaned with each incontinent episode; the catheter bag should be hanging off the floor but draining to gravity; and, a cover should be placed over the bag so urine shall not be visible. She stated indwelling catheter bags were changed every seven days and indwelling catheter tubing every 30 days; and, these tasks were documented in the Treatment Administration Record (TAR) when completed. The ADON said that in-service training on catheter care, maintenance and cleaning, how often bags and catheter are changed were provided to staff by the infection control preventionist. The ADON further stated that the facility had placed an order for catheter bag covers for any residents with indwelling Foley catheter. Review of the facility policy on Urinary Catheters and Incontinence reviewed and revised on January 4, 2024 included that the facility strives to ensure that very resident receives the necessary care and services that will maintain the highest practicable physical, mental, and psychosocial well-being, to assist with meeting this. The facility will provide all necessary treatment and services to prevent urinary tract infections and help restore as much normal bladder function as possible. The facility policy on Urinary Catheter Care reviewed on January 2, 2024 included to be sure the catheter tubing and drainage bag are kept off the floor.

Based on observations, staff interviews and review of the facility policies/procedures, the facility failed failed to keep two of the four medication carts locked and under the direct supervision of authorized staff; and, failed to ensure that medications were not left unattended on the medication cart. The facility also failed to keep two of the four medication carts locked and under the direct supervision of authorized staff in an area where residents could access them. Findings include: During an observation of the medication cart conducted on March 6, 2024 at 7:50 a.m., there was an uncapped syringe and pill cup filled with an assortment of pills that were left unattended on a cart. During an observation of the medication storage areas with a Licensed Practice Nurse (LPN/staff #161) conducted on March 6, 2024, at 1:50 p.m., two unlocked and unsupervised medication carts were in an unlit alcove of Hall B of the facility. These carts had over-the-counter medications easily accessible in the top drawer of both carts. In an interview with the LPN (staff #161) immediately following the observation, the LPN stated that a resident could take and ingest medications that were not theirs to take. During an interview with the Assistant Director of Nursing (ADON/staff #72) on March 7, 2024, at 2:06 p.m., the ADON stated that nurses were expected to lock the medication carts and the facility's EHR when stepping away from the screen and medication cart. She also stated that this could lead to a resident grabbing medication or having access to personal health information. Review of the facility policy Medication Administration reviewed in October of 2023 revealed that nurses must ensure that the medication cart is securely locked at all times when not in the nurse's view.

Based on observation, staff interviews, and review of facility policy and procedure, the facility failed to implement infection control practices for resident care when preparing insulin for medication administration; and, failed to clean single-resident insulin pens prior to administration. The deficient practice could result in resident to developing infection and complication. Findings include: During a medication administration observation with license practical nurse (LPN/staff #123) conducted on March 6, 2024 at 10:44 a.m., the LPN was preparing insulin medication for one resident and the LPN did not wipe the single-resident use needle insertion site with an alcohol swab on before placing the needle for administration. In an interview with the assistant of director of nursing (ADON/staff # 72) conducted on March 7, 2024 at 2:06 p.m., the ADON stated that nurses were expected to follow the 5 rights of medication administration, lock their computer screens and medication carts when stepping away. The ADON stated that it was expected for nurses to check blood sugars and insulin orders prior to insulin administration; and that, for nurses to clean the top of the container of insulin and the skin injection area with an alcohol swab prior to administering the insulin. Further, the ADON stated that the possible impact of not cleaning the top of the container of the site of injection prior to administration would be a risk for infection and cellulitis. Review of the facility policy on Medication Administration revealed that nursing staff will administer injections using the current standard of practice and following guidelines; and, proper administration technique will be used (e.g., maintenance of sterility, correct needle size, correct).

Based on clinical record review, interviews, and facility policy, the facility failed to ensure the physician was notified regarding changes of one resident's low blood pressure (#5), one residents (#6) urine output, and not administering two residents (#6, #7) pain medications within parameters. The deficient practice could result in physicians not being notified of changes in residents' conditions. The sample was 4. -Regarding Resident #5 Resident #5 was admitted on [DATE] with diagnoses that included duodenal ulcer, hypertension, enterocolitis due to clostridium difficile, gastric ulcer, type 2 diabetes mellitus with diabetic neuropathy, acute post hemorrhagic anemia, and need for assistance with personal care. Review of physician's orders revealed an order for: - Lisinopril Oral Tablet 20 mg (milligram), an angiotension-converting enzyme inhibitor, give one tablet one time a day dated December 29, 2022. - Lasix 40 mg Tablet, a diuretic, give by mouth one time a day for edema dated January 2, 2023. - Lasix 40 mg tablet by mouth one time a day for edema dated January 3, 2023. Review of the clinical record revealed blood pressure results as followed: -December 31, 2022: 95/53 -January 21, 2023: 82/45 -January 22, 2023: 81/43 Review of the Minimum Data Set admission assessment dated [DATE], revealed a Brief Interview of Mental status score of 14, which indicated intact cognition, and indwelling catheter. The review further revealed that the resident had not rejected any care, and a diagnosis of hypertension. Review of the Care plan initiated January 12, 2023, revealed no plans for hypertension or foley catheter. Review of the Medication Administration Record (MAR) dated January 2023, revealed that Lisinopril was not administered as ordered, due to low blood pressure of 99/59 on January 19, 2023. Further review of the January 2023 MAR revealed no evidence that the physician was notified regarding the medication not being administered as ordered, or regarding the low blood pressure results on January 19, 2023. Review of the clinical record revealed no evidence that the physician was notified regarding the blood pressure results on the other days mentioned above. An interview was conducted on March 2, 2023 at approximately 1:00 PM with a Licensed Practical Nurse (LPN/staff #12), who stated that nurses take residents blood pressure prior to administration of blood pressure medications. She stated that any systolic blood pressure under 90 should be reported to the provider, and the notification should be documented in the clinical record. The LPN reviewed the clinical record and stated that there was no evidence in the clinical record that the provider had been notified regarding low blood pressure readings on 2 occasions in January 2023 and one occasion in December 2022. She stated that she would have expected that the nurse would have notified the provider regarding the resident's change in blood pressures, and would have expected any notification to be documented in the clinical record. An interview was conducted on March 2, 2023 at 2:00 PM with the Director of Nursing (DON/staff #14), who stated that if a medication is not administered, the nurse should document the reason, and notify the physician. She further stated that physician notification should be documented in the clinical record. She further stated that the physician should be notified if a resident's blood pressures are outside of normal parameters. She stated that the resident's blood pressure had been documented as hypotensive on multiple occasions, and she would have expected the physician to be notified, and the notification documented in the clinical record. The DON also stated that there is no evidence in the medical record that the physician had been notified regarding holding the Lisinopril on January 19, 2023, or the low blood pressure results. She stated that she knew the nurses had notified the physician regarding the low blood pressure results, but that there is no evidence of physician notification in the clinical record. She further stated that it was important to monitor the blood pressure results as the resident was on a diuretic, which can cause hypotension. She also stated that that risk of not reporting the low blood pressure results could result in the physician not being aware of the changes, and not ordering an intervention. Review of the facility policy titled, Measuring Blood pressure, revealed that a normal blood pressure is generally defined as normal when the systolic pressure is in the range of 101 to 129 and diastolic pressure is in the range of 61-84 mm/hg (millimeters of mercury). Hypotension is defined as blood pressure less than 100/60mm/hg. -Regarding Resident #6 Resident #6 was admitted to the facility on [DATE] with diagnoses that included osteomyelitis, colostomy, paraplegia, and pressure ulcer of sacral region, stage 4. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The review also revealed presence of a foley catheter. Review of a care plan initiated on September 20, 2022 revealed a plan regarding altered elimination related to indwelling foley catheter. Interventions included catheter care per facility policy, observe for changes in elimination patterns and report. Further review revealed a plan revealed the resident has pain or is at risk for pain related to wounds and disease process, and will be provided medications for relief. Interventions included to administer analgesics as ordered, assess for effectiveness of pain medication administered, assess for pain level every shift. Review of the current physician orders revealed an order for: - Tramadol HCL tablet 50 mg, an opiate narcotic, give by mouth every 6 hours as needed for pain 6-10/10, dated October 31, 2022. - Routine catheter care per facility protocol every shift dated September 12, 2022 -Catheter care every shift and as needed, report concerns to physician, dated September 12, 2022. -RE: medication administration Review of the December 2022 MAR, revealed that Tramadol had been administered for a pain level of 5 on 4 occasions, outside of the ordered parameters, and no evidence in the clinical record that the provider had been notified. Further review of the December 2022 MAR also revealed that Tramadol had been administered with less than 6 hours between dosages on December 13, 2022. Review of the January 2023 MAR, revealed that Tramadol had been administered for a pain level of 5 on two occasions. This was outside of physician ordered parameters for the medication. Review of February 2023 MAR, revealed that Tramadol had been administered for a pain level of 5 on three occasions. This was outside of physician ordered parameters for the medication. An interview was conducted on March 3, 2023 at approximately 1:00 PM with a Licensed Practical Nurse (LPN/staff #12), who reviewed the clinical record and stated that Tramadol had been administered outside of parameters on multiple occasions, with no evidence of physician notification. She also stated that Tramadol had been administered with less than 6 hours between dosages on December 13, 2022. The LPN further stated that medications should be administered as ordered, and that this did not meet the expectations. An interview conducted on March 2, 2023 at 12:35 PM with the DON (staff #14), who stated that she was aware that the Tramadol had been administered outside of parameters on multiple occasions, and there was no evidence that the physician had been notified. She further stated that if the resident requested the medication to be administered outside of the ordered parameters, the provider should be informed/notified, and the call should be documented in the clinical record. -RE: Foley output monitoring: Review of the Treatment Administration Record (TAR) Routine Catheter Care per facility protocol in cc's (cubic centimeter): - Dated January 2023: revealed no evidence that cc's had been monitored on 4 occasions during day shift and on 1 occasion on the night shift. It further revealed the urine output was less than 1200 cc's/day (cubic centimeter) on 10 occasions, six of which were both shifts. - Dated February 2023: revealed no evidence that the cc's for foley output had been assessed/documented on 8 occasions on the day shift, and 11 occasions on the night shift. It further revealed that on another 10 occasions the cc's documented were less that 1200 cc/day. An interview was conducted on March 1, 2023 at approximately with a Certified Nursing Assistant (CNA/staff #13), who stated that urine output is documented by CNA's in the clinical record. She also stated that it is documented each shift in cc's. An interview was conducted on March 2, 2023 at approximately 1:00 PM with a Licensed Practical Nurse (LPN/staff #12), who stated that urine output is documented by CNAs and nurses. She further stated that nursing documents the foley output in cc's on the TAR, and that CNAs empty the foley catheter bag, and report the output in cc's to nursing. An interview conducted with the DON (staff #14) on March 2, 2023 at 2:00 PM, who stated that she did not see any evidence that nursing had monitored the urine output in cc's on 19 occasions, and there was no evidence that the physician had been notified regarding urine output less than 1200 cc/day on another 10 occasions in February 2023. She also stated that certified nursing assistants (CNA), empty the foley catheter bag and report the foley output in cc's to nursing, and then nursing would document on the TAR. -Regarding Resident #7 Resident #7 was admitted on [DATE] with diagnoses that included falls, protein-calorie malnutrition, muscle weakness, abnormalities of gait and mobility and fracture of right femur Review of the physician's orders revealed orders that included - Acetaminophen ER tablet 650 mg, a pain reliever, give 1 tablet by mouth every 6 hours as needed for pain 1-5/10 dated February 10, 2023. -Acetaminophen 325mg give 2 tablet by mouth every 6 hours for pain 1-3/10 dated February 08, 2023. Review of a plan of care that was initiated February 9, 2023, revealed a plan for pain or risk for pain related to hip repair. Interventions included administer analgesics as ordered by the doctor. Review of an admission MDS dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. Review of the February 2023 MAR revealed that the Acetaminophen: - 650 mg tablet for pain level of 1-5/10, had been administered for a pain level of 6 on one occasion, and a pain level of 7 on two occasions. -325 mg tablet for pain level of 1-3/10, had been administrated on 1 occasion for pain level of 7, and on 1 occasion for pain level of 8. An interview was conducted on March 2, 2023 at approximately 1:00 PM with a Licensed Practical Nurse (LPN/staff #12), who stated that they follow the physician orders as written for medication administration, including any parameters. She stated that when a medication is not administered, the provider should be notified, and the notification should be documented in the clinical record. An interview conducted on March 02, 2023 at 2:00 PM with the Director of Nursing (DON /staff #14), who stated that she was aware that the acetaminophen had not been administered as ordered and had fixed the pain scale in February 2023. She stated that she reviewed the clinical record and that all the resident (#7) wanted was the Tylenol, but staff did not document why the medication was administered outside of parameters, or that the provider had been notified. Review of the facility policy titled, Medication Administration, revealed that a physician order for all prescription and over the counter medications are required. Any time a medication is refused or omitted the nurse will document this in the MAR to include a narrative explanation in the nurses' notes as to the reason and any further actions to be taken as a result of the omission, and notification of the physician. A pain assessment utilizing an accepted standard pain scale will be used in assessing the severity and the appropriate medication will be given based on the physician orders.

Based on clinical record review, interviews, and facility policy, the facility failed to ensure two resident's (#6, #7) medications were administered per physician ordered parameters. The sample was 3. The deficient practice could result in ineffective management of residents' blood pressure and pain. -Regarding Resident #6 admitted to the facility on [DATE] with diagnoses that included osteomyelitis, colostomy, paraplegia, and pressure ulcer of sacral region, stage 4. Review of the Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. Review of a Care Plan initiated September 20, 2022 revealed that the resident had pain or is at risk for pain related to wounds and disease process and will be provided medications for relief. The care plan interventions included administer analgesics as ordered by physician. Review of the physician orders dated October 31, 2022 revealed an order for Tramadol HCL tablet 50 mg (milligrams), give by mouth every 6 hours as needed for pain 6-10/10. Review of the December 2022 MAR, revealed that Tramadol had been administered for a pain level of 5 on 4 occasions, and no evidence in the clinical record that the provider had been notified. Further review of the December 2022 MAR also revealed that Tramadol had been administered with less than 6 hours between dosages on December 13, 2022. Review of the January 2023 MAR, revealed that Tramadol had been administered for a pain level of 5 on two occasions. Review of February 2023 MAR, revealed that Tramadol had been administered for a pain level of 5 on three occasions. An interview was conducted on March 2, 2023 at approximately 1:00 PM with a Licensed Practical Nurse (LPN/staff #12), who reviewed the clinical record and stated that Tramadol had been administered outside of parameters on multiple occasions in December 2022, and January, February 2023. She also stated that this did not meet the facility process as physician orders were not followed as written. She also stated that Tramadol had been administered with less than 6 hours between dosages on December 13, 2022, which also did not follow physician orders. She also stated that there was no evidence that the provider had been notified in December 2022, January or February 2023 regarding administration of Tramadol outside of physician orders. The LPN further stated that medications should be administered as ordered, and that this did not meet the expectations. She stated that the risk could result in overmedication, and that the physician might not be aware of the resident's pain level. An interview conducted on March 2, 2023 at 2:00 PM with the DON (staff #14), who stated that she was aware that the Tramadol had been administered outside of parameters on multiple occasions, and there was no evidence that the physician had been notified. She further stated that if the resident requested the medication to be administered outside of the ordered parameters, the provider should be informed/notified, and the call should be documented in the clinical record. -Regarding Resident #7 Resident #7 was admitted on [DATE] with diagnoses that included falls, protein-calorie malnutrition, muscle weakness, abnormalities of gait and mobility and fracture of right femur. Review of a Care Plan initiated February 9, 2023 revealed that the resident was at risk for pain related o a hip repair, and interventions included to administer analgesics as ordered by Doctor. Review of an admission MDS dated [DATE] revealed a BIMS score of 15, which indicated intact cognition. Review of the physician's orders revealed orders that included - Acetaminophen ER tablet 650 mg give 1 tablet by mouth every 6 hours as needed for pain 1-5/10 dated February 10, 2023. -Acetaminophen 325mg give 2 tablets by mouth every 6 hours for pain 1-3/10 dated February 08, 2023. Review of the February 2023 MAR revealed that the Acetaminophen had been administered: - 650 mg tablet for pain level of 1-5/10, had been administered for a pain level of 6 on one occasion, and a pain level of 7 on two occasions. -325 mg tablet for pain level of 1-3/10, had been administrated for a pain level ob 1 occasion for pain level of 7, and on 1 occasion for pain level of 8. An interview was conducted on March 2, 2023 at approximately 1:00 PM with a Licensed Practical Nurse (LPN/staff #12), who stated that medications should be administered as ordered by the physician. She further stated that the physician should be notified if the orders are not followed or a medication is not administered as ordered. She further stated that any physician notification should be documented in the clinical record. An interview conducted on March 02, 2023 at 8:21 AM with the Director of Nursing (DON /staff #14), who stated that she was aware that the acetaminophen had not been administered as ordered and had fixed the pain scale in February 2023. She also stated that she reviewed the clinical record and that staff did not document why the medication had been administered outside of parameters, and did not document that the physician had been notified. Review of the facility policy titled, Medication Administration, revealed that a physician order for all prescription and over the counter medications are required. Any time a medication is refused or omitted the nurse will document this in the MAR to include a narrative explanation in the nurses' notes as to the reason and any further actions to be taken as a result of the omission, and notification of the physician. A pain assessment utilizing an accepted standard pain scale will be used in assessing the severity and the appropriate medication will be given based on the physician orders

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#6) received care and treatment in accordance with professional standards of practice regarding catheter care. The deficient practice has the potential to cause infection and the spread of bacteria. Findings include: admitted to the facility on [DATE] with diagnoses that included osteomyelitis, colostomy, paraplegia, and pressure ulcer of sacral region, stage 4. Review of physician orders revealed the following order: -Catheter care every shift and as needed (PRN) report concerns to MD every shift, dated September 12, 2022. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The review also revealed presence of a foley catheter. Review of a care plan initiated on September 20, 2022, revealed a plan of altered elimination exhibited by indwelling foley catheter. Interventions included catheter care per facility policy, and observe for changes in elimination pattern and report. Review of the 2022 September Treatment Administration Record (TAR) revealed no evidence that foley catheter care had been completed as ordered on 3 occasions. Review of the Certified Nursing Assistant (CNA) Point of Care (POC) Catheter Care Task dated September 2022 revealed no evidence that foley catheter care had been provided on 1 occasion on the day shift, and on 3 occasions on the night shift. Review of the October 2022 TAR revealed evidence that catheter care had been completed as ordered. Review of the October 2022 CNA POC Foley Care revealed no evidence that catheter care had been provided on 3 occasions on the day shift and 3 occasions on the night shift. Review of the November 2022 TAR revealed that foley catheter care had been completed as ordered. Review of the November 2022 CNA POC Catheter care Task revealed no evidence that foley catheter care had been provided on 3 occasions on the day shift and on 7 occasions on the night shift. Review of the December 2022 TAR revealed no evidence that foley catheter care had been completed as ordered on one occasion. Review of CNA POC Catheter care Task dated December 2022 revealed no evidence that catheter care had been provided on 3 occasions for day shift, and 10 occasions for the night shift. Review of the January 2023 TAR revealed no evidence that foley catheter care had been completed as ordered on one occasion. Review of the CNA POC Catheter care Task dated January 2023, revealed no evidence that catheter care had been provided on 7 occasions on both the day and night shifts. Review of the February 2023 TAR revealed no evidence that foley catheter care had been completed as ordered on 5 occasions. The review further revealed no evidence that the output from the catheter had been assessed on 14 shifts that month. Review of the Point of Care (POC) Catheter Care dated February 2023, revealed no evidence that catheter care had been provided by a CNA on four occasions on the day shift, and three occasions on the night shift. An observation of catheter care was conducted on March 2, 2023 at approximately 10:00 AM with a two CNAs (CNA/staff #15, CNA/staff #13). During the observation the CNA filled one basin with soapy water, and one with rinse water. The CNA moistened a wash cloth in the soapy water, and cleansed the from the meatus down penis shaft. During the observation one CNA removed that clean soapy water, and disposed of it in the bathroom, while the other CNA used a rinse cloth and wiped around the meatus, then using the same wash cloth wiped down the catheter tubing from insertion site toward the catheter bag. The catheter tubing had not been washed with soapy water, and during the rinse procedure the CNA was not observed to change the position of the wash cloth while wiping from the meatus down the catheter tubing. After the catheter care was completed the CNA replaced the resident's pants and repositioned the resident, then removed the supplies off the bedside table. The CNA was not observed to remove her gloves after the catheter care and sanitize her hands before replacing the resident's pants or cleaning the supplies off of the bedside table. An interview was conducted on March 1, 2023 with a Certified Nursing Assistant (CNA/staff #13), who stated that CNAs complete catheter daily, not nursing. An interview was conducted on March 2, 2023 at 12:35 PM with a CNA (staff #15), who stated that a separate washcloth should be used for cleaning/rinsing from the urethra down the catheter tubing. Further interview was conducted on March 2, 2023 at 12:35 PM with CNA (staff #13), who stated that they make sure hands are sanitized, provide privacy. Gather equipment soap/water, make sure resident is covered. She stated that she forgot to re-apply clean gloves, after the process, then proceeded to reposition the resident and put a clean pad underneath. While doing peri care from urethra down them penis, with a soapy washcloth, and then rinse with the clean water. She stated that she was told that she could fold the wash the wash cloth and then use the clean side. The CNA also stated that the risk of not using soapy water could result in the risk of infection, microorganisms. She also stated that they document catheter care in the POC on each shift. An interview was conducted on March 2, 2023 at approximately 1:00 PM with a Licensed Practical Nurse (LPN/staff #12), who stated that resident #6 has a colostomy and a foley catheter. She stated that routine catheter care includes peri-care to keep the resident clean. She also stated that catheter care should be completed every shift, as ordered. She stated that if catheter care is not completed as ordered it could result in infection, or the catheter not draining appropriately. An interview was conducted on March 2, 2023 at 2:00 PM with the Director of Nursing (DON/staff #14), who stated that she would expect that the foley tubing would be cleaned with soapy water and that the washcloth would be folded with each stroke. She also stated that once catheter care is completed, the CNA should remove her gloves, sanitize and place on clean gloves to turn/reposition the resident, and to clean the supplies. She stated that the risk could result in bacteria not killed, and the risk of spreading germs to patients and other areas. The DON also stated that she reviewed the clinical record and that the CNA's POC charting had not been completed on 5 occasions in February 2023, or on 14 occasions in January 2023. The DON also stated that she expected the CNA's to document catheter care in the POC, and to report to nursing, so they can document on the TAR. Review of the facility policy titled, Urinary Catheter Care, revealed to use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Discard disposable items into designated containers. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Maintain an accurate record of the resident's daily output, per facility policy and procedure. A review of the facility policy titled, Hydration and Prevention of Dehydration, revealed that if potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan, and the physician will be notified

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure one resident (#46) received care and treatments consistent with professional standards of practice to promote healing of shearing, and to prevent the reoccurring of shearing and the development of multiple avoidable stage II pressure ulcers. The deficient practice could result in the development and worsening of pressure ulcers. Findings include: Resident #46 was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan initiated on July 24, 2014 and revised on April 17, 2021 revealed the resident required assistance with Activities of Daily Living (ADL) related to obesity and risk for further declining condition related to mental status. The goal was that the resident would achieve maximum functional mobility. Interventions included bariatric bed for repositioning and use of a mechanical lift and two staff assistance for transfers. A care plan initiated on July 25, 2014 and revised on April 17, 2021 revealed the resident had or was at risk for skin breakdown related to impaired mobility related to [CONDITION(S)], incontinence of bowel and bladder and abnormal labs. The goal was that the resident's skin would be managed through staff monitoring and interventions. Interventions included to encourage or assist the resident in shifting of position as needed and to address any incontinence care as needed. Review of a care plan initiated on July 6, 2018 and revised on April 17, 2021 revealed the resident had potential for impairment to skin integrity due to being overweight and required assistance with dressing, toileting, bathing, and transfers. The goal was that the resident would have no complications related to the ulcer of the left lateral lower abdomen. Interventions included identify/document potential causative factors and eliminate/resolve where possible. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 13 on the Brief Interview for Mental Status (BIMS) which indicated the resident had intact cognition. The MDS assessment included the resident was totally dependent on staff for bed mobility, transfers, dressing, personal hygiene, and toilet use. The assessment included the resident was at risk for developing pressure ulcers and did not have any unhealed pressure ulcers at stage 1 or higher. The assessment also included the resident had other lesion(s) other than ulcers, rashes, or cuts and that the resident was on a turning/repositioning program. Continued review of the clinical record revealed the resident developed multiple wounds. An interview was conducted with the Director of Nursing (DON/staff #200) on May 27, 2021 at 9:02 AM. The DON stated that she and the former wound nurse had identified the resident's pressure ulcers and shearing wounds were related to the positioning of the brief and how the resident was being pulled up in the bed. Staff #200 stated an in-service addressing repositioning and sheering was provided to the staff in August 2020 and September of 2020. Review of the facility's documentation revealed in-service signature sheets dated August 19, 2020 that stated the topic was shearing and September 10, 2020 that stated the topic was shearing/repositioning. However, despite in-services and identification of causative factors and in-services, no evidence was revealed that staff consistently turned the resident with a Hoyer lift or what was implemented regarding the tight brief or that the care plan was updated to include these interventions. Regarding the left thigh shearing and pressure ulcer: -The Weekly Skin Check dated November 12, 2020 revealed the resident had shearing to the left rear thigh that measured 3.0 cm x 1.8 cm. A wound care provider note dated November 12, 2020 included there was shearing to the left thigh (#13) that measured 3.0 cm x 1.8 cm. The note included this was an initial exam. A Weekly Skin Check dated December 10, 2020 revealed measurements for three shearing wounds but did not include measurements for or that there was a shearing wound to the left thigh. Review of the wound care provider note dated December 10, 2020 revealed the shearing to the left thigh (#13) measured 1.2 cm x 3.5 cm. The Weekly Skin Check dated December 17, 2020 revealed the shearing to the front left thigh measured 0.9 cm x 3.0 cm. The wound care provider note dated December 17, 2020 revealed the shearing to the left thigh (#13) measured 1.2 cm x 3.5 cm. Review of the Weekly Skin Checks dated December 24 and 31, 2020 included the resident had shearing to the left front thigh. Measurements on December 24, 2020 were 1.0 cm x 3.0 cm and the measurements on December 31, 2020 were 7.0 cm x 7.5 cm. Review of the Weekly Skin Check dated January 6, 2021 revealed the left thigh had a stage II pressure ulcer (#13) that measured 2.0 cm x 3.2 cm. The Weekly Skin Check dated January 13, 2021 included the stage II pressure ulcer to the left thigh measured 2.0 cm x 4.0 cm. A wound care provider note dated January 13, 2021 revealed the resident had a stage II pressure ulcer to the left thigh (#13) that measured 2.0 cm x 4.0 cm. A Weekly Skin Check dated January 20, 2021 revealed the left rear thigh stage II pressure ulcer measured 3.5 cm x 11 cm. The wound care provider note dated January 20, 2021 revealed the left thigh stage II pressure ulcer (#13) measured 3.5 cm x 11 cm. The note included the wound was deteriorating. The Weekly Skin Check dated January 27, 2021 revealed the left thigh stage II pressure ulcer measured 3.5 cm x 11 cm. A wound care provider note dated January 29, 2021 included the stage II pressure ulcer to the left thigh (#13) measured 3 cm x 3 cm and was improving. The Weekly Skin Check dated February 3, 2021 revealed the stage II pressure ulcer to the left thigh measured 3.0 cm x 11 cm. The wound care provider note dated February 3, 2021 included the left thigh stage II pressure ulcer (#13) measured 3.0 cm x 11 cm and was deteriorating. The Weekly Skin Check dated February 10, 2021 revealed the stage II pressure ulcers to the left rear thigh measurements were 1.0 cm x 3.2 cm. Review of the wound care provider note dated February 10, 2021 revealed the stage II pressure ulcer to the left thigh was improving and had the same measurements. A provider note dated February 18, 2021 stated the stage II pressure ulcer to the left thigh measurements were 1.0 cm x 2.5 cm and that the wound was improving. The Weekly Skin Check dated February 23, 2021 included the stage II pressure ulcer to the left thigh measurements were 1.0 cm x 2.5 cm. The Weekly Skin Check dated February 25, 2021 included the measurements to the left thigh stage II pressure ulcer were 0.7 cm x 0.6 cm. Review of the wound care provider note dated February 25, 2021 included the stage II pressure ulcer to the left thigh was improving and included the same measurements. A Weekly Skin Check dated March 4, 2021 included the rear left thigh stage II pressure ulcer measured 2.5 cm x 2.0 cm. The wound care provider note dated [NAME] 4, 2021 included the left thigh pressure ulcer measured 2.5 cm x 2.0 cm and that there was no change in the wound progress. A Weekly Skin Check dated March 11, 2021 included the left thigh stage II pressure ulcer measured 1.0 cm x 2.5 cm. The wound care provider note dated March 11, 2021 included the measurements to the stage II left thigh pressure ulcer were 2.0 cm x 2.5 cm and included the wound was improving. A Weekly Skin Check dated March 18, 2021 revealed the left thigh stage II pressure ulcer measured 1.5 cm x 1.0 cm. The wound care provider note dated March 18, 2021 included the same measurements and that the wound was improving. A Weekly Skin Check dated March 25, 2021 stated the measurements for the stage II pressure ulcer to the left thigh were 4.6 cm x 1.7 cm. A Weekly Skin Check dated April 1, 2021 stated the measurements for the stage II pressure ulcer to the left thigh were 4.5 cm x 1.5 cm. The Weekly Skin Check dated April 8, 2021 included the left rear thigh stage II pressure ulcer measured 1.0 cm x 2.1 cm. Review of the wound care provider note dated April 8, 2021 revealed the stage II pressure ulcer to the left thigh measured 1.0 cm x 2.1 cm and that the wound was improving. The Weekly Skin Check dated April 15, 2021 stated the stage II pressure ulcer to the left rear thigh measured 1.2 cm x 1.5 cm. The Weekly Skin Check dated April 22, 2021 stated the stage II pressure ulcer to the left thigh measured 3.0 cm x 1.5 cm. Review of the wound care provider note dated April 22, 2021 included the stage II pressure ulcer to the left thigh measured 3.0 cm x 1.5 cm and that there was no change in the wound progress. A Weekly Skin Check dated April 29, 2021 stated the stage II pressure ulcer to the left thigh measured 2.7 cm x 1.3 cm. The Weekly Skin Check dated May 6, 2021 revealed the left thigh stage II pressure ulcer measured 1.0 cm x 10.0 cm. The Weekly Skin Check dated May 13, 2021 included the stage II pressure ulcer to the left thigh measured 1.0 cm x 8.0 cm A Weekly Skin Check dated May 20, 2021 revealed the stage II pressure ulcer to the left thigh measured 1.2 cm x 0.8 cm. Further review of the clinical record revealed the resident continued to have the stage II pressure ulcer to the left thigh. -A Weekly Skin Check dated October 15, 2020 revealed the resident had shearing to the left posterior thigh that measured 1.5 cm x 3.0 cm. A wound care provider note dated October 15, 2020 included the resident had MASD (Moisture Associated Skin Damage) to the left posterior thigh (#12) that measured 1.5 cm x 3.0 cm. The note included this was an initial exam. Review of the wound care provider note dated October 22, 2020 revealed the left posterior thigh (#12) was an acute MASD and has received an outcome of Transfer of Care. The note included there was a scant amount of drainage. Review of the clinical record revealed the wounds were measured and assessed weekly, and the resident received ordered wound treatments. However, review of the clinical record did not reveal specific interventions were identified and implemented. Regarding the left buttock shearing and pressure ulcer: -A Weekly Skin Check dated October 22, 2020 revealed the resident had shearing to the left buttock that measured 1.2 cm x 0.8 cm. Review of the wound care provider note dated October 22, 2020 included the left buttock (4a) had shearing that measured 1.2 cm x 0.8 cm. The note included the shearing had reopened/reoccurred and that this was an initial exam. Continued review of the Weekly Skin Checks and the wound care provider notes revealed the shearing to the left buttock was resolved on November 12, 2020. -A Weekly Skin Check dated January 6, 2021 revealed the resident had a stage II pressure ulcer to the left buttock that measured 1.5 cm x 6.0 cm. The Weekly Skin Check dated January 13, 2021 included the stage II pressure ulcer to the left buttock measured 1.0 cm x 4.0 cm Review of the wound care provider note dated January 13, 2021 revealed the stage II pressure ulcer to the left buttock (#16) measured 1.0 cm x 4.0 cm and that the wound was improving. Review of the Weekly Skin Check dated April 1, 2021 revealed 0 cm x 0 cm measurements for the left buttock. A review of the wound care provider note dated April 8, 2021 revealed wound #16 was an acute stage II pressure ulcer that had received an outcome of Transfer of Care. The note included the wound was improving. Review of the clinical record revealed the wounds were measured and assessed weekly, and the resident received ordered wound treatments. However, review of the clinical record did not reveal specific interventions were identified and implemented. Regarding the right thigh shearing and pressure ulcer: Review of the wound care provider note dated November 23, 2020 revealed the resident had shearing to the right rear thigh that measured 1.2 cm x 3.5 cm and that this was the initial exam. A Weekly Skin Check dated November 26, 2020 included the resident had shearing to the right rear thigh that measured 1.2 cm x 3.5 cm. A Weekly Skin Check dated December 3, 2020 stated the shearing to the right rear thigh measured 0.5 cm x 4.5 cm. A Weekly Skin Check dated December 10, 2020 stated the shearing to the right rear thigh measured 0.5 cm x 4.5 cm, and 0.3 cm x 2.0 cm. The wound care provider note dated December 10, 2020 revealed the right thigh shearing measured 0.5 cm x 4.5 cm. The Weekly Skin Check dated December 17, 2020 included the shearing to the right front thigh measured 0.5 cm x 4.0 cm. The wound care provider note dated December 17, 2020 included the shearing to the right thigh (#14) measured 0.5 cm x 4.5 cm. Continued review of the Weekly Skin Checks revealed that the Weekly Skin Check dated January 6, 2021 stated the right thigh had a stage II pressure ulcer that measured 0.4 cm x 0.6 cm. The Weekly Skin Check dated January 13, 2021 included the right thigh had a stage II pressure ulcer that measured 0.1 cm x 0.3 cm. However, review of the wound care provider note dated January 13, 2021 revealed the right thigh had shearing that measured 0.1 cm x 0.3 cm. The Weekly Skin Check dated January 20, 2021 included the right rear thigh stage II pressure ulcer measured 0.5 cm x 0.8 cm. The wound care provider note dated January 20, 2021 revealed the right thigh shearing measured 0.5 cm x 0.8 cm. The Weekly Skin Check dated January 27, 2021 revealed the wound to the right thigh had resolved. A wound care provider note dated January 29, 2021 included the shearing to the right thigh had resolved. A review of the Weekly Skin Checks and the wound care provider notes did not reveal evidence the discrepancy of the type of wound to the right thigh was clarified. Review of the clinical record revealed the wounds were measured and assessed weekly, and the resident received ordered wound treatments. However, review of the clinical record did not reveal specific interventions were identified and implemented. Regarding the sacrum/coccyx/sacrococcyx shearing and pressure ulcer: -The Weekly Skin Check dated September 10, 2020 revealed the resident had shearing to the sacrum that measured 0.3 cm x 1.0 cm. Review of the wound care provider note dated September 10, 2020 revealed the resident had shearing to the sacrococcyx (#10) that measured 0.3 cm x 1.0 cm. The note included this was an initial exam. A Weekly Skin Check dated September 17, 2020 revealed the shearing to the sacrum had resolved. Review of the Weekly Skin Checks and the wound care provider notes did not reveal further documentation regarding the sacrum/sacrococcyx until January 6, 2021. A Weekly Skin Check dated January 6, 2021 included the resident had a stage II pressure ulcer to the sacrum that measured 0.3 cm x 0.4 cm. Review of a Weekly Skin Check dated January 13, 2021 revealed the sacrum stage II pressure ulcer measured 2.0 cm x 1.0 cm. A wound care provider noted dated January 13, 2021 included the resident had a stage II pressure ulcer to the sacrococcyx (10a) that measured 2.0 cm x 1.0 cm. The note included the status was reopened/reoccurred. Review of the Weekly Skin Check dated January 20, 2021 did not include a wound to the sacrum but included a stage II pressure ulcer to the right buttock. The wound care provider note dated January 20, 2021 stated wound 10a was a stage II pressure ulcer to the right buttock. The Weekly Skin Check dated January 27, 2021 stated the wound to the right buttock was resolved. A provider note dated January 29, 2021 stated the right buttock (#10a) stage II pressure ulcer was resolved. -The Weekly Skin Check dated October 1, 2020 revealed the resident had a stage II pressure ulcer to the coccyx that measured 0.5 cm x 0.2 cm. A wound care provider note dated October 1, 2020 included the resident had a stage II pressure ulcer to the sacrococcyx (#11) that measured 0.5 cm x 0.2 cm. The note included this was the initial exam. Review of the Weekly Skin Check dated October 8, 2020 and the wound care provider note dated October 8, 2020 revealed the stage II pressure ulcer to the coccyx/sacrococcyx (#11) had closed. Review of the clinical record revealed the wounds were measured and assessed weekly, and the resident received ordered wound treatments. However, review of the clinical record did not reveal specific interventions were identified and implemented. Regarding the right buttock shearing and pressure ulcer: -The Weekly Skin Check dated September 3, 2020 revealed the resident had a shearing wound to the right buttock that measured 0.3 centimeters (cm) x 0.3 cm. Review of the wound care provider note dated September 3, 2020 stated the resident had a shearing wound to the right buttock (#7) that measured 0.3 cm x 0.3 cm. and that this was the initial exam. Further review of the Weekly Skin Checks and the wound care provider notes revealed weekly wound measurements and assessments were conducted and that the right buttock wound was resolved on October 1, 2020. Additional review of the Weekly Skin Checks and the wound care provider notes revealed no documentation regarding the right buttock until January 20, 2021. The Weekly Skin Check dated January 20, 2021 revealed the resident had a stage II ulcer to the right buttock that measured 0.5 cm x 1.0 cm. A review of the wound care provider note dated January 20, 2021 included the stage II pressure ulcer to the right buttock (10a) had received a status of reopened/reoccurring. The note also included the pressure ulcer measurements were 0.5 cm x 1.0 cm. Continued review of the Weekly Skin Checks and the wound care provider notes revealed the stage II pressure ulcer to the right buttock received an outcome status of resolved on January 27, 2021. -Review of the wound care provider note dated December 17, 2020 revealed the stage II pressure ulcer to the right buttock (#15) was resolved. The Weekly Skin Check dated December 17, 2020 did not include anything regarding the right buttock. Review of the wound care provider notes prior to December 17, 2020 revealed shearing to the right buttock and did not include a stage II pressure ulcer to the right buttock. Review of the clinical record revealed the wounds were measured and assessed weekly, and the resident received ordered wound treatments. However, review of the clinical record did not reveal specific interventions were identified and implemented. Regarding the right gluteal fold shearing: The Weekly Skin Check dated September 3, 2020 revealed the resident had a shearing wound to the right gluteal fold that measured 0.5 cm x 1.5 cm. Review of the wound care provider note dated September 3, 2020 stated the acute shearing wound (#8) to the right gluteal fold measured 0.5 cm x 1.5 cm and that this was the initial exam. Continued review of the Weekly Skin Checks and the wound care provider notes dated October 8, 2020 revealed the shearing to the right gluteal fold had closed. The Weekly Skin Check dated October 22, 2020 revealed the resident had shearing to the right gluteal fold that measured 1.5 cm x 12 cm. Review of the wound care provider note dated October 22, 2020 included the shearing to the right gluteal fold (#8) had reopened/reoccurred and measured 1.5 cm x 1.2 cm Further review of the Weekly Skin Checks and the wound care provider notes dated November 12, 2020 revealed the shearing to the right gluteal fold had resolved. A Weekly Skin Check dated December 31, 2020 revealed shearing to the right gluteal fold measured 10 cm x 3.0 cm. However, the Weekly Skin Check dated January 6, 2021 did not reveal any further documentation regarding the right gluteal fold. Regarding the left gluteal fold shearing: The Weekly Skin Check dated September 3, 2020 revealed the resident had shearing to the left gluteal fold that measured 4.0 cm x 9.0 cm. A wound care provider note dated September 3, 2020 revealed the acute shearing to the left gluteal fold (#9) measured 4.0 cm x 9.0 cm and that this was the initial exam. Review of the Weekly Skin Checks and the wound care provider notes from September 3, 2020 until December 17, 2020, revealed weekly wound measurements and assessments were conducted. The wound care provider note dated December 17, 2020 revealed the shearing to the left gluteal fold had resolved. Additional review of the clinical record revealed treatments were provided as ordered and that all wounds had resolved except for the wound to the left thigh. However, although the resident developed shearing, multiple stage II pressure ulcers, and still being at risk for skin breakdown; no evidence was revealed that the specific interventions identified, using a Hoyer lift to turn the resident and the positioning of the brief, were consistently implemented to decrease the risk of skin breakdown. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound care observation was conducted on May 27, 2021 at 7:55 AM with the wound Licensed Practical Nurse (LPN/staff #81). The resident was observed laying in a bariatric bed with a pressure reducing mattress in place. The wound to the medial anterior right thigh was observed closed and the peri wound area pink and dry. The wound measured 4.7 cm (centimeters) in length by 2.0 cm in width and there was no drainage or odor. The wound was cleaned with a wound cleanser and pat dry. A dressing with [MEDICATION(S)] was applied to the wound. The resident did not display any discomfort during the procedure. An interview was conducted with the wound nurse (staff #81) on May 27, 2021 at 7:40 AM. She stated the resident was on bedrest at one time because of wounds but that those wounds had healed. Staff #81 stated the resident needs a lot of assistance for repositioning. The wound nurse stated the resident's wounds were caused by using a disposable brief that was too tight and using a sheet to slide the resident up in bed. She stated the pressure injuries were from shearing. The wound nurse stated staff should use a Hoyer lift to reposition the resident. She also stated that sometimes the staff just use a sheet with one staff member on each side of the bed to reposition the resident. On May 27, 2021 at 8:22 AM, an interview was conducted with an LPN (staff #14). She stated the staff use a Hoyer lift to move the resident in bed. The LPN also stated that she has stood at the head of the bed and pulled the resident up by using just a draw sheet. The LPN stated the briefs were too tight and caused a shearing/pressure injury on the inside of the resident's legs. She stated the Certified Nursing Assistants (CNAs) should leave the resident out of briefs for the resident's skin to heal. The LPN stated that because of the amount the resident voids, the CNAs will place the resident back into the tight briefs. An interview was conducted with a CNA (staff #90) on May 27, 2021 at 8:40 AM. She stated the CNAs do not use a Hoyer lift with resident #46. The CNA stated that they manually scoot the resident with a sheet. Staff #90 stated the resident voids a lot and is always soiled. She stated that she was not instructed on how to care for the resident when it comes to repositioning. On May 27, 2021 at 8:46 AM, an interview was conducted with another CNA (staff #117). This CNA stated that one staff member stands on each side of the resident's bed holding the sheet underneath the resident and slides the resident up in bed using the sheet. The CNA stated that the resident is too heavy to lift so it is more of a slide. Staff #117 stated that the staff used to use a Hoyer lift but she believes the resident is scared of the lift now. The CNA stated that today, May 27, 2021, she was informed for the first time that the resident should not be placed in a brief so that the resident's skin can heal. An interview was conducted with the Director of Nursing (DON/staff #200) on May 27, 2021 at 9:02 AM. The DON stated the care plan for resident #46 should have specific interventions to address prevention of shearing of the skin and should be in the care plan under skin interventions. The DON stated the resident voided large amounts, the position of the brief, and being pulled up in bed were all factors to the sheering. She stated the former wound nurse and the current wound nurse had instructed the staff on how to position the brief and how to reposition the resident to decrease the occurrences of skin breakdown. A facility policy titled Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Through the use of comprehensive assessments of all residents we assure that any resident who enters the facility without a pressure ulcer will not develop one unless unavoidable and any resident who has a pressure ulcer on admission has the appropriate treatment to promote healing and prevent any other pressure wounds. This policy will also be utilized for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Appropriate treatments and interventions will be put in place on any resident at risk for skin breakdown, or who already has skin breakdown, and a care plan will be initiated. Any resident who is unable to turn/reposition themselves will be assisted by staff at least every two hours while in bed or more as the resident needs. The policy included the use of transfer/draw sheets and trapeze to decrease friction, support surfaces for pressure redistribution, and control of incontinence will be utilized.

Based on closed clinical record review, interviews, facility documentation and policy and procedures, the facility failed to ensure that one resident (#1) was free from neglect. The deficient practice could result in residents not being provided the necessary services to prevent harm. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A care plan for Diabetes Mellitus initiated on [DATE] included a goal that the resident would have no complications related to diabetes. Interventions included to administer diabetes medication as ordered and monitor/document for side effects and effectiveness and to avoid exposure to extreme heat or cold. A Minimum Data Set quarterly assessment dated [DATE] included a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS also included the resident required extensive assistance with activities of daily living. Physician orders [REDACTED]. ,[DATE] units give 8 units. Notify the physician if three consecutive blood sugars are over 350. Another physician's orders [REDACTED]. A physician's progress note dated [DATE] revealed the resident was stable and mobile via his wheelchair throughout the unit and no concerns were noted. Review of the [DATE] Medication Administration Record [REDACTED]. The scheduled times for the sliding scale coverage were 5:30 a.m., 11 a.m. and at 4 p.m. The documentation showed that the resident's blood sugar was 125 at 5:30 a.m. on [DATE]. The MAR indicated [REDACTED]. The documentation showed that the resident was given the scheduled dose of [MED] 5 units at 7 a.m. prior to the morning meal. The MAR further showed that at 11 a.m., the resident's blood sugar was 56, and no [MED] was given. A nursing progress note dated [DATE] at 10:45 a.m. included the resident reported that he thought his blood sugar was dropping. His sugar was checked and it was 56, and the resident received orange juice and a donut. His blood sugar was rechecked after 45 minutes and it was 125. Further review of the [DATE] MAR indicated [REDACTED]. In the section to document the blood sugar there was an x and the nurses initials were in the 4 p.m. time slot, along with a 12. Per the chart codes, a 12 indicated Other/See Progress Notes. The documentation also showed that the scheduled [MED] [MED] 5 units before meals was not administered at 4 p.m. on [DATE]. Instead a code 10 was documented for the 4 p.m. time slot, along with the nurses initials. Per the chart codes, a 10 indicated that no [MED] was needed as BS was less than sliding scale. However, no blood sugar was documented. Review of the clinical record including the progress notes revealed no documentation that the resident's blood sugar was checked anywhere from 3 p.m. to 5 p.m. A nursing progress note dated [DATE] at 5:49 p.m. included documentation that the resident had coded. Following that note, there was an entry at 6:41 p.m., which stated the resident was seen at approximately 1:00 p.m. in the hallway outside of his room and that he would be back to get his medications and have his finger stick done. The note included that the nurse went looking for the resident around 4:30 p.m. and did not locate him. The resident's family member arrived shortly before 5:00 p.m. and located the resident who was unresponsive in his wheelchair and brought him inside. The resident was taken to his room, a code was called, 911 was notified and CPR was initiated. According to the facility's investigation conducted on [DATE], the resident had been assessed prior to the incident for wandering and elopement risk and it was determined that the resident was not at risk. The investigation included the resident had eaten dinner and was then found deceased by a family member out on the dining room patio around 5 p.m. A statement from a CNA (Certified Nursing Assistant/staff #11) reported that he saw the resident in the hallway around 3 p.m. and he looked fine. A statement from the resident's nurse (licensed practical nurse/LPN/staff #5) included that she went looking for the resident at approximately 4:15 p.m. on [DATE], when he did not come back for his blood sugar to be checked. She reported that she checked the activity area, patio and dining room and patio lobby. Per the LPN's statement, the resident's family member arrived shortly before 5 p.m. and found the resident outside on the patio by the dining room around a corner. The resident was unresponsive, ashen, fingers cyanotic and cool to touch and he was taken to his room. A code was called and CPR was initiated. Paramedics arrived and the resident was pronounced dead at 5:36 p.m. The investigation also included a statement from a dietary aid (staff #20), who reported that she saw the resident outside around 5 p.m., but didn't think anything was wrong, as there are always people going out there. The aid reported that around 5 p.m., she saw the family member struggling to get the resident inside and she went to help. She reported the resident looked as if he was asleep. She said his right side was wet and she saw the hose outside, which was broken and had been spraying on him. During an interview conducted on [DATE] at 9:39 p.m. with the resident's family member, she stated that she had come in to see the resident around noon and he seemed ok at that time and then she left about 12:15 p.m. She said that she returned around 5:00 p.m. and the resident was not in his room, so she went to look for him. She said that she found him outside on the right side of the dining room patio by the garden hose, which had a leak and was spraying on him. She said that he looked like he was asleep and she tried to arouse him but was unable, so she brought him in to the nursing station and told the nurses, who then took him to his room and started to work on him. During an interview conducted on [DATE] at 1:15 p.m. with a CNA (staff #10), she stated that she was assigned to the unit where the resident resided and that the resident was alert and oriented and able to move around the unit on his own, once he was in his wheelchair. She stated that she saw the resident last between 12:00 p.m. and 1:00 p.m. (on [DATE]) in the dining room eating lunch. She said no one asked her to look for the resident, and later heard that a family member found him on the dining room patio. An interview was conducted on [DATE] at 1:30 p.m. with a CNA (staff #11), who stated the resident was pretty independent once he was in his wheelchair and would come and go as he pleased. He said the last time he recalled seeing the resident on [DATE] was around 3:00 p.m. in the dining room. He stated that he had not been asked to go look for the resident, but heard that his family member found him on the patio by the dining room. During an interview conducted on [DATE] at 2:00 p.m. with a LPN (staff #5), she stated the resident was alert and oriented and pretty independent once in his wheelchair. She said the resident would often go outside on the other patio which is monitored. She said earlier on [DATE], the resident had a low blood sugar of 56 and was given orange juice and a donut. She said his blood sugar was rechecked and was 125. She said the resident went to lunch and she then saw him later about 3:05 p.m., when he told her that he would be back for his medications. She stated that a family member brought the resident in from outside about 5:05 p.m. and he was unresponsive and 911 was called. During an interview conducted on [DATE] at 5:15 p.m. with the Administrator (staff #15), he stated that staff are to make contact with the residents when they are outside, but there was no set policy for performing those checks. An interview was conducted on [DATE] at 5:40 p.m. with the dining room supervisor (staff #14). She stated that she saw the resident around 4:30 p.m. in the dining room, as the resident was leaving to go out on the patio. She said the resident appeared to be alert and oriented. She said when she went by about 10 minutes later, he was sitting on the patio and did not appear in distress. She said that she did not interact with him at that time, although she stated that when resident's are outside they should be checked every 15 minutes, but there is no record keeping of the checks. She added that after that she went back into the office and did not see him again. During an interview conducted on [DATE] at 5:50 p.m. with a dietary aide (staff #20), she stated that she saw the resident about 4:20 p.m. in the dining room and thought he was waiting for his order. (However, this is not included in her written statement which was part of the facility's investigation). She stated that she did not see the resident afterwards until about 5:30 p.m., when the family member was bringing the resident inside and she was asked to hold the door. An interview was conducted on [DATE] at 6:00 p.m. with a dietary aide (staff #21), who stated that she did not recall seeing the resident on [DATE] either in the dining room or on the patio, although she said that they are to check on the resident's every 15 minutes if they are on the patio and offer fluids to them. During an interview conducted on [DATE] at 6:45 p.m. with the Director of Nursing (staff #16), she stated their policy was for staff to lay eyes on the residents every 15 minutes and that dietary staff are to monitor the dining room and the patio next to it, and the receptionist it to monitor the front of the building. She stated there was no formal policy, but it was an expectation. The facility was unable to provide any documentation that 15 minute checks were completed for this resident, when he was outside on the patio on [DATE], nor any documentation of how the resident was monitored to avoid extreme heat as care planned. The facility was also unable to provide any documentation that the resident's blood sugar was checked anytime between 3 p.m. and 5 p.m., prior to the resident being found out on the patio on [DATE]. According to the weather history for Casa Grande for Saturday, [DATE], the outside temperature was 110 degrees Fahrenheit between 3:51 p.m. and 5:51 p.m., with broken clouds and a humidity of 28%. Based on the heat index provided by the National Weather Service, the temperature would have felt like 117 degrees Fahrenheit. Per the National Weather Service Heat Index graph, 110 degrees was in the danger zone. Review of the Abuse and Neglect policy revealed the facility is committed to the physical, mental, social and emotional well being of the residents and has adopted a zero tolerance related to resident abuse. The policy included that neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness.

Based on observations, clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to provide care and services to four residents (#'s 6, 80, 247 and 346) with pressure ulcers. Findings include: -Resident #80 was admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a weekly skin check dated February 12, 2016, revealed the resident had no skin breakdown or open areas. Review of the weekly skin check dated February 16, 2016, revealed the resident had an opened area with a dark red base on the right heel, which measured 3.5 by 3.5 by 0.1 cm. A nursing note also dated February 16, 2016, included that the resident had an open weeping blister on the right heel. Per the note, the resident thought that it happened on the wheelchair pedal when he had no shoes on. A weekly non-pressure ulcer report dated February 19, 2016, included documentation that the resident had sustained trauma to the right heel from the wheelchair on February 16. Per the documentation, the new area measured 3.5 by 3.5 by 0.1 cm. There was no description of the wound. A care plan identified that the resident was at risk for skin breakdown due to immobility, incontinence, end stage [MEDICAL CONDITION] and diabetes. The care plan was updated on February 26, 2016 to reflect an open area to the right heel due to trauma. The goal was to have no further skin breakdown. Interventions included for heel protectors and elevate heels off of bed, provide preventative skin care per protocol, wound care as ordered and review skin weekly with description of wound to include: measurements, description, progress and notify MD of changes. Review of the weekly non-pressure ulcer report dated February 26, 2016, revealed no documentation of an open area on the right heel. The weekly skin check dated February 26, 2016, included the resident had no breakdown or open areas. The weekly skin check dated February 29, 2016 included the resident had developed a new wound on his left heel, which measured 1.9 by 3 cm and the depth was unable to be determined (UTD). There was no further description of the wound. In addition, there was no further clinical record documentation regarding the right heel, since February 19. The weekly pressure ulcer report dated March 4, included the following: right heel dark area, which measured 3.2 by 2.7 cm and the depth was UTD; left heel with dark blebs which measured 3 by 1.9 cm and the depth was UTD. The skin care plan was updated on March 9, and included that the resident had bilateral heel wounds, with a blister to the left heel. Interventions included to encourage or assist in shifting position every two hours while in bed and every one hour when up in a chair, and observe skin daily during routine care and report changes. From March 8 through 17, there was no documentation that the resident's heels had been assessed. The next assessment of the heels was completed 11 days later. Per the weekly pressure ulcer report dated March 18, 2016, the right and left heel both measured 2 by 2 cm and depth was UTD, the right heel was dark in color and the left heel had dark blebs. Review of a Braden Scale assessment dated [DATE] revealed the resident was assessed to be at risk for pressure sore development. A quarterly MDS assessment dated [DATE], included that the resident's cognition was intact with a BIMS score of 13, and that the resident required limited assistance with bed mobility, transfers, dressing, ambulation, toileting and hygiene. The assessment also included that the resident was at risk for the development of pressure ulcers and that two stage 2 pressure ulcers were present. Further review of the pressure ulcer assessment documentation revealed that from March 25 through April 15, the heels were consistently assessed. According to the documentation on April 15, the right heel measured 3 by 3.5 cm and depth was UTD and was dark in color, and the left heel measured 3 by 2.5 cm and the depth was UTD and had dark blebs. The next wound assessment was not completed until 10 days later on April 25, 2016. A wound care initial consultation by a physician included the right and left heels were unstageable with black eschar, and both measured 3.5 by 2.2 cm, with minimal exudate. Per the weekly skin check dated May 2, 2016, the documentation showed that a blister was present to the right and left heels. The weekly pressure ulcer report dated May 6, 2016 included the right heel measured 3 by 2.8 cm and the depth was UTD and was dark in color, and the left heel measured 3.8 by 2.2 and the depth was UTD with dark blebs. This was the last date that the right and left heels were included on the weekly pressure ulcer report. Review of the wound care consultation note dated May 9, 2016 by the physician documented the following: Right heel -Measured 3.6 by 2 and depth was UTD -Granulation was present (no percent) -Minimal exudate present - Dry slough present (no percent) -Color: black Left heel -Measured: 3.2 by 2 and was UTD. -Minimal granulation present -Exudate present -Dry slough present (no percent) -Color: black Further review of the clinical record revealed that the next pressure ulcer assessment was completed 14 days later on May 23, 2016. The wound care consultation note by the physician included the following: Right heel -Measured: 4.3 by 2 and depth was UTD -25% granulation -exudate present -Slough present (no percent) -Odor was present -Color: red and black Left heel -Measured: 3.8 by 1.7 and depth was UTD -Granulation 25% -Exudate present -Slough present (no percent) -Color: red and black The next wound assessment was completed 14 days later on June 6, 2016. The wound care consultation note by the physician included the following: Right heel -Measured: 3.2 by 1.1 and depth was UTD -90% slough present -[MEDICAL CONDITION] -Color: yellow Left heel -Measured: 3.5 by 1.5 and depth was UTD -50% granulation -50% slough -Color: red and yellow The pressure ulcers were assessed next on June 13, 2016. The wound care consultation note by the physician included the following: Right heel -Measured: 2.6 by 1 and depth was UTD -Granulation present -90% slough -[MEDICAL CONDITION] resolved -Color: red and yellow Left heel -3.3 by 1.8 and depth was UTD. -60% granulation -Slough present (no percent) -Color: red and yellow Review of a Braden Scale assessment dated [DATE] revealed the resident was assessed to be at risk for pressure sore development. The next wound assessment was completed 13 days later on June 26, 2016. Per the wound care consultation note by the physician the following was included: Right heel -Measured: 2.8 by .8 and depth was UTD -100% slough present -Odor present Color: yellow Left heel -Measured: 3.1 by 1 and depth was UTD. -60% granulation -Slough present (no percent) -Color: red and yellow An annual MDS assessment dated [DATE], included a BIMS score of 15, which indicated the resident was cognitively intact. The MDS also noted that the resident required extensive assistance with bed mobility, transfers and toilet use. The assessment also included that the resident was at risk for the development of pressure ulcers, that a stage 1 or higher was present and that two unstageable pressure ulcers were present. Continued review revealed that there was no documentation that the resident's heels were thoroughly assessed from June 27 through July 17, 2016. The next wound assessment was completed on July 18, 2016, which was 22 days after the last assessment. The wound care consultation note by the physician included the following: Right heel -No measurements of the length and width of the pressure ulcer -Depth was UTD -Granulation none -Slough present (no percent) -Color: yellow Left heel -No measurements of length and width of the pressure ulcer -Depth was UTD -Granulation 50% -Color: red, yellow -Improved This assessment also included that the resident was now diagnosed with [REDACTED]. A nursing note dated July 18, 2016, included that the resident was sent to the hospital for evaluation and treatment of [REDACTED]. According to the clinical record documentation, the resident was returned to the facility on [DATE]. Review of the clinical record documentation revealed that a thorough assessment of the resident's heels had not been completed until July 28, 2016, 4 days after admission. Review of the wound summary dated July 28, 2016 completed by a licensed nurse included the following: Right heel -2.5 by .50 by .20 cm and was unstageable, with 70% pale pink non granulating tissue Left heel -1.0 by 1.50 cm and was unstageable with 40% slough According to the wound care consultation note dated August 1, 2016, the resident was on antibiotic therapy for osteo[DIAGNOSES REDACTED] of the right heel. The assessment also included the following: Right heel -Measured: 2.3 by 0.9 by 1 cm -Granulation, exudate and slough present (no percents). Color: red -Improved Left heel -Measured: 1.3 by 0.7 by 0.2 cm -Granulation present (no percent) -Minimal exudate -No slough -Color: red The next assessment was completed on August 15, 2016. The wound consultation note included the following: Right heel -Measured: 2 by 0.6 by 0.9 cm -Granulation, exudate and slough present (no percents) -Color: red -Improved Left heel -Measured: 0.8 by 0.4 by 0.3 cm. -Granulation and exudate present (no percents) -Minimal slough (no percent) -Color: red -Improved The pressure ulcers were assessed next on August 17, 2016 and then not again until nine days later on August 26. Per the wound summary, the right heel measured 2 by .50 by .20 cm with 70% pale pink non granulating tissue and was unstageable, and the left heel measured .7 by 1.0 by 0 depth and had 90% pale pink non granulating tissue and was unstageable. Further review of the wound assessment documentation revealed that the heels were not assessed weekly as follows: -the next nursing assessment was completed 11 days later on September 6 -the next nursing assessment was completed 10 days later on September 16 -the next nursing assessment was completed 13 days later on September 29 -the next nursing assessment was completed 12 days later on October 11 The next assessment was completed on October 17, 2016 by the physician. There were no previous physician assessment notes since August 15. The wound care follow up note included the following: Right heel -1.3 by 0.3 by 0.4 cm with 100% granulation tissue Left heel -1.0 by 0.8 by 0.1 cm with granulation tissue A care plan for pressure ulcers was initiated on October 19, 2016 to reflect that a pressure ulcer was present to the right and left heel. The goal was that the pressure ulcer will show signs of healing and remain free from infection. Interventions included to administer treatments as ordered and monitor effectiveness; assess/record/monitor wound healing, measure length, width and depth where possible; and to assess and document status of wound perimeter, wound bed and healing progress; report improvements and declines to MD; monitor/document/report to MD any changes in skin status, appearance, color, wound healing, signs of infection, wound size (length x width x depth), and stage. An interview was conducted on October 24, 2016 at 1:30 p.m. with staff #151. Staff #151 stated that the pressure ulcer assessments were suppose to be provided weekly. -Resident #346 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the admission data collection form dated October 7, 2016 revealed documentation that the resident had a wound to the left buttock, with slough present. However, the documentation did not include any measurements of the wound, a description of the surrounding skin, or if any odor or drainage were present. An at risk for skin breakdown care plan was developed on October 7, 2016, which identified that the resident was at risk due to impaired mobility, and included the presence of a pressure ulcer on the left buttocks. A goal included that the resident's skin would be managed through staff monitoring and interventions. The care plan interventions included the following: encourage or assist the resident in shifting positions as needed; observe the skin daily during routine care and report changes and provide preventive skin care protocol. The Braden Scale assessment dated [DATE], identified that the resident was at risk, with a score of 16 (a score of 15-16 identified a resident to be at risk). A physician's order for wound treatment was obtained on October 8, 2016, for the wound on the resident's left buttock. The daily skilled data collection note dated October 8, 2016, included the resident was alert and oriented, was able to move all extremities, and that the resident required a wheelchair for mobility. However, the note also included that the resident did not have any skin breakdown or open areas. Further review of the daily skilled data collection notes from October 9, through 18, 2016, revealed discrepancies regarding the presence of a wound on the left buttock. The documentation also included to see the weekly skin assessments for measurements and details. The physician's initial wound care consultation dated October 10, 2016, included that an unstageable pressure ulcer was present on the resident's left buttock, which measured 8.5 cm (centimeters) by 4.0 by UTD (unable to determine) depth. The documentation also included that slough was present (the percent of slough was not documented), that the color was yellow and that the periwound was intact. A review of the nursing wound summary dated October 13, 2016 revealed that an unstageable pressure ulcer was present on the resident's left buttock upon admission, which measured 8.5 by 4.0 cm with 90 % slough and an unknown depth. An admission MDS (Minimum Data Set) assessment dated [DATE], included that the resident's cognition was intact with a BIMS (Brief Interview for Mental Status) score of 15 and assessed the resident to require extensive assistance of two with bed mobility and transfers. The MDS further noted that the resident was at risk for pressure ulcer development and had an unstageable pressure ulcer with slough. A pressure ulcer treatment observation was conducted on October 19, 2016 at 2:00 p.m., with the Wound Nurse/LPN (licensed practical nurse/staff#151). During this observation, a large unstageable pressure ulcer was observed on the resident's left buttock, with slough present. Also, there was another smaller unstageable pressure ulcer to the left of the larger pressure ulcer at the 7:00-8:00 o'clock position. The smaller pressure ulcer was observed to be oval shaped, approximately one inch in length, and was covered with slough. At this time, staff #151 was observed to measure the larger pressure ulcer and administer the prescribed treatment. However, she was not observed to measure the smaller pressure ulcer or provide a treatment. Review of the nursing wound assessment documentation for October 19, 2016, revealed the following: -Unstageable pressure ulcer on the left buttock, which was present on admission. -Measured 9.5 by 4.0 cm by unknown depth -40% pale pink non-granulating tissue. -60% non adherent slough. -Periwound was normal. -No exudate. -Wound edges were distinct There was no documentation regarding the smaller pressure ulcer to the resident's left buttocks or that the physician was notified of the second unstageable pressure ulcer. Review of a nursing wound assessment dated [DATE], now revealed the following: -Unstageable pressure ulcer present on the inferior aspect of the left buttock, facility acquired and identified on October 19. -Measured 1.8 by 0.5 by unknown depth. -100% loosely adherent slough. -Periwound with [DIAGNOSES REDACTED]. -Wound edges separated from base. A nursing note dated October 20, 2016, included that the physician (wound doctor) was notified of the second wound to the left buttocks and an order for [REDACTED].>Interviews were conducted on October 16, 19, and 20, 2016, with staff #151. In regards to the daily skilled data collection documentation, staff #151 stated that they were inaccurate, as they did not identify that the resident had an unstageable pressure ulcer on the left buttocks. Staff #151 stated the documentation was suppose to be based on an actual view of the resident's skin. Regarding the smaller pressure ulcer that was observed during the pressure ulcer treatment observation on October 19, staff #151 stated that she had observed the pressure ulcer prior to October 19, but was unsure if it was present when the resident was last assessed by the wound doctor on October 10. She stated that she had not considered the smaller unstageable pressure ulcer as a separate pressure ulcer, because it was in the same area as the larger pressure ulcer. Staff #151 said that she considered them as one unstageable pressure ulcer, although the pressure ulcers were separated by intact skin. Staff #151 stated that she has only been the wound nurse for the past several months and was not sure about pressure ulcer staging, but was scheduled for a wound certification class. -Resident #6 was admitted on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed that the resident had multiple admissions and discharges from June through August 2016. Review of the August 8, 2016 admission nursing note revealed the resident had dressings to multiple wounds. The nursing note did not include documentation that a complete and thorough assessment of the wounds had been completed, as the type of wounds, location, measurements and description of the wound beds were not included. A Braden Scale for Predicting Pressure Sore Risk dated August 9, 2016, identified the resident was at risk for developing pressure sores. An at risk for skin breakdown care plan was developed on August 11, 2016. Interventions included to encourage or assist the resident in shifting positions as needed; observe skin daily during routine care and report changes; provide preventive skin care per protocol; and to review skin weekly with description of wound to include: measurements, description, progress and physician notification of changes. The care plan did not reflect that the resident had multiple pressure ulcers. A wound summary report dated August 11, 2016, which was three days after admission included the following: Left Ischial Tuberosity (hip/buttock area) -A stage 2 pressure ulcer (blister) which measured 11.5 by 14 by 0.1 cm -[MEDICATION NAME] tissue 80% -Pale pink non-granulating tissue 20% -Periwound: normal -Wound edges: distinct and attached Right Ischial Tuberosity -A stage 2 pressure ulcer (blister) which measured 3.5 by 5 by 0.1 cm -Intact skin was 20% and 80% pale pink non granulating tissue -Periwound: normal -Wound edges: distinct and attached Coccyx -A stage 4 pressure ulcer, which measured 5 by 2 by 4 cm -100% bright pink/red tissue -Periwound: normal -Wound edges: separate from the base -Undermining at 12:00 O'clock: 4 cm An admission MDS assessment dated [DATE], included the resident was cognitively intact with a BIMS score of 15, required supervision with transfers, required limited assistance for dressing and toileting and was non-ambulatory. A refusal of treatment dated August 15, 2016, and signed by this resident, included that a low air loss mattress had been offered to the resident but that he had refused. A physician's wound assessment dated [DATE], (one week after admission) included that the resident had wounds on the buttocks as follows: Left buttock -Unstageable, which measured 13.5 by 15 cm by UTD depth -Slough present (percent was not documented) -Color: yellow Right buttock -Unstageable, which measured 5 by 8 cm by UTD depth -Slough present (percent not documented) -Color: yellow Sacrum -A stage 4, which measured 5.8 by 2 by 3 cm -Undermining at 12 O'clock at 4.2 cm -Granulation and exudate present A review and comparison of the August 11, 2016, pressure ulcer assessment and this assessment revealed that the stage 2 pressure ulcers on the resident's right and left buttock had deteriorated and were now identified as unstageable pressure ulcers. This wound assessment also included that the resident was at risk for wound complications, due to non-compliance. The next nursing weekly wound assessment was dated August 19, 2016, and included the following: Left buttock -Unstageable pressure ulcer -Measured: 13.5 by 15 cm by UTD depth -Slough loosely adherent 80% -No exudate Right buttock -Unstageable pressure ulcer -Measured: 5 by 8 cm by UTD depth -No exudate -Periwound: normal -Wound edge: distinct and attached -No undermining or tunneling Coccyx -Stage 4 pressure ulcer -Measured: 5.8 by 2 by 3 cm -No exudate -Periwound: normal -Wound edge: separate from base -Undermining from 12 to 2:00 O'clock at 2 cm The next pressure ulcer assessment was provided on August 29, 2016, which was ten days after the last assessment. This assessment included the following: Left buttock -Measured 13.3 by 13.5 by 0.2 cm -Granulation present, however, the percent was not documented -Exudate present -No slough -Color: red -Improved Right buttock -Measured 4.5 by 6.5 by 0.2 cm -Granulation present, however, the percent was not documented -Exudate present -No slough -Color: red -Improved Coccyx -Measured 5.5 by (width not documented) by 2.7 cm depth -Granulation present, however, the percent was not documented -Exudate present -No slough present -Undermining at 12:00 O'clock at 4.7 cm -Color: red -Chronic Further review of the clinical record revealed that the next assessment of the resident's pressure ulcers was not completed until 14 days later on September 12, 2016. The assessment documentation included the wounds were improving. Continued review of the clinical record revealed the resident's pressure ulcers were assessed weekly from September 13 through 25, 2016 and showed improvement. The next pressure ulcer assessment was completed on October 3, 2016, which was eight days after the previous assessment (from September 25). and included the following: Left buttock -Measured 5.6 by 2.6 by 0.1 cm -Granulation present (no percent) -Exudate: minimal -No slough -Color: red Right buttock: Resolved Coccyx -Measured 5.5 by 1.5 by 2.2 cm -Undermining at 12:00 O'clock of 5.5 cm -Granulation present (no percent) -Exudate present -No slough -Color: red This pressure ulcer assessment also included to refer the resident to surgeon at the wound clinic for closure of sacral ulcer. On October 10, 2016, another pressure ulcer assessment was conducted and included the following: Left buttock -Measured 5.2 by 1.7 by 0.1 cm -Granulation present (no percent) -No exudate. -No slough -Color: red -Improved Coccyx -No measurements were included -Granulation present (no percent) -Undermining present (no location or depth documented) -Color: red -Stable -Awaiting referral to wound clinic for flap evaluation However, a nursing wound assessment dated [DATE], included the following: Coccyx -Measured 5.5 by 1.5 by 2.2 cm, with undermining at 12:00 O'clock at 5 cm. The next pressure ulcer assessment was completed eight days later on October 19, 2016 and included the following: Left buttock -Measured: 4 by 1.5 by 0.1 cm -No exudate Coccyx -Measured: 5.5 by 1.5 by 2.2 cm -Undermining at 12:00 O'clock of 5 cm -No exudate A pressure ulcer care plan was developed on October 19, 2016, and included that the resident had a pressure ulcer on the left buttock and coccyx. On October 24, 2016, a pressure ulcer assessment was conducted and included the following: Left buttock -Measured: 4.3 by 1.5 by 0.1 cm -No exudate Coccyx -Measured 5.5 by 1.5 by 3 cm -Undermining at 12:00 O'clock of 3 cm -No exudate An interview was conducted on October 24, 2016 at 1:30 p.m. with staff #151. Staff #151 stated that the pressure ulcer assessments were suppose to be provided weekly. -Resident #247 was admitted to the facility on [DATE], for after care following joint replacement surgery. [DIAGNOSES REDACTED]. The resident was discharged on [DATE]. A review of the Admission Data Collection dated May 21, 2016, revealed the resident was alert and oriented to person and place and required a wheelchair for mobility. The documentation also included that the resident had a blister on her right buttocks, which measured 1 by 1.5 cm, with some redness noted and that barrier cream was applied. However, upon admission there was no physician's order for any barrier cream. A care plan dated May 21, 2016 identified that the resident was at risk for skin breakdown. The care plan interventions included to provide preventative skin care per protocol; review skin weekly with description of wound to include: measurements, description and nursing documentation and to notify the physician of changes. Review of the daily skilled data collection note dated May 21, 2016, revealed that skin breakdown was present and to see the weekly skin assessment for measurements and details. A wound care initial consultation note dated May 23, 2016, included the following regarding the right buttock pressure ulcer: color-pink; periwound-intact; measurements-1 by 1.5 cm with depth of a blister. The note further included that a suspected deep tissue injury was present on the right buttock and the treatment plan included for barrier cream. Again, there was no physician's treatment order for any barrier cream. A weekly skin check dated May 27, 2016 included documentation that skin breakdown was present. However, the documentation did not include that a thorough assessment had been completed, inclusive of measurements and a description of the pressure ulcer. Review of the daily skilled data collection notes from May 23, through May 31, 2016, revealed that skin breakdown was present, however, there was no further documentation regarding the status of the right buttock pressure ulcer. In addition, further review of the clinical record including the physician progress notes [REDACTED]. Review of the recapitulation of physician order's for May 2016 revealed there were no orders for any treatment for [REDACTED]. In addition, the May 2016 TAR (Treatment Administration Record) did not include any documented evidence that a treatment had been prescribed or administered. An interview was conducted on October 26, 2016 at 9:00 a.m. with a LPN (Licensed Practical Nurse/staff #25). She stated there should have been a complete assessment, which included measurements and a description of the pressure ulcer. She stated that the facility's current process when a resident has a pressure ulcer would include a complete and full assessment of the pressure ulcer, weekly. She also stated if there was a change in the pressure ulcer, another full assessment should have been done and the physician notified immediately. The wound nurse (LPN/staff #130) was interviewed on October 26, 2016 immediately following the interview with staff #25. Staff #130 stated if a resident was admitted to the facility with a pressure ulcer, then a thorough assessment should be provided. She also stated if a resident with a pressure ulcer was admitted they would immediately be included in wound rounds and the physician would be notified, and a treatment order would be obtained and administered. Review of the Resident Admission policy revealed that all residents will receive an initial assessment upon admission and will identify the patient's baseline data and special needs, and that this information will be used to establish the plan of care. A comprehensive evaluation of the resident will be conducted by the nurse utilizing the review of medical information provided in the clinical documentation .as well as physical observations and assessments conducted. Upon admission, the nurse will perform an initial head-to-toe assessment within 2 hours of arrival. A Registered Nurse will do a head-to-toe assessment within 24 hours of admission if initial assessment is done by an LPN. A facility policy titled, Prevention and treatment of [REDACTED]. The policy also included the following: -A comprehensive skin assessment will be completed on all new residents within two hours of admission. -Appropriate treatments and interventions will be put in place on any resident at risk for skin breakdown, or who already has skin breakdown, and a care plan will be initiated. -Facility protocols for wound care will be used. -Nursing will notify the DON/ADON (Director of Nursing/Assistant Director of Nursing) of any new pressure wounds or declining ulcers. -Any wound that does not show improvement within 14 days will have MD notified and treatment options discussed. -A thorough skin assessment will be conducted weekly by the nurse; the status of all pressure ulcers or other skin issues .will be documented using the designated tool to include the characteristic of the wound such as: measurements, bed/base, wound margins, exudate, odor, peri-wound.

Based on clinical record reviews, staff interviews, hospital documentation, and policy review, the facility failed to meet professional standards of quality, by failing to ensure one resident's (#68) wounds were consistently assessed and monitored, failed to ensure hospital orders for contact precautions were transcribed to the admission orders [REDACTED]. Findings include: -Resident #68 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a nurse's note from January 15, 2014, that documented the resident had an incision with 110 staples across one side of the abdomen to the other, with sutures above and below. The resident also had four Jackson Pratt (JP) drains on her abdomen and a wound under her left abdominal fold. physician's orders [REDACTED]. [MEDICATION NAME] powder was also ordered to be applied to all skin creases/areas of sweating every shift. Another physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for January 2014, revealed the physician's orders [REDACTED]. On January 16, 20 and 22, there was no documentation the wound care treatments were done. There were also multiple shifts with no documentation that the drain sites were painted with [MEDICATION NAME]. Review of the skin integrity care plan dated January 21, 2014, revealed the resident had a surgical site. One of the interventions was to observe skin daily during routine care and report changes. No other skin issues were noted. Further review of the clinical record including nurse's notes revealed there was no consistent assessment documentation of the condition of the left groin wound or the left abdominal fold wound, as identified upon admission. There was also no evidence that the abdominal incision with 110 staples, which had sutures above and below, was consistently assessed and monitored. According to a nurse's note dated January 24, 2014, the resident left the facility against medical advice (AMA), ten days after admission. Clinical record documentation showed that the resident went to the hospital on January 24, 2014. Review of a hospital History and Physical (H&P) dated January 24, 2014, revealed the resident's chief complaint was a post-panniculectomy abdominal wall infection and that the resident left the facility AMA, due to poor care. The documentation included that the resident noticed her wounds were getting worse and infected. The H&P documented that the resident had "a broken wound at the incision site with draining purulent material from multiple areas of abdominal wound..." There was also full-thickness necrosis of the skin. It was also documented that the resident was admitted to a specialty hospital and that given her extensive abdominal wound infection, she carried a poor prognosis for healing. During an interview conducted on April 17, 2014, the treatment nurse stated that she has only been in her position for about a month and a half. She reported that the floor nurses were doing the treatments prior and it was discovered that treatments were not being done; as a result they implemented having a treatment nurse. She stated that she remembered resident #68's wound, because it was an extensive dressing change. She reported that two people were required to perform the dressing change, as one person had to hold up the abdominal flap. The treatment nurse stated that the resident had open areas along her incision and they were to put xeroform on them. She also reported that there was a lot of drainage from the wound. During an interview conducted on April 16, 2014, a Registered Nurse (RN) reported that treatments are to be documented on the TAR. An interview was conducted with the Director of Nursing (DON) on April 16, 2014. She stated that she would expect treatments to be documented on the treatment record. After reviewing the resident's TAR, she admitted that there were gaps. When asked if she could explain the xeroform order regarding any open areas the resident had, she was unable to provide any documentation and stated she would have to clarify what the wound orders meant. Review of the facility's policy on wound care revealed that wound care needs to be documented in the resident's medical record, as well as any change in the resident's condition. The documentation should include an assessment of the wound bed color, size, and drainage etc., when inspecting the wound. -Resident #165 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital transfer orders dated January 12, 2014, reflected an order for [REDACTED]. However, review of the physician's admission orders [REDACTED]. Review of the closed clinical record, including nursing notes, did not reflect that the resident was placed on contact precautions from January 13 to January 20. On April 16 at 8:37 a.m., the DON and Assistant Director of Nursing (ADON) stated that all information regarding a [DIAGNOSES REDACTED]. During an interview with the DON on April 17 at 3:46 p.m., the DON stated that they had no policy regarding transfer orders. -Resident #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the pain care plan dated February 28, 2014, revealed the resident had generalized back pain. Approaches included to administer [MEDICATION NAME] as ordered by MD (physician) and observe for changes in daily routine. physician's orders [REDACTED]." Review of the clinical record revealed there was no documentation that the physician's orders [REDACTED]." Also, there was no documentation that the physician's orders [REDACTED]. During an interview conducted at 12:00 p.m. on April 17, 2014, a registered nurse stated that prior to the administration of 1 or 2 [MEDICATION NAME], the nurse should have contacted the physician for clarification. He stated that for a pain of "0," he would not administer one tablet of [MEDICATION NAME] and that the order needed clarification. He also stated that the pain scale for administration needed to be clarified, as the orders overlapped for a pain scale of "5."

Based on clinical record review, staff interview, hospital and facility documentation, and policy review, the facility failed to ensure one resident (#73) was free from significant medication errors. Findings include: Resident #73 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed physician's orders [REDACTED]. This was the only blood pressure (BP) medication that was ordered for the resident. Further review of resident #73's clinical record revealed that his BP varied, with systolic ranging from the low 100's to the 150's. According to the facility's investigative documentation, resident #73 was given multiple medications in error, on November 4, 2013 at 8:00 a.m. Per the report, a nurse (staff #1) was preparing medications for another resident, when resident #73 came up to her demanding his medications. Staff #1 gave resident #73, the other resident's medications. The medications given in error to resident #73 were as follows: [MEDICATION NAME] 0.2 mg, [MEDICATION NAME] 100 mg, and [MEDICATION NAME] XL 90 mg (all blood pressure medications). Additional medications given to resident #73 in error were as follows: [MEDICATION NAME] 800 mg ([MEDICATION NAME] binder), aspirin 81 mg ([MEDICATION NAME]), [MEDICATION NAME] 250 mg ([MEDICATION NAME]), folic acid 1 mg (vitamin), multivitamin 1 tablet, [MEDICATION NAME] 75 mg (blood thinner), [MEDICATION NAME] 500 mg (anti [MEDICAL CONDITION]), sensibar 90 mg (used to lower calcium levels), [MEDICATION NAME] 5 mg (used to treat mild to moderate dementia), and [MEDICATION NAME] 500 mg (anti epileptic). As a result of the medication errors, resident #73's BP was monitored as follows: at the time of the incident it was 162/84, at 10:00 a.m. it was 142/62, at 12 p.m. it was 114/54 and at 4:45 p.m. it was 92/56. Review of the nursing notes revealed that at 8:00 p.m. on November 4, 2013, the resident's blood pressure was now 88/50. The physician was notified and orders were obtained to give IV (intravenous) fluids. physician's orders [REDACTED]. Nursing notes at 10:20 p.m., documented the resident's BP was 78/40 and an order was obtained to send the resident to the hospital. Review of the Emergency Department records dated November 4, 2013, revealed the resident presented with lethargy and [MEDICAL CONDITION]. The hospital history and physical (H&P) included the resident had left-sided facial droop and weakness and was suspected to be having neurological symptoms "secondary to cerebral hypoperfusion from [MEDICAL CONDITION]." The resident was admitted to the hospital for further monitoring. An interview was conducted on April 17, 2014 at 8:45 a.m. with staff #1. Staff #1 stated that she was preparing another resident's medications, when resident #73 came up to her and wanted his medications, because he was on his way to the dining room. Staff #1 stated she put the other resident's medication cup aside and prepared resident #73's medications. She said that instead of giving resident #73 his medications, she accidentally gave resident #73 the wrong cup of medications. She stated that she noticed it right away and her manager and the physician were notified. Review of the facility's policy on administering medications revealed that medications shall be administered in a safe and timely manner and that medications must be administered in accordance with the orders. The policy further included that the resident's identity must be verified prior to administration.

Based on closed clinical record reviews, facility documentation, staff interviews, policy review and documentation from the Centers for Disease Control and Prevention (CDC), the facility failed to maintain an infection control program that identified specific pathogens and trends, and failed to ensure infection control measures were implemented regarding room placement involving two residents (#165 and #280). Findings include: -Review of the facility's infection control logs from May 2013 to April 2014, revealed that infections were being tracked in categories such as; UTI (urinary tract infections), eye infections, respiratory infections, and gastrointestinal (GI) infections. However, specific organisms such as;[DIAGNOSES REDACTED] (clostridium difficile), MRSA (methicillin resistant staphylococcus aureus), E-coli (escherichia coli) were not being identified. In addition, the infection control data did not include that specific organisms were being tracked or that any clustering of specific infections were being monitored, in order to implement corrective action regarding any trends that may be identified. During interviews with the ADON on April 16 and 17, the ADON stated that each month she would obtain information on infections from each unit by the type of infection, such as GI or eye infection, through review of antibiotic orders. She explained that she would then graph this information and compare it to the month prior. In reviewing the March 2014 infection control logs, it was noted that there was a cluster of UTIs in the A hall, which were identified as nosocomial. The ADON could not explain the type of organism causing the UTIs and stated that she would need to review each resident's lab result to determine this. With regards to analysis of the information obtained at the end of each month, the ADON stated she was currently not monitoring organisms and did not receive monthly reports of cultures from their contracted lab. -Resident #280 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed the resident did not have a [DIAGNOSES REDACTED]. Nursing notes dated January 13, 2014, documented that resident #280 was admitted at 5:00 p.m., to the D hall and was admitted for physical and occupational therapy. The resident was assessed to be incontinent of bowel. An Admission Data Collection dated January 13, 2014, documented the resident had a history of [REDACTED]. physician progress notes [REDACTED]. This note documented that the resident was admitted for rehabilitation and UTI. physician progress notes [REDACTED]. A physician's progress note dated January 23, 2014, now revealed that the resident had a current complaint of diarrhea. The plan was to have the resident checked for[DIAGNOSES REDACTED]. A lab report dated January 23, 2014 reflected a positive result for the[DIAGNOSES REDACTED] bacteria. physician's orders [REDACTED]. Review of a care plan for[DIAGNOSES REDACTED] infection revealed to administering medications as ordered and report pertinent lab results to the physician. The interventions did not include the need for contact precautions. A physician progress notes [REDACTED]. Review of the January 2014 facility infection control logs for the D hall, revealed that resident #280's[DIAGNOSES REDACTED] infection was nosocomial in etiology. The date of onset was January 23. -Resident #165 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital transfer orders dated January 12, 2014, revealed an order for [REDACTED]. According to the closed clinical record, resident #165 was admitted at 8:15 p.m., on the same day, to the same room as resident #280 (who did not have a [DIAGNOSES REDACTED]. A nursing note dated January 14 at 4:12 a.m., included that resident #165 had[DIAGNOSES REDACTED]. The note did not reflect that the resident was on contact precautions. A nursing note dated January 17 at 7:51 a.m., included the resident had a large loose stool, prior to leaving for dialysis. Further review of the clinical record revealed there was no care plan that addressed a [DIAGNOSES REDACTED]. Review of a census list revealed that resident #165 was moved from the room of resident #280 on January 20, seven days after admission. The documented reason for the room change was "HAS[DIAGNOSES REDACTED] NEEDS TO MOVE TO ALL[DIAGNOSES REDACTED] ROOM." A nursing note dated January 22, documented the resident continued on oral [MEDICATION NAME] and was positive for[DIAGNOSES REDACTED]. The physician progress notes [REDACTED]. Subsequent physician progress notes [REDACTED]. The facility's infection control logs for January 2014 were reviewed and identified that resident #165 had a [DIAGNOSES REDACTED]. In addition, the resident was documented to have been in the same room as resident #280, who upon admission did not have a [DIAGNOSES REDACTED]. An interview was conducted on April 16, 2014 at 8:36 a.m., with a registered nurse on the D Hall. The RN explained that there were no private rooms in this hall and that each room allowed for two residents who would need to share a bathroom. She stated that if they were to receive a resident on admission with an infectious disease requiring isolation, they would be placed in a room of their own. She continued by explaining that if a resident became positive for an infection requiring isolation, such as[DIAGNOSES REDACTED], and was currently with a roommate, the resident requiring isolation would be moved to another room. On April 16, 2014 at 12:52 p.m., the Admissions Director stated that when she receives information on residents who require isolation precautions, she would determine placement along with nursing staff who are more familiar with the residents. She stated that if it was found that a resident with isolation orders had not been placed on isolation, then it would be a nursing decision to move the resident if this occurred on the weekend. During the weekday, she explained this decision would be made by the Director of Nursing (DON) and social services, who would be alerted by nursing staff. The ADON reviewed resident #165's clinical record and could not locate evidence that the resident was started on contact precautions upon admission. The ADON located a document in which the facility nurse received report from the transferring hospital that the resident had a [DIAGNOSES REDACTED]. Review of a facility policy and procedure on contact precautions revealed that infections requiring Contact Precautions included GI infections and residents with diarrhea associated with[DIAGNOSES REDACTED]. The policy included to place the individual in a private room if it is not feasible to contain excretions, blood and body fluids (e.g., the individual is incontinent on the floor, or wanders and touches others). If a private room is not available, the senior nurse on duty is to assess other resident placement options, such as cohorting. Review of the 2007 Centers for Disease Control and Prevention (CDC) guidelines regarding[DIAGNOSES REDACTED] revealed that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands who have touched a contaminated surface or item. For the prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, it stated to use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines also stated to use gloves and gowns when entering patients room and during care and for all interactions that may involve contact with the patient or potentially contaminated areas in the patients environment. In addition, the CDC guidelines included that[DIAGNOSES REDACTED] infected patients continue to shed organisms for a number of days following the cessation of diarrhea. The guidelines also stated to implement an environmental and disinfection strategy to ensure the adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently The CDC Guidelines further included that a single patient room is preferred for patients who require Contact Precautions. However, when a single patient room is unavailable, consultation with infection control personnel is recommended to assess the various risks associated with the other placement options (e.g., cohorting, keeping the patient with an existing roommate).

Based on clinical record reviews, staff, physician, and resident interviews, and facility policy review, the facility failed to ensure drug regimens for eight residents (#s 187, 253,242, 59, 100, 197, 16, and 261) were free of unnecessary drugs. Resident #187 sustained actual harm. The sample size was 12. Findings include: -Resident #187 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed an admission order dated September 13, 2012, for the use of [MEDICATION NAME] (anticoagulant) 5 milligrams (mg) daily to prevent [MEDICAL CONDITIONS]. A care plan for at risk of bleeding related to [MEDICATION NAME] use dated September 13, 2012, included a goal that the PT levels will be within normal range and to have no excessive bleeding. The following interventions were documented: observe for presence of bleeding-urine, stool, nosebleeds, emesis, observe for any complaints of pain, notify physician of coffee ground emesis, give and hold anticoagulant medications per physician's orders. According to the physician orders and the September Medication Administration Record (MARs) from September 14 through 18, the [MEDICATION NAME] was being held and/or adjusted based on the INR (International Normalized Ratio) lab results that were done. Review of a laboratory report dated September 19, 2012, included the INR was 4.17 (recommended range (2.0-3.0). A physician's order dated September 19, 2012, documented to hold the [MEDICATION NAME] today and recheck the PT/INR daily. Review of the PT/INR/[MEDICATION NAME] Flowsheet for September 20, revealed the INR was 2.1. A physician's order dated September 20, 2012, included the resident to receive [MEDICATION NAME] 3 mg by mouth daily. Review of the PT/INR/[MEDICATION NAME] Flowsheet for September 21, revealed the INR was 2.4. According to the September MAR, [MEDICATION NAME] 3 mg was administered on September 21. Further review of the clinical record revealed there was no documentation that the INR was done on September 22 and 23, despite orders for daily INRs. Review of the September MAR revealed [MEDICATION NAME] 3 mg was given on September 22 and 23, despite no INR results. Review of the laboratory report dated September 24, the resident's INR was a critical level at 5.1. A physician's order dated September 24, included to administer Vitamin K 5 mg by mouth x1 STAT (immediately) and to hold the [MEDICATION NAME] and recheck the INR on Thursday (September 25). According to the September MAR, the [MEDICATION NAME] was held on September 24, and 25, however, there was no documentation that the Vitamin K was administrated. There was also no clinical record documentation that the INR was done on September 25, as ordered. Further review of the MAR revealed the [MEDICATION NAME] was held on September 26, however, there was no documentation that the INR was done that day. Review of the PT/INR/[MEDICATION NAME] Flowsheet revealed that the next INR was done on September 27, and was 1.8. Continued review of the clinical record revealed there was no documentation that INRs were done daily on September 28, 29, or 30, and there were no physician's orders to discontinue the daily INRs. Review of the September MAR revealed the [MEDICATION NAME] was given on September 27 through 30, despite no INR results and no physician orders to restart the [MEDICATION NAME]. The next INR was done on October 1, and was at a critical level of 8.0. A physician's order was written on October 1, 2012, to hold the [MEDICATION NAME] today and recheck the INR tomorrow. The INR on October 2, was 6.9. Per the October MAR, the [MEDICATION NAME] was held on October 1 and 2. However, there was no INR done on October 3 and the MAR documentation showed that [MEDICATION NAME] 3 mg was administered, despite there was no physician orders to restart the [MEDICATION NAME]. Review of the laboratory report dated October 4, 2012, revealed the INR level was now so high that it was unable to be calculated and the PT ([MEDICATION NAME] time) level was greater than 120 (normal range 9.1-11.8). These critical results were phoned to the facility by the lab and the physician was notified. A physician's progress note dated October 4, 2012, documented the INR was 12.0. A physician's order dated October 4, 2012, included to discontinue the [MEDICATION NAME] and to do daily INR's and to monitor for bleeding and notify provider. According to the PT/ INR/[MEDICATION NAME] Flowsheet the INR on October 5 was 8.0. Physician orders dated October 5, included to continue to hold the [MEDICATION NAME]. Per the PT/INR/[MEDICATION NAME] Flowsheet, the INR was done on October 6, and remained at 8.0. Review of the October MAR, revealed the [MEDICATION NAME] was not given on October 5 and 6 and had been discontinued as of October 4. A Daily Skilled Nurse's Note dated October 6, 2012, documented the resident was alert and responsive. The resident was diaphoretic and unresponsive in the bathroom while sitting on the toilet. The physician was notified and came into the facility to examine the resident. A physician progress notes [REDACTED].<3. Physician orders dated October 6, 2012 included for IV fluids. A nurse's note at 8 p.m. on October 6, included the resident was alert and oriented to self only, had a poor appetite, was incontinent of bowel and bladder, and there were no further episodes of [MEDICAL CONDITION]. A physician's order dated October 7, included for Vitamin K 2.5 mg by mouth x 1, which was given. A Daily Skilled Nurse's Note dated October 7 at 7:45 p.m., revealed the resident's INR was > 8 this morning and that Vitamin K was given. The note further documented that a family member was visiting this morning and reported the resident vomited, but had no further emesis throughout the day. An entry at 6 a.m. documented that at 4:40 a.m., the nurse went into the resident's room and heard labored breathing. The resident was diaphoretic and pale. Blood pressure was 98/63, pulse 147, respirations 40, oxygen saturation 95%, and blood sugar was 243. An ambulance was called and the resident was transported to the hospital. Review of the hospital documentation revealed the resident presented with altered mental status and was found to be lethargic at the nursing facility. She was on [MEDICATION NAME] and labs showed her INR was >12. Documentation included her labs were indicative of severe [MEDICAL CONDITION] and an NG tube suctioning showed grossly coffee ground matter, which was positive for occult blood. She was also severely hypotensive and was given a blood transfusion and placed on a ventilator. An interview was conducted on February 26, 2013, with a registered nurse (RN). The RN stated that the INR's are done in house, as the facility has their own machine for testing. He also stated that when [MEDICATION NAME] is put on hold, it should not be restarted without an order. An interview was conducted on February 27, 2013, with the director of nursing (DON). The DON stated that she did not know why the [MEDICATION NAME] was restarted without an order, and does not know why nursing did not follow the physician's order for daily INR's. An interview was conducted on February 28, 2013, with a RN. The RN stated that daily INR's should have been done on this resident and does not know why that did not occur. She also stated that there should be an order to restart the [MEDICATION NAME] when it is put on hold before it is given. An interview was conducted on February 28, 2012, with a physician. The physician stated that the [MEDICATION NAME] was not properly managed for this resident, and he did not know that the resident's daily INR's were not being done as ordered. He also stated that the resident should not have received the [MEDICATION NAME] without an order from the physician to restart the medication. Review of the facility's policy on Administration of [MEDICATION NAME] revealed, "The day shift nurse is responsible for reporting all INR's to the physician prior to the next dose due, and document on the PT/INR flowsheet the outcome of that communication and is responsible for writing a telephone order and transcribing any changes to [MEDICATION NAME] or continuing hold orders and communicating any changes to the oncoming shift...Before administering any dose of [MEDICATION NAME] the most recent or current INR must be checked and that value must be recorded below the dose initialed for when administered...Any [MEDICATION NAME] doses held will follow the standard procedure for medications not given, that dose will be circled with your initial and reason why it was not given will be recorded on the back of the MAR and must be communicated to the next shift..." -Resident #253 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A physician's order was written on January 15, 2013, for the use of Calcium 600 mg with vitamin D 200 units to be given orally one time each day for a supplement. Review of the resident's MAR for February, 2013, revealed that the resident was not receiving the prescribed Calcium with vitamin D. During an interview with a RN on February 27, 2013, the RN stated that the resident has been refusing to take the supplement, so he no longer offered it. He also stated that he did not have an order to discontinue the medication. Review of the facility's policy on Medication Monitoring and Management revealed "...Refusal or inability of the resident to take medications is evaluated, documented, and responded to appropriately..." Issue regarding informed consent for resident #100: -Resident #100 was admitted to the facility December 21, 2012 with [DIAGNOSES REDACTED]. Other pertinent information included the resident was ninety years old. Review of the closed clinical record included physician admission orders [REDACTED]. On December 27, 2012, the [MEDICATION NAME] was discontinued, and [MEDICATION NAME] (benzodiazepine used for sedation) 30 mg by mouth at bedtime was ordered. A thorough review of the closed clinical record, including physician and nurse's progress notes, did not include documented evidence that the resident/resident's representative had been provided informed consent related to the use of multiple [MEDICAL CONDITION] medications. A facility form, entitled "Consent for use of Psychoactive Medications", was found, with the resident's representative and a facility staff witness signature, but the entire form, consisting of the recommended drug, dosage, frequency, targeted behaviors/symptoms, and potential side effects, was entirely blank. During an interview conducted February 21, 2013 at 10:45 a.m., licensed staff stated that when a resident is prescribed a new psychoactive medication, or when a resident is newly admitted , she reviews the physician's orders for the medications, completes the consent form, then reviews the medications with the resident/resident's representative, and has them sign the form. Facility policies and procedures were requested; a nursing guidelines directive was provided, and stated, under Informed Consent: written informed consent should be obtained from the person for whom the medication is being prescribed, before the use of any [MEDICAL CONDITION] medication...if the person is not capable of giving informed consent, the appropriate surrogate consent giver should be contacted to provide consent. Regarding atypical anti-psychotics and resident #100: Review of the closed clinical record included physician's admission orders [REDACTED]. There was no indications for use of this anti-psychotic medication documented on the order sheet. Review of the MAR for December 2012 also did not include a reason for the use of this medication; the January MAR listed the resident [DIAGNOSES REDACTED]. Review of the resident's [MEDICAL CONDITION] drug use care plan, dated December 24, 2012, indicated the medication was for [MEDICAL CONDITION]. During an interview conducted February 27, 2013 at 10:00 a.m., the facility consultant pharmacist stated that altered mental status was not specific enough of a [DIAGNOSES REDACTED]. Review of Saunders "Nursing Drug Handbook, 2013" included, under [MEDICATION NAME], a black box warning, that elderly patients with dementia related [MEDICAL CONDITION] are at an increased risk for mortality due to [MEDICAL CONDITION] events. -Resident #261 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed a physician's order February 8, 2013, for [MEDICATION NAME] ([MEDICATION NAME]) 7.5/325 mg one to two orally every four hours as needed for pain. However, the order did not indicate when to give one tablet and when to give two tablets. Continued review of the clinical record revealed the MAR that documented the [MEDICATION NAME] was transcribed as one to two orally every four hours as needed for pain and was documented as administered at least nine times February 9 - 19, 2013. Further review of the clinical record revealed a physician's order dated February 8, 2013, [MEDICATION NAME](hypnotic) 10 mg at bedtime as needed for [MEDICAL CONDITION]. Additional review of the clinical record did not reveal documentation that the resident was informed of the risks and/or benefits of [MEDICATION NAME] administered to the resident on February 19, 2013. During an interview conducted on February 21, 2013 at 1:20 p.m., the resident stated he was given a sleeping pill last night but that he did not know anything about the sleeping pill. During an interview conducted on February 21, 2013 at 2:00 p.m., a RN stated there is a consent the residents sign informing them about the medications such as hypnotics before the medication is administered. The RN also stated prn pain medications would be transcribed onto the MAR using a standing order that one tablet would be administered for pain 1 -5 and two tablets would be administered for pain 6 - 10. The facility's policy "[MEDICAL CONDITION] Drug Use" included "Written informed consent should be obtained from the person for whom the medication is being prescribed before the use of any [MEDICAL CONDITION] medication..." The facility's policy "Standing Physician Orders" included approved standing orders are limited to admission standing orders, diabetic accucheck and sliding scale orders, intravenous access device flush protocols, and non-complicated wound care and skin care orders. The facility's policy "PRN Orders" included "PRN orders must clarify the circumstances for offering or giving the medication..." -Resident #242 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of medical record revealed a daily skilled nursing note dated January 8, 2013 which stated "1300: Pt received wrong medication of [MEDICATION NAME] 100 mg and [MEDICATION NAME] inhaler. DON, husband, doctor to be notified". The daily skilled nurse's note continued with "1500: Pt. continues to show no adverse effects to medication error. 18:00 doctor recently notified, Pharmacy notified no major concerns at this point, Pt continues to function within normal limit, no signs or symptoms of distress." There was no indication of additional vital sign documentation located in the resident's medical record. An interview was conducted with the resident's family member on February 28, 2013 at 9:10 a.m. The family member stated that the resident did not take any inhalers and that the resident did not take medications in the afternoon. According to the family member this information was told to the nurse. The family member said that the nurse insisted the resident take the medication and shoved the inhaler in the resident's mouth. An interview was conducted with an licensed practical nurse (LPN) on February 28, 2013 who stated the nurse that gave the wrong medication came out to her and informed her he had given the wrong medication and was very upset by it. She stated she told him to fill out an incident report, to report it to the DON and the resident's doctor. She further stated that any additional vital sign documentation would be placed on the incident form and would not be in the resident's medical record. An interview was conducted with the DON. She was able to produce a medication error report which indicated the resident was medicated with [MEDICATION NAME] and an inhaler. She stated that an unusual occurrence report should have been completed for this incident however no incident report was able to be located. Review of the facility policy on medication administration) just after the dose is prepared and the medication put; away...8). Residents are identified before medication is administered using (TWO) methods of identification. methods of identification include: A. checking photograph attached to medical record. B. calling resident by name, C. having the resident verify his/her last name. D. If necessary, verifying resident identification with other facility personnel... 15) Medications supplied for one resident are never administered to another resident." Further review revealed..."five rights - right resident, right drug, right dose, right route and right time are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally just after the dose is prepared and the medication is put away. -Resident #16 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed that the resident has and order for [MEDICATION NAME] 1 gram in 10 milliliters (ml), by mouth four times a day. The doses were scheduled for 7:00 a.m., 12:00 p.m., 4:00 and 8:00 p.m.. The resident attended a meal in the assisted dining room during the second seating each day which have meal times of 7:45 a.m., 11:45 a.m., and 4:45 p.m.. Interview was conducted with a Pharmacist on February 27, 2013 who said that for [MEDICATION NAME] to be effective it must be given an hour before meals and on an empty stomach. Interview was conducted with the LPN on February 28, 2012, and said that she administered the resident's medications to her at 7:30 a.m. this morning prior to her being taken to the dining room. When asked about the [MEDICATION NAME] she said the resident received it at 7:30 a.m. also. She went on to add that she did not know that [MEDICATION NAME] needed to be given one hour before meals on an empty stomach. -Resident #59 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed that the resident had an order dated December 15, 2011 for [MEDICATION NAME] 2 mg/ml, give 0.25 to 1 ml or 0.5 mg to 2 mg three times daily as needed. No documented evidence of any parameters for which dose to give were contained in the order. Review of the resident's medication administration record revealed that the resident was given 0.25 ml up to 1 ml but no parameters as far as behaviors were documented why for each dose. Interview with the LPN on February 28, 2013 caring for the resident after reviewing the orders for [MEDICATION NAME] said that he would have to get the order clarified with the doctor as it would be difficult to decide which dose to give based on no parameters for behaviors. Interview with the minimum data set (MDS) coordinator an LPN was conducted on February 28, 2013 and she said that she would have to clarify the orders for the [MEDICATION NAME] as there are no behaviors identified for the different doses of medications. -Resident #197 was admitted on [DATE], with [DIAGNOSES REDACTED]. Clinical record review revealed a physician's order dated November 20, 2012 for [MEDICATION NAME] 0.5 mg twice a day. The [DIAGNOSES REDACTED]. Review of the MAR for the months of January and February 2013 revealed that the resident received the medication daily as ordered. Further clinical record review revealed that the facility pharmacy consultant conducted a medication review on December 17, 2012 and noted that the [MEDICATION NAME] did not have an adequate [DIAGNOSES REDACTED]. The form required a physician's response and a blank line for the allowable [DIAGNOSES REDACTED]. In an interview with a LPN at 2:30 p.m. on February 26, 2013, she stated that [MEDICATION NAME] is normally ordered and administered to assist with a resident's negative behaviors such as crying or outbursts. She stated that this resident is on [MEDICATION NAME] for uncomplicated dementia and she stated that uncomplicated dementia is not a typical [DIAGNOSES REDACTED]. During an interview with the DON at 3:00 p.m. on February 26, 2013, she stated that [MEDICATION NAME] is normally used for psychological issues such as agitated dementia, [MEDICAL CONDITION], bi-polar disease among other psychological issues but she stated that some drugs are used for off label purposes at times. Review of facility policy and procedure revealed a policy regarding antipsychotic medication use that noted that antipsychotic medications will only be used for certain conditions/diagnoses. The policy listed these and one noted dementia illness but the policy noted that this would include associated behavioral symptoms. No other allowable condition/[DIAGNOSES REDACTED]. Clinical record review, for resident #197, revealed a physician's order dated November 20, 2012 for [MEDICATION NAME] 0.5 mg twice a day. The [DIAGNOSES REDACTED]. Review of the MAR for the months of January and February 2013 revealed that the resident received the medication daily as ordered. Further review of the MAR revealed no evident documentation that the resident was being monitored for any antipsychotic behavior while on the antipsychotic medication. The resident was being monitored for anxiety and depression daily, but not for dementia or negative behaviors. In an interview with a LPN at 2:30 p.m. on February 26, 2013, she stated that [MEDICATION NAME] is normally ordered and administered for behaviors such as crying or outbursts. She stated that when a resident is on [MEDICATION NAME], she will monitor the resident for the specific behavior or behaviors that the medication is prescribed for and she would document this information on the behavior monitoring flow sheets in the resident's MAR. She stated that this resident is on [MEDICATION NAME] for dementia and she stated that this is not a typical [DIAGNOSES REDACTED]. During an interview with the DON at 3:00 p.m. on February 26, 2013, she stated that the nurses on the floor would use the facility's behavior monitoring sheets, which are found in the MAR, to monitor [MEDICAL CONDITION] medication use. She stated that the behavior monitoring sheets would be completed for the behavior or behaviors that the resident is receiving the medication for. She was unable to state how dementia would be monitored on the behavior monitoring sheets. Review of facility policy and procedure revealed a nursing guideline regarding [MEDICAL CONDITION] drug use that noted that the a resident's response to the medication should be carefully monitored during the use of the medication. A facility policy for antipsychotic medication use noted that the staff will document in detail a resident's target symptom(s). The policy continued by noting that the staff will document and report information regarding the effectiveness of any interventions, including antipsychotic medications. Clinical record review, for resident #197, revealed a physician's order dated October 14, 2012 for [MEDICATION NAME] 0.25 mg every eight hours. The order was changed on December 11, 2012 to [MEDICATION NAME] 0.25 mg oral one tablet twice per day. Continued clinical record review revealed no evident documentation that the benefits and side effects of the medication were explained to the resident or the resident's legal representative.

Based on clinical record review, hospital record review, staff interviews, review of facility policy and procedure, and review of facility documentation, the facility failed to provide physician ordered supervision for one resident (#4) who sustained an unwitnessed fall resulting in a clavicle and rib fractures, failed to ensure a care-planned intervention of a bed sensor was operational for one resident (#7) who sustained a fall and resulting hip fracture, failed to ensure implemented fall precautions were physician ordered and were assessed to be appropriate for one resident (#5), and failed to ensure residents utilizing the restorative dining area were provided appropriate supervision. The sample size for accidents and supervision was 10, the sample size for residents utilizing restorative dining was 14. Findings include: -Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Resident Care Plan for Falls dated August 17, 2011, revealed that resident #4 utilized a bed alarm and chair alarm. Review of the Admission Minimum Data Set (MDS) dated [DATE], revealed that resident #4 was able to walk independently in her room and in the corridors. Also revealed was that there had not been any documented falls. Despite this, a review of the clinical records revealed that resident #4 had 15 unwitnessed documented falls in less than one year; with three of the falls requiring transfers to the emergency room . Review of the resident's physician's orders [REDACTED]." Review of the Nurse's Notes dated October 31, 2011, revealed a note stating "one on one service can't be provided. POA notified of this." Also documented that Seroquel will be given as needed. Review of the Resident Care Plan, Risk For Falls dated November 8, 2011, revealed a scoop mattress on bed. Care Plan was updated once on November 23, 2011, after resident had a fall, and revealed one addition of a sensor mat on wheel chair. A review of the MDS change in status assessment dated [DATE], revealed that the resident needed extensive assistance to walk in her room and the corridors, and that there were two falls without injuries, and one fall with injury. Review of the Nurse's Notes dated November 23, 2011, revealed that the resident was found on the floor of her room crying out. The resident was complaining of the left side of her head hurting and pain in her left arm. The resident's physician was notified and an x-ray of the left arm and shoulder were ordered. Review of facility documentation related to the November 23, 2011, fall included the fall was unwitnessed. Review of the x-ray report dated November 23, 2011, revealed no fracture or dislocation was present. Review of the Nurse's Notes dated November 25, 2011, revealed that the resident was complaining of severe left arm pain and was given pain medication. Review of the Nurse's Notes dated November 27, 2011, revealed that the resident was sent to the emergency room for evaluation of her left arm and shoulder after the fall on November 23, 2011. Review of the x-ray dated November 27, 2011, revealed a distal fracture of the left clavicle and fractures of the left second and fourth ribs. -Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident care plan dated September 1, 2011, revealed interventions that included tabs monitor, bed sensor, and therapy screen. Review of the Quarterly MDS assessment dated [DATE], revealed that resident #7 had no falls, and was able to walk in her room and the corridors independently. However, clinical record review revealed that resident #7 had four documented unwitnessed falls over a five month period. Review of the MDS assessment completed on December 9, 2011, revealed that the resident needed extensive assistance with transfers, and that walking in her room and corridors had not occurred during the observation period. Also documented under falls since admission was the following: one with no injuries, and one with injuries. A review of the Nurse's Notes dated December 24, 2011, revealed that resident #7 was found on the floor of her room with a skin tear to her left elbow and complaining of left leg pain. The resident was sent to the emergency room for evaluation. A review of x-ray dated December 24, 2011, revealed a displaced left subcapital hip fracture. A review of the Post Fall Incident assessment dated [DATE], revealed the resident was put into bed by a certified nursing assistant (CNA) and the sensor alarm on the bed was not connected to mat and the battery was dead. A review of the Post Fall Progress Note date December 24, 2011, revealed that resident #7 was found sitting on the floor in the middle of room and sustained a left elbow skin tear and was complaining of left leg pain. Also documented was that the alarm on bed was not connected to the call box or mat and the battery was dead. An interview was conducted with the director of nursing (DON) on February 28, 2012. The DON stated that each resident was evaluated for falls. She further stated that an order for [REDACTED]. An interview was conducted with a registered nurse (RN) on February 28, 2012. The RN stated that nursing re-evaluated a resident who was a fall risk, each time there was a fall. She also stated that an order for [REDACTED]. -Resident #5 was admitted on [DATE], with [DIAGNOSES REDACTED]. Clinical record review revealed a fall assessment dated [DATE], revealed documentation that the resident had not had any previous falls but she was assessed to have a fall risk score of 22. A score greater than 10 was indicative of a high risk for falls. This high risk for falls was primarily related to her medications, overall health conditions, and limitations for balance, mobility, and cognitive status. A risk for falls care plan was initiated on January 14, 2012. The goals included that the resident would not have any falls and that her bed would be kept in the low position. Nurse's notes dated January 15, 2012, revealed documentation that the resident was alert and oriented and needed assistance of one person to the bathroom and for transfers. Nurse's notes revealed that on January 17, 2012 at 6:40 a.m., the resident got wrapped in her bed linen, rolled out of bed, and landed on the floor. A care plan update dated January 17, 2012, revealed that fall precautions were in place and that the patient was to continue with physical and occupational therapy. Further documentation revealed that a tabs monitor (alarm), a low bed and a shear mat (padded floor mat) were to be in place. Nurse's notes dated January 18 through 26, 2012, revealed documentation that the resident was on fall precautions. On January 19, 2012, it was documented that a "mattress was at the side of the bed". Nurse's notes dated January 27, 2012, revealed documentation that the resident was alert and oriented and able to transfer on her own, but that she would ask for stand by assist. Nurse's notes dated January 28, 2012 revealed documentation that at 08:00 a.m., the resident complained that her "wrist hurt a little". At 1:00 pm, results of a doctor ordered x-ray revealed that the resident sustained [REDACTED]. On January 29, 2012, the resident was documented to have a splint in place. physician's orders [REDACTED]. Nurse's notes dated February 1, 2012, revealed documentation that the resident was found lying on the floor in front of her wheelchair. It was noted that the resident had a laceration and hematoma over her left eye and that she complained of left hip pain. It also revealed that the alarm was not sounding and that 911 was called. Despite the fact that interventions of a low bed and shear mat were in place, there was no evidence documented that these interventions were appropriate for this resident. The resident with a history of hypotension was now potentially rising from a bed in the low position onto a shear mat, possibly contributing to her fall. On February 27, 2012 at 1:00 p.m., an interview was conducted with a Physical Therapist. He stated that neither Physical Therapy nor Occupational Therapy are responsible for evaluating the safety of the physical interventions, such as a shear mattress or alarms, for residents. He stated that nursing decides who and what interventions are implemented. An interview was conducted with a Registered Nurse (RN) on February 28, 2012 at 1:55 p.m. The RN stated that if a resident has a shear mattress or alarms they must be ordered by the physician. She also stated that it is determined by the fall risk assessment who receives fall interventions. She also stated that when a resident's cognitive status improves, the care plan and interventions should be re-assessed. An interview was conducted on February 28, 2012 at 2:05 p.m. with the acting Director of Nursing (DON). She stated that there are multiple factors, such as the risk for falls assessment and overall mental status that determine which resident's alarms and/or floor mats. She stated that when a resident was admitted it was the judgment of nursing staff to implement devices and that a physician's orders [REDACTED]. A review of the facility's policy for Fall Risk Assessment revealed "...Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. In conjunction with the Attending Physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling..." -Restorative dining was observed on February 28, 2012, during the breakfast meal. During the times when the RNA staff was removing residents and bringing additional residents, other residents in the dining room in various stages of eating their breakfast, were left unattended. During an interview with the RNA immediately following the observation, and in response to a specific question, stated she did not have help in the restorative dining room on Tuesday and Thursday, as the other RNA was off.

Based on observations, clinical record reviews, hospital documentation reviews, resident interviews, staff interviews, facility policy, and review of facility documentation, the facility failed to ensure that six residents (#s 1, 2, 3, 4, 5, and 6) were appropriately assessed for safe smoking which resulted in the condition of Immediate Jeopardy. The facility also failed to provide adequate supervision for one resident (#23), a known wandering and behavioral risk, to prevent an altercation with another resident which resulted in actual harm, and failed to provide adequate supervision to prevent resident #22, a known fall risk, from sustaining a fall with injury. Findings include: Issue regarding smoking: -Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an Initial Data Collection Tool/Nursing Service dated June 28, 2011, which revealed the resident was alert and oriented. The Lifestyle section "History of Tobacco Use, # of Years" was blank. The Additional Nursing Comments section documented "95% O2 (oxygen) sats (saturation) on 2L (liters) via NC (nasal cannula)." The resident's clinical record revealed a physician's orders [REDACTED]." There was no documentation in the resident's clinical record that the resident was assessed to be safe to smoke independently. An observation was made of the resident on July 12. 2011 at 8:10 a.m. The resident propelled his wheelchair out the front entrance of the facility. An emergency oxygen cylinder was observed attached to the back of the resident's wheelchair. The resident was observed to take a cigarette and lighter out of his front shirt pocket. The resident was observed to light his cigarette. The resident's oxygen cylinder was observed to be turned off but the gauge on the cylinder indicated that the oxygen cylinder was full. The resident was not supervised by staff while he smoked outside. An immediate interview was conducted with the resident on July 12, 2011. When the resident was asked if his oxygen cylinder was turned on, the resident stated "I don't know, check to see if it is on 0 (off) or 2 (2 liters per minute)." The resident further stated "Smoking with oxygen isn't as bad as they say but you need to take precautions." The resident stated that he had not been assessed by licensed staff members to ensure that he was able to smoke independently. An interview was conducted with an LPN (licensed practical nurse) on July 12, 2011. The LPN stated that she did not know that the resident smoked. The LPN stated that when a resident was admitted to the facility she assessed the resident to ensure that they were "cognitively with it" and safe with a lighter and cigarettes. The LPN stated that she did not document in resident clinical records when she conducted a smoking assessment. The LPN further stated that the facility did not have a policy regarding monitoring residents while they smoked. -Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an Initial Data Collection Tool/Nursing Service dated April 28, 2011, which revealed the resident was alert and oriented. The Lifestyle section "History of Tobacco Use, # of Years" revealed that the resident smoked since she was a teenager. There was no documentation in the resident's clinical record that the resident was assessed to be safe to smoke independently. The resident's clinical record revealed Nurse's Notes dated May 12, 2011, which documented "It was noted this a.m. that the cushion on pt's (patient's) W/C (wheelchair) had a large burn hole along with a few small burned holes on a few pairs of her pants. Pt. stated she does go outside to smoke. The burned cushion was caused by the wind she stated. Nurse took pt's cigarettes and lighter (three loose cigarettes). Explained she may continue to smoke but should be accompanied by staff." A review of the resident's clinical record revealed a resident care plan was developed on May 12, 2011, after the incident, which documented "Potential for burns related to pt. smoking." An interview was conducted with an LPN on July 12, 2011. The LPN stated that she completed the care plan after the burn holes were found in the resident's wheelchair cushion and clothing. The LPN stated that smoking assessments were not completed by the facility. When asked how she could ensure a resident was safe to smoke independently without completing a smoking assessment, the LPN stated "I guess you don't." -Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an Initial Data Collection Tool/Nursing Service dated July 5, 2011, which revealed the resident was alert and oriented. The Lifestyle section "History of Tobacco Use, # of Years" revealed that the resident had a [AGE] year history of smoking.. There was no documentation in the resident's clinical record that the resident was assessed to be safe to smoke independently. An observation was made of the resident on July 12, 2011 at 7:45 a.m. The resident was observed seated in her wheelchair outside the front entrance of the facility. The resident was observed seated next to resident #1. Both residents were observed smoking cigarettes and had cigarettes and lighters on their possession. The resident was not supervised by staff while she smoked outside. An interview was conducted with the resident on July 12, 2011. The resident stated that if she needed assistance while she was outdoors smoking that she was able to go indoors herself. The resident further stated "we usually catch someone coming in the parking lot or I can ring the front doorbell for her (resident #1)." When asked if she had been assessed by licensed staff members to ensure that she was safe to smoke independently, the resident stated that no one even asked her if she smoked when she was admitted to the facility. An interview was conducted with an LPN on July 12, 2011. The LPN stated that when she arrived at work at 6:00 a.m. every morning there was usually "a lady out there" smoking. The LPN stated that she thought residents should be supervised while smoking. -Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an Initial Data Collection Tool/Nursing Service dated July 6, 2011, which revealed the resident was alert and oriented. The Lifestyle section "History of Tobacco Use, # of Years" was checked. There was no documentation in the resident's clinical record that the resident was assessed to be safe to smoke independently. An interview was conducted with the resident on July 12, 2011. The resident stated that she had her own cigarettes and lighter on her possession. The resident stated that she smoked outside independently and that she was not assessed by licensed staff members to ensure that she was safe to smoke independently. The resident stated that staff usually came outdoors every 15 to 30 minutes to see if she wanted to come back in to the facility. -Resident #4 was admitted to the facility on [DATE], with peripheral vascular disease. The resident was identified to smoke. There was no documented evidence that this resident was assessed to be a safe smoker in the clinical record. -Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident's clinical record was reviewed and there was no documented evidence that the resident was assessed for independent safe smoking practices. The resident was observed on July 12, 2011, smoking outside and in front of the building. An interview was conducted on this same date and the resident said that she had her cigarette materials on her wheelchair. The resident also confirmed that she had no supervision when she smoked nor has she ever been assessed for safe smoking by the facility. A certified nursing assistant (CNA) was interviewed on July 12 and stated that she takes the residents outside to smoke in the front of the building. The CNA said that she did not provide supervision but only alerted the receptionist when a resident was outside. The CNA said that there were discussions to move the smoking areas approximately two months ago but had not heard anything else since then. The care giving staff were interviewed on July 12, 2011, and they confirmed that the residents who smoke were responsible for their own cigarettes and lighters and that the staff did not monitor the smoking materials. The receptionist was interviewed on July 12, 2011, and she stated that she did not monitor the oxygen tanks of the residents. The receptionist gave an example of a former resident who used an electric wheelchair and he would remove his own tubing. The tank would remain on the wheelchair when he went out to smoke according to the receptionist. An interview was conducted with a CNA on July 12, 2011. The CNA stated that residents were able to go outside whenever they want to smoke. The CNA further stated that she did not think that the residents should be outside smoking unsupervised. An interview was conducted with the DON (director of nursing) on July 12, 2011. The DON stated that the facility did not have a smoking policy and "we are working on it" (developing a smoking policy). An interview was conducted with the administrator on July 12, 2011. The administrator stated that a smoking policy was not "fully implemented". It was during this interview that the administrator provided the Quality Assurance meeting minutes, dated May 25, 2011, and it documented "Old Business...Administration still reviewing the smoking policy." Issue regarding a resident to resident altercation: -Resident #23 was admitted to facility on December 10, 2010, with [DIAGNOSES REDACTED]. Clinical record review revealed an interdisciplinary care plan dated January 25, 2011, for resident #23 that included interventions for the resident's cognitive loss, including for staff to administer dementia medications as ordered, assess for poor judgement and to redirect or assist with decision making, and to redirect the resident when inappropriate by offering sweets. A social service progress note dated February 8, 2011, included that the resident's wife was concerned with the resident's mood and behavior. Also documented was that the resident had become verbally aggressive with her to the point that "she doesn't want to visit." The resident's wife also was documented to have informed the facility that her husband had threatened physical contact. Continued review of this February 8, 2011, social services note revealed that resident #23 had recently had a reduction in an anti-psychotic medication. Documented in this note was that the nurse practitioner (NP) stated that she would request a psychological evaluation. The resident's clinical record revealed a physician order [REDACTED]. Despite this over one week delay in ordering a psychological evaluation and given the fact that the resident had had a recent reduction in anti-psychotic medication as well as the facility being aware the resident had threatened physical contact, no evidence was revealed that resident #23's care plan had been revised to ensure existing interventions were appropriate, or that changes in supervision levels or frequency were provided to keep resident #23 and other residents safe. On February 19, 2011 at 6:00 p.m. a nurses notes documented that the resident was aggressive when awake. The resident would walk up and down the unit's hallway, rummaging through other resident's property, folding fists if passing other residents "in readiness to act." Also included was that the resident "needs close monitoring." Again, even though the resident continued to demonstrate aggressive and threatening behaviors, no documented evidence was located in the resident's clinical record that his plan of care had been re-evaluated and additional interventions utilized to ensure his and other resident's safety. On February 22, 2011 at 9:00 a.m., a nurse's note documented that the nurse heard a loud thud down the hall in another resident's room. Further documented was that the resident was found in another resident's room lying on the floor holding his head. The other resident was documented to have stated that resident #23 entered his room and was "up in his face yelling at him." At this point the other resident stated he pushed resident #23 and he fell . Resident #23 began to complain of back and chest pain and an order was received to send resident #23 to the emergency room . Hospital documentation dated February 22, 2011, included resident #23 had a head injury and a T3 (thoracic) compression fracture. Issue regarding fall: -Resident #22 was admitted to the facility April 28, 2011, with a [DIAGNOSES REDACTED]. Resident's #22's clinical record revealed that the resident fell on [DATE], while shopping and sustained a right hip fracture that had to be surgically repaired. On April 28,2011, an initial nursing assessment was done and revealed that the resident was alert and oriented, understood and was able to wait for assistance before getting out of bed, and needed one to two person assist on ambulation and toileting since she had a recent history of falls. Despite the fact that the resident was a known fall risk, a fall risk evaluation that was started on April 28, 2011, was never completed by the staff. In addition, the resident's clinical record review revealed a blank resident care plan for risk for falls. The resident's clinical record revealed a 14 day MDS assessment for activities of daily living dated May 10, 2011, that the resident should have a two person physical assist when using the toilet. The resident's clinical record revealed an occupational therapy progress summary that documented treatment goals for May 10, 2011, that stated for toileting the resident should have supervision with a CGA (contact guard assist). An activities of daily living flow sheet dated May 10, 2011, documented that the resident should have limited assistance with one staff member for toileting. The nurse's notes for May 10, 2011 at 2:00 p.m. assessed the resident to be alert and oriented to time, place and date. The resident's clinical record revealed nurse's notes on May 10, 2011 at 6:15 p.m. that nursing was alerted by the resident's roommate that resident #22 fell in the bathroom after ambulating there on her own. Resident #22 said she attempted to wipe herself while standing and fell backwards on the toilet. The resident further stated she felt like she had "twisted" her hip. A second fall risk assessment was completed May 17, 2011. A second resident care plan for falls was also completed but was undated. The NP was notified and an order was received to send the resident to the emergency room immediately. Hospital documentation revealed that resident #22 had a dislocation of the right hip hemiarthroplasty that underwent a closed reduction in the emergency room . During an interview conducted on July 20, 2011 at 1:50 pm., CNA revealed that the nurse who cared for the resident would supervise the care of a resident with recent hip surgery, and that therapy would have to assess the resident for how much assistance the resident would require. An interview was conducted with an LPN on July 20, 2011, at 12:45 p.m. regarding how to care for a recent hip surgery resident. Staff stated that most residents admitted status [REDACTED]. Licensed staff further stated that she would then inform the CNA's in how to care for the resident. If there should be a change in orders during the shift, those changes would then be passed on to the CNA's. A review of the facility's policy resident falls and risk assessment states included that "the facility is committed to appropriate and timely assessment of resident risk and corresponding interventions to prevent injury...".

Based on clinical record reviews, family and staff interviews, and review of the Arizona State Board of Nursing professional standards of practice, the facility failed to ensure that one resident (#2) received proper care and services related to the insertion of a tube to allow feeding. As a result the resident [MEDICAL CONDITION] and required emergency surgery. The sample size was four. Findings include: Resident #2 was initially admitted on [DATE], with [DIAGNOSES REDACTED]. Per the initial physician and nursing notes, the resident was assessed to have significant cognitive impairment and was unable to effectively communicate. In January, 2011, the resident developed dysphagia (swallowing impairment) and the family made a decision to surgically insert a feeding tube to potentially allow the resident to receive nutrition and hydration. On January 24, 2011, the resident was transferred out of the facility to have a feeding tube surgically placed. Per instructions, and upon return to the facility on the same day, the resident was not to have any feeding solution or medications administered for 24 hours. According to a nursing note entry dated January 25, 2011 at 7:45 p.m., the resident had pulled out the feeding tube. Additional nursing notes documented the Nurse Practicioner (NP) was notified and an order was given for the Licensed Practical Nurse (LPN and identified as staff #1) to immediately insert a catheter tube into the feeding tube opening or site. Further nursing notes documented this procedure was completed by staff #1 and the tube was checked for placement, "With good results". Continued review of the clinical record revealed an order from the NP dated January 26, 2011 at 4:00 p.m. that the resident was to be administered the prescribed feeding, [MEDICATION NAME], accompanied by water flushes. There was no evidence the order specified the feedings and flushes were to be initiated only after there was confirmation that the tube was correctly inserted and placed as determined by an x-ray, designated as the standard of practice to ensure correct placement. This order was documented by a LPN and identified as staff #2. A Treatment Administration Record (TAR) documented the resident was administered the prescribed [MEDICATION NAME] and water flushes on January 26, 2011, as evidenced by initials of staff #2. Per a nursing note entry dated January 26, 2011 at 9:30 p.m., the resident was found in bed with respirations, "fast and deep, B/P 84/48, temperature 99.5, pulse at 148 and respirations at 50." Further documented was that the placement of the tube inserted earlier, "appeared to be in place..." Also documented was that the staff checked for tube placement and there was no residual noted. The NP was notified and a order was given to send the resident to the emergency room . A review of the emergency room notes dated January 26, 2011, documented the resident's feeding tube had been earlier removed and facility staff, "did not check to see if it was in place or not and they proceeded the feeding and they fed the peritoneal cavity, and the patient came [MEDICAL CONDITION]." The resident was then intubated and placed on a mechanical ventilator and emergency surgery was completed to wash out the tube feedings and secretions. Hospital documentation revealed the resident was initially in the Intensive Care Unit and remained in the hospital for 14 days. An interview was conducted with staff #2 on February 17, 2011. The staff stated he had begun the [MEDICATION NAME] and medication administration on January 26, 2011, via the tube that had been earlier inserted by staff #1. He further stated he had checked for correct placement of the tube by inserting air by a syringe through the tube and then would listen for the air by use of a stethoscope. He stated he believed this was an adequate method for checking for proper tube placement. An interview was then conducted with the Director of Nursing (DON) and the Nurse Practicioner (NP) on February 17, 2011. The NP stated she had intended that the feeding solution and water flushes were only to be administered after the tube placement was confirmed with a X-ray, "Absolutely need to check for placement via a x-ray." Both she and the DON stated a mistake had been made when the fluids were administered prior to confirmation that the tube was correctly placed. Per the Arizona State Board of Nursing Professional Standards of Practice and specifically under the scope of practice of a LPN, the following was included, "Implement aspects of a client's care consistent with the LPN scope of practice in a timely and accurate manner including: Following nurse and physician orders [REDACTED].