Every finding on record at Plaza Healthcare

Based on observation, interviews, and review of facility policy and procedure, the facility failed to ensure that expired medication were not available for use. The deficient practice could lead to residents receiving medications that are expired.Findings include:An observation was conducted on May 7, 2026 at 9:38 A.M. with Licensed Practical Nurse (staff #142). The observation of the medication cart revealed eight medications loose at the bottom of the medication cart under the resident medication cards. At this time the Resident Nurse Unit Manager (staff #16) removed the medications from the cart and placed them in a medication cup.Immediately after the observation an interview was conducted on May 7, 2026 at 9:40 A.M. with RN Unit Manager (staff #16) who stated he did observe the eight pills loose and the bottom of the cart and that they were not identifiable. The RN stated that the risk of loose medications in the medication cart and not in the original container, could result in residents not receiving medication as ordered and the medication count could be off. The RN stated he is not sure who organizes and cleans the medication carts.A second observation was conducted on May 7, 2026 at 9:59 A.M. with RN Unit Manager (staff #16) of five medication rooms. The following observations revealed:North Subacute Dialysis - four 10ml syringes of Sodium Chloride were observed in the medication refrigerator freezer with an expiration date of January 1, 2026. Subacute South Medication Room - an open bottle of Fish Oil 1,600mg ,without an open date, was observed in the refrigerator.An interview was conducted with RN (staff #16) on May 7, 2026 at 10:15 A.M. who stated that the risk of expired medications could cause harm to residents and that the medications would not be effective, and further stated when medications are opened should be labeled with an open date.A third observation on May 7, 2026 at 11:10 A.M., with Registered Nurse Unit Manager (staff #15), of Station 2 Medication Room revealed Chlorhex Gluconate Solution .12% with an expiration date of December, 22, 2025. An interview was immediately conducted with RN (staff #15) on May 7, 2026 at 11:12 A.M. who stated that the Chlorhex Gluconate Solution 12% (germicidal mouthwash) expired on December 22, 2025 she further stated that expired medications administered to a resident could result in adverse or delayed effects of the medication.Further observation of another medication cart was conducted on May 7, 2026 at 10:19 A.M. with LPN (staff #21), which revealed one white pill lying loose on the bottom of the medication drawer that was not identifiable or labeled. Additionally, a Milk of Magnesium bottle was open and had an observed expiration date of April, 2026, along with Pramoxine Hydrochloride1% (to treat pain/itching) with an expiration date of January, 2024, and Biofreeze Gel (treats temporary pain) with an expiration date of March 2025. Immediately following an interview was conducted on May 7, 2026 at 10:30 A.M. with LPN (staff #21) who stated she observed a white pill at the bottom of the drawer and was not able to name the medication and stated it was not identifiable. The LPN immediately discarded the medication. The LPN further stated the risk of administering expired medications to a resident could result in the resident becoming ill. An interview was conducted with Director of Nursing (DON/ staff #34) on May 8, 2026 at 9:05 A.M. who stated that the process of handling expired non-narcotic medications would be to place the medication in the bin located in the medication storage room to return to the pharmacy, or the medication would be destroyed. She further stated the destruction of narcotics is performed by two DON's. The DON also stated that the proper way to label and store medications is with the pharmacy labels, and over the counter medications should be labeled, checked for expiration and open dates. The DON stated that the risk of having expired medications in the medication cart or in the medication rooms could result in the medications being ineffective and liquid medications could become moldy and harbor infection. The DON stated that it is the responsibility of the night nurses to clean and organize the medication carts every night, and should check to make sure medications are not expired and there are no loose medications in the drawers. The DON stated that loose medications in the medication cart could lead to diversion of medications or medications could be administered to the wrong resident. The DON further stated that liquid medications in the refrigerator should be labeled with a date and time of when the bottle was opened, and the date when the medication should be discarded.Review of facility policy titled Medication Storage in the Facility, dated January, 2026, revealed that outdated medications are to be removed from stock and disposed of according to procedures for medication destruction. Medication storage areas are kept clean, well lit, and free from clutter

Based on observation, interviews, and review of facility policy and procedure, the facility failed to ensure that professional standards of practice and facility policies were followed for administration of medications via gastrointestinal tube. The deficient practice could cause the resident to aspirate, cause infection, and medications being administered to the wrong resident.Findings include:A medication administration observation was conducted with Licensed Practical Nurse (LPN/staff #142) on May 7, 2026 at 8:28 A.M. The LPN was observed carrying a tray with a clear cup of medications crushed in water and also a cup of water. When entering the resident's room the LPN introduced herself, but was not observed to identify the resident by the wrist band prior to medication administration. When administering the medication by gastrointestinal tube the resident was observed lying supine and the head of bed was not elevated. The LPN removed a syringe out of a dated, sealed bag that was lying in a container on the side table next to the resident's bed. Next, the LPN drew up the crushed medications mixed with water from the clear cup into the syringe and administered the medication with the syringe into the resident's gastrointestinal tube. Then the LPN removed water from the clear cup into the syringe and flushed the gastrointestinal tube. The LPN was observed to place the syringe onto the container at the bedside table without placing the syringe into the dated bag, or rinsing the syringe with water. The resident was observed to be lying flat on the bed with the head of the bed down when the LPN left the resident room.An interview was conducted immediately after the observation with LPN (staff #142) on May 7, 2026 at 8:30 A.M., who stated that the syringe used for gastrointestinal tube medication administration should be placed in a plastic bag that is dated and then placed in the container on the bedside table. The LPN stated the risk of not placing the syringe used for gastrointestinal tube medication administration in the bag could cause bacteria or infection to the resident.A second medication administration observation was conducted with LPN (staff #142) was conducted on May 7, 2026 at 8:45 A.M. The LPN was observed carrying a tray with a clear cup of medications crushed in water and also a cup of water, and entered another resident's room to administer medication via gastrointestinal tube. The LPN was observed introducing herself to the resident, and identified the resident by the wrist band. When administering the medication by gastrointestinal tube the resident was observed to be lying supine, and the head of bed was not elevated at the time. The LPN removed a syringe out of a bag that was sealed and dated from a container sittng on the side table next to the resident's bed. The LPN then checked the gastrointestinal tube for placement and residual by pulling back on the syringe and administered water to flush gastrointestinal tube. Next, the LPN then drew up the crushed medications mixed with water from a clear cup into the syringe and administered the medication to the resident by the gastrointestinal tube. The LPN then placed the syringe used for medication administration into a bag that was dated and placed in a container on the resident bedside table without rinsing the syringe with water. The resident was observed to be lying flat and the head of the bed down when the LPN left the room.An interview was conducted immediately after the observation with LPN (staff #142) on May 7, 2026 at 8:50 A.M. who stated the head of the bed should be at a 30-40 degree incline when administering the medications into a gastrointestinal tube. The LPN stated the risk of not elevating the head of the bed could cause the resident to aspirate medications.A medication observation was conducted on May 7, 2026 at 9:20 A.M. with Registered Nurse (RN/staff #41). The RN prepared the medications by crushing all of the medications together and added water to the medications in a clear medication cup. The RN was observed carrying a tray with a cup of water and the medication cup with medications mixed in water. The RN then removed 30cc of water from the clear cup with a syringe and then administered the water into the gastrointestinal tube, however the RN was not observed to check for placement or residual of the gastrointestinal tube prior to flushing with water. Next, the RN drew up the medications that had been crushed and in water with the syringe and administered the medications via gastrointestinal tube. Next, the RN drew up 30cc of water from the clear cup and flushed the gastrointestinal tube. The RN was observed to place the syringe used for the medication administration of the gastrointestinal tube in a container on the bedside table and not in a dated bag that was dated. The syringe was not rinsed after medication administration, or prior to placing in the container on the bedside table.An interview immediately after was conducted with RN (staff #41) on May 7, 2026 at 9:25 A.M who stated that she administered some of the 30cc of water to flush the gastrointestinal tube and then pulled back on the syringe to check placement of gastrointestinal tube and then continued administering the remaining water to flush the gastrointestinal tube. RN stated this was the procedure at the facility to check for gastrointestinal tube placement or residual prior to medication administration by gastrointestinal tube. The RN stated that the syringe used for medication administration of a gastrointestinal tube should be placed in a bag that is dated to protect the resident from bacteria or infection.An interview was conducted on May 7, 2026 at 11:45 A.M. with Director of Nursing (DON/ staff #34) who stated the process and procedure for administering medication via gastrointestinal tube is started by checking the placement and residual of the gastrointestinal tube by pulling back on the syringe placed in the gastrointestinal tube. Next, the staff is to flush the gastrointestinal tube with water, and then proceed to administer one crushed or liquid medication at a time through the gastrointestinal tube. Once completed, the staff is to place the syringe used for medication administration via gastrointestinal tube in a bag that is dated, and sealed. She further stated that a new syringe is required every 24 hours for a medication administration through a gastrointestinal tube. The DON stated that if a syringe used for medication administration is not placed in a bag that is not dated and sealed could cause a resident infection due to contamination. Also, medications are to be given one at a time due to possible interactions of multiple medications given at the same time or the medications could clog the gastrointestinal tubing if given together. Furthermore, medications are to be crushed one at a time and not all together.A second interview was conducted on May 9, 2026 at 9:55 A.M. with DON (staff #34), who stated that prior to medication administration via gastrointestinal tube the head of the bed should be elevated at least 30-40 degrees prior to medication administration and elevated for 30-45 minutes after medication administration. The DON stated if the process is not followed it could cause the resident to aspirate medications. A policy titled, Medication Administration and General Guidelines, dated January 2026, revealed staff must identify residents by checking the identification band. A policy titled, Nasogastric, Gastric and Jejunostomy, Medication Administration, reviewed March, 2025, revealed to elevate the head of the bed to 30-45 degrees, check gastric contents for residual feeding prior to medication administration, and to rinse the syringe with tap water and place in graduated cylinder.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to maintain medical records that are complete and accurate in accordance with professional standards for 4 of 26 sampled residents (# 9, 240, 241, 236). The deficient practice could result in records that do not accurately and completely reflect the care and services provided to residents. Findings include: -Regarding Resident #236 Resident #236 was admitted on [DATE] with diagnoses that included chronic respiratory failure with hypoxia, tracheostomy, morbid obesity, anxiety disorder, psychotic disorder with delusions, and type 2 diabetes with retinopathy of the right eye. A Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of a facility self-report dated November 15, 2024 revealed that the resident reported she was missing 6 sports bras, 4 panties and $40.00 in cash to a nurse. However, review of the clinical record revealed no evidence that the resident reported the missing items and money to nursing on November 15, 2024, or that the claim was being investigated. The facility provided no evidence that a Make it Right form had been completed for the resident's missing items on November 15, 2024. Review of a care plan revised on November 22, 2024, revealed no evidence of the missing items or money reported by the resident on November 15, 2024. The last update was dated October 23 2024, revised on 11/22/2024, that revealed the resident continues to make unfounded accusations. An interview was conducted on January 22, 2025 at 3:39 PM with a Social Worker (staff # 88), who stated that a thorough investigation is conducted when items are reported missing, including searching the resident's room and laundry. She further stated they have a Make it Right program that will replace the missing items if they are not found. The Social Worker stated they document reports of missing items in progress notes and keep a list of the items replaced through the Make it Right program. The Social Worker stated that they would document in the clinical record that the resident reported missing items, and on the Make it Right list. She stated that before she documented in the clinical record, she would try to find the items, then document in the clinical record and on the Make it Right list. She further stated that Resident #236 had made false accusations in the past regarding missing items. She also stated that an investigation was conducted regarding the items reported missing on November 15, 2024, and the missing items and money were not found. She reviewed the clinical record and stated that there was no evidence of social services documentation in the clinical record regarding the resident's report of missing items and money. An interview was conducted on January 23, 2025 at 8:56 AM with Social Services (staff # 87), who stated that they would investigate any reports of missing items, and if the items were not found the resident would be reimbursed. She stated that they noticed a trend that the resident would say that items were missing. She further stated that the last 2 occasions that the resident alleged theft would not be documented in the clinical record because an investigation had been conducted. Staff #87 stated that the resident had admitted to law enforcement that she was not being honest regarding her November 15, 2024 report of missing items and money. She further stated that documentation of missing items would be found in the Make it Right program notes. Staff #87 reviewed the clinical record and stated that there was no evidence of the resident's report of missing items and money on November 15, 2024. An interview was conducted on January 23, 2025 at 10:31 AM with a Licensed Practical Nurse (LPN/staff #126), who stated that nurses should document follow-up notes, change of condition, daily notes, and anything outside of that in progress notes. She also stated that if a resident reported missing items or money, she would inform the unit manager or the Director of Nursing (DON), let the resident know that they were searching for the items, and document who she spoke to in a progress note. She further stated that this process would not be any different for a resident who complains of missing items regularly. An interview was conducted on January 23, 2025 at 2:59 PM with the Chief Clinical Officer (CCO/staff # 218), who stated that she would expect social services to document reports of missing items, and complete an investigation. She further stated that reports of missing items are not in the medical record because it is not a medical issue. She also stated that the missing items and investigation should be documented in the care plan. An interview was conducted on January 23, 2025 at 12:48 PM with an LPN (staff #164), who stated that any reports of missing money or items reported by residents should be documented in progress notes. He further stated that he would document everything that occurred on his shift, and that is the facility expectation. 50166 -Regarding Resident #241: Resident #241 was initially admitted to the facility on [DATE] with diagnoses that included mood disorder with depressive features, adjustment disorder with mixed anxiety and depressive mood, and osteomyelitis. A progress note dated July 29, 2023 revealed an x-ray result from July 28, 2023 was reviewed with no indication regarding why the x-ray was ordered. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. A care plan initiated on February 1, 2024 revealed a focus that indicated the resident was making statements and accusations which were unfounded. -Regarding Resident #9: Resident #9 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease and acquired absence of the right leg below the knee. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was 15, which indicated intact cognition. Review of the facility investigation on January 23, 2025 revealed that on December 28, 2023, Resident #241 was playing a basketball arcade game in the dining room when Resident #9 wheeled his wheelchair into the back of Resident #241 from behind which made Resident #241 ' s wheelchair move into a metal bar underneath the basketball arcade game and pinned his leg. The residents continued to play the game together for 17 minutes, and nothing was reported to the staff until December 29, 2023 when the resident requested the police be notified of the incident. The facility investigation revealed that the police, the Arizona Department of Health Services, Adult Protective Services, and the ombudsman were notified of the incident. The investigation revealed that the clinical team was going to meet to review the plan moving forward. A progress note dated January 3, 2024 revealed that Resident #9 completed a verbal reevaluation for electric wheelchair use with no indication regarding why the evaluation was ordered. A request was made for all documentation in the clinical record regarding the incident between resident #241 and Resident #9, and the facility was not able to provide evidence that the incident occurred and to whom it was reported. The facility investigation was not included anywhere in the clinical record. Review of the video footage of the incident on January 23, 2025 revealed that Resident #9 did wheel his wheelchair behind Resident #241 ' s wheelchair and Resident #241 stated you got me, but it ' s alright. An interview was conducted on January 23, 2025 at 12:55 p.m. with an RN (Staff #224), who stated that if an allegation of abuse were made, she would first report it, but then she would document in the progress notes as well as in the daily nursing notes. In her notes, Staff #224 stated she would need to include the time of the incident, what the allegation was about, the patient involved, what was reviewed, who was notified, and what was done as a result of everything. Staff #224 stated that she would do both an incident report and progress note, and that it was not a personal preference, but it was facility policy to document incidents and allegations of abuse in the chart and progress notes. Staff #224 stated that the importance of documenting incidents in the clinical record would be to show a history of behaviors and to keep a true log of what has happened with residents to know if there are patterns. An interview was conducted on January 23, 2025 at 3:03 p.m. with an LPN (Staff #282), who stated that if an allegation of abuse were made, she would make a note in the progress notes that indicated who was notified and that the investigation would be continued by the unit manager. Staff #282 stated that it was facility policy to document incidents and allegations in the clinical record and progress notes, and the importance of doing so would be to protect the resident and herself to make sure someone else was in the loop. Staff #282 stated that if they did not document in the clinical record, there was risk of not protecting the residents because management needed to know things had occurred so something could be done to protect the residents. 51159 -Regarding Resident # 240 Resident #240 was admitted on [DATE] with diagnosis that included acute kidney failure, acute respiratory failure, pneumothorax, and depression. Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A Facility self-report dated July 21, 2023, revealed that the resident reported to a Certified Nursing Assistance (CNA) that $ 331.00 cash was missing from his wallet. However, there was no evidence in the clinical record that the resident ' s report of missing money on July 21, 2023, had been reported to nursing, or that nursing reported the complaint to administration, and that the claim was being investigated. Review of a revised care plan dated July 23, 2023 revealed no evidence of missing money reported by the resident on July 21,2023. An interview was conducted on January 23, 2025 at 12:38 PM with Certified Nursing Assistant (CNA/Staff # 264) who stated that when missing items are reported to her she will inform the nurse and unit manager, they will notify the social worker, and staff will look for the missing item. The CNA also stated that they do their documentation on the computer. An interview was conducted on January 23, 2025 at 12:48 PM with Licensed Practical Nurse (LPN/Staff #164), who stated that she will notify the unit manager immediately for missing items, and inform the unit manager if the item has not been found. The LPN also stated that they will ask another staff to help them find the item. The LPN further stated that social services deals with missing money a bit more. The LPN stated that if money is missing or stolen they believe that documentation would be in the progress notes. The LPN stated that documentation would include management notification, including any follow-up p of the investigation. The LPN (Staff # 164) stated that the facility expectation is to document thoroughly, and take accountability. An interview was conducted on January 24, 2025 at 11:44 AM, with a Social Worker (staff #88) at 11:44 AM, who stated that social services looks out for their resident ' s psychosocial physical being, and advocates for their residents.She stated that when it comes to missing/stolen money or abuse they will immediately report the allegation to the supervisor. She stated that reports of missing items/money will be documented in progress notes and that there is a follow up in regards to the investigation that will also be included. She stated that they want to ensure that they are doing the right thing for the residents Review of the policy titled, Documentation Guidelines, revealed that documentation guidelines to ensure accurate, consistent, and compliant record keeping.

Based on observation, staff interviews, and facility policies, the facility failed to ensure that infection prevention and control standards were maintained regarding catheter bags for two of four sampled residents (#637, 636). The deficient practice could result in the spread of infection to residents. Findings include: -Regarding Resident #636: Resident #636 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and traumatic brain injury. A care plan initiated on January 16, 2025, revealed the following focus: -Risk for infection related in invasive devices. -History of BPH (benign prostatic hyperplasia) and potential for urinary retention. During an observation conducted on January 23,2024 at 1:12 PM, Resident #636's urinary catheter bag was observed to be lying on the floor. An interview was conducted on January 23, 2025 at 1:35 PM with a Certified Nursing Assistant (CNA/staff #25), who stated that catheter bag should never touch the floor due. Further interview was conducted on January 23, 2025 with CNA (staff #25) who stated that catheter bags should not touch the floor due to infection control issues. She further stated that the risk could result in the spread of infection. An interview was conducted on January 23, 2025 at 2:59 PM with the Chief Clinical Officer (CCO/Staff #218), who stated that urinary catheter bags should be placed in a privacy bag for the dignity of the resident, and should never be lying on the floor. She further stated that the risk of a urinary catheter bag lying on the floor could result in the spread of infection and possible urinary tract infection, even with the privacy bag cover. An additional observation was conducted on January 24, 2025, and the resident's catheter was observed to have been placed in a plastic basin, and the plastic basin was on the floor. This was after the Chief Clinical Officer interview on January 23, 2025. -Regarding resident #637: Resident #637 was admitted on [DATE] with diagnoses that included Acute Kidney Failure, Dependence on renal dialysis, Sepsis, and Urinary Tract Infection (UTI). Review of Resident #637's order summery dated January 16, 2025 indicated an order for a suprapubic catheter to gravity drainage, 16 French, 10 cubic centimeter balloon. Further review of Resident #637's order summery revealed an order dated January 16, 2025, which indicated catheter care per facility protocol as needed and every shift. Further review of the comprehensive care plan dated January 17, 2025, included Resident #637 has use of a suprapubic catheter and is at risk for infection related to neurogenic bladder. Tasks included catheter care every shift and as needed, change drainage bag as needed for leaking, and check catheter securing device every shift and replace as needed. An observation was conducted January 21,2025 at 1:58pm of resident #637. The resident's catheter bag was observed to be lying on the floor next to the bed while the resident was asleep. During observations conducted on January 22, 2025 at 8:05am and 2:06pm, and January 23, 2025 at 8:30am, the catheter bag was observed touching the floor. Another observation conducted on January 24, 2025 at 8:58am, of the catheter bag had been placed in a privacy cover and a plastic bucket was under the bag to avoid touching the floor. An interview was conducted on January 23, 2025 at 8:53am with a Licensed Practical Nurse (LPN/Staff #269), who stated that catheter care is performed by Certified Nursing Assistants (CNA), and that catheters are replaced at least once a month or as needed, and CNAs should be cleaning the insertion site daily. An interview was conducted on January 23, 2025 at 10:18am with a CNA (Staff #138) who stated that catheter care is routinely performed twice a day or as needed. He also stated that catheter bags are emptied once a day and as needed. An interview was conducted on January 23, 2025 at 2:59pm with an LPN (Staff #300), who stated that catheter bags should not be on the floor or touching the floor. She also stated that the bag should be placed so it can hook on bedside rail, and not touching the floor. The LPN stated the risk of the catheter bag laying on the floor could result in an infection. A policy and procedure titled catheter care, includes a Nursing Reference Policy dated January 2021 stating, Plaza Healthcare recognizes authors [NAME] and/or [NAME] as examples of professional references for education for clinical staff. Review of [NAME] on Indwelling Urinary Catheter Care and Removal (pg. 433) states, don't place the drainage bag on the floor, to reduce the risk of contamination and subsequent catheter-associated urinary tract infection.

Based on observations, staff interviews, and policy review, the facility failed to ensure food was properly labeled. The deficient practice may allow residents to consume foods that are unsafe for consumption. Findings include: During an initial tour of the kitchen conducted on January 21,2025 at approximately 11:17 AM, with the Dietary Director (staff #277) and the Dietitian (staff #112), a ziplock bag labeled pork breast was observed in the walk-in refrigerator with the dates December 30, 2024 and January 06, 2025 written on the ziplock bag. However, there was no identification of the open or expiration dates. The pork breast was 22 days past from December 30, 2024 and 15 days past January 06, 2025 from the initial tour of the kitchen on January 21, 2025. Dietary Director ( Staff # 227) was unable to identify the open and expiration date for the pork breast. An interview was conducted on January 21, 2025 at approximately 11:17 AM with Dietary Director ( Staff # 277) who stated that the pork breast was this month's special , and that frozen meals would base it off of the expiration date. An interview was conducted on January 24, 2025 at 10:45 AM with a Kitchen [NAME] (Staff #65 ), who stated that leftover food items would need labeling. Kitchen [NAME] ( Staff #65) stated food labeling would include the date the item was opened and the expiration date. Kitchen [NAME] (Staff #65) stated that the pork breast was from the December 2024 kitchen menu, and that he forgot to discard. Kitchen [NAME] ( Staff #65), who stated that food items that are not labeled with the open and expiration dates would be discarded. The Kitchen [NAME] (Staff #65) stated that items are inspected for expiration dates in the pantry, walk-in refrigerator and freezer. The Kitchen [NAME] (Staff #65) stated that they discard items that are expired immediately. An interview was conducted on January 24, 2025 at 10:38 AM with the Kitchen manager ( Staff # 277) who stated that they would not use anything in the kitchen that is past the expiration date. The Kitchen manager (Staff#277) stated that she would not serve residents food items with no proper labeling. The Kitchen (staff # 277) stated that they would follow their facilities guidelines in regards to labeling. A policy titled Food Storage revealed that frozen meat/ poultry and foods need to be labeled and dated.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure that one sampled residents (#36) was safe to self-adminster medication. The deficient practice could result in a medication overdose. Findings Include: Resident #36 was initially admitted on [DATE] and re-admitted on [DATE] with a diagnosis of acute kidney failure,hyperlipidemia, and cerebral infarction. The Nursing Assessment PPS (NP) Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. A Care Plan dated October 23, 2024 revealed no indication of a focus for medication self-administration. An observation was conducted on January 22, 2025 at 8:20 am of the residents (#36) room, and three medications were observed on the residents bed side table. The medications included Osha Root Rocky Mountain Throat Syrup, Salonpas Lidocaine Plus Pain Relieving Cream , and Fluid Extract Mullein Leaf 2,000mg. Review of the clinical record revealed no evidence of a medication self-administration order. Further review of physician orders revealed no evidence of orders for the following medications: - Osha Root Rocky Mountain Throat Syrup, -Salonpas Lidocaine Plus Pain Relieving Cream -Fluid Extract Mullein Leaf 2,000mg Review of the clinical record revealed no evidence of a medication self-administration assessment. An interview was conducted on January 22, 2025 at approximately 8:20 AM with Resident #36, who stated that her son brought in the medication , and that she could not remember when this occurred. An interview was conducted on January 22, 2025 at 08:34 AM with a Licensed Practical Nurse (LPN/staff #83 ) who entered the resident ' s room and stated that there were three containers sitting on the bedside table that included Osha Root Rocky Mountain Throat Syrup, Salonpas Lidocaine Plus Pain Relieving Cream , and Fluid Extract Mullein Leaf 2,000 mg. The LPN stated that she has to speak with the Assistant Director of nursing (ADON) to find out what was going on with the medications found on the resident 's bedside table. The LPN also stated that she was not aware of the medication at bedside. An interview was conducted on January 24, 2025 at 1:00 PM with LPN who stated that residents cannot bring cigarettes, alcohol,or medications . The LPN (Staff # 257) stated that if medications were to be brought to the facility by the family and found by staff the staff will put it into a zip lock bag for the family to come by and pick it up. The LPN (Staff # 257) stated the physicians will be made aware along with the social worker when medication is found at the bedside table of the resident . The LPN (Staff #257) stated that they will let the resident know they can ' t have medication that are not ordered by the physician. The LPN (Staff #257 ) stated that there needs to be order for self administration and there are no residents that are on self administration. An interview was conducted on January 24, 2025 at 1:28 PM with the Chief Clinical Officer (CCO/staff #218), who stated that she oversees all of the clinical staff. The CCO (Staff #218) stated that during admission staff will do a head to toe, and skin assessment. The CCO (Staff #218) reviewed their facility policies and stated that if residents request to do self administered they will conduct an assessment to determine resident cognitive status, ability to name the medication. The CCO (Staff #218) stated that they will also need to know if residents are able to tell time and day, and the side effects of the medication. The CCO (Staff #218) stated that they would monitor the side effects, and no controlled substance would be allowed to self administer. The CCO (Staff #218) stated that when staff give medication to residents they should stay at their bedside to ensure that the resident takes their medication. The CCO (Staff #218) stated there were times when families would bring in medication or supplements and in that case education will be provided to the resident and family regarding medication administration and the family will be asked to take the medication back. The CCO (Staff #218) stated that staff will inform the unit manager when a family or representative has brought in medication, and tell the family to take it back. The CCO (Staff #218) stated that there is nothing in the resident # 36 records for self admission and she will be the one to know. The CCO (staff #218) stated that there are no residents in the facility that are self administrators. A review of the policy titled Self-Administration of Medication, revealed that the interdisciplinary team will assess the resident to determine if self-administration of medication is clinically appropriate, safe, and feasible to honor the resident request and to maintain the resident ' s independence consistent with individualized plan of care.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that resident (#30) was not abused by another resident (#54). The deficient practice could result in residents being harmed emotionally and physically. Findings include: -Regarding Resident #30: Resident #30 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 10 indicating the resident had a moderate cognitive impairment. A progress note dated October 19, 2024 revealed remains at baseline and no new issue to report. Pt was social and engaged well with nurse. Pt played bingo with her peers. Pt was resting in room at end of shift with call light within reach. A care plan revised on October 29, 2024 revealed that resident #30 has times of verbal aggression and jovial facetious banter that may be misconstrued by others. -Regarding Resident #54: Resident #54 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, stage 5, dependence on renal dialysis, acute kidney failure with tubular necrosis. The annual minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident cognition is intact. The care plan date revised on October 24, 2024 revealed resident at times is not aware of boundaries with others and need redirection due to poor impulse control and will attempt to multitask during activities that can be distracting to others. Interventions included to offer/remind to use headphones to listen to his phone. An attempt to conduct an interview with resident on October 30, 2024 at 10:00 a.m. was made. Resident was at a dialysis appointment. An interview was conducted October 30, 2024 at 10:46 a.m. with resident #9. Resident #9 stated she was at bingo for the first time and was seated right next to resident #30. She stated resident #54 was upset because resident #30 won the round of bingo. She stated resident #54 called resident #30 a whore, fucking bitch and a mother fucking whore. She stated I felt weird because it was my first time going to bingo. An interview was conducted on October 30, 2024 at 10:58 a.m. with resident #54. Resident #54 initially stated he did not want to discuss the issue that is over with, but then decided to share his side of the story. Resident #54 stated he was at bingo and was seated at a table by himself, listening to music. He stated resident #30 was seated at a table next to his playing bingo. He stated resident #30 kept disturbing and harassing him. Resident #54 stated I did not call her a black bitch. An interview was conducted on October 30, 2024 at 11:09 a.m. with the Receptionist (staff # 48). Staff #48 stated that she was seated next to resident # 30 on Saturday, October 19, 2024, during a bingo game. She stated she was at the table assisting residents with their numbers and assisting the activities assistant and seated at the table was resident #30. She stated resident #54 was seated at a table next to theirs. Staff #48 stated resident # 30 was excited, vocal and a little loud. She stated resident #54 kept asking resident #30 to be quiet, she stated resident #54 became irritated and turned and called resident #30 a black bitch. Resident #30 became upset like she could not believe he said that to her.' She stated before resident #54 called her a bitch and he had asked resident #30 to be quite and she told him to shut up and that was when he turned around and called her that name. Staff #48 stated she did not intervene because she thought they were joking and she was unsure. Staff #48 stated she tried calming resident #30 down because she was very upset. She stated the game continued for another 10 minutes with both residents seated next to one another. Staff #48 stated when the game was over she took resident #30 to the lobby and went back to work. Staff #30 stated she did not report the incident to anyone. Staff #48 stated that she has had abuse training in the last year, in person. An interview was conducted October 30, 2024 at 11:34 a.m. with the Activities Assistant (staff/ # 77). Staff # 77 stated I don't know too much just that the two residents were sitting in front of me and they were bantering back and forth with their typical behavior. She stated that it did not seem that it was escalating. Staff # 77 stated after Bingo was over, resident #30 was sitting in the lobby and stated did you hear what that N word called me - he called me a black bitch she appeared upset and angry. Staff #77 stated she immediately reported it to her boss through text. Staff #77 stated she was told by her supervisor if it were to happen again to stop the bingo game and have the residents removed. Staff #77 stated she was never informed by staff #48 about what had happened and that the expectation would be for her to have informed her and stop the altercation between the residents. She stated the unit nurse was informed and asked that resident's #30 and #54 not attend bingo the following day. An interview was conducted October 30, 2024 at 12:10 p.m. with Social Services Director (staff # 62). Staff #62 stated that she supervises the receptionists and that Staff #48 is under her directive. Upon hire staff complete in person training with verbal abuse is part of the curriculum. Staff #62 stated as a social worker they are expected to report immediately. Staff #62 stated she completed education with staff #48 when she became aware that she had not reported to anyone of the altercation between the two residents. She stated staff #48 should have stopped it immediately and if she did not feel comfortable should have informed staff #77 who was in the room with her or told a supervisor. Staff #62 stated she was disappointed in the way that she reacted or failed to react to the situation as it was clearly verbal abuse and failed to intervene and report the incident immediately. Staff #62 stated the facility has to protect the residents not just sit back and observe and that it does not matter what department you are in, that you are responsible for intervening and reporting. Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property states it is the policy of the facility that each resident will be free from abuse. Abuse can be verbal, mental, sexual, or physical abuse, corporal punishment, misappropriation of resident property, or involuntary seclusion. -Verbal abuse is defined as the use of oral, written, or gestural language that willfully includes disparaging or derogatory terms to resident's or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure staff intervened and reported resident to resident verbal abuse. The deficient practice could result in residents not being protected from further abuse and appropriate corrective action taken. Findings Include: - Regarding Resident #30: Resident #30 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 10 indicating the resident had a moderate cognitive impairment. A progress note dated October 19, 2024 revealed remains at baseline and no new issue to report. Pt was social and engaged well with nurse. Pt played bingo with her peers. Pt was resting in room at end of shift with call light within reach. A care plan revised on October 29, 2024 revealed that resident #30 has times of verbal aggression and jovial facetious banter that may be misconstrued by others. -Regarding Resident #54: Resident #54 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, stage 5, dependence on renal dialysis, acute kidney failure with tubular necrosis. The annual minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident cognition is intact. The care plan date revised on October 24, 2024 revealed resident at times is not aware of boundaries with others and need redirection due to poor impulse control and will attempt to multitask during activities that can be distracting to others. Interventions included to offer/remind to use headphones to listen to his phone. An interview was conducted October 30, 2024 at 10:46 a.m. with resident #9. Resident #9 stated she was at bingo for the first time and was seated right next to resident #30. She stated resident #54 was upset because resident #30 won the round of bingo. She stated resident #54 called resident #30 a whore, fucking bitch and a mother fucking whore. She stated I felt weird because it was my first time going to bingo. An interview was conducted on October 30, 2024 at 10:58 a.m. with resident #54. Resident #54 initially stated he did not want to discuss the issue that is over with, but then decided to share his side of the story. Resident #54 stated he was at bingo and was seated at a table by himself, listening to music. He stated resident #30 was seated at a table next to his playing bingo. He stated resident #30 kept disturbing and harassing him. Resident #54 stated I did not call her a black bitch. An interview was conducted on October 30, 2024 at 11:09 a.m. with the Receptionist (staff # 48). Staff #48 stated that she was seated next to resident # 30 on Saturday, October 19, 2024, during a bingo game. She stated she was at the table assisting residents with their numbers and assisting the activities assistant and seated at the table was resident #30. She stated resident #54 was seated at a table next to theirs. Staff #48 stated resident # 30 was excited, vocal and a little loud. She stated resident #54 kept asking resident #30 to be quiet, she stated resident #54 became irritated and turned and called resident #30 a black bitch. Resident #30 became upset like she could not believe he said that to her.' She stated before resident #54 called her a bitch and he had asked resident #30 to be quite and she told him to shut up and that was when he turned around and called her that name. Staff #48 stated she did not intervene because she thought they were joking and she was unsure. Staff #48 stated she tried calming resident #30 down because she was very upset. She stated the game continued for another 10 minutes with both residents seated next to one another. Staff #48 stated when the game was over she took resident #30 to the lobby and went back to work. Staff #30 stated she did not report the incident to anyone. Staff #48 stated that she has had abuse training in the last year, in person. An interview was conducted October 30, 2024 at 11:34 a.m. with the Activities Assistant (staff/ # 77). Staff # 77 stated I don't know too much just that the two residents were sitting in front of me and they were bantering back and forth with their typical behavior. She stated that it did not seem that it was escalating. Staff # 77 stated after Bingo was over, resident #30 was sitting in the lobby and stated did you hear what that N word called me - he called me a black bitch she appeared upset and angry. Staff #77 stated she immediately reported it to her boss through text. Staff #77 stated she was told by her supervisor if it were to happen again to stop the bingo game and have the residents removed. Staff #77 stated she was never informed by staff #48 about what had happened and that the expectation would be for her to have informed her and stop the altercation between the residents. She stated the unit nurse was informed and asked that resident's #30 and #54 not attend bingo the following day. An interview was conducted October 30, 2024 at 12:10 p.m. with Social Services Director (staff # 62). Staff #62 stated that she supervises the receptionists and that Staff #48 is under her directive. Upon hire staff complete in person training with verbal abuse is part of the curriculum. Staff #62 stated as a social worker they are expected to report immediately. Staff #62 stated she completed education with staff #48 when she became aware that she had not reported to anyone of the altercation between the two residents. She stated staff #48 should have stopped it immediately and if she did not feel comfortable should have informed staff #77 who was in the room with her or told a supervisor. Staff #62 stated she was disappointed in the way that she reacted or failed to react to the situation as it was clearly verbal abuse and failed to intervene and report the incident immediately. Staff #62 stated the facility has to protect the residents not just sit back and observe and that it does not matter what department you are in, that you are responsible for intervening and reporting. Review of the facility policy titled Abuse, Neglect, Mistreatment and Misappropriation of Resident Property states it is the policy of the facility that each resident will be free from abuse. Abuse can be verbal, mental, sexual, or physical abuse, corporal punishment, misappropriation of resident property, or involuntary seclusion. -Verbal abuse is defined as the use of oral, written, or gestural language that willfully includes disparaging or derogatory terms to resident's or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator. Review of the facility policy titled Event Reporting-Resident states it is the policy of this facility to identify information/events related to residents. An adverse event is an incident resulting in harm to the resident. Examples: S fall, choking, elopement or attempted elopement, medication error, trauma causing self-decannulation or trauma causing a g-tub dislodgement, injuries of unknown origin, resident t-to-resident altercation, resident-to-employee altercation, or an employee-to-resident altercation.

Based on observations, staff interviews, and policy review, the facility failed to ensure staff followed infection control standards related to wearing PPE (personal protective equipment). The deficient practice could result in transmission of infection including COVID-19. Findings include: An observation was conducted on June 13, 2022 at 11:07 am in the facility kitchen. Staff #178 (dishwasher) and staff #203 (cook) were observed with N95 face masks that were improperly worn. Both staff members had their masks lowered and their noses were exposed. Another observation was conducted on June 15, 2022 at 10:50 am. Staff #203 was again observed wearing his N95 mask with his nose exposed. An interview was conducted with the facility's Infection Preventionist (IP/staff #21) on June 14, 2022 at 2:48 pm. She stated the facility was in COVID-19 outbreak status and that all staff and visitors in the building should wear an N95 face mask and eye protection. An interview was conducted with the director of nutritional services (staff #179) on June 15, 2022 at 1:39 pm. Staff #179 stated all of the staff in the kitchen are required to wear an N95 mask and eye protection at all times in the facility. Signs observed posted in the facility included unvaccinated and not boosted staff, and vaccinated and boosted staff were to wear a K/N95 face mask and eye protection. The facility's policy Core Principles of COVID-19 Infection Prevention included at all times wearing a face mask that covers the mouth and nose.

Based on observations, staff interviews, and policy review, the facility failed to ensure staff members wore hair restraints appropriately, kitchenware was clean, and that fans were clean. The deficient practice could increase the risk of foodborne illness. Findings include: Regarding hair restraints During the initial kitchen observation conducted on June 13, 2022 at 11:07 a.m., a staff member working in the food line was observed wearing hair restraints that did not have all of her hair restrained. She had her hair up in a French twist-bun fashion with only half of the back of her head covered by the hairnet, while the rest of her hair was exposed, and loose hair was hanging down. A second observation was conducted on June 15, 2022 at approximately 10:50 a.m. During this observation, the same staff member was observed with half of the back of her head and hair exposed, with loose hair hanging down. In an interview with the director of nutritional services (staff #179) conducted on June 15, 2022 at 1:39 p.m., he stated that if the staff has hair, they have to wear hairnets or a hat in the kitchen. A facility policy titled Personal Hygiene/Safety/Food Handling revised May 6, 2021, stated that hair must be appropriately restrained or completely covered. Regarding clean kitchenware During an observation of ready-to-use dishes conducted on June 16, 2022 at 10:30 a.m., four dirty dessert bowls were observed stored with the clean stack. The dishes had visible debris that were remnants of food items it had contained. An interview with the director of nutritional services (staff #179) was conducted on June 16, 2022 at 10:32 a.m., he said that staff must visually inspect utensils and plates to ensure they are clean and clear of debris. He said this is usually done prior to storing the items and again prior to use. Regarding ceiling fans During the initial kitchen observation conducted with the director of nutritional services (staff #179) on June 13, 2022 at 11:07 a.m., fans mounted on the wall were observed dirty, and covered with dust debris that was hanging off the fans. One fan was blowing directly at the food line and the other was by a sink. Staff #179 stated that the fans should have been cleaned. He also said they would be cleaned immediately. A facility policy titled Cleaning Schedules revised on August 31, 2018, stated that the food and nutrition services staff shall maintain the sanitation of the food and nutrition services department.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure that a care plan was implemented for one resident (#64) regarding safety plan interventions. The sample size was 24. The deficient practice could cause residents not to receive care as ordered and negatively impact residents' mental status. Findings include: Resident #64 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on December 17, 2021 revealed the resident has an alteration in mood status due to depression, anxiety, paranoia and [CONDITION(S)] disorder. Safety plan interventions included female staff only for changing and bathing. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) with a score of 15, which indicated the resident had intact cognition. The MDS assessment also indicated that the resident was totally dependent on staff for toileting and bathing activities. Review of the bowel and bladder elimination log for the month of May 2022, revealed that a male staff member provided the care activity for the resident on May 28. Review of the toilet use log for the month of May 2022, revealed that a male staff member provided the care activity on May 9, 13, and 28. Review of the bowel and bladder elimination log for the month of June 2022, revealed that a male staff member provided the care activity for the resident on June 8 and June 12. Review of the toilet use log for the month of June 2022, revealed that a male staff member provided the care activity for the resident on June 12. During an interview conducted on June 13, 2022 at 1:50 p.m., the resident stated that she had told staff numerous times that she does not want a male staff assisting her for certain activities. She said that the facility continued to disregard her request. She stated that she is totally dependent on the staff for assistance and care. An interview was conducted on June 15, 2022 at 8:37 a.m. with a Certified Nursing Assistant (CNA/staff #145), who stated that requests for same gender attendants are honored. She said there would never be a reason for the request not to be followed. On June 15, 2022 at 9:02 a.m., a Licensed Practical Nurse (LPN/staff #42) was interviewed, who stated that a resident's request for same gender caregiver will be honored. An interview with a CNA (staff #154) was conducted on June 15, 2022 at 01:23 p.m. Staff #154 stated that he has provided care such as toileting for opposite gender residents. He said that those residents have never expressed concern or discomfort. He stated that he normally asks the resident if it is okay prior to providing the care activity. He stated if a resident does have concerns or prefers a same gender caregiver, he informs the nurse. He stated that it has not happened to him since he started at the facility two weeks ago. He said that the CNA that performs the task is the one that documents on the log that it was completed. An interview was conducted on June 16, 2022 at 10:45 a.m., with the Director of Nursing Level I (DON/staff #204), who stated that the expectation is that staff would try to accommodate resident's choices and preferences with regards to same gender caregiver for specific tasks. She said they are normally able to do so about 90% of the time. However, the DON stated that once in a while they have to let the resident know that they might not be able to accommodate due to staffing restraints. She also stated that they have more female staff than male. She said that with regards to the care plan, the expectation is that it is followed. She stated this means that if it is in regards to same gender specific tasks, if they do not have the staffing on the floor then they have to float somebody from another area to provide the activity in order to follow the care plan. She said that she did not know off the top of her head of a resident whose care plan calls for a specific gender to perform an activity. The care plan for resident #64 was reviewed with staff #204, and she verified that it states female only for changing and bathing. Staff #204 reviewed the May 2022 thru June 2022 bowel and bladder elimination log for the resident revealing a male CNA provided the activity. She stated that it is a problem since it did not follow the care plan. She also said that the care plan's specifics are also an issue since it does not allow for impact from staffing constraints. Review of the facility policy titled, Interdisciplinary Team Guidelines, Care Planning, last reviewed March 2022, revealed the Interdisciplinary Team (IDT) will allow the resident and/or representative to participate in a person-centered care planning process. The IDT will allow the resident and/or representative to participate in establishing the desired goals and outcomes of care.

Based on clinical record review, facility document, staff interviews, and review of policies and procedures, the facility failed to ensure one resident's (#17) responsible party was provided written notice prior to a room change, or after the room change occurred. The sample size was 2. The deficient practice could result in residents not receiving written notices prior to a room change. Findings include: Resident #17 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Acknowledgement of Change form in the medical record, revealed room change forms had been completed for the following dates: 7/6/2021, 10/5/2021, 12/30/2021, 1/11/2022, and 1/18/2022. Review of the quarterly Minimum Data Set assessment dated [DATE], revealed the resident was in a persistent vegetative state/non-discernible consciousness. Review of the medical record census list revealed the resident received a room change on June 4, 2022. Further review of the medical record Acknowledgement of Change for Internal Room Transfer form, revealed no documentation for the room change conducted on June 4, 2022. Review of the progress notes revealed an attempt to notify the representative on June 4, 2022 at 13:40 PM of the room change, but voicemail was full. Further review of the progress notes revealed no documentation that the resident representative had been notified, or additional attempts were made after the initial call. Review of the medical record revealed no evidence that the representative had been notified of the room change in writing, prior to or after the room change occurred. An interview was conducted on June 15, 2022 at 12:50 PM with a Registered Nurse (RN/staff #214), who stated that the facility policy for room transfers is to complete a room change form in the medical record. She also stated that the resident and/or representative would be notified. She further stated that representative notification would be documented in the medical record nursing progress notes. The RN stated the reason for informing the resident or family, would be so they would be aware that the resident was in a different room when they came to visit. She stated that the resident should be notified of a room change, but was not sure if they have the right to choose, whether or not they want to change rooms. An interview was conducted on June 15, 2022 at 1:35 PM with an RN (staff #213), who stated that they would notify the resident/representative regarding room transfers, to make sure they know why the room change occurred. She also stated that the notification would then be documented in the medical record. The RN stated that there is no written notification that the resident/representative would need to sign. An interview was conducted on June 15, 2022 at 2:47 PM with the Director of Social Services (staff #2), who stated that the process for room changes includes notifying the resident, if alert and oriented, then notifying the new roommate. She also stated that they have a room transfer form that is completed in the medical record that includes the date of the room change and who was notified. She stated that if the resident is not alert/oriented they would contact the representative. She further stated that the room transfer form is completed every time the resident is moved to another room. The Social Services Director stated that the risk of not completing the room change form would be that there would be no way of showing resident/representative consent and notification of the room change, if medically necessary. She also stated that it does not follow the facility process to document a call made to the representative, but not complete the room change form. She reviewed the medical record and stated that according to the census, resident #17 had a room change on June 4, 2022. She further stated that she did not see documentation of a room change form completed by nursing. She then stated that if the move was on a Saturday, the room transfer form does not need to be completed, that the form is just for Social Services. She stated that they should have continued to try to contact the representative to let them know about the room transfer. She also stated that there was no documentation in the medical record of subsequent calls to notify the representative of the room transfer, or documentation of written notification. The Director of Social Services stated that this did not follow the facility process, that there is no documentation that the family was aware of the transfer. An interview was conducted on June 15, 2022 at 3:15 PM with the Director of Medical Records (staff #229), who stated that social services completes the room transfer forms. She also stated that the room transfer form should be completed anytime there is a room change, and that on the weekends the nurses would be expected to complete the room transfer form. An interview was conducted on June 16, 2022 at 8:16 AM with the Unit Director of Nursing (DON/staff #192), who stated that facility policy for room transfers is to notify the resident/family or representative, then complete the room change form. He also stated that if the room change occurred on a weekend that nursing would call the family and complete the room change form. He further stated that nursing would document the call to the resident's representative in the progress notes. He reviewed the medical record and stated that the resident was moved to another room because the facility needed an isolation room. He further stated that this room change was not for a medical emergency for the resident. He stated that the unplanned room change took place to create another room for a COVID positive resident. He further stated that the room change was not conducted for resident safety/medical emergency, but for the facility needs. He reviewed the medical record and stated that there was documentation in the progress notes, that a call was attempted to the resident's representative, but no message was left, and there was no record of further calls. The Unit DON stated that resident #17 is not alert/oriented, and has limited family involvement. He stated that he assumed that the resident representative saw the facility number, and would know to call back. He further stated that there was no documentation in the medical record that the responsible party had received written notice, or received any other notification of the room transfer. During an interview conducted on June 16, 2022 at 12:06 PM with the Administrator (staff #102), he stated that he was aware of the room transfer issue and that they will be reviewing the process in the next quality assurance meeting. He also stated he felt that there could be changes made to the current transfer process. Review of the facility policy titled, Resident Room Transfer and Notification Protocol, revealed that Social services will document the room move and upload the room transfer sheet in the document section. If there is a need for a room transfer due to medical or safety necessity and the process cannot wait for normal business hours, the room transfers will be initiated by the Nurse Supervisor. The nurse supervisor or designee will document in the progress note and complete the Room Transfer Notice indicating that the transferring resident and the receiving resident have been properly notified. The nurse supervisor will assure that the patient room change is documented in the progress notes along with detailed information and that the medical record is updated to reflect the proper room. Social services will audit the following business day to assure all items related to the room transfer were completed per protocol. Review of the facility policy titled, Room Assignment Notification, revealed that as medical needs change, the facility may request to transfer the resident to the appropriate unit. The Social Services designee or nurse will provide an advance notice when a room transfer is needed, unless in the event of a medical emergency.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#79) and/or their representative were informed of the risks and benefits of a [CONDITION(S)] medication prior to receiving the medication. The sample size was 5. The deficient practice could result in residents and/or their representatives not being aware of the risks and benefits of psychoactive medications. Findings include: Resident #79 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Records (MARs) from February 2022 through May 2022, revealed [MEDICATION(S)] was first administered February 17, 2022 and [MEDICATION(S)] was first administered February 25, 2022. However, further review of the clinical record revealed no evidence the resident or the resident's representative were informed of the risks and benefits of receiving [MEDICATION(S)] and [MEDICATION(S)] prior to the medication being administered. Continued review of the clinical record revealed Psychoactive Medication Consent forms that included risks and benefits for [MEDICATION(S)] dated March 7, 2022 (18 days after initial administration) and [MEDICATION(S)] dated March 31, 2022 (34 days after initial administration). An interview was conducted on June 16, 2022 at 8:13 AM with Social Services (staff #4). She stated that when a resident has been ordered [CONDITION(S)] medications, nursing typically informs the resident or family representative the resident has been ordered the medication, what it is for, and obtains consent. She further stated there is a form that gets scanned into the resident's clinical record which medical records oversees. An interview was conducted on June 16, 2022 at 8:29 AM with the Health Information Director (staff #229). She stated their department conducts audits to ensure there is a consent in place when there is a [CONDITION(S)] medication order. Staff #229 stated they review all orders daily to ensure there is a consent form in the medical record. She further stated the unit secretary is the person who uploads the consent into the medical record. An interview was conducted on June 16, 2022 at 8:31 AM with the Director of Nursing (DON/staff #192). He stated that for [CONDITION(S)] medications, the physician will put in an order and nursing will initiate a Psychoactive Medication Consent Form which requires an indication for use and target behavior. The DON stated nursing will put in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated consents are usually uploaded the next day by the unit secretary. Staff #192 stated medical records audit the orders daily to ensure the consents are in place. The facility's policy titled Informed Consent reviewed March 2022, revealed it is the policy of the facility to facilitate, when necessary, the obtaining of informed consent for medical services that require informed consent. The resident has the right to have the information presented in the language or means of communication she/he understands. The resident will be provided with adequate information for the resident or representative to make an informed decision on the proposed treatment including medications. Informed consent will be verified by the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on staff interviews, facility documentation and policy and Center for Medicare & Medicaid Services(CMS) and Center for Disease Control (CDC) guidance the facility failed to ensure that unvaccinated staff was tested as required based on the level of community transmission. Findings include: An interview with the infection Preventionist ( IP/staff #4) on December 28, at 12:41 p.m. She stated that she was out of the building due to illness. She further stated that unvaccinated staff were to be tested twice per week and if a staff member was not in the building and able to accommodate that testing schedule, they should be tested as soon as they return to the building. An interview was conducted on December 28, 2021 at 1:42 p.m. with the administrator (staff #12)and the assistant administrator (staff #19). They stated that there was a facility policy that was updated in August of 2021 that the work week was split into two subsections and that some staff that work a short week might only be tested on ce in a week. This is to accommodate staff that work 3 , 12 hour days or are not in the building because they work as needed or are on vacation. An additional interview with staff #12 was conducted at 2:35 pm. on December 28, 2021. He stated that the testing protocols that are being followed are based on a program put together by a group of staff. This group include respiratory therapists (RT) whom often work 3 days per week, 12 hour shifts. The staff agreed that the program they put together is the best way to handle testing for so many staff and such varied schedules. He said the weekly schedule started on Sunday and runs through Saturday. He further stated that if a staff member works Monday through Wednesday, they would be tested 1 time per week as it does not make sense to test the staff member on Wednesday if they would not return to the building until Monday .He stated that this was the testing policy that they have followed through out the COVID pandemic and it had worked well for the facility. An additional interview was conducted with staff # 19 on December 28, 2021 at 3:05 p.m. She stated that staff #7 was tested on ce in the week ending December 25th because he was not in the building on December 20 or 21 , 2021. A list of unvaccinated staff was provided and staff # 7 , a certified nursing assistant (CNA) was included on that list,. On a list of employee vaccination status it was revealed that staff # 7 signed a vaccine refusal. He was classified as a full time employee. An updated listed of employee testing was provided and it was revealed that staff #7 was not tested on [DATE], but was tested on [DATE] with a negative result. The document revealed he was only tested on ce during the week and in the note section it stated not working first half of week. A time card (punch detail ) was provided for staff #7 for the pay period of December 20,2021 through December January 1, 2021. Staff #7 clocked in to the building on December 23, 24, 25, 26 and 27. A flyer hanging in the area of staff screening revealed that mandatory unvaccinated staff COVID testing was held every Tuesday and Thursday in the resident dining room. The flyer read You must get tested twice per week. The facility policy COVID -19 Employee Testing Process updated August 5, 2021 revealed that employees that are not vaccinated will be required to test for COVID-19 according to County Positivity Rates (routine testing).The policy revealed that employee must be tested on the scheduled testing day each week. The week is defined as Sunday through Saturday. The test day is on Tuesdays, if testing once per week, and Tuesdays and Thursdays if testing twice per week. Employees that are required to test twice per week must test once Sunday through Wednesday and again, Thursday through Saturday. The facility policy COVID -19 Employee testing guidelines updated September 14, 2021 revealed that employees are to test according to county positivity rate and facility outbreak status, The policy further revealed that routine testing of unvaccinated staff should be based on the extent of the virus in the community. High (red) community transmission required staff testing twice a week. The facility policy titled Covid 19 Policy and Protocol revised September 2021 revealed that the facility routine testing of unvaccinated staff would be according to county community transmission. The CDC website revealed that the community transmission rate for Maricopa County was high (red) for the week of December 12- 18, 2021 CMS guidance QSO-20-38NH revised September 10, 2021 revealed that the facility should test all unvaccinated staff at the frequency prescribed in the published table which was based on the level of community transmission reported in the past week. The published table revealed that minimum testing frequency of unvaccinated staff for areas of high (red) community transmission was twice per week. CDC guidance Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated September 10, 2021 revealed that in nursing homes, unvaccinated health care providers( HCP)should continue expanded screening and testing based in the level of community transmission. Facilities located in counties with substantial to high community transmission, unvaccinated HCP should have a [CONDITION(S)] test twice a week. The guidance further revealed that if unvaccinated HCP work infrequently at these facilities, they should ideally be tested within the 3 days before their shift (including the day of the shift).

Based on clinical record review, observation, family and staff interviews, and policy review, the facility failed to ensure one resident's (#128) dietary preferences were honored. The deficient practice could result in residents receiving food not according to their preference. Findings include: Resident #128 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 4 on the Brief Interview for Mental Status (BI[CONDITION]), indicating the resident had severe cognitive impairment. The MDS assessment also included the resident did not have a swallowing disorder, received nutrition via feeding tube, and was receiving speech therapy. A weekly menu dated February 9 through15, 2020 revealed the menu was filled out by the resident's family and included the resident was not to receive slurried bread. On February 11, 2020 at 10:05 a.m., an interview was conducted with the resident's family member. The family member stated the resident requests for meals are not being honored. The family member stated the resident is provided food that the resident will not eat. The family member stated that it was specifically requested the resident not receive slurried bread. The family member stated the staff was spoken to on several occasions about the resident's preferences and yet staff continues to send slurried bread with the resident's meals. During an observation conducted of the resident's lunch tray on February 11, 2020 at 11:16 a.m., the resident's lunch ticket on the tray was observed to have in capital letters no slurried breads. The resident's plate was observed to have slurried bread and pureed carrots on it. An interview was conducted with the Registered Dietitian (RD/Staff #310) on February 11, 2020 at 11:18 a.m. Staff #310 observed resident #128's meal ticket and lunch tray, and stated slurried bread should not be on the resident's plate. She stated the tray line staff should be checking each tray against the ticket to make sure it matches which includes any likes, dislikes, and allergies [REDACTED].>An interview was conducted on February 12, 2020 at 10:34 a.m. with the dietary director (staff #2[AGE]), who stated the meal ticket stays with the tray as it goes through the tray line. Staff #2[AGE] stated the dishwasher puts condiments on the tray, then the cook plates the food, and then the dietary aid adds the beverages and anything else the tray needs and places it on the cart. Staff #2[AGE] stated everyone who looks at the ticket should be making sure the tray matches the ticket. On February 12, 2020 at 1:18 p.m., an interview was conducted with the Certified Nursing Assistant (CNA/staff #42) working on resident #128's hall. Staff #42 stated she delivers the meal trays to the resident rooms on her hall. The CNA stated she checks the tray to make sure it is for the correct resident, the tray does not have anything on it that the resident is not supposed to have, adaptive equipment is present as needed, and that the diet matches. Staff #42 further stated that she is not aware of any residents on her hall receiving the wrong foods on their trays. The CNA also stated that she was not aware of any problems with resident #128's meal trays. During an interview conducted on February 12, 2020 at 1:44 p.m. with the Director of Nursing (DON/ Staff #2[AGE]), the DON stated all of the staff is expected to look at the tray and compare it to the ticket before providing the meal to the resident. The facility's policy on Resident Rights- Food and Nutrition Services Department revised August 31, 2018, revealed reasonable accommodations should be made by the food and nutrition services department to those residents with food preferences.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure an unnecessary drug was not administered to one resident (#127), by failing to ensure a prn (as needed) [MEDICAL CONDITION] medication order was limited to 14 days and/or by failing to provide rationale documentation by the provider for extending the medication beyond 14 days with the duration for the prn order. The deficient practice could result in residents receiving [MEDICAL CONDITION] medications without medical necessity. Findings include: Resident #127 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the physician order [REDACTED]. The Medication Administration Record [REDACTED]. Review of the February 2020 MAR indicated [REDACTED]. During an interview conducted on February 14, 2020 at 11:25 a.m. with a Registered Nurse (RN/staff#66), the RN stated [MEDICATION NAME] is a schedule II medication and that a stop date is not needed. He stated that in accordance with the law, the electronic medical record system will void the prescription and require a new prescription every [AGE] days. The RN stated he was unaware of any other regulation regarding prn [MEDICATION NAME]. In an interview with the Director of Nursing (DON/staff #2[AGE]) conducted on February 14, 2020 at 11:30 AM, the DON stated that she is a member of the [MEDICAL CONDITION] medication committee that meets monthly and discusses all residents receiving [MEDICAL CONDITION] medications. She stated that it is in this meeting she would be made aware of and address the issue of PRN orders that do not comply with the regulation. The DON stated the pharmacist also attends these meetings and would make recommendations to the physician directly from the meeting. The facility's policy titled Psychoactive Medications revised October 2018 revealed it is the policy of the facility to have a 14-day limitation on all prn orders. The policy also revealed prn orders for [MEDICAL CONDITION] medications (excluding antipsychotic medications) may be extended beyond 14 days and if the provider believes it is appropriate to extend the order, the physician will document the clinical rationale for the extension and provide a specific duration of use.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident's (#61) drug regimen was free of unnecessary drugs, by failing to administer pain medication according to the physician ordered parameters. The deficient practice could result in residents receiving pain medications that may not be necessary. Findings include: Resident #61 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's care plan initiated on May 17, 2018 revealed the resident had chronic pain related to spasms and [MEDICAL CONDITION]. The goal was that the resident would express pain relief at a level acceptable to the resident. Interventions included administering medications as ordered and notifying the physician if the medication was ineffective. Review of the physician's orders [REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BI[CONDITION]) score of 15, which indicated the resident was cognitively intact. The assessment also included the resident had occasional pain and was administered prn pain medications. Review of the Medication Administration Record [REDACTED] Additional review of the clinical record revealed no documentation that the physician was notified the resident was administered two tablets of [MEDICATION NAME]-[MEDICATION NAME] 5/325 mg outside of the ordered parameters or that the physician gave an order to administer 2 tablets for pain levels outside of the ordered parameters. An interview was conducted with a Licensed Practical Nurse (staff #261) on [DATE] at 10:04 AM. Staff #261 stated that one tablet of [MEDICATION NAME]-[MEDICATION NAME] should have been given for pain levels of 4-7. Staff #261 said if the resident specifically asked for 2 tablets, the nurse should have called the physician for an order to administer 2 tablets and documented it. An interview was conducted with the Chief Clinical Officer (staff #2[AGE]) on 2/14/20 at 10:50 AM. Staff #2[AGE] stated that the 2 tablets of [MEDICATION NAME]-[MEDICATION NAME] were given to the resident in error unless the physician was notified and permission was given to administer 2 tablets. Staff #2[AGE] also stated that if the physician gave permission, it should be documented in the progress notes. The facility's policy for administration of drugs revealed medications must be administered in accordance with the written orders of the attending physician.

Based on record reviews, staff interviews and review of policies and procedures, the facility failed to ensure that the care was provided to two resident's (#1, #2) in a manner that promoted freedom from accident hazards. The deficient practice could result in residents being injured or suffering pain due to being improperly repositioned without adequate staff assistance. The sample size was two of four residents. Findings include: -Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated [DATE] included that the resident had severely impaired skills for daily decision making, was totally dependent on staff assistance from two or more staff for bed mobility, and totally dependent on one staff assist for hygiene. The assessment included that resident #1 had functional limitation in range of motion impairment on both right and left sides and upper and lower extremities, and had multiple active [DIAGNOSES REDACTED]. A written plan of care included that the resident has an ADL (Activity of Daily Living) self-care performance deficit related to musculoskeletal impairment, functional [MEDICAL CONDITIONS], [CONDITION]I ([MEDICAL CONDITION]), and incontinence. The care plan included multiple interventions including that the resident has total dependence for bed mobility and required 2 person physical assistance. The plan of care also included that the resident had potential for pain related to contractures to bilateral hands, fingers, knees and ankles, foot drop, generalized pain, muscular/skeletal disorder and not being able to verbalize pain or discomfort due related to vegetative state. The care plan included to provide non-pharmacological interventions included repositioning, and to observe and report non-verbal signs of pain to the nurse. Review of clinical record revealed a form titled Documentation Survey Report v2 for November 2019. The form included an entry dated November 25, 2019 at 3:51 a.m. initialed by a CNA (#287) that documented the resident was totally dependent on on 2 person physical assist for bed mobility. A Nursing Change of Condition note dated November 25, 2019 at 3:41 p.m. included that the resident's right arm had swelling and discoloration, and an X-Ray was ordered. An Interact Change in Condition Evaluation dated November 25, 2019 included that the resident had swelling of the right antecubital (elbow), discoloration of the palm of the right hand, and swelling of the front of the right shoulder. The evaluation included that the resident had had an X-Ray with results of a right humerus fracture, the physician was notified and the resident was sent to the emergency department. A Nursing Change of Condition note dated November 26, 2019 at 2:11 p.m. included that the resident had returned to the facility with findings of an old fracture. A physician's Progress Note dated November 26, 2019 included that the resident had an old history of previous fracture (right humerus) and that an X-Ray showed that the old fracture had been re-fractured. The note included that the resident had contractures and poor bone quality from having been bed bound for [AGE] years. The note included that the re-[MEDICAL CONDITION] was not preventable and that there were no signs of trauma or abuse. An interview was conducted on [DATE] at 10:25 a.m. with a CNA (#234). The CNA stated that she had provided care to resident #1, was familiar with the resident and his care needs and was sometimes assigned to provide care to him. Staff #234 stated that she thought that resident #1 required assistance from only one staff to be turned and repositioned and that she turned and repositioned him by herself when she provides him with care. Staff #234 stated that it was easy to find out the care needs of the resident by looking in the computer, or if an off-going CNA gives her a report on the resident at the beginning of her shift, but this does not always happen. During an interview conducted on [DATE] at 11:30 a.m. with a night shift CNA (#287) he stated that on the night shift of November 25, 2019 he had provided care to resident #1 and that there were not enough staff that night. Staff #287 stated that he did not have any assistance from another staff to provide care to resident #1 and that he turned and repositioned the resident by himself when providing ADL care. Staff #287 stated that he used a draw sheet to turn and reposition the resident without additional assistance and that because the resident was unresponsive, he did not know if the resident experienced pain when being turned and repositioned. During an interview conducted on December 12, 2019 at 10:30 a.m. with a CNA (#198) she stated that it takes 2 CNA's to safely turn and reposition resident #1 because his knee is contracted and when you turn him you might bang his knee on the bed. -Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] included that resident #2 had a BI[CONDITION] score of 15, which indicated the resident was cognitively intact, had function impairment of bilateral upper and lower extremities, and was totally dependent on 2 or more staff for bed mobility and personal hygiene. A written care plan included that the resident has an ADL self care performance deficit related to chronic pain, limited mobility, musculoskeletal impairment, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The care plan included multiple interventions including that the resident required the assistance of 2 staff for bed mobility. The care plan also included that the resident had pain related to debility, generalized pain and discomfort, lower back pain, bilateral shoulder pain, muscle spasms, and is at risk for breakthrough pain. The care plan included that the resident's pain is aggravated by movement and repositioning. Review of a Documentation Survey Report v2 for entries dated November 1, through November 25, 2019 revealed initialed entries that the resident was totally dependent on 2 staff physical assist for bed mobility each day. An interview was conducted on [DATE] at 11:30 a.m. with CNA/#287, who stated that he had provided care to resident #2 on November 25, 2019 on the night shift. Staff #287 stated that when he reported for duty that night, the off-going CNA told him that staff #2 required two CNA's to turn and reposition the resident and to provide incontinence care, and to get help before providing care to the resident. Staff #287 stated that the there was not enough staff that night so he turned and repositioned the resident by himself, but was unable to complete incontinent care alone because it was too difficult for him to do without additional assistance. Staff #287 stated that when he repositioned the resident onto his right side he thought the resident may have had pain, but he wasn't sure, and he did not report it to the nurse and stated I didn't think it was a big deal, but I should have reported it. During an interview conducted on December 12, 2019 at 10:30 a.m. with a CNA/#198 12/9/19 at 10:30 a.m., she stated that it takes two CNA's to safely turn and reposition resident #2. An interview was conducted on December 9, 2019 at 8:35 a.m. with the Director of Nursing/staff #323. Staff #323 stated that the care needs of residents who are dependent on staff for turning and repositioning, whether to use one or two staff depends on the resident's ability to move easily. Staff #323 stated that for resident's who are totally dependent on staff, they require two staff assistance to be repositioned for safety, and to prevent pain and discomfort to the resident. A policy and procedure titled Resident Occurrence included a statement that read It is the policy of this facility to be aware of a risk for falls or accidents due to medical complexities. A policy and procedure titled Resident Care Plans included a statement that read It is the policy of this facility for each resident to have a plan of care. The resident's plan of care will serve as a guide to rendering care and services to the resident.

Based on record reviews, staff interviews and review of policies and procedures, and review of the State Agency data base, the facility failed to ensure that an allegation of neglect for one resident (#1) was thoroughly investigated. The deficient practice could result in staff who may have neglected the resident being allowed to continue to provide care to additional residents, which could result in further neglect of residents. The sample size was one resident. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. An annual MDS (Minimum Data Set) assessment dated [DATE] included that the resident had severely impaired skills for daily decision making, was totally dependent on staff assistance from two or more staff for bed mobility, and totally dependent on one staff assist for hygiene. The assessment included that resident #1 had functional limitation in range of motion impairment on both right and left sides and upper and lower extremities, and had multiple active [DIAGNOSES REDACTED]. The assessment included that there were no indications or signs that the resident was experiencing pain. A written plan of care included that the resident has an ADL (Activity of Daily Living) self-care performance deficit related to musculoskeletal impairment, functional [MEDICAL CONDITIONS], [CONDITION]I ([MEDICAL CONDITION]), and incontinence. The care plan included multiple interventions including an intervention added to the care plan on July 13, 2018 that the resident has total dependence for bed mobility and required 2 person physical assistance, and required 1 person physical assistance for personal hygiene. A Nursing Change of Condition note dated November 25, 2019 at 3:41 p.m. included that an aide had informed the nurse (LPN/Licensed Practical Nurse, staff #278) that the resident's right arm had swelling and discoloration. The note included that staff #278 and another nurse (who was not identified in the note) looked at the resident's arm and confirmed the findings (that the resident's right arm was swollen and discolored). The note included that the physician was made aware, an X-Ray was ordered STAT (urgent or immediately) and that the resident did not have any signs of pain or distress. A Nursing Change of Condition note dated November 25, 2019 at 3:53 p.m. included that the physician and the day shift nurse had visualized the resident's right arm in the morning and the physician did not want the resident sent out (to the hospital). An Interact Change in Condition Evaluation dated November 25, 2019 included that the resident had swelling of the right antecubital (elbow), discoloration of the palm of the right hand, and swelling of the front of the right shoulder. The evaluation included that the resident had had an X-Ray with results of a right humerus fracture, the physician was notified at 4:47 p.m. and the resident was sent to the emergency department. Review of the state Agency data base revealed that an alleged injury of unknown origin had been reported to the State Agency on November 25, 2019 at 5:05 p.m. and included that the resident had a confirmed right humerus fracture, the resident was on a ventilator and suffered from a [MEDICAL CONDITION]. A Nursing Change of Condition note dated November 26, 2019 at 2:11 p.m. included that the resident had been sent to the hospital for [MEDICAL CONDITION] to the right upper arm and had returned to the facility with findings of an old fracture. Review of a facility investigative report regarding the injury of unknown origin reported on November 25, 2019 revealed a summary which included that on the morning of November 25, 2019 a nurse had noted that the resident's blood pressure was elevated, and had asked a CNA (Certified Nursing Assistant) to recheck the blood pressure. The report included that when the CNA rechecked the resident's blood pressure, she reported to the nurse that the resident's arm looked wrong and that nurse, after assessing the resident's arm notified the physician, who examined the resident and did not note any changes in the resident's right arm. The report included that later in the day at 2:45 p.m. a CNA who had showered the resident reported the findings two nurses, who assessed the resident and noted some redness and discoloration to the right upper arm,. The report included that the Physician was notified, and ordered and X-Ray, and when results of the X-Ray showed that the resident had a [MEDICAL CONDITION] humerus, the resident was sent to the hospital. The report included a conclusion that read it cannot be determined when this fracture took place but it can be assumed it occurred in or around 11/25/19 and Neither can it be determined how this fracture took place. The report also included in the conclusion that there was no evidence revealed as a result of the investigation of any intentional injury to, or abuse of the resident by employees of the facility. Review of the facility investigation regarding the injury of unknown origin reported on November 25, 2019 reveled the following written interview statements: -A written statement dated November 25, 2019 by a CNA (#314) included that after being assisted by another CNA (#64) to transfer the resident to a shower seat with a mechanical lift, he noticed that he was unable to clean under the resident's right arm, because he was unable to move the resident's arm, and he notified the nurse. -An investigation statement dated November 25, by an LPN (#278) included that on November 25, 2019 at an aide had informed her that the resident's right arm looked off and discolored, and that she and an LPN (#20) confirmed that the resident's arm appeared swollen, discolored and cool to touch. The statement included that the physician was notified, an X-Ray was ordered. The statement included that the X-Ray results were confirmed, and the resident was sent to the hospital. -An investigation statement dated November 27, 2019 by an LPN (#20) included that when passing morning medications, the nurse noticed that the resident's blood pressure was elevated and asked a CNA (#234) to re-check the blood pressure. The statement included that staff #234 then asked the nurse to look at the resident's arm before she attempted to re-check the blood pressure, and when the staff #20 assessed the resident's arm it didn't look right. The statement included that the staff #20 notified the physician, and the physician and the nurse (together) assessed the resident's arm. The statement included that later in the shift, the resident's (right) arm was swollen and discolored and that the physician had been notified. Further review of the facility investigation regarding the injury of unknown origin reported on November 25, 2019 revealed the following items not included in the investigation: -There were no witness statements included in the investigation from the CNA (#287) who had provided direct care to the resident or the night shift LPN (#336) on the over-night shift which began on November 24, and ended on November 25, prior to the morning medication pass when the injury was initially discovered by staff, who may have had knowledge regarding the source of the resident's fracture to the right humerus. -There were no witness statements included in the investigation from the CNA (#234) who was the staff who had actually been first to note the change in the appearance of the resident's right arm on November 25, 2019. -There were no witness statements from the CNA (#64) who had participated in the resident's care that morning , by assisting another CNA (#314) to move the resident onto a shower chair with a mechanical lift, who also may have observed a change in the resident's right arm. During an interview conducted on [DATE] at 10:50 a.m. with the Chief Executive Officer (#327), he stated that the information provided in the investigation reported on November 25, 2019 was the entire investigation and that there were no additional staff interviews that had not been included. An interview was conducted on December 9, 2019 at 8:55 a.m. with a Resource Nurse/staff #226. During then interview, #226 stated that she oversees investigations including the investigation of the injury of unknown source that occurred on November 25, 2019. Staff #226 stated that when conducts an investigation she interviews nurses, and asks staff what happened before, during and after the incident. Staff #226 stated that for the investigation of the injury of unknown origin she established a time frame and looked at the morning when the nurse asked the CNA/#234 to recheck the resident's blood pressure, and that the first person to observe that the resident's arm looked unusual was the CNA (#234) who re-checked the resident's blood pressure in the morning. However, staff #226 stated that she did not interview staff #234 because she was not in the building at the time she was conducting the investigation, however she could have interviewed her over the phone, and she did not. Staff #226 stated she did not interview any staff from the night shift because she felt there had not been an issue on the night shift, and that if anything had happened to the resident the nurse would have documented it in the progress notes, and there were no notes that anything unusual had occurred. When asked how she was able to rule out any unusual occurrences on the night shift without interviewing any staff on the night shift, staff #226 stated something that is a change in condition gets documented in the progress notes and I have no reason to believe that anything happened. During and interview conducted on December 9, 2019 at 10:42 a.m. with the Chief Executive Officer (#327), he stated that when an investigation is conducted they interview the employees who provided care to the resident. Staff #327 stated that regarding this particular investigation it was determined that the resident's injury had occurred the day that it was found by staff and that staff interviews needed to be conducted, including interviews of the night shift staff who provided care top the resident, prior to the day shift, which was when the injury was found. A policy and procedure titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property included a statement that abuse and neglect exist in many form and to varying degrees and the abuse and neglect included injuries of unknown origin, when the source of the injury was not observed by any person, or the injury could not be explained by the resident, or the injury is suspicious because of the extent of the injury, or the location of the injury. The policy included a statement that reports of abuse, including injuries of unknown source are promptly and thoroughly investigated, and that the investigative process is used to try to determine what happened.

Based on observations, clinical record review, resident and staff interviews, and policy, the facility failed to ensure one resident (#58) who needed respiratory care was provided care consistent with professional standards of practice. Findings include: Resident #58 was readmitted on (MONTH) 8, (YEAR), with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated (MONTH) 9, (YEAR) revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The assessment also included the resident was receiving oxygen therapy. Review of the physician's orders [REDACTED]. The care plan revealed the resident required oxygen therapy related to dyspnea and ineffective gas exchange with a goal of having no signs or symptoms of poor oxygen absorption. Interventions included giving medications as ordered by the physician, observing and documenting side effects and effectiveness, observing for signs and symptoms of respiratory distress and reporting to the physician as needed. During an observation conducted on (MONTH) 10, (YEAR) at 1:47 p.m., the resident was observed receiving 4 liters of oxygen per nasal cannula. Review of nursing notes dated (MONTH) 10, (YEAR) revealed no evidence the resident was receiving 4 liters of oxygen or that the physician was notified. During an interview conducted with the resident on (MONTH) 12, (YEAR) at 10:38 a.m., the resident was observed receiving oxygen at 4 liters via nasal cannula. The resident stated that she has been on oxygen for two years and that a couple of months ago the oxygen rate was changed to 4 liters. An interview was conducted on (MONTH) 12, (YEAR) at 11:01 a.m. with a licensed practical nurse (LPN/staff #101). Staff #101 stated that if a resident's oxygen saturation is 90% or less and/or the resident is having shortness of breath, nurses are to notify the physician for orders, implement the orders, and document the incident. After checking resident #58 oxygen rate, she stated that the rate may have been increased last night because of decreased oxygen saturation. The LPN reviewed the clinical record and stated the oxygen order is for 2 liters and that the resident should not be on 4 liters. An interview was conducted on (MONTH) 12, (YEAR) at 1:21 p.m. with a registered nurse (RN/staff #187). He stated that nursing staff are to follow physician's orders [REDACTED]. During an interview conducted on (MONTH) 12, (YEAR) at 1:39 a.m. with the Assistant Director of Nursing (ADON/staff #30), the ADON stated that if a change is made to a resident's oxygen rate, the nurse is expected to notify the physician and obtain orders to titrate the oxygen rate. An interview was conducted on (MONTH) 12, (YEAR) at 1:50 p.m. with the Director of Nursing (DON/staff#80), a nurse consultant (staff #313), and the Director of Quality Assurance (staff #248). The DON stated that the expectation is for the nursing staff to follow the physician's orders [REDACTED].#80 stated that if a resident begins to experience respiratory distress, nurses are to initiate oxygen therapy, notify the physician, complete a nursing assessment, and continue to monitor the resident's respiratory status. After reviewing the oxygen order, the DON stated that if the oxygen rate was increased to 4 liters, the expectation is that the nurse notify the physician. The facility's policy titled Oxygen Administration revealed oxygen therapy be administered upon a physician order [REDACTED]. The policy included to set oxygen flow rate as ordered. The policy also revealed in the absence of a physician's orders [REDACTED].

Based on clinical record reviews, hospital and medical examiner information, interviews, and review of facility policies, the facility failed to ensure the physician of one resident (#1) was fully informed of the resident's status throughout the day following a fall, resulting in a delay in necessary treatment and services and the resident's subsequent death. The facility also failed to ensure the phone number used by staff to notify the responsible party of the resident #1 was correct. Findings include: Resident #1 was admitted to the facility on [DATE] status [REDACTED]. A "late entry" nursing note from 9:20 a.m. on August 14 revealed the resident fell out of the wheelchair and hit his head, sustaining an abrasion to the right temple. The physician was notified of the fall, and neurological checks were started. According to the neurological sheet, at 12:30 p.m. the resident's status changed. His blood pressure (BP) increased to 238/125, his pulse increased to 75, the resident's level of consciousness changed from alert to agitated, and his speech went from confused to slurred. There was no indication the physician was made aware of these changes. A nursing note included that at 2:30 p.m., two hours after the initial change, the resident's BP was 236/125 and the physician was contacted. At that time [MEDICATION NAME] (antihypertensive) was ordered. The resident's BP remained elevated through the day, and he remained agitated with slurred speech. After another dose of [MEDICATION NAME] and a dose of [MEDICATION NAME] (antihypertensive), the physician ordered to have the resident sent to the emergency department since his BP was not being controlled. The paramedic report revealed that upon arrival, the resident was found unresponsive to painful stimuli and with pupils that were fixed. His BP was 215/118 with a pulse of 110. Hospital documentation revealed the resident presented in the ER unresponsive in a comatose state with fixed and dilated pupils. Noted was a contusion to the right side of his face that was red and swollen. He was subsequently diagnosed with [REDACTED]. Per an interview with a representative from the Office of the Medical Examiner, the resident's cause of death was [MEDICATION NAME] force trauma to the head, and the manner was accident. On October 6, the certified nursing assistant (CNA) who was assigned to care for this resident on August 14 was interviewed. He said the resident was lucid and talking clearly in the morning, he even asked the CNA to put the television to the History channel. In the afternoon the CNA noted the resident displaying a change in condition. According to the CNA the resident was no longer making eye contact or talking with him, and had become agitated, trying to take off his clothes and the bed sheets, which was unusual behavior. At the first sign of this change, which the CNA thought was at 3:30 p.m., the CNA asked the registered nurse (staff #1) if the resident was going to be sent out to the hospital, and was told the physician wanted to try to stabilize the resident with medications. Staff #1 was interviewed on October 6, 2010. He stated he had not noticed any change in the resident's condition from his baseline, and that the only issue of concern was the elevated BP. The physician was informed of the BP but since no "alarming" change was identified by this nurse, nothing else was communicated to the physician. He further said the agitation displayed by the resident, for which he administered [MEDICATION NAME], was not unusual for this resident. That was despite the evidence that prior to that day no behaviors had been documented. The shift supervisor was interviewed and said she had been in phone contact with the physician, providing information based on what staff #1 was telling her, and that staff #1 did not report any change in status beyond the increased BP. She further said she did not review the neurological check record prior to contacting the physician. On October 8, 2010, the physician was interviewed and said she had been called about the elevated BP but had not been informed of any mental status change. She was told by the nurse that the resident exhibited no change from his baseline. She said if she had been told about a change in speech or that the resident became agitated, it would have been a "trigger" that something serious may have occurred, and that different treatment was needed. The facility policy concerning changes in condition specified that a change in condition was expected to be identified through nursing assessment, and that the nurse was to notify the physician of the change in order to obtain treatment orders. In addition to the concern above, the responsible party of resident #1 was not made aware of the fall until she went to the facility to visit the resident, over three hours after the fall occurred. Documented in the nursing note was that the responsible party could not be contacted since the phone number on the face sheet was "out of service." The responsible party then told the nurse that the phone number he had been calling was an old one. Review of the Admission Information form revealed the correct phone number had been provided by the responsible party, but had not been transcribed onto the face sheet that was in the clinical record. Per the medical records director, as reported during an interview on October 6, the information on the face sheet had come from the document completed by the admission department with information obtained from the hospital. Once the Admission Information form was completed, her protocol was to compare that data with what was in the computer and make any necessary changes. A new face sheet would be printed and placed into the clinical record. A review of the computer system revealed the correct number was inputted. The medical records director said she was unsure what happened to the corrected form.

Based on clinical record and hospital record reviews, interviews, medical examiner information, and review of the Nursing Standards of Practice, the facility failed to ensure one registered nurse (staff #1) provided necessary monitoring and oversight to two residents, one of whom (#1) experienced a change in condition following a fall, and another (#4) who displayed suicidal behaviors. Both residents subsequently died . Also, the facility failed to ensure interim care plans were appropriate to meet the needs of three residents (#s 2, 6 and 7) concerning pressure ulcer development risk. Twelve residents were sampled. Findings include: -Resident #1 was admitted to the facility on [DATE] status [REDACTED]. Review of the daily vital sign monitoring form revealed the resident consistently had elevated blood pressure (BP), yet the diastolic read over 100 only once and the systolic routinely ran in the 160s or below. In addition, the resident was prescribed [MEDICATION NAME] (antianxiety) as needed, for anxiety evidenced by restlessness and the resident pulling on catheter lines and tubes. The Behavior Flow records for July and August show that through [DATE], the resident displayed neither of the monitored behaviors. In addition, through [DATE] the resident had not received any dose of the [MEDICATION NAME]. At 8:15 a.m. on [DATE], the resident fell and hit his head. Neurological checks were then done and recorded at regular intervals. However, the registered nurse responsible for the care of the resident (staff #1), completed the neurological form incorrectly, in that the area to code pupil reaction was not coded in accordance with the instructions. Pupils were to be "normal, sluggish, fixed or dilated." Staff #1 simply wrote "-" without explanation as to what that meant. At the time of the fall, the resident's BP was ,[DATE], speech was coherent and he was alert. Documented at 12:30 p.m., the resident's blood pressure rose to ,[DATE] and his pulse increased. His consciousness changed from alert to agitated and his speech became slurred. It was not until two hours later at 2:30 p.m., that the physician was made aware of a change in status, and then was only informed by staff #1 of the rise in blood pressure, not in the changes in mental status. The physician ordered [MEDICATION NAME] (antihypertensive) with accompanying instruction to send the resident to the hospital if the BP did not decrease. The [MEDICATION NAME] was administered. At 3:45 p.m. the physician was informed that the resident's BP remained elevated, and an order for [REDACTED]. Again, there was no evidence the physician was informed of the resident's ongoing mental status change, as the neurological sheet continued to show the resident was agitated and had slurred speech. Noted on the Behavior sheet was that the resident was both restless and pulling out his tubes. [MEDICATION NAME] was administered at 3:50 p.m. due to "agitation." Staff #1 administered the drug in the absence of any evaluation as to the causative factors of the behavior, particularly in light of the fact the resident had fallen and hit his head earlier in the day. The physician was called at 4:30 p.m. due to a BP of ,[DATE], and [MEDICATION NAME] was ordered. The resident's speech remained slurred and his consciousness was described as "calm," which was not one of the codes to be used on the neurological form. Therefore, staff #1 again failed to document the resident's status correctly, in addition to failing to fully inform the resident's physician of his total status. At 6:30 p.m. the resident's BP was ,[DATE], and the physician ordered the resident be sent to the emergency department (ED). At 7:15 p.m., he left the facility. The paramedic report revealed that upon arrival, they found the resident unresponsive to painful stimuli and with pupils that were fixed. His BP was ,[DATE] with a pulse of 110. Hospital documentation revealed the resident presented in the ED unresponsive in a comatose state with fixed and dilated pupils. He was subsequently diagnosed with [REDACTED]. Shortly before 11 p.m. he died . Per an interview with the Office of the Medical Examiner representative, the resident's cause of death was [MEDICATION NAME] force trauma to the head, and the manner was accident. Staff #1 was interviewed on [DATE]. He said he had not noticed any change in the resident's condition from his baseline, and that the only issue of concern was the elevated BP. He informed the physician of the BP, but since no "alarming" change was identified by the nurse, nothing else was communicated to the physician. He further said the agitation displayed by the resident, for which he administered [MEDICATION NAME], was not unusual for this resident. That was despite the evidence that prior to that day no behaviors had been documented. Also on [DATE], the certified nursing assistant (CNA) who was assigned to care for this resident on [DATE] was interviewed. He said the resident was lucid and was talking clearly in the morning. The CNA took the resident's vital signs throughout the day, and for the first few hours they were stable, but in the afternoon he noted the resident displaying a change in condition. According to the CNA the resident was no longer making eye contact or talking with him, and had become agitated, trying to take off his clothes and the bed sheets, which was unusual behavior. At the first sign of this change the CNA asked staff #1 if the resident was going to be sent out to the hospital, and was told the physician wanted to try to stabilize the resident with medications. The CNA then said that "even an unlicensed person" such as himself could identify the resident's change in condition and that he needed to be sent to the hospital. On [DATE] the physician was interviewed and said she had been called about the elevated BP but had not been informed of any mental status change. She was told the resident displayed no change from baseline beyond the increased BP, and that his neurological status was stable from prior to the fall. She said if she had been told about a change in speech or that the resident became agitated, it would have been a "trigger" that something serious may have occurred, and that hospital transfer would be appropriate. The decision to send resident #1 to the hospital that evening was based solely on the failure of the BP to respond to the medication. The purpose of monitoring neurological status according to the policy titled Observation of Neurological Signs was "to detect clinical manifestations of increased intracranial pressure." The procedure included assessing for changes in level of responsiveness, observing for restlessness and purposeless movement, and assessing the pupils for any changes. Changes were to be reported to the supervisor and physician. The Change of Condition policy included the purpose of the policy was, "to determine a change of condition through nursing assessment." According to the American Nurses Association Standards of Practice, standards of care included assessment which involved the collection of "comprehensive data pertinent to the patient's health or situation." The collected data was to then be analyzed to determine issues. Medication use was to be "based on clinical indicators, the patient's status needs, and the results of diagnostic tests." -Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a [MEDICAL CONDITION] (trach), and was assessed by a specialist to "...have difficulty surviving without her trach." The admission Minimum Data Set, dated dated dated [DATE], included [DIAGNOSES REDACTED]. Progress note documentation revealed the resident was attention seeking and would voice [MEDICAL CONDITION] of removing her trach, and that the resident did remove [MEDICAL CONDITION] to the incident that caused her death. The resident's behavior started to escalate on [DATE], in that she removed [MEDICAL CONDITION] "wanted to die." Staff successfully reinserted her trach, but the resident's behaviors continued. As a result of this incident, the resident was placed on 15 minute checks. The nurse's note dated [DATE], at 3 p.m., documented that the resident threatened to pull out her trach, that she wanted [MEDICAL CONDITION], and that she wanted to die. On [DATE], at 4 p.m., a nurse manager documented that the resident was threatening to pull out [MEDICAL CONDITION]. Documented was that the crisis team was called to evaluate the resident. Further documented was that the resident continued on 15 minute checks. On [DATE], at 5:05 p.m., the nurse manager documented that she was informed by the respiratory therapist that the resident was once again threatening to pull out her trach. The evening shift nurse's note dated [DATE], documented that the resident had been trying to pull out trach. Per the documentation, the resident reported that she was "going crazy" and that she wanted to go to the hospital. The social service progress note dated [DATE], documented that she was notified that the resident was voicing suicidal ideation and making attempts to pull out her trach. The progress note documented that she called the resident's counselor and requested that the crisis team be dispatched. The social worker documented that the resident made statements that she did not want to live, what's the point, that she wanted to go to God, and that if she had a razor she would end it. Further documented was that the resident was on 15 minute checks. The respiratory note dated [DATE], documented that the resident stated at 5 p.m. that she just did not want to live anymore and that she was going to pull out her trach. The therapist documented that he notified nursing staff members. The resident was seen by the crisis counselor note dated [DATE], at 8:30 p.m. Documented was that the resident was having [MEDICAL CONDITION] for the past two days. The option of emergency hospital transfer was discussed, however, the resident was not sent to the hospital and the 15 minute checks were continued. The nurse's note dated [DATE], at 12:55 p.m. documented that the resident was agitated and was calling out loudly and frequently. The next nurse's note was dated [DATE], at 3:45 p.m., and documented was that the resident was found with [MEDICAL CONDITION] at 3:20 p.m. The nurse documented that the resident was on 15 minute visual checks due to threats to extubate herself. The resident was not revived and her body was released to the county coroner. The cause of death was suicide by asphyxia. The certified nursing assistant who was assigned the resident's care the day of her death was interviewed on [DATE], and reported that he had not been informed of the resident's [MEDICAL CONDITION], or that she required frequent monitoring. The RN (staff #1) assigned the resident's care on [DATE] was interviewed and stated the resident was "very vocal, very needy" and "wanting people with her all the time." Staff #1 reported that he had seen the resident many times in the past with [MEDICAL CONDITION], twisted to the side and sometimes she had pulled at the plastic tube, but he had never had seen her actually pull [MEDICAL CONDITION]. Staff #1 was aware of the resident's threats to pull out her trach, and that he provided the every 15 minute supervision. Staff #1 stated that he did not engage in conversation with the resident on that day because there are "boundary issues between a caregiver and a patient." Despite the fact that staff #1 did not talk with the resident, in order to assess her needs, he stated that he did not feel she was suicidal and that 15 minute checks were adequate. The facility policy on nursing supervision included that nurses were to provide "quality care" to residents. Monitoring of residents was to be based on "the medical needs" of the resident and that "acuity levels of residents determine the time for monitoring and the level of supervision required." The Rules of the State Board of Nursing, effective [DATE], included the following as unprofessional conduct: "Failing to take action appropriate action to safeguard a patient's welfare..." Concerning the failure to develop appropriate interim care plans to meet the needs of three residents identified at risk for skin breakdown, the following information is pertinent. -Resident #2 was admitted on [DATE], status [REDACTED]. The Admission Nursing Review included both of the resident's heels were "pink," as was the right outer ankle, and no breakdown was noted. The admission nursing note included the coccyx, heels and ankles were free of breakdown. A Braden Scale was done and showed the resident was at high risk for pressure ulcer development. An interim care plan was put in place for pressure ulcer risk, yet failed to include any specific interventions staff were to implement to prevent skin breakdown. Admission physician orders [REDACTED]. The [DATE] MDS identified the resident's skin was desensitized to pressure, that pressure-relieving device was used in the bed, that a turning schedule was in place, and that protective skin care was being done. None of those interventions were identified on the interim care plan. Subsequently, the resident developed pressure ulcers to the left heel, bilateral buttocks, and bilateral heels. The interim care plan, which was the tool expected to be used by staff in addressing the resident's needs, was not updated to include the ulcers or the interventions, such as low air loss mattress or treatments. -Resident #6 was admitted on [DATE], and was identified at risk for skin breakdown. An interim care plan was initiated for pressure ulcer, yet like that of resident #2, it lacked specific interventions staff were to implement to prevent skin breakdown. Nine days later a pressure ulcer was identified to the left buttock. Despite the actual skin breakdown, the care plan did not reflect the ulcer or the interventions and treatments that were in place. -Resident #7 admitted to the facility on [DATE], with no skin breakdown. Admission physician orders [REDACTED]. An initial care plan was developed which indicated the resident was at risk for pressure ulcer development, yet no specific interventions were included on the care plan for staff to implement to minimize the potential for skin breakdown. On [DATE] a nursing note was written to reveal the resident had stage 1 and stage 2 pressure ulcers to the buttocks. A physician order [REDACTED]. The care plan did not reflect the actual breakdown or the treatment. A nurse was interviewed on [DATE] and said initial interim care plans were simply a check off sheet that were broad in spectrum. They were completed by the admitting nurse and may or may not include specific information regarding care and treatment to be provided to the resident. The physician order [REDACTED]. The director of nursing (DON) was also interviewed on [DATE]. She explained the initial care plan was to include the most pertinent areas for the nurses to focus on. The format of the care plans was a list of check boxes, and the nurse was to check the generic information, but that they would "just know" what interventions were in place, otherwise they were to refer to the physician order. Also, it was "not necessarily" expected that the initial care plan would be updated to be relevant, but that the permanent care plan presented the whole picture of the resident. The DON said that when the resident was first admitted staff would know what interventions were in place to care for the resident and they would not need to be specified on the initial care plan. Yet, once the resident had been in the facility for a while a more specific care plan was needed. However, she then said staff would not know the resident very well in the first 24 to 72 hours after admission. The policy covering interim care plans included staff were to "Determine the resident's most critical need and check off interventions with clarification as indicated. This will serve to provide care direction until the permanent care plan is completed...This should be filed in the chart so that staff have access for direction of care." The Wound Protocol policy included, "An interim plan of care for potential or actual risk of breakdown will be developed on admission and followed until the permanent plan of car (sic) is completed."

Based on clinical record review, hospital and medical examiner information, interviews, and review of facility policies, the facility failed to ensure that appropriate care and services were provided to one resident (#1) following a fall on [DATE] at 8:15 a.m., which resulted in a preventable delay in necessary treatment and services for a head injury, and the resident's subsequent death. Findings include: Resident #1 was admitted to the facility on [DATE] status [REDACTED]. Admission physician orders [REDACTED]. [MEDICATION NAME], another antihypertensive, was ordered on [DATE], in addition to the medications already in place. On [DATE], a telephone order was written for [MEDICATION NAME] as needed for anxiety evidenced by restlessness and the resident pulling on catheter lines and tubes. According to the July Behavior Flow Record the resident did not display any behaviors. Also, there was no documentation that [MEDICATION NAME] was administered that month. The Behavior record for August showed that through the 13th the resident did not display either of the monitored behaviors, restlessness and pulling on life-sustaining tubes. In addition, through [DATE] [MEDICATION NAME] was not administered. A "late entry" nursing note, written by staff #1, an RN, at 9:20 a.m. on [DATE] revealed the resident fell out of the wheelchair at 8:15 a.m. that morning. According to the facility's investigation of the fall, the resident fell on to a carpeted floor and sustained abrasions to the right outer canthus (edge of the eye) and right temple. No further assessment of the injuries was done. The physician was notified of the fall. Neurological checks were started after the fall. The resident's blood pressure (BP) at the time of the fall was ,[DATE]. Documentation on the medication record showed that the resident had received the morning doses of antihypertensive medications as ordered. Review of the daily vital sign monitoring form revealed the resident consistently had elevated BP, yet the systolic pressure routinely ran in the 160's or below, and the diastolic pressure read over 100 only once, normally reading in the 80's. Staff #1 did not correctly complete the neurological form, as the area to code pupil reaction was not coded in accordance with the instructions. Pupils were to be "normal, sluggish, fixed or dilated." The nurse simply wrote "-" without explanation as to what that meant. As noted on the neurological check sheet, at 10:15 a.m., one hour after the fall, the resident's systolic BP increased to 192, where it remained until checked at 12:30 p.m., at which time the BP had elevated to ,[DATE]. In addition to the high BP at 12:30 p.m., the resident's pulse had increased to 75, his level of consciousness changed from alert to agitated, and his speech went from coherent to slurred. There was no indication staff #1 took these changes into consideration or interpreted the results as changes, and thereby the physician was not made aware of this condition change. The next nursing note was not completed until 3:15 p.m., and recorded that at 2:30 p.m. the resident's BP was ,[DATE]. The physician was contacted and ordered 0.1 milligrams (mg) of [MEDICATION NAME] (fast-acting medication used to lower BP) to be given "now" with accompanying instruction to send the resident to the hospital if the BP did not decrease. The medication record showed at 2:50 p.m. the [MEDICATION NAME] was administered. It was nearly an hour later, at 3:45 p.m., that the physician was informed that the BP remained elevated at ,[DATE]. There was no evidence that during the hour interim any monitoring of the resident's condition, including mental status, was done. At 3:45 p.m. an order for [REDACTED]. Again, there was no evidence the physician was made aware of the ongoing mental status change, as the neurological sheet continued to show the resident was agitated and had slurred speech. In addition, there was no evidence staff #1 did a complete assessment of the resident's status including eye contact, speech content, and orientation to place and time. Noted on the behavior sheet was that the resident was both restless and pulling out his tubes. [MEDICATION NAME] was administered at 3:50 p.m. due to "agitation," in the absence of any evaluation of the potential causative factors of the behavior, particularly since the resident had not displayed any behavior previously, and had the fall earlier in the day. The physician was called at 4:30 p.m. due to a BP of ,[DATE]. It was not until 5:30 p.m. that any intervention was done, which was the administration of [MEDICATION NAME] (BP lowering medication used during hypertensive crisis). There was no indication that in the hour between placing a call to the physician and obtaining the order for Labetatol any specific monitoring or assessment was done. With the administration of [MEDICATION NAME], the resident had been given seven doses of antihypertenisve medication that day. Despite the level of use of that type of medication, staff #1 failed to assess the resident beyond his BP, and take into consideration the other neurological indicators which had changed. The resident's speech remained slurred and his consciousness was described as "calm," which was not one of the codes to be used on the neurological form. Therefore, staff #1 again failed to document the resident's status correctly. An hour later, at 6:30 p.m., the BP was ,[DATE], and the physician ordered the resident be sent to the emergency department. No documentation was found showing what and if anything was done for the resident in the interim while staff waited for the arrival of the paramedics. Per the paramedic report, the ambulance was dispatched at 6:48 p.m. and arrived at the facility at 7:01 p.m., at which time the resident was found unresponsive to painful stimuli and with pupils that were fixed. His BP was ,[DATE] with a pulse of 110. The facility documentation did not include the resident was unresponsive at any point. Hospital documentation revealed the resident presented in the ER unresponsive in a comatose state with fixed and dilated pupils. Noted was a contusion to the right side of his face that was red and swollen. He was subsequently diagnosed with [REDACTED]. Shortly before 11 p.m. he died . Per an interview with the Office of the Medical Examiner, the resident's cause of death was "[MEDICATION NAME] force trauma to the head," and the manner was "accident." On [DATE], the certified nursing assistant (CNA) who was assigned to care for this resident on [DATE] was interviewed. He said the resident was lucid and was talking clearly in the morning, he even asked the CNA to put the television to the History channel. The CNA was the person who took the resident's vital signs throughout the day. For the first few hours they were stable, but in the afternoon he noted the resident displaying a change in condition. According to the CNA the resident was no longer making eye contact or talking with him, and had become agitated, trying to take off his clothes and the bed sheets, which was unusual behavior. At the first sign of this change the CNA asked the nurse if the resident was going to be sent out to the hospital, and was told the physician wanted to try to stabilize the resident with medications. About an hour before being sent out to the hospital the CNA took a manual pulse and noted an irregular beat with periods of apnea; he reported that to the nurse. The CNA then said that "even an unlicensed person" such as himself could identify the resident's change in condition and that he needed to be sent to the hospital. Staff #1 was also interviewed on [DATE]. He said that he had not noticed any change in the resident's condition from his baseline, and that the only issue of concern was the elevated BP. The physician was informed of the BP but since he identified no "alarming" change, nothing else was communicated to the physician. When asked what would constitute a significant change that would be reported to the physician, staff #1 stated a change in respiratory status, complexion changes, diaphoresis, and skin temperature change. He failed to mention any change in level of consciousness or awareness. The nurse further said the agitation displayed by the resident on the afternoon of [DATE], for which he administered [MEDICATION NAME], was not unusual for this resident. That was despite the evidence that prior to that day no behaviors had been documented and no [MEDICATION NAME] had been given. The shift supervisor was interviewed the same day, and said she had been in phone contact with the physician based on what staff #1 was telling her, and that the nurse did not report and change in status beyond the increased BP. She further said the nurse completed the neurological sheet but that she did not review it prior to contacting the physician. On [DATE] the physician was interviewed and said she had been called about the elevated BP but had not been informed of any mental status change. She was told the resident displayed no change from baseline beyond the increased BP, and that his neurological status was stable from prior to the fall. She said if she had been told about a change in speech or that the resident became agitated, it would have been a "trigger" that something serious may have occurred, and that hospital transfer would be appropriate. The decision to send resident #1 to the hospital that evening was based solely on the failure of the BP to respond to the medication. The purpose of monitoring neurological status according to the policy titled Observation of Neurological Signs was "to detect clinical manifestations of increased intracranial pressure." The procedure included assessing for changes in level of responsiveness, observing for restlessness and purposeless movement, and assessing the pupils for any changes. Changes were to be reported to the supervisor and physician. The Change of Condition policy included the purpose of the policy was, "to determine a change of condition through nursing assessment." Procedure to follow included prompt notification to the physician in order to obtain treatment orders.

Based on clinical record reviews, interviews, hospital documentation review, observations and facility policy, the facility failed to ensure necessary care and services were provided to one resident (#2) to prevent the development of avoidable pressure ulcers and the subsequent deterioration of those ulcers. The facility also failed to ensure pressure ulcers for two other residents (#s 6 and 7) were identified timely and monitored appropriately. Seven residents with pressure ulcers were sampled, and 43 current facility residents had pressure ulcers. Findings include: -Resident #2 was admitted on [DATE], status [REDACTED]. The transfer physician orders [REDACTED]. The Admission Nursing Review included both of the resident's heels were "pink," as was the right outer ankle, and no breakdown was noted. The admission nursing note included the coccyx, heels and ankles were "free of breakdown." A Braden Scale was done and showed the resident was at high risk for pressure ulcer development. An interim care plan was put in place for pressure ulcer risk, yet failed to include any specific interventions staff were to implement to prevent skin breakdown. Admission physician orders [REDACTED]. On June 9, the weekly skin assessment showed no breakdown. The June 14 Minimum Data Set revealed was that the resident required total assistance with his activities of daily living. It also identified the resident's skin was desensitized to pressure, that a pressure-relieving device was used in the bed, that a turning schedule was in place, and that protective skin care was being done. Those interventions were neither identified on the interim care plan nor explained in further detail. The first mention of a skin issue for this resident was on a pressure ulcer flow sheet initiated on June 15, for a deep tissue injury (DTI) measuring 3.5 centimeters (cm) by 5.5 cm to the left heel. The noted treatment was to monitor the area and float the resident's heels. The telephone order included to monitor the DTI and report any changes to the physician, but did not include floating the heels. Also, what the "monitoring" was to consist of was not specified. No referral to the facility wound nurse was made at that time. Documented on June 20 on the weekly skin assessment form was that a large area of unblanchable skin was discovered to the buttocks, with a stage 2 pressure ulcer on each buttock. A pressure flow sheet was initiated for an ulcer to the sacrum and the left buttock, which showed the ulcer measured 10 cm by 15 cm with a wound bed that was "red and black," and had serosanguinous exudate. It was noted as a stage 2. The nursing ordered treatment was A&D mixed with zinc oxide to the buttocks and sacrum three times a day and as needed. A physician telephone order was written for the wound nurse to evaluate the buttocks wounds. It was not until the following day, June 21, that a flow sheet for the right buttock ulcer was initiated. The wound nurse progress note dated June 21 included the resident's left heel was "hardened black tissue, eschar?" That was six days after the area was discovered and identified as a DTI, with no documentation in the interim as to the deterioration of the ulcer. The progress note also recorded that on the right inner heel was a purple blister, and there was "[MEDICATION NAME] discoloration" to the sacrum that extended to the left buttock. The ulcer to the right buttock was identified as stage 3; the previous day it had been documented as a stage 2. There was no clarification as to whether the ulcer had deteriorated in that day or if it had initially been assessed incorrectly. Physician orders [REDACTED]. According to the pressure ulcer flow sheets, on June 21 the sacrum/left buttock ulcer was "unstageable," yet had been noted as a stage II the previous day, the left heel wound bed was obscured with "black leathery eschar," and the purple blister to the right inner heel was a "sDTI (suspected DTI)?" that measured 3.3 cm by 3.3 cm. The right buttock ulcer measured 3.0 cm by 2.0 cm. Review of the treatment record showed a lack of evidence that on June 21 through 25 the gel boots were used during the 3 p.m. to 11 p.m. shift. Included in a June 23 nursing note was that the resident's heels continued to decline, and that a Clinitron Rite Hite bed was being considered. A physician evaluated the resident's ulcers on June 24, and questioned if all four were DTIs. However, as noted above, the left heel ulcer was covered with eschar, the sacrum/left buttock had originally been staged a II, and the right buttock ulcer wound bed was granulation tissue. Also on June 24, a permanent care plan addressing the pressure ulcers, and including the treatments and interventions, was put in place. That was nine days after the first ulcer was discovered. On June 28 the wound nurse wrote the left heel wound bed continued to be obscured by eschar, and the right inner heel, previously suspected to be a DTI, was unstageable due to the wound bed now being completely covered by eschar. The sacrum/left buttock ulcer was unstageable as the wound bed was now covered with slough, and previously was "[MEDICATION NAME]." Also, the right buttock ulcer, which the previous week had a wound bed of granulation, was now covered 25% with slough. In addition, a new ulcer was discovered to the left inner heel; that too was noted as a sDTI. The resident was sent to the hospital on June 28 per the request of his family. Provided by the facility was an investigation of the development of this resident's pressure ulcers to the buttocks and heel (which heel was not specified). Other than a turning/repositioning program (parameters unspecified) and the use of nutritional supplements, the investigation failed to identify the lack of preventative measures provided to the resident. The interventions that were identified were those that were put in place on June 21, six days after the first discovery of skin breakdown. The conclusion determined from the nurse's investigation was that the resident was experiencing a change in condition in the 72 hours leading up to the skin breakdown. That was based on orders for lab tests, fluid replacement, and a chest x-ray in addition to an "increase" in his blood glucose. How the link between a possible acute illness and skin breakdown was made was not explained. During an interview on October 6, the wound nurse explained the procedure followed for the identification and treatment of [REDACTED]. She, the wound nurse, then reviewed all admission forms, and if she identified any concerns she would follow up with the floor nurse. Regarding resident #2, after looking at the admission skin assessment during the interview, she said the "pink" heels and ankle would have been a concern, yet she failed to intervene. Due to his high risk for breakdown and pink heels, the resident "should have" had Premium Posey boots (he did not receive these until after heel ulcers had already developed). She then said the first time she saw this resident was on June 21. Concerning bed surfaces, the wound nurse said the standard mattress provided to all residents was sufficient for someone with up to a stage 3 pressure ulcer, but for someone with more than one ulcer or with an ulcer greater than stage 3, a special surface, such as a low air loss mattress or Clinitron Rite Hite bed, would be needed. When asked about her role in prevention she said she did not play a direct role, but that basic precautions were taken such as repositioning, weekly skin assessments, and Braden scale completion. She also had no role in the development of the interim care plans. -Resident #6 was admitted to the facility on [DATE] status [REDACTED]. A Braden Scale completed on admission revealed the resident was high risk for pressure ulcer development. The Admission Nursing Review skin assessment revealed the resident had no pressure ulcers. An interim care plan was started which addressed the resident's risk for pressure ulcer development, however there were no interventions specified to be done to prevent the resident from ulcer development. Due to missing the right side of his skull the resident was to be positioned on his left side only, per physician order. Despite this order, and that he was at high risk for skin breakdown, further assessment of his needs and the consideration of a specialized repositioning program and/or an alternate bed surface was not done. Nursing notes included only that the resident was positioned from his left side to his back and vice versa. The first identification of skin breakdown was on August 15 when, according to a nursing note, a "red and purple area" with the "top layer" of skin removed was noted to the left buttock. Santyl was ordered as treatment. This was reported to the wound nurse. On August 23 a permanent care plan was put in place, and rather than a specific repositioning program given the restrictions placed on the resident, the care plan included to turn and position every two hours and as needed, not mentioning the restriction of the right side. Until August 28 there was no documentation about the condition of the left buttock ulcer. Then on that date the physician wrote that the ulcer's wound bed was obscured by eschar and slough. It remained that way until September 16 when the physician sharp debrided it. Eschar and slough remained in the wound bed through September 23, and slough was present until the time of the survey. In addition to the left buttock, on September 15 a large area of shearing, measuring 7.0 cm by 3.7 cm, was present to the left hip. Again, no specific program was implemented addressing the inability to position the resident on his right side. By September 23 the resident had developed five total pressure ulcers, to the left buttock, hip and heel, and right outer and inner heel. The depth of the three new ulcers, to the left and right heels, was unable to be determined according to the physician documentation. There was no explanation as to why the depth could not be determined. On September 29 the wound nurse documented the resident had been to the emergency department on September 24 and 27, for over four hours each time, to have a [MEDICAL TREATMENT] catheter changed. The note included that after the resident returned on September 24, "unable to complete evaluation of ulcers (secondary to) no wound nurse on weekends." Also included in that progress note was that another four pressure ulcers were identified, to the left outer heel, left lateral ankle, right inner mid-foot, and right fifth metatarsal. Three of the four had eschar present; the fourth was a sDTI. Without the comprehensive skin assessment upon the resident's return from the hospital on either day, it cannot be assumed the ulcers developed during that time. The certified nursing assistant assigned to care for this resident on October 7 was interviewed that day. She stated the resident could not lie on his right side due to his skull, but that no individualized program was in place for repositioning, only that a Clinitron bed was now in use. She further had no knowledge of the resident's ulcers other than the one to the sacrum. When interviewed on October 7 the wound nurse stated the resident's extensive and rapid breakdown occurred while he was in the emergency department on two days. She also explained that all of the nurses did skin assessments and treatments and referred any new breakdown to her. -Resident #7 admitted to the facility on [DATE], with no skin breakdown according to the Admission Nursing Review. However, a nursing note upon admission indicated there was some skin breakdown but without specific information as to what type of breakdown was observed, or where it was located. Admission physician orders [REDACTED]. An initial care plan indicated the resident was at risk for pressure ulcer development, yet no specific interventions were documented to minimize the potential for skin breakdown. On September 27 a nursing note was written to reveal the resident had stage 1 and stage 2 pressure ulcers to the buttocks. Per the flow sheets, both ulcers' wound beds were pink. A physician order [REDACTED]. No evidence was present in the clinical record that the treatment was done on September 30 or October 5. Documentation on the flow sheets on October 7 revealed the two ulcers had joined and now had a wound bed completely covered with eschar and slough. No change in treatment was obtained despite the deterioration of the ulcer. The unit manager and charge nurse were interviewed on October 7. They said the ulcers were present on admission, but were unable to provide any evidence of that. Further they said a registry nurse had completed the admission nursing review form and that whenever a registry nurse did that form one of then would go and do another skin assessment. They were also unable to provide documented evidence that a second assessment was done. The wound nurse, during an interview on October 6, explained the facility wound care program, specifying that she was only involved with pressure-related ulcers. The nurses on each unit performed the daily treatments, with the wound nurse making rounds twice a week, once to measure the ulcer and once with the physician. The physician assessed the ulcers, particularly stage 3 and above. RNs assessed the ulcers the physician did not. The wound nurse did not visualize the skin of every newly admitted person, only those whose initial skin assessments presented some concern. However, if the initial skin assessments were incomplete or inaccurate, she would not know unless, at a later time, the resident developed breakdown and was referred to her. The Wound Protocol policy included, "The Wound Protocol will be followed to assure timely and complete assessment, treatment, and that healing occurs per MD order." The wound QA nurse was to document a progress note for all newly admitted resident, identifying "all areas of risk and areas of strength along with preventative interventions." The QA wound nurse was expected to stage all pressure ulcers.

Based on clinical record review, interviews, and facility documentation review, the facility failed to ensure that one resident (#4) who displayed mental and psychosocial adjustment difficulty, including expressing thoughts of suicide and making previous threats and attempts to remove her [MEDICAL CONDITION] (trach), received appropriate treatment and services, in order to reduce or correct the resident's behaviors and prevent the resident from removing [MEDICAL CONDITION], which resulted in her death. Findings include: Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident received respiratory services, [MEDICAL CONDITION]. The resident was evaluated by an ear, nose, and throat specialist who documented that the resident [MEDICAL CONDITION] "and will be so indefinitely." The resident had "marked flaccidity of the hypopharynx and the palate with complete collapse on inspiration." Documented also was, "Looking at the patient exteriorly, she would have difficulty surviving without her trach." The admission Minimum Data Set (MDS) assessment dated [DATE], reflected the resident was oriented, required extensive to total assistance with functional activities, and had [DIAGNOSES REDACTED]. The corresponding Resident Assessment Protocol summary dated [DATE], identified the resident's "constant attention seeking behaviors," and lack of motivation to participate in care routines. Included was for the resident to receive a psychological follow-up. Care plans were developed on [DATE]. The care plan regarding the risk for altered psychosocial well-being was related to negative attitude towards placement, being withdrawn, and drug-seeking behaviors. Goals included for the resident to verbalize coping mechanisms regarding psychosocial well being, for the resident not to harm herself or others, and that the resident would respond positively to 1:1 visits as needed. The interventions were to be provided by social services and activities. Specifically, social services was to "allow & encourage resident to verbalize feelings; discuss ways of coping, support groups, etc; encourage activity participation; provide resources or information, and to provide psych services as needed. Another care plan identified the resident's moods interfering with daily routines, with the goal for the resident to exhibit three or fewer "moods" weekly. Interventions included for social services to provide "support visits" to address the resident's mood and allow the resident "to vent," and to "listen attentively and attempt to resolve the area of upset." There was no care plan regarding the resident's constant attention seeking behaviors, and there was a lack of evidence that staff were implementing the care plan interventions. The resident received ongoing visits from a psychiatric (psych) nurse practitioner (NP) for medication management (the resident was prescribed [MEDICAL CONDITION]), but there was no evidence that the resident was ever evaluated by a psychiatrist or a psychologist. The NP would document the resident's psych behaviors and recommend behavioral approaches for staff, but there was no evidence that staff care planned these behaviors and recommendations, or were trained on the behavioral approaches,as this facility did not have a behavior unit. The resident was prescribed [MEDICAL CONDITION] which were often not care planned. There was also conflicting documentation regarding the resident's diagnoses, as the NP would consistently diagnose Borderline Personality Disorder, while physician documentation indicated [MEDICAL CONDITION] Disorder. The summation of the NP's behavioral documentation included the following: -[DATE]: The NP documented the resident was feeling depressed, anxious, and "not herself." Also documented was that the resident "is frustrated, but not suicidal due to situation." -February 11, 2010: The NP documented that the resident had chronic psychosocial issues and poor coping mechanisms "which lead to further impaired mood and inability to tolerate anything uncomfortable." The NP also referenced "counseling" visits being provided the resident, to help the resident with feeling hopeless regarding her illness. -February 24, 2010: The NP documented that the resident was seen per request due to recent appearance of [MEDICAL CONDITION] activity, but that it was thought to be a pseudo-[MEDICAL CONDITION], which was documented to be "not uncommon behavior in personality disorders." The NP documented the resident was recently upset about not being moved to a facility closer to family. The resident was tearful, anxious, and stated that she "is ready to die;" however, the NP assessed the resident to not be suicidal and to have no intent or plan. The resident was also assessed to have poor coping skills, chronic difficulty in relationships, and thrived on negative attention. -[DATE]: The NP documented that the resident was doing better overall, but was "down and frustrated" regarding ventilator use. -[DATE]: The NP questioned the [MEDICAL CONDITION] Disorder diagnosis (versus Borderline Personality Disorder) and questioned the effectiveness of a prescribed antipsychotic. The NP documented that the resident was going to continue to display manipulative attention seeking behaviors and that in addition to counseling, the resident needed structured conversations and for staff not to "play into any games." -[DATE]: The NP documented that the resident continued to present with behavioral issues that were often with certain staff members and she had staff that she preferred. The NP documented that this type of behavior was not unusual for someone with a personality disorder, and recommended that staff should avoid making comments or conversation about other staff members in her presence. -[DATE]: The NP note reflected that staff reported the resident was having outbursts of crying spells and asking to go home. The resident also continued to have behavioral issues with certain staff and would try to split staff. The resident was also evaluated by an outside emergency crisis representative on several different occasions due to escalated mood/behaviors that impacted her health and safety, and received routine "counseling" services through another outside behavioral health company. A "counselor" visited the resident 14 times from February 10 through [DATE]. The counselor routinely did not leave any progress notes, in order to ascertain the focus of the counseling, the resident's response, and the effectiveness. Documented on [DATE] was that the counselor met with staff to address the resident's negative attention seeking behaviors and lack of motivation, but there was no evidence of staff training or education on behavioral responses. An emergency crisis representative evaluated the resident on February 6, 2010, due to the resident having increased tearfulness and demands for pain medication, as well as making statements that she wanted to pull out her trach. Documented was her history of a previous suicide attempt years ago. Counseling was recommended for chronic depression. The crisis representative evaluated the resident on [DATE], due to [MEDICAL CONDITION]. Documented was that during the evaluation, the resident again threatened to pull out her trach, stating that she could do it "right now." The resident reported not wanting to live anymore, that she was really lonely, and that for the past two days she had suicidal thoughts of wanting to pull out her trach. The crisis counselor documented that she spoke with the resident's routine counselor, who reported that the resident "will experience [MEDICAL CONDITION] from time to time and then she will be fine within a couple of hours." Social services notes were reviewed and revealed a lack of ongoing support and monitoring of psychosocial issues for the resident's well-being. The social services note of [DATE], included that the resident received 1:1 activity visits. Documented was that the resident exhibited agitation, yelling out, and refusing care. There was no documentation that the social worker visited with the resident to provide psychosocial support, as identified in the care plan as encouraging the resident to verbalize feelings, "vent," or discuss with the resident ways of coping and support groups. Further, there was no evidence that the care plan was updated to reflect agitation and yelling, nor was any behavioral monitoring initiated. The social service noted dated [DATE], documented that the resident was upset regarding the discharge of her roommate. Documented was that the social worker reminded the resident "to use encouragement to work hard towards going home." Also documented was that the resident talked about her progress, but "always" followed her progress with negative statements. There was no evidence of implementation of the social service interventions of discussing ways of coping, or providing more support visits. Nursing notes also revealed a lack of evidence that appropriate care was being provided the resident for psychosocial issues: The nursing dated [DATE], included that the resident had behavioral "issues" of calling out, argumentative speech, and "disregard for her own safety." Documented was a reinforcement of "safety issues and dialog" with the resident was "ongoing." There was no documentation as to what behaviors the resident was exhibiting that put her at safety risk. The nurse's note of [DATE], reflected "behavior difficulties" of calling out, hanging onto the overbed table, and "argumentative demeanor." There was no documentation of staff response to the resident's behaviors, nor was any behavioral monitoring implemented. The nurse's note dated [DATE] at 8 p.m., documented that the resident was pulling at her trach, complaining that it hurt, and that she did not want it anymore. Per the note, the nurse and respiratory therapist (RT) explained to the resident that she continued to need [MEDICAL CONDITION] she was receiving supplemental oxygen through it. The resident was noted to complain of shortness of breath and was very anxious. A one time order for [MEDICATION NAME] was obtained, for an anxiety attack. The resident pulled out [MEDICAL CONDITION] [DATE]. Documented in the facility's incident/accident report was that the resident was found by the nurse with [MEDICAL CONDITION] her hand at 3 p.m. Per the report, the resident stated she would pull out [MEDICAL CONDITION] if it was reinserted, but staff did reinsert it. The incident/accident report contained an area for additional comments and/or steps taken to prevent recurrence, but this was left blank. The areas for notification of physician and family was left blank also. The RT note of [DATE] documented the resident pulled [MEDICAL CONDITION] at 3 p.m., because she wanted to die. The RT documented that [MEDICAL CONDITION] reinserted, but not before the resident threatened to pull it out again. The late entry nurse's note dated [DATE] at 3 p.m., included the resident was in bed at 3 p.m. the previous day, and as the nurse walked past the room, the resident called out that she was going to pull out her trach. The nurse documented that as she turned and walked into the room she found [MEDICAL CONDITION] the resident's hand. [MEDICAL CONDITION] replaced by the RT and the unit manager placed the resident on 15 minute checks. The care plan that addressed the resident's moods of depression and anxiety was revised on [DATE], to include the problem of "[MEDICAL CONDITION]." The goal was for the resident to verbalize feelings to decrease suicidal ideation. Approaches included to follow psych recommendations, but the specific recommendations were not listed. There were also new interventions of providing 15 minute checks, "to ER for consult if pt (resident) pulls @ trach," and "Enclude (sic) family support." The resident's behaviors continued to escalate: The nurse's note dated [DATE] at 3 p.m., documented that the resident was threatening to pull out her trach, and that she was noted by staff to "slowly move hand toward trach" and would withdraw her hand when staff started to intervene. The resident was documented to tell staff that she wanted [MEDICAL CONDITION], and wanted to die. The crisis psych service representative was notified of the behavior. Documented also in the nurse's note was that when staff were not watching the resident, she made no attempts towards pulling her trach. Also, it was documented that the resident's family member was notified of the incident and was asked to come to sit with the resident. The nurse documented that the resident was on 15 minute checks and that the resident would be monitored. There was no documentation that a family member ever came to the facility to sit with the resident, or that other interventions were provided the resident to address her psychosocial needs. The social service progress note dated [DATE] documented that the resident was voicing suicidal ideation and making attempts to pull out her trach. Documented was that the social worker called the resident's counselor and requested that the crisis representative respond. The social worker documented that the resident made statements she did not want to live ("what's the point"), that she wanted to go to God, and that if she had a razor she would "end it." On [DATE] at 4 p.m., the unit manager nurse documented that she responded to the resident's threats to pull out her trach. The crisis team was contacted and an emergency intervention and psych evaluation was requested. Documented was that the nurse and the social worker took turns sitting with the resident, until the crisis counselor arrived. The next nursing entry, completed at 4:30 p.m., included that the physician was notified and the 15 minute checks continued. The nursing entry completed at 5:05 p.m., included that the RT reported the resident was again threatening to pull out her trach. The nurse responded to the resident, who requested an increase in pain medication and antianxiety medication. The nurse documented that the physician was contacted and declined the resident's request. There was no evidence of any psychosocial interventions or behavioral management. Further, closer supervision was not provided by staff. The RT note of [DATE] at 5:20 p.m., reflected the resident's intent to pull out her trach, and "I just don't want to live anymore." On the evening of [DATE], a nursing note revealed the resident's assigned certified nursing assistant (CNA) reported the resident was trying to pull out [MEDICAL CONDITION] that she kept saying she "is going crazy and wants to go to the hospital." Also documented was the resident's increasing agitation and that she was throwing items "out the door." At 9 p.m. that night a nurse's note included that the crisis counselor was in to see the resident, but the resident asked her to leave, threatened again to pull out her trach, and requested a sleeping pill, (which was given). After consultation staff, the crisis counselor documented the recommendation for hospital transfer. Also documented was the concern with "petitioning" the resident, and therefore the decision was made to keep the resident in the facility with ongoing 15 minute checks and that staff were to "play it by ear." The social service note dated [DATE], documented that she asked the counselor if she had left any notes in the chart, since she had been out to see the resident on Thursday ([DATE]). The counselor stated that she did "not leave notes on the chart due to privacy." A nurse's note from [DATE], included the resident was agitated, calling out loudly and frequently, every ,[DATE] minutes. There was no evidence that the resident's mental and psychosocial needs were evaluated and addressed. Noted by an RN (staff #1) on [DATE] was that the resident was on 15 minute visual checks due to threats to extubate herself, and that she was found with [MEDICAL CONDITION] out at 3:20 p.m. A full code was called and cardiopulmonary resuscitation initiated. The resident was not able to be resuscitated and her body was released to the Office of the Medical Examiner. The official cause of death, as reported by the representative at the Medical Examiner's office, was suicide by asphyxia. The facility reported this incident to the state survey agency (SA), and their report indicated that the resident's psych behaviors of attention seeking with threats to remove [MEDICAL CONDITION] being assessed, monitored, and responded to appropriately. However, the review of the resident's clinical record revealed a lack of specific behavioral care plans, a lack of the care plans being updated with pertinent information, a lack of evidence that the psych NP's behavioral recommendations were being implemented, a lack of behavioral monitoring, a lack of evidence that direct care staff were able to meet the resident's behavioral needs, and a lack of appropriate oversight of counseling services. Further, there did not appear to be appropriate rationale to manage this resident's psychosocial needs in the facility, versus the hospital. Nursing staff were interviewed during the investigation, and they reported that the resident had attention-seeking behavioral issues of frequent call light use and staff splitting. The nurses were aware of the resident's threats to remove her trach. During an interview with the social worker (SW) conducted on [DATE], she stated that on the afternoon of [DATE], she talked with the resident who was "down and suicidal." The SW stated that the whole time she was with the resident the resident stated she wanted to die and was threatening to pull her trach. The SW reported that the resident's attention seeking behaviors had increased over the previous four weeks, and that for the past week or two the resident's mood was on a "down slide." The SW stated that there were discussions of a 1:1 sitter, but that this was not provided. She also said the resident liked 1:1 attention. The nurse who worked the day shift on [DATE] was interviewed and stated that the crisis counselor was notified as the resident threatened to pull out her trach. This nurse stated that she talked with the resident a couple of times throughout the day and that the resident was upset because her family members did not come to see her. This nurse stated that the resident "maybe needed someone to talk to." On [DATE], a telephone interview was conducted with the weekend RN supervisor who worked on [DATE] and 22. The RN supervisor stated that the resident would make comments that she would pull out [MEDICAL CONDITION] then say that she would not do it. She further stated that the resident was on 15 minute checks and that 1:1 supervision was not provided because the resident was "not doing anything" at the time to warrant closer supervision. This RN stated that the resident "just wanted attention" but also added that she did not provide direct care and had not personally talked with the resident that day. A CNA who had cared for the resident on [DATE], was interviewed, and stated that she did not believe the resident would really pull out her trach. The CNA stated that the resident had been more depressed, isolative, and withdrawn the previous few weeks because the family was not visiting. The CNA confirmed the 15 minute checks, and also stated that the facility did provide 1:1 sitters in the past, for a resident at risk for falls, but not to this resident. The psych NP was interviewed, and stated that she could not recall if she was notified that the resident pulled out [MEDICAL CONDITION] [DATE]. The NP stated that the resident had "messed" with [MEDICAL CONDITION] months and that she was impulsive and attention seeking secondary to her borderline personality disorder. The NP stated that the resident required more behavioral management, but that it was her opinion that the resident was never suicidal and that she did not think the resident's death was intentional. The CNA who had cared for the resident on [DATE], the day the resident expired, was interviewed and stated that he worked a 16 hour shift that day and had not been told that the resident was suicidal or on 15 minute checks. The respiratory therapist (RT) assigned the resident on [DATE], was interviewed and stated that the resident had threatened and made gestures to remove [MEDICAL CONDITION] [DATE], and again on the day shift on [DATE]. Per the RT, she reported the resident's threats and gestures to the RN on duty (staff #1). The therapist further stated that she checked on the resident more frequently than every 15 minutes due to being very concerned about the resident's safety. Staff #1 was interviewed and reported that he had seen the resident many times with [MEDICAL CONDITION] or twisted to the side, and sometimes she had pulled at the plastic tube, but he had never had seen her actually pull [MEDICAL CONDITION]. He stated that she would put on her call light and ask the RT to reposition the trach. Staff #1 stated that he often cared for the resident, that she was very vocal, very needy and wanting people with her all the time. Staff #1 stated that he did not engage the resident in conversation on [DATE], due to "boundary issues between a caregiver and a patient." Staff #1 stated that he did not feel the resident was suicidal even though he had not interacted with her. A representative from the crisis team was interviewed telephonically, and reported was that a counselor or a social worker would be dispatched to assess and evaluate the resident. He stated that they are only consultants and that it was ultimately the facility's responsibility to monitor and ensure the resident's safety. Administrative staff were interviewed and considered the resident's needs as being met, through the provision of counseling and psych services provided.

Based on clinical record review, hospital record review, paramedic record review, staff interview and review of facility records, the facility failed to provide the necessary supervision and services to prevent one resident (#4) from removing her tracheostomy (trach) despite a history of self decannulation and suicidal ideation, which resulted in her death. Findings include: Resident #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required a tracheostomy (trach), and per the evaluation by an ear, nose, and throat specialist, was trach dependent "and will be so indefinitely." The resident had "marked flaccidity of the hypopharynx and the palate with complete collapse on inspiration." Documented also was, "Looking at the patient exteriorly, she would have difficulty surviving without her trach." The admission Minimum Data Set, dated dated dated [DATE], included [DIAGNOSES REDACTED]. The resident received behavioral services from an emergency crisis intervention company, and ongoing visits from a nurse practitioner and a counselor. Progress note documentation revealed the resident was attention seeking and would voice suicidal ideations of removing her trach, and that the resident did remove her trach prior to the incident that caused her death. The resident's behavior started to escalate on [DATE], in that she removed her trach. Staff successfully reinserted her trach, but the resident's behaviors continued. The facility's incident/accident report documented that the resident was found by the nurse with her trach in her hand on [DATE] at 3 p.m. Per the report, the resident stated that she would pull out the trach again if it was reinserted. Regarding this incident, the respiratory progress note (dated [DATE]), documented the resident stated that she pulled out her trach because she wanted to die. The trach was reinserted, but not before the resident threatened to pull out the trach again. The nurse's note dated [DATE], at 3 p.m., revealed a late entry for [DATE], at 3 p.m., and included that the resident was placed on 15 minute checks. The nurse's note dated [DATE], at 3 p.m., documented that the resident threatened to pull out her trach and she would slowly move her hand toward her trach; however, when the nurse placed her hand on the resident the resident would pull her hand away from the trach. The resident did verbalize to staff that she wanted the trach out and that she wanted to die. Further documented was that the nurse notified the resident's family member and requested that someone sit with the resident. The resident's family member stated that he would see if he could make it. The nurse documented that the resident was on 15 minute checks and that the resident would be monitored. There was not documentation that a family member ever came to the facility to sit with the resident. On [DATE], at 4 p.m., a nurse manager documented on the nurse's that she spoke with the resident that she had been informed of her threats to pull her trach "out again." Documented was that the crisis team was called to evaluate the resident. Administrative further documented that the resident continued on 15 minute checks and that the resident's family member was called and asked if he would sit with the resident. On [DATE], at 5:05 p.m., the nurse manager documented that she was informed by the respiratory therapist that the resident was once again threatening to pull out her trach. The evening shift nurse's note dated [DATE], documented that the resident had been trying to pull out trach. Per the documentation, the resident reported that she was "going crazy" and that she wanted to go to the hospital. The social service progress note dated [DATE], documented that she was notified that resident #4 was voicing suicidal ideation and making attempts to pull out her trach. The progress note documented that she called the resident's counselor and requested that the crisis team be dispatched. The social worker documented that she remained at the resident's bedside and that the resident would reach up to pull out her trach; however, she was easily redirected. The resident made statements that she did not want to live, what's the point, that she wanted to go to God, and that if she had a razor she would end it. Further documented was that the resident was on 15 minute checks. The respiratory note dated [DATE], documented that the resident stated at 5 p.m. that she just did not want to live anymore and that she was going to pull out her trach. The therapist documented that he notified nursing staff members. The crisis counselor note dated [DATE], at 8:30 p.m., documented,the resident was seen for suicidal ideation, having had the ideation for the past two days. Documented was the option of emergency hospital transfer; however, the resident was not sent to the hospital and the 15 minute checks were continued. The nurse's note dated [DATE], at 12:55 p.m. documented that the resident was agitated and that she complained of stomach pain for which she was given an analgesic. The resident stated that she needed to go to the hospital and after being administered the analgesic stated that she thought she could stay in the facility. The resident was calling out loudly and frequently. The next nurse's note was dated [DATE], at 3:45 p.m., and documented was that the resident was found with her trach pulled at 3:20 p.m. The nurse documented that the resident was on 15 minute visual checks due to threats to extubate herself. The resident was not revived and her body was released to the county coroner. The cause of death was suicide by asphyxia. Staff were interviewed on [DATE], and staff consistently stated that they were aware of the resident's behaviors and threats to remove her trach, but that this behavior was attention seeking and that they had not considered that the resident would actually remove her trach (despite the resident previously removing her trach). The social worker stated that on [DATE], the resident was "down and suicidal" and threatening to remove her trach. This staff member stated that the resident was placed on 15 minute checks and that there was talk of a 1:1 sitter; however, one was not provided. She stated that the resident did like 1:1 attention. During a nurse interview, it was reported that on [DATE], she had talked with the resident a couple of times, and that the resident was upset, and that maybe the resident "needed someone to talk to." This nurse stated that 15 minute checks were implements, and that 1:1 supervision was "not indicated." The nurse supervisor (who had been on duty [DATE] and [DATE]) stated that the resident would make comments that she would pull out her trach and then say that she would not do it. She further stated that the resident was on 15 minute checks and that 1:1 supervision was not provided because the resident was not doing anything at the time to warrant one. She further explained that the resident "just wanted attention;" however, she admitted that she did not provide direct care and had not personally talked with the resident that day. The CNA who had cared for the resident on [DATE], stated that the resident threatened several times and she made gestures as if she were going to pull out her trach on the evening shift. This CNA stated she could not believe the resident "actually did it" and reported that the resident had been more depressed, isolative, and withdrawn the past few weeks. The CNA who was assigned the resident's care on [DATE], stated that he worked a 16 hour shift that day and that he was not told that the resident was suicidal or on 15 minute checks. The respiratory therapist assigned to resident #4 on [DATE] was interviewed, and stated that the resident threatened and made gestures to remove the trach on [DATE], and again on the day shift on [DATE]. Per the therapist she reported the resident's threats and gestures to the RN assigned the resident (staff #1). The therapist further stated that she checked on the resident every 5 minutes due to being "very concerned about the resident's safety." The RN (staff #1) assigned the resident's care on [DATE] was interviewed and stated the resident was very vocal, very needy and wanting people with her all the time. Staff #1 reported that he had seen the resident many times with her trach misplaced, twisted to the side and sometimes she had pulled at the plastic tube, but he had never had seen her actually pull the trach out. He stated that he did not engage in conversation with the resident on that day because there are "boundary issues between a caregiver and a patient." Despite the fact that staff #1 did not talk with the resident, he did not feel she was suicidal and that 15 minute checks were adequate. The facility policy on nursing supervision included that nurses were to provide "quality care" to residents. Monitoring of residents was to be based on "the medical needs" of the resident and that "acuity levels of residents determine the time for monitoring and the level of supervision required." Based on the resident's escalating behaviors and ongoing suicidal ideation (of removing her trach), and her ability to independently remove her trach in seconds, the acuity of the situation was increased, the facility provision of 15 minute monitoring was inadequate and inappropriate. Another policy regarding behavioral monitoring, included, "When more in depth monitoring of behaviors is identified, the flow sheet identifying 'Every 15 minute checks' will be instituted" and that the form could be modified to reflect less frequent monitoring. This policy included no provision of more frequent monitoring and the facility failed to provide any policy/procedure on 1:1 supervision/monitoring.