Every finding on record at Prescott Valley Nursing & Rehabilitation

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that residents were provided copies of their personal and medical records upon written request within the required timeframe for one resident (#82). The deficient practice could result in resident rights being violated.Findings include:Resident #82 was admitted to the facility on [DATE], with diagnoses that included lack of coordination, difficulty walking, weakness, anemia, repeated falls, shortness of breath, hyperkalemia, hypertension, atherosclerotic heart disease, and adult failure to thrive.A review of a General Durable Power of Attorney (POA) document dated and signed on April 2, 2023, was uploaded into Resident #82's medical record and revealed that he elected to have his daughter act as his POA.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of an Arizona HIPAA (Health Insurance Portability and Accountability Act) Medical Release Form revealed that Resident #82 requested copies of his entire medical record, including consultations, developmental/behavioral, discharge summary, hospital records & reports, immunizations, history and physical, laboratory reports, prescriptions, treatments or tests, and X-ray reports. The form also revealed that the indicated reason for disclosure was for treatment and personal records, and that the resident authorized his daughter/POA to receive the records. The form revealed that it was completed on April 15, 2026, and that the resident signed the request. Review of a Medical Records Request Tracking Log revealed that on April 15, 2026, Resident #82 made a personal request for medical records. The log further revealed that the facility emailed to follow up on the record request on May 15, 2026, an invoice for the records on May 18, 2026, and the records were given to the requester on May 19, 2026. The log also revealed that Resident #82 was the requester, and that the records were released to the resident's daughter/POA.Review of an email dated May 14, 2026, at 1:39 p.m. was sent from Resident #82's daughter/POA to the facility's regional Business Office Consultant (Business Office Consultant/Staff #58) and revealed that her father requested medical records almost a month prior, and they had not received a response or the records. The email also revealed that Resident #82's daughter/POA handed the authorization form to the certified social worker (Social Services/Staff #4), and that she had been difficult to speak with. Review of an email dated May 14, 2026, at 1:52 p.m. revealed that the Business Office Consultant sent the email from Resident #82's daughter/POA to the admissions coordinator (Admissions/Staff #18), and said that he had received an email regarding the medical records request for Resident #82. Review of an email dated May 14, 2026, at 2:07 p.m. revealed that the Admissions Coordinator, Staff #18, sent the email to the Medical Records Director (Medical Records/Staff #70). Review of an email dated May 15, at 2:07 p.m. revealed that Medical Records, Staff #70, responded to Resident #82's daughter/POA and apologized for the delay in Resident #82's record request because the facility did not have someone in the medical records position for quite some time. The email also revealed that Medical Records told the daughter/POA that she would be happy to fulfill Resident #82's request, and asked if she would be invoicing the daughter/POA or Resident #82. Review of an email dated May 15, 2026, at 3:44 p.m. revealed that Resident #82's daughter/POA requested more information from Medical Records, Staff #70, on the cost of paper versus electronic records, which method would be faster, and where she would need to pick up paper copies.Review of an email dated May 15, 2026, at 4:10 p.m. revealed that Medical Records, Staff #70, told Resident #82's daughter/POA the cost differences and that she was waiting on the release of Resident #82's records, so neither should take long or be difficult to do. Review of an email dated May 18, 2026, at 8:02 a.m. revealed that Resident #82's daughter/POA responded to Medical Records, Staff #70, and elected to have the medical record electronically, asked if the records would be available within the week, and asked about the estimated timeframe. Review of an email dated May 18, 2026, at 3:44 p.m. revealed that Medical Records, Staff #70, told Resident #82's daughter/POA that the records were available and ready for pick-up, requested to let her know when she was available, and thanked her for her patience through the process. Review of an email dated May 19, 2026, at 8:11 a.m. revealed that Resident #82's daughter/POA would pay the invoice and pick up the records that afternoon. An interview was conducted on June 10, 2026, at 2:08 p.m. with Resident #82's daughter/POA, who stated that her father made a medical records request on April 14, 2026, and that they did not receive a response to the request until May 15, 2026. Resident #82's daughter/POA stated that her father signed the authorization form and gave the form to Social Services, Staff #4, and that when they did not receive a response from the facility, she sent a follow-up email to a different employee from the facility because Social Services would not answer calls. Resident #82's daughter/POA stated that the records were not released until May 18, 2026. An interview was conducted on June 10, 2026, at 3:09 p.m. with Social Services, Staff #4, who stated that she did not handle medical records requests, but that she was helping out before the facility hired someone to work in medical records, so she was sending requests to the facility's regional medical records personnel as soon as she was able to, but that she had her own job to do, so it was only when she had time. The Social Services Director stated that she was helping out for approximately 2 months, and that the medical records request turnaround timeframe was a week, but that she was told they had a month to process everything. An interview was conducted on June 10, 2026, at 3:19 p.m. with the Medical Records Director, Staff #70, who stated that her process when she received a medical records request was to print a copy of the request and put it in her file while she worked on it, and then she would pull all of the records that were requested. The Medical Records Director stated that, depending on the size of the request, it might take minutes, hours, or until the next day for the file to be made, and then she would send it to the facility's regional medical records resource to make sure it is okay to release. The Medical Records Director stated that she would hold on to the initial request and that she kept a tracking log that detailed the date of the request, the date the facility responded to the request, the date the records were ready, and the date that the requester received the requested records. The Medical Records Director stated that the required timeframe to fulfill a resident's medical records request was 10 days, but that when she started, it was taking her a week to fulfill them. The Medical Records Director also stated that no one was doing the medical records job for 2 months before she filled the position, and that there was one woman she apologized to specifically for the delay in fulfilling the records request. The Medical Records Director stated that the woman she apologized to was Resident #82's daughter, and further stated that she had the log, request form, and email thread about the request. The Medical Records Director stated that Resident #82 signed and requested the records himself on April 15, 2026, the daughter emailed the facility on May 6, 2026 asking for an update, then again emailed the regional resource on May 15, 2026, and that the records request was not fulfilled until May 19, 2026, which was roughly 1 month and 4 days after the request was made. An interview was conducted on June 10, 2026, at 4:12 p.m. with the Director of Nursing (DON/Staff #10), who stated that the process when they received a medical records request was to have the requestor fill out a form through the medical records department, and that she did not know the required timeframe for fulfilling the request but she thought that 30 days was reasonable.A follow-up interview was conducted on June 11, 2026, at 7:50 a.m. with the DON, Staff #10, who stated that she wanted to change her answer regarding the timeframe for fulfilling a medical records request, and that once medical records were received, the facility would have 15 days to respond. The DON stated that the medical record request form for Resident #82 was completed on April 15, 2026, and that it was fulfilled on May 19, 2026, which was more than 15 days. A follow-up interview was conducted on June 11, 2026, at 10:00 a.m. with the Social Services, Staff #4, who stated that she received the filled-out request from Resident #82's daughter on April 15, 2026, and that it took over a month for the facility to fulfill the initial request. An interview was conducted on June 11, 2026, at 10:04 a.m. with the Administrator (Administrator/Staff #39), who stated that if a medical records request came from the resident, the facility was able to quickly process the request within 24 hours. The Administrator stated that the facility did not have a policy regarding medical records requests, but that, according to the regulation, they had 24 hours to fulfill a medical records request for a resident. The Administrator stated that there was an issue with Resident #82's medical records request because it was not channeled to the right person, and that the resident made the medical records request himself on April 15, 2026, while he was a resident at the facility. The Administrator stated that Resident #82's medical record request should have been fulfilled on April 16, 2026, but it was not completed until May 19, 2026, which was beyond the date. The Administrator stated that her expectation for fulfilling the medical records request would be within 24 hours, as per the regulation, and that the risk of failing to promptly do so would be a delay in services, or a violation of residents' rights in their access to medical records. A request was made on June 10, 2026, for a medical records request policy, and the Regional Nurse Consultant (Regional RN Consultant/Staff #21) stated that they did not have a specific policy, but they did have a records request guide or training document that the facility followed for record requests. A request was made on June 11, 2026, for medical records policies, and the Regional RN Consultant, Staff #21, stated that they did not have any other medical records policies other than the guide that was provided.Review of a Record Request guide, dated May 1, 2026, revealed that all personal requests for active residents must be completed within 24 hours of receipt. The guide revealed that it was essential that Medical Records process these requests immediately to prevent any delays in providing records.Review of the Code of Federal Regulations (CFR) S483.10(g)(2) revealed that The facility must provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it was readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays). The CFR also revealed that the facility must allow the resident to obtain a copy of the records or any portions thereof (including in an electronic form or format when such records are maintained electronically) upon request and 2 working days' advance notice to the facility.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of three sampled residents (#82). The deficient practice could result in harm to the resident.Findings include:Resident #82 was admitted to the facility on [DATE], with diagnoses that included lack of coordination, difficulty walking, weakness, anemia, repeated falls, history of falling, shortness of breath, hyperkalemia, hypertension, atherosclerotic heart disease, and adult failure to thrive.An admission fall risk evaluation dated March 29, 2026, revealed that the resident had a history of 1-2 falls in the last 3 months, was chair-bound and required assistance with toileting, and had balance problems while standing, walking, and sitting. The evaluation also revealed that the resident had a fall risk score of 9.0 and that he was a moderate fall risk.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS also revealed that the resident had active diagnoses of repeated falls and a history of falling. The MDS revealed that the resident had a fall in the month before admission, and that the resident had a fall in the 2-6 months before admission. A provider order dated April 7, 2026, included a Swimmer's AP (anteroposterior, from front to back) and Lateral X-ray (thoracic spine), one time only for pain.A care plan focus initiated on April 7, 2026, revealed that the resident had an ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited mobility, and pain. The care plan had interventions to have 1-2 people assist in ambulation and encourage him to use the call bell for assistance. The care plan interventions also included that the extent and type of assistance might fluctuate within the day or day to day, depending on the resident's level of strength, pain, or mood, and that he may require more or less staff assistance.A provider order dated April 7, 2026, included Methocarbamol Oral Tablet 500 MG, 1 tablet by mouth one time only for pain. A medication administration record (MAR) for April 2026 revealed that Methocarbamol Oral Tablet 500 MG, 1 tablet, was administered on April 8, 2026.A provider order dated April 8, 2026, included Acetaminophen Oral Tablet 325 MG, 2 tablets by mouth every 6 hours for pain.A medication administration record (MAR) for April 2026 revealed that Acetaminophen Oral Tablet 325 MG, 2 tablets every 6 hours, was administered until the resident was discharged on April 23, 2026, with only one dose not administered at 11:00 a.m. on April 8, 2026. A provider order dated April 8, 2026, included Methocarbamol Oral Tablet 500 MG, 1 tablet by mouth every 6 hours as needed for back pain/muscle spasms for 14 Days. A provider encounter progress note dated April 9, 2026, at 3:45 p.m. revealed that the resident had an assisted sit onto the floor, and that he did not have any obvious injuries initially. The note further revealed that the resident complained of back pain a couple of hours later, so the facility ordered X-rays. The note also revealed that the resident reported to the provider that his fall was secondary to making a wrong turn when he was ambulating to the shower room, and that he reported it was just an accident.Review of the findings for a spine X-ray dated April 10, 2026, revealed that the X-ray was taken due to pain and a history of cancer. The X-ray revealed that there was normal alignment of the thoracic spine with no fractures, and mild osteopenia (reduced bone mineral density) and spondylosis (spinal osteoarthritis characterized by joint degeneration and bone spurs) were demonstrated.A discharge MDS dated [DATE], revealed that the resident did not have any falls since admission or the prior assessment; however, the provider's encounter progress note revealed that there was 1 fall after the prior assessment. There was no evidence in Resident #82's clinical record of any risk management, change in condition, skin, pain, fall, or therapy assessments being conducted on or after April 7th, 2026, regarding the fall documented by the provider. There was no evidence of a care plan focus or interventions for falls or fall risk in Resident #82's clinical record.There was no evidence in the clinical record that a fall was documented by nursing staff on April 7, 2026. An interview was conducted on June 10, 2026, at 2:08 p.m. with Resident #82's daughter, who stated that she partially witnessed a fall on April 7, 2026, because when she got to the facility, her dad was lying on the ground with a group of staff around him. The resident's daughter stated that she saw the medical records, and there was a documented assisted sit to floor while he was being ambulated to the shower room. The resident's daughter stated that she did not see the fall, but that she got there right after it happened. An interview was conducted on June 10, 2026, at 4:12 p.m. with the Director of Nursing (DON/Staff #10), who stated that a fall would be defined as a change in elevation, and could include a person falling from a chair to the floor, a bed to the floor, or an assisted sit onto the floor. The DON stated that her expectation if someone were to experience an assisted sit onto the floor would be to aid them to the floor as carefully as possible, contact the nurse, and the nurse would be expected to do an evaluation and take vitals to ensure the resident was safe. The DON also stated that staff would be expected to get the resident back into a chair or their bed, neuro checks initiated, and there were 6 assessments that staff were expected to complete for every fall that occurred, including fall risk, pain, skin check, therapy, risk management, and change in condition. The DON stated that she would review the assessments with staff, and they would reevaluate, update the care plan, including intervention, and the date that the fall happened so that it was recognized, and the family, DON, and physician needed to be notified. The DON stated that she recalled Resident #82, and that he did have falls while he was here at the facility. The DON stated that she could recall that Resident #82 had a fall around the corner of the shower room, that she did not recall the day, and that a certified nursing assistant (CNA) was walking him. The DON further stated that the CNA was permitted to ambulate the resident because he had been ambulating with physical therapy, and that the CNA helped him to the floor. The DON stated that therapy witnessed the fall but could not recall who was there, and that the family was not there when the fall occurred, but they arrived right after. The DON opened Resident #82's clinical record and stated that he had diagnoses of difficulty walking and a history of falls, and that the fall was not documented in the care plan. The DON stated that she could not find any assessments or progress notes regarding the fall, but that she recalled the fall occurred. A follow-up interview was conducted on June 11, 2026, at 7:50 a.m. with DON, Staff #10, who stated that she looked into the clinical record and found that Resident #82 did have a fall that occurred on April 7, 2026. The DON stated that she spoke with the NP after the last interview, and the NP confirmed that the fall occurred. The DON stated that they did not do a care plan revision, any assessments, or progress notes for the fall, and that it was not documented outside of the NP note. The DON stated that it was her expectation that, after a fall, nursing staff would complete the risk management, change in condition, skin, pain, fall, and therapy assessments. The DON further stated that it was her expectation that the care plan be updated after a fall to include education, interventions, and the date and time of the fall that occurred. The DON stated that everyone needed to be notified of the fall, including family, the DON, and the physician, and interventions such as fall mats needed to be implemented. The DON further stated that there was no documentation that the resident's daughter/Power of Attorney (POA) had been notified, and that the instructions for what staff were expected to do were posted at each nurse's station. The DON stated that she spoke with the NP to discuss education and systemic changes regarding falls and the post-fall process. An interview was conducted on June 11, 2026, at 8:49 a.m. with a CNA, Staff #80, who stated that she had a resident who experienced a fall in April of 2026 when she got him up to go to the shower, and that she slowly brought him down to the ground after his knees gave out. The CNA stated that he was permitted to use a walker with therapy, so she ambulated him to the shower room. The CNA stated that she recalled it was Resident #82 who experienced the fall, and that he was so tall that it was difficult for her to catch him. The CNA stated that she grabbed the Licensed Practical Nurse (LPN/Staff #65), who came over to help him get into a wheelchair, and they took his vitals. The CNA stated that she did not know if the LPN assessed the resident, but that the LPN reported the fall to the DON while the CNA took his vitals. The CNA stated that the resident's daughter showed up when the resident was on the ground and was mad that the CNA could not catch him. The CNA stated that the daughter did not witness the fall, but that she was there after when they were trying to assist the resident into the chair. The CNA stated that the resident was not using a walker after the fall and that therapy staff were the only ones to ambulate the resident after the fall. The CNA stated that she recalled the resident had a fall mat after the fall. An interview was attempted on June 11, 2026, at 8:58 a.m. with the LPN, Staff #65, with no success.An interview was conducted on June 11, 2026, at 8:59 a.m. with the Nurse Practitioner (NP/Staff #43), who stated that when there was a fall at the facility, there was charting that the facility staff needed to complete. The NP stated that when a fall would occur, the DON and NP were notified, and she would request to see vital signs and neuro checks. The NP further stated that she would usually look through nursing progress notes to catch falls documented in the record. The NP stated that she vaguely recalled Resident #82, and that according to her notes, he did have a fall at the facility on April 6th or 7th of 2026. The NP stated that there was no documentation in the record about the fall aside from her own note, and that the facility did not complete any assessments or progress notes, and she did not know if the care plan was updated. The NP stated that despite her note saying that the facility updated the care plan, she did not know if they did, but that she always put that in her note and assumed that the care plan would be updated. The NP also stated that Resident #82 confirmed and corroborated that he had a fall, and that he admitted he made a wrong turn. The NP stated that she was surprised that they were ambulating the resident to begin with because his condition was rough. Review of an undated policy titled, Fall Management Program, revealed that the facility would provide the highest quality care in the safest environment for the residents residing in the facility. The policy revealed that the facility developed a fall management program that intended to prevent resident falls through meaningful assessments, interventions, education, and reevaluation. The policy further revealed that following a resident's fall, the licensed nurse would complete an incident report and a Post Fall Assessment & Investigation within 24 hours or as soon as practicable. The policy revealed that the licensed nurse would review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated. The policy revealed that the IDT (interdisciplinary team) Committee would meet within 72 hours of a fall to review and document the summary of the event, following a fall, root cause analysis, referrals, as necessary, and interventions to prevent future falls. The policy also revealed that Fall Risk Assessments would be maintained in the resident's medical record, and the IDT Committee would document findings and recommendations in the resident's medical record. The policy revealed that nursing staff would document the resident's response to interventions being utilized in the resident's medical record, and that the resident's care plan would be updated as necessary.

Number of residents sampled:Number of residents cited:FFTE THAT 5 STAFF MEMBERS HAVE COMPLETED BEHAVIORAL HEALTH TRAININGBased on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#37, #5, #27, #16, and #56) received behavioral health training. The deficient practice could result in staff not being equipped to provide residents with behavioral health care and services. Findings include:-Regarding Staff #37Review of the personnel record for a Registered Nurse (RN/staff #37) revealed a hire date of November 1, 2024. Additionally, the personnel file revealed a signed job description dated October 17, 2024 that outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #37 had completed Behavior Health training. -Regarding Staff #5Review of the personnel record for a Certified Nursing assistant (CNA/staff #5) revealed a hire date of November 1, 2024. Additionally, the personnel file included a signed a job description dated October 17, 2024 that outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes However, review of the training log did not reveal any evidence that staff #5 had completed Behavioral Health training. -Regarding Staff #27Review of the personnel record for the Activity Director (staff #27) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated October 19, 2024 which outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #27 had completed Behavioral Health training. -Regarding Staff #16Review of the personnel record for a Dietary Supervisor (staff #16) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated March 16, 2025 which outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes However, review of the training log did not reveal any evidence that staff #16 had completed Behavioral Health training. -Regarding Staff #56Review of the personnel record for a Social Worker (staff #56) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated October 23, 2024 which outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #56 had completed Behavioral Health training. During an interview with a Registered Nurse (RN/staff #29) conducted on August 19, 2025 at 8:10 a.m., staff #29 stated that staff receives monthly Inservice training with topics that includes Abuse/Neglect. According to the RN, training is important to ensure that staff knows how to properly care for their residents. Staff #29 said that the impact of staff not receiving training is that they can end up interfering with a process or miss something that is required to provide professional care. An interview with a Certified Nursing Assistant (CNA/staff #88) was conducted on August 19, 2025 at 12:19 p.m. Staff #88 stated that if staff does not have the training required of their position it can result in resident not receiving the appropriate care or hurt the resident. During an interview with the Director of Nursing (DON/staff #14) conducted on August 19, 2025 at 1:28 p.m., staff #14 stated that training is important for competency and to provide an avenue to ask questions if unsure of the procedure. The DON noted that the impact of not having the required training is that staff might not address the situation appropriately or contact the appropriate people. The facility did not have a policy on staff training requirements. However, review of the facility's Inservice Training Schedule revealed that staff are provided Dementia care training in the month of October. Review of the Facility assessment dated [DATE] indicated that the facility's training program included an orientation process and ongoing training. According to the facility's assessment their training plan includes the topics of Dementia, cognitive impairment, and special needs.

Number of residents sampled:Number of residents cited:FFTE THAT 5 STAFF MEMBERS HAVE COMPLETED IC TRAINING Based on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#37, #5, #27, #16, and #56) are educated on infection control and prevention. The deficient practice could result in staff not being familiar with process and procedures for the control and prevention of infection. Findings include:-Regarding Staff #37Review of the personnel record for a Registered Nurse (RN/staff #37) revealed a hire date of November 1, 2024. Additionally, the personnel file revealed a signed job description dated October 17, 2024 that outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #37 had completed Infection Prevention and Control training. -Regarding Staff #5Review of the personnel record for a Certified Nursing assistant (CNA/staff #5) revealed a hire date of November 1, 2024. Additionally, the personnel file included a signed a job description dated October 17, 2024 that outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes However, review of the training log did not reveal any evidence that staff #5 had completed Infection Prevention and Control training. -Regarding Staff #27Review of the personnel record for the Activity Director (staff #27) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated October 19, 2024 which outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #27 had completed Infection Prevention and Control training. -Regarding Staff #16Review of the personnel record for a Dietary Supervisor (staff #16) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated March 16, 2025 which outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes However, review of the training log did not reveal any evidence that staff #16 had completed Infection Prevention and Control training. -Regarding Staff #56Review of the personnel record for a Social Worker (staff #56) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated October 23, 2024 which outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #56 had completed Infection Prevention and Control training. During an interview with a Registered Nurse (RN/staff #29) conducted on August 19, 2025 at 8:10 a.m., staff #29 stated that staff receives monthly Inservice training with topics that includes Abuse/Neglect. According to the RN, training is important to ensure that staff knows how to properly care for their residents. Staff #29 said that the impact of staff not receiving training is that they can end up interfering with a process or miss something that is required to provide professional care. An interview with a Certified Nursing Assistant (CNA/staff #88) was conducted on August 19, 2025 at 12:19 p.m. Staff #88 stated that if staff does not have the training required of their position it can result in resident not receiving the appropriate care or hurt the resident. During an interview with the Director of Nursing (DON/staff #14) conducted on August 19, 2025 at 1:28 p.m., staff #14 stated that training is important for competency and to provide an avenue to ask questions if unsure of the procedure. The DON noted that the impact of not having the required training is that staff might not address the situation appropriately or contact the appropriate people. The facility did not have a policy on staff training requirements. However, review of the facility's Inservice Training Schedule revealed that staff are provided Infection Control training in the month of June. Review of the Facility assessment dated [DATE] indicated that the facility's training program included an orientation process and ongoing training. According to the facility's assessment their training plan includes the topics of Infection Control.

Number of residents sampled: 21Number of residents cited: 17The facility failed to ensure residents right to personal privacy and confidentiality of his or her medical recordsBased on record review, staff interviews, review of facility documentation and policy, the facility failed to protect residents' right to personal privacy and confidentiality of his or her personal and medical records. The deficient practice could result in an unauthorized access to residents' personal and medical records.Findings include:During a medication administration observation task on August 19, 2025 starting at 4:09 AM with Licensed Practical Nurse (LPN)/Staff #94, Staff #94 administered Hydromorphone 4 MG (milligram) two tablets by mouth as ordered for pain for Resident #67. At 4:13 AM, Staff #94 left Resident #67 room without performing hand hygiene. Staff #94 proceeded to her medication cart after leaving Resident #67 room. At 4:16 AM, Staff #94 left her medication cart laptop computer screen unlocked to use the bathroom. The medication cart with the unlocked laptop computer screen was parked in front of the nursing station. While the laptop computer screen was unlocked, the Point Click Care (PCC) medical information for Resident #67 was visible. The information from the unlocked laptop screen starting from the upper left side corner included Resident #67's identifiable information such as Resident's photograph, name, next to her name in parenthesis were 8-digit numbers, Status Current, room location, gender, date of birth , age, physician's name, allergies, code status; to the right upper corner included Resident #67's current vitals signs. The screen also revealed 4-rectangular shaped: two grayish colored rectangular in shape located on the left side of the PCC screen which has the PRN Senna Plus Oral Tablet 8.6-50 MG and the other one with PRN Tylenol Oral Tablet 325 MG information; on the right side of the screen, one yellow colored rectangular shape which has the PRN Hydromorphone HCL (hydrochloride) Tablet 4 MG; and a greenish colored rectangular shape which has the Gabapentin Oral Capsule information. At 4:20 AM, Staff #94 returned back to her medication cart. An interview was conducted with Staff #94 regarding medication administration process. Staff #94 stated that the process during medication administration pass include to always lock the medication cart when leaving the cart and lock the screen which would show this screen is hidden,. Staff #94 stated that her computer screen was left unlocked, and when a computer screen is left unlocked someone walking by can see the resident's information and can lead to invading residents' privacy, HIPPA (Health Insurance Portability and Accountability Act) violation, which is not okay.Additional attempts to continue with medication administration observation task was conducted on August 19, 2025. At 4:58 AM, LPN/Staff #84 was informed by the surveyor that she will be observing her for medication administration pass. Staff #84 then left her medication cart, walked towards the nursing station and left her medication cart laptop computer screen unlocked. While Staff #84 was gone with her medication cart laptop computer screen unlocked, the following information in PCC were visible:-there were 16 residents on the screen;-there were three residents identified in each yellow colored rectangular shape, and each resident had a photograph of their face, name, in parenthesis 9-digit number, and their room number location. These three residents were Resident #53, Resident #8, and Resident #1;-there were four residents identified in a whitish colored rectangular shape, and each resident had a photograph of their face, name, in parenthesis 9-digit number, and their room number location. These four residents were Resident #52, Resident #50, Resident #69, and Resident #56; and-there were nine residents identified in a greenish colored rectangular shape, and each resident had a photograph of their face, name, in parenthesis 9-digit number, and their room number location. These nine residents were Resident #13, Resident #7, Resident #68, Resident #35, Resident #2, Resident #40, Resident #61, Resident #23, and Resident #58.On August 19, 2025 at 4:59 AM, Staff #84 returned to her medication cart and stated that she left the computer screen wide open and she thought she had closed it.On August 19, 2025 at 5:36 AM, a follow up interview was conducted with LPN/Staff #84. Staff #84 stated that the process during medication administration include preparing the medication and knocking on the door before entering the resident's room. She stated that she identifies each resident through the picture in the PCC and resident's wrist band. Once in the resident's room, she set the resident up in bed then she gives the medications to the resident. She stays with the resident until the medication is taken so she knows that the resident swallowed the pill and resident is okay.An interview was conducted on August 19, 2025 at 10:09 AM with a Registered Nurse (RN)/Staff #82. Staff #82 stated that one of her roles is administering medication, and the process involves checking the medication order, hand sanitize before start pulling the medication pack, then she gives the medication to the resident, she make sure the resident have water, have apple sauce to take with the medication based on her report sheet, locks her medication cart, and locks her computer by pulling down the top of the laptop to protect resident's privacy. She stated that the risk if her computer screen was unlocked is HIPPA, health information protection act violation. She stated she locks the computer screen located on the medication cart by clicking on the yellow lock-on and the screen will show This screen is Hidden meaning it is locked. Furthermore, she stated that she hands sanitize before she picks up her medication punch cards, and after leaving the resident rooms. She hands sanitize so not to pass any germs to prevent infecting herself and others.An interview was conducted on August 19, 2025 at 11:15 AM with the Director of Nursing (DON)/Staff #14. The DON stated that during medication administration, her staff follows the five rights: right medication, right resident, right dose, and right time. She stated that her staff reads the medication orders, prepare the medications, make sure everything is correct before entering the resident's room, knock on the door first, take the medications to administer to the resident and medications are not left at the bedside. Regarding hand hygiene, the DON stated that she expects her staff to wash their hands frequently, use hand sanitizer when hands are not soiled, and her staff hand sanitized between residents. The DON stated that the risk without performing hand hygiene is infection and cross contamination, and her expectation for her staff is from one room or resident to another, her expectation for her staff is to use the hand sanitizer. Regarding process and expectation for laptop screen located on the medication cart, the DON stated that before the nurse walks away from the cart, she expects her staff to close the screen and lock the medication cart because when the laptop screen is not closed while the nurse walks away from her medication cart, the risk is violation of resident's privacy. At the end of the interview, the DON stated that her staff should be locking there computer screen and washing their hands.Review of facility's policy titled, Resident's Rights, date revised on August 2020 revealed State and federal laws guarantee certain basic rights to all residents of the facility. (E.) Privacy and confidentiality including the right to privacy in his/her specific oral, written, and electronic communications.

Based on record review, staff interviews, review of facility documentation and policy, the facility failed to provide a written notice notifying one resident (#71 and #73) upon transfer to an acute care hospital setting of the bed hold which specifies the duration of bed-hold including reserve payment, and the facility failed to send notification of transfer of discharged residents to the representative of the Office of the State Long-Term Care Ombudsman. Findings include: -Regarding Resident #71: Resident #71 was admitted to the facility on [DATE]. Review of Resident #71 Minimum Data Set (MDS) admission assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15.0, cognitively intact. The MDS revealed active diagnoses which included Anemia, Heart Failure, Hypertension, Benign Prostatic Hyperplasia (BPH), Renal Insufficiency, Diabetes Mellitus (DM), Arthritis, and Hip Fracture. Review of care plan revealed Resident #71 was at increased risk for falls. Review of progress notes dated June 11, 2025 revealed a change of condition. Resident was noted to have altered mental status (AMS), fever, oxygen saturation at 86% on room air, and had a malodors urine. The staff applied oxygen via nasal cannula. Resident was also receiving an antibiotic called Cefdinir for respiratory infection. The staff notified the nurse practitioner regarding resident's status and an order was received to send the resident to the emergency room for further evaluation. The staff also notified resident's family member regarding resident's transfer to the hospital. Review of discharge MDS dated [DATE] revealed resident was discharged on June 12, 2025 to a short-term general hospital. Another review of progress note dated June 12, 2025 revealed Resident's family member informed facility that Resident #71 was admitted for pneumonia and will be in the hospital for approximately two days or more if needed. Review of Resident's medical record revealed no documentation of bed hold notification provided to the Resident and his or her family member or representative. An interview was conducted on August 18, 2025 at 10:25 AM with a Licensed Practical Nurse (LPN)/Staff #88. Staff #88 stated that the process regarding resident on change of condition is to notify the provider about the resident's change in condition and get an order to transfer the resident to the hospital for emergent or non-emergent. For instance, Staff #88 stated that when a resident has pneumonia, if the provider instructed her that it is an emergent, she will call 911. After a resident is transferred out to the hospital, she stated that the facility has a bed hold form. She will speak with the resident's family member about the bed hold, the cost of the bed hold is in the form, and the form also states hold for 24-hours. The bed hold form is then turned in to medical records so the form can be uploaded in PCC (Point Click Care). On August 18, 2025 at 2:54 PM, the Administrator/Staff #333 stated that the facility does not have a bed hold document for Resident #71. Review of facility's policy titled, Bed Hold, date revised October 24, 2022 revealed a bed hold procedure, VII Transfer to an Acute Care Hospital which states the facility notifies the resident or his/her representative, in writing, of the bed hold policy, any time the resident is transferred to general acute care hospital. Review of facility's policy titled, Transfer and Discharge, date revised June 2020 revealed VII (A-B). Bed Hold which states that before the facility transfers a resident to a hospital, the facility will provide written information to the resident or his/her personal representative which specifies the duration of the bed hold during which the resident is permitted to return and resume residence in the nursing facility, the facility policies regarding bed-hold periods permitting a resident to return; and at the time of transfer, the facility will provide the resident and a family member or personal representative written notice which specifies the duration of bed-hold policy, and will inform the resident of his or her rights to exercise a bed hold provision. -Regarding Resident #73 Resident #73 was admitted to the facility on [DATE] with diagnoses of urinary tract infection, hypertension, chronic kidney disease, congestive heart failure, and hypothyroidism. A progress note dated August 1, 2025 documented that the resident's son called and was on his way to pick up the resident to take her home AMA (Against Medical Advice). The note indicated t hat the resident's son arrived with his transport, packed the resident's things and left. An AMA Release form dated August 1, 2025 revealed that the document contained wet signatures certifying that the resident had been advised of the risks involved with leaving against medical advice. Review of the resident's Transfer/Discharge Report revealed that the resident discharged AMA (Against Medical Advice) on August 1, 2025. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's discharge was unplanned. The assessment noted that the resident has a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. A written request was submitted to the facility on August 18, 2025 at 3:40 p.m. requesting Ombudsman Notification for the last three months. An email sent by the Social Worker (staff #56) to the Ombudsman dated August 18, 2025 revealed that she sent a list of all the residents that were discharged in the last six months. The email indicated that going forward staff #56 would be sending the Ombudsman monthly emails at the end of the month of discharges. The email contained an apology for the mistake. During a conversation with the Administrator (staff #333) on August 18, 2025 at 4:20 p.m., staff #333 stated that the email forwarded regarding Ombudsman notification was all they have and that notification was not accomplished prior to that email. Review of the facility policy titled Transfer and Discharge revised June 2020 indicated that residents are transferred and discharged from the facility in compliance with state and information to the continuing care provider.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure 7 residents (#1, #7, #49, #2, #25 and #18 were) with diagnosis of serious mental illness were referred for PASARR (Pre-admission and Resident Review) Level II evaluation. The deficient practice could result in residents not receiving the services according to their assessed needs.Findings include: -Resident #1 was admitted on [DATE] with diagnosis of schizoaffective disorder, bipolar type. The PASARR Level I screening dated April 29, 2025 revealed that the resident met the criteria for 30 day Convalescent Care. SMI (serious mental illness) included schizoaffective disorder and bipolar disorder. Psychotropic medications prescribed within the last 6 months included Clozapine (antipsychotic) and Divalproex (anticonvulsant). The psychotropic medication consent dated April 29, 2025 included an order for Clozapine on April 28, 2025 for schizophrenia. The care plan dated April 29, 2025 revealed that the resident required antipsychotic medications for diagnosis of schizoaffective disorder. Intervention included to administer medications as ordered. The admission MDS (Minimum Data Set) assessment dated [DATE] included an active diagnosis of schizophrenia and the resident was not currently considered by the state level II PASARR process to have SMI The NP (nurse practitioner) encounter note dated May 19, 2025 revealed the resident was in the facility receiving ongoing skilled physical and occupational therapy prior to switching over to long term care. Diagnosis included schizoaffective disorder, bipolar type. Active medication included Clozapine. The general progress note dated May 25, 2025 included that the resident was alert and able to make needs known, needed reminders on boundaries on how to address needs. The general progress note dated May 30, 2025 revealed the resident returned from his appointment and there were no changes to his psychiatric medications. The skilled evaluation dated June 11, 2025 included the resident was admitted on [DATE] and was receiving both skilled nursing and skilled therapy services. The general progress note dated July 6, 2025 revealed the resident was admitted on [DATE] and was receiving both skilled nursing and skilled therapy services. The quarterly MDS assessment dated [DATE] included an active diagnosis of schizophrenia and was receiving antipsychotics on a routine basis. The federally mandated visit note dated August 1, 2025 revealed a diagnosis of schizoaffective disorder, bipolar type that appeared to be fairly well-controlled at this time. Review of the clinical record revealed no evidence that the resident was discharged from the facility; and that, the resident was administered with Clozapine as ordered by the physician since his admission at the facility on April 28, 2025. Further review of the clinical record revealed that another PASRR Level I screening was not completed after resident #1 stayed longer than 30 days until August 5, 2025. The PASRR Level I screening dated August 5, 2025 revealed that the PASSR screening was completed because of a status/medication change. SMI included schizoaffective disorder. Psychotropic medications prescribed within the last 6 months included Clozapine and Divalproex. According to the documentation, there was no referral necessary for any Level II. Despite documentation that the resident had a SMI, there was no evidence that the resident was referred for Level II determination. -Resident #7 was admitted on [DATE] with diagnoses of Parkinson's disease without dyskinesia, mental disorder not otherwise specified and bipolar disease The care plan dated November 3, 2023 revealed the resident had Parkinsonism, history of bipolar disorder, depression, psychiatric illness, and bipolar with psychosis exacerbation. The progress note dated April 9, 2025 included diagnoses of bipolar disorder and psychiatric illness. Active medications included Aripiprazole (antipsychotic), Bupropion (antidepressant) and Mirtazapine (antidepressant). The Federally Mandated Visit not dated June 11, 2025 revealed a diagnosis of bipolar disorder. Per the documentation, the resident followed-up with psychiatry as necessary. Active medications included lamotrigine (anticonvulsant), bupropion and Aripiprazole. The quarterly MDS assessment dated [DATE] revealed active diagnoses of anxiety disorder and bipolar disorder. The assessment also included that the resident received antipsychotics on a routine basis. The annual wellness visit note dated August 6, 2025 included a diagnosis of bipolar disease. Active medications included lamotrigine, bupropion and Aripiprazole. Despite documentation that the resident #7 had Bipolar disorder as diagnosis and resident was receiving psychotropic medications, there was no evidence that the PASRR screening was completed for resident #7 until August 6, 2025. The PASRR Level I screening dated August 6, 2025 included the PASRR review type was for a status/medication change. SMI included bipolar disorder. Mental Illness included anxiety disorder. Psychotropic medications prescribed within the last 6 months included Aripiprazole, Bupropion and Lamotrigine. The documentation included there was no referral necessary for any Level II determination. The annual MDS assessment dated [DATE] included active diagnoses of anxiety disorder and bipolar disorder; and that, the resident was receiving antipsychotics on a routine basis only. The assessment also included that the resident was not currently considered by the state level II PASRR process to have a serious mental illness and/or ID or a related condition. Despite documentation that the resident had a SMI, there was no evidence that the resident was referred for Level II determination. -Resident #49 was admitted on [DATE] with diagnoses of major depressive disorder and bipolar disorder. The care plan dated March 11, 2024 revealed the resident was on antipsychotic medications related to history of bipolar disorder. The quarterly MDS assessment dated [DATE] revealed active diagnoses of anxiety disorder, depression, bipolar disorder and PTSD (post-traumatic stress disorder). The NP encounter note dated June 27, 2025 included assessments of Bipolar 1 disorder, PTSD, hallucinations and anxiety. The NP encounter note dated July 23, 2025 revealed a diagnosis of bipolar 1 disorder. Review of the clinical record revealed that resident was receiving psychotropic medications such as Bupropion, Clonazepam (antianxiety), Escitalopram (antidepressant) and Aripiprazole. Despite documentation that the resident #49 had SMI such as Bipolar 1 disorder, anxiety and depression and was receiving psychotropic medications, there was no evidence that the PASRR screening was completed for resident #7 until July 24, 2025. The PASRR Level I screening dated July 24, 2025 included the PASRR review type was for a status/medication change. SMI included major depression and bipolar disorder. Mental Illness included PTSD. Psychotropic medications prescribed within the last 6 months included Aripiprazole, Bupropion, Escitalopram, Clonazepam, Hydroxyzine (antihistamine) and Lamotrigine. The documentation included there was no referral necessary for any Level II determination. -Resident #2 was admitted on [DATE] with diagnoses of dementia and major depressive disorder. The care plan initiated April 29, 2025 revealed that the resident required antidepressant medications such as Escitalopram and Bupropion for diagnosis of depression. The PASARR Level I screening dated April 29, 2025 revealed that the resident met the criteria for 30 day Convalescent Care. SMI included major depression. Psychotropic medications prescribed within the last 6 months included Bupropion and Escitalopram. The psychotropic medication consent forms dated April 29, 2025 included that the resident had Bupropion prescribed on April 28, 2025 and Escitalopram prescribed on April 29, 2025. The MAR (medication administration record) revealed that Bupropion and Escitalopram were administered as ordered from April 29 through June 11, 2025. There was no evidence found in the clinical record that a PASRR Level I screening was completed after the resident #2 stay longer than 30 days from admission; and that, resident #2 was referred to Level II determination. According to the documentation in the clinical record, the resident was transferred to the hospital on June 11, 2025 because of a fall incident; and, was readmitted back at the facility on June 20, 2025. The NP (nurse practitioner) encounter/admission note dated June 23, 2025 revealed that the resident was admitted at the hospital on June 11 and had surgery for his trochanteric fracture. The documentation also included that the resident had some delirium postoperatively; and, medications included Quetiapine Fumarate (Generic name for Seroquel-antipsychotic). Diagnoses included acute delirium, major depressive disorder and insomnia. There was no evidence found in the clinical record that another PASRR Level 1 screening was completed until July 14, 2025. The PASRR Level I screening dated July 14, 2025 included the PASRR review type was for a status change. SMI included major depression. Psychotropic medications prescribed within the last 6 months included Hydroxyzine. The documentation included there was no referral necessary for any Level II determination. There was no evidence found that the resident was referred to any Level II determination. In an interview with the the social services director (SSD/staff #56) conducted on August 19, 2025 at 10:38 a.m., the SSD stated that she was taught by previous administrators to complete a PASRR Level I screening when a resident was admitted at the facility and when there are medication/status changes. She stated that she never referred any resident for a Level II evaluation/determination even when the resident has SMI or mental disorder. During an interview with the administrator conducted on August 19, 2025 at 12:59 p.m., the administrator stated that the expectation was that PASRR screening was done correctly in accordance with state and federal regulations. He stated that Level II referral was driven by resident's diagnosis of SMI and medications; and that, if the screening triggered for level II then the expectation was for staff to send the referral State for Level II determination. The administrator further stated that the risk for not completing PASRR screening for residents included the facility not meeting the resident's needs. Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure six residents (#1, #7, #49, #2, #25 and #18) with diagnosis of serious mental illness were referred for PASRR (Preadmission Screening and Resident Review) Level II evaluation. The deficient practice could result in residents not receiving the services according to their assessed needs. Findings include: -Regarding Resident #25: Resident #25 was admitted to the facility on [DATE] with diagnosis that included Obstructive Uropathy, Anxiety Disorder and Major Depressive Disorder. Review of Resident #25's Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.0, intact cognition; Resident had been bothered by feeling down, depressed, or hopeless mood; have trouble falling asleep or staying asleep, or sleeping too much; feeling tired or having little energy; sometimes feels lonely or isolated from those around her; and resident is taking antipsychotic, antianxiety, and antidepressant medications. Review of care plan revealed Resident is on antipsychotic medication therapy related to history of major depressive disorder. Review of physician orders revealed an order for clonazepam oral tablet 0.5 MG (milligram) to give one tablet by mouth at bedtime related to Major Depressive Disorder, Aripiprazole oral tablet 2.0 MG to give one tablet by mouth one time a day related to Major Depressive Disorder, and Sertraline HCl (hydrochloride) oral tablet 100 MG to give two tablets by mouth one time a day related to Major Depressive Disorder. Review of Resident #25's PASRR document dated August 4, 2025 revealed: Section B of the form revealed that Resident #25 has a major depression serious mental illness (SMI) and anxiety disorder; History of Psychiatric Treatment Section revealed that Resident has not received any mental health services, and has not experienced significant life disruption because of mental health symptoms currently or within the past 2 years; Resident has not had a recent psychiatric/behavioral evaluation; and Resident is prescribed psychotropic medications now and within the last 6 months. And, Section D of the PASRR document revealed Resident was not referred for Level II determination. Despite documentation that the resident had a SMI, there was no evidence that the resident was referred for Level II determination. An interview was conducted on August 19, 2025 at 10:26 AM with the Social Service Director/ Staff #56 in her office. Staff #56 stated that her responsibilities include assessment; reviewing resident's code status upon admission; working with residents throughout their stay for discharge planning; setting up home health and durable medical equipment (DME); and assisting with faxing ALTCS (Arizona Long Term Care System) verification. She also completes residents' PASRR upon admission for every admission, and do it again when a resident is for instance going on hospice care or when a psychotropic medication is added. She stated that regarding PASRR Level II, she was supposed to submit it to the State. She stated that PASRR was new to her and she is trying her best to learn it. She stated that she completed Resident #25's PASRR form on August 4, 2025, she made the determination not to refer the resident for Level II, but was not aware that she was not supposed to do the determination part. Staff #56 stated that she will call the PASARR Program on the AHCCCS (Arizona Health Care Cost Containment System) website to learn more about PASRR. An interview was conducted on August 19, 2025 at 11:15 AM with the Director of Nursing (DON)/Staff #14. The DON stated that regarding PASRR, some of their residents comes with their PASRR document from the hospital, and most of the time the PASRR document is not up to date from the hospital. The DON stated that their admission coordinator used to handle the residents' PASRRs and currently, their social services department completes their residents' PASRRs. An interview was conducted on August 19, 2025 at 12:59 PM with the Administrator/Staff #333. The Administrator stated that his expectation regarding PASRR is that it should be done correctly in accordance with state and federal regulations. He stated that Level II PASRR is driven by diagnosis and medications. If triggered for level II, he stated that it is send out for referral. He stated that the risk of not sending out the PASRR Level II referral is that the facility might not meet their residents 'needs. Review of facility's policy titled, Pre-admission Screening Resident Review (PASRR), no date of revision revealed if Level I screening results indicate that the applicant should receive the Level II screening, the facility should contact the appropriate state agency for additional screening. i. The state agency will arrange for Level II screening and determine whether the individual should be admitted to the facility and, if so, what services the individual will need.

Based on clinical record review, staff interviews and review of facility policy, the facility failed to ensure medications were administered following the parameter set for 2 of 5 sampled residents (#2 and #52). The deficient practice could result in resident not receiving the appropriate treatment they need. Findings include:-Resident #2 was admitted on [DATE] with diagnoses of mild dementia with other behavioral disturbance, age-related osteoporosis with current pathological fracture, major depressive disorder and low back pain.A physician orders dated April 28, 2025 included for Hydrocodone-Acetaminophen (opioid) 5-325 mg 1 tablet by mouth every 6 hours PRN for pain 6/10 not to exceed 3 grams/24 hours and pain assessment every shift using PAINAD (Pain Assessment in Advanced Dementia) or verbal scale 0-10.The health status note dated April 29, 2025 revealed the client was alert and oriented x 1, denied any pain or discomfort during the night and had no behavior issues.The NP (nurse practitioner) encounter note dated April 30, 2025 included that the resident was admitted to the facility on [DATE] from another local skilled nursing facility. and was transferred at the facility for ongoing long term care. The documentation included that the resident was alert and cognitively impaired. Medications included Acetaminophen (analgesic) 325 mg (milligrams) give 2 tablets by mouth every 4 hours PRN (as needed) for elevated temperature >100 degrees Fahrenheit not to exceed 3 grams/24 hours; Ibuprofen 400 mg by mouth every 6 hours PRN for pain; Hydrocodone-Acetaminophen 5-325 mg 1 tablet by mouth every 6 hours PRN for pain 6/10 not to exceed 3 grams/24 hours. ; and lidocaine external patch (topical analgesic) apply to the back topically every 12 hours as needed for pain and remove after 12 hours.The general progress note dated May 3, 2025 revealed that pain medication was given for back pain and was effective. The documentation did not include the resident's pain level.The order for the Hydrocodone-Acetaminophen every 6 hours PRN for pain 6/10 was transcribed onto the MAR (medication administration record) for May 2025. The documentation in the May 2025 MAR revealed that Hydrocodone was administered on May 3, 4, 12, and 17. However, the documentation in the MAR did not include the resident's pain level.The order for pain assessment every shift was transcribed onto the TAR (treatment administration record) for May 2025 and it revealed that pain level to the resident was as follows:May 3- pain level of 2 for day shift and 0 for night shift;May 4 - pain level of 4 for day shift and 0 for night shift;May 12 - pain level of 5 for day shift and 0 for night shift; and,May 17 - pain level of 4 for day shift and 0 for night shift.There was no evidence found in the clinical record of any reason why the Hydrocodone was administered outside of the physician-ordered parameter; and that, the physician was notified.The pain care plan dated June 2, 2025 included the resident required pain management related to hip fracture, recent falls and low back pain. Interventions include the administration of prescribed pain medications, such as transdermal pain patches, oral analgesics, and anticonvulsants, as ordered by the physician.The NP encounter note dated June 6, 2025 revealed that the resident was alert and oriented x 2, was cognitively impaired, and had a pain level of 2/10.The order for Hydrocodone-Acetaminophen every 6 hours PRN for pain 6/10 continued to be transcribed onto the MAR for June 2025. Review of the June 2025 MAR revealed that the medication was administered on June 1, 7 and 9. However, the pain level was not documented. The MAR also included this medication was discontinued on June 12, 2025; and the orders for pain assessment every shift was also discontinued on June 12, 2025.Review of the June 2025 TAR revealed that the resident had pain level of 0 for both the day and night shift on June 1 and 9; and had a pain level of 4 for day shift and pain level of 1 for night shift on June 7, 2025.There was no evidence found in the clinical record of any reason why the Hydrocodone was administered outside of the physician-ordered parameter; and that, the physician was notified.The general progress notes dated June 11, 2025 revealed that the resident was found on the floor, was hollering out in pain and was transferred to the hospital.A skilled evaluation note dated June 21, 2025 included that the resident was re-admitted on [DATE]; and that, the resident was alert and oriented to person and place.The NP encounter/admission note dated June 23, 2025 revealed that the resident had been in his usual state of health until June 11 when he had a fall, was transferred to the emergency room where he was found to have a fracture of the left hip secondary to ground-level fall and, the resident was admitted to the hospital where he underwent IM (intramedullary) nail for his trochanteric fracture. The documentation also included that the resident reported that his pain was controlled, had no visible signs of pain; and that, pain appeared to be fairly well-controlled. Assessment included Fracture of the left hip due to osteoporosis with routine healing.A skilled evaluation note dated June 25, 2025 revealed resident was alert and oriented to person and place and had a pain level of 0.The weight and vitals report revealed the resident had pain level that ranged from 0 through 5 from June 26 through 30, 2025.An NP encounter note dated June 30, 2025 included that the resident's pain was not controlled and had Tylenol (analgesic) for pain medication. According to the documentation, Norco (brand name for Hydrocodone-Acetaminophen) was ordered.A physician order dated June 30, 2025 revealed for Hydrocodone-Acetaminophen 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain 4-10.The NP encounter note dated July 9, 2025 included that the pain control was questionable and prognosis was poor or declining.The general progress note dated July 9, 2025 revealed that pain medications were administered.This order was transcribed onto the MAR for July 2025 and revealed that the medication was administered on July 9 at 1:51 p.m. and July 13 at 6:59 a.m. and 2:28 p.m. for pain level of 3.The weight and vitals report revealed the resident had a pain level of 3 on July 9, 2025 at 1:51 p.m., July 13 at 6:59 a.m. and July 13 at 2:28 p.m.The clinical record revealed no evidence of any reason why the Hydrocodone was administered outside of the physician-ordered parameter; and that, the physician was notified. -Resident #52 was admitted on [DATE] with diagnoses of hypertension, heart failure and atrial fibrillationThe NP encounter note dated May 19, 2025 revealed the resident was alert and oriented to self and place. Diagnoses included atrial fibrillation, bradycardia and congestive heart failure. Medication included Metoprolol Succinate ER 25 mg give 1 tablet by mouth related to essential hypertension, hold for SBP of <100 or HR of <60.The physician order summary included for Metoprolol Succinate ER (Extended Release) 25 mg give 1 tablet by mouth one time a day related to essential hypertension, hold for SBP (systolic blood pressure) of <100 or HR (heart rate) of <60 (order date of August 5, 2024). This order was transcribed onto the MAR from June 1 through August 18, 2025 and revealed documentation that the medication was administered to the resident on multiple dates in June, July and August even when the documented pulse was <60.There was no evidence found in the clinical record of any reason why Metoprolol was administered outside of the ordered parameter and that the physician was notified.In an interview with a licensed practical nurse (LPN/staff #84) conducted on August 19, 2025 at 4:13 a.m., the LPN stated that all medications should be administered as ordered following the parameters ordered by the physician.An interview was conducted with a registered nurse (RN/Staff #82) on August 19, 2025, at 8:10 a.m. The RN stated that medications are administered according to the parameters ordered by the physician. She stated that if the medication order includes specific parameters with an OR condition (e.g., heart rate or blood pressure thresholds), and the resident's vital signs meet either one of those parameters, the medication should be held; and, the physician is notified. She stated that if staff do not follow ordered parameter for administering blood pressure medications, then the medication can make the resident really dizzy because of a drop in blood pressure.During an interview with the Director of Nursing (DON/staff #14) conducted on August 19, 2025 at 9:42 a.m., the DON stated that all medications including pain medications should be administered as ordered following the physician ordered parameters. She stated that if the order for metoprolol says hold if SBP <100 or HR <60, the staff were expected to hold the medication if one of this parameter was not met and document in the progress note. The facility policy on Medication Administration revealed that medication will be administered by a Licensed Nurse per the order of the Attending Physician or licensed independent practitioner, or as consistent with the state law. Review of the facility policy on Pain Management included that the licensed nurse will administer pain medications as ordered and document medication administered on the MAR. The licensed nurse will assess the resident for pain and document results on the MAR each shift using the 1-10 pain scale or PAINAD scale. The shift pain score will indicate the highest pain level that occurred on that shift.

Based on observations, staff interviews and facility policy review, the facility failed to ensure that a treatment cart was kept locked when unsupervised and unattended. The deficient practice could result in unauthorized staff and residents having access to medications and residents receiving the wrong medication. Findings include:-On August 17, 2025, at 9:45 a.m., an observation was conducted in the Sunflower unit. An unattended and unlocked treatment cart was found positioned next to a weighing station, directly across from a resident's room. The cart contained various wound care supplies, including topical medications such as Nystatin (antifungal), Mupirocin (antibiotic), Triamcinolone (corticosteroid), and Ketoconazole (antifungal), as well as sterile gauze and other wound treatment items. No staff member was present at the cart. The nurse assigned to the unit was located at the nurse's station, approximately 20 feet away.A second observation conducted on August 19, 2025 at 4:08 a.m., revealed the same treatment cart in the Sunflower unit was again left unlocked and unattended. At the time, two certified nursing assistants (CNAs) were standing about 25 feet away, while the licensed practical nurse (LPN, staff #84) on duty was at a medication cart located at the far end of the nurse's station-approximately 50 feet from the unattended treatment cart.An interview with the LPN (staff #84) was conducted at 4:13 a.m. on August 19, 2025. The LPN stated that the nurse responsible for wound care during the previous shift had left the treatment cart open and unlocked. She admitted she had not noticed the cart was unsecured upon starting her shift. Further, the LPN said that treatment carts should always be locked when not in use and immediately proceeded to secure the cart. In an interview with the Director of Nursing (DON/staff #14) conducted on August 19, 2025 at 9:42 a.m., the DON stated that treatment cart just like a medication cart should not be left opened when unattended. The facility policy on Personnel Authorized to Handle Medications in the facility with revision date of August 2020 included that it was their policy that only authorized personnel have access to medications in the facility. Review of the facility policy on Storage of Medications, revised on August 2020 revealed that the medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Number of residents sampled:Number of residents cited:FFTE THAT 5 STAFF MEMBERS HAVE COMPLETED RESIDENT RIGHTS TRAINING.Based on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#37, #5, #27, #16, and #56) are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents. The deficient practice could result in staff not being familiar with residents' rights. Findings include:-Regarding Staff #37Review of the personnel record for a Registered Nurse (RN/staff #37) revealed a hire date of November 1, 2024. Additionally, the personnel file revealed a signed job description dated October 17, 2024 that outlined responsibilities and knowledge to effectively perform the job which included Resident Rights. However, review of the training log did not reveal any evidence that staff #37 had completed Resident Rights training. -Regarding Staff #5Review of the personnel record for a Certified Nursing assistant (CNA/staff #5) revealed a hire date of November 1, 2024. Additionally, the personnel file included a signed a job description dated October 17, 2024 that outlined responsibilities and knowledge to effectively perform the job which included Resident Rights. However, review of the training log did not reveal any evidence that staff #5 had completed Resident Rights training. -Regarding Staff #27Review of the personnel record for the Activity Director (staff #27) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated October 19, 2024 which outlined responsibilities and knowledge to effectively perform the job which included Resident Rights. However, review of the training log did not reveal any evidence that staff #27 had completed Resident Rights training. -Regarding Staff #16Review of the personnel record for a Dietary Supervisor (staff #16) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated March 16, 2025 which outlined responsibilities and knowledge to effectively perform the job which included Resident Rights. However, review of the training log did not reveal any evidence that staff #16 had completed Resident Rights training. -Regarding Staff #56Review of the personnel record for a Social Worker (staff #56) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated October 23, 2024 which outlined responsibilities and knowledge to effectively perform the job which included Resident Rights. However, review of the training log did not reveal any evidence that staff #56 had completed Resident Rights training. During an interview with a Registered Nurse (RN/staff #29) conducted on August 19, 2025 at 8:10 a.m., staff #29 stated that staff receives monthly Inservice training with topics that includes Resident Rights. According to the RN, training is important to ensure that staff knows how to properly care for their residents. Staff #29 said that the impact of staff not receiving training is that they can end up interfering with a process or miss something that is required to provide professional care. An interview with a Certified Nursing Assistant (CNA/staff #88) was conducted on August 19, 2025 at 12:19 p.m. Staff #88 stated that if staff does not have the training required of their position it can result in resident not receiving the appropriate care or hurt the resident. During an interview with the Director of Nursing (DON/staff #14) conducted on August 19, 2025 at 1:28 p.m., staff #14 stated that training is important for competency and to provide an avenue to ask questions if unsure of the procedure. The DON noted that the impact of not having the required training is that staff might not address the situation appropriately or contact the appropriate people. The facility did not have a policy on staff training requirements. However, review of the facility's Inservice Training Schedule revealed that staff are provided Resident Rights training in the month of January. Review of the Facility assessment dated [DATE] indicated that the facility's training program included an orientation process and ongoing training. According to the facility's assessment their training plan includes Resident Rights and facility responsibilities.

Number of residents sampled:Number of residents cited:FFTE THAT 5 STAFF MEMBERS HAVE COMPLETED RESIDENT RIGHTS TRAININGBased on documentation, staff interviews, and facility policies the facility failed to ensure that five staff members (#37, #5, #27, #16, and #56) are educated on abuse, neglect, exploitation, and misappropriation of resident's property. The deficient practice could result in staff not being familiar with the prevention and reporting of abuse, neglect, exploitation, and misappropriation of property. Findings include:-Regarding Staff #37Review of the personnel record for a Registered Nurse (RN/staff #37) revealed a hire date of November 1, 2024. Additionally, the personnel file revealed a signed job description dated October 17, 2024 that outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #37 had completed Abuse training. -Regarding Staff #5Review of the personnel record for a Certified Nursing assistant (CNA/staff #5) revealed a hire date of November 1, 2024. Additionally, the personnel file included a signed a job description dated October 17, 2024 that outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #5 had completed Abuse training. -Regarding Staff #27Review of the personnel record for the Activity Director (staff #27) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated October 19, 2024 which outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #27 had completed Abuse training. -Regarding Staff #16Review of the personnel record for a Dietary Supervisor (staff #16) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated March 16, 2025 which outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes However, review of the training log did not reveal any evidence that staff #16 had completed Abuse training. -Regarding Staff #56Review of the personnel record for a Social Worker (staff #56) revealed a hire date of November 1, 2024. Additionally, the personnel file contained a signed job description dated October 23, 2024 which outlined responsibilities and knowledge to effectively perform the job which included attending and participating in scheduled in-service training and educational classes. However, review of the training log did not reveal any evidence that staff #56 had completed Abuse training. During an interview with a Registered Nurse (RN/staff #29) conducted on August 19, 2025 at 8:10 a.m., staff #29 stated that staff receives monthly Inservice training with topics that includes Abuse/Neglect. According to the RN, training is important to ensure that staff knows how to properly care for their residents. Staff #29 said that the impact of staff not receiving training is that they can end up interfering with a process or miss something that is required to provide professional care. An interview with a Certified Nursing Assistant (CNA/staff #88) was conducted on August 19, 2025 at 12:19 p.m. Staff #88 stated that if staff does not have the training required of their position it can result in resident not receiving the appropriate care or hurt the resident. During an interview with the Director of Nursing (DON/staff #14) conducted on August 19, 2025 at 1:28 p.m., staff #14 stated that training is important for competency and to provide an avenue to ask questions if unsure of the procedure. The DON noted that the impact of not having the required training is that staff might not address the situation appropriately or contact the appropriate people. The facility did not have a policy on staff training requirements. However, review of the facility's Inservice Training Schedule revealed that staff are provided Abuse/Neglect quarterly. Review of the Facility assessment dated [DATE] indicated that the facility's training program included an orientation process and ongoing training. According to the facility's assessment their training plan includes the topics of Abuse, Neglect, and Exploitation. The facility policy titled Abuse Prevention and Prohibition Program revised October 24, 2022 stated that covered individuals will be trained through orientation and on-going training sessions no less than annually. The Abuse training covers who responsible individuals are for reporting, abuse prevention, identification/recognition of signs/symptoms of abuse/neglect, protection of residents, investigation, and interventions.

Based on observations, staff interview and review of facility policy, the facility failed ensure infection control standards were followed by staff during meal service; and, failed to ensure hand hygiene was performed between residents during medication administration. The deficient practice could result in food-borne illness and transmission of infection to residents and staff. Findings include: -A dining observation was conducted on August 18, 2025, at 12:10 p.m. A certified nursing assistant (CNA/staff #41) was assisting a female resident at a dining table by preparing a ham sandwich. The CNA was wearing a glove on her right hand only; her left hand was bare. She used a bread knife in her gloved right hand to cut the sandwich while holding the sandwich in place with her ungloved left hand. After cutting the sandwich, the CNA removed the glove from her right hand and pressed down on both halves of the sandwich using her bare hands. She then picked up one half of the sandwich with her right bare hand and placed it in the resident's mouth. After the resident took a bite, the CNA returned the sandwich to the plate. She then picked up a box of tissues from the table using her right bare hand and handed it to another staff member at a table behind her. At 12:25 p.m., after the other staff member left, the CNA turned around and touched and adjusted the chair behind her using both bare hands. She then used her right bare hand to pick up the sandwich again and placed it in the resident's mouth. An interview was conducted with CNA (staff #41) on August 18, 2025 at 12:33 p.m. She stated that the resident was fully dependent on staff for all activities of daily living (ADLs), including eating, but was able to express her needs. The CNA stated that the resident was given an alternate meal (a ham sandwich) because she did not like the main entrée. The CNA said she was wearing only one glove while preparing the sandwich; and that, she was feeding the resident with her bare hands, stating that the resident preferred not to be fed with gloved hands when eating a sandwich. On August 19, 2025, at 9:42 a.m., an interview was conducted with the Director of Nursing (DON) who stated that staff were expected to follow infection control protocols and perform hand hygiene when assisting residents with meals. When asked specifically about staff handling food with bare hands, the DON did not provide a comment. Review of the facility policy on Dining Services Standards revealed that the facility staff will ensure the prevention of infection in the food service department to ensure the residents are provided with a positive meal experience. Personnel should adhere to the Infection Prevention Policy. Nutrition and Food Services personnel in direct contact with food will wear plastic or vinyl disposable gloves. No bare hand contact is made with ready to eat food. -During a medication administration observation task on August 19, 2025 starting at 4:09 AM with Licensed Practical Nurse (LPN)/Staff #94, Staff #94 administered Hydromorphone 4 MG (milligram) two tablets by mouth as ordered for pain for Resident #67. At 4:13 AM, Staff #94 left Resident #67 room without performing hand hygiene. Staff #94 proceeded to her medication cart after leaving Resident #67 room. At 4:16 AM, Staff #94 left her medication cart laptop computer screen unlocked to use the bathroom. Additional attempts to continue with medication administration observation task was conducted on August 19, 2025. At 4:58 AM, LPN/Staff #84 was informed by the surveyor that she will be observed for medication administration pass. On August 19, 2025 at 5:04 AM, Staff #84 was observed preparing the medications, Baclofen oral tablet 20 MG give one tablet and oxycodone-acetaminophen 7.5-325 MG one tablet, for Resident #8. At 5:07 AM, Staff #84 entered Resident's room and administer the medications. At 5:09 AM, medication observation was completed and Staff #84 left the resident's room without performing hand hygiene. Staff #84 proceeded to touched the computer/laptop and signed off the narcotic count sheet. On August 19, 2025 at 5:10 AM, Staff #84 was observed preparing the medications, Requip 0.5 MG (milligram) one tablet by mouth daily to be staggered with Sinemet administration times and Levothyroxine 75 MCG (microgram) one tablet, for Resident #53. At 5:13 AM, Staff #84 entered the resident's room and administer the medications. At 5:17 AM, medication observation was completed and Staff #84 left the resident's room without performing hand hygiene. Staff #84 walked towards her medication cart and touched her laptop computer located on the medication cart. An interview was conducted on August 19, 2025 at 5:36 AM with LPN/Staff #84. Staff # 84 stated that the process for medication administration involves pulling/preparing the medications out of the cart, knocking on the resident's door, then administer their medications. She identifies each resident by looking at their pictures in PCC (Point Click Care) and wrist band. She sets the resident up in bed first then she can administer their medication. She stays with the resident until the resident had taken the medications so she knows that the resident had swallowed the pills and that the resident is okay. Staff #84 stated that regarding hand hygiene, she performs it when going in and out of the residents' rooms. She used the hand sanitizer before entering the room and after leaving the room so she won't pass germs for infection control. She stated that if not hand sanitized, there is a risk of passing germs and illnesses to the resident. An interview was conducted on August 19, 2025 at 10:09 AM with a Registered Nurse (RN)/Staff #82. Staff #82 stated that one of her roles is administering medication, and the process involves checking the medication order, hand sanitize before start pulling the medication pack, then she gives the medication to the resident, she make sure the resident have water, have apple sauce to take with the medication based on her report sheet, locks her medication cart, and locks her computer by pulling down the top of the laptop to protect resident's privacy. She stated that the risk if her computer screen was unlocked is HIPPA, health information protection act violation. She stated she locks the computer screen located on the medication cart by clicking on the yellow lock-on and the screen will show This screen is Hidden meaning it is locked. Furthermore, she stated that she hands sanitize before she picks up her medication punch cards, and after leaving the resident rooms. She hands sanitize so not to pass any germs to prevent infecting herself and others. An interview was conducted on August 19, 2025 at 11:15 AM with the Director of Nursing (DON)/Staff #14. The DON stated that during medication administration, her staff follows the five rights: right medication, right resident, right dose, and right time. She stated that her staff reads the medication orders, prepare the medications, make sure everything is correct before entering the resident's room, knock on the door first, take the medications to administer to the resident and medications are not left at the bedside. Regarding hand hygiene, the DON stated that she expects her staff to wash their hands frequently, use hand sanitizer when hands are not soiled, and her staff hand sanitized between residents. The DON stated that the risk without performing hand hygiene is infection and cross contamination, and her expectation for her staff is from one room or resident to another, her expectation for her staff is to use the hand sanitizer. Regarding process and expectation for laptop screen located on the medication cart, the DON stated that before the nurse walks away from the cart, she expects her staff to close the screen and lock the medication cart because when the laptop screen is not closed while the nurse walks away from her medication cart, the risk is violation of resident's privacy. At the end of the interview, the DON stated that her staff should be locking their computer screen and washing their hands. Review of facility's policy titled, Hand Hygiene, date revised on June 2020 revealed facility staff must perform hand hygiene such as using Alcohol-based hand hygiene products to decontaminate hands immediately upon entering and exiting a resident occupied area, and before moving from one resident to another.

Number of residents sampled: 21Number of residents cited: 1The facility failed to ensure that an allegation of abuse was reportedBased on closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to conduct and submit an investigation report for an allegation of abuse for one resident (#3). The deficient practice could result in abuse allegations not being investigated and reported. Findings include: Resident #63 (alleged victim) was admitted to the facility on [DATE] with diagnoses of anxiety disorder, cognitive communication deficit, hypertension, and acute respiratory failure. A nursing note dated August 6, 2025 documented that resident reported that there was a strange man with a long beard, about 6 feet tall who stood at her door and stared at her. Additionally, the resident also reported that the resident across the hall tried to come into her room and that she told the other resident no. According to the note the other resident then shut the resident #63's door and began to make moaning noises outside of her room. Further review of the resident's record did not reveal any documentation regarding the resident #63's reported interaction with the other resident. There was no indication of any follow-up regarding the incident or that the issue was addressed. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. An interview was conducted with resident #63 on August 17, 2025 at 12:50 p.m. Resident #63 stated that a resident (#22) who had dementia used to be across the hall from her. She said that resident #22 would sit outside her door and enter her room without asking. Resident #63 revealed that resident #22 entered her room shouting and slammed her door. According to resident #63, she reported the incident to a nurse but nothing was done. Additionally, resident #22's daughter came into her room uninvited, threatened, and yelled at her. Resident #22 stated that both incidents made her feel scared and felt assaulted. She said that she was afraid of resident #22's daughter due to her aggressiveness. Resident #22 noted that resident #22's son also frightened her since he stood by her door staring at her. She indicated that she feared he would come into her room. She conveyed that she was frantically thinking of what she would do if he did. Resident #63 said that she reported the incident to the staff but no action was taken. When her friends came to visit, resident #22 would not move from her doorway. She said that the incident with the resident #22's son took place approximately on August 6, 2025. Resident #63 indicated that the incident with resident #22's daughter took place on August 8 at around 6:30 p.m. Additionally, the incident in which resident #22 slammed resident #63's door occurred on August 8, 2025. Resident #63 stated that she reported the incident to Social Services (staff #56), the charge nurse assigned that night, and the RN (Registered Nurse/staff #82) on August 8, 2025. Resident #63 became visibly upset during the interview as she relayed the incidents. She said that resident #22 threw stuff, moaned, and groaned which frightened her. An interview with a Certified Nursing Assistant (CNA/staff #50) was conducted on August 19, 2025 at 4:08 a.m. The CNA noted that resident #63 did mention approximately last week to inform the other residents to move away from her door since it was bothering her. During an interview with a Registered Nurse (RN/staff #29) conducted on August 19 2025 at 8:10 a.m., staff #29 stated that when they are notified of an allegation or witness abuse, the staff have to stop the abuse and remove the resident from the situation. The RN said that reporting abuse is important for the safety of the staff and residents. Staff #29 noted that the impact of abuse is that it affects safety and residents feel like the cannot trust the staff. Additionally, abuse can affect the residents psychologically. The RN stated that resident #63 told her that she had issues with someone coming into her room. The RN said that she informed staff #56 (Social Worker). According to staff #29, the Social Worker (staff #56) spoke with resident #63 immediately. Following the discussion between staff #56 and resident #63, staff #29 was told that resident #22 had to be watched. The RN said that someone had seen resident #22 coming out of resident #63's room. Staff #29 stated that if resident #63 had expressed to a staff that an incident scared and intimidated her then yes, it would be qualified as abuse. According to staff #29, she heard that resident #22 had gone into another resident's room and that resident was unhappy. Staff #29 said that the incident happened approximately 2-weeks ago. The RN noted that reporting and investigating allegations of abuse is important so that residents trust and know that their rights are not being abused and that they have the right to not feel threatened. An interview with a Social Worker (staff #56) was conducted on August 19, 2025 at 9:44 a.m. Staff #56 stated that it is important that the facility prevents residents from being abuse. The Social Worker said that the impact of residents being subjected to abuse is that the residents might get hurt and injured. Staff #56 admitted that resident #63 told her in passing on August 8, 2025 about residents coming up and sitting by her door. The Social Worker said that resident #63 told her that she was frightened and that she responded by asking resident #63 if she activated her call light. She relayed that the resident seemed frustrated. Staff #56 said that reporting and investigating abuse is important to make sure that residents are not in imminent danger. Investigations help determine what happened and see if there are any witnesses. An interview with the Director of Nursing (DON/staff #14) was conducted on August 19, 2024 at 1:28 p.m. Staff #14 stated that her expectation is that allegations of abuse are reported immediately. This is important in order to take the risk factor away. The DON said that the staff should have reported it immediately and removed the resident from that situation. According to staff #14, she first heard about the abuse allegation when the member of the survey team informed them about the allegation. She noted that it was not appropriate that the alleged incident was not reported to her and the administrator. During an interview with the Administrator (staff #333) conducted on August 19, 2025 at 2:09 p.m., staff #333 stated that allegations of abuse should be reported to him as soon as it happens. This is important in order to ensure resident is safe and to start the investigation. The impact of not reporting is that there is a potential for abuse to occur. The Administrator said that if the incident was witnessed then it should have been brought to their attention. The facility policy on Abuse Prevention and Prohibition Program revised October 24, 2022 revealed that facility staff are mandatory reporters. The policy noted that facility staff members will report known or suspected instances of abuse to the Administrator, or his/her designee. Per the policy, each resident has the right to be free from abuse. Additionally, the policy indicated that staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, or mistreatment. The policy indicated that the facility will report allegations of abuse immediately but no later than 2-hours after discovery. Review of the facility policy on Resident Rights revised August 2020 indicated that all residents have a right to a dignified existence. Additionally, the policy noted that residents have the right to voice grievances and have the facility respond to those grievances in a prompt manner.

Number of residents sampled: 5Number of residents cited: 1Based on clinical record review, staff interviews and facility policy review, the facility failed to ensure 1 of 5 sampled resident (#2) or resident representative was informed of the risks and benefits, options, and alternatives related to the use of a psychotropic medication prior to its administration. The deficient practice could result in resident not able to exercise his right to choose an option he prefers. Findings include: Resident #2 was admitted on [DATE] with diagnoses of mild dementia with other behavioral disturbance, cognitive communication deficit and major depressive disorder.The admission record sheet of the resident's clinical record revealed that the resident had two family members who were documented as emergency contacts and POA (power of attorneys) for care.The general progress note dated April 28, 2025 revealed the resident was admitted at the facility and the resident's family arrived shortly thereafter. Per the documentation, all medication orders were noted.The admission evaluation dated April 28, 2025 included that the resident was alert and oriented to person and situation, had clear speech usually understands verbal content and had adequate hearing and vision.A physician order dated April 28, 2025 included the following: Bupropion (antidepressant) ER (extended release) 150 mg (milligram) by mouth one time a day for anxiety and restlessness related to major depressive disorder; and, Escitalopram Oxalate (antidepressant) 10 mg by mouth one time a day related to major depressive disorder.The care plan initiated April 29, 2025 revealed that the resident required antidepressant medications such as Escitalopram and Bupropion for diagnosis of depression. Intervention included to give medications as ordered and to educate the resident/family/caregiver about risks, benefits and side effects and/or toxic symptoms of the medications.The PASRR (Pre-admission Screening and Resident Review) Level I Screening dated April 29, 2025 revealed that the resident had a serious mental illness of major depression. Medications included Bupropion and Escitalopram.The health status note dated April 29, 2025 included that the resident was alert and oriented x 1.The psychotropic medication consent forms dated April 29, 2025 included that the resident had Bupropion prescribed on April 28, 2025 and Escitalopram prescribed on April 29, 2025. The forms included condition/reason for medication, expected results, side effects/risks and length of treatment . According to the documentation on the forms, a consent was given by the resident in person on April 29, 2025. However, these forms were not signed by the resident or resident representative. The forms included an instruction to print the forms, have resident or representative sign the forms and to place signed copy in the clinical chart.The encounter note dated April 30, 2025 revealed the resident was cognitively impaired.The skilled evaluation dated May 1, 2025 included that the resident was alert and oriented to person and situation, had short-term memory impairment and impaired decision making ability.Review of the clinical record revealed no evidence that these forms were signed by the resident or resident representative.The MAR (medication administration record) revealed that Bupropion and Escitalopram were administered as ordered from April 29 through June 11, 2025. There was no evidence found in the clinical record that the resident or representative was informed of the risks and benefits related to the use of Bupropion and Escitalopram prior to its administration from April 29 through June 11, 2025. According to the documentation in the clinical record, the resident was transferred to the hospital on June 11, 2025 because of a fall incident. The hospital discharge summary with print date of June 19, 2025 revealed discharge diagnoses of dementia documented as stable and acute delirium documented as improved. It also included to add Seroquel (antipsychotic) 12.5 mg twice a day to ensure the resident gets adequate sleep. The documentation also included to avoid all narcotics or benzodiazepines at this time due to the resident's acute delirium as that may be contributing to the development of delirium.A physician order dated June 20, 2025 included for Quetiapine Fumarate 25 mg, give 0.5 tablet by mouth twice a day for mild dementia with other behavioral disturbance.The care plan dated June 20, 2025 revealed the resident was at risk for falls and had limited physical mobility related to use of antipsychotic.A skilled evaluation note dated June 21, 2025 included that the resident was admitted on [DATE]; and that, the resident was alert and oriented to person and place.The NP (nurse practitioner) encounter/admission note dated June 23, 2025 revealed that the resident had a fall on June 11 and was transferred to the hospital where he was admitted and had surgery for his trochanteric fracture. The documentation also included that the resident had some delirium postoperatively which after a few days began to improve. Medications included Quetiapine Fumarate (Generic name for Seroquel-antipsychotic) 25 mg, 0.5 tablet by mouth twice a day related to mild dementia with other behavioral disturbance. Diagnoses included Acute delirium, major depressive disorder and insomnia. The documentation also included that acute delirium nearly resolved prior to admission; and that, the resident had been a bit withdrawn than he had been previously. Per the documentation, will need to work on keeping the resident active and fluids to flush any residual statics out of his system.The skilled evaluation note dated June 24, 2025 included that the resident was alert and oriented to person and situation.The skilled evaluation note dated June 25, 2025 included that the resident was alert and oriented to person and place.The order for Quetiapine twice daily was transcribed onto the MAR for June 2025 and was documented as administered from June 20 through June 25, 2025.However, the clinical record revealed no evidence that the resident or resident representative was informed of the risks and benefits, options or alternatives related to the use of Quetiapine prior to its administration from June 20 through June 25, 2025.The physician order dated June 25, 2025 included for Quetiapine 25 mg give 0.5 tablet by mouth at bedtime for hospital delirium for 7 days, taper and discontinue.The general progress note dated June 25, 2025 revealed that the client had orders for Seroquel (brand name for Quetiapine) twice daily was changed to at bedtime. Per the documentation, the resident was presently a bit lethargic and the resident reported he felt drunk.An NP encounter note dated June 30, 2025, listed Quetiapine 25 mg (half a tablet by mouth twice a day) as an active medication since June 20, 2025 prescribed for mild dementia with behavioral disturbances.The order for Quetiapine at bedtime was transcribed onto the MAR for June 2025 and was documented as administered as ordered from June 25 through July 1, 2025.However, there was no evidence found in the clinical record that the resident or resident representative was informed of the risks and benefits, options or alternatives related to the use of Quetiapine prior to its administration from June 25 through July 1, 2025.An alert note dated July 7, 2025 revealed that resident had signs and symptoms of UTI (urinary tract infection) and new orders of antibiotic for 7 days were confirmed and that the family was notified.The general progress note dated July 9, 2025 included that the resident was on oral antibiotic for UTI; and that, the resident's emergency contact/POA visited for a few minutes that day.The consent for antipsychotic or neuroleptic medication treatment included psychiatric conditions and/or maladaptive behaviors of dementia with psychosis and depression which was non-responsive to traditional medications. Per the documentation, the resident had agitations and hallucinations. Course of therapy included Quetiapine 12.5 mg by mouth twice daily. The risks and benefits related to the use of Quetiapine was blank and this form was signed by the physician and the NP and dated July 9, 2025. However, there was no evidence that this was signed by the resident or resident representative.The clinical record revealed no documentation of the reason why the consent was signed by the physician and the NP but not the resident or the resident representative.A physician order dated July 10, 2025 included for Quetiapine Fumarate 25 mg, give 0.5 tablet by mouth at bedtime for behaviors. This order was transcribed onto the MAR for July 2025.Review of the July 2025 MAR revealed that Quetiapine was administered as ordered from July 11 through July 17, 2025 and discontinued on July 17, 2025.The clinical record revealed that on July 12, 2025, the resident was admitted to hospice service for nutritional deficiency.On July 17, 2025, a physician order was written to increase the dose for Quetiapine 25 mg from half a tablet to 2 tablets by mouth once daily for agitation and restlessness.The July 2025 MAR revealed documentation that the increased dose of Quetiapine was administered as ordered from July 17 through July 21, 2025. It also included that the documentation that this order was discontinued on July 22, 2025.A physician order dated July 22, 2025 included for Quetiapine 25 mg give 3 tablets by mouth at bedtime for agitation and restlessness. This order was transcribed onto the July and August 2025 MAR.The July and and August 2025 MAR revealed documentation that Quetiapine was administered as ordered from July 22 through August 18, 2025. However, there was no evidence found in the clinical record that the resident or resident representative was informed of the risks and benefits, options or alternatives related to the use of Quetiapine prior to its administration from July 11 through August 18, 2025.An interview was conducted with a licensed practical nurse (LPN/staff #88) was conducted on August 18, 2025 at 2;29 p.m. The LPN stated that when a resident is prescribed with a psychotropic medication such as anxiolytics or antipsychotics, a consent must be obtained prior to its administration. In an interview with another LPN (staff #84) conducted on August 19, 2025 at 4:13 a.m., the LPN stated that when a resident is admitted with or prescribed psychotropic medications-such as antipsychotics or antidepressants-a consent form must first be signed by the resident or their representative. She said the consent form includes the name of the medication, its purpose, and information about potential side effects, risks, and benefits. She also said that a physician's order must be in place, which includes the diagnosis and the target behavior the medication was intended for. Further, the LPN said that once the consent was signed, the medication is administered as prescribed, following any specified parameters; and, if the resident or representative refuses to sign the consent, she would notify the provider and wait for further instructions. An interview was conducted on August 19, 2025 at 8:10 a.m. with a registered nurse (RN/staff #82) who stated that when a resident is prescribed a psychotropic medication, a consent form must be completed and this form was usually signed by the resident. She said that a physician's order was required for the medication, and the signed consent must be in place before the medication can be administered. The RN also stated that the pharmacy reviews the use of psychotropic medications, and the duration of use may depend on the resident's diagnosis. An interview with the Director of Nursing (DON/staff #14) was conducted on August 19, 2025, at 9:42 a.m. The DON stated that when a resident is admitted with, or prescribed, a psychotropic medication, a consent form must be completed and signed by the resident or their representative prior to administration; and that, if consent was not provided, staff were expected not to administer the medication and to notify the provider. The DON said that when consent is obtained, the medication is given as ordered, and staff were responsible for monitoring the resident for the target behavior the medication was intended to address, as well as any potential side effects. She also said that there must be a physician for the psychotropic medication that must include both the diagnosis and the specific target behavior. According to the DON, consent forms may be in either paper or electronic format and must include the name of the psychotropic drug, its purpose, potential side effects, risks, and benefits. She further stated that staff were expected to document any resident behaviors in the clinical record. The DON stated that antipsychotic medications such as Seroquel were often prescribed during hospital stays prior to a resident's admission; and, upon admission to the facility, the facility's provider typically either discontinues or reduces the dose of such medications, depending on the resident's condition. Regarding Resident #2, the DON stated that the only consent found for the use of Seroquel was the one signed by the nurse practitioner (NP) and the provider, as the resident does not have a family member available to provide consent. She stated that Resident #2 was currently at the end of life, becomes easily agitated and restless, and that Seroquel was effective in helping to calm the resident.The facility policy on Psychotherapeutic Drug Management revised on June 2020 included a purpose to ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition. The psychotherapeutic medication order will include informed consent from resident and/or surrogate decision maker for each drug and for each increase in dosage as per state guidelines. The licensed nurse will not administer the psychotherapeutic medication until an informed consent form has been obtained and documented by the Attending Physician from the resident and/or surrogate decision maker, unless it is an emergency.Review of the facility policy on Informed Consent revised August 2020 revealed a purpose that the facility respects the resident's right to make an informed consent decision prior to deciding to undergo certain medical therapies and procedures. The use of an informed consent will be done for the use of psychotherapeutic drugs. The resident or representative must sign an informed consent. When obtaining consent for use of psychotherapeutic drugs, the resident will: receive an informed consent form stating the risks and benefits for the use of these medications; when admitted with orders for psychotherapeutic drugs, licensed staff will verify with the resident that the risks and benefits have been explained to them prior to consent or use; have risks and benefits for use explained to them; and have consent remain in place until the medication is discontinued or until consent is revoked by resident/responsible party. in an emergency, treatment may be initiated without informed consent if an unanticipated condition in which immediate action is necessary exist and are documented in the resident's medical record and if there is documentation in the resident's record that the resident or resident representative specifically requests that he or she not be informed of the risks of the recommended treatment or procedure. There must be documentation in the medical record for these exceptions to be used.

Number of residents sampled: 21Number of residents cited: 1The facility failed to ensure that one resident (#63) was free from abuseBased on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of one resident (#63) to be free from abuse by another resident (#22). The deficient practice could result in further abuse of residents and appropriate action not taken. Findings include: -Resident #63 (alleged victim) was admitted to the facility on [DATE] with diagnoses of anxiety disorder, cognitive communication deficit, hypertension, and acute respiratory failure. A care plan pertaining to anti-anxiety medication related to anxiety disorder revised July 22, 2025 indicated that the resident was prescribed medication to treat anxiety symptoms as needed. Further review of the care plan did not indicate or document any issues or interventions related to resident-to-resident altercation/incidents. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. Further review of the August 1, 2025 MDS assessment indicated that the resident was negative for psychosis indicators, behavioral symptoms, and wandering during the assessment period. A nursing note dated August 6, 2025 documented that resident reported that there was a strange man with a long beard, about 6 feet tall who stood at her door and stared at her. Additionally, the resident also reported that the resident across the hall tried to come into her room and that she told the other resident no. According to the note the other resident then shut the resident #63's door and began to make moaning noises outside of her room. Further review of the resident's record did not reveal any documentation regarding the resident #63's reported interaction with the other resident. There was no indication of any follow-up regarding the incident or that the issue was addressed. An interview was conducted with resident #63 on August 17, 2025 at 12:50 p.m. Resident #63 stated that a resident (#22) who had dementia used to be across the all from her. She said that resident #22 would sit outside her door and enter her room without asking. Resident #63 revealed that resident #22 entered her room shouting and slammed her door. According to resident #63, she reported the incident to a nurse but nothing was done. Additionally, resident #22's daughter came into her room uninvited, threatened, and yelled at her. Resident #22 stated that both incidents made her feel scared and felt assaulted. She said that she was afraid of resident #22's daughter due to her aggressiveness. Resident #22 noted that resident #22's son also frightened her since he stood by her door staring at her. She indicated that she feared he would come into her room. She conveyed that she was frantically thinking of what she would do if he did. Resident #63 said that she reported the incident to the staff but no action was taken. When her friends came to visit, resident #22 would not move from her doorway. She said that the incident with the resident #22's son took place approximately on August 6, 2025. Resident #63 indicated that the incident with resident #22's daughter took place on August 8 at around 6:30 p.m. Additionally, the incident in which resident #22 slammed resident #63's door occurred on August 8, 2025. Resident #63 stated that she reported the incident to Social Services (staff #56), the charge nurse assigned that night, and the RN (Registered Nurse/staff #82) on August 8, 2025. Resident #63 became visibly upset during the interview as she relayed the incidents. She said that resident #22 threw stuff, moaned, and groaned which frightened her. A progress note dated August 17, 2025 stated that she wanted staff to intervene when there are residents outside her room by her door. The note indicated that resident #63 was informed that staff are busy and if they are unable to intervene, the resident should activate her call light for assistance. An interview with a Certified Nursing Assistant (CNA/staff #50) was conducted on August 19, 2025 at 4:08 a.m. Staff #50 stated that resident #63 is an accurate historian who would voice out concerns. The CNA said that resident #63 is vocal about her needs. However, staff #50 denied any knowledge of any incidents involving resident #63. The CNA noted that resident #63 did mention approximately last week to inform the other residents to move away from her door since it was bothering her. Staff #50 said that it is important that residents are not subjected to abuse because the facility is their home. The residents have the right to be safe and protected. According to the CNA the impact of abuse on residents is that it becomes harder for them to adjust to their living situation and it can cause unnecessary stress. During an interview with a Registered Nurse (RN/staff #29) conducted on August 19 2025 at 8:10 a.m., staff #29 stated that when they are notified of an allegation or witness abuse, the staff have to stop the abuse and remove the resident from the situation. The RN said that protecting and mitigating abuse is important for the safety of the staff and residents. Staff #29 noted that the impact of abuse is that it affects safety and residents feel like the cannot trust the staff. Additionally, abuse can affect the residents psychologically. The RN described resident #63 as alert and oriented. Staff #29 stated that resident #63 told her that she had issues with someone coming into her room. The RN said that she informed staff #56 (Social Worker). According to staff #29, the Social Worker (staff #56) spoke with resident #63 immediately. Following the discussion between staff #56 and resident #63, staff #29 was told that resident #22 had to be watched. The RN said that someone had seen resident #22 coming out of resident #63's room. Staff #29 stated that if resident #63 had expressed to a staff that an incident scared and intimidated her then yes, it would be qualified as abuse. An interview with a Social Worker (staff #56) was conducted on August 19, 2025 at 9:44 a.m. Staff #56 stated that it is important that the facility prevents residents from being abuse. The Social Worker said that the impact of residents being subjected to abuse is that the residents might get hurt and injured. Staff #56 admitted that resident #63 told her in passing on August 8, 2025 about residents coming up and sitting by her door. The Social Worker said that resident #63 told her that she was frightened and that she responded by asking resident #63 if she activated her call light. She relayed that the resident seemed frustrated. -Resident #22 (alleged perpetrator) was admitted on [DATE] with diagnoses of dementia, delirium, depression, and anxiety disorder. Review of the resident's care plan revealed that her diagnoses of dementia, delirium, depression, and anxiety disorder were not mentioned or had interventions. Further review of the care plan did not indicate or document any issues or interventions related to resident-to-resident altercation/incidents. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 indicating that resident has moderate cognitive impairment. The MDS also documented that the resident was negative for indicators of psychosis, behavioral symptoms, and wandering during the assessment period. A progress note dated August 8, 2025 documented that resident #22 was observed in neighbor's doorway just sitting there, and not saying anything. The note indicated that the resident was told that she should not be sitting there and when the staff member looked up, the resident was shutting the neighbor's door. According to the note, the neighbor came out very upset and stated that this had happened at least three previous times. The note stated that a social worker attempted to talk to the resident but she got very upset and refused to listen. The note indicated that the nurse convinced the resident to stay away from the neighbor's door and was pleasant for the rest of the shift. Review of the facility investigator's (Social Worker/staff #56) memo dated August 17, 2025 documented that according to resident #63, a resident from across the hall had wandered into her room and slammed the door. Additionally, the memo indicated that resident #63 shared that the other resident would sit outside her room to stare at her which frightened her. The memo noted that staff #56 informed resident #63 to notify staff when incidents occur so they can address it. The memo noted that resident was educated that she needed to press the call light and staff would intervene as they see it happen. An interview with a Certified Nursing Assistant (CNA/staff #50) was conducted on August 19, 2025 at 4:08 a.m. Staff #50 stated that resident #22 suffered from dementia, had a habit of wandering, and sitting in the hallway, and talking in the hallway. During an interview with a Registered Nurse (RN/staff #29) conducted on August 19 2025 at 8:10 a.m., staff #29 stated resident #22 had good and bad days with some cognitive impairment. The RN described the resident as loud, boisterous who wanders the hall. According to staff #29, she heard that resident #22 had gone into another resident's room and that resident was unhappy. Staff #29 said that the incident happened approximately 2-weeks ago. An interview with the Director of Nursing (DON/staff #14) was conducted on August 19, 2024 at 1:28 p.m. Staff #14 stated that her expectation is that allegations of abuse are reported immediately. This is important in order to take the risk factor away. The DON said that the staff should have reported it immediately and removed the resident from that situation. Additionally, staff #14 stated that residents should not go into another resident's room without permission. The DON noted that resident #22 liked to walk in the hallway. Furthermore, she commented that they encouraged resident #63 to use the call light to deter similar situations. Staff #14 stated that given that there was a progress note related to the event, the likelihood that it happened should have been relayed to her. The facility policy on Abuse Prevention and Prohibition Program revised October 24, 2022 revealed that facility staff are mandatory reporters. The policy noted that facility staff members will report known or suspected instances of abuse to the Administrator, or his/her designee. Per the policy, each resident has the right to be free from abuse. Additionally, the policy indicated that staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, or mistreatment. Review of the facility policy on Resident Rights revised August 2020 indicated that all residents have a right to a dignified existence. Additionally, the policy noted that residents have the right to voice grievances and have the facility respond to those grievances in a prompt manner.

Number of residents sampled: 5Number of residents cited: 1Based on observations, clinical record review, staff interviews and facility policy review, the facility failed to ensure there was adequate indication, non-pharmacological interventions and monitoring of behaviors and side effects related to the use of antipsychotic medication for 1 of 5 sampled residents (#2). The deficient practice could result in unnecessary use of antipsychotic medication for the resident. Findings include: Resident #2 was readmitted on [DATE] with diagnoses of mild dementia with other behavioral disturbance, cognitive communication deficit and major depressive disorder.The hospital discharge summary with print date of June 19, 2025 revealed discharge diagnoses of dementia documented as stable and acute delirium documented as improved. It also included to add Seroquel (antipsychotic) 12.5 mg (milligrams) twice a day to ensure the resident gets adequate sleep; and, to avoid all narcotics or benzodiazepines at this time due to the resident's acute delirium as that may be contributing to the development of delirium.The hospital PASRR (Pre-admission Screening and Resident Review) Level I screening dated June 19, 2025 revealed the resident ha no serious mental illness (SMI).A physician order dated June 20, 2025 included for Quetiapine Fumarate 25 mg, give 0.5 tablet by mouth twice a day for mild dementia with other behavioral disturbance. There was no target behavior included in the order.The care plan dated June 20, 2025 revealed that resident was at risk for social isolation, fall and limited physical mobility related to use of high risk medications such as antipsychotics and had impaired cognitive functions related to dementia. Interventions included to anticipate and meet resident's needs and to administer medications as ordered.The skilled evaluation notes dated June 21 and June 22, 2025 included that the resident was alert and oriented to person and place and there were no changes in mood and behavior noted.The NP (nurse practitioner) encounter/admission note dated June 23, 2025 revealed that the resident had a fall on June 11 and was transferred to the hospital where he was admitted and had surgery for his trochanteric fracture. The documentation also included that the resident had some delirium postoperatively which after a few days began to improve. Medications included Quetiapine Fumarate (Generic name for Seroquel) 25 mg, 0.5 tablet by mouth twice a day related to mild dementia with other behavioral disturbance. Diagnoses included Acute delirium, major depressive disorder and insomnia. According to the documentation, acute delirium nearly resolved prior to admission; and that, the resident had been a bit withdrawn than he had been previously. Per the documentation, will need to work on keeping the resident active and fluids to flush any residual statics out of his system.The skilled evaluation dated June 23, 2025 included that the was alert and oriented to person and situation, does not follow direction or suggestion related to waiting for help with transfers and assistance, was impulsive, had short term memory deficit and had no changes to mood and behavior noted.The skilled evaluations dated June 24 and 25, 2025 revealed there were no changes to mood and behavior noted.The general progress note dated June 25, 2025 included that the client had orders for twice daily Seroquel and the order was changed to at bedtime; and that, the resident was presently a bit lethargic and reported feeling drunk.The skilled evaluation dated June 26, 2025 revealed that there were changes noted in behavior. However, the documentation did not include the specific behavior the resident had.A general progress note dated that the resident took off the fresh dressing to his left lower thigh and placed it on the wall.The activity notes dated June 26, 2025 revealed that the resident attended the Resident Council/party and the Movement Studio Dancers.The skilled evaluations dated June 27, 28 and 29, 2025 revealed there were no changes to mood and behavior noted.The NP encounter note dated June 30, 2025 included Quetiapine Fumarate 25 mg, 0.5 tablet by mouth twice a day related to mild dementia with other behavioral disturbance was an active medication since June 20, 2025. Past medical history included specified dementia and cognitive communication deficit. Diagnoses included fracture of the left hip, hypertension and debility. It did not include any SMI or mental disorders.The activity notes dated June 30, 2025 revealed that the resident attended bingo and zoo babies.The general progress note dated June 30, 2025 included that the resident was calling out and kept sitting up in bed; and that, Benadryl (antihistamine) was given for restlessness and it was effective. There was also no evidence that target behavior and side effects related to the use of Seroquel was monitored and documented. There was also no evidence that non-pharmacological interventions were used, monitored and documented to address the resident's noted behavior of calling out. Despite the lack of documentation of psychotic behaviors such as hallucinations or delusions, review of the MAR (medication administration record) for June 2025 revealed that the resident received Seroquel from June 20 through July 1, 2025.The general progress note dated July 1, 2025 revealed that the resident continued to have some confusion, was restless and calling out at bed time. Per the documentation, the resident was given Benadryl which helped the resident sleep. The skilled evaluations dated July 2, 2025 revealed there were no changes to mood and behavior noted.A general progress note dated July 2, 2025 included that the resident's roommate reported over the last few days and that the resident was taking food from the roommate's dresser.The physician encounter note dated July 3, 2025 included that the half tablet twice daily Quetiapine was an active medication since June 20, 2025. Assessments included unspecified mild dementia with other behavioral disturbance, cognitive communication deficit and major depressive disorder.The skilled evaluations dated July 4 and 5, 2025 revealed there were no changes to mood and behavior noted.The skilled evaluation dated July 6, 2025 included that there were changes noted in the resident's behavior; and that, the resident was calling out. Per the documentation, the provider was notified and the resident was started on 1st generation antihistamine every 6 hours as needed.The NP encounter note dated July 7, 2025 revealed that the resident had UTI (urinary tract infection) and was being treated with antibiotics.The skilled evaluation note dated July 7, 2025 included that there were changed in the resident's behavior; and that, the resident was yelling out which may be related to UTI that the resident was being treated for currently.The alert note dated July 8, 2025 revealed that at approximately 5:30 a.m., the resident was hollering out in pain, was visibly uncomfortable and grimacing/moaning/groaning and indicated that he was having pain in his groin. Per the documentation, the resident had pulled his urinary catheter out farther than it was intended to go.The skilled evaluations dated July 8, 2025 revealed there were no changes to mood and behavior noted.The NP encounter note dated July 9, 2025 included diagnoses of mild dementia with other behavioral disturbance, adult failure to thrive and UTI. Per the documentation the resident's dementia continued to decline.The consent for antipsychotic or neuroleptic medication treatment signed by the physician and the NP and dated July 9, 2025 included psychiatric conditions and/or maladaptive behaviors of dementia with psychosis and depression which was non-responsive to traditional medications. Per the documentation, the resident had agitations and hallucinations. Course of therapy included Quetiapine 12.5 mg by mouth twice daily. Despite the continued lack of target behaviors and/or lack of indication for the use of Seroquel, a physician order was written on July 10, 2025 for Quetiapine Fumarate 25 mg, give 0.5 tablet by mouth at bedtime for behaviors. The order did not include the diagnosis and specific target behavior Seroquel was ordered for and the monitoring of side effects related to the use of Seroquel.An activity note dated July 10, 2025 revealed that the resident attended Christmas in July and Pass the Present game.The general progress note dated July 10, 2025 included that the resident was very agitated, was calling out and was tearing his attends to shreds; and that, the resident was on oral antibiotics and was given his scheduled and as needed pain medications. The documentation also included that after breakfast he was sleepy almost hard to arouse; and that, the NP was notified.The general progress notes dated July 13, 2025 revealed that the resident was calling out early that morning and was going to exit doors and wanting to go out. The order for Quetiapine at bedtime was transcribed onto the MAR for July 2025. Review of the MAR revealed that Quetiapine was administered as ordered from July 11 through July 17, 2025.On July 17, 2025, a physician order was written to increase the dose for Quetiapine 25 mg from half a tablet to 2 tablets by mouth once daily for agitation and restlessness.The Order change note dated July 17, 2025 revealed that the order for Seroquel 25 mg give 2 tablets by mouth one time a day for agitation and restlessness was entered in the electronic record.However, further review of the clinical record revealed no documentation that the resident was agitated and restless and had psychotic behaviors such as hallucinations or delusions.There was also no evidence that target behavior and side effects related to the use of Seroquel was monitored and documented. There was also no evidence that non-pharmacological interventions were used, monitored and documented to address the resident's agitation or restlessness. The order for Quetiapine 25 mg 2 tablets daily was transcribed onto the MAR for July 2025. Review of the MAR revealed that Quetiapine was administered as ordered from July 17 through July 21, 2025.Despite the lack of documentation of psychotic behaviors such as hallucinations or delusions and lack of documentation of agitation and restlessness for which the Seroquel was ordered for, a physician order was written on July 22, 2025 to increase the dose of Quetiapine 25 mg from 2 tablets to 3 tablets at bedtime.The quarterly MDS (Minimum Data Set) assessment dated [DATE] included that the resident had a BIMS (Brief Interview for Mental Status) score of 1 indicating the resident had impaired cognition; and, resident had no potential indicators of psychosis such as hallucinations and delusions. Active diagnoses included depression and non-Alzheimer's dementia and disorientation; and, the resident had no psychotic disorder. The MDS also included that the resident was receiving an antipsychotic on a PRN (as needed) basis only. Despite the continued lack of documented behaviors and/or lack of indication for the use of Seroquel, the MAR for July and August 2025 revealed that the resident continued to receive Seroquel as ordered by the physician.An observation was conducted on August 17, 2025 at 12:15 p.m. Resident #2 was sitting in his wheelchair at the dining table. There were four other residents and 2 staff at the same dining table with Resident #2 who was calm, not agitated or restless and was responding appropriately to staff interaction. During an observation conducted on August 18, 2025 from 9:44 a.m. through 10:49 a.m., resident #2 was sitting in his wheelchair by the reception area/lobby and was looking outside of the big side window. He was calm, would occasionally doze off, was not agitated or restless, and was responding well with the nurse who frequently checks on him. At 10:15 a.m., another male resident joined in the area with a female staff who were engaged in an interactive conversation. Resident #2 was not bothered with this and continued to cycle of dozing off and looking back out on the big side window. For the duration of the observation, Resident #2 did not call or yell out, and he was not agitated or restless.An interview with a certified nurse assistant (CNA/staff #41) was conducted on August 18, 2025 at 12:33 p.m. The CNA stated that Resident #2 was alert and can sometimes tell staff needs and wants. She stated that the used to talk with other residents but the resident is not able to now. She stated that Resident #2 had no behaviors such as agitation, hallucination or delusions and was not restless. She further stated that the resident was nice and calm. In an interview with another LPN (staff #84) conducted on August 19, 2025 at 4:13 a.m., the LPN stated that when a resident is admitted with or prescribed psychotropic medications-such as antipsychotics or antidepressants-a consent form must first be signed by the resident or their representative. She said the consent form includes the name of the medication, its purpose, and information about potential side effects, risks, and benefits. She also said that a physician's order must be in place, which includes the diagnosis and the target behavior the medication was intended for. Further, the LPN said that once the consent was signed, the medication is administered as prescribed, following any specified parameters; and, if the resident or representative refuses to sign the consent, she would notify the provider and wait for further instructions.An interview with the Director of Nursing (DON/staff #14) was conducted on August 19, 2025, at 9:42 a.m. The DON stated that when a resident is admitted with, or prescribed, a psychotropic medication, a consent form must be completed and signed by the resident or their representative prior to administration; and that, if consent was not provided, staff were expected not to administer the medication and to notify the provider. The DON said that when consent is obtained, the medication is given as ordered, and staff were responsible for monitoring the resident for the target behavior the medication was intended to address, as well as any potential side effects. She also said that there must be a physician for the psychotropic medication that must include both the diagnosis and the specific target behavior. She further stated that staff were expected to document any resident behaviors in the clinical record. The DON stated that antipsychotic medications such as Seroquel were often prescribed during hospital stays prior to a resident's admission; and, upon admission to the facility, the facility's provider typically either discontinues or reduces the dose of such medications, depending on the resident's condition. Regarding Resident #2, the DON stated that Resident #2 was currently at the end of life, becomes easily agitated and restless, and that Seroquel was effective in helping to calm the resident. She further stated that the resident's behavior should be documented in the skilled evaluation notes.The facility policy on Psychotherapeutic Drug Management revised on June 2020 included a purpose to ensure the resident receives only those medications, in doses and for the duration clinically indicated to treat the resident's assessed condition. Psychotherapeutic drugs will only be utilized with a physician order and will never be used for convenience of staff. The facility will utilize individualized, non-pharmacological approaches to care (e.g., purposeful and meaningful activities). The psychotherapeutic medication order will include the diagnosis for the medication and indications and manifestations of the disorder treated i.e. auditory hallucinations, hitting others, etc. CMS (Centers for Medicare and Medicaid Services) has identified the following as inappropriate reasons to use antipsychotics: wandering, restlessness or mild anxiety; impaired memory; insomnia; poor self-care or inattention or indifference; fidgeting or nervousness and uncooperativeness. Nursing responsibility included monitoring psychotropic drug use daily noting any adverse effects, monitoring the presence of target behaviors on a daily basis charting only by exception (i.e., charting only when the behaviors are present) and reviewing the use of the medication with the physician and the interdisciplinary team at least quarterly to determine the continued presence of target behaviors and/or the presence of any adverse effects of the medication use. It also included that monitoring should also include evaluation of the effectiveness of non-pharmacological approaches prior to administering PRN medications. The medication will be written on the Medication Administration Record (MAR) with the following information: Medication, dose and time of administration; manifestations for the drug i.e. hitting others, etc.; side effects of the drug i.e. drooling, dry mouth, abnormal gait.

Number of residents sampled: 21Number of residents cited: 1The facility failed to ensure that abuse policy was implementedBased on clinical record, staff interviews, review of facility documentation, policy and procedures and the State Agency (SA) database the facility failed to implement their policy regarding conducting thorough investigation of abuse allegation and protecting residents from further abuse for one resident (#63). The deficient practice could result in abuse continuing and not being prevented. Findings include: Resident #63 (alleged victim) was admitted to the facility on [DATE] with diagnoses of anxiety disorder, cognitive communication deficit, hypertension, and acute respiratory failure. A nursing note dated August 6, 2025 documented that resident reported that there was a strange man with a long beard, about 6 feet tall who stood at her door and stared at her. Additionally, the resident also reported that the resident across the hall tried to come into her room and that she told the other resident no. According to the note the other resident then shut the resident #63's door and began to make moaning noises outside of her room. Further review of the resident's record did not reveal any documentation regarding the resident #63's reported interaction with the other resident. There was no indication of any follow-up regarding the incident or that the issue was addressed. An interview was conducted with resident #63 on August 17, 2025 at 12:50 p.m. Resident #63 stated that a resident (#22) who had dementia used to be across the hall from her. She said that resident #22 would sit outside her door and enter her room without asking. Resident #63 revealed that resident #22 entered her room shouting and slammed her door. According to resident #63, she reported the incident to a nurse but nothing was done. Additionally, resident #22's daughter came into her room uninvited, threatened, and yelled at her. Resident #22 stated that both incidents made her feel scared and felt assaulted. She said that she was afraid of resident #22's daughter due to her aggressiveness. Resident #22 noted that resident #22's son also frightened her since he stood by her door staring at her. She indicated that she feared he would come into her room. She conveyed that she was frantically thinking of what she would do if he did. Resident #63 said that she reported the incident to the staff but no action was taken. When her friends came to visit, resident #22 would not move from her doorway. She said that the incident with the resident #22's son took place approximately on August 6, 2025. Resident #63 indicated that the incident with resident #22's daughter took place on August 8 at around 6:30 p.m. Additionally, the incident in which resident #22 slammed resident #63's door occurred on August 8, 2025. Resident #63 stated that she reported the incident to Social Services (staff #56), the charge nurse assigned that night, and the RN (Registered Nurse/staff #82) on August 8, 2025. Resident #63 became visibly upset during the interview as she relayed the incidents. She said that resident #22 threw stuff, moaned, and groaned which frightened her. Review of the SA database revealed that a self-report was submitted by the facility on August 17, 2025. The report indicated an allegation in which another resident would come into the alleged victim's room. However, it did not fully detail information on what occurred nor did it indicate who the alleged perpetrator was. Regarding resident #22 (alleged perpetrator) Resident #22 (alleged perpetrator) was admitted on [DATE] with diagnoses of dementia, delirium, depression, and anxiety disorder. A progress note dated August 8, 2025 documented that resident #22 was observed in neighbor's doorway just sitting there, and not saying anything. The note indicated that the resident was told that she should not be sitting there and when the staff member looked up, the resident was shutting the neighbor's door. According to the note, the neighbor came out very upset and stated that this had happened at least three previous times. The note stated that a social worker attempted to talk to the resident but she got very upset and refused to listen. The note indicated that the nurse convinced the resident to stay away from the neighbor's door and was pleasant for the rest of the shift. Review of the facility investigator's (Social Worker/staff #56) memo dated August 17, 2025 documented that according to resident #63, a resident from across the hall had wandered into her room and slammed the door. Additionally, the memo indicated that resident #63 shared that the other resident would sit outside her room to stare at her which frightened her. The memo noted that staff #56 informed resident #63 to notify staff when incidents occur so they can address it. The memo noted that resident was educated that she needed to press the call light and staff would intervene as they see it happen. Further review of the facility's investigator's memo dated August 17, 2025 revealed that no other residents or staff members were interviewed regarding the allegation. Additionally, the memo did not indicate any other fact-finding activity other than an interview with resident #63. An interview with a Certified Nursing Assistant (CNA/staff #50) was conducted on August 19, 2025 at 4:08 a.m. The CNA noted that resident #63 did mention approximately last week to inform the other residents to move away from her door since it was bothering her. During an interview with a Registered Nurse (RN/staff #29) conducted on August 19 2025 at 8:10 a.m., staff #29 stated that when they are notified of an allegation or witness abuse, the staff have to stop the abuse and remove the resident from the situation. The RN said that protecting and mitigating abuse is important for the safety of the staff and residents. Staff #29 noted that the impact of abuse is that it affects safety and residents feel like the cannot trust the staff. Additionally, abuse can affect the residents psychologically. The RN stated that resident #63 told her that she had issues with someone coming into her room. The RN said that she informed staff #56 (Social Worker). According to staff #29, the Social Worker (staff #56) spoke with resident #63 immediately. Following the discussion between staff #56 and resident #63, staff #29 was told that resident #22 had to be watched. The RN said that someone had seen resident #22 coming out of resident #63's room. Staff #29 stated that if resident #63 had expressed to a staff that an incident scared and intimidated her then yes, it would be qualified as abuse. According to staff #29, she heard that resident #22 had gone into another resident's room and that resident was unhappy. Staff #29 said that the incident happened approximately 2-weeks ago. The RN noted that reporting and investigating allegations of abuse is important so that residents trust and know that their rights are not being abused and that they have the right to not feel threatened. An interview with a Social Worker (staff #56) was conducted on August 19, 2025 at 9:44 a.m. Staff #56 stated that it is important that the facility prevents residents from being abuse. The Social Worker said that the impact of residents being subjected to abuse is that the residents might get hurt and injured. Staff #56 admitted that resident #63 told her in passing on August 8, 2025 about residents coming up and sitting by her door. The Social Worker said that resident #63 told her that she was frightened and that she responded by asking resident #63 if she activated her call light. She relayed that the resident seemed frustrated. Staff #56 said that reporting and investigating abuse is important to make sure that residents are not in imminent danger. Investigations help determine what happened and see if there are any witnesses. An interview with the Director of Nursing (DON/staff #14) was conducted on August 19, 2024 at 1:28 p.m. Staff #14 stated that her expectation is that allegations of abuse are reported immediately. This is important in order to take the risk factor away. The DON said that the staff should have reported it immediately and removed the resident from that situation. During an interview with the Administrator (staff #333) conducted on August 19, 2025 at 2:09 p.m., staff #333 stated that his expectation is that staff follow policy. The Administrator said that allegations reported should be investigated thoroughly to ensure resident is safe. The impact of not following policy and investigating is that there is a potential for abuse to occur. The facility policy on Abuse Prevention and Prohibition Program revised October 24, 2022 stated that each resident has the right to be free from abuse. The policy indicated that policy served to ensure that the facility establishes, operationalizes, and maintains an abuse prevention and prohibition program designed to protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse. Additionally, the policy indicated that staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, or mistreatment. The policy noted that the facility promptly and thoroughly investigates reports of abuse. The policy also highlighted the steps that may be taken to investigate an allegation of abuse.

Number of residents sampled: 1Number of residents cited: 1Based on clinical record review, staff interviews, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure an MDS (Minimum Data Set) significant change in status assessment (SCSA) was completed for one sampled resident (#2) related to hospice admission. The deficient practice could result in resident not comprehensively assessed and needs not being met.Findings include:Resident #2 was admitted on [DATE] with diagnoses of mild dementia with other behavioral disturbance, cognitive communication deficit and major depressive disorder.The skilled evaluation dated June 21, 2025 revealed that the resident was admitted at the facility on June 20, 2025.The NP (nurse practitioner) encounter/admission note dated June 23, 2025 revealed that the resident had a fall on June 11 and was transferred to the hospital where he was admitted and had surgery for his trochanteric fracture. Diagnoses included debility, major depressive disorder and insomnia.The alert note dated July 7, 2025 included that the resident had signs and symptoms of UTI (urinary tract infection) and had orders for antibiotic therapy for 7 days.The alert notes dated July 8 and 10, 2025 revealed that resident had a trend of eating <51% and was offered a substitute.The Hospice RN (registered nurse) Start of Care visit note dated July 12, 2025 included that the resident's condition was life limiting and the resident had elected hospice care. Per the documentation, the primary or significant secondary hospice diagnosis was non-disease specific; and that, the resident had a functional decline to dependence in 2 or more ADLs (activities of daily living). The narrative included that the resident was admitted on hospice for nutritional deficiency.The client coordination note report dated July 12, 2025 revealed that the resident's prognosis was 6 months or less if the disease runs its normal course.The hospice note dated July 14, 2025 included that the resident was admitted to hospice on July 12, 2025 for a diagnosis of nutritional deficiency.The care plan dated July 14, 2025 revealed the resident had a terminal prognosis related to hospice admission and was admitted to hospice on July 12, 2025 for a diagnosis of nutritional deficiency.The physician order dated July 16, 2025 revealed that the resident was admitted to hospice on July 12, 2025 for a diagnosis of nutritional deficiency.The general progress note dated July 18, 2025 included that the resident received showers from hospice staff.Despite documentation that the resident was admitted on hospice, the clinical record revealed no evidence that an MDS significant change in status assessment (SCSA) was completed for resident #2.A quarterly MDS assessment dated [DATE] revealed that the resident had a condition or chronic disease that may result in a life expectancy of less than 6 months and resident was on hospice care.In an interview with the MDS nurse (staff #70) conducted on August 19, 2025 at 8:06 a.m., the MDS nurse stated that the MDS significant change assessment (SCSA) was a comprehensive assessment and usually completed whenever a resident was enrolling or getting off hospice or when a resident had a significant change in ADLs function. He stated that when a resident was going on or off hospice, he uses the hospice admission or discharge date as reference in creating the assessment. He stated that he does not know when the significant change assessment is due after he creates them as he was new to the position and started his training only on around July 16. However, he said that he usually reach out to their corporate MDS staff for guidance. He said that the corporate staff completed the MDS assessments for the residents at the facility when the previous MDS nurse left the facility in June 2025. During the interview, a review of the clinical record was conducted with the MDS nurse who stated that Resident #2 had an order for hospice and was admitted on hospice on July 12, 2025. He said that there was no significant change assessment but the quarterly assessment had coded hospice. The MDS nurse further stated that it was possibly because the significant change assessment was combined with the quarterly MDS assessment completed on July 25, 2025; and that, this was acceptable.In an interview with the administrator conducted on August 19, 2025 at approximately 2:30 p.m., the administrator stated that when the previous MDS nurse quit, the MDS was being completed by corporate MDS resource while the current MDS nurse (staff #70) was training. The RAI manual included that the SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan. An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. The ARD must be less than or equal to 14 days after the IDT's determination that the criteria for an SCSA are met (determination date + 14 calendar days). The MDS completion date (item Z0500B) must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met. This date may be earlier than or the same as the CAA(s) completion date, but not later than. The RAI also included that an assessment Combination refers to the use of one assessment to satisfy both OBRA and PPS assessment requirements when the time frames coincide for both required assessments. In such cases, the most stringent requirement of the two assessments for MDS completion must be met. Therefore, it is imperative that nursing home staff fully understand the requirements for both types of assessments in order to avoid unnecessary duplication of effort and to remain in compliance with both OBRA and PPS requirements.

Number of residents sampled:Number of residents cited:TFFTE THAT ONE STAFF MEMBER HAD CURRENT CPR TRAINING Based on documentation, staff interviews, and facility policies the facility failed to ensure that one staff member (#1) was had current CPR (Cardiopulmonary Resuscitation) training consistent with their role. The deficient practice could result in staff being qualified/trained to provide CPR when needed by residents. Findings include: Review of the personnel record for a Certified Nursing Assistant (CNA/staff #1) revealed a hire date of [DATE]. Additionally, the personnel file revealed a job description in which identified one of the qualifications for the position of CNA to have a current BLS (Basic Life Support)/CPR certification. The job description was signed by the employee on [DATE] indicating acknowledgement of the requirements to effectively perform the position. However, there was no evidence that staff #1 had a current BLS/CPR certification. An interview with a Certified Nursing Assistant (CNA/staff #88) was conducted on [DATE] at 12:19 p.m. Staff #88 stated that personnel without current CPR certification are pulled from the floor. According to the CNA, if staff does not have the training required of their position it can result in resident not receiving the appropriate care or hurt the resident. During an interview with the Director of Nursing (DON/staff #14) conducted on [DATE] at 1:28 p.m., staff #14 stated that training is important for competency and to provide an avenue to ask questions if unsure of the procedure. The DON noted that the impact of not having the required training is that staff might not address the situation appropriately or contact the appropriate people. Review of the facility policy titled Cardio-Pulmonary Resuscitation (CPR) revised [DATE] indicated that the facility maintains CPR capability with CPR/AED (automated external defibrillator) standard by setting facility-wide staffing and renewal requirements. The policy stated that CNAs and other direct care staff are strongly encouraged to hold CPR certification and that at least one CNA per shift must hold current CPR certification.

Based on observation, interviews, review of clinical record, and facility policy, the facility failed to ensure adequate supervision consistent with the resident's needs was provided to one resident (#3) to prevent an accident of spilling a hot liquid beverage. The deficient practice resulted in the resident sustaining a burn.-Findings include:Resident #3 was admitted to the facility May 31, 2025, with diagnoses of encephalopathy, attention and concentration deficit, cognitive communication deficit, frontal lobe and executive function deficit, weakness, and Alzheimer's disease.A brief interview for mental status (BIMS) assessment dated [DATE] revealed the resident had a score of 2, indicating severe cognitive impairment.The General Progress note dated May 31, 2025, revealed Resident #3 arrived via transport in a wheelchair, was a 2-person transfer into bed, and required 2-person assistance to change. Per the documentation, the resident was unable to verbalize needs or acknowledge the use of the call light, was combative with brief changes and medication distribution, and needed continuous rounds.The Hot Liquids Safety Evaluation dated May 31, 2025, revealed that Resident #3 did not have moderately to severely impaired cognition, despite documentation of cognitive impairment and combativeness. The evaluation also revealed that that the resident was not easily agitated, had no frequent impulsive acts/short tempered, had no weakness or paresis in the resident's upper extremities, and, had a mood that did not vary over the course of the day. Interventions selected from the Hot Liquids Safety Evaluation were for resident to use the dominant hand for drinking, for the temperature of drinks not to exceed 140 degrees, and for the resident to drink hot liquids while sitting at table only. However, there was no evidence found that the care plan was updated to include the interventions for the resident to use the dominant hand for drinking, for the temperature of drinks not to exceed 140 degrees, and for the resident to drink hot liquids while sitting at table only.A Mood/Behavior Note dated June 1, 2025, revealed the Certified Nursing Assistant (CNA) reported that when Resident #3 was checked in the morning, the resident was anxious and panicky. Per the documentation, Resident #3 had a diagnosis of Alzheimer's mixed with vascular dementia; and that, the encounter was of a serious nature. It also included that the resident told the CNA, I (referring to Resident #3) want to watch you (referring to the CNA) bleed. Further, the documentation included that the Director of Nursing (DON) and nurse practitioner (NP) were made aware of the behavior and statement made by Resident #3.The Skilled Evaluation note dated June 1, 2025 included that Resident #3 was oriented to person, was confused, had short term memory impairment, and had impaired decision-making ability.A General Progress Note dated June 1, 2025, revealed the resident was experiencing mood/behaviors in the evening when medications were given, and had pushed her medications away. Per the documentation, Resident #3 got agitated, raised her voice, had garbled speech, was impulsive, had tried to get up on her own, did not comprehend how to use the call light and had a disregard for her own safety. The documentation also included that the resident had done these the last two nights since admission; and that, the resident eventually took her medications after she was slowly instructed and explained to. Further, the documentation included that consistent rounding on Resident #3 was crucial to avoid a potential fall.An Occupational Therapy (OT) Evaluation dated June 2, 2025, revealed Resident #3 was right-hand dominant, had cognitive impairments, and required supervision or touching assistance when eating.The OT treatment encounter notes dated June 2 and June 3, 2025, included the resident required partial/moderate assistance with eating.The OT treatment encounter note dated June 4, 2025, revealed resident required set-up or clean-up assistance with eating.The OT treatment encounter note dated June 5, 2025, included resident #3 required supervision or touching assistance with eating.A provider encounter note dated June 6, 2025, revealed Resident #3 had significant dementia, so reminders were difficult, and that, she had poor impulse control and no safety awareness, so future falls were likely.The OT treatment encounter note dated June 9, 2025, included the resident required supervision or touching assistance with eating.A Change of Condition note dated June 10, 2025, revealed the resident was having difficulty taking her evening medications and was holding them in her mouth. The documentation included that the resident had difficulty understanding how to drink through a straw; and that, the straw was removed and the resident required total assistance to drink from the cup. Further, the documentation included that this seemed to only happen in the evenings during med pass.A Skilled Evaluation note dated June 12, 2025, revealed Resident #3 had an increase in confusion and behaviors today more than baseline due to cognition. The documentation included the resident was anxious and aggressive, had physical and verbal aggression with exit-seeking behaviors, and was continually getting out of her wheelchair and attempting to walk unassisted.An e-Mar (electronic Medication Administration Record) note dated June 14, 2025, revealed the resident was moved to a different table as she continued to turn and kept grabbing and putting hands on another resident sitting next to her.A Skilled Evaluation note dated June 14, 2025 included Resident #3 had some anxiety and minimal behaviors this morning, continued with inability to follow simple commands, and had no safety awareness leading to non-compliance with plan of care.The OT treatment encounter note dated June 17, 2025, included the resident required supervision or touching assistance with eating.The care plan dated June 17, 2025 revealed the resident had an Activities of Daily Living (ADL) deficit due to impaired balance and limited mobility. An intervention dated June 17, 2025 revealed that the resident required one staff participation to eat.The OT treatment encounter note dated June 23, 2025 included the resident required supervision or touching assistance with eating.An e-Mar note dated June 24, 2025 revealed the resident was displaying aggression and agitation toward a CNA.A Health Status Note dated June 25, 2025 included that at approximately 8:30 p.m., the resident was sitting on the floor in front of her bathroom. Per the documentation, the resident was not able to explain or tell nurse what she was trying to do.An e-Mar - Medication Administration Note dated June 25, 2025, revealed Resident #3 refused all medications in the evening and was verbally aggressive.A Discharge Planning note dated June 26, 2025 revealed the resident had no safety awareness and needed cues for all care including transfers, toileting, eating, dressing, and pressing her call light. Per the documentation, the resident was impulsive, and gets up without asking staff for help and that, this was also due to the resident's cognition.The OT treatment encounter note dated June 27, 2025 included the resident required supervision or touching assistance with eating.The general Progress note dated June 28, 2025 revealed that Resident #3 was up and down for the first three hours of the shift, had attempted to transfer herself three different times. The documentation included that the medication cart was parked outside of the resident's room where the nurse could watch her every move. Further, the documentation included that the resident was impulsive and persistent, but was not verbally aggressive.A General Progress Note dated June 29, 2025 included that the resident tried to go into other residents' rooms in another hall. Per the documentation, the resident was brought back to the hall where her room was; and that, she was verbally aggressive to the CNA and nurse for trying to keep her upright in her wheelchair. It also included that the resident attempted to scoot out of her wheelchair, was offered help to her bed but was verbally abusive again; and, had refused and spit all medications onto the floor.A Change of Condition note dated June 30, 2025 revealed the resident had a ground-level fall this morning onto her right side, and favoring her right arm. An x-ray for the right humerus/shoulder was ordered.The General Progress Note dated June 30, 2025 revealed the resident arrived back to the facility from the hospital; and, the resident had a proximal right humerus fracture, and a sling was applied. Per the documentation, the nurse reported that the resident had to have the sling on during the day and off in bed.There was no evidence that Resident #3 was re-assessed for safety with hot liquids after returning from the hospital with a right (dominant hand) humerus fracture until July 2, 2025, after an incident involving Resident #3 spilling hot coffee on herself.The clinical record was reviewed, and there was no evidence or documentation found in the clinical record regarding any incident on July 1, 2025, during breakfast time, that Resident #3 spilled coffee on herself.A Skilled Evaluation dated July 1, 2025, at 9:08 AM, revealed Resident #3 was very anxious, unable to sit still, which is her baseline. Her legs were swinging in the wheelchair, and she could not sit still.A General Progress Note dated July 1, 2025, revealed that the resident refused to go to the dining hall or even get out of bed for lunch today, even with two different staff encouraging her. Therapy worked with her, and was able to get her out of bed and assist her with lunch. Resident is right-handed and therapy worked with her to use her left hand. Therapy stated she will need assistance with meals. After therapy worked with the resident, the resident has been sleeping in bed.A General Progress Note dated July 1, 2025, revealed Resident #3 was up this evening in her chair so the CNA and nurse could keep an eye on her. She was extremely restless.The OT treatment encounter note dated July 1, 2025, revealed the resident required partial/moderate assistance with eating. Additionally, the documentation included that the resident had an injury to right upper extremity sustained and was now in sling. Skilled interventions included compensatory training to increase independence in self-feeding, self-feeding techniques; and, training in one-handed techniques during self-feeding.The OT treatment encounter note dated July 2, 2025 included the resident required partial/moderate assistance with eating.A Skin/Wound Note dated July 2, 2025 revealed the hall staff reported that Resident #3 sustained a burn of her right side of her abdomen yesterday with hot fluids; and that, the burn area was red and had a blister noted. It also included that the NP (nurse practitioner) was informed and silver sulfadiazine (SSD) cream was ordered to start twice a day until resolved.A Health Status Note dated July 2, 2025, included that the CNA reported that she reported to the charge nurse yesterday that the resident had an incident with hot liquid yesterday morning; and that, the resident was wet on her shirt and hands. Per the documentation, the charge nurse gave the direction to apply an ice pack; and that, the charge nurse would assess the patient. An ice pack was applied to the area at time of incident. The documentation also included that the CNA reported this morning that the resident has a red area on her abdomen and the wound nurse was called to look at the area. According to the documentation, the area was assessed by the nurse and the NP and it showed evidence of a burn, and has a blister at the lower portion of the burn; and that, silver sulfadiazine cream was applied to the area. Further, the note included an action plan to make sure coffee was lukewarm rather than hot, and to add ice if needed.A Summary for Providers note dated July 2, 2025 revealed the change in skin color or condition. The Functional Status Evaluation revealed the resident needed more assistance with ADLs, and had pain. The documentation included that a burn was noted to abdomen post incident of spilling coffee with recommendations to apply SSD (silver sulfadiazine) cream twice a day and leave open to air.A Weekly Skin Check dated July 2, 2025, revealed a red area on the abdomen, on the front of the right iliac crest, with a blister on the bottom section.A Pain Evaluation dated July 2, 2025, revealed Resident #3 did not have the ability to verbalize or communicate, had occasional labored breathing, had occasional moan or groan, sadness, was frightened, or was frowning, was tense, and had distressed pacing, or fidgeting.A Hot Liquids Safety Evaluation dated July 2, 2025, revealed the resident had moderately to severely impaired cognition, mood that varies over the course of the day, was easily agitated, hadweakness/paresis in the upper extremities, and had impaired functional mobility. Interventions included for the resident to use a cup with a lid, for temperatures of drinks not to exceed 140 degrees Fahrenheit, for the resident to drink hot liquids while sitting at table only, and for the resident to wear clothing protector/lap protector.A provider encounter note dated July 2, 2025, revealed the resident was very uncomfortable and Tylenol (analgesic) was not treating her pain adequately; and that, the plan was to order for oxycodone (narcotic opioid). Per the documentation, the resident's new fracture was resetting her progress with therapy and she will need to start all over; and, the resident's cognition was requiring increased time with therapies. New diagnosis included burn involving 2% total body surface area. The plan was to get an order for Silvadene in place, and have the wound care nurse practitioner look at the resident. Further, the documentation included that a care plan will be started to give the resident warm coffee versus hot coffee to avoid further injuries.Despite documentation of provider recommendations and interventions, there was no evidence that the care plan was updated to include the following interventions: serve the resident warm coffee instead of hot coffee, temperature of drinks not to exceed 140 degrees Fahrenheit, for resident to drink hot liquids while sitting at a table only, and for resident to wear clothing protector/lap protector.A care plan initiated and dated July 3, 2025, revealed the resident had dehydration or potential fluid deficit due to cognition. Intervention added on July 3, 2025 included only for Lids for hot fluids. The other recommendation/interventions such serving the resident warm coffee instead of hot coffee, temperature of drinks not to exceed 140 degrees Fahrenheit, drinking hot liquids while sitting at a table only and for resident to wear clothing protector/lap protector.A late entry General Progress Note dated July 3, 2025 revealed that on July 1, 2025, at approximately 7:45 a.m., a CNA (Staff #71) reported to the nurse (Staff #33) who was walking to the medication cart that Resident #3 had spilled some coffee on her; and that, the resident's clothes were changed by the CNA and an icepack was applied to the resident's abdomen. Per the documentation, the nurse checked the area after the resident's clothes were changed and an ice pack applied; and that, there was slight redness noted to the abdomen after the resident was done with breakfast.Another late entry General Progress Note dated July 3, 2025 included that on July 1, 2025 at approximately 10:00 a.m., the resident was checked very frequently for safety checks; and, the CNA had asked the nurse if it was okay to remove the icepack and this nurse stated that it was. The documentation included that the nurse checked the area and saw the same amount of redness to the resident's abdomen as earlier and after the icepack was removed.A Weekly Skin Check dated June 7, 2025, revealed a red area on the resident's right abdomen with scabbed area from a blister that has popped.A Nutritional Note dated July 7, 2025, revealed the resident was sitting in the dining room table during lunch on July 2, 2025, and spilled hot coffee on her lap. Per the documentation, the resident had an order for a lid and to drink hot liquids at the table; and, needed supervision and assistance with meals.Despite documentation, the clinical record revealed no evidence of any orders or reason why the other interventions were not included in the resident's care plan.There was no evidence that supervision and assistance with meals was provided to the resident to include the use of a lids for hot liquids or to drink hot liquids at the table.There was no documentation found in the clinical record of reason why these interventions were not implemented.A physician order dated July 9, 2025, revealed an order for an adaptive equipment - adult training cup. However, the order did not include specific directions related to its use and when will this cup be used.An observation was conducted July 11, 2025, at 8:23 a.m. Resident #3 was sitting at a table in the dining area of the unit and had a cup of juice in front of her. The Director of Nursing (DON) was sitting next to her and was assisting her with eating. The resident was not served with any hot beverage.An observation was conducted with the Lead Dietary Aide (Staff #87) on July 11, 2025, at 10:14 a.m. Staff #87 calibrated the thermometer in a cup of ice to confirm an accurate thermometer read, and then poured a cup of coffee from the coffee machine on the 400-hall unit, and took the temperature of the coffee. Staff #87 stated that the temperature of the coffee just poured was 156 degrees Fahrenheit (F).A skin observation of Resident #3 was conducted with a Licensed Practical Nurse (LPN / Staff #89) on July 11, 2025, at 11:40 a.m. The resident gave consent for observation, and in the privacy of the resident's room, the nurse lifted the resident's shirt to reveal the resident's abdomen. On the front of Resident #3's abdomen, toward her right side, was a red area of skin surrounding a scab. An interview with Staff #89 was conducted at this time, and Staff #89 stated that's a scab from the blister and it looks like it's shrinking. Staff #89 stated that the size of the blister was 2 centimeters (cm) by 3 cm.An additional observation was conducted of Resident #3 on July 11, 2025, at 12:39 p.m. A CNA (Staff #21) delivered a lunch tray to Resident #3 who was sitting up in her bed in her room, and the CNA remained in the room to assist the resident. The resident had an open cup with juice, with no lid, and no adaptive cup.An interview was conducted with a CNA (Staff #10) on July 10, 2025, at 3:11 p.m. The CNA stated that she was familiar with the residents on the 400 Hall, and that Resident #3 had dementia and is confused, and needs assistance and cues in order to eat. The CNA stated that Resident #3 is pretty impaired in her safety awareness and cognition.An interview was conducted with another CNA (Staff #21) on July 10, 2025, at 3:17 p.m. who stated that Resident #3 can sometimes feed herself if staff assist by cutting up her food and picking up the fork for her to get started, but sometimes staff have to provide total assistance with eating. The CNA stated that Resident #3 is pretty confused and while eating about a week and a half ago, the resident spilled coffee and had a blister. After the incident, the CNA stated that now we put lids on all hot drinks.An interview was conducted on July 10, 2025, at 3:26 p.m. with a Dietary Aide (Staff #60), who stated that both coffee makers (the one in the kitchen and the one on the 400 hall unit) have temperature controls that are set to 160 degrees F, and that back in November 2024, the facility had requested that dietary staff maintain the coffee machine temperature at 160 degrees, and check the temperature using thermometers when the coffee is poured to ensure it is 160 degrees. Staff #60 stated that there was not concern of coffee being too hot because dietary staff had not gotten any complaints of it being too hot, and that to his knowledge, nobody had spilled hot coffee on themselves.A phone interview was conducted on June 11, 2025, at 8:59 a.m. with a Registered Nurse (RN/staff #33), who stated she had never done any assessments for hot liquid risk, but that maybe the dietary staff completes this assessment. She stated she was the floor nurse at the time of the incident when resident #3 spilled her coffee. The RN said that she was walking past the CNA to her med cart at a little before 8:00 a.m. when she heard the CNA say that the resident spilled coffee on herself; and Staff #33 instructed for the CNA to stick an ice pack on it, and I'll (Staff #33) come look at it. The RN stated that she went and assessed the resident a little later at approximately between 9:00 a.m. and 9:30 a.m. and saw that the resident had no ice pack on, had a light redness on the abdomen; and, she assumed the redness was from the ice pack. The RN said that she looked at the resident's legs, arms, and abdomen, but that she did not look at the groin area; and that, she did not let anyone know of the incident and did not write a progress note about the incident on July 1.An interview was conducted with a CNA (Staff #71) on July 11, 2025, at 10:01 a.m. The CNA stated that she served residents in the unit coffee by getting a cup from the cupboards in the unit dining area, and pouring a cup of coffee from the coffee machine that was also located in that same dining area, and then serving those cups to the residents in the dining room. The CNA stated that on July 1, 2025, she assisted in getting Resident #3 to the dining area, then she poured the cup of coffee from the machine and set the cup of coffee with no lid on in front of Resident #3, and left the dining area to get up the next resident for breakfast. She stated that she got the next resident up for breakfast and brought that other resident into the dining area. The CNA stated that this was when she noticed that Resident #3 had spilled coffee on herself, and that the clothing of Resident #3 was wet on the front of her shirt and pants from the coffee. The CNA said that she changed the resident's clothing right away and informed the nurse (Staff #33) that there was redness on the resident's skin extending from her abdomen near the rib cage to her mid-thighs on both her legs. The CNA said that she checked on the resident's skin later in the day, and that the redness had gone down a little, but the area was still red. The CNA said that during the incident, there was one of the nurses at the nurse station who was coming in and out of the dining room; but, there were no staff at the dining table with Resident #3. The CNA said that the following day, on July 2, she was getting Resident #3 ready in the morning and checked her skin again, and that was when she noticed that she had a blistered area on the right side of her abdomen. The CNA said she told the nurse right away; and, after that incident, the facility management did an in-service training with everybody. She further stated that staff are now supposed to put lids on coffee cups and cool the coffee down before serving to the residents.A telephonic interview was attempted with a wound nurse / Registered Nurse (Staff #13) on July 11, 2025, at 12:27 p.m. A voicemail was left for a return call, and the staff did not return the call.An interview was conducted with an Occupational Therapist (OT / Staff #46) on July 11, 2025, at 12:42 p.m. The OT stated that she evaluated Resident #3 when she first admitted to the facility, and assessed the resident to have severe cognitive impairment, and that therapists were working on basic skills, including self-feeding. The OT stated that Resident #3 had been getting worse, and has been requiring more assistance. Staff #46 stated that Resident #3 would not be able to use any adaptive equipment for self-feeding because of her cognition.An additional interview was conducted with the Dietary Aid (Staff #60) on July 11, 2025, at 12:50 p.m. who stated that the kitchen has two-handled cups with lids and a drinking spout, and stated that it is called an adult training cup.An interview was conducted with the Director of Nursing (DON / Staff #90) on July 11, 2025, at 1:30 PM. The DON approached the surveyor and made a statement that Resident #3's order for the adaptive adult training cup is for hot beverages only.An interview was conducted with the Assistant Director of Nursing (ADON / Staff #106) on July 11, at 2:58 p.m., who stated that the nurses assess residents' risk with hot beverages by completing a hot liquids assessment for all residents upon admission, and that the admitting nurse is mostly the staff who completes the assessment. The ADON stated that staff would know to implement those interventions on the hot liquids assessment by word of mouth through report, and by notifying dietary, and those items are discussed by management in morning meetings. The ADON stated that temperatures of hot beverages are taken by dietary, and that nurses and CNAs do not temp the liquids before giving beverages to residents. The ADON confirmed she was at the facility on the date of Resident #3's coffee-spill incident on July 1, and to her knowledge, no management was notified of the incident. The ADON stated that Resident #3 was at the dining room table in the 400 unit and she had coffee spilled on herself, and the CNA took her to change her clothes, and notified the nurse. The ADON stated there was an ice pack applied to the resident. The ADON stated that she did not know how many times the nurse looked at the resident's skin on July 1. The ADON stated that the morning of July 2, 2025, she was informed of the incident by the floor nurse, and the resident had a blister on her abdomen and that the wound nurse was involved in assessing it and getting an order for treatment. The ADON stated that the wound nurse determined that the resident's skin condition was a blister, and it was assumed it came from the coffee spill because the CNA was relaying the details of the incident at that time on July 2. The ADON stated that in the beginning of the resident's stay, she did not require assistance with eating, however when the resident returned to the facility from the hospital with a new humerus fracture in her arm, then she needed assistance with eating, and that is when she would have needed assistance with hot liquids. The ADON also stated that Resident #3 has always been impulsive and has had anxiety and behaviors. The ADON stated that the hot liquids assessment was completed on initial admission, but was not completed for the resident when she returned from the hospital with her humerus fracture. The Hot Liquids Safety Evaluation dated May 31, 2025, was reviewed together regarding the intervention that hot beverage temperatures not to exceed 140 degrees. The ADON stated that it would take a matter of seconds for a CNA to fill a cup of coffee on the 400 hall and hand it to resident at the dining table in the same room. The ADON also stated that I don't think you could determine how fast (the coffee) would take to cool down and the CNAs don't temp the coffee when they pour and serve it in the 400-hall dining area.An additional interview was conducted with the DON on July 11, 2025, at 3:19 p.m. The DON stated that the nursing staff assess residents' cognition upon assessment through the initial admission assessment and through the BIMS assessment that is completed. The DON stated that that the nursing staff assess each resident's risk for hot liquids on admission, and also quarterly, and also if there has been a change in that resident and it needs to be re-assessed. The DON stated that the importance of that assessment is to prevent burns and injury acquired from hot liquids. The DON stated that the assessment asks questions such as determining the resident's dominant hand, if the resident needs a particular degree liquid, if the resident has weaknesses in their hand or extremities, tremors, and that it also addresses the resident's cognition. The DON stated that all of those factors determine the resident's risk with hot liquids. The DON stated that the interventions on that assessment such as beverage lids and temperature would be care-planned and communicated to the CNAs. The DON stated that the facility implements the temperature intervention when the hot beverage is poured and brought to resident, that she would imagine the temperature of the beverage would drop by the time the resident is served. The DON stated she believed it is the kitchen staff's responsibility to ensure the hot beverages are within the parameters, and that the staff on the 400-hall do not temp the coffee there, that the temperature is set from the machine. Regarding Resident #3's coffee-spill incident, the DON stated it happened around 7:45 in the morning, and that she did not know if the CNA was there. The DON stated she did not know who served the resident coffee. The DON stated that she was not aware of any staff who were at the table with the resident at the time of the incident. The DON stated that the resident spilled the coffee, and then the CNA noticed it, and stopped to notify the nurse about the coffee spilled on the resident, the nurse said she would come in and evaluate her, and then the CNA changed the resident's clothes. The DON stated the CNA took off the resident's clothing that was soaked, and the nurse and evaluated the resident's skin and asked the CNA to put ice on it. After the CNA changed the resident's clothes, the resident was taken back out to breakfast. After breakfast, the DON said that the nurse looked at the resident again and thought the redness was from the ice pack, and the nurse removed the ice and left it open to air and dry. The DON stated that the nurse told her, in follow-up conversations, that she put eyes on the resident's skin twice, and it was red both times. The following day, the CNA (Staff #71) let the nurses know, because she had worked the day before, and she wanted the nurse to know about the situation. The DON stated that the wound nurse (Staff #13) assessed the resident and determined it to be a burn, and got orders from the provider to treat it. The DON stated that after this incident, that the facility has done in-services to staff regarding the hot liquid safety assessment, and making sure liquids are not too hot, and that they are not supposed to be higher than 140 degrees. The DON stated that the resident she should have been re-assessed for hot liquids risk after her return from the hospital with the humerus fracture. The DON stated that moving forward, if Resident #3 asks for coffee, then staff will take the temperature of it and be sure it is less than 135 degrees.Review of the State Operation Manual, Appendix PP, issued August 8, 2024, revealed that for water temperature of 155 degrees F, the contact time required for a third degree burn to occur is 1 second.Review of the facility policy titled Food Temperatures, revised December, 2020, revealed the purpose is to provide the nutrition services department with guidelines for food preparation and service temperatures. Acceptable serving temperature of coffee indicated at equal to or greater than 135 degrees F.Review of the facility policy titled Behavior Management, revised June 2020, revealed the purpose is to implement the most desirable and effective interventions to change, modify, decrease, or eliminate behaviors that are distressing to the resident, and/or are decreasing or negatively impacting the residents' quality of life. Additionally, to ensure that Facility Staff performs a timely and appropriate assessment of the resident's behavioral symptoms and implement appropriate interventions. The concept of behavior management is an interdisciplinary process. The key components of this process are identifying residents whose behaviors may pose a risk to self or others and developing individual and practical care strategies based on assessed needs. The facility must provide necessary behavioral health care and services which include ensuring that the necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.Review of the facility policy titled Care Planning, revised October 24, 2022, revealed the purpose is to ensur

Based on observations, clinical record reviews, resident and staff interviews, and policy review, the facility failed to consistently assess two resident's (#56 and #71) ability to smoke safely and failed to provide supervision while smoking for one resident (#56) with cognitive impairment. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care were identified. The facility also failed to ensure that a potentially hazardous chemical was not left in an area accessible to cognitively impaired residents. Findings include: On June 10, 2014 at 2:00 p.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator was informed of the facility's failure to assess resident #56's ability to smoke safely, despite having cognitive impairment and failed to provide supervision when smoking. The facility also failed to consistently assess resident #71's ability to smoke safely. During the survey, it was discovered that resident #71 had possession of her smoking materials and had been giving cigarettes to resident #56. Facility staff were aware that resident #56 was cognitively impaired and had been found outside smoking unsupervised and the facility did not implement any corrective action. The Administrator presented an immediate plan of correction, which was accepted at 3:20 p.m. on June 10, 2014. This plan included safety measures the facility was going to implement, in order to protect all residents and provide a safe environment. Multiple observations were conducted of the facility implementing their plan of correction, which included supervision of both resident #71 and #56, staff in-services regarding smoking restrictions, and staff keeping resident #71's smoking materials. The Condition of IJ was abated on June 11, 2014 at 9:48 a.m., due to the corrective measures taken by the facility. -Resident #56 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored 7 of 15 on the Brief Interview for Mental Status, which indicated the resident had severe cognitive impairment. In the Care Area Assessment section, Cognitive Loss/Dementia triggered as a potential problem area and would be addressed in the plan of care. Review of the care plan addressing impaired cognitive functioning related to dementia included to closely monitor the resident's movement within the facility and remind the resident to stop at the nurse's station for a walkie talkie, before taking a walk. A review of the clinical record revealed nurses notes dated April 3, 2014, that included, "Resident found outside on patio smoking. Resident was reminded that this facility is a non smoking facility." Nurses notes dated April 15, 2014 included, "...Resident outside smoking prior to breakfast and this RN (registered nurse) explained that this is a non-smoking facility and resident yelled stating, "I am free to do what I want." Physician notes dated April 24, 2014 included "Pt (patient) seen and examined on patio today. She is feeling well with no concerns verbalized today. Staff reports she is smoking some and that daughter brought her some cigarettes." The resident informed the physician that she "is only smoking a little." The physician further documented "Smoking cessation strongly encouraged." The note also included that "Staff reports more confusion and delusional symptoms..." According to the quarterly MDS assessment dated [DATE], the resident scored 3 of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. A review of the resident's care plans revealed that none addressed the resident's smoking, nor were there any safety measures implemented, despite documentation that the resident was cognitively impaired and was found outside smoking. Further review of the clinical record revealed there was no documentation that this resident was assessed to be a safe smoker and was able to smoke independently. At 1:00 p.m. on June 9, 2014, resident #56 was observed on the patio sitting at a table. The resident was not smoking, however; the resident did not have a walkie talkie with her, as care planned. An attempt was made to interview the resident, however; the resident was not interviewable, due to long and short term memory problems. During an interview conducted at 8:10 a.m. on June 11, 2014, a nurse manager stated that on the evening of June 10, a family member of resident #56 had searched the resident's purse and found a packet of cigarettes, a cigarette lighter and cigarette butts. -Resident #71 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Smoking Safety Tool dated January 9, 2013, indicated the resident was able to independently smoke safely and was able to use tobacco related products appropriately. However; the documentation also included that the resident has dropped a cigarette. The assessment further included that the "Resident Care Plan does or will indicate Interventions of: Protective smoking aprons or other assistive devices." According to the annual MDS assessment dated [DATE], the resident scored 15 of 15 on the Brief Interview for Mental Status, indicating no cognitive impairment. The MDS also assessed the resident to require supervision and setup help only for eating and personal hygiene and that the resident had impairment on one side of her upper extremity (shoulder, elbow, wrist, hand). Review of a care plan related to little or no activity involvement revealed that the resident preferred activities which included the following: daily visiting with staff/peers, spending hours outside smoking, and helping her roommate. A care plan addressing fall risk included to "provide resident a walkie-talkie prior to going outside in wheelchair and instruct to call for assist when needed to maximize resident safety." Further review of the resident's care plans revealed there was no evidence that a care plan had been developed to address the resident's smoking, the need for a smoking apron while smoking or how smoking materials would be handled. During a random observation conducted at 2:20 p.m. on June 9, 2014, resident #71 was observed at the 100/200 hall nurses station, informing a Certified Nursing Assistant (CNA) that she was going outside to smoke. The resident was observed donning a smoking apron and going outside on the patio. The resident removed a packet of cigarettes and a lighter from a small bag. No staff or other residents were observed on the patio at this time. During a random observation conducted at 12:45 p.m. on June 10, 2014, resident #71 was observed going out to the patio. The resident was observed donning a smoking apron and then got out her smoking materials from her bag. The resident placed a water bottle and the bag on the table. During this observation, resident #71 stated that she was grandfathered in as a smoker in the facility. The resident laughed and said that the water bottle was her fire extinguisher, in case she dropped her cigarette she could use the water to put out the fire. The resident stated that there was one other resident (#56) in the facility that comes outside and smokes. She stated that sometimes resident #56 had her own cigarettes, but wanted to use her lighter, and other times the resident would ask her for a cigarette. She stated that she has given the resident a cigarette, but that she needs to tell the resident no, because she can't afford to buy cigarettes for herself and for the other resident. When asked when the last time resident #56 was outside smoking with her, she said yesterday before breakfast. The resident further stated that she keeps her lighter in the small bag and asks staff for a packet of cigarettes in the morning. She said she smokes about 7 to 10 cigarettes a day and keeps the remaining cigarettes in the small bag. Review of the clinical record revealed there was no documentation that the resident was reassessed on an ongoing basis for safe smoking. The last smoking assessment was completed on January 9, 2013, per the Smoking Safety Tool. In an interview, the nurse manager stated that this resident should have been reassessed for safe smoking. During an interview conducted at 1:10 p.m. on June 10, 2014, a CNA assigned to care for residents #56 and #71 stated that when resident #71 wishes to go outside to smoke, she has to go to the nurses station and get a cigarette and ask for the lighter. During an interview conducted at 1:20 p.m. on June 10, 2014, the RN assigned to care for resident #71 and #56 stated that she was not aware of the process regarding the residents' smoking. She recommended speaking to the nurse unit manager. During an interview conducted at 1:30 p.m. on June 10, 2014, the registered nurse/unit manager stated that she believed that only one resident was allowed to smoke (resident #71). However, she also stated that she was aware that resident #56 has been going outside and smoking. She stated resident #56 is very confused and does not follow directions "very well." She further stated that she spoke to the resident's family member and reminded her that the resident was in a no smoking facility and that the resident was not allowed to smoke. She said that the resident's smoking was documented in the clinical record. When asked if resident #56 was assessed for safe smoking and was care planned, she stated that she did not think so. The nurse manager stated that resident #71, would have a difficult time refusing to give resident #56 a cigarette if she asked for one. She also said that it was not resident #71's responsibility to keep resident #56 from smoking. A review of the Smoking Policy and Procedure dated April 1, 2012 revealed, "Smoking is never permitted anywhere within the facility property, interior or exterior of the building." The policy included that only residents that were grandfathered in as current smokers can continue to smoke in outdoor areas where proper receptacles are available to contain ash and cigarette butts. The policy also stated that additional smoking regulations include, but are not limited to "Smoking by residents classified as not responsible shall be prohibited Exception to: When the resident is under direct supervision..." -During a random observation in the library conducted at 9:15 a.m. on June 9, 2014, a container of Super Sani-Cloth (germicidal disposable wipes) was observed on a book shelf. The container included the following warning: "...hazards to Humans and Domestic Animals. DANGER; Causes irreversible eye damage. Harmful if absorbed through skin. Do not get in eyes or on clothing..." The container contained no germicidal disposable wipes, however; it did contain approximately a 1/4 cup of fluid that had a strong disinfectant like smell. In an interview, the nurse manager stated that residents with poor judgement are in the area of the library at times. Additional observations were conducted on June 10 and 11, 2014. The Sani-Cloth container was still on the library book shelf. During an interview conducted at 9:20 a.m. on June 11, 2014, the receptionist that sits across from the library stated that residents regularly go into the library alone. She also stated that she was not aware that the Super Sani-Cloth container had been left in the library within reach of residents. An observation was conducted on June 12, 2014, of resident #56 who has cognitive impairment, ambulating in the area just outside of the library. During an interview conducted on June 12, 2014, a RN stated that the Super Sani-Cloth container should not have been left in the library where residents would have access to the container. A review of the Housekeeping and Laundry Departments Safety Rules revealed "...Do not leave any chemicals unattended in resident rooms or in any area to which residents have access. Store chemicals in a locked area."