Every finding on record at Pueblo Springs Rehabilitation Center

Based on review of facility documentation, staff interviews, and facility policy, the facility failed to ensure necessary information regarding a resident's transfer to the hospital was documented in the clinical record for one resident (#74). The deficient practice could result in an inappropriate transfer and lack of continuity of care. Findings include: Resident #74 was admitted on [DATE] with pertinent diagnoses including hemiplegia, aphasia, dementia, thyrotoxicosis, atrial fibrillation, and hyperlipidemia. The Care Plan revealed the resident was on anticoagulant therapy related to atrial fibrillation with a noted intervention of monitor and document signs and symptoms of complications, sudden changes in mental status, or significant or sudden changes in vital signs. A review of census documentation in the clinical record revealed the resident left the faciity on August 16, 2026. However, there was no documentation in the clinical record related to that transfer.A review of physicians' orders revealed no orders related to the resident's transfer or discharge. An interview was conducted with the resident's representative (RR #5) on August 24, 2026 at 11:13 a.m. The representative stated that resident #74 was sent to the hospital on August 16, 2026. The representative stated that she didn't know the resident was refusing medications, or that she would have shown up at the facility to fix that issue. The representative further stated that she wasn't notified about the resident transfer, and it wasn't until she called the building and spoke to the social worker the following day that she found out the resident was transferred to the hospital. An interview was conducted with the Licensed Practical Nurse (LPN/staff #20) on August 24, 2026 at 12:36 p.m. The LPN stated that resident #74 was able to wheel around but not able to walk, and that resident #74 was aphasic and was hard to understand. The LPN stated that the resident had been refusing all medications. The LPN stated that resident #74 was sent to the hospital for altered mental status. The LPN further stated that in the event of a resident transfer, the process was to notify the physician for orders, notify the director of nursing, call the paramedics, complete the paperwork, and then document the above steps in the resident's chart. A telephonic interview was conducted with the Licensed Practical Nurse (LPN/staff #30) on August 24, 2026 at 12:47 p.m. The LPN stated that she was the one who transferred resident #74 to the hospital in the above incident. The LPN stated that on August 16, 2026 the resident was anxious, started drooling, and showed signs of altered mental status. The LPN further stated she notified the director of nursing and was told to get an order for medication to help with the symptoms, but didn't hear back from the provider. The LPN stated at shift change shortly after the director of nursing was notified again and ordered the resident be sent to the hospital. The LPN stated that there was nothing documented in the clinical record regarding the incident because she was never trained how to do the transfer form. The LPN concluded that she should have entered a progress note in regarding the transfer and the resident's condition. An interview was conducted with the Director of Nursing (DON/staff #40) on August 24, 2026 at 2:36 p.m. The DON stated she was aware of the incident regarding resident #74. The DON stated that during the incident staff #30 couldn't reach the doctor. The DON further stated that approximately 1.5 hours later she was called that the resident was not improving and instructed the nurse to call emergency services and send the resident to the hospital. The DON stated that there was no documentation about the transfer of resident #74 in the clinical record. The DON stated that the proper process would be to do an E-interact transfer form with the pertinent information about why the resident was being sent out. The DON stated that staff #30 told her she didn't know how to do the transfer assessment. The DON concluded that the lack of documentation related to the transfer was not their standard, that a progress note should have been put in capturing what happened with resident #74, and that it's not consistent with the facility policy standards. Review of the facility policy titled 'Resident Assessment and associated processes' revised April 2025 revealed it is the policy of this facility that residents will be assessed, and the findings documented in their clinical health record. These will be comprehensive, accurate, standardized reproducible assessment of each resident and will be conducted initially and periodically as part of an ongoing process through which each resident's preferences and goals of care, functional and health status, and strengths and needs will be identified.

Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (resident #5). The deficient practice could result in residents not receiving medications that are physician ordered and necessary. Findings include:-Resident #5 was admitted to the facility on [DATE] with diagnoses that include cirrhosis with liver failure, ascites, weakness, difficulty in walking, edema and diabetes mellitus type 2. A review of the admission MDS (Minimum Data Set) assessment dated [DATE] noted the resident had a BIMS of 15, indicating no cognitive impairment. The care-plan initiated [DATE] revealed the resident has hypotension related to medication use, with a goal of remain free of complications through the review date and noted interventions of administer medications as ordered, and monitor for side effects and effectiveness.The care-plan initiated [DATE] revealed the resident has oxygen therapy related to cirrhosis, with a goal of no signs and symptoms of poor oxygen absorption and noted interventions of administer medications as ordered by physician, and monitor for side effects and effectiveness.Review of the physician's orders dated [DATE] revealed Rifaximin oral tablet 200mg milligrams with provider instructions to give 1 tablet by mouth one time a day for liver cirrhosis.A review of progress notes dated [DATE] at 10:23 a.m. revealed that Rifaximin 200mg was not given and coded as Other / see nursing notes, due to pending order. A review of progress notes dated [DATE] at 07:12 a.m. revealed that Rifaximin 200mg was not given and coded as Other / see nursing notes, due to pending delivery from pharmacy. A review of progress notes dated [DATE] at 10:27 a.m. revealed that Rifaximin 200mg was not given and coded as Other / see nursing notes, due to unavailable. A review of progress notes dated [DATE] at 09:12 a.m. revealed that Rifaximin 200mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of progress notes dated [DATE] at 09:04 a.m. revealed that Rifaximin 200mg was not given and coded as Other / see nursing notes, due to pending. A review of progress notes dated [DATE] at 09:26 a.m. revealed that Rifaximin 200mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of progress notes dated [DATE] at 07:10 a.m. revealed that Rifaximin 200mg was not given and coded as Other / see nursing notes, due to pending. A review of progress notes dated [DATE] at 08:38 a.m. revealed that Rifaximin 200mg was not given and coded as Other / see nursing notes, due to pending order. Review of the physician's orders dated [DATE] revealed Rifaximin oral tablet 550mg milligrams with provider instructions to give 1 tablet by mouth one time a day for liver cirrhosis.A review of progress notes dated [DATE] at 09:28 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, due to pending pharmacy order. A review of progress notes dated [DATE] at 08:30 a.m. revealed that Rifaximin 550 mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of progress notes dated [DATE] at 10:36 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of provider progress notes dated [DATE] at 11:57 a.m. revealed pt states started feeling tremors and feeling her mind is more foggy. Has not received Rifaximin. Will discuss with nursing what needs to be done for pharmacy to send medication. A review of progress notes dated [DATE] at 08:27 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of progress notes dated [DATE] at 09:10 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of progress notes dated [DATE] at 09:28 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of provider progress notes dated [DATE] at 4:56 p.m. revealed Pt seen in room today. Still waiting on Rifaximin. Wanting suppository from staff. Pain controlled. Continue current rehab plan of care. A review of progress notes dated [DATE] at 10:10 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of progress notes dated [DATE] at 08:54 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of progress notes dated [DATE] at 09:10 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of progress notes dated [DATE] at 09:08 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, however, no reason was documented. A review of progress notes dated [DATE] at 08:33 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, due to pending pharmacy delivery. A review of progress notes dated [DATE] at 09:27 a.m. revealed that Rifaximin 550mg was not given and coded as Other / see nursing notes, due to Pending Auth. A review of progress notes dated [DATE] at 4:08 p.m. revealed that the resident on observation was lethargic, vital signs taken, blood pressure was 64/41, pulse 110, respirations 12, temperature 98.3, blood sugar 189, resident refusing to take oral fluids, and that the provider, and ADON said to call 911 and send resident to the hospital. The note concludes that the resident was taken to the local hospital and that the next of kin was called with no response. An interview conducted with a Licensed Practical Nurse (LPN/staff #35) on [DATE] at 9:30 a.m. Staff #35 stated that resident #5 was young, and had a lot of liver issues. Staff #35 stated she wasn't sure why the medication was changed from 200mg to 550mg, but that she assumes it was because of cost. Staff #35 stated it happens occasionally, when it's an expensive medication they don't want to fill it. Staff #35 further stated that rifaximin is very expensive. Staff #35 stated that when they don't have a medication she notifies the management and notify the doctor, then the doctor and management address the issue. Staff #35 accessed the clinical record for resident #5 during this interview and pulled up the resident's administration record. Staff #35 stated that resident #5 was here for a little while and that resident #5 didn't receive any doses of rifaximin because we didn't have the medication. When asked why the medication was not available staff #35 stated they will tell me needs a prior auth or something special. Staff #35 further stated that there is no real alternative to this medication, and that it's important to get medications as ordered because the conditions can get worse without them, or you could end up in the hospital. Staff #35 concluded that yes, the resident should have gotten this medication. An interview conducted with a Licensed Practical Nurse (LPN/staff #45) on [DATE] at 9:30 a.m. Staff #45 stated the name of the pharmacy the facility uses, and that when medications are ordered by the provider they are delivered by the pharmacy several times a day. Staff #45 stated that if a medication is out, the process is to notify management, and then the doctor, to see if they want to change things, discontinue the order, or put it on hold. Staff #45 stated that medications typically don't come if they are super expensive. Staff #45 stated that not getting necessary medications could lead to the resident getting sicker or ending up in the hospital. An interview was conducted on [DATE] at 12:28 p.m. with the Director of nursing (DON/staff #70). Staff #70 stated that resident #5 was here on a skilled stay with Medicare A as a payer source. Staff #70 stated that the resident did not get rifaximin while in the facility. She further stated that the order was changed to 550mg from 200mg and was still not delivered because it needed an authorization because it's a high cost med. Staff #70 continued that the resident eventually rolled long term care as a payer source but that they didn't obtain a carve out for the medication, which would have reduced the cost. Staff #70 stated that it fell through the cracks. Staff #70 concluded that not receiving these medications can cause the patient to become worse, and that resident #5 was sent to the hospital, and later expired. A review of facility policy titled 'Pharmaceutical services' reviewed [DATE] revealed it is the policy of this facility to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident. A review of facility policy titled 'Medication administration' reviewed [DATE] revealed it is the policy of this facility that medications shall be administered as prescribed by the attending physician.

Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that food was labeled, stored and plated in accordance with professional standards, and that personal items were not located on food preparation counters. The deficient practices could result in food-borne illnesses. Findings include: An initial kitchen observation was conducted on June 3, 2025 at 09:51 A.M. in conjunction with the dietary manager, (Staff #28). The lead cook, (Staff #71) was also present. During observation of the food preparation area, non-food personal items including two portable speakers were located on the food preparation areas. A round black speaker with attached wires was observed next to two sealed loaves of bread and a red rectangular speaker with multiple black smudges was observed in the area adjacent, nearest the stove. On June 3, 2025 at 10:06 A.M. a black cell phone was observed on the food preparation area next to the round black speaker, with an open pan of broccoli located in front of it. An observation of the freezer dated June 3, 2025 at 09:56 A.M. revealed one bag of frozen donuts, five pounds of mangos, two bags of corn, six bags of green beans, one bag of frozen French fries, 2 bags of tater tots, one open bag of taquitos, one bag of English muffins, one bag of chicken tenders stored with no labels, to include open or expiration dates. The freezer observation also included the presence of a frozen lemon meringue pie with one fourth of the pie missing with no observable date the item was opened. The dry storage area observed on June 3, 2025 at 10:06 A.M. revealed three dented cans of fancy baked beans stored with regular canned goods. Planned observation of pureed food preparation on June 4, 2025 at 11:24 A.M. was postponed as the food processor was drying and unavailable. A second food processor was identified for use, the cook (Staff #71), placed food into the blender and placed the wet lid on top of the food waiting to be pureed. The cook was informed of the observation and the puree process was discontinued. A tray-line observation was conducted on June 4, 2025 at 11:24 A.M. A dietary aide (Staff #46) was observed to remove four plate covers from drying rack, that were still wet when placed over the plates. A dietary aide (Staff #53) was observed to place ungloved fingertips on the inside of plate covers twice. The dietary manager (Staff #28) and the lead cook (Staff #71) were informed of the observation and the trays were removed from the food delivery cart. The dietary aide (Staff #53) was observed to wash her hands and don gloves. An interview with the dietary manager (Staff #28) was conducted on June 3, 2025 at 10:05 A.M The dietary manager stated that dented cans should not be stored on the shelf with regular stored cans. The dietary manager stated that having dented cans stored on the shelf with regular canned items did not meet her expectations and identified the risk as using food from cans that should not be utilized for food preparation. Staff #28 reported that dented cans should be returned to the vendor (Shamrock). The dietary manager confirmed the observations of undated items in the refrigerator and freezer and stated that all food should be dated ensuring that the 'first in-first out' process for food rotation would be followed and that food products would be utilized by the use by date. She stated that unlabeled food items and keeping dented cans on the shelves with other cans did not meet her expectations and that she would be conducting a staff in-service for all kitchen staff. The dietary manager stated the risk of not dating items to include food going bad. She reported that her expectation for the tray line was that meals are served on time, following the correct dietary orders including diet type and allergies and at the correct temperature. The dietary manager stated that wet food covers or food processors and staff touching the inside of plate covers did not meet her expectations due to the related risk of potential food borne illnesses. An interview was conducted with the lead cook (Staff #71) on June 4, 2025 at 11:03 A.M. The cook stated that blender or food processor may not be used if it is wet. The item must be completely air dried without use of towels. The cook identified the risk of using wet food processors as cross-contamination. An interview was conducted with dietary aide (Staff #46) on June 4, 2025 at 11:06 A.M. The dietary aide stated that items are labeled and dated when they are taken out of boxes. Staff #46 stated that if something was unlabeled, he would ask the cook or manager about it. An interview with the Administrator (Staff #55) was conducted on June 4, 2025 at 1:18 P.M. The administrator stated that it is expected that all food is dated upon delivery to include the use by date. Staff #55 stated that the risk of not following this practice would be serving expired food. Staff #55 stated that non-food items should not be on counters used for food preparation. The administrator stated that this did not meet her expectations as there is a risk of cross-contamination. The administrator stated that it is not acceptable to touch the inside of plate covers with bare fingers and identified the associated risk of cross contamination and infection control. A review of the policy titled Food Storage, noted to be undated revealed that food is to be stored, prepared and transported at appropriate temperatures and by methods designed to prevent contamination or cross-contamination. The policy noted that foods which require temperature control for safety are to be covered, labeled and dated if stored and not for immediate use. The policy further noted that stock must be rotated with each new order received to ensure the freshness and highest quality of all foods.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#284) was free from physical abuse from other residents (resident #15). The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #284 was admitted to the facility on [DATE], with diagnosis that include quadriplegia, urinary tract infections, diabetes mellitus type 2, weakness, hypertension, pressure ulcers, spinal stenosis, anxiety, insomnia, and myocardial infarction. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had severe cognitive impairment. A behavioral care-plan initiated December 26, 2024 revealed the resident is at risk for impaired cognitive function / dementia with noted intervention to use simple directive sentences, and provide cues as necessary, and to stop and return if agitated. This further indicates resident vulnerability due to impaired cognition. Review of information received from the SA complaint tracking system revealed that January 24, 2024, at 1:09 p.m. a facility reported incident was received that revealed on January 24, 2024 at 12:30 p.m. The administrator was informed that there was an incident that occurred between resident #284 and another resident in the main hall near the guest bathrooms. Resident #284 stated the other resident pushed him in the shoulder, and that staff had immediately separated the residents. A review of progress notes for resident #284 dated January 24, 2024 at 12:30 p.m. stated resident #284 was sitting in the hallway in a wheelchair with feet positioned flat on the floor. Resident sitting in wheelchair with feet positioned flat on the floor. Another resident was ambulating with therapy staff and accused resident #284 of trying to trip him as his feet were pointed outwards. Residents exchanged words and the other resident pushed him in the shoulder. Residents were immediately separated. The note concludes that the resident was assessed and no injury was noted, as well as notifications being made to family, the provider, and the ombudsman. An interview was conducted with a Licensed Nursing Assistant (LNA/staff #20) on June 5, 2025 at 7:35 a.m. The LNA stated that abuse is verbal, physical, mental, refusing to assist residents, and not answering lights. The LNA also stated that when abuse occurs in a resident to resident situation the first thing is to intervene, make sure they are safe, report it forward, and make sure they stay safe until someone assists. The LNA stated that the expectation is that abuse is not allowed to occur, and that the risk of abuse is trauma to the residents. The LNA concluded that she was not aware of any staff to resident abuse. An interview was conducted with resident #284 on June 5, 2025 at 11:44 a.m. The resident stated that he was punched by the other resident by the smoking area in the upper arm. The resident stated that he was lucky I didn't hit him back and that he thinks he got in his way. The resident concluded that the facility moved the other resident away from him and he didn't see the other resident after that. An interview with the Director of Nursing (DON/staff #50) was conducted on June 6, 2025 at 11:44 a.m. The DON stated that Abuse has many definitions. Physical abuse is like slapping someone, physically touching someone they don't want to be touched. The DON stated that the administrator is the abuse coordinator, and that if a staff member suspected abuse they would notify her or the administrator, and she would notify the administrator since she hasn't been in the facility for that long, and that the staff just know the administrator better. The DON stated that when abuse is suspected, they notify the police and make a report. The DON stated that the police usually don't show up but they do it to get a case number. The DON stated that when abuse occurs they usually switch the residents to different areas of the building, and if something really bad happens they would transfer to different facility. During the interview the DON accessed the clinical record for resident #284 and stated that the staff assessed for redness and injury, and the provider was notified related to the incident. The DON also stated that the notes were different from the report as it stated that it was pushed vs hit. The DON concluded with this incident that it did not meet her expectations. A review of facility policy titled Reporting alleged violations of abuse, neglect, exploitation or mistreatment revised October of 2023 revealed that it is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, exploitation and mistreatment. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff, of other agencies serving the resident, resident representatives, families, friends, and other individuals.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure that medical record were complete and accurate for four residents (#27, #16, #14, and #30). The deficient practice could lead to care team members not being aware of a resident's status, and could lead to missed or services rendered. Findings include: -Regarding Resident #27 Resident #27 was admitted [DATE] with diagnosis including hemiplegia and hemiparesis affecting right dominant side, dysarthria, end stage renal disease, moderate protein calorie malnutrition, hypertension, major depressive disorder-recurrent, anemia, insomnia, gastro-esophageal reflux and dependence on renal dialysis. A review of the MDS (minimum data set) dated April 18, 2025 revealed a BIMS (brief interview of mental status) of 15, indicating intact cognition. A review of the POC (plan of care) documentation for meals in the electronic health record revealed that on May 19, 2025 at 6:58 A.M. the resident had received breakfast and ate 76-100% of the meal. On May 29, 2025 breakfast was documented at 7:03 A.M with 76-100% consumed. On June 2, 2025 breakfast was documented at 6:55 A.M. noting 76-100% consumed. On June 3, 2025 breakfast was noted at 6:59 A.M with 76-100% consumed and on on June 5, 2025 breakfast was noted at 6:47 A.M. with 76-100% consumed. All aforementioned POC entries were made by CNA (Certified Nursing Assistant ) staff #14. -Regarding Resident #16 Resident #16 was admitted on [DATE] with diagnosis including alcoholic cirrhosis of the liver, hyperlipidemia, atherosclerotic heart disease, hypertension, major depressive disorder-recurrent, right knee contracture, and insomnia. A review of the MDS dated [DATE] revealed a BIMS score of 14, indicating intact cognition. A review of the POC documentation for meals in the electronic health record revealed that on May 29, 2025 at 7:02 A.M. the resident had received his breakfast and ate 51-75% of the meal. On June 2, 2025 breakfast was noted at 6:53 A.M. with 76-100% consumed. On June 3, 2025 breakfast was noted at 6:57 A.M. with 76-100% consumed and on June 5, 2025 breakfast was noted at 6:46 A.M with 76-100% consumed. All aforementioned POC entries were made by staff #14. -Regarding Resident #14 Resident #14 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, chronic kidney disease, human immunodeficiency virus, age-related osteoporosis, hypertension, bi-polar disorder, protein calorie malnutrition, insomnia, chronic pain syndrome, obstructive and reflux uropathy and schizoaffective disorder. A review of the MDS dated [DATE] revealed a BIMS score of 13, indicating intact cognition. A review of the POC documentation for meals in the electronic health record revealed that on May 29, 2025 at 7:03 A.M. the resident had re4ceived his breakfast and ate 51-75% of the meal. On June 2, 2025 at 6:56 A.M. breakfast was noted at 6:56 A.M with 51-75% consumed. On June 2, 2025 breakfast was noted 7:00 A.M. with 51-75% consumed and June 5, 2025 breakfast was noted at 6:48 A.M. with 51-75% eaten. All aforementioned POC entries were made by staff #14. An observation was conducted on June 5, 2025 at 8:10 A.M. revealing that breakfast trays had just been delivered to the north unit. An interview was conducted on June 5, 2025 at 8:08 A.M. with Dietary Aide, staff #46. Staff #46 stated that the breakfast trays had just been delivered to the north unit. When asked if this was the standard time for breakfast on the north unit, he stated that it was and that the north unit never receives their breakfast trays before 8:00 A.M. An interview was conducted on June 5, 2025 at 8:10 A.M. with MDS Coordinator, staff #43 who was assisting with breakfast tray delivery to the resident rooms. Staff #43 stated that the trays had just arrived and that this was the normal time for breakfast on the north unit. An interview was conducted on June 5, 2025 at 8:12 A.M. with CNA,staff #45. Staff #45 stated that she just delivered the breakfast tray for resident #27. Staff #45 stated that charting for meals is done after meal delivery. Staff #45 further stated that any documentation in the POC prior to delivery and consumption of the meal would be considered 'false' documentation and is not allowed. Staff #45 stated that the risk to resident if a meal was documented prior to delivery/ consumption would include that staff would not know what the resident actually ate. An interview was conducted on June 5, 2025 at 8:15 A.M. with resident #27. Resident #27 stated that he had just received his breakfast tray a few minutes ago. He stated that this was about the normal time for breakfast, but sometimes they run late. An interview was conducted on June 5, 2025 at 8:24 A.M. with LPN (Licensed Practical Nurse) staff #137. Staff #137 stated that CNA's document the meals after tray delivery and never before as this would be falsification. Staff #137 stated that the risk could include not knowing if the resident actually ate or not. Staff #137 stated that trays went out around 8:00 A.M. this morning. The LPN pulled up the POC for resident #27 and stated that it revealed that the resident had already received his breakfast tray at 6:47 A.M. and that the percentage eaten had also already been logged. Staff #137 stated that she wasn't sure if she was reading it correctly, but if she was, it should not have occurred prior to meal delivery. An interview was conducted on June 5, 2025 at 8:47 A.M with the DON (Director of Nursing), staff #50. Staff #50 stated that the expectation of charting of tasks, such as meals, takes place after the task has been completed to ensure accurate documentation of when the resident has last eaten and that the amount eaten is accurately reflected. Staff #50 stated that the risk for inaccurate documentation would include not knowing if the resident has eaten or not and a potential for weight loss. Staff #50 pulled up the POC for the residents and confirmed that it was documented that the residents had received their meals prior to 7:00 A.M. this morning. Staff #50 stated that she not seen trays go out that early for breakfast. Staff #50 stated that this was inaccurate documentation and stated that in-service for documentation would be implemented. An interview was conducted on June 5, 2025 at 10:51 A.M. with CNA, staff #14. Staff #14 stated that documentation of meals generally occurs after the meals but stated that this morning was such a heavy shower day that she had 'pre-charted' the meals and at the end of the day she would review the meal slips and make any corrections. Staff #14 stated that per facility protocol advanced charting is not permitted. She stated that she had documented in advance and that it should not have occurred. Staff #14 stated that risk could include not knowing what the resident actually ate, a change in diet and if they had struggled with their meal. -Regarding Resident #30 Resident #30 was admitted to the facility on [DATE] with the diagnosis of major depressive disorder, recurrent, unspecified. A review of an MDS (Minimum Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 14. The assessment also revealed that weight loss of 5% ore more within the last month of 10% or more in the last 6 months were either no or unknown. An interview with the Resident #30 had been conducted on June 4, 2025 at 11:01AM where the resident stated that they are aware of the significant weight loss that had experienced within one month and had repeatedly told staff of their dissatisfaction of the food and refuses their food if it's bland. An interview was conducted on June 4, 2024 at 12:43PM with a CNA (Certified Nursing Assistant/Staff #66), where Staff #66 stated that meal intakes are monitored through a Plan of Care chart on a resident's electronic health record that determines the different percentages to determine the amount of food and fluids a resident intakes per meal, per shift. Staff #66 also stated that they were familiar to Resident #30's care, advising that the resident is able to independently eat their food and prefers to eat in their room. An interview was conducted on June 4, 2024 at 12:35PM with and LPN (Licensed Practical Nurse/Staff #24), where Staff #24 stated that Resident #30 has refused meals and care in the past. Staff #24 also stated that they are aware of Resident #30's unintended weight loss, and stated that the interventions in place included providing the resident with an Ensure supplement two times a day; frequent monitoring of the resident's intakes and refusals of care. Staff #24 also stated that the documentation of intake amount and vitals is the responsibility of the aides and that the risk of a resident not receiving care plan interventions to assist with a nutritional deficit is the potential for further unplanned weight loss, pressure ulcers and skin breakdown, and as well as changes in their vitals and condition. An observation was made on June 4, 2025 at 12:51PM where Resident #30 had received their lunch for the day. Another observation was made on June 4, 2025 at 3:26PM where Resident #30 reported not touching their lunch. Upon further observation of the resident's tray, it had appeared to be in the same position as it had been left during the 12:51PM observation. During this observation, Resident #30 reported that they were not hungry anymore and that they will probably drink an Ensure that was provided to him in the morning of June 4, 2025 right before dinner. A review of Resident #30's Plan of Care Response for amount eaten on June 4, 2025 revealed that the resident had eaten 51% to 75% of their breakfast and of their lunch. An interview with a CNA (Staff #49) on June 5, 2025 at 9:05AM had been conducted, where Staff #49 stated provided a demonstration on how they've been expected to determine the amount of food eaten by a resident, and where to document the amount eaten on the resident's electronic health records. The demonstration included the images that provide CAN's assistance to determine the amount of food eaten. Staff #49 also stated that the completion of the documentation would be done once the tray of the meal is picked up by the resident so that the documentation of the amount eaten is accurately translated into the resident's electronic health records, and that the risk of not documenting, and, not accurately documenting the amount of food eaten indicates that the task was not done. Staff #49 stated that inaccurate documentation puts the risk of providers and nurses not knowing the current condition of the residents, what they eat, when they eat, when they get up, if they can walk, if they can't walk, what their vital signs are. Staff #49 stated that they were familiar with the Resident and their care and stated that inaccurate documentation of the amount of food of a meal Resident #30 eats can a significant effect on the resident's care being that Resident #30 has undergone significant weight loss as of recent. Staff #49 had also stated that the day before, June 4, 2025, Resident #30 did not eat their breakfast at all, and had advised that for lunch on June 4, 2025, Staff #49 had picked up the resident's meal tray at lunch around 1:30PM and 2:00PM and notated that Resident #30 ate 75% to 100% of their meal. Staff #49 had then demonstrated how they would determine the percentage of the amount eaten ion a Resident's tray to accurately determine the amount of food a resident has actual ate. In regards to the documentation of Resident #30's amount eaten on June 4, 2025, Staff #49 stated that they were the individual who had completed that documentation. Staff #49 then went through the Plan of Care responses regarding the amount eaten by Resident #30, and stated that they are unsure how they could have missed that and must have mis-documented the amounts of the actual food eaten for another resident. An interview was conducted on June 6, 2025 at 10:32AM with a Registered Dietician (Staff # 48), where Staff #49 stated that when completing a nutritional assessment and to determine suitable interventions, an assessment is done to determine if the resident requires changes to their diet; if they require assistive devices are utilize assistive devices themselves; and as well as any diagnosis or underlying conditions that can contribute to the resident's nutritional status. Staff #49 also stated that they will review and heavily rely on the resident's electronic health records for documentation and notes left by the direct care staff, such as the residents Plan of Care responses; progress notes; and the residents medication and treatment administration record; on top of interviews with the direct care staff; as this information comes from the staff that spend more time with the resident on a day to day basis that he may be unable to do. Staff #49 stated that these are a few items of review that are imperative to an accurate nutritional assessment as the risk of an inaccurate assessment can result in significant weight loss; fat and muscle wasting; poor quality of life with no energy, and that they may just give up if they aren't able to get up and get around; a hydration risk; and as well as a higher risk for hospitalization. Staff #49 also stated that the risk of inaccurate documentation utilized in the completion of a nutritional assessment can lead to inaccurate interventions or the lack of interventions; resident's may be given insufficient number of supplements and interventions to maintain adequate nutritional status. In regards to Resident #30, Staff #49 reported that the resident had experienced a significant weight loss of 15% prior to their arrival as the Registered Dietician to the facility and is aware that the resident is currently receiving larger portions and an Ensure supplement twice a day. Staff #49 then reviewed the Plan of Care responses for amount eaten and determined that given the current amount eaten as documented in the Plan of Care responses, the current interventions in place appear adequate. It was then shared with the Registered Dietician that there had been observations and interviews that determine the facility documentation may not be as accurate as it states and that a finding regarding the inaccurate documentation of amount eaten will be under review. An interview on June 6, 2025 at 11:22AM with the DON (Director of Nursing/Staff #50) was conducted where Staff #50 stated that the facility's expectation regarding the documentation of a Resident's amount eaten is the responsibility of the aides and if this is not accurately documented, a resident is at risk for significant weight loss, and, there can be a lack of nutritional interventions. Staff #50 stated that accurate documentation is important as the nutritional assessment completed by the Registered Dietician may rely on the information provided in a resident's electronic health records. Staff #50 stated that documentation for the response of the amount eaten can be changed if a staff member incorrectly inputs an entry but strongly discourages doing that as aides are expected to submit the response after they pick up the resident's meal tray. A review of the policy entitled Documentation and Charting with a revision date of July, 2023 revealed that the documentation and charting is an account of the resident's care, treatment, response to care, symptoms, etc., as well as the progress of the resident's care A review of the policy entitled Nutrition with a revision date of July 2024 revealed that daily intake of the resident's meal shall be recorded by the nursing assistants in the resident's medical record.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure that staff follows appropriate infection control practices. The deficient practice could result in a spread of preventable illness to residents and staff. Findings included: Resident #56 was admitted to the facility on [DATE] with the diagnosis of quadriplegia, unspecified. A care plan focus initiated on October 14, 2024 revealed that the resident has a suprapubic catheter and that staff is to use enhanced barrier precautions when providing services. Another care plan focus initiated on October 14, 2024 revealed that the resident has a diabetic ulcer and that staff is to use enhanced barrier precautions when providing services. On June 4, 2025 there was an observation at 11:22AM where an LPN (Licensed Practical Nurse/Staff #73) where Staff #73 walked out of the room of Resident #56 with their gloves still on, and holding some type of device in their hand, and had put the device back into the medication cart. The room was also observed to have an Enhanced Barrier Precaution sign. An interview was then conducted with Staff #73 on June 4, 2025 at 11:26AM, where Staff #73 stated that the expectations with those on transmission-based precautions is to ensure a gown, a mask, and gloves are outside a resident's room or a hall if there are more than one resident with a signage that declares the usage of enhanced barrier precautions. Staff #73 also stated that if there is the need to utilize any protective equipment such as gloves, gowns, masks, or a face shield, is to be disposed within a resident's room prior to exiting the room. Staff #73 also stated that hand hygiene is to be completed before and after entering a resident's room, and, before and after proceeding resident care. In regards to Resident #56, Staff #73 stated that the resident has an enhanced barrier precaution sign due to having a suprapubic catheter and as well as open wounds that he is currently receiving treatment for. Staff #73 also stated that utilizing personal protective equipment such as gowns and a mask is only required for dressing changes and direct care to the catheter. Staff #73 also stated that they were just going into the room of Resident #73 to obtain his blood sugar levels before lunch and that the expectation is that staff only need to wear gloves when obtaining blood sugar levels, even when there is an enhanced barrier precaution sign located near the door of a resident. Another interview was conducted on June 4, 2025 at 12:43PM with a CNA (Certified Nursing Assistant/Staff #66), where Staff #66 stated that the facility's protocol for a resident on enhanced barrier precautions is to ensure gloves and gowns are worn when providing care. Staff #66 also stated that if there is a concern for airborne or contact precautions, then the expectation is to ensure a mask is also utilized. Staff #66 also stated that all protective equipment is to be taken off and disposed in the resident's room, prior to exit, by taking of the gown first, and then the gloves. Staff #66 also stated that hand hygiene is to also be completed before and after providing patient care, whether it was to provide the resident with a blanket, with their meal tray, or to take their vitals, hand hygiene is expected at all times, and, as well as, disinfecting any equipment that was used. Another interview was conducted on June 4, 2025 at 2:51PM with the Infection Preventionist and Wound Care Nurse (Staff #83), where Staff #83 stated that the protocol for a resident on enhanced barrier precautions, staff is expected to utilize the personal protective equipment that can be located in front of or near the door of a resident that has been identified for enhanced barrier precautions. Staff #83 also stated that she does play a role with that identification of resident's that have been put on enhanced barrier precautions with ensuring the proper precautions are listed and in visual of the resident's door, and as well as communicating any changes to a resident's care with staff. Staff #83 also stated that resident's that may be ordered or have these medical conditions that include having a wound; a catheter; a peripherally inserted central catheter (PICC) line; a feeding tube; antibiotics; an intravenous (IV) line; and obtaining blood sugars; and to also use handwashing hygiene when completing any of the tasks mentioned. In regards to the observation on June 4, 2025 at 11:22AM, Staff #83 stated that if a nurse is administering medications, if the medication can go into a cup for the resident, then they would not need to utilize a gown, however, if a nurse is administering medications through an IV, through an injection, a patch, or to check a resident's blood sugars, that would require staff to utilize a gown when administering such medications to a resident under enhanced barrier precautions. An interview on June 6, 2025 at 11:22AM with the DON (Director of Nursing/Staff #50) was conducted where Staff #50 stated that the facility's expectations regarding enhanced barrier precautions is that facility staff and as well as guests is to follow any signage that may be located in front of a resident's room, and to utilize personal protective equipment such as gloves and gowns when completing tasks such as re-positioning a resident; assisting with personal hygiene; and as well as any other patient care. Staff #50 also stated that if the facility's expectations are not followed, that can put staff and the residents at risk for the spread of infections. In regards to the observation on June 4, 2025 At 11:22AM, Staff #50 stated that when administering medications to a resident in a room with a sign that indicates the usage of enhanced barrier precautions certain routes and medications will require a staff member to utilize proper protective equipment. If a staff member were to obtain the blood sugar levels of a resident with such signage, then staff is expected to utilize gloves and a gown due to being exposed to a bodily fluid such as blood. A facility policy titled, Infection Control Prevention and Control Program Standard and Transmission based Precautions, revealed that proper personal protective equipment is to be used when providing care exposes a staff member to blood and bodily fluids.

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to implement written policies and procedures that prevent the misappropriation of the property of one resident (Resident #299). The deficient practice can result in the lack of prevention for future occurrences. Findings include: Resident #299 was admitted to the facility on [DATE] with the diagnosis of cellulitis of the left lower limb. The resident was then discharged on January 31, 2023. A review of an MDS (Minimum Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) had not been completed and a staff assessment had been completed. Indicating that the resident's cognitive function was assessed and documented by staff, either because the BIMS interview with the resident was not completed or not feasible. A record request was submitted on June 5, 2025 at 12:45PM to review the inventory sheet of Resident #299. At 12:52PM on June 5, 2025, Administrator (Staff #55) had stated that the facility does not have an inventory sheet for the Resident #299. Staff #55 stated that they are unsure what had happened on the day of admission for Resident #299 and stated that an inventory sheet was not completed for the resident. An interview was conducted on June 6, 2025 at 9:03AM with a CNA (Certified Nursing Assistant/Staff #49) where Staff #49 stated that when the facility receives a new admission, they are expected to meet and greet the resident, gather their inventory to create a detailed inventory sheet, they will also obtain their vitals, provide assistance to get comfortable and acclimated to the facility, and provide education to the resident regarding the facility's day to day opportunities and services. Staff #49 also stated that during the admission process, an admission packet would be completed and that the packet includes an inventory list. Staff #49 also stated that the expectation with the inventory list is that it is to be filled out within the first two hours, that not completing the inventory list immediately can have the risk of making the facility liable and question of whether the items were present at admission or not. An interview was conducted on June 6, 2025 at 9:17AM with a LPN (Licensed Practical Nurse/Staff #24) where Staff #24 stated that the admission process includes the completion of an inventory sheet that is expected to be completed within 24 hours of admission. Staff #24 also stated that the inventory sheet serves as an opportunity for a resident to provide staff with the value of their inventory, including valuable items, so that in the event that an item would go missing, the facility will have the opportunity to repay the resident with the value of the item. Review of the facility policy titled, Admission/Discharge/Transfer, Inventory of Personal Affects, revealed that the facility will take reasonable steps to protect the personal property of the residents. The policy also revealed that when a resident is admitted to the facility, an inventory of the resident's personal effects shall be done by a staff member of the facility. The inventory should record all of personal clothing, valuable articles, etc. that are brought into the facility with the resident and retained by the resident. The policy also stated that once the inventory process is completed, the indicated form will be signed by the resident and responsible party, as well as the staff member, and that a copy of the sheet should be given to the resident.

Based on review of the clinical record, interviews, and observations the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was updated to accurately reflect changes in the condition of resident #88. The deficient practice can result in a resident not receiving recommended services to promote and attain the highest level of well-being. Resident #88, was re-admitted to the facility on [DATE] with diagnoses that include alcoholic cirrhosis of the liver, major depressive disorder-recurrent, insomnia, and history of a myocardial infarction. An order for Mirtazapine 7.5 mg by mouth at bedtime for depression was discontinued on September 19, 2023. Review of a progress note dated March 4, 2024 revealed the resident had an altercation with another resident, and had to be separated for safety. Review of progress notes dated March 4, 2024 - March 6, 2024 revealed Change of Condition documentation for altercation with another resident. The Ineffective Coping related to Alcohol abuse, care plan-initiated May 10, 2024 revealed an intervention to offer professional support and referral for mental health and/or substance center. A progress note dated September 30, 2024 revealed the resident was able to communicate effectively and make his needs known. In addition, he exhibited no adverse, negative behaviors at this time. An order for Trazodone HCL 50 mg was initiated on October 1, 2024, give 1 tablet by mouth at bedtime for depression as evidenced by inability to stay/fall asleep. The quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview Mental Status score of 14, indicating the resident had intact cognition. The Behavioral Symptoms were coded as 0 for physical and verbal symptoms during the 7-day look back period. A progress note dated April 27, 2025 revealed the staff had suspicion of alcohol intoxication. In addition, the writer describes the resident as being verbally aggressive. Also, the resident was observed going into another resident's room to use their restroom. The facility documented contacting the provider to relay these findings. A progress note dated May 23, 2025 revealed the resident was encouraged to find different way to handle a dispute without yelling and using foul language. A progress note dated June 4, 2025 provided a summation that the resident has irritability and verbal aggression. The provider ordered to continue medications as prescribed and to follow up with behavioral health per resident preference. Review of facility documentation dated June 4, 2025 revealed that an internal investigation was to be conducted, because the resident was identified as an alleged perpetrator in a resident to resident altercation the weekend prior. Review of facility documentation revealed that an internal 5-day investigation began on June 4, 2025 in which the resident was identified as an alleged perpetrator in a resident to resident altercation. The CNA Response History dated June 5, 2025 for Behavior Symptoms, revealed no entries over the 30 day look back period. The clinical record does not support the facility's Interdisciplinary Team (IDT) attempt to review PASARR recommendations. An interview was conducted with the resident on June 5, 2025 at 11:01 a.m., who admitted to getting into a couple of disagreements as of late at the facility. The resident revealed the incidents are never anything to serious that he cannot handle. The resident revealed feeling safe at the facility. An interview with Licensed Practical Nurse (LPN/Staff# 24) conducted on June 6, 2025 at 9:08 a.m., revealed if concerns about a resident's mental well-being arise, those concerns are reported to the doctor, Director of Nursing, social services, and if it warrants, the crisis team. An interview was conducted with the admissions director (Staff # 8) on June 6, 2025 at approximately 10 a.m. The director identified a purpose of the PASSR is to ensure residents receive the appropriate level of care for each resident. The director further stated that the PASSR is performed pre-admission, and is also repeated after 30 days of residency. The director explained that the importance of a Level 2 PASSR referral is to ensure the resident receives the correct level of care, and to ensure the staff are adequately trained to meet the level of care that may be needed. During review of the clinical record, the director identified September 18, 2023 as the most current PASSR for the resident. The director also identified the following inconsistences with the current PASSR: -Substance related disorder was not selected, despite resident having a substance related disorder. - Issues with interpersonal behaviors and adaptation to change was not selected, despite the resident being involved in several adverse behavioral incidents at the facility. -Mirtazapine 7.5 mg daily is listed as an active medication, despite it being discontinued on September 19, 2023. The director stated that the current PASSR does not accurately reflect the status of the resident, should be updated to remedy, as the current version does not meet facility expectation. An interview with the DON (Staff #50) on June 6 , 2025 at approximately 11:45 a.m., revealed the facility expectation is to keep the resident's PASSR accurate and current. The DON revealed the importance of the PASSR is to make sure the residents are receiving the right care for their level of need. After review of the clinical record, the DON was unable to find documentation supporting accuracy of the current PASSR. The facility's Behavioral Health policy provides residents with the necessary behavioral health care and services. The policy also defines Substance use disorder as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment. Procedurally, the facility's Interdisciplinary Team (IDT) will review PASARR recommendations. The facility's Change of Condition policy with the review date of July 2024, revealed that it is the policy of this facility that all changes in resident condition will be communicated to the physician. In addition, the licensed nurse responsible for the Resident will continue assessment and documentation. The facility's Documentation and Charting policy, with the revision date of July, 2023 revealed that the facility is to provide an account of the progress of the resident's care. The PASARR policy, with the revision of May, 2025 refers to the state's AHCCS Pre-admission Screening and Resident Review (PASAR) policy. The Arizona Health Care Cost Containment System (AHCCCS) with the effective date of May 15, 2023 revealed that PASRR Level 1 Screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for Mental Illness (MI) and/or Intellectual Disability (ID). In addition, Nursing Facilities (NF) are required to request Resident Reviews for individuals experiencing a Significant Change in condition.

Based on observations, clinical record reviews, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that nutritional status was accurately assessed and documented in accordance to professional standards for one resident (#30). The deficient practice can result in additional residents experiencing weight loss, without adequate interventions. Findings include: Resident #30 was admitted to the facility on [DATE] with the diagnosis of major depressive disorder, recurrent, unspecified. A progress note dated April 10, 2025 revealed that the resident had been seen by a registered dietitian to discuss the Resident's unintended weight loss of 15% within one month. The progress note also revealed that Resident #30 had expressed personal dissatisfaction with the food options provided in the facility, leading to the poor intake and refusals of many meals. The progress note also revealed that Resident #30 agreed to speak to the dietary manager regarding food preferences to optimize their intake by mouth and to increase the amount of Ensure the resident drinks to twice a day to prevent further weight loss until Resident #30's intake by mouth increases. A review of an order dated April 10, 2025 revealed that the resident is to be provided an Ensure supplement two times a day for weight management, and to record the percentage of the amount consumed. A review of a care plan focus with the revision date of April 10, 2025 revealed that the resident had a significant weight loss of 15% within one month in relation to the decline in Resident #30's by mouth intake. The care plan focus also included an intervention that staff should monitor and report to the Medical Director as needed for any signs and symptoms of decreased appetite, any further unexplained weight loss, stomach pain, nausea or vomiting. A review of an MDS (Minimum Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 14. The assessment also revealed that weight loss of 5% ore more within the last month of 10% or more in the last 6 months were either no or unknown. A review of a quarterly evaluation dated May 1, 2025 revealed that the resident experienced significant weight loss in one month, likely related to a sharp decline in by mouth intake. The evaluation also revealed that the patient was 25-100% in intake, with many meal refusals, and, that the resident is 100% with receiving the Ensure supplemental two times a day. The evaluation also stated that the resident reported a lack of interest in the food options being offered. The evaluation provided nutritional interventions that included, ensuring the resident eats 2000-2300 kcal and 75-90 grams of protein in one day; to serve the resident larger portions; to encourage increased intake by mouth; continue to provide Ensure supplements twice a day; assist the resident and honor food preferences via the facility's selective/alternative menu. An interview with the Resident #30 had been conducted on June 4, 2025 at 11:01AM where the resident stated that they are aware of the significant weight loss that had experienced within one month and had repeatedly told staff of their dissatisfaction of the food and refuses their food if it's bland. An interview was conducted on June 4, 2024 at 12:43PM with a CNA (Certified Nursing Assistant/Staff #66), where Staff #66 stated that meal intakes are monitored through a Plan of Care chart on a resident's electronic health record that determines the different percentages to determine the amount of food and fluids a resident intakes per meal, per shift. Staff #66 also stated that they were familiar to Resident #30's care, advising that the resident is able to independently eat their food and prefers to eat in their room. An interview was conducted on June 4, 2024 at 12:35PM with and LPN (Licensed Practical Nurse/Staff #24), where Staff #24 stated that Resident #30 has refused meals and care in the past. Staff #24 also stated that they are aware of Resident #30's unintended weight loss, and stated that the interventions in place included providing the resident with an Ensure supplement two times a day; frequent monitoring of the resident's intakes and refusals of care. Staff #24 also stated that the documentation of intake amount and vitals is the responsibility of the aides and that the risk of a resident not receiving care plan interventions to assist with a nutritional deficit is the potential for further unplanned weight loss, pressure ulcers and skin breakdown, and as well as changes in their vitals and condition. An observation was made on June 4, 2025 at 12:51PM where Resident #30 had received their lunch for the day. Another observation was made on June 4, 2025 at 3:26PM where Resident #30 reported not touching their lunch. Upon further observation of the resident's tray, it had appeared to be in the same position as it had been left during the 12:51PM observation. During this observation, Resident #30 reported that they were not hungry anymore and that they will probably drink an Ensure that was provided to him in the morning of June 4, 2025 right before dinner. A review of Resident #30's Plan of Care Response for amount eaten on June 4, 2025 revealed that the resident had eaten 51% to 75% of their breakfast and of their lunch. An interview with a CNA (Staff #49) on June 5, 2025 at 9:05AM had been conducted, where Staff #49 stated provided a demonstration on how they've been expected to determine the amount of food eaten by a resident, and where to document the amount eaten on the resident's electronic health records. The demonstration included the images that provide CAN's assistance to determine the amount of food eaten. Staff #49 also stated that the completion of the documentation would be done once the tray of the meal is picked up by the resident so that the documentation of the amount eaten is accurately translated into the resident's electronic health records, and that the risk of not documenting, and, not accurately documenting the amount of food eaten indicates that the task was not done. Staff #49 stated that inaccurate documentation puts the risk of providers and nurses not knowing the current condition of the residents, what they eat, when they eat, when they get up, if they can walk, if they can't walk, what their vital signs are. Staff #49 stated that they were familiar with the Resident and their care and stated that inaccurate documentation of the amount of food of a meal Resident #30 eats can a significant effect on the resident's care being that Resident #30 has undergone significant weight loss as of recent. Staff #49 had also stated that the day before, June 4, 2025, Resident #30 did not eat their breakfast at all, and had advised that for lunch on June 4, 2025, Staff #49 had picked up the resident's meal tray at lunch around 1:30PM and 2:00PM and notated that Resident #30 ate 75% to 100% of their meal. Staff #49 had then demonstrated how they would determine the percentage of the amount eaten ion a Resident's tray to accurately determine the amount of food a resident has actual ate. In regards to the documentation of Resident #30's amount eaten on June 4, 2025, Staff #49 stated that they were the individual who had completed that documentation. Staff #49 then went through the Plan of Care responses regarding the amount eaten by Resident #30, and stated that they are unsure how they could have missed that and must have mis-documented the amounts of the actual food eaten for another resident. An interview was conducted on June 6, 2025 at 10:32AM with a Registered Dietician (Staff # 48), where Staff #49 stated that when completing a nutritional assessment and to determine suitable interventions, an assessment is done to determine if the resident requires changes to their diet; if they require assistive devices are utilize assistive devices themselves; and as well as any diagnosis or underlying conditions that can contribute to the resident's nutritional status. Staff #49 also stated that they will review and heavily rely on the resident's electronic health records for documentation and notes left by the direct care staff, such as the residents Plan of Care responses; progress notes; and the residents medication and treatment administration record; on top of interviews with the direct care staff; as this information comes from the staff that spend more time with the resident on a day to day basis that he may be unable to do. Staff #49 stated that these are a few items of review that are imperative to an accurate nutritional assessment as the risk of an inaccurate assessment can result in significant weight loss; fat and muscle wasting; poor quality of life with no energy, and that they may just give up if they aren't able to get up and get around; a hydration risk; and as well as a higher risk for hospitalization. Staff #49 also stated that the risk of inaccurate documentation utilized in the completion of a nutritional assessment can lead to inaccurate interventions or the lack of interventions; resident's may be given insufficient number of supplements and interventions to maintain adequate nutritional status. In regards to Resident #30, Staff #49 reported that the resident had experienced a significant weight loss of 15% prior to their arrival as the Registered Dietician to the facility and is aware that the resident is currently receiving larger portions and an Ensure supplement twice a day. Staff #49 then reviewed the Plan of Care responses for amount eaten and determined that given the current amount eaten as documented in the Plan of Care responses, the current interventions in place appear adequate. It was then shared with the Registered Dietician that there had been observations and interviews that determine the facility documentation may not be as accurate as it states and that a finding regarding the inaccurate documentation of amount eaten will be under review. An interview on June 6, 2025 at 11:22AM with the DON (Director of Nursing/Staff #50) was conducted where Staff #50 stated that the facility's expectation regarding the documentation of a Resident's amount eaten is the responsibility of the aides and if this is not accurately documented, a resident is at risk for significant weight loss, and, there can be a lack of nutritional interventions. Staff #50 stated that accurate documentation is important as the nutritional assessment completed by the Registered Dietician may rely on the information provided in a resident's electronic health records. Staff #50 stated that documentation for the response of the amount eaten can be changed if a staff member incorrectly inputs an entry but strongly discourages doing that as aides are expected to submit the response after they pick up the resident's meal tray. A review of the policy entitled Documentation and Charting with a revision date of July, 2023 revealed that the documentation and charting is an account of the resident's care, treatment, response to care, symptoms, etc., as well as the progress of the resident's care A review of the policy entitled Nutrition with a revision date of July 2024 revealed that daily intake of the resident's meal shall be recorded by the nursing assistants in the resident's medical record.

Based on clinical records, resident and staff interviews, and facility documents, the facility failed to ensure that residents are not abused by staff. -Resident #61 was admitted on [DATE] with diagnoses of paraplegia. A care plan dated 11/10/17 included that this resident had an ADL Self Care Performance Deficit related to paraplegia, disease process, limited mobility and included that this resident requires staff participation to use the toilet, with transfers, and to reposition and turn in bed and to encourage to use bell to call for assistance. Review of the clinical did not find notes regarding this incident. Review of the Medication Administration Record (MAR) included that medications were provided by a Licensed Practical Nurse (LPN/staff #126) during the time of the incident. An interview was conducted on 12/7/23 at 10:29 AM, with resident #61 who said he had been on the call light a lot that day and that a nurse came in and tried to yank the call light out of his hand but that it had gotten caught up on his bed rails. He said he had not seen the staff member who attempted to pull the call light out of his hand since the incident and did not know his name. He said that the facility staff said that the nurse won't work here again. An interview was conducted on 12/8/23 at 1:43 PM, with this LPN (staff #126) who said that resident #61 just wouldn't stay off the light and he pulled the call light out of the wall while trying to yank it out of the resident's hand, then he just left before any further escalation could occur. An interview was conducted with an LPN (staff #89) who said that abuse is not taking care of the patient and that abuse can be verbal, financial, misappropriation of funds, neglect, sexual, or physical. She said that she had not seen abuse and that if she had seen abuse she would remove the staff member and report the incident to the Administrator and Director of Nursing (DON). She said that if a patient is on the call light a lot and staff rip a call light out of the wall it is abuse. An interview was conducted on 12/8/23 at 2:39 PM, with the DON (staff #17) who said that staff should should treat the residents kindly, and with respect and care. She said that staff pulling out a call light is not ok at all and does not meet her expectations. An undated employee handbook section titled Section Three: A Culture of Accountability included gross misconduct is a violation of the rules set forth in this Handbook, our code of conduct or any other policy of a more serious nature and that they include physical, fiduciary, verbal or emotional/psychological abuse of a resident.

Based on clinical records and staff interviews, the facility failed to ensure that a resident was free from preventable accidents (#4). Findings include: Resident #4 was admitted on [DATE] with diagnoses of fracture of right lower leg, fracture of left lower leg, Acute Hypercapnic Respiratory Failure (AHRF), cirrhosis, Diabetes Mellitus, O2, weakness. A Minimum Data Set (MDS) assessment dated [DATE] included that this resident had a Brief Interview for Mental Status (BIMS) score of 15, which showed no impairment. This document included that transfers were 1 person extensive assistance and that walking had only occurred 1-2 times during the week lookback period. A care plan dated 5/30/23 included that this resident has Activities of Daily Living self care performance deficit related to AHRF, cirrhosis, DM, O2, weakness and that this resident requires 1 staff participation with transfers. A progress note dated 8/23/2023 included Per nursing Medstar Transportation reported that the patient had fallen. On assessment, the patient was sitting on the floor facing the wall where the lights are located. Medstar had stated that the patient had fallen slowly to the floor. Patient was leaving to a paracentesis appointment at TMC. Contacted Dr. Vo who approved that the patient make the appointment. Patient denied hitting her head or losing consciousness. No change in orientation was noted. Patient was assisted onto the gurney by Medstar and two staff members of the facility. Patient then c/o pain to the left ankle. Dr. Vo gave a verbal order for an Xray to the left leg after returning to the facility. A head-to-toe assessment was performed. Patient left for the appointment. Xray done with results of There is an acute mildly displaced fracture of proximal tibia metaphysis . There is an acute mildly displaced fracture of fibula metaphysis. The patella, distal femur, proximal are intact. There is no deep sulcus sign to suggest anterior cruciate ligament tear. The bony mineralization is mildly decreased. There is no joint effusion. Moderate narrowing of the medial and patella-femoral joint spaces, Per Dr. vo patient was sent to TMC. An interview was conducted on 12/7/23 at 3:08 PM, with a Certified Nursing Assistant (CNA/staff #73) who said that she was giving another resident a shower, and when she came out she saw the staff from Medstar who said I dropped our patient, you need to tell the nurses. She said that they didn't ask us for any help transferring resident #4. She said that they went right to the room. An interview was conducted on 12/8/23 at 1:56 PM, with one of the Med Star drivers who said he and his partner talked to the person at the nursing station and were told to go to the patient's room. He said that they went into the room and the resident was sitting at the edge of bed. He said that he asked her if she can stand or walk or anything and that she said that if she could, she could. He said that the resident got up with a walker near to her bed and that they were going to help her, but one step and leg gave out from her. He said that the resident stood up and she went straight on her butt and she sat on her leg was in a sitting up position. He said that he left the room and got someone. He said that the facility insisted that she go to her appointment. He said that he didn't know this patient. An interview was conducted on 12/8/23 at 9:02 AM, with a Licensed Practical Nurse (staff #213) who said that it depends if the transport staff are familiar with the patient. She said that if they are not familiar they are supposed to stop at the nurses station, then we will send with the CNA, or if we are not busy I will assist them. She said that this resident's legs just stayed deformed, and that this resident got foot drop after that. This nurse said that this resident never walked while she was here but would stand with Physical Therapy just to sit back down and that she never walked. This nurse said that this resident would not ever try to stand or walk. An interview was conducted on 12/8/23 at 2:39 PM, with the DON (staff #17) who said that my expectations are that they check in with the nursing staff and that a staff member go with them to the room to assist with the transfer. She said that doesn't meet expectations because staff should be present, because never know what is going to happen regardless of what the resident's baseline is. This DON said that they do not have a policy that addresses that the staff should be doing a handoff to transport staff.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure level I PASRR (preadmission screening and resident review) was completed for three residents (#8, #48 and #45). This deficient practice could result in residents not receiving the appropriate level of care. Findings include: -Resident #8 was admitted on [DATE] with diagnoses of major depressive disorder, anxiety disorder, unspecified mood disorder, insomnia and bipolar disorder. The PASRR level I screening dated December 19, 2022 included the resident had met the 30-day convalescent criteria. The care plan dated December 20, 2022 revealed that the resident received antidepressant and antipsychotic medications. A review of the MDS (minimum data set) dated March 29, 2023 revealed a BIMS (brief interview of mental status) score of 15 suggesting that resident #8 is cognitively intact. Despite documentation that the resident continued to reside at the facility, there was no evidence found that the another PASRR level I screening was completed until April 23, 2023. The PASRR screening dated April 23, 2023 included that resident had bipolar disorder, anxiety disorder and depression; and had no primary diagnosis of dementia or Alzheimer's disease. Further, the documentation included that resident did not meet the 30-day convalescent care, respite admission and terminal state or severe illness. Further, the documentation included that a referral to level II determination was required. -Resident #48 was admitted on [DATE] with diagnoses of other specified disorders of the brain, major depressive disorder, schizoaffective disorder and anxiety disorder. A level I PASRR screening dated December 16, 2021 revealed the resident did not have a primary diagnosis of dementia and serious mental illness. The documentation also included that there was no referral for any level II determination necessary. Review of the care plan dated December 17, 2021 included that resident use of psychotropic medications related to schizoaffective disorder as evidenced by disruptive behaviors to staff related to paranoid delusions. A care plan dated March 8, 2022 included antidepressant medication use related to depression as evidenced by self-isolation, worry and irritability. The care plan entry dated June 6, 2022 revealed that the resident was at risk for impaired cognitive functions or thought processes related to psychiatric medications. A review of the MDS dated [DATE] revealed a BIMS score of 15 indicating the resident was cognitively intact. The physician progress note dated March 23, 2023 included the resident was alert and oriented x 3. Assessments included schizoaffective disorder and depression. Plan included sertraline (antidepressant) for depression and quetiapine (antipsychotic) for schizoaffective disorder. Despite documentation that the resident has diagnosis of serious mental illness, there was no evidence found in the clinical record that another PASRR level I screening was completed until April 23, 2023. The PASRR screening dated April 23, 2023 included that resident had schizoaffective disorder, major depression and anxiety disorder; and, had no primary diagnosis of dementia or Alzheimer's disease. Further, the documentation included that resident did not meet the 30-day convalescent care, respite admission and terminal state or severe illness. Further, the documentation included that a referral to level II determination was required. 47954 -Resident #45 was admitted on [DATE] with primary diagnosis of Schizoaffective disorder. The level I PASRR screening dated June 24 2022 included resident had no primary diagnosis of dementia and serious mental illness (SMI). It also included that the resident was admitted for convalescent care; and that, no referral for any level II was necessary. The care plan dated July 12, 2022 included that resident use antidepressant medication related to depression as evidenced by self-isolation and verbalization of sadness. The physician progress notes dated February 22, March 22 and April 12, 2023 included an assessment of schizophrenia. Plan included Seroquel (antipsychotic) for bipolar-type schizoaffective disorder. Despite documentation the resident had diagnosis of SMI; and that, the resident continued to stay at the facility 30 days after admission at the facility, the clinical record revealed no evidence that another level I PASRR screening was completed after June 24, 2022. In an interview conducted with the admissions director (staff #31) on April 24, 2023 at 11:30 a.m., staff #31 stated that PASRR screening was handled by admissions staff and the social worker. Staff #31 stated that the initial PASSR screening come from the hospital; however, if the resident was not on convalescent leave or has other exclusions, then the resident should be reassessed for the need to elevate to a level II PASRR at that point and as needed for significant changes. During the interview, a review of the clinical record was conducted with staff #31 who stated that for resident #8, the records showed that the last PASRR assessment was conducted in 2022 and it should have been sent for a level II referral. However, staff #31 stated that resident #8 level II referral had not been referred to the State for review then or subsequently. Regarding resident #48, the admissions director stated that the last PASRR conducted for resident #48 was in 2021; and, it also had not been referred for a level II assessment at that time or subsequently. Further, staff #31 stated that risk for not doing PASRR screening could be potentially result in residents not receiving the correct level of care. An interview was conducted with the administrator (staff #91) on April 24, 2023 at 11:42 a.m. Staff #91 stated that his expectation was that PASRR screening are completed in a timely manner; and that, risk factors include not having up to date information about resident's current status, in regards to making sure residents are at the appropriate level of care. A review of facility policy on Resident Assessment - PASRR reviewed May 2020 revealed that it is their policy to ensure that each resident is properly screened using the PASRR specified by the State.

Based on resident and staff interviews, clinical record review, and facility policy and procedure, the facility failed to ensure pain medications were administered as ordered by the physician for four residents (#8, #45, #192 and #28). The deficient practice could result in residents receiving unnecessary medications. Findings include: -Resident # 8 was admitted on [DATE] with diagnoses of Parkinson's disease, diastolic congestive heart failure, fibromyalgia, and chronic pain. The care plan dated December 22, 2022 revealed that the resident is prescribed an opioid for pain and is monitored for adverse outcomes from opioid use. Additionally, the care plan noted that the expected benefit of opioid use is to reduce 'acute/ chronic' pain conditions. The physician order dated February 14, 2023 revealed an order for Tramadol (narcotic analgesic) one tablet every 6 hours for chronic pain. A review of the MDS (minimum data set) assessment dated [DATE] revealed that resident had a BIMS (brief interview of mental status) score of 15 indicating the resident was cognitively intact. The assessment also included that the resident was on scheduled pain medications. The progress note dated March 30, 2023 revealed the resident had one dose of Tramadol remaining in the morning; and that, the provider had been informed. The note also included that the last dose was noted to have been administered at midday; and, was waiting for a refill. A review of the MAR (medication administer record) revealed that resident #8 had not received Tramadol for chronic pain management from March 31 through April 3, 2023. There was no evidence found in the clinical record that the physician was notified that Tramadol was not administered as ordered from March 31 through April 3, 2023. The clinical record also revealed no evidence that the physician had discontinued Tramadol for the resident. Despite the documentation that resident did not have Tramadol, the prescription for the Tramadol was not renewed until April 3, 2023. A physician visit note dated April 3, 2023 included that pain control was adequate at this time and to continue current pain regimen. The documentation included that scripts were given for Tramadol for a 4-week supply. The progress note dated April 3, 2023 revealed the resident was educated on Tramadol; and that, the prescription for Tramadol was renewed. An interview was conducted April 19, 2023 at 9:53 a.m. with resident #8 who stated that she had pain, had been out of Tramadol previously; and that, she had to wait 'several' days for her medication to be refilled. Resident #8 stated that she spends a lot of time crying due to the pain; and that, this issue of her pain not being addressed had been relayed to the licensed practical nurse (LPN/staff #79) as well as the administrator. Further, she stated she did not feel 'heard' by the pain management doctor. In an interview with the LPN (staff #79) conducted on April 20, 2023 at 11:01 a.m. the LPN stated that she was off on March 30, 2023 when resident #8 did not received Tramadol; and that, the pain management doctor came to the facility. She stated that when she returned on March 31, 2023, she found the medication refill request for resident #8 was in the wrong folder because of a miscommunication. The LPN said she reached out to the pain management doctor but she was informed that the doctor was out of the office and would not return until April 4, 2023. The LPN stated that there was no back-up coverage for the pain management doctor for resident #8. During the interview, a review of the clinical record was conducted with the LPN who stated that the resident had been out of the previously prescribed Tramadol from March 31 through April 03, 2023 because the script had not been renewed. She stated that this happened because the renewal request had been placed in the wrong folder. The LPN said that when a resident runs out of narcotics, the script had to be renewed. She stated that she also reached out to the pain management and another provider if he might issue the renewal script; however, she never heard back from them. The LPN stated that she received the renewal prescription for the Tramadol on April 3, 2023. Further, the LPN said that risks of not receiving prescribed scheduled pain medications can include pain, withdrawals, anxiety, weakness, and lack of resident participation in activities. An interview was conducted on March 20, 2023 at 11:15 a.m. with a certified nursing assistant (CNA/staff #37) who stated that if a resident reports pain, she would ask the resident the location and severity of the pain. She stated that she would then look at potential non-pharmaceutical approaches, to include repositioning, in an effort to alleviate the pain and notify the nurse on duty. During an interview conducted with clinical resource coordinator (staff #108) on April 20, 2023 at 11:26 a.m., staff #108 stated that the expectation was to assess the resident for pain at least once a shift and medicate the resident accordingly, either via scheduled or PRN (as needed) medications. Staff #108 stated that if a script was due to expire then the expectation was for nursing staff to notify the provider and obtain an expedited script, to facilitate obtaining the medication either the same day or the next day. Additionally, she stated that medication can also be obtained via Pyxis, if an existing order was in place. 47954 -Resident #45 was admitted on [DATE] with diagnoses of schizoaffective disorder, depression, and anemia. The care plan dated July 5, 2022 revealed the resident had potential for acute/chronic pain. Intervention included to administer analgesia medication as per orders and to follow pain scale. The physician order dated November 4, 2022 included for oxycodone (narcotic analgesic) 5 mg (milligrams) and to give 5 mg by mouth every 6 hours as needed for a pain scale of 4-10. This order was transcribed onto the MAR (medication administration record) for February, March and April 2023 However, review of the MAR for February, March and April 2023 revealed that there were multiple days that oxycodone was documented as administered for documented pain scales between 0 and 3. The quarterly MDS (Minimum Data Set) dated April 8, 2023 included a BIMS (Brief Interview for Mental Status) score of 15 indicating that the resident was cognitively intact. There was no evidence found in the clinical record why oxycodone was administered outside of the ordered parameter; and that, the physician was notified. -Resident #192 was admitted on [DATE] with diagnoses that included osteomyelitis, pressure ulcer, type 2 diabetes, gastroesophageal reflux disease, and hypertension. The care plan dated April 18, 2023 revealed the resident had acute/chronic pain related to bilateral diabetic food infections. Interventions included to follow pain scale and to medicate as ordered. The physician order dated April 20, 2023 included an order for ibuprofen (non-steroidal anti-inflammatory drug/NSAID) 400 mg and to give 400 mg every 6 hours as needed for pain on a scale of 1-3. The admission MDS dated [DATE] included a BIMS score of 15 indicating the resident had intact cognition. The order for oxycodone was transcribed onto the MAR for April, 2023. Review of the MAR for April revealed that ibuprofen was documented as administered as ordered with pain scales between 7 and 9 multiple times. Further review of the clinical record revealed no evidence of a reason why the medication was administered outside the ordered parameter; and that, the physician was notified. -Resident #28 was admitted on [DATE] with diagnoses of pneumocystis, type 2 diabetes, hypertension, anxiety, and gastroesophageal reflux disease (GERD). The care plan dated February 1, 2023 revealed the resident was prescribed an opioid for substance abuse and pain. Intervention included to administer opioid as prescribed. The physician order dated March 1, 2023 included for oxycodone 15 mg and to give 15 mg by mouth every 4 hours as needed for pain on a scale of 6-10. This order was transcribed onto the MAR for March and April 2023. Review of the MAR for March and April 2023 revealed that oxycodone was administered as ordered for documented pain scales between 0 and 5 in multiple dates. Continued review of the clinical record revealed no evidence why the medication was administered outside of the ordered parameter; and that, the physician was notified. The admission MDS dated [DATE] included a BIMS score of 15 indicating that the resident had intact cognition. An interview was conducted on April 25, 2023 at 10:21 p.m. with a licensed practical nurse (LPN/staff #79) who stated that medications have ordered parameters to avoid side effects. The LPN also stated that in the event a medication was missing or being given out of parameter she would notify the physician to see if a medication change was warranted. The LPN stated that giving medications outside of parameter could result in side effects; and that she would not to give the resident something that would cause them to bottom out more. An interview was conducted on April 25, 2023 at 11:20 a.m. with the director of nursing (DON/Staff #105) who stated that different kinds of medications have ordered parameters such as medications for blood pressure, pain, and insulin; and that, vital signs such as blood pressures and blood sugars can change minute to minute. The DON also stated that following the pain medication parameters was important because of the risk of sedating a resident. She stated that the expectation was for staff to medicate their residents based on the pain scales; and that, staff should be coordinating with the provider to make sure pain scales and medications are correct. Further, the DON stated that potential side effects of administering outside of parameters include respiratory failure, over sedation and insufficient pain control. The facilities policy on Nursing Administration reviewed on September of 2022 included that medication(s) received, refused, and response to medication will be documented on the Medication Administration record (MAR). It also included to monitor pain status and treatment effects on a regular basis, e.g., during routine medication pass; and, to consult with the physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures. The facility policy on 'Pain Management' with a revision date of September 2022 revealed that resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. Furthermore, the policy reflects that pain status and treatment effects are monitored on a regular basis and a physician is consulted for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures.

Based on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available for use one resident (#28). The deficient practice could result in resident not receiving necessary medications ordered by the physician. Findings include: Resident #28 was admitted [DATE] with diagnoses of acute kidney failure, pneumocytosis, type 2 diabetes, hypertension, anxiety, and gastroesophageal reflux disease (GERD). The admission MDS (Minimum Data Set) dated February 7, 2023 noted a BIMS (Brief Interview for Mental Status) score of 15, indicating that the resident was cognitively intact. The care plan dated February 10, 2023 revealed the resident was on diuretic therapy related to edema. Interventions included to administer medications as ordered and to report pertinent lab results to physician. A physician order dated February 1, 2023 revealed for Lokelma (potassium binder) oral packet 10 gr(grams) two packets be given by mouth one time a day for high levels of potassium. The MAR (Medication Administration Record) for March 2023 revealed that Lokelma were documented as code 2 indicating hold/see nursing notes on March 3, 4, 5, 11 and 12. The EMAR (electronic MAR) note dated March 3, 2023 included that Lokelma was on order. Review of the eMAR notes revealed Lokelma was documented as not available on the following dates and time: -March 3, 2023 at 8:16 a.m.; -March 5, 2023 at 6:46 a.m.; -March 11, 2023 at 9:16 a.m.; and, -March 12, 2023 at 8:47 a.m. Further review of the clinical record revealed no evidence that Lokelma was administered as ordered; and that, the physician or pharmacy were notified. An interview was conducted on April 25, 2023 at 10:21 a.m. with a licensed practical nurse, (LPN/staff #79) who stated that if a medication was not available she would check the medication room, the pyxis, and the overstock. The LPN said that if the medication is not available, she would notify the provider and if the order can be changed, stopped or put on hold. During an interview with the director of nursing (DON/Staff #105) was conducted on March 25, 2023 at 11:20 a.m., the DON stated that they get 3 times a day delivery for medications; and, they can also get stat medications if needed if it was after 7:00 p.m. The DON stated that they have had some medications unavailable in the past; and, because of this, everyone was given access to their pyxis system. The DON stated the expectation was that in the event a medication was unavailable, the floor nurses should let her know or notify a provider so that the provider can make changes if necessary. Review of facility policy on Nursing Administration included that it is their policy to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) to meet the needs of each resident.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure the physician was notified of significant changes in weight for one resident (#20) with diagnosis of congestive heart failure (CHF). Sample size was 3. The deficient practice may result in resident having adverse complications. Findings include: Resident #20 admitted on [DATE] with diagnoses of sepsis, acute kidney failure and congestive heart failure (CHF). The hospital documentation dated January 12, 2022 revealed the resident was admitted to the hospital on December 30, 2021 after presenting with difficulty breathing, shortness of breath and chest pain; and that, the resident was treated for CHF exacerbation and admitted to the facility for inpatient rehabilitation. Per the documentation, patient education information included instruction for daily weight monitoring to identify sudden weight gain. The documentation indicated that a sudden weight gain could mean that heart failure was getting worse. Symptoms included shortness of breath, swelling in the legs and feet or in the abdomen, and sudden weight gain of more than 2 pounds in 1 day or 5 pounds in 1 week. Additional review of the documentation revealed the resident received Bumex (bumetanide/diuretic) 2 milligrams (mg) = 8 milliliters (mL), intravenous push, daily while he was hospitalized . A physician order dated January 12, 2022 included for O2 (oxygen) at 1-5 liters via nasal cannula every shift for diagnosis of pneumonia and shortness of breath. Instructions included to titrate to maintain saturation levels of 89% or greater. A care plan dated January 12, 2022 revealed the resident had altered cardiovascular status related to CHF exacerbation and hypertension. Goal was that the resident will remain free from signs and symptoms of cardiac complications. Interventions included to assess for shortness of breath and cyanosis. Another care plan dated January 12, 2022 revealed the resident had nutritional problem/ potential nutritional problem related to CHF exacerbation as evidenced by poor intakes. The goal was that the resident maintains adequate nutritional status as evidenced by maintaining weight with no signs or symptoms of malnutrition. Interventions included weekly weights for 4 weeks and then monthly if stable. Review of the Weight Summary dated January 13, 2022 revealed the resident weighed 208.4 pounds (lbs.). A late entry physician progress note dated January 17, 2022 included that the resident's family had called with concerns about the resident passing a small amount of urine. The note revealed bumetanide was ordered to be given as soon as the medication came in. The note indicated that a Foley catheter was inserted and 380 milliliters (mL) of clear yellow urine drained out. Plan was to continue monitoring of lab reports and urine amounts. A nursing progress note dated January 17, 2022 included that the resident reported that he was on diuretic in the hospital and he was not getting it. Per the documentation, the medication was not available in the medication dispensing machine; and that, the pharmacy was called and the medication would be sent that afternoon. A physician order dated January 17, 2022 revealed a STAT order for Bumetanide 1 mg give one tablet daily for CHF. A nursing progress note dated January 17, 2022 revealed that the resident told his family that he wanted to go to the hospital. Per the note, the resident's family was contacted and agreed to send the resident to the hospital the following morning. Review of the Medication Administration Record (MAR) revealed that bumetanide was administered on January 17, 2022 at 9:31 p.m. A nursing progress note dated January 18, 2022 included the resident the resident was sent to the emergency room (ER) per the family's daughter's request due to concerns of kidney injury. Another nursing progress note dated January 18, 2022 included that the resident's family was notified that the resident will be returning at the facility. Per the documentation, the resident's family stated that the resident had been expressing concerns with lung issues; and that, the resident would be seen by an in-house provider and will have consultation with pulmonologist. A nursing progress note dated January 19, 2022 included the resident returned to the facility with no new orders. A 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 indicating resident had intact cognition. Per the assessment, the resident required extensive 2-person physical assistance for most activities of daily living; and, had an active diagnosis of heart failure. A care plan dated January 20, 2022 included that the resident was on diuretics to CHF. Goal was that the resident would be free from any discomfort or adverse side effects of diuretic therapy. Interventions included to administer medications as ordered. The physician progress note dated January 20, 2022 revealed the resident's oxygen saturation level was 91% and his weight was 208 lbs. (pounds). An electronic medication administration record (eMAR) note dated January 22, 2022 included a change of condition for urinary retention. A physician's progress note dated January 24, 2022 revealed the resident's weight at 208.4 lbs. However, a review of the Weights and Vitals record revealed on January 24, 2022 the weight was 218.0, which was a gain of 9.6 pounds in 11 days. Further, the clinical record revealed no evidence that the provider was notified. The physician progress note dated January 26, 2023 revealed the resident complained of pain in the lower extremities; but, denied swelling and tenderness. Review of the clinical record did not indicate that edema was being monitored. A nursing note dated January 26, 2022 revealed the resident's Foley had been removed at 8:00 p.m. The O2 Saturation Summary dated January 27, 2022 at 9:00 a.m. revealed the resident's O2 sat was at 90% via nasal cannula. A late entry physician's progress note dated January 27, 2022 at 10:37 a.m. revealed the resident had complained of shortness of breath, and had been placed in semi-isolation. The resident was status post Foley removal and per the note, the resident was voiding well. An eMAR administration note dated January 28, 2023 at 3:18 p.m. revealed the resident had a temperature of 100. However, the clinical record revealed no documentation that the provider was notified. Review of nursing progress notes dated January 29 and 30, 2022 revealed the resident was incontinent of urine. The Weights and Vitals Record dated February 2, 2022 revealed weight was 215.0 lbs. A nursing progress note dated February 2, 2022 at 1:15 p.m. revealed the resident was found sitting on his buttocks in his restroom between the doorway and the toilet, with his legs in front of him. Per the note, no visible injuries were identified and he denied discomfort. Per the note, the physician's assistant had been notified. However, there was no documentation to indicate the resident had been fully assessed, including vital signs having been obtained. A physician progress note dated February 7, 2022 at 11:49 a.m. included the resident was in the hall, and complained of lower extremity swelling and had stated he was on Bumex. According to the note, the resident said that he was voiding and was in his wheelchair most of the day and denied shortness of breath. A nursing progress note dated February 7, 2022 at 5:22 p.m. revealed the resident had increased bilateral edema. It also included that he was seen by the nurse practitioner; and that, his diuretic was increased to 2 mg a day. A physician's order dated February 7, 2022 included for bumetanide 2 mg daily for CHF. A physician progress note dated February 8, 2022 revealed the resident was still stating his legs were swelling bilaterally. Per the note, nursing suggested he raise his legs up after laying in the bed. Further, the note included weight was 215 lbs. However, review of the Weights and Vitals Record dated February 8, 2022 at 1:49 p.m. revealed the weight of 222 lbs. which was a weight gain of 7 pounds in 5 days. The clinical record revealed no evidence that the provider had been made aware of the significant weight gain. A nursing progress note dated February 9, 2023 at 3:43 p.m. included the resident's family called regarding the swelling in the resident's lower extremities. Per the note, after confirming with the kitchen staff that the resident was on a low salt diet, the resident was asked and agreed to lay down for a few hours to help with the edema. On February 9, 2022 at 7:17 p.m. a nursing progress note revealed the resident was found unresponsive in bed, with no signs of life, including no rise of the chest, no apical pulse and eyes dilated. An interview was conducted on March 27, 2023 at 1:22 p.m. with the registered dietician (RD/staff #105) who stated that a change in nutritional status could be identified by a weight loss or gain of 5% or more in one month, 7.5% in 3 months, or 10% in 6 months. She stated that generally she pays more attention to weight losses. She stated that significant weight gains might be related to CHF and/or diuretic use. She stated that if a resident's weight increased from 208 to 222 lbs. in one month (almost 7%) it would be fluid-related and/or swelling. She stated that if CHF were involved, she would think it would be a fluid shift. The RD stated that daily weights for residents with CHF had still not been fully addressed in the facility, and that for now weights are monitored as ordered. She stated that with the consistent increase in the resident's weights, there should have been a follow up with the RD and the provider to evaluate the weight gain. She stated that the process includes weights being obtained by the restorative nurse assistant, reported to the nurse, and then the nurse notifies the provider. She stated that the nurse would document in the progress notes specifically when the provider had been notified. During an interview conducted with a licensed practical nurse (LPN/staff #100) on March 27, 2023 at 1:46 p.m., the LPN stated that residents were weighed upon admission to establish a baseline. She stated that the most common treatments for residents with CHF included oxygen therapy, diuretics, vital signs every 8 hours and daily weights. She stated that daily weights were pretty much standard for CHF residents; and that the RNAs (restorative nursing assistants) weigh the residents and would tell her if there was a change in resident's weight. She stated that if there was a weight change, the nurses would notify the doctor and then the conversation would be documented in the progress notes. She stated that if it was not in the progress notes, that means it did not happen. Further, the LPN stated that if a resident had significant edema, weight gain and who was not voiding she would notify the doctor and send him out because it could be a kidney issue. On March 27, 2023 at 2:22 p.m. an interview was conducted with an LPN (staff #22) who stated that when a resident was admitted to the facility, admissions would give her the resident's packet and she would input the resident's orders. She stated that she would type in the orders and then verify them with the provider over the phone. She stated that most of the time, if a resident was on a diuretic at the hospital they will usually receive one at the facility. She stated that the facility protocol for CHF residents included obtaining daily weights. When the resident's weights were stable, the weights may be changed to weekly. She stated that the RNAs would let the nurses know if there was a weight gain and the nurses would let the provider know so orders could be obtained. She stated that the RNA will document a progress note that would include that they notified someone. She stated that if the resident was gaining weight and not urinating, she would want to know. She stated that the risks to the resident would include pain, fever, their kidneys could shut down, and ultimately, they could get sick and die. A phone interview was conducted on March 28, 2023 at 8:21 a.m. with the MDS nurse (staff #88) who stated that she was responsible for creating residents' initial care plans upon admission. She stated that after that, she will fine tune or add any additional care plans to meet the resident's needs. She stated that a CHF care plan should include monitoring for shortness of breath, edema, swelling and weights per provider orders, daily or weekly. She also stated that CHF should be its own care plan. The MDS nurse said that if weight monitoring is not included in the resident's care plan, this would not meet her expectations. She stated that it was imperative to monitor weights because significant weight gains can happen fast and may cause a whole other list of problems. On March 30, 2023 at 1:53 p.m. an interview was conducted with the Director of Nursing (DON/staff #31) who stated that the facility will obtain weights on new residents weekly and/or per physician's orders. She stated that RNA completes the weights and any changes in weights are sent to the RD for further review. She stated that changes in weights will be provided to the nurse, the RD and the physician would be notified. She stated that if the resident had a notable increase in weight, her expectation was that the physician would be notified. She stated that progress notes should be entered into the system indicating that the information was passed along. She stated that if it was not documented, she would not know whether or not the provider had been alerted about a change in the resident's condition. She stated that the risks for not ensuring the provider was made aware of significant weight gains may include fluid overload, extreme swelling, blood pressure issues, hospitalization and possibly death. The Professional Standards policy, revised 5/2022, included that it was the policy of the facility that services provided by the facility meet professional standards of quality and be provided by qualified persons in accordance with each resident's care plan. Professional standards of quality means services are provided according to accepted standards of clinical practice. Standards regarding quality care practices may be published by a professional organization, licensing board, accrediting body or other regulatory agency. Care will be given by qualified persons in accordance with the resident's care plan. The Comprehensive Person-Centered Care Planning policy, reviewed 8/2022, included that it was the policy of the facility that the interdisciplinary team shall develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The Change of Condition Reporting policy, reviewed 7/2021, included that it was the policy of the facility that all changes in resident condition would be communicated to the physician. All nursing actions, physician contacts and resident assessment information will be documented in the nursing progress notes.

Based on observations, staff interviews, and review of facility documentation and policy, the facility failed to ensure there was sufficient staff to meet the needs of residents. The average daily census was 69 residents. The deficient practice could result in residents' needs not being met. Findings include: Review of the Facility Assessment, updated February 2022 included a purpose to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. The assessment would help make decisions about direct care staff needs, as well as capabilities to provide services to the residents in the facility. Using a competency-based approach focused on ensuring that each resident was provided with care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. According to the Assessment, the following staffing levels were required in order to meet the needs of the residents: Registered Nurses (RNs): 1-2 for day shift, 1-2 for for evening shift and 1 for night shift; Licensed Practical Nurses (LPNs): 3-4 for days, 2-3 for evenings, and 2-3 for nights. Certified Nursing Assistants (CNAs): 7-9 for days, 7-9 for evenings, and 4-5 for nights. Restorative CNAs: 2 full-time days. Review of the daily staffing postings dated January 10, 2022 through February 10, 2022 revealed a census which ranged from 62 to 77 residents, with an average resident census of 69. Review of the staffing information revealed staffing levels were less than the number required as indicated by the Facility Assessment, including: RNs - 12 out of 31 day shifts; 5 out of 31 evening shifts; and 26 out of 31 night shifts. LPNs - 14 out of 31 day shifts; 15 out of 31 evening shifts; and 8 out of 31 night shifts. CNAs - 25 out of 31 day shifts; 29 out of 31 evening shifts; and 4 out of 31 night shifts. RNAs - 22 out of 31 day shifts. On March 30, 2023 at 12:33 p.m. an interview was conducted with the staffing coordinator (staff #83) who stated that she had been in the position for about a month. She stated that she tries to maintain a 1:12 ratio for the CNA staff to resident ratio. She stated that the higher the census, the more staff were needed. She stated the facility utilize agency staffing and that the agency staff are added to the staff postings. She stated that when there are no RNAs, therapy will pick up the services for that day. She stated that inadequate CNA staffing would result in longer waits for call lights to be answered, a slower meal pass, and/or no showers provided for residents. She stated that it would be a desperate day to have only 4 CNAs on the floor. However, review of the staffing documentation conducted with staff #83 revealed there were less than 5 CNAs working either days or evenings on 7 out of 31 shifts. An interview was conducted on March 30, 2023 at 1:53 p.m. with the Director of Nursing (DON/staff #31) who stated that it was her expectation that nurse/CNA staffing would be provided in accordance with the Facility Assessment. The Sufficient Staff policy, revised 5/2022, included that it was the policy of the facility to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosis of the facility ' s resident population in accordance with the facility assessment.

Based on review of facility documentation, staff interviews, and policy, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The average daily census was 69. The deficient practice could result in residents not receiving more advanced care when needed. Findings include: Review of the staff postings and nursing staff punch detail provided no evidence that an RN was on duty on January 29, 2022. An interview was conducted on March 30, 2023 at 12:23 p.m. with the staffing coordinator (staff #83) who stated that the expectation was that an RN would be on duty for at least 8 consecutive hours, 7 days per week. She stated that she had about a dozen staffing agencies that she could call; and, she adds agency staff to the staff postings. She stated that not having an RN on duty would not meet the expectations. Further, staff #83 stated there were some things that an RN can do that the LPNs (licensed practical nurse) could not. On March 30, 2023 at 1:53 p.m., an interview was conducted with the Director of Nursing (DON/staff #31) who stated that her expectation was that nurse staffing would be provided in accordance with the facility assessment; and that, an RN would be on duty at least 8 hours per day, 7 days per week. The Sufficient Staff policy, revised 5/2022, included it was the policy of the facility to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment.

Based on clinical record review, staff interviews, facility documents and policy, the facility failed to ensure that 2 residents (#32 and #78) are not abused by staff. The deficient practice could result in staff abuse of residents. Findings include: -Resident #32 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis, major depressive disorder and anxiety disorder. An Annual Minimum Data Set (MDS) dated [DATE] included that this resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. This document included that the resident required limited 2 person assistance for transfers and that the resident required extensive 2 person assistance for bed mobility. A care plan initiated June 6, 2021 included that the resident had an self care performance deficit related to dysphagia and left sided weakness with interventions of requiring staff participation with transfers and turning in bed. A review of the clinical record did not find any documentation regarding abuse between this resident and a staff member. A report was received by the State Agency (SA) on December 6, 2022 from the facility which included A CNA overheard another CNA yelling and cussing at a patient after the patient was yelling and cursing at her. The CNA was an outside agency CNA who is suspended from our facility as we investigate. The CNA was sent home after the incident occurred and was immediately separated from the patient. An interview was conducted on January 12, 2023 at 3:08 PM with a Certified Nursing Assistant (CNA/staff #100) who said that she had to kick staff #36 out of the room because the resident told her repeated to not to get that shoulder and then the resident and staff #36 started screaming at each other. She said that staff #36 told the resident to shut the f up. She said that she told her to get out of the room and she finished doing the transfer herself. She said that was the first time she saw staff #36 act like that and that before that she would have said #36 was a good CNA. An attempt was made to interview staff #36 on January 13, 2023 at 11:01 AM. A message was left on the voicemail. An interview was conducted on January 13, 2023 at 1:32 PM with resident #32 who said that staff #36 was trying to take a towel off his chest, and that she didn't realize she had a handful of his chest hair. The resident said that he asked her 2 times to stop and that she said to shut up, she'll take care of me. This resident said that he told her he'd kick her ass. He said that staff #100 was the one that wrote the incident up and that staff #100 was in the room at the time of the incident. He said that staff #100 told staff #36 to stop because she was hurting him and that she finally let go and stormed off. He said that the two staff were transferring him from the gurney to the bed after a shower. An interview was conducted on January 23, 2023 at 3:43 with an LPN/Assistant Director of Nursing (staff #115) who said that this resident had an incident with the agency CNA and that the facility asked her to leave right there and then. She said that the facility had two different stories because 1 CNA said that he cussed at her, 1 CNA said that she cussed at him. She said that the facility provided education to the staff. -Resident #78 was admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis, Major Depressive Disorder, and anxiety disorder. An Annual Minimum Data Set (MDS) dated [DATE] included that this resident had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. This document included that the resident required extensive 1 person assistance for bed mobility and required supervision and setup assistance for eating. A care plan dated October 26, 2021 included that the resident had a potential for mood problem related to admission abusive language towards staff with interventions that when the resident becomes aggressive/abusive to calmly talk with the resident and if the resident continues to leave him alone to calm down and attempt to re-approach at a later time. A 5 day report dated July 21, 2022 included that a CNA (staff #100) said, I saw (staff #49) bump into the table that had resident #78 food on it and some of it spilled on the table and him. Resident #78 started cussing at (staff #49), calling her a fucking bitch and to be more careful. resident #78 said a lot of other things. (staff #49) said back to him Don't you be cussing at me. I'll whoop your ass. Resident #78 responded by saying Don't you fucking swear at me. (staff #49) said that she doesn't put up with this bullshit and left the room. This document also included that another CNA (staff #58) said (staff #49) was assisting had resident #78 with his tray. had resident #78 asked for the tray to be repositioned. While she was doing that, I think had resident #78 bumped the table and spilled the food. (Staff #49) said she would get something to clean it up and the patient said fuck this. (Staff #49) told had resident #78 that she cannot speak to her like that. Patient continued to cuss at her. (Staff #49) got really upset and said Fuck this, I'm gonna whoop your ass if you keep talking to me like this. She then left the room yelling in the hallway and making a scene. I helped (staff #100) clean up. This document concluded that The leadership team at the facility has completed their investigation related to the above allegation. After interviewing multiple staff members and residents, Pueblo Springs has concluded that TNA (staff #49) was verbally aggressive towards resident #78. We do not condone this behavior by any means. We have reported this to the agency that (staff #49) works for and have taken steps to ensure that (staff #49) never returns to the facility. An interview was conducted on January 13, 2023 at 4:26 PM with the acting Director of Nursing (staff #136) who said that her expectation was that abuse needs to be reported, thoroughly investigated, type up the 5 day and send in the report. She said that is was also her expectation that abuse not occur in the facility. She said that it did not meet her expectation that staff yell and curse at a patient. A policy titled Abuse: Prevention of and Prohibition Against revealed that it is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This document included that the facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. This document defined verbal abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability.

Based on clinical record review, staff interviews, facility documents and facility policy, the facility failed to ensure that a physician was informed of changes in condition for one resident (#4). The deficient practice could result in other residents' physicians and responsible parties not being notified and conditions worsening. Findings include: Resident #4 was admitted on [DATE] with diagnoses of end stage renal disease and dependence on renal dialysis. A 5 day scheduled Minimum Data Set (MDS) dated [DATE] included that this resident had dependence on renal dialysis. A care plan dated July 18, 2022 included needs hemodialysis related to renal failure with interventions including monitor AV shunt for bruit and thrill and to document (+) present (-) not present. This document included to notify physician if not present. A Physician's order dated June 28, 2022 included to monitor AV site for bruit and thrill and to document + for present and - for not present every shift, dialysis center to maintain shunt. A Treatment Administration Record (TAR) for November and December, 2022 included that the order for monitoring the AV site in November showed 27 incidents and in December showed 18 incidences that bruit and thrill was not present. Review of the clinical record revealed that the physician was not informed that the resident's AV site did not have bruit or thrill. Progress note dated December 28, 2022 included that the resident was sent to the hospital for low blood pressure and a clogged fistula, and that this resident returned from the hospital. These notes include that the resident stated that nothing was done with her dialysis access and that they may end up having to place a new one. However, review of the clinical record revealed that the physician was not informed that the resident was transported to the hospital or of the results of the hospital visit upon the resident's return. A nursing note dated December 30, 2022 included that this resident was sent to the hospital for low blood pressure and a clogged fistula. An interview was conducted on January 13, 2023 at 3:43 PM with a Licensed Practical Nurse/Assistant Director of Nursing (LPN/staff #115) who said that dialysis sent the resident to the hospital and that she did not know if dialysis informed the physician. She reviewed the chart and said that the only note that she sees was that the resident was sent to the hospital for that shunt. She said that the provider should have been notified if there was a negative because a negative means that staff is not getting a bruit and that the provider should know if the resident is in the hospital. An interview was conducted on January 13, 2023 at 4:26 PM with the acting Director of Nursing (staff #136) who said residents on dialysis should get pre and post vital signs, monitor the sight for inspection, and that they should fill out the dialysis sheets. She said that a negative sign would mean no bruit or thrill and at that point they would want to notify the doctor. She said that it did not meet her expectations that hospital stay and records were not communicated to the physician. She said that if the resident was sent to the hospital from the dialysis, it is the responsibility of the facility to notify the physician that the resident has been sent to the hospital. A policy titled Change in condition reporting revealed that it was the policy of the facility that all changes in resident condition will be communicated to the physician.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to assess and monitor and provide supervision to one resident (#17) to prevent elopement. The deficient practice could result in resident elopement, placing residents at risk for harm in the community. Findings include: Resident #17 was admitted on [DATE] with diagnoses of multiple fractures, dysphagia, schizophrenia, and bipolar disorder. An Admission Minimum Data Set (MDS) dated [DATE] included that this resident had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident was severely cognitively impaired. This document included that the resident required extensive 2 person assistance for transfers and that the resident required supervision 1 person assistance for locomotion off unit. This document also included that this resident required care for surgical wounds and pressure wounds. Review of the care plan did not include elopement or the resident's improved mobility. A Psychiatry Progress note dated November 16, 2022 included that the resident was in a hit and run while a pedestrian and that the resident required restraints while in the hospital due to severe agitation as a result of his injuries. This note included that the resident has intermittent agitation and that he is able to transfer with assistance from bed to chair and back again. A progress note dated December 5, 2022 included that this resident said that he needs to leave, there is a staff member who is saying his gang name. This note included that the resident was repeating over and over that he had to leave and he did not want to do what his dad used to do but would not clarify what that was. This note included the staff member called the resident's mother who said that over the past few days that she had noticed a change in the resident's behavior and that she wondered if the resident was having some kind of mental change. The note revealed staff allowed the resident and his mother to speak and the staff and mother encouraged the resident to stay. This note included that behavioral health was contacted and a one time as needed medication was ordered and that an officer would be there soon to speak with the resident. However, no plan was implemented for future elopement. A progress note dated December 5, 2022 included (This resident) came into this writer's office and asked to speak to his mother on speaker with me. We called her and again both of us explained the importance of him staying at the facility, (this resident) asked his mother what she wanted him to do. She told him she would prefer he stay and continue to get the care he needs. (This resident) agreed to stay, and this writer took him back to his room. (This resident) said he was really tired and would be going to bed to get some sleep. (Behavioral health staff) told (This resident) they would come follow up with him tomorrow. A progress note dated December 10, 2022 included that this resident has left facility, whereabouts are unknown and that the staff had informed the resident's mother that resident is missing, and that it was his second attempt today to leave the facility. A Quality Improvement Plan/Action Plan dated December 12, 2022 included that the resident left from the facility through the window in their room and that facility leadership was unaware that he had exited through the window prior to the second time. This document included the facility will continue to provide education related to the elopement process and reportable events for new team members. An interview was conducted on January 12, 2023 at 10:59 AM with a Licensed Practical Nurse (LPN/staff #132) who said that she was there on the day he eloped. She said that but that he was fine in the morning, he was not assigned to her but she said hi in the morning, and he was acting normally. She said that his roommate came and told me and she alerted his nurse, staff #49. She said that was the first time he eloped. She said that the nurse had gotten an order and the resident was gone again. An interview was conducted on January 12, 2023 at 11:31 AM with a Registered Nurse (RN/staff #49) who was assigned the resident at the time of his elopement. This RN said that if a resident elopes that staff should tell the administrator right away, call police, and call the next of kin. She said that she did not know how the resident had gotten out of the building and that he had done it before. She said to keep residents from eloping, the doors to the building are locked and that there was usually a person at the front of the building. She said that people were saying the resident got out through the window. She said that she did not know who the resident's nurse was at the time of the elopement and then said that she did what she was supposed to do for an elopement which was call the administrator, call the police and call the family. She said that she did not remember what happened that day or if she had put any interventions in place to stop the resident from eloping other than the facility having locked doors. An interview was conducted on January 13, 2023 at 11:15 AM with a Certified Nursing Assistant (CNA/staff #84) who said that staff had told him that the resident walked out of the door once and then climbed out a window once. This CNA stated that he was told that the resident was asking for his mother. An interview was conducted on January 13, 2023 at 3:43 with an LPN/Assistant Director of Nursing (staff #115) who said that the resident was at the facility a little over a month and that initially he was not able to get out the wheelchair. She said that the staff were doing treatments on his legs. She said that he would always tell his mom he wanted to leave but she said she could not take care of him. She said that she saw him waiting by the front desk. She said that the management actually did not even know about the first attempt until the nursing staff notified me after he eloped and that they did an in-service and education. She said that the staff member was fairly new and did not know and was provided education on how to proceed when something like that happens. She said that the staff said they had closed the doors and locked the patio door because they go out there to smoke and she thinks that's why he used the window. She said the CNAs did say they were checking on him but the nursing shift was about to change over and that's when he left out of the window. This LPN said that he was found at St Mary's and that he did not have any harm. An interview was conducted on January 13, 2023 at 4:26 PM with the acting Director of Nursing (staff #136) who said that the resident had eloped and that he was at the bus stop, they were calling the provider and he left. She said that they had already done an inservice on this incident. A policy titled Elopement revealed that is the policy of this facility to ensure that the facility provides a safe and secure atmosphere for all residents in the facility and that residents identified to be high risk for elopement will have an appropriate plan of care developed to address the risk.

Based on closed clinical record review, staff interviews, hospital records and policies and procedures, the facility failed to ensure that one resident (#120) received sufficient fluid intake to prevent dehydration. Findings include: Resident #120 was admitted from the hospital on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. Review of a hospital visit summary dated (MONTH) 13, (YEAR) revealed that resident #120 was admitted after suffering a fall, with pain in the left hip. Laboratory values included the following: Creatinine = 1.5 (normal range 0.9-1.3; Blood Urea Nitrogen (BUN) = 36 (normal range 6-20); Chloride level = 105 (normal range 101-111) and Sodium Level = 140 (normal range 136-145). A hospital physician's discharge summary included that resident #120 had acute pain secondary to a fracture, leukocytosis, coronary [MEDICAL CONDITION] and dementia. Per the summary, the resident was adequately nourished but mildly dehydrated, and that an indwelling urinary catheter had been placed in the hospital, due to complications from the pubic fracture. An initial nursing admission record dated (MONTH) 13, (YEAR), included the resident was admitted for status [REDACTED]. The documentation included the resident was alert to time and person but was confused, and was able to follow simple commands. Also noted was that the resident had difficulty swallowing, oral mucosa was pink and moist, and the resident had an indwelling urinary catheter in place, due to a pelvic fracture and pain. The admission physician orders [REDACTED]. An initial care plan included the resident had a nutritional problem or potential nutritional problem, however, it did not include any specific information or interventions for ensuring the resident received adequate food/fluids. A nurse's note dated (MONTH) 14, (YEAR) revealed the resident was alert and oriented x 1, and was forgetful and confused at times. The note included the resident was able to feed self with set up help, and required extensive assistance with bed mobility and transfers. Another nurse's note dated (MONTH) 14, (YEAR) included the resident had been tugging on his urinary catheter and the physician was notified. Per the note, the catheter was discontinued and Will continue to monitor for voiding. However, there was no clinical record documentation that the resident's urinary output was monitored, after the indwelling catheter was removed. Review of the fluid intake record for resident #120 revealed the resident consumed the following daily fluid amounts: -December 14: 780 cc (cubic centimeters) -December 15: 1860 cc -December 16: 1320 cc A nutrition/hydration risk evaluation dated (MONTH) 16, (YEAR) which was signed by the dietician, revealed the resident fed himself, eats 50-75 % of most meals, consumed between 1000 - 2000 cc of fluids daily, and was on diuretic medication. The evaluation included that the resident was a low risk for dehydration. A nurse's note dated (MONTH) 17, (YEAR) at 2:14 p.m. included the resident had blood coming from his penis and that his urine had a strong odor. A physician's orders [REDACTED]. Review of the fluid intake record revealed the resident consumed the following daily fluid amounts: -December 17: 1200 cc -December 18: 1200 cc -December 19: 1320 cc The results of the urinalysis were reported to the facility on (MONTH) 19, (YEAR) at 2:51 a.m. Per the report, the resident had a large amount of blood and leukocyte esterase in the urine and a blood urine quantitative value of 300 (normal range is negative). However, there was no clinical record documentation that the physician was notified of the urinalysis results on (MONTH) 19. A physician's orders [REDACTED]. A dietary admission evaluation dated (MONTH) 20, (YEAR), included the resident received a regular diet with thin liquids, and fed himself with limited to extensive set up assistance. The evaluation included that the resident required fluid intake amounts of 1584-1650 ml per day. This was the first documentation of the amount of fluids the resident required to maintain adequate hydration. The documentation further included that the resident should consume a minimum average of 72% of meals to meet minimum energy requirements, and that the resident was not meeting his needs. Per the documentation, the resident had a low oral intake, was consuming 1380 ml of fluids daily, (which was less than the required amount) and was receiving a diuretic. Will implement fortified foods and will continue to monitor oral intakes. Further review of the fluid intake record revealed the resident consumed the following daily fluid amounts: -December 20: 1200 cc -December 21: 1880 cc The laboratory results were reported to the facility on (MONTH) 22, (YEAR) at 8:03 a.m., which included that the resident had Proteus Mirabilis (bacteria) in his urine greater than 100,000 per ml. A physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR (Medication Administration Record [REDACTED]. A medication administration note dated (MONTH) 22, (YEAR) at 10:03 a.m. included the resident was unable to be awakened. A daily skilled note dated (MONTH) 22, (YEAR) at 6:29 p.m., included that the resident's blood pressure was 102/54, the resident was alert and oriented and had no sensory changes. Continued review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the resident's fluid intake and meal records dated (MONTH) 22, (YEAR), revealed the resident had refused to eat, and received only 180 ml of fluids for the day as follows: 60 ml at 1:13 a.m., no fluids at 1:43 p.m., and 120 ml of fluids at 9:11 p.m. Further review of the clinical record revealed no evidence that the physician was notified on (MONTH) 22, of the resident's drop in blood pressure and that medications were held, that staff were unable to awaken the resident, and that the resident had refused to eat and had only received 180 ml of fluids for the day. According to the SBAR Communication Form dated (MONTH) 23, (YEAR) at 2:45 a.m., the resident was unresponsive, his blood pressure was 70/40 and that the unresponsiveness had started on (MONTH) 23. The documentation included that 911 was called and the resident was transferred to the hospital. A change in condition note dated (MONTH) 23, (YEAR) included the resident was unresponsive, his blood pressure was 70/40, and the primary care clinician had been notified. Review of a hospital admission record dated (MONTH) 23, (YEAR) at 3:06 a.m., revealed the resident was admitted to the critical care unit with the following Diagnoses: [REDACTED]. Review of the hospital laboratory results dated (MONTH) 23, (YEAR) at 3:08 a.m. revealed the following: BUN 204 (normal range 8-23), Creatinine 6.3 (normal range 0.67-1.17) Sodium 149 (normal range 136-145), Potassium 6.5 (normal range 3.4-5.1) and Chloride 119 (normal range 98-107). A hospital history and physical dated (MONTH) 23, 107 at 5:29 a.m. included the resident had severe acute kidney injury and [MEDICAL CONDITION] most likely from severe dehydration. The documentation included patient does appear very dehydrated. A hospital discharge note dated (MONTH) 30, (YEAR) included the resident had been admitted to in-patient hospice care for a [DIAGNOSES REDACTED]. An interview was conducted on (MONTH) 21, (YEAR) at 2:41 p.m., with a CNA (Certified Nursing Assistant/staff #86). Staff #86 stated that she would immediately notify the nurse if a resident has not taken any fluids or has not urinated, and would report symptoms of dehydration immediately to the nurse. An interview was conducted on (MONTH) 22, (YEAR) at 9:37 a.m., with the dietitian (staff #105). After reviewing the dietary evaluation, staff #105 stated that the recommended fluid intake for resident #120 was 1584 ml-1650 ml daily, and the recommendation took into account that the resident received a diuretic medication. An interview was conducted on (MONTH) 22, (YEAR) at 10:00 a.m. with a LPN (Licensed Practical Nurse/staff #9). Staff #9 stated that upon notification by a CNA that a resident has not received any fluids or food, he would immediately assess the resident and notify the physician. An interview was conducted on (MONTH) 22, (YEAR) at 11:12 p.m., with the Director of Nursing (DON/staff #104). During the interview, staff #104 stated that if a resident refused to eat or has not taken any fluids, the nurse should notify the physician immediately. After reviewing the resident's fluid intake amounts for December, staff #104 stated that the amount of fluids which were recorded on the fluid intake record did not take into account the extra fluids that were provided by the nurses with medications. She also stated that the fluid amounts documented by the CNA's were in error for (MONTH) 22, as the resident must have taken in more fluids than the amounts which were documented. She further stated that when abnormal laboratory results are received, the nurse notifies the physician immediately and then writes a notation that the laboratory results were reported to the physician. Another interview was conducted with staff #104 on (MONTH) 22, (YEAR) at 2:31 p.m. Staff #104 stated that she was unable to provide any additional documentation that the nurse had notified the physician on (MONTH) 22, nor any documentation that the resident was provided additional fluids or received the recommended fluid amounts each day. A policy titled, Hydration included the purpose of the policy was to ensure that the resident receives sufficient amount of fluids, based on individual needs to prevent dehydration. The facility will provide each resident with sufficient fluid intake to maintain proper hydration and health. Per the policy, sufficient fluid means the amount of fluid needed to prevent dehydration and maintain health. Risk factors included increased fluid loss and fluid needs, functional impairment that make it difficult to drink or communicate fluid needs and dementia, in which a resident forgets to drink. The policy also included The physician will be notified of any signs of dehydration, for further orders. Review of a Change of Condition Reporting policy revealed that all changes in condition will be reported to the physician, and that unusual signs and symptoms will be communicated to the physician promptly.

Based on observations, clinical record reviews, staff and resident interviews, facility documentation and policy review, the facility failed to ensure that seven residents (#'s 363, 37, 193, 358, 359, 364 and 365) who smoked had been assessed to smoke safely and failed to determine if residents were able to retain their smoking materials in a safe manner. As a result, the Condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. Findings include: At 10:18 a.m. on February 23, 2016, the Condition of Immediate Jeopardy and Substandard Quality of Care were identified, due to residents smoking without being assessed to smoke safely. Despite the facility being a non-smoking facility, one resident was observed smoking on facility property, without supervision. In interviews with staff, they were aware that multiple residents were smoking on the premises. Seven residents were identified to smoke and they had not been assessed to smoke safely, in order to determine if they required supervision or protective wear while smoking. Also, residents were keeping their cigarettes and lighters in their room, without the facility determining if residents could safely retain their smoking materials. The Administrator and the Director of Nursing were informed of the facility's failure to ensure the safety of residents who smoked. The Administrator presented a plan of correction at 4:10 p.m. on February 23, 2016. The plan of correction now included a smoking policy which allowed residents to smoke, with supervision. The Administrator was informed that the plan of correction needed to address if there were specific smoking times, how supervision would be provided for residents when smoking, how residents will access smoking materials, the need for safety equipment in designated smoking areas, and a more immediate completion date for staff inservices. The Administrator presented a second plan of correction at 6:10 p.m. on February 23, 2016, and the plan of correction was accepted. On February 24, 2016 from 8:00 a.m. to 2:10 p.m., multiple observations were conducted of residents being supervised out on the patio while smoking. Multiple staff were interviewed regarding the new smoking policy and inservice training. Staff were knowledgeable of the new smoking procedures. In addition, all residents who smoke had a smoking assessment completed to determine if they could smoke safely. As a result of the facility implementing their plan of correction, the Administrator and Director of Nursing were notified that the Condition of Immediate Jeopardy was abated at 2:10 p.m. on February 24, 2016. -Resident #363 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed documentation that the resident was alert and oriented, but had some periods of confusion. A notification of the facility's non-smoking policy was located in the resident's clinical record and was signed by the resident on February 14, 2016. A nursing note dated February 21, 2016, included that the resident spends most of his time on the outside patio. On February 23, 2016 at 9:23 a.m., another resident was observed coming in from the patio. This resident had a strong odor of cigarette smoke. At this time, an interview was conducted with a Certified Nursing Assistant and she stated that residents go out and smoke, even though they know they are not supposed to. She stated they sign a form when they come in to the facility that they are not allowed to smoke. On February 23, 2016 at 9:34 a.m., resident #363 was observed to self-propel in the wheelchair, with one arm very slowly. Resident #363 was then wheeled outside to the patio by another resident. Further observation revealed that resident #363 was observed with a lit cigarette cupped in his right hand which was resting on his right leg, and smoke was seen coming from the resident's hand. An interview was conducted with resident #363 at this time. When asked if he was smoking, he stated yes, what's the problem. A progress note dated February 23, 2016 at 9:37 a.m., which was completed by the Director of Nursing, indicated the resident was caught smoking and was educated on the non-smoking policy and offered smoking cessation products. A progress note dated February 23, 2016 at 10:09 a.m. by the Social Services Director included the resident was told of the no smoking policy and was offered smoking cessation materials, which he declined. Although the documentation showed that staff had spoken with the resident regarding smoking, there was no clinical record documentation that any interventions were implemented to monitor the resident due to his non compliance with smoking or assess his ability to smoke safely. Another interview was conducted with resident #363 on February 23, 2016 at 10:05 a.m. The resident stated that he keeps his cigarettes and lighter with him. He also stated he knows that he is not supposed to smoke. A Safe Smoking Evaluation was completed on February 23, 2016 at 4:13 p.m. The assessment revealed the resident was not able to light a cigarette and hold it, without risk of danger to self or others and was not able to safely extinguish a cigarette and place it the proper receptacle. Per the documentation, there were concerns about the resident's ability to smoke independently, therefore; the resident was identified to require monitoring when smoking. -Resident #365 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed documentation that the resident was alert and oriented. A notification of the facility's non-smoking policy dated February 3, 2016 was located in the resident's clinical record and was signed by the resident. A nursing note dated February 9, 2016 included that the resident unplugs his intravenous pump and goes outside to smoke. A physician's progress note dated February 12, 2016, included that the resident was advised to quit tobacco use. A non-complaint care plan regarding the facility's non-smoking policy was developed on February 22, 2016. A goal included that the resident would not smoke while at the facility and to offer smoking cessation material. A nursing note also dated February 22, 2016, included that the resident was offered smoking cessation materials but he refused them, that the physician was aware and that the facility's non-smoking policy was reiterated with the resident. Although the documentation showed that staff had spoken with the resident regarding smoking, there was no clinical record documentation that any interventions were implemented to monitor the resident due to his non compliance with smoking or assess his ability to smoke safely. A resident interview was conducted on February 23, 2016 at 9:30 a.m. at which time the resident stated that he does go outside to smoke. He stated that sometimes he goes to the patio on the west nursing station or out front on the side of the building to smoke. The resident also stated that he keeps his cigarettes and lighter in his pocket. On February 23, 2016 at 9:50 a.m., an interview was conducted with a Certified Nursing Assistant (CNA), who stated that the resident smoked and that he was suppose to go off property to smoke but that sometimes he just goes out on the patio to smoke. Another interview was conducted on February 23, 2016 at 9:55 a.m., with a LPN (Licensed Practical Nurse), who also stated that the resident smokes but was unaware of where the resident's smoking materials were kept. -Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was alert and oriented. Further review of the clinical record revealed a notification of the facility's Non-Smoking Policy which was signed by the resident on January 28, 2016. On February 23, 2016 at 9:00 a.m., an interview was conducted with a CNA. When questioned regarding the whereabouts of resident #37, the CNA stated that the resident might be outside of the building smoking. She stated that the resident does go out of the building to smoke. Further review of the clinical record revealed there was no documentation that the resident had been assessed to smoke safely. An interview with resident #37 was conducted on February 23, 2016 at 12:15 p.m. The resident stated that he smokes and keeps the cigarettes and matches or lighter in his room. He stated that he goes out of the facility to smoke and currently has half a pack of cigarettes with him in his room. -Resident #359 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed documentation that the resident was alert and oriented. Further review of the clinical record revealed a Non-Smoking Policy notification which was signed by the resident on January 29, 2016. A behavioral symptom care plan dated February 22, 2016 revealed the resident was exhibiting behavior issues of non-compliance with facility's non-smoking policy. Goals included that the resident will have less than zero episodes per week for one month. Interventions included educating the resident on risks and consequences of non-compliance. Although concerns were identified regarding the resident being non compliant with smoking, there was no clinical record documentation that interventions were implemented to monitor the resident or assess the resident for safe smoking. In an interview with the resident conducted on February 23, 2016 at 9:10 a.m., she stated that she goes out by the sidewalk to smoke. The resident said that she keeps her cigarettes and lighters with her in her room. The resident stated that she was informed that the facility was a non-smoking facility and knows that smoking is not allowed within the facility's premises. -Resident #193 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed documentation that the resident was alert and oriented. Further review of the clinical record revealed a Non-Smoking Policy notification which was signed by the resident on February 5, 2016. A non-compliant care plan regarding the facility's no smoking policy was developed on February 22, 2016. Interventions included educating the resident on risks and consequences of noncompliance. Although, the documentation showed that the resident was non compliant with smoking, there was no clinical record documentation of any interventions that were implemented to monitor the resident or that the resident was assessed to smoke safely. In an interview with the resident conducted on February 23, 2016 at 9:10 a.m., he stated that he smokes on the facility's front porch and around the corner outside of the building along the sidewalk. The resident stated that he has cigarettes and a lighter with him inside his room. He said that there are no staff that supervises him when smoking. He further stated he was told that he cannot smoke, within the facility's property. -Resident #358 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was alert and oriented. A review of the physician's orders [REDACTED]. Review of the clinical record revealed a non-smoking policy notification which was signed by the resident on February 2, 2016. An interview with the wound nurse was conducted on February 23, 2016 at 9:03 a.m. In attempting to locate the resident, the nurse was asked if she knew where the resident was, and she stated that the resident was probably outside smoking in the courtyard. An observation of the courtyard was conducted on February 23, 2016 at 9:05 a.m. The area was clearly marked with signage that read, no smoking. At this time, no residents were observed smoking, however, there were multiple cigarette butts scattered on the ground. On February 23, 2016 at 9:33 a.m., a LPN stated the resident (#358) is alert and oriented. She stated this is a non smoking facility and all residents sign a form stating so. She further stated that she is aware the resident smokes, but does not know where he goes to smoke. She stated she does not know where he obtains his smoking materials or where he keeps them. A resident interview was conducted on February 24 at 12:48 p.m. The resident was aware of the new smoking policy and stated that he no longer needs to sneak out and hide to smoke. -Resident #364 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Nurses Notes dated February 1, 2016, revealed the resident was alert and oriented. A review of the clinical record revealed the resident had signed a letter on February 1, 2016, which acknowledged that smoking was not allowed in the facility or on the premises. During an interview at 11:00 a.m. on February 22, 2016, the Administrator stated that the facility was a no smoking facility and therefore; they had no residents who smoked. During an interview conducted at 1:50 p.m. on February 22, 2016, a receptionist stated that some residents go outside to smoke and she tells them that they are not allowed to smoke on the premises, but they still go outside and smoke. During an interview conducted at 2:59 p.m. on February 22, 2016, the Director of Nursing (DON) stated that since the facility was a no smoking facility, the residents signed a letter acknowledging that no smoking is allowed in the facility or on the premises. She stated that they do not complete Smoking Assessments on residents in the facility. During an interview conducted at 9:25 a.m. on February 23, 2016, a CNA stated that residents are not supposed to smoke on the premises, however, she was aware that some of the residents go outside to smoke. During an interview conducted at 9:28 a.m. on February 23, 2016, resident #364 stated he did smoke and had his cigarettes and lighter on his person. A copy of the facility's no smoking policy and procedure was requested on February 23, 2016. The Administrator stated that they do not have a smoking policy, as the facility was a non-smoking facility, but provided a Non-Smoking letter that is given to residents upon admission, which is signed by the resident/family member. According to the Non-Smoking Facility letter, the facility became a Non-Smoking facility on September 1, 2014. The letter included that smoking and tobacco use of any kind will be prohibited on the center's premises which included all internal and external areas, parking lots and all entrances and exits. Additionally, signs are placed through out the exterior of the facility to help raise awareness of our smoke free facility. The letter did not include procedures regarding how the facility would implement the no smoking policy or what actions would be taken for failure to comply with the facility's no smoking policy. A review of the new Smoking Policy and Procedure created on February 23, 2016, revealed the facility will ensure safe resident smoking practices, and comply with all State, Federal, and Community regulations. The procedures included: An assessment will be completed upon admission to determine if a resident smokes and what measures need to be taken to ensure their safety. The policy included residents will be supervised while smoking and wear a smoking apron for safety as determined. The facility will establish a smoking schedule with designated smoking times. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely. All smoking materials (cigarettes, pipes, electronic smoking devices, lighters, matches, etc.) will be kept at the nursing stations. The licensed nurse will dispense smoking materials to the residents. Residents may not have any smoking materials in their possession. Residents may only smoke in designated smoking areas and signage will be posted throughout the facility identifying smoking and non-smoking areas. This form will be included in the admissions paperwork to inform people of our smoking policy and procedure.

Based on clinical record reviews, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one resident (#124) who was admitted with pressure sores received the necessary treatment and services to promote healing and failed to ensure physician orders [REDACTED].#347) with a pressure sore. The sample size was three. Findings include: -Resident #124 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a physician History and Physical dated November 19, 2015 revealed the following: Chief Complaint: Resident has a pressure ulcer on the right heel, coccyx ulcer .Current Diagnosis: [REDACTED]. A physician progress notes [REDACTED].Right heel ulcer .continue with wound care . A care plan dated November 20, 2015 included the resident was at risk for skin alteration related to impaired mobility. The care plan also identified that the resident had left buttock shearing/abrasion. The goal included that the skin will be free of alteration within the disease process. Approaches were for nursing to do treatments as ordered and encourage to reposition frequently. The care plan did not include that the resident had a pressure ulcer on the right heel. A physician's orders [REDACTED]. Review of the clinical record revealed that a Skin Assessment was completed on November 20, 2015. However, the assessment did not include that the resident had any pressure sores. A physician progress notes [REDACTED].Right heel ulcer .continue with wound care . A physician progress notes [REDACTED].continue with wound care . Review of the admission MDS (Minimum Data Set) assessment dated [DATE], revealed the resident was cognitively intact. Under Section M. Skin, no pressure ulcers were documented. Further review of the clinical record revealed there was no documentation of any treatment orders that were obtained upon admission through the end of November for the right heel and the coccyx/buttocks area, despite documentation that wound care was being provided. There was also no documentation on the November 2015 Treatment Record of any wound care that was being provided to either area. In addition, there was no clinical record documentation that the right heel pressure ulcer and the coccyx/buttock area were thoroughly assessed (i.e. measurements of the wounds, description of the wound bed and surrounding skin, any drainage) from November 19 through 30. A nursing note dated December 3, 2015 documented Wound care for right heel ulcer. A nursing note dated December 4, 2015 included Wound care continues to right heel and Resident has opening on his right buttocks clean and covered by this nurse. Wound nurse to assess. According to a wound nursing note dated December 4, 2015 (recorded as a late entry on December 8, 2015), the resident had shearing/friction to the left buttocks which measured superior 3.5 cm (centimeters) x 7 cm; inferior 4 x 6 cm; wound beds with red/pink tissue; surrounding skin sloughing; area blanchable. Treatment included the following: buttocks cleanse with NS (normal saline), pat dry with gauze, apply [MEDICATION NAME], cover with padded dressing, air mattress overlay for prevention and for turning/repositioning during routine rounds as tolerated. This was the first thorough assessment of the buttock/coccyx area since admission. The wound note further documented the resident's right heel had scarring and a small area that was approximately 1 x 1 cm which was calloused and had a darkened pigmentation. The note stated to apply skin prep to bilateral heels. This wound note did not include a thorough assessment of the right heel. A physician's orders [REDACTED]. Cleanse with NS. Pat dry with gauze. Apply [MEDICATION NAME]. Cover with padded dressing. Once a day. This was the first physician order [REDACTED]. A physician's orders [REDACTED].Floating/Off Loading Heels .Turning Repositioning During Rounds As Tolerated . A physician's orders [REDACTED]. Prevention/protection . This was the first physician's orders [REDACTED]. A wound nursing note dated December 11, 2015 (recorded as a late entry 17 days later on December 28, 2015) documented that the resident had shearing/friction to left buttocks as follows: superior 3.3 x 6.9 cm; inferior 4 x 6 cm, pink tissue with surrounding skin sloughing, and blanchable. The note included that the resident was still non-compliant with turning from side to side and flips over onto his back shortly after being re-positioned. Per the note, the right heel had scarring and was calloused, with darker pigmentation, with no open areas, and to continue with same treatment. A physician order [REDACTED]. Cleanse with NS. Pat dry with gauze. Apply [MEDICATION NAME]. Cover with padded dressing. Once a day on Monday, Wednesday, Friday . The next wound assessment was completed on December 23, 2015, twelve days after the last assessment. The note included Patient's shearing/friction to left buttocks superior 3 x 6 cm, inferior 3.3 x 6.2 cm. Both with pink tissue and blanchable. Small amount of sanguineous drainage. Old skin sloughing with new skin under. Patient non-compliant when changing positions. When put on side he turns over onto his back. Attempted to turn patient on his side x 4. Continue with same treatment. A wound nursing note dated December 28, 2015 documented Patient's shearing/friction to buttocks 6 x 12 cm (all one wound). Blanchable. Wound bed with slough scattered throughout. Surrounding skin sloughing with [DIAGNOSES REDACTED]. Patient still non-compliant with turning from side to side - flips over onto his back shortly after being repositioned. Right heel scarring and calloused. Darker pigmentation. No open areas. Continue same treatment. There was no clinical record documentation that the physician was called regarding the deterioration of the wound now having slough. There was also no documentation that the resident was informed of the risks associated with non compliance with turning, despite ongoing concerns. A wound nursing note dated January 7, 2016 which was 10 days after the last assessment documented Patient's buttocks with shearing/friction/denuded (all one wound) 5.5 x 11.5 cm. Wound bed with pink/red tissue with approximately 10% slough scattered. Wound margin with [DIAGNOSES REDACTED]. Blanchable. Small amount of sanguineous drainage. Continue treatment. Patient continues to be non-compliant with turning onto his side. When patient is put on his side within short period of time he has flipped onto his back again. Writer explained to patient the importance of changing positions to relieve pressure. A wound nursing note dated January 15, 2016 documented Patient's denuded area to left and right buttocks: 4.5 x 10 cm. Wound bed with pink tissue and approximately 10% slough scattered. Area remains blanchable. Wound margin sloughing. Scant sero-sang drainage. No change in treatment. Patient non-compliant with changing positions. Encouraging patient to stay off his back more. Continued review of the clinical record revealed that no care plan addressed the resident's ongoing non-compliance with turning from side to side, nor any interventions to address the concern. A wound nursing note dated January 19, 2016 (recorded as a late entry eight days later on January 27, 2016) documented .Patient's open wound to left and right buttocks 4.5 x 10 cm. Wound bed with pink tissue and less than 10% slough scattered. Blanchable. Wound margins denuded. Moderate amount of sero-sang drainage with slight odor prior to cleaning wound . The next wound assessment was completed 15 days later on February 3, 2016. The note included Patient's shearing/friction to left and right buttocks 4 x 7.7 cm. Wound bed with red tissue. Remains blanchable. Wound margin with [DIAGNOSES REDACTED]. Moderate amount of sero-sang drainage with no odor. Patient continues to be encouraged to change positions. Continue same treatment. According to a nursing note dated February 11, 2016, the resident was discharged with skin intact. The documentation also noted the following: [DIAGNOSES REDACTED].Recapitulation of stay: Patient was admitted from hospital for rehab with therapies and wound care . An interview was conducted on March 2, 2016 with the wound nurse/LPN (licensed practical nurse). The LPN stated that the discolored area on the resident's heel was a scar and could have been an old pressure sore. The LPN stated that the wound on the resident's buttocks was shearing and not a pressure sore. An interview was conducted with the DON (Director of Nursing) on March 2, 2016. The DON stated that the resident's non-compliance with turning should have been care planned. The DON stated that the resident's wounds were not pressure because they were blanchable. An interview was conducted with another LPN on March 3, 2016. When asked why she documented Wound care for right heel ulcer on December 3, 2015, as there was not an order for [REDACTED]. Another interview was conducted with the DON on March 3, 2016. The DON stated that the physician documentation dated November 20, 2015 to continue wound care was an error, as wound care did not begin until December 7. The DON stated the licensed nurse's first assessment must have been incorrect on December 4, as the wound was on the left buttocks and not the right as originally identified by the licensed nurse. The DON stated that the December 11, assessment by the wound nurse could have been more detailed. The DON stated that skin assessments should be done weekly and she did not know why skin assessments by the wound nurse were not done between December 11 and 23. The DON further stated that pressure ulcers should be assessed weekly, but the areas on the resident's heel and buttocks were an alteration in skin rather than a pressure sore. An interview was conducted with the resident's physician on March 3, 2015. The resident's physician stated that on the History and Physical dated November 19, 2015, he meant to document that the resident had a history of [REDACTED]. -Resident #347 was admitted on [DATE], for a hospice respite stay. [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed the resident was admitted with an unstageable pressure ulcer to the outer area of the right foot. A Pressure Ulcer Report dated February 22, 2016, also documented that the resident was admitted with an unstageable pressure ulcer on the right lateral foot which measured 3 cm (centimeters) by 3 cm. However, review of the physician's orders [REDACTED]. On February 23, 2016 at 9:30 a.m., an interview was conducted with the LPN (licensed practical nurse) who had documented the February 19, admission note. The LPN stated that she did not call the physician for orders regarding the resident's pressure ulcer, because she thought that the hospice provider was doing the wound care. An interview was conducted with the RN (registered nurse) supervisor on February 23, 2016. She stated that she transcribed the resident's admission orders [REDACTED]. She stated that orders should have been included with the admission orders [REDACTED]. On February 24, 2016 at 2:25 p.m., an interview was conducted with the DON (Director of Nursing). The DON stated that if a resident is admitted with a pressure ulcer, the admission nurse should verify orders for treatments and call the physician. After reviewing the resident's clinical record, the DON stated that the nurse should have called the hospice provider for treatment orders. A review of the facility's Pressure Ulcer Staging Guide which the facility obtained from the National Pressure Ulcer Advisory Panel identifies a stage 2 pressure ulcer as .without slough or bruising . The Pressure Ulcer Staging Guide identifies a stage 3 pressure ulcer as .Slough may be present . The Pressure Ulcer Staging Guide identifies a Deep Tissue Injury as .Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear . A review of the facility's policy regarding the Prevention of Pressure Ulcers revealed the purpose is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. Review the resident's care plan to assess for any special needs of the resident. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in conditions are recognized, evaluated, reported to the practitioner, physician, and family, and addressed.

Based on clinical record reviews, facility documentation, hospital records, staff and resident interviews and policy review, the facility failed to ensure that three residents (#'s 60, 336 and 337) were free of significant medication errors. Findings include: -Resident #60 was readmitted to the facility on [DATE], was discharged to the hospital on June 12, 2015. The resident was readmitted to the facility on [DATE] and then discharged back to the hospital that same day. [DIAGNOSES REDACTED]. Review of the clinical record revealed that prior to being readmitted to the facility on [DATE], the resident had orders for the following medications: [REDACTED]. However, upon readmission to the facility on [DATE], [MEDICATION NAME] 30 mg was discontinued and so was the [MEDICATION NAME]. The readmission orders [REDACTED]. A nursing note dated June 18, 2015 included that at 8 p.m., the resident had asked for his prn (as needed) pain and sleep medications, which were administered. The note did not include which medications were given. The note further included that the resident was administered those medications, because the nurse was unaware that they had been discontinued. Review of the June 2015 MAR (Medication Administration Record) revealed no documentation that [MEDICATION NAME] or a [MEDICATION NAME] had been administered on June 18. However, according to the Controlled Substance Records, the resident received [MEDICATION NAME] 30 mg and [MEDICATION NAME] 15 mg on June 18, 2015 at 10 p.m. (Although the above nursing note included the medications were given at 8 p.m.) Further review of the nursing note dated June 18, 2015 revealed that at 9 p.m., when it was time for the resident's blood pressure (BP) medicine, his BP was 85/65 and the BP meds were held. At 9:55 p.m., the note included that the charge nurse found the resident unresponsive and orders were received to administer [MEDICATION NAME] (drug used to counter the effects of opioid overdose), apply a non-rebreather mask with oxygen at 10 liters, and to call 911. According to the emergency room records dated June 18, 2015, the resident was not acting right and he may have unintentionally been given too much [MEDICATION NAME]. The documentation also noted that the resident had a [MEDICATION NAME] on his lower back and that [MEDICATION NAME] was given at the facility with good effect. Additional documentation included a [DIAGNOSES REDACTED]. The documentation further included that apparently his nurse medicated him with medications that had been discontinued and that the physician had been notified of the medication error. Review of the facility's documentation and the resident's clinical record revealed no documentation that the resident had a [MEDICATION NAME] on. Further review of the facility's documentation revealed that the resident returned to the facility on [DATE] and there were some changes in the dose of [MEDICATION NAME] upon readmission. A LPN (Licensed Practical Nurse) administered 30 mg of [MEDICATION NAME] instead of 20 mg. The LPN involved in the medication error was a new graduate and had resigned from her position following this occurrence. The documentation regarding this incident only referred to the resident receiving the incorrect dose of [MEDICATION NAME] and did not address any other medications which were given. An interview was conducted on February 25, 2016 at 10:15 a.m., with the DON (Director of Nursing) who stated that the admissions nurse verified the orders with the physician upon readmission and the discontinued orders were removed from the computerized MAR. An interview was conducted on February 25, 2016 at 11:37 a.m., with the resident who stated that he was overdosed when he returned to the facility. The resident stated he asked for his medications and a new nurse administered him the wrong medications, which caused him to be sent to the hospital. Another interview was conducted on February 25, 2016 at 1:25 p.m., with the DON, who stated that although she had not been the DON at the time of the medication error, she was aware of the incident and the resident had returned from the hospital and had been over medicated with [MEDICATION NAME] and [MEDICATION NAME]. During the survey, the LPN involved in the medication error was unable to be contacted. -Resident #336 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status score of 11, which indicated the resident had moderate cognitive impairment. Review of a progress note by a LPN dated May 17, 2015 at 9:30 a.m., revealed the resident received another resident's medications. The medications included the following: [MEDICATION NAME] (narcotic) 40 milligrams (mg), [MEDICATION NAME] (opioid) 40 mg, [MEDICATION NAME] (narcotic) 10 mg, [MEDICATION NAME] (to treat high blood pressure) 20 mg, [MEDICATION NAME] (to treat high blood pressure) 0.2 mg, and Vitamin C, all in oral tablet form. The note indicated the resident's physician and Director of Nursing were notified and no new orders were received. The note included that the resident would be monitored. Another nursing progress note dated May 17, 2015 included that the resident's vital signs and oxygen levels were monitored. At 1:30 p.m., the resident was alert and stable with no complaints. At 2:00 p.m., the family requested the resident be sent to the hospital and the resident was transferred via ambulance. Review of the hospital Emergency Physician documentation dated May 17, 2015, revealed the chief complaint on arrival was ingestion of a harmful substance. The resident was accidentally given [MEDICATION NAME], and [MEDICATION NAME], which were not her medications. The note stated the family became concerned because the resident was appearing very sleepy and was not responding, as well as earlier noted. The documentation included that upon arrival, the resident responded to painful stimulation. [MEDICATION NAME] was administered and the resident responded within 30 seconds. The note further stated the medications which were accidentally administered to the resident were longer acting and the resident would have to be admitted in the event additional doses of [MEDICATION NAME] had to be administered. Review of the hospital discharge summary dated May 20, 2015, revealed a [DIAGNOSES REDACTED]. Per the facility's investigative report, the LPN involved in the medication error reported that it had been very busy and she became distracted and gave the resident the wrong medications. The report also included that as a result of the resident being given the wrong medications, the resident's blood pressure dropped and the resident became lethargic and was sent to the Emergency Department. An interview was conducted on February 25, 2016 at 9:58 a.m., with the LPN who had administered the wrong medications to the resident. The LPN stated that resident #336 asked her for her medications, so she opened the drawer and had two resident's medications and grabbed the wrong cup and gave it to her. -Resident # 337 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the PT/INR ([MEDICATION NAME] time/International Normalized Ratio) laboratory results dated [DATE], revealed the resident's PT level was 25.4 (reference range 9.6 - 12.8) and the INR level was 2.41 (reference range 2.00 - 3.00; therapeutic range for moderate intensity anticoagulation was 2.5 - 3.5). A review of the physician orders [REDACTED]. A review of the clinical record revealed that between January 17 and March 20, 2015, the physician was notified regularly of the PT/INR results as ordered and responded as needed with changes to the [MEDICATION NAME] dosage. physician's orders [REDACTED]. However, review of the Medication Administration Record [REDACTED]. The documentation further included that the resident did not receive any [MEDICATION NAME] on March 21, 23 and 25, 2015. According to the PT/INR laboratory results dated [DATE], the resident's PT level was 41.9 and the INR level was 4.14. A Nurses Note dated March 27, 2015 included that the nurse practitioner was called with the critical labs and an order was received to report the PT/INR lab results on March 29. A physician's orders [REDACTED]. During an interview conducted at 2:00 p.m. on February 25, 2016, a LPN stated that [MEDICATION NAME] was an important medication and if the medication was not administered per the physician's orders [REDACTED]. The nurse also stated that upon discovering a medication error, he would call and report the error to the physician and then notify the DON. A facility policy titled, Administering Medications included Medications shall be administered in a safe and timely manner, and as prescribed.

Based on clinical record review, facility documentation, staff interviews, and review of facility policies and procedures, the facility failed to provide adequate supervision to prevent a fall, which resulted in facial injuries to one resident (#365). The sample size was seven. Findings include: Resident #365 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission nursing assessment dated [DATE], revealed the resident required total assistance with bed mobility. A Fall Risk assessment dated [DATE], revealed the resident was at risk for falls. An admission MDS (Minimum Data Set) assessment dated [DATE], identified that the resident required a two person physical assist for bed mobility and for turning from side to side. Review of the resident's care plans revealed that they did not address how many staff should assist the resident for bed mobility. A nursing note dated April 19, 2014, documented "Patient fell at 2:30 a.m. onto the floor onto the right side of her face while being changed. One inch laceration to forehead and the bridge of her nose. Moderate amount of blood, no bruising at this time. Patient was cleaned up, wounds cleaned with normal saline and steri strips added. Dr...was on call and notified of fall..." Review of the facility's investigation revealed that the patient fell at 2:30 a.m. onto the floor while being changed by CNA (certified nursing assistant). A CNA was providing peri care to the resident, the resident coughed and jolted and fell out of bed. The CNA tried to stop her from going to the floor, but she was unable. The report included the following areas were reviewed: Bedfast: 2 person extensive assist for all ADLs (activities of daily living). A nursing note dated April 20, 2014 documented "...Patient nose appears to be unaligned...Call out to Dr...for possible orders for x-ray." Another nursing entry dated April 20, documented "Xray orders given and completed as ordered...nose positive for fracture...discoloration continues to areas on face..." Review of facility documentation revealed a Corrective/Disciplinary Action Form dated April 21, 2014, which included that the CNA involved in the incident was provided a written warning regarding the area of ADLs. Oral counseling was given and "one on one inservice on proper ADL technique and compliance with staff assistance in ADL support." The CNA who was involved in the incident was unable to be contacted by telephone. An interview was conducted with the Administrator on December 16, 2014. The Administrator stated that the CNA was providing peri-care to the resident by herself and the resident coughed and jolted out of bed. The Administrator further stated that while a resident may require two staff to assist with bed mobility, sometimes staff are busy and there is only one staff available. An interview was conducted with the interim DON (Director of Nursing) on December 16, 2014. The interim DON stated that two staff should assist residents who require extensive assistance with bed mobility. The DON stated that CNA's should follow the care plan or get report from licensed nursing staff, as to how many staff are needed to assist a resident. An interview was conducted with the clinical consultant on December 16, 2014. The clinical consultant stated that CNA's are instructed through the care plan if they require two staff for bed mobility. An interview was conducted with a CNA on December 17, 2014. The CNA stated that she gets report from other CNA's or from the resident's care plan, as to how many staff are needed to assist a resident. An interview was conducted with another CNA on December 17, 2014. The CNA stated that she would refer to the resident's care plan, as to how many staff are needed to assist a resident. An interview was conducted with an LPN (licensed practical nurse) on December 17, 2014. The LPN stated that she would give verbal report to the CNA's, as to how many staff are needed to assist a resident. Review of the facility's policy regarding Managing Falls and Fall Risk revealed "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling."