Every finding on record at Quiburi Mission Nursing & Rehabilitation

Based on record review, staff interviews, and review of facility documents and policy, the facility failed to send a notice of discharge to the State Ombudsman for one resident (#59). The deficient practice could result in the residents not being followed up for transfer or discharges concerns. Findings include:Resident #59 was admitted to the facility on [DATE], with diagnoses of metabolic encephalopathy, type 2 diabetes mellitus, and hypertension.The Resident's Hospital Discharge Summary revealed that the Resident was discharged from the hospital to the facility for therapy services.The Discharge Planning/Discharge progress notes dated 2/15/2026, revealed that the Resident arrived at the facility accompanied by his family. Documentation indicated the resident's family member expressed concern that the assigned room did not have adequate space for the resident's belongings. Documentation further revealed the family elected to take the resident home against medical advice (AMA).Review of the electronic medical record, including the AMA Release Form dated 2/15/2026, revealed that the Resident was discharged to home with the responsible party on 2/15/2026.On 04/29/2026, at 10:25 AM, the Administrator (Staff #600) was requested to provide documentation of discharge notices sent to the Ombudsman for the last 6 months.On 04/30/2026 at 8:29 AM, the administrator documented on CMS Form 807 that the ombudsman did not require the facility to send discharge notices directly to her. The Administrator further documented that social service staff were addressing residents whose discharge notices had not been sent.On 4/30/2026, at 8:54 AM, the Administrator (Staff #600) provided an additional written statement acknowledging that sending discharge notices to the Ombudsman was a regulatory requirement and indicated the facility would send notices for discharged residents moving forward.A phone interview was conducted on 04/30/2026, at 9:57 AM with the Ombudsman. The Ombudsman stated that she had periodically received discharge notices in the past, including notices from the previous administrator (Staff #666), but had not received discharge notices from the facility after 12/4/2026. The Ombudsman confirmed the facility is required to provide discharge notices per regulation.A review of the facility's policy titled Transfer and Discharge which was revised on 04/2025, revealed that the purpose of the policy was to ensure that the residents are transferred and discharged from the facility in compliance with the state and federal laws and to provide a complete, safe, and appropriate discharge planning and necessary information to the continuing care provider.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#100) to be free from abuse by another resident (#200). This deficient practice could result in further instances of resident to resident abuse. Findings include:-Resident #100 (Perpetrator) was admitted to the facility on [DATE], with diagnosis that include Alzheimer's disease, epilepsy, and depression.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment. A review of a behavior care-plan Initiated November 19, 2025 revealed that resident #100 has a behavior problem related to agitation and aggression towards other residents and staff, with a goal of the resident will have fewer episodes of behaviors, and noted interventions of anticipate and meet the resident's needs, and minimize potential for the resident's disruptive behavior by offering tasks which divert resident's attention.-Resident #200 (Victim) was admitted to the facility on [DATE], with diagnoses that include weakness, acute kidney failure, Wernicke's encephalopathy, and dementia. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0 which indicated the resident had severe cognitive impairment. A review of progress notes for resident #100 dated November 28, 2025 at 8:00 p.m. revealed resident #100 had been aggressive with another resident, and was seen having resident #200 pushed up against the door to our quiet room. It further documented that resident #200 stated that resident #100 hit resident #200 in the right rib cage. The note concludes that resident #100 was sent to the hospital to find appropriate placement for him.A review of a change of condition assessment for resident #200 dated November 28, 2025 at 10:14 p.m. revealed resident #200 was involved in a resident to resident altercation and alleges that resident #100 punched him in the ribs. It also revealed they ordered an x-ray to rule out injuries for resident #100, and to monitor for bruising and apply cold packs as needed. However, nothing was noted on the skin assessments in the resident clinical record, and no x-ray results were found.A review of provider progress notes for resident #100 dated November 29, 2025 at 8:03 a.m. revealed resident #100, since admission, had been noted to be increasingly restless with aggressive responses, and per the nursing staff incidents occur if he gets too close to another resident and they tell him to back off he will become verbally aggressive. The note also revealed the resident also once grabbed a butter knife during a prior incident. However, there are no details related to that incident present elsewhere in the clinical record.An interview was conducted with a Certified Nursing Assistant (CNA/staff #5) on December 5, 2025 at 10:54 a.m. The CNA stated that normally resident #100 is usually [NAME], but sometimes he would get agitated and they would just redirect him. The CNA stated he didn't witness the altercation between resident's #100 and #200 but he heard about it, and that it was an altercation. The CNA also stated it was the first time he knew of that resident #100 got physical with another resident. The CNA concluded that there are several types of abuse, including physical, verbal, neglect, and that abuse is doing something others wouldn't want them to do.An interview was conducted with a Registered Nurse (RN/staff #10) on December 5, 2025 at 11:02 a.m. The RN stated that she was familiar with the altercation, and that she wasn't sure if the police got involved following the incident. The RN stated that resident #100 was very restless, constantly pacing, and lacked understanding of boundaries. She further stated that resident #100 tended to to irritate other residents. The RN further stated after the incident resident #100 was sent to the hospital due to needing placement. The RN stated she was the one who put the note in on resident #100 about the altercation. The RN stated that absolutely this falls under abuse, and that abuse is anything that negatively affects the physical or mental health of the resident. The RN concluded that she feels resident #100 was provoked, but it was not acceptable. An interview was conducted with the Assistant Director of Nursing (RN/staff #15) was conducted on December 5, 2025 at 11:39 a.m. The RN stated that resident #100 is young to be a resident, and has Alzheimer's. She stated that it was hard for him, because he's very physically fit but needed his brain to be busy, and before his diagnosis of Alzheimer's he was on the go constantly, and thinks he was a mechanic. The RN stated that resident #100 tended to sundown, and was high anxiety and easy to set off from things like loud voices. She noted that even things like dietary staff cleaning and scraping plates could set him off. The RN stated she was familiar with the incident, and that resident #100 was found pressing resident #200 up against a door, and that resident #200 stated he was punched in the ribs by resident #100. The RN stated they did an x-ray to rule out injuries but that during assessments no injuries were noted. The RN concluded that resident #100 was sent to the hospital following the incident and ultimately went home with his spouse. An interview was conducted with the Director of Nursing (RN/staff #50) was conducted on December 5, 2025 at 12:34 p.m. The DON stated that what was relayed to her about the incident was that a CNA came around the corner and saw resident #100 pinning resident #200 against a door. She stated that resident #100 had spacing issues, and that immediately following the incident the residents were separated and resident #100 was placed on a 1 to 1 with him until he left the facility for the hospital. The DON stated that resident #200 stated he was punched in the side, but that no bruising, tenderness or injuries were noted. The DON concluded that abuse is any unwelcome or unaccepted behavior, like physical, sexual, or verbal abuse, and that the incident does not meet her expectations with how residents should be treated.A review of facility policy titled 'Abuse, neglect, exploitation, and misappropriation prevention program' revised January, 2025 revealed residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on review of the clinical record, facility documentation, review of the State Agency Database and interviews the facility failed to ensure one resident was treated with respect and dignity. The deficient practice could result in residents not feeling safe. Findings include: Resident #1 was admitted on [DATE] with diagnoses that include obesity, unspecified mood disorder, and acute cholecystitis. The quarterly Minimum Data Set (MDS) assessment was completed on May 1, 2024. During the MDS assessment a Brief Interview for Mental Status (BIMS) was conducted and revealed that resident #1 had a score of 15 which indicated the resident was cognitively intact. A report was received by the State Agency (SA) on April 15, 2024 that indicated a resident was being mistreated by a Certified Nursing Assistant (CNA). The facility conducted an initial investigation which included an interview with resident #1 on April 15, 2024. Resident #1 indicated that staff #12 had taken over an hour to assist her when the call light went on. The resident also continued to indicate that staff #12 was rude by stating there have been people sitting in their shit all day, when the staff returned to provide care. The facility report also indicates that staff #12 was suspended during the course of the investigation. At the completion of the facility's investigation, staff #12 was provided education on customer service and has been re-assigned to a different unit to mitigate the possible of encountering resident #1. An interview was conducted on May 22, 2024 at 10:06 AM with resident #1. Resident indicated that she felt safe in the facility but had an issue with staff #12. Resident #1 indicated when she needed help a few weeks ago, staff #12 made a comment that made her feel bad. Resident #1 indicated she felt she needed to report it because she didn't know if staff #12 was making similar comments to other residents who might not be able to speak up for themselves. A phone interview was conducted with staff #12 on May 23, 2024 at 11:29 AM. Staff #12 indicated that it was a busy day on April 14, 2024 as several residents were having issues with loose stool. Staff indicated that when they went into resident #1's room to answer the call light, the resident informed staff she had bowel movement and needed to be cleaned up. Staff stated she responded to resident #1 with there are other individuals sitting with shit, but staff stated she did not say that with malice. Staff continued to indicate she had a lot going on during the shift and she had left the resident's room to remove herself from an escalating situation. Staff stated she took full responsibility and regreted it. Staff continued to state that the floor nurse took over with providing cares to resident #1 and she no longer worked in that unit. An interview was conducted with the facility Administrator (staff #5) on May 23, 2024 at 2:51 PM. Staff #5 referenced the facility's dignity policy when asked about dignity. Staff #5 said the expectation is for the employees and residents to have positive interactions and employees provide good customer service to the residents being served. When reviewing the situation between resident #1 and staff #12, staff #5 indicated that staff #12 did not meet their expectation of how the staff should interact with residents. Staff #5 continued by indicating that staff #12 has been coached on how to better respond in that situation and that staff #12 agreed she could have responded in a different manner. A review of the facility's policy titled, Resident Dignity- Rehab/Skilled, last reviewed/revised on November 16, 2023 stated, Ideas for maintaining a resident's dignity may include, but not be limited to: . treating residents with respect .

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure the environment remained free of accident hazards existing from unattended medications. The deficient practice of unattended medications does not align with accepted professional standards of practice and may result in undesirable medication-induced harm. Findings included: On March 6, 2024 at 9:14 AM a medication blister pack was observed unattended at the nurse's station where it was accessible to residents. The medication was Metformin Hydrochloride 500 milligram, a medication for diabetes mellitus. This observation prompted an interview with a nearby Licensed Practical Nurse (LPN/Staff # 77) who stated overhearing that a nurse had removed it from the medication cart after learning it had been discontinued for a resident (# 28). Staff #77 stated it should not have been left where it was but instead be placed in the medication room and notify pharmacy to have the medication picked up. Staff # 77 counted how many tablets were left on the blister pack which were 55 total. Staff #77 stated the risk with leaving the medication unattended were it may cause residents to have an allergic reaction or have hypoglycemia if taken by a resident who does not have diabetes. Staff # 77 assured medications should be locked away and then proceeded to take the medication blister pack to the medication room after the interview. An interview was conducted on 06, 2024 at 12:00 PM with Director of Nursing (DON/Staff # 9) who stated that the risks of leaving the unattended medication, Metformin is upset stomach or allergy. If they take one, it would possibly not cause much, but who is to say they might not take many. Staff # 9 stated leaving medication unattended did not meet facility expectations. Review of the facility's Clinical Services Policy titled, Medication: Acquisition Receiving Dispensing and Storage (reviewed/revised 03/02/2023) revealed: -Medication will be stored in a locked medication cart, drawer or cupboard. Only the person passing medications and the director of nursing services and/or designee will be permitted to have access to the keys to the medication storage areas.

Based on record review, staff interviews, and review of policy, the facility failed to notifiy the Ombudsman of transfer/discharge for two residents (#23, #2). Findings included: -Resident #23 was admitted to the facility on [DATE] with diagnoses of respiratory failure unspecified with hypoxia, heart failure, and transient cerebral ischemic attack. Review of the most recent MDS (Minimum Data Set) revealed a BIMS (brief interview of mental status) score of 15, indicating no cognitive impairment. Facility census list revealed resident #23 was on a hospital leave on August 8, 2023 until August 14, 2023 and again on September 2, 2023 until September 9, 2023. An interview was conducted on March 6, 2024 at 2:18 P.M. with the Administrator (staff #12) and Director of Nursing (DON\staff #57). Staff #12 stated that no notification of transfer to the hospital was given to the family of resident #23 because resident was her own representative. In addition, the administrator stated they do not notify the ombudsman of any transfers/discharges, so there was no notification of transfer for resident #23. 49325 -Resident # 2 was admitted into the facility on [DATE] with diagnoses of acute respiratory failure with hypoxia, anxiety disorder, heart failure, and depression. A review of the admission MDS dated [DATE], revealed the resident had a BIMS score of 15, indicating cognitively intact. Review of an order summary report dated February 26, 2024, revealed Home Health was ordered to evaluate and treat for skilled nursing to monitor for signs and symptoms of acute respiratory failure, complications with chronic obstructive pulmonary disease, coronary artery disease, congestive heart failure after stay at skilled nursing facility following hospitalization for acute respiratory failure. Will need occupational and physical therapy to consult for safety and possible treatment in home. Review of a Discharge Summary report revealed resident was discharged on [DATE] at 10:30 AM. On March 07, 2024 at 10:12 AM a document request for Ombudsman notification of resident #2's discharge was made to the Social Service Director (staff #55) and he stated that he did not update ombudsman about any discharges. Staff #55 further stated that the administrator would likely be the one responsible for most of the communication with the ombudsman. An interview was conducted with the Administrator (Staff #12) on March 07, 2024 at 10:15 AM. The administrator stated that discharges are approached as an interdisciplinary team. Further, the administrator stated that facility policy was that ombudsman should be notified of discharges and was something they have to work on. He further stated that he realized that they needed improvement on the discharge process and that if it is in the facility policy that it should be done to meet the facility's expectations. Staff #12 stated per regulation the ombudsman should be notified of facility-initiated discharges because they are a spokesperson for the resident so they are not discharged against their will. Staff #12 reiterated ombudsman was the voice for the residents and that they needed to improve their process. Review of facility policy titled, Discharge and Transfer - Rehab/Skilled, Therapy & Rehab reviewed/revised on January 3, 2024, revealed that with a facility-initiated transfer or discharge, the location must send a copy of the GSS # 223A or other state-required form to a representative of the Office of the State Long-Term Care Ombudsman.

Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure that a resident (#52) was free from abuse from another resident (#53). Failure to ensure the resident was free from abuse resulted in an trochantric hip fracture. Findings include: -Resident #53 was admitted on [DATE] with diagnoses of dementia, emotional lability, and post traumatic stress disorder. Review of this resident's care plan did not include interventions for aggressive behaviors towards other residents. A progress note dated 9/13/23 included, Resident has been restless throughout the shift, unable to get R to sit down for any length of time. Resident has been going in and out of other R rooms taking things and then giving them to other Rs. Resident becomes verbally aggressive with other R and staff when redirect is attempted . A self report filed on 10/15/23 included Residents (#53) and (9#) both reside in the special care unit. Resident (#9) pushed on the entry/exit door, causing an alarm. (Resident #53)'s room is next to this door, and she frequently rearranges her closet. In response to the alarm, (Resident #53) hit (Resident #9) with the plastic clothing hangers she was holding. Residents separated, PCP notified. A progress note dated 10/25/2023 which included that Resident #53 threw a blanket at another R when the other R attempted to give (resident #53) her personal items back. However, review of the care plan did not find care planning interventions added for the incidents on 10/15/23 or 10/25/23. -Resident #52 was admitted on [DATE] with diagnoses of unspecified dementia. A facility self report dated 10/26/2023 included that Nurse in Special Care Unit heard loud noise from resident (#53)'s room, which is in the special care unit. Saw resident (#52) on the floor and resident (#53) standing. When asked what happened, (resident #53) stated I pushed her. (resident #53) has been placed on 1:1 care. (resident #52) will be transported to the hospital for evaluation. Hospital records for 10/26/23 from Tucson Medical Center included that this resident was admitted for a left trochanteric fracture and was provided a nailing trochanteric fixation. A care plan dated 10/27/20 included that the resident has a behavior symptom related to dementia with intervention to intervene as necessary to protect the rights and safety of others and to redirect if wandering becomes a danger to her or other residents. A progress noted dated 10/27/2023 included that the writer and the Director of Nursing Services notified Resident #52's daughter via telephone that resident #52 had a fall yesterday as a result of a resident to resident altercation, and was sent to the hospital per doctor order. This note included that this resident was at Tucson Medical Center and has a left hip fracture. During an interview conducted on 3/8/2024 at 11:59 AM with a Registered Nurse Clinical Care Leader (RN/staff #61) who said that she recalled there were two incidents with resident #53 and that the staff would redirect. She reviewed resident #53's care plan and said that she did not see the care plan was updated after the incident on 10/15/2023 or on 10/25/2023. An interview was conducted on 3/8/2024 at 12:30 PM with the Director of Nursing (DON/staff# 57) who said that care plans need to be updated immediately when there is an incident. The DON stated that resident #53 said she had pushed resident #52 when she was in resident #53's room. The DON further added that the two resident had always intermingled well together in the past. She said that her expectations are that we do not have abuse and that we have interventions to keep the residents safe. A policy titled Abuse and Neglect - Rehab/Skilled, Therapy & Rehab reviewed 7/6/23 revealed that the purpose of this policy was to ensure that residents are not subject to abuse by anyone, including but not limited to other residents.

Based on clinical records, staff interviews, and the facility policy and procedures, the facility failed to follow the catheter care in accordance with professional standards for one resident #18. The deficient practice could increase the risk for resident discomfort, injury and infection. Findings include: Resident #18 was admitted on [DATE] with diagnosis including muscle wasting and atrophy, nutritional deficiencies, anxiety disorder, adult failure to thrive, age-related physical debility, protein-calorie malnutrition and palliative care. A review of the quarterly MDS (minimum data set) dated September 06, 2023 revealed a BIMS (brief interview of mental status score of 08, suggesting moderate cognitive impairment. The MDS further revealed that resident #18, currently has an in-dwelling catheter in place. A review of the physician orders revealed an order dated May 17, 2022 for a suprapubic catheter size 16 French with a 10 ml balloon, contingent on drainage. A review of the care plan dated December 20, 2023 revealed that a suprapubic catheter was in place for an anatomical abnormality. The care plan further notes interventions of monitoring for pain or discomfort, monitoring for UTI's (urinary tract infections), catheter care per shift and reporting any unusual observations to the nurse. An observation was conducted on March 4, 2024 at 2:45 PM. Resident #18 was seated in his wheelchair, being pushed by a Licensed Practical Nurse (LPN/staff #23) and the catheter bag was observed to be dragging on the floor underneath the wheelchair. An observation was conducted on March 6, 2024 at 8:50 AM. Resident #18 was observed seated in his wheelchair outside of the room on hall 300. The catheter bag was observed to be touching the floor underneath the resident's wheelchair. An observation was conducted on March 6, 2024 at 10:20 AM. Resident #18 was still observed in his wheelchair with the catheter bag touching the floor. An interview was conducted on March 6, 2024 at 10:05 AM with a Certified Nursing Assistant (CNA/ staff #84). The CNA stated that that regarding catheter bags, she would check for color of the output, ensure that the bag is covered for dignity and that it is off the ground. An interview was conducted on March 6, 2024 at 10:11 AM with staff #77 an LPN. Staff #77 stated that she would always check for the amount and color of the output when a resident is on a urinary catheter. She stated that she would make sure that the bag is covered and that it is not directly on the floor. She further stated that if the catheter bag was on the floor, it could pull out and cause damage to the resident. When resident #18 was pointed out to staff #77, she stated that the bag should not be on the floor. Staff #77 applied gloves and looked underneath the wheelchair and stated that she would have to see about how the bag could be elevated off the floor as she was unable to adjust it higher. She further stated that the tubing was yucky and needed to be changed as well. An interview was conducted on March 6, 2024 at 10:29 AM with the Director of Nursing (DON/staff #9). She stated that her expectation is that catheter bags stay low enough for drainage but stated that they should never touch the ground. She further stated that the risk could be an infection control issue. A review of the facility policy entitled catheter care, revised February 10, 2023 revealed that catheter tubing should never be allowed to touch the floor. The policy further states that in order to prevent urethral injury, avoid pulling or placing tension on the catheter. However, on several occasions the catheter bag was observed directly on floor with the potential for causing tension as the bag fills.

Based on observations, staff and resident interviews, and policy review, the facility failed to ensure one resident #18 was assessed for the safe use of enabler bars prior to installation and informed of the risks and benefits of their use. The sample size was 16. The deficient practice could impact the residents knowledge of the risks and benefits of enabler bars and cause potential injury if the resident was not an appropriate candidate for enabler bars. Findings include: Resident #18 was admitted on [DATE] with diagnosis including muscle wasting and atrophy, anxiety disorder, adult failure to thrive, age-related physical disability, protein-calorie malnutrition, and palliative care. A review of the quarterly MDS (minimum data set) dated September 06, 2023 revealed that the resident has a BIMS (brief interview of mental status) score of 08, suggesting moderate cognitive impairment. Section G of the MDS revealed that resident #18 is an extensive 2-person assist with transfers, and bed-mobility. Section P of the MDS revealed that bed rails are not used; however, enabler bars were present on the resident's bed. A review of the physician orders revealed no evidence of an order for enabler bars. A review of the care plan revealed that resident #18 had an ADL (activities of daily living) performance deficit and that he required 1-2 staff assistance and weightbearing support as well as 1-2 staff assistance for bed mobility. Transfers were noted to require a total lift with a medium high back sling and 2 staff. A review of the electronic health record, under all sections for resident #18, revealed no evidence of an assessment for enabler bars. An observation on March 04, 2024 at 2:36 PM revealed the presence of enabler bars on the resident's bed. A subsequent observation on March 06, 2024 at 8:18 AM revealed an enabler bars on the resident's bed. The enabler bars were observed to have a little wiggle when touched. An interview was conducted on March 06, 2024 at 8:20 AM with staff #84 a CNA (Certified Nursing Assistant). Staff #84 stated she believes that residents are assessed for grab or enabler bars. She further stated that if staff observe any concerns after the bars are installed that they would immediately alert maintenance and submit a work order. She stated that the turn-around is generally the same day. An interview was conducted on March 06, 2024 at 8:23 AM with staff #75 LPN (Licensed Practical Nurse). Staff #75 stated that residents are assessed for suitability of grab or enabler bars. She stated that maintenance installs the bars and periodically reviews them. She stated that if staff observe any concerns, the issues is reported, a work order placed and generally resolved the same day. An interview was conducted on March 06, 2024 at 8:45 AM with staff #27, the Maintenance Director. Staff #27 stated that he had just reviewed the safety of the grab and enabler bars on hall 300 and had not observed any concerns. He stated that he was not familiar with the resident assessment portion but did reveal that the enabler bars were directly attached to the bed frame via a bolt and pin actions, which is designed to have a little give to facilitate the up and down movement of the bars. Staff #27 reviewed the installation, security and safety of the enabler bars for resident #18. No further concerns for the installation of the enabler bars. An interview was conducted on March 6, 2024 at 9:40 AM with staff #77 a LPN. Staff #77 stated that an evaluation and mobility assessment is conducted prior to the installation of grab bars. She stated that the grab or enabler bars should also be care planned. She stated that she was unsure if a consent was needed. She stated that the expectation is that these steps are completed prior to installation on the resident's bed. Staff #77 stated that the risk could include impact on the resident's ability to safely transfer. An interview was conducted on March 06, 2024 at 12:30 PM with staff #9 the DON (Director of Nursing). Staff #9 stated that the expectation is to follow procedures as set forth in the facility policy. She stated that this would entail an resident assessment, data collection and an informed consent. She stated that there was no evidence of the assessment and consent for resident #18 in the record. Staff #9 stated that the risk is that it could be construed as a type of restraint for the resident. A review of the facility policy entitled Bed Safety with a review date of September 28, 2023 revealed that placement of bed rails, side rails and assist bars are applied for a medical provider-identified medical necessity. The policy further stated that medical necessity is supported by a resident assessment and data collection documentation which denotes that the resident is able to assist or be independent with bed mobility. The polciy further revealed that an informed consent would be obtained from the resident and/ or family and then documented in the medical record; however, the record revealed no evidence of data collection for enabler bars, assessment or an informed consent for resident #18.

Based on review of the clinical record and staff interviews, the facility failed to ensure that a Level 2 PASARR (pre-admission screening and resident review screening tool) was completed for one sampled resident (#15). The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #15 was admitted on [DATE] with diagnoses that included morbid obesity, type 2 diabetes mellitus, and enterocolitis. Review of the care plan dated 3/19/21 revealed the resident was receiving an antidepressant medication due to depression, and psychopharmacological medication due to schizoaffective disorder. Review of a Level I PASARR dated 4/5/2021 included diagnoses of Schizoaffective Disorder, Major Depression, Paranoid Disorder, and Anxiety Disorder were marked. However, further record review revealed resident #15 did not have any other PASARRs or a Level II that was submitted for further recommendation in services. Review of the physician orders revealed and order for: Abilify tablet 2 milligrams (mg) by mouth one time a day related to Schizoaffective Disorder dated 5/19/22 Cymbalta capsule delayed release particles 30 mg by mouth two times a day for depression related to Major Depressive Disorder, recurrent, severe with psychotic symptoms dated 8/30/22 Trazodone 150 mg daily for Depression/insomnia dated 9/06/22 An interview was conducted with the Social Services Director (staff #56) on 10/27/22 at 9:35 AM. Staff #56 stated that normally the PASARR comes from the hospital upon the resident's admission to the facility, and if the resident is coming from home they have to complete the PASARR. Staff 56 stated there are 3 nurse managers in the facility and that a nurse case manager keeps up on level 2 PASARR. An interview was conducted on 10/27/22 at 1:23 PM with the Director of Nursing (DON/staff #17), who stated the PASARR should come from the hospital with the resident. The DON stated that it does not, the facility will need to complete the PASARR to ensure residents are appropriate for the facility.

Based on clinical record review and staff interviews, the facility failed to ensure that one resident (#45) received the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) prior to the service end date. The sample size was 3. The deficient practice could result in unforeseen charges to the resident. Findings include: Resident #45 was admitted to the facility on [DATE] with diagnoses that included primary hypertension, unspecified fracture of left pubis, sequela, and Alzheimer's disease. Review of the SNF Beneficiary Protection Notification Review form presented to the facility to complete, revealed the resident Medicare Part A Skilled Services Episode start date was 01/11/22. The form contained a handwritten note that from 01/11/22 to 03/25/22, the resident was discharged to the hospital. Next to the question how was the Medicare Part A Service Termination/Discharge determined, was written 04/03/22 - 04/28/22. The form also indicated a NOMNC and SNFABN was provided to the resident. A SNF ABN was provided. The form was signed by the resident's representative on 01/11/22. However, there was no additional documentation provided to illustrate the care, reason for Medicare non-coverage, or estimated costs the resident and/or the resident's representative might incur. The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 00 on the brief interview for mental status, indicating severely impaired cognition. A NOMNC form was provided that stated the Effective Date Coverage of your current Skilled Nursing (Medicare A Therapy) services will end 02/25/22. The form was signed by the resident's representative dated 03/01/22. The form also contained written information to sign and return the form in the prepaid envelope provided. The form was not dated to indicate that it had been provided prior to the deadline for immediate appeal. Review of the Part A discharge Minimum Data Set assessment dated [DATE] revealed the resident's Medicare Part A end of stay was 04/28/22. The resident was admitted on [DATE], had an admission MDS assessment dated [DATE], a discharge MDS assessment to an acute hospital return anticipated dated 03/23/22, and an entry tracking record dated 04/01/22. On 10/27/22 at 11:04 a.m., an interview was conducted with the Social Services Director (staff #10). She stated that she was not the member of staff responsible for providing NOMNCs or SNF ABNs. She stated that the receptionist completes those forms. At 11:10 a.m. on 10/27/22, an interview was conducted with the Business Office Coordinator (staff #65). She stated that she did not know about it. An interview was conducted on 10/27/22 at 1:35 p.m. with the Director of Nursing (DON/staff #17). She stated that she knew that advanced beneficiary notices need to be given before discharge and should include any charges that may be incurred out of pocket. The DON stated that the conversation between the resident's representative and the facility was verbal, and not written down. She stated that the bills had been paid on time every month.

Based on review of the Facility Assessment, staff interview, and review of policy and procedure, the facility failed to ensure that the facility-wide assessment was thoroughly completed, by failing to ensure the Facility Assessment included an evaluation of the overall number of facility staff needed to ensure sufficient number of qualified staff were available to meet each resident's need. The deficient practice could result in inadequate staffing levels. Findings include: Per the facility assessment, the facility staffs based on census number and acuity of residents. Staffing assignments are adjusted based on resident acuity and needs. If it is determined that current staffing levels/assignments are no longer effective, the Quality Assurance and Performance Improvement (QAPI) principles and model for improvement will be used to reevaluate and redesign staffing practices in order to meet acuity and needs of residents. However, further review of the assessment did not reveal an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff members were available to meet each resident's needs. An interview was conducted on 10/27/22 at 1:35 p.m. with the Interim Executive Director (staff #1). She stated that the components of the facility assessment include a physical description of the facility, the resident census, and the services they provide. She stated that further, the demographics of the residents and their conditions, key personnel in the building, the approximate number of staff members that are needed to meet the needs of the residents, and their competencies should be identified. She stated that adequate needs must be described in the facility assessment and that the consequences of not adequately defining these elements might mean the standard of care might not be upheld. The facility's policy titled Facility Assessment - Rehab/Skilled, reviewed/revised 10/27/2020, stated the purpose is to evaluate the resident population and identify resources needed to provide the necessary care and services. The policy stated the facility conducts and documents a facility-wide assessment to determine what resources are needed to care for residents competently during both day-to-day operations and emergencies. The facility reviews the assessment as necessary, and at least annually. The policy stated the facility's resources included all personnel, including managers, staff (both employees and those who provide services under contract) and volunteers, as well as their education and/or training, and any competencies related to resident care. The policy did not include an evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff members were available to meet each resident's need.

Based on clinical record review and staff interview, the facility failed to ensure two residents (#26 and #39) did not receive unnecessary medications. The sample size was 5. The deficient practice increases the risk for residents to receive medications unnecessarily. Findings include: -Resident #26 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to occlusion or stenosis of small artery, hemiplegia affecting the left non-dominant side, and vascular dementia. A potential for dehydration/fluid deficit care plan revised 01/09/20 related to diuretic use had a goal to be free from symptoms of dehydration and to maintain moist mucous membranes and skin turgor. Interventions included weighing the resident on Monday, Wednesday, and Friday. Review of the physician orders included: -Furosemide (diuretic) 20 milligrams (mg); give 20 mg in the morning every Monday, Wednesday, and Friday related to localized edema. Hold for systolic blood pressure (SBP) less than 110. Start date 05/11/22. -hydralazine HCl (vasodilator) 25 mg; give 25 mg three times a day related to essential hypertension. Hold for SBP less than 120. Start date 06/10/22. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 00 on the brief interview for mental status, indicating severe cognitive impairment, and required extensive one to two-person physical assistance for most activities of daily living. However, review of the August 2022 Medication Administration Record (MAR) revealed that hydralazine HCl was administered on 3 occasions when the resident's SBP was less than the ordered parameter: -08/10 for a BP of 112/64 -08/14 for a BP of 119/64 -08/15 for a BP of 113/93 The September 2022 MAR revealed that Furosemide was administered on 1 occasion when the resident's BP was less than the ordered parameter: -09/23 for a BP of 94/67 Review of the MAR for September 2022 revealed that hydralazine HCl was administered more than 5 times when the resident's BP was below the parameter, including: -09/02 for a BP of 114/62 -09/09 for a BP of 116/65 -09/10 for a BP of 119/69 -09/23 for a BP of 94/67 -09/30 for a BP of 102/57 The October 2022 MAR indicated that Furosemide HCl was administered on 2 occasions when the resident's BP was below parameters: -10/05 for a BP of 101/62 10/21 for a BP of 109/77 In addition, the October 2022 MAR revealed for 5 administrations of hydralazine HCl when the resident's BP was less than the ordered parameter: -10/19 for a BP of 119/70 -Twice on 10/21 for BPs of 109/77 and 109/77 -Twice on 10/23 for BPs of 115/66 and 115/66 An interview was conducted on 10/27/22 at 12:44 p.m. with a Licensed Practical Nurse (LPN/staff #46). She stated that her process for medication administration included obtaining the resident's blood pressure before she administers medications. She stated that if the resident's blood pressure is too low, she will hold the medication. She stated that if the resident's blood pressure was really low, she would notify the physician. The LPN stated that the risks of administering an antihypertensive medication when the resident's blood pressure is too low would include a lower blood pressure, dizziness, or falls. The LPN stated that if the medications were administered, they would be considered unnecessary, and would be medication errors. On 10/27/22 at 2:14 p.m., an interview was conducted with the Director of Nursing (DON/staff #17). She stated that nurses should not administer the medication if the blood pressure was lower than the parameter. The DON stated that the nursing process would include notification of the provider, resident, family/representative, and the DON. She stated that the resident should also be monitored more closely. She stated that nursing staff would be re-educated. 46563 -Resident #39 was admitted on [DATE] and readmitted on [DATE] with diagnoses of encounter for other orthopedic, hypertension, and dysphagia. Review of a physician's order dated 6/24/2022 included Metoprolol Tartrate 50 mg tablet, 50 mg by mouth every morning and at bedtime for hypertension. Hold for SBP less than 110, HR (heart rate) less than 60. Review of the care plan initiated on 6/28/2022 revealed that there was not a focus, goal, or intervention regarding resident #39 use of Metoprolol Tartrate for hypertension. Review of the resident #39 vitals for blood pressure revealed the resident #39 received Metoprolol Tartrate while the blood pressure was below 110 in August 2022, on 8/1/2022, 8/2/2022, and 8/3/2022. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 1, indicating the resident had severely impaired cognition. Review of the resident #39 vitals for blood pressure revealed the resident #39 received Metoprolol while blood pressure was below 110 in October 2022, on 10/2/2022, 10/16/2022, and 10/22/2022. In an interview conducted on 10/27/22 at 1:23 PM with the DON (staff #17), the DON stated that the process and expectation for following medication administration with parameters, is that the medications need to be given within the parameters.

Based on clinical record review and staff interviews, the facility failed to ensure a complete discharge summary was completed regarding one resident (#49). The sample size was 2. The deficient practice could result in an ineffective transition to post-discharge care and increases the risk factors leading to preventable readmission. Findings include: Resident #49 was admitted to the facility on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, chronic kidney disease, and hypertension. The resident was discharged [DATE]. Review of the discharge minimum data set assessment dated [DATE] included a BIMS score of 15, which indicated the resident had intact cognition. Review of physician orders revealed an order dated 8/11/2022 for home health to evaluate and treat for skilled nursing, safety evaluation, physical therapy (PT)/occupational therapy (OT) after hospital stay for subdural hematoma with subsequent craniotomy; and an order dated 8/12/2022 for home health to evaluate and treat for skilled nursing transition of care, safety evaluation, PT/OT after hospital stay/SNF stay for subdural hematoma with subsequent craniotomy. Continued review of physician orders did not reveal an order for resident #49 to discharge home. Further review of the clinical record revealed there was not a discharge summary completed regarding resident #49 discharge home, or a progress note related to resident #49 discharge home. A nursing note entered by a Registered Nurse on 8/16/2022 at 10:36 am stated the writer had called and spoke with resident #49's spouse regarding welfare after discharge. The spouse reported being excited about the home health nurse and physical therapy coming in to help, that resident #49 was doing alright but could use the help. The spouse also stated the spouse reported that so far everything was alright and expressed appreciation for resident #49's physician. During an interview conducted on 10/27/22 at 1:23 PM with the Director of Nursing (staff #17), she stated the process and expectation is that a resident is discharged to a safe environment. The DON reviewed resident #49 clinical record, there was no discharge summary, discharge progress note, or discharge order.

Based on clinical record reviews, observations, staff interviews, and review of policy and procedure, the facility failed to ensure two of five sampled residents (#40 and #47) receiving [CONDITION(S)] medications had consistent evidence of behavioral interventions, monitoring for side effects/adverse effects, identification and monitoring of target mood/behaviors, and/or non-pharmacological approaches. The deficient practice could result in a lack of identifying if targeted symptoms were improving or declining and residents experiencing possible adverse consequences. Findings include: -Resident #40 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depressive episodes, adult failure to thrive, and dementia. Review of an Abnormal Involuntary Movement Scale (AIMS) dated December 28, 2018 revealed that the resident had no abnormal movements. Additional review of the clinical record revealed no evidence of another AIMS test completed for the resident. Review of the physician's orders revealed an order dated September 25, 2020 for [MEDICATION(S)] (antidepressant) 5 milligrams (mg) 1 tablet by mouth in the morning for depression, apathy, and anorexia. Continued review of the physician orders did not reveal orders to monitor for adverse medication side effect, target mood/behaviors, or non-medication interventions related to the antidepressant use. Review of the care plan initiated on September 28, 2020 revealed the resident used antidepressant medication related to depression and anorexia. The goal was that the resident would show decreased episodes of signs/symptoms of depression and be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included reporting to the nurse the following signs and symptoms: confusion, mood change, change in normal behavior, hallucinations/delusions, social isolation, [CONDITION(S)], withdrawal, decline in ability to help with/do ADLs (activities of daily living), continence, cognitive functions, constipation, fecal impaction, no voiding, shuffle gait, rigid muscles, difficulty ambulating, balance problems, accidents, dizziness/[CONDITION(S)], falls, movement problems, tremors, diarrhea, fatigue, [CONDITION(S)], appetite loss, weight loss, muscle [NAME], or nausea/vomiting and to monitor the resident's condition based on clinical practice guidelines or clinical standards of practice related to the use of [MEDICATION(S)]. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of zero which indicated severely impaired cognition. The assessment also revealed the resident was moving or speaking so slowly that other people could have noticed, or the opposite, being so fidgety or restless that the resident was moving around a lot more than usual for 12-14 days over the two weeks look back period. The assessment included the resident received 7 days of an antidepressant medication. Review of the Medication Administration Records (MAR) for April 2021, May 2021, and June 2021 revealed the resident received [MEDICATION(S)] daily as ordered. Further review of the clinical record including these MARs and the Treatment Administration Records (TAR) for April 2021, May 2021, and June 2021, did not reveal documentation of monitoring for adverse medication side effect, target mood/behaviors, or non-medication interventions related to the antidepressant use. Multiple random observations conducted on different dates and times of the resident sitting in the wheelchair revealed the following: -On June 21, 2021 at 2:51 p.m., the resident was observed with the right hand on the right thigh exhibiting a continuous rolling motion of the thumb and forefinger of the right hand; -On June 22, 2021 at 3:27 p.m., the resident was observed the left hand over the right with the left thumb consistently stroking the dorsal part of the right middle finger. The left arm was observed to have a tremor-like movement that occurred intermittently.; -On June 23, 2021 at 7:30 a.m., the resident was observed with a continuous subtle rolling motion of the thumb and forefinger of the right hand; and a continuous pinching movement on the right arm by the left hand.; and, -On June 23, 2021 at 9:40 a.m., the resident was observed exhibiting a continuous light pinching movement on the right arm using the left hand. An interview was conducted with a Registered Nurse (RN/staff #26) on June 24, 2021 at 10:40 a.m., who stated that when a resident is on a [CONDITION(S)] medication, staff chart behaviors every day. She stated that before administering the drug, she would make sure the resident did not have any side effects from the medication. She stated that she would look for behaviors (i.e. crying, sleeping a lot, anger issues). Staff #26 stated that for some residents she would use music therapy or therapeutic education. The RN stated that the monitoring of behaviors, side effects, and interventions was done every shift and documented with initials on the MAR and a progress note. The RN stated that an antidepressant is a [CONDITION(S)] medication and monitoring was required. The nurse reviewed the clinical record for resident #40 and stated there was no monitoring being done and that it would need to be added. The RN stated that if monitoring was not being done, the risk would be that staff could miss something, especially side effects. The RN stated that she had observed an occasional pill rolling movement for resident #40 but that she had not documented or notified the doctor of the potential abnormal movement. An interview was conducted on June 24, 2021 at 1:35 p.m. with the Director of Nursing (DON/staff #8). She stated that, for a resident receiving a [CONDITION(S)] medication, there should be ongoing documentation in the electronic MAR each shift. She stated that a resident receiving a [CONDITION(S)] medication should have an order for daily documentation including adverse side effects and behaviors. She stated she would also like the staff to include therapeutic interventions. On review of the clinical record for resident #40, she stated that the resident did not have monitoring for side effects/target behavior/intervention. She stated that the risk was that the facility could be giving an unnecessary medication, not enough medication to treat the resident, and/or the facility may not be managing the resident's signs and symptoms properly. -Resident #47 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, vascular dementia, depressive episodes, and [CONDITION(S)] disorder. A physician order dated February 28, 2020 included to document signs and symptoms of depression: somnolence, refusal of care, decreased appetite. Monitor for adverse reactions: [MEDICATION(S)] (depression): dry mouth, loss of appetite. [MEDICATION(S)] (depression as evidenced by poor appetite) dizziness, drowsiness, headache, [CONDITION(S)], nervousness, diarrhea. [MEDICATION(S)]/[MEDICATION(S)] ([CONDITION(S)] disorder) nausea and vomiting, drowsiness, weight gain, weakness. Non-pharmaceutical approaches: Therapeutic communication, music therapy, watching old movies, two times a day for depression. This order was transcribed onto the MARs and TARs. Continued review of the physician's orders revealed the following: -An order dated December 21, 2020 for [MEDICATION(S)] (anticonvulsant) delayed release sprinkle 125 mg give 1 capsule by mouth two times a day for bi-polar disorder. -An order dated March 2, 2021 for [MEDICATION(S)] (antidepressant) 15 mg give 1 tablet by mouth at bedtime for depression as manifested by lack of appetite/weight loss. -An order dated March 3, 2021 for [MEDICATION(S)] [MEDICATION(S)] (antidepressant) delayed release sprinkle 30 mg give 1 capsule by mouth in the morning for depression with pain. However, the order did not include a specific target behavior(s) for the [MEDICATION(S)] or [MEDICATION(S)] use. Review of an annual MDS assessment dated [DATE] revealed a BIMS score of 2 which indicated the resident's cognition was severely impaired. The assessment included that in the two weeks look back period, the resident exhibited feeling down, depressed, or hopeless 2-6 days; and moving or speaking so slowly that other people could have noticed, or the opposite, being so fidgety or restless that the resident had been moving around a lot more than usual for 12-14 days. The assessment included that the resident received daily antidepressant medication. Review of the MARs/TARs for March 2021, April 2021, May 2021, and June 2021 revealed the resident received [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]. The documentation on the MARs included responses of +, -, and N/A without the included information to define what the symbols indicate such as whether it was the target behavior or a side effect. The documentation also did not differentiate between side effects and behaviors; the number of episodes exhibited and, did not indicate whether non-pharmacological approaches were attempted or administered related to the [CONDITION(S)] medication use. Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 which indicated the resident's cognition was severely impaired. The assessment included that in the two weeks look back period, the resident exhibited little interest or pleasure in doing things 2-6 days; trouble concentrating on things and moving or speaking so slowly that other people could have noticed, or the opposite, being so fidgety or restless that the resident had been moving around a lot more than usual for 12-14 days. The assessment also included the resident received daily antidepressant medication. Review of the nursing progress notes from March 1, 2021 through June 24, 2021 included inconsistent documentation of behaviors such as wandering, exit seeking, hallucinations, anxiety, agitation, and restlessness, which were not indicated as the target behaviors for the prescribed medications. The target behavior of poor appetite was not consistently documented on. The notes describing behaviors did not consistently include non-pharmacological approaches. There was not a progress note for every day/every shift regarding the antidepressant use/monitoring; in some instances where a + sign was indicated in the MAR, the corresponding progress note for that day did not document any behaviors and/or side effect; and in some instances where a - or N/A was indicated the note contained behavior documentation. An interview was conducted with a RN (staff #16) on June 24, 2021 at 11:44 a.m. She stated that for a resident receiving [CONDITION(S)] medication there would be documentation each shift on the MAR for mood/behavior, side effects, and therapeutic interventions based on the medication being administered. The RN stated that they conduct meetings once a month where they review [CONDITION(S)] medication and discuss regular dose reductions and that sometimes the pharmacist is at the meeting and will discuss dose reduction with them. Staff #16 stated that if she thought the mood/behavior/side effect concern was significant, she would document a mood/behavior note in the progress notes. The RN stated that if the entry on the MAR included a + sign, the reader should be able to see what the plus sign meant, and what intervention was done by facility staff in response to the plus sign, by looking in the progress notes. An interview was conducted with the DON (staff #8) on June 24, 2021 at 1:35 p.m. She stated that staff would document on the MAR each shift for residents that were receiving [CONDITION(S)] medications. She stated that the + sign meant to her that the medication(s) was effective. She stated that she would also write a progress note on how the resident was doing that day. She stated that she did not know why any staff would write N/A. She stated that if the nurse marked something on the MAR there should be a note explaining why they marked it and how they responded. She stated she expected that there would be a note relating to the [CONDITION(S)] medication use every shift/every day in the progress notes, especially if the resident was on more than one medication. Review of the facility policy for [CONDITION(S)] medications revealed: The purpose is to evaluate behavior interventions and alternatives before using [CONDITION(S)] medications and to eliminate unnecessary [CONDITION(S)] medications. The definition of behavioral interventions was: Individualized non-pharmacological approaches that are provided as part of a supportive physical and psychosocial environment and are directed toward understanding, preventing, relieving and/or accommodating a resident's distress or loss of abilities, as well as maintaining or improving a resident's mental, physical, or psychosocial well-being. The definition of [CONDITION(S)] medication was: Any drug that affects brain activities associated with mental processes and behavior. There drugs include, but are not limited to, drugs in the following categories: anti-psychotic; anti-depressant; anti-anxiety; and hypnotic. Each resident's drug regime must be free from unnecessary drugs. An unnecessary drug is any drug when used: in excessive does including duplicate drug therapy; for excessive duration; without adequate monitoring; without adequate indications for its use; and in the presence of adverse consequences that indicate the dose should be reduced or discontinued. Throughout the administration of the [CONDITION(S)] medications, the following must be completed: Mood and behavior documentation must continue in order to indicate the effect the medication has on the behavior; Monitor for side effects of the medication. If a side effect occurs or worsening of a known side effect is noted, the nurse will make a note in the progress notes-Psychopharmacological medication/physical restraint in the electronic medical record and notify the physician and family/legal representative of this change in condition; monitor for effectiveness and potential adverse side consequences; the reduction committee will review the need for [CONDITION(S)] medications at least every three months and document the rationale for continuing the medication. The committee also will need to evaluate: The resident's target symptoms and the effect of the mediation on the severity, frequency, and other characteristics; whether the resident experienced any medication-related adverse consequences during the previous quarter. Non-pharmacological interventions are recommended before medication interventions, attempt should be documented in the resident care record.

Based on observation, staff and resident interviews, facility documentation and policy and procedure, the facility failed to ensure sufficient staff were available on a 24-hour basis to provide nursing care to residents in a timely manner. The facility census was 52. The deficient practice resulted in residents needs not being met timely. Findings include: During the initial phase of the survey, 5 out of 15 sampled residents identified concerns of not having enough staff as they had to wait anywhere from 30 minutes to over 2 or more hours for call lights to be responded to, on no specific shifts, resulting in incontinence, undue pain, and residents becoming agitated due to the long call light response times. Another concern mentioned was that residents who required assistance with meals were not being fed in a timely manner. As a result, the facility's staffing documentation and a random selection of payroll records were reviewed and included the following: June 5, 2021: there were 3.5 Certified Nursing Assistants (CNAs) who worked the day shift and the resident census was 52. June 11, 2021: there was a cumulative total of 3 CNAs who worked partial hours on the evening shift and the resident census was 51. June 17, 2021: there were 2 CNAs who worked the night shift and the resident census was 52. On June 21, 2021 at 1:02 p.m., a dining observation was conducted on the secured dementia unit (SCU). 7 residents were seated in the assisted dining area. A Certified Nursing Assistant (CNA/staff #35) was observed as she assisted one of the residents with her meal. After providing multiple bites of food to the resident, staff #35 abruptly got up from the table and walked across the dining room to assist another resident. Within several minutes, staff #35 returned to the first resident and attempted to resume feeding her. The resident refused the next bite. After a great deal of encouragement, the resident resumed her meal. However, staff #35 got up a second time to assist a different resident. When she returned to the table to assist the first resident again, the resident refused to eat. The resident ate about 25-50% of her meal. An interview was conducted with the CNA (staff #35) on June 21, 2021 at 1:17 p.m. She stated that usually there are 2 staff assisting with meals, and that sometimes one of the activities staff comes to assist when she is there alone. The CNA stated that frequently there are not enough staff to assist the residents with their meals, but that they do their best. On June 23, 2021 at 8:07 a.m., an interview was conducted with a Registered Nurse (RN/staff #31). She stated that officially, the main dining room is available at 6:30 a.m. She stated that residents that need assistance usually eat at about 8:00 - 8:30 a.m. The RN stated that staffing has been worse since the pandemic and that there are no paid feeding assistants. She stated that the more independent residents are able to get up and walk down to breakfast and the residents that need assistance with eating must wait until all the residents are up and in the dining room before they will be assisted. She stated that on that date there was one CNA per main hall (100 hall and 300 hall) and one float. The RN stated that on the secured unit, there was one nurse and one CNA. She said that in addition, the staffing coordinator who was also a CNA, was assisting with breakfast. An interview was conducted on June 23, 2021 at 11:45 a.m. with the Director of Nursing (DON/staff #8). She stated that her goal will always be to staff at 3.91 hours Per Patient Day (PPD) (Hours divided by census = labor per diem). The DON reviewed the facility Nursing Department PPD for May 23, 2021 through June 19, 2021 and stated that all the last numbers in the PPD column reflected less than 3.91, indicated that there was less staff during that time period. On June 23, 2021 at 1:38 p.m., an interview was conducted with the Restorative Nurse (staff #16). She stated that there has been a shortage of staff, and that it was not because they were picky about who they hire, there was just no one to hire. She stated that the time she spends helping out on the floor is time she could be doing restorative care. Staff #16 stated that restorative care should be available to the residents on a full-time basis. She stated that on most days she conducts an exercise class in the day room and that she tries to invite as many residents as she can. Staff #16 stated that nurses help out when there is only one CNA on the floor. She stated direct resident care is what is most important. An interview was conducted on June 23, 2021 at 2:14 p.m. with the Staffing Coordinator (staff #22). She stated that the facility has had an exodus of staff over the past few months and that they have been struggling for about 3 months. She stated that ideally, at the current census, staffing for days and evenings would include 5 CNAs for each shift: 2 CNAs on the SCU (for 12 residents), and 3 CNAs on the other two main units - one on each hall and a floater. Staff #22 stated that each of the other two main units (100 hall and 300 hall) had an average of 19-20 residents on them. In addition, she stated there should be one nurse on each cart - 3 total. She said that the night shift should be staffed with at least 3 CNAs and 2 nurses. Staff #22 stated that the CNAs utilize teamwork to accomplish their tasks. She stated that when there are only 2 CNAs, they try to get the showers done before breakfast. Staff #22 stated they are all sort of rising to the occasion to do the best that they can do to make sure the residents' needs are met. On June 23, 2021 at 3:01 p.m., an interview was conducted with a CNA (staff #62). She stated that she was assigned 19 residents that day. She stated that sometimes there was a CNA that floated between the two main units to help care for residents. She stated that the other unit also had 19 residents assigned to 1 CNA. She stated that the administrative staff help out sometimes. The CNA stated that she had a lot of residents that require lifts on hall 100, including 4 total lifts and 6 sit - to-stands. She stated that there were a lot of lifts to do by herself and that she has become comfortable using the Hoyer lift alone. She stated that she knows she is not supposed to, but when there are only 2 CNAs caring for 38 or 39 residents and no one else is around, she does not know what else to do. The CNA stated that if there were 2 CNAs on the night shift, they would help get residents up in the morning. The CNA also stated there was only one CNA working the night shift for at least 2 out of every 3 days that she works. Regarding meals, she stated that every one of the residents must be at the table before anyone gets served. She stated that she assists 9 residents at her table and the residents are used to it. The CNA stated that the residents at her table do not receive drinks before they eat breakfast. She stated safety for everyone was her concern regarding lack of staffing. The CNA stated she can keep up with toileting, but not really with showers. She stated that they have been short-staffed for quite a while, including before the pandemic. An interview was conducted on June 24, 2021 at 1:46 p.m. with the facility administrator (staff #54). She stated that she was responsible to update the facility assessment and that she updated it July 29, 2020. She stated that the purpose of the facility assessment was to evaluate the resident population and the necessary resources to provide care and services. The administrator reviewed the facility assessment and stated that the term resources included personnel (managers and staff). She stated that the assessment did not specifically include a number, or staff to resident ratio. She stated that if she had included numbers in the assessment she could be cited if her staffing levels were lower. Staff #54 stated that her first line of defense in addressing the staffing issues in the facility was to utilize agency. Staff #54 stated she began using agency staff in January 2021, but that she had not reached out to the county or the state for assistance. Review of the Facility Assessment revealed: -34 residents required extensive assistance with bed mobility; 17 required 2+ person physical assistance; and 5 were totally dependent. -27 residents required extensive assistance with transfers; 14 required 2+ person physical assistance; and 7 were totally dependent. -7 residents required extensive assistance with eating; 24 required 1-person assistance; 35 required supervision; and 3 were totally dependent. -35 residents required extensive assistance with toileting; 10 required 2+ person physical assistance; and 5 were totally dependent. -34 residents required extensive assistance with personal hygiene; 2 required 2+ person physical assistance: and 5 were totally dependent. The facility's policy titled Nursing Services Staff - Rehab/Skilled revised/reviewed May 27, 2021 stated the purpose was to provide appropriate staff for resident care in the nursing services department. The policy stated the facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record reviews, observations, resident and staff interviews, and review of policy and procedure, the facility failed to ensure a care plan was developed for one resident (#41) related to [CONDITION(S)], for one resident (#47) related to anticoagulant use, and for one resident (#10) related to skin condition/treatment. The sample size was 15. The lack of care plan development has the potential for staff to be unaware of the residents identified problems, how care and services are to be delivered, and the staff who are responsible to provide the necessary care and services. Findings include: -Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated that the resident had intact cognition. Observation of the resident were conducted at the following times: -June 21, 2021 at 11:39 a.m. Both of the resident's legs and feet were observed to be edematous. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rest were not elevated and no use of compression stockings was observed. -June 23, 2021 at 2:17 p.m. The resident was observed in the beauty shop. Unable to visualize the resident's legs at this time. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rest were not elevated. -June 23, 2021 at 2:24 p.m. The lower portion of the resident's legs were observed to have bilateral lower leg [CONDITION(S)]. The resident stated that she did not realize that her legs had [CONDITION(S)]/were puffy. She stated that she did not do anything to decrease the puffiness including elevating her legs. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rests were not elevated and no use of compression stockings was observed. -June 24, 2021 at 9:08 a.m. The observation was conducted in the resident's room. The resident was in the wheelchair sitting at the bedside table. The observation revealed that the resident's bilateral lower legs/ankles continued to be edematous. The foot rest were not elevated and no use of compression stockings was observed. Review of the current care plan did not reveal a care plan had been developed to address the resident's [CONDITION(S)]. An interview was conducted with a Registered Nurse (RN/staff #29) on June 24, 2021 at 12:55 p.m., who stated that resident #41 had [CONDITION(S)] bilaterally to the lower extremities that started after the beginning of this year when the resident had a weight gain. After reviewing the resident's care plan, the RN stated that there was no care plan related to the resident's [CONDITION(S)]. The RN also stated that the facility expectations were not met related to care planning of a resident with [CONDITION(S)]. An interview was conducted on June 24, 2021 at 1:50 p.m. with the Director of Nursing (DON/staff #8). The DON stated that she would expect ongoing [CONDITION(S)] to be on the care plan with interventions. -Resident #47 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an annual MDS assessment dated [DATE] revealed the resident received 7 days of an anticoagulant medication. A quarterly MDS assessment dated [DATE] revealed the resident received 7 days of an anticoagulant medication. Review of the current care plan did not reveal a care plan for the anticoagulant medication use. An interview was conducted with a RN (staff #16) on June 24, 2021 at 11:44 a.m., who stated that high risk medications, including anticoagulants, should be on the care plan. The RN stated that it was important for an anticoagulant to be on the care plan so that staff could give better care, know the things to watch for and monitor for. She stated the goal would be for the resident to have a good outcome. The nurse reviewed the care plan for resident #47 and confirmed there was no care plan developed for the use of the anticoagulant medication. In an interview conducted with the DON (staff #8) on June 24, 2021 at 1:46 p.m., the DON stated that she expected high risk medications, including anticoagulants, to have a care plan. She stated that the care planning would be important so that staff would know what they needed to monitor for related to the use of an anticoagulation medication. The DON reviewed the clinical record for resident #47 and stated that there was no care plan for the anticoagulant use. -Resident #10 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with normal saline, apply Santyl ointment to wound beds, followed by hydrophobic microbe binding dressing with hydrogel cut to fit wound areas, pad toes with extra gauze then wrap with kerlix and secure with Coban. A quarterly MDS assessment dated [DATE] included a BIMS score of 10, indicating the resident had moderate cognitive impairment. The MDS assessment also included that there was an application of ointments and dressing to the feet. Review of the Treatment Administration Record (TAR) for 06/2021 revealed the application of ointment and wrappings were recorded as completed on Wednesdays and Saturdays. However, review of the care plan did not reveal a care plan had been developed for the resident's skin care and treatment to the feet. During observations conducted on 6/21/2021 at 09:15 AM and 12:19 AM, and on 6/22/2021 at 10:14 AM, the resident was observed with wraps on the legs and feet. On 6/24/2021 at 10:45 AM, an interview was conducted with the DON (staff #8). She stated that the care plan is a guidance for person centered care that is specific for each resident. The DON stated the MDS Coordinator (staff #58) is responsible for the MDS assessment and the care plan. She stated information is gathered by review of the clinical record and by talking to people. Staff #8 stated that if a care area is not in the care plan, there is a possibility the resident would not receive the correct care. The DON stated that the skin care for resident #10 should have been included in the care plan. The facility's policy regarding care plans reviewed/revised 10/16/202 stated that the comprehensive care plan includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have an individualized, person-centered, comprehensive plan of care. The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. The policy also stated that the care plan will address the relationship of items or services required and facility responsibility for providing those services. Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment.

Based on staff interviews, review of the clinical record, and policy and procedure, the facility failed to ensure one sampled resident (#14) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Preadmission Screening and Resident Review (PASRR) Level I Screening Document dated August 28, 2014 revealed the resident had a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .e., paranoid), mood disorder, or [CONDITION(S)]. Despite documentation that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further instructions included to document behaviors related to [CONDITION(S)], such as refusing care, yelling at staff, hitting, and delusional ideas. Monitor for adverse side-effects such as: dizziness, tardive dyskinesia, difficulty swallowing, and [CONDITION(S)]. A nursing progress note dated January 7, 2020 at 10:13 a.m. stated the resident had been incontinent of bowel that morning and had a significant amount of bowel movement on her. Staff providing care suggested that she go to the shower in order to get properly clean. The resident refused and in an angry tone said she was not going to take a shower. A nursing progress note dated March 6, 2020 at 1:51 p.m. revealed the resident had refused her medications stating she did not want to take any more pills. On April 10, 2020 at 1:34 p.m., a nursing progress note included the resident had refused lunch and wanted to stay in bed. The resident's family member called at 1:30 p.m., but the resident did not want to talk to the family member. A Nutrition Status note dated April 28, 2020 at 11:03 a.m. included that the resident had an insidious weight loss of about 20 pounds within the past 6 months, and that the weight loss was likely beneficial due to the resident's high body mass index. Review of a nursing progress note dated May 5, 2020 at 6:57 p.m. included the resident had been in bed since breakfast and refused lunch and dinner. A nursing progress note dated May 21, 2020 at 1:05 p.m. stated the resident went to bed after breakfast and refused to get up for lunch and refused the noon medications. A depression care plan dated June 4, 2020 related to self-isolation, tearfulness, and antidepressant medication had a goal the resident would remain free of signs or symptoms of depression, anxiety, or sad mood. Interventions included to monitor/record/report to health care provider as needed risk for harm to self, suicidal plan, past attempt at suicide, risky actions (stockpiling pills, saying goodbye to family, giving away possessions, writing a note, etc.), intentionally harmed or tried to harm self, refusing to eat or drink, refusing medication or therapies, sense of hopelessness or helplessness, impaired judgement or safety awareness. Review of a communication with resident/family nursing note dated June 15, 2020 at 12:26 p.m. stated that consent was needed to send the resident to the hospital for further evaluation, medical workup, possible aggressive rehabilitation and psychiatric evaluation to rule out underlying issues contributing to her health decline. The note stated that there was also the chance that further psychiatric evaluation and treatment may be necessary once other health conditions were ruled out. A transfer to hospital nursing note dated June 15, 2020 at 1:15 p.m. revealed the resident was transferred to the emergency room for altered mental status. A nursing progress note dated June 18, 2020 at 12:15 p.m. stated the nurse had called the hospital for an update on the resident. Per the report, results of the tests performed had not concluded that the issues the resident was experiencing were related to anything physiological. The note included the resident was scheduled for a geripsyche consult that day. The note also included the resident was receiving both occupational therapy and physical therapy and participating well. Review of a nursing progress note dated June 22, 2020 at 2:21 p.m. stated that the nurse called the medical center to request an update on the resident. The note stated that the resident had been transferred and admitted to a geropsychiatric facility until the resident's condition stabilized. Review of the clinical record revealed the resident was readmitted to the facility on [DATE]. A nursing progress note dated July 8, 2020 at 1:10 p.m. stated that per the report obtained from the geropsychiatric nurse, the resident had improved since being admitted to the facility. The resident had been getting out of bed every day, eating meals, ambulating with a front walker, and had been on a regular toileting schedule which had improved some of her skin conditions. In addition, the note stated that the resident had some medication adjustments while at the center. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, an order revealed for twice daily documentation of signs and symptoms of [CONDITION(S)] including yelling at staff, hitting, refusing care, or delusional ideas; signs or symptoms of depression including self-isolation and tearful episodes; adverse reactions to antipsychotic, anxiolytic, and antidepressant medications including dizziness, weight, drowsiness, weakness, headache, unusual bleeding, or jaundice; and non-pharmacological approaches including therapeutic communication, music therapy, and going for a walk two times a day. A review of a care plan initiated on July 9, 2020 revealed the resident had a behavior symptom related to [CONDITION(S)]/[CONDITION(S)] disorder, depression as evidenced by delusional thoughts regarding how the resident receives no care and assistance and then becoming so depressed that the resident does not want to eat, drink, get out of bed, and experienced acute ADL (activities of daily living) functional decline. The goal was that the resident would have fewer episodes of behaviors. Interventions included providing reassurance and encouragement. Interventions included to discuss with health care provider and family regarding the on-going need for use of medication. A PASRR Level I Screening Document dated July 28, 2020 revealed the resident had serious mental illnesses that included [CONDITION(S)], [CONDITION(S)], and psychotic/delusional disorder. The screening document additionally revealed the resident had an anxiety disorder and that the symptoms related to adapting to change included hallucinations, excessive irritability, and physical threats (with no potential for harm), and that within the past two years, the resident had an inpatient psychiatric hospitalization . The document indicated that the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The document stated that the resident did not meet the criteria for respite admission for up to 30 days, and that she did not meet the criteria for nursing facility approval as a result of terminal state or severe illness. However, the document concluded that no referral was necessary for any Level II. The document was signed by a Registered Nurse (RN/staff #29). Attempts were made to conduct an interview with staff #29 on June 24, 2021 but were unsuccessful because staff #29 was unavailable. An interview was conducted on June 24, 2021 at 2:20 p.m. with the Social Services Director (staff #46). She stated that it is her responsibility to obtain and/or complete the PASRR screenings. She stated that she asked the nurse case manager (staff #29) to sign off on it after completion, just to make sure she had filled it out correctly. She stated that was why the nurse had signed the document. She reviewed the resident's PASRR screening dated July 28, 2020 and stated that a PASRR Level II screening was definitely something that Social Services should have put into place, especially since the resident has a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that to her knowledge, the resident has never been assessed by a psychiatrist. She stated that she would definitely say that PASRR Level II services, including counselling, should have been implemented into the resident's plan of care. On June 24, 2021 at 3:08 p.m., an interview was conducted with the Director of Nursing (DON/staff #8). She stated that a PASRR screening should be completed before the resident is admitted to the facility. She stated that Social Services is responsible to collect that information from the hospital prior to the resident's admission, or provide the evaluation upon admission. The DON stated that it was her expectation that the Director of Social Services complete the PASRR evaluation. She stated that having a nurse complete the PASRR did not meet her expectations. The DON stated that she really did not know too much about the PASRR process or to whom the screening documentation should be sent. The DON stated that as long as it was well-managed, the facility may safely care for individuals with SMI/level II designation. The DON stated that a counselor sees residents, such as resident #14, and those appointments do not require a referral. She stated that the counselor communicates with the provider. The DON stated that in 2017, she remembered she felt like the resident needed to be evaluated by specialists because she felt like the facility was failing the resident. She stated that the resident went to a geropsychiatric consultation for about a week sometime later. She stated that when the resident came back, she had been prescribed serious amounts of [MEDICATION(S)] (antipsychotic) and that she did not know whether that was such a good thing either. Review of the Facility Assessment revised July 2020 revealed that the facility does not accept referrals for residents who are screened as Level II PASRR from referral sources, and that if a resident begins to show signs that they need specialized care that would involve Level II PASRR-type services, the facility would arrange an outside consultation and initiate transfer planning per policy and procedure to ensure a resident's individual needs can be met if they cannot be met at the facility any longer. Together with consultation sources/outside organizations, the facility works to identify the best plan to ensure resident needs, quality of care, and quality of life can be met and sustained. The facility policy titled Pre-Admission Screening and Resident Review (PASARR) reviewed/revised December 21, 2020 stated its purpose is to determine admission criteria for residents with mental illness and/or mental [CONDITION(S)] and to ensure that individuals with [CONDITION(S)], serious mental disorder or intellectual disability receive the care and services they need in the most appropriate setting. The policy stated that an individual is considered to have a serious mental disorder if the individual meets the following requirements on diagnosis, level of impairment, and duration of illness: the individual has a major mental disorder diagnosable under the Diagnostic and Statistical Manual of Mental Disorders which included [CONDITION(S)], mood, paranoid, panic, or other severe anxiety disorder, somatoform disorder, personality disorder, or other mental disorder that may lead to chronic disability but not a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Level I screening will be reviewed to determine whether a Level II screening is required. The Level II screening is conducted by the agency designated by the State to determine whether the prospective resident requires the level of services provided by the location or whether the individual requires specialized services. If a Level II screening is required and was not completed before admission, the location may be denied payment.

Based on observations, clinical record review, resident and staff interviews, and review of policy and procedure, the facility failed to ensure that one sampled resident (#41) received treatment and care in accordance with professional standards of practice relating to the presence of [CONDITION(S)]. The deficient practice could result in residents not receiving treatment and care for [CONDITION(S)]. Findings include: Resident #41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 14, which indicated that the resident had intact cognition. Observation of the resident were conducted at the following times: -June 21, 2021 at 11:39 a.m. Both of the resident's legs and feet were observed to be edematous. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rest were not elevated and no use of compression stockings was observed. -June 23, 2021 at 2:17 p.m. The resident was observed in the beauty shop. Unable to visualize the resident's legs at this time. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rest were not elevated. -June 23, 2021 at 2:24 p.m. The lower portion of the resident's legs were observed to have bilateral lower leg [CONDITION(S)]. The resident stated that she did not realize that her legs had [CONDITION(S)]/were puffy. She stated that she did not do anything to decrease the puffiness including elevating her legs. The resident's legs were observed to be in a dependent position, bent at the knee, and resting on the wheel chair foot rests. The foot rests were not elevated and no use of compression stockings was observed. -June 24, 2021 at 9:08 a.m. The observation was conducted in the resident's room. The resident was in the wheelchair sitting at the bedside table. The observation revealed that the resident's bilateral lower legs/ankles continued to be edematous. The foot rest were not elevated and no use of compression stockings was observed. Continued review of the clinical record did not reveal documentation about the [CONDITION(S)] to the resident legs or any orders/intervention for the [CONDITION(S)]. An interview was conducted on June 24, 2021 at 10:55 a.m. with a Certified Nursing Assistant (CNA/ staff #43). Staff #43 stated that she would be able to see if a resident had swelling in their legs when she was giving care/dressing the resident. The CNA stated that if the swelling was new she would let the nurse know and that the nurse would usually tell her to put on Ted hose to keep the swelling down. She stated that resident #41 had swelling in the legs on and off and mostly in the right leg. The CNA stated that nothing was being done for the resident's swelling, but that the resident would lay down between meals which improved the swelling in the resident's legs. The CNA also stated that she had reported the swelling to the nurse. An interview was conducted on June 24, 2021 at 12:55 p.m. with a Registered Nurse (RN/staff #29). She stated that if she observed a resident with [CONDITION(S)] or it was reported to her, she would notify the physician. She stated that sometimes the physician would increase the [MEDICATION(S)] (diuretic) dose or do compression therapy (contraindicated with arterial insufficiency). The RN stated that if there was no contraindication to compression therapy they would use [NAME] stockings, ace bandages, or Ted hose. She stated that she would also encourage elevation of the edematous part because it would help with dependent [CONDITION(S)]. She stated that a review of the resident's medical record should reveal documentation from nursing that identified the resident's [CONDITION(S)], recorded communication with the physician, and that the [CONDITION(S)] should be on the resident's care plan with interventions. The RN stated resident #41 had [CONDITION(S)] bilaterally to the lower extremities and that the leg [CONDITION(S)] started earlier this year when the resident had a weight gain. Staff #29 stated that compression therapy had been tried with the resident but that the resident did not like it/refused it. Staff #29 stated that the intervention for this resident's [CONDITION(S)] was for the resident to lay down between meals. She stated that laying down decreased the resident's [CONDITION(S)] a little bit, for a little while. She stated that the resident was on a diuretic. However, after reviewing the resident's medications, the RN stated that there was no diuretic ordered. The nurse reviewed the care plan and stated that the resident's [CONDITION(S)] was not on the care plan. The nurse reviewed the clinical record and stated that the documentation did not include the resident's [CONDITION(S)]. The RN stated that she had not spoken to the physician about the resident's [CONDITION(S)]. The RN further stated that the facility expectations were not met related to documentation and care planning of a resident with [CONDITION(S)]. An interview was conducted on June 24, 2021 at 1:50 p.m. with the Director of Nursing (DON/staff #8). The DON stated that she would expect that the presence of [CONDITION(S)] would be identified by facility staff, and addressed with the physician. She stated that the communication with the physician should be documented. The DON stated that she would expect ongoing [CONDITION(S)] to be on the care plan with interventions. She stated that the risk of undocumented [CONDITION(S)] was that a resident's [CONDITION(S)] may not be relayed to the next nurse or the resident may not have labs obtained as needed. The DON stated the identification, assessment, and communication to the physician regarding the presence of [CONDITION(S)] was important to ensure needed new interventions/medications were implemented. Review of a facility policy for [CONDITION(S)] checks reviewed/revised June 23, 2021 revealed: The purpose was to determine the level and monitor the status of [CONDITION(S)] present. [CONDITION(S)] is an abnormal accumulation of fluid in the intercellular body spaces or tissue. To treat [CONDITION(S)], you must treat the underlying cause of the [CONDITION(S)]. Baseline data for [CONDITION(S)] should be part of the resident's clinical record. The policy also revealed to document that the charge nurse/physician was notified and any treatment ordered on the Treatment Administration Record (TAR), eAdmin Record or PN-Health Status as appropriate.

Based on clinical record reviews, staff interviews, policy review, and the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure the Minimum Data Set (MDS) assessments for two residents (#49 and #39) were accurate. The sample size was 15. The deficient practice could result in MDS assessments not being accurate, and data that is not accurate for quality monitoring. Findings include: -Resident #49 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated 3/12/2021 revealed the resident had chronic pain/discomfort related to RA. The goal was that the resident would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. Review of the admission MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate impaired cognition. Review of the assessment also revealed the pain assessment interview should be conducted with the resident. However, further review of the assessment revealed the pain assessment interview was not conducted with the resident. An interview was conducted with the MDS Coordinator (staff #58) on 06/24/2021 at 08:58 AM. She stated that she completes most of the sections on the admission MDS assessment. The MDS Coordinator stated the Director of Nursing (DON/staff #8) completes the pain section of the MDS assessment. An interview was conducted with the DON (staff #8) on 06/24/2021 at 09:30 AM, who stated that the MDS Coordinator notifies her when the pain assessment is due and that she completes the pain assessment portion of the MDS assessment. The DON also stated that ideally, the pain portion of the MDS assessment should always be completed. She reviewed the MDS assessment section for pain and stated that it was not completed as required and could result in the resident's pain not being addressed. Review of the facility's MDS 3.0 (Minimum Data Set) RAI - Rehab/skilled policy reviewed/revised 12/16/2020 revealed the MDS interviews must be conducted during the designated observation period. The pain assessments are preferably completed the day before, or the day of the Assessment Reference Date (ARD). Complete means that the interview questions have been saved, signed and locked. The policy also revealed that if any discipline is unable to complete its section (due to vacation, illness, etc.), the RN coordinator will assign another person to complete this section within the time frame. The RAI Manual revealed that obtaining information about pain directly from the resident, sometimes called hearing the resident's voice, is more reliable and accurate than observation alone for identifying pain. Information about pain that comes directly from the resident provides symptom-specific information for individualized care planning. Attempt to conduct the interview with all residents. This interview is conducted during the look-back period of the ARD. Directly asking the resident about pain rather than relying on the resident to volunteer the information or relying on clinical observation significantly improves the detection of pain. Resident self-report is the most reliable means for assessing pain. The RAI manual also revealed pain assessment provides a basis for evaluation, treatment need, and response to treatment. -Resident #39 was admitted on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Weights and Vital Summary revealed the resident's oxygen saturation was 97% on oxygen via nasal cannula on 06/02/2021 at 6:25 PM, 96% on oxygen via nasal cannula on 06/03/2021 at 4:12 AM, 98% on oxygen via nasal cannula on 06/04/2021 at 8:20 AM, 90% on oxygen via nasal cannula on 06/05/2021 at 9:03 PM, 94% on oxygen via nasal cannula on 06/07/2021 at 12:38 AM, and 97% on oxygen via nasal cannula on 06/08/2021 at 9:40 AM. A review of the admission MDS assessment dated [DATE] revealed a BIMS score of 13, denoting no cognitive impairment. However, the MDS assessment did not include that the resident had been using oxygen since admission. At 10:06 AM on 06/24/2021, an interview was conducted with the MDS Coordinator (staff #58). She stated the information to be entered for the assessment would have come from the admission packet, and that she would review the clinical record for diagnoses, comorbidities, special services, wound care, and medications. Staff #58 stated oxygen therapy should have been entered into Section O of the MDS assessment. Staff #58 stated that she reviewed the Treatment Administration Record (TAR) and that the TAR did not include documentation for oxygen, and for that reason she did not include oxygen therapy in the MDS assessment. A review of the facility's policy and procedure for MDS assessment reviewed/revised 12/16/2020 stated that during the observation period each team member will review the electronic medical record (EHR) to determine if there is accurate documentation to support coding for the MDS. Review of the RAI manual stated to review the resident's clinical record to determine whether or not the resident received oxygen within the last 14 days. The manual also stated to code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to the resident to relieve [CONDITION(S)] in this item. The RAI manual also included .the importance of accurately completing the MDS cannot be over emphasized. The MDS is the basis for the development of an individualized care plan . Further, Federal regulations require that the assessment accurately reflects the resident's status.

Based on observation, clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#3) was treated with respect and dignity during dining. The census was 52. The deficient practice could negatively impact the psychosocial well-being of residents. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nutritional care plan initiated on December 5, 2017 and last revised on March 30, 2021 included a goal that the resident would maintain adequate nutritional status. Interventions included to monitor/document/report to the physician as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals, and for the staff to provide assistance/cueing/encouragement as tolerated and as needed. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 10 which indicated the resident had moderate impaired cognition. The assessment included the resident required extensive assistance of one person with eating. During a dining observation conducted on June 23, 2021 at 12:43 PM, resident #3 was observed being assisted in the dining room by a Certified Nursing Assistant (CNA/staff #62). Staff #62 was observed sitting with her back turned to the resident talking to staff. Staff #62 was observed to turn occasionally to give resident #3 a bite of food and turn away from the resident without observing how the resident was chewing. The CNA rarely spoke to the resident. The CNA was observed at one point resting her hand on her head for approximately 30 - 60 seconds looking away while giving the resident some bites of food. An interview was conducted on June 23, 2021 at 1:32 PM with this CNA (staff #62), who stated that today she had only one person to assist with dining. The CNA stated that she was assisting resident #3 and entertaining another resident. She stated the other resident did not need assistance with eating. This CNA stated that she should have been watching to make sure the resident was not choking, chewing properly, and not pocketing. Staff #62 stated resident #3 pockets food and that she tries to gives the resident a lot of liquids to try and get the food down. Staff #62 stated sometimes management will say something about facing the resident and talking to the resident when feeding the resident. An interview was conducted on June 23, 2021 at 2:12 PM with a Registered Nurse (RN/staff #67). The RN stated that she would expect CNAs assisting residents with eating, to sit near the residents so they could see the residents face to face, tell the residents what they are eating, encourage them to eat, and talk to the residents. The RN stated that it was not right to assist a resident with eating not facing the resident or talking to the resident. In an interview conducted with the Director of Nursing (DON/staff #8) on June 24, 2021 at 2:17 PM, the DON stated that her expectations for staff assisting residents with dining is that the staff need to focus on the resident. The DON stated staff not facing a resident and not talking to a resident while assisting the resident with dining did not meet her expectation. A facility's policy titled Dignity in Dining - Food and Nutrition Services reviewed/revised April 5, 2021 stated the purpose is to provide dining in a manner that enhances resident dignity. The policy included employees promote resident independence and dignity in dining by treating each resident like an individual and focusing on making the dining experience as individualized as possible.

Based on clinical record reviews, facility and hospital documentation, staff interviews and policy review, the facility failed to ensure that one resident (#107) was free from physical abuse by resident (#108), and failed to ensure that one resident (#38) was free from physical abuse by resident (#58). Findings include: -Resident #107 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A nurses note dated (MONTH) 26, (YEAR) revealed the resident was admitted from home for two weeks of respite care. Another nurses note dated (MONTH) 26, (YEAR) included that nursing had walked by the resident's room three times in the last hour and all three times heard resident talking to himself . An interim care plan dated (MONTH) 28, (YEAR) included the resident had an ADL (activity of daily living) self care performance deficit related to dementia. A nurses note dated (MONTH) 29, (YEAR) included Resident is alert and oriented x 3 .Resident is very restless at night, sleeping off and on. He talks to himself, and appears agitated at times with his thoughts . According to the progress notes dated (MONTH) 30, (YEAR), the resident was moved to the special care unit, after he attempted to go outside to the parking lot. Per the note, the resident was alert and oriented x 3, and able to make most needs known. The notes also included that following an abrupt move to the SCU (special care unit/a secure unit) in the late afternoon (due to safety concerns), the resident was confused and shaken. -Resident #108 was admitted to the facility on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed resident #108 resided on the special care unit. A review of the nurses notes dated (MONTH) 4, (YEAR) revealed the resident was alert and oriented, and able to make most needs known. The physician's orders [REDACTED]. A comprehensive care plan dated (MONTH) 4, (YEAR) addressed that the resident had a [DIAGNOSES REDACTED]. Another care plan included the resident had a communication problem related to being hard of hearing and having dementia. The interventions included to monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed. An admission Minimum Data Set (MDS) assessment dated (MONTH) 10, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The nurses notes dated (MONTH) 12, (YEAR) included the resident stays in room for most of the day, but does come out for meals. A nurses note dated (MONTH) 2, (YEAR) revealed the resident was irritable and demanding of staff, uncooperative at times. A nurses note dated (MONTH) 13, (YEAR) included Resident had an outburst at another resident that was being loud, rude, and demanding during dinner. A Social Service Note dated (MONTH) 5, (YEAR) included documentation that the resident was becoming agitated and upset, because he didn't remember the answers to the questions. The note also included that the resident's behavior was unusual and that she will evaluate the resident again the next morning. A quarterly MDS assessment dated (MONTH) 5, (YEAR) revealed the resident exhibited verbal and behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) and that behaviors occurred 1 to 3 days during the seven day look back period. A Social Service Note dated (MONTH) 6, (YEAR) revealed the resident refused to be interviewed and stated Probably, I will not remember the answers, I want to be alone. The resident then .turned uncooperative, and agitated, started to yell/scream, refused to be interviewed. Per the clinical record documentation, resident #108 received a new roommate (resident #107) on (MONTH) 30, (YEAR). Review of the facility's Reportable Event Report revealed that at 9:35 a.m. on (MONTH) 31, (YEAR), resident #107 was in his room with his roommate (resident #108.) The report included that staff heard resident #108 yelling at resident #107 to Get the f__k outa my way! You've pushed my buttons too far! The report included that prior to entering the room, several staff members heard a loud thump and upon entering the room, staff found resident #107 on the floor on his left side near the bathroom with his walker nearby. Staff reported that resident #108 was standing nearby with a clenched fist saying, I did it and I'll do it again. The report further included that resident #107 complained of new onset of lower back pain and was sent to the emergency room and was diagnosed with [REDACTED]. According to the hospital History and Physical dated (MONTH) 31, (YEAR), resident (#107) came from a nursing home and was pushed backward by a roommate. The documentation included that the resident sustained [REDACTED]. Further review of the facility's Reportable Event Report revealed the police were notified and that resident #108 was transferred to the hospital for a geri-psych evaluation. During an interview conducted at 1:45 p.m. on (MONTH) 20, (YEAR), the Director of Nursing (DON/staff #17) stated that at the time of the incident she was in a conference room outside of the secure unit and the two residents were in their room, which was next door to the conference room. She said that she heard a loud noise (yelling) and jumped up and ran to the resident's room. Staff #17 stated that she saw resident #107 laying on the floor between the first bed and the door. Staff #17 stated that resident #108 was standing with his fist clenched and he said I did it and I will do it again. She stated that she stood between the two residents while resident #107 was assessed. During an interview conducted at 2:05 p.m. on (MONTH) 30, (YEAR), with the Staff Development Coordinator (registered nurse/staff #66), she stated that she had just arrived at work when she was told of the situation. She said she went to the residents' room and resident #107 was on the ground and resident #108 was standing about five feet away. She said that another staff member was trying to keep resident #108 away from resident #107. She said resident #107 did not say much, as he was moaning in pain and appeared to be shocked and scared. Staff #66 stated that when resident #107 was asked what happened he was shaking, and could not say what had occurred. An interview was conducted at 1:38 p.m. on (MONTH) 31, (YEAR) with the Administrator (staff #88), who stated that a resident to resident altercation would be considered abuse, if a resident had to be sent to the emergency room for treatment. -Resident #38 was admitted to the facility on (MONTH) 7, (YEAR), with [DIAGNOSES REDACTED]. Review of a care plan revealed the resident had a mood problem related to disease process. A goal included that the resident will have fewer episodes of crying and anger. Interventions included to observe for signs and symptoms of racing thoughts or euphoria, increased irritability, frequent mood changes, and [MEDICAL CONDITION]. Another care plan identified that the resident had psychosocial well-being problems related to ineffective coping. Interventions included to remove resident to a calm safe environment, allow to vent feelings when conflict arises, and discuss resident's feelings relative to fearfulness. Review of a quarterly MDS assessment dated (MONTH) 12, (YEAR), revealed the resident had a BIMS score of 10, which indicated that the resident had moderate cognitive impairment and required extensive assistance with activities of daily living. -Resident #58 was admitted on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. Review of the clinical record revealed there was no documentation that resident #58 had any aggressive behaviors toward other residents. None of the resident's care plans included the resident was physically aggressive. According to the facility's investigation, a resident to resident altercation occurred on (MONTH) 5, (YEAR) at approximately 7:20 p.m., between resident #38 and her roommate resident #58. Resident #38 reported to a Certified Nursing Assistant that her roommate kicked her three times. Resident #58 denied kicking resident #38, but was then heard yelling at resident #38 for telling staff. The two residents were immediately separated and resident #58 was placed on 1:1 supervision. Review of the progress notes dated (MONTH) 6, (YEAR) at 11:50 a.m., revealed resident #38 was involved in a resident to resident altercation with her roommate the night before. The note included that resident #38 reported that her roommate kicked her through the curtain. When asked if she was uncomfortable being around the roommate she replied .I was a little scared and that she was not afraid of her now. No injuries were noted to resident #38. Review of a Nursing Home to Hospital Transfer Form revealed resident #58 was easily irritated and had kicked another resident. According to a Discharge MDS assessment dated (MONTH) 6, (YEAR), resident #58 was assessed to have memory problems and exhibited physical behavior symptoms. Further review of the clinical record revealed resident #58 was transferred to the hospital on (MONTH) 6, (YEAR), for a psychiatric evaluation. During an interview on (MONTH) 31, (YEAR) at 2:23 p.m. with the Director of Nursing (staff #17), she stated that she received a phone call that resident #38 had been kicked by the roommate. She stated that they kept the residents separated. Staff #17 stated that resident #38 did not sustain any injury, but was fearful at the time. She further stated that resident #58 was transferred out for a psych consult. During an interview on (MONTH) 31, (YEAR) at 2:44 p.m. with the Administrator (staff #88), he stated that he was made aware of the incident by phone and that the Director of Nursing did the investigation and reported the results to him. He further stated that the resident was sent out for a geri-psych evaluation. Review of the facility's Abuse and Neglect policy revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subjected to abuse by anyone, including but not limited to employees, other residents, consultants, volunteers, employees of other agencies serving the resident, family members, legal guardians, friends or other individuals.

Based on clinical record reviews, staff interviews, and review of policies and procedures, the facility failed to provide care and services to prevent the development of pressure ulcers for two residents (#'s 2 and 64). The sample size was 3. Findings include: -Resident #64 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Nursing Admission Data Collection note dated March 13, 2015, revealed there were no concerns with any skin conditions related to the resident's heels. A Braden Scale for Predicting Pressure Sore risk dated March 13, 2015, indicated the resident was at high risk for developing pressure ulcers, which was attributed to the following conditions: limited sensory perception; confined to a bed; did not make even slight changes in body or extremity position without assistance; and poor nutrition. The assessment included interventions to reduce the risk of skin breakdown as follows: frequent turning with a planned schedule, pressure reduction support and to protect the heels. A physician's order dated March 17, 2015, included to perform weekly skin checks on Tuesdays. The Minimum Data Set (MDS) admission assessment dated [DATE], included that the resident had severe cognitive impairment and required extensive assistance of one person for bed mobility and transfers. Per this assessment, the resident was at risk for developing pressure ulcers, but did not have any. A care plan was initiated on March 20, 2015, related to a history of pressure ulcers, due to immobility. Interventions included to provide pressure relieving/reducing devices on bed and chair. There were no interventions regarding protecting the heels, such as floating the heels or for the use of protective boots/booties. Review of the clinical record revealed no documentation that the resident's skin was assessed from March 14 to March 24, 2015. According to the Wound RN Assessment note dated March 25, 2015, the resident now had a suspected deep tissue injury (DTI) to the left heel, which was staged as an unstageable pressure ulcer. This assessment did not include any measurements or description of the wound. A physician's order dated March 25, 2015, included for skin prep to the left heel, two times a day for a DTI. Review of the TAR for March 2015 revealed the skin prep to the left heel was not documented as being done twice a day as ordered on March 29 and 30. The Wound Data Collection note dated March 31, 2015 included the left heel pressure ulcer measured 2.4 centimeters (cm) by 3 cm. The wound bed was described as 100% eschar (necrotic tissue). The note also included documentation that the wound was to be measured at least once every 7 days. Review of the TAR for April 2015 revealed the skin prep to the left heel was not provided twice a day as ordered on April 1, 3, 4, 5, and 6. Per the Wound Data Collection note dated April 7, the left heel pressure ulcer had increased in size, as the wound now measured 2.8 cm by 3.9 cm. The wound bed continued to be described as having 100% eschar. A nursing progress note dated April 9, 2015, included documentation that booties were on the resident's feet. This was the first and only documentation that the resident had any interventions in place to protect the heels. The April 16, 2015 Wound Data Collection note for the left heel did not include any wound measurements, nor a description of the wound bed. The April 21, Wound Data Collection note included the left heel wound measured 2.0 cm by 3.1 cm. The wound bed was described as 100% eschar. The April 28, Wound Data Collection note revealed the left heel wound bed had 100% eschar, however, there were no measurements of the wound. Further review of the April 2015 TAR revealed the skin prep to the left heel was not provided twice a day for 11 days from April 7 through 30. Continued review of the care plan related to a history of pressure ulcers revealed the care plan was not revised to reflect that the resident had an unstageable pressure ulcer. The care plan also did not reflect that any new interventions were implemented. Review of the May 6, 2015 Wound Data Collection note for the left heel included the wound measured 2.5 cm by 2 cm. The wound bed was described as having 25% eschar. The May 12, 2015 Wound Data Collection note did not include any wound measurements. The wound bed was described as having 100% eschar. The May 19, 2015 Wound Data Collection note for the left heel included the wound measured 1.5 cm by 1.2 cm and the wound bed was 100% [MEDICATION NAME]. The May 26, 2015 Wound Data Collection note included the heel was resurfaced. According to the May 2015 TAR, the skin prep was not documented as being provided twice a day as ordered on the following days: May 1-5, 9,14, 20, 22, 27 and 31. There was no physician's order to discontinue the skin prep in May 2015. Continued review of the clinical record revealed there was no further documentation regarding a left heel wound from May 27 through June 2015. Per the June 2015 TAR, the skin prep continued to be applied to the left heel, however, there were six days when the the skin prep was not provided twice a day, as ordered. A physician's order dated June 26, 2015, now included to discontinue the skin prep. From July through August 2015, there was no clinical record documentation of a wound to the left heel. According to the August 2015 TAR, no skin assessments were completed on August 10 or 17. A physician's order dated August 29, 2015, included for skin prep to the left heel and cover with [MEDICATION NAME] dressing for protection, every other day for a DTI. Despite the above order, there was no clinical record documentation that an assessment of the left heel was completed. Per the August 2015 TAR, the skin prep and [MEDICATION NAME] dressing was not provided on August 29 or 31. The first assessment documentation regarding the left heel pressure ulcer was on the Wound Data Collection note dated September 16, 2015, which was 19 days after the physician's order from August 29. The left heel was described as a dried healed pressure ulcer. A physician's order dated September 22, 2015, included for skin prep to be applied to the left heel every other day for a DTI. A review of the September 2015 TAR, revealed the skin prep was provided every four days, instead of every other day as ordered. In addition, from September 17 through October 19, 2015, there was no clinical record documentation regarding an assessment of the left heel. An observation was conducted on October 19, 2015 at 1:00 p.m., of the resident lying in bed. The resident's feet were not off loaded and the heels were resting on the mattress. Another observation was conducted on October 20, 2015 at 11:10 a.m., of the resident sitting in her wheelchair, with her feet resting on the foot rests. The resident had slippers on, but the heels were not offloaded. A wound observation was conducted on October 20, 2015 at 2:45 p.m., with a licensed nurse. The resident's left heel was observed to have a white, dry scab like area, which was partially detached from the heel and measured 5 cm by 1 cm. According to the Wound RN assessment note dated October 20, 2015, the wound measured 5 cm by 1 cm. There was no description of the wound bed. During an interview with a certified nursing assistant (CNA) on October 22, 2015 at 10:45 a.m., she stated that since the resident is immobile in bed, she should be repositioned at least every 2 hours and her heels should be floated while in bed to protect them from pressure ulcers. She stated when the resident sits in a wheelchair, she should have soft boots on her feet. The CNA stated she could not recall seeing any booties for the resident. An interview was conducted with a licensed practical nurse (LPN) on October 22, 2015 at 11:15 a.m., who stated that residents who are at risk for developing pressure ulcers, need to be repositioned frequently and heels should be floated, while in bed. She further stated that the resident should have heel protectors, such as booties on their feet when sitting in the wheelchair. She stated the boots require an order from the physician and should be documented on the TAR. An interview with the Director of Nursing (DON) was conducted on October 22, 2015 at 12:45 p.m. She confirmed that the resident's pressure ulcer risk care plan should have included individualized interventions, such as booties for her feet. The DON stated an order should have been obtained for booties for her feet and then documented on the TAR. She further stated that she expects the nurses to provide complete and thorough skin assessments at least weekly that include measurements of the wound, description of the wound bed, any drainage and to provide treatments as ordered. -Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE], revealed the resident was cognitively intact, and was at risk for the development of pressure ulcers, however, did not have any pressure ulcers present. In Section G. of the MDS, the resident was assessed to require extensive assistance for bed mobility, was totally dependent with transfers, and required extensive assistance to total dependence with locomotion. Review of the Braden Scale for Predicting Pressure Sore Risk for January 2015 revealed a score of 15, which indicated the resident was at mild risk for pressure ulcer development. A care plan for the potential of pressure ulcer development listed a goal that the resident would not acquire any pressure ulcers. The care plan included the following interventions: assist to turn and reposition frequently when in bed or wheelchair to prevent pressure areas, and provide a low air loss mattress. Review of the clinical record revealed there was no documentation that the resident had any pressure ulcers present from March 2015 through April 9, 2015. Review of the weekly skin assessment dated [DATE] revealed the resident had multiple wounds. The documentation did not include the location of the wounds, nor did it include any measurements, staging of the wounds, or a description of the wounds beds. The skin assessment also noted to refer to the wound data collection documentation and the wound RN assessment notes. However, there was no corresponding wound data collection documentation, nor a RN wound assessment note dated April 10. In addition, there was no documentation that the physician was notified of the resident's multiple wounds on April 10. A physician's orders was obtained on April 11, 2015 which included to cleanse the left and right outer malleolus with normal saline, apply a nickel thick layer of Santyl (enzymatic [MEDICATION NAME] ointment used to remove necrotic tissue) to the wound bed from edge to edge, and cover with a foam dressing. Despite the physician's order for wound treatment for two wounds, there was still no documentation of any thorough assessments of the wounds, which had been completed. A care plan was initiated on April 13, 2015 for Actual Impairment to Skin Integrity related to decreased mobility. The care plan included the resident had bilateral unstageable pressure ulcers on the outer malleolus. The goal included that the resident would have no complications related to pressure ulcers. Interventions included the following: monitor location and size of the wounds, report signs of infection to the provider, utilize a pressure reducing mattress, use pillows to float heels while in chair, use sheepskin padding to corners of wheelchair, elevate heels off bed, and needs protection for the feet (booties). The first thorough assessments of the resident's pressure ulcers were not completed until April 14, 2015, four days after being identified. Per the wound data collection sheets dated April 14, the resident had an unstageable pressure ulcer to the left lateral malleolus, which measured 2.5 x 2.0 centimeters (cm), with no depth documented. The wound was described as a circular wound which was covered with 75% yellow slough. The tissue surrounding the wound was described as intact and blanchable. A wound data collection sheet also dated April 14, included the resident had an unstageable pressure ulcer to the right lateral malleolus, which measured 1.5 x 1.2 cm. The wound bed was described as having 100% slough and that there was too much slough to determine the depth. The surrounding skin was described as reddened, with raised edges. Review of the TAR (Treatment Administration Record) for April 2015 included the orders for wound treatments to the right and left malleolus. However, there was no documentation that the treatments were provided on April 19 and 28. A care plan identified that the resident was a nutritional risk related to unstageable right and left malleolus pressure ulcers. Review of the Wound Data Collection sheets dated May 5, 2015 revealed the pressure ulcer to the left lateral malleolus measured 1.7 x 1.4 x 0.3 cm and had 75% slough and was a circular shaped wound, with raised edges that were hardened, purple, and red. The pressure ulcer to the right lateral malleolus measured 1.1 x 1.3 x 0.2 cm and had 50% slough and the edges were hardened and raised. Further review of the TAR for May 2015 revealed no documentation that wound treatments were provided to the right and left malleolus pressure ulcers on May 3, 6, 15, 16, 17, 22, or 24, and no wound treatment was provided to the right outer malleolus on May 27. Physician's orders dated May 28, 2015 included the following: cleanse the right and left malleolus with sterile water and pack wounds with ExcelGinate AG dressing, then cover with circular foam dressings every day shift for unstageable pressure ulcers. Review of the Wound Data Collection sheets dated June 2, 2015 revealed the pressure ulcer on the left lateral malleolus was 1.2 x 0.9 x 0.1 cm with 25% slough, and edges were slightly raised. The right lateral malleolus measured 1.2 x 1.3 x 0.3 cm with a pink wound bed and no slough, and the edges were slightly raised. The TAR for June 2015 indicated no wound treatments were provided to the right and left malleolus pressure ulcers on June 20, 21, and 23. Clinical record documentation showed that the wounds were assessed weekly from May through June 2015. Review of the Wound Data Collection sheets dated July 7, 2015 indicated the left lateral malleolus measured 1 x 1.2 cm and had no slough, with pink wound margins and surrounding skin. The right lateral malleolus measured 1 x 1.4 x 0.5 cm and had no slough, with pink wound margins. Physician's orders dated July 7, 2015 included to cleanse the left outer malleolus with normal saline and apply a thick layer of silver hydrogel to the wound bed, pack full with triple helix collagen powder, and cover with fenestrated circular foam dressing every day shift. A physician's order dated July 21, 2015 indicated to cleanse the wounds on the right and left malleolus with normal saline and apply collagen to the wound beds and cover with fenestrated circular foam dressing every day shift. The TAR for July 2015 indicated no wound treatments were provided to the right and left malleolus pressure ulcers on July 5 and 17. A physician's order dated August 7, 2015 included for PT to evaluate and treat for wound modalities for pressure ulcers on bilateral outer malleolus. A physician's order dated August 19, 2015 indicated to apply skin prep three times a day for an unstageable pressure ulcer to the left malleolus. Review of the PT notes dated August 11, 2015, revealed the resident was referred for treatment to improve wound healing and closure. The PT notes listed the onset date for the wounds as April 10, 2015. The goal of therapy was for increased healing of the wounds. The wound to the left malleolus measured 0.5 x 0.4 cm and the wound to the right malleolus measured 1.2 x 0.7 x 0.3 cm. The TAR for August 2015 indicated no treatment was provided to the right malleolus on August 11, 23, 24, 25, and 29. In addition, there was no documentation of the skin prep treatments to the left malleolus on August 20-second shift, August 25-first and second shift, August 26-third shift, August 29-second shift, August 30 -third shift, and August 31-third shift. Another physician's order dated September 25, 2015 included to apply skin prep to the right and left lateral malleolus three times daily for unstageable pressure ulcers. The TAR for September 2015 indicated no wound care treatments were provided to the right lateral malleolus on September 8, 11, 12, and 22. Also, the three times daily application of skin prep were missed on 15 shifts to the left lateral malleolus. Clinical record documentation showed that the wounds were assessed weekly from July through September 2015. Review of the Wound Data Collection sheets dated September 23, 2015 revealed the pressure ulcer to the left lateral malleolus was described as resurfaced. The pressure ulcer to the right lateral malleolus measured 1.0 x 1.5 cm and was scabbed over, without redness, [MEDICAL CONDITION], or drainage. Documentation on the October 2015 TAR indicated that the skin prep was not done on two shifts between October 1 and October 21. The Wound Data Collection sheet dated October 20, 2015 indicated the pressure ulcer to the right lateral malleolus measured 0.8 x 0.5 cm and was described as a scab. An observation was conducted on October 21, 2015 at 8:55 a.m. The resident was being pushed in a geri chair from the dining room to her room. The resident was observed to have both legs laterally (outward) rotated, with the lateral malleolus of each ankle resting against the chair, with no pillows or other devices to off load pressure. The resident was observed wearing thick socks. A wound care observation was then conducted with the wound nurse present. Inspection of the left lateral malleolus revealed the wound was healed and the wound nurse recommended discontinuation of the treatment to the left malleolus and would obtain an order. The pressure ulcer on the right lateral malleolus had a black scabbed area in the center of the wound, which measured 0.8 x 0.5 cm, and the surrounding tissue was pink. No drainage was noted. The wound nurse provided treatment as ordered. In an interview conducted with the resident on October 21, 2015 at 9:05 a.m., the resident stated that her legs always turn out and rest against the chair or bed. In an interview with a Certified Nursing Assistant (CNA) on October 21, 2015 at 9:30 a.m., the CNA stated they put pillows under her ankles to float the heels to prevent pressure in that area, but the resident doesn't like the pillow and will kick them out. An interview was conducted with the wound nurse on October 21, 2015 at 11:49 a.m., who stated that the resident lays with her legs rotated outward causing the lateral malleolus of the right and left ankles to rest on the bed or chair. She stated the resident had heel protectors, but refused to wear them. She stated the resident wears thick socks which are a negotiated compromise with the resident. The wound nurse also stated that the resident should have pillows to elevate her feet and ankles, when in the bed or geri chair. Review of the facility policy titled, Wound and Pressure Ulcer Management revealed the purpose was to provide current and consistent standards of practice in wound care management. The policy indicated to include a comprehensive management program to prevent the development of a pressure ulcer and implement interventions identified on the care plan, including nutritional interventions and specialty surfaces. According to the facility policy titled Pressure Ulcers, the purpose was to provide appropriate assessment and prevention of pressure ulcers, as well as treatment when necessary. Based on the resident's comprehensive assessment, the facility will use prevention and assessment interventions to ensure that a resident entering the facility without pressure ulcers, does not develop a pressure ulcer unless the individuals clinical condition demonstrates that this was unavoidable. Review of a facility policy titled, Wound Care included that the pressure ulcer/wound care resource packet is designed to provide you with the resources and tools needed to provide care and services for your residents, who are at risk for skin breakdown. The wound care programs and pressure ulcer guidelines and protocols have been developed and implemented to ensure that quality services are provided to residents. The policy included to conduct a structured risk assessment as soon as possible to identify individuals at risk of developing pressure ulcers and develop and implement a risk based prevention plan for individuals identified as being at risk. The policy regarding Repositioning to Prevent and Treat Heel Pressure Ulcers included the following: The reduction of pressure and shear at the heel is an important point of interest in clinical practice. Ensure that the heels are free of the surface of the bed. Apply heel suspension devices.

Based on observations, clinical record reviews, resident and staff interviews, and review of facility policies and procedures, the facility failed to ensure that three residents (#'s 24, 34, and 38) were provided adequate supervision while smoking, which resulted in the Condition of Immediate Jeopardy (IJ). The facility also failed to ensure that hazardous chemicals and syringes with needles were secured. The sample size was four. Findings include: Issue regarding unsupervised smoking: On May 21, 2013 at 1:40 p.m., the Condition of IJ to Resident Health and Safety (level K) was identified to be present. The administrator and the director of nursing were informed of the facility's failure to safeguard multiple residents from the potential hazard of unsafe smoking practices. Specifically, one resident was observed to have an emergency oxygen cylinder which was not always turned off while smoking. Although the facility had designated smoking hours, they were aware that these residents were non-compliant with the facility's designated smoking hours. The administrator presented the first immediate plan of correction at 3:30 p.m. on May 21, 2013 but this plan was unacceptable. The administrator presented the second plan of correction at 4:14 p.m. but this plan was unacceptable. The administrator presented the third plan of correction at 4:36 p.m. but this plan was unacceptable. At 4:40 p.m. on May 21, 2013, the administrator presented a fourth plan of correction. This plan included measures to ensure resident safety and was accepted on this same date at 4:48 p.m. The Condition of IJ was abated on May 22, 2013 at 12:45 p.m. due to the corrective measures taken by the facility. -Resident #24 was readmitted [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a change of condition MDS (Minimum Data Set) assessment, dated March 14, 2013, that documented that the resident was cognitively intact with no memory impairment and that the resident had displayed verbal aggressive behaviors towards staff and others and had a worsening of behavioral symptoms. Continued review of the resident's clinical record revealed a Tobacco Use assessment dated [DATE]. The assessment documented that the resident had modified independence with decision making and currently used tobacco, with concerns noted. The assessment further documented that the resident smoked cigarettes five to ten times per day at all times of the day. The resident was assessed to be able to light her own cigarette. Further review of the May 8, 2013, assessment revealed documentation that the resident had been assessed to need a smoking apron, supervision, and her oxygen was to be left inside the building. The resident was assessed to use oxygen with no physician's order to remove the oxygen to allow the resident to smoke. Additional review of the resident's clinical record revealed a care plan that was updated May 8, 2013, that documented the resident's need of supervision during smoking due to poor safety practices. The care plan identified the resident's smoking times as 10:00 a.m.., 2:00 p.m., and 8:00 p.m., the the resident would wear a smoking apron, the resident's oxygen would be removed prior to smoking, and all smoking materials would be stored at the nurses' station. Continued review of the resident's clinical record revealed an Acknowledgement of Smoking Policy form dated May 9, 2013. The policy was documented to be as follows: -All lighters, matches, and other forms of ignition must be held at the nurses' station and not in residents' room. -All tobacco products must be held at the nurses' station and not in residents' rooms. -After smoking, all left over cigarettes, matches, lighters, and other forms of ignition must be turned back to the nurses' station. -All smokers were required to wear an apron that is designed as a garment to protect the resident from burns and injury. -Oxygen was prohibited in all smoking areas for the safety of residents and under no circumstance should a resident smoke around oxygen or be receiving oxygen while smoking. -Supervised smoking times would be at 10:00 a.m.., 2:00 p.m., and 8:00 p.m., each day. -The facility would do periodic re-assessments to determine whether supervision during smoking was required. -Failure to follow the outlined policy and procedures would result in revocation of smoking privileges. The policy documented a signature of a social services staff and a notation that the resident refused to sign the acknowledgment, stating that the resident would not follow these rules. An observation was made on May 21, 2013, of resident #24 on the smoking patio, with other residents. The resident was observed to have oxygen present, not wearing a smoking apron, and no staff were present with the resident. The resident was observed with smoking material and was smoking a cigarette. During an interview conducted on May 21, with the resident, the resident stated that she did not need a smoking apron or required supervision. On May 21, 2013, during an interview with the Administrator, the Administrator stated that the resident had become extremely non-compliant with the facility's rules about smoking. The facility had become a non-smoking facility, but the resident had be "grandfather" in to be allowed to smoke as long as the rule were followed. The Administrator stated the resident had been given a 30 day notice due to non-compliance with the smoking rules. An interview was conducted on May 22, 2013, with a CNA (certified nursing assistant) who was familiar with resident #24. The CNA stated that resident #24 had recently become very defiant regarding her cigarette smoking, refusing to leave her oxygen in building, refusing to allow staff to lock up smoking materials, and refusing to let staff know when she went out to smoke. The CNA stated that she had observed the resident outside smoking with oxygen. -Resident #34 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed an April 24, 2013, quarterly MDS assessment that documented that the resident was cognitively intact, with no memory impairments, and had no behavioral disturbances. The clinical record further revealed a Tobacco Use assessment dated [DATE], that documented the resident smoked cigarettes and was independent with decision making. The assessment further documented that the resident would wear an apron while smoking and smoking materials would be stored. Continued review of the resident's clinical record revealed a care plan dated May 8, 2013, that documented that the resident was independent with smoking and that the resident would wear an apron while smoking and that tobacco products and lighters would be kept at the nurses station. An observation was made on May 22, 2013, of the resident on the smoking patio smoking with other residents. An interview was conducted with the resident, whereas, the resident stated that prior to today (May 22, 2013) the resident had her smoking materials with her and that they were not locked up at the nurses' station. -Resident #38 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed a tobacco use assessment dated [DATE], which identified the following concerns with the resident: -had modified independence to make decisions regarding daily life task. -had a dexterity problem that would affect his ability to smoke or use tobacco products. -had physical limitations that could interfere with his ability to get outside and back into the center independently. -used tobacco products two to five times a day, in the morning, afternoon, and evening. -sometimes could light his own cigarette. -required the use of a smoking apron. -required supervision. Review of a care plan to address the use of tobacco products revealed a goal to safely use tobacco products in the designated area. The interventions to achieve that goal included the following: -resident needs supervision with tobacco use, due to poor safety practices. -supervise the resident to smoke. -smoking schedule: 10:00 a.m., 2:00 p.m., and 8:00 p.m. -light cigarette for the resident. -put smoking apron on the resident. -keep tobacco products at the nurse's station. Multiple resident observations were conducted on May 21, 2013, of the designated resident smoking patio. During these observations, resident #38 was observed sitting in his wheelchair outside on the patio at varies times, smoking without supervision. A smoking apron was being utilized, however, it only was laying across the resident's knees and not fully covering the resident's trunk area. A resident interview was conducted on May 21, 2013, regarding staff supervision when outside smoking. Per the resident, the facility staff never came outside when he was smoking. A facility document titled, Acknowledgement of Smoking Policy included that the resident required supervision whenever he smoked. This policy also included that the facility's smoking policy had been explained to the resident and that a copy of the policy had been provided to the resident. Outlined in this policy were the smoking standards, which included the following: -After smoking, all left over cigarettes, matches, lighters, and other forms of ignition must be turned back into the nursing station. -All smokers are required to wear an apron that is designed as a garment to protect the resident from burns and injury. -Supervised smoking times. -Failure to follow the outlines policy and procedures will result in revocation of smoking privileges. This policy also included documentation that the resident refused to sign the agreement and that he had stated, "I have lived here for 5 yrs and no one is going to tell me when to smoke. I will smoke when I want." Issues regarding potential hazardous materials: -During a random observation conducted on May 29, 2013 at 12:40 p.m., an emergency crash cart was observed positioned next to the social service office and across from the nursing station. The emergency crash cart had three unlocked, clear, plastic drawers, one of which contained numerous syringes with needles attached. Further observation of this cart revealed that it was not equipped with a means of securing the drawers, and therefore allowing the contents of the drawers to be readily accessible to residents. Following this observation, an interview was conducted with the DON (Director of Nursing), who stated that she was not aware that syringes with needles were located inside the cart. The DON agreed that all the contents of the cart were therefore accessible to residents, staff and visitors. The facility was unable to provide a policy regarding the security of the emergency crash cart, and its contents. -An environmental tour was conducted on May 23, 2013, with the maintenance director of the CNA supply room located in the central hallway, where residents could have access. In the supply room was an unlocked cupboard, which contained two quart spray bottles of Bath Mate Acid Free Washroom Cleaner Concentrate. A review of the MSDS (Material Safety Data Sheet) identified Bath Mate as a health hazard and included "Eye contact: Corrosive. Causes permanent eye damage including blindness. Inhalation: May cause irritation and corrosive effects to nose, throat, and respiratory tract. Ingestion: Corrosive: May cause burns to mouth, throat, and stomach. Harmful if swallowed. May cause kidney effects. May cause central nervous system effects, including headaches and dizziness." Also in an unlocked cupboard under the sink was a 64 ounce bottle of Sta - Flo Liquid Starch. Review of the MSDS identified Sta - Flo Liquid Starch as a health hazard and included "Skin Contact: May cause irritation. Eye Contact: May cause irritation." An interview was conducted with the maintenance director on May 23, 2013. The maintenance director stated that the chemicals should have been stored in the dirty utility room which was locked. A review of the facility's policy regarding Laundry Room and Laundry and Housekeeping Equipment documented that hazardous cleaning solutions, chemicals, poisons and substances, need to be labeled and stored in a safe place and secured so that they are not accessible to non-staff.

Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that one resident (#51) received adequate supervision and interventions to prevent two falls with injuries. Findings include: Resident #51 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The initial assessment done at the time of admission revealed that the resident was at risk for falls related to a history of falls, weakness, and an unsteady gait. Despite resident #51's [DIAGNOSES REDACTED]. Review of the clinical record revealed that the resident fell on [DATE], that resulted in right shoulder and knee pain. Clinical record review revealed no changes or additional interventions documented on the resident's fall care plan. A second fall on April 15, 2011, resulted in a right hip fracture. Review of the Incident Details report dated April 15, 2011, revealed that this fall occurred at 2:00 p.m. and the resident was found sitting on her buttocks in the bathroom with her head on the trash can. Also documented was that the resident was complaining of right hip pain and was transferred to a local emergency room . Review of the Interdisciplinary Progress Notes dated April 20, 2011, revealed that the resident was readmitted to the facility with a non-operable right femur fracture. Review of the clinical record revealed that the Comprehensive Care Plan for falls dated April 20, 2011, now had been reviewed and included the following interventions: fall assessment per protocol, resident has mild dementia, and remind her to use call light. Despite the fact the resident had sustained a fall that resulted in a fractured hip/femur, the resident had been identified as a fall risk upon admission, the resident had a primary [DIAGNOSES REDACTED]. Further review of the clinical record revealed the Comprehensive Care Plan for Falls was again updated on April 23, 2011, and included the following: fall assessment per protocol, transfer-2 person, physical assist-1, no ambulation at this time. No additional interventions were documented, including the use of a bed alarm and wheel chair alarm. Continued review of the clinical record revealed that the resident sustained [REDACTED]. Documentation included the resident was not injured except for abrasions on May 27. Again, no additional interventions such as bed or wheel chair alarms, frequent checks, a low bed, or padded safety mats were documented in the falls care plan, or were documented to have been evaluated and not appropriate for the resident. Resident #51 sustained a sixth fall on May 29, 2011, which resulted in a deep forehead laceration and a neck fracture. Review of the Incident Details report dated May 29, 2011, revealed that the resident was found on the floor of her room, on her left side in a fetal position with a deep laceration to the forehead requiring direct pressure to control bleeding. The resident was transferred to a local emergency room . Review of the hospital records dated June 17, 2011, revealed that the resident had fallen and suffered a fracture of the cervical two body. A review of the Falls Care Plan dated June 22, 2011, revealed the following changes: Low bed, and one to one sitter. During an interview conducted on March 9, 2012, the registered nurse (RN) stated that at the time of the two falls with injuries, the resident had in place a bed and wheel chair alarm. She also stated that for interventions such as a lap belt or bolsters, a consent must be signed by the Power of Attorney and the case manager had to approve their use as well as the physician. During an interview conducted on March 9, 2012, the director of nursing (DON) stated that at the time of these two falls that resulted in injuries, the only intervention in place was a bed alarm, however, she further stated that she would have wanted these additional precautions in place: 15 minute checks by staff, soft belt restraint, bolsters on bed, low bed, and a 24 hour sitter. Review of the facility's policy on Prevention and Management of Falls Practice Guidelines revealed that "...Upon admission each resident will be evaluated to determine his or her risk for falling. Include the following components for review: Identification of environmental hazards and any individual resident risk of an accident, including the need for supervision, evaluation and analysis of the hazards and risks related to potential falls, implementation of interventions, including adequate supervision, monitor the effectiveness of the interventions and modify the interventions as necessary..."