Every finding on record at Sabino Canyon Rehabilitation & Care Center

Based on clinical record review, staff interviews, and policy review, the facility failed to execute and document the transfer/discharge process in accordance with the regulation and facility policy for 1 of 21 sampled residents (#3). The deficient practice could result in incomplete and inaccurate medical records for residents.Findings include: Resident #3 was admitted to the facility on [DATE], with diagnoses that included displaced fracture of the base of the neck of the left femur, muscle weakness, displaced simple supracondylar fracture, hypertension, hyperlipidemia, obstructive and reflux uropathy, cognitive communication deficit, polyneuropathy, and muscle weakness. An admission Minimum Data Set (MDS) dated [DATE], revealed that a Brief Interview for Mental Status (BIMS) was conducted with a score of 7, which indicated severe cognitive impairment. Resident #3's face sheet revealed that she had a discharge date of February 22, 2026, and that she was discharged to an acute care hospital. Resident #3's census list revealed that she had a discharge date of February 22, 2026. A nursing progress note dated February 22, 2026, at 6:03 a.m. revealed that the resident was transferred to the hospital due to an altered mental status and being non-responsive to verbal stimuli, only to tactile stimuli. The note also revealed that the family and son were notified via phone and that attending answering service was updated on the patient's condition with two calls. A progress note dated February 23, 2026, at 11:09 a.m. revealed that the resident's son and his wife picked up all of the resident's belongings left in the facility. Review of Resident #3's clinical record on June 26, 2026, at 9:34 a.m. revealed no evidence that a discharge MDS was initiated or completed. A follow-up review of Resident #3's clinical record on June 26, 2026, at 11:01 a.m. revealed that a discharge MDS dated [DATE], was initiated and in progress with sections A, B,C, D, E, GG, H, I, J, K, M, N, O, P, and Q being completed on June 26, 2026, after an interview with the MDS assistant (MDS assistant/Staff#58). There was no evidence in Resident #3's clinical record of a physician's order to transfer to the hospital. An interview was conducted on June 26, 2026, at 9:38 a.m. with a registered nurse (RN/Staff#182), who stated that the process for transferring a resident to the hospital included a physician's order for the transfer, a diagnosis list, medication list, contacting the provider and family, complete the e-interact transfer assessment, and documenting in a progress note where the resident went. The RN stated that there was never an instance where the facility would not complete a transfer assessment because it was required. The RN stated that a discharge MDS needed to be completed for the resident transferring to the hospital, and that the risk of failing to complete the transfer assessment and discharge MDS would be that if something happened to the resident during the transfer and documentation was absent, then there could be a negative outcome for the resident, and their last status would not be shown in the documentation. The RN opened the record of Resident #3 and stated that she was admitted on [DATE], and was discharged on February 22, 2026, to the hospital. The RN stated that there wasn't a transfer assessment completed for the resident's transfer to the hospital and that the E-interact assessment should have been completed. The RN also stated that there was no discharge MDS completed for Resident #3 and that this transfer did not meet the facility's policy expectations for transfers/discharges. An interview was conducted on June 26, 2026, at 9:49 a.m. with the MDS assistant, Staff #58, who was filling in for the MDS coordinator for the day, and stated that when transferring a resident to the hospital, they were required to complete a discharge MDS. The MDS assistant stated that if the transfer was unplanned, they would indicate it in the discharge MDS and document where the resident was going. The MDS assistant also stated that they would only know what to mark on the discharge MDS through the documentation, so if there wasn't any, she would have to dig for the information. The MDS assistant further stated that if the resident was transferred and out of the facility for less than 24 hours, she believed they would not need to complete a discharge MDS. The MDS assistant stated that when a resident transferred to the hospital, an E-transfer assessment needed to be completed with a progress note that explained what happened to them. The MDS assistant also stated that the risk of failing to complete a transfer assessment and discharge MDS for a resident going out to the hospital was that the facility would not be fully keeping track of their residents, there was insurance risks, and that if the resident was in the facility's care last and something happened to them, the lack of completed assessments and documentation could result in harm to the resident if they were not 'on top of it.' The MDS assistant opened the clinical record for Resident #3 and stated that she was admitted to the facility on [DATE], and discharged on February 22, 2026, but the MDS assistant could not find a reason for the discharge. The MDS assistant found a progress note that showed the resident went to the hospital and stated that the facility did not complete a transfer assessment. The MDS assistant further stated that the facility also did not complete a discharge MDS, and that they needed to complete a discharge MDS because she did not return to the facility. The MDS assistant stated that they did not follow their process correctly for transferring the resident, and that the risk of failing to complete the transfer assessment and discharge MDS in this case was that it took her forever to figure out what happened to the resident during the interview, because they failed to track her status, and they still did not know what happened to her. An interview was conducted on June 26, 2026, at 10:14 a.m. with the Director of Nursing (DON/Staff#15), who stated that she expected that when transferring a resident to the hospital, staff would complete a progress note about the transfer. The DON further stated that they would have to complete the E-interact transfer assessment. The DON amended her statement and stated that she would expect the transfer assessment or a progress note that met the sections of the E-interact transfer assessment, and that the progress note needed to include when, where, and why the resident was transferred, and who was notified. The DON stated that a discharge MDS should have been completed for a resident going out to the hospital, and that there was no instance in which it should not have been completed. The DON stated that the risk of failing to complete the transfer assessment was that a needed party might not get all of the information it needed, and that the risk of failing to complete the discharge MDS was that the Centers for Medicare & Medicaid Services (CMS) would not get information regarding the resident's status, and that the patient's information would be inaccurate. The DON opened Resident #3's clinical record and stated that she was admitted on [DATE], and that she was not an active resident because she was discharged on February 22, 2026. The DON stated that the resident was discharged to the hospital for altered mental status, that the resident's son was notified, and that the facility failed to open and complete a discharge MDS for the resident. The DON stated that the facility did not complete a transfer form for the resident and did not obtain a physician's order for the transfer, and she further stated that there should have been an order. The DON stated that the handling of Resident #3's transfer did not meet her expectations, and the failure to complete a discharge MDS also did not meet her expectations. A review of a policy titled, Accuracy of Assessment (MDS 3.0), dated July 2025, revealed that it was the policy of the facility to verify that the assessment accurately reflected the resident's status. The policy revealed that the RN assessment coordinator was responsible for certifying the overall completion of the MDS, and that backdating a completion would not be acceptable. A review of a policy titled Criteria for Transfer and Discharge, dated May 2022, revealed that when the facility transferred or discharged a resident, the facility would ensure that the transfer or discharge was documented in the resident's medical record and that appropriate information was communicated to the receiving health care institution or provider. The policy further revealed that when the facility discharged or transferred a resident, their medical record should have included documentation of the basis for the transfer. The policy also revealed that the information provided to the receiving provider must include the following information at a minimum: contact information of the practitioner responsible for the care of the resident, the resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. The policy also revealed that a copy of the form for the physician to complete when a person was discharged or transferred should have been attached as Attachment A. The facility was cited for this deficient practice February 4, 2026 and was in the process of correcting this deficiency during the dates Identified. The facility did not allege compliance until March 6, 2026 and this deficiency occurred on February 22, 2026.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that the discharge Minimum Data Set (MDS) assessment was completed and accurate for 1 of 21 sampled residents (#3). The deficient practice could result in incomplete and inaccurate medical records for residents.Findings include:Resident #3 was admitted to the facility on [DATE], with diagnoses that included displaced fracture of the base of the neck of the left femur, muscle weakness, displaced simple supracondylar fracture, hypertension, hyperlipidemia, obstructive and reflux uropathy, cognitive communication deficit, polyneuropathy, and muscle weakness.An admission MDS dated [DATE], revealed that a Brief Interview for Mental Status (BIMS) was conducted with a score of 7, which indicated severe cognitive impairment.Resident #3's face sheet revealed that she had a discharge date of February 22, 2026, and that she was discharged to an acute care hospital. Resident #3's census list revealed that she had a discharge date of February 22, 2026. A nursing progress note dated February 22, 2026, at 6:03 a.m. revealed that the resident was transferred to the hospital due to an altered mental status and being non-responsive to verbal stimuli, only to tactile stimuli. The note also revealed that the family and son were notified via phone and that attending answering service was updated on the patient's condition with two calls. A progress note dated February 23, 2026, at 11:09 a.m. revealed that the resident's son and his wife picked up all of the resident's belongings left in the facility. Review of Resident #3's clinical record on June 26, 2026, at 9:34 a.m. revealed no evidence that a discharge MDS was initiated or completed. A follow-up review of Resident #3's clinical record on June 26, 2026, at 11:01 a.m. revealed that a discharge MDS dated [DATE], was initiated and in progress with sections A, B,C, D, E, GG, H, I, J, K, M, N, O, P, and Q being completed on June 26, 2026, after an interview with the MDS assistant (MDS assistant/Staff#58). An interview was conducted on June 26, 2026, at 9:38 a.m. with a registered nurse (RN/Staff#182), who stated that the process for transferring a resident to the hospital included a discharge MDS that needed to be completed for the resident transferring to the hospital, and that the risk of failing to complete the discharge MDS would be that if something happened to the resident during the transfer and documentation was absent, then there could be a negative outcome for the resident, and their last status would not be shown in the documentation. The RN opened the record of Resident #3 and stated that she was admitted on [DATE], and was discharged on February 22, 2026, to the hospital. The RN stated that there was no discharge MDS completed for Resident #3 and that they did not meet the facility's policy expectations for the completion of the MDS. An interview was conducted on June 26, 2026, at 9:49 a.m. with the MDS assistant, Staff #58, who was filling in for the MDS coordinator for the day, and stated that when transferring a resident to the hospital, they were required to complete a discharge MDS. The MDS assistant stated that if the transfer was unplanned, they would indicate it in the discharge MDS and document where the resident was going. The MDS assistant also stated that they would only know what to mark on the discharge MDS through the documentation, so if there wasn't any, she would have to dig for the information. The MDS assistant further stated that if the resident was transferred and out of the facility for less than 24 hours, she believed they would not need to complete a discharge MDS. The MDS assistant stated that the risk of failing to complete a discharge MDS for a resident going out to the hospital was that the facility would not be fully keeping track of their residents, including insurance risks, and that if the resident was in the facility's care last and something happened to them, the lack of completed assessments and documentation could result in harm to the resident if they were not on top of it. The MDS assistant opened the clinical record for Resident #3 and stated that she was admitted to the facility on [DATE], and discharged on February 22, 2026, but the MDS assistant could not find a reason for the discharge. The MDS assistant found a progress note that showed the resident went to the hospital and stated that the facility did not complete a discharge MDS, and that they needed to complete the MDS because she did not return to the facility. The MDS assistant stated that they did not follow their process for completing the MDS when a resident transferred or was discharged , and that the risk of failing to complete the discharge MDS in this case was that it took her forever to figure out what happened to the resident during the interview, they failed to track her status, and they still did not know what happened to her. An interview was conducted on June 26, 2026, at 10:14 a.m. with the Director of Nursing (DON/Staff#15), who stated that she expected that when transferring a resident to the hospital, a discharge MDS should have been completed for a resident going out to the hospital, and that there was no instance in which it should not have been completed. The DON stated that the risk of failing to complete the discharge MDS was that the Centers for Medicare & Medicaid Services (CMS) would not get information regarding the resident's status and that the patient's information would be inaccurate. The DON opened Resident #3's clinical record and stated that she was admitted on [DATE], and that she was not an active resident because she was discharged on February 22, 2026. The DON stated that the resident was discharged to the hospital for altered mental status, that the resident's son was notified, and that the facility failed to open and complete a discharge MDS for the resident. The DON stated that the facility's failure to complete a discharge MDS did not meet her expectations. A review of a policy titled, Accuracy of Assessment (MDS 3.0), dated July 2025, revealed that it was the policy of the facility to verify that the assessment accurately reflected the resident's status. The policy revealed that the RN assessment coordinator was responsible for certifying the overall completion of the MDS, and that backdating a completion would not be acceptable. A review of a policy titled Criteria for Transfer and Discharge, dated May 2022, revealed that when the facility transferred or discharged a resident, the facility would ensure that the transfer or discharge was documented in the resident's medical record and that appropriate information was communicated to the receiving health care institution or provider. The policy further revealed that when the facility discharged or transferred a resident, their medical record should have included documentation of the basis for the transfer. The policy alos revealed that the information provided to the receiving provider must include the following information at a minimum: contact information of the practitioner responsible for the care of the resident, the resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. The policy also revealed that a copy of the form for the physician to complete when a person was discharged or transferred should have been attached as Attachment A.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that resident medical records were completed accurately for two of two residents (#19 & #42) regarding Minimum Data Set (MDS) assessment and pain medication administration record. The universe was 104. The deficient practice could result in incomplete documentation in resident medical records. Findings include: - Regarding Resident #42: Resident #42 was admitted on [DATE] with the diagnoses that included concussion without loss of consciousness , cognitive communication deficit and other symbolic dysfunction. Review of the resident medical record admission Minimum Data Set (MDS) that was submitted to the Centers for Medicare & Medicaid Services (CMS) and accepted on June 22, 2025, revealed that Resident #42 was admitted to the facility on [DATE]. The MDS also revealed that a Brief Interview for Mental Status (BIMS) was conducted with a score of 15, which indicated no cognitive impairment. The MDS further revealed the resident exhibited rejection of care and evaluations that are necessary to achieve the resident's goals for health and well-being at a frequency of one to three days. The MDS revealed that Resident #42 had active diagnoses of coronary artery disease, hemiplegia, traumatic brain injury, disc degeneration, dysphagia, muscle weakness, and scoliosis. No diagnosis of depression was identified on MDS dated [DATE]. Subsequent review of the resident medical record MDS for resident #42 submitted to CMS and accepted for dates September 22, 2025, December 23, 2025, and March 24, 2026 for resident #42 revealed no diagnosis of depression. Review of the Medication Administration Record (MAR) revealed Sertraline HCL 50 milligram (mg) one tablet by mouth one time a day for depression as evidenced by negative statements was ordered by the physician on July 29, 2025. Resident #42 remained on Sertraline 50 mg one tablet by mouth one time a day for depression until physician order dated October 24, 2025, changed the dose of Sertraline HCL to 100mg one tablet by mouth one time a day for depression as exhibited by negative statements. The MAR did not have depression listed as a diagnosis until the Director of Nursing (DON/RN/#15) entered the diagnosis on June 25, 2026 to the resident electronic health record. A review of the medical records for resident #42 on June 26, 2026 noted the DON #15 entered the diagnosis of depression for resident #42 under the active diagnosis list in the electronic health record . An interview with resident #42 on June 25, 2026 at 1:24 P.M. revealed the resident was aware she was taking Sertraline 100mg one tablet a day for depression and negativity. She stated she was unaware of how long she had been taking the medication. She stated she does not have any negative symptoms and does believe that it does decrease her symptoms of being negative to others. Resident #42 does participate in the care plan meetings and they review her medications at that time. An interview was conducted on June 25, 2025 at 1:13 P.M. with DON/staff #15 who stated the resident was taking Sertraline for negative thoughts and does not talk nice at times. She reviewed resident #42 chart under medical diagnosis and she stated that depression was not listed, but should be. An interview was conducted on June 26, 2026 at 9:20 A.M. with MDS Assistant (RN/staff #58) stated that she is the primary person responsible to complete and submit the resident MDS. The Staff #58 stated that she completes the MDS with a seven day look back period by reviewing the resident electronic health record and if the information is not correct the MDS could be inaccurate. Staff #58 stated that if a resident is taking Sertraline HCL for depression the diagnosis should be in the resident electronic medical record under medical diagnosis and should be on the MAR. She stated that the March 24, 2026 MDS was submitted to CMS with no indication of depression listed under active diagnosis. Staff #58 stated the risk of the MDS not being accurate could be flagged by CMS for not accurately submitting MDS and could cause an insurance issue. Also, it could possibly harm the resident if the resident does not have a diagnosis for the medication they are receiving. -Regarding Resident #19: Resident #19 was readmitted on [DATE], with a diagnosis that included cerebrovascular disease, dementia, severe protein-calorie malnutrition, obstructive pulmonary disease, type 2 diabetes mellitus, chronic respiratory failure, senile degeneration of the brain, insomnia, hyperlipidemia, hypertension, depression, and mood disorder. A care plan initiated on September 04, 2025, had a focused area that Resident #19 was prescribed an opioid for chronic pain; the potential for adverse outcome from opioid use was low risk. A physician order dated September 04, 2025, had an order for Hydromorphone Hydrochloride(HCL) 2 milligrams (MG) Tablets. Give 1 tablet by mouth every 8 hours for pain. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04, indicating Resident #19 was severely cognitively impaired. Review of the Narcotics sheet for Resident #19 dated April 03, 2026, for Hydromorphon 2 mg tablet revealed that on May 01, 2026, one tablet was taken out of the medication cart at 2:00 PM; however, it was not documented in the Medication Administration Record (MAR). Review of the Narcotics sheet for Resident #19 dated April 03, 2026, for Hydromorphon 2 mg tablet revealed that on May 13, 2026, one tablet was taken out of the medication cart at 06:20 AM; however, it was not documented in the MAR. Review of the Narcotics sheet for Resident #19 dated May 28, 2026, for Hydromorphon 2 mg tablet revealed that on June 06, 2026, one tablet was taken out of the medication cart at 09:00 PM; however, it was not documented in the MAR. Review of the Narcotics sheet for Resident #19 dated May 28, 2026, for Hydromorphon 2 mg tablet revealed that on June 14, 2026, one tablet was taken out of the medication cart at 10:00 PM; however, it was not documented in the Medication MAR. Review of the Narcotics sheet for Resident #19 dated June 16, 2026, for Hydromorphon 2 mg tablet revealed that on June 22, 2026, one tablet was taken out of the medication cart at 10:00 PM; however, it was not documented in the Medication MAR. An interview was conducted on June 26, 2026, at 09:26 AM with Licensed Practical Nurse (LPN/staff #51), who stated that the facility process for administering scheduled pain medications is to first look over the order, get the medication, check the name of the medication and resident, double-check the dosage, give it to the resident, log in to the narcotics book and check it on the MAR, must be in both places. She stated that Resident #19 should have had Hydromorphone HCL 2 mg tablet checked off in the MAR. She stated that if it is not marked in only one place, then it could risk issues such as Resident #19, where his medication time frame could be missed or a staff member could miss medication, or give the medication too soon. An interview was conducted on June 26, 2026, at 10:03 AM with the Director of Nursing (DON/staff #15), who stated that the facility process for administering scheduled pain medication is that the nurse will verify the order and the resident, then they will administer the medication and document in the Medication Administration Record. She stated that the narcotics sheet will help verify if the medication was given to the resident or not. She stated that for Resident #19, his MAR was not documented for Hydromorphone when reviewing the chart. The DON did not offer any risks or possible harm for the resident. Reviewed the policy Medication Administration-Oral Revised date May 2025, revealed that it is the policy of the facility to accurately prepare, administer, and document oral medication. When administering unit doses, document administration of medication Facility policy titled: Documentation and Charting, revised 10/2025 states a complete account of the resident care, treatment, and response to the care, signs and symptoms, etc. as well as the progress of resident's care. Facility policy titled Accuracy of Assessment (MDS 3.0), reviewed 7/2025 states it is the policy of this facility to verify that the assessment accurately reflects the resident's status. To verify that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. The physical, mental and psychosocial condition of the resident determines the appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medcial social workers, dietitians, and other professionals in assessing the resident and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs. On an assessment or correction request, the RN Assessment Coordinator is responsible for certifying overall completion once all individual assessors have completed and signed their portion(s) of the MDS. When MDS records are completed directly on the facility's computer (e.g., no paper form has been manually completed) the RN Coordinator signs and dates the computer-generated hard copy or provides an electronic signature. Backdating a completion is not acceptable. A registered nurse (RN) must sign and certify that the assessment is completed. Review of a facility policy titled Psychoactive Medication, revised 10/2025 states it is the policy of the facility to maintain every resident's right to be free from use of psychoactive medication. A physician's order is necessary for the use of psychoactive medication. No psychoactive medication will be utilized without a specific physician's order or without a diagnoses specific condition and will include the target behavior.

Based on observations, staff interviews, and a review of facility policy and procedures, the facility failed to ensure that infection control standards were maintained when using reusable medical equipment to obtain resident vital signs and that enhanced barrier precautions were followed. The deficient practices could result in the spread of infection to residents.Findings include:During a vital sign documentation observation conducted on June 25, 2026, at approximately 2:47 p.m., a Certified Nursing Assistant (CNA/staff #33) was observed entering a resident room occupied by resident #28 and resident #2 to obtain blood pressure and pulse oximeter readings for both residents. The observation revealed that the CNA knocked on the resident's door and did not perform hand hygiene before entering the room. Observation of a sign posted outside of the resident's room revealed that both residents were on Enhanced Barrier Protections (EBP). Observation of the CNA revealed that she greeted resident #28 in bed A and placed the blood pressure cuff on the resident's arm and the pulse oximeter on his finger. Observation revealed that the CNA removed the blood pressure cuff from the resident's arm and hung it on the cart without sanitizing the equipment after use. Observation further revealed that the CNA also removed the pulse oximeter from the resident's finger and placed it in her pocket without sanitizing the equipment after use. Observations revealed that the CNA did not perform hand hygiene after she assessed the resident's vital signs. The CNA was observed moving the blood pressure cart to resident #2 bed B. Hand hygiene was not performed by the CNA as she moved from the resident #28 in bed A to resident #2 in bed B. Observations revealed that the CNA placed the same blood pressure cuff on the resident's arm and same the pulse oximeter on his finger. Observations further revealed that the CNA removed the blood pressure cuff from the resident's arm and hung it on the cart without sanitizing the equipment after use. Observations revealed that the CNA removed the pulse oximeter from the resident's finger and placed it in her pocket without sanitizing the equipment after use. Observations revealed the CNA retrieved lip balm from her pocket and applied it on her lips in the resident's room. Observations revealed that the CNA exited the resident's room with the blood pressure cart and did not perform hand hygiene or sanitize the equipment after use on both resident #28 and resident #2. The CNA/staff #33 entered the room of resident #8 on June 25, 2026 at approximately 2:54 p.m. to assess the vital signs of the resident. A sign posted outside the resident's room revealed that the resident was on EBP. The CNA did not perform hand hygiene, did not put on a gown and gloves, and did not sanitize the blood pressure cuff or pulse oximeter before she entered the resident's room. The CNA placed the blood pressure cuff on the resident's arm and the pulse oximeter on his finger. The CNA removed the blood pressure cuff from the resident's arm and hung it on the cart without sanitizing the equipment after use. The CNA removed the pulse oximeter from the resident's finger and placed it in her pocket without sanitizing the equipment after use. CNA/staff #33 exited the resident room and did not perform hand hygiene.An interview was conducted on June 25, 2026, at 2:57 p.m. with CNA/staff #33. CNA/staff #33 confirmed that she did not sanitize either the blood pressure cuff or the pulse oximeter between resident uses. She stated that facility policy is for the blood pressure cuff and pulse oximeter to be sanitized between each use and that the devices are sanitized using the bleach wipes observed to be present and full on the blood pressure equipment cart. She stated potential outcomes that could result from medical equipment not being sanitized between resident use, which included bacteria and germs could travel from resident to resident. CNA/staff #33 confirmed she was not wearing a gown or gloves in an EBP room. She stated that the facility policy was to wear a gown and gloves in EBP rooms when providing care. She further stated that her actions were not compliant with facility policy and could result in germs being spread between residents. An interview was conducted on June 25, 2026, at approximately 3:33 p.m. with the Director of Nursing (DON/staff #15). The DON stated that facility policy was for reusable medical devices, such as blood pressure cuffs and pulse oximeters, to be sanitized after each resident use and that bleach wipes are used to sanitize them. She stated potential outcomes that could result from not sanitizing reusable medical devices between resident use included the spread of infection. The DON stated that CNA/staff #33's observed failure to sanitize reusable medical devices between resident uses did not meet facility expectations. The DON stated that gowns and gloves must be worn by team members in an EBP room when providing direct care to a resident in a close contact environment. She stated that CNA/staff #33's observed failure to wear a gown and gloves in resident rooms with EBP while using reusable medical devices to obtain a resident's vital signs did not meet facility expectations.The facility's policy titled, Infection Prevention and Control Program (IPCP) Standard and Transmission-Based Precautions, dated April 2025, revealed that it was the policy of this facility to implement infection control measures to prevent the spread of communicable diseases and conditions. Procedures included proper use of Personal Protective Equipment (PPE) when applicable, hand hygiene, environmental cleaning and disinfection, and reprocessing of reusable medical equipment. The facility policy further revealed that a gown and gloves must be used during high-contact resident care activities for residents on EBP. The policy further revealed that for residents on EBP, frequent cleaning/disinfection of shared equipment and environmental surfaces, changing PPE, and performing hand hygiene between residents may be implemented. Facility policy review revealed Standard Precaution Procedures that included proper selection and use of PPE, hand hygiene, and reprocessing of reusable medical equipment.

Based on clinical record reviews, interviews, and review of facility policies, the facility failed to ensure a discharge summary was completed for one resident (#64). The deficient practice could result in an unsafe discharge for residents.Findings include:Resident #64 was admitted to the facility on [DATE] with diagnoses of foot drop of the left foot, wrist drop of the left wrist, and a fracture of the lower end of the left radius. Review of the discharge Minimum Data Set (MDS), dated [DATE] indicated that Resident #64's return was not anticipated. The same MDS indicated staff assessed her cognitive skills for daily decision making as independent.Review of the clinical chart revealed a progress note, dated December 10, 2025 at 2:38 P.M., indicated that a referral was sent to another facility per the request of the resident's family member.A second progress note, dated December 11, 2025 at 7:30 P.M., indicated that the receiving facility had received authorization through the resident's health insurance and had accepted the resident. It also stated Transfer scheduled for (December 12, 2025).The last progress note, dated December 12, 2025 at 3:49 P.M., revealed that a report was called to staff at the receiving facility and the resident was sent with her belongings and medications on hand.Further review of the clinical record did not reveal a discharge summary on file.An interview was conducted on February 4, 2026 at 12:11 P.M. with Social Services (SS/Staff #44). Staff #44 explained that discharge summaries are completed by the nurse who does the assessment and then social services will complete another section of it. Information such as home health agencies or any durable medical equipment (DME) that the resident is needing, future provider appointments, the Ombudsman's office and the facility's contact information is included in the summary. However, Staff #44 included that they do not do discharge summaries for residents who transfer out of the facility and nothing is documented in the chart. She added that they typically send a packet, via e-mail, with medication information, provider notes, health & physical information, therapy notes, medication list and a transfer order to the receiving facility. Staff #44 described Resident #64 as being transferred because she went to another facility.An interview was conducted on February 4, 2026 at 12:44 P.M. with the MDS Coordinator/Unit Manager/Licensed Practical Nurse (LPN/Staff #10). Staff #10 described a resident discharge as when a resident leaves the building. A transfer would be when they go to another facility or hospital and we expect them to come back. Staff #10 looked at Resident #64's MDS list in the clinical record and shared that she was discharged and her return was not anticipated. She added that this would be considered a discharge. Staff #10 shared that social services would open the discharge process and identify any resources that a resident might need such as home health services. Then the nurses will do the clinical portion of the discharge process. Staff #10 further added that she was not able to locate a discharge summary in Resident #64's clinical record. Staff #10 reviewed the progress notes in the clinical chart and shared that social services had sent the resident's referral on (December) 10th and the insurance was accepted on (December) 11th, while the resident left the faciity on (December) 12th. She added that she assumed the discharge summary was not opened up because she was going to another facility.An interview was conducted on February 4, 2026 at 1:09 P.M. with the Social Services Director (SSD/Staff #13). Staff #13 described a discharge as when a person leaves the facility to go home and a transfer is when a patient is moved from one facility to a different facility. She also explained that a discharge summary is done when a person is discharging from the facility to their place of residence. She further explained that the facility does not do discharge summaries for residents who transfers to another facility. The discharge summaries have a nursing section for clinical information in addition to a section where home health and DME information can be added. The transfer information is sent to the receiving facility over the phone via a nursing report.A request was made on February 4, 2026 at 1:25 P.M. for the facility's discharge summary policy. At 1:50 P.M., the Administrator/Staff #1 informed surveyor that the facility did not have a policy related to this.A policy titled, Discharge Planning Process indicated it was last revised in September 2023. The policy stated that It is the policy of this Facility that the discharge planning process focuses on the resident's discharge goals, involving the residents as active partners. The discharge process should effectively transition them to post-discharge care, and minimize clinical or other factors which are related to the possibility of a readmission. The policy did not have language related to a Resident's Discharge Summary.

Based on clinical record reviews, interviews, and review of facility policies, the facility failed to ensure that a resident's discharge rights were honored during a discharge appeal. The sample size was 3. The deficient practice could result in the resident not being able to receive services to support their recovery.Findings include:Resident #32 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis, morbid (severe) obesity, and type 2 diabetes.Review of the discharge Minimum Data Set (MDS), dated [DATE], indicated Resident #32 completed a Brief Interview for Mental Status (BIMS) and scored a 15 which indicated she was cognitively intact.Review of the Progress Notes in Resident #32's clinical chart revealed an entry, dated September 25, 2025 at 4:55 P.M. The entry stated that the resident was given a Notice of Medicare Non-Coverage (NOMNC) with a last date of service as September 27, 2025. The note indicated the discharge date was September 28, 2025. It also indicated that Resident #32 disagreed with the discharge and was considering filing an appeal.Review of a second Progress Note, dated September 26, 2025 at 2:21 P.M. indicated Resident #32 filed an appeal.Additional review of Progress Notes revealed a note dated September 27, 2025 at 10:26 A.M. that noted Resident #27 was discharging home.Further review of Progress Notes gave no indication that the resident was discharging a day early on her own accord or that the resident was reminded that her actual discharge date was the next day at no cost to her.The final Progress Note, in Resident #32's, clinical record revealed a note written on September 29, 2025 at 1:23 P.M. The note revealed that Resident #32 was contacted and informed that she had won her appeal and was able to return to the facility.Review of the actual NOMNC form indicated the last day of Skill Nursing Facility Services was September 27, 2025. It also indicated the resident has the right to appeal the decision to end Medicare coverage of your services. The bottom of the form revealed a signature that belonged to Resident #32 with a date of September 25, 2025.An interview was conducted on October 21, 2025 at 2:26 P.M. with Resident #32 via telephone. She explained that she was not aware that she could stay at the facility while her NOMNC appeal was pending and that she had felt forced to leave on September 27, 2025. She also shared that she felt conflicted about leaving because she didn't feel ready but she also missed her home.An interview was conducted on October 21, 2025 at 1:32 P.M. with Social Services (Staff #47). Staff #47 shared that residents are able to stay at the facility while appealing the upcoming discharge. However, she also shared, that if they do not get an appeal status prior to their discharge, they would be responsible to pay for the costs of services if the appeal is denied. Staff #47 also added that without therapy services, the cost for a bed is $250 a day. Staff #47 indicated that Resident #32 did file an appeal however, the appeal was faxed to the facility on a Saturday which was September 27, 2025. Staff #47 indicated that she does not work weekends.An interview was conducted with Social Services Supervisor (Staff #63) on October 22, 2025 at 8:26 A.M. Staff #63 shared that residents are able to stay at the facility while a NOMNC appeal is pending and they will still provide therapy services. She added that the facility does not discharge residents while the appeal is pending but they do explain to residents that they might be responsible for the costs of services provided past the coverage date if the appeal is denied. Staff #63 indicated that Resident #32 appealed her discharge on [DATE] and the facility was notified of the outcome of the appeal on September 29, 2025. Staff #63 was not able to identify why Resident #32 was discharged a day before her planned discharge date of September 28, 2025. She also acknowledged that she had no way of knowing if Resident #32 discharged on her own the day before because there was no progress note indicating that.An interview was conducted on October 22, 2025 at 9:02 A.M. with Director of Nursing (DON/Staff #8). Staff #8 explained that the NOMNCs are issued to residents and they are then informed of when their discharge date is. However, there is a process for appeals if a resident wants to appeal the discharge and residents are informed that they are able to stay at the facility while the appeal is being processed. Staff #8 added that residents are informed that might have to private pay (pay out of pocket) a day or two while the appeal is going through if the appeal is denied. She also indicated that residents are able to discharge, if they wanted to, while the appeal is pending. Staff #8 explained that Resident #32 was issued a NONMNC on September 25, 2025 and the last date of service was September 27, 2025 and she was set to discharge on [DATE]. She added that resident #32 appealed the discharge on [DATE]. Staff #8 was asked to read the discharge policy and she indicated that the policy stated the resident was not to be discharged if there was an appeal. Staff #8 indicated that Resident #32 was alert and oriented and could have left the faciity on her own free will. However, she was not able to provide documentation that Resident #32 left the faciity on her own. Staff #8 shared that the risk to the resident, if they are discharged while an appeal is pending, is that the resident could be unsafe.Review of the policy titled, Criteria for Transfer and Discharge, indicated that it was last revised in October 2024. Section 2 of the policy states If the resident exercises his or her right to appeal a transfer or discharge notice, the Facility shall not transfer or discharge the resident while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident.

Based on clinical record reviews, staff interviews, facility documentation, and facility policy, the facility failed to ensure one resident was free from preventable accidents including elopement. This deficient practice could result in life-threatening injuries. Findings include: -Resident #100 was admitted to the facility on [DATE] with diagnoses that include diabetes mellitus type 2, lupus, vascular dementia, chronic kidney disease, depression, and hypertension. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 11, indicating mild cognitive impairment. A care-plan initiated April 29, 2025 revealed the resident is at risk for falls related to multiple diagnoses, including a history of 7 falls from May 6, 2025, to August 22, 2025. There are noted interventions of 1:1 as staffing allows, continue wander guard, and resident in room with high traffic area near nurse's station. This indicating the resident is high risk for falls. A care-plan initiated August 22, 2025 revealed the resident had an elopement episode and was an elopement risk / wanderer, with a goal of safety will be maintained and noted interventions of document wandering behavior, attempt diversional interventions, and one to one as staffing allows. This indicates the resident is high risk for elopement. An elopement assessment risk evaluation dated April 29, 2025 revealed the resident was assessed with a score of 3, indicating very low risk for elopement. An elopement assessment risk evaluation dated August 18, 2025 revealed the resident had dementia, and was given an elopement score of 11, indicating high elopement risk. A progress note dated July 30, 2025 at 6:30 a.m. revealed that a CNA heard a noise from resident #100's room and rushed to the room, found resident #100 on the floor, got patient up with 2-assist (two staff members required), started neuro checks (an assessment to check the mentation of the resident), and that resident #100's vital signs were within normal range. A progress notes date August 22, at 6:00 p.m. revealed the fire department arrived at the facility and notified a licensed nurse that resident #100 was found outside of the facility and as being transported to the local hospital as a precaution. The note further states that the son was made aware, and that the local police department called related to the incident, as well as the provider was made aware. A progress note dated August 22, 2025 at 10:30 p.m. revealed staff received report from nurse the local hospital, and assessments were largely negative except that the resident had a left knee skin tear. An IDT progress note dated August 25, 2025 at 10:07 a.m. revealed review of incident on August 22, 2025 that resident #100 was found outside of the facility, had a reported fall and was transferred to the emergency room. It further states the resident was returned to the facility with a negative CT scan to head, and negative x-rays to neck and face, and also noted the resident had some edema to arms, with a pending x-ray. It also noted that a new wander guard was in place as a precaution. A progress note dated august 25, 2025 at 6:05 p.m. revealed resident #100 left the facility for a right arm fracture via wheelchair with transport and accompanied by staff. A progress note dated August 25, 2025 at 7:00 p.m. revealed that transportation was set up for the resident to see an orthopedic surgeon, and that the son was at the appointment with resident #100. A progress note dated August 25, 2025 at 9:15 p.m. revealed that resident #100 returned to the facility accompanied by staff/CNA. A provider progress note, signed August 29, 2025 at 10:10 a.m. revealed staff reported to provider recent incident of patient elopement. Resident #100 left the facility through the front door, and states she sneaked out and walked off property believing a casino was right there. It states resident #100 asked a passerby for directions and continued walking. Resident #100 was found by paramedics near a different nursing facility. It further states the resident fell and sustained an upper extremity injury, and that the initial evaluation at the local hospital missed the fracture, and increasing pain and swelling prompted transfer to different local hospital where x-rays confirmed the fracture. It further stated that orthopedic surgery is scheduled for repair and rotator cuff. The note concludes that resident #100 continues to have delusional behavior, and that the delusions contributed to resident #100's elopement and subsequent injury. A review of therapy notes dated September 26, 2025 revealed the resident was on precautions for falls, non-weight bearing for right upper extremity, right shoulder periprosthetic fracture, a sling for comfort, and a history of dementia. A review of hospital records for resident #100 dated August 22, 2025 at 5:43 p.m. revealed resident #100, with an unknown medical history, dementia, and on blood thinners, was found down. It further stated the resident was a memory care patient, found on the street. The note continues that resident #100 has pain in her face, blood around her nose, and denies other recent illness or injury. It states resident #100 highly endorses some pain, and that she does not recall why she fell. The summary concludes that at this time, symptoms consistent with patient wandered off and tripped, and that the resident was being sent back to the facility. Review of information received from the SA complaint tracking system on August 26, 2025 at 2:15 p.m. revealed that resident #100 had left the care facility and was never reported missing. The fire department located her an hour after she was last seen at the facility following a fall. The report concludes that the facility is neglecting resident #100 and not doing their job. An interview was conducted with a Certified Nursing Assistant (CNA staff/#20) on September 26, 2025 at 12:07 p.m. The CNA stated she has been a CNA for 25 years. The CNA stated that resident #100 doesn't like her because I remind her of the woman her husband cheated on him with. The CNA stated that resident #100 is not alert and oriented at all, and very demented. An interview was conducted with a Licensed Practical Nurse (LPN staff/#30) on September 26, 2025 at 12:50 p.m. The LPN stated resident #100 is in and out, and that she knows my name and remembers people she likes, and that she is not alert and oriented, at best alert and oriented 1-2(to person and place). The LPN stated that the resident can walk, and is doing restorative with restorative aids that can walk the patient. The LPN states that she does walk, but usually it's with someone. When asked about the incident the LPN states that she went out the door, and that's why she's on a 1 to 1. The LPN stated that the last time she saw resident #100 that day was on her way to bingo, and that resident #100 is constantly delusional, with resident #100 telling people she is pregnant, and stated she said don't worry, these are tears of joy I found my husband at the casino. The LPN stated that in the event of an elopement they are supposed to call a code yellow and announce it on the intercom. An interview was conducted with a Registered Nurse (RN staff/#40) on September 26, 2025 at 1:17 p.m. The RN stated she has been here for a year, and had heard of the incident. She stated that resident #100 is not alert and oriented, alert and oriented a 2 on a good day. She states that resident #100 gets better and worse. She stated that I can go into her room in the morning and be normal, and in the evening she's back to confusion. The RN further stated that the resident states delusional things like she is pregnant, and has a lot of behaviors. The RN stated that she thinks all the doors have wander guards, and that the door on the 100 hall has a wander guard that didn't work before. The RN further stated that the patio door on 100 wander guard doesn't work. The RN stated that she was told that resident #100 got out, and was found down the street with bruises. The RN stated that the resident fell in front of a store, and stated she said she was going to the casino. The RN stated that when a resident elopes they are supposed to notify everyone, start a code yellow and announce the room number and check outside. An interview was conducted with the Assistant Maintenance Director (staff/#45) on September 26, 2025 at 1:37 p.m. Staff #45 stated that the facility uses a ticket system where staff can submit tickets to fix broken things in the facility. He further stated that he doesn't fix all things, mostly things like doors and smaller things, the bigger repairs are handled by the Director, including wander guards. Staff #45 further stated that most doors in the facility have stop alarms on doors and not wander guards. He stated the only door that has a working wander guard was the front door, and that the rest have generic alarms. He concluded that they have a test wander guard at the reception desk and it is tested regularly. An interview was conducted with a Certified nursing assistant (CNA staff/#50) on September 26, 2025 at 1:55 p.m. The CNA stated that here the day the incident occurred. The CNA stated she remembers seeing resident #100 in the morning, and that she is always all over the place. The CNA stated that she walks around a lot, wanders, and has a walker and can walk around. The CNA stated that she was always trying to go out at night to the casino with her cousin. She stated they would redirect her and tell resident #100 her cousin was coming in the morning. The CNA further stated that there was never a code yellow called while she was in the facility, and that she heard about everything that happened after she came back. The CNA concluded that she remembers it being short staffed that day, that she doesn't think there was a CNA on that unit where resident #100 resides for evening shift, and stated I just remember they were really panicked about CNA's. An interview was conducted with a Registered Nurse (RN staff/#60) on September 26, 2025 at 2:40 p.m. The RN stated that nobody knew resident #100 was gone. The RN stated that EMS took her to the hospital and that the police came to the facility to inform us that she was found. The RN stated resident #100 was last seen in the activities room, but that she moves around a lot. The RN stated that resident #100 often states I wanted to go to the casino, and that they had no idea how resident #100 got out of the facility. The RN stated that after the incident occurred and the police reported to us that she was found, that they checked all the doors to see how she got out. The RN concluded that the resident gets confused easily and moves around just fine with a walker. An interview was conducted with the Director of Nursing (DON staff/#75) on September 26, 2025 at 3:23 p.m. The DON stated she was aware of the incident with resident #100, and that the resident walks up and down the units, and was not exit seeking. The DON stated that she didn't have a change of condition prior to the incident, and that sometimes she has delusions, says she's pregnant, and usually has these behaviors when she has retention so that's when they go to check on her. The DON stated resident #100 hasn't had exit seeking behavior since the incident. The DON stated that the fire department showed up and told them resident #100 was found, and stated yeah we didn't even know she was gone. The DON stated that they were not short staffed, and the resident was found at cross streets a few blocks away. The DON stated that resident #100 stated she was going to the casino. The DON stated there are no cameras in the hallways of the facility, so there was no way to see which way the resident exited. The DON concluded that nobody called a code yellow because nobody knew resident #100 was gone. A review of facility policy titled 'Resident Assessment' revised August 2024, revealed that it is the policy of this facility that services provided by the facility meet professional standards of quality and be provided by qualified persons in accordance with each resident's care plan.A review of facility policy titled 'Elopement / Unsafe Wandering' revised December 2024, revealed that it is the policy of this facility to provide a safe environment, as free of accidents as possible for all residents through appropriate assessment, interventions, and adequate supervision to prevent accidents related to unsafe wandering or elopement while maintaining the least restrictive manner for those at risk for elopement.

The facility failed to ensure a durable medical equipment (DME), wheelchair, in compliance with a provider's order was provided upon discharge to meet one resident's (#11) basic need for safe discharge. The deficient practice could place residents not meeting their highest practical level of medical, physical and psychosocial well-being while at home.Based on closed record review, staff interviews, review of facility's documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a durable medical equipment (DME), wheelchair, in compliance with a provider's order was provided upon discharge to meet one resident's (#11) basic need for safe discharge. The deficient practice could place residents not meeting their highest practical level of medical, physical and psychosocial well-being while at home.Findings include:Resident #11 was admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus (DM), hypertension, cellulitis, urinary tract infection (UTI), and history of falls.Review of care plan initiated on January 10, 2024 revealed resident was at risk for impaired cognitive function/dementia or impaired thought processes; activities of daily living (ADL) self-care performance deficit; and at risk for falls related to sepsis, recent Covid infection, acute respiratory failure, urinary tract infection (UTI), and metabolic encephalopathy.Review of five-day Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12.0, moderately impaired. Review of social service summary progress notes dated January 17, 2024 revealed resident was admitted status post hospitalization for severe sepsis, UTI, bilateral lower extremity cellulitis, right buttock decubitus ulcer needing debridement and wound was closed, resident lives alone in a single story home, prior level of function (PLOF) was independent with ADLs and ambulation, does not own any durable medical equipment (DME), and discharge plan is to go back home with family to stay with her and home health.Review of another care plan initiated on January 23, 2024 revealed resident has bowel and bladder incontinence related to impaired mobility.Review of physician's progress notes dated January 26, 2024 revealed that resident was complaining of overall weakness and fatigue. Resident was educated on improving her nutrition and increasing water intake during the day. Physician ordered lab work to rule out any electrolyte deficiency. Review of another social service progress notes dated January 30, 2024 revealed resident and representative was presented with Notice of Coverage (NOC) for last coverage day of February 1, 2024; a discharge date of February 2, 2024; appeal option was explained; resident signed the form with no issues or questions; resident to discharge to home with home health services; and resident family member was from out of town to physically assist resident.Review of records title, LN-Daily Skilled V3.0 - V 2, dated January 29, 2024 revealed resident used wheelchair for mobility, propels self and requires moderate assistance of one for ADL care.Review of records title, LN-Daily Skilled V3.0 - V 2, dated January 31, 2024 revealed resident used wheelchair for mobility, propels self for short distances and requires assistance with ADL care.Review of discharge MDS assessment dated [DATE] revealed a BIMS score of 10.0, moderately impaired; resident's discharge performance assessment revealed that resident required substantial/maximal assistance for toileting hygiene; partial moderate assistance for shower/bathe self, sit to stand, chair/bed -to-chair transfer, toilet transfer, and lower body dressing; supervision/touching assistance for once standing, the ability to walk at least 10 feet in a room, corridor, or similar space; and walk for at least 50 feet was not attempted due to medical condition or safety concerns. Review of record titled, Discharge summary and Post-Discharge Plan of Care - V 4, dated February 2, 2024 revealed resident's discharge transportation was through insurance transportation.Review of the States Agency ‘s complaint tracking system revealed that on February 2, 2024, a fire district department responded to a call to assist a person who was sent home and was unable to walk on her own. The facility made accommodation to provide the resident with a wheelchair but did not make sure that the equipment was with the resident prior to discharge. The resident's representative was not capable of helping the resident into the house. An ambulance was sent to pick up the wheelchair from the facility so the resident would not be confined to her bed.Another review of social service progress note dated February 2, 2024 revealed the following:- social service received a call from a fire district department stating that resident was at home without a wheelchair and resident is not ambulatory;- the resident's wheelchair was delivered at the facility;- social service asked if a resident's family would be able to come and pick up the wheelchair or social service can call the durable medical equipment company to deliver the wheelchair to the resident's home address but social service could not give a date or time of delivery; - the resident's wheelchair was not given to resident at time of discharge due to social service did not see resident leave; and-at approximately 5:00 PM, the fire department arrived at the facility and picked up the resident's belongings which included the resident's wheelchair, resident's [NAME] monitor and resident's two shirts. An interview was conducted on July 8, 2025 at 1:53 PM with a certified nursing assistant (CNA/Staff #20) in the conference room. Staff #20 stated that the skilled unit is the same as the long-term care unit. Her responsibilities include taking vital signs (VS), passing ice and water, helping the residents change their briefs, and getting the residents ready for therapy. She stated that during discharge process, she mainly gets the resident's belongings together, some residents have their own wheelchair and or walkers, and if the resident did not come in with a walker or a wheelchair, the nurse will notify her if the resident was full weight bearing or not.An interview was conducted on July 8, 2025 at 2:14 PM with Physical Therapy Assistant (PTA/Staff #18) in the therapy room. Staff #18 stated that his responsibility includes following the physical therapist (PT) plan of care and he works with the residents daily. Regarding the discharge process, he gives assessment report to the PT. In addition, he stated that the PT evaluates the residents' need for DMEs, the social service orders the DMEs, and it's preferably for the DMEs to be delivered at the facility so the resident can use it prior to leaving the facility but sometimes it does not work that way.An interview was conducted on July 8, 2025 at 2:23 PM with a Certified Occupational Therapy Assistant (COTA/Staff #15) in the conference room. Staff #15 stated that she is responsible for daily treatment assigned to her, daily documentation, and communicating to PTA. She stated that most residents have wheelchair as their baseline on evaluation. She stated that if a resident requires a maximum assistance to the bathroom, resident would be needing a wheelchair, elevated toilet seat, depends on how much help the resident might need at home, and a recommendation for home health for continuation of care to prevent regression. She stated that every Tuesday, there is a rehab staff meeting discussing for example residents' nearing discharge and alternate placement. The discharge discussion starts way before discharge date . She stated that if a resident requires a maximum assistance, the rehab department makes recommendations to social services for DMEs. The rehab staff will give to social services the DME measurements because residents comes in different sizes, the social service will get the DME ordered, and the wheelchairs and or walkers can be delivered on day of discharge. When the DME is not delivered on the day of discharge, the social service can call the company delivering the wheelchair or walker equipment to make sure it is delivered, and sometimes the residents who need the DMEs such as a wheelchair or a walker at home can borrow the facility's equipment if the equipment was not delivered upon discharge.An interview was conducted on July 8, 2025 at 2:38 PM with Registered Nurse (RN/Staff #30) in the conference room. Staff #30 stated that regarding discharge process, she makes sure that there is a written order so prescriptions can be refilled, the DMEs are set up by the social worker, she will notify the social worker or the director of nursing (DON) if the DME was not delivered prior to discharge or the day of discharge. She stated that a DME is important to prevent risk of fall or injury, and it is a way for a resident to get back to recovering and have a normal function as much as possible.An interview was conducted on July 8, 2025 at 3:09 PM with the Social Service Director/Staff #29. Staff #29 stated that her responsibility includes discharge planning, dealing with residents' complaints, and as a resource for the community. Staff #29 stated that discharge planning begins on admit and it includes home health and DMEs. She stated that the interdisciplinary team (IDT) meets on Tuesdays and Wednesdays to talk about residents' progress and if the residents are meeting their goals. Regarding the Notice of Medicare Coverage (NOMC), she gives the form to the resident 2 to 3 days from their last covered day and resident can have the opportunity to appeal. Furthermore, she stated that regarding what equipment the resident needs upon discharge, the therapy department helps determine what DME the resident needs, she will ask the provider to order it and asked the equipment to be delivered prior to discharge. If a resident left the facility without their DME, sometimes residents will not wait until their equipment comes, she stated that she will follow up by calling the company to make sure the resident receives the equipment. If the resident needs the equipment at home, she stated that ideally the equipment would have been delivered because she sends referrals in advance, home health services will not let her send referrals greater than 48 hours, but for DME referrals, she sends the DME referrals as soon as she is sure the resident needs the equipment. She stated that Resident #11 left the facility early on February 2, 2024 without her wheelchair, resident's wheelchair was left at the facility, and the fire department came and picked up the resident's wheelchair. An interview was conducted on July 10, 2025 at 8:16 AM with a Therapy Program Manager/Staff #33. Staff #33 stated that DME depends on what equipment the resident already have prior, and she will try to get the resident back to using the equipment prior to their level of function. If a resident needs a new equipment to use, she stated that she will give recommendation to the social service to order the equipment, and the recommendation is based on near discharge date . She stated that a wheelchair is recommended if a resident was not walking, resident is not at their baseline, or not walking long distances. If the resident's wheelchair was not delivered on discharge day, she stated that they can loan the equipment. She does not want a resident leaving the facility without the equipment if the equipment was recommended because it is a safety concern, to prevent a fall and injury. She stated to always provide resources and equipment to residents on discharge if their equipment did not come on time. A phone interview was conducted on July 10, 2025 at 8:57 AM with a DME company/Staff #400. Staff #400 stated that orders from the facility are faxed to their office and the DME order is added to the resident's account. Staff #400 stated that Resident #11's wheelchair was delivered on February 1, 2025 at bedside, in the resident's room. An interview was conducted on July 10, 2025 at 2:49 PM with the Director of Nursing (DON)/Staff #40. The DON stated that regarding a wheelchair, it depends on the order and recommendation from therapy, and sometimes resident or family request a wheelchair and not based on recommendation. The DON stated that the doctor gives orders for the DME, therapy recommends the DME, the nurse gets the order from the provider, social service orders the DME and faxes the order to a DME provider company. The DME can be delivered at the facility or at the resident's home. The DON stated that there was an order for a wheelchair for Resident #11 on January 30, 2024. The DON stated that the DME company will only deliver the day of discharge. The DON stated that sometimes their facility will let the resident borrow the facility's wheelchair. In addition, she stated that if the wheelchair was delivered and the resident left, she will call to have the wheelchair picked up. She stated that if resident left without the wheelchair, she is assuming that the resident is not wheelchair bound. If resident without a wheelchair, resident's family can pick up or the DME company can pick up the wheelchair from the facility and deliver it to the resident's house. DON stated that Resident #11's wheelchair was picked up by the fire department at 5:00 PM. The DON stated that Resident #11 therapy notes revealed that resident is ambulatory for 12 feet, had a walker at home, and resident might need, would need a wheelchair for longer distances. The DON stated that a longer distance would be farther than 12 feet. Review of facility's policy, Discharge or Transfer, last revised on July 2024 revealed that it is the policy of the facility to provide the Resident with a safe organized structured transfer and or discharge from the facility that will meet their highest practical level of medical, physical and psychosocial well-being. (3) Transfer/discharge: Home (G) CNAs to inventory all personal items and insure all belongings are accounted for.

Based on observations, review of records, maintenance log, and policy, and staff and resident interviews, the facility failed to provide a safe, clean, comfortable, homelike environment for 21 out of 86 residents sampled and ensure that all areas in the facility are in good repair. The deficient practice could result in accidents and or impact resident health. Findings included: -Resident #225 was admitted on [DATE] with diagnoses including a malignant neoplasm of the right upper lobe of the bronchus or lung, emphysema, chronic obstructive pulmonary disease, asthma muscle weakness and difficulty walking. An MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. -Resident #224 was admitted on [DATE] with diagnosis including hydrocephalus, chronic systolic heart failure, difficulty walking, depression and anxiety. An MDS assessment dated [DATE] revealed no BIMS score. An observation on August 21, 2023 at 9:17 AM in a room with resident #225 and #224 revealed water leaking from the ceiling on the far-left side of the room. The water was observed to have soaked through a paper posting which had been affixed to the wall and had seeped behind the wall as evidenced by the appearance of raised areas or pockets visible underneath the paint. -Resident #248 was admitted on [DATE] with diagnoses including osteomyelitis of the left ankle and foot in infectious and parasitic disease, cellulitis of the left lower limb, muscle weakness, difficulty walking, sepsis and acquired absence of right leg below the knee. An MDS assessment dated [DATE] revealed a BIMS score of 14, indicating that the resident is cognitively intact. An observation on August 22, 2023 at 8:25 AM in a room with resident #248 revealed visible moisture pockets on the left-sided wall of the room, which were noted to be directly below an observed leak in the ceiling corner. -Resident #236 was admitted on [DATE] with diagnosis including surgical aftercare, muscle weakness, difficulty walking, unspecified osteoarthritis, and depression. An MDS assessment dated [DATE] revealed no current BIMS score. -Resident #237 was admitted on [DATE] with diagnosis including chronic kidney disease, acute kidney failure, end stage renal disease, muscle weakness, difficulty walking and liver transplant status. An MDS dated [DATE] revealed a BIMS score of 15, indicating the that the resident is cognitively intact. An observation on August 22, 2023 at 8:40 AM in a room with resident #236 and #237 revealed that a large rectangular ceiling tile had been removed in the bathroom and not replaced. An interview was conducted on August 21, 2023 at 9:17 AM with resident #225 and resident #224. Resident #225 stated that the observed water leakage was not just an occurrence on this date, but that the leakage had been there for a few days. Resident #224 stated that staff was aware of the leak, but stated that she was not sure what the facility was doing about it. An interview was conducted on August 22, 2023 at 8:25 AM with resident #248. The resident stated that the leak began several days ago, uncertain of the exact date. He stated that he had observed moisture pockets on the left side of the room emanating from the ceiling. He stated that when it rains there is condensation on the blinds as well. The resident stated that he had addressed the issue with staff, unable to recall which staff member, but stated that he had not observed anyone coming into his room to address the issue. An interview was conducted on August 22, 2023 at 8:40 AM with resident #236 and resident #237. Both residents stated that there was a leak above their bathroom toilet. Resident #236 stated that no one had come through the room door to fix the leak, but someone had accessed the bathroom via the ceiling to make repairs. Resident #236 stated that she thought the leak had started with the 'last big rain' in July of 2023. She stated that staff would just come in and wipe off the floor every time it rained and place a basin by the toilet to catch the water as needed. An interview was conducted on August 22, 2023 at 10:20 AM with staff #40 (maintenance supervisor). Staff #40 stated that he had been working at the facility for [AGE] years. He stated that the number one maintenance issue in the facility currently was the roof. He stated that the roof had become a major issue on July 28, 2023 after the last [NAME] storm. He stated that the facility has a vinyl roof and the [NAME] had left little craters on it. He stated that prior to the [NAME] storm in July of 2023, the roof had 'minor' issues with leakage, primarily occurring in and around resident bathrooms and room vents. He stated that the roof had been patched using a fabric membrane covered with tar when leaks occured. He stated that the facility had started an insurance claim the Monday (July 31, 2023) following the [NAME] damage. However, the roofer came out on August 21, 2023. Staff #40 further stated that in the interim when leaks are identified, they are swept up and buckets are placed under the identified leaks to catch any water. He stated that he had a handwritten list of rooms that had identified leaks and provided a copy of the list at the time of the survey. He stated that those residents with room leaks, if requested, were offered a room change and that the facility would try to clean the existing room as quickly as possible. Since the roof was still leaking in numerous places and the current patching efforts had not resolved the issue, he stated that the facility was working with an adjuster to replace the roof. Staff #40 stated that the facility had not tested for mold and stated that mold was not an issue as long as air was circulating. He stated that only stale air would cause mold formation on wet surfaces. Staff #40 stated that he had one assistant in the maintenance department, staff #9, who was currently assisting with the identified leaks in the rooms. A review of the maintenance logs revealed the following open and in-progress work orders: leak from the fire suppression system, window sill repair, and bathroom ceilling tile. Other than the leak from the fire suppression system, no other work orders were noted as active despite leaks identified by the maintenance supervisor. A review of the maintenance logs from September 2022 to July 2023 revealed documentation of closed work orders (order as reflected in TELS) to include multiple ceiling and window leakage, bathroom floor flooding, and ceiling tile replacements. A review of the incidents and accidents policy with a review by date of November 2022, revealed that the purpose of the policy is to implement and maintain measures to avoid hazards and accidents. However, the projected replacement of the roof has not yet occurred and serves potential for further leaks with additional rain storms. A review of the facility maintenance policy with a review date of May, 2023 revealed that the policy is in place to ensure that the facility remains in good working order for resident and staff safety. However, observations during the survey revealed leaks throughout the building and no definitive date for the roof repair. The policy further revealed that the facility utilizes the TELS for maintenance requests and tracking work orders. 45311 2. -Resident #58 was admitted on [DATE] with diagnoses that included diabetes, anxiety disorder and depression. An admission MDS assessment dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. During an observation conducted on August 21, 2023 at 9:57 AM the window sill was noted to be covered with a white bath blanket. The blanket was wet to touch and had diffused brown staining in different areas. The resident's room presented a musty odor. An interview was conducted with resident #58 on August 21, 2023 at approximately 10:00 AM. She stated that it had rained and she heard a lot of drips and that she saw water on her night stands. She stated she saw the water coming in from the window sill. She said she had been in the facility for about 3 weeks and noticed when it rained, the window leaked. She stated the staff put a blanket on the window to stop the water from dripping on the floor and keep her paperwork and personal items on the nightstand from getting wet. She stated the window continued to leak and was worried about mold, stating it could make her very sick. -Resident #11 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, depression, and dementia. An annual MDS assessment dated [DATE] revealed a BIMS score of 14, indicating intact cognition. On August 21, 2023 at 10:29 AM the resident was observed lying in bed watching television. During the observation, it was noted that there were 4 gray wash basins placed on top of a white towel on the foot of the resident's bed. The 4 gray wash basins were placed under the white tiled ceiling that was leaking, and the basins contained water in various amounts. Further, a large black trash can was identified near the foot of the bed on the floor under another area of the ceiling that was leaking. The resident's room presented a musty odor, and the white tiled ceiling presented brown spots of varying degrees. An interview was conducted with resident #11on August 21, 2023 at approximately 10:35 AM. He stated he had been a resident of the facility for over 4 years. He stated that water dripped from the ceiling every time it rained. He stated the facility had always used basins and trash cans to catch the water, and that they painted over the brown marks after the rain. He stated he had never been offered a different room when his ceiling was leaking. He stated that the ceiling leaks continued to be a problem every time it rained but the facility was not doing anything about it. -Resident #16 was readmitted to the facility on [DATE] with diagnoses that included cerebrovascular accident, hemiplegia, asthma, and respiratory failure. A quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating intact cognition. During an observation conducted on August 22, 2023 at 8:03 AM, the resident was lying in bed watching television. The sound of water actively dripping was identified to be coming from the ceiling near the air conditioning vents. A towel was noted to be placed on the floor below the dripping ceiling and it was observed to be wet. [NAME] marks were observed surrounding the wet area of the ceiling. An interview was conducted on August 22, 2023 at 8:07 AM, with resident #16 who stated he was not sure how long he had resided in the facility. He stated that no one came in to do anything about the water leaking from the ceiling and that something was wrong up there (pointing at the ceiling). -Resident #8 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident, hemiparesis, seizure disorder and anxiety disorder. Review of the quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, indicating no cognitive impairment. During an observation conducted on August 22, 2023 at 8:09 AM, the resident was noted to be lying in bed watching television. There were brown marks on the white tiled ceiling above the sink, approximately 24 inches long and about 5-8 inches wide, with brown/black discolorations identified. An interview was conducted on August 22, 2023 at approximately 8:11 AM with resident #8 who stated she had resided in the facility for about 2 years, but had been in her current room for about a year. She stated the brown stain on the ceiling was always there and that it got bigger every time it rained. She stated she had gotten used to the musty smell. She also stated that a family member was visiting one day and said the brown/black stain on the ceiling might be mold. She stated that sometimes she had a problem with difficulty breathing, but that the nurses give her oxygen to help her. -Resident #25 was admitted on [DATE] with diagnoses that included depression, anemia, and dementia. A quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, indicating moderately impaired cognition. During an observation conducted on August 22, 2023 at 8:27 AM in resident #25's room, a gray wash basin on a towel was noted on the floor by the sink. The basin contained water. Further observation revealed water bubbles present by the air conditioner register and brown stains on the white tiled ceiling. A musty smell was identified in resident #25's room. An interview was conducted on August 22, 2023 at 8:30 AM with resident #25. The resident stated he had been in the facility for 2 months. He stated his room leaked every time it rained, since he was admitted . He stated that no one in the facility had come in to fix the problem. 42319 3. -An observation was conducted on August 25, 2023 at 8:34 AM of a heavy musty-like smell in the 200 hall. -Resident #39 was admitted on [DATE] with diagnoses of contracture of muscle and Diabetes Mellitus due to underlying condition with diabetic neuropathy. An Annual MDS dated [DATE] included a BIMS score of 15, indicating that this resident is cognitively intact. An observation conducted on August 22, 2023 at 10:02 AM in resident #39's room, included a flat basin placed underneath a stain on the ceiling with some water in it. An interview conducted with resident #39 immediately after this observation included that the ceiling leaked during the monsoons through the fire sprinkler and one other spot. This resident said it was okay to move the bucket (basin) as he almost tripped over it several times and usually moved it under the sink when it was not actually leaking. He said that he had been in the facility for 2.5 years and it had also leaked in a previous room he had been residing in on the previous years. -Resident #28 was admitted on [DATE] with diagnoses of type 2 Diabetes Mellitus and hydronephrosis with renal and ureteral calculous obstruction. An annual MDS assessment dated [DATE] did not include a BIMS score. This document included that this resident made herself understood and has clear comprehension of others. An observation on August 22, 2023 at 8:21 AM in resident #28's room included water on the windowsill. An interview with resident #28 conducted immediately after this observation included that the room she was in had been leaking for the last 6 years. She said that her roommate was sprayed by the rain coming in the windowsill and that she said that her roommate said that she gets cold but that she herself was not bothered. -Resident #34 was admitted on [DATE] with diagnoses of dementia and neuromuscular dysfunction of bladder and was in room [ROOM NUMBER] at the time of the survey. A quarterly MDS assessment dated [DATE] did not include a BIMS score. An interview conducted on August 21, 2023 with resident #34's representative revealed that this person had noticed a leak in the resident's room for 3 years. This representative stated that the entire hallway leaks. -Resident #10 was admitted on [DATE] with diagnoses of muscle weakness, cognitive communication deficit and mood disorder. An Annual MDS dated [DATE] did not include a BIMS score. This document included that this resident makes herself understood and has clear comprehension of others. An observation conducted on August 22, 2023 at 8:36 AM in resident #10's room included rust on the edges of the air conditioning vent and a bubble on the paint underneath from the vent going down the wall which had the appearance of a water pocket underneath the paint. An interview conducted immediately after the observation with resident #10 included that during rains, there was a leak that came in at the air conditioning vent and that it stunk but that she did not suffer any problems due to the smell. 48932 4. -Resident #243 was admitted to the facility on [DATE] with diagnoses of muscle weakness, difficulty walking, major depressive disorder, and morbid obesity. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident was moderately cognitively impaired. An interview was conducted with resident #243 on August 22, 2023 in the room and the resident stated the water leaking from the ceiling by the bathroom door started yesterday, August 21, 2023. The resident stated she did not remember the name of the staff person she spoke with about the leak. The resident stated when she asked the staff member what they were gonna do about the leak, the staff said they could not do anything at the moment. After the interview, an observation was conducted and identified a dried water mark on the flood behind the television. Resident #243 stated there was a water damage on the ceiling before the storm. No strange smell was observed; however, the ceiling appeared to look wet with brown plaster coming off of it. -Resident #301 was admitted to the facility on [DATE] with diagnoses of polyneuropathy, restless leg syndrome, and depression. The admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 10 which indicated the resident was moderately cognitively impaired. On August 22, 2023 at approximately 8:13 AM a towel was observed to be rolled up against the window on the windowsill of resident #301 room. When asked about the purpose of the towel, the resident stated she did not know and staff had put it there earlier in the morning. -Resident #9 was admitted to the facility on [DATE] with diagnoses of kidney disease, muscle weakness, and anemia. A review of the most recent quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 10 which indicated the resident was moderately cognitively impaired. An observation conducted on August 22, 2023 at approximately 8:16 AM in resident #9's room identified a dry water stain on the bathroom ceiling. -Resident #282 was admitted to the facility on [DATE] with diagnoses of muscle weakness, acute osteomyelitis, and difficulty walking. A review the quarterly MDS assessment dated [DATE] revealed the resident had BIMS score of 15 which indicated the resident was cognitively intact. An interview was conducted on August 22, 2023 at 8:29 AM with resident #282 and he stated, when it rains, the water leaks as he showed the HVAC that had been leaking. He stated the leaks started a few storms ago and the facility had told them they were patching the room. An observation at approximately 8:30 AM of the room, identified the HVAC vents to be black. On August 22, 2023 at 8:04 AM two trash cans were observed to be in the 200 hallway collecting water from the ceiling. A review of resident council meeting minutes for the past year indicated there were no discussions about water leaks in the facility prior to the current resident council meeting which was held on August 22, 2023.

Based on resident and staff interviews, review of clinical records and facility policies, and observations of current practice, the facility failed to ensure that one resident (#23) out of 19 sampled, received adequate supervision to prevent medication accidents. The deficient practice could result in the resident sustaining medication accident-related injuries. Findings included: Resident #57 was admitted on [DATE] with diagnoses that included fracture of the sacrum, pneumocystosis, muscle weakness, chronic obstructive pulmonary disease, and depression. A review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident is cognitively intact. An observation conducted on August 21, 2023 at 11:34 AM revealed a medication cup containing 3 white elongated tablets on the resident's bedside tray table. When the resident was asked about the tablets, he stated that because he has a hard time swallowing, staff generally leave the medications with him. There were no staff present. Additional observation occurred on August 23, 2023 at 7:32 AM. A round pill was observed in a cup on the resident's tray table. When asked, the resident stated that it was his 'Tums' medication left for him by staff. A review of the electronic health record, including physician orders, care plan, assessments and progress notes, revealed no evidence of an order to self-administer medications or a resident assessment gauging the resident's ability to self-administer medications. An interview was conducted on August 23, 2023 at 7:39 AM with a Licensed Practical Nurse (staff #124) who stated that staff administering medications must always observe the residents take and swallow the medication. He further stated that medications must not be left with a resident to self-administer. Staff #124 stated that he did leave the medications with resident #57 on August 21, 2023 and had intended to crush them for the resident but had forgotten. He stated that this was his error. He stated that he was uncertain which medications were left at bedside but thought they may have been Colace and vitamin C. He stated that the risk for leaving medications at bedside for this resident could be a choking hazard or that he may not take the medications as prescribed. Staff #124 stated he had not yet administered the morning medications for August 23, 2023. He reviewed the health record and was unable to identify the medication observed in the medication cup, assumed to be 'Tums' as there was no evidence of a corresponding medication entry either that morning or the previous night. An interview was conducted with the Administrator (staff # 125) and the Director of Nursing (DON/staff #126) on August 23, 2023 at 7:42 AM. The administrator stated that when a resident wanted to self-administer any medication, they must first be assessed to determine if they are appropriate to self-administer medications, they must also have an order in place to self-administer and it must be care planned. The DON stated that nurses are expected to observe the resident and stay in the room until all medications have been taken unless a resident has been authorized to self-administered the medication. Staff #126 stated that resident #57 did not have a self-administration order for medications. She stated that the risk could include the resident not taking the medication and that staff would not know which medication had been taken by the resident. Staff #126 reviewed the resident's file and stated that even the 'Tums' would have to be documented in the system but had not been for either that morning or the previous evening. A review of the facility's policy titled, Self Administration of Medication under the Care and Treatment section with a review by date of May 2023, revealed that if a resident wished to self-administer medications, the interdisciplinary team (consisting of the medical director or primary care physician, director of nursing or other nursing representative and social services) would assess the resident and indicated this in the chart. However, no evidence of the interdisciplinary team review was observed in the resident's chart.

Based on observations, staff interviews and facility policy, the facility failed to ensure that a safe and sanitary kitchen environment was followed in regards to a dry storage scoop and proper drying techniques. Findings included: An observation conducted on August 21, 2023 at 8:46 AM with the Dietary Supervisor (staff #44) revealed that a bin containing oatmeal had a scoop inside sitting on the oatmeal and metal pans were stacked together on a storage shelf in a manner which did not allow ready air flow and when separated, drops of water were found between the pans. An observation conducted on August 23, 2023 at 8:10 AM with the Dietary Supervisor (staff #44) revealed that a bin containing oatmeal had a scoop inside sitting on the oatmeal and metal pans were stacked together on a storage shelf in a manner which did not allow ready air flow and when separated, drops of water were found between the pans. The dietary manager removed the scoop and restacked the pans loosely. An interview was conducted on August 25, 2023 at 10:06 AM with the Dietary Supervisor (staff #44) who said that the staff are not supposed to leave the scoop in the oatmeal bin and that dishes and pans are supposed to be placed on a shelf and that they are supposed to make sure they are dry before stacking on the shelves. A policy titled, Food Storage was updated November 2009 revealed that food items should be stored in accordance with good sanitary practice. This document included that dry storage will be kept free of scoops.

Based on clinical record review, observation, staff interviews, and policy review, the facility failed to ensure one resident (#35) was consistently provided the necessary treatment and services to promote the healing of pressure ulcers. The sample size was 2 residents. The deficient practice could result in delayed healing of pressure ulcers. Findings include: Resident #35 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on January 12, 2015 revealed the resident had the potential for pressure ulcer development related to immobility and non-adherence to repositioning, and a history of pressure injury to the right and left buttocks. The care plan problem was updated on May 24, 2022 to reflect MASD (moisture associated skin damage) to the right buttock, and on June 16, 2022 to reflect a pressure injury to the coccyx extending to the bilateral buttock. The interventions included treatments as ordered. Review of a LN (licensed nurses)- Skin Evaluation - PRN / Weekly dated May 5, 2022 at 5:51 p.m. revealed the resident had no pressure ulcer. Review of the LN- Skin Evaluation - PRN / Weekly dated May 23, 2022 at 4:45 p.m. stated the resident had an open area to the right and left of the sacrum. The evaluation also stated orders were in place and that the wound team will follow. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Treatment Administration Records (TAR) for May 2022 and June 2022 revealed no evidence the treatment was provided on May 23, 2022 and June 2, 2022. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] revealed a score of 15 on the Brief Interview for Mental Status which indicated the resident had intact cognition. The assessment also included the resident had one unstageable pressure ulcer. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR for July 2022 revealed no evidence the treatment was provided on July 12, 13, and 14, 2022. Continued review of the clinical record revealed no documentation regarding whether the treatments were provided or not provided on these dates. A wound treatment observation was conducted on July 28, 2022 at 10:31 a.m. with an LPN (Licensed Practical Nurse/staff #13). Staff #13 set up the wound equipment, washed her hands, and donned a clean pair of gloves. The LPN then removed the old dressing and cleansed the coccyx wound. She doffed dirty gloves, washed her hands, donned gloves, and measured the coccyx wound. The LPN then applied [MEDICATION(S)] and covered the wound with a [MEDICATION(S)] dressing. She then cleaned up. However, review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The instruction stated to cleanse the coccyx wound with wound cleanser, pat dry, apply Santyl and 4X4, and tape. An interview was conducted on July 28, 2022 at 12:15 a.m. with the Director of Nurses (DON/staff #117). Staff #117 stated she already knew about the treatment error because staff #13 told her that she applied [MEDICATION(S)] on the coccyx wound instead of Santyl ointment. Staff #117 stated her expectation related to pressure wound care is to follow the physician order. An interview was conducted on July 28, 2022 at 2:13 p.m. with staff #13. The LPN stated she was doing wound rounds last week, and did not know the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that after providing the wound treatment, she called the wound doctor to change the treatment order to [MEDICATION(S)]. She also stated she made a mistake by doing the treatment first with [MEDICATION(S)] instead of Santyl as ordered. The facility policy, Wound Management, stated a resident having pressure ulcers will receive necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. The policy also stated that once the wound has been identified, assessed, and documented, nursing staff shall administer treatment to each affected area as per the physician order. All wound treatments shall be documented in the resident's clinical record at the time they are administered.

Based on observations, staff interviews, manufacturer instructions, and review of policy, the facility failed to ensure appropriate infection control protocol was followed during point-of-care glucose testing. The deficient practice increases the risk for transmission of infectious disease and/or bloodborne pathogens. Findings include: On 07/27/22 at 7:10 a.m., an observation of point-of-care glucose testing was conducted with a Licensed Practical Nurse (LPN/staff #83) on the Transmission Based Precautions unit. Staff #83 obtained a small storage basket which measured approximately 4 inches by 4 inches from the medication cart. Inside the basket approximately 20 packaged alcohol wipes, a container of testing strips, multiple lancets and a glucometer were identified. Staff #83 picked up the basket and walked to the doorway of a resident's room. She placed the basket on top of the PPE (Personal Protective Equipment) cart and was observed to don the appropriate PPE required to enter the resident's room. Staff #83 then picked up the basket of supplies and entered the room to conduct blood glucose testing on the resident. Staff #83 placed a glucose test strip into the glucometer as she asked the resident which finger they would like to use. She placed the basket onto the resident's bed in front of her. She rested the glucometer back into the basket while she obtained alcohol wipes from the basket, opened them, and cleaned the resident's finger. While the finger dried, she obtained a lancet from the basket. She pierced the resident's finger. She squeezed out a drop of blood then wiped it with the alcohol wipe. She placed the alcohol wipes and wrappers on the resident's bed in front of her. She took the glucometer out of the basket and obtained a drop of blood on the test strip. She placed the glucometer with the test strip in it onto the resident's bed in front of her, picked up the alcohol wipes again, and cleaned the resident's finger while the test was processing. When the glucometer provided the reading of the blood glucose level, she repeated the number to the resident. Staff #83 was then observed to remove the test strip from the glucometer and to place the glucometer back into the basket. She held the test strip, alcohol wipes, and lancet in one gloved hand. With the other hand, she removed her glove with the aforementioned items contained inside. She removed the second glove and gathered the first one into it. She held the gloves in one hand. She placed the basket with the testing supplies on the PPE cart just outside the resident's room and doffed her PPE while still holding the gloves in her hand. Staff #83 walked to the medication cart and placed the basket on top of it. She disposed of the gloves into the sharps container that was located on the side of the cart. She used hand sanitizer. She looked into the cart and stated that there were no bleach/germicidal wipes located inside. She left the cart to walk to the nursing station to obtain a container of bleach wipes. She donned clean gloves and removed a bleach wipe from the container. She cleaned the glucometer with the wipe for approximately 10 seconds and then held the glucometer in front of the small fan that was situated on top of the cart to dry. She then placed the glucometer back into the basket and proceeded to conduct testing in the same manner for two more residents. On 07/27/22 at 1:25 p.m., an interview was conducted with an LPN (staff #118). She stated that when she conducts point-of-care blood glucose testing, she will gather her supplies which includes gloves, alcohol wipes, glucometer, lancet and test strips. She stated that she puts the gloves on. She stated she will not take the little basket with her, only the supplies necessary for the test. She stated that she will wipe the resident's finger with an alcohol wipe, pierce the finger with the lancet, wipe again, and apply a drop of blood onto the strip. She stated that she will not put the glucometer on the bed. She stated that she will hold it in her hand until she gets a reading. She stated that she will bring the glucometer out with the strip in it, then inject it into the sharps box. She stated she will also put the lancet into the sharps box. The LPN stated that she has had in-service training, and that is the standard protocol. The LPN stated that putting the basket down on the bed will transfer bacteria from one room to the next. She stated she will not put the glucometer onto the bed for the same reason. The LPN stated she will not put the glucometer back into the basket because of the risk for bloodborne pathogens. On 07/27/22 at 1:37 p.m., an interview was conducted with an LPN (staff #20). She stated that after conducting blood glucose testing, she will wipe the glucometer down with bleach wipes and set it on a tissue on the cart to dry. She stated that she then uses an alternate glucometer for the next resident. An interview was conducted on 07/28/22 at 10:13 a.m. with the Director of Nursing (DON/staff #117). She stated that her expectation is that nurses place a barrier down and assemble the necessary supplies for blood glucose testing onto it to take into the resident's room. She stated that after completing the fingerstick, her expectation is that nurses will clean the glucometer with bleach wipes and wait for 5 minutes prior to subsequent use. The DON stated that it would not meet her expectation for the nurse to take all the supplies into the resident's room or not to place a barrier down. The DON stated that it would not meet her expectations to place anything on the bed at all. The facility policy titled Glucometer, Cleaning and Decontamination of, revised 05/2022, stated it is the policy of the facility to follow recommended guidelines from the Centers for Disease Control (CDC) or manufacturer's guidelines. The procedure included verifying the glucometer is placed on a barrier prior to laying the glucometer on the medication cart and/or the over bed table after each use. Disinfect the exterior surfaces after each use following manufacturer's directions or may use a cloth/wipe with either an EPA-registered detergent/germicide with a tuberculocidal of HBV/[CONDITION(S)] label claim, or a dilute bleach solution of 1:10 (one-part bleach to 9 parts water) to 1:100 concentration. Review of the glucometer manufacturer guidelines, EVENCARE G2 Caring for the Meter included that cleaning and disinfecting the meter is very important in the prevention of infectious disease. According to the guidelines, cleaning also allows for subsequent disinfection to ensure germs and disease-causing agents are destroyed on the meter.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure prompt efforts were made to resolve one sampled resident's (#205) grievance about missing clothing. The deficient practice could result in resident grievances not being resolved promptly. Findings include: Resident #205 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission note dated April 15, 2022 at 5:37 a.m. stated the resident was transferred from the hospital to the facility for physical therapy and occupational therapy due to status fall. An admission MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 which indicated the resident was cognitively intact. The special treatments section included occupational and physical therapy. Review of social services note dated May 11, 2022 at 5:30 p.m., stated all move in paperwork for discharge was completed. Resident #205 was going to an assisted living facility the following day. An interview was conducted on July 27, 2022 at 10:26 a.m. with the social services director (staff #100). Staff #100 stated her job responsibilities included assessments, discharge planning and grievances. Staff #100 stated she remembered resident #205. She stated that the family did not notify her about the missing clothes until after the resident was discharged . She stated she wrote a grievance after the family told her but the grievance was still in process. She stated in the process meaning she asked for the cost value of the missing items and that the family was supposed to get back to her with the amount for reimbursement, or the description of the missing item. However, review of the record of grievances provided by the facility from January 2022 through July 2022 did not include a grievance for resident #205's missing clothing/personal items. An interview was conducted on July 28, 2022 at 9:23 a.m. with a CNA (Certified Nursing Assistant/staff #115). Staff #115 said grievance is a complaint from a resident such as missing items in which she would report to the charge nurse. She stated the process for missing personal items is to first look at the inventory list. She stated if there was no inventory of it on the list, she would have the resident describe it and look for it in the laundry. Staff #115 stated if she cannot find the missing items, she would notify the charge nurse, then the DON and the administrator for one of them to fill out the grievance form. She stated she has to follow a chain of command. An interview was conducted on July 28, 2022 with the ADON (assistant director of nursing/ staff #101). Staff #101 stated the process for personal items included completing the inventory list on admission and that at discharge the resident/family have to sign the inventory of personal belongings form. Staff #101 stated during discharge if the resident's inventory form was not found, the resident would complete a grievance form and give it to the social worker and the items will be replaced. He stated if the family notifies the social worker, the social worker will fill out the grievance form and notify nursing/laundry to look for the items. Review of the facility policy, Grievance Process, stated the facility allows residents, families, guests and employees to voice concerns and make timely efforts to resolve such concerns. The purpose of the grievance process is to assure that concerns are quickly and thoroughly evaluated and acted upon in order to resolve issues which affect the quality of life and care for residents in the facility. Copies of the concern/grievance resolution form are available throughout the facility. The forms are to be initiated when concerns or complaints are made. The Administrator/designee responds to the individual expressing the concern within a reasonable time frame of the initial concern to acknowledge receipt and describe steps taken toward the resolution.

Based on clinical record review, staff interview, facility documentation, and policy reviews, the facility failed to ensure services met professional standards of quality regarding medication administration for one resident (#205). The sample size was 5. The deficient practice could result in residents not receiving physician ordered medications. Findings include: Resident #205 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician order dated April 15, 2022 stated [MEDICATION(S)] (diuretic) 2 milligrams one tablet by mouth every 23 hours as needed for fluid retention; take with potassium if weight reaches 170 pounds. The care plan did not include the resident being administered diuretic medication. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for May 2022 revealed the resident weighed 174.3 pounds on May 8, 2022. Further review of the May 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing clinical progress notes revealed no evidence as to whether [MEDICATION(S)] was administered or not. An interview was conducted on July 28, 2022 at 9:54 a.m. with the assistant director of nursing (ADON/staff #101). Staff #101 stated management of fluid volume overload included monitoring of residents' weights, and ensuring the resident is being medicated for it. He stated a PRN order means a medication is to be given only as needed, depending on the parameter on the physician order. The ADON stated the parameter should be followed as ordered by the physician, then after the medication has been administered, he would monitor the effectiveness of the PRN medication. Review of the facility policy, Professional Standards, stated it is the policy of the facility that services provided by the facility must meet professional standards of quality and be provided by qualified persons in accordance with each resident's care plan. Review of the facility policy, Physician Orders, stated it is the policy of the facility to accurately implement orders in addition to medication orders (treatments, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident plan of care.

Based on staff interviews, clinical record review, and review of policy and procedures, the facility failed to ensure one resident (#35) was not administered unnecessary medications, by failing to ensure medications were administered in accordance with physician orders. The sample size was 5 residents. The deficient practice increases the risk for residents to receive medications that may not be necessary. Findings include: Resident #35 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. The assessment also revealed the resident required extensive 1-2 person physical assistance for most activities of daily living and reported frequently experiencing pain levels of 5. Regarding opioid administration: An opioid care plan dated 11/18/19 related to potential for adverse outcomes for opioid use had goals for the resident to be free of adverse reactions to opioid use and to remain free from pain/level of comfort acceptable to the resident. Interventions included administering the opioid as prescribed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/06 at 5:45 a.m. for a pain level of 0; 06/20 at 9:18 p.m. for a pain level of 1; and 06/23 at 7:00 p.m. for a pain level of 2. The July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 07/28/22 at 9:12 a.m. with a Licensed Practical Nurse (LPN/staff #20). She stated that if she gave [MEDICATION(S)]-acetaminophen for a pain level of 2, the resident may build a tolerance to the medication, may get dizzy, and it may lead to falls. The LPN stated that she would give acetaminophen instead. She stated she would consider the administration to be a medication error and/or overmedicating the resident. An interview was conducted on 07/28/22 with the Director of Nursing (DON/staff #117). She stated that prior to administration of medication, her expectations are that the nurse will check the resident's pain levels and follow the physician ordered parameters. She stated that it did not meet her expectations for opioid analgesics to be administered outside of the parameters. Regarding antihypertensive administration: Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Hold if systolic blood pressure (SBP) is less than 110 or if the heart rate (HR) is less than 60. Review of the June 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on 07/28/22 with the DON (staff #117). She stated that prior to the administration of medication, her expectations are that the nurse will check the resident's vitals and follow the physician ordered parameters. She stated that she would consider the administrations to be medication errors and unnecessary medications. She stated that the nurses are aware and have been educated. The DON stated that the administrations did not meet her expectations. The facility policy titled Physician Orders, revised 05/2022, revealed it is the policy of the facility to accurately implement orders, in addition to medication orders, only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on clinical record reviews, staff interviews, and policy and procedure, the facility failed to ensure that advanced directives were available and correct for 2 residents (#156 & #164). The sample size was 7. The deficient practice could result in residents receiving services not in accordance with their wishes. Findings include: -Resident #156 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated July 19, 2022 revealed no advance directive information. Review of the physician order dated July 24, 2022 revealed the resident was full code status. A subsequent order dated July 26, 2022 revealed the resident's advanced directive status was revised to do not resuscitate (DNR). A review of the electronic clinical record and the paper chart on July 26, 2022 at 11:04 a.m. revealed no evidence of a signed advanced directive. A paper copy of the resident's advanced directive for DNR was provided upon request with signatures dated July 19, 2022. An interview with the Director of Nursing (DON/staff #117) was conducted on July 27, 2022 at 9:36 a.m. She stated that when a resident is admitted advanced directive paperwork is filled out. The DON stated signed paperwork is put into the paper chart which is to be the reference point if a critical situation occurs. She stated this is where the staff immediately go to verify a resident's advanced directive wishes. The DON stated that all advanced directive paperwork is expected to be in the resident's record within 24 hours of admittance. The DON stated that DNR form for resident #156 was signed on July 19, 2022 and was not uploaded into the resident's electronic health record or in the hard chart. She said that the paperwork was in medical records. She said that since no paperwork was available in the resident's chart, the resident would have been treated as a full code in an emergency which was not the resident's wishes. The DON also stated that no advance directive information was in the electronic health record and that it had been corrected with an order and a designation on the banner. -Resident #164 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the care plan dated July 20, 2022 revealed no advance directive information. Review of the electronic health record revealed an order dated July 24, 2022 that the resident's code status was full code. On July 26, 2022, several staff members attempted to find the resident's paper chart which was unable to be located. Approximately 20 minutes later a registered nurse (RN/staff #101) stated that the chart was located in the medical records office. Review of the paper chart on July 26, 2022 at 11:07 a.m. revealed no signed advanced directive paperwork in the paper chart. An orange DNR form was located in the chart. The form was folded in half and the words Full Code were hand written on the orange paper. Staff #101 stated that this was the process for full code residents in the facility. Staff #101 was asked for the signed full code paperwork at that time and he stated there was no signed advance directive paperwork in the hard chart. An interview was conducted with the social services supervisor (staff #100) on July 26, 2022. She stated that the admitting nurse reviews and enters the advance directive information into the residents' electronic health record. She stated that she, as the social services supervisor, audits the resident records to ensure all advance directive information is in place and all the information matches the resident choice. Staff #100 said that missing paperwork or paperwork that does not match is a concern. She said that clinical staff would refer to the hard (paper) chart in an emergency as the default. An interview with the DON (staff #117) was conducted on July 27, 2022 at 9:36 a.m. The DON stated that resident #164 did not have signed paperwork in the medical record that the staff had the resident sign the form yesterday. She stated that the orange form that was folded in half and had full code handwritten on it does not meet the expectation or the facility policy. The DON stated that she had never seen that done in a chart before and it had been corrected. The full code paperwork was signed and dated 7/26/22 and a copy was now in the resident's chart. Review of the facility policy Advance Directives (5/2022) revealed that the facility will recognize and respect the resident choice regarding advance directives. Upon admission the social services or admissions staff will inquire about the resident's wishes regarding his/her advance directives and include the information in the resident's medical record. The physician and care plan team are to be made aware of the resident's advance directive status and of any changes made to the status.

Based on clinical record review, review of facility records, and staff interviews, and review of policies and procedures, the facility failed to ensure that care and services were provided for one resident (#22) in accordance with professional standards of practice. The deficient practice could result in additional residents not being provided care and services in accordance with professional standards of practice. Findings include: Resident #22 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Initial Admission Record dated May 24, 2022 did not include that the resident had any wounds or discoloration of the skin on the resident's buttocks. A Nursing Note dated May 25, 2022 included Pt. has discoloration to the right ischium that has a moderate size hard, painful mass, . NP (Nurse Practitioner) present and said send to hospital for I&D (incision and drainage). An Administrative Note dated May 25, 2022 included that per the wound nurse, resident #22 had an appointment on May 25, 2022 at 3:20 at an outpatient surgical center. Review of records from the surgical center revealed a note dated May 25, 2022 at 3:50 p.m. which included that resident #22 had a shallow abscess on the right buttock and that the abscess had a 2.0 x 3.0 cm (centimeter) are that was surgically debrided to facilitate wound care. The note included that resident #22 was prescribed 100 mg. (milligrams) of [MEDICATION(S)] (an antibiotic) twice daily for a week and would need a wound dressing to be changed daily after showering. A review of the clinical record for resident #22 did not include that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . or to change a wound dressing on the resident's right buttocks wound daily after showering had been obtained or transcribed into the clinical record. Review of the clinical record for resident #22 did not include any documented evidence that the resident had been provided a shower from May 24, through May 28, 2022. A Discharge MDS (Minimum Data Set) assessment dated [DATE] included that resident #22 had been discharged to the community. An interview was conducted on June 9, 2022 at 9:05 a.m. with an MA (Medical Assistant/staff #115). The MA (who works at the outpatient surgical center) stated that resident #22 did attend his appointment, and that he had an abscess on his buttocks. The MA stated that the physician prescribed [MEDICATION(S)] twice a day for one week, and dressing changes to the buttocks. During an interview conducted on June 9, 2022 at 3:51 p.m. with an LPN (Licensed Practical Nurse /staff #10), she stated that when she spoke with resident #22 he complained of a tender area on his buttock that was hard and resembled a bruise. Staff #10 stated that she provided an observation of the wound, and that it definitely appeared to be a cyst. Staff #10 stated that when resident #22 returned from the appointment at the outpatient surgical center, he did have a dressing that had been placed by a surgeon. Staff #10 stated that she did not receive any paperwork from the surgical group until today (June 9, 2022) and that resident #23 had a clean dry dressing. Staff #10 stated that she would usually seek clarification from the surgeon (regarding wound care) because often the surgeons do not want a dressing changed until they examine the wound. Staff #10 stated that she was not aware of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted on June 10 at 10:03 a.m. with a CNA (Certified Nursing Assistant/staff #107), she stated that she knows when residents have appointments because the nurse lets us know and we have an appointment book so we can get the residents ready right away at the beginning of the shift. Staff #107 stated that when the resident returns from an appointment, staff get them changed, check their vitals and take care of them. Staff #107 stated residents go appointments with records and return with records, and that if the resident does not return with records, nurses is notified. During an interview conducted on June 10, 2022 at 10:09 a.m. with an RN (Registered Nurse/staff #94), she stated that when residents are sent out to appointments, the nurses have to follow up after an appointment and if there is no paperwork from the physician's office, staff can call the doctor's office to obtain the records. Staff #94 checked the electronic medical record for resident #22 and was unable to find physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview conducted on June 10, 2022 at 10:38 a.m. with the Unit Manager (RN/staff #37), he stated that when he remembered that resident #22 had went out for an incision and drainage (at the outpatient surgical clinic), and that the Nurse Practitioner had examined the patient and had diagnosed that the resident had an abscess. Staff #37 stated that resident #22 returned from the outpatient surgical center without any physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #37 reviewed the resident's electronic clinical record and stated that he did not see any follow up and that someone should have followed up on that appointment. During an interview conducted on June 10, 2022 at 3:45 p.m. with the DON (Director of Nursing/staff #106), she stated that her expectation was that the physician that the resident had an appointment with communicates any new changes in care to the facility. Th DON stated that if the resident does not with records, staff will follow up including the wound nurse or ADON (Assistant Director of Nursing). The DON stated that it did not meet her expectation that this resident did not receive the follow up care ordered by a physician, and that there was no policy for following up on an appointment for outside care. A policy titled Wound Management-Documentation revealed that treatments ordered by the physician will be used. A policy titled Wound Management included that in order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: A. Stabilize, reduce or remove any existing any underlying risks. and B. Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition.

Based on clinical record review, review of facility records, and staff interviews, and review of policies and procedures, the facility failed to ensure that residents are provided care and services to prevent the development of or worsening of pressure ulcers for two residents (#23, #47). The deficient practice could result in the development or worsening or pressure ulcers for additional residents. Findings include: -Resident #23 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan dated April 29, 2022 included that resident #23 had a pressure ulcer and potential for pressure ulcer development and that resident #23 had a left heel unstageable pressure ulcer with eschar. The care plan included an intervention to assess/record/monitor wound healing, measure length, width and depth where possible, assess and document the status of the wound perimeter, document wound bed and healing progress and to report improvements and declines to the physician. A Skin Evaluation dated April 29, 2022 included a left heel deep tissue injury and bilateral lower extremity discoloration. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record did not include an assessment of the left heel deep tissue injury from April 28, through May 4, 2022. A Skin Pressure Ulcer Weekly assessment dated [DATE] included that resident #23 had a wound present at admission, and that the wound was a left heel unstageable pressure wound with 100% stable black/brown eschar measuring 3.6 cm (centimeters) by 2.5 cm. An Admission MDS (Minimum Data Set) assessment dated [DATE] included that resident #23 had an unstageable pressure wound that was present upon admission. During an interview conducted on June 9, 2022 at 3:51 p.m. with the Wound Nurse (staff #10), she stated that she observed the initial assessment of the left heel wound for resident #23 and that if a record is not in the computer or downloaded it is does not exist. -Resident #47 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An Initial Care Plan dated May 31, 2022 included that resident #47 had a pressure ulcer or potential for pressure ulcer development, and listed interventions that included to administer treatments as ordered, and monitor for effectiveness and to assess/record/monitor wound healing, measure length, width and depth where possible, to assess and document status of the wound perimeter, the wound bed and healing progress, and to report improvements and declines to the physician. An Initial Admission Assessment Record dated May 31, 2022 included Left heel has [MEDICATION(S)] foam covering/mushy heel. However, review of the clinical record did not include an assessment of the left heel wound from May 31, through June 2, 2022. A Skin Pressure Ulcer Weekly assessment dated [DATE] included resident #47 had a wound present at admission, which was a Deep Tissue Injury measuring 3.1 cm x 2.5 cm. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission MDS (Minimum Data Set) assessment dated [DATE] included that resident #47 had one unstageable pressure wound that was present on admission. During an interview conducted on June 10, 2022 at 3:45 p.m. with the DON (Director of Nursing/staff #106), she stated that the admitting nurse will note the wounds and describe the wounds but they do not stage or measure unless they have had extra training. The DON stated that the wound nurse will follow open surgical wounds, pressure ulcers and other ulcers like vascular, diabetic, abscesses as well any open wound, and that staff should assess those wounds fully within 24-48 hours. The DON stated that not assessing the wounds within 24-48 hours does not meet her expectations. A policy titled Wound Management included that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. The policy included that in order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: A. Stabilize, reduce or remove any existing any underlying risks. B. Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition.

Based on clinical record review, review of facility records, staff interviews, and review of policies and procedures, the facility failed to ensure that infection control standards were maintained during wound care for one resident (#24). The deficient practice could result in the spread of infection. Findings include: Resident #24 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Care Plan dated January 19, 2022 included that resident #24 had a pressure injury to right heel, and included that the pressure injury will show signs of healing and remain free from infection. The care plan listed interventions that included to administer treatments as ordered. A Quarterly MDS (Minimum Data Set) assessment dated [DATE] included that resident #24 had two stage 3 pressure wounds present upon admission. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included to cleanse with wound cleanser, pat dry, apply Medi-honey, and cover with 4 x 4, wrap with kerlix and secure daily. During an observation of wound care conducted on June 9, 2022 at 3:51 p.m. with the Wound Nurse (staff #10) the following observations were made: -Staff #10 gathered her supplies, entered the resident's room, placed items on a table and washed her hands, set up her supplies, donned gloves. -Staff #10 removed the existing bandage from the resident, doffed her gloves, washed her hands, donned gloves and cleaned the heel wound. -Staff #10 changed her gloves but did not sanitize her hands and cleansed a wound on the resident's shin. -Staff #10 again changed gloves, without sanitizing her hands and measured the wound on the shin, and the wound on the heel. Staff #10 then doffed and donned new gloves without sanitizing her hands, opened new tube of Medi-honey, applied Medi-honey to the wounds and wrapped the wounds with kerlix. During an interview conducted on June 9, 2022 with staff#10 immediately after the wound observation, she said that she should have just brought the cart down because her hand sanitizer was on the cart, and that she should have sanitized her hands between changing her gloves. During an interview conducted on June 10, 2022 at 3:45 p.m. with the DON (Director of Nursing/staff #106), she stated that her expectation for infection control during wound care was that wound care is performed using clean procedure, and that the staff should be changing gloves between wound areas and sanitizing hands between donning and doffing gloves. The DON stated that a nurse donning gloves, touching items, doffing gloves and then donning gloves again without sanitizing their hands does not meet her expectation. A policy titled Complex Wound Management revealed that all treatments involving breaks in the skin require clean technique, unless otherwise ordered by the physician.

Based on observations, clinical record review. staff interviews, and review of facility policies and procedures, the facility failed to adequately supervise one resident (#1) outdoors and, as a result, the resident died . The sample size was three. Findings include: Resident #1 was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed a physician's Progress Note dated [DATE] which documented "Mentation appropriate". A review of the resident's clinical record revealed a physician's Progress Note dated [DATE], which documented "Mentation depressed." A review of the resident's clinical record revealed a physician's Progress Note dated [DATE] which documented "Mentation depressed." A Comprehensive Resident Admission Evaluation dated [DATE], revealed the resident was alert and oriented to time, place and person. A review of Progress Notes dated [DATE] documented "Resident also set off alarm on unit 300 by going outside alarmed door. Resident informed that that area is restricted/alarmed for safety reasons. Resident stated 'he just wants to go out and smoke." Progress Notes dated [DATE] documented "1530 Patient witnessed attempting to sit in w/c (wheelchair) in courtyard when it rolled back and he slid to the ground. Did not hit head, no complaints of pain, injury, sitting in w/c when found by staff. Assisted back to building, educated on sitting in w/c and not using it as a walker." Progress Notes dated [DATE] at 1521 documented "Resident had an episode of exit seeking behavior. Left facility via 200 east side door. When staff attempted to get resident back inside he refused stating he lived only a couple of blocks away and that he was going home. Staff was finally able to convince resident to stay and he returned to facility with no further attempts to leave." Progress Notes dated [DATE] documented, "Alert and oriented x ,[DATE]. with intermittent confusion." Progress Notes dated [DATE] documented "Patient seen smoking outside on patio independently. Patient was reminded that there are scheduled times for smoking and he must have an employee with him when he smokes." Progress Notes dated [DATE] documented "Patient continues to walk outside with front wheeled walker." Progress Notes dated [DATE] at 2313 documented "Patient heard calling for help, found alone on sidewalk near door in courtyard. Stated had been pacing, waiting for cigarette smoke time, and fell on knees, heard a loud pop in right knee, blood oozing out of gauze dressing...transported to St. Joe's hospital per doctor order." A review of the resident's clinical record revealed the resident returned to the facility on [DATE] at 1836. Progress Notes dated [DATE], documented "Pt noted to have a fall on patio on [DATE], reported tripping over bush was evaluated at ER noted to have torn ligament..." Progress Notes dated [DATE] documented "Resident left facility via...transport to go out to hospital for out patient procedure..." Resident was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The physician ordered MS Contin 60 milligrams (mg) to be administered three times a day every day. The physician also ordered Oxycodone HCL 30 mg four times a day to be administered each day. The resident's clinical record revealed a Comprehensive Resident Admission Evaluation dated [DATE], which revealed the resident was alert and oriented to time, place, and person. The resident's clinical record revealed a Progress Note dated [DATE], which documented "Patient alert and oriented x 2...Patient was out for smoke breaks." The resident's clinical record revealed a Progress Note dated [DATE], which documented "Patient very lethargic. Both doses of pain medication was held due to extreme lethargy..." The resident's clinical record revealed a Progress Note dated [DATE], which documented "Patient continues to be lethargic scheduled pain medication was held, MD aware of lethargy." A physician's orders [REDACTED]. The resident's clinical record revealed a Progress Note dated [DATE], which documented "Alert and oriented with confusion, lethargic, refusing care..." The resident's clinical record revealed a physician's Progress Note dated [DATE] which documented "Drowsy keeps eyes closed, does not acknowledge provider. Per nursing patient seems sedated." The resident's clinical record revealed a Progress Note dated [DATE] which documented "Alert and oriented with confusion, lethargic, refusing care..." Progress Note dated [DATE] documented "Patient alert and oriented." The resident's clinical record revealed Progress Notes dated [DATE] at 1422 which documented "Patient alert and oriented x 2, mid day OxyContin held patient drowsy and lethargic, was out for scheduled smoke breaks." Progress Notes dated [DATE] at 1852 documented "Patient alert and oriented x 3." Progress Notes dated [DATE] at 1311 documented "On bed Fowler position requesting for smoke and pain meds...CNA accompanied the patient to the patio." Progress Notes dated [DATE] at 2116 commented "Patient went out for smoke accompanied by the CNA." Progress Notes dated [DATE] at 1430 documented "...0720 On lying claimed he has pain scale ,[DATE] Oxycodone 30 mg given...Went out for smoke in the courtyard with escort."" A review of the resident's clinical record revealed MS Contin 60 mg was administered per physician's orders [REDACTED]. Progress Notes dated [DATE] at 2201 documented "Computer was down due to Internet problems. This note could not be done right after code...Received report at 1400. This writer was notified at approximately 1445 that patient was outside. This writer went to go see patient and found the patient in his wheelchair outside in the sun. Patient aroused by painful stimuli via sternal rub. Patient blinked his eyes and slightly moved his head. Patient was wheeled inside into room. Patient had a thready pulse and was unresponsive and not breathing. Patient was transferred on to bed. Patient was placed on non rebreather at high flow oxygen and CPR was started at approximately 1455. 911 was called. Paramedics arrived and care was turned over. Dr...was notified." A review of hospital documentation dated [DATE] documented "Patient presents with Cardiac Arrest, Respiratory Arrest, and Hyperthermia." A review of hospital documentation revealed the resident's rectal temperature was 107.3 degrees Fahrenheit on [DATE] at 1559. Hospital documentation dated [DATE] documented "He appears cachectic. He has a sickly appearance. He appears distressed. He is intubated." Hospital documentation dated [DATE] documented "This is an elderly male who comes in after cardiac arrest. The patient was revived in the field with trauma pulses although they are very faint. Patient has extreme Hyperthermia with passive colon use, a core blanket and ice was applied...noted to have hypotension...aggressive IV fluid hydration which was not successful in increasing blood pressure..." Hospital documentation dated [DATE] documented "...Presented with MSOF (multi-system organ failure), severe coagulopathy, and persistent shock. He subsequently coded x 2. He has no reliable pulse on multiple pressors and HCO3 (bicarbonate). His neuro exam is consistent with brain death...I recommend withdrawal of care." Hospital documentation dated [DATE] at 0826 documented "...Patient's condition is not consistent with any chance of meaningful recovery and is in fact consistent with death. Agree to withdraw support now..." A review of hospital documentation, Death Note/Discharge Summary documented "...Cardiac arrest, severe Hyperthermia, hypotension..." An interview was conducted with staff member #3, a registered nurse, on [DATE]. Staff member #3 stated that she observed the resident seated in his wheelchair on the patio between 2:30 p.m. and 2:50 p.m. on [DATE]. Staff member #3 stated that she went up to the resident and called him by name and he did not respond. Staff member #3 stated that she obtained the assistance of two other nurses to bring the resident indoors. Staff member #3 stated that the resident appeared to be sleeping as he was making a "snoring sound." An interview was conducted with staff member #4, a registered nurse, on [DATE]. Staff member #4 stated that on [DATE] she was told by staff member #3 that the resident was outside. Staff member #4 stated that she went outside and the resident didn't look good, was slouched back in his wheelchair, and his head was turned to the left. Staff member #4 stated that she tried to arouse the resident by calling his name and touching him. When the resident did not respond, staff member #4 stated that she began a sternal rub. Staff member #4 stated that the resident blinked his eyes and very slightly moved his head. Staff member #4 stated that the resident's pulse was thready and his breathing was shallow. Staff member #4 stated that she could not obtain a pulse on the resident so CPR was started and 911 was called. Staff member #4 stated that the resident's face was "really flushed" and his skin was hot to the touch. An interview was conducted with the administrator on [DATE] on the outdoor patio. The administrator stated that the resident was seated in his wheelchair on the sidewalk of the patio which was in partial to full sun on [DATE] An interview was conducted with staff member #5, a registered nurse, on [DATE]. Staff member #5 stated that an RN asked her to assist her with the resident on [DATE]. Staff member #5 stated that the resident did not look good and was slumped over to the left. Staff member #5 stated that the resident had clear liquid coming out of his mouth and nose. Staff member #5 stated that the resident did not appear to be breathing. Staff member #5 stated that CPR (cardio pulmonary resuscitation) was started and 911 was called. Staff member #5 stated "I have no idea" when asked what type of monitoring is required when residents are outside independently. An interview was conducted with staff member #1, a CNA (certified nursing assistant) on [DATE]. Staff member #1 stated that he took the resident outside at about 1:00 p.m. on [DATE] because the resident wanted to eat his lunch out on the patio. Staff member #1 stated that he went inside to get the resident his cigarettes and returned to the patio at about 1:10 p.m. Staff member #1 stated that he stayed with the resident until he smoked two cigarettes. Staff member #1 stated that he asked the resident if he wanted to come back into the building and the resident stated no. Staff member #1 stated that he returned to the building at 1:30 p.m. to complete his job assignments. Staff member #1 stated that when he left the facility at 2:00 p.m., he told staff member #2 that the resident was still outside. Staff member #1 stated that when a resident is outside, monitoring is done on a "case to case situation." An interview was conducted with staff member #2, a CNA on [DATE]. Staff member #2 stated that when she came to work at 2:00 p.m. on [DATE], she was told by staff member #1 that the resident was outside on the patio. Staff member #2 stated "I peeked out there to see if he was there at 2:30 p.m." Staff member #2 stated that the resident looked like he was sleeping. Staff member #2 stated that she did not go out in the courtyard to check on the resident. Staff member #2 stated she did not check on the resident any more. Staff member #2 stated that she had planned on going out to the courtyard again to check on the resident but that other staff brought him in at 2:45 p.m. before she could check on the resident. Staff member #2 stated that she did not know if there was a facility policy on how often residents should be monitored when they are outdoors but, as a CNA, she would check on her assigned residents every 20 minutes. There was no evidence through staff interviews that the resident was monitored by staff while he sat outdoors in the patio from 1:30 p.m. until 2:45 p.m. A review of the Weather Channel monthly forecast revealed the high temperature in Tucson, Arizona was 102 degrees Fahrenheit. Random interviews with CNA's and licensed nursing staff on [DATE], revealed that when residents were outdoors they should be checked on by staff every 5, 15, or 30 minutes. An interview was conducted with the administrator on [DATE]. The administrator stated that staff should check frequently on residents when they were outdoors. A review of the facility's policy Resident Safety documented "Make routine visits to check on the resident's condition and comfort."