Every finding on record at Springdale Village Post Acute

Based on resident and staff interviews, facility documentation and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need.Findings include: The PBJ (Payroll-Based Journal) Staffing Data Report revealed the facility triggered for excessively low weekend staffing for FY (fiscal year) Quarter 2 2025 (January 1 - March 31), and Quarter 4 2025 (July 1 - September 30). Per the report, submitted weekend staffing data was excessively low. The PBJ revealed the facility triggered for failure to have licensed nursing coverage 24 hours/day for FY Quarter 1 2025 (October 1- December 31), FY Quarter 2 2025 (January 1 - March 31). Per the report, submitted 24 hours/day licensed nursing coverage was excessively low. The 2026 Facility Assessment, reviewed February 2026, revealed that the facility was licensed to provide care for 122 residents and had an average daily census of 35-50, which consisted of both long and short-term stays. The 2026 Facility Assessment revealed that staffing decisions are determined at the facility level (corporate input may be included) to ensure there are enough staff with appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care. The policy further revealed that the facility will consider staffing needs for each shift, such as day, evening and night, and will adjust as necessary based on any changes to its resident population. Review of the facility timeclock punch details for members of the nursing staff revealed that there was not continuous 24 hours of nursing coverage on the dates of:May 31, 2025June 1, 2025June 2, 2025June 6, 2025June 7, 2025June 8, 2025June 9, 2025June 12, 2025June 13, 2025June 14, 2025 Daily staffing posting documentation was requested to be reviewed for the dates of May 31, 2025 through June 14, 2025. The Director of Nursing (DON/Staff #61) stated that he was unable to locate the documents. An interview was conducted on May 18, 2026 at 11:54 a.m. with the ombudsman who shared concerns residents have brought to her that included concerns such as long wait times for call lights to be answered and that call lights are not answered in the evenings. An interview was conducted with Certified Nursing Assistant (CNA/Staff #57) on May 19, 2026 at 1:28 p.m. The CNA stated that she had never been on duty when a nurse was not present. An interview was conducted with Registered Nurse (RN/Staff #48) on May 19, 2026 at 1:41 p.m. The RN stated that she has enough time to complete her duties and that she is responsible for 15 to 16 residents on average, with 23 being the maximum number of residents she has provided care for in the past. She stated that staffing needs are determined based upon acuity and number of patients. The RN stated that she had never been the sole nurse working at the facility in the past. An interview was conducted on May 19, 2026 at 1:52 p.m. with the Director of Nursing (DON/Staff #61). The DON stated that a resident's acuity, needs, and diagnoses are considered when determining staffing requirements and assignments. He stated that staffing is based on state standard PPD (staffing hours per patient day) and that acuity is reviewed upon admission. The DON stated that census is considered when scheduling staffing. He further stated that the facility assessment included a determination of the level and competency of staff needed to meet each resident's needs each day and during emergencies. The DON stated that there is an alternate staffing plan to account for when staff members are unable to work their scheduled shifts. He further stated that the facility scheduled an extra nurse for weekend coverage. The DON stated that staffing needs are determined based upon acuity and patient needs and that the facility did not use agency staff. The DON stated that there are no days when there are no licensed nurses available to provide care for residents and the staffing concerns his organization inherited from the previous owner of the facility did not meet expectations. The DON stated a potential consequence of not having licensed nurses staffed in a 24-hour period is that there would be no ability to assess clinically to treat and provide medications to residents. Facility policy titled Nursing Services Sufficient Staff, revised March 2026, revealed It is the policy of the facility to have sufficient nursing staff with the appropriate competencies and skillsets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment.

Based on review of facility documentation, staff interviews and facility policy, the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The deficient practice has the potential to affect resident care.Findings include:Review of the PBJ (payroll-based journal) Fiscal Year (FY) Quarter 2, 2025 (January 1 - March 31) revealed No RN hours on the following dates:January 1, 2025January 2, 2025January 3, 2025January 4, 2025January 5, 2025January 6, 2025January 7, 2025January 8, 2025January 9, 2025January 10, 2025January 11, 2025January 12, 2025January 13, 2025January 14, 2025January 15, 2025January 16, 2025January 17, 2025January 18, 2025January 19, 2025January 20, 2025January 21, 2025January 22, 2025January 23, 2025January 24, 2025January 25, 2025January 26, 2025January 27, 2025January 28, 2025January 29, 2025January 30, 2025January 31, 2025February 1, 2025February 2, 2025February 3, 2025February 4, 2025February 5, 2025February 6, 2025February 7, 2025February 8, 2025February 9, 2025February 10, 2025February 11, 2025February 12, 2025February 13, 2025February 14, 2025February 15, 2025February 16, 2025February 17, 2025February 18, 2025February 19, 2025February 20, 2025February 21, 2025February 22, 2025February 23, 2025February 24, 2025February 25, 2025February 26, 2025February 27, 2025February 28, 2025Review of the PBJ FY Quarter 3 2025 (April 1 - June 30) revealed no RN hours on the following dates:April 6, 2025May 31, 2025June 7, 2025June 8, 2025June 14, 2025A request was made on May 17, 2026 at 8:29 a.m. to obtain punch details for all licensed staff, which included RN hours. Director of Nursing (DON/Staff # 61) revealed that they did not have access to all the dates listed on the request.Review of the facility timeclock punch details from May 31, 2025 to June 14, 2025 revealed the following dates with no RN on duty for 8 consecutive hours:May 31, 2025June 1, 2025June 7, 2025June 8, 2025June 14, 2025Review of the facility timeclock punch details from March 1, 2025 to March 6, 2025 revealed 2 dates with no RN on duty for 8 consecutive hours:March 1, 2025March 2, 2025An interview was conducted on May 18, 2026 at 11:54 a.m. with the Ombudsman. The Ombudsman shared concerns residents have brought to her that included concerns such as long wait times for call lights to be answered and that call lights are not answered in the evenings.An interview was conducted with Registered Nurse (RN/Staff #48) on May 19, 2026 at 1:41 p.m. The RN stated that she has enough time to complete her duties and that she is responsible for 15 to 16 residents on average, with 23 being the maximum number of residents she has provided care for in the past. She stated that staffing needs are determined based upon acuity and number of patients. The RN stated that she had never been the sole nurse working at the facility in the past.An interview was conducted on May 19, 2026 at 1:52 p.m. with (DON/Staff #61). The DON stated that a resident's acuity, needs, and diagnoses are considered when determining staffing requirements and assignments. He stated that staffing is based on state standard PPD (staffing hours per patient day) and that acuity is reviewed upon admission. The DON stated that census is considered when scheduling staffing. He further stated that the facility assessment included a determination of the level and competency of staff needed to meet each resident's needs each day and during emergencies. The DON stated that there is an alternate staffing plan to account for when staff members are unable to work their scheduled shifts. He further stated that the facility scheduled an extra nurse for weekend coverage. The DON stated that staffing needs are determined based upon acuity and patient needs and that the facility did not use agency staff. The DON stated that there are no days when there are no licensed nurses available to provide care for residents and the staffing concerns his organization inherited from the previous owner of the facility did not meet expectations. He stated that he was made aware of the facility's one-star staffing rating. The DON stated a potential consequence of not having licensed nurses staffed in a 24-hour period is that there would be no ability to assess clinically to treat and provide medications to residents.Facility policy titled Nursing Services Sufficient Staff, revised March 2026, revealed It is the policy of the facility to have sufficient nursing staff with the appropriate competencies and skillsets to provide nursing and related services to promote resident safety and attain or maintain the highest practicable mental, psychosocial well-being of each resident, as determined by resident assessment and individual plans of care and considering the number, acuity and diagnosis of the facility's resident population in accordance with the facility assessment.

Based on observation, staff interviews and policy review, the facility failed to ensure current nurse staffing information was posted on a daily basis. The deficient practice could result in staffing information not being readily available to residents and visitors.Findings include:Upon entry, an observation was conducted on May 17, 2026 at 7:34 a.m. in the facility lobby. The date listed on the daily staffing posting posted in the facility lobby was observed to be May 14, 2026. The daily posting revealed 1 RN scheduled from 6 a.m. to 6 p.m., 3 LPN's from 6 a.m. to 6 p.m., 5.66 CNA's from 6 a.m. to 6 p.m., 0 RN hours posted from 6 p.m. to 6 a.m., 3 LPN's from 6 p.m. to 6 a.m., and 4 CNA's from 6 p.m. to 6 a.m.A second observation occurred on May 17, 2026 at 1:16 p.m., which revealed the daily staff posting was updated to the date of May 17, 2026.An interview was conducted on May 19, 2026 at approximately 1:52 p.m. with the Director of Nursing (DON/Staff #61). The DON stated that it is the facility expectation that daily staffing postings are updated daily and displayed in the facility lobby. He further stated that daily staffing postings not being updated and posted for the dates of May 15, 2026 and May 16, 2026 did not meet facility policy.Review of the 2026 Facility Assessment Policy titled, Staffing Charts, revealed that nurse staffing information is posted on a daily basis and included the facility name, current date, census, total number and actual hours worked per shift for registered nurses, licensed practical/vocational nurses, and certified nurse aides. The facility policy further revealed that staffing information is posted at the beginning of each shift and in a prominent location that is readily accessible to residents and visitors.

Based on clinical record review, staff interviews, and facility policy and procedure review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level 1 evaluation was completed after 30 days for 1 of 18 sampled residents (Resident #14) with adiagnosis of Serious Mental Illness (SMI). This deficient practice occurred within a resident census (universe) of 70. Failure to complete the required PASRR screening and referral process may result in residents with serious mental illness not being identified for, assessed for, or receiving necessary specialized mental health services and supports. -Regarding Resident #14Resident #14 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, diabetes mellitus, muscle weakness, rheumatoid arthritis, and hypertension.A care plan initiated on August 18, 2025 lists resident has self-care performance deficit due to bipolar disorder, potential for mood problem related to disease process and medication side effects, potential for pressure ulcer development due to bipolar disorder, psychotropic medication use related to bipolar disorder, acute and chronic pain related to bipolar disorder.A care plan initiated on August 18, 2025 and revised on December 11th, 2025 indicated that the resident required an Antimanic Agent used to treat Bipolar disorder. Also, Activities of Daily Living (ADL) Self Care Performance Deficit r/t Addison's, encephalopathy, bipolar disorder, and impaired mobility. Psychotropic medications use, related to behavior management for bipolar disorder as evidenced by mood swings.An order summary revealed the following orders:-Lithium Carbonate oral capsule 600mg, give 1 capsule by mouth one time a day every Monday, Wednesday, Friday, Saturday for Bipolar Disorder, dated August 21, 2025.A Pre-admission Screening and Resident Review (PASRR) Level 1, dated August 7, 2025, for resident #14 revealed the resident had a Mental Illness (MI) that included bipolar disorder. The screening was completed by Wellsprings Therapy Center of [NAME], and it indicated convalescent care (30days).Further review of the medical record revealed no evidence that a Level 1 PASRR was not completed until December 1, 2025 and did not identify whether a Level 2 was indicated. Also, a Level 2 PASRR had not been submitted to the appropriate State-designated agency for review for resident #14.A Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated moderate cognitive impairment. The resident was administered high risk medication that included an antimanic agent, Lithium 600mg every day Monday, Wednesday, Friday and Sunday for bipolar disorder.An interview was conducted on May 18, 2026 at 11:15 A.M. with the Social Services Director (staff #10) and Case Manager (staff # 37) who stated that it is her responsibility to complete PASRR Level 1 after 30 days from admission, and PASRR Level 2 evaluations. She stated that on admission she ensures that the PASRR Level 1 is completed and accurate, and if the resident has a mental illness a PASRR Level 2 evaluation will be completed and submitted. Staff #10 stated that a Level 2 PASRR should be completed and submitted for any resident with a mental illness diagnosis or an intellectual disability. She stated that for resident #14, there was a Level 1 PASRR on admission from Wellsprings Post-Acute dated August 7, 2025, and no follow up PASRR was completed by the facility. An interview was conducted on May 18, 2026 at 2:21 P.M. with the Director of Nursing (DON/staff #27) who stated a PASRR Level 2 is to be sent to the State-designated authority for review when there is an MI diagnosis. The DON stated the risk of not completing the Level 1 and Level 2 PASRR could result in not implementing the appropriate level of care and services for a resident.An interview was conducted on May 19, 2026 at 7:10 A.M. with Administrator (staff #80) who stated that the DON was not able to find a 30-day Level 1 PASRR for resident #14 who was admitted on [DATE]. Also, there was no Level 2 PASRR submitted to the state designated authority for review. The facility policy titled, PASRR with a review date of March 2026, revealed that the facility admits only residents whose medical and nursing care needs can be met. All new admissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASRR) program. A Level 1 PASRR screen is conducted for all potential admissions to determine if the individual meets the criteria for a MD, ID or RD. If the Level 1 screen indicates that the individual may meet the criteria, he or she is referred to the state PASRR representative for the Level 2 evaluation and determination screening process.

Based on interviews, review of the clinical record, review of facility documentation, and review of facility policy and procedures, the facility failed to ensure that physician orders for weekly weights were followed for two residents (#77 and #14) in accordance with professional standards. The deficient practice could result in a lack of monitoring of weight changes and malnutrition. -Regarding Resident #77 Resident #77 was admitted to the facility on [DATE], with diagnoses that included displaced trimalleolar fracture of the right lower leg, muscle weakness, lobar pneumonia, coccidioidomycosis, type 2 diabetes, schizophrenia, depression, chronic kidney disease, polyneuropathy, hyperlipidemia, and a history of transient ischemic attack and cerebral infarction. A physician's order dated February 5, 2026, revealed weekly weights for 4 weeks, every day shift, every 7 days for 4 weeks. An admission nutrition evaluation dated February 6, 2026, revealed that the resident was at risk for malnutrition with a mini nutrition assessment (MNA) score of 8.0. A progress note dated February 6, 2026, at 10:24 a.m. revealed that an MNA was conducted, and found the resident to be at risk for malnutrition with a score of 8.0. A weight summary revealed a weight taken on February 6, 2026, at 1:22 p.m. of 219.6 Lbs on a mechanical lift scale. A weight summary revealed a weight taken on February 22, 2026, at 2:25 p.m. of 219.6 Lbs on a mechanical lift scale. An admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. A care plan focus revised on March 13, 2026, revealed a focus on the resident's nutritional problem or potential problem, and revealed that she was at risk on the Mini Nutritional Assessment with interventions to monitor and report to the doctor as needed for signs and symptoms of decreased appetite or unexpected weight loss. The care plan also revealed an intervention initiated on February 10, 2026, to complete weekly weights for 4 weeks and then monthly if stable. Review of the electronic medication and treatment administration record (eMAR/eTAR) revealed that a weight value was taken on February 6, 2026, and February 13, 2026, and the resident refused to be weighed on February 27, 2026. The eMAR/eTAR revealed no evidence that a weight was taken or refused by the resident on February 20, 2026. -Regarding Resident #14 Resident #14 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism. A physician's order dated March 2, 2026, revealed weekly weights for 4 weeks, every day shift, every 7 days for 4 weeks. A care plan focus initiated on March 2, 2026, revealed a focus on the resident's nutritional problem or potential problem, and revealed that she was at risk on the Mini Nutritional Assessment with interventions to monitor and report to the doctor as needed for signs and symptoms of decreased appetite or unexpected weight loss. A progress note dated March 5, 2026, at 12:43 a.m. revealed that an MNA was conducted, and found the resident to be at risk for malnutrition with a score of 9.0. A progress note dated March 10, 2026, at 5:53 p.m. revealed that they were unable to obtain a weight. A progress note dated March 17, 2026, at 5:32 p.m. revealed that the Restorative Nursing Assistant (RNA) was scheduled to obtain the resident's weight the next day. A weight summary revealed a weight taken on March 5, 2026, at 10:29 a.m. of 156.6 Lbs on a wheelchair scale. A weight summary revealed a weight taken on March 20, 2026, at 5:51 p.m. of 156 Lbs on a standing scale. A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated severe cognitive impairment. An admission nutrition evaluation dated March 9, 2026, revealed that the resident was at risk for malnutrition with an MNA score of 9.0. Review of the eMAR/eTAR revealed no evidence that a weight value was taken on March 3, 2026, or March 24, 2026. It was also revealed that on March 10, 2026, and March 17, 2026, weight values were not taken with an indication to see the nursing notes. An interview was conducted on March 30, 2026, at 1:47 p.m. with a Restorative Nursing Assistant and Certified Nursing Assistant (RNA/CNA/Staff#40), who stated that it was the facility's process to weigh every resident at least monthly, but that they do weekly weights for residents who have orders from the doctor for weekly weights. The CNA stated that weights were documented in the CNA tasks in the electronic health record (EHR), and that if she noticed changes in a resident's meal consumption or weight changes, she would communicate with the dietician and nursing staff, and they would request weights for the resident. The CNA stated that she could recall Resident #77, and that she only remembered weighing her once. The CNA further stated that Resident #77 did not eat well, and they often had to feed the resident because she wouldn't eat on her own. The CNA stated that she was sure the resident lost weight because of how little she was eating. An interview was conducted on March 30, 2026, at 1:58 p.m. with Licensed Practical Nurse (LPN/Staff#26), who stated that newly admitted residents were weighed once a week at least, and that weights were documented in the medical chart. The LPN stated that the doctor would be notified of weight changes and that she would reach out to the doctor if a resident experienced a weight loss greater than 2 pounds a week. The LPN stated that the physician would put in an order for weekly weights for select residents, and that the importance of following the physician's order for weekly weights was to ensure that residents were getting proper nutrients and that there was no concern with their intake. The LPN stated that the risk of not following the physician's order for weekly weights was malnutrition. The LPN opened the medical record for Resident #77 and stated that she was admitted on [DATE], and was discharged on March 21, 2026. The LPN further stated that Resident #77 had a physician's order initiated on February 5, 2026, for weekly weights on the day shift, every 7 days, and for 4 weeks, but that the physician's order was not followed because Resident #77 only had 2 weights taken from February 5, 2026, to March 21, 2026. The LPN stated that she was Resident #77's nurse a few times, she did not think that she had weight orders for her, and she could not tell the resident was losing weight because she would not get out of bed despite the nursing staff's attempts to get her up. An interview was conducted on March 30, 2026, at 2:22 p.m. with a Dietetic Technician (DT/Staff#31), who stated that weights should have been done weekly for residents who were at risk for malnutrition on admission and for newly admitted residents. The DT stated that the doctor would put in the order for weekly weights for 4 weeks, even if it was a readmission, and that her process for ensuring that residents were eating a sufficient amount was by looking at their weekly weights and meal intake, as it was documented in the medical chart. The DT stated that concerns were communicated to the Director of Nursing (DON/Staff#87), and that the RNA/CNA, Staff #40, would take the resident's weights. The DT stated that she remembered Resident #77, and she could recall that the resident had a decreased meal intake. The DT looked at the medical chart and stated that the resident was admitted on [DATE], and was discharged on March 21, 2026, and that during her stay, she was only weighed 2 times, both at 219.6 pounds, and that 2 weights were struck out in the medical chart. The DT stated that she struck out the resident's final weight of 200.6 pounds, 2 days after the resident was discharged . The DT further stated that she struck it out because she wanted her to be reweighed, but that if the resident was already gone when she struck it out, she would say the resident's final weight in the facility would be 200.6 pounds, despite her striking it. The DT stated that Resident #77 should have been weighed weekly because it was part of their protocol, and that based on the medical chart, the physician's orders were not followed for the 4 weekly weights. An interview was conducted on March 30, 2026, at 2:44 p.m. with the Director of Nursing (DON/Staff#87), who stated that their long-term care residents were expected to be weighed monthly, and that newly admitted residents would be on weekly weights for 4 weeks. The DON stated that weights were documented under the eMAR and eTAR, and that refusals would also be documented. The DON stated that the importance of following physician orders for weekly weights was to identify if there was a major loss or gain, so they could understand why there was a weight change. The DON further stated that the risk of not following the physician's orders for weekly weights would be that they wouldn't be able to identify the weight changes. The DON opened resident #77's medical chart and stated that she only had two weights taken while she was at the facility, and that she had an order initiated on February 6, 2026, for weekly weights for 4 weeks. The DON opened the eMAR and stated that, according to the documentation, the physicians' order was not followed, and that there was a hole in the documentation on the eMAR. The DON further stated that it was his expectation that staff would document a reason for the weight not being done, and that if there was a refusal, they would circle back with the resident. Review of a policy titled Physician Orders, with a revision date of March 2026, revealed that the facility's policy was to accurately implement orders, including medication orders, treatments, and procedures. The policy further revealed that treatment or related procedure orders would be transcribed in the eMAR and eTAR. Review of a policy titled, Vital Signs - Weight and Height, with a revision date of March 2025, revealed that a resident's height and weight would be recorded as the physician's orders indicate, and should be documented in the health record. The policy also revealed that if the resident was unable to be weighed, the reason should have been recorded, and other provisions should be taken to monitor the resident's size.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure two of three sampled residents (#15 and #43) reviewed for advance directives right to formulate an advance directive. The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident ' s life. Findings Include: -Regarding Resident #15 Resident #15 was admitted to the facility on [DATE] with diagnoses that included pneumonia, COVID-19, chronic obstructive pulmonary disease, hypoxemia, type 2 diabetes, protein-caloric malnutrition, anxiety, and dysphagia (difficulty swallowing). A physician ' s order dated February 6, 2023 was written for full code. A care plan initiated on February 6, 2023 revealed a focus on Resident #15 having an advance directive of full code with an intervention to call for help immediately and begin basic life support if the resident became unresponsive. A Medicare 5-Day Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score was 13, which indicated no cognitive impairment. There was no electronic or physical evidence in Resident #15 ' s clinical record of a signed advance directive or acknowledgement. Additionally, there was no evidence of a discussion with the resident or his representatives regarding his code status. -Regarding Resident #43 Resident #43 was admitted to the facility on [DATE] with diagnoses that included local infection of the skin and subcutaneous (fatty tissue just below the skin) tissue, sepsis (the body's overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death), pneumonia due to streptococcus (bacterial) pneumoniae, COVID-19, acute systolic heart failure, history of traumatic brain injury, type 2 diabetes, hypertension, depression, and morbid obesity. A physician ' s order dated January 27, 2023 was written for full code. A care plan initiated on January 27, 2023 revealed a focus on Resident #43 having an advance directive of full code with an intervention to call for help immediately and begin basic life support if the resident became unresponsive. There was no electronic or physical evidence in Resident #43 ' s clinical record of a signed advance directive or acknowledgement. Additionally, there was no evidence of a discussion with the resident or his representatives regarding his code status. An interview was conducted on April 9, 2025 at 8:15 a.m. with a Registered Nurse (RN/Staff#111) who stated that the facility ' s process for advance directive paperwork was to complete the physical form right away. The RN stated that the document would ultimately be uploaded and located in the Electronic Medical Record (EMR), but there should always be a copy of it in the building. An interview was conducted on April 9, 2025 at 8:28 a.m. with a Certified Nursing Assistant (CNA/Staff#115) who stated that if a resident were found unresponsive, she would need to find the full code or do not resuscitate (DNR) paperwork in the EMR or report sheet at the nurses station. An interview was conducted on April 9, 2025 at 9:58 a.m. with a Licensed Practical Nurse (LPN/Staff#201) who stated that on admission, staff needed to have residents or representatives sign a lot of paperwork that included advance directives. The LPN stated that they would input the code status into the EMR and physically store the paperwork with the Director of Nursing (DON). The LPN stated that the facility did not store hard charts at the nurses station, and if there was a refusal to sign paperwork it would need to be documented in the medical record. The LPN stated that the risk of not having physical or electronic documentation in the EMR would be that residents may not have their wishes honored, and it could be a problem in case of an emergency. An interview was conducted on April 9, 2025 at 10:46 a.m. with the Director of Nursing (DON/Staff#123) who stated that it was her expectation on admission for staff to complete the advance directive paperwork with the residents or their families. The DON stated that a copy of the advance directives should be maintained as a physical copy at the nurses stations, and there should always be something filled out on the forms. The DON stated that the risk of not filling out the advance directive paperwork would be that residents may not have their preferences honored, and they could be rehospitalized . The DON also stated that she could not find evidence of advance directives in the physical or electronic charts of Resident #15 or Resident #43. Review of a policy titled, Advance Directives, revealed that the facility needed to inform and provide written information to all residents regarding their right to accept or refuse medical treatment. The policy also revealed that a copy of the resident ' s advance directive was required to be included in the medical record after the advance directive had been issued.

Based on clinical record review, interviews with staff, and facility policies, the facility failed to ensure that 2 residents (#23 & #62) representatives were informed after a change in condition. Findings include: Resident #23 was admitted on [DATE] with diagnoses of metabolic encephalopathy, Parkinson's disease, and cerebral infarction. A care plan initiated on December 28, 2022 included that this resident was at risk for falls related to weakness and/or debility. A 5-day scheduled assessment Minimum Data Set (MDS) dated [DATE] included that this resident was moderately cognitively impaired and that this resident required extensive assistance for most activities of daily living including transfers. A narrative note dated January 15, 2023 included that this resident experienced a fall and that provider was notified of the fall however, family not notified. An interview was conducted on April 10, 2025 at 10:02 A.M. with a Registered Nurse (RN/staff #23) who said that a soon as a resident falls, staff do an assessment, perform a head to toe skin check, start neurological monitoring, and once the resident is deemed safe to move, the staff will get the resident back in bed, and then do a risk management assessment and start monitoring for a change in condition. This nurse said that staff will inform the Director of Nursing, the resident's family members and the resident's provider. An interview was conducted on April 10, 2025 at 10:24 A.M. with the Director of Nursing (DON/staff #200) This DON said that her expectations for a fall would be that staff would do a head to toe to make sure there were no injuries, check vitals, then make the Medical Doctor, the resident's family and herself aware, and then fill out risk assessment out. This DON said that it does not meet her expectation that a family was not notified and said that there's the risk of the family no knowing and getting upset, and there's a risk of harm if the resident is confused and is unable to provide an accurate history when family would know. An interview was conducted on April 10, 2025 at 10:24 A.M. concurrently with a clinical resource (staff #240) who reviewed resident #23's clinical record and said that there was nothing in the record regarding notification of the family. Regarding Resident #62: Resident #62 was admitted on [DATE] with dysphagia, hemiplegia, hemiparesis, cognitive communication deficit, and depression. A progress note dated April 5, 2023 revealed Resident #62 was discovered walking outside the front door of the facility around 7:00 p.m. to 7:30 p.m. The resident was redirected by staff to his room and the nurse notified a corporate nurse. A progress note dated April 7, 2023 at 4:02 p.m., revealed that the resident was found outside the building, and that a social worker reported that per the Administrator, the resident was to be sent to an emergency room, and a case manager would notify family. A progress note dated April 8, 2023 indicated that Resident #62 was transported from the facility at 7:00pm and that the outgoing nurse had reported that a case manager was to call family. The clinical record dated April 7, 2023 through April 8, 2023, revealed no evidence that the family was notified. An interview was conducted with a Licensed Practical Nurse (LPN/Staff # 201) on April 10, 2025 at 10:21 a.m., stated that if an elopement takes place, the Director of Nursing (DON) or Executive Director (ED) can delegate contacting the family to the nurses. who would document in the Electronic Medical Record (EMR) in our progress notes any contacts or attempted contacts to family. An interview was conducted with the DON (Staff # 9) stated family, physician, and all other appropriate agencies would be notified when a resident elopes. The DON reviewed Resident #62's clinical record and stated that when Resident #62 left the building the first time all notifications and assessments were not appropriately made as well as no care plans indicating the resident's risk for elopement. A review of the facility's policy on Elopement/Unsafe Wandering dated September, 2024 included that when the resident has been located and/or returns to the facility, the attending physician and resident representative will be notified of the resident's return and the resident status. A policy titled Fall Management system reviewed March, 2025 included that the attending Physician and family/responsible party shall be notified of the fall and the resident status.

Based on clinical record review, interviews with staff, and facility policies, the facility failed to ensure that professional standards were followed in regards to care planning and an interdisciplinary review of the fall regarding one resident (#210). Findings include: Resident #210 was admitted on [DATE] with diagnoses of encephalopathy, aphasia, and depression. An admission Minimum Data Set (MDS) dated [DATE] included that this resident was severely cognitively impaired and that this resident required partial/moderate assistance for transfers from chair to bed and toilet transfers. A care plan initiated on March 19, 2025 included that this resident was at risk for falls related to to a history of falls and cognitive impairment. This care plan's latest update was on March 20, 2025. A nursing note dated March 21, 2025 included that the resident was observed on the floor by the Certified Nursing Assistant (CNA) and that the resident said that she slid off the bed. This note included that the nurse assessed the resident and the resident has stable VS. BP 131/85, 86 bpm, 98.3, 96% RA, 20rr. This note included that the resident denied pain and had no loss of mobility and that the provider, the Director of Nursing and family member were notified. A nursing note dated April 1, 2025 included this nurse heard a CNA calling for help, went to a resident room to the CNA and observed the resident sitting on the floor with her back to the bathroom door. This note included that the resident said that she walked into the door and fell and has a bruised and small hematoma to her forehead. This note included that an assessment was performed, the resident helped back into bed and that the resident's family and providers were notified. However, no care plan update or interdisciplinary meeting was found in the clinical record for these falls. An interview was conducted on April 10, 2025 at 10:02 A.M. with a Registered Nurse (RN/staff #23) who said that a soon as a resident falls, staff do an assessment, perform a head to toe skin check, start neurological monitoring, and once the resident is deemed safe to move, the staff will get the resident back in bed, and then do a risk management assessment and start monitoring for a change in condition. This nurse said that staff will inform the Director of Nursing, the resident's family members and the resident's provider. An interview was conducted on April 10, 2025 at 10:24 A.M. with the Director of Nursing (DON/staff #200) This DON said that her expectations for a fall would be that staff would do a head to toe to make sure there were no injuries, check vitals, then make the Medical Doctor, the resident's family and herself aware, and then fill out risk assessment out. This DON said that it does not meet her expectation that a family was not notified and said that there's the risk of the family no knowing and getting upset, and there's a risk of harm if the resident is confused and is unable to provide an accurate history when family would know. An interview was conducted on April 10, 2025 at 10:24 A.M. concurrently with a clinical resource (staff #240) who reviewed resident #23's clinical record and said that there was nothing in the record regarding notification of the family. A policy titled Fall Management System reviewed March, 2025 included that it is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. This document included that a resident's existing care plan will be updated. The care plan interventions will address those elements determined by investigation as probable causal factors that contributed to the fall.

Based on clinical record review, interviews and facility policy review, the facility failed to ensure one resident's (#110) medication was administered according to physician orders. The deficient practice could result in medication errors that could harm residents. Findings include: Resident #110 was admitted to the facility on [DATE]. 2023 with a diagnosis of anemia in chronic kidney disease, chronic obstructive pulmonary and type 2 diabetes. Review of the MDS (Multiple Date Set) dated February 24. 2023 reveals a BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment. Review of the discharge instructions and medication orders from the hospital state cyclobensaprine 10 mg oral tablet, 1 tab oral three times a day as needed for spasms. Review of the orders upon admission to the facility, that were transcribed from the hospital discharge sheet show the same order states cyclobenzaprine HCI oral tablet 10 mg, give 3 tablet by mouth every 8 hours as needed for spasms. Review of the MAR TAR (Medication Administration Record and Treatment Administration Record) for February 2023 reveal Resident #110 received the incorrect dose of cyclobenzaprine on the following dates: February 1, 2023 in the AM, February 24, 2023 in the AM, February 25, 2023 in the AM and PM, February 26, 2023 in the AM and February 27, 2023 in the AM. Review of the MAR TAR for March 2023 reveal Resident #110 received the incorrect dose of cyclobenzaprine on the following dates: March 1, 2023 in the AM, March 2, 2023 in the AM, March 3, 2023 in the AM and the PM, March 5, 2023 in the AM and March 7, 2023 in the AM. On March 7, 2023 at 7:00 PM the order was changed to read cyclobenzaprine HCI oral tablet 10 mg, give 1 table by mouth every 8 hours as needed for spasms. Review of the MAR TAR from March 8, 2023 through March 23, 2023 reveal the medication was given according to physician orders. An interview was conducted on April 10, 2025 at 11:01 AM with Director of Nursing (staff #200). She stated the orders are transcribed from the discharge instruction from the hospital when a resident admits. Pharmacy reviews the medication and so does staff #200 to ensure doses are accurate and then they are verified with the physician. When asked to review the cyclobenzaprine order, staff #200 stated oh, that is wrong, She was overmedicated. I cannot speak to what happened because the facility had different owners at that time. Review of the facility's policy for Nursing Services/Physician Orders dated May 2021 and reviewed on August 2021, August 2022, August 2023 and August 2024 states admission orders are reviewed with the physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to properly monitor one of three sampled residents (#62) who were at risk of elopement. The deficient practice could result in elopement, and physical injury. Findings include: Resident #62 was admitted on [DATE] with dysphagia, hemiplegia, hemiparesis, cognitive communication deficit, and depression. There was no evidence of a completed admission Minimum Data Set (MDS) assessment. An Elopement Screen dated April 5, 2023, revealed that the resident had a history of wandering, exhibited exit seeking behavior, and had no previous history of exiting a facility or home without supervision. The resident was determined to be at risk to elope and to be placed on elopement risk protocol. A care plan was initiated April 7, 2025, revealed there was no evidence of a focus or risk of elopement placed in the comprehensive care plan. Review of the clinical record revealed no evidence of a wander risk assessment after the elopement. A progress note dated April 5, 2023, revealed Resident #62 was discovered walking outside the front door of the facility around 7:00 p.m. to 7:30 p.m., the resident was redirected by staff to his room and the nurse notified a corporate nurse. Further review of the clinical record revealed no evidence that the provider or family were notified. A progress note dated April 7, 2023 at 4:02 p.m., revealed that the resident was found outside the building, and that a social worker reported that per the Administrator, the resident was to be sent to an emergency room, and a case manager would notify family. A progress note dated April 8, 2023 indicated that Resident #62 was transported from the facility at 7:00pm and that the out going nurse had reported that a case manager was to call family. The clinical record dated April 7, 2023 through April 8, 2023, revealed no evidence that the family was notified. An interview with a Licensed Practical Nurse (LPN/Staff # 201) on April 10, 2025 at 10:21 a.m., stated that residents are assessed for elopement risk on admission. If a resident is assessed to be an elopement risk, they wear special bands on their wrist letting us know that they are at risk. The LPN stated that when a resident elopes staff will look for the resident and notify either the Director of Nursing (DON) or the Executive Director (ED). If we locate the resident, we get the resident back into the building and assess resident for any injuries. The LPN stated that the DON or ED would be the one to inform the family. An interview with the DON (Staff # 9) on April 10, 2025 at 11:35 a.m., stated that residents are identified as an elopement risk by doing an assessment on admission, and that the resident would be given a yellow wrist band indicating that the resident would be an elopement risk. The DON also stated that a focus of elopement would be added into the care plan to monitor resident for unsafe wandering. If an elopement occurs, a code yellow is called and the staff will start looking for resident. If we cannot find resident, we notify police and family. Once resident is found we bring back to facility and assess the resident for any injuries, then we go through notifications of family, physician, and all other appropriate agencies. The DON reviewed Resident #62's clinical record and stated that when Resident #62 left the building the first time all notifications and assessments were not appropriately made, as well as no care plans indicating the resident's risk for elopement. A review of the facility's policy on Elopement/Unsafe Wandering dated September 2024, included that the facility will assess residents with capabilities of ambulation or mobility in wheelchair to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempts to elope. The policy also revealed that residents that are at risk for elopement will have individualized care plan developed that includes measurable objectives and timeframes.

Based on clinical record review, interviews, facility policy review, State Agency complaint tracking system, the facility failed to ensure medical records were complete and readily accessible for one resident (#110). The deficient practice could result pertinent medical information being missed by staff members which could be harmful. Findings include: Resident #110 was admitted to the facility on [DATE]. 2023 with a diagnosis of anemia in chronic kidney disease, chronic obstructive pulmonary and type 2 diabetes. Review of the MDS (Minimum Data Set) assessment dated [DATE]. 2023 reveals a BIMS (Brief Interview for Mental Status) score of 15, indicating no cognitive impairment. The complaint filed at the State Agency on March 9, 2023, revealed that while the resident was admitted to the facility she did not receive the insurance authorized time for therapy. Review of the facility documentation revealed the facility ownership had changed on March 1, 2025. The clinical record revealed no documentation of any entries prior to March 1, 2025. An interview was conducted on March 8, 2025 at 1:10 PM with the Administrator, staff #100. He stated the facility could not obtain certain parts of the electronic records from the previous owners. He had contacted them and the access was denied. An interview was conducted on April 10, 2025 with the Therapy Director, (staff #800) who stated he was assisting staff members in trying to obtain the records needed but were not able to access anything previous to February 1, 2025. The State of Arizona law Statue 12-2297 states a health care provider must retain the original or copies of an adult patient's medical records for at least six years after the after the last date the patient received medical or health care services from that provider, according to the Arizona legislature.

Based on observation, clinical record review, interviews with residents and staff, and review of facility policy, the facility failed to ensure appropriate infection control guidelines were implemented and followed for one resident (#1). The deficient practice could result in the spread of infectious disease. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, allergic rhinitis, and type 2 diabetes mellitus with diabetic polyneuropathy. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident's cognition was intact. Review of the Certified Nursing Assistant (CNA) task log for bowel movements revealed an entry on January 1, 2025 at 9:39PM, which indicated Resident #1 had experienced three episodes of loose/ diarrhea stools. It was also revealed that the bowel movements charted on January 1, 2025 at both 4:23PM and 9:39PM were incontinent bowel movements, when the resident was previously charted as mostly continent. Review of the nursing progress notes revealed a health status/progress note dated January 2, 2025 at 05:48AM, which revealed that the resident was experiencing diarrhea, and a stool sample was sent to the lab to rule out clostridium difficile (c.diff). Review of the care plan revealed a focus that the resident had a diagnosis that required enhanced barrier precautions (EBP) to be utilized. There was no evidence found to reveal that contact precautions should be utilized. Review of the Physician Orders revealed no evidence that contact precautions had been ordered. Initial observation of Resident #1's room on January 2, 2025 at 10:19AM revealed signage for EBP outside of the resident's room in addition to a cart with PPE. There was no signage for contact precautions outside of the resident's room. Interview was conducted with Resident #1 on January 2, 2025 at 10:20AM, who confirms she began having diarrhea yesterday on January 1, 2025, and that she was still having the diarrhea. She stated that she believed it to be some sort of flu. Interview was conducted on January 2, 2025 at 12:56PM with a Certified Nursing Assistant (CNA/Staff #3) who stated that she knew of two residents on the unit experiencing diarrhea and vomiting. She states that these residents are on contact precautions, not enhanced barrier precautions. Interview was conducted on January 2, 2025 at 12:43PM with a Licensed Practical Nurse (LPN/ Staff #16) on January 2, 2025 at 12:43PM, who stated that she knew of two residents with diarrhea at the moment, one of which was Resident #1. She could not confirm how long the diarrhea had been ongoing. She states that for these residents, contact precautions should be used and that these residents were encouraged to isolate in their rooms. She also confirms that Resident #1 had a C-diff culture pending. Interview was conducted on January 2, 2025 at 1:31PM with the Infection Preventionist (IP/Staff #8), who stated that she would consider 2 episodes of diarrhea in a shift to be a concern. She explains that for residents with multiple episodes of diarrhea, these residents were placed on contact precautions. Review of the infection control mapping for December 30, 2024 to January 1, 2025 revealed multiple resident rooms being monitored for loose stools and/or vomiting. Resident #1's room was not included in the rooms being monitored, despite having symptoms. Interview was conducted on January 2, 2025 at 3:37PM with the Administrator (Staff #21), who also stated that residents with recent diarrhea were placed on contact precautions and that these precautions should have been in place at the time of the survey. She further states that residents being tested for c-diff should have contact precautions in place. Review of the facility policed titled, Clostridium Difficile, revealed that clostridium difficile infection is suspected in residents with acute, unexplained onset of diarrhea (three or more unformed stools within 24 hours). The policy also states that residents with diarrhea and suspected CDI are placed on contact precautions while awaiting laboratory results.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#1) to be free from abuse by staff. The deficient practice could result in appropriate action not taken and further abuse of residents. Findings include: Resident #1 was readmitted on [DATE] with diagnoses of cerebrovascular disease (CVA), dementia and major depressive disorder. The care plan dated August 22, 2024 revealed that the resident was at risk for skin breakdown related to a decline in mobility/transfers/repositioning. Interventions included to administer ointments or medications as ordered as preventative measure and to assist resident to reposition while in bed or wheelchair as needed. The care plan on ADLs (activities of daily living) dated August 22, 2024 revealed that the resident was at risk for ADL self-care performance deficit related to weakness/debility. Interventions included staff participation was required with bathing, turning and repositioning, moving on and off unit, daily hygiene needs and toileting. A review of the facility staffing schedule document for September 27, 2024 revealed that the certified nurse assistant (CNA/staff #141) was on the schedule for the night shift. A health status progress note dated September 28, 2024 revealed that a certified nursing assistant (CNA) notified nursing staff of skin tear and bruising to resident #1 right forearm. Per the documentation, staff assessment revealed bruising and skin shearing to the lower right arm; and that, the administrator, charge nurse, and nurse practitioner were notified. The nursing note dated September 28, 2024 included a Braden Scale score of 12 indicating the resident was high risk for pressure ulcer. The Brief Interview for Mental Status (BIMS) Evaluation dated September 30, 2024 included a score of 99 indicating resident was unable to complete the interview. Per the documentation, the resident memory problems and ability to make decisions regarding tasks of daily life was severely impaired. Another BIMS evaluation dated October 1, 2024 included a score of 3 indicating the resident had severe cognitive impairment. The discharge summary dated October 2, 2024 included that resident was discharged to hospice. Reason for discharge was that goals were met. The facility's 5-day report dated October 3, 2024 revealed that during the morning rounds, the CNA identified that the resident had bruising on her right forearm consistent with being squeezed by a hand with scratches that would be consistent with fingernails. Per the documentation, the employee that cared for the resident could have been found to be more aggressive than necessary; and that, the allegation was verified by evidence collected during their investigation. In an interview with the administrator (staff #1) conducted on October 3, 2024 at 2:48 p.m. the administrator stated that resident #1 was admitted in the facility for respite and had gone home. The administrator stated that the resident #1 had a roommate (resident #2); and, the alleged certified nursing assistant (CNA/staff #141) worked from 6 p.m. to 6 a.m. at the time of the alleged incident. The administrator stated that the resident's roommate (resident #2) reported that resident #1 was swinging her arm and the CNA (staff #141) grabbed the arm of resident #1 and told resident #1 not to hit the CNA or the CNA will hit the resident back. The administrator stated that there were bruising like four fingers marking of right hand identified and found on the arm of resident #1. The administrator stated that they interviewed their staffs, notified the police, ombudsman, medical director, spoke to the resident's family, and notified the staffing agency for the CNA (staff #141). An interview was conducted via phone on October 3, 2024 at 3:31 p.m. with a CNA (staff #78) who stated that she received a report from the alleged CNA (staff #141) who told her that resident #1 and her roommate (resident #2) were good and had no problem. The CNA stated that had taken the resident's vital signs on the resident's left arm; and that, later she came back to provide resident #1 care and she removed the blanket covering on resident's right arm and when the resident raised her right arm, she saw marks on the resident's skin that she did not see on September 27, 2024. The CNA said that she saw three round markings in the front of the arm and one round marking in the back of the right forearm. The CNA stated that she then called the registered nurse (RN/staff #61) who asked resident #1 what happened. The CNA said that resident #1 reported that a black cat scratched her. However, the CNA said the nurse asked the resident's roommate what happened; and the roommate reported that resident #1 went to swing at the alleged CNA (staff #141) who then grabbed the resident's arm and told resident #1 do not hit or the CNA (staff #141) would hit the resident back. Further, the CNA stated that they received in-service training on abuse conducted by the administrator on September 28, 2024. A phone interview was conducted on October 3, 2024 at 3:45 p.m. with the RN (staff #61) who stated that at around 7:30 a.m. at the time of the incident, a CNA (staff #78) reported that the right arm of resident #1 had what looked like a hand print. The RN said that the resident's roommate (resident #2) reported that the alleged CNA (staff #141) came in to change resident #1 who was trying not to be changed; and that, the alleged CNA (staff #141) said that she will not have some old lady tell her that they were going to be changed. The RN said that resident #1 said it was a black cat; and, she reported the incident to the administrator at around 8:00 a.m. She said that the supervisor, administrator and police came; and there was a mandatory in-service on September 28, 2024. A phone interview with the alleged CNA (staff #141) was attempted on October 3, 2024 at 4:21 p.m. but was unsuccessful. Staff #141 did not answer nor returned the call. An interview with the hospice nurse (staff #142) was conducted on October 3, 2024 at 4:55 p.m. The hospice nurse said that she visited resident #1 on September 27, 2024 the day resident was admitted to the facility and the resident did not have wounds or bruises. She stated that she heard that the incident happened on the weekend. Further, she stated that the resident was found to have bruising and skin tear on her right forearm, scabbed and open to air. A review of facility's policy titled, Abuse and Neglect Policy, revised October 2022 revealed residents have the right to be free from abuse, neglect, and it includes but is not limited to freedom from verbal, mental, neglect, or physical abuse.

Based on clinical record review, staff interviews, and the Resident Assessment Instrument (RAI) 3.0 User's manual, the facility failed to ensure the completion of comprehensive Minimum Data Set (MDS) assessments for three residents (#8, #10, #12) within the regulatory time frames. The deficient practice could result in inadequate assessment of resident needs. Findings include: Regarding Resident #8 Resident #8 was admitted to the facility on [DATE]. Review of the MDS revealed both an annual assessment dated [DATE] and a quarterly assessment dated [DATE] were still In Progress. The annual and quarterly assessments were not completed in the required timeframe for resident #8. Regarding Resident #10 Resident #10 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Review of the MDS revealed a quarterly assessment dated [DATE] was In Progress. The MDS assessment for resident #10 was not completed in the required timeframe. Regarding Resident #12 -Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the discharge assessment MDS dated [DATE] revealed it was In Progress. The discharge MDS for resident #8 was not completed in the required timeframe. An interview was conducted with the MDS coordinator/Licensed Practical Nurse (LPN/Staff #38) on April 2, 2024 at 9:49 AM. Staff #38 indicated he started his role as the MDS coordinated in mid-January and was aware there was a backlog. He also indicated that the MDS coordinator position had been vacant for a while prior to him taking the position so they were not being completed. Due to this, he and another contractor were doing 5 extra MDS assessments a week in an effort to get caught up. Staff #38 also indicated the facility was aware of the issue and there was a Quality Assurance and Performance Improvement (QAPI) plan in place to improve in this area. An interview was conducted with the Director of Nursing (DON/staff #33) and the facility Administrator (ADM/Staff #6) on April 2, 2024 at 10:02 AM. Both staff members acknowledged the facility was behind in the MDS assessments and indicated since they both took over in their roles, they had identified the issue of MDS assessments not being completed in a timely manner. Staff #6 indicated the person who was tasked with completing the MDS had quit and the facility did not have anyone who was qualified and knew how to do the MDS. Both staff members indicated they monitor the MDS completion progress each week during their weekly At Risk meetings and track the numbers of outstanding MDS assessments. Review of the RAI 3.0 User's manual, dated October 2023 revealed the Assessment Reference Date must be within 366 days after the previous Omnibus Budget Reconciliation Act (OBRA) assessment; the MDS completion must be no later than 14 calendar days after the above ARD; quarterly assessment must be completed with 92 days of the previous OBRA assessment; and discharge return not anticipated be within 14 days of the discharge date .

Based on observations, interviews, review of records, documents and policy, the facility failed to develop and implement a care plan for one resident (#4). The deficient practice could result in the resident's care needs not being met. Findings included: Resident #4 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, atrial fibrillation, depression, anxiety disorder, and seizures. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact; and, resident received antipsychotic and antidepressant medications. Review of the physician orders revealed the following orders: abilify oral tablet 10 milligrams (mg) one tablet by mouth one time a day for bipolar disorder dated November 27, 2023 and end date on November 30, 2023; abilify 10 mg one tablet by mouth at bedtime for bipolar disorder frequent mood changes dated December 29, 2023; anti-psychotic medication use: observe closely for significant side effects, sedation, drowsiness, dry mouth, constipation, blurred vision, extra pyramidal reaction, weight gain, edema, postural hypotension, sweating, loss of appetite, urinary retention date of November 27, 2023; anti-anxiety medication use: observe closely for significant side effects, sedation, drowsiness, ataxia (drunk walk), dizziness, nausea, vomiting, confusion, headache, blurred vision, skin rash dated November 27, 2023; paroxetine hydrochloride oral tablet 20 mg two tablets by mouth one time a day for depression dated November 30, 2023; anti-depressant medication use: monitor for significant side effects: drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin), excess weight gain dated December 20, 2023. The care plan dated March 25, 2024 for the use of antidepressant medication revealed to, Specify medications related to (r/t). The goals included the resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date and the resident will show decreased episodes of signs and symptoms of depression through the review date; however, there were no specific interventions included in the care plan as well as the specific medication. The care plan dated March 25, 2024 related to the resident having depression. The goals included the resident will remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood by/through review date; however, there were no specific interventions included in the care plan as well as the specific medication. An interview was conducted on April 3, 2024 at 10:24 AM with a licensed practical nurse (LPN/staff #50). The LPN stated that the care plan process began during admission and was based on the needs of the resident and the integration of resident's diagnoses and medication. The care plan also included any changes, progression or decline of the resident. Staff #50 stated that the care plan needed to be adjusted as needed to fit the resident's needs. For example, a care plan would include a resident with a foley catheter, an intravenous line on antibiotic, or be a two persons assist, or anything specific for that resident would be in the care plan. The care plan included an initial problem, set goals, and interventions to achieve the resident's goals. In addition, the LPN stated that the care plan was updated as needed, during weekly risk assessment, and for instance during a change in condition such as a fall. An interview was conducted on April 3, 2024 at 10:31 AM an LPN (staff #51). She stated that a care plan, baseline care plan was completed for each resident. The LPN (staff #51) added that the MDS used the information from the baseline care plan to complete a comprehensive care plan. Further, she stated that the care plan was updated as the resident's needs changed. Staff #51 explained that in the care plan staff put information such as depression, anti-anxiety medication, and also the use of non-pharmacological and pharmacological psychotropic medication. She stated that the care plan would be patient specific. The Interdisciplinary Team (IDT) met every three months for care plan updates. An interview was conducted On April 3, 2024 at 11:44 AM with the director of nursing (DON/staff #33) with the administrator (staff #6) present. The DON stated that the residents were assessed on admission using diagnoses, medication ordered, ancillary orders, and ancillary services to create a care plan for the resident. The care plan had a focus or problem, a measurable goal, and interventions to help facilitate the goal. The care plans were updated daily, quarterly, any change in the resident's condition, or other subjects where a care plan needed to be updated. In addition, the DON stated that care plans can be reviewed by any staff; however, there were no designated staff to complete the care plans. All members of the IDT added to the care plan. The DON further stated that the care plan should be complete--that all components of the care plan should be included such as the focus or problem, the goals, and the interventions. If there were no intervention, the goals of the care plan would not be met. Review of facility's policy on Care Plans, revised on March 2022 revealed that the baseline care plan included instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including but not limited to the following such as, initial goals based on admission orders and discussion with the resident/representative; physician orders; dietary orders; therapy services; social services; and PASARR (Pre Admission Screening and Resident Review) recommendation, if applicable. The resident and /or representative are provided a written summary of the baseline care plan that includes, but is not limited to the following such as stated goals and objectives of the resident; a summary of the resident's medications and dietary instructions; any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and any updated information based on the details of the comprehensive care plan, as necessary.

Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that three staff members (#35, staff #15, and staff #17) had current cardiopulmonary resuscitation (CPR) certification training on file. The deficient practice could put the resident's safety at risk and could result in needs not being met. Findings included: On [DATE] at 11:14 AM, a review of employees' files was conducted along with the Human Resources (HR) Director and Business Office Director (staff #52). During the employees' files review the following were identified: - License Practical Nurse (LPN/staff #35) CPR certification expiration date [DATE]. - Certified Nursing Assistant (CNA/staff #15) CPR certification expiration date [DATE]. - Certified Nursing Assistant (CNA)/staff #17) CPR certification expiration date [DATE]. On [DATE] at 12:35 PM, an interview was conducted with Staff #52 and he stated that he oversaw the operation for the HR and business office, performed and provided standard operating procedure for HR which included full screening and scheduling interview, conducted onboarding, ensuring paper work and packets were up to date, and verified licenses, fingerprint cards, and references. He said he also updated employee files. Staff #52 stated that he did not know the policy on licenses and certifications. He added that staff would be removed from the schedule immediately if their license expired. He would notify the staff, Director of Nursing (DON), and the administrator when a license or certification was expired. An interview was conducted on [DATE] at 8:29 AM with the Director of Nursing (DON)/Staff #33 and the Administrator/Staff #6. They stated that the hiring process included obtaining the staff's CPR certification. A follow up interview was conducted on [DATE] at 8:56 AM with the DON and he stated that it was the responsibility of the staff member to keep up and stay current with their CPR and that staff were given time to complete their CPR certification. Staff with an expired CPR certification were not allowed to assist in any CPR activity. Review of a punch detail record revealed that LPN (staff # 35) worked approximately 860 from [DATE] through [DATE] with an expired CPR certification on file. Review of a punch detail record revealed that CNA (staff # 15) worked approximately 175 hours from February 18, 2024 through [DATE] with an expired CPR certification on file. Review of a punch detail record revealed that CNA (staff #17) worked approximately 140 hours from February 18, 2024 through [DATE] with an expired CPR certification on file. The facility's policy related to CPR Procedure dated [DATE] revealed that CPR certification was a mandatory requirement for all clinical positions. In addition, the policy specified that in the event of a medical emergency within the workplace, employees who are CPR certified were expected to respond according to their training. Further, the policy stated that by adhering to this CPR procedure, the facility aims to maintain a safe and prepared workforce capable of responding effectively to medical emergencies.

Based on clinical record review, interviews, and review of facility policy and procedure, the facility failed to ensure a discharge summary was completed for a resident (#14) discharge. The deficient practice could result in an unsafe discharge for residents. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses of dementia, kidney disease, and type 2 diabetes. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 indicating moderate cognitive impairment. Review of a progress note indicated resident #14 received a notice of discharge on December 29, 2023 and transferred to a sister facility on January 2, 2024. The progress note did not indicate a full discharge summary was provided to the resident or the resident's representative at the time of discharge. An interview was conducted with the Director of Social Services (staff #72) on April 3, 2024 at 8:53 AM. Staff #72 indicated they were not sure what the facility's policy was related to required paperwork when discharging a resident. Staff #72 indicated they were not sure who was responsible to ensure the completion of the resident's discharge summary. Staff #72 also indicated that she was responsible to ensure that a resident was able to access resources upon discharge. When asked what the risks would be of a resident or their representative not obtaining a discharge summary upon discharge, staff indicated the residents would not be able to get outside services once they are discharged . Staff #72 stated, timeliness is important to their care and good communication,. An interview was conducted on April 3, 2024 with the Director of Nursing (DON/staff #33) at 9:10 AM. Staff #33 indicated they were still new in the role and was getting up to speed on the facility's policies and procedures. Staff #33 stated I don't know what the process is for discharge right now, but I know what I would like to see the process be. Staff #33 indicated they would like to see a transfer form which would include a recapitulation of the resident's stay which would also include progress notes and a communication of the discharge or transfer of the resident. Staff #33 also indicated that they have been having conversations with staff who participates in the discharge process about including residents' goals for discharge in their care plan regardless if the residents were actually discharge or not. When asked about the risks associated with not providing residents or their representative with a copy of a discharge summary, they indicated that it could lead to distress and/or psychosocial harm to the residents and/or their representative. A review of the facility policy titled, Discharge Planning Process, which was implemented in November 2017, indicated that the Discharge Summary was to be included in the discharging resident's discharge plan.

Based on interviews, facility documents and employee record review, the facility failed to ensure that the activities program was directed by a qualified professional. The deficient practice could result in the activities program not being directed by a qualified professional Findings included: On [DATE] at 11:14 AM, a review of staff #21's file was conducted with the Human Resources (HR) Director and Business Office Director (staff #52). On [DATE] at 12:35 PM, an interview was conducted with Staff #52 and he stated that he oversaw the operation for the HR and business office, performed and provided standard operating procedure for HR which included full screening and scheduling interview, conducted onboarding, ensuring paper work and packets were up to date, and verified licenses, fingerprint cards, and references. He said he also updated employee files. Staff #52 stated that he did not know the policy on licenses and certifications. He added that staff would be removed from the schedule immediately if their license expired. He would notify the staff, Director of Nursing (DON), and the administrator when a license or certification was expired. On [DATE] at 9:00 am, the Administrator (staff #6) provided a document that revealed staff # 21's employment timeline. The document revealed that staff #21 was hired as an activity assistant on [DATE] and was promoted to the Director of Activity position in 2013. The document further revealed that per regulation, the activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who- (i): [left blank] (ii) Is: (A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after [DATE]; or (B) Has 2 years of experience in social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or (C) Is a qualified occupational therapist or occupational therapy assistant; or (D) Has completed a training course approved by the State. The document stated that staff #21 met the qualifications of a qualified professional under (ii)B; however, Staff # 21 did not meet the other qualification as required per regulation: (i) Is licensed or registered, if applicable, by the State in which practicing. On [DATE] at 8:40 AM, an interview was conducted with Activity Director (staff #21). Staff #21 stated that she has been in the Activity Director role for ten years and a total thirteen years with the company. Her role as an Activity Director included organizing monthly activity calendars with three to five activities and organizing staff calendars. She stated that there's activities seven days a week, on holidays and evenings, and also depending on resident's needs. She stated that she started as an activity assistant in 2011 for two years. During her role as an activity assistant, she assisted the activity director, doing documentation, everything what a director would do. She stated that the documentation involved what they do for residents daily, performing assessment for new admission, and developing care plans. For instance, for a resident assessment, the resident was assessed for skill level and preferences. If a resident wanted to be independent, they were provided leisure materials such as magazines, books, or face time with family members. Furthermore, she stated her experience included attending activity professional group meetings organized by the activity director. She added, the meetings she attended included going to other facilities and meeting with other activity directors. Staff #21 said the last time she attended a meeting with other activity directors was in 2019. She stated that she has not taken any courses or training approved by the State.

Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure that one resident (#4) was administered pneumococcal vaccine. The deficient practice could result in residents not receiving vaccines. Findings included: Resident #4 was admitted on [DATE] with diagnoses of type 2 diabetes mellitus, atrial fibrillation, asthma, chronic obstructive pulmonary disease, and seizures. The admission Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating cognitively intact. Review of a document titled, Consent/Pneumonia Vaccine revealed a signed consent to receive the pneumonia vaccine on her initial admitted in August 23, 2023 and on November 26, 2023 readmitted . Her record revealed that an immunization of Pneumococcal PCV13 vaccine was required and there was no evidence that the resident received the vaccine. An interview was conducted on April 4, 2024 at 8:56 AM with the Infection Preventionist (IP) (staff #53) and Director of Nursing (DON/staff #33). The DON stated that immunization of residents required consent and then the consent was uploaded into the system. They further added that immunization was offered upon admission and during the flu season. During the interview the DON verified the resident #4 's record and confirmed the resident consented to receiving the vaccination but the resident did not receive the pneumonia vaccine.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure the comprehensive care plan was updated to reflect the changing needs of 1 out of 2 sampled residents (#3). The deficient practice could increase the risk for further falls and injuries. Findings include: Resident #3 admitted on [DATE] with diagnoses of a displaced intertrochanteric fracture of the right hip, primary hypertension and cognitive communication deficit. The admission clinical evaluation with Braden Scale note dated August 11, 2022 revealed the resident had an admitting diagnosis of fracture of the right hip and had a history of falls. The admission Minimum Data Set assessment dated [DATE] revealed the resident required extensive assistance for most activities of daily living (ADLs) and a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. A care plan dated August 17, 2022 revealed resident was at risk for falls related to unsteady gait and/or balance and weakness and/or debility. The goal was that the level of independence be maintained to the best of the resident's ability while reducing the likelihood of falls or injury. Intervention included to keep the bed at the lowest level as needed. The care plan also included that the resident was found on the floor on November 9, 2022 and was unsure how the incident occurred. Review of a narrative progress note dated November 10, 2022 at 5:35 a.m. revealed the resident was found on the floor in a sitting position, with the left leg crisscrossed under the right leg, with her upper body against the bed and her left hand gripping the grab bar. The note included the resident was alert and oriented, had grippy socks on, call light within reach, bed locked and room light was on at the time of the fall. Per the documentation, the resident was last observed at 4:50 a.m. prior to the fall; and immediate intervention included low bed and every 15-minute checks. An incident note dated November 10, 2022 included resident was sitting on the floor with left leg crisscrossed under the right leg, with her back leaning against bed and her left hand gripping the grab bar. Per the documentation, the bed was in the lowest position at the time of the fall. Resident was assisted back to bed x 3, neuro and safety checks every 15 minutes were initiated and resident was instructed to use the call light when in need of assistance. Review of the fall care plan revealed revision dates of November 10 and 22, 2022. However, there was no evidence found the care plan was revised to include new interventions were put in place and implemented to prevent a fall. The incident note dated November 30, 2022 revealed the resident was found on the floor sitting on her bottom, legs out in front of her with no footwear and the call-light was not on. Per the documentation, the floor was dry, the bed was locked and in lowest position. A narrative note dated November 30, 2022 included the resident was found sitting on her bottom with her legs straight out in front of her. Per the documentation, the resident did not use the call light and was barefoot at the time of the fall. Immediate intervention implemented post fall included non-skid socks. An interview was conducted on December 15, 2022 at 9:02 a.m. with a Licensed Practical Nurse (LPN/staff #87) who stated that post-fall process included an assessment, notification of the provider and family, completion of an incident report/risk management report, implementation of neuro checks, and updating the care plan to prevent further falls. He stated that no matter how many times a resident fall, the care plan is revised to add new interventions that may include moving the resident closer to the nurse station or implementing one-on-one supervision. During an interview conducted on December 15, 2022 at 1:35 p.m., the Director of Nursing (DON/staff #72) stated that her expectations was that the resident's care plan is updated with new interventions after a fall incident. The facility policy on Comprehensive Person-Centered Care Plan included that a comprehensive, person-centered care plan that include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of the residents are on-going and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team must review and update the care plan when the desired outcome is not met and at least quarterly, in conjunction with the quarterly MDS assessment. The facility policy on Managing Falls and Fall risks revealed that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. It also included that if falling recurs, despite initial interventions, staff will implement additional or different interventions of indicate why the current approach remains relevant. The Goals Objectives, Care Plans policy, revised December 2022 included care plans shall incorporate goals and objectives that lead to the resident's highest obtainable level of independence. Care plans will be updated with new changes of condition. The Managing Falls and Fall Risk policy revised March 2018, included based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.

Based on clinical record reviews, resident and staff interviews, facility documentation and policies and procedures, the facility failed to ensure that physician orders [REDACTED].#9) resulting in ongoing vaginal pain, failed to ensure the physician was notified regarding elevated blood sugars for one resident (#13), failed to ensure there was a physician's orders [REDACTED]. The deficient practice resulted in one resident experiencing ongoing vaginal pain without treatment. The deficient practice could also result in complications related to elevated blood sugars without physician interventions and the physician not being aware of a resident's therapy plan of care. Also, a resident could experience a decrease in mobilty/range of motion if RNA services were not provided. Findings include: -Resident #9 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 9, (YEAR) included the resident was at risk for alteration in comfort and pain, related to a [MEDICAL CONDITION]. Interventions included to administer medication for pain relief and assess effectiveness, and to assess the resident's pain status on an ongoing basis. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 3, 2019 revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. A health status note dated (MONTH) 7, 2019 included the resident had been on an antibiotic for a urinary tract infection and continued to complain of vaginal itching and discomfort. The nurse practitioner (NP) was called and new orders were given. A physician's orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. However, instead of initials indicating the medication was given, a 9 was documented which according to the chart code it meant other/see nurse notes. There was no documentation that the [MEDICATION NAME] was given. Review of the eMAR (electronic Medication Administration Review) note dated (MONTH) 8, 2019 for the above order revealed the following documentation: waiting on medication, start date changed. There was no documentation on the MAR indicated [REDACTED]. A NP's note dated (MONTH) 9, 2019 included the resident was having vaginal itching and discomfort similar to a yeast infection. The plan was to give fluconazole (antifungal) one time for a yeast infection and that it was okay to use over the counter [MEDICATION NAME] topical cream for vaginal itch. A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED] A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The corresponding eMAR note dated (MONTH) 9, 2019 revealed the family was to supply the above medication. A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. The medication was administered on (MONTH) 11, and was effective. The MAR indicated [REDACTED]. A health status note dated (MONTH) 11, 2019 revealed the resident had vaginal itching and [MEDICATION NAME] cream was applied as ordered. A health status note dated (MONTH) 12, 2019 included the resident complained of burning in her vagina and it is being treated with [MEDICATION NAME]. A physician's orders [REDACTED]. Further review of the (MONTH) 2019 Medication Administration Record [REDACTED]. A quarterly MDS assessment dated (MONTH) 5, 2019 revealed the resident's Brief Interview for Mental Status (BIMS) score was 15, which indicated the resident was cognitively intact. A health status note dated (MONTH) 13, 2019 included the resident was complaining of burning with urination and vaginal discomfort, the physician was aware and gave an order to obtain a urine sample, which was collected. A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. On (MONTH) 14, there was a 9 which indicated to see the nurses notes. An eMAR note dated (MONTH) 14, 2019 for the above order included the medication was not in stock and the dosage was to be determined. Review of the clinical record revealed no documentation that the [MEDICATION NAME] Cream was administered for 5 days as ordered. A physician's orders [REDACTED]. Review of the MAR for (MONTH) 2019 included the above order. However, a 9 was documented, which indicated to see the nurses notes for (MONTH) 3 and 4. There was no other documentation that this order was administered. A corresponding eMAR note dated (MONTH) 3, 2019 revealed the medication was on order. An eMAR note dated (MONTH) 4, 2019 included the medication was not available pharmacy sending. A health status note dated (MONTH) 4, 2019 included the NP was notified to clarify the above order and a duration for the medication was obtained. A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. A 9 was documented, indicating to see the nursing notes. Review of the eMAR notes for the above medication included can't find rx. A NP note dated (MONTH) 5, 2019 included this was the monthly visit and follow up for vaginal itching. The resident was complaining of vaginal irritation and itchiness. The plan was for [MEDICATION NAME] to be given for three days. A physician's orders [REDACTED]. Review of the MAR for (MONTH) 2019 included the above medication order, however a 9 was documented, indicating to see the nurse's notes. A corresponding eMAR note dated (MONTH) 5, 2019 included the above medication was on order. A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. On (MONTH) 8, the medication is documented as administered. Review of the eMAR notes dated (MONTH) 6 and 7 included the medication was on order. The eMAR note dated (MONTH) 9, revealed waiting for medication from pharmacy. The eMAR note dated (MONTH) 10, revealed the medication was on order. A physician's orders [REDACTED]. Review of the (MONTH) 2019 MAR indicated [REDACTED]. A corresponding eMAR note dated (MONTH) 15, 2019 for the above medication revealed not available will ask pharm to send. Review of the clinical record revealed no documentation the [MEDICATION NAME] 3 Combo Pack was given on (MONTH) 15, 16 or 17. Further review of the clinical record revealed no evidence that the physician was notified that the medications were not available for the resident. Review of the (MONTH) 2019 MAR indicated [REDACTED]. An eMAR note dated (MONTH) 24, at 1:16 p.m., included that [MEDICATION NAME] 5-325 mg was given by mouth for a pain scale of 6-10 for pain in vagina. A physician's orders [REDACTED]. An interview with resident #9 was conducted on (MONTH) 25, 2019 at 8:49 a.m. The resident stated that she was concerned regarding not having an appointment for her vaginal pain and discomfort. She stated some time ago she had an order for [REDACTED]. She stated there was no follow up after she did not receive the full treatment of [REDACTED]. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. In a follow up interview with resident #9 on (MONTH) 27, 2019 at 9:47 a.m., she stated that when she is sitting in her wheelchair which she does most of the day, she feels like there is a knife sticking up her, and that it has been this way for a couple of weeks. She stated that she has made staff aware and they tell her they will contact the doctor, but she is unsure if they have. She also stated that when she urinates, she feels burning and itching. An interview with a Licensed Practical Nurse (LPN/staff #93) was conducted on (MONTH) 27, 2019 at 12:07 p.m. Staff #93 is familiar with the resident's care. Staff #93 stated that she is aware the resident has complained of vaginal discomfort and was aware that [MEDICATION NAME] and creams were ordered for her vaginal discomfort, but was unsure if the treatments were carried out as ordered. She stated the resident has a history of wearing several layers of briefs and has been educated on the risks of doing so, but she continues to do it. In an interview with a Registered Nurse (RN/staff #112) on (MONTH) 27, 2019 at 5:22 a.m., she stated that if a medication is not available, she will pass on the information to the day shift to call the pharmacy, because the pharmacy does not have an after hours line that the night shift can call. She stated she would also inform the physician to let them know. She stated contacting the physician and/or pharmacy would be documented in the eMAR notes. An interview with the Director of Nursing (DON/staff #16) was conducted on (MONTH) 28, 2019 at 11:51 a.m. She said the nurses should contact the pharmacy and physician or nurse practitioner if a medication is unavailable. She also stated if a medication was administered, it should have been documented. Further, she stated that she was not sure why the nurses would not have documented if a medication was administered. Review of a facility policy titled Quality of Life-Dignity with no date included, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Review of a facility policy titled Medication and Treatment Orders with no date included, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of a facility policy titled, Change in Condiditon/MD-Designee notification dated 12/01/2018 included, It is the policy of Allegiant Healthcare that resident change of condition is identified for proper treatment and implementation. The physician is informed of resident events and/or change in resident's condition. -Resident #13 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) recapitulation of physician orders [REDACTED]. BS (blood sugar) between 0-70, call physician and initiate [DIAGNOSES REDACTED] protocol BS of 71-150 give 0 units BS of 151-200 give 3 units BS of 201-250 give 5 units BS of 251-300 give 7 units BS of 301-350 to give 10 units BS 351+ give 12 units and call the physician Review of the MAR's (medication administration record) from (MONTH) 1, (YEAR) through (MONTH) 31, (YEAR), revealed the above Humalog insulin sliding scale orders. Further review revealed the resident exhibited blood sugars greater than 351 approximately 6 occasions in (MONTH) and October, approximately 14 occasions in (MONTH) (YEAR) and 9 occasions in December. However, review of the clinical record revealed no documentation that the physician was notified of the elevated BS at the time that the elevated BS were identified. A care plan which was revised on (MONTH) 10, (YEAR) included the resident had type II diabetes. The goals were for the resident to not have complications related to diabetes and to be free from signs and symptoms of hypo/[MEDICAL CONDITION] through the review date. An intervention included medications as ordered by the physician. Review of the MAR's from (MONTH) 1, 2019 through (MONTH) 31, 2019 continued to include the order for Humalog insulin per sliding scale subcutaneously before meals and at bedtime as follows: BS 0-70, call physician and initiate [DIAGNOSES REDACTED] protocol BS 71-150 give 0 units BS 151-200 give 3 units BS 201-250 give 5 units BS 251-300 give 7 units BS 301-350 give 10 units BS 351+ give 12 units and call physician. Review of the MAR from (MONTH) 1, 2019 through (MONTH) 31, 2019 revealed resident had BS levels greater than 351 as follows: approximately 20 occasions in January, approximately 20 occasions in (MONTH) and 5 occasions in March. However, review of the clinical record revealed no documentation the physician was notified of the elevated BS at the time they were identified. A physician's note dated (MONTH) 21, 2019 included the resident had type II DM with [MEDICAL CONDITION]. Per the documentation, the resident had a very poor dietary compliance and BS was difficult to control. Review of the (MONTH) 2019 MAR indicated [REDACTED]. During the month, there were three occasions when the resident's BS was greater than 351. There was no evidence found in the clinical record that the physician was notified of the elevated BS in (MONTH) 2019. According to a NP (nurse practitioner) note dated (MONTH) 6, 2019, the BS logs were reviewed and BS ranges in the mid-high 300's within the last month. Assessment included Type II DM with chronic complications. The plan included to continue to monitor BS before meals and at bedtime and report BS over 400. Despite documentation in the NP note to report BS over 400, the physician's orders [REDACTED]. The (MONTH) 2019 physician orders [REDACTED]. BS 0-70, call physician and initiate [DIAGNOSES REDACTED] protocol BS 71-150 give 0 units BS 151-200 give 3 units BS 201-250 give 5 units BS 251-300 give 7 units BS 301-350 give 10 units BS 351+ give 12 units and to call physician. Review of the nursing progress notes from (MONTH) (YEAR) through (MONTH) 31, 2019 revealed only one progress note dated (MONTH) 30, 2019 which documented a voicemail message was left for the NP regarding BS readings of 595 and 513. In an interview with a licensed practical nurse (LPN/staff #93) conducted on (MONTH) 27, 2019 at 8:01 a.m., she stated that she will administer the sliding scale order according to the resident's blood sugar. She stated she will contact the physician for a certain BS result, when there is an order. She said that she will document in the clinical record that she informed the physician of the BS reading and what the physician had recommended or ordered. An interview with a registered nurse (RN/staff #5) was conducted on (MONTH) 27, 2019 at 10:55 a.m. Staff #5 stated when a resident is on insulin sliding scale, she will administer the insulin dose appropriate for the BS reading of the resident. She said if the BS is outside of the prescribed parameter, she will give a certain amount of insulin as ordered and then call the physician. She stated she will call the physician if the resident's BS level is high, even if there's no order to do so. She said she will then document in the progress note that she called the physician and the orders she received. During an interview with another LPN (staff #77) conducted on (MONTH) 28, 2019 at 12:55 p.m., he stated there usually is a physician's orders [REDACTED]. He stated if the BS is above or below the ordered parameter, there are usually specific interventions and instructions to call the physician. He stated if the BS is above 351, there is usually an order to give 10 units or 12 units of insulin and to call the physician. He also said he would always call the physician if the resident's BS reading was above or below the prescribed parameters. He said that he will document in the progress note that he called the physician and the orders he received. An interview with the Assistant Director of Nursing (ADON/staff #9) was conducted on (MONTH) 28, 2019 at 2:16 p.m. Staff #9 stated the nurses are expected to follow the physician ordered parameters; call the physician if the resident's values are above or below or abnormal; and should document it in the clinical record. She stated she could not think of any reason why the nurse would not document that they called the physician for any value above or below the prescribed parameter. Review of a policy titled, Administering Medications revealed that medications are administered in a safe and timely manner, and as prescribed. Review of a policy titled, Change in Condition/Physician-Designee Notification revealed The physician is notified of resident events . and notify the physician/designee of a clinical problem. The physician/designee develops a working [DIAGNOSES REDACTED]. Further, the policy included to document in the medical record all attempts to notify the physician/designee. -Resident #275 was admitted on (MONTH) 7, 2019. [DIAGNOSES REDACTED]. A nurse's progress note dated (MONTH) 12, 2019, revealed the resident had a fall on (MONTH) 12, 2019 and was sent to the hospital. A health status progress note dated (MONTH) 13, 2019 by the unit clerk included the resident was inpatient at the hospital, with a [DIAGNOSES REDACTED]. Per the note, no current discharge plan as of yet as they need to fit resident with a brace. Review of the clinical record revealed the resident was readmitted to the facility on (MONTH) 16, 2019, with [DIAGNOSES REDACTED]. Review of the treatment administration records (TAR) for (MONTH) 2019 revealed the following: Use TLSO (Thoracolumbosacral orthosis) brace when out of bed every shift which was initiated on (MONTH) 16, 2019, and discontinued on (MONTH) 16, 2019. A Physical Therapy plan of care dated (MONTH) 17, 2019, by a physical therapist (PT/staff #125) included under precautions that the resident is a fall risk and wears a TLSO brace for all out of bed activities. Further review of the PT treatment notes dated (MONTH) 17, 19, 20, 24 and 25, 2019 revealed the resident was wearing a TLSO brace during therapy. However, review of the admission physician's orders [REDACTED]. Review of the resident's care plans revealed no documentation that the resident was utilizing a TLSO brace. There was also no CNA documentation that the resident utilized a TLSO brace. During an observation conducted on (MONTH) 26, 2019 at 9:40 a.m., a CNA was observed wheeling the resident in a wheelchair down the hallway. The resident was observed wearing a TLSO brace. At this time, the resident was taken to the therapy gym and the resident was observed participating in therapy excerices with the brace on. An interview was conducted on (MONTH) 26, 2019 at 10:47 a.m. with a CNA (Certified Nursing Assistant/staff #40). Staff #40 stated that resident #275 can not be up greater than 30 degrees, without a TLSO brace on. An interview was conducted on (MONTH) 26, 2019 at 11:06 a.m. with a RN (Registered Nurse/staff #97), who stated the resident should have his brace on at all times when he gets out of bed. She stated there should be a physician's orders [REDACTED].#97 reviewed the current physician orders [REDACTED].#97 said the nurses and the CNAs should document that the resident uses a TLSO brace when getting out of bed. An interview was conducted on (MONTH) 26, 2019, at 11:10 a.m. with the Director of Nursing (DON/staff #16). The DON stated that resident #275 is supposed to use a TLSO brace when out of bed. She stated that a physicians order should have been written for the TLSO brace. She further stated that the brace should have been care planned so that it could be initiated as a task for the CNA's. The resident's care plans were reviewed with the DON and there was no mention of a TLSO brace. An interview was conducted with the Director of Rehab (staff #128) on (MONTH) 26, 2019 at 11:22 a.m. He stated that resident #275 is to be wearing a TLSO brace when out of bed and it is documented in the therapy evaluation. He stated that after the evaluation, therapy will verbally communicate it to nursing and to the CNA's, and that the nurse should have written an order for [REDACTED].>An interview was conducted with the physical therapist (PT/staff #125) on (MONTH) 26, 2019 at 12:06 p.m. Staff #125 stated that when a resident is admitted , therapy will conduct an initial evaluation and will communicate with nursing staff if any precautions like a TLSO brace need to be followed. She stated it is in the hospital documentation that resident #125 needs to wear the TLSO brace when out of bed. The facility's policy and procedure titled Splint/Brace revealed that Splints and braces are worn on the recommendation of the occupational or physical therapist and on the order of the physician and to document the activity of the placement of the brace in the electronic medical records. -Resident #10 was readmitted to the facility on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Review of the care plan initiated on (MONTH) 29, (YEAR) for self-care performance deficit revealed the resident required extensive assistance from 2 staff members for bed mobility, dressing, and personal hygiene and for transfers in and out of bed or chair. The goal was for the resident to reach her rehabilitation goals and return home safely. A physical therapy screening/re-evaluation dated (MONTH) 23, 2019, included the resident had been assessed for rehabilitation potential. The documentation stated the resident had no change in function with no new recommendations, and that the resident would be placed on the restorative nursing program. Review of the Restorative Nursing Training Program dated (MONTH) 23, 2019, revealed the resident was to receive upper extremity and lower extremity strengthening exercises to maintain and maximize range of motion, mobility, and function. The frequency was not included. The quarterly Minimum Data Set assessment dated (MONTH) 7, 2019, revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The MDS assessment also included the resident had received one day of restorative treatment for [REDACTED]. Review of the RNA documentation for (MONTH) 2019, revealed the resident received 15 minutes of active range of motion exercises and 15 minutes of passive range of motion exercises on (MONTH) 2, 14, and 25. The documentation included the resident refused restorative treatment on (MONTH) 1. Further review revealed no documentation the resident had been offered or received restorative treatments for any other day in (MONTH) 2019. During an interview conducted with the resident on (MONTH) 24, 2019 at 10:09 a.m., the resident stated that she was not receiving any therapy or services. She said she felt like she was just stuck in bed. An interview was conducted on (MONTH) 26, 2019 at 11:05 a.m. with a Restorative Nursing Assistant (RNA/staff #114). She stated the therapy department provides the RNA with information about which residents are to receive RNA services, as well as directions for the type and frequency of services. The RNA stated that if the directions did not include a frequency, she would provide RNA services three times a week, because that is considered a standard frequency. She said she documents RNA treatments provided or refused in the resident's electronic record and in the progress notes. The RNA stated that resident #10 should be receiving RNA treatments three times a week for upper and lower extremity strengthening, including weights, kicks, and knee bends. She said the reason the resident had not received regular treatments in (MONTH) is because of doctor appointments, going out of town, and being pulled to work as a nurse aide. During an interview conducted on (MONTH) 26, 2019 at 1:12 p.m. with the Director of Nursing (DON/staff #16), the DON stated the frequency for RNA treatments is as tolerated not three times a week. She said they try to conduct weekly meeting or least monthly meeting to discuss the residents' progress. The DON stated the meetings do not focus on a specific frequency of treatments or auditing RNA treatment records for completion. She said as long as treatments are being provided as tolerated, and the residents' abilities are maintained, the RNA program would be considered effective. An interview was conducted on (MONTH) 26, 2019 at 3:47 p.m. with the Director of Therapy (staff #128). He said there was no standard frequency for the number of RNA treatments to be provided each week. Staff #128 stated that treatments should be provided as needed to maintain the resident's abilities. He said the treatments would be considered effective as long as the resident did not have a decline in abilities. Staff #128 stated that if a decline is observed, a therapy screening would be initiated and he would initiate therapy services for the resident. Review of the facility's policy regarding Restorative Nursing Program revealed the restorative nursing program was designed to maintain or improve a resident's abilities to the highest practicable level. Residents will be assessed in accordance with the facility's assessment protocols. Residents will receive services from restorative aides when they are assessed to have a need for such services, including passive or active range of motion. A resident's restorative nursing plan would include the type of activities to be performed and the frequency of activities. Restorative aides will perform the activities and document it in the electronic record. The policy included the Restorative Coordinator will provide oversight of the restorative aide activities, and they will meet monthly to evaluate the effectiveness of the plan.

Based on observations, clinical record review, interviews and policy review, the facility failed to ensure that one resident's (#10) environment was free from accident hazards, which resulted in a fall with injury and subsequent hospitalization . The deficient practice could result in further falls with injuries. Findings include: Resident #10 was readmitted to the facility on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. Review of the self care deficit care plan initiated on (MONTH) 28, (YEAR), revealed the resident required contact guard assistance from staff for transfers in and out of the bed, chair or wheelchair. Review of a care plan for fall risk revised on (MONTH) 9, (YEAR), revealed the resident was at risk for falls related to unsteady gait and/or balance. The goal included for the resident's level of independence to be maintained while reducing the likely hood of falls or injury. Interventions included to keep the floor free from clutter and observe the resident in her personal environment for safety. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 28, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also documented that the resident required limited assistance from staff for transfers, and that the resident had not had any falls since admission. A nursing progress note dated (MONTH) 6, (YEAR) stated, writer was told by aide that patient was using curling iron in her room, placing it on bed. Aide spoke to patient concerning this. This writer went to speak with patient, asked if anyone spoke with her about the curling iron, patient replied no one had spoke to her about it. Writer informed patient that she cannot use the curling iron (which was on her night table) in this facility due to fire code regulations. Patient acknowledged with ok. Review of a social services progress note dated (MONTH) 6, (YEAR), revealed the social worker and case manager spoke with the resident about the curling iron, and there was an agreement that the resident would only use the curling iron when supervised by staff in the shower room. The curling iron was removed from the resident's room and was given to nursing to store. The note further stated that the social worker talked with the resident about her belongings being disorganized and intruding on her roommates side of the room. The note also included that a power strip was observed hanging from the resident's bed and that maintenance was informed, and the plan was to mount the power strip for the resident's safety. A nursing progress note dated (MONTH) 20, (YEAR) at 3:48 p.m. stated, aide found patient yelling out, lifted dresser of pt's R leg, then called writer to room. Writer found patient lying flat on her back on floor, bare feet, call light not on. Patient had numerous wires and cords tangled around her feet and under her back .patient has a large hematoma on her R leg, no other injuries noted. A nursing progress note dated (MONTH) 20, (YEAR) at 4:00 p.m., stated emergency medical transport (EMT) reported that the resident's hematoma had ruptured when moving the resident for transport, and there was a significant amount of blood in the room that needed to be cleaned. Review of the facility's post fall huddle report dated (MONTH) 20, (YEAR), revealed the resident was transferring herself from the bed to the wheelchair, and the bed was not locked. The resident fell on to the floor, then got tangled in her numerous cords causing the nightstand to fall on her. The report stated the cause of the fall was the bed was not locked and there were too many cords near the resident. The resident was sent to the hospital. The report concluded that the intervention to prevent the fall from happening again would be to make sure the bed was locked. However, the report did not address the issue of the resident becoming tangled in numerous cords and pulling the nightstand down on top of her. Further review of report revealed an attached staff in-service sign-in sheet dated (MONTH) 20, (YEAR). The subject was ensure patients bed in the locked position every shift. The subject matter did not address the concern regarding the numerous cords. Review of the hospital records revealed a physician's progress note dated (MONTH) 26, (YEAR), stating the resident had [MEDICATION NAME] trauma to the right lower extremity resulting in hematoma. The resident was status [REDACTED]. The note stated blood loss was anticipated with dressing changes given the large open friable wound and venous hypertension. A hospital physician's progress note dated (MONTH) 27, (YEAR), indicated the resident received received a transfusion of 1 unit of blood due to low hemoglobin levels. Review of the clinical record revealed the resident was readmitted to the facility on (MONTH) 29, (YEAR). Review of the care plan for fall risk revealed an intervention was added on (MONTH) 7, 2019, to ensure the locks on the bed were in the locked position. However, the care plan did not address the concern regarding the numerous cords as a causative factor in the fall. An interview was conducted with the resident on (MONTH) 24, 2019 at 10:01 a.m. She stated that in (MONTH) (YEAR), she was transferring from her bed to the wheelchair. She said that she leaned on the bed which was unlocked, and the bed rolled away from her and she fell . She said on the way down, she grabbed something on the nightstand/dresser, and the dresser fell on her leg. She said she received a crush wound on her right leg. At this time an observation of the resident's room was conducted and the room appeared cluttered. The entire wall facing the foot of the resident's bed was lined with equipment, including an electric wheelchair in the corner of the room, a wooden chair and a manual wheelchair. The seat of the wooden chair contained linens and an oscillating fan which was approximately 18-24 inches tall. The seat of the manual wheelchair contained a large package of incontinence briefs, a hoyer sling and two wheelchair footrests. Further observations revealed there was a dresser next to the resident's bed, which was approximately 3 feet tall, 2 feet wide and 2 feet deep. The dresser had one top drawer and a bottom cabinet. On top of the dresser were stacks of papers, a nebulizer machine and a bi-pap machine, each with cords dangling down the side and back of the dresser. There was also an oxygen concentrator and a portable air conditioner near the head of the resident's bed. Both machines were plugged in and operating. In addition, there were cords observed on the floor under and behind the resident's bed, however, no cords were observed on the floor in foot traffic areas. The resident's bed was locked. An interview was conducted on (MONTH) 26, 2019 at 9:58 a.m., with a charge nurse (staff #5). She said the resident was transferring herself from the bed and the bed moved away from her and the resident fell . She said the dresser then fell on top of the resident's right leg. She said when she arrived in the resident's room, staff had already removed the dresser from on top of the resident's right leg. She said the resident had cords wrapped around her legs from a power strip that had been attached to the dresser. She said the resident was completely tangled in cords. She said the bed was away from the resident at an angle. She stated the resident had a solid hematoma on her right leg. She said she worked on making room for the EMT to arrive, and when they came in the room, she left to prepare paperwork for the resident's transfer to the hospital. She said the EMT then came and told her they broke the hematoma in the room and there was a lot of blood. An observation of the resident's room was conducted on (MONTH) 26, 2019 at 11:40 a.m. The resident's bed was in the locked position. The resident's dresser was still stacked with papers, the nebulizer and the bi-pap machine. There was a curling iron resting on the handle of the dresser drawer, with a cord that was not plugged in. During the observation, the resident said she did not use the curling iron independently, but she calls staff to assist her when she wants her hair curled. She said the curling iron was designed to shut off automatically after ten minutes of non-use. The electric wheelchair, the manual wheelchair and the wooden chair still remained against the wall which was opposite of the foot of the resident's bed, with the same linens, supplies and equipment stacked on top. The oxygen concentrator and the portable air conditioner were still near the head of the resident's bed. Both machines were plugged in and operating. There was no power strip observed on top of or attached to the resident's dresser. However, there were still several cords which were dangling from the dresser drawer and down the side and back of the dresser from the [MEDICAL CONDITION] machine, the nebulizer machine and the curling iron. An interview was conducted on (MONTH) 26, 2019 at 3:09 p.m., with a Licensed Practical Nurse (LPN/staff #87). She said that she heard a noise coming from the resident's room, and she went to see what was going on. She said when she arrived, the resident was on the floor and staff were clearing the room. She said staff used a hoyer lift to get the resident back into bed, and that the resident had a hematoma on her right leg. She said within thirty minutes, EMT's had arrived and were preparing the resident for a transfer to the hospital. She said the EMT's stated the hematoma had burst around the time the resident transferred to stretcher. She said the EMT's then left with the resident. An observation was conducted from the doorway of the resident's room on (MONTH) 27, 2019 at 5:46 a.m. The curling iron was still resting on the resident's dresser handle, with the cord dangling down the front of the dresser. The [MEDICAL CONDITION] machine was on top of the dresser, along with a gallon-sized water jug and stacks of papers. The top dresser drawer was partially open, with the nebulizer machine resting inside the drawer. There were cords trailing down the side and back of the dresser. The resident's electronic health record (EHR) was reviewed on (MONTH) 27, 2019. Across the top of the screen was a banner which stated, curling iron will be kept in cabinets above charts at nurses station. An interview was conducted with the Director of Nursing (DON/staff #16) on (MONTH) 27, 2019 at 6:40 a.m. She said the banner on the EHR is not really part of the resident's care plan. She said she did not know who had access to view or modify the banner. She said that she did have access, but she did not know what other staff members could access it. Another interview was conducted with staff #16 on (MONTH) 27, 2019 at 10:42 a.m. She said her expectation for fall and accident prevention was for staff to keep the room free of clutter, keep the call light and common items within reach of the resident, and ensure beds were locked. She said some residents had a preference to accumulate personal items, but staff would be expected to keep the room orderly. She said the appropriateness of having a power strip would be evaluated by maintenance and that residents were not to have extension cords. Regarding this resident's fall, she stated that she was aware that the resident's bed ended up at an angle away from the resident. She said the resident's cords were on top of the dresser and that is what had caused it to fall on the resident's leg. She said at the time, the resident was very specific about the arrangement of her room, and she would spread her items to the other side of the room. She said staff would educate the resident that she could only use her side of the room and had attempted to clean up the resident's room multiple times. Review of a facility's policy for Safety and Supervision of Residents revealed that resident safety and accident prevention was a facility-wide priority. Employees should be trained on potential accident hazards and demonstrate competency on how to identify and prevent avoidable accidents. Facility oriented and resident oriented approaches would be used together to consider the hazards identified in the environment and individual resident risk factors, and then adjust interventions accordingly. Risk factors and environmental hazards would include: bed safety, falls and safe movement of residents.

Based on clinical record review, facility documentation, staff and resident interviews and policy review, the facility to transfer one resident (#48) in a safe manner. Findings include: Resident #48 was admitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of a Fall Risk Screen dated April 21, 2015 revealed the resident was a moderate risk for falls. It further included that the resident had no falls within the last six months and required hands-on assistance to move from place to place. A quarterly Minimum Data Set (MDS) assessment dated [DATE], included the resident's Brief Interview for Mental Status (BIMS) score was 12, which indicated the resident had moderate cognitive impairment. The MDS also assessed the resident as requiring extensive assist of two persons for transfers. A care plan identified that the resident had an activities of daily living (ADL) self performance deficit, related to a stroke. A goal included for the resident to accept help from staff as needed to assure that all ADL needs are met. An intervention included the resident requires extensive x 2 staff participation with transfers (initiated on January 27, 2014). Another care plan identified the resident was at risk for falls related to unsteady balance, due to a left AKA. A goal included to be free of falls through the next review. Interventions included to assess resident's need for toileting or repositioning, call light within reach, encourage resident to call for assistance and chair alarm in place to alert staff to potential attempts to stand. A nursing incident note dated May 28, 2015 included that staff #3, a certified nursing assistant (CNA) was assisting resident #48 in the shower room. The CNA was transferring the resident to a chair and her right leg gave out. The resident complained of pain to her left shoulder, so the CNA lowered the resident to the floor. Review of a nursing health status note dated May 28, 2015 revealed the physician was notified and ordered for an x-ray to the left shoulder. Physician orders [REDACTED]. Review of the x-ray results dated May 28, 2015 revealed the resident had an interval acute fracture of the proximal left humerus. Physician orders [REDACTED]. Review of the facility investigative report revealed that on May 28, 2015, a licensed practical nurse (LPN) entered the shower room at the request of a CNA (staff #3) and the resident was laying on the floor next to the toilet, with right leg extended, and the left arm appeared longer than the right arm and was internally rotated. The report included that the resident had her affected arm over the shoulder of the CNA, became weak and the CNA lowered her to the floor, causing her left arm to extend while on top of the CNA's arm/shoulder. The investigation further included that the CNA did not use a gait belt during the transfer and the resident sustained [REDACTED]. Per the report, the CNA did not follow facility policy for using a gait belt with all transfers. Review of staff #3's personnel record revealed a general orientation checklist, which included a section on body mechanics/safety/incident reports. This was signed by CNA #3 on September 17, 2014. The file also included a gait belt sign out form, which was signed by staff #3 in 2014. In addition, the file contained an employee counseling notice dated June 1, 2015, which included the CNA transferred the resident without a gait belt and the resident had to be lowered to the floor and sustained a fracture of the left humerus, as a result of being held under the arms. It was also documented that due to the violation of company policy and subsequent injury to the resident, the employee will be terminated. The fall risk care plan was updated on June 2, 2015 after the incident to include the use a gait belt and two persons for all transfers. An interview was conducted on January 26, 2016 with resident #48. She stated that she received a fracture of her left arm, after a CNA asked her to raise her arm during a transfer. She stated that the CNA was tall and it was hard to raise her arm up high, so he used his arm to raise it higher. She said that after he raised her arm, she heard a pop and had pain in her left arm and was lowered to the floor by the CNA. She stated that there was only one CNA transferring her and that a gait belt was not used during the transfer. An interview was conducted on January 26, 2016 with the LPN who worked on May 28. She stated that she was called into the shower room on May 28, to assess the resident. She stated there was only one CNA in the shower room and that she did not see a gait belt. An interview was conducted with a CNA on January 26, 2016, who has provided care to the resident. The CNA stated that she transfers resident #48 with a gait belt and one person assist. She stated that transfer information for residents is on the ADL sheets. She said that the facility policy for transferring residents that need assistance is to use a gait belt for all transfers, including while showering. Another interview was conducted with another CNA on January 27, 2016, who stated that all residents are transferred with a gait belt, according to their policy. She further stated that transfer information is found on the ADL sheets. An interview was conducted on January 27, 2016 with an LPN, who stated that the type of assistance a resident needs is on the care plan and also on the ADL sheets. During an interview conducted with the Director of Nursing (DON) on January 27, 2016, she stated that all new hires are given general orientation which includes a section on body mechanics and involves gait belt usage. She also stated that all CNA's are given a gait belt upon hire and required to sign a gait belt sign out form. The DON further stated that interventions on care plans are to be implemented and the facility policy is to use a gait belt with all transfers. Review of a facility policy regarding gait belts included that staff must utilize a gait belt during all assisted transfers and ambulation activity. The policy further stated that if a resident becomes faint or weak and starts to fall, utilize the gait belt to lower them gently to the floor, without injury to them or yourself. The policy also noted that gait belts are to be worn at all times by CNA's.

Based on clinical record review, observations, staff interviews, and review of facility policies, the facility failed to ensure that one resident (#246) did not develop contractures and additionally failed to provide care and services to prevent the contractures from worsening. The sample size was one of three. Findings include: Resident #246 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was also admitted on hospice care for end stage [MEDICAL CONDITION]. The physician's admission orders [REDACTED]. However, a physician's orders [REDACTED]. The therapy evaluation was unable to be located in the clinical record and therefore, neither confirmation that the evaluation had actually been provided or a review of the evaluation was able to be completed. A skin integrity care plan dated July 7, 2011, was developed and included as an intervention to provide AROM (Active Range of Motion) and PROM (Passive Range of Motion). However, no documented evidence was able to be located in the clinical record that the range of motion services had actually been provided. A review of the physician's progress notes from August through October 2011, included that no contractures were present. However, the physician's progress notes dated November and December 2011, included that mild contractures were now present. A physician's orders [REDACTED]. According to the documentation, services were provided regarding proper geri-chair positioning to reduce skin breakdown and fall risk. The occupational therapy evaluation documentation also included that the resident had a right upper extremity and bilateral lower extremity contractures. Although the therapy evaluation included that treatment of [REDACTED]." Therapy services were then discontinued on February 9, 2012. A continued review of the physician's progress notes from January through April 2012, revealed documentation that included the contractures of the resident's hips and knees maybe worsening slightly but that they were unavoidable. In addition, the April 2012, physician's progress note also included that although the resident's overall prognosis was poor, the resident was continuing to gain weight over time, which may have extended her prognosis. A continued review of the clinical record also revealed conflicting documentation regarding the presence of contractures. Although the physician and occupational therapist had identified that contractures were present, the monthly nursing summaries through April 2012, included that no contractures were present. A further review of the clinical record revealed no documented evidence that ROM was provided to prevent the development of contractures and subsequent worsening once they developed. During multiple observations conducted throughout the survey, the resident was observed either seated in a geri-chair or in bed. During these observations, the resident appeared to have bilateral lower extremity contractures. No splints or other devices were observed to be on resident. An interview was conducted on May 2, 2012 at 1:30 p.m., with a CNA (Certified Nursing Assistant), who stated that the resident had bilateral lower extremity contractures and that range of motion exercises were not provided. A second interview was conducted on May 2, 2012 at 2:00 p.m., with the DON (Director of Nursing), who stated that the resident did have contractures of the lower extremities. Following a review of the resident's clinical record, she stated that the monthly nursing assessments were inaccurate regarding the absence of contractures. The DON also stated that range of motion exercises to prevent and/or treat contractures could have been ordered by the physician and provided RNA (Restorative Nursing Assistant) staff, despite the resident's hospice status. At this time, she stated that she was unable to locate any documented evidence that services to prevent and/or prevent further worsening of the contractures, was able to be located in the clinical record. Another interview was conducted on May 2, 2012, with the unit manager, who had completed the monthly nursing assessments. She confirmed that the resident had lower extremity contractures and then acknowledged the inaccurate assessments regarding the absence of contractures. The unit manager stated that she must have been in a hurry when she completed the monthly assessments. Following a review of the resident's skin integrity care plan intervention, to provide AROM and PROM exercises, the unit manager stated that she was not aware of that care plan intervention, and confirmed that range of motion exercises had not been provided for this resident. An interview was also conducted on May 2, 2012, with the occupational therapist who had completed the January 2012, evaluation regarding geri-chair positioning. She stated that she had not seen the resident prior to January 2012, nor had she had been informed of the development of the contractures in November 2012. The occupational therapist acknowledged that she was aware of the contractures in January 2012, but had been informed by nursing staff that the contractures were, "Status quo," and was not aware that the contractures may have actually worsened. In addition, the occupational therapist stated that she was not aware that a hospice resident was eligible to receive range of motion services by the RNA (Restorative Nursing Assistant) but had she known, she probably would have recommended RNA range of motion services in January 2012, when she evaluated the resident for positioning in the geri-chair. A final interview was conducted on May 2, 2012, with the DON, who stated that all residents, inclusive of hospice residents, were eligible to be screened by therapy and have RNA range of motion services provided. The DON further stated that although it was facility policy for all residents to have a therapy screen quarterly, none had been completed for this resident. A facility policy titled, Management of Contractures, included, "To provide a method of assessing and treating residents for the presence of contractures, or risk factors for development of contractures." The policy also included the following: "2. Residents at risk will be placed on a contracture management program that may include AROM (Active Range of Motion), PROM (Passive Range of Motion), splinting, and any other appropriate therapeutic measures. 4. Resident's (sp) will be re-assessed quarterly by therapist. 5. Resident's plan of care will be updated with any changes as needed," Another policy titled, Rehab Services Policies and Procedures, included, "Long term care and assisted living patients may be screened upon Center and/or physician request at the time of a documented change in status.

Based on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure that appropriate and timely care and services were provided to prevent and/or minimize the risk for the development of pressure ulcers and failed to ensure that the pressure ulcers were consistently monitored and assessed for two resident (#s 176 and 110). The sample size was two of three residents with a pressure ulcer. Findings include: -Resident #176 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged on [DATE], to another state with family. A Braden Scale for predicting pressure ulcers, dated August 13, 2010, included documentation that the resident was identified to be a high risk, with a score of 11. Per the Braden Scale guidelines, a score of 12 or less represented a high risk for the development of pressure ulcers. No additional Braden Scale assessments were able to be located in the resident's clinical record. The nursing admission assessment also dated August 13, 2010, include documentation that the resident had several scrapes and scratches on the lower extremities, a callous on the left heel and an area of excoriation around the rectum. The assessment did not include any documentation that the resident had a pressure ulcer upon admission to the facility. Although a physician's orders [REDACTED]. The admission MDS (Minimum Data Set) assessment dated [DATE], included documentation that the resident had short term memory deficit, moderately impaired cognitive skills, and inability to always understand others. Per the MDS assessment, the resident required extensive assistance for bed mobility, transfers, and ambulation. The MDS assessment did not include any documentation that the resident had a pressure ulcer. Although the resident had previously been identified to be at risk for the development of a pressure ulcer, the MDS assessment did not include documentation that a pressure ulcer relieving device for the bed/chair was provided or that the resident was on a turning/repositioning program. A review of the daily skilled nursing note entries revealed that on August 27, 2010, the resident was identified to have a decubitus ulcer and that care was provided. However, the narrative nursing note entry did not include a complete and thorough assessment of the decubitus ulcer. No description, measurement, site or stage of the newly developed pressure ulcer was included in this entry. In addition, no prescribed treatment order was able to be located in the resident's clinical record, to address the decubitus ulcer. A continued review of the daily skilled nursing note entries from August 28, through September 7, 2010, revealed discrepancies regarding the actual status of the resident's skin integrity. Multiple entries included documentation that a pressure ulcer was present, while other entries had no documentation that a pressure ulcer had developed. A physician's orders [REDACTED]. A physician's progress note dated September 3, 2010, included, "Pt. not seen by wound care yet. Orders written for 2 wks earlier. Not yet seen." The weekly nursing skin assessment dated [DATE], only included that the resident had a skin tear, bruise, and surgical wound and no documentation regarding the presence of a pressure ulcer. A review of the resident's clinical record revealed that the physician ordered wound consultation was not obtained until September 7, 2010, which was 10 days after the physician's orders [REDACTED]. The wound clinic consultation report dated September 7, 2010, included documentation that the resident now had an unstageable pressure ulcer on the left buttocks. Per the report, the following treatments were prescribed for the left unstageable pressure ulcer: -Skin prep to the peri wound, adhesive foam, preferably [MEDICATION NAME] foam if available, twice a week and as needed. -Air loss mattress. -An offloading sitting device: Roho cushion. Although a risk for skin breakdown care plan was developed (dated August 23, 2010), a care plan to address the now diagnosed unstageable pressure ulcer on the resident's left buttocks was unable to be located in the resident's clinical record. A daily skilled nursing note entry dated September 8, 2010, included documentation that the resident now had a pinpoint dark brown spot on the right buttocks and no documentation regarding the unstageable pressure ulcer on the left buttocks. Furthermore, a weekly wound report dated September 8, 2010, included documentation that on September 7, 2010, the resident developed an unstageable pressure ulcer on the left buttocks. However, as previously stated, the pressure ulcer was first identified on August 27, 2010, not September 7, 2010. According to the September 8, 2010, wound assessment documentation, the wound bed was black, the surrounding skin was red/pink and unblanchable, the wound edges were reddish, and the pressure ulcer measured 0.4 by 0.4 (centimeters was not documented on this assessment). The status of the dark brown area on the resident's right buttocks was not included on this weekly wound report. In addition, the daily skilled nursing note entries dated September 9, and 10, 2010, revealed no documentation regarding the unstageable pressure ulcer on the resident's left buttocks or the dark brown area on the resident's right buttocks. A review of the August and September 2010, physician's orders [REDACTED]. A physician's orders [REDACTED]. However, a review of the previous physician's orders [REDACTED]. An interview was conducted on February 7, 2011, with the DON (Director of Nursing) regarding the lack of monitoring, assessment and treatment for [REDACTED]. At this time, she stated that neither a nursing assessment or evidence that a treatment had been administered prior to September 8, 2010, was able to be located in the resident's clinical record. The DON also stated that nursing should have initiated a skin assessment, including measurements, wound description, and stage of the pressure ulcer when it was first identified, and then should have contacted the resident's physician to obtain a treatment order. She further stated that nursing should have informed the unit manager and subsequently the wound nurse. A second interview was conducted on February 8, 2011 at 9:00 a.m., with the DON. At this time, she stated that she was unable to locate any documented evidence in the resident's clinical record that included that the resident was on a turning and repositioning program, or that any pressure ulcer relieving devices were implemented. -Resident #110 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Resident assessment dated [DATE], revealed the resident did not have any pressure ulcers. Continue review of the clinical record revealed a care plan dated September 2, 2010, regarding skin integrity with a goal of keeping the skin intact. Interventions included to assist the resident with positioning every 2 hours, keep the resident's skin clean and dry, skin care as directed, and encourage fluids. Further review of the clinical record revealed a Braden Scale used for predicting pressure ulcer risk that scored the resident was a 13 which was a moderate risk. Additional review of the clinical record revealed an Admission MDS dated [DATE], that documented the resident did not have any pressure ulcers. The care plan dated September 11, 2010, documented the resident was at risk for skin breakdown related to assistance required with bed mobility and wearing of briefs for dignity. Interventions included pressure relieving mattress to bed, body/skin audit weekly, report any red or open areas, dietary to evaluate nutritional needs, and check and change incontinent pads every 2 hours and as needed. Weekly nursing skin assessments documented on September 2, 14, 21, & 28, 2010, that the resident's skin was intact. However, review of the clinical record revealed a nurse's note dated September 20, 2010, that the resident had acquired a Stage 2 pressure ulcer to the right buttock. The weekly wound report dated September 20, 2010, documented the left buttock pressure ulcer was pink and measured 3.2 x 4.3 cm (centimeters) with no drainage, tunneling, or undermining. A physician's orders [REDACTED]. every shift and as needed. The weekly skin check report dated September 23, 2010, documented the stage 2 pressure ulcer to the left buttock measured 4.2 x 3.2 cm. This sheet was not a part of the clinical record and was provided by the Director of Nursing (DON). However, review of the daily skilled nursing notes revealed on September 23, 2010, the skin was normal but on September 24 there was a pressure ulcer and on September 25 the skin was normal. There was no further documentation regarding the status of the pressure ulcer, whether it persists or was resolved, whether it was the right or left buttock or both. Review of the Treatment record revealed no documentation that the [MEDICATION NAME] had been applied on September 27 & 28, 2010 on the 10:00 p.m. to 6:00 a.m. shift. During an interview conducted on February 8, 2011 at 1:45 p.m., a Registered Nurse stated there should have been another entry regarding the pressure ulcer on the weekly wound report. This RN also stated that it should have been documented on the back side of the weekly wound report if the pressure ulcer had resolved. The RN also stated there was a skin sheet that should contain documentation regarding the pressure ulcer that does not go into the clinical record. This RN stated she was unable to state what happened with this pressure ulcer. A facility policy titled, Skin Integrity and Wound Care Management, included the following: "1. All residents shall be assessed for pressure ulcer risk using the Braden scale upon admission and weekly for first four weeks of admission. Risk is reassessed quarterly thereafter and with any significant change of condition. 2. The interdisciplinary plan of care will address problems, goals and interventions a. Directed toward prevention and/or resolution of the pressure ulcer and/or skin integrity concerns identified. 3. A thorough skin assessment is conducted by the licensed nurse: a. Upon admission b. Upon notification by the nursing assistant of any changes c. Upon any observed change d. Weekly as assigned on the skin assessment schedule 7. A pressure ulcer flow sheet is kept for all pressure ulcers showing the history of pressure relief interventions and treatments. 8. Pressure ulcer monitoring is to be done daily and recorded on the daily pressure ulcer monitoring form. 12. The physician will be promptly notified of pressure ulcers and any other types of wounds or skin conditions requiring treatment." The policy also included in the section titled, Wound Assessment Guidelines, the following: "1. Wounds are assessed and measure AFTER cleansing. 2. Wounds measurements are recorded in centimeters. 4. Reddened area surrounding a wound should be measured separately i.e. 3 cm reddened area extends from wound edges."

Based on observation, clinical record review, staff interviews, facility record review and facility policy review, the facility failed to ensure that two residents (#s 56 and 114) were free of accident hazards. One resident (#56) sustained harm. Findings include: -Resident #56 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was totally dependent on staff and required two staff for physical assistance for bed mobility and transfer. Further clinical record review revealed an activities of daily living (ADL) care plan with a date of December 23, 2010, that included the resident required two staff for bed mobility and to use a Hoyer lift for transfers. Review of the facility's CNA (Certified Nursing Assistant) book revealed an ADL care plan for the resident which included that the resident must have two CNAs during any care provided to the resident. Continued clinical record review revealed nurse's notes with documentation dated January 7, 2011, that included a registered nurse (RN) was called to the resident's room by a certified nursing assistant (CNA) and the resident was found on the floor. Additional documentation revealed the resident was assessed for injuries and found to have a bruise on her left thigh and scrape on her left posterior thigh area. Additional clinical record review revealed subsequent nurse's notes documentation also dated January 7, 2011, that included hat the CNA had reported that she was positioning the resident on the Hoyer sling with no additional assistance and as she turned the resident on her side the brakes on the bed failed resulting in the bed moving and subsequently the resident falling from the bed onto the floor. Continued record review revealed a physician's telephone order dated January 7, 2011, to include x-ray bilateral hips related to pain/fall. Additional documentation revealed a final radiology report dated January 7, 2011, with findings of bilateral femoral hip fractures. In an interview conducted on February 9, 2011, the CNA stated that as a part of her normal procedure she was working independently with the resident and had attempted to position the resident onto a Hoyer sheet. She additionally stated that as she moved the resident toward her, the brakes of the bed failed and the bed moved which resulted in the resident falling from the bed and onto the floor. In an interview conducted on February 9, 2011, licensed staff stated that CNAs were notified verbally in shift report and in writing by way of the CNA's ADL book if a resident required any specific care needs. He additionally stated that the expectation was for the CNA staff to review the CNA's ADL book on a daily basis. In an interview conducted on February 9, 2011, a CNA stated that they received report at the beginning of the shift from the nurse. She also stated that if the nurses are busy they can go to the CNA's ADL book and get information on how to care for the resident. In an interview conducted on February 9, 2011, the Director of Nursing stated that at the beginning of the shift the licensed staff gave verbal updates as to the required care of a resident. She also stated that it was the expectation of all CNA staff to look in the CNA ADL book on each shift which gave instructions on how to care for the residents. -Resident # 114 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record included the resident's "Fall Risk Assessment" dated August 8, 2010 that recorded the resident was at high risk for falls. The resident's admission MDS dated [DATE], recorded the resident had a fall within the last 30 days. Review of the resident's "Fall Care Plan" opened on August 19, 2010, revealed that the resident was at risk for further falls. Approaches included checking the resident's personal alarm every hour at night and frequent monitoring to prevent falls or injury. Review of the "Fall Risk Assessment" dated November 2, 2010, recorded that the resident continued to be high risk for fall. Review of the nurse's note dated January 12, 2011 included, "resident was found sitting on the floor in front of her w/c (wheelchair) with no apparent injuries. Safety alarm went off as she sat on the floor". Review of the nurse's note January 16, 2011, included "resident slid out of chair onto floor this was witnessed by housekeeper". Review of the "Post Fall Investigation" dated January 16, 2011, included additional intervention, "OT (Occupational Therapy) seating evaluation". Further review of the clinical record did not reveal evidence that an OT seating evaluation was ever conducted. The resident was observed on February 4, 2011, sitting in her wheelchair without a personal alarm in place. Following the observation, an interview with the licensed staff was conducted and revealed that the resident used both personal alarm in her wheelchair and bed. When the licensed staff also observed the resident without a personal alarm in place, she stated, "She doesn't have one on but should". The CNA present during the interview, stated, "The clasp was broken and I didn't know if she should have one on or not". An interview was conducted on February 4, 2011, with a licensed staff who revealed that the resident had sustained a fall in the last 30 days. Further explanation included that the resident was in her room and slid out of her wheelchair. During an interview with the Rehabilitative Director on February 4, 2011, he stated, "a seating evaluation was not completed". Review of the "Fall Prevention Policy" included, "...Post Fall Evaluation: E. DON (Director of Nursing) and/or designee will review all paperwork related to all falls and ensure that appropriate corrective action has been implemented. F. An interdisciplinary fall committee will also review all falls and referrals to therapies will be initiated when appropriate..."