Every finding on record at Tempe Post Acute

Based on clinical record review, observations, and staff interviews, the facility failed to ensure that the comprehensive person-centered care plan was reviewed and revised to address Type 2 Diabetes Mellitus for one resident (Resident #6). This deficient practice could result in inadequate monitoring of blood glucose levels, increasing the risk of a hypoglycemic event for the resident. The universe was 70, and the sample size was 3.Findings include: Resident #6 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus (DM), congestive heart failure, and hypertension. A care plan, dated February 12, 2026, revealed a focus area for Diabetes Mellitus with a goal to have no complications related to diabetes through the review date and interventions including administering diabetes medications as ordered by the doctor and monitoring and documenting for side effects and effectiveness. The resident was discharged and re-admitted to the facility on [DATE], following a hospitalization for generalized weakness, failure to thrive, and functional decline, with active diagnoses including Type 2 DM without complications, congestive heart failure, and hypertension. A care plan, dated July 24, 2026, revealed the most recent plan of care for Resident #6, which omitted Type 2 Diabetes Mellitus from her current plan of care, no active focus areas, interventions, or goals for managing her blood glucose levels or monitoring for hypoglycemia. A nursing progress note, dated July 25, 2026, at 7:53 PM, revealed that the resident had new-onset lethargy and hypotension, and the physician was notified. A physician progress note, dated July 27, 2026, at 11:35 AM, revealed that the nurse practitioner noted increased confusion, weakness, and poor oral intake, and ordered STAT laboratory studies. Under the assessment and plan, the nurse practitioner stated that for her Type 2 Diabetes Mellitus, blood glucose should be monitored before meals and at bedtime, her diabetic diet and prescribed medications should be continued, and her regimen should be adjusted based on glucose trends. However, no active orders or care plan documentation were identified for blood glucose monitoring. A clinical record of blood glucose, dated July 28, 2026, at 2:50 AM, revealed a blood glucose value of 34.0 mg/dL, indicating severe hypoglycemia. A nursing progress note, dated July 28, 2026, at 3:27 AM, revealed that the resident had pitting edema in all extremities, was hypotensive, bradycardic, and desaturating at 70% on room air, and was transferred emergently to a hospital via paramedics. A discharge Minimum Data Set (MDS) assessment, dated July 28, 2026, revealed that the resident was able to understand and be understood, had clear speech, and had adequate hearing and vision. An interview was conducted on July 30, 2026, at 2:02 PM with a certified nursing assistant (CNA/Staff #884). She stated that she has worked at the facility for over two years and is responsible for checking resident temperatures at the beginning of her shift when the nurses are doing vitals. She stated that she is not responsible for checking anything for residents with diabetes and is not really aware of any of the symptoms or signs of high or low blood sugar. She stated that if she had any concerns about a resident, she would grab her nurse first thing. She stated that for low blood sugar, she would expect to give glucagon or, if the resident is able to eat or drink, give them juice and snacks and notify the doctor. She stated that there should be orders for those things and that if there is a diabetic resident with no orders, the staff should notify the doctor to try to get some orders. She explained that if a resident is diabetic, the lack of a care plan or active monitoring orders means that staff would be unaware that the resident is diabetic, which risks missed signs of hypoglycemia. An interview was conducted on July 30, 2026, at 2:10 PM with a licensed practical nurse (LPN/Staff #789). He stated that for a resident diagnosed with Type 2 DM, staff should check blood sugars in the morning and at night. He reviewed the resident's active orders and stated that he did not see any active orders for blood glucose monitoring or medications such as insulin or glucagon for the month of July. He reviewed the care plan and stated that he did not see anything in her care plan for the month of July regarding her diabetes, even though she had an active diagnosis of diabetes. He stated that the risks of not having a diabetes care plan or monitoring orders include a hypoglycemic event. He explained that she had her blood sugar checked only one time during her admission. He stated that when her vitals were dropping and she became hypotensive, bradycardic, and required oxygen, staff did not find that her blood sugar was low until they were preparing her for discharge and checked her blood sugar, and he believed this occurred because of her diabetes. An interview was conducted on July 30, 2026, at 2:57 PM with the director of nursing (DON/Staff #857). She stated that the process for residents with Type 2 diabetes upon admission depends on the patient, but they should monitor signs and symptoms for diabetes and develop a plan of care. She reviewed the record and stated that she did not see any orders for blood glucose monitoring and confirmed that diabetes was not on her care plan for the July admission. She reviewed the nurse practitioner note dated July 27, 2026, and stated that the note directed that blood glucose should be monitored before meals, and she agreed that they should have been managing her diabetes. She stated that the risk of not care planning for Type 2 diabetes is a failure of disease process management, which leaves the staff unaware that a resident is diabetic and unable to monitor for signs of hypoglycemia. A review of the facility's policy titled Comprehensive Person-Centered Care Planning, revised May 2022, revealed that it is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. 1. Within 48 hours of the resident's admission, the facility will develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care. 2. The baseline care plan will include minimum healthcare information necessary to properly care for a resident including, but not Limited to: a) Initial goals based on admission orders, b) Physician orders, c) Dietary orders, d) Therapy services, e) Social services; and f) PASARR recommendations, if applicable.

Based on clinical record review, staff interviews, observations, and facility policies, the facility failed to ensure that one resident (Resident #6) received needed treatment, monitoring, and care in accordance with professional standards of practice for Type 2 Diabetes Mellitus. This deficient practice resulted in the resident's blood glucose level falling below the normal range, placing the resident at risk for a hypoglycemic event (low blood sugar). The universe was 70, and the sample size was 3.Findings include: Resident #6 was admitted to the facility on [DATE], with diagnoses including Type 2 Diabetes Mellitus (DM), congestive heart failure, and hypertension. A care plan, dated February 12, 2026, revealed a focus area for Diabetes Mellitus with a goal to have no complications related to diabetes through the review date and interventions including administering diabetes medications as ordered by the doctor and monitoring and documenting for side effects and effectiveness. Resident #6 was discharged and most recently readmitted to the facility on [DATE], with active diagnoses including Type 2 DM, Transient Cerebral Ischemic Attack, Adult Failure to Thrive, Unspecified Atrial Fibrillation, Heart Failure, Unspecified Asthma, Mild Protein-Calorie Malnutrition, Acidosis, Anemia, and generalized muscle weakness. A care plan, dated July 24, 2026, revealed the most recent plan of care for Resident #6, which omitted Type 2 Diabetes Mellitus from her current plan of care and contained no active focus areas, interventions, or goals for managing her blood glucose levels or monitoring for hypoglycemia. A review of physician orders revealed there were no active physician orders for blood glucose monitoring, daily fingerstick checks, insulin, or oral hypoglycemic medications upon her readmission. However, review of discontinued physician orders revealed that during prior admissions the resident had physician orders for Blood Glucose checks twice daily, Glucophage (Metformin) 1,000 mg by mouth twice daily, Jardiance (Empagliflozin) 25 mg by mouth daily (later adjusted to 10 mg daily), Humalog (Insulin Lispro) sliding scale before meals, Glucagon 1 mg intramuscularly as needed for symptomatic blood glucose below 65 mg (milligrams)/dL (deciliter), and a hypoglycemia protocol directing staff to administer 4 ounces of juice or two glucose tablets with a protein supplement for blood glucose below 65 mg/dL and recheck the blood glucose in 15 minutes. These diabetes-related physician orders were all discontinued by February 13, 2026, and were not reinstated upon the resident's readmission on [DATE], despite her continued diagnosis of Type 2 Diabetes Mellitus. A laboratory report, dated July 26, 2026, at 7:09 a.m., with sample collected on July 25, 2026, at 10:20 p.m., revealed her blood glucose was 65 mg/dL, the lowest value within the laboratory reference range. It further revealed she had a critically low albumin level of 0.8 g (grams)/dL and total protein of 3.8 g/dL, indicating severe deconditioning and protein-calorie malnutrition. A Nurse Practitioner progress note, dated July 27, 2026, at 11:35 a.m., revealed that the resident was assessed for increased confusion and documented a clinical directive under her plan for Type 2 Diabetes Mellitus to monitor blood glucose before meals and at bedtime, continue a diabetic diet and prescribed medications, and adjust her regimen based on glucose trends. Further review of her active orders revealed no order for blood glucose monitoring. There was no documented evidence that the physician or nurse practitioner was notified that the ordered monitoring was not being performed. A discharge Minimum Data Set (MDS) discharge assessment, dated July 28, 2026, revealed that the resident was able to understand and be understood, had clear speech, and had adequate hearing and vision. A blood glucose monitoring record, dated July 28, 2026, at 2:50 a.m., revealed the resident's blood sugar was critically low at 34.0 mg/dL. This check was her first and only fingerstick blood sugar check during the four-day admission. A nursing progress note, dated July 28, 2026, at 3:27 a.m., revealed the resident was hypotensive (low blood pressure), bradycardic (low pulse), and had a critically low oxygen saturation of 70% on 5 liters of oxygen via nasal cannula. It further revealed that night nurses attempted to straight catheterize the resident, obtaining only 5 milliliters of urine, and increased oxygen delivery to her to 8 L/min via oxygen mask at 82% before paramedics emergently transferred her to a hospital. An interview was conducted on July 30, 2026, at 2:02 p.m. with a Certified Nursing Assistant (Staff #884/CNA) who had over two years of experience at the facility. She stated that she checks resident temperatures at the beginning of the shift when nurses perform vital signs. Regarding diabetes care, Staff #884 stated she was not aware of any of the symptoms or signs of high or low blood sugar. She stated that if she had any concerns, she would grab my nurse first thing. She stated that for low blood sugar, staff should give glucagon, or if the resident can drink or eat, give them juice/snacks and notify the doctor. She defined low blood glucose symptoms as cold, sweaty, and hard to arouse. She stated the risk of failing to monitor diabetic residents without active orders is that a resident with diabetes could deteriorate without staff's knowledge, and she stated that a nurse should immediately call the doctor to obtain monitoring orders if a diabetic resident is admitted without them. An interview was conducted on July 30, 2026, at 2:10 p.m. with a Licensed Practical Nurse (Staff #789/LPN). Staff #789 reviewed the resident's electronic health record and stated that she was diabetic, but there were no orders for blood glucose monitoring and no active orders for blood sugar injections like insulin or glucagon. He stated there was nothing in her care plan for July regarding her diabetes, and her blood sugar was only checked a single time during her stay. He stated that when she deteriorated, her heart rate and blood pressure were dropping, and they were attempting to get her oxygen up. He stated they checked her blood sugar right before discharging her and found it was low, which he believed was because of her diabetes. He further stated that the risk of failing to obtain orders and a care plan for a resident with Type 2 Diabetes is a severe, unmonitored hypoglycemic event. An interview was conducted on July 30, 2026, at 2:40 p.m. with a Registered Nurse (Staff #205/RN). Staff #205 stated that if a resident is admitted with a diagnosis of Type 2 Diabetes but has no meds or diet specified, the professional standard is to check blood sugars twice daily and call the doctor to ensure there are no monitoring orders. She further stated that the risk of failing to monitor blood sugars is that the resident could bottom out (hypoglycemia), which would cause confusion, shakes, sweating, and hunger, and she noted that she would refer such a resident to the dietitian to monitor their intake and keep them at baseline. An interview was conducted on July 30, 2026, at 2:57 p.m. with the Director of Nursing (DON/Staff #857). The DON reviewed the resident's clinical record and stated there were no active orders for blood glucose monitoring during her stay, except for the single check performed at discharge. She reviewed the Nurse Practitioner's progress note dated July 27th, which directed that her blood glucose should be monitored before meals, and stated that the facility had failed to implement this monitoring. She reviewed the care plan and stated that diabetes was completely omitted from her care plan. She stated that the risk of not care-planning Type 2 Diabetes is a failure of disease process management. She stated that without a care plan or orders, nursing and care staff would remain unaware that the resident is diabetic. She stated that the resident's risk of hypoglycemia should have been identified and addressed upon admission by obtaining the hospital report and immediately contacting the physician for orders. Review of the facility policy titled Blood Glucose Monitoring, reviewed July 2026, states that it is the policy of this facility to check and monitor finger stick blood glucose levels as ordered by the physician. Review of the facility policy titled Physician Orders, revised September 2025, revealed that it is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. 3. admission orders are reviewed with the physician upon admission based on the discharge instructions from the discharging facility and are transcribed accordingly.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that adequate supervision was provided to ensure that Resident #11 did not elope. The deficient practice could result in residents being injured, abused, or lost.Findings include:Resident #11 was admitted to the facility on [DATE], and discharged on May 9, 2026, with diagnosis that included aphasia, depression, and anxiety.A physician order dated April 13, 2026, revealed that Resident #11 may go out on pass with medications and responsible party.A physician order dated April 13, 2026, was written for levetiracetam oral tablet 100 mg/ml (milligram/milliliter) to give 5ml by mouth two times a day for seizure disorder.An elopement evaluation dated April 13, 2026, revealed that Resident #11 did not have a history of elopement or an attempted while at home, or while at the facility.A care plan dated April 14, 2026, revealed that Resident #11 was at risk for a communication problem related to expressive aphasia, stroke.A progress note dated April 14, 2026, at 3:07 p.m. revealed that the Resident had a communication board, tablet, and smart phone to utilize to communicate with staff and resident is able to understand when staff is talking to her. The progress note then revealed that resident was educated on when she is required to sign out when leaving building and notifying nurse if she leaves building. The progress note revealed that the resident is long term care and is educated on the risks of being outside during hot season and risk of dehydration and heat stroke and resident nodded to confirm understanding.An admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 08, indicating moderate cognitive impairment. Further review of MDS assessment revealed no behaviors had been exhibited during the assessment period.A progress note dated May 9, 2026, at 4:11 p.m. revealed that the Resident #11 was last administered the medication diphenhydramine HCl Capsule 25 mg, to give 1 tablet by mouth, every 6 hours as needed for itching.A nursing progress note dated May 10, 2026, at 1:11 a.m. revealed that the resident was identified as being absent from the facility during bedside medication pass. The progress note indicated that staff believed the resident was out with family and called family to confirm. The progress note relayed that the resident's family communicated that the resident was not with them, but was taken to the hospital for evaluation of heat exposure. The progress notes further relayed that an investigation was initiated immediately and the medical director was notified of the situation. A hospital report dated May 9, 2026, at 8:32 p.m. revealed that the resident was found on the curb by Emergency Medical Services (EMS) next to her motorized scooter, agitated and confused. The report further revealed that the resident was brought to the emergency room (ER) and found to be encephalopathic, agitated, and hyper thermic to greater than 40C (degree Celsius), presumed heat stroke. The report revealed that the resident was intubated and started on cooling therapy.A review of medication administration record (MAR) dated May 2026 at 8 p.m., revealed that no medication was administered as Resident #11 was absent from the facility.A facility Reportable Event Report submitted to the State Agency on May 10, 2026, revealed that on May 9, 2026, at approximately 7:30 PM- Certified Medication Assistant (CMA, staff #143) was starting her medication pass and noticed that Resident #11 was not available or in her room. CMA reported to a Licensed Practical Nurse (LPN, staff # 139), that the resident was not in her room. CMA then called daughter several times to ask about resident being out on pass with family. CMA and other staff started looking in rooms in the facility and the outside patio to try to locate the resident. CMA stated that she got a response from family at 10:00 p.m. and family told CMA that the resident was not with them and that she was in hospital. Per report, the Administrator (staff #131) was immediately notified and an investigation was initiated and incident was notified to the police, ombudsman, Department of Health Services (DHS), Adult Protective Services (APS) and interviewed staffs and residents were conducted. The investigation conclusion revealed that the incident was an isolated unanticipated event due to Resident #11 did not having any previous behaviors of attempting to leave the facility.A review of a Residents Signed Out form from February 13, 2026, to May 11, 2026, revealed no evidence that Resident #11 signed out before leaving the facility.An interview was conducted on May 12, 2026, at approximately 9 a.m., with a receptionist (staff # 169) who stated that she works at the facility from Monday to Friday from 8 a.m. to 4:30 p.m. and another receptionist (Staff #180) works from Monday to Friday from 4:30 p.m. to 9 p.m. The receptionist stated that residents/visitors use the front lobby from 8 a.m. to 5 p.m. to go in and out of the building and then after 5 p.m. the front lobby door closes. The receptionist stated that the front lobby is locked by the receptionist after 5 p.m. and then the receptionist turns on the alarm at the nurse station. The receptionist also stated that the alarm at the nurse's station will sound if the door is not locked at the front lobby. The receptionist further stated that after 5:00 p.m., residents/visitors use the west side back entrance of the facility to enter the building and sign a log-in form at the nurse's station. The receptionist also stated that when resident's leave the facility, the resident had to notify the nurse and fill out the Resident Sign Out Form at the nurse's station and then the nurse would notify the receptionist at front lobby. The receptionist further stated that she was not aware that the resident eloped, as it happened on weekend when she was not working and not sure if anyone follow-up on that. The receptionist further stated that the risk of resident's leaving the building without notifying staff could result in heat stroke due to staying too long outside. An interview was conducted on May 12, 2026, at 10:35 a.m., with a Licensed Practical Nurse (LPN, staff # 139), who stated that she worked Wednesday through Thursday and every other weekend. The LPN stated that the facility process when residents leave the facility, included notifying the nurse and signing out on the Resident Sign Out form. The LPN stated that Resident #11 was alert, oriented, non-verbal, had a tracheostomy, and did not have any valve for speech and would communicate through hand gestures. The LPN stated that she was in the facility on May 9, 2026 and had cared for the resident on the date of the incident. The LPN stated that a Certified Medical Assistant (CMA, staff # 143) told her that she was looking for Resident #11 and the LPN assisted in searching rooms and the outside patio, and that the CMA had attempted several times to reach the resident's daughter. The LPN also stated that at 10:00 p.m. the resident's family informed her that the resident was in the hospital, and the Administrator (Staff #131) was notified immediately. The LPN further stated that risk resident elopement from the facility could result in heat stroke or accident An interview was conducted on May 12, 2026, at 11:32 a.m. with a CMA (staff # 143), who stated that she works night shift Wednesday, Thursday, and every other weekend from 6 p.m. to 6 a.m. Staff #143 The CMA stated that residents are expected to notify the nurse and sign-out on the sign-out form whenever they are leaving the facility. The CMA stated that the facility does not encourage residents to go out around 10 a.m. or 5 p.m. because its hot outside. The CMA further stated that she was familiar with Resident #11 and the resident did not have a wandering behavior. The CMA stated that on May 9, 2026, around 7:30 p.m., she was starting her medication pass and did not see Resident #11 and started looking in rooms and the outside patio. The CMA stated that she then called Resident #11's daughter who told the CMA that her mom was not with her but was in the hospital, and that the Administrator (staff #143) was notified. The LPN then stated that risk if a resident eloped from the facility it could result in dehydration or accidents. An interview was conducted on May 12, 2026, at 12:05 p.m. with an LPN (staff # 89) who state that she is dayshift nurse and works on Friday, Saturday, and Sunday from 6 a.m. to 6 p.m. Staff #89 stated that facility process if resident had to go out of the building then they have to notify charge nurse and fill out resident sign in and out form. Staff #89 stated that she is aware of Resident #11 and worked with her first time on last Saturday, May 9, 2026. Staff #89 stated that on May 9, 2026 at 7:30 a.m. she was in bed sleeping when she entered the room to give Resident #11 medications. Staff #89 woke Resident #11 for medications and then Resident #11 went back to bed. LPN then stated that at 9:30 a.m. Resident #11 passed by the nurse station to go to the activities. LPN further stated that at 12:15 to 12:30 p.m., she gave Resident #11 her diphenhydramine HCl, 1 capsule, 25 milligram(mg) for itching then checked resident around 4 p.m. regarding any concern with the itching and charted in her clinical record. LPN stated that Resident #11 did not communicate that she was leaving the building. Staff #89 stated that risk if residents with low BIMS score eloped then they would be at risk for injury, heat stroke, and dehydration. An interview was conducted on May 12, 2026, at 12:35 p.m. with the Administrator (Staff #131), who stated that facility process when residents go in and out of building depends on whether the resident is in skilled or long-term care (LTC). The Administrator stated that resident's in the skilled unit require, an order to go out for appointments or medical necessity. The Administrator further stated that resident's resident in the LTC unit require a standing order to go in and out of the facility. The Administrator also stated that LTC residents need to notify the nurse and fill out the sign-out form before going out of the building. The Administrator also stated that there are no cameras in the building and there is only exit door for residents to go in and out of facility. The Administrator stated that on May 6, 2026, around 10:45 p.m. to 11 p.m., CMA (staff #143) notified him that Resident #11 was not found in the building. The Administrator further stated that around 2:30 p.m. on May 9, 2026, Resident #11 went to receptionist (staff #142) and asking for her daughter's address to send flowers for Mother's Day. The Administrator then stated that around 7:30 p.m., CMA (staff #143) went to administer medications to Resident #11 and she could not find the resident. The Administrator stated that the CMA called the resident's daughter who informed the CMA stated that Resident #11 was in the hospital. The Administrator stated that he assumed that Resident #11 left the building before 5 p.m. through the front door on May 9, 2026. The Administrator stated that the investigation was started, notified the police, ombudsman, Department of Health Services (DHS), Adult Protective Services (APS) and interviewed staffs and residents. The Administrator and the Director of nursing (DON, staff #158) stated that all staff were provided wandering and elopement training on Sunday, May 10, 2026. An interview was conducted on May 12, 2026, at 1:15 p.m. with the Resident's daughter who stated that her mother got her address from the facility to send her flowers for Mother's Day. The Daughter further stated that, Resident #11 left the faciity on May 9, 2026, around 10 a.m. and that she received a call from the ER around 5 p.m. The resident's daughter stated that the ER staff told her that Resident #11's scooter was dead, and that the resident appeared to have had a heat stroke, was dehydrated, and had been sent to the Intensive Care Unit (ICU). The resident's daughter further stated that the facility called her around 10:55 p.m. to inform her that the facility could not find the resident. The resident's daughter stated that , she got upset with the CMA (staff #143) because facility staff were looking for the resident all day and could not find her until 10 p.m. on Saturday, May 9, 2026. The resident's daughter stated that Resident #11 did not have any behavior or history of wandering or elopement. A follow-up interview was conducted on May 12, 2026, at 3:21 p.m. with the Director of Nursing (DON (staff # 158), who that the facility process to ensure residents with low BIMS score are safe by providing the care they need and then residents care plan would reflect if they have exit seeking behavior like trying to leave the building and interventions included wonder guard, close to nurse station, and frequent monitoring and Resident #11 did not meet those qualifications. The DON then stated that she is not sure what was the Resident #11 BIMS score when she elopes the building but using her nursing assessment and judgement, Resident #11 wanted to have flowers for her daughter and knew Mother's Day was coming. DON then stated that risk if resident with low BIMS score elope then resident would be confused, not able to come back to the facility and then there is safety issue as well. Review of the facility policy titled, Elopement/Unsafe Wandering, reviewed on May, 2026, revealed that if a resident is unable to be located, it is considered a facility-wide emergency and the missing resident procedures will be initiated if the resident is unaccounted for after a thorough search of the building and grounds, immediately notify Administrator, Director of Nursing Services, Resident's legal representative or emergency contact, attending physician and law enforcement officials.

Number of residents sampled: Number of residents cited: Based on observations, resident and staff interviews, and record review, the facility failed to ensure that one of the samples resident's (#103) room air conditioning (AC) unit and filters were clean and intact. The deficient practice had the potential health and safety risk for residents residing in the room due to unfiltered air to circulate in the room.Findings included:Resident #103 was admitted to the facility on [DATE], with diagnoses including COVID-19, sepsis due to E. coli, liver abscess, Klebsiella pneumoniae, Diabetes Mellitus Type II, and other comorbid conditions.A Care Plan initiated on February 22, 2026, documented Resident #103 had bacteremia due to Klebsiella and was receiving intravenous antibiotics. The care plan goal included remaining free from complications related to the infection and continuing antibiotics as ordered. During an interview with resident #103 in his room on March 3, 2026, at 10:00 a.m., Resident #103 stated the air conditioning unit in the room was working but was dirty. The resident pointed out that the top of the AC unit which was dusty and stated it had been that way since admission. Observation of resident's room AC unit on March 3, 2026 at 10 am revealed a visible layer of dust on the top surface of the AC unit. Further, two AC filters were also observed with visible dust accumulation. Two subsequent observations on March 4, 2026 at 1:08 a.m and again on March 5, 2026 at 12:37 p.m revealed that the top of the AC unit remained dirty and dusty, and the filters remained full of dust. The Heating, Ventilation, and Air Conditioning (HVAC) inspection log in the facility's Direct Supply TELS(R) preventive maintenance system indicated the last HVAC inspection was completed on December 31, 2025.During an interview on March 6, 2026, at 10:54 a.m., Maintenance Manager (Staff #50) stated AC units and filters were cleaned monthly and additionally as needed. During another observation of Resident #103's AC unit on March 6, 2026, at 11:03 a.m., the right AC filter was observed with an approximately 30-centimeter hole. Staff #50 stated the filter had been cleaned on March 5, 2026; however, the damaged filter had not been replaced. Staff #50 confirmed the top of the AC unit was dirty and stated the hole in the filter would prevent proper filtration and allow unfiltered air to circulate in the room, which could increase the risk of residents becoming ill.Review of the facility policy titled Equipment Maintenance, revised in 2007 and reviewed in May 2021, indicated maintenance staff are responsible for maintaining equipment in accordance with manufacturer instructions and documenting maintenance activities in the TELS(R) logging system, including the date, description of the maintenance performed, and verification of completion. The policy further stated routine equipment inspections and maintenance activities are to be recorded in the facility's TELS(R) work history report.

Based on observations, resident and staff interviews and review of facility policies and procedures, the facility failed to maintain clean and sanitary environment as evidenced by not changing visibly soiled linens in a timely manner for one sampled resident (#103). The deficient practice could result in an unsanitary environment, increased risk for infection, and decreased resident comfort.Findings include:Resident #103 was admitted on [DATE] with diagnoses that included COVID-19, sepsis due to E. coli, abscess of the liver, Klebsiella pneumonia, Diabetes Mellitus Type II, and other comorbid conditions.A Care Plan initiated on February 22, 2026 stated that Resident #103 had bacteremia due to Klebsiella and was receiving intravenous antibiotics for the infection.The resident's progress record upon admission indicated that the resident was alert and oriented and able to make needs known.During the initial observation on March 3, 2026 at 10:00 a.m., Resident #103 stated that the bedding, including the linens, had not been changed since admission on [DATE].During a follow-up observation on March 4, 2026 at 11:08 a.m., the resident again stated that the bedding, including the linens, had not been changed since the date of admission.A subsequent observation on March 5, 2026 at 12:37 p.m. revealed that stains were observed in the area where the resident was seated. The stains appeared to be food residue from the resident's meal.During an additional observation on March 6, 2026 at 11:03 a.m., the same linens remained on the bed as evidenced by the stains that was still present. The resident again stated that the nursing staff had not changed the bedding.During resident interview on March 6, 2026 at 11:55 AM, the resident stated that he showered on March 4, 2026. However there was no documentation that the resident received shower on March 4, 2026.A review of the shower record indicated that the resident had one documented shower on February 27, 2026 at 1:59 p.m.An interview with Certified Nursing Assistant (CNA) Staff #7 was conducted on March 6, 2026 at 10:00 a.m. Staff #7 further stated that the usual practice was to change bed linens 3 times per week, particularly after residents showered or if linens became soiled due to drainage or stains. Staff #7 stated that residents' beddings, including linens, were typically changed when residents showered. The CNA explained that staff normally changed the linens, draw sheets, fitted sheets, pillowcases, top sheets, and blankets if they were soiled. Staff #7 stated that the standard practice was to change the bed linens while the resident was in the shower.Additionally, another CNA, Staff #35, on March 6, 2026 at 10:00 a.m stated that residents were expected to receive showers twice weekly. Staff #35 stated that failing to provide regular showers and linen changes could increase the risk of infection, pressure injuries, and unsanitary conditions.An interview with Registered Nurse Staff #33 was conducted on March 6, 2026 at 10:30 a.m. Staff #33 confirmed that CNAs reported that bedding was changed after each shower session, which occurred twice weekly. Staff #33 stated that bedding included linens, pillowcases, draw sheets, fitted sheets, and blankets.An interview with the Director of Nursing (DON), Staff #18, was conducted on March 6, 2026 at 11:30 a.m. Staff #18 stated that bedding was changed on scheduled shower days or as needed. Staff #18 confirmed that residents were scheduled to receive showers twice weekly or upon request. Staff #18 further stated that the facility did not maintain a bedding change log and reported that the resident had experienced 3 shower episodes since admission. However, a review of the resident's shower record indicated that the resident had received only one shower on February 27, 2026 at 1:59 p.m. Staff #18 also acknowledged that failure to change bedding regularly could result in unsanitary conditions and increase the risk of infection.A review of the policy titled Quality of Life, revised in November 2007 and reviewed in September 2025, stated that maintenance and restorative programs would be provided to residents in accordance with each resident's comprehensive assessment. The policy further stated that bathing would be offered twice weekly unless residents requested more or fewer showers, or as otherwise needed. The policy also stated that daily care, including personal hygiene, oral care, transfers, grooming, dressing, mobility, and ambulation, would be provided according to the resident's assessed needs and level of support and would be documented in the medical record accordingly.

Based on observations, staff interviews, and a review of facility policies and procedures, the facility failed to ensure staff followed food safety practices by not wearing gloves while serving food. This deficient practice had the potential to result in food contamination, which could cause illness or food poisoning among residents.Findings Include:On March 4, 2026, at 12:30 p.m., during the procedure of taking the temperature of food from the test tray in the conference room, the survey team observed that Staff #65, who was also the kitchen manager, had a bandage on her right hand. Staff #65 did not wear gloves during this procedure. A red spot was observed on the outer part of the bandage.An immediate interview with Staff #65 was conducted on March 4, 2026, at 12:45 p.m. Staff #65 stated that the cut was a scratch that occurred earlier that morning on March 4, 2026. Staff #65 further stated that her skin was very thin and easily scratched; however, on that morning, while in the soiled utility room, she accidentally struck her right hand on one of the shelves. Staff #65 stated that she went to a nurse on one of the floors to have the skin tear cleaned and covered with a bandage.Staff #65 further stated that she was not supposed to serve food with a bandage and bare hands and acknowledged that, according to kitchen normal practice, gloves should be worn when serving food if there is an open skin tear covered with a band aid. Staff #65 confirmed that serving food with an open wound covered by a bandage without wearing gloves could encourage cross-contamination and potentially spread infection to residents and staff. Staff #65 also stated that she was not scheduled to serve in the kitchen on the morning of March 4, 2026; however, her kitchen staff indicated that they needed her input during the tray line observation, which led to her involvement in serving trays, including the test tray temperature check in the conference room. Staff #65 further stated that the facility's expectation for proper kitchen food preparation and safety required that any open skin tear on the hands be cleaned, covered, and that gloves be worn while serving food to prevent contamination and the potential spread of harmful bacteria or infection among residents and staff.A review of the policy titled Infection Prevention and Control Program, reviewed in September 2025, indicated that facility personnel were expected to conduct themselves and provide care in a manner that minimized the spread of infection. The policy further stated that facility staff with skin lesions were not permitted to have direct contact with residents or their food. Additionally, a review of the policy titled Employee Sanitary Practices, dated 2018, indicated that kitchen staff were required to follow all federal, state, and local requirements. The policy further stated that these requirements included the expectation that all nutrition and food service employees practice good personal hygiene and safe food-handling procedures.

Based on clinical review, staff interviews, and facility policy, the facility failed to ensure that physician orders were followed according to professional standards regarding blood sugar monitoring for two out of five sampled residents (#215 and #46). The deficient practice could result in residents with high blood sugar. Findings Include: -Regarding resident #215: Resident #215 was admitted to the facility on [DATE] with diagnoses that included Type II Diabetes Mellitus without complications. The care plan for Diabetes Mellitus initiated on November 09, 2024 included an intervention of diabetes medication as ordered by doctor; monitor/document for side effects and effectiveness. The Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 00 indicating severe cognitive impairment. Review of the physician's order dated November 8, 2024, revealed an order for, Insulin Lispro solution 100 unit/milliliter (ml), inject as per sliding scale: if 0 - 60 =0 units asymptomatic or symptomatic blood sugar (BS) 60 and below; see as needed orders; 61 - 150 = 0 units; 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 12 units; 351 - 400 = 15 units; 401+ = 18 units recheck, if still elevated in 60 minutes call medical doctor (MD), subcutaneously before meals and at bedtime. Review of the Medication Administration Record (MAR) dated November 2024 revealed the following: -November 10, 2024, BS was 447 and 18 units of insulin was administered. -November 12, 2024, BS was 463 and 18 units of insulin was administered. -November 13, 2024, BS was 430 and 18 units of insulin was administered. -November 16, 2024, BS was 491 and 18 units of insulin was administered. -November 17, 2024, BS was 449 and 18 units of insulin was administered. -November 18, 2024, BS was 415 and 18 units of insulin was administered. -November 19, 2024, BS was 402 and 18 units of insulin was administered. -November 20, 2024, BS was 401 and 18 units of insulin was administered. A review of the clinical record revealed no evidence that the BS was rechecked or that the physician was notified for the above dates regarding blood sugar. An interview was conducted on November 21, 2024 at 8:40 AM with a Certified Nursing Assistant (CNA/staff #17) who stated that blood sugar checks are done whenever they are scheduled. She also stated that the blood sugar results are given to the nurses and the nurses document the results in the electronic record. She further stated that she would notify the nurse about blood sugar results in any situation but especially if the resident is below 90 or over 250. In an interview with a Licensed Practical Nurse (LPN/staff #82) on November 21, 2024 at 8:41 AM, who stated that the process for administering insulin included: checking the blood sugar, depending on the result the resident could have either a standard and/or sliding scale order to give insulin, wiping the resident area with an alcohol pad, and administering the medication. She also stated that she would follow the sliding scale as it was written in the order. The LPN (staff #82) reviewed the physician order of insulin lispro for resident (#215) and verified that if the blood sugar was above 401 it should be rechecked in 60 minutes and if it is still 400 to notify the physician. The LPN then reviewed the above dates and blood sugar results in the resident's clinical record and stated that the blood sugars should have been rechecked after the initial result but there was no evidence showing that it had been completed. She also stated that the physician should have been notified. The LPN (staff #82) stated that the risks to the resident of not rechecking the blood sugar or notifying the physician could result in the resident passing out. She further stated that not following the physician's order for insulin lispro did not meet facility expectations. An interview was conducted on November 21, 2024 at 8:57 AM with the Director of Nursing (DON/staff #7) who stated that the process for administering insulin would be based off of the physician's order and nursing assessment. She stated that the physician orders regarding insulin would be followed. The DON (staff #7) reviewed the above dates and documented blood sugars in the resident's (#215) clinical record, and stated that the blood sugars should have been rechecked. She further reviewed the resident's clinical record and stated that there was no evidence of the blood sugars being rechecked after the initial result according to physician's orders, or that the physician was notified. The DON stated that the risks to the resident of not rechecking the blood sugar or notifying the physician could include that the resident's blood sugar could stay elevated and that they would not be addressing his diabetes. She further stated that not following physician orders did not meet facility expectations. 51239 - Regarding resident #46: Resident #46 was admitted on [DATE] with diagnosis that included Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of the physician's order dated October 29, 2024, revealed an order for, Insulin Lispro solution 100 unit/milliliter (ml), inject as per sliding scale: if 0 - 60 =0 units asymptomatic or symptomatic blood sugar (BS) 60 and below; see as needed orders; 61 - 150 = 0 Units;151 - 200 = 0 Units;201 - 250 = 2 Units;251 - 300 = 4 Units;301 - 350 = 6 Units;351 - 400 = 8 Units;401+ = 10 Units RECHECK, IF STILL ELEVATED IN 60 MINUTES CALL MD, subcutaneously before meals and at bedtime. The care plan for Diabetes Mellitus initiated on October 30, 2024 included an intervention of diabetes medication as ordered by doctor; monitor/document for side effects and effectiveness. The Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 15 signifying the resident had no cognitive impairment. Review of the Medication Administration Record (MAR) dated November 2024 revealed that on November 04, 2024, resident's BS was 407 and 10 units of insulin was administered. A review of the clinical record revealed no evidence that the BS was rechecked or that the physician was notified for the above date regarding blood sugar. An interview was conducted on November 21, 2024 at 10:14 AM with the Director of Nursing (DON/staff #7) who reviewed the MAR/TAR for November 2024. The DON (staff #7) reviewed the November 04, 2024 and documented blood sugars in the resident's (#46) clinical record, and stated that the blood sugars should have been rechecked. She further reviewed the resident's clinical record, she stated that the blood sugar was first checked at 10:53 and then it was checked at 15:38 and she stated that it should been as physicians order. She further stated that not following physician orders did not meet facility expectations. The facility's policy, Physician Orders, revised in September of 2024 revealed to accurately implement orders in addition to medication orders, only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on observations, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen. The deficient practice could result in a potential for food borne illness. The resident census is 51. Findings include: During an initial walk through of the kitchen conducted with the Kitchen Manager (staff #46). On December 12, 2023 at 8:07 AM conducted initial kitchen tour with Staff #46, the Food Service Director. Logs for freezer, fridge, dishwasher, cleaning bucket, food temps, cleaning schedule, and sanitizing concentration were reviewed and revealed the log titled Cleaning List for Cook Daily hanging on clipboard nailed to wall was not completed for the Monday AM shift prior to morning food service. Additionally reviewed the Cleaning List for Dishwasher log hanging on clipboard nailed to wall and which revealed the Monday AM the cleaning list for dishwasher log was not completed prior to morning food service. Observed five empty crushed boxes stored near food prep area, food debris under enclosed refrigerator shelf with black sticky substance on the floor approximately six inches in diameter. On December 13, 2023 12:25 AM Observed several empty crushed boxes stored near food prep area, and food debris under food prep table. On December 14. 2023 at 10:16 AM, observed a live roach on door in Kitchen Manager's office, the Kitchen Manager (staff #46) stated that it was a roach and smashed it on the door with a floor duster. At approximately 10:35 AM conducted a tour of the kitchen and observed the following; 1) food debris under two food prep tables and near baseboards with a toaster above one food prep table, 2) five empty cardboard boxes with two open empty containers of processed mashed potatoes. The Kitchen Manager stated that this was trash and explained that the trash will be emptied right away because of the risk of cross contamination, this trash pile was observed 6 inches away from a push cart of prepared desert cakes, 3) thawing processed ham under running water while sitting on top of a metal strainer three inches away from a sheet of uncovered tray of desert cake, with water observed splashing near uncovered tray of desert cake, 4) a white bath towel under a mobile refrigerator and the kitchen manager pulled the white bath towel from under the refrigerator and stated that the risk of the towel could harbor bacteria and stated somebody must've spilled something here, the white bath towel appeared crusted dry with a brown stain, 5) one dead roach under canned food shelf and the kitchen manager stated it looks like a dead bug, and one live roach crawling across the floor and the kitchen manager stepped on the insect, 6) standing water under dry food storage shelf with vinyl baseboard partially peeled from the wall and crusted lifted floor tile from what appeared to be a water leak from the wall, 7) baseboards behind the ice machine in the resident dining room had three dead roaches and debris build up next to a floor drain sink that had black debris particles build-up caught in filter trap, the surrounding tile around the drain sink were broken and had exposed sub-floor. Reviewed Maricopa County Food Inspection Report from October 2, 2023 and revealed a finding statement of: the floor drains under the hand wash sink in the cook line area under the prep table with excess soil residue/old food debris present. PIC stated that all areas would be cleaned. Reviewed the pest service log from Burns Pest Elimination and revealed an invoice for Commercial Healthcare Program (December 2023) with no description of services. Reviewed the pest service log from Atomic Pest Control, LLC and revealed services with locations (June 10, 2023 to September 21, 2023) with no service requests for the kitchen. Reviewed the work orders for the kitchen (October 1 - December 13, 2023) with no service request for pest elimination or water leaks.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#10) received dialysis servicves as per physician's orders. The sample was 3. The deficient practice could result in residents not getting the required treatment to manage their condition. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD), dependence on renal dialysis, and chronic metabolic acidosis. A Care Plan initiated April 5, 2023 and revised on April 17, 2023 revealed that the resident needed dialysis regarding renal failure and had a permacath to the right chest. Interventions noted included to encourage resident to go for the scheduled dialysis appointments and also included that the resident received dialysis on Monday/Wednesday/Friday. Regarding dialysis orders: The physician order dated April 5, 2023 included that the resident had dialysis on Monday/Wednesday/Friday. Review of an undated document titled Dialysis PT List - with schedules revealed a list of residents on dialysis which included resident #10. The document indicated that resident #10 is scheduled for dialysis on Monday, Wednesday, and Friday. However, dashboard section that was marked as special instructions on the resident's electronic record indicated that the resident received dialysis on Tuesday, Thursday, and Saturday. During an interview with the Dialysis Center Administrator (staff #1) conducted on May 1, 2023 at 1:26 p.m., he stated that the resident was scheduled for dialysis three times a week (Tuesday, Thursday, and Saturday). Staff # 1 stated the resident missed his dialysis appointment on April 6, 2023 and April 15, 2023 and no reason was provided. During an interview with a Licensed Practical Nurse (LPN/staff #48) conducted on May 2, 2023 at 3:02 p.m., she stated that the orders for dialysis should match the information on the dashboard under special instructions which stated where the dialysis takes place, the day/times for dialysis, and the pick-up times. Following the interview, resident #10's clinical record was reviewed with staff #48. The order for dialysis was compared to the special instructions on the dashboard. Staff #48 agreed that the information did not match. Staff #48 stated that if the information did not match then the resident would not be ready to go on their appointment, the resident would not get their vitals taken before and after the dialysis. Furthermore, the shunts/fistula would not be checked at the appropriate times. Staff #48 also noted that a staff member unfamiliar with the resident and the scheduled dialysis days would find the conflicting information between the orders and the dashboard confusing which can lead to the nurse erroneously doing monitoring on a different date. An interview with the Medical Records Supervisor/Transportation (staff #25) was conducted on May 2, 2023 at 3:55 p.m. Staff #25 stated that the Admissions Department set up the special instructions on the dashboard. Medical records confirm with the dialysis center that the information on the dashboard is accurate since this is what they use to schedule transportation. Staff #25 also stated that the special instructions on the dashboard should match the orders. However, she stated that if the information between the orders and dashboard conflicts, that they follow the information on the special instructions since that information is what is verified with the dialysis center. Staff #25 stated that transportation did not look at orders since once they verify the days/times with dialysis center, they place that information on the excel sheet for quick reference of who goes where and when. An interview was conducted on May 2, 2023 at 4:14 p.m. with the Director of Nursing (DON/staff #20). Staff #20 stated that dialysis information can be viewed under special instructions on the dashboard, communication board, and orders for site and dialysis. She stated that her expectation of her nurses when conflicting information between the dashboard and orders exist is for them to know which information is correct. The DON stated that the negative impact of the conflicting information is bad communication and confusion. Following the interview, the DON reviewed the resident's clinical record and agreed that the special instructions on the dashboard and the orders had conflicting information. Regarding missed dialysis: A rounding report from the dialysis center dated April 18, 2023 indicated under treatment history that the resident has had zero missed treatments in the last 30 and 60 days. However, the chart portion for the last 6 completed treatment did not contain information regarding pre/post blood pressure, dialytic weight loss, pre/post weight, average blood flow restriction, and actual treatment time for April 6 and April 15. Review of resident #10's April 2023 Treatment Sheet for dialysis revealed that the resident received treatment on the following days: April 8 (Saturday) April 11 (Tuesday) April 13 (Thursday) April 18 (Tuesday) April 20 (Thursday) During an interview with the Dialysis Center Administrator (staff #1) conducted on May 1, 2023 at 1:26 p.m., he stated that the resident was scheduled for dialysis three times a week (Tuesday, Thursday, and Saturday). Staff # 1 stated that the resident missed his dialysis appointment on April 6, 2023 and April 15, 2023 and no reason was provided. Staff #1 stated that resident did not receive dialysis on April 22, 2023 because the resident declined treatment due to having a bowel movement. Staff #1 also stated that the resident was 1.5 hours late to the dialysis appointment, never made it to the treatment area and just wanted to go back home. Staff #1 noted that in the event that a resident arrived at the dialysis center soiled, they have gowns that the resident can change into. He stated the dialysis center can help clean up the resident and position them for isolation so they can receive their treatment. Review of the resident's record revealed no documentation on the reason behind missed dialysis on April 6 and April 15, 2023. A progress note dated April 22, 2023 documented that the resident was taken to dialysis center in the morning. The note stated when the resident #10 arrived at the dialysis center, it was noted that she had a bowel movement during transport and the dialysis center refused to have the resident sit for dialysis treatment due to bowel movement. The note further included that the resident was instructed per dialysis staff to return to facility and the transport driver was unable to assist resident with brief change. The progress note indicated that the dialysis staff refused to assist resident and had resident return to facility. Review of the order summary revealed a physician order dated April 22, 2023 which indicated a change of condition for missed dialysis. It noted that provider, resident, and responsible party were notified/aware and agreeable to plan of care. A progress note dated April 23, 2023 indicated that the resident presents with moderate weakness. Resident was noted to be alert with confusion after missing dialysis the day prior. A progress note dated April 24, 2023 indicated that the resident missed dialysis on Saturday. It noted that a call was placed to the dialysis center to see if resident can do a make-up time. However, there were no spots open that day and resident was to resume regular schedule the next day. Review of the order summary revealed an order dated April 25, 2023 which directed for orders to be on hold due to the resident being sent to the emergency department as a result of a change of condition for missed dialysis, altered mental status, lethargy, not alert and oriented to person, place, or time. The order noted that the nurse practitioner was advised. During an interview with a Licensed Practical Nurse (LPN/staff #48) conducted on May 2, 2023 at 3:02 p.m., she stated that the facility has a terrible time with transport. She stated there are times when transport does not come and one of the staffs have to take the resident to the dialysis. She stated there has also been instances when the dialysis facility refused to provide a resident with treatment since the resident was soiled. She noted that in resident #10's case, she had to be sent out to the hospital on April 25, 2023 because she was sick due to missed dialysis on April 22, 2023. She stated transport did not pick her up on April 22, 2023 so they had to take her. She stated reason for missed dialysis appointments should be documented in the notes. Staff #48 stated that she believes that April 22, 2023 was not this resident's first missed appointment and said she might have missed another dialysis appointment due to transport. An interview with the Medical Records Supervisor/Transportation (staff #25) was conducted on May 2, 2023 at 3:55 p.m. Staff #25 stated that issues with transportation for dialysis happened often. She noted that the residents with a specific health plan are the ones that have transportation issues. She stated transport does not come in for them and stated that although they have assisted residents with filing grievances against their health plan concerning transportation, the facility does not track people or the company to see how often transportation issues have occurred. Staff #25 provided a memo dated the same day, which stated that the transportation/medical records does not keep a log of appointments and transportation for residents. Staff #25 also stated that the way they track if a resident was taken to an appointment is the nurse/CNA lets them know when a resident does not get picked up and then they call transport to see if the driver is on the way. She stated if the transportation is really late then they call the provider to see if the resident can still be seen or if the resident needs to be rescheduled. If the appointment is emergent then there is a bus available and one of the staffs takes the resident. An interview was conducted on May 2, 2023 at approximately 4:14 p.m. with the Director of Nursing (DON/staff #20). Staff #20 stated that missed dialysis appointments should be documented on the resident's chart if they were not provided dialysis. She also stated that her expectation is for her staff to reschedule the resident if the dialysis treatment was missed for whatever reason. When asked about resident #10's missed appointments on April 6 and April 15, she said she was not aware that the resident had missed appointments. The facility policy titled Dialysis (Renal), Pre and Post Care revised March 2009 and reviewed March 2023 indicated that documentation should assess care given, and condition of renal dialysis access. It also dictated that all assessments be documented in the clinical record as needed. The agreement between the long-term care facility and the dialysis center signed on August 20, 2020, revealed that the long-term care facility shall be responsible for arranging for suitable and timely transportation of ESRD residents to and from the ESRD dialysis unit, to include the selection of the mode of transportation, qualified personnel to accompany the ESRD residents, and transportation equipment. Review of the facility policy titled Physician Orders revised May 2021 and reviewed August 2022 stated that it is the policy of the facility to accurately implement orders in addition to medication orders, treatment procedures. It also stated that medication, treatment or related procedure orders are transcribed in the eMAR (electronic Medication Administration Record), eTAR (electronic Treatment Administration Record) accordingly. Review of the facility policy titled Documentation and Charting revised July 2022 stated that it is the facility's policy to provide an account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well of the progress of the resident's care.

Based on facility documentation, clinical record review, family and staff interviews, and policy review, the facility failed to provide housekeeping services necessary to maintain a clean and homelike environment for one resident (#200). The sample size was 13. The deficient practice could result in residents not being provided a safe and clean environment. Findings include: Resident #200 was admitted to the facility on [DATE] with diagnoses that included [CONDITION(S)], weakness, hypertension, and [CONDITION(S)]. Review of an admission progress note dated October 5, 2022 revealed the resident and the resident's family member disapproved of the admission process and were waiting to be transferred to a facility closer to the resident's home. Review of a facility grievance dated October 5, 2022, revealed a statement by a family member of the resident that when they arrived at the room there were dirty linens and trash left in the room. The facility investigation notes dated October 6, 2022, revealed that the room had not been cleaned by housekeeping prior to the resident's admission to the room. The facility investigation included education of admission and housekeeping departments about the new admission process. The history and physical progress notes dated October 6, 2022, revealed evidence that the resident was not happy with the facility and requested transfer to another facility. Review of a discharge Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. An interview was conducted via telephone on November 8, 2022 at 9:46 AM with the resident's family member, who stated that when they came into the resident's room there was dirty linen, a pitcher with water, a dirty cup, and mail with the name of another resident on the dresser, no call-light and that light bulbs were not working. She stated that she complained to staff, but the dirty items were not removed prior to the resident's discharge from the facility. The family member further stated that she filled out a grievance form in the evening, and was contacted by Social Services the next day. The resident's family member stated that the staff member apologized, but none of the areas that she had complained about were addressed. The family member also relayed that the Social Services staff member had stated that she would not leave her family member at the facility under those circumstances. An interview was conducted on November 9, 2022 at 10:49 AM with a housekeeper (staff #33), who stated that after a resident is discharged from the facility, housekeeping will deep clean the room. She stated that a deep clean included cleaning everything from top to bottom, bed mattress, bedframe, tables, cabinets, remotes, window sill, walls, chairs, dressers and drawers. She also stated that any belongings left are placed in a bag and given to her supervisor. Staff #33 also stated that there should not be any trash, dirty linen or any personal belongings left in the room after it is deep cleaned. The housekeeper further stated that she has received orientation on how to deep clean a room after a resident is discharged . An interview was conducted on November 9, 2022 at 11:00 AM with the Housekeeping Supervisor (staff #84) who stated that the facility process for deep cleaning a resident room after discharge included cleaning inside and outside of furniture, and removing any soiled linens or other items. She stated that any personal paperwork would be removed from the room and given to the case manager. She further stated that all trash would be collected and removed from the room. Staff #84 stated that they do not check to see if lights are working, but they clean the call lights and ensure that there is a call light in the room. The housekeeping supervisor stated that she was aware of a complaint that a resident room was not cleaned prior to admission. She also stated that there was miscommunication on who was going to clean the room. She further stated that the resident was admitted to a room that had not been cleaned on October 5, 2022. She also stated that this was brought up in a standup meeting the next morning, that the room had not been properly set up. An interview with the Director of Nursing (DON/staff #300) was conducted on November 9, 2022 at 3:42 PM. The DON stated that the family did place a grievance, and that the resident's room had not been cleaned due to miscommunication. Review of the facility policy titled, Housekeeping Services, revealed it is the facility policy to require effective sanitation. Thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. In resident care areas cleaning of horizontal surfaces will be done daily and more frequently if spillage or visible soiling occurs. Trash will be removed from all areas to prevent spillage and odor.

Based on closed clinical record review, staff interview, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure the MDS (Minimum Data Set) assessment was accurate for one resident (#103). The sample size was 13. The deficient practice could result in an inaccurate assessment and resident not receiving the appropriate care and services needed. Findings include: Resident #103 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The fall care plan dated April 17, 2021 revealed the resident was at risk for falls related to decreased mobility. Interventions included keeping the call light within reach and anticipating and meeting the resident's needs. The IDT-BIMS (interdisciplinary team- Brief Interview for Mental Status) note dated October 11, 2021 revealed a score of 15 indicating the resident was cognitively intact. The quarterly MDS assessment dated [DATE] revealed the resident did not have any falls since admission or prior assessment. The NP (nurse practitioner) note dated November 11, 2021 included the resident had plateaued with progress with therapy services, continued to attend outpatient therapy services 3 times a week and was recently evaluated for the restorative therapy program in the facility. The Fall risk evaluation dated November 26, 2021 included the resident had no history of falls in the past 3 months, and had a score of 7 indicating the resident had medium risk for falls. The fall care plan was revised to state the resident had a fall on November 26, 2021 and had pain. Interventions included the resident being sent out to the hospital for pain. The incident note dated November 26, 2021 included the resident was found on the floor in her room. Per the documentation, the resident reported that she had a nightmare, woke up attempting to run and fell out of bed. It also included that the resident complained of pain to the back of her head, hips and right shoulder and that the resident was sent to the hospital. The fall committee IDT note dated November 29, 2021 included the resident was having a bad dream, found herself on the floor and complained of pain in the shoulder and back. Despite documentation that the resident had a fall, the discharge MDS assessment dated [DATE] did not code the resident had a fall. An interview was conducted on November 11, 2022 at 11:26 a.m., with the MDS Coordinator (staff #42) who stated that when coding for falls in the MDS, she reviews the risk management report, progress notes and therapy notes for the look back period to see and determine the number of fall the resident had from the last ARD (assessment reference date) assessment. She stated that if there was a fall, she would then code appropriately whether or not the resident had injury according to the RAI manual. During the interview, a review of the clinical record was conducted with staff #42 who stated that based on the risk management report, resident #103 had a fall on November, 26, 2021. She stated that the fall should have been captured and coded on the December 28, 2021 discharge MDS assessment. However, staff #42 stated that the fall was not coded. The RAI manual revealed steps for assessment of fall that stated to review all available sources for any fall since the last assessment, no matter whether it occurred while out in the community, in an acute hospital, or in the nursing home, nursing home incidents reports, fall logs and the medical record (physician, nursing, therapy and nursing assistant notes). The RAI instructed to code 1- yes, if the resident had fallen since the last assessment.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure medications were administered as ordered by the physician for two residents (#101 and #199). The sample size was 5. The deficient practice could result in residents not receiving prescribed treatment to meet their assessed needs. Findings include: Resident #101 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . coli (Escherichia coli), Pseudomonas aeruginosa, pancytopenia and [CONDITION(S)]. The initial admission record dated October 24, 2021 included the reasons for the admission were wound care and IV antibiotics. The admission note dated October 24, 2021 included the resident was alert and oriented x 4, able to voice needs and had new IV (intravenous) antibiotics Vanco and [MEDICATION(S)] for left foot surgical wound. The History and Physical note dated October 24, 2021 included an assessment of the left foot gunshot wounds status post [MEDICAL RECORD OR PHYSICIAN ORDER] . The social service summary dated October 25, 2021 included the resident was readmitted at the facility after hospitalization for low WBC. The note also included that the resident's IV antibiotics continued to November 15, 2021. The care plan with no initiation date revealed the resident had infection of the foot surgical wound infection and was on IV antibiotics. Interventions included administering antibiotics as ordered by the physician. A physician order with a start date of October 25, 2021 revealed the following: -[MEDICATION(S)] (antibiotics) 400 milligrams IV every 8 hours for 21 days for left foot infection; and -[MEDICATION(S)] (antibiotics) 1.25 grams IV three times a day for 21 days for left foot infection. These orders were transcribed onto the IV MAR (medication administration record) for November 2021 and revealed the boxes for the following dates not marked as administered: -[MEDICATION(S)]: November 3 (6:00 a.m. dose); November 7 (2:00 p.m. dose) and November 13 (10:00 p.m. dose); and -[MEDICATION(S)]: November 3 (6:00 a.m. dose); November 5, 6, 7 and 12 (2:00 p.m. dose) and November 13 (10:00 p.m. dose) The eMAR (electronic MAR) notes dated November 3 and November 4, 2021 revealed the resident's [MEDICATION(S)] trough was elevated. However, continued review of the clinical record revealed no documentation of a reason why [MEDICATION(S)] was not administered on November 5, 6, 7, 12 and 13; why [MEDICATION(S)] was not administered on November 3, 7 and 13, 2021; and that the physician was notified. In an interview with the assistant director of nursing (ADON/staff #99) conducted on November 10, 2022 at 11:00 a.m., the ADON stated that when she received an order from the physician, she transcribes it in the electronic record and administer the medications as ordered by the physician once it becomes available from the pharmacy. She stated that she will then document in the electronic record whether or not the medication was administered or the resident refused. The ADON also stated that if the resident refused, she will also document the reason and will notify the physician. She stated that once the nurse documents that medications are given, the MAR will show a check mark, the nurse's initials and the time it was given. The ADON stated that there was also a code to use for resident refusal and that is code 1-drug refused; and that whether or not the medication was administered to the resident, the nurse is expected to document in the electronic record. During an interview with the DON (staff #300) conducted on November 10, 2022 at 11:40 a.m., she stated that physician orders for medications are transcribed onto the electronic record by the nurse who received it. The DON also said that all medications are administered as ordered by the physician and documented in the MAR including resident refusals. Regarding resident #101, she stated that one of the reasons [MEDICATION(S)] may have not been administered was the [MEDICATION(S)] trough. The DON did not give any reason why [MEDICATION(S)] was not administered to the resident as ordered, and that she will review the resident's records and will get back for an answer. However, she never did. -Resident #199 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] <110 dated September 15, 2022. Review of the care plan initiated on September 15, 2022 revealed a focus of hypertension related to medications, with interventions to give medications as ordered, and to monitor for side effects. Review of the MAR dated September 2022 revealed evidence that [MEDICATION(S)] 12.5 mg had been administered with a systolic blood pressure less than 110 on four occasions. Further review of the clinical record revealed no evidence that the physician had been notified regarding the administration of [MEDICATION(S)] outside of ordered parameters. An interview was conducted on November 8, 2022 at 2:51 PM with a Licensed Practical Nurse (LPN/staff #30), who stated that the facility policy is to follow physician orders as written, including parameters. She reviewed the September 2022 MAR and stated that according to documentation, [MEDICATION(S)] had been administered outside of ordered parameters on four occasions, and that it did not meet the facility policy. The LPN further stated that the risk could result in hypotensive issues. An interview had been conducted on November 9, 2022 at 3:21 PM with the DON (staff #300) who stated the facility policy is to follow physician orders as written, including parameters. The DON also stated that she would expect the provider to be notified and a nursing note, if a medication is administered outside of parameters. The DON reviewed the September 2022 MAR and stated that [MEDICATION(S)] had been administered outside of physician ordered parameters on four occasions. The DON also stated that there was no evidence that the physician had been notified. She further stated that this did not meet her expectations and the risk could include the risk of [CONDITION(S)]. Review of the facility policy titled, Physician Orders, revealed that it is the policy of this facility to accurately implement orders only upon the written order.

Based on closed clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#104) was provided with showers. The sample size was 3. The deficient practice could result in residents not maintaining personal hygiene. Findings include: Resident #104 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #104's discharge date was December 7, 2022. The initial admission record dated November 7, 2021 revealed the resident was alert and oriented to time, place and person and was able to follow simple commands. The ADL (activities of daily living) care plan dated November 8, 2021 revealed the resident had an ADL self-care performance deficit related to weakness, pain, [CONDITION(S)], cerebral aneurysm and spinal stenosis. Interventions stated the resident required assistance and for staff to give assistance with routine personal hygiene, washing hands, adjusting clothing, cleaning self, transferring on/off the toilet and using the toilet. The shower schedule sheet for the day and evening shift revealed that each resident room had a twice a week schedule for showers. The sheet also included an instruction that shower sheets need to be completed and signed by the nurse. The skin monitoring/skin observation-shower notes dated November 9, 12, 15, and 22 were signed by the CNA (Certified Nursing Assistant) and revealed the resident had dry skin. The boxes for shower, tub-bath, bed bath and refusal of shower/bath were not marked. The notes did not indicate whether or not showers, tub-bath or bed bath was provided and/or the resident refused. The skin monitoring/skin observation-shower note dated November 19, 2022 was signed by the CNA and a licensed nurse and revealed that a shower was provided to the resident. Review of the CNA documentation from November 7 through December 7, 2021 revealed that showers were marked as provided on November 19 and 22; and that the resident refused showers on November 8 and 24, 2021. The rest of the boxes were marked as NA (not applicable) and a code of 8 which indicated the activity did not occur. The clinical record revealed from November 7 through December 7, 2021, the resident received only 2 showers in approximately 29 days of stay at the facility. It also revealed no evidence the resident refused showers other than on November 8 and 24, 2021 as documented. An interview was conducted with a staffing coordinator (staff #37) on November 9, 2022 at 11:20 a.m. Staff #37 stated that since September 2022 the average census was approximately 50-53. She stated the staffing pattern for this census will be two nurses, four CNAs in the am and pm shift plus one RNA whose main task is to provide showers to residents scheduled that day. In an interview with the restorative nurse assistant (RNA/staff #26) conducted on November 9, 2022 at 11:34 a.m., she stated that she had been an RNA since January 2022. The RNA said that shower schedules are written and maintained in the shower binder located at the nurse station. She stated that the schedule is based on resident room number, and residents are scheduled to receive showers twice a week. She stated that if a resident refuses showers, she will ask again, inform the resident that it is their scheduled showers and they may not receive showers the next day, and will also offer a bed bath to the resident. The RNA stated that if the resident continued to refuse she would document it in the shower sheet and she would try to quote what the resident said as to the reason for refusal. She said that at the end of her shift, she will give the completed shower sheets to the wound nurse who will sign off on the sheet. She stated she mainly gives the completed sheet to the wound nurse just in case she had identified skin issues such as a rash, so the wound nurse would assess the identified skin issue and provide treatment if needed. She said if the wound nurse is not available any nurse can sign the shower sheet. The RNA also said that if the resident repeatedly refuses showers, she will report it to the nurse and case manager because it is important the residents receive their showers. She stated if she provides showers, bed bath, tub bath or the resident refused, she will mark the appropriate box on the shower sheet. She stated if she signed the sheet but the boxes for showers, bed bath, tub bath or resident refused are not marked, it just means that she forgot to mark it but that she provided the service, however, the nurse had to sign the sheet. During an interview with the assistant director of nursing (ADON/staff #99) conducted on November 10, 2022 at 11:00 a.m., she stated that after the RNA provides the showers, the shower sheet is submitted to her and if she is not available, the charge nurse can review and sign the shower sheet. She stated that she reviews what the RNA wrote in the shower sheet and if there are skin issues identified like a rash or open area. The ADON stated that when she signs the shower sheet, it means that she reviewed the sheet and the resident was assessed. When asked what it means when the nurse signature section was blank, she stated that a charge nurse can also sign the sheet. An interview was conducted with the director of nursing (DON/staff #300) on November 10, 2022 at 11:40 a.m. The DON stated that showers are provided by the RNAs and the shower schedules are in the binder at the nurse station. She stated when RNAs are not available, the CNAs can also provide the showers. The DON said that when showers are provided, the RNAs will document on the shower sheet including any skin findings that they have observed during the provision of showers. She also stated the RNA should also mark whether showers/tub bath or bed bath was provided or the resident refused. The DON further stated that the nurse signs the shower sheets and the ADON/wound nurse (staff #99) conducts weekly checks of the shower sheets as well. Regarding resident #104, the DON did not comment when asked about the reason why showers were not documented as administered. The facility policy on Services to Carry Out ADL revealed that it is their policy that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with a written plan of care. The policy also included that if a resident is unable to carry out activities of daily living, the necessary services to maintain good nutrition, grooming and personal oral hygiene will be provided by qualified staff. The policy further revealed that bathing will be offered at least twice weekly and as needed per resident request, and ADL care provided will be documented in the medical record accordingly.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that one resident (#249) was consistently provided meals to maintain adequate nutrition. The sample size was 5. The deficient practice could result in nutritional needs of residents not being met. Findings include: Resident #249 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Initial Admission Record assessment dated [DATE] revealed that the resident was alert and oriented to time, place, person, and able to follow simple commands. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on January 22, 2022 revealed the resident had a potential nutritional problem of increased protein needs regarding the chronic wound of foot. The goal was that the resident would maintain adequate nutritional status by consuming 75% of meals. Interventions stated to provide, serve diet as ordered, and monitor intake and record meals. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Mini Nutritional Assessment (MNA) signed on January 27, 2022 revealed a score of 8 which indicated that the resident was at risk for malnutrition. Review of a daily skilled note dated January 27, 2022 indicated that there were no nutritional deficits observed. Review of the January 2022 task charting log titled Amount Eaten revealed no information regarding food intake for resident #249 on the following dates and meal times: 23 - dinner 24 - lunch 30 - dinner Further review of the February 2022 Amount Eaten documentation log revealed no evidence that the resident was provided food on the following dates and meal times: 1 - breakfast and lunch 2 - breakfast and lunch 5 - dinner 6 - breakfast, lunch, and dinner 8 - breakfast and lunch During an interview with the Registered Dietitian (RD/staff #303) conducted on November 8, 2022 at 11:45 a.m., she stated that residents can receive double portions as well as seconds upon request. During an interview with the Case Manager Director/Social Services (staff #27) conducted on November 9, 2022 at approximately 2:16 p.m. Staff #27 stated that one of the most common grievances was food. She stated that it was also normally the easiest to resolve since it can be fixed the same day. An interview was conducted with the Dietary Supervisor (staff #102) on November 9, 2022 at 2:47 p.m. Staff #102 stated that Certified Nursing Assistants (CNAs) track and record the amount of food that each resident eats in the resident's electronic record. She then goes into the system to see what the CNA charted. Staff #102 stated that when she is in the kitchen and/or dining room she can potentially see how much the residents ate. She stated that each resident can select from the menu and that each resident has a tray card. She stated each tray prepared has a tray card that the dietary aids use to guide them on what a resident would be served. Staff #102 stated the CNA documents and let her know if a resident refused a meal. She stated if a resident refuses a couple of times then she would speak with the dietitian to see if something can be done to increase the resident's food intake. She stated the refusal is documented in the resident's electronic record. Staff #102 stated that if a resident has an appointment, they are given a sack meal that they can take with them. She stated if the sack meal is refused, then a meal will be made ready for when the resident returns from the appointment. Resident #249's Amount Eaten log was reviewed with staff #102. Staff #102 stated that she is not sure why there are blanks on the log but that she thinks it might mean that the resident did not receive or eat the food. Staff #102 stated that her expectation is that the CNA gives her the tray ticket if a resident does not eat. An interview was conducted with a Certified Nursing Assistant (CNA/staff #22) on November 9, 2022 at 3:29 p.m. Staff #22 stated that part of a CNA's duties regarding monitoring resident food intake is to chart amount eaten, queuing residents to eat and drink, and to ensure that a resident is eating. Staff #22 stated that if a resident does not eat much, they offer a snack. The CNA stated they are to document a resident's amount eaten in their electronic record. The CNA stated that if a resident refuses to eat, they encourage them to eat, document, and notify the nurse. Staff #22 stated that CNAs cannot force residents to eat but they can encourage and try again about 3 times then after that inform the nurse. Staff #22 stated they offer resident snacks like apple sauce. Resident #249's Amount Eaten log was reviewed with staff #22. Staff #22 stated that the log is not supposed to be blank and that it means nobody charted. Staff #22 stated that if it is not written then it never happened. She said that yes, it might mean that the resident did not get a meal. She stated that CNAs are trained to document. She also stated that once a year they go over documentation and that there is always someone you can ask if you do not know how to document. An interview was conducted on November 10, 2022 at 8:25 a.m. with the Director of Nursing (DON/staff #300). The DON stated that meal intake should be documented. Staff #300 stated that CNAs are trained on how to document via online training and by the Minimum Data Set (MDS) Coordinator. She stated the expectation is that meal intake is documented and that the log has no blanks. Furthermore, she stated that a blank means incomplete documentation. The DON stated refusal should also be documented in the resident's record and that it is reported to the nurse. She stated the nurse would then do an assessment and document on the progress note. The facility policy titled ADL, Services to carry out reviewed July 2022 stated that residents are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's Documentation and Charting policy as outlined in the Nursing Meeting agenda dated September 14, 2022, indicated that it is the facility's policy and procedure that a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care is documented and charted. The policy also stated that if it is not documented it did not get done.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#156) was free from an unnecessary drug, by failing to ensure adequate behavior monitoring was done for medications that were psychotropics. The sample size was 5. The deficient practice could result in residents being at risk for behaviors not being monitored, and not monitoring medication effectiveness. Findings include: Resident #156 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders revealed the following orders: -Dated November 2, 2022 for [MEDICATION(S)] 100 mg (milligram) 1 tablet by mouth at bedtime for agitation as evidenced by mood swings/restlessness. -Dated November 4, 2022 for [MEDICATION(S)] 100 mg 1 tablet by mouth at bedtime for [CONDITION(S)] related to [CONDITION(S)] as evidenced by mood swings. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, further review of the clinical record revealed no evidence that the resident was monitored for behaviors or side effects related to [CONDITION(S)] medications. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. The MDS assessment also revealed mild depression. An interview was conducted on November 10, 2022 at 10:35 AM with a Licensed Practical Nurse (LPN/staff #71), who stated that every time a resident is placed on a [CONDITION(S)] medication there is also an order to monitor behaviors and side effects. She further stated that it is the facility policy to obtain a physician's order to monitor [CONDITION(S)] side effects and behaviors, and document them on the MAR. The LPN reviewed the clinical record and stated the resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that this does not meet the facility policy and could result in behaviors and side effects not being monitored/identified. An interview was conducted on November 10, 2022 at 10:48 AM with the Director of Nursing (DON/staff #300), who stated that the facility policy is to obtain a physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She reviewed the medical record and stated that the resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated that there was no order for side effect and behavior monitoring, or evidence on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy titled, Psychoactive Medication, revealed that it is the policy of the facility to maintain every resident's rights to be free from the use of psychoactive medication. Each resident requiring psychoactive medications will have ongoing assessments and care plan reviews. No psychoactive medication will be utilized without a specific physician's order, and will include the target behavior. Monitor and track progress towards the therapeutic goal and detect the emergence or presence of any clinically significant adverse consequences. Unanticipated decline or newly emerging or worsening symptoms are recognized and evaluated. Review of the facility policy titled, Documentation and Charting, revealed it is the facility policy to provide: -a complete account of the resident's care, response to the care, as well as the progress of the resident's care, signs/symptoms. -guidance to the physician in prescribing appropriate medications and treatments. -nursing service personnel with a record of the physical and mental status of the resident.

Based on closed record review, staff interviews and review of facility documentation, the facility failed to ensure that assistance with personal hygiene was provided to one resident (#33). The deficient practice could result in resident hygiene needs not being met. Findings include: Resident #33 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADL (activities of daily living) care plan dated June 24, 2022 included the resident had ADL self-care performance deficit related to fracture of right femur, fall history, diabetes mellitus and hypertension. Interventions included to encourage to participate to the fullest extent possible with each interaction and to discuss feelings about self-care deficit. The daily skilled note dated June 25, 2022 included the resident was alert and oriented x 4, required assistance of one person with ADLs/mobility, limited assistance with one person with bed mobility, transfer and toilet use. Review of the CNA (certified nursing assistant) notes for July and August 2022 revealed there were boxes on personal hygiene that were blank for multiple dates. The clinical record revealed no documentation why the resident did not receive personal hygiene on the dates that were left blank. There was also no documentation that the resident refused personal hygiene. During an interview conducted on August 10, 2022 at 1:56 p.m. with a CNA (staff #21), she stated showers and baths are also documented on a shower sheet in a book; and that, the nurse has to sign and date these sheets. The CNA stated that personal hygiene includes all of the ADL care; and that, all cares delivered are documented in the electronic record once per shift before she goes home at the end of her shift. In another interview conducted on August 10, 2022 at 2:05 p.m. with another CNA (staff #96), she stated that all personal hygiene care as well as showers/baths are documented in the electronic record; and that, all of the charting must be done before she can go home after her shift. She stated staff also completes shower sheets for both showers and bath, that the nurse had to sign. Further, she said resident's ADL activities are documented under the personal hygiene task in the electronic record. An interview was conducted on August 10, 2022 with the Director of Nursing (staff #57) who stated she expected that her staff should chart as appropriate and that charting is completed by the end of their shift. During the interview, a review of the clinical record was conducted with the DON who stated she could not explain the missing documentation for the CNAs and could not say whether or not personal hygiene was provided to the resident on the boxes that were left blank.

Based on an observation, staff interviews, and facility policies and procedures, the facility failed to ensure that one resident (#15) was clinically appropriate and safe for self-administration of medications. The deficient practice could result in the resident not able to take medications as prescribed. Findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan on cognition (initiation date of September 14, 2020) included the resident was at risk for impaired cognitive function/dementia or impaired thought process related to dementia. Intervention included giving step by step instructions one at a time as needed to support cognitive function. The care plan revised on March 17, 2021 included the resident had swallowing problem related to coughing or choking during meals due to dysphagia. It also included that the resident was on mechanically altered diet. Interventions included checking of the mouth after meal for pocketed food and debris and instructing the resident to eat in an upright position, to eat slowly, and to chew each bite thoroughly. The quarterly Minimum Data Set (MDS) dated [DATE] did not include a Brief Mental Status Interview (BIMS) score. However, the assessment coded the resident had signs and symptoms of a possible swallowing disorder. Symptoms include coughing and choking during meals or when swallowing medications. The care plan revised on May 12, 2021 included the resident was at risk for altered respiratory status/difficulty breathing related to residents preferred to eat food that was not on therapeutic diet texture. Intervention included educating the resident the importance of complying with diet order for safety to prevent aspiration. The annual Minimum Data Set (MDS) dated [DATE] did not include a BIMS score and coded the resident did not have signs or symptoms of a swallowing disorder. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . However, the nutritional care plan with revision date of June 10, 2021 included the resident had potential nutritional problem related to dementia and dysphagia. Swallowing difficulties related to altered diet texture as evidenced by diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for August 2021 revealed medications were administered to the resident as ordered. Further review of the clinical record revealed no evidence the resident was assessed for and was clinically appropriate for self-administration of medications. During an observation conducted on August 16, 2021 at 11:25 a.m., there was a small plastic medication cup containing a small oval white pill, a small oval orange pill and a plastic cup of water on the resident (#15's) bedside tray table in his room. Resident #15 stated the medication must be his but he did not know why he was taking the medication or when it was given to him. During this observation and interview, the resident's roommate joined the conversation and stated that the pills was brought to resident #15 last night by the night shift nurse who told the resident she would be back to make sure the resident took them. However, the roommate said that the night shift nurse never came back. An interview was conducted on August 16, 2021 at 11:27 a.m. with a Licensed Practical Nurse (LPN/staff #16) who saw the small plastic medication cup with small oval white and orange pills and a plastic cup of water on the resident's bedside tray table. Staff #16 stated she gave the resident his medication this morning in the dining room and had not been in his room until now. Staff #16 then took the pills to the medication cart, reviewed the resident's medication, and identified the pills as follows: -[MEDICATION(S)] Tablet 10 MG ([MEDICATION(S)]) give 1 tablet by mouth at bedtime for [CONDITION(S)]; and, -[MEDICATION(S)] HCl Tablet 5 MG give 1 tablet by mouth two times a day for dementia. Staff #16 also reviewed the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #16 also said she will notify the physician that the resident did not receive his medication per their protocol; and, follow the instructions received. Regarding resident #15, staff #16 stated the resident was not allowed to take medication by himself. Further, staff #16 stated that the previous night shift nurse was supposed to remain with the resident to ensure the medication is taken because there was a risk of the resident taking the medication at the wrong time or another resident could have taken the medication. An interview was conducted on August 18, 2021 at 8:32 a.m. with the Director of Nursing (DON/staff #18) who stated that the nurse administering the resident's medication should be with the resident while the resident is taking medications to ensure the resident takes all the medications. The DON also said that it is also for the following safety reasons: To ensure that -The resident does not take medications later or outside of the scheduled time; -The resident does not aspirate; and, - Someone else other than the resident does not take the medications. The DON also stated an evaluation for self-administration was not done for resident #15 who was is not able to self-administer medications. The facility policy, Medication Administration, reviewed May 2021 stated that it is their policy that medications shall be administered as prescribed by the attending physician. Only licensed medical and nursing personnel or other lawfully authorized members may prepare, administer, and record the administration of medications. The facility's policy, Self-Administration of Medications reviewed May 2021 included that it is their policy to respect the wishes of alert, competent residents to self-administer prescribed medications as allowable under State regulations. The purpose of the policy was to determine the ability of alert residents to participate in self-administration of medications and to maintain the safety and accuracy of medication administration. The policy also stated that if a resident desire to participate in self-administration, the interdisciplinary team will assess and periodically re-evaluate the resident based on change in the resident's status. The resident's cognitive, communication, visual and physical, ability to carry out will be evaluated. If the resident is a candidate for self-administration of medications, this will be indicated in the chart. Nursing will be responsible for monitoring self-administered doses in the resident's medication administration record.

Based on record review, interviews, and policy review the facility failed to ensure the necessary care and services by failing to include diet orders on admission for one resident (#105). The deficient practice could result in the resident not receiving the correct diet consistent with their status upon admission. Findings include: Resident #105 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital visit summary with a printed date of August 8, 2021 revealed the resident was a vegetarian. An initial admission note dated August 8, 2021 revealed the resident was alert and oriented to time, place and person and had no swallowing difficulty. The admission nursing note dated August 8, 2021 included that the resident reported to the nurse that he was a vegetarian and wanted the kitchen to be aware. A review of the resident's care plan with initiation date of August 9, 2021 revealed the resident had a potential nutritional problem of suboptimal energy intake related to loss of appetite and difficulty eating with pain or neck collar. The goal was to maintain adequate nutritional status by consuming greater than 75% of meals and 100% of supplements. Interventions included to provide and serve diet as ordered; and to honor resident rights to make personal dietary choices and provide dietary education as needed. The physician admission progress note dated August 9, 2021 revealed the resident was alert and oriented x3 and had no new acute neurological deficits noted. The clinical record revealed documentations that the resident was independent with eating and required no set-up or physical help from staff. The mini nutritional assessment dated [DATE] included the resident had moderate decrease in food intake and had a score of 10 indicating that resident was at risk for malnutrition. Review of the clinical record revealed there was no evidence of a diet order from August 8 through 10, 2021. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with resident #105 conducted on August 16, 2021 at 11:05 a.m., he stated that he was a vegetarian and told staff about it when he was admitted at the facility. He said that there was an instance when he was given soup with meat in it and he ate a little before he realized that it contained meat. The resident also stated that there was also a time when he was served with meat on a sandwich and he was offered an alternate meal. However, the resident stated that at that point, he did not want to eat after that. The resident further stated that he stopped going to the dining room since that happened. In an interview with a Licensed Practical Nurse (LPN/staff #36) conducted on August 18, 2021 at 10:27 a.m., the LPN said the floor nurse admits the resident when they arrive at the facility; and, the admissions team uploads the hospital records including the diet orders for the resident into the electronic medical record. The LPN said the floor nurse enters the orders and reviews them with the physician who will be caring for the resident during the stay. He also said that diet orders are sometimes on the discharge paperwork from the hospital; or, the nurse can ask while receiving report from the hospital; or, call the hospital for diet orders; or can even ask the resident upon admission. The LPN stated the diet order is entered with the medication orders, right before the resident gets to the facility. He stated the diet orders then go to the kitchen through the electronic medical record and the kitchen manager can follow up if needed. An interview with the dietary manager (staff #64) was conducted on August 18, 2021 at 10:37 a.m. The dietary manager said the nursing staff usually puts in diet orders. However, if she knows the diet order for a resident, she can also enter it in the electronic record. The dietary manager said when a patient has no diet order, she will look and double check through the progress notes for any diet order. She stated she will then go to the nurse who will enter or tell her the diet order. The dietary manager said she has access to the electronic medical record and they use a program menu to you plus that allows diet orders to cross over to the kitchen's system almost instantly. During an interview with the Director of Nursing (DON/staff #18) conducted on August 18, 2021 at 12:05 p.m., the DON said that she, the Assistant Director of Nursing (ADON) or charge/floor nurse can enter orders in the electronic record. The DON said when the admissions team informs them of a new resident admission, a packet of paper records from the hospital is given to the nurse who will review the records and orders with the physician. The nurse would then enter the orders in the electronic record and admit the resident when they arrive the facility. The DON stated that the facility holds a daily clinical meeting every morning and they review the admissions from the previous day. The DON stated that on the weekends the nursing manager will review the admissions. The DON said diet order for a resident should be in the hospital visit summary, discharge summary, or it can be verified with the hospital nurse giving report to the facility. The DON further stated diet orders should be entered in the electronic record upon admission because the program communicates with the kitchen and prints off the resident's meal ticket. When a resident does not have a diet order, the DON said the nurse would be told that the resident did not get a meal. The nurse can then write the order, communicate it to the kitchen, and get the resident a meal. The DON further stated that diet order should be entered as an actual order and not just in the admission note. The DON said dietary staff would not receive the information without an actual order. The DON further stated that the hospital visit summary is available for review to every nurse including the admission nurse. Regarding resident #105, the DON said the resident should not be waiting 3 days for a diet order and the nurse could have called the physician or the discharging hospital to get an order if it was not listed on the patient's discharge paperwork. The DON also stated that the hospital visit summary could have been used to enter the diet order in the electronic record when the resident was admitted on [DATE]. Review of the facility's policy titled, Transmission of Diet Orders, revealed that the food and nutrition service department will receive written notification of a patient's diet order as soon as possible after admission, readmission, or following a diet order change. Nursing staff will send the diet order to the food and nutrition services department as soon as possible after admission or diet change using written communication or electronic communication if applicable. When the food and nutrition services department has been made aware of a new admission but has not been notified regarding the diet order, a regular diet will be served. Staff should make every attempt to the proper diet order first. Meal identification cards/tickets will be adjusted to reflect changes in diet and food preferences as needed. The facility's policy on Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure Level II PASRR (Preadmission Screening and Resident Review) was completed for one resident (#2). The deficient practice could result in residents with mental health disorder not evaluated and not receiving the care and service appropriate to their needs. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the PASRR Level I signed by resident #2 and dated April 23, 2021 revealed that the resident was required to undergo a Level II evaluation as a condition of admission to, or continued residence in the facility. The documentation also included the resident did not meet criteria for 30-day convalescent care and respite admission for up to 30 calendar days. Review of the clinical record revealed the resident was receiving [CONDITION(S)] medications for anxiety and mood stability. The Admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview Mental Status (BIMS) score of 10 indicating the resident had a moderate cognitive impairment. It also revealed the resident had not been evaluated by Level II PASRR and determined to have serious mental illness. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment revealed a Patient Health Questionnaire - 9 (PHQ-9) of 9 indicating the resident had mild depression. The MDS also coded that the resident received anti-anxiety and antidepressant during the last 7 days of the assessment. A review of the care plan dated May 6, 2021 included antipsychotic medication use related to [CONDITION(S)] Disorder as evidenced by mood swings and anti-anxiety medication use related to anxiety disorder as evidenced by restlessness. Interventions included medications as ordered. The care did not include PASRR Level II evaluation. Review of the clinical record revealed no evidence that the resident was referred to PASRR Level II evaluation. The clinical record also revealed no evidence of any reason why the resident was not referred to PASRR Level II. On August 17, 2021 at 2:16 p.m., an interview was conducted with the Case Manager (#47), who stated that it was her responsibility to ensure a PASRR Level I is completed for each resident. If the hospital completes the PASRR Level I, she reviews it for accuracy and makes corrections if there are errors. Staff #47 also said that if the resident was admitted to the facility without a PASRR Level I, she will complete one. Staff #47 explained that PASRR Level I is done to determine if the facility is a suitable placement to provide care and to see if a PASRR Level II is needed. During the interview, staff #47 reviewed the PASRR Level I dated April 23, 2021 and stated that the form was incomplete and was missing page 2 that included the resident's mental diagnoses. Staff #47 also reviewed the resident's clinical record and stated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, staff #47 stated that a PASRR Level II should have been completed to determine if the resident #2 needed additional behavioral health services. However, staff #47 said that PASRR Level II was not done and the resident was at risk of not receiving available and needed services. Staff #47 stated that based on the clinical record documentation, she did not refer resident #2 to the State for a Level II evaluation and did not know why. Staff #47 further stated that it was her mistake. The facility policy on PASRR stated that it is their policy to ensure each resident is properly screened using the PASRR specified by the State. Mental disorder is defined in paragraph (k)(3)(2) of the SOM, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by an individual or entity other than the State mental health authority prior to admission: -That because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility and; -If the individual requires such level of services, whether the individual requires specialized services. Further, the policy included that the facility will refer to the State's AHCCCS Pre-admission Screening and Resident Review (PASRR) policy.

Based on observations, resident and staff interviews and review of the clinical record, the facility failed to ensure there was a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in negative resident outcomes. Findings include: Resident #105 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The initial assessment dated [DATE] revealed the resident was using oxygen via nasal cannula. The admission note dated August 8, 2021 included the resident was alert and oriented x4 and was on oxygen 1 liter The admission care plan dated August 9, 2021 revealed the resident had a respiratory infection and was on oxygen therapy for a pulmonary nodule. Intervention included 2 liters per minute (LPM) of humidified oxygen via nasal cannula continuously. The physician new admission progress note dated August 9, 2021 revealed the resident was alert and oriented x3. Impressions included new cough which was potentially a developing [CONDITION(S)] (CHF) or aspiration pneumonia. Plan included to continue supplemental oxygen. The nurse practitioner (NP) note dated August 12, 2021 revealed the resident was alert and oriented x 3, sitting up in bed and continued on 2 LPM of oxygen. Review of the daily skilled notes dated August 12 through 15, 2021 revealed the resident was alert and oriented x 3 and had oxygen via nasal cannula. A review of the resident's vitals summary from August 8 through 15, 2021 revealed that oxygen saturation levels were monitored twice daily while using a nasal cannula or while on room air. Despite documentation the resident had oxygen via nasal cannula, the clinical record revealed no evidence of any physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was also no evidence that oxygen care was provided to the resident from August 8 through 16, 2021. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Continuous oxygen at 2 LPM via nasal cannula, may be titrated from 1- 5 LPM to keep oxygen saturation above 90%; -Change oxygen tubing every week and if soiled every night shift and as needed; -Pulse oximetry every shift and as needed to monitor oxygen saturation During an observation conducted on August 16, 2021 at 10:57 a.m., resident #105 had the nasal cannula on and was receiving oxygen at a rate of 2 LPM while in his bed in his room. The resident stated he had been on oxygen therapy since he was admitted at the facility. In another observation conducted on August 17, 2021 at 3:50 p.m. the resident was in his room and had the oxygen on at 2 LPM via nasal cannula. There was a sign posted on the resident's room door that read oxygen in use. There was also an oxygen concentrator placed next to the resident's bed; and the resident stated he had been on oxygen since before he was admitted to this facility. An interview was conducted with Licensed Practical Nurse (LPN/staff #36) on August 18, 2021 at 9:53 a.m. The LPN stated when a new resident is admitted at the facility, the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #36 said all orders are reviewed by the floor nurse and the physician on duty who then activates these orders as needed. The LPN stated he had not noticed resident #105 wearing a nasal cannula but had noticed that an oxygen concentrator was in the resident's room. Staff #36 stated staff also checks the oxygen saturation of the resident. An interview was conducted on August 18, 2021 at 11:07 a.m. with certified nursing assistant (CNA/staff #14) who stated she would know that a resident is on oxygen because she sees the oxygen concentrator or cannula in the resident room. Regarding resident #105, the CNA said she had cared for the resident since his admission at the facility; and, the resident always wears his nasal cannula and she had never seen him without it. On August 18, 2021 at 2:05 p.m., an interview was conducted with the Director of Nursing (DON/staff #18) who stated that when a resident is admitted , the process includes the admission coordinator giving the admission packet to the floor nurse who enters the orders in the electronic record and will also review the orders with the physician. The DON said that once the orders are reviewed, they are initiated and printed to be sent to the pharmacy. The DON said that oxygen orders should be in the resident record and equipment should be in room when resident arrives. The DON also said that her expectation was for the orders including oxygen use to be accessible upon the resident's arrival; and, the nurse on the unit is expected to review all the orders and begin the orders as needed. The DON further stated that if an order such as oxygen use was not entered in the resident record it is a problem because the facility was not following what the doctor ordered; and hence, could a problem for the resident. An interview was conducted with another LPN (staff #28) on August 19, 2021 at 11:17 a.m. Staff #28 stated that when a resident was admitted to the facility, the floor nurse receives verbal report from the hospital which included the resident diagnoses, orders and history. Staff #28 said that when the resident arrived, the nurse was expected to enter the orders in the record, call and verify the orders with the physician. She stated the physician had access to the electronic health record so the physician could see the orders and could make changes if needed. Staff #28 said that once the physician cleared the orders they can be activated. Regarding resident #105, the LPN stated that she had cared for this resident several times since his admission; and that the resident had always had his oxygen nasal cannula in place. Staff #28 said that she had never had an issue with him being non-compliant with the use of his nasal cannula. She further said that if the resident was on oxygen, it would show up on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that the CNAs checks and documents the resident's oxygen saturation in the clinical record as well. Staff #28 further stated that a resident should always have an order before oxygen administration. The facility policy Medication Administration revised May 2021 revealed that medications shall be administered as prescribed by the attending physician. It further stated that medications must be administered in accordance with the written orders of the attending physician. The facility policy Physicians Orders dated May 2021 revealed that no drugs or biologicals shall be administered except upon the order of a person lawfully authorized to prescribe for and treat human illness. It further stated that all drug and biological orders shall be written, dated and signed by the person lawfully authorized to give such an order. The facility policy Oxygen Administration reviewed on July 2021 revealed that oxygen therapy is administered by a licensed nurse as ordered by the physician or as a nursing measure and as an emergency measure until the order can be obtained.

Based on clinical record reviews, observations, staff interviews and policy and procedures, the facility failed to ensure the necessary care and treatments were provided for two residents (#50 and #27), with pressure ulcers. Findings include: -Resident #50 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on February 7, 2017. A facility form titled nursing bath check dated January 11, 2017 included that no skin issues were present. Regarding the coccyx: A nursing note dated January 18, 2017 included the resident had a skin abrasion on the coccyx and that an order for [REDACTED]. A nurse practitioner (NP) order dated January 18, 2017 included to cleanse the open area on the coccyx with normal saline, pat dry and apply the Duoderm every three days and PRN (as needed). A Braden risk assessment dated [DATE] identified that the resident was at mild risk for the development of pressure ulcers. According to a nursing skin bath check form dated January 19, 2017, the resident had a pressure ulcer on the coccyx. This form included a section to identify the site, type and stage of the pressure ulcer, the measurements and an area to write a narrative nursing note regarding the assessment. However, the documentation only included that the coccyx continued with redness and that there was an opened area, which was covered with Duoderm. A quarterly MDS (Minimum Data Set) assessment dated [DATE], assessed the resident to have moderate cognitive impairment, was non-ambulatory, and required extensive assistance with bed mobility and personal hygiene. The MDS also included that a stage 2 pressure ulcer was present. A care plan identified that the resident was at risk for skin breakdown related to fragile skin, incontinent of bowel, and due to requiring assistance with transfers. The goal was that the resident would not show any complications with skin integrity. Interventions included the following: inspect skin daily with cares and for nursing assistant to report any concerns to the nurse, moisturize dry skin as needed, position body with pillow/support devices and to protect bony prominences. Further review of the clinical record revealed there was no order for the Duoderm to the coccyx. There was also no documentation that the coccyx wound had been thoroughly assessed which included measurements, a description of the wound bed and surrounding tissue, if any drainage was present, or any staging of the pressure ulcer, from January 18-31. Review of the January 2017 Treatment Administration Record (TAR) revealed there was no documentation that Duoderm was being applied to the coccyx. Review of a nursing skin bath check form dated February 2, 2017 revealed a pressure ulcer was present on the resident's coccyx. Again, the documentation did not include the site, stage, measurements or a description of the wound bed. Five days later, on February 7, 2017, a NP progress note included that an unstageable pressure ulcer was present on the coccyx and that eschar covered the wound bed. A nursing assessment was completed on February 7, 2017 and included the following; -Unstageable pressure ulcer which measured 10.5 by 5 cm. -Eschar and slough obscured the wound bed (no percent of each was documented). -The edges were slightly macerated and the skin was beginning to lift in several areas. -Strong odor present. -Moderate amount of serosanguineous drainage was present. -The site was painful. Review of the pressure ulcer treatment orders for the coccyx dated February 7, 2017 included the following: -Cleanse with normal saline. -Pat dry. -Apply Santyl to the wound bed. -Cover with barrier island dressing. -Administer the treatment every three days and PRN. -Low air loss mattress. -Turn and reposition every three hours. Per the clinical record documentation, the resident was discharged to the hospital on February 7, 2017. Regarding the right gluteal fold: A nursing note dated January 13, 2017, included the resident had a skin abrasion on the right gluteal fold and that Duoderm was applied. However, review of the clinical record revealed there was no physician's order for Duoderm for the right gluteal fold. In addition, the January 2017 TAR did not include that Duoderm was being applied to the right gluteal fold. There was no further clinical record documentation of a thorough assessment of the right gluteal fold from January 13 through February 6. There was also no documentation that the physician/NP was notified of the wound during this time frame. A NP note dated February 7, 2017, now included the resident had a right gluteal fold pressure ulcer, which had eschar covering the wound bed. A nursing assessment dated [DATE] described the right gluteal fold pressure ulcer as follows: -Unstageable pressure ulcer which measured 4.5 by 5 cm (centimeters). -The site was covered in approximately 80% eschar and 20% slough. -The edges were red and macerated. -A small amount of serosanguineous drainage was present. -A slight foul odor was present. -The site was painful. Review of the right gluteal fold pressure ulcer treatment orders dated February 7, 2017 included the following: -Cleanse with normal saline. -Pat dry. -Apply Santyl to the wound bed. -Cover with barrier island dressing. -Administer the treatment every three days and PRN. -Low air loss mattress. -Turn and reposition every three hours. Regarding the left buttocks: Review of the clinical record revealed no documentation that the resident had a pressure ulcer to the left buttocks in January 2017. Review of the February 2, 2017 nursing skin bath check form revealed the resident now had a pressure ulcer to the left buttocks. However, the documentation did not include a thorough assessment of the pressure ulcer, which included measurements, a description of the wound bed and surrounding tissue, if any drainage was present and the stage of the pressure ulcer. There was no further clinical record documentation regarding the left buttocks pressure ulcer from February 2 through 6. There was also no documentation that the physician/NP had been notified during this time frame and there were no treatment orders obtained. Further review of the resident's care plans including one for at risk for skin integrity revealed that the care plans were not revised to reflect the development of multiple pressure ulcers and there were no additional interventions which were implemented to prevent further skin breakdown. An interview was conducted on April 18, 2017 at 11:05 a.m. with the Director of Nursing (staff #42). She stated licensed staff who had completed the nursing bath check forms, should have provided a complete and thorough assessment of the pressure ulcer. She stated that she was unable to provide any documentation that the pressure ulcer on the resident's coccyx and had been thoroughly assessed. In regards to the February 2, 2017 nursing bath check form which identified that another pressure ulcer was present on the resident's left buttocks, staff #42 stated that she was unable to locate any documentation that the pressure ulcer had been assessed. Staff #42 further stated that complete and thorough pressure ulcer assessments should have been provided which included the stage, measurements and a description of the pressure ulcers. An interview was conducted on April 18, 2017 at 10:00 a.m., with the resident's physician (staff #96). She stated that she was able to recall this resident, however, the NP primarily cared for the resident and that she would see the resident every few months. Staff #96 stated that she became aware of the pressure ulcer issues when the NP reported to her that two unstageable pressure ulcers were discovered on February 7. An interview was conducted on April 18, 2017 at 2:20 p.m., with the Assistant Director of Nursing (wound nurse/registered nurse/staff #35). She stated that she was not aware of the January 19 or February 2, assessments which had identified that pressure ulcers were present. She stated the licensed staff should have notified her of the change in the resident's skin and should have notified the NP/physician and obtained treatment orders. Staff #35 stated that she was first made aware of the pressure ulcers on February 7. On April 19, 2017 at 9:00 a.m. a follow up interview was conducted with the staff #42. She stated that the facility did not have standing treatment orders, and that pressure ulcer treatment orders should have been obtained from the NP or physician and then documented on the TARs. On April 19, 2017 at 2:20 p.m., an interview was conducted with the NP (staff #97). Staff #97 stated that she had been called regarding a change in the resident's condition on February 6, and ordered multiple laboratory test and diagnostic studies to be done. She stated she then saw the resident on February 7, 2017, and observed two unstageable pressure ulcers on the resident's coccyx and buttocks. She stated that she had not previously been notified of the two unstageable pressure ulcers. -Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. Regarding the coccyx pressure ulcer: Review of the nursing day 1 admission assessment dated [DATE] revealed the resident had one stage II sacral/coccyx pressure ulcer, which measured 1 x 1 x 0 cm and another stage II sacral/coccyx pressure ulcer, which measured 3 x 3 x 0 cm. There was no description of the wound beds. Review of the nursing day 2 post admission assessment dated [DATE] revealed the two coccyx pressure ulcers had connected together. Review of the nurses weekly wound note dated March 16, 2017 revealed the coccyx stage II pressure ulcer was present on admission, and measured 3 x 3 x 0 cm. The wound was described as having a a pink wound bed with 100% [MEDICATION NAME] tissue, no odor, no tunneling or undermining was present, and had dry/intact wound edges. The note included the wound was stable and covered with an allevyn dressing. According to a skin care plan dated March 16, 2017, the resident was at increased risk for skin breakdown related to a loss of mobility, nutritional compromise and incontinence. The care plan included that the resident was admitted with a stage II pressure ulcer to the coccyx. Interventions were as follows: inspect skin daily with cares and nursing assistant to report any problems to the nurse; air mattress; position the resident's body with pillows/support devices; protect bony prominences and treatments as ordered. Despite documentation of the resident having a stage II pressure ulcer to the coccyx, there were no physician ordered treatment for [REDACTED]. Wound treatment orders were obtained two days after admission on March 17, 2017. A physician's order included to cleanse the coccyx wound with normal saline, pat dry, apply skin prep around the wound edges, apply hydrogel to the wound bed, cover with a barrier island dressing every Monday, Wednesday and Friday and as needed for soilage/dislodgement. Review of the Braden Risk assessment dated [DATE] revealed the resident was at moderate risk for developing pressure sores. This assessment included the resident had very limited sensory perception, was always incontinent, had very limited mobility and had a potential problem with friction and shear. Also the following risk factors were listed: head of bed elevated most of the day, required assistance with ADL's and had fragile skin. Review of the admission MDS assessment dated [DATE] revealed the resident was assessed to have severe cognitive impairment and required extensive assistance of two persons with bed mobility and hygiene. The MDS also included the resident was at risk for pressure ulcer development and had two stage 2 pressure ulcers upon admission. The coccyx pressure ulcer was assessed eight days after the last assessment. According to the nurses weekly wound document dated March 24, 2017, the stage II coccyx pressure ulcer measured 3 x 2 x 0 cm, with no tunneling or undermining, had a scant amount of serous drainage, no odor, and the surrounding tissue had normal firmness. The wound bed was described as follows: loose dark purple skin obscuring parts of the wound bed, edges are purple, rolled and macerated from moisture exposure, wound bed also has dark, pink [MEDICATION NAME] tissue (30% [MEDICATION NAME] tissue and 70% loose purple skin). The wound was documented as being stable. Review of the nurses weekly wound document dated March 30, 2017 revealed the stage II coccyx pressure ulcer measured 3 x 3 x 0 cm with a 100 % [MEDICATION NAME] tissue, wound edges were intact but exposed to moisture from stool, the wound edges were no longer rolled, and the dark purple skin was receding from the wound bed. The wound bed was described as being completely smooth, with no tunneling and no undermining and the wound was stable. A physician's order dated April 5, 2017 included to discontinue the previous treatment and to cleanse the coccyx wound with normal saline, pat dry, apply a nickel-thick layer of Santyl to the wound bed, apply skin prep around the wound perimeter, and cover with a barrier island dressing twice a day and as needed, and to initial and date the dressing. Review of the nurses weekly wound document dated April 6, 2017 revealed the coccyx pressure ulcer measured 2.4 x 2 x 0 cm and the wound bed had 100% slough, due to constant exposure to moisture, the edges were flat with dark discoloration, and no tunneling or undermining was present. The pressure ulcer was identified as a stage II, despite having 100% slough covering the wound bed. The note further included the wound had declined and the physician was notified on April 5. Review of the April 2017 TAR revealed that the Santyl treatment to the coccyx was not performed as ordered on April 7 and 8, during the 6 a.m. - 2 p.m. shift, and was not performed on April 10, 11, and 12, during the 2 p.m. - 10 p.m. shift. Review of the nurses weekly wound document dated April 12, 2017 revealed the coccyx wound was unstageable with 100% slough and measured 3 x 2 x 0 cm, with a small amount of serosanguineous drainage, no tunneling or undermining, and had intact wound edges. The note included to continue with treatment and the wound was stable. Review of the April 2017 TAR revealed that the Santyl treatment to the coccyx was not performed as ordered on April 15 during the 6 a.m. - 2 p.m. shift, and was not performed on April 17 during the 2 p.m. - 10 p.m. shift. A physician's telephone order dated April 17, 2017 included to discontinue the previous treatment and to cleanse the coccyx wound with normal saline, pat dry, apply skin prep to the wound edges, loosely pack the wound bed with Dakins 0.25% soaked 2 x 2 gauze, and to cover with a barrier island dressing twice a day. Further review of the resident's care plans, including the skin care plan revealed they were not revised to reflect that the coccyx wound had deteriorated to an unstageable pressure ulcer, nor were there additional interventions to prevent further skin breakdown. An observation of pressure ulcer care was conducted with the wound nurse (staff #35) at 11:15 a.m. on April 18, 2017. She stated the coccyx wound started as one open area, not two as documented in the admission assessment. Staff #35 stated she had measured the wounds yesterday and was going to use those measurements (however, there was no clinical record documentation of any measurements on April 17). Staff #35 stated that the coccyx wound was all slough and now that the slough cap had come off, it has depth and has deteriorated. She stated the wound had undermining from 12 o'clock to 3 o'clock. At this time, the coccyx wound was observed to be approximately the size of a quarter, and had a red/white center, surrounding tissue was pink and there was a dark area on the outer aspect of the wound. Review of the nurses weekly wound document dated April 18, 2017 revealed the coccyx pressure ulcer was now a stage IV and measured 3.5 x 3.3 x 1.3 cm, with undermining present from 12 o'clock to 3 o'clock (with a distance of 1.3 cm), the wound bed had 100% pink [MEDICATION NAME] tissue, no tunneling was present, and the surrounding skin was not boggy. The note included that the wound had declined and the physician was notified on April 17. Review of the April 2017 TAR revealed the Dakins treatment to the coccyx wound was not performed as ordered on April 18, during the 2 p.m. - 10 p.m. shift. An interview was conducted with the wound nurse (staff #35) at 11:15 a.m. on April 18, 2017. She stated that the resident is turned every 2 hours and as needed, and is on a low air loss mattress. She stated the coccyx wound was not stable. Another interview was conducted with staff #35 on April 20, 2017 at 11:58 a.m. She stated that if the wound measurements are increasing, it means the wound has gotten worse. She stated the coccyx wound started as two spots with an island of skin between them and then the areas connected into one pressure ulcer. Regarding the left trochanter pressure ulcer: Review of the nursing day 1 admission assessment dated [DATE], revealed the resident had a left trochanter stage II pressure ulcer, which measured 3 x 2 x 0 centimeters (cm). Review of the nursing day 2 post admission assessment dated [DATE], revealed the left trochanter was described as having a pink peri wound bed and the center of the wound was scabbed over. Review of the nurses weekly wound document dated March 16, 2017 revealed the resident had pressure ulcer on the left trochanter, which was present upon admission and measured 2 x 1 x 0 cm. The wound bed was described as having 20% pink granulation tissue, 80% slough, with no tunneling or undermining, intact wound edges, and the wound was covered with an allevyn dressing (although there was no physician's order for this). Despite documentation the wound bed had 80% slough, the pressure ulcer was identified as a stage II. A physician's order for wound treatment was not obtained until two days after admission. A physician's order dated March 17, 2017 included to cleanse the left trochanter with normal saline, pat dry, apply skin prep around the wound edges, apply hydrogel to the wound bed, and cover with a barrier island dressing, every Monday, Wednesday and Friday during the day shift and as needed for soilage/dislodgement. Further review of the skin care plan revised on March 18, 2017 revealed the resident was admitted with a stage II pressure ulcer on the left hip. An additional intervention included to turn and reposition the resident every 2 hours. The next assessment of the left trochanter pressure ulcer was completed eight days after the previous assessment. Per the nurses weekly wound document dated March 24, 2017, the left trochanter pressure ulcer measured 2 x 1 x 0 cm, the wound bed had 60% slough and 40% [MEDICATION NAME] tissue with pink wound edges, and no tunneling or undermining were present. The note included the surrounding tissue was firm and similar to scar tissue. Again, the pressure ulcer was identified as a stage II, despite the wound bed being covered with 60% slough. The wound was documented as stable. Review of the nurses weekly wound document dated March 30, 2017 revealed the left trochanter hip stage II pressure ulcer had improved and was 2 x 1 x 0 cm, the wound bed was described as having 100% [MEDICATION NAME] tissue, with no tunneling or undermining, no drainage and had intact wound edges. Review of the April 2017 TAR revealed the hydrogel wound treatment was completed on Monday April 3, however, the treatment was not performed on Wednesday, April 5. Review of the nurses weekly wound document dated April 6, 2017 revealed the left trochanter stage II ulcer measured 2 x 1 x 0 cm, the wound bed had 100% [MEDICATION NAME] tissue, with no tunneling or undermining, no drainage, and intact wound edges. The note included to continue with the current treatment of [REDACTED]. Further review of the April 2017 TAR revealed that the hydrogel wound treatment was not performed as ordered on Friday, April 7 and on Monday, April 10. As the last wound treatment was documented as being done on April 3, and the next wound treatment was documented as being done until Wednesday April 12, the documentation showed that the wound treatment was not done for a period of eight days. Review of the nurses weekly wound document dated April 12, 2017 revealed the left trochanter hip ulcer was now unstageable and measured 1 x 1 x 0 cm, the wound bed had 100% slough, with no tunneling or undermining, had dry wound edges, and a scant amount of serosanguineous drainage was present. The note included the wound was stable, however, the wound had deteriorated from having 100% [MEDICATION NAME] tissue on April 6, to having 100% slough. Further review of the clinical record revealed there was no documentation that the physician was notified of the deterioration of the wound. Further review of the resident's care plans, including the skin care plan revealed they were not revised to reflect that the left hip wound had deteriorated to an unstageable pressure ulcer, nor were there additional interventions to prevent further skin breakdown. An observation of pressure ulcer care was conducted with staff #35 at 11:15 a.m. on April 18, 2017. Staff #35 stated that she had measured the left trochanter wound yesterday and was going to use those measurements (however, there was no clinical record documentation of any wound measurements for the left trochanter on April 17). At this time, the left hip wound was observed to be dime size with a whitish area in the center of the wound, and the surrounding tissue was pink. The hip area also had a new abrasion from the previous dressing being removed. Staff #35 stated the wound bed had possible scar tissue or slough, as it was difficult to determine. Review of the nurses weekly wound document dated April 19, 2017 revealed the left trochanter pressure ulcer was unstageable and measured 1.9 x 1.6 x 0 cm. The note further included the wound bed was obscured with 100% slough, with no tunneling or undermining, had a scant amount of bloody drainage, wound edges were pink and intact, and surrounding tissue was firm with normal color. The wound was documented as being stable, despite increasing in size (from the last assessment on April 12). An interview was conducted with staff #35 on April 20, 2017 at 11:58 a.m. She stated that in terms of wound documentation, stable means that the treatment seems to be effective and the wound is not getting worse. She stated that if the wound measurements are increasing and there is slough instead of [MEDICATION NAME] tissue, the wound has gotten worse. She stated that the week of April 12, 2017 she was out of town and if the wound went from a stage II to unstageable, this is deterioration and the wound should not have been documented as stable. Regarding the bilateral heels: Review of the nursing day 1 admission assessment dated [DATE] revealed the resident's right and left heels were boggy. Review of the nurses weekly wound documentation dated March 17, 2017 revealed the resident's left heel went from boggy (per the admission assessment) to a suspected deep tissue injury (SDTI), measuring 2.5 x 1 x 0 cm. The left heel was described as having a faint discoloration, with intact skin. There was no mention of the condition of the right heel. A physician's order dated March 17, 2017 included to apply heel protectors to both heels every shift and to float the heels every shift while in bed. Review of a skin care plan revised on March 18, 2017 revealed the resident was admitted with right and left heels, which were slightly discolored. Further review revealed that the care plan was not revised to reflect the need to apply heel protectors to both heels every shift and to float the heels every shift while in bed. Review of the nurses weekly wound document dated March 24, 2017 revealed the left heel had a SDTI which had improved. The wound measured 2 x 0.5 x 0 cm and was light maroon in color, skin was intact, and surrounding skin was dry and mildly calloused with no bogginess. The note also included that the discoloration of the left heel was shrinking, due to heels being floated while in bed. Review of the nurses weekly wound document dated March 30, 2017 revealed the left heel was identified as a SDTI, with a faint maroon area which measured 2 x 0.5 x 0 cm and the skin was dry and intact, with no bogginess. The note included the surrounding tissue and heel had firmed, due to heels being floated and that the wound had improved. A change of condition MDS assessment dated [DATE] revealed the resident was rarely or never understood and had severe cognitive impairment. Per the MDS, the resident required extensive assistance with bed mobility and hygiene. The MDS also included the resident had a SDTI. According to the April 2017 TAR, the order to apply the heel protectors to both heels was included, however, there was no documentation that the treatment had been done during the 6 a.m. - 2 p.m. shift on April 2. Review of the nurses weekly wound document dated April 6, 2017 revealed the left heel was a SDTI which was improving and measured 1.8 x 0.5 x 0 cm, with a faint red discoloration, no bogginess, and the skin was dry and intact. The note included that the heels were floated and heel protectors were being used. Review of the April 2017 TAR revealed no documentation that the heel protectors to both heels were applied as ordered during the 6 a.m. - 2 p.m. shift on April 7, 8, and 10, and during the 2 p.m. - 10 p.m. shift on April 9 and 10. The April TAR also included the order to float both heels every shift while in bed. However, there was no documentation that the heels were floated as ordered during the 6 a.m. - 2 p.m. shift on April 7, 8, and 10, and during the 2 p.m. - 10 p.m. shift on April 9, 10, and 11. Review of the nurses weekly wound document dated April 12, 2017 revealed the left heel SDTI measured 1.5 x 3.5 x 0 cm and the skin was dry and intact. The note did not describe the color of the SDTI area on the left heel. The note included the wound was stable, however, the wound measurements had increased from the previous assessment. The documentation also included that the physician was last notified on April 5, 2017. Review of the nurses bath skin check dated April 18, 2017 revealed the resident had the following wounds: right and left heel discoloration, however, the documentation did not include measurements or a description of the discolorated areas. An observation of pressure ulcer care to the bilateral heels was conducted with the wound nurse, staff #35 at 11:15 a.m. on April 18, 2017. She stated that she had measured the wounds yesterday and was going to use those measurements (however, there was no clinical record documentation of any measurements of the heels on April 17). At this time, the resident was observed to have a dime sized maroon colored area on the left heel. Staff #35 stated this wound had improved. The right heel was observed to have a maroon discoloration which was approximately 2 x 2 cm on the heel, and [MEDICAL CONDITION] was present in both feet. Review of the nurses weekly wound document dated April 19, 2017 revealed the left heel suspected deep tissue injury measured 1.6 x 0.5 x 0 cm, with maroon discoloration and skin was dry and intact, with no bogginess and 3 plus [MEDICAL CONDITION] was present. The wound was described as stable. Further review of the nurses weekly wound document dated April 19, 2017 revealed there was a new onset of a discoloration on the right heel, which previously had no suspected SDTI. The right heel was described as having a maroon discoloration which measured 1.5 x 1.5 x 0 cm, skin was dry and intact with no bogginess and had 3 plus [MEDICAL CONDITION] was present. The wound was described as stable. However, this wound was not present the previous week. The documentation also included that the physician was notified on April 18, 2017. An interview was conducted with the staff #35 on April 20, 2017 at 11:58 a.m. She stated that if the heels are boggy, this is looked at as a SDTI. Regarding the right heel, she stated there was a change in color to the right heel this week and it should not have been documented as stable. She stated the right heel had no SDTI until yesterday, and that's why nothing was documented before. She further stated that if a new wound is identified, it should be measured on the same day. Regarding the right gluteal fold pressure ulcer: Review of the nursing bath skin check dated March 24, 2017 revealed the resident had two new wounds. The wounds were described as a right gluteal fold abrasion which measured 1 x 1 x 0 cm with a scab, which was directly under the edge of the brief. The second wound was described as a maroon colored area to the right gluteal fold which was directly under where the edge of the brief meets the skin. The wound measured 2 x 1.5 x 0 cm, with no bogginess, with swelling and warmth present. Review of the nurses weekly wound document dated March 24, 2017 revealed a new shearing wound was present on the right gluteal fold which measured 1 x 1 x 0 cm, and had 20% [MEDICATION NAME] tissue and 80% was covered with a scab. There was no drainage and the wound edges were macerated from moisture. The wound was documented as being a partial thickness wound with no tunneling or undermining, and was stable. This assessment did not include the second wound which was described as a maroon colored area in the above assessment. A physician's order dated March 24, 2017 included to cleanse the right gluteal fold with normal saline, pat dry, and cover with barrier island dressing every evening shift and as needed for soilage/dislodgement. Review of the nurses weekly wound document dated March 30, 2017 revealed a shearing wound was present to the right gluteal fold which measured 1 x 1 x 0 cm and the wound bed was 100 % pink [MEDICATION NAME] tissue with macerated edges that are frequently exposed to moisture, no drainage, partial thickness and no tunneling or undermining were present. The note included that [MEDICATION NAME] should be applied with each incontinent episode, and that the wound had improved. However, there was no physician's order to apply [MEDICATION NAME]. In addition, there was no documentation regarding the second wound which had been previously identified as a maroon colored area. Review of the April 2017 TAR revealed there was no documentation that the treatment to the right gluteal fold was completed as ordered on April 1. A physician's order dated April 5, 2017 included to discontinue the previous order and to cleanse the right gluteal fold open areas with normal saline, pat dry, apply skin prep around the wound perimeter, cut Duoderm to fit the wound sites, and to apply the Duoderm on the skin every other day on the day shift and as needed for soilage/dislodgement. Review of the nurses weekly wound document dated April 6, 2017 revealed the right gluteal fold wound was still a shearing wound which measured 1 x 1 x 0 cm, and was moisture denuded, and the surrounding skin was presenting signs of moisture breakdown. The wound was described as having a mixture of dark pigmented skin, light pink skin, and very pale skin, representing moisture exposed layers. The wound bed was described as having 20% [MEDICATION NAME] tissue, (TRUNCATED)

Based on clinical record reviews, staff and resident interviews, hospital documentation, and policy review, the facility failed to ensure one resident (#109) was administered medications as ordered and failed to ensure that pain assessments were consistently provided for one resident (#5). Findings include: -Resident #109 was admitted to the facility on [DATE] at 3:30 p.m., with [DIAGNOSES REDACTED]. A History and Physical documented the resident did not have the capacity to make or communicate an informed consent regarding treatment options. Admission physician's orders [REDACTED]. puff every day. The admission orders [REDACTED]. Review of the Nursing Progress Notes dated February 15, 2014, revealed the resident's lung sounds had bilateral crackles throughout, expiratory wheezing, and oxygen saturation was 99%. A Nursing Progress Note dated February 16, 2014, included the resident was alert with frequent moments of anxiety related to shortness of breath and expiratory wheezing, which was noted throughout. The note also stated that [MEDICATION NAME] was given for anxiety. Review of the Resident Care Plan dated February 16, 2014, revealed the resident was alert and oriented at times, with some confusion. The care plan identified that the resident had swallowing and choking/aspiration problems and required oxygen at two liters/minute per nasal cannula. The care plan did not address any other respiratory concerns or needs. According to the Medication Administration Record [REDACTED]. In addition, the [MEDICATION NAME] was not administered in the a.m. on February 16, nor was the [MEDICATION NAME] administered on February 16. Review of the Medication Notes dated February 16, 2014, revealed that the [MEDICATION NAME] and the [MEDICATION NAME] were not given, as they were unavailable. Review of the clinical record revealed there was no documented evidence that the physician had been notified, nor was there documentation that the pharmacy had been contacted, in order to obtain the medications. Further review of the February 2014 MAR indicated [REDACTED]. Per the documentation, the medication was not administered from February 14 through 17. Review of the Intake and Output Record for February 2014 revealed the following: February 14-800 cubic centimeters (cc's) output; no intake noted February 15-total of 850 cc output; no intake noted February 16-total of 1000 cc output; no intake noted February 17-total of 750 cc output; no intake noted Review of the Nursing Progress Notes dated February 18, 2014, revealed the resident was agitated and requested to be placed in the recliner. The resident was moved to the recliner via a Hoyer lift, and continued having difficulty breathing and agitation. The note included the resident's lungs were diminished bilaterally, rhonchi was present, the resident's face and upper extremities were pale, oxygen saturation was low at 82%, respirations were 26, blood pressure was 100/72, and temperature was 99.8 Fahrenheit. The physician was called, and new orders were received to send the resident to the emergency room by ambulance. Review of the SBAR (Situation, Background, Assessment, Recommendation) documentation dated February 18, 2014, revealed the resident may have possible aspiration; fluid accumulation and/or may have fluid overload. The assessment also stated that the resident appears to be short of breath, complains of pain all over, with increased confusion and agitation. A physician's orders [REDACTED]. Review of the Resident Transfer Form dated February 18, 2014, revealed the resident was sent to the hospital for respiratory distress by 911 transport. The documentation also noted that the resident was a full code. According to the Hospital Admission History and Physical (H&P) dated February 18, 2014, the resident was sent from a skilled nursing facility, where the resident was noted to be in respiratory distress when the paramedics arrived at the ER. The resident was promptly intubated and sent to the intensive care unit (ICU). The assessment also noted that the resident had 2 plus [MEDICAL CONDITION] to bilateral ankles, was in [MEDICAL CONDITION] and was ventilator dependent. The documentation further included that the resident had chronic right sided heart failure, severe [MEDICAL CONDITION], septic shock and aspiration pneumonia, [MEDICAL CONDITION]. A hospital Consultation Report dated February 18, 2014, included the resident was brought to the hospital because of worsening shortness of breath and a cough. The resident had a chest x-ray that showed extensive right-sided pneumonia. The report also noted that the resident was [MEDICAL CONDITION], hypotensive, and had bandemia (an excess of immature white cells released by bone marrow into the blood). Review of a Consultation Report dated February 19, 2014, revealed that according to a family member, the resident had gained weight since she left the hospital last week and now had [MEDICAL CONDITION] to both legs. An interview was conducted on January 6, 2015, with a licensed practical nurse (LPN). The LPN stated that medications are usually delivered to the facility by pharmacy, within four hours of admission. She stated that if a medication was not delivered by pharmacy, she would call the pharmacy to investigate the reason. An interview was conducted on January 6, 2015, with the Director of Nursing (DON). The DON stated that this resident should have received the medications ordered by the physician, and does not know why this resident did not receive the [MEDICATION NAME], and the [MEDICATION NAME] as ordered. An interview was conducted on January 6, 2015, with the pharmacist. The pharmacist stated that the longest it should take for the facility to receive medications is twelve to thirteen hours. He also stated that the pharmacy was not out of the [MEDICATION NAME], or [MEDICATION NAME]. He stated the order for the [MEDICATION NAME], and [MEDICATION NAME] was not received until February 16, 2014, and that these medications were sent to the facility on [DATE], on the evening run. An interview was conducted on January 7, 2015, with an LPN. The LPN stated that if a medication is not in the facility, he would contact the physician and pharmacy and document this in the nurse's notes. He stated that he would never circle his initials and write on the MAR "unavailable." He further stated that it is a medication error when medications are not given as ordered. Review of the facility's policy on physician's orders [REDACTED]. -Resident #5 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A care plan to address the resident's pain was developed. Interventions included to monitor the resident's pain and to notify the physician if the pain was unrelieved, if there were changes in the pain, or if there were new pain related issues. A review of the December 2014 and January 2015 MARs (Medication Administration Records) revealed that the resident had been prescribed and administered multiple scheduled and as needed pain medications. However, the clinical record including the nursing notes, and the MARs and TARs (Treatment Administration Record), did not reveal any documentation that the resident's pain had been consistently assessed in December 2014 and January 2015. During a resident interview conducted on January 8, 2015, the resident stated that she does experience generalized pain, leg pain and left eye and temple pain. Per the resident, she does receive pain medication, which helps to alleviate her pain. An interview was conducted on January 8, 2015, with an LPN (Licensed Practical Nurse) who stated that pain assessments were suppose to be provided every shift. An interview was conducted on January 8, 2015, with the DON (Director of Nursing), who stated that it was the facility's policy for pain assessments to be provided every shift and documented on the TAR. Following a review of the clinical record, the DON stated that she was unable to locate documented evidence that the resident's pain was assessed every shift. Another interview was conducted with the DON on January 8, 2015. At this time, the DON stated that when the resident was readmitted in October 2014, their computer system did not automatically populate the area on the TAR, to assess pain every shift. A facility policy titled Pain Evaluation and Management included, "...all residents have the right for appropriate pain assessment and pain management..." The policy also included to properly identify, treat and manage pain and discomfort, and that if a resident has a [DIAGNOSES REDACTED].

Based on closed clinical record review, staff interviews, facility documentation, manufacturer's instructions and policy review, the facility failed to ensure one resident (#30) was positioned properly during a Hoyer lift transfer. Findings include: Resident #30 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Activities of Daily Living (ADL) care plan revealed that the resident had a self care deficit related to cerebrovascular accident (CVA) with [DIAGNOSES REDACTED] on the right side and dementia, and was to be transferred with the assistance of two staff, with a Hoyer Lift. Review of the Nursing Progress Notes dated January 5, 2015, revealed that the nurse was called into the resident's room by the certified nursing assistant (CNA/staff #1). The resident had been transferred using the Hoyer lift and somehow slipped out of the sling onto the floor. The resident was lying on her right side, with the Hoyer sling still attached. The note also included the resident had a skin tear to the right leg and when the resident was turned to her back, it was noticed that the right leg appeared to be dislocated/fractured and 911 was called. According to the facility's investigative report, the resident was being transferred with the Hoyer lift by two CNAs (one facility CNA and one registry CNA). The resident was leaning out of the sling and landed on the floor. Per the documentation, the resident was leaning to the side, due to [DIAGNOSES REDACTED] affecting dominant side and the CNAs were unable to stop her from falling. The resident was sent to the hospital and admitted with a femur fracture. The report also included that the Hoyer lift and sling were checked and verified for safety and that education and competency regarding Hoyer lift transfers and positioning during Hoyer lift transfers were being completed, with the CNA and staff. An interview was conducted on January 6, 2015, with a licensed practical nurse (LPN). The LPN stated the two CNA's told her that the resident had slipped out of the Hoyer sling, when being transferred from the wheelchair to the bed. She also stated that the hospital let the facility know that the resident had fractured her right femur. An interview was conducted on January 7, 2015, with staff #1. Staff #1 stated that she and another CNA (staff #2) were attempting to transfer the resident using the Hoyer lift, when the resident fell out of the sling. Staff #1 stated that the resident was tired and was leaning to the right and the other CNA was standing on the left side of the lift. Staff #1 stated that the resident slipped out on the right side, as the Hoyer was being moved. Staff #1 also stated that she should have repositioned the resident in the sling, prior to lifting her out of the wheelchair. An interview was conducted with the Director of Nursing (DON) on January 7, 2015. The DON stated that there was no documented evidence that the CNA's were trained in the use of the Hoyer lift. Review of the Hoyer lift user manual instructions revealed "...Warning-DO NOT use this product or any available optional equipment without first completely reading and understanding these instructions and any additional instructional material such as owner's manuals, service manuals or instruction sheets supplied with this product or optional equipment. If you are unable to understand the warnings, cautions or instructions, contact a healthcare professional, dealer or technical personnel before attempting to use this equipment-otherwise, injury or damage may occur..." The facility's policy on Mechanical Lift Transfers included to provide safe resident transfers for each resident. The policy stated to verify that the resident is properly on the sling and verify that everything is properly connected.

Based on a review of the closed clinical records, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#105) was not administered a medication that he was allergic too, and failed to ensure that one resident (#104) was administered [MEDICAL CONDITION] medication as ordered. The sample size was 5. Findings include: -Resident #105 was admitted on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. According to a quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident was cognitively intact. A nursing note dated October 30, 2013, included that laboratory studies and a chest x-ray were ordered, and the resident was subsequently prescribed and administered [MEDICATION NAME] (antibiotic) 500 mg (milligrams) by mouth twice a day for seven days for a [DIAGNOSES REDACTED]. However, the closed clinical record also documented that the resident had an allergy to [MEDICATION NAME]. (Saunders Nursing Drug Handbook 2015 included that [MEDICATION NAME] is a [MEDICATION NAME] antibiotic). Despite the allergy documentation, the [MEDICATION NAME] was administered from October 30, through November 4, 2013, per the October and November 2013 MAR. There was no documented evidence that the use of the [MEDICATION NAME] and the allergy to [MEDICATION NAME], had been clarified with the NP (Nurse Practitioner) or the physician. A review of the nursing note entries form October 31, 2013, through November 5, 2013, included the following: -October 31, 2013: the resident had occasional audible wheezing, dry cough, and was administered scheduled SVN (Small Volume Nebulizer) breathing treatments every four hours. -November 1, 2013: an IV (Intravenous) was started, fluids were administered, and the scheduled breathing treatments continued to be administered and were helpful for the audible wheezing. -November 2, 2013: IV fluids continued to be administered, the resident had an expiratory wheeze and shortness of breath, and the scheduled breathing treatment was administered and provided relief. -November 3, 2013: resident was observed with a blanket over his head this morning and stated, "I'm visiting my brother and someone just beat him up. The people in my head are dancing around." The resident had expiratory wheezes and shortness of breath and was administered the prescribed breathing treatment, with relief. -November 4, 2013: resident was witnessed having a conversation with no one else in the room, was confused grabbing at the air, and the nurse practitioner would be notified regarding the "Hallucinations." The documentation also included that the resident's face appeared to be bloated/puffy. An NP progress note dated November 4, 2013, included that the resident had audible wheezing upon entering his room, the resident was weaker in comparison to the week prior, and staff had reported that the resident had increased hallucinations over the weekend. The NP progress note also included that the resident's family was contacted and the residents current condition and plan of care was discussed. Per the note, the family member reported that the resident was allergic to [MEDICATION NAME]. As a result, the [MEDICATION NAME] would be discontinued and the resident would be administered [MEDICATION NAME] for the pneumonia. A review of the November 2013, physician's orders [REDACTED]. November 1: -IV fluids -[MEDICATION NAME] SVN every four hours for three days. -[MEDICATION NAME] dose pack-take as directed for wheezing. November 4: -[MEDICATION NAME] SVN breathing treatment every four days. -Oxygen 2 liter per minute via nasal cannula. -[MEDICATION NAME] 80 mg intramuscularly injection-now for wheezing. -[MEDICATION NAME] 50 mg by mouth-now for wheezing. -[MEDICATION NAME] (an antibiotic) 500 mg by mouth daily for seven days. November 5: -[MEDICATION NAME] 50 g by mouth-now for an allergic reaction. A physician's progress note dated November 5, 2013, included that the resident was confused at times, was still having hallucinations, and was administered [MEDICATION NAME] with an allergy to [MEDICATION NAME], and had developed a reaction. The physician's assessment further included: Anaphylactic reaction to the [MEDICATION NAME]. A physician's progress note dated November 7, 2013, included that the resident had an allergic reaction to the [MEDICATION NAME], but he was now more awake and alert, with no hallucinations and that he was almost back to normal, and that the facial swelling and redness had decreased. The facility's investigative report dated November 7, 2013, included that a medication error had occurred. According to the documentation, on October 30, 2013, a RN (Registered Nurse) had received an order from the NP for [MEDICATION NAME], which she then gave to a LPN (Licensed Practical Nurse) to transcribe and fax to the pharmacy. Per the report, the pharmacy called the facility, to confirm the order and the allergy to [MEDICATION NAME]. However, the medication was administered without further communication with the NP or the physician regarding the allergy. The investigative report also included that on November 4, the NP discovered that the resident had a swollen face, hallucinations, and trouble breathing, and that the NP concluded that the resident was anaphylactic. At that time, the MAR indicated [REDACTED]. Per the documentation, the medication ([MEDICATION NAME]) was immediately discontinued. An interview was conducted on January 6, 2015 at 9:10 a.m., with the LPN involved in the medication error. The LPN stated that she had been pulled to a different hall and that she was not familiar with the residents on the hall. According to the LPN, the RN had received an order for [REDACTED]. The RN on duty at the time, was unavailable for an interview. Another interview was conducted on January 6, 2015 at 9:10 a.m., with the DON (Director of Nursing), who stated that the licensed staff should have verified the resident's allergy with the NP, when the order was received and when the pharmacy questioned the [MEDICATION NAME] order. The DON stated that the licensed staff did not make a connection between the resident's symptoms and the start of the [MEDICATION NAME], and that they thought the symptoms were related to the [DIAGNOSES REDACTED]. A facility policy titled, General Dose Preparation and Medication Administration included the following: 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 4.1.4. Check for allergies [REDACTED]. -Resident #104 was readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident was also on hospice services and was discharged from the facility on July 8, 2014. A review of the February 2014 recapitulation of physician's orders [REDACTED]. -[MEDICATION NAME] 16.2 mg administer two tablets by mouth twice a day. -[MEDICATION NAME] 16.2 mg administer three tablets by mouth daily at 1:00 p.m. -[MEDICATION NAME] XR 100 mg administer two capsules by mouth twice a day at 8:00 a.m. and 8:00 p.m. -[MEDICATION NAME] XR 100 mg administer one capsule by mouth everyday at 1:00 p.m. The February 2014 nursing note entries did not include any documented evidence that the resident had any [MEDICAL CONDITION] activity. Review of the March 6, 2014, laboratory test results revealed that the resident's [MEDICATION NAME] level was 18.1 (therapeutic range is 15-40). A physician's orders [REDACTED]. A physician's progress note dated March 11, 2014, included the resident had a [DIAGNOSES REDACTED]. Review of a Significant Change MDS assessment dated [DATE], revealed the resident had severe cognitive impairment and had a [MEDICAL CONDITION] disorder/[MEDICAL CONDITION]. A care plan to address a [DIAGNOSES REDACTED]. A nursing note entry dated March 15, 2014, included the staff had witnessed the resident have [MEDICAL CONDITION] activity, which lasted approximately three to four minutes, during the dinner meal. According to the documentation, the resident was taken to her room, vital signs were monitored until the resident came out of it, and the physician was notified. No orders were received at that time. Another nursing note entry dated March 17, 2014 at 11:25 a.m., included the resident's [MEDICATION NAME] had been mistakenly discontinued. According to the documentation, the NP was notified and orders obtained to resume the previous [MEDICATION NAME] order. A physician's orders [REDACTED]. obtain a [MEDICATION NAME], free [MEDICATION NAME] and [MEDICATION NAME] levels in the morning. On March 18, 2014, the prescribed laboratory tests were obtained and sent to the facility on [DATE]. The lab results showed that the resident's [MEDICATION NAME] level was now only 9.6 (therapeutic range is 15-40). A physician's progress note dated April 11, 2014 included, "Last month, there were doses of her [MEDICATION NAME] that were missed. She did have, what staff reported as [MEDICAL CONDITION] activity. She has not had any further [MEDICAL CONDITION] activity. The facility has been monitoring her [MEDICATION NAME] administration since the incident." Review of the facility's investigative report revealed that the resident's [MEDICATION NAME] had been discontinued in error on March 10, 2014, resulting in the resident missing seven days of the [MEDICATION NAME]. The report included the licensed staff had discontinued the wrong medication from the MAR. Per the documentation, the NP was notified and the order was resumed on March 17, 2014. An interview was conducted on January 7, 2015, with the DON (Director of Nursing), who confirmed that a medication error had occurred, when the [MEDICATION NAME] was mistakenly discontinued, instead of the [MEDICATION NAME]. Another interview was conducted on January 7, 2015 at 1:45 p.m., with the RN (Registered Nurse) involved in the medication error. The RN stated that he had misread the physician's orders [REDACTED]. Review of a facility policy titled, physician's orders [REDACTED].

Based on clinical record review, review of facility documentation, staff and resident interviews, and review of policy and procedures, the facility failed to treat one resident (#94) in a dignified manner, which resulted in emotional harm. Findings include: Resident #94 was admitted on [DATE], with [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of the clinical record revealed that the resident was [AGE] years old and was admitted to the secured unit of the facility, due to unsafe wandering. Clinical record documentation also included that the resident was receiving behavioral health services related to [DIAGNOSES REDACTED]. A nutritional care plan revised on February 1, 2013, identified that the resident had a history of [REDACTED]. Review of the physician's orders revealed an order dated March 1, 2013, which included to have the resident remain in the dining room for an hour after eating. The physician orders did not document the rationale for this. A care plan dated April 25, 2013, addressed psychosocial issues, impaired coping mechanisms, and bulimia. Goals included the resident would not have more than two emesis a week, and not call out more than one time per shift. Interventions were as follows: approach the resident warmly and positively; convey acceptance of resident; discuss fears with resident; discuss implications of not complying with therapeutic regime with resident; assist the resident in developing communication skills/mechanisms; provide the resident with an opportunity to express herself; and to monitor emesis episodes. A behavioral health service note dated April 30, 2013, documented the resident had been observed making herself vomit and was losing weight. The note included that the resident was not having any paranoid behaviors at this time and would be seen again in four weeks. The next behavioral health service note was dated June 10, 2013. Documentation revealed that the resident was stable, had gained some weight, mood was stable, had not been vomiting as much and denied feeling depressed or anxious. The note concluded that there would be a follow up in two months. A nurse practitioner (NP) note dated July 17, 2013, included the resident had gained two pounds and that staff reported to her that she had not had any recent episodes of bulimia. The note concluded that the resident was in good spirits and that she was not depressed anymore. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident was assessed as being able to make herself understood and had the ability to understand others with clear comprehension. The resident also scored a 12 on the brief interview for mental status (BIMS), which indicated minor impairment in cognition. Review of the August 2013 recapitulation of physician orders revealed the resident was receiving [MEDICATION NAME] 15 milligrams (mg) every night for depression and [MEDICATION NAME] 20 mg at bedtime for depression and [MEDICAL CONDITION]. Physician orders dated August 13, 2013, revealed the [MEDICATION NAME] was discontinued. No reason was documented. According to nursing notes there were multiple references regarding this medication being discontinued and that there were no adverse reactions noted. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation included few behaviors had occurred. A nursing note dated August 16, 2013 at 4:30 p.m., documented that the resident told the nurse that she was not hungry and was not going to eat dinner and would like to go to her room. Due to ongoing concerns of weight loss, episodes of emesis and that she had refused dinner three times this week, the nurse asked the resident to wait for a few minutes. The nurse then asked staff to assist her in the resident's room while she verified that she was "not hoarding unhealthy food in her room." The nurse found a large box of Captain Crunch cereal (which was half empty) on the floor by the bed. Per the note, the nurse took the box of cereal out of the resident's room and told the resident that she was going to put it in the cupboard in the multipurpose room. The resident responded by saying "I haven't been eating it, I promise." The nurse then educated the resident about eating properly so she would not loose weight. The resident said she understood, but then asked if the nurse would return the cereal to her room. The nurse told the resident that she had to check with her supervisor, because she thought having the cereal in her room violated a health code and for now would keep it in the cupboard. The resident responded by telling the nurse that she was going to her room because she was not eating supper. The nurse replied by telling the resident that if she changed her mind and felt hungry to let her know and she would give her something to eat. An additional entry later that evening at 5:45 p.m. included the resident came into the dining room for dinner and stated, "Now I'm hungry, can I eat?" The resident ate a few bites, and then said she was full and asked if she could have some ice cream. The nurse educated her on the importance of eating two or three more bites of her dinner and then have the ice cream for a snack. The resident stated, "Never mind I'm full, I don't want anything else, I'm just going to my room." The nurse explained to the resident that the doctor had written an order to encourage the resident to remain in the dining room for an hour after meals, in an attempt to assist her in learning to eat properly and gain weight. The resident refused to stay in the dining room and went to her room. At 7:00 p.m., an entry noted that the resident had returned to the dining room stating that she was hungry and asked if she could have a snack. The nurse gave the resident a snack and she ate 100 percent of it. The note also documented that the resident stayed in the dining room for an hour afterwards. Review of a behavioral health service note dated August 19, 2013, revealed that the resident had been taken off one of her medications for depression ([MEDICATION NAME]), and that there had been no issues from this change. The note stated that the resident was stable, had not had any vomiting episodes and had gained two pounds. The note concluded by stating that there would be a follow up in four weeks. Review of a nursing note dated August 20, 2013, revealed the resident was staring at another resident and the nurse told her it was not nice to stare, and the resident got upset and said she was going to her room. The nurse then realized that the resident had snacks in her room and was concerned that she would indulge herself and experience an episode of emesis. The nurse entered the resident's room and explained to her that she needed to remove the cereal and that if she wanted some, she would give her some, but that her snacks need to be monitored due to her episodes of emesis and weight loss. The note documented the resident became upset and threw some clothes on the floor saying "Those are dirty, now you can have them." The nurse told her she threw them on the floor so she could pick them up. As the nurse was walked away, the resident became belligerent and yelled swear words and continued to scream obscenities at the nurse. The facility conducted an investigation regarding the above incident. Per the investigative documentation, the resident was in the dining area during dinner time when she was observed to be staring at either the nurse or another resident when an LPN told her not to stare, as this was rude behavior. The resident became upset and left the dining room. The LPN went to the resident's room where she removed the resident's cereal, at which time the resident became upset and words were exchanged. The resident reported this incident to the morning LPN and certified nursing assistant (CNA) and told them that she was afraid of this nurse. Continued review of the facility's investigation revealed a witness statement from a CNA who was in the dining room on the evening of August 20. The statement included that the resident was staring at the nurse during the dinner meal and the nurse told the resident to stop looking at her. This upset the resident and she went to her room. The nurse followed her and when the nurse returned to the dining room, she told the CNA that the resident had called her an inappropriate name. Review of a statement from a CNA who was in the dining room at the time revealed that she saw the resident looking at the nurse and the nurse said to the resident for her to look at the movie and not at her. The resident got upset and left her dinner. The CNA stated that later she heard the nurse and the resident yelling, but could not hear what was said. Review of a statement from a CNA who worked the morning after the incident revealed that the resident told her the nurse wouldn't let her have dinner or a peanut butter sandwich and that she took her cereal out of her room. Review of a written statement by an LPN who worked the morning after the incident revealed that the resident came to the main dining area and told her that her dinner was taken away from her the night before and that she was told to go to her room. She said the nurse followed her and took her cereal away from her. She said that the resident admitted becoming angry and used swear words. This statement noted that the cereal was observed in the main room on top of the refrigerator when the resident reported the issue. The resident was noted to be crying and wanted to talk to social services. According to a written statement by the LPN involved in this incident included that she had no intent of abusing the resident, but that she was afraid for the resident's health. She stated that this resident had a history of [REDACTED]. On the day of the incident, she said that she had taken the cereal away, because she was afraid the resident would eat it and not want to eat her meal. She stated that the resident agreed to this approach. She said that when the event happened, the resident was staring at her and she told the resident that it was rude to stare. This upset the resident and caused her to leave the dining room, so she let the resident cool off. She then approached the room and told the resident that she did not know why she was upset with her, but that it would be okay. She admits to taking the cereal again because she was afraid that the resident would eat it and have emesis. She said that she told the resident why she was taking it and then told her that she was not withholding the cereal from her. Her written statement also stated that prior to this incident, she had been working with the resident with her food choices and had focused on teaching the resident to eat from the important food groups first, and put off desserts and snacks until after she had eaten the more healthy foods. She worked diligently everyday with the resident during her 3:00 p.m. snack and dinner time to help her attain her weight gain goals. She further noted that she contacted a supervisor after taking the resident's cereal out of her room and asked if it was okay to do so. She notes that the supervisor told her that it was "totally appropriate" and she put the cereal in the cupboard. Review of a written statement from a registered nurse (RN) revealed that she had advised the LPN prior to the event to use her best judgement and act in the best interest of the resident in regards to taking her snacks away from her. Further review of the investigation revealed that the allegation of abuse was unsubstantiated, however, the LPN involved in this incident was transferred to a different unit in the facility, per the psychologist's assessment that the resident had increased agitation and behavior after the event. Nursing notes dated August 21, 2013, included the resident was still upset about the event and was very teary when she requested to see social services and the nursing supervisor. The note also included that the resident had requested to go to bed and did not attend activities. Nursing notes dated August 22, 2013, documented that the resident had a "very teary day," with several episodes of crying throughout the day. The resident expressed that she was afraid and wanted her "mommy." Per the note, the resident spent most of her morning in bed and the nurse encouraged her to come out for her favorite activities which she did, only to burst into tears when she arrived. After the noon meal, she requested to go to bed. Another entry on this same date reported that a CNA was giving a shower to the resident this morning and the resident had an episode of crying that "appeared very hard and sad to the CNA." Further review of the nursing notes revealed that on August 23, 2013, the resident had another day with episodes of crying with desires to stay in her room. The nurse noted that this was very unusual behavior for the resident. The resident told the nurse that she was fearful of the staff member who she had a disagreement with and that she was mean to her. Review of the NP notes revealed that on August 24, 2013, the resident was seen because of the event that happened on August 20, 2013. The resident reported being afraid of the staff member and was crying and asking for her "mommy." The note further reads that staff reported that the resident had been quiet since the event with increased episodes of tearfulness, which is not her usual behavior. The note included that the NP called the resident's behavioral provider because of the change with the resident. The note further included "this is a completely different person" and that she had been doing very well with her bulimia and had gained weight, prior to this event. The NP was concerned that this event would revert her to her prior ways, which included inducing emesis. A behavioral health service note dated August 26, 2013, revealed that there had not been a four week gap as anticipated before the resident received services again. Instead, the behavioral health services had received a call from the facility's NP regarding the incident. Per the note, the resident had been tearful for several days after the event and was not eating her dinner and was staying in her room a lot. The NP was concerned that the resident would have a relapse if she did not receive immediate behavioral health services. The note stated that she had been very stable in the past few weeks without vomiting and was eating and gaining weight. The resident was noted to be feeling sad, angry and unsafe since the event. The resident stated that her dessert was often taken away from her to punish her, she was forced to eat her vegetables before she was allowed to eat anything else, and if she started crying she was sent to her room. The note stated that the resident's cereal had been taken from her twice and was put up high so the resident could not get it. The note also documented that there was no rule that the resident could not have her snacks in her room. The resident's mood was described as anxious, due to the issues with the nurse and that she would need a lot of emotional support and reassurance from staff. The note further stated that the plan would be to call the case manager to set up weekly counseling to deal with these issues. The note concluded that the resident had no [MEDICAL CONDITION] and that it would not be advisable to have the nurse return to the unit to care for the resident. A follow up was scheduled for two weeks. A nursing note dated August 26, 2013, included behavioral service staff visited with the resident and that per the recommendation, counseling sessions were going to be established through the case manager. The resident's nutritional care plan was now updated on August 26, to reflect that the resident enjoys having cereal in her room and enjoys snacking throughout the day. A nursing note dated September 5, 2013, noted that the resident was visited on September 4, by two counselors for 30 minutes and no information regarding what occurred during these sessions could be obtained. A behavioral health service note dated September 19, 2013, revealed that the resident was doing well since she had no contact with the nurse and her mood was stable and she had no vomiting. A follow up was scheduled to occur in four weeks. An interview was conducted on September 24, 2013 at 1:20 p.m., with the LPN who worked the morning following the incident. She stated that the resident's mother had brought the cereal in and it was very special to the resident. She said that the resident had just started developing a relationship with her mother after many troubled years. She said that while the resident did have some issues with emesis and a history of bulimia, there was no medical reason for her not to have her cereal or for staff to control her food. She said that she has never seen an issue with this resident and her food and has seen the resident eating all kinds of foods without a problem. She said the first time the nurse took the cereal from her she put it in a high cabinet and that the resident, who normally brings the cereal to breakfast was without it. When asked, the resident told her that the nurse had taken it from her. She said after that incident she gave the cereal back to the resident. Another incident occurred on August 20, 2013, and she stated that the next day, she observed the cereal above the tall refrigerator, which was out of the resident's reach. She said on this same date, the resident came to the dining room crying and told her that she was afraid of the nurse and didn't want her to come back. She further stated that the resident was very upset for three days, had episodes of crying, would not come out of her room, and had skipped several lunches. She said all this behavior was very unusual for this resident. She said the resident would tell anyone who was near her about the incident and that she was upset. She said that as a direct result of this event, the nurse practitioner contacted the case manager and got weekly counseling for this resident. She further stated that she felt the resident had a big change from her normal after the incident and that the resident had never had a reaction like this to staff before. During an interview with the resident at 2:00 p.m. on September 24, 2013, she stated that the nurse took her food away on several occasions, especially focusing on her desserts at dinner time. She said that the nurse took her desserts from her every night when she worked. She stated that the nurse took her cereal away from her at least twice, because she might eat it between meals. She said the nurse never told her that she could have the cereal if she wanted, but instead just took the cereal away and put it on top of the refrigerator where she could not reach it. She said that the cereal was special to her and that it was given to her by her mother. She stated that she felt as though the nurse was being mean to her and she had cried over this issue and that it had made her very sad. She said that she has never had any issues with certain foods causing her to have emesis, but that she just needs to watch her portion sizes. An interview was conducted on September 24, 2013 at 3:00 p.m., with the CNA who witnessed the incident on August 20. She said the resident was eating her meal and was looking at the nurse when the nurse said, "What are you looking at? Look at the television, not me." She said this was firm and that the nurse was mean about it. She said the resident began crying and left the room. She stated that after the resident left the dining room, the nurse went to the resident's room and she heard yelling between the two, but could not tell what was said. She stated there had been ongoing issues between the resident and this nurse prior to the event and that the nurse used food as a method of controlling the resident. She stated that the nurse would take the resident's dessert away and tell staff that the NP would not let the resident have certain foods. She said the cereal was up on the refrigerator in view of the resident and that she felt the nurse took the cereal away to be mean to the resident. An interview was conducted on September 24, 2013 at 3:10 p.m., with the LPN who removed the cereal from the resident. She stated that she no longer works on the unit with this resident, because a mutual decision was made with her and the facility. She said that she does not remember the details of the issue exactly, but that she remembered the resident had a three day run with food, which included a few concerning behaviors. She stated that she was worried about the resident's eating and her losing weight. She stated she could not recall what happened that evening. She said she remembers discussing the issues with her supervisor prior to the event on August 20, who told her that it was okay to take the cereal away because it might cause the resident to throw up. She said she did not mean to intentionally try to hurt this resident. She said that she had seen the resident throwing up at times and that she was concerned about this behavior. She said she felt as though this was all a misunderstanding. She said she did remove the cereal, but only to supervise the resident more and she was afraid the resident was going to eat too much and have emesis. She said that she let the resident know about taking the cereal away and that she would give her some if she asked for it. She said that she did not yell at the resident. She said that she had many conversations with the NP about this resident, however, did not recall any specific instructions from the NP to take the resident's cereal or other food from her. She stated that she recalled an order from the doctor for the resident to remain in the dining room after meals for an hour. She stated that she did not recall the care plan giving her specifics on how to treat this resident's care regarding food, but she recalled that the care plan noted to monitor the resident's diet, because of her issues. An interview was conducted on September 24, 2013 at 4:10 p.m., with an LPN who worked the night of the incident. She stated that the resident had told her that she was afraid of the nurse. She said the resident had also received counseling regarding the issue. She said that the resident was throwing up for attention and that she never witnessed any issues with certain types of food causing issues with the resident. She said that the only interventions that she was aware of regarding the resident's food was that the NP wanted the resident to stay in the dining room after meals, so they could monitor her for emesis and that the resident was to receive small portions. She said when she came onto the unit that night, she noticed the cereal box was on the refrigerator. She said the nurse was controlling with the resident's food and would take the resident's dessert and put it aside to get the resident to eat other foods that the nurse felt were more nutritious, like her vegetables. She said she remembered the resident had told several staff that she was scared of the nurse. During an interview with the resident's NP at 10:00 a.m. on September 25, 2013, she stated that she heard about the incident three days after it happened. She said that when she observed the resident, the resident was crying and was asking for her mommy. She said that this was very unusual behavior for this resident and that she has never seen or heard of her acting this way. She said the resident always wanted to please people, but she did not want to see that nurse again. She said the resident was very concerned by this so she set up counseling services. She said the resident had been seen weekly for counseling for a month because of this issue. She said she became aware that the nurse was getting the resident to eat certain foods before other foods and that there was no reason for this. She said she never mentioned this type of intervention and that there were no orders like this and that she did not care what foods the resident ate, as long as she was eating, due to a history of bulimia, [MEDICAL CONDITION] bypass, emesis, and weight loss. She said that it was very clear to staff that she wanted the resident eating small portions, encouraging her to eat slowly, and have her wait in the dining room for an hour after meals. She finally stated that there was no reason for the resident's cereal to be taken away and that she did not feel as though the cereal would have caused any emesis. An interview was conducted on September 25, 2013 at 2:45 p.m., with the RN who was the charge nurse at the time of the incident. at 2:45 p.m. She stated that she remembered that the nurse came to her with a concern about the resident's snacks and was afraid that the resident was eating all the snacks instead of eating her meal, and would then purge. She said that she told the nurse that she did not know the resident well, but that she should use her best judgement in the situation. She stated that she did not say that it was okay to take the resident's food away, rather, encouraged the nurse to do what seemed right for the resident. She stated that she felt as thought snacks can be in resident's rooms as they wish. In an interview with the medical director at 8:20 a.m. on September 26, 2013, she stated that she would not expect that nursing would take snacks from residents. In an interview with the director of nursing (DON) at 11:40 a.m. on September 26, 2013, she stated that since the resident's mother gave her the cereal box, she believed that the cereal box meant more to the resident than just a normal box of cereal. She further stated that she felt as though there was a misunderstanding about the nurse's intention to remove the cereal box and that this became traumatic for the resident. Review of the facility policy and procedures revealed that while the facility had a policy regarding how to store resident's personal food, there were no specifics about the availability for resident's to keep food in their rooms. In addition, there was no specific policy that addressed promoting care of resident's in a dignified manner.

Based on closed clinical record reviews, observations, staff interviews, facility and hospital documentation, and policy review, the facility failed to ensure safety devices were in place and functioning to assist in the prevention of accidents for one resident (#151), failed to ensure one resident (#39) was transferred safely, failed to ensure a Bar-B-Q grill was stored safely, and failed to ensure that a soiled utility room door was locked. Findings include: -Resident #151 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed a nursing progress note dated March 26, 2013, that documented the resident forgets safety precautions for ambulating and does not wait for assistance when in need of transfers. A physician's orders [REDACTED]. A fall risk care plan was initiated on March 26, 2013, which included safety concerns related to the resident having abusive behaviors with aggressiveness and poor safety awareness. Interventions included for a bed alarm, chair alarm, and floor mat. The use of the high/low bed was not included in the care plan. Review of a form titled, Fall Data Collection dated March 26, 2013, revealed the resident was identified to be at high risk for falls, due to a [DIAGNOSES REDACTED]. According to the March 2013 Treatment Record (TAR) the following fall precautions were being utilized: floor mat, wheelchair and bed alarms and high/low bed. On March 26, 2013, initials indicated that these devices were in place. Review of the facility's investigative documentation dated March 27, 2013, revealed the resident was in her wheelchair out on the patio with activity staff and other residents, when she attempted to stand and walk and slid down in front of her wheelchair. No injury was noted. The facility was unable to provide any documented evidence that the wheelchair alarm was in place at the time of the fall. A physician's orders [REDACTED]. A nursing progress note dated March 28, 2013 at 4:00 a.m., revealed that the resident was found on the floor by a certified nursing assistant (CNA). The resident had a 0.5 by 0.5 cm abrasion to the right forehead, with slight swelling and possible bruising noted closer to her hairline. Neuro checks were initiated and vital signs were stable. There was no documentation at this time if the bed alarm was in place at the time of the fall. A nursing progress note dated March 28, 2013 at 6:26 a.m., revealed that the pressure mat alarm was removed from her bed, due to a failure of the alarm to sound when the resident fell out of the bed earlier that morning. The documentation further included that a new tab alarm was put on the resident. The facility was unable to provide any documented evidence that an investigation was completed regarding the second fall. Nursing progress notes dated March 28, 2013, revealed that at approximately 8:40 p.m., the resident was found on the floor partially under her bed, with the floor mat pushed away from her body. The alarm was on the resident's bed and the tab portion was still connected to the resident's gown, however, the alarm had not sounded. Per the note, the alarm was in the "on" position and when the nurse set the alarm down after verifying it was on, the alarm sounded. The note included the resident was sitting in a pool of blood from a head wound and the bed was raised to safely move her head and shoulder out from under the bed. Review of the facility's investigation dated March 28, 2013, revealed the resident was found on the floor of her room by support staff. Upon entering the room, the resident was on the floor on her right side with her head and shoulders wedged under the bed frame. Blood was surrounding the resident's head on the floor. The floor mat was in place, but was pushed partially away from the resident's bed. The alarm portion was attached to the bed and in the "on" position and the tab portion was still attached to the resident, but the alarm had not sounded until it was picked up by staff. The bed was noted to be in the low position and had to be raised to move the resident. The resident was also noted to have a skin tear to the right side of her face. A physician's orders [REDACTED]. Review of the Resident Transfer Form dated March 28, 2013, documented that the resident was found on floor next to the head of her bed and there was copious amounts of blood surrounding her head area, with clots visible. The resident also had a large skin tear to the right side of her face. According to the hospital records dated March 29, 2013, the resident had a subdural hemorrhage and was admitted to the intensive care unit (ICU) at a level one trauma facility. An interview with a CNA was conducted on September 25, 2013 at 7:50 a.m. The CNA stated that the tab alarms are checked every few hours to make sure batteries and the magnets are functioning properly. She also stated that staff would check on a resident more frequently if they were determined to be a fall risk. An interview was conducted on September 25, 2013, with a licensed practical nurse (LPN). The LPN stated that safety precautions would be implemented at the time of admission if a resident was identified as a fall risk. Possible interventions included a pressure alarm, tab alarm, frequent checks by staff, and the bed in the lowest position. She said that the care plan would also be re-assessed. She stated if the resident continued to fall, one to one care would be put into place. She further stated that an incident report would be completed after each fall. An interview was conducted on September 25, 2013, with the director of nursing (DON). The DON stated that she does not know why the tab alarm did not sound when the resident fell out of bed on March 28. She stated that it is not documented when the alarms are checked. She also stated that if a low bed is ordered, it should be documented on the care plan. An interview was conducted with a CNA on September 25, 2013. The CNA stated that the two reasons that the tab alarms do not sound when a resident has fallen are due to a bad battery or a defective magnet. An interview was conducted with an LPN on September 25, 2013. The LPN stated that this resident did not have a tab alarm on her wheelchair at the time of the first fall (on March 27). She also stated that this resident was high risk for falls and was very combative and non-compliant. An interview was conducted on September 25, 2013, with the LPN who was caring for this resident on March 28, when the resident fell out of bed and sustained a head injury. She stated that the resident had a tab alarm in place, but that it was not sounding at the time of the fall, even though the magnet was not connected. She further stated that she picked up the alarm off of the resident's bed, and when she set it down again, it started alarming. Review of the facility's policy on Fall Prevention Protocol revealed "...All residents who are assessed as being at high risk for falls will be identified and individualized fall precautions will be developed for that resident...Preventative measures shall be taken to decrease the number of falls whenever possible...If the assessment finds the resident at risk, implement appropriate interventions/precautions..." -Resident #39 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance of two persons for transfers. A review of the activity of daily living care plan revealed the resident was identified to have an ADL self care deficit related to weakness from a CVA and cognitive impairment related to Alzheimer's dementia. Interventions included for the use of a Hoyer lift for transfers. The care plan did not include the need for two person assistance for transfers, as identified in the MDS. Review of the nurse's notes dated December 26, 2012, revealed the resident had complained of right leg pain. An x-ray was done, which revealed a fracture of the right proximal femur and hip. The resident was transferred to the hospital at 7 p.m. Hospital documentation included that the resident had advanced dementia and was admitted with an apparent fall while at the facility, in the days prior to admission. The documentation further included that the resident had a right hip fracture with generalized osteoporosis. Review of the facility's investigative documentation revealed that the resident was being given a shower and became very agitated, and her arm slipped out of the sling of the Serra lift. The CNA got behind the resident, undid the belt on the sling and slowly lowered the resident to the floor to a sitting position. The report included the CNA transferred the resident by herself using the Sara lift, and that the resident should not have been transferred using one person. The reported further stated that the resident required two persons for transfers. In addition, the written statements from staff pointed out that the CNAs have cheat sheets, which include transfer information for each resident and are located in a binder at the CNA desk. The report included that the CNA was unaware of the cheat sheets and was not aware the resident required a two person transfer. The CNA involved in the above incident was unable to be contacted at this time. An interview with a CNA was conducted on September 26, 2013. She stated she had been provided an ADL sheet (activities of daily living sheet) at the beginning of her shift and it includes transfer information on the residents. She further stated that she became aware of these sheets about two weeks ago. An interview was conducted with the CNA coach/mentor on September 26, 2013. She stated that all new CNAs are informed about the ADL sheets during their orientation. She further stated that on coming CNAs receive verbal report from the off going CNAs at the beginning of their shift, which includes how the resident is transferred. An interview was conducted with the director of nursing (DON) on September 26, 2013, who stated that when a part time or new CNA is working, it is the responsibility of the CNA coach to inform the new CNAs of the ADL sheets found in a book on each unit. Review of a policy regarding Transfer Techniques revealed to obtain help as identified on the care plan/care card and obtain assistance of another individual if necessary for a safe transfer. According to the Care Plan policy, the care plan will ensure the resident receives the appropriate care required to maintain or attain their highest level of practicable function possible. -An observation was made at 3:00 p.m. on September 23, 2013 that a Bar-B-Q grill with attached propane tank was sitting on the patio of an inner courtyard off the 200 Hall. The grill was attached to a propane tank and lifting the tank determined that the tank did contain a substantial amount of propane due to the heaviness of the tank. Further observation of the grill indicated that one of the flame adjustment control knobs on the grill was left in the "on" position thus allowing gas to leak if the valve on the propane tank was turned to the "on" position. The grill was equipped with a push to start igniter which was located on the face control panel of the grill in easy reach. Interview was conducted with the maintenance director on September 23, 2013 at 4:40 p.m. and said about the grill that it being on the patio was his fault, as the facility wanted to have a barbecue on that unit about two weeks ago and he should have been returned it to it's normal area of storage in the assisted living area. He said that the grill with the propane should not be connected unless the grill is to be used. Interview with the Administrator on September 26, 2013, and said he was aware that there had been a barbecue on Labor Day and the grill was on the patio but did not understand why having the grill and propane tank on the patio was such a hazard. -On September 26, 2013, station 1, an observation was made of the soiled utility room. The door to the soiled utility room was not secured to prevent resident access to this area. An interview was conducted with the director of maintenance after this observation. The Director said that he was not sure why there was no locking mechanism on the door leading to the soiled utility room.

Based on clinical record review, review if hospital records, staff interviews, and review of facility documentation, the facility failed to implement the care plan interventions regarding physical assistance for safe transfers of two residents (#s 1 and 2) which resulted in falls with actual harm. The sample size was six. Findings include: -Resident #1 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that the resident had impaired short and long term memories, severely impaired cognitive skills for daily decision making, and was totally dependent upon others for all activities of daily living. The resident was further assessed to required a two person physical assistance for transfers. Review of the care plans revealed that the resident required assistance for transferring from one position to another related to below the knee amputation, cerebral vascular accident, and dementia. The goal was for the resident to receive the necessary physical assistance. The documented intervention was for the CNAs to provide two persons for physical assist with a mechanical aid or transfer belt. Review of the progress notes revealed there was no progress note written for November 13 or 14. On November 15, 2011 at 8:30 a.m., licensed staff documented on a progress note that during the a.m. report, the night shift nurse reported that the resident's right leg appeared distorted. The nurse assessed the leg to have a "bump/distortion" at the mid right thigh region and the resident complained of pain when the leg was touched. The progress note dated November 15, at 12:55 p.m., documented that a new order was obtained for morphine as needed and to maintain bed rest until the results of the x-ray were obtained. Licensed staff documented that the resident's right lower extremity was not in alignment. The progress note dated November 15, at 3 p.m., documented that the results of the x-ray indicated a spiral fracture of the right femur. The x-ray report dated November 15, documented that the resident had osteoporosis and an acute spiral fracture of the distal femur. The progress note dated November 15, at 5:10 p.m., documented the resident left by stretcher for the hospital at approximately 5:15 p.m. The hospital record dated November 15, documented that the resident presented in the emergency department with a complaint of having been dropped at the nursing home "today prior to her arrival at the hospital." The hospital record documented that the resident was in a splint and that the right distal thigh had an "obvious" deformity that was tender to palpation. The resident's final [DIAGNOSES REDACTED]. The facility investigative report dated November 18, documented the following: On November 13, at approximately 4:30 p.m., staff #1 and staff #2 began to transfer the resident from the bed to a chair when the resident's right leg became tangled with staff #1's leg which resulted in staff #1 falling to the floor. Staff #2 held on to the resident and lowered her to the ground. Following the incident staff #1 asked the nurse to assess the resident and no injuries were assessed at the time. The facility investigative report further documented: On November 14, the resident complained of pain, but not specific and on November 15, staff reported to administration that the resident had swelling to the leg. An x-ray showed a spiral fracture. The resident was sent to the hospital. During an interview conducted on November 29, the director of nurses stated that the resident should have been transferred with a mechanical lift or gait transfer belt per the resident's plan of care. Staff #1 a CNA stated during a telephone interview conducted on November 30, that the resident was a two person transfer and that she has never used a mechanical lift for the resident. She stated that somehow during the transfer of the resident from the bed to the geri-chair her legs got twisted with the resident's right leg causing her to fall backwards to the floor with her legs intertwined with the resident's leg. Per staff #1 the resident also ended up on the floor with staff #1's leg under the resident's after staff #2 lowered her to the floor by holding on to the back of the resident's pants. Staff #1 acknowledged that during the transfer of the resident a mechanical aid or transfer belt was not used. She further stated that she did not have a transfer belt and that the facility did not provide one. During a telephone interview conducted on November 30, staff #2 stated that she assisted staff #1 in the transfer of the resident from the bed to a geri-chair without the use of a transfer/gait belt or mechanical lift. She stated that normally it was a facility practice to use a gait belt. She acknowledged that when staff #1 fell backwards there was nothing to hold onto and she had to lower the resident to the floor by holding on to the back of the resident's pants. Staff #2 further stated that when the resident went down to the floor she noticed that the resident was sitting on her knee which was bent back behind her. She stated that she and staff #1 then picked the resident up and transferred her to the geri-chair. -Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE], documented the resident had cognitively intact memory for daily decision making. She was also assessed to require extensive assistance with most activities of daily living including a two person assistance with transfers. Review of the care plans revealed that the resident required assistance for transferring from one position to another related to cerebral vascular accident, dementia, and decreased mobility. The goal was for the resident to receive the necessary physical assistance. The documented intervention was for nursing staff to provide two persons for physical assist with a mechanical aid or transfer belt when transferring the resident. Review of the progress notes revealed there was no progress note written by the a.m. nurse on September 13. The progress note dated September 13, at 10:23 p.m., documented that the a.m. "nurse reported" that the resident was sliding down from the chair many times, but she did not fall. Per the progress note at bedtime while changing the resident, the CNA notified the nurse of a large bruise and swollen right ankle. The progress note dated September 14, at 6:01 p.m., documented that the resident was assessed to have bruising, swelling, and pain of the right ankle on the evening shift on September 13. Per the progress note the nurse practitioner examined the resident and the resident complain of pain in the right ankle, right middle finger, right hip, and pelvic area. Additional x-rays were ordered and in the mean time the results for the right ankle x-ray showed that the resident had at least one fracture and possibly two fractures of the right malleolus. The resident was transported to the hospital for further evaluation. The facility investigative report documented that on the p.m., shift on September 13, the CNA, staff #4 assisted the resident in the bathroom without using the Sara lift or gait belt. Per the report the resident lost her grip and she fell to her right side. Another CNA came in to assist staff #4 and the resident was placed back into the wheelchair. The report documented the resident was sent to the hospital for further evaluation of fractures of the right ankle and bruising and contusions to the right finger. The facility found that staff #4 transferred the resident without a lift or gait belt and that she did not slip, but "fell " on the floor of the bathroom. The nurse practitioner visit note dated September 14, documented that the facility staff alerted the nurse practitioner of the resident's fall of yesterday and subsequent edema. The resident reported pain to the right ankle, finger, and hip. Per the nurse practitioner the resident stated that she landed on her pelvis. The nurse practitioner note further documented that the hospital emergency room nurse reported that the resident had a stable fracture of the right ankle and that she was negative for any other fractures. During a telephone interview conducted on November 21, the CNA, staff #4 stated that she was assigned to resident #2 on the day shift on September 13. She stated the resident did not fall. Staff #4 reported that she was across the hall and saw the resident sliding out of the wheelchair so she pushed her quickly to the grab rail in the bathroom and stood her up. Per the CNA the resident started going down to the floor so she yelled for help and when no one came she lowered the resident to the floor. Staff #4 stated that another CNA came and helped he pick the resident off the floor. Staff #4 stated that after she put the resident into bed she reported the incident to staff #5, the nurse on duty. Staff #4 acknowledged that she did not use a mechanical lift or transfer belt to transfer the resident. She stated she did not need one because the resident could stand. During an interview conducted on November 22, a CNA stated that on the day shift on September 13, staff #4 called her and asked if she could help her. The stated that when she saw the resident on the bathroom floor laying on her back with her face, she stated staff #4 told her to just hold the resident and then she lifted the resident up to the wheelchair. The CNA reported that she asked if the resident was a mechanical lift and staff #4 said no and she also stated she did not need help putting the resident to bed. Per the CNA, staff #4 also did not use a gait/transfer belt when she hoisted the resident off the floor. The facility's general safety rules policy documented the following: "It is the responsibility of each employee to perform his/her duties in a safe manner and to report unsafe conditions to a supervisor, manager of Safety Director...Gail belts and/or mechanical lifts should be utilized in accordance with organizational policy and/or resident needs as dictated by the plan of care..." The facility's care plan policy documented the following, "The care plan will ensure the resident..." receives "...the appropriate care required to maintain or attain the resident's highest level of practicable function possible..." The facility's mechanical lift transfer policy documented that a mechanical lift was used to safely transfer a resident unable to transfer in any other manner. The mechanical lift manual documented that "Although Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case."

Based on reviews of the clinical record, facility documentation and policies, and staff, resident, and family interviews, the facility failed to implement written policies and procedures that prohibit neglect for one resident (#1). A certified staff member neglected resident #1 by failing to ensure that appropriate transfer assistance was provided that resulted in a fall with injury and pain, and licensed staff neglected the resident by failing to assess the resident's right leg, reported by the resident on multiple occasions to be the cause of subsequent pain following the fall, which resulted in a delay in identification of a fracture. The sample size was three residents. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had [DIAGNOSES REDACTED]. The MDS assessment also reflected that the resident had short term memory problem and moderately impaired decision making skills, and minimal communication deficits. Per the MDS, the resident was totally dependent with transfers, required partial physical support for sitting balance, and had limitations in range of motion on one side that involved the hand, arm, leg, and foot. The clinical record revealed documentation of the resident's range of motion limitations, but a baseline assessment identifying the degree of limitation in the resident's right lower extremity was not documented, to use as a comparison to assess if any changes had occurred in the resident's right leg. A review of the care plan revised on April 15, 2010, revealed a focus of "Requires assistance for TRANSFERRING from one position to another related to: [MEDICAL CONDITION], dementia, and decreased mobility." The intervention was to provide two persons for transfers with the mechanical lift or transfer with a transfer belt. The goal was for the resident to receive the necessary physical assistance. The care plan also revealed the problem for falls related to [MEDICAL CONDITION], dementia, depression and decreased mobility. The interventions included to have commonly used articles within easy reach, transfer and change positions slowly, ensure environment is free of clutter and for the resident to wear proper and non-slip footwear. The goal was "No injury from falls." A review of the Progress Notes dated May 24, 2010, revealed "As per CNA (certified nursing assistant) resident was sliding from the bed during AM care and she lowered the resident to the floor while pushing the W/C (wheelchair) away, resident hit right side of his head with the W/C." Documented also was, "Slight redness noted forehead and small abrasion right ear lobe. Resident lifted back to bed with 3 person assist. Neurochecks done...Tylenol given at 0730 AM for headache...Resident C/O (complained of) right leg pain, no swelling or ecchymosis noted. Tylenol given at 1240 PM for right leg pain..." The Resident Incident Report dated May 24, 2010, included that the CNA reported that the resident slid off the bed during morning care/transfer. The CNA (staff member #1) reported that she lowered the resident to the floor while she pushed the wheelchair away and the resident hit the right side of his head and ear on the wheelchair. The incident report had missing areas of documentation, regarding the task of transferring and whether the resident's foot wear was appropriate. The report further revealed that the CNA did not apply a transfer belt around the resident. The incident report documented that the follow-up action to be taken to prevent future occurrences was "Transfer evaluation to be done to be determined proper transfer technique." The report also revealed that the mechanical device used to transfer the resident was a Sera Lift. Documented was that the resident had weakness/paralysis on the right side that contributed to the lowering the resident to the floor. Further review revealed no reference to the resident's need for two person transfer assistance as identified in the resident's care plan, or that the required assistance was not provided. A review of the physician's progress notes dated May 24, 2010 revealed that the resident was complaining of pain and the nurse practitioner (NP) documented that she would order an x-ray of the resident's right ankle (as that is where the resident indicated pain) and prescribe a narcotic [MEDICATION NAME] ([MEDICATION NAME]). The NP completed a comprehensive assessment of the resident's right leg. Documented was that the resident's pedal pulses were positive, and that no bruising, [MEDICAL CONDITION] or hematoma was noted. The NP noted that the resident's pain did not increase upon right lower leg palpation, and that the resident had active and passive range of motion, which was somewhat limited "per his baseline." The x-ray was negative on this date, but the review of the nursing progress notes from May 25 through June 1, 2010, revealed that the resident complained of pain in his right leg almost daily. Further review of these progress notes revealed a lack of even a basic assessment of the resident's right leg being provided by nurses during these eight days. In addition, there was a lack of documented evidence that referrals were being made to the medical provider regarding the resident's ongoing pain. The nursing progress notes also revealed that on June 1, 2010, the resident's family member requested an x-ray of the resident's right hip and right knee due to the resident's frequent complaints of pain. The note further revealed that the NP was notified and the x-rays were ordered. A review of the Final Radiology Report dated June 2, 2010, revealed that the resident had a subcapital [MEDICAL CONDITION] femur with proximal displacement of the distal fragment. The resident was seen by orthopedic services and was transferred to the hospital on June 14, 2010, for surgery to his right hip. The May and June 2010 medication records were reviewed and revealed that the licensed nurses administered the resident [MEDICATION NAME] 16 times from May 25 through June 2, all for right hip and/or leg pain. Licensed nurses administered the resident Tylenol on five occasions, again, for right leg and/or hip pain. Again, there was no evidence that nurses were providing even a basic assessment of the resident's right leg and hip area. An interview was conducted on October 22, 2010, with the CNA (staff #1) who had been involved in the resident's fall incident. Staff #1 stated that the morning of May 24, 2010, she was scheduled to give showers, but was reassigned to assist in providing care to residents. Staff #1 stated that she had dressed the resident while he was in bed due to his right side paralysis and weakness. When she had the resident dressed, she sat him up on the edge of the bed in order to transfer him into the wheelchair. Per staff #1's statement, she left the resident unattended on the edge of bed, and was getting the Sera Lift ready to transfer him, when the resident began to slide off the bed and away from her. Staff #1 stated that she could not stop the resident from falling but managed to push the wheelchair away and put a pillow under his head before he "hit the floor." Staff #1 stated that she had not reviewed the resident's care plan to ascertain the level of assistance he required, nor had she received any training, in-services, or counseling on proper transfer assistance/techniques following the incident. Staff #1 could also not answer why she failed to obtain assistance before she attempted to transfer the resident. It was also unclear as to why staff #1 would reach for a pillow instead of assisting the resident in intercepting the fall. During an interview conducted with the Director of Nursing (DON), he stated that he received the Resident Incident Report and that the report was reviewed by the interdisciplinary team (IDT.) The DON stated that the IDT team determined the resident's fall was not caused by neglect, so therefore the incident was not investigated or reported to the State survey agency. The DON further stated that staff #1 was "careless" and had not followed the resident's care plan. The DON reported that when he spoke to staff #1 she was not aware of the "closet care plan" (a copy of the resident's care plan that instructs CNAs regarding the care the resident requires). When asked what follow-up was taken to prevent a future occurrence, the DON stated that since the CNA was transferring the resident when he fell , her transferring technique was "observed." After a review of staff #1's employee file, the DON stated that he had no documented evidence that the staff members transfer technique was evaluated after the fall. The DON also stated that he had no documented evidence that staff member #1 received any counseling or training for not providing care to meet the resident's needs. During an interview conducted on October 25, 2010, the director of social services stated that she provided in-service orientation regarding Resident Rights and Abuse Prohibition to new staff. A review of the Social Services Orientation revealed that residents have the right to be free from abuse, neglect and restraints. The orientation also revealed that neglect was the failure to provide safe care; not meeting physical, medical and emotional needs. A review of the facility's Resident Protection Policy and Procedure revealed the objectives, "To comply with and exceed the protection required by law. This includes at a minimum the seven step approach to abuse and neglect detection and prevention..." Three of the seven components were identification, investigation and reporting. The policy and procedure defines neglect as "Conduct by a caregiver...is not part of the resident's treatment plan and, through substantial carelessness or negligence, does any of the following: Causes or could reasonably be expected to cause pain or injury to a resident..."