Every finding on record at The Legacy Rehab & Care Center

Based on staff and resident interviews, review of facility documentation, and review of facility policies and procedures the facility failed to ensure residents were free from avoidable accidents related to transportation for 1 of 18 sampled residents (resident #44). The universe was 85. The deficient practice could lead to potential avoidable injuries. Findings include: Resident #44 was re-admitted to the facility on [DATE] with diagnoses of unspecified gangrene, acute kidney failure, and acute respiratory failure. The revised care plan dated April 30, 2026 revealed a problem related to potential injuries from falls. Interventions included to assist in ambulating and transferring, and to observe, record and correct all unsafe conditions. Review of the care plan revealed a problem related to an actual fall on May 7, 2026 with interventions to ensure all safety measures are in place during transportation. Further review of the care plan revealed a problem related to the need for supplemental oxygen due to poor oxygenation. Interventions included to ensure oxygen tank is turned on and nasal cannula is in place prior to leaving the resident. An admission minimum data set (MDS) assessment dated [DATE] revealed Resident #44 had a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. Further review of the MDS revealed the resident required the use of a walker for mobility and moderate staff assistance with showering and toileting. Additional review of the MDS indicated the resident was receiving continuous supplemental oxygen. An Incident Note dated May 7, 2026 at 3:00 p.m. revealed that while the resident was being transported in a van, the resident's wheelchair tipped backwards. The note documented that the resident reported hitting her head and that the driver pulled over and assisted the wheelchair back to an upright position. The resident denied pain and declined transfer to the hospital when offered, stating she wanted to go to her scheduled appointment. Upon the resident's return to the facility, a skin assessment was completed and the resident was noted to have a small bump to head without bruising and a skin tear with flap to the left upper outer arm. The note further revealed the provider was notified and new orders were received for skin treatments, monitoring the mid-back for possible bruising, monitoring the bump to the back of the head, and neuro checks. The note stated that the resident's daughter was present in the room during assessment. The incident note further revealed the resident stated she was sitting in her wheelchair and then flipped back and hit her back on the oxygen tank behind her and hit her head. The resident stated the incident frightened her but reported she was otherwise fine. A Post-Fall evaluation dated May 7, 2026 at 3:03 p.m. revealed the fall occurred unwitnessed in the transportation van with injury. The evaluation further revealed a wheelchair was involved, the resident was wearing oxygen at the time of the incident, and reported a pain level of 4/10, and the responsible parties were notified. A Skin Check note dated May 7, 2026 at 3:06 p.m. revealed Resident #44 sustained a new in-house acquired Type 1 skin tear with flap to the left upper outer arm without skin loss, pain, or signs/symptoms of infection. The note revealed the resident was also noted to have a bump to the back of the head without bruising following a fall, and monitoring for possible bruising was initiated. A physician's order dated May 7, 2026 at 4:53 p.m. included to cleanse skin tear to left upper outer arm with wound wash, re-approximate skin and apply Steri-Strips, and monitor every shift until the wound has resolved. A Communication with Family, Next-of-Kin, Power-of-Attorney note dated May 7, 2026 at 5:09 p.m. revealed Resident #44's son was concerned regarding his mother's fall and choice to not go to the hospital for treatment and evaluation. The note revealed the son was notified that neuro checks have been initiated and if the resident has any change of condition, increased pain, the facility would send her to hospital. Review of the Medication Administration Record and Treatment Administration Record (MAR/TAR) for May 2026 revealed clinical staff administered treatment to the skin tear on the left upper outer arm as ordered. Review of a Corrective Action form dated May 8, 2026 revealed a fact which stated the Transportation Driver (Staff #7) failed to follow policy and procedure while on transport and the Staff #7 responded to that statement by saying he should have double checked. Further review of the form revealed an impact which stated failure to follow proper policies and procedures can result in harm. Review of the form revealed the Transportation Driver received a verbal warning regarding the incident. Further review of the form revealed both the Administrator (Staff #49) and Staff #7 signed the Corrective Action form. Review of a Job Summary for Van Driver position revealed the essential job functions of the employee included to secure residents in and out of the vehicle and provide outstanding customer service in transportation of residents. Review of the Resident Transport Training revealed staff are checked-off prior to transporting a resident which included areas such as; both wheelchair brakes are locked and ratchet straps applied and properly secured. An observation was conducted on May 12, 2026 at 2:07 p.m. of Resident #44. The resident was observed to have a large white gauze bandage wrapped around her left upper arm with no dates or labels. Resident #44 could not recall the last time the bandage was applied. An interview was conducted on May 12, 2026 at 2:07 p.m. with Resident #44. Resident #44 stated she was being transported for an appointment out of the facility and the transportation staff (Staff #7) must have forgotten to lock her wheelchair in place. Resident #44 stated when the driver was taking a turn her wheelchair tipped backwards with her in it and she hit a tote box on a shelf in the vehicle and then landed on her oxygen tank. Resident #44 further stated that the transportation staff pulled over and offered to take her to the hospital to which she declined. Resident #44 stated it was the worst thing that had ever happened to her and she was so shaken up after the incident that she could hardly sleep. An interview was conducted on May 14, 2026 at 12:44 p.m. with transportation driver (Staff #7). Staff #7 stated that prior to transporting a resident in a wheelchair, staff are expected to follow scheduled departure times and ensure the resident is brought to the front for transport. Staff #7 stated he ensures the resident is positioned correctly in the wheelchair and, if the resident is able to respond, he speaks with them to confirm readiness for transport. Staff #7 stated he will check that the wheelchair is functioning properly, including the foot pegs, and verify whether the resident requires oxygen. Staff #7 stated residents are wheeled out and loaded into the van, the wheelchair is secured using clamps and a four-point tie-down system, and the resident is secured with a seatbelt. Staff #7 stated the wheelchair should not move once secured. Staff #7 stated he received training from the previous driver through side-by-side instruction and competency checklists, and annual training is completed thereafter. Staff #7 stated the goal is to ensure residents are transported safely. Staff #7 further stated an incident involving Resident #44, during which he forgot to secure the two front clamps on the wheelchair. The Staff #7 further stated the wheelchair tipped backward while the resident remained seated in the chair. Resident #44 stated he stopped the vehicle in the median, assisted in lifting the chair back upright, and offered to take her to the hospital in which the resident declined. Staff #7 stated the resident reported hitting her head and was observed rubbing her head at the time of the incident, although no visible injuries were observed. Staff #7 stated he immediately notified the administrator, completed an incident report, and then received disciplinary training and a verbal warning. An interview was conducted on May 14, 2026 at 1:21 p.m. with the facility's administrator (Staff #12) and Maintenance Director (Staff #49). Staff #49 stated he will ride along and complete a checklist with new drivers that ensures the new staff know how to properly hook up wheelchairs, restraining of the seat, using the van lift, and how to check the vehicles fluids, tire pressure, and oil. The Staff #12 stated her and Staff #49 will occasionally do a re-check on skills if the drivers are not executing the skills correctly. Staff #49 further stated that he has never had to re-educate any of the drivers and there had never been any incidents regarding resident transportation. Staff #49 stated his number one priority is safety of the residents and the drivers. Staff #49 stated that the drivers are expected to ensure that the wheelchair foot pegs are on the wheelchair and the brakes on the wheelchair work. Staff #49 stated that drivers are expected to load the resident onto the van safely and ensure all four points of the wheelchair restraints are locked, further indicating that if only one or two straps are used the wheelchair is not properly secured. Staff #12 stated that the incident regarding Resident #44 happened because the ratchet straps must have come un-done which had never happened before. Staff #49 stated that the ratchet straps must not have been properly secured when Staff #7 drove out of the parking lot, Resident #44's wheelchair flipped backwards in which the driver pulled into the middle lane to assess Resident #44. Staff #49 stated that there were no physical injuries; however, recanted and stated Resident #44 sustained a skin tear to the left arm. Staff #12 stated Resident #44 refused to go to the hospital and a fall protocol was initiated for the resident. Staff #12 further stated the Transportation Driver did a good job and met her expectations. Review of the Safety and Supervision of Residents last revised May 6, 2026 revealed that resident safety, supervision, and assistance to prevent accidents is a facility-wide priority. Further review of the policy revealed the facility strives to make the environment as free from accident hazards as possible.

Based on closed record review, staff interviews, and review of facility policy, the facility failed to ensure that discharge notifications were made for one of seven residents (#16) to the representative of the Office of the State Long-Term Care Ombudsman. The deficient practice can result in further notifications of resident discharge not being provided to the Ombudsman.Findings include:Resident #16 was admitted on [DATE], and discharged on November 19, 2023, with the diagnosis that included unspecified fracture of the lower end of the right femur, subsequent encounter for closed fracture with routine healing.A baseline care plan with the initiation date of November 10, 2023, revealed that Resident #16 will receive the necessary therapy services to return home safely.An admission MDS (Minimum Data Set) dated November 17, 2023, revealed a BIMS (Brief Interview of Mental Status) score of 15, which indicated that the resident had intact cognition. The MDS assessment also revealed that Resident #16 did not exhibit previous behavior of wandering.A progress note dated November 19, 2023, revealed that Resident #16 left the facility Against Medical Advice (AMA). The progress note revealed that Resident #16 signed an AMA form once the risks of leaving the facility AMA and verbalized her understanding of leaving.A review of the documented email notifications to the ombudsman dated December 11, 2023, regarding the discharges from November 2023, revealed that Resident #16 was not included on the provided list.An interview was conducted on September 9, 2025, at 11:31 AM with Staff #20 and #21. Staff #21, Social Services Director, had been training Staff #20 to transition into the role of Social Services Director. Staff #21 stated that as the Social Services Director, their role is to provide and begin discussions of a discharge plan starting from the day of admission, and to work in a collaborative effort with the Interdisciplinary Team (IDT) and all responsible parties to ensure that the interventions and goals established will assist with the discharge plan. Staff #21 stated that discharge readiness is determined by the IDT and responsible parties, and that once a discharge has taken place, notification of discharge is made to several entities. Notification of discharge will be provided to the resident, emergency contacts, responsible parties, case managers, Adult Protected Services (APS), and the Ombudsman. Staff #21 stated that the Ombudsman will be notified within a monthly report that included all those who have been discharged from the facility, that included residents who left the facility AMA. While reviewing the sample of 7 residents, Staff #21 stated that Resident #16 discharged from the facility AMA on November 19, 2023; and that, the discharge should have been included within the Ombudsman's monthly report for December 2023. After a review of her personal records, Staff #21 confirmed that Resident #16 had not been included in her monthly report sent to the Ombudsman in December of 2023.An interview was conducted on September 9, 2025, at 12:16 PM with an LPN (Licensed Practical Nurse/Staff #24) who stated that their role in the discharge process is to ensure that residents have all of their belongings and medications upon discharge. Staff #24 stated that if a discharge is planned, the discharge documentation will include goals, interventions, and a summary of care, to ensure continuity of care following discharge. If a resident leaves AMA, Staff #24 stated that there is a specific form that is reviewed with the resident and/or family to ensure understanding of the risks of leaving the facility AMA. The resident is encouraged to sign the document, confirming their understanding of the risks of discharging from the facility AMA.An interview was conducted on September 9, 2025, at 2:45 PM with the Director of Nursing (DON/Staff #22), who stated that the expectation for social services is to notify all responsible parties of all facility discharges. Staff #22 stated that the responsible parties included APS, law enforcement, if applicable department heads, and the ombudsman through the facility's monthly report for all discharges. Staff #22 stated that it would not meet the facility's expectations if the notification of discharge to the Ombudsman regarding the Resident #16 had not been made. A policy titled 'Notice of Discharge' revealed that the facility will provide the Ombudsman a copy of all facility discharge notices as soon as practicable. The policy also revealed that the facility will send a copy of a discharge notice, including AMA discharges, to a representative of the Office of the State LTC Ombudsman as soon as practicable.

Based on observations, staff interviews and review of facility policy the facility failed to ensure that hot was temperatures remained in the safe range in the resident rooms. Findings include: During the initial screening of the residents conducted on February 6, 2023 at 2:03 PM, the water temperatures at the restroom sink in room [ROOM NUMBER] was checked and it was 130.6 degrees F. The resident was unable to use the sink. During the initial screening of the residents conducted on February 6, 2023 at 2:15 PM, the water temperature at the restroom sink in room [ROOM NUMBER] was checked and it was 131.4 degrees F. The resident was unable to use the sink. Additional water temperatures were obtained on February 6, 2023 at 2:20 PM in the following rooms: Room # 203 the water temperature was 126.0 degrees F. Room # 204 the water temperature was 127.5 degrees F. Room # 304 the water temperature was 131.9 degrees F. Room # 307 the water temperature was 131.6 degrees F. Room # 308 the water temperature was 130.6 degrees F. Room # 314 the water temperature was 130.2 degrees F. Room # 404 the water temperature was 131.1 degrees F. Room # 405 the water temperature was 128.8 degrees F. Room # 407 the water temperature was 130.0 degrees F. Room # 415 the water temperature was 128.0 degrees F. The administrator (staff #101) was notified on February 6, 2023 at 2:50 PM of the water temperatures being outside of the required temperatures, and the maintenance director accompanied by the surveyor to check temperatures which remained high. During an interview conducted on February 6, 2023 at 3:00 PM with the the Maintenance Manager (staff #32), he stated that he was unaware of the water temperature being that high and that he would immediately correct the temperatures. During observations conducted on February 7, 2023 revealed water temperatures in the follow rooms to be: room [ROOM NUMBER] - 114.1 and room [ROOM NUMBER] - 112.4. Room # 313 the water temperature was 114.1 degrees F. Room # 314 the water temperature was 112.4 degrees F. During observations conducted on February 8, 2023 at 2:14 PM revealed water temperatures in the following rooms to be: Room # 201 the water temperature was 111.5 degrees F. Room # 202 the water temperature was 109.0 degrees F. Room # 204 the water temperature was 111.0 degrees F. Room # 213 the water temperature was 110.0 degrees F. Room # 304 the water temperature was 105.0 degrees F. Room # 317 the water temperature was 109.0 degrees F. Room # 402 the water temperature was 105.5 degrees F. Room # 214 the water temperature was 106.0 degrees F. For burn prevention, federal guidelines advise that you keep domestic water temperatures below 120 degrees Fahrenheit, although this temp can still cause burns if exposure reaches five minutes. Arizona Administrative Code S 9-10-819, Section R9-10-819 - Environmental Standards; A. A manager shall ensure that:; 6. Hot water temperatures are maintained between 95 F and 120 F in areas of an assisted living facility used by residents. Review of the facility policy Monitoring of Proper Water Temperatures states, It is the policy of this facility to maintain proper water temperatures through out the facility to ensure water temperatures are safe to prevent any accidents and to ensure proper infection prevention throughout the facility. Additionally it states 3. All resident rooms will be maintained between 105 and 120 degrees F.

Based on clinical record review, staff interviews and review of facility policy, the facility failed to ensure that a required Pre-Admission Screening and Resident Review Level II was completed for one resident (#3). Findings include: Review of the clinical record revealed a Pre-Admission Screening and Resident Review Level 1 dated September 17, 2021 which indicated a need for a Level II determination for Mental Illness. Additionally there was an email from the resident's case manager dated September 10mg 2021 which stated that the resident should have a Level II assessment completed. During the initial screening conducted February 7, 2023 at 9:21 AM, review of the clinical record dated September 17, 2021 the resident was assessed with a Pre-Admission Screening and Resident Review Level I and was recommended for a PASSAR Level II. There was no documentation in the clinical record for the Level II PASSAR. Review of the MDS Quarterly assessment dated [DATE] the resident is moderately cognitively impaired with a Brief Interview for Mental Status of 11 and requires extensive to total dependence for his activities of daily living. The resident is incontinent of both bowel and bladder. The resident does exhibit the rejection of evaluations or care, one to three days during the assessment period. Care plans were located for: Advanced Directives; Type 2 diabetes mellitus with hypoglycemia without coma; Risk for Ineffective Therapeutic Regimen Management; Major depressive disorder, recurrent, unspecified Depression; Anxiety disorder, unspecified, Impaired Coping, Risk for Harm; Risk for Self-Care Deficit: Bathing, Dressing, Feeding; Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors During an interview conducted on February 8, 2023 at 11:29 AM with a Certified Nursing Assistant, the Admissions Coordinator (staff #89), she stated that they do the initial PASARR Level 1 on admission and that after the admission further Pre-Admission Screening and Resident Reviews are completed by the Social Worker. During an interview conducted on February 8, 2023 with the Medical Records Coordinator (staff #12), she stated that she does not thin the Pre-Admission Screening and Resident Reviews from the clinical record and that she did not have any in the resident's thinned chart. During an interview conducted on February 8, 2023 at 11:43 with a Certified Nursing Assistant (staff #44), she stated that she was covering for the Social Worker who was out on leave. She added that she was not employed at the facility when the resident was admitted and was unaware of the missing Pre-Admission Screening and Resident Review Level II. She then reviewed resident's #3 file along with this writer and was unable to locate any documentation of a Level II assessment other than identifying the need for a Level II assessment from the social worker (staff #13). During an interview conducted on February 8, 2023 with the Director of Nursing (staff #45), she stated that she does not work with the resident's Pre-Admission Screening and Resident Reviews, that they were handled by the admissions office and the Social Worker. Review of the facility's policy Pre-Admission Screening and Resident Review, it states that 3. All individuals with mental disorders and intellectual disability will be referred to the State for all Level two determination prior to admission.

Based on an observation, staff interviews, and facility policy, the facility failed to maintain infection prevention and control when delivering meal trays. The census was 46 residents. The deficient practice could result in transmission of infection, including COVID-19, within the facility. Findings include: An observation was conducted on November 30, 2021 of a dietary server (staff #12) delivering in-room lunch meal trays to 10 residents. The following was observed: -In a room, the staff member picked up and moved the television remote and moved the bedside table before placing the meal tray on the bedside table. -In another room, the staff member picked up and moved a cup that was on the bedside table before placing the meal tray on the bedside table. -In a different room, the staff member picked up and moved a knife that was on the bedside table before placing the meal tray on the bedside table. -In another room, the staff member picked up and moved the television remote before placing the meal tray on the bedside table. -In another room, the staff member used her hand to open the privacy curtain before placing the meal tray on the bedside table. -In a different room, the staff member used her hand to open the privacy curtain and removed clean items from the meal tray to place them onto the bedside table. -In another room the staff member picked up and moved a cup that was on the bedside table and touched items on the meal tray before placing the meal on the bedside table. -In a final room, the staff member used her hand to open the privacy curtain before placing the meal tray on the bedside table. -The staff member did not perform hand hygiene before, during, or after serving each meal tray to the 10 residents. An interview was conducted by telephone on December 2, 2021 at 11:18 a.m. with the dietary server (staff #12). She stated that she needed to perform hand hygiene sometimes after coming out of a resident's room. She stated that she tries not to touch anything when she delivers a meal tray. She stated that if she touched anything in the room she would sanitize her hands before picking up the next clean tray. She acknowledged that she did not do hand hygiene during the observed meal deliveries because she didn't think that she had touched anything. She stated that she probably should have done hand hygiene. An interview was conducted on December 2, 2021 at 11:37 a.m. with the Corporate Infection Control and Minimum Data Set Nurse (staff #89). She stated that hand hygiene was required between each resident if the staff member touched the resident or items in the resident's vicinity as the staff would not know what was on the bedside table or resident's belongings. She stated that staff delivering in-room meal trays would start with clean hands and should be doing hand hygiene between each tray delivery even if they do not touch the resident or resident's belongings. She stated that hand hygiene was important to prevent transporting anything, including infection, from room to room. She stated that the observations during in-room meal delivery did not meet her expectation for hand hygiene and presented a risk for transmission of infection in the facility. An interview was conducted on December 2, 2021 at 12:42 p.m. with the Director of Nursing (DON/staff #90). She stated that she expected staff to do hand hygiene between residents if the staff member touched the resident, resident's belongings, or items in the resident's vicinity (including the privacy curtain, cups/utensils, television remote etc.). She stated that performing hand hygiene was important to maintain infection prevention/control in the building and to prevent the spread of germs and infection. She stated that the meal delivery observations did not meet her expectations for hand hygiene. Review of the facility policy for in-room dining service dated 2018 did not address hand hygiene. Review of the facility policy for hand hygiene, dated July 14, 2021, revealed that hand hygiene continues to be the primary means of preventing the transmission of infection. The policy included that in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. The policy included to complete hand hygiene with alcohol-based hand sanitizer before and after direct contact with residents and after contact with objects in the immediate vicinity of the resident.

Based on clinical record review, staff interviews, and facility policy, the facility failed to notify one resident (#44) and the resident's representative in writing of a transfer and failed to send a copy of the notice to the Office of the State Long Term Care Ombudsman. The deficient practice could result in residents, resident representatives, and the Ombudsman not being provided a written notice of transfers. Resident #44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A weekly wound observation tool dated August 23, 2021 noted that upon assessment of the resident's incision to the right groin, the wound had worsened. The physician was notified and new orders were received to send to the resident to the hospital. The resident and resident's wife were updated on the current status of the incision. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A transfer note dated August 23, 2021 noted that the resident had a large hard lump with redness to the right groin incision site. The note stated the resident was receiving antibiotics and the site looked like it had worsened. Orders were received and the the resident was sent to the hospital. The resident's family was notified. The resident was to be transported with a facility driver. A transfer and discharge notice form revealed the resident's name at the top of the form with a date of August 18, 2021 (prior to the resident's hospitalization ). The form indicated that the resident's transfer was necessary for welfare and the facility could not meet the resident's needs in the building. The form included a section that provided information for appealing the action which included information regarding several State agencies with contact information. The section for transfer/discharge date was dated August 23, 2021. At the bottom of the form, there was the resident's signature with a date of August 18, 2021. Review of the clinical record revealed no evidence that the resident and the resident's representative were notified in writing at the time of the resident's transfer to the hospital. There was also no evidence that the Ombudsman was provided a copy of this transfer. An interview was conducted on December 2, 2021 at 2:50 PM with the Social Services Director (SSD/staff#31). She stated that on admission, she will go over the transfer/discharge notice with the resident and/or their representative, fill out the notice, and obtain a signature at that time. She said that if a resident is transferred/discharged later, she will be notified by staff or during meetings. She said that the nurses are responsible for the transfer including documenting the reason for the transfer in the clinical record. She said that once a resident is transferred or discharged , she will go back to the transfer/discharge form that she went over with the resident and/or their representative on admission and fill in the date that the resident was sent out of the facility. When asked how the resident and the resident's representative would be made aware of this information at the time of the discharge if this information was signed on admission, she stated that they would get the signed copy on admission, however the reason and the date would not be marked on the resident's copy. She stated that she was also notified by the administrator that she needed to send a copy of the transfer/discharge notice to the Ombudsman every month per federal regulation. She said that the notice had not been sent to the Ombudsman as she had never done that while working as the SSD of the facility. She said she was not aware of this requirement until the administrator told her about it. During an interview on December 2, 2021 at 3:01 PM with the Director of Nursing (DON/staff#90), she stated that her expectation for residents being transferred to the hospital is that the nurse complete an assessment prior to transfer. She stated that staff should notify the physician then talk to the resident and representative about the transfer and document the details of the transfer in the resident's clinical record. She stated that she is unsure who is responsible for getting the transfer/ discharge form completed because she was unaware that a written notice is required. She reviewed this resident's record and said that the transfer/discharge form that was completed does not meet expectations since the form was signed on admission which was prior to the transfer to the hospital. An interview was conducted on December 2, 2021 at 3:15 PM with the administrator (staff #107). She stated she is aware that the transfer/discharge notice is required to be provided in writing at the time of transfer or discharge and the resident should be provided a copy of the bed hold policy as well. The administrator further stated that the Ombudsman should also be notified when a resident is transferred or discharged . She stated she would be speaking to SSD and the Ombudsman because there is a possible problem with the current practice. She reviewed the resident's clinical record and said that there is no evidence that the resident and the resident's representative were notified in writing of the transfer at the time of the transfer because the form was signed on admission and not when the resident was transferred. She said she was aware that the SSD is not sending a copy of the notice to the Ombudsman. The facility's transfer and discharge policy revealed that the facility will allow residents to remain in the facility and not transfer or discharge unless the transfer or discharge is necessary for the resident's welfare and their needs cannot be met by the facility. The procedure included that the facility will notify the resident or the resident's representative of the reasons for transfer or discharge and record these reasons in the clinical record. Upon notification, the facility will provide notice of the right to appeal to the State with applicable contact information. Residents' will be provided with a 30 day notice prior to the date of the transfer unless the resident's urgent medical needs require more immediate transfer. In this case, this notice will be provided as soon as practicable. The policy included that the facility must send notice of discharge to the resident and resident representative and send a copy of the discharge notice to the Ombudsman.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure medications were administered as ordered for one resident (#10). The sample size was 13 residents. The deficient practice could result in residents not receiving medications as ordered by the physician. Findings include: Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan dated October 21, 2021 revealed the resident was at risk of fluctuating blood sugar, was at risk for potential seizures, was at risk of bruising/bleeding related to anticoagulants, had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to administer medications per physician orders. The annual Minimum Data Set (MDS) assessment dated [DATE] included the resident received pain medication, insulin injections, antidepressant, and anticoagulant medications during the 7 days look-back period. Review of the October 2021 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Insulin Detemir Solution 100 unit/Milliliter (ML), inject 25 unit subcutaneously one time a day for type 2 DM. This order was discontinued on October 28, 2021 -[MEDICATION(S)] solution 100 unit/ml, inject 45 unit subcutaneously at bedtime related to type 2 DM. -[MEDICATION(S)] 20 milligrams (mg) by mouth at bedtime related to [CONDITION(S)]. -[MEDICATION(S)] 15 mg by mouth at bedtime related to major depressive disorder. -[MEDICATION(S)] 5 mg by mouth at bedtime related to unspecified [CONDITION(S)]. This order was discontinued on October 25, 2021 -[MEDICATION(S)] 12.5 mg by mouth two times a day for blood pressure. This order was discontinued on October 22, 2021 -[MEDICATION(S)] Capsule Delayed Release 20 mg by mouth two times a day for [CONDITION(S)] (GERD). -[MEDICATION(S)] 100 mg by mouth two times a day for chronic migraines. -[MEDICATION(S)] 20 mg by mouth three times a day for muscle spasms. -[MEDICATION(S)] 600 mg by mouth three times a day related to chronic pain syndrome. -Novolog solution 100 unit/ml, inject per sliding scale subcutaneously before meals and at bedtime for DM. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, the resident's morning doses of insulin detemir solution, the [MEDICATION(S)], and the Novolog were not documented as administered on October 6. There was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the clinical record including the Electronic Health Record (EHR) and the paper record revealed no documentation to indicate why the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with a Certified Medication Aide (CMA/staff #2) on December 2, 2021 at 11:10 a.m. She stated there is a scheduled CMA that help nurses pass medication on the morning shift and the CMA helps as needed in the evening shift. She stated there is no scheduled CMA on night shift. She stated during medication administration, a scheduled medication can be given any time between an hour before the scheduled time and an hour after the scheduled time. She stated if a medication cannot be given, then the CMA reports to the nurse who then will report to the physician. She stated is a resident is refusing a medication, an attempt is made 2 or 3 times and if the resident still refuses then the nurse is notified. She stated the MAR must be checked off and cannot be left blank. She stated all medications given must be checked or document appropriately why the medication was not given. An interview was conducted with a Licensed Practical Nurse (LPN/Staff #94) on December 2, 2021 at 11:25 a.m. She stated the nurse assigned to the unit will pass medication during the night shift. She stated medications such as blood pressure medication would not be given if a resident blood pressure is low and outside the parameter set by the physician. In that case, she stated appropriate reason would be marked on the MAR. She stated if a resident refuses a medication the nurses document that the resident refused. She said that the nurse can also document in the nursing notes. She stated that a scheduled medication can be given between an hour before and hour after the scheduled time. She stated the nurses should take some sort of action in the clinical record rather than leaving the MAR blank. She stated if a medication cannot be given then the nurse should assess the resident and notify the physician why the medication was not given. The physician should be made aware if a medication was not administered. She said that if a medication was not delivered from pharmacy there should be a reason why which should be documented. An interview was conducted with the Director of Nursing (DON/staff #90) on December 2, 2021 at 12:06 p.m. She stated there are different reasons why a medication would not be given. She stated when the medications are not given due to unavailability then the expectation is for the nurses to notify the physician and order medication so that it can be picked up that same day. She stated if a medication is held, given late, or the resident refused then her expectation is for the nurses to document appropriately as well as notify the physician. She stated her expectation is for the nurses to document what happened instead of leaving a blank on the MAR. She said that the EHR provides options for documenting why a medication is not given. She stated the nurses also can document the reason in a nursing note. She stated that a blank on the MAR meant that the medication was not given or the medication administration was not documented. She stated the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . She reviewed the October 2021 MAR for the resident and said that the blanks did not mean the medications were not given as it could be they just were not documented by the nurse. She stated the reason why the medication was not given should be documented either on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] The facility policy titled Medication Administration, dated July 14, 2021, stated that medications shall be administered in a safe and timely manner, and as prescribed. The policy included that all medications must be administered in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy included that if a medication is withheld, refused or given at a time other than scheduled time, the individual administering must initial and circle the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy revealed that the individual administering the medication must initial the resident MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on review of facility documentation, staff interviews and policy and procedure, the facility failed to ensure the nurse staffing information was complete and accurate. Findings include: Review of the nurse staffing postings for (MONTH) 2019 revealed the following issues: -July 2: A Licensed Practical Nurse (LPN) was listed as a Registered Nurse (RN). -July 3, 5 and 6: There were no postings for these dates. -July 7: The posting did not include any information regarding the night shift staffing. -July 10: There was no nurse staffing posting information for this date. -July 15: The nurse staffing posting did not include any information regarding the night shift staffing. -July 19 and 22: The nurse staffing posting did not include the facility's census or the night shift staffing information. -July 23: The nurse staffing posting did not include the facility's census for the day shift or any night shift staffing information. -July 25: The nurse staffing posting did not include the census or the night shift staffing information. -July 26: A Medication Technician (MT) was listed as an RN and the night shift staffing was not included in the posting. -July 27: The nurse staffing posting did not include the day shift staffing information. -July 28: The nurse staffing posting did not include the night shift census. On (MONTH) 1, 2019 at 8:23 a.m., an interview was conducted with the Director of Nursing (DON/staff #152). In regard to the missing information on the nurse staffing postings, she stated that the receptionist must not have updated it. She said the receptionist is responsible to ensure the postings are complete and accurate. She stated that the medication technician is not a nurse and should not have been listed as one. She said technically, that individual is a Certified Nursing Assistant. On (MONTH) 2, 2019 at 8:52 a.m., the facility receptionist (staff #64) was interviewed. She stated it is her responsibility to fill out the nurse staffing posting information for the day shift, and that other staff are responsible for posting it on the weekends and on Mondays. She said the evening secretary completes it for the evenings. She stated that he is a new employee, and that she has been training him to do the postings. She said that she gets her information from the nursing sign-in sheets, after staff sign in for their shift. She said she uses that information to fill out the posting for that shift. She stated that she only posts the day shift information for Tuesday-Friday. She said that she has tried to check the evening secretary's work to ensure the form is filled out correctly. Review of a facility policy titled, Nurse Staffing Posting Information revealed to post information on a daily basis, which included the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. Further, the policy stated within two hours of the beginning of each shift, the number of licensed nurses (Registered Nurses and Licensed Practical Nurses) and the number of unlicensed personnel (Certified Nursing Assistants/CNA's) directly responsible for resident care will be posted in a prominent location and shall be accessible to residents and visitors, and that the data shall be in a clear and readable format. The policy further included that the information recorded on the form shall include the resident census at the beginning of the shift for which the information is posted, the type (RN, LPN, CNA) and category (licensed or non-licensed) of nursing staff working during that shift; the actual time worked during that shift for each category and type of nursing staff; and the total number of licensed and non-licensed nursing staff working for the posted shift.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that one out of five sampled residents (#24) was provided medications as ordered by the physician, in accordance with professional standards of practice. Findings include: Resident #24 was admitted on (MONTH) 9, 2014, with [DIAGNOSES REDACTED]. An annual Minimum Data Set (MDS) assessment dated (MONTH) 29, 2019 revealed the resident had moderate cognitive impairment. Section G of the MDS indicated the resident required extensive assistance with bed mobility, transfers, eating and toileting. A [MEDICAL CONDITION] medication care plan related to the use of [MEDICATION NAME] included an intervention to administer medication as ordered by the physician. A care plan related to [MEDICAL CONDITION] included an intervention to give medications as ordered. Review of the physician's orders [REDACTED]. -Memantine [MEDICATION NAME] (HCL/anti-Alzheimer's agent) 5 milligrams (mg) twice daily -[MEDICATION NAME] (anxiolytic) 0.5 mg twice daily for anxiety. -Entacapone (anti-Parkinson agent) 200 mg one tablet three times daily for [MEDICAL CONDITION] -[MEDICATION NAME] HCl ([MEDICATION NAME]) 25 mg four times daily for itching -[MEDICATION NAME] lotion topical application for dry skin every morning -[MEDICATION NAME] (anesthetic) 4% patch apply topically every morning, remove every evening -Donepezil HCl (anti-Alzheimer's agent) 10 mg daily for [MEDICAL CONDITION] -[MEDICATION NAME] (antihypertensive) 2.5 mg every evening for hypertension -Ropinirole HCl (anti-[MEDICAL CONDITION] agent)1 mg three times daily for [MEDICAL CONDITION] -[MEDICATION NAME]-[MEDICATION NAME] Extended Release (ER) 50 mg-200 mg three times daily for [MEDICAL CONDITION] -[MEDICATION NAME] HCl (antihypertensive) 0.2 mg twice daily for hypertension -[MEDICATION NAME] (urinary tract [MEDICATION NAME]) 5 mg twice daily -Vitamin D-3 1000U (vitamin supplement) every evening Review of the (MONTH) 2019 Medication Administration Record (MAR) revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 27 at 7 p.m. for Memantine HCl -On (MONTH) 14 and 25 for [MEDICATION NAME] -On (MONTH) 12 at 6 a.m. for Entacapone -On (MONTH) 25 at 6 p.m. and (MONTH) 26 at midnight for [MEDICATION NAME] There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 3, 9, 13, 17, 20, 24, 25, 26, 27 and 31 at 7 p.m. for Memantine HCl -On (MONTH) 5, 10, 12, 17 and 31 for [MEDICATION NAME] lotion -On (MONTH) 2 and 3 in a.m., (MONTH) 4 and 5 in p.m., (MONTH) 6 in a.m./p.m., (MONTH) 9 in a.m./p.m., On (MONTH) 12 and 13 in a.m., (MONTH) 14 in a.m./p.m., (MONTH) 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 in a.m., (MONTH) 25 in a.m./p.m., (MONTH) 26, 27, 28 and 29 in a.m., (MONTH) 30 in a.m./p.m. and (MONTH) 31 in a.m. for the [MEDICATION NAME] 4% patch. -On (MONTH) 25 for Donepezil HCl There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 9 and 6 at 6 p.m. for [MEDICATION NAME] -On (MONTH) 9 and 15 at 6 p.m., (MONTH) 16 at midnight, (MONTH) 23 at midnight and (MONTH) 30 at midnight for [MEDICATION NAME] HCl -On (MONTH) 2, 7, 14, 15, 21, 22, 28 and 29 at 7 p.m. for Memantine HCl -On (MONTH) 7 for [MEDICATION NAME] lotion -On (MONTH) 1, 2, 3, 4, 5, 6, 7, 8 in a.m., (MONTH) 9 in a.m./p.m., (MONTH) 11, 12, 13, 14 and 15 in a.m., (MONTH) 16 in a.m./p.m., (MONTH) 17, 18, 19, 20, 21 in a.m., (MONTH) 22 in a.m./p.m., and (MONTH) 23, 25, 26, 27, 28, 29 and 30 in a.m. for [MEDICATION NAME] 4% patch -On (MONTH) 9, 16 and 22 for Donepezil HCl -On (MONTH) 26 for [MEDICATION NAME] There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 7 at midnight and (MONTH) 24 at 6 p.m. for [MEDICATION NAME] HCl -On (MONTH) 6 and 20 at 7 p.m. for Memantine HCl -On (MONTH) 19, 20, 24, 25 and 31 in p.m. for [MEDICATION NAME] 4% patch There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 4 at 2 p.m. for Ropinirole HCl -On (MONTH) 4 at 2 p.m. for [MEDICATION NAME]-[MEDICATION NAME] ER -On (MONTH) 4 at 6 p.m. for [MEDICATION NAME] -On (MONTH) 4 at 2 p.m. for Entacapone -On (MONTH) 4 at 12 p.m. for [MEDICATION NAME] HCl -On (MONTH) 4 at 6 p.m. for Memantine HCl -On (MONTH) 5, 6, 14, 19, 20, 21, 26, 27 and 28 in a.m. and (MONTH) 29 in p.m. for [MEDICATION NAME] 4% patch -On (MONTH) 4 for Donepezil HCl There was also no documentation that the resident refused these medications or that the medications had been held. Review of the (MONTH) 2019 MAR revealed there was no documentation that the resident was administered the following medications: [REDACTED] -On (MONTH) 19 at 8 p.m. for Ropinirole HCl -On (MONTH) 19 at 8 p.m. for [MEDICATION NAME]-[MEDICATION NAME] ER -On (MONTH) 19 at 10 p.m. for Entacapone -On (MONTH) 5 at midnight for [MEDICATION NAME] HCl -On (MONTH) 19 and 20 at 8 p.m. for [MEDICATION NAME] HCl -On (MONTH) 19 and 20 at 8 p.m. for [MEDICATION NAME] -On (MONTH) 3, 4, 5, 6, 19 and 20 in p.m. for [MEDICATION NAME] 4% patch -On (MONTH) 13, 19 and 20 for Vitamin D-3 -On (MONTH) 19 and 20 for [MEDICATION NAME] There was also no documentation that the resident refused these medications or that the medications had been held. An interview was conducted on (MONTH) 31, 2019 at 1:43 p.m., with the Director of Nursing (DON/staff #152 ). She stated that her expectation for nursing in regard to documentation is to sign the MAR to show that the medication was given, held or that the resident refused the medication. She said if the medication administration documentation is incomplete, they get the nurses in as soon as possible to complete it. She stated she wasn't sure why the medication administration record for resident #24 had so much missing documentation from nursing, and had no explanation for it. An interview was conducted on (MONTH) 2, 2019 at 9:04 a.m. with a Licensed Practical Nurse (LPN/staff #7) regarding the process for medication documentation. She stated that if she needs to hold a medication for any reason she documents it. She said if a resident refuses the medication she throws it away, then documents that they refused and why. In regards to resident #24, she acknowledged there was missing documentation on the MAR, but she said that her process is always to document it. According to a facility policy titled, Medication Administration the individual administering medications must initial the resident's medication administration record on the appropriate area, after giving each medication, and before administering the next. Documentation must include administration sites, as necessary. Any topical medications given must be documented on the treatment administration record. If a medication is withheld, refused, or given at a time other than the scheduled time, the individual administering must initial and circle the MAR space provided, document on the as needed sheet regarding the reason, and notify the physician.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure there were clinical indications and adequate monitoring for the use of [MEDICAL CONDITION] medications for one resident (#15), and failed to ensure that gradual dose reductions (GDR) were implemented or that there was documentation that GDR's were contraindicated. The deficient practice could result in unnecessary medication administration for residents. Findings include: Resident #15 was admitted to the facility on (MONTH) 23, 2019, with [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. Care plans dated (MONTH) 23, 2019 identified that the resident was receiving [MEDICATION NAME] and [MEDICATION NAME]. Interventions included to administer the medication per physician's orders [REDACTED]. Review of the pharmacy review dated (MONTH) 25, 2019 revealed the following recommendation to the physician: [MEDICATION NAME] may reduce the metabolism of [MEDICATION NAME] which may result in increased EPS (extrapyramidal symptoms) as well as fall risk. Consider either reducing [MEDICATION NAME] by 50% or [MEDICATION NAME] by 50%. The pharmacy review contained a space for the physician to agree or disagree with the recommendation. In front of agree there was a slash, with written documentation by the physician to decrease [MEDICATION NAME] by 50%. The form was signed by the physician on (MONTH) 9, 2019. An admission Minimum Data Set (MDS) assessment dated (MONTH) 30, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact. The assessment revealed the resident had received an antipsychotic and an antidepressant during the 7 day lookback period. Review of a history and physical dated (MONTH) 5, 2019, revealed [DIAGNOSES REDACTED]. The psychiatric review of systems included denies depression, anxiety, complaint of memory loss, mental disturbance, suicidal ideation, hallucinations, paranoia. The physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. According to the Weekly Psychiatric Medication Monitoring forms for (MONTH) 2019, there was also no evidence that the resident was monitored for any targeted behaviors related to depression or [MEDICAL CONDITION]. Review of the MAR for (MONTH) 2019 revealed the resident continued to receive [MEDICATION NAME] 25 mg and [MEDICATION NAME] 0.5 mg daily, and was monitored for adverse reactions related to [MEDICAL CONDITION] medication use. Review of the Weekly Psychiatric Medication Monitoring forms for (MONTH) 2019, revealed the resident was monitored for targeted behaviors of depression related to [MEDICATION NAME] use, and [MEDICAL CONDITION] related to the use of [MEDICATION NAME]. Per the documentation, the resident had no behaviors related to depression or [MEDICAL CONDITION]. The MAR for (MONTH) 2019 included the resident continued to receive [MEDICATION NAME] 25 mg and [MEDICATION NAME] 0.5 mg daily, and was monitored for adverse reactions related to [MEDICAL CONDITION] medication use. The Weekly Psychiatric Medication Monitoring forms for (MONTH) 2019, revealed no evidence that the resident was monitored for any targeted behaviors related to depression for [MEDICATION NAME]. The documentation also showed that the resident was not monitored for targeted behaviors related to [MEDICATION NAME] during the weeks of (MONTH) 4 and 12. During the weeks of (MONTH) 18 and 25, the resident had only one behavior related to [MEDICAL CONDITION]. Review of the MAR for (MONTH) 2019 revealed the resident continued to receive [MEDICATION NAME] 25 mg and [MEDICATION NAME] 0.5 mg daily, and was monitored for adverse reactions related to [MEDICAL CONDITION] medication use. Review of the Weekly Psychiatric Medication Monitoring forms for (MONTH) 2019, revealed the resident was monitored for targeted behaviors related to [MEDICATION NAME] and [MEDICATION NAME]. Per the documentation, the resident had demonstrated ten behaviors related to depression or [MEDICAL CONDITION]. According to a pharmacy review dated (MONTH) 30, 2019, the pharmacist recommended for a dose taper for [MEDICATION NAME] and [MEDICATION NAME]. The recommendation also requested a quarterly note for [MEDICATION NAME]. Review of the MAR for (MONTH) and (MONTH) 2019 revealed the resident continued to receive [MEDICATION NAME] 25 mg and [MEDICATION NAME] 0.5 mg daily, and was monitored for adverse reactions related to [MEDICAL CONDITION] medication use. Review of the Weekly Psychiatric Medication Monitoring forms for (MONTH) and (MONTH) 2019, revealed the resident was monitored for targeted behaviors of depression and [MEDICAL CONDITION]. Per the documentation, the resident had no behaviors of depression and [MEDICAL CONDITION]. Further review of the clinical record revealed no evidence that a gradual dose reduction was implemented for [MEDICATION NAME] or [MEDICATION NAME] or that a GDR was contraindicated. An interview was conducted on (MONTH) 1, 2019 at 2:34 p.m., with the Director of Nursing (DON/staff #152). She said for [MEDICAL CONDITION] medications, the physician would document the necessity of the medication in a psychiatric progress note. However, she said there were no psychiatric provider notes in this resident's chart. She stated her expectation is that residents who are on [MEDICAL CONDITION] medications should receive weekly monitoring for targeted behaviors. Staff #152 said if there were any changes or concerns, the physician should be notified. She said targeted behavior documentation for this resident was missing for (MONTH) 2019, and was partially missing for (MONTH) 2019. She also stated her expectation is that pharmacy recommendations would be addressed as quickly as possible and the nurse would be expected to transcribe new orders from the pharmacy recommendations. She said the order to reduce [MEDICATION NAME] by 50% on (MONTH) 6, had not been transcribed or implemented, but it should have been. She said the pharmacy recommendations for (MONTH) 30, had been placed in the psychiatric providers notebook for review, but the recommendations were still in the notebook and had not been addressed yet. Review of the facility's [MEDICAL CONDITION] Medication Use policy revealed that residents will only receive [MEDICAL CONDITION] medications when necessary to treat a specific condition for which they are indicated and effective. The prescriber and facility staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, symptoms and risks. Nursing staff will document an individual's target behavior(s). The provider will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. Based on assessing the resident's symptoms and overall situation, the provider will determine whether to continue, adjust, or stop existing antipsychotic medication. The facility's policy for Gradual Dose Reduction (GDR) for [MEDICAL CONDITION] Medications stated the pharmacist would evaluate the dose, duration and continued need for all medications during the monthly medication review. Within the first year that a resident was admitted on a [MEDICAL CONDITION] medication or after a new order for a [MEDICAL CONDITION] medication, the pharmacist would recommend a GDR in two separate quarters, unless clinically contraindicated. Upon receipt of a pharmacy recommendation, the provider would assess the resident and determine if a GDR was appropriate or clinically contraindicated, and the provider would document such on the recommendation form.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure that pharmacy recommendations were implemented and that the physician/provider responded to pharmacy recommendations for one resident (#15). The deficient practice could result in unnecessary medication administration for residents. Findings include: Resident #15 was admitted to the facility on (MONTH) 23, 2019, with [DIAGNOSES REDACTED]. The admission physician's orders [REDACTED]. Review of the pharmacy review dated (MONTH) 25, 2019 revealed the following recommendation to the physician: [MEDICATION NAME] may reduce the metabolism of [MEDICATION NAME] which may result in increased EPS (extrapyramidal symptoms) as well as fall risk. Consider either reducing [MEDICATION NAME] by 50% or [MEDICATION NAME] by 50%. The pharmacy review contained a space for the physician to agree or disagree with the recommendation. In front of agree there was a slash, with written documentation by the physician to decrease [MEDICATION NAME] by 50%. The form was signed by the physician on (MONTH) 9, 2019. However, review of the physician's orders [REDACTED]. There were no orders to decrease the [MEDICATION NAME] by 50%. Review of the physician's orders [REDACTED]. Review of a pharmacy recommendation dated (MONTH) 30, 2019 revealed recommendations for a dose taper for [MEDICATION NAME] and [MEDICATION NAME]. The recommendation also requested a quarterly note for [MEDICATION NAME]. Review of the clinical record revealed no evidence that the physician/provider had responded to the (MONTH) 2019 pharmacy recommendations. An interview was conducted on (MONTH) 1, 2019 at 2:34 p.m., with the Director of Nursing (DON/staff #152). She stated the pharmacy reviewed medication regimens for each resident on admission, every 30 days and as needed. She stated her expectation is that pharmacy recommendations would be addressed as quickly as possible, and the nurse would be expected to transcribe new orders which were written on pharmacy recommendations. She said the order to reduce [MEDICATION NAME] by 50% on (MONTH) 6, 2019 had not been transcribed or implemented, but it should have been. She said the pharmacy recommendations for (MONTH) 30, 2019 had been placed in the psychiatric provider's notebook for review, but the recommendations were still in the notebook and had not been addressed yet. Review of the facility's Medication Regimen Review policy revealed the consultant pharmacist would review the medication regimen of each resident at least monthly. The physician would respond in writing on the report with the action being taken and sign and date the report. Reports would be reviewed and written/verbal orders would be received within 7 working days of receipt of the review. The facility's policy for Gradual Dose Reduction (GDR) for [MEDICAL CONDITION] Medications stated the pharmacist would evaluate the dose, duration and continued need for all medications during the monthly medication review. Within the first year that a resident was admitted on a [MEDICAL CONDITION] medication or after a new order for a [MEDICAL CONDITION] medication, the pharmacist would recommend a GDR in two separate quarters, unless clinically contraindicated. Upon receipt of a pharmacy recommendation, the provider would assess the resident and determine if a GDR was appropriate or clinically contraindicated, and the provider would document such on the recommendation form.

Based on observations, clinical record reviews, interviews and policy review, the facility failed to ensure one resident (#238) who was receiving oxygen had physician orders [REDACTED].#67) was receiving oxygen as ordered by the physician. The deficient practice could result in respiratory complications. Findings include: -Resident #238 was admitted to the facility on (MONTH) 9 2019, with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 10, 2019, revealed the resident had poor oxygenation and needed supplemental oxygen related to [MEDICAL CONDITION]. A nurse's note dated (MONTH) 10, 2019, revealed the resident was receiving oxygen via nasal cannula. However, review of the admission physician orders [REDACTED]. A nurse's note dated (MONTH) 21, 2019 revealed the resident was receiving oxygen at a rate of 2 liters per minute. A nurse's note dated (MONTH) 25, 2019 revealed the resident was receiving oxygen at a rate of 3 liters per minute. An observation of the resident was conducted on (MONTH) 29, 2019 at 2:27 p.m. The resident was observed with oxygen in place via nasal cannula at a rate of 3.5 liters per minute. An interview was conducted with a Licensed Practical Nurse (LPN/staff #10) on (MONTH) 31, 2019 at 3:05 p.m. She said oxygen should not be administered without a physician's orders [REDACTED]. She said that is where the mistake was made. An interview was conducted on (MONTH) 1, 2019 at 2:34 p.m., with the Director of Nursing (DON/staff #152). She said that oxygen should be administered by following the physician orders. She stated her expectation is that the nurse would assess the resident on admission and review the physician's orders [REDACTED]. She said the facility also has standing orders to administer oxygen to a resident for shortness of breath at any time, which could be implemented. She said these standing orders could be used temporarily as a bridge until the physician could be contacted to obtain an order for [REDACTED].> -Resident #67 was admitted on (MONTH) 10, 2019, with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan dated (MONTH) 10, 2019 included a problem of poor oxygenation and the need for supplemental oxygen related to [MEDICAL CONDITION] or other respiratory conditions. The interventions included to monitor for signs of shortness of breath, make sure the oxygen tank is turned on and that the nasal cannula is in place. Review of a nurses progress notes on (MONTH) 30, 2019, revealed the resident's oxygen saturation was 97% on 2 Liters of oxygen. A nurses note on (MONTH) 5, 2019 included the resident's oxygen saturation was 95% on 2 Liters of oxygen. Review of the medication administration records (MAR's) for May, (MONTH) and (MONTH) 2019, revealed the resident was receiving oxygen continuously at 2 liters per minute via nasal cannula. The quarterly Minimum Data Set (MDS) assessment dated (MONTH) 22, 2019, revealed a Brief Interview for Mental Status score of 14, which indicated the resident was cognitively intact. The MDS also included the resident had shortness of breath and received oxygen therapy. During an observation conducted on (MONTH) 29, 2019 at 11:55 p.m., the resident was observed resting in bed, without any oxygen on. The resident was in an isolation room. On (MONTH) 30, 2019 at 10:25 a.m., the resident was observed sitting in a wheelchair in her room, without any oxygen in place. The oxygen concentrator was in the corner of the room. Another observation was conducted on (MONTH) 31, 2019 at 3:18 p.m. of the resident in bed, without any oxygen on. An interview was conducted on (MONTH) 31, 2019 at 3:18 p.m., with a LPN (Licensed Practical Nurse/staff #170). The nurse stated that the resident is supposed to be on oxygen at 2 Liters continuous per nasal cannula. At this time, the nurse checked resident #67's oxygen saturation level and it was at 96%. The nurse then placed the oxygen on the resident via nasal cannula. Staff #170 stated that since the resident was 96% on room air, she will contact the physician to see if they can get an order for [REDACTED]. Staff #170 said if the resident is taking the oxygen off, then they need to assess the resident and notify the physician, because it is very important for the heart to get the oxygen it needs. Staff #170 stated that she was not aware the resident was without oxygen. An interview was conducted on (MONTH) 1, 2019 at 12:53 p.m., with a CNA (staff#110). Staff #110 stated that if a resident is on continuous oxygen they are supposed to be on it at all times. She stated if a resident refused oxygen, she would let the nurse know. An interview was conducted on (MONTH) 1, 2019 at 1:10 p.m., with a LPN (staff #163). Staff #163 stated that if a resident has orders for oxygen at 2 Liters continuously, then they should be on oxygen at all times. She stated that if the resident was refusing oxygen, they should educate the resident about the risks and notify the physician, and they would need to document it. She also stated that by the end of the shift, it would need to be care-planned that the resident is refusing and has been advised of the risks. An interview was conducted on (MONTH) 1, 2019 at 3:09 p.m., with the DON (Director of Nursing/staff #152). The DON stated if a resident already has orders for oxygen on the treatment administration record, she expects the nurses to verify the flow rate that the resident is receiving. She stated if a resident is on continuous oxygen, they should be on it continuously. She stated if a resident refused oxygen, she would expect the nurse to do an assessment, check the oxygen saturation level and then discuss it with the provider, so they can make a recommendation to continue or change the oxygen to as needed or discontinue it. Review of the facility's policy for Oxygen Administration revealed the purpose of oxygen therapy is to provide sufficient oxygenation to the blood stream and tissues. The policy included that oxygen therapy is administered as ordered by the physician, or as an emergency measure until the order can be obtained.

Based on observations, clinical record review, staff and resident interviews and policy review, the facility failed to provide care and services for one resident (#25) who was admitted with an indwelling urinary catheter. The deficient practice poses an increased risk for catheter complications. Findings include: Resident #25 was admitted to the facility on (MONTH) 12, 2019 and readmitted on (MONTH) 25, 2019. [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 19, 2019 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS also included the resident had an indwelling catheter. Review of a physician's order dated (MONTH) 26, 2019 revealed for a Foley (indwelling urinary catheter) 16 French, 10 cubic centimeter (cc) balloon per medical doctor protocol for a [DIAGNOSES REDACTED]. A care plan dated (MONTH) 26, 2019 included the resident had a Foley catheter in place, due to a stage 4 sacral wound. Review of the clinical record revealed a hospital progress note dated (MONTH) 23, 2019 which stated that the resident had been admitted to the hospital on (MONTH) 15, 2019. A nurse progress note included that the resident was readmitted from the hospital on (MONTH) 25, 2019. A physician's progress note dated (MONTH) 25, 2019 included the resident had a Foley catheter in place. However, review of the admission physician's orders dated (MONTH) 25, 2019 revealed there were no orders for the indwelling urinary catheter, which included the size of the catheter and the balloon size, how often the catheter should be changed, or for any catheter care. An observation of resident #25 was conducted on (MONTH) 29, 2019 at 2:02 p.m., and a urinary catheter was in place. At this time, an interview was conducted with resident #25 regarding catheter care. She stated that staff do not clean it each shift, but they try to clean it daily. Another observation of resident #25 was conducted on (MONTH) 1, 2019 at 11:04 a.m. and a urinary catheter was observed to be in place. The current physician orders were reviewed in the a.m. on (MONTH) 1, 2019, and there were no orders for the indwelling catheter, which included the size of the catheter and the balloon size, how often the catheter should be changed, or for any catheter care. The (MONTH) and (MONTH) 2019 Treatment Administration Records (TARs) were also reviewed in the a.m. on (MONTH) 1, 2019, and there was no documentation regarding the urinary catheter or any documentation that catheter care was provided. An interview was conducted with a Certified Nursing Assistant (CNA/staff #121) on (MONTH) 1, 2019 at 11:25 a.m. She stated that she knows that resident #25 had a Foley catheter in place when she most recently returned to the facility from the hospital. She stated that she does perineal care each morning at the end of the shift and with any incontinent episodes, for her residents that have a catheter. Staff #121 said that she does not have a place to document the care. An interview was conducted with a Licensed Practical Nurse (LPN/staff #7) on (MONTH) 1, 2019 at 12:00 p.m. She stated that a resident with a Foley catheter would have physician's orders for the catheter size and care. She stated the nurse does the catheter care two times a shift and documents the care in the electronic record on the TAR. After reviewing the physician orders for resident #25, the nurse stated that the resident did not have current orders for the indwelling catheter or for the care of the catheter. Upon reviewing the TAR, she stated there were no entries related to the indwelling catheter and no documentation that catheter care had been provided. She stated the resident had recently returned from the hospital and the catheter was present prior to the hospitalization and was in place when she returned from the hospital. The physician's orders were reviewed again in the p.m. on (MONTH) 1, 2019 and now included orders for a 16 French Foley catheter with a 10 cc balloon for a stage 4 coccyx pressure ulcer and for Foley care per protocol. Review of the (MONTH) 2019 TAR revealed entries dated (MONTH) 1, 2019, which included for indwelling Foley catheter care as follows: check tubing every shift to ensure it is secured to the thigh; monitor skin integrity every shift where tubing lays; allow Foley drainage by gravity; change Foley bag 1 time a month; and change indwelling Foley catheter 16 French 10 cc (balloon) one time a month and as needed; replace [MEDICATION NAME] securing Foley tubing to thigh as needed; irrigate bladder with 60 cc 0.9% normal saline as needed to maintain patency; and change Foley bag as needed. An interview was conducted with the Director of Nursing (DON/staff #152) on (MONTH) 2, 2019 at 8:07 a.m. She stated that if a resident has an indwelling urinary catheter in place, there should be physician's orders for its use, which include the tube size and balloon size. She stated there should also be orders that correspond with the facility's catheter protocol, which includes securing the tubing, tubing placement, skin assessment, catheter care, drain by gravity, catheter change orders, bag change orders and flushing orders. She stated the CNA's are responsible for catheter care at least one time per shift, and the nurse's are responsible to make sure the care was given and to document the care in the TAR each shift. She acknowledged that on return from the hospital there were no orders obtained for the catheter or for the catheter care for resident #25, and that there was no documentation that catheter care was being provided during the current stay. She stated the lack of orders and documentation of care for this resident did not meet her expectation or facility policy, and would increase the risk for urinary tract infections, pain and discomfort. Review of the facility policy regarding Urinary Catheters revealed that indwelling catheters will be cared for in a manner to prevent infections and cross contamination. The policy included that prevention of infection measures included providing catheter care on a regular basis.

Based on observation, clinical record review, interviews and policy review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected one resident's (#238) status. The deficient practice could result in inaccuracies within resident's clinical record. Findings include: Resident #238 was admitted to the facility on (MONTH) 9 2019, with [DIAGNOSES REDACTED]. Review of a care plan dated (MONTH) 10, 2019, revealed the resident had poor oxygenation and needed supplemental oxygen related to [MEDICAL CONDITION]. A nurse's note dated (MONTH) 10, 2019, revealed the resident was receiving oxygen via nasal cannula. Another nurse's note dated (MONTH) 21, 2019, revealed the resident was receiving oxygen at a rate of 2 liters per minute. However, the admission MDS assessment dated (MONTH) 22, 2019 included documentation that the resident had not received oxygen while at the facility. An observation of the resident was conducted on (MONTH) 29, 2019 at 2:27 p.m. The resident was observed to have oxygen on at a rate of 3.5 liters per minute, via nasal cannula. An interview was conducted with a Licensed Practical Nurse (LPN/staff #10) on (MONTH) 31, 2019 at 3:05 p.m. She stated the resident was admitted to the facility with oxygen. Staff #10 said the admitting nurse did not obtain an order from the physician to continue to administer oxygen at the facility. An interview was conducted on (MONTH) 1, 2019 at 1:13 p.m., with the MDS coordinator (staff #23). She stated that she reviews the physician's orders [REDACTED]. She said that based on the physician orders [REDACTED]. She said she did not remember if she had observed this resident to determine if he was receiving oxygen. She stated the MDS assessment should have shown that the resident was receiving oxygen, whether the administration was continuous or intermittent. An interview was conducted on (MONTH) 1, 2019 at 2:34 p.m., with the Director of Nursing (DON/staff #152). She stated her expectation is that the MDS assessment accurately reflects the resident's condition. Review of the Resident Assessment policy revealed that all sections of the MDS assessment should be completed accurately and completely.

Based on clinical record review, staff interviews, and policy, the facility failed to ensure medical records were accurately documented and/or complete for two residents (#21 and #86) regarding advanced directives. Findings include: -Resident #21 was readmitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A form titled, Resident Advanced Directives was signed by the resident on (MONTH) 6, (YEAR), which included the resident did not wish to be resuscitated in the event of an emergency where the heart and breathing stop. A form titled, State of Arizona, Prehospital Medical Care Directive (Do Not Resuscitate) was signed by the resident on (MONTH) 6, (YEAR). The form informs emergency medical technicians or hospital personnel to do not resuscitate the patient and is to be signed by the patient, the patient's witness, and their health care provider. Further review of the form revealed the form was signed by the resident and a Licensed Practical Nurse but was not signed by the health care provider. Review of the physician's recap orders dated (MONTH) (YEAR), revealed an order that the resident was a full code. The resident's face sheet also listed the resident as being full code status. During an interview conducted with the administrator (staff #103) on (MONTH) 24, (YEAR) at 2:01 p.m., she stated that the code status is reviewed with the resident or their representative upon each admission. She also stated that the code status for this resident should have been updated in the electronic record and the full code order should have been removed. The administrator stated that the nurses are trained to follow the forms in the medical record which indicate the code status. -Resident #86 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. Review of the resident's advance directives form revealed no evidence the date had been completed on the form. During an interview conducted with a Licensed Practical Nurse/staff #95 on (MONTH) 23, (YEAR) at 11:23 a.m., she stated that it is necessary for all advanced directive forms to be completed with a date. An interview was conducted with the Director of Nursing/staff # 90 on (MONTH) 23, (YEAR) at 11:35 a.m. She stated that the admission nurse is responsible for the completion of the advanced directive form, including the date. The facility's policy regarding medical records included the following: It is the policy of this facility to maintain medical records in accordance with current applicable laws. Procedure: Medical records will be maintained for each resident that are complete.

Based on clinical record review, staff interviews, policy, and the RAI (Resident Assessment Instrument) manual, the facility failed to ensure one resident (#1) was assessed using the Standardized Quarterly Review assessment once every 3 months. Findings include: Resident #1 was admitted on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 11, (YEAR), revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. Review of the clinical record revealed the resident was discharged to the hospital on (MONTH) 14, (YEAR) with return anticipated and was readmitted to the facility on (MONTH) 6, (YEAR). Continued review of the clinical record revealed a 5 day MDS assessment was completed on (MONTH) 13, (YEAR), a 14 day MDS assessment was completed on (MONTH) 19, (YEAR), and a 30 day MDS assessment was completed on (MONTH) 5, (YEAR). However, there was no evidence that the (MONTH) quarterly MDS assessment had been completed. An interview was conducted on (MONTH) 22, (YEAR) at 1:40 p.m. with the MDS nurse (staff #139). The MDS nurse stated that the next quarterly MDS assessment for resident #1 should have been completed on (MONTH) 24, (YEAR). The MDS nurse also stated that the quarterly MDS assessment was not completed because when the MDS assessments were being scheduled for the month of April, the resident was still in the hospital. During an interview conducted on (MONTH) 22, (YEAR) at 1:52 p.m. with the administrator (staff #103), the administrator stated that the 5 day MDS assessment completed on (MONTH) 13, (YEAR) was not coded correctly. He stated that the assessment should have been coded as the quarterly MDS assessment. A facility's policy titled Resident Assessment (MDS) Accuracy and Timing revealed the MDS assessment timing is determined by the RAI manual. The RAI manual included that a quarterly MDS assessment for a resident must be completed at least every 92 days following the previous OBRA assessment of any type. The manual also included that the quarterly assessment is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.

Based on clinical record review, resident and staff interviews, facility documentation, and policy, the facility failed to ensure four residents (#339 & #25 and #28 & #58) were free from resident to resident abuse. Findings include: -Resident #339 was admitted on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. An admission care plan dated (MONTH) 22, (YEAR), revealed the resident exhibited unsafe wandering related to a decline in cognitive status and poor decisions that put the resident at risk for upsetting other residents. Interventions included to monitor for any needed safety checks, anticipate needs, monitor for increased restlessness, and redirect to safe areas. The goal was for the resident to be able to wander safely on the unit, free from injury to himself or others. The admission Minimum Data Set (MDS) assessment dated (MONTH) 29, (YEAR), revealed the resident was assessed to have severe cognitive impairment with short and long term memory loss. In addition, the resident was assessed to exhibit wandering behavior that intruded on the privacy of other residents. Revisions to the care plan dated (MONTH) 21, (YEAR), revealed the resident had a problem of swearing and insulting other residents and exhibiting negative physical behavior that included hitting, kicking, spitting, pinching, or biting other residents and staff. Interventions included removing him from the situation if he was showing signs of agitation and to remind him calmly about the necessity to refrain from physically acting out. The goal was for him to respond to calming interventions at the earliest signs of aggressive tendencies, to be free of physical altercations with injury involving other residents, and to accept necessary help from staff without causing injury to self and others. Review of the nursing notes from (MONTH) 30 through (MONTH) 21, (YEAR), revealed documentation that the resident had been observed on multiple occasions (over 8 occasions) to exhibit wandering behaviors into other residents' rooms. A nursing note dated (MONTH) 21, (YEAR), revealed the resident was wandering aimlessly down the halls and would curse at staff when attempts were made to redirect him away from entering residents' rooms. Review of a nursing note dated (MONTH) 23, (YEAR), revealed the resident threatened the staff with raised fists and entered a resident's room and urinated on the floor despite staff attempting to intervene. A nursing note dated (MONTH) 26, (YEAR), revealed the resident was not cooperating with staff as evidenced by repeatedly going into other residents' rooms, spitting on the floor, and kicking at a window in the dining room. The note also included that the resident did not take redirection well, would not go to bed, and that other residents did not want him in their rooms. -Resident #25 was admitted to the facility on (MONTH) 22, (YEAR), with [DIAGNOSES REDACTED]. An admission care plan dated (MONTH) 22, (YEAR), revealed the resident had a problem of unsafe wandering related to a decline in cognitive status and poor decisions that put the resident at risk for upsetting other residents. Interventions included to monitor for any needed safety checks, anticipate needs, monitor for increased restlessness, and redirect to safe areas. The goal was for the resident to be able to wander safely on the unit, free from injury to himself or others. The care plan included the resident exhibit negative physical behavior that included hitting, kicking, spitting, pinching, or biting towards other residents and staff. Interventions included removing him from the situation if he was showing signs of agitation and to remind him calmly about the necessity to refrain from physically acting out. The goal was for him to respond to calming interventions at the earliest signs of aggressive tendencies, to be free of physical altercations with injury involving other residents, and to accept necessary help from staff without causing injury to self and others. An admission MDS assessment dated (MONTH) 29, (YEAR), revealed the resident was assessed to have severe cognitive impairment with short and long term loss. In addition, the resident was assessed to display behavioral symptoms that significantly intruded on the privacy of others and significantly disrupted the living environment. A review of the nursing notes from (MONTH) 1 through 26, (YEAR), revealed no evidence the resident had increased behaviors of wandering or exhibiting aggressive behaviors towards other residents. Review of the facility's documentation revealed an altercation between resident #339 and resident #25 captured on the facility's camera system that occurred on (MONTH) 26, (YEAR). The documentation included that at approximately 8:09 p.m., resident #339 stopped his wheelchair in front of the doorway of resident #25's room. Resident #25 walked out of his room and immediately grabbed a hold of resident #339 with both hands. Resident #339 then grabbed the left arm of resident #25 to block him. Resident #339 then raised his fist and struck resident #25 in the nose. The two residents then grabbed each other. Resident #339 stood up from the wheelchair. Eventually both residents fell to the floor. An outside agency nurse saw the altercation and located a facility nurse for intervention. Resident #25 sustained a bloody nose that required first aid treatment. The documentation further included that there were no obvious injuries noted for resident #339. During an interview conducted with the administrator/staff #103 on (MONTH) 23, (YEAR) at 9:29 a.m., she stated that there had been no prior altercations between the two residents. An interview was conducted with the outside agency nurse/staff #153 on (MONTH) 23, (YEAR) at 9:43 a.m. She stated that she could not recall any specific details about the physical altercation between the two residents on the secured unit. An interview was conducted with a Registered Nurse/staff #75 on (MONTH) 23, (YEAR) at 10:03 a.m. She stated that resident #339 had some behaviors that had escalated in the past month and that he was not open to redirection. She stated that resident #339 would enter other residents' rooms and had a tendency to become loud, angry, and verbally aggressive. Staff #75 stated that resident #25 tended to be pleasant, liked his room, and only wanted himself and his roommate to enter his room. During an interview conducted with a Certified Nursing Assistant/staff #78 on (MONTH) 23, (YEAR) at 10:18 a.m., she stated that she had provided care for both residents. She stated that resident #339 could be aggressive with staff and would sometimes try to hit her or swing out at her. Staff #78 stated that resident #25 liked his room and did not want other residents to come into his room. An attempt to interview resident #25 on (MONTH) 24, (YEAR) at approximately 1:00 p.m., was unsuccessful. Another interview was conducted with the administrator/staff #103 on (MONTH) 25, (YEAR) at 8:51 a.m. She identified the altercation as abuse and stated that all residents have the right to be free from abuse. -Resident #58 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated (MONTH) 17, (YEAR), revealed a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The assessment also included the resident displayed verbal behavioral symptoms directed toward others and other behavioral symptoms that was not directed toward others. Review of the care plan initiated (MONTH) 26, (YEAR), revealed the resident had verbal behaviors of screaming disruptive sounds and screaming/cursing at others and behaviors of making inappropriate sexual comments to the female staff and other residents. Interventions included redirecting behaviors as able, utilizing different staff members, offering food, fluids, activities, 1:1 conversation, psychiatrist consults as needed, and to document all behaviors. The quarterly MDS assessment dated (MONTH) 15, (YEAR), revealed resident a BIMS score of 15 which indicated the resident was cognitively intact. The assessment also included the resident had no behavioral symptoms. -Resident #28 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A review of the admission MDS assessment dated (MONTH) 6, (YEAR), revealed a BIMS score of 8 which indicated the resident was moderately cognitively impaired. The assessment included the resident displayed physical behavioral symptoms directed toward others. Review of the care plan initiated on (MONTH) 7, (YEAR), revealed the resident exhibited behaviors of making sexual comments at staff and grabbing staff bottoms. Interventions included redirecting all behaviors as able, psychiatric consults as needed, reminding the resident that his behaviors are inappropriate, offering food, fluids, and activities, and documenting all behaviors. A review of the quarterly MDS assessment dated (MONTH) 4, (YEAR), revealed a BIMS score of 9 which indicated the resident was moderately cognitively impaired. The assessment included the resident had had no behavioral symptoms. During an interview conducted with resident #28 on (MONTH) 22, (YEAR) at 9:30 a.m., he stated that another resident (#58) threw coffee creamer all over him that morning. Resident #28 stated that the housekeeper saw it happen and helped him get cleaned up. He also stated that he had just reported the incident to his nurse. The incident was reported to the administrator (staff #109) on (MONTH) 22, (YEAR) at 9:40 a.m. During an interview conducted with resident #58 on (MONTH) 23, (YEAR) at 1:30 p.m., resident #58 stated that he threw coffee creamer at resident #28 because resident #28 would not stop moving the cart which caused him to spill his coffee. He stated that resident #28 had threatened to throw coffee at him first. Resident #58 stated that resident #28 is always playing games and hitting his arm with his wheelchair. He also stated that once resident #28 hit him in the chest with his fist. Resident #58 stated that he had never hit resident #28. He stated that he did not report these incidents to anyone. Review of the facility's documentation regarding the incident that occurred on (MONTH) 22, (YEAR), revealed an interview with resident #58 and resident #28. Resident #28 stated that he and resident #58 were attempting to get coffee of the coffee cart. He stated that he put two packs of sugar in his coffee but was unable to reach the trash bag, so he pulled the coffee cart toward him. He stated that is when resident #58 threw coffee creamer on him. Resident #58 stated he and resident #28 was getting coffee at the same time. He stated that resident #28 kept pulling the cart to made his coffee spill, so he threw the coffee creamer at him. The facility's documentation also included that during the interviews, the residents spoke of another incident that occurred. Resident #58 stated that resident #28 tried to block his way so he slapped resident #28 in the chest. He stated that resident #28 then slugged him in the chest. The facility's documentation also included that resident #28 stated that he hit resident #58 in the chest after being hit by resident #58 two days ago outside of the therapy room. He further stated that there were no witnesses and that he did not report the incident to anyone. An interview was conducted with the Director of Nursing (DON/staff #90) on (MONTH) 23, (YEAR) at 2:19 p.m. The DON stated that she had been reviewing their camera videos and did not see any altercations between the two resident. She stated that she interviewed the therapy department and that they could not confirm the two residents were in the therapy room at the same time. During an interview conducted with the administrator and the DON on (MONTH) 25, (YEAR) at 8:53 a.m., the administrator stated that resident #58 admitted that he had hit resident #28 in the chest. The facility's policy titled Abuse Prevention Program included the following: It is the policy of this facility for our residents to have the right to be free from abuse. Our facility is committed to protecting our residents from abuse by anyone including from other residents.

Based on resident and staff interview and clinical record review, the facility failed to ensure one resident (#13) was able to make choices regarding the preference for no male care givers. Findings include: Resident #13 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Review of the resident's functional capacity revealed the resident was identified as total dependence or extensive assistance and required one to two persons to assist her with the activities of daily living except for eating which required only supervision. Review of the Resident Mood Interview indicated the resident had a score of 15, which indicated she was depressed but according to the behavior section the resident did not exhibit any behaviors during this review period. Review of the nursing progress notes for January and February 2017 revealed the resident frequently refused medications, care, and would yell at staff to get out of her room. Review of the nursing progress notes for the month of March 2017 revealed only a few days where the resident had documented episodes of yelling at staff, yelling out into the halls, and refusing medications. During an interview with the resident on March 14, 2017 at 10:44 a.m., the resident stated that she did not want a man caregiver providing her incontinent care. Review of the resident's care plan revealed a problem titled, At times I say racial remarks to staff, but did not include any concerns regarding male caregivers. In an interview conducted with a Certified Nursing Assistant (CNA/staff #61) on March 16, 2017 at 10:47 a.m., the CNA stated she performs all types of daily care for the resident which includes showers, providing continent care, getting the resident ready for meals, and dressing the resident. She further stated to reduce the resident's anxiety; they work with her to keep things to her preference. The CNA further stated the resident stated she did not want males providing her care including showering her and she does not want more than 3 people in her room at a time. Staff #61 stated if a male CNA attempts to assist the resident, the resident tells the male CNA to get out. The CNA stated she has known about the resident preference regarding no male care givers for about a month. In an interview conducted with a Licensed practical Nurse, (LPN/staff #136) on March 16, 2017 at 11:13 a.m., the LPN stated she never heard the resident did not want male CNAs providing her care. The LPN stated it should be on the care plan so everyone is aware of the resident's preference. In an interview conducted with the Director of Nursing (DON/staff #92), on March 16, 2017 at 11:14 a.m., the DON stated there is a regular schedule for review of the care plans to ensure they are all updated for the resident. The DON stated that if a resident has a preference no male care giver, then it should be cared planned so all staff are aware.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that one resident (#3) received proper treatment, in order to determine if an assistive device could improve or maintain the resident's visual abilities. Findings include: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated the resident had moderate cognitive impairment. The assessment also identified that the resident had impaired vision (sees large print, but not regular print in newspapers/books) and the resident did not have corrective lenses. In Section V. Care Area Assessment, the problem area of Visual Functioning had triggered and a decision was made to proceed to care planning. A review of the clinical record revealed the resident received a diabetic eye examination on February 21, 2015. However, there was no documentation that a refraction evaluation (eye exam that measures a persons prescription for eye glasses or contact lenses) was completed, in order to determine if corrective lenses would improve or correct the resident's visual deficit. During an interview conducted at 8:15 a.m. on December 17, 2015, a certified nursing assistant stated that the resident did not have glasses. During an interview conducted at 8:20 a.m. on December 17, 2015, a licensed practical nurse stated that she had never seen the resident wearing glasses. During an interview conducted at 8:25 a.m. on December 17, 2015, the MDS Coordinator stated that if a resident has impaired vision they should have obtained an order for [REDACTED]. A policy for Obtaining Orders for Consults Outside of the Facility revealed when a change in assessment is noted in a resident's level of function, the responsible party will be contacted for permission to coordinate corresponding consults such as dental and ophthalmic services and the assessment, discussion with responsible party, and outcome will be documented in the medical record.

Based on review of the clinical records, staff interviews, and policies and procedures, the facility failed to ensure that [MEDICAL TREATMENT] assessments were consistently completed for two residents (#s 106 and 189). Findings include: -Resident #189 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The orders also included the following: immediately after [MEDICAL TREATMENT] check for bleeding from the arteriovenous (AV) shunt site; monitor for signs of electrolyte imbalance x 3 on Tuesday, Thursday and Saturday; and check for thrill and bruit 3 times a week on Tuesday, Thursday and Saturday. Review of the clinical record revealed that there were multiple times in November and December 2015, with no documentation of any pre and/or post [MEDICAL TREATMENT] assessments which were completed, including no documentation that the AV shunt site was checked for bleeding after [MEDICAL TREATMENT], or that the resident was monitored for electrolyte imbalance after [MEDICAL TREATMENT] or that the shunt site was checked for thrill and bruit on [MEDICAL TREATMENT] days. An interview with a Licensed Practical Nurse (LPN) was conducted on December 17, 2015. The LPN stated that she is suppose to take vital signs, weight, and check the shunt site before the resident leaves the building for [MEDICAL TREATMENT] and when the resident returns to the facility. She also stated that the nurses are suppose to chart the assessments in the nurse's notes and/or on the treatment administration record (TAR). An interview was conducted with the Administrator on December 17, 2015, who stated that [MEDICAL TREATMENT] assessments should be done prior to and upon returning and should be charted in the nurse's notes and/or on the TAR. The Administrator stated the nurse's should be monitoring the [MEDICAL TREATMENT]. However, she was unable to locate this information. -Resident #106 was admitted on [DATE], with [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Review of the [MEDICAL TREATMENT] care plan revealed the following interventions: check the shunt site for bleeding; check for signs and symptoms of electrolyte imbalance immediately after [MEDICAL TREATMENT]; and to monitor the [MEDICAL TREATMENT] site for signs and symptoms of infection. A review of the clinical record including the Treatment Administration record (TAR) for October 2015, revealed that pre and post [MEDICAL TREATMENT] assessments were not completed on October 28, and the dressing from the shunt was not removed on October 29, the next morning after [MEDICAL TREATMENT] or on October 31, the next morning after [MEDICAL TREATMENT]. An interview with a LPN was conducted on December 17, 2015 at 1:13 p.m. She stated that before the resident leaves for [MEDICAL TREATMENT], she will assess the resident's vital signs, check the [MEDICAL TREATMENT] site for bruit and thrill and check for signs of bleeding. She stated that she will do the same process immediately following the resident's return from [MEDICAL TREATMENT] and four hours later. Further, she stated that the next morning after [MEDICAL TREATMENT], the dressing will be removed and the [MEDICAL TREATMENT] site is left open to air and she will document everything in the nurse's notes and TAR. In an interview with the Director of Nursing (DON) conducted on December 17, 2015 at 1:52 p.m., she stated that she expects the nurses to follow the [MEDICAL TREATMENT] policy, unless the physician has a different order. At this time, the clinical record and the October 2015 TAR were reviewed with the DON and she confirmed that there was no documentation that pre and/or post [MEDICAL TREATMENT] assessments were completed on October 28, nor any documentation that the dressing was removed the next morning after [MEDICAL TREATMENT] on October 29, and October 31. A facility policy for [MEDICAL TREATMENT] included that the shunt site will be assessed by a nurse for patency and thrill/bruit, prior to each [MEDICAL TREATMENT] appointment. Upon return from [MEDICAL TREATMENT], the nurse will immediately assess the shunt site for signs of bleeding, and monitor the resident for signs of electrolyte imbalance, including weakness, lethargy, altered mental status, and fast or slow pulse. The policy further included that the shunt site assessment will be repeated four hours post return from [MEDICAL TREATMENT] and that the nurse is to document completion of the assessment and notify the physician of any abnormal assessment or changes in condition.

Based on clinical record reviews, staff interviews, facility documentation and policy review, the facility failed to ensure that adequate supervision was provided and that safety measures were consistently implemented for three residents (#183, #182, and #13) to help prevent falls. The sample size was 5. Findings include: -Resident #183 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Fall Risk assessment dated [DATE], revealed a score of 12, indicating the resident was at high risk for falling. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident required extensive assistance with transfers and activities of daily living. The resident was also identified to have had multiple falls. Review of the falls care plan from September 1, 2013 through December 31, 2013, revealed the resident was at high risk for falling, due to Parkinson's disease, dementia, decreased safety awareness, removes alarms, transfers without assistance, and had delusions. Some of the interventions included the following: implement every hour toileting, implement ambulation schedule, wedge cushion on wheelchair, tab alarm on wheelchair, pressure alarm on back of chair to remind resident to sit back, move resident closer to nurse's station, low bed with mat, and consult the pharmacist for a medication review. According to the facility falls investigative documentation revealed from September 1, 2013, through December 31, 2013, the resident fell more than twelve times from the bed/chair or while standing and had five trips to the emergency room for injuries. Review of the closed clinical record, including the facility investigative documentation revealed that for each fall, there was a lack of documentation regarding what safety measures were in place at the time of each fall. In addition, there was a lack of documentation of any increased supervision that was consistently provided. A physician's orders [REDACTED]. A quarterly MDS assessment dated [DATE] identified that the resident continued to require extensive assistance with transfers and sustained multiple falls. Review of the facility's investigative documentation dated January 30, 2014, revealed the resident tried to stand up from the commode, lost her balance and fell backwards, hitting her head on the bedside table. The report documented that the resident's sensor pad alarm was alarming. However, there was no further documentation regarding if any other safety measures were in place at the time of the fall, as care planned. A physician's orders [REDACTED]. Review of the facility's fall investigative documentation dated March 4, 2014, revealed that the resident was observed on the floor and had hit the side of her face. The report also stated that the resident fell after requests for her to sit still. Again, there was a lack of documentation if safety measures were in place at the time of the fall. A physician's orders [REDACTED]. Further review of the closed clinical record revealed that from January 1, 2014, through March 4, 2014, this resident had more than thirty falls and two trips to the emergency room . The resident was readmitted on [DATE]. Despite the high number of falls, there was no falls care plan that was developed upon readmission. An interview was conducted on November 5, 2014, with the Administrator. In regards to the lack of a care plan completed upon readmission, she stated that when this resident came back to the facility on [DATE], she was unable to get out of bed. An interview was conducted on November 5, 2014, with a licensed practical nurse (LPN). The LPN stated that for a resident who is at risk for falls the following interventions could be implemented: fifteen minute checks, mats, chair and bed alarms, pocket care plans indicating fall risk, move resident closer to the nurse's station, check for urinary tract infection, psychological evaluation, medication review, and toileting schedule. She also stated that care plans are updated after each fall. She further stated that sometimes a resident is put on one to one if necessary. An interview was conducted on November 7, 2014, with an LPN. The LPN stated that when a resident falls, an incident report is done, and the falls care plan is copied and stapled to the incident report, but no documentation is done to indicate what interventions were in place at the time of the falls. -Resident #182 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Falls Care Plan dated June 7, 2013, revealed the resident had a history of [REDACTED]., assist in ambulation, transferring, toileting-check comfort level every two hours, bed in low position, assess for need of other safety interventions such as low bed, toileting schedule, etc, observe for functional decline due to psychotropic use, and observe, record, and correct all unsafe conditions. Review of the Fall Risk assessment dated [DATE], revealed a score of 16, which indicated the resident was at high risk for falls. Review of a resident care plan dated June 10, 2013, revealed that the resident was non-compliant with alarms and the interventions were for safety checks in place and education. According to the facility's investigative documentation for July and August 2013, revealed that this resident fell on [DATE] and 28, 2013 and on August 14, 17, and 27, 2013, for a total of five falls in five weeks. Some of the falls resulted in lacerations, skin tears, a minor head injury, and several trips to the emergency room for evaluation and treatment. Further review of the clinical record and the facility's investigative documentation revealed that there was a lack of consistent documentation regarding if safety measures as care planned, were in place at the time of the falls and that increased supervision was consistently provided. An interview was conducted on November 6, 2014, with an LPN. The LPN stated that when a resident is at risk for falls, they are assessed, and the appropriate interventions implemented. She also stated that when a resident continues to fall, additional interventions are implemented, such as thirty minute or fifteen minute safety checks. -Resident #13 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was alert and oriented to person only. A Fall Risk assessment dated [DATE], assessed the resident to not be a fall risk, despite the resident having six falls from April to July 14, 2014. Review of the falls care plan revealed the resident was at high risk for falls, due to self transfers and loss of balance, and picking items off of floor. Interventions included the following: investigate the cause of a fall, reassess the need for appropriate assistive devices, administer pain medication per physician's orders [REDACTED]. The quarterly MDS assessment dated [DATE], revealed the resident had severe cognitive impairment and required extensive assistance with bed mobility and transfers. The assessment also included the resident had multiple falls. Further review of the clinical record revealed that the resident had more than eight falls from April 2014 to October 2014. The Falls Care Plan was revised multiple times with additional interventions initiated such as: 15 minute safety checks, tab/pressure alarm for wheelchair and bed, two hour toileting schedule, two hour turning schedule, an ambulation schedule, wedge cushion in wheelchair, mattress to floor next to bed per family's request, and non-slip pad to wheelchair. However, according to the clinical record and the facility's investigative documentation, it was unable to be determined if the care planned interventions were in place at the time of the falls. There was also a lack of documentation of any increased supervision that was consistently provided. An interview was conducted on November 7, 2014, with an LPN. The LPN stated that the interventions that are currently in place for this resident to prevent falls are bed and chair alarms, floor mattress, bed in low position, frequent toileting, and 15 minute safety checks. She also stated that when a resident falls, an incident report is done, and the falls care plan is copied and stapled to the incident report, but no documentation is done on the incident report to indicate the interventions that were in place at the time of the falls. Review of the facility's policy on Falls and Fall Risk Management revealed that staff were to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falls and to try to minimize complications of falling. The policy also included that these interventions are to be based on previous evaluations and current data. If falling recurs, staff will complete a root cause analysis of each fall, and will implement additional or different interventions. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped. The policy further included that if the resident continues to fall, staff will re-evaluate the situation and determine if it is appropriate to continue or change current interventions.

Based on observation, clinical record review, hospital record review, staff interviews, observations, and facility policy review, the facility failed to ensure that four residents (#s 153, 128, 25, and 116) received the care and services to promote the healing of existing pressure ulcers and promote the prevention of pressure ulcer development. All four residents sustained actual harm. The sample size was six. Findings include: -Resident #116 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of an admission assessment dated [DATE], revealed that a measurement of the resident's sacrum pressure ulcer as 1 cm X 0.4 cm X 0.5 cm and an open area on coccyx with slough present. A review of the nursing notes dated November 12, 2011, revealed that the resident required complete staff performance to position in bed and that the resident did not help in repositioning at all. The resident was not able to make slight changes in body/extremity position without assistance. On November 14, 2011, the physician ordered to apply [MEDICATION NAME], apply [MEDICATION NAME] border dressing every day and as needed until the pressure ulcer healed. Then to monitor the pressure ulcer for signs and symptoms of infection. The nurses notes dated November 16, 2011, revealed the following documentation: "Upper sacrum measuring a length of 1 cm length by 0.5 cm width by 0.5 cm depth, tissue type necrotic, progress: worsened." The physician then ordered to discontinue the current treatment to the pressure ulcer on this same date and then begin to cleanse coccyx wound with wound wash, then to apply santyl to black eschar. Apply [MEDICATION NAME] border dressing every day and as needed. A review of the initial MDS assessment dated [DATE], revealed documentation that the resident was totally dependent for bed mobility with two person assistance. The resident was admitted with a stage IV pressure ulcer that measured 0.4 cm X 0.5 cm X 0. Section V of the MDS CAA noted that the resident triggered for pressure ulcers and directed staff to address this issue in the care plan. Review of physician orders [REDACTED]. The clinical record review and the care plan interventions lacked documentation that the gel cushion had been implemented. A review of the resident's care plan dated November 22, 2011, revealed skin integrity addressed. The care plan lacked documented evidence of care planning for non-compliance by the resident with turning/repositioning. Nurses notes dated November 23, 2011, revealed the following wound assessment, "Upper sacrum 3 cm X 1.5 cm X 0.5 cm. Moderated amount of exudate, Necrotic tissue. Progress-becoming larger with noted mild odor to wound". An assessment documented on November 30, 2011, revealed, "4 cm X 4 cm X 0.5 cm moderate exudate, necrotic tissue. Progress; becoming larger, noted foul strong odor. Order obtained for culture and sensitivity of wound. Antibiotic therapy started. Orders changed for treatment of [REDACTED]. On December 1, 2011, the physician discontinued the previous wound care to cleanse the pressure ulcer to coccyx with wound wash apply santyl to necrotic area prep peri wound with skin prep. Apply [MEDICATION NAME] to necrotic area cover with [MEDICATION NAME] dressing daily and as needed. An assessment dated [DATE], revealed that 27 days after the resident's admission an order was obtained for an alternating pressure mattress due to resident's paralysis and inability to reposition self. Wound measurements were documented at this time as "...4.5 cm X 4.4 cm X 1 cm. Undermining from 9 o'clock to 2 o'clock at 0.5 cm. Moderate amount of exudate. Necrotic tissue. Progress; becoming larger Moderate amount of odorous drainage..." Review of physician orders [REDACTED]. Per nurses noted dated December 9, 2011, the "resident stated that she could not lay on side because it hurt her back" Resident educated at this time regarding wound healing and repositioning. No further reference of the the resident's non-compliance with repositioning was documented during this time period. The gel cushion was again re-ordered a second time on December 17, 2011, by the physician. An assessment on December 14, 2012 documented the following wound measurements, 5.5 cm length X 4 cm width X 2 cm depth. Undermining noted from 12 o'clock to 6 o'clock at 2 cm. Moderated amount of exudate Necrotic tissue. progress: becoming deeper, Stage IV, noted muscle. 30% adherent yellow slough, 40% necrotic tissue and 30% red tissue. A review of physician orders [REDACTED]. This was unrelated to the resident's pressure ulcer. The resident returned from the hospital December 22, 2011. Upon return to the facility, the physician discontinued the order to send the resident to the original wound clinic and ordered her sent to another wound clinic as soon as possible. Wound measurements dated February 17, 2012, from the wound clinic documented as follows: 6.5 cm X 1.4 cm X 1.2 cm, on continuous wound vac at 125 mmHg (negative pressure). No debridement was performed. A review of the physician orders [REDACTED]. A review of the resident's lab results dated March 3, 2012, revealed that a segment of bone from coccyx was positive for osteo[DIAGNOSES REDACTED]. Wound measurements dated March 23, 2012, from wound clinic as follows, 7.0 cm X 3.9 cm X 2.1 cm, continuous wound vac with negative pressure. Debridement performed. Wound measurements dated April 6, 2012, from wound clinic as follows: 5.8 cm X 4.6 X 3.0; wound vac at 125 mmHg, continuous; debridement performed exposed bone. Wound measurements dated April 13, 2012, from wound clinic as follows: 6.5 cm X 3.2 cm X 2.1 cm; wound vac at 125 mmHg continuous. Debridement performed, exposed bone. An interview conducted with a CNA conducted on April 26, 2012, revealed that she was unable to recall how long the resident had a gel cushion on her wheelchair. An interview conducted with a LPN on April 26, 2012, revealed that she could not explain why a gel seat cushion had been ordered in November, December and again in February. The nurse further revealed that the resident had not been sent to the first wound clinic secondary to family preference for another wound clinic, however, she could not explain why it took 21 days for the appointment to be made other than her hospital stay of three days may have delayed the appointment decision. The nurse was unable to explain why a Clinitron bed had not been ordered or an attempt made to obtain insurance approval for one when her pressure ulcer had worsen. An interview with the DON was conducted on April 26, 2012. The DON stated that the resident had been non-complaint with repositioning and was unable to explain why the care plan did not address this. -Resident #26 was admitted to the facility originally on June 21, 2006 and readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the treatment record revealed that for the months of January and February 2012 each box was initialed by a nurse that the TED hose were put on the resident in the morning and removed in the evenings. Review of the weekly skin check sheet which was completed by nursing staff on a Monday night revealed that on February 6, 2012, the resident's skin was documented to be intact. Nursing staff documented that TED hose were applied every morning and removed every evening, however a pressure ulcer on the resident's right heel was not located until February 13, 2012, when it was noted to have eschar. The weekly skin check sheet documented treatment was to be off loading heels. Review of physician's orders [REDACTED]. It was documented that the resident had a 1 X 1 cm area with eschar. Review of the treatment record for February 2012 revealed that these orders were followed beginning on February 13, 2012, and were initialed by the day and evening shift by all the nursing staff. Review of the weekly skin check sheet dated February 20, 2012, revealed a stage two ulcer on the resident's left buttock. It was noted to be 1 cm X 0.5 cm in size and treatment was started. The right heel pressure ulcer was not assessed. Review of pressure ulcer record revealed that on February 27, 2012, a suspected deep tissue injury was discovered on the resident's right heel. When discovered the area was 1.1 X 1 cm and was black/brown in color. The record indicated that this was a new finding and that the physician and dietary were notified. It also indicated that the care plan was updated. There was no documented evidence to show that the care plan was updated at this time. Continued review revealed the following week on March 6, 2012, the right heel was staged at stage III pressure ulcer and had increased in size to 1.3 cm X 1.1 cm with a depth of 0.2 cm and had light drainage. The ulcer was 80% red and 20% yellow and was causing the resident pain at 5 on a scale of 10 with 10 being the worst pain. Review of the pressure ulcer record revealed the wound continued to increase in size and depth however no new physician's orders [REDACTED]." Review of the resident care plan revealed that the care plan was not updated until March 8, 2012, to include pressure ulcers on left buttock stage II and right heel stage III, related to nutritional status and non compliance with turning and off-loading heels. The goal listed for the resident was that the pressure ulcers would exhibit signs of healing and be free from infections by April 8, 2012. Approaches included to report changes in skin status to physician, to monitor the effectiveness of response to treatment, to complete weekly skin check, and to complete a Braden Scale Risk assessment. Review of the pressure ulcer record revealed that the wound continued to increase in size and on March 20, 2012 it was noted to be 2.2 cm X 1.4 cm X 0.4 cm deep with moderate drainage. The response to treatment continued to be documented as "Fair." There was no evidence that the physician was notified and no new physician orders [REDACTED]. Review of physician's orders [REDACTED]. It further stated to resume the use of TED hose once wound had healed. Although the resident had continuing treatment for [REDACTED]. The resident score was 18, which indicated the resident was not at risk for pressure sore development. An interview was conducted with a CNA on April 26, 2012 at 9:25 a.m. The CNA stated that the CNA's put the resident's TED hose on and off. On in the morning and off at night. She further stated that she always checked the resident's feet and legs during the process. An interview was conducted with a LPN on April 26, 2012 at 9:30. She stated that the nurses should initial the treatment records for the residents. She further stated that the nursing staff who initial the treatment records have performed the treatment listed. She stated that if the nurses initialed the treatment record then the nurses put the TED hose on in the morning and off in the evening. She stated that they look at the resident's skin prior to putting on and after taking off the TED hose. The nurse further stated she did not know how a resident who has TED hose applied daily could go from intact skin to having eschar on a heel. An interview was conducted with a LPN on the 200 hall on April 26, 2012, who stated that the nurse or the CNA's would put on and take off the TED hose. She stated that the nurse places their initials on the treatment record document that the nurse saw that the TED hose were on or off, or that the nurse put them on and took them off. She did not know how a resident who was having someone look at their heels twice a day could go from intact skin to eschar and skin breakdown. The nurse further stated that she thought she had heard quite a long time ago that the resident had "Boggy heels". Review of the resident's skin assessment sheets did not document that boggy heels were previously identified. An interview was conducted with the DON who stated that the nursing staff were responsible to put on and take off the resident's TED hose. She stated she would look into it as she did not know how a resident went from clean intact skin to a pressure ulcer with eschar. -Resident #153 was admitted to the facility on [DATE], he was readmitted on [DATE], with [DIAGNOSES REDACTED]. The clinical record review revealed an admission resident data collection form dated February 24, 2012. Page two of the form contained an area for skin condition with the instructions to use the diagrams provided and indicate all body marks such as old/recent scars (surgical and other), bruises, discolorations, abrasions, pressure ulcers, or questionable markings. The form further instructed the nursing staff to indicate the size and depth in centimeters as well as color and drainage. The site diagram on the form was marked with circles on the inner aspect of both elbows, the left wrist, the lower back/bottom area and the front and back of both ankles. The diagram did not have a circle to indicate a problem with the resident's abdominal fold area. The area for comments was left blank, the special treatments and procedures area was blank and the box to indicate that a pressure ulcer record should be reviewed was left blank. A Braden scale for predicting pressure sore risk was completed on February 26, 2012, which gave the resident a total score of 15. The form stated a score of 15 to 16 indicated a low risk of pressure sore development Review of physician's orders [REDACTED]. Review of the dietary assessment dated [DATE], revealed that the resident was a low risk for skin conditions and stated the resident's skin was intact. Although orders were received on February 27, 2012, to apply butt paste to the resident's coccyx no care plan was created. Review of the resident's care plan dated March 7, 2012, revealed a problem of impaired skin integrity related to urine and or bowel incontinence, diabetes, altered nutritional status and recent decline in activity of daily living, mobility. This was manifested by a stage II pressure ulcer, the care plan did not specify where the ulcer was located. The approaches included doing a skin assessment per policy, evaluate the ulcer healing per policy and reduce pressure and friction. The goal listed was to regain skin integrity in one month. Review of the MDS 14 day admission assessment dated [DATE], Section G, revealed that the resident required extensive assistance of two staff members for bed mobility, transfer, dressing and toileting. It further revealed that the resident required full staff performance every time for personal hygiene as he was totally dependent. Further review of the MDS 14 day admission assessment Section H stated that the resident had an indwelling urinary catheter and was always incontinent of bowel and was not on a toileting program. On March 12, 2012 a new stage II pressure ulcer was identified on the resident's right lower buttock, it began as a 1 cm by 2 cm pink sore but it grew in size and was assessed to have combined with the right ischium wound on April 3, 2012 and had increased in size to 5.4 cm by 4 cm by 0.1 cm in depth. The pressure ulcer record recorded the response to treatment as "Fair" but there was no indication that an order to change the treatment of [REDACTED]. Further review of the care plan revealed it had been updated on March 12, 2012 to reflect the new stage II to right lower buttocks, cleanse with normal saline cover with [MEDICATION NAME] every three days until healed. This was discontinued on March 16, 2012, and the new physician's orders [REDACTED]. Review of the pressure ulcer records for resident #153 revealed he had developed multiple pressure ulcers. During the month of April 2012 the resident was being treated for [REDACTED]. On April 10, 2012 the lower right buttock/right ischism wound was assessed to be a stage III and was now 7.4 cm by 7 cm and was 0.2 cm deep with a moderate drainage. It was assessed to be responding poorly to treatment. The physician was notified and new treatment orders were obtained. Review of physician's orders [REDACTED]. Review of the pressure ulcer record for the resident's coccyx revealed that it was assessed on April 11, 2012, to have healed into two smaller wounds. Although the resident was receiving daily treatment to that wound, a new ulcer was not discovered until it had reached stage III on the resident's left lower buttock. The initial measurement of the wound on the resident's left lower buttock indicated it was 6.4 cm by 8 cm in size and was 0.2 cm deep with moderate drainage, had no odor and was red in color. Further review of the physician's orders [REDACTED]. Review of the weekly skin check sheet dated April 16, 2012, did not mention the left lower buttock stage III wound or its treatment. Review of the resident care plan did not reveal any updates or interventions regarding the new pressure ulcer. On April 20, 2012, the resident was sent to the hospital for further evaluation due to a change in condition of his oxygen saturation. Review of the hospital wound clinic recommendation dated April 23, 2012 for care of the resident's wounds included dressing changes every 48 hours with skin prep to the skin surrounding the wound, [MEDICATION NAME] AG as a primary dressing and cover with [MEDICATION NAME] border or CombiDERM. The resident was readmitted to the facility on [DATE], the resident's wound were assessed and measured and the weekly skin sheet documented that the wounds were "Present on admission." Review of the resident data collection tool dated April 26, 2012 revealed under skin conditions that the body diagram was marked to indicate problem areas on both inner elbows, the resident's left knee and right heel. Also marked were several areas on the resident's bottom. The comments included on the form indicated that the resident had skin tears on right and left antecubital areas due to IV placement, he had an open wound on his right heel, a small scabbed area over his right knee. The special treatments and procedures listed included the heel wound would be cleansed, [MEDICATION NAME] AG, [MEDICATION NAME] heel foam and wrap with Kerlix would be done for the resident's heel. It further stated that the resident's sacral area would receive barrier cream daily. Review of physician's orders [REDACTED]. On April 30, 2012, the order was clarified to include to clean open area on posterior scrotum with soap and water apply protective barrier cream twice day and and as needed when the resident was soiled. Then to clean open area on left sacrum with soap and water apply protective barrier cream twice day and as needed with the goal to heal without complications. Review of a care plan dated April 26, 2012, for altered skin condition as evidenced by skin tear, bruise and abrasion listed a goal of will remain free from infection through next review in 90 days. Approaches included treatment per orders, weekly skin assessment, dietary supplement per best practice guidelines and pressure relieving alternating air mattress, to reposition the resident every two hours and as needed. To provide incontinent care every two hours and as needed, to apply moisture barrier skin care as needed and heel protectors/boots. Review of the Braden Scale for predicting pressure sore risks dated April 29, 2012, revealed a score of 13 which indicated a moderate risk of developing pressure sores. The resident was observed sitting in his wheelchair outside his room on April 30, 2012. He was sitting with his feet on the floor, no heel protection or boots were in evidence. The resident asked for assistance to get back into bed and a CNA was located to assist the resident. The resident was later observed to be lying on his back in bed. No heel protectors or boots were iobserved. An observation was made of the resident's bed. It had an air waffle mattress overlay but was not an alternating air mattress. The resident was again observed on May 1, 2012, to be lying on his back in bed, no heel protectors or boots were observed at this time. An observation of the resident's wounds was made on May 2, 2012 at 2:00 p.m. The right and left lower buttock wounds were both stage III wounds with the loss of the full thickness of skin. An interview was conducted with the LPN on May 2, 2012. The LPN stated that the wounds looked deeper to him than the last time he had viewed them. He was unsure if the butt paste was an effective treatment for [REDACTED]. He further stated if the treatment was okay with them it was okay with him. An interview was conducted with the DON who stated she had not heard of using butt paste on stage III wounds. -Resident #128 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission order was written on January 5, 2012, for wound care as follows: sacral, right hip, left heel, right foot and right knee-clean wound with cleaner, apply [MEDICATION NAME] AG two layers, cover with [MEDICATION NAME] dressing, change every three days and as needed. Review of the Braden Scale for Predicting Pressure Sore Risk dated January 6, 2012, had a score of 13 which is considered a moderate risk for the development of pressure ulcers. However, the resident was admitted with one stage IV pressure ulcer, and four unstageable pressure ulcers which should have made the resident a high risk for pressure ulcers. Review of the Pressure Ulcer Records for resident #128 dated January 6, 2012, revealed the following pressure ulcers: Pressure ulcer #1- Right hip-an unstageable pressure ulcer that measured 6.2 cm by 5.4 cm with no depth documented. Pressure ulcer #2-Coccyx-stage III pressure ulcer that measured 5 cm by 3.5 cm with a depth of 0.4 cm. Pressure ulcer #3-Right foot-an unstageable pressure ulcer that measured 3 cm by 1.6 cm with no depth documented. Pressure ulcer #4-Right knee-unstageable pressure ulcer that measured 2.4 cm by 2.9 cm with no depth documented. This pressure ulcer was documented as healed five days later. The admission MDS assessment dated [DATE], noted that the resident had one stage III, one stage IV, and four unstageable pressure ulcers. The MDS assessment noted that the resident was totally dependent on staff for bed mobility. A physician's orders [REDACTED]. Review of the Skin/Wound Treatment Record for February, 2012, revealed that no documented evidence that wound care was done for the pressure ulcer #2- the coccyx, left heel (not previously identified on January 6, 2012, on the pressure ulcer records), pressure ulcer #3-right foot, and pressure ulcer #4-right knee from February 27 to March 3, 2012, a total of five days. Review of the Activities of Daily Living for February, 2012, bed mobility revealed no documented evidence that the resident had been turned at all during the day shift for 12 days and the night shift for three nights. However, this totally dependent resident was care planned to be turned every two hours. A physician's orders [REDACTED]. Review of the Pressure Ulcer Record dated March 6, 2012, revealed that a new pressure ulcer was observed on the left outer foot that was brown and a suspected deep tissue injury that measured 3.1 cm by 1.2 cm with no documented depth. Review of the Pressure Ulcer Records dated March 14, 2012, revealed the following pressure ulcer measurements: Pressure ulcer #1-Right hip-8 cm by 8.1 cm with a depth of 0.6 cm-moderate drainage, 40 percent necrotic slough, 60 percent beefy red Pressure ulcer #2-Coccyx-4.9 cm by 3.1 cm with a depth of 0.2 cm-moderate drainage, 100 percent pink with a poor healing response Pressure ulcer #3-Right foot-2.2 cm by 1.7 cm with a depth of 0.2 cm-light drainage, 100 percent beefy red with a poor healing response. Pressure ulcer #4-new pressure ulcer on left inner foot by big toe that was black, a suspected deep tissue injury, that measured 0.9 cm by 1.8 cm with no documented depth. A review of the physician's orders [REDACTED]. Further review of the Pressure Ulcer Records for March 20, 2012, revealed the following new pressure ulcers not previously identified: Pressure ulcer #5-Right inner great toe-black/brown, suspected deep tissue injury that measured 1.1 cm by 1 cm with no documented depth. Pressure ulcer #6-Right inner foot- purple/black/brown, suspected deep tissue injury that measured 2.2 cm by 2.3 cm with no documented depth. Pressure ulcer #7-Left inner heel- black/brown/purple, suspected deep tissue injury that measured 2.1 cm by 1.5 cm with no documented depth. Pressure ulcer #8-Right outer ankle- black/brown, suspected deep tissue injury that measured 0.6 cm by 0.3 cm with no documented depth. Review of the clinical record for resident #128 revealed no documented evidence that the physician was notified of the change in condition of the resident's pressure ulcers. Review of the Pressure Ulcer Record dated April 10, 2012, revealed a new pressure ulcer on the right heel, purple and boggy, suspected deep tissue injury that measured 4.8 cm by 3.4 cm with no documented depth. Also revealed were the following pressure ulcer measurements: Pressure ulcer #1-Right hip-red/black/yellow, 7.5 cm by 7.5 cm with a depth of 0.5 cm, moderate drainage, four odor, undermining 10-3 at 1.4 cm. Pressure ulcer #2-Coccyx-red, 3.5 cm by 1.8 cm with a depth of 0.2 cm, moderate drainage, undermining from 12 to 6 o'clock-0.2 mg. Pressure ulcer #3-Right foot-red 3.2 cm by 2.1 cm, with a depth of 0.2 cm, light drainage, and poor response to treatment. Pressure ulcer #4-Left inner foot-red, 2.2 cm by 2.0 cm with a depth of 0.1 cm, light drainage, and poor response to treatment. Pressure ulcer #5-Right inner great toe-purple/black, 1.8 cm by 1.8 cm, no depth and no drainage. Pressure ulcer #6-Right inner foot-purple/red, 3.8 cm by 3.2 cm with no depth and no drainage. Pressure ulcer #7-Left inner heel-red, 1.6 cm by 1.0 with a depth of 0.1, and light drainage. Pressure ulcer #8-Right outer ankle-healed. A review of the physician's orders [REDACTED]. An observation of a pressure ulcer dressing change on April 25, 2012, by the wound nurse revealed the following: Pressure ulcer #1- Right hip- 50 percent granulated, 40 percent slough, and 10 percent black, 8.0 cm by 7.5 cm with a depth of 0.3 cm. Pressure ulcer #6- Right inner ankle- black/brown, 4.0 cm by 4.2 cm with a depth of 0.1 cm. Pressure ulcer #4- Left ankle- 50 percent brown, 30 percent slough, and 20 percent granulated, 2.0 cm by 2.2 cm with a depth of 0.1 cm. An interview was conducted on April 30, 2012, with a CNA. The CNA stated that residents are turned every two hours when they were bed fast. She further stated that turning was documented in the CNA's treatment book each day as well as the number of times the resident was turned. An interview was conducted with a LPN on April 30, 2012. The LPN stated that pressure ulcer wound care was documented in the treatment book and signed off at the time care was provided. During an interview conducted on May 1, 2012, with a RN, she stated that pressure ulcer care was documented on daily notes, and in the treatment book at the time that the care was provided. Review of the facility's policy on Pressure Ulcers/Skin Breakdown revealed "...The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores: for example, immobility, recent weight loss, and a history of pressure ulcer(s)....Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation to that area and subsequent destruction of tissue...For a person in bed: Change position at least every two hours or more frequently if needed...Immediately report any signs of a developing pressure ulcer to the supervisor...The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family, and addressed..."