Every finding on record at The Rehabilitation Center at the Palazzo

Based on observation, clinical record review, facility documentation and staff interviews, the facility failed to ensure that medications were stored in locked compartments, for one resident (#3) out of 3 sampled, in accordance with policy, physician orders and with professional standards of practice. The deficient practice could result in a resident not taking the medication as prescribed, accidentally ingesting the medication or another resident accidentally taking the medication. Findings include:Resident #3 was admitted on [DATE] with diagnosis including bilateral osteoarthritis of the knee, osteoarthritis of the left shoulder, type 2 diabetes mellitus without complications, morbid obesity, restless leg syndrome, spondylosis without myelopathy or radiculopathy lumbo-sacral region, hypotension, localized edema, hypertension, major depressive disorder-recurrent, adjustment disorder, cerebral infarction due to thrombosis of right middle cerebral artery, altered mental status, atrial fibrillation, anemia, cerebral edema, shortness of breath and generalized anxiety.The discharge minimum data set (MDS) dated [DATE] revealed that the resident had a brief interview of mental status score of 13, indicating that the resident was cognitively intact.The physician orders revealed that the resident was Nystatin External Powder 100,000 unit/gm to be applied topically to affected areas. The physician orders revealed no evidence of an order for medication self-administration.The electronic health record revealed no evidence that the resident had been assessed for self- administration of medications.The care plan revealed no evidence that the resident had been authorized to self-administer any medications.An observation was conducted on August 25, 2026 at 10:55 AM in the room of resident #3. The resident was observed lying in a bariatric bed with an oxygen canula in place, as well as a fall mat to the right side of the resident's bed, a pressure reducing mattress and enabler bars on both sides of the bed. The following medications were observed on the bedside table to the right of the resident's bed: Nystop medicated powder, 15 grams which noted to apply to the affected area 2-3 times a day and a 10-ounce bottle of Goldbond medicated powder. An interview was conducted on August 25, 2026 at 10:55 AM with resident #3 who stated that both powders had been there for a while, but was unable to recall how long.An interview was conducted on August 25, 2026 at 10:59 AM with certified nursing assistant (CNA/ staff #11) who stated that medications include things like tablets but stated that she wasn't sure if anything over the counter would be considered a medication. She stated that if there was a powder in the resident's room, she would have to ask the nurse if it could be applied and stated that usually the nurses would keep powders locked up in the medication carts. The CNA stated that she would be able to apply antifungal powder but it would have to be the nurse to give it to her to apply on the resident. She stated that if a medication was in a resident's room, the risk could include that the resident may not understand what the medication is used for and apply it incorrectly.An interview was conducted on August 25, 2026 at 11:06 AM with CNA/ staff #37 who was observed to come out of resident #3's room. The CNA stated that a medication can be used to reduce pain or as treatment such as with chronic diseases. The CNA stated that medications can not be kept at bedside. She stated that medications must be with the nurse in the locked medication cart. The CNA stated that she looks for medications at bedside every time she enters a resident's room. The CNA and surveyor then entered the resident's room and the CNA observed the Nystop and Goldbond medicated powders on the resident's bedside table and stated that these should not be there. She stated that both were medications. She stated that the risk for the medications at bedside could include the resident ingesting the medication. The CNA removed both medications and brought them to the nurse.An interview was conducted on August 25, 2026 at 11:17 AM with licensed practical nurse (LPN/ staff #85) after CNA / Staff #37 brought her the medications removed from the room of resident #3, who stated that medications should not be in a resident's room at bedside. The LPN reviewed the resident's electronic health record and stated that the Nystatin Powder was prescribed by the physician but that the were was no evidence of an order for the Goldbond Medicated Powder. The LPN reviewed the resident's record for a self-administration order and stated that there was no order for the resident to be able to self-administer medications. The LPN stated that there was no assessment or care planning for medication self-administration. The LPN stated that all medications should be kept locked in the medication cart. The LPN stated that the risk could include accidental ingestion.An interview was conducted on August 25, 2026 at 11:26 AM with the director of nursing (DON/ staff#100) who stated that a medication can be prescribed or not prescribed and administration routes can include intravenous, oral, topical, subcutaneous, inhaled, eye drops, or ear drops. The DON stated that medicated powders are medications and that residents were not allowed to have medications at bedside unless they were assessed for being able to safely self-administer medication and an order was in place. The DON stated that resident #3 was not able to self-administer medications. The DON reviewed the electronic medical record for resident #3 and stated that there were no orders for medication self-administration, no an assessment and no care plan entry. The DON stated that medicated powders should be stored and locked in the medication cart. The DON stated that risk to the resident could include the resident not using the medications as intended, not using the right directions or timing or could possibly ingest the medication.The facility policy titled Medication Storage in the Facility revised January of 2025 revealed that only licensed nurses, pharmacy personnel and those lawfully authorized are allowed access to medications.The facility policy titled Medication Administration-General Guidelines effective October 2017 revealed that residents are allowed to self-administer medications when specifically authorized the attending physician and in accordance with procedures for self-administration of medications and that medications are administered in accordance with written orders of the attending physician.

Based on the clinical record review, facility documentation, and staff interviews, the facility failed to notify the Office of the State Long-Term Care Ombudsman (OSLTCO) of one resident's transfer (Resident #1). The deficient practice had the potential to limit the Ombudsman's ability to advocate for residents' rights and ensure safe, appropriate transitions of care.Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses that included unspecified dislocation of the left knee, subsequent encounter; paraplegia, unspecified; depression, unspecified; and muscle weakness (generalized).An admission MDS (minimum data set) assessment dated [DATE], revealed a BIMS (Brief Interview of Mental Status) score of 14, which indicated intact cognition. A skilled nursing facility to skilled nursing facility transfer referral dated February 6, 2026, revealed that a referral to another skilled nursing facility was made due to the resident's request.A social services progress note dated February 6, 2026, revealed that a skilled nursing facility to skilled nursing facility transfer referral was submitted to another facility.A social services progress note dated February 10, 2026, at 2:24 PM revealed that skilled nursing facility to skilled nursing facility transfer procedures were discussed with Resident #1's family member/ POA (power of attorney) on February 6, 2026. The progress note further stated that on February 10, 2026, the family member clarified that she was not actually the resident's family member or the POA, and that Resident #1 consented to have her treatment and care discussed with this individual. The progress note also revealed that a discussion was made with the individual regarding the potential transfer and that discharge planning would continue through the coordination of the social services director and the interdisciplinary team, and the attending physician. A notice of transfer or discharge date d February 10, 2026, at 3:58 PM revealed an effective transfer or discharge date of February 10, 2026, to another skilled nursing facility because the health of Resident #1 had improved sufficiently and she no longer required services provided by the facility, and, that if she should want to appeal the transfer/discharge, she would have needed to do so within 10 days of the notification.A nursing progress note dated February 10, 2026, at 4:31 PM revealed that the resident left the facility and that a discharge assessment had been completed. The note also stated that the transfer was reported to a POA/family member.There was no evidence of additional information regarding the discussion of the discharge planning or the notification to the ombudsman at the same time as the resident regarding the transfer or discharge in the resident's progress notes.There was no evidence of information regarding discharge planning in the resident's care plan.On March 25, 2026, at 11:47 AM, a telephone interview was conducted with the OSLTCO (Office of the State Long-Term Care Ombudsman). The OSLTCO stated that the notice of discharge had not been received in a manner that would advocate for the resident's rights to appeal the notice and stay in the facility. The OSLTCO had also stated that transfers and discharges of emergency hospital transfer or death are acceptable notifications at the end of each month. However, the OSLTCO stated that for any other types of discharges, the facility must provide notice of discharge to the resident or representation at least 30 days before the discharge on [DATE], at 12:00 PM, a telephone interview was conducted with Resident #1. Resident #1 stated that a male staff member completed her admittance to the facility and expressed the desire to look into long-term care placement. Resident #1 stated that the male staff had told her she had been admitted to the wrong facility due to the facility being a short-term care facility, and that she would need to request looking into another facility. Resident #1 further stated that the male staff member did not say why the facility could not allow her to reside in the facility as a long-term resident. Resident #1 stated that due to this interaction with this male staff member, her overall view of the facility had been upset and geared her mind to find a facility that would accept her wishes for long-term care. Resident #1 stated that she received notification of a potential placement on Monday, February 9, 2026. Resident #1 also stated that the day of her discharge, February 10, 2026, she was provided a document to sign and had been unable to sign her full name, so she just signed an 'R' as an initial. Resident #1 stated she had been unaware of the opportunity to appeal the transfer and discharge, and that she could have had the opportunity to discuss the transfer and her concerns regarding the transfer with an ombudsman. Resident #1 stated that she had been unaware of the process until she had the opportunity to have a conversation with the ombudsman and her current facility.On March 25, 2025, at 12:23 PM, an interview was conducted with the social services director (Staff #80), who stated that the discharge process starts at the time of admission and will continue throughout their stay. Staff #80 also stated that transfers do occur if a resident decides to; at that point, the physician is included to assist with the communication from facility to facility. Staff #80 stated that if a short-term stay wishes to become a long-term stay, that discussion will develop over IDT (interdisciplinary team) meetings, where it would be determine of a long-term stay can be accommodated. Staff #80 stated that the facility is at capacity and that should a current short-term resident request to become a long-term stay resident, the facility would send the resident to another facility. Staff #80 stated that this has been an ongoing discussion where she has had to advocate for residents and provide re-education to leadership regarding the detail that each bed in the facility can be a long-term stay if they were to have the coverage for the stay. Staff #80 also stated that the beds in the facility are dually certified, and there should be no issues regarding whether a resident can stay or will require a transfer or discharge. Regarding Resident #1, Staff #80 stated that she had both skilled insurance and long-term care insurance. Staff #80 also stated that Resident #1 would have been a resident who could have stayed in the facility long-term due to the dually certified bed; however, Resident #1 expressed displeasure and unhappiness regarding their care and stated a desire to leave the facility. Staff #80 stated she did not ask Resident #1 what about her care made her unhappy due to a previous conversation where the resident declined to share her preferences with care. Staff #80 also stated that regarding the notification to the OSLTCO monthly, and that she had been unaware of any other expectations regarding discharges, such as transfers.On March 25, 2026, at 2:36 PM, it was advised by the DON (director of nursing/Staff #120) that there was no evidence of a facility policy for the notification to the ombudsman.On March 25, 2026, at 2:55 PM, an interview was conducted with the DON (Staff #120). Staff #120 stated that the facility expects to document everything, regarding the notification to the OSLTCO monthly, and that she had been unaware of any other expectations regarding discharges, such as transfers.A policy titled 'Transfer and Discharge (including AMA)', last reviewed April 15, 2024, revealed that it is the policy of this facility to permit each resident to remain in the facility and not initiate transfer or discharge for the resident from the facility, except in limited circumstances.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure weekly skin assessments were provided for one resident (#21) of three sampled residents, as ordered by the physician and failed to ensure that physician orders for one resident (# 28) for diagnostic testing were addressed in a timely manner following an unwitnessed fall. The deficient practice could lead to an injury being missed and a delay in care being provided to the resident and result in skin impairments developing or worsening without staff intervention.Findings include: -Regarding Resident #28 Resident # 28 was initially admitted on [DATE], discharged on 1/12/2025 and readmitted following a change of condition on 1/16/2025 with diagnoses that included acute on chronic diastolic (congestive) heart failure, type II diabetes mellitus with hyperglycemia and chronic kidney disease, adjustment disorder with depressed mood, unspecified, mood disorder, patient’s non-compliance with other medical treatment and regimen, history of falling, personal history of (healed) traumatic fracture, acute pain due to trauma. A quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive deficits. The Patient Health Questionnaire-9 (PHQ-9) revealed a score of 3, which indicated mild mood depression. Section E of the MDS revealed no hallucinations, delusions, behavioral symptoms towards self or others, rejection of care, or wandering. Section GG of the MDS revealed that the resident required substantial/maximal assistance in the ability to roll from lying on the back to the left and right side, and return to lying on the bed, and was dependent in sitting to lying, chair to bed, or bed to chair transfers. Section J of the MDS revealed that the resident experienced frequent pain that required scheduled and PRN medications, with the worst pain rated at 7 out of 10 on the pain scale. A physician orders last reviewed 6/15/15 revealed: orders for a wheelchair cushion to protect skin integrity and mobility, bed against the wall to increase living space and ease of ambulation, catheter care, anti-anxiety monitoring every shift and daily, pain and psychiatric services evaluations. A review of the comprehensive care plan dated 4/9/2025 revealed: Risk of injuries related to falls due to history of falls, MS, medications, and patient choice to have an air overlay mattress. The care plan specified that the resident is at risk for injuries from falls related to weakness, decreased balance, limited movement/ range of motion of the right lower extremity, history of falls, MS, medications, and the patient's choice to have an Air Overlay Mattress. The care plan revealed that the resident had an unwitnessed fall on 1/9/2025 with minor injury and that an x-ray report dated 1/12/2025 showed a displaced intertrochanteric femoral fracture with no hip dislocation. Interventions included to ensure that resident’s call light was in reach and to provide prompt response to requests for assistance, place resident’s bed against the wall to increase living space and functionality of the room, encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility, encourage resident to wear appropriate footwear when mobilizing in wheelchair, fall mat at bedside and lab monitoring that included urinalysis, macroscopic with reflex to culture, urine culture, complete blood count with differential and platelet, comprehensive metabolic panel, hemoglobin A1c with eAG/Ammonia and B-type Natriuretic Peptide. A progress notes labeled “late entry” authored by the facility administrator dated 1/9/2025 at 3:45 A.M. stated, According to the Staff Nurse: Patient was found on the floor, on the side of the bed, sitting on his bottom, knees slightly bent. Small skin tear to the front of his left hand and the big toenail is loose and bloody; this writer provided first aid. The patient was put back in bed using Hoyer lift, neuro checks in progress, bed moved against the wall for safety precautions, and floor mat beneath bed, call light within reach. Resident refused to go to the hospital for further evaluation, c/o hip pain, prn Percocet administered. The resident stated that he slid out of bed. Neuro check, put back in bed using Hoyer and two other staff for assistance, skin assessment, first aid done on right big toenail and skin tear on left hand, contacted provider and DON. A eINTERACT SBAR Summary for Providers note dated 1/9/2025 at 04:14 A.M. indicating Primary Care Provider's Feedback following contact by the facility revealed: that the Primary Care Provider responded with the following feedback: A. Recommendations: Follow up with wound nurse for further treatment. Bed in lowest position. PRN Percocet for pain management. B: New Testing Orders - other - none at this time. C. New Intervention Orders - Other -None at this time. A review of records provided by the facility revealed that an order for two-view left hip and 2-view left pelvis x-rays was ordered on 1/9/2025 at 11:47 A. M. via telephone. The order was labeled as having a normal urgency rating. A review of records provided by the facility, dated 1/10/2025 at 03:59 P.M., revealed that Registered Nurse (RN/Staff # 35) contacted the mobile imaging company to inquire about a pending ordered x-ray and was advised, “Yes, we do have that patient on file.” The imaging was noted to be still pending. A review of records provided by the facility revealed that a urinalysis was collected on 1/11/2025 at 05:30 A. M. and received at the lab on 1/11/2025 at 12:55 P.M. A review of records provided by the facility dated 1/11/2025 at 11:11 A.M. revealed a progress note written by Licensed Practical Nurse (Staff # 8), which revealed that the resident had a significantly altered mental status with an inability to administer medications due to safety risk. The nurse practitioner was notified. A progress dated 1/11/2025 at 03:04 P.M. revealed that provider orders were received that included an infusion of normal saline at 50 mL/per hour for a total of 500 mL and Rocephin 1 gram IV daily for 10 days. IV insertion was recorded at 02:00 P.M., and staff were awaiting the arrival of antibiotics from the pharmacy. A review of records provided by the facility, dated 1/11/2025 at 03:32 P.M. revealed that the Director of Nursing (DON), (Staff #79), was advised by staff that imaging had not yet been completed. The DON contacted the mobile imaging company, which advised that they planned to come later that day. The note further included information from the resident who stated, “I am not having any more pain than I normally have in my hips. That’s normal for me, so hard to tell if it's worse or not.” A review of records provided by the facility dated 1/12/2025 at 03:01 A.M. revealed a progress note written by Licensed Practical Nurse (LPN), (Staff # 84) that indicated the patient had altered mental status, and exhibited some confusion, but was cooperative with care. The same LPN noted at 04:39 A.M. that the resident complained of hip pain. A review of records provided by the facility, dated 1/12/2025 at 06:09 P.M. revealed a progress note written by Licensed Practical Nurse (Staff # 8) which revealed that the resident had a slightly improved altered mental status and was able to follow commands and answer questions appropriately. The LPN noted that the resident still had complaints of hip pain, and the x-ray was done. Staff # 8 reported that the facility was awaiting imaging results. A review of records provided by the facility revealed that urinalysis results were reported on 1/12/2025 at 07:49 A.M, which indicated a final urine culture result of Mixed gram-positive and gram-negative flora > 1000,000CFU/mL. The comments indicated that there were multiple organisms present resembling urogenital flora; therefore, no further work-up was indicated. A review of records provided by the facility dated 1/12/2025 at 07:15 P.M. revealed a progress note written by Licensed Practical Nurse (Staff # 8), which revealed that x-ray results came back indicating a broken femur. The resident was transported to an acute care hospital. The notes indicate that the resident’s son was notified of the transfer. A undated facility interdisciplinary team (IDT) Fall Committee attended by the DON, ADON, Facility Director, Medical Director, nursing representative and rehabilitation representative identified the root cause of the fall as the resident was rolling himself in bed utilizing the mobility bars and reaching rope when he slid off the bed onto the floor on the left side of his bed. The resident was recently placed on an air mattress due to a regressing pressure wound. Risk versus benefit was weighed with the wound surgeon and physician team prior to placement of the air mattress. The resident reportedly was not compliant with weight shifting and relieving pressure by getting from the wheelchair to bed throughout the day. Fall committee interventions included moving the bed against the wall to increase living space and functionality of the room, a fall mat at bedside, removal of air mattress with replacement by foam surround low-air loss mattress, Physical Therapy services, Occupational Therapy evaluation, and consideration of restorative nursing evaluation post-therapy. An interview was conducted with a Certified Nursing Assistant (CAN/Staff # 88), on 6/26/2025 at 11:39 A.M. The CNA reported that if a resident fell while she was on duty, she would help the resident and notify the nurse. She stated that she received training on safe patient handling techniques when she was hired. An interview was conducted with Resident (# 28) on 6/26/25 at 11:15 A.M. The resident stated that he remembered the incident and reported that his right leg does not work well and that his body tends to 'scootch' to the left. He stated that he used ropes attached to his bed to turn himself. He reported that he was turning to his left side, and the air mattress on top of the bed mattress slipped, and he fell over the side of the bed. The resident stated that when he fell, he landed between the wall and the bed and could not get up. Resident # 28 stated that when he fell, he could not reach the call light and spent some time on the floor before he received help. The resident reported that he was able to reach the remote to the television and increased the volume, which alerted staff that he needed help. The resident stated that when staff responded, they used the Hoyer lift to get him back into bed. Resident # 28 states that the orthopedic surgeon explained that there is no way to be sure if the fall caused the fracture or if the return to the bed in the lift was a contributing factor. The resident reported that he had significant pain following the fall that was increased from his baseline discomfort related to Multiple Sclerosis. Resident # 28 stated that his family was not notified of his injury until he called his sister to advise her of the injury and continuing pain. The resident reported that his sister then called his son and medical power of attorney to let him know of the event. He further stated that the fall occurred shortly after the unexpected death of his wife, who had been his point of contact for the facility. He has now identified his son as his medical power of attorney. The resident stated that he is now recovered and anticipates that he will be released from care by the orthopedic surgeon at his next visit in the coming weeks. An interview was conducted with the Director of Nursing (DON/Staff # 79), on 6/26/2025 at 11:30 A. M. The DON stated that she recalled events relating to the resident's fall. She states that the resident was being monitored for a shearing injury, even though he is completely mobile using rails and could turn himself from side to side independently. The DON reported that the resident often refused to offload pressure and preferred to sit in his wheelchair, so a low air mattress was applied to his bed. The DON stated that when he fell, nursing staff reported the injury and an electronic order from the provider was processed for a mobile x-ray. She states that the family was notified, but she did not remember which family member was called. She further stated that the process is to start at the top of the resident's contact list with the most important contact and continue down the list until someone is reached. The DON reported that the resident initially declined to go to the hospital for an X-ray and preferred that a mobile X-ray be done. The DON reported that she was in close contact with the resident following the fall, and she did not feel it was necessary to seek more urgent care pending imaging results, as the resident's pain was not reported to be higher than his baseline. The DON reported that the mobile x-ray company did not respond timely and staff called to check on the x-ray service's arrival and she followed up when she was notified that the service had not arrived to request service. Staff # 79 stated that the patient was sent to the hospital prior to receiving the imaging results. She reported that the resident has frequent hospitalizations related to his recurrent urinary tract infections and issues with a clogged suprapubic catheter. She states that the delay from 1/9/25 injury to 1/12/ hospitalization did meet her expectations due to her knowledge of the resident and her assessment that he did not complain of extra pain, so her decision not to send the resident out for imaging in an acute care setting made sense. The DON did not mention the change in mental status that was reported in the progress notes. A telephone interview was conducted on 6/26/25 at 12:19 P.M. with the resident’s son who confirmed that he received no notification of his father's injury by the facility. He reported that his father notified his aunt (father's sister) to report the event 2-3 days after the fall who contacted him to let him know of the injury, and that the resident remained in pain. He stated that his father told him the technician who took the X-ray at the facility told the father 'okay, this is broken' and later his father was transferred to the hospital. The son stated that following the hospitalization, he came to the facility to talk with the facility staff to discuss what happened. He stated that he spoke with 2 nurses (did not have names) and was advised that they would have the Assistant Director of Nursing (ADON) contact him, but he did not receive any follow-up calls. He reports he received no notification of a recent hospital visit relating to the need to address a clogged catheter that occurred on 6/12/2025. He stated that these instances 'gave him pause' and he contacted attorneys, but based on conversation with them and subsequent conversation with his father, he confirmed that the resident feels safe in the facility and has elected to remain in the facility at this time. A review of the Accidents and Supervision policy, last reviewed on 4/22/2024, revealed that it is the policy of the facility that the resident environment will remain free of accident hazards as is possible. The policy further states that each resident will receive adequate supervision and assistive devices to prevent accidents. The policy indicates that supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents, which is defined by type and frequency and based on the individual resident’s assessed needs and identified hazards in the resident's environment. A review of the Fall Risk Assessment policy, last reviewed on 4/22/2024, indicated that it is the policy of the facility to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The policy indicated that risk assessments will be completed upon admission, quarterly, or when a significant change is identified. A review of the Incidents and Accidents Policy last reviewed 3/16/2024 indicated that it is the policy of the facility to utilize “Risk Management” in the resident’s electronic health record (PCC) to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Compliance guidelines within the policy indicate that incident/accident reports are part of the facility’s performance improvement process and are confidential quality assurance information -Regarding Resident #21 Resident #21 was admitted to the facility on [DATE] with diagnoses that included epilepsy, type two diabetes mellitus with diabetic polyneuropathy, and hemiplegia and hemiparesis affecting left non-dominant side. Review of the physician orders revealed an order, dated August 3, 2023, which ordered a weekly skin check and Braden scale to be completed on every Thursday. This order was discontinued on February 11, 2024. Further review of orders revealed an order, dated February 15, 2024, which ordered weekly skin checks every Thursday, and this order was active until discontinued on April 14, 2024. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed that the resident had one sided impairment in a lower extremity, and required substantial or maximal assistance with rolling left and right. The MDS indicated that the resident was also frequently incontinent of bladder and always incontinent of bowel. The MDS revealed that the resident was at risk of developing pressure ulcers, and did not have any pressure ulcers at the time of assessment. Review of the charted skin assessments revealed skin assessments completed on the following dates: February 1, 2024 February 14, 2024 March 21, 2024 April 11, 2024 There was no evidence found that skin assessments were completed between February 2, 2024 to February 13, 2024. There was no evidence found that skin assessments were completed between February 15, 2024 to March 20, 2024. There was no evidence found that skin assessments were completed between March 22, 2024 to April 10, 2024. Based on this review, weekly skin assessments were not completed as ordered by the physician. Additionally, a review of the nursing progress notes from these time periods revealed no evidence that a full skin assessment was completed during the described time periods. Interview was conducted on June 26, 2025 at 12:57PM with a Certified Nursing Assistant (CNA/Staff #88), who stated that nurses complete the skin checks for residents, though CNAs would also alert nurses if they see any skin issues while conducting showers. Interview was conducted on June 26, 2025 at 1:15PM with a Licensed Practical Nurse (LPN/Staff #73), who stated that nurses should complete weekly skin checks on residents, which are often scheduled on a resident’s shower day. The LPN stated that these skin checks should be documented in the Electronic Health Record (EHR) under Assessments. The LPN explained that the purpose of the skin checks is to make sure the resident is not having skin breakdown. The LPN stated that the risk of not completing a skin check as ordered would be that the resident may have developed wounds or their wounds would have worsened. Interview was conducted on June 27, 2025 at 10:39AM with the Director of Nursing (DON/Staff #79), who stated that nurses should conduct weekly skin checks. The DON stated that the wound nurse will also do a skin check when checking wounds, and that CNAs will also do skin checks on shower days. The DON stated that head-to-toe assessments and admission skin assessments should be documented in the EHR. When asked about Resident #21’s skin checks, the DON confirmed she was aware that there were periods of time that the skin checks were not completed, and she stated that it was one nurse that missed them. The DON explained that the process at that time was to have one nurse complete all of the skin checks, but the process had since been changed, and now the floor nurses complete their own skin checks. Review of the facility policy titled, Pressure Injury Prevention and Management, revealed that licensed nurses should conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after any newly identified pressure injury, and findings should be documented in the medical record.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide continence and shower care according to professional standards for one resident (#102). The deficient practice could result in skin breakdown.Findings Include:-Resident (#102) was admitted to the facility on [DATE] with diagnoses that included a urinary tract infection, multiple sclerosis, and anxiety disorder. The hospital summary dated September 15, 2022 included that the resident had an open area on buttocks with measurements: length: 4 mm, width 3 mm, and depth 0.A wound care weekly observation dated September 16, 2022 revealed left buttock with moisture associated skin damage (MASD). Measurements were length 4 mm, width 3 mm and depth 0. An order dated September 16, 2022 and discontinued on September 18, 2022 revealed cleanse left buttocks with NSS- pat dry - apply Xeroform - cover with bordered gauze every night shift for wound care. An order dated September 18, 2022 and discontinued October 6, 2022 revealed cleanse left buttocks with NSS- pat dry - apply Xeroform - cover with bordered gauze every night shift for wound care and every 1 hours as needed for wound care. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident had moisture associated skin damage (MASD)A skin assessment dated [DATE] revealed an open area to the left buttock, and redness to the groin. There were no measurements included. The order dated September 24, 2022 and discontinued October 6, 2022 revealed complete skin observation (Form in PCC) check skin & sign shower Sheet every evening shift every Wed, Sat for shower. A skin observation form dated September 27, 2022 revealed that the resident received a bed bath with skin intact and no concerns. The care plan dated September 30, 2022 revealed the resident has potential impairment to skin integrity related to decreased mobility, bowel and bladder incontinence, left buttock MASD, status post left ankle fracture, status post left hip fracture, status post left distal hip fracture, resistant with cares, makes personal choice not to allow staff to move left leg and to not turn off back. Interventions included to apply moisture barrier as needed, observe skin condition on a weekly basis, and provide incontinence care as needed . Wash, rinse, and pat dry peri area. A skin assessment dated [DATE] revealed no new skin issues. Review of the Medication Administration Record (MAR) dated September 2022 revealed that skin observations and nightly wound care were completed. Review of the ADL Toileting task sheet (urine task sheet) dated September 2022 revealed:-15 times the activity did not occur-8 times there was no documentation-0 refusalsReview of the bowel task sheet dated September 2022 revealed:-9 times there was no documentation-0 refusalsReview of the ADL Toileting task sheet (urine task sheet) dated October 2022 revealed:-7 times the activity did not occur-2 times the resident was not available-0 refusalsReview of the bowel task sheet dated October 2022 revealed:-7 times the activity did not occur-2 times the resident was not available-0 refusalsNote that paper shower forms were requested and not provided. An interview was conducted on June 27, 2025 at 1:23 p.m. with the Director of Nursing (DON/staff #79), who stated that the resident was admitted to the facility on [DATE] and discharged on October 6, 2022. She stated that the MDS dated [DATE] revealed that the resident required two plus assistance with transfers and toileting, but assumed that the resident was not using the toilet. She stated that the staff are supposed to complete the task sheets every shift, so there should be documentation three times a day. She reviewed the task sheet for bowel care dated September 2022 and stated that there were no refusals documented and there was no documentation for 9 shifts indicating the task did not occur. She reviewed the bladder task sheet dated September 2022 and stated that there were no refusals documented, no documentation for 8 shifts, and 15 times the activity did not occur. Then she stated that the residents are supposed to receive a shower twice a week and reviewed the bathing task sheets for September 2022 and stated that the resident received two showers from September 15 through September 30, 2022. She stated that there are risks to not being changed or showered regularly: UTI, skin issues, shearing, yeast infections, and pressure ulcers. An interview was conducted on June 27, 2025 at 1:54 p.m. with a certified nursing assistant (CNA/staff #89), who stated that she received training on continence care and showers. She stated that continence care and showers are documented in the electronic record and showers are provided twice a week. She stated that showers are also documented on a paper form. She stated that if the resident refuses continence care and/or showers, she documents the refusal in the electronic record. She also documents the refusal on the paper shower forms along with skin issues and if the resident is not getting a shower, there is a risk of skin breakdown, odor and rashes. She stated that continence care is provided every two hours or as needed and the risk of not providing care is not smelling fresh, UTI, and an open sore. The facility policy, Incontinence Policy states that all residents that are incontinent will receive appropriate treatment and services.

Based on personnel file review, interviews, and policy review, the facility failed to complete a yearly performance review for 1 of 2 sampled Certified Nursing Assistants (CNA/Staff #12). The deficient practice could result in insufficient and inadequate care for residents.Findings include: Review of the personnel file for a CNA (Staff #12), revealed a hire date of July 13, 2023, for hourly employment. Review of the file did not reveal a yearly performance review had been completed or any evidence of that a performance review had been conducted for the year of 2024 or 2025. An interview had been conducted on June 26, 2025 at 2:59PM with the Director of Nursing (DON/Staff #79) where Staff #79 stated that the facility implemented a broad spectrum pay assessment for CNA's that is reviewed alongside county requirements to update pay amount accordingly. Staff #79 stated that the facility does not complete one on one reviews with staff to discuss their overall performance. Staff #79 stated that the extent of a performance review is relied on formal complaints regarding a staff's work ethics, areas that may have been discussed as a trend, infection control practices utilizing infection control mapping, and review of physical documentation; and that review will dictate what trainings are planned for staff. Staff #79 did state that the risk of not implementing a performance review procedure can result with staff losing the opportunity for improvement. Staff #79 did state, that although there is currently no structure to the performance review process, that the facility is currently implementing a procedure for the completion of one on one reviews that will be to discuss the overall performance of a CNA, and to appropriately provide trainings utilizing the performance review results. A review of title 42 CFR S483.35 (e) (7) revealed that a facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. Review of the facility's employee handbook revealed that performance evaluations should be an ongoing discussion of feedback between supervisors and employees. The handbook also revealed that evaluations are established on an annual, documented basis, as a standard to formalize an interactive conversation about the performance of an employee. The handbook also revealed that the performance reviews do not always result into a pay raise, however, a performance review should be completed. The handbook also stated that the performance evaluation will require the signature of the employee who is undergoing a performance review. A review of a facility policy titled 'Performance Evaluations' had been provided by the facility on June 27, 2025, which revealed that a performance evaluation will be completed annually, and to occur during the same time as the employee's compensation review.

Based on observation, staff interviews, and policy review, the facility failed to ensure that medications were dated when opened. The deficient practice could result in reduced drug effectiveness and adverse reactions.Findings include:During a medication observation conducted on 6/25/2025 at 09:40 A.M., one 50 mL, multi-dose vial of 1% lidocaine was observed in the medication refrigerator with no opened-on date.An interview with Licensed Vocational Nurse (LVN), (Staff # 63) was conducted on 6/25/2025 at 09:10 A.M., who reported that medications should be labeled when opened, and if not needed to refrigerate, may be kept until the manufacturer's expiration date. The LVN stated that medications should be stored in a locked cart or in the medication storage room at all times and stated that the risk to the resident could be to use expired medicine.An interview with Licensed Vocational Nurse (LVN), (Staff # 41), was conducted on 6/25/2025 at 8:45 A. M. who stated that blister-packed medications should always be placed back into the cart when the cart is not attended by a nurse and that the medication cart should be locked. The LVN stated that this is for patient privacy as well as to decrease the risk of medications being removed by other staff or residents. Staff # 41 stated that the impact of leaving medications on the medication cart would be that someone may take medications that are not prescribed and cause them harm.An interview with the Assistant Director of Nursing (Staff # 81), was conducted on 6/26/2025 at 09:17 A. M., who stated that all liquids, insulins, and over-the-counter (OTC) medications should have an open date. The ADON stated that twenty-eight days after they are opened, they are discarded. Staff # 81 stated that non-refrigerated liquids and OTCs are okay to use until the manufacturer's expiration date. The ADON reported that medications received in bubble packs at reordered when 5 days are left on the card, which minimizes waste and potential risk of administering expired medications. The ADON stated that an opened but unlabeled vial in the medication storage room does not meet expectations and that the risk is that the medicine may not be effective for treating the patient. Staff #81 reported that controlled substances are double locked, whether they are in the medication cart or in the medication storage. Unsecured medications on the unit do not meet expectations, and the impact to the resident is that patient information could be shared inadvertently or someone could take the medications. The ADON confirmed that controlled substances are double locked, whether they are in the medication cart or in the medication storage. Unsecured medications on the unit do not meet her expectations, and the impact to the resident is that patient information could be shared inadvertently or someone could take the medications. An interview was conducted with the Director of Nursing (DON) (Staff # 79) on 6/26/2025 at 09:57, who reported that all medications are bubble-packed when received. Staff # 79 reported that opened medication vials are good for twenty-eight days and that opened and unlabeled medications would not meet expectations. The DON identified the risk as that if medication is not labeled, staff don't know when to discard it.Review of the Medication Monitoring policy reviewed 1/5/2025 revealed that Medications shall be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications.Review of the Medication Storage policy review 1/5/2025 revealed that the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with policy and procedure.

The facility failed to provide and environment free from accident hazards for one resident (#21) and failed to ensure adequate supervision to ensure one resident (#105) did not elope. The deficient practice could result in residents being injured, abused, or lost. -Regarding Resident #105-Resident (#105) was admitted on [DATE] and re-entered on September 8, 2024, with diagnoses that included hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, repeated falls, adjustment disorder, and type II diabetes. The care plan dated September 30, 2022 revealed that the resident is at risk for injuries from falls related history of falls, weakness, decreased balance, medications, Lymphangioleiomyomatosis (LALM), and Marijuana use. Interventions included to provide cueing, supervision, and assistance as indicated.The Elopement Risk Evaluation dated September 8, 2024 revealed that the resident was not a risk for elopement. The fall assessment dated [DATE] revealed the resident has fallen one to two times within the last six months and was a moderate risk for falling.The order summary included an order dated September 11, 2024 for a change of condition, date of fall was September 10, 2024 that included a hematoma, neuro-checks started. Every shift for three days monitor for new injuries, mood changes, ambulation changes, cognition changes, and/or other changes off baseline. The MDS dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact. It included one fall since admission or prior assessment with an injury. It also revealed that the resident was able to use electric wheelchair independently. Review of the order summary revealed: -orders for outside physical therapy appointments included an order for transportation. -there was no start date for the order, may not go out on leave of absence or pass unless with family member and coordinated with the Social Services Assistant (SSA), Director of Nursing (DON), or the Assistant Director of Nursing (ADON). All appointments must be scheduled for transport with the unit secretary.A nurse note dated October 15, 2024 revealed that the resident was brought back to the facility via a gurney from the hospital. According to the day nurse report, the resident went out and was found passed out. The resident was then transported to the hospital. A physician note dated October 16, 2024 revealed that the resident left for an appointment yesterday and was later found in her chair on 19th Avenue with an altered mental status (AMS). Paraphernalia was later found in her room. She was brought to the hospital and observed. Review of the Medication Administration Record (MAR) dated October 16, 2024 revealed that the resident was being monitored for a change of condition (COC) every shift for three days after returning from the hospital.A nurse note dated October 16, 2024 included that the resident is back in the facility after a brief time in the hospital emergency room due to falling asleep at the train rail. The resident was waiting for the train to take her to therapy outside of the facility, when according to the resident, she was enjoying the sun and closing her eyes in her electric wheelchair. A pedestrian called 911 and they took her to the hospital for evaluation. The Director of Nursing (DON), Social Services Assistant (SSA) and Executive Director (ED) went to speak with the resident. The Assistant Director of Nursing (ADON) had spoken t the resident last week about not following transportation directions. The resident usually sets up her own transportation, but lately has been cancelling rides home or not catching the train and coming back to the facility late. The DON, SSA, and ED spoke to the resident about passes being tweaked. The resident is to take transportation set up by the facility from this point forward, and all passes out of the facility besides medical transport need to be accompanied by a family member for safety. The resident agreed to this. The Social Services note dated October 16, 2024 revealed that the ADON, ED, and SSA met with the resident on October 16, 2024 to discuss the risks and complications of leaving the facility on her own. The resident declines insurance transportation and prefers to set up her own. This implies that the resident takes public transportation and there have been several occasions where the resident leaves and does not come back within the hours it would take for her to come back. The resident cancels her transportation and goes elsewhere for hours without informing the facility. On October 15, 2024, the resident was found with AMS at the Metro Rail Station and paramedics were called and she was taken to the emergency room. On October 16, 2024, the SSSA and a certified nursing assistant (CNA) had to go to the hospital to pick up the resident's motorized wheelchair. The DON, ED, and SSA explained the risks, complications, and liability to the resident at length and in detail. The resident agreed with everything. She understands that if she is to go to a medical appointment, she will need to go with medical transportation, and if she wishes to go elsewhere, she will need a family member to go with her. There have other times when the resident leaves during heat advisory days and takes her motorized wheelchair to shopping centers that are miles away. A skin wound treatment note dated October 17, 2024 revealed that the resident was observed by other staff at the building sitting outside of the facility gates on the main road slumped over in her wheelchair. A large fluid filled blister was identified to the resident's upper right leg. The physician was notified and received orders to clean with alcohol, aspirate with needle and cover with island dressing. Serous fluid was aspirated from the blister. The resident tolerated the procedure well with no complaint of discomfort during the procedure. The SSA progress note dated October 17, 2024 revealed that the hospital records stated that the resident was positive for THS at the hospital emergency room. During the morning meeting, staff were informed that the resident had left to an appointment alone in her motorized wheelchair. At around 2:45 p.m., the DON and the ADON were informed by the Maintenance Director that the resident was passed out on the sidewalk of 19th Avenue. The DON, ADON, and nurse went to evaluate the resident. She was passed out and appeared to be under the effects of a substance. She stated that she did not recall meeting with the ED, DON, and SSA on October 16, 2024. The resident had a permanent smirk on her face and could not fully open her eyes. She was unable to operate the electric wheelchair. The ADON had to maneuver the electric wheelchair, operating the joystick while slowly and safely wheeling the resident back to the facility. The DON contacted the physician and he ordered a drug testing panel. The DON, ADON, and the SSA met with the resident on October 17, 2024 once the resident was in bed and alert. They discussed the dangers, risks, complications, and liabilities regarding the resident's habitual leaving the facility on her own with the excuse of going to a medical appointment and she is out of the facility for several hours and staff is unaware of her whereabouts. When the resident was found today, she had several shopping bags from different stores. At this time, the resident will not be able to use her motorized wheelchair. She is a danger to herself. The elopement screening dated October 17, 2024 revealed that the resident was a high risk for elopement with a score of 14. The care plan dated October 17, 2024 revealed that the resident is an elopement risk as evidenced by leaving the community unattended after being instructed not to, impaired safety awareness, Marijuana use.The care plan dated October 17, 2024 revealed that the resident has a substance abuse problem related to Marijuana use as evidenced by positive testing and AMS. Interventions included to remain nonjudgmental. Be alert to changes in behavior. Report changes to the nurse/physician. Review definition of drug dependence and categories of symptoms (patterns of use, impairment caused by use, tolerance to substance). An interview was conducted on June 25, 2025 at 9:00 a.m. with the (DON/staff #79), who stated that the brief interview for mental status score (BIMS), fall risk assessment, and the elopement risk assessment is used to determine if it is safe for a resident to leave the long-term care facility on the second floor and go out independently. She stated that if a resident wants to go out of the building and leave the property, a physician order is needed. The resident had orders to go to appointments once or twice a week, which included medical transport, but the resident refused the transport and would would take the train. The resident would come back late, hours after her appointment, and would be high. She stated that they tried to counsel the resident about taking the medical transportation because it was too hot outside. She stated that the second time, the resident was out by the rail line, she and staff ran out there and the resident was high and she kept wheeling to the left towards the traffic and we had to wheel her in manually. She stated that the resident was sent out to the hospital both times she was found by the train tracks and tested positive for Marijuana. An interview was conducted on June 25, 2025 at 12:11 p.m. with the Unit Coordinator/Social Services Assistant (#23), who stated that she schedules the outside appointments for the residents which includes transportation. She stated that the transportation driver comes up to the second floor to pick up the resident for his/her appointment and she goes to get the resident. If a resident refuses transportation and wants to go to an outside appointment on his/her own, they are allowed to go if they are capable. She stated that she discusses with the management team to see if a resident can go to appointments on their own: DON, ADON, nurses, and the SSA Director. The team decides if the resident can leave the facility alone, and it depends if the resident is alert and oriented, and a fall risk. She stated that if she sets up transportation with the appointment, and the resident refuses the transportation, she notifies the family to see if family can come and pick the resident up and take the resident to the appointment. She redirects the resident and would also see if she could reschedule the appointment if family can't come. If the resident continues to try and leave, she reports it to the DON and the ADON. If the resident leaves it is considered an elopement. Only long-term residents are allowed to go downstairs to the first floor, and the concierge is expected to stop the long-term resident from leaving the building and call the long-term care unit to let staff know that a resident is trying to leave. She stated that she is not required to keep the appointment forms for the residents, so she doesn't have a record of resident (#105) going to outside appointments on October 15 and 17, 2024. She reviewed the resident's clinical record and stated that she couldn't find any documentation showing that the resident attended outside medical appointments on the above dates, but there were orders for the appointments. She remembered one time when the resident refused the transportation and wanted to go by herself. She told the resident that they would have to reschedule and the resident insisted she could go in her motor scooter, but finally agreed to stay here. She stated that the resident was allowed to go downstairs by herself and would just leave. She would go to the store and back, Fry's Grocery Store in her scooter. She is aware that residents need an order/pass from the physician to leave the building and believes that the SSA takes care of it. It was her understanding that the resident was allowed to leave the building. She was not aware of the resident being found in her wheelchair by the light rail. She stated that the risk to being left outside is a heat stroke. An interview was conducted on June 25, 2025 at 1:08 p.m. with the (SSA/staff #65), who stated that resident can go downstairs after they are assessed for falls and would include a resident in a wheelchair because the resident could still be a risk. The brief interview for mental status score (BIMS) of 13 or higher would be required for cognition. She would also look at the resident's diagnoses and a history of drug use. A resident with a history of drug use would not be safe to go downstairs alone because family, friends, a boyfriend could bring drugs, and the resident could leave the building to go drug seeking. The front desk monitors who is going downstairs, and would notify her if a resident is trying to leave who should not leave. She goes out to redirect the resident. Transportation is set up for all residents going out to outside appointments and if the resident refuses the transportation and wants to go by her/himself, the interdisciplinary team would have to determine if it was safe: drug use, get lost, cognition. fall risk and the psychosocial, such as is the family okay would all need to be evaluated. Then she stated that the staff on the first floor would address any concerns, but are considered independent of the long-term care unit. The facility policy, Elopement states that the facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. -Resident #21 Resident #21 was admitted to the facility on [DATE] with diagnoses that included epilepsy, repeated falls, and hemiplegia and hemiparesis affecting left non-dominant side. Review of the care plan revealed a problem focus, initiated on June 30, 2023, which revealed that Resident #21 was at risk for injuries from falls. Interventions in place included ensuring the call light was in reach and providing cueing/supervision as indicated. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed that the resident had one sided impairment in a lower extremity, and required substantial or maximal assistance with rolling left and right. The MDS indicated that the resident was independent to move from lying in bed to sitting on the side of the bed, and he required partial or moderate assistance to transfer from chair to bed. Review of the nursing progress notes revealed a nurse's note, dated February 13, 2024, which indicated that Resident #21 was alert and oriented x2, had some confusion, and could not always verbalize his needs. Review of the nursing progress notes revealed a note dated February 14, 2024, which indicated that Resident #21 was found on the floor around 12:10AM. The note revealed that a new alternating pressure pad was in place at the time of the fall, and that no fitted sheet was in place at the time of the fall. The note indicated that Resident #21 explained that his bed was uncomfortable and that he had slid down the bed. The note revealed that the resident was placed back in bed after applying a fitted sheet to the mattress and assessing the resident. Further review of the nursing progress notes revealed an IDT meeting note, dated February 18, 2024, which reviewed that Resident #21 had experienced a fall on February 14, 2024. The note indicated that the resident was uncomfortable in bed and slipped on the flat sheet covering the mattress topper. The note revealed that following the event, the care plan was updated to include a fitted sheet on the bed to reduce fall risk during transfer or when lying in bed. Interview was conducted on June 26, 2025 at 12:57PM with a Certified Nursing Assistant (CNA/Staff #88), who stated that if a resident is a fall risk, interventions are put in place such as a low bed, a fall mattress on the floor by the bed, call light within reach, and checking on them often. The CNA also stated that all residents should have full linens on their beds. Interview was conducted on June 26, 2025 at 1:15PM with a Licensed Practical Nurse (LPN/Staff #73), who stated that staff attempt to prevent falls to the best of their ability, using interventions such as frequent checks, a low bed, call light within reach, and the use of a fall mattress if they had fallen before. The LPN also stated that all residents have standard linens on their beds, which are made by the shower aids. Interview was conducted on June 27, 2025 at 10:02AM with Resident #21, who confirmed that he had experienced a fall while at the facility, and confirmed that he had slid out of bed. The resident declined providing any further detail. Observation revealed that Resident #21 was in bed with his call light within reach at the time of interview. Interview was conducted on June 27, 2025 at 10:39AM with the Director of Nursing (DON/Staff #79), who stated that interventions in place to help residents from slipping out of bed included keeping the bed in the lowest position and the use of a fall mattress if indicated. When asked about Resident #21’s fall, the DON recalled that Resident #21 would roll himself in bed. The DON stated that the resident had a low air-loss mattress in place, and when he rolled, he slid down the side of the bed. The DON also confirmed that at the time, the resident had a flat sheet in place but no fitted sheet on the bed. The DON explained that following the fall, a new air mattress was purchased, which had foam around the edges, assisting in fall prevention. The DON also stated that the care plan was updated to specifically address the need of a fitted sheet on the bed. Review of the facility policy titled, Accidents and Supervision, revealed that the resident environment should remain as free of accident hazards as possible.

The facility failed to ensure appropriate infection control measures were implemented and followed for one resident (# 44) related to tube feeding. The deficient practice could result in a spread of preventable illness to residents and staff.Findings include:Resident # 44 was readmitted to the facility on [DATE], with diagnoses that included hydrocephalus, hyperosmolality and hypernatremia, epilepsy, history of benign neoplasm of the brain, presence of cerebrospinal fluid drainage device, dysphagia, muscle weakness, diabetes insipidus, presence of cardiac pacemaker, hypothyroidism, gastrostomy, bilious vomiting, acute kidney failure, altered mental status, other post-procedural endocrine and metabolic complications and disorders, unspecified abdominal pain, autoimmune thyroiditis, hyperlipidemia and urinary incontinence. Review of resident #44's care plan revealed a focus, initiated 4/16/2025, that stated the resident is at nutritional risk and required tube feeding related to dysphagia. Interventions in place for this focus included the use of enhanced barrier precautions. Review of physician orders revealed a physician's order dated 3/8/2025, which indicated that Enhanced Barrier Precautions (EBP) were in place. The order indicated that Personal Protective Equipment (PPE) was required for high resident contact care activities, related to having a feeding tube, and specifically specified that a gown and gloves are required when assisting with device care or use, including central line, urinary catheter, or feeding tube.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the resident had a feeding tube while a resident. The MDS revealed that the resident received 51% or more of her total calories through tube feeding, and averaged 501cc per day or more of fluids by IV or tube feeding.Observation of medication administration through the patient's gastrostomy tube was conducted on 6/25/2025 at 08:09 A.M. with a Licensed Vocational Nurse (Staff # 41). Prior to discontinuing the tube feeding at the ordered hour and administering the medications, the LVN gathered and prepared all required materials and performed hand hygiene. The LVN then donned gloves, but no gown. The LVN discontinued the tube feeding, flushed the tube and administered crushed and liquid medications through the tube without issue. The LVN flushed the tube again following the medication administration, removed gloves and performed hand hygiene prior to administering ordered oral medication. The entire medication process was conducted by the LVN without the use of a gown. An interview was conducted with Certified Nursing Assistant (CNA), Staff # 88 who stated that staff know which residents require Enhanced Barrier Precautions (EBP) by the sign that is hung outside their door. The LVN reported that she receives information during shift-to-shift report and stated that they walk from room-to-room to evaluate the patients. Staff # 88 identified the risk of not using EBP as spreading infections. An interview was conducted on 6/26/2025 at 09:17 A. M. with the Assistant Director of Nursing, (Staff # 81), who reported that staff are advised of the need for EBP by signs outside of the resident's room. The ADON reported that bins for Personal Protective Equipment (PPE) are stored in the hallway with receptacles in the room for use when discarding PPE. Staff # 81 stated that staff are to gown and glove when providing care to residents who require EBP and that staff receive training on EBP upon hire and at monthly staff meetings. The ADON stated that care provided without donning a gown would not meet expectations, as the risk to residents and staff would be that it is not up to facility standard. An interview was conducted with the Director of Nursing (Staff # 79) on 6/26/2025 at 10:06 A. M., who stated that she would expect EBP to be used when providing care for any residents with feeding tubes, urinary catheters, or wounds. She also stated that a gown and gloves should be used anytime a staff is providing advanced care to a resident on EBP. The DON states that EBP practices are overseen by periodic audits and reinforced by required training. Training is provided to agency and facility staff upon hire to the facility and annually. The DON stated that the risk of not following EBP would be the potential spread of infection to staff and residents. Review of the Routine Cleaning and Disinfection Policy, reviewed on 1/5/2025, revealed that transmission-based precautions refer to actions (precautions) that are based upon the means of transmission (airborne, contact or droplet) in order to prevent or control infections. The policy further states that staff will look for precautions signage prior to entering resident's room and use standard precautions, including appropriate personal protective equipment, for all rooms, unless transmission-based precautions are identified. The policy revealed that staff are to adhere to transmission-based precautions as indicated on precaution signs.

Based on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was processed for determination of need for PASRR level II for one resident (# 42). The deficient practice could result in residents not receiving the appropriate services they need.Findings include: Resident # 42 was admitted to the facility on [DATE], with diagnoses that included esophageal varices with bleeding, acute post-hemorrhagic anemia, bipolar disorder, and alcoholic cirrhosis of the liver with ascites. The admission Minimum Data Set (MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Review of the resident's Care Plan that was initiated on 5/15/2025 included a focus that included the resident has potential for altered activity participation related to decreased mobility and weakness, with a related goal that the resident will participate in preferred group activities daily through the next review date. Interventions to reach the care plan's goals included that staff will respect the resident's preferences for enjoying independent activities and provide opportunities for resident to enjoy activities, staff will encourage resident to participate in activities of resident's choosing, and staff will assist resident to the day room/transfer resident out of bed for sensory stimulation. The care plan did not specify a focus, goals, or interventions related to antipsychotic medication.Medication order for resident # 42 included Fluphenazine 5 mg, 1 tablet by mouth every day for bipolar as evidenced by mood lability, Melatonin 3 mg, 2 tablets by mouth daily at bedtime as needed.A review of the resident's electronic health record identified that there was no level I or level II PASRR.Review of the electronic health record revealed an informed consent for psychotropic medications dated 5/3/2025, signed by the resident for the above medications. Consent was indicated for melatonin, identified as to treat inability to sleep. The resident did not indicate consent for the ordered fluphenazine.Progress note dated 5/8/2025, and signed by Certified Nurse Practitioner included diagnoses of other stimulant abuse, in remission, schizoaffective disorder, unspecified, anxiety disorder, unspecified, bipolar disorder, unspecified, and alcohol abuse, uncomplicated. The note further indicated that the resident was diagnosed with bipolar disorder, and that the diagnosis was identified ten years ago. The provider stated that the resident endorsed a longstanding psychiatric history and stated that her mental health is being managed by an outside provider. The resident endorsed ongoing auditory hallucinations that were non-distressing and episodes of racing thoughts. The provider identified no agitation, aggression, anxiety, or cognitive impairment.An interview was conducted with Staff # 65, Social Services Director, on 6/26/2025 at 09:51 A.M. Staff # 65 reported that residents arrive to the facility with a level I PASRR, and that she creates a new level I document if they stay at the facility for 30 days or more. The Social Services Director states that she uses a 'bible' based on the facility census and keeps a calendar to manage the 30-day follow-up requirement. The Social Service Director stated that the company changed hands last November and has received no new tax identification number, and stated that without this number, she is unable to provide a level II referral to the state as required; however, she creates the documents and maintains them in files secured in her office. Staff # 65 states that she has raised the issue with the Facility Director and the Director of Nursing. Staff # 65 was asked to pull up the electronic health record for resident # 42 to locate and identify the level I PASRR. Upon her review of the resident's electronic health record, she stated that she could not find the document. Staff # 65 stated that this did not meet her expectation since admissions should have downloaded and further stated, We have been having some problems with that. When asked about the risk to the resident if PASRRs are not completed, she stated that they may not receive needed care or services.An interview with staff # 57 Facility Director was conducted on 6/26/25 at 13:50 P.M. The Facility Director stated that he was aware of the issue regarding the state tax ID and related National Provider Identifier (NPI) number. The Facility Director stated that he has been in frequent communication with his corporate office, the facility legal team and the Social Services Director to resolve the issue. The Facility Director further stated that the issue has a negative impact on facility revenue as due to the delay in obtaining the new tax identification and NPI numbers, he is unable to bill for Arizona Health Care Cost Containment System (AHCCCS) care. The Facility Director stated that the issue does not meet his expectations, but identified the barrier to resolution as outside of his influence.Email records provided by the facility, identified as INC0058578 to the Arizona Health Care Cost Containment System (AHCCCS) Provider Support system, dated 5/16/25, indicated that the facility Social Services Director (Staff # 65) contacted them to request assistance in creating a user account. The specific help inquiry stated I cannot create an account as my company went through change of ownership. We do not have a new AHCCCCS ID or Tax ID. The attached response from Customer Support, AHCCCCS stated, We're showing that your account has not been updated and you will not be able to do so until you have the new AHCCCS credentials.A level I PASRR obtained from the facility and generated from the hospital dated 6/26/2025, signed by, a Registered Nurse Case Manager (RNCM) indicated no indication for level II screening.A level II PASRR obtained from the facility, generated by the Social Services Director (Staff # 65) dated 5/7/2025, indicated referral for level II PASRR determination for mental illness (MI) only.A review of the facility administrative manual, # 5005.3 Preadmission Screening and Resident Review (PASRR) Policy revised 11/30/2023 noted guidelines for initial admissions from general acute care hospital using the Department of Health's PASRR online system to complete the PASRR process prior to discharging an individual to a SNF regardless of payor source. The policy further addresses PASRR documentation, stipulating that a copy of the level I screening and determination must be kept in the resident's current medical chart to allow access for Medi-Cal field office verification. Licensing and Certification monitoring, and Centers for Medicare & Medicaid Services (CMS) verification. The policy also states that PASRR documentation will be included in the resident's medical record.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that an allegation of misappropriation for one resident (#38) was reported to the State Agency within the required time frame of twenty-four hours.Findings include:Resident #38 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, cirrhosis of the liver, and acquired absence of right leg above knee.Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition.Review of the facility-reported incident, submitted to the State Agency on March 15, 2024 at 3:59PM, revealed that Resident #38 had an unknown amount of cash and a debit card in his possession on March 12, 2024 at approximately 7:30PM, which was verified by staff. The report indicated that on March 13, 2024 around 11:00AM, Resident #38 reported to the facility that the money and debit card were missing. The report indicated that staff searched for the missing items all day on March 14, 2025, and that the debit card was found on March 15, 2025, but the money was not located. There was no evidence found that this incident was reported prior to March 15, 2025 at 3:59PM, which would indicate that this alleged violation of misappropriation was not reported within the mandated time frame of twenty-four hours.Interview was conducted on June 26, 2025 at 12:57PM with a Certified Nursing Assistant (CNA/Staff #88), who stated that if a resident reported that their items or money was missing, this would have to be reported to the nurse and the social worker, who would then take over.Interview was conducted on June 26, 2025 at 1:15PM with a Licensed Practical Nurse (LPN/Staff #73), who stated that if a resident reported items missing, the staff would first look for it and then would report it to the Director of Nursing or Assistant Director of Nursing. The LPN stated that missing items are usually reported right away.Interview was conducted on June 27, 2025 at 10:39AM with the Director of Nursing (DON/Staff #79), who stated that once a resident reports items or money as missing, the staff start looking for it right away. The DON stated that the items are often located, though it may be later. The DON stated that if the item cannot be found the same day, the facility will report it as missing. The DON explained that once they deem that the items cannot be found, the facility will also start reporting to the appropriate agencies, including the State Agency, treating it as misappropriation. When asked about the facility's timeline for reporting misappropriation, the DON explained that she prefers to report all alleged violations, including misappropriation, within two hours. She clarified that she starts the time from when the facility finishes looking for the item and could not find it, which she stated could sometimes take one or two hours. When asked about Resident #38's missing funds, the DON stated that Resident #38 had several items go missing around this time, and the items were mostly quickly located. She explained that in this case, the resident had asked the staff to hold off reporting or treating the items as missing. The DON stated that this was mostly driven by the resident. The DON acknowledged that the missing funds were not reported within twenty-four hours, stating that she knew it was a little later but that she still wanted to report it. The DON also stated that the funds were eventually found one or two months later in the resident's belongings.Review of the facility policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, revealed that it is the policy of the facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property, to the Administrator and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes.Review of the facility policy titled, Abuse, Neglect and Exploitation, revealed that the facility should report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies within specified timeframes, including not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure adequate supervision was provided for one resident (#204), in a public area who was exploited by assisted living staff. The deficient practice could result in residents being exploited.Findings include:The resident was admitted to the facility on [DATE] with diagnoses that included major depression, chronic kidney disease, and repeated falls.The Skilled Nursing Facility admission Agreement dated July 7, 2022 by the resident states that the facility strongly encourages residents not to keep valuables, checks, credit cards or cash sat the facility. If the resident requires anything, the facility will arrange to meet this obligation and add any cost to the resident's monthly bill. The clinical record revealed that the resident had a diagnosis for unspecified dementia dated September 7, 2022.A progress note dated September 13, 2022 revealed that the resident spoke with the Social Services Assistant (SSA/staff #65) and asked if she could keep six, $20.00 bills. The SSA reminded the resident that it would be best for her not to keep any cash, credit cards or valuable in her room or with her. On September 13, 2022, the SSA emailed the financial office and gave the resident the option to open a resident trust account and the resident wanted the trust. The SSA will follow up and assist with this. An SSA progress note dated September 14, 2022 included that a care plan meeting was held and the SSA reminded the resident not to keep valuables or money. The SSA also educated the resident on labeling personal belongings and adding them to the inventory sheet at the nurse's station. The clinical record revealed that the resident a diagnosis for bipolar disorder dated September 13, 2023. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. It also included that the resident had a diagnosis for non-Alzheimer's dementia. Review of the 5-day investigation dated January 22, 2024 revealed that the resident's checkbook ledger showed that checks were written to the assistant living caregiver (#100), who was terminated on January 25, 2024 for standard of conduct, acceptance of gifts or anything of value. Per company policy, employees are not able to accept checks from residents. The resident mentioned that she had a friend/employee at the facility that helps her with her finances and errands. The caregiver stated that she accepted $385 dollars for a phone purchased for the resident and $7000.00 for a storage unit that she said, she tore up and asked the resident to write the check directly to the storage unit. The care plan dated January 23, 2024 revealed that the resident had forgetfulness at times related to dementia. Interventions included to keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Review of the clinical record did not reveal an inventory list for personal belongings. An interview was conducted on June 24, 2025 with the Social Services Director (SSA/staff #65), who stated that nursing staff completes the inventory list for personal belongings when a resident is admitted to the facility. She stated that if the certified nursing assistant (CNA) lets her know that a resident has valuables, she talks to the resident and offers to lock it up in the safe in her office and she documents that she had the conversation with the resident in the clinical record. She stated that they discourage the residents from bringing valuables to the facility by telling the resident that if he or she is going to stay in the facility, you don't need cash here or any valuables and she offers to call the family member to pick it up. She keeps the ATM cards of some of the residents because the cards have gone missing, but that happened years ago. The CNAs/nurses did not let her know that the resident had her checkbook and wallet, but the resident always had a little purse with her and carried it around. She acknowledged that she never had a conversation with the resident about the purse or if she had personal belongings of value in the purse that she wanted stored for safety. She reviewed the resident's documentation and stated that the inventory list for personal belongings was not there. The SSA stated that a woman from hospice came to the facility and reported to her and the Director of Nursing (DON/staff #79) that she had concerns that someone was taking advantage of the resident and suggested that the SSA and DON check the resident's room. She stated that the resident was in the hospital at this time, and they checked her room. They found jewelry, a checkbook and ledger, legal documents, and an IPAD in the resident's room. They reviewed the ledger and noted that a lot of checks were written to a man and woman. The woman was a caregiver (#100) for independent living and assisted living which are located at the same site as long-term care. She stated that the caregiver met the resident when she resided in assisted living, but the checks were written while the resident was living in long-term care, which is on the second floor, and the caregiver was charged with theft. She stated that the resident would sign out and go by herself to the first floor where there is a restaurant and bar to meet with her friends from independent and assisted living. An interview was conducted on June 24, 2025 at 10:29 a.m. with the Director of Nursing (DON/staff #79), who stated that the resident was on life support at the hospital and a man from the church (priest) came her to see if the resident had an advance directive in place. He stated that the resident told him that there was a staff member who was taking care of her finances and he was concerned. Once the caregiver was identified, she was suspended immediately from Assisted Living and an investigation was started. The DON thought that the resident and the caregiver (#100) were meeting in the open area on the first floor. She stated a team assessed the resident for risk of elopement and falls and it was determined that she was safe to goes downstairs and walk around by herself. She stated that the caregiver (#100) was arrested and charged and was terminated due to reasonable suspicion. She also stated that an admission packet is completed with the resident during admission, which includes a statement about the facility storing the resident's valuables, which the resident is required to sign. that can be stored and the resident signs the form. She stated that the checks and ledger were given to the police department. An attempt was made on June 24, 2025 at 11:29 a.m. to contact the detective in charge of the case. A second interview was conducted on June 25, 2025 at 9:00 a.m. with the (DON/staff #79), who stated that she does not have an inventory list for the resident personal belongings which is supposed to be completed when the resident is admitted . If the CNA sees anything of value, they offer to write down the valuables on the sheet and may lock it up in the Social Services safe. She stated that the resident transferred from assisted living to long-term care in 2022. The Social Services Director did see the resident with a purse along with other staff, but she is not aware of any documentation of discussing the contents of the purse or offering to store the contents. She stated that the caregiver (#100) did say that she had accepted a small amount of money for a phone for the resident and the resident was complaining that it was taking forever to get the cell phone and did not find a phone amongst the resident's belongings. An interview was conducted on June 25, 2025 at 12:11 p.m. with the Unit Coordinator/Social Services Assistant (#23), who stated that only long-term care residents are allowed to go downstairs to the first floor to the bar and restaurant area. She stated that there are residents from independent living, the memory care unit, and assisted living as well. Friends and family members are allowed to come to the first floor to visit with the residents from all the areas. She stated that a resident needs to be able to ambulate independently and must not have any cognition issues to go to the first floor alone. She stated that she knows all the residents, so would know who can go downstairs. She stated that there are currently 58 residents on this floor. She has a census, but doesn't have any documentation regarding which residents are independent and can go downstairs alone, but she is able to look up the resident's profile to see if the resident is a fall risk. However, she doesn't know which document she would look at to determine cognitive status and if a resident has a cognitive issue, the resident must be accompanied by a CNA if one is available. She also stated that she knows the residents, but not all the staff working at the nurse's station by the elevator would know about all the residents and it is possible that a resident could get by to the elevator if she was typing or on the phone, but she would still stop them. The staff down by the bar area are supposed to supervise the residents from this unit and would call if something was wrong or suspected anything, but usually just sees staff dealing with their own residents. The facility's policy, Abuse, Neglect, and Exploitation states that it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident, # 10 of sixty-nine residents. The deficient practice could result in the resident not receiving care consistent with the signed advance directive.Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident, # 10 of sixty-nine residents. The deficient practice could result in the resident not receiving care consistent with the signed advance directive. Findings include: Resident # 10 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including multiple sclerosis, local infection of the skin and subcutaneous tissue, atrial fibrillation, pressure of left heel (unstageable) osteomyelitis of vertebra, sacral and sacrococcygeal region, peripheral vascular disease, heart failure, chronic pain syndrome, iron deficiency anemia, acute kidney failure, muscle weakness, post-hemorrhagic anemia, chronic obstructive pulmonary disease, essential hypertension, arthritis, anxiety disorder, hyperlipidemia, neuromuscular dysfunction of bladder, migraine, and history of urinary calculi. The Minimum Data Set (MDS) for significant change in status dated 6/16/2025 revealed a Brief Interview of Mental Status (BIMS) score of 13, which indicated no cognitive deficits. The Patient Health Questionnaire-2 (PHQ-2) revealed a score of 00, which indicated no alteration in mood. Section E of the MDS indicated no evidence of delusions, psychosis, or behaviors, but revealed instances of the resident rejecting care. The face sheet (Kardex) on the electronic health record revealed the advance directives as do not resuscitate (DNR). A review of the miscellaneous documents in the electronic health record dated 3/3/ 2025 revealed the resident's desire for cardiopulmonary resuscitation as well as IV hydration, blood transfusions, but declined to receive nutrition by tube feeding. A review of the physician orders dated 06/26/2025 revealed the initial order for code status as full code. Additional orders included maintenance of a rectal collection bag in place at all times, low air low-air-loss mattress for skin integrity, staff to attempt care in pairs whenever staffing allows, nocturnal enteral feeds, catheter, IV, and PICC line care. Wound care orders included orders to cleanse wounds by gently dabbing, with the notation that A Cell is still in place on wound bed, change soaked gauze and then apply dry dressing on top only. Do not remove anything but gauze. Medication orders included Zosyn 4.5 gm, Pantoprazole 1 by mouth daily for GERD, Piperacillin Sodium-Tazobactam Sodium) use 4.5 gram intravenously every 8 hours for VRE in the urine and osteomyelitis until 7/11/2025, apixaban 5 mg 1 tablet by mouth 2 x /day, diltiazem HCL ER Oral Tab Extended Release 240 mg 1 tablet by mouth daily for essential hypertension, gabapentin 100 mg 1 capsule by mouth 2 times a day for neuropathy, oxycodone 5 mg 1 tablet by mouth every 4 hours as needed for pain- document result/effectiveness or non-pharmacological interventions: E-effective, N-not effective. A review of the comprehensive care plan dated 3/14/2025 revealed that the resident had an advance directive and had documentation in the medical record electing full code status initiated on 3/4/2025. The focus of the care plan revealed that the resident had an advance directive and had documentation in their medical record related to code status that indicated a desire for full code status which was initiated on 3/4/2025. The care plan included the goal that the resident wishes will be honored and maintained. Interventions to achieve the goal indicated that the resident's choice for code status would be honored. An interview conducted with Resident # 10 on June 24, 2025 at 09:50 A.M. confirmed her desire for advance directives to be full code. She confirmed that she signed advance directive documents and did not require a representative to do so. The resident stated however, that her family is aware of her decision concerning advanced directives. An interview was conducted with Staff # 88, Certified Nursing Assistant (C NA) on 6/26/25 11:39 A.M. The CNA stated that she receives information during shift-to-shift report and stated that the CNAs walk from room to room to evaluate the patients during change of shift. The C NA stated that staff know if the patient is a full code because they wear armbands that indicate their code status. Staff # 88 reported that the code status is also on the Kardex. An interview with Staff # 65, the Social Services Director was held on 6/26/25 at 09:51 A.M. This writer requested employee (#65) pull up and review the electronic health record for resident # 10. The Social Services Director identified and confirmed the discrepancy between the face sheet in the electronic health record and the resident's advance directives election. She reported that records are audited by medical records staff and the ADON and stated that when discrepancies are noted, the medical records department should have notified nursing of the discrepancy. Staff # 65 stated that if this resident were to code, facility staff would not do anything because the advance directive on the face sheet in the electronic health record indicated that the resident had elected a do-not-resuscitate status. The Social Services Director further stated that this discrepancy did not meet expectations because if the resident coded, staff would check the chart first and then call 911 and notify the family of a change in the resident's condition. When first responders arrived, they would ask to see the 'orange card' that reflects the resident's pre-hospital directive. The Social Services Director stated that the impact on the resident could be that when the staff attempted to retrieve the pre-hospital directive from the code book at the nurses' station, it would not be there, and they would not have started the resuscitation effort that was chosen by the resident. An interview was conducted with the Assistant Director of Nursing (ADON), Staff # 81 on 6/26/2025 at 09:17 A.M, who stated that the facility uses an intercom system to announce code arrests that occur within the facility. Staff # 81 stated that the resident's code status is available on the landing page of the electronic health record. Staff # 81 stated that the miscellaneous tab in Point Click Care (PCC), the facility's electronic health record, holds consent forms designating the resident's election for advance directives. The ADON stated that he and the Medical Records Coordinator audit advance directives through this system. The ADON stated that the audit involves reviewing advance directive orders and cross-checking them with the forms signed by the resident or the resident's representative. The ADON stated that If DNR status is elected, the orange cards (pre-hospital directives) are placed in a DNR book housed at the nurses' station. Staff # 81 stated that the code status needs to be aligned with the information that appears at the top of PCC code status. He further stated that if the resident elects a DNR status, all staff receive guidelines on their advance directive election through an orange binder or DNR binder, that keeps the orange prehospital directives for all residents who have elected DNR status, which is located at the nurses' station. When asked which the staff would review first, the ADON stated that staff would first check the electronic record to determine code status. Staff # 81 stated that finding a discrepancy between the information in the electronic health record and the consent signed by the resident would not meet his expectations. The ADON stated that the risk to the resident is that if the record was marked as DNR and the resident had elected a full code status, the resident could not get the care that they wanted. No interview was conducted with the Medical Records Coordinator as they are on planned leave and unavailable. An interview was conducted with the Director of Nursing (DON) staff # 79 on 6/26/25 at 10:06 A. M. The DON stated that in the event of a code arrest on the unit, the CNA would ask the nurse or check the code book and call for help. The DON was asked to pull up and review what code status was reflected on the resident's face sheet in PCC. It is listed as DNR. Then asked DON to pull up the resident's election for advance directives. When she did, she identified and confirmed the resident's wishes to be full code based on the signed advance directive form. She stated that this did not meet her expectations, and the risk to the resident was that if the advance directives are not clearly communicated, it could result in death. A review of Resident's Rights Regarding Treatment and Advance Directives, reviewed on 4/15/2024, revealed that it is the policy of this facility to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate and advance directive. The policy stipulated that upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff.

Based on clinical record review, interviews, and review of policies, the facility failed to ensure one resident (#4), was free from significant medication errors, related to the resident receiving medications ordered for another resident. The deficient practice could result in complications and adverse medication side effects. Findings include: Resident #4 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis affecting left non-dominant side and right dominant side, anxiety disorder, quadriplegia, psychoactive substance dependence., adjustment disorder with anxiety, retention of urine. Review of the clinical record revealed no evidence of an investigation regarding medication administration dated March 30, 2023. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. Review of a care plan, initiated April 18, 2023, revealed a focus that included: -Has communication problem related to soft voice, usually understood. Review of nursing progress note dated March 29, 2023 at 3:29 PM revealed the resident can make needs known, but can be very difficult to understand. Review of the Medication Administration Record dated March 2023 revealed the following orders that were current on March 30, 2023: -Miconazole Nitrate External Powder 2%, apply to neck, chest topically every day shift for fungal rash. -Senna Oral Tablet 8.6 milligram (mg) give 1 tablet by mouth one time a day for bowel care -Morphine 10mg/ml (milliliter), 0.25mg (2.5mg) every 1 PRN PO/SL pain or trouble breathing every 1 hours as needed for pain/trouble breathing Review of nursing note dated March 30, 2023 at 1:29 AM, late entry, revealed that the medications administered: Lipitor 40mg, Neurontin 600mg, Keppra 750mg, Lopressor 50 mg, ranolazine ER 500mg, Flomax 0.4 mg, Tylenol 650 mg, Lantus 55 units. Further review of nursing progress notes date March 30, 2023 at 1:32 AM, late entry, revealed having a hard time seeing pulling medications in a dim lit hallway by exit sign as time is 1:00 AM and attempting to complete an 8:00 PM medication pass. Knocked on door announced my presence and turned on light, approached the patient bed and called name on medication cards as patient had no armband on and patient responded yes. This writer named the medications given to patient. Upon completing returned to medication cart and realized this was not the correct patient. Vital signs taken: blood pressure 139/67; Pulse 60; respirations 16; glucose 99. Immediately provided orange juice with two packs of added sugar. Called hospice nurse and gave a report. Hospice nurse returned call and stated to send patient to hospital and call 911. 911 called, stayed with the resident until paramedics arrived. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] revealed an unplanned discharge with return anticipated, to an acute hospital. Review of hospital history and physician dated March 30, 2023 at 4:41PM revealed the resident was brought in for evaluation after mistakenly being given atorvastatin 20 mg, Tylenol 650mg, Neurontin 600mg, Keppra 750mg, Lopressor 50mg, ranolazine 500mg, Flomax 0.4mg, and Lantus 55 units at the care facility at approximately 1:00 AM. The note also revealed that per the nurse, the patient was given another patients medication at the care facility. The history stated that on presentation to the emergency room , laboratory data showed evidence of sepsis due to urinary tract infection and hypoglycemia, hypotension and that the resident was administered 2 liters of intravenous fluid bolus and started on pressor due to refractory hypotension. The note continued stating that the patient appeared obtunded and sleepy, not able to answer any questions, admitted for critical care. Review of the facility complaint filed with the Arizona State Board of Nursing on April 7, 2023 at 12:07 PM revealed the description of the incident as medications administered to the wrong resident, the nurse failed to change the screen in the medical record to the resident she administered the medication. The complaint further stated that the electronic medical record has the residents' pictures as an identification, however, the nurse was looking at the wrong screen, and someone else's picture. Review of the facility medication error incident report revealed that a registry nurse administered the wrong medications. The report listed poor lighting as a predisposing environmental factor. Review of hospital records dated April 2, 2023 at 14:00, revealed an assessment/plan of treatment related to medication overdose that occurred at the long-term care. An interview was conducted on September 07, 2023 at 07:59 AM with the Administrator (staff #2), who stated that there was an adverse effect on March 30, 2023, that was reported to the nursing board, but it was not investigated any further than that. She stated that she would have expected that the previous administrator would have completed a self-report to the state, in addition to the nursing board, because of the adverse effect. She also stated that she was informed of the incident when she started as Administrator at the facility. She stated that the medication error occurred on March 30, 2023 when a registry nurse did not do the 5 rights prior to medication administration. She further stated that the resident was sent to the emergency room for treatment. The Administrator stated that the agency nurse was reported to the Arizona State Board of Nursing, and did not return to the facility. An interview was conducted on September 7, 2023 at 08:59 AM with a Licensed Practical Nurse (LPN/staff #33), who stated that there are pictures of all resident on the electronic medical record (EMR) to assist with resident identification during medication administration. He stated that when he administers medications he identifies the resident with the picture on the electronic medical record (EMR) and the identification bracelets. He stated that the facility policy for medication administration includes to follow the 5 rights (right: time, resident, dose, medication, route). He also stated that at night he would turn on the overbed light to identify the resident. An interview was conducted on September 7, 2023 at 09:09 AM with an LPN (staff #45), who stated that prior to medication administration she would check the EMR photo, the name on the room door, wrist tag, and also ask the resident his/her name. She also stated that the risk of administering medications to the wrong resident could result in harm or death. An interview was conducted on September 7, 2023 at 09:12 AM with Director of Nursing (DON/staff #5), who stated that when she administers medications the resident is identified by a wrist tag and the EMR photo. He also stated that he is aware of another resident receiving the wrong medication and was told the resident was sent to the hospital. He further stated that the resident was administered another patient's medication, and sent to hospital. He reviewed the clinical record and stated that there was no evidence that an investigation or self-report had been completed, expect for the medication error form. He also stated that he would have expected a full investigation that included interviews with residents and staff. Review of the facility policy titled, Medication Errors, revealed that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. A medication error means the observed or identified preparation or administration of medications which is not in accordance with the prescriber's order, or accepted professional standards and principles which apply to professionals providing services. A Significant medication error means one which cause the resident discomfort or jeopardizes his/her health and safety. The facility shall ensure medications will be administered as follows according to physician's orders, and in accordance with accepted standards and principles which apply to professionals providing services. To prevent medication errors and ensure safe medication administration, nurses should verify the right medication, dose, route, and time of administration, right resident and right medication. Review of the facility policy titled, Incidents and Accidents, revealed it is the policy of this facility for staff to report, investigate and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident. An incident is defined as an occurrence or situation that is not consistent with the routine care of a resident or with the routine operation of the organization. Incidents that risk to the level of abuse or neglect, will be managed and reported according to the facility's abuse prevention policy. Incidents/Accidents that require an incident/accident report include medication or treatment errors. Review of the facility policy titled, Medication Administration, revealed that medications are administered as ordered by the physician and in accordance with professional standards of practice. Identify resident by photo in the Medication Administration Record (MAR), review MAR to identify medication to be administered. Verify resident name. Review of the facility policy titled, Abuse, neglect and Exploitation, revealed that it is the policy of the facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will have written procedures that include reporting of all alleged violations to the state agency and to all other required agencies within specific timeframes. Taking all necessary actions as a result of the investigation that include analyzing the occurrence to determine why abuse, neglect occurred, training staff, identification of staff on changes made.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident's (#11) drug regimen was being monitored and the PRN (as needed) psychotropic medications had a limited duration. The facility census is 49. The deficient practice could result in residents receiving psychotropic medications that may not be necessary. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses that included anxiety, depression, and dementia. The [quarterly] Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was 11 indicating the resident had a moderate cognitive impairment. A review of resident #11's Care Plan, initiated on 12/13/2022, revealed the resident was at risk for behavior issues such as screaming/yelling, throwing objects, restlessness. Interventions included administering medications as ordered and monitoring/documenting for side effects and effectiveness of medications, report ongoing symptoms of depression to medical provider (revised on 06/16/2023). A review of resident #11's physician orders indicated the resident was to take the following medications: -buspirone HCI (anti-depressant) -Divalproex Sodium (mood stabilizer) -Divalproex Sodium (mood stabilizer -Duloxetine HCI (anti-depressant) -Escitalopram Oxalate (Anti-depressant) -oxycodone (opioid) A review of the September 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed there was no indication of: -Behavior monitoring (self-injurious behavior, screaming, throwing objects, and restlessness) being performed as a result of the resident taking psychotropic medications. -Opioid PRN medication (oxycodone) having a limited duration. Review of the Medication Regimen Review (MRR) dated 08/16/2023 stated Psychotropic medication reminder: Continue to monitor and document behaviors for the psychoactive medications buspirone, duloxetine, escitalopram, trazodone, and divalproex for dementia with agitation to ensure the safety, effectiveness and appropriateness. An interview was conducted on 09/06/2023 at 1:10 PM with Certified Nursing Assistant (CNA # 41). CNA #41 stated she had been working at the facility for 1 1/2 years and she was familiar with resident #11. CNA #41 shared that resident #11 had behaviors when her husband was not visiting. CNA #41 stated she would attempt to redirect the resident when there was an outburst and she knew how to redirect the resident because she knew the resident well. The CNA would then inform the floor nurse of the resident's behaviors for them to monitor and her expectation was the RN would document the behaviors in the resident's chart. CNA #41 indicated she did not know where behavior monitoring information was accessible to her during her shift. In an interview with Registered Nurse (RN #45) on 09/07/2023 at 8:45 AM it was revealed that she would expect that symptom/behavior monitoring as well as medication effectiveness would be on the TAR. RN #45 reviewed resident #11's TAR and acknowledged there was no medication monitoring and symptom/behavior monitoring on the chart. She stated the resident was recently discharged and readmitted to the facility and the monitoring was not put back onto the chart. When asked who is responsible to add or make changes to the TAR, she stated that any nurse is able to do it. When asked about resident #11's oxycodone PRN end date, RN #45 stated she was not sure why there was no end date in place. An interview was conducted with the Director of Nursing (DON #5) on 09/07/2023 at 11:14 AM. DON acknowledged that resident #11 had current orders for several psychotropic medications and there was no monitoring for symptoms, side effects, or effectiveness on the resident's TAR. He stated his expectation was for RNs to ensure monitoring was on the TAR and if it wasn't it would be brought to his attention right away so it could be added in. When asked about the policy regarding the duration of PRN medications that are psychotropics, he stated that the use of those medications was limited to 14 days unless indicated for extended use by a physician. Upon review of the resident's orders for PRN medications, he indicated that he was not sure why there was no end date in place. Review of a facility policy titled, Psychotropic Medication, dated 07/18/2023, indicated, PRN orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. The policy also indicated the effectiveness of the medications must be demonstrated by monitoring and documentation of the resident's response to the medication(s).

Based on clinical record review, staff interviews, and facility policies and procedures, the facility failed to ensure the clinical record for one resident (#4) contained the required notification/documentation to the receiving provider. The deficient practice could result in the receiving provider not being informed of the resident's status. Findings include: Resident #4 was admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis affecting left non-dominant side and right dominant side, anxiety disorder, quadriplegia, psychoactive substance dependence., adjustment disorder with anxiety, retention of urine, history of transient ischemic attack, and cerebral infarction. Review of the clinical record revealed the resident was discharged to the hospital on March 30, 2023. Further review of the clinical record revealed no evidence that the receiving provider had been notified of the resident's status/condition and reason for transfer. Review of the clinical record revealed no evidence that a discharge summary had been completed. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had an unplanned discharge to an acute care provider. An interview was conducted on September 7, 2023 at 09:12 AM with the Director of Nursing (DON/staff #5), who stated that the discharge summary was completed on paper prior to August 2023. He reviewed the clinical record and stated that there was not evidence that a discharge summary had been completed, or of notification to the receiving provider. Review of the facility policy titled, Transfer and Discharge (including AMA - Against Medical Advice), revealed that transfer to another provider, for any reason, the following information must be provided to the receiving provider: -Contact information of the practitioner who was responsible for the care of the resident -All information necessary to meet the resident's needs including resident status, reason for transfer. Obtain physician's orders for emergency transfer, contact provider of the hospital, ensure necessary information is provided as part of the facility's transfer form. Document assessment findings and other relevant information regarding the transfer in the medical record.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure that one resident's (#33) care planned interventions were reassessed for effectiveness and revised as needed. Resident #22 was admitted on [DATE] with diagnoses that included major depressive disorder and claustrophobia. A physician order dated December 22, 2022 directed for the resident's behavior to be monitored every shift in relation to the medication Sertraline for depression as evidenced by flat affect and self-isolation. It also indicated to monitor anti-depressant side effects every shift. Review of the admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The assessment did not indicate that the resident was receiving psychological therapy. Review of a care plan initiated on January 5, 2023 revealed that the resident uses antidepressant medication. The interventions indicated to observe for/document/report to physician as needed ongoing signs/symptoms of depression that are unaltered by antidepressant medications. A care plan with a focus on the resident's mood problem was initiated on January 5, 2023. The interventions indicated for the resident to have behavioral health consults as needed, and to allow resident adequate time to talk, and encourage him to express his feelings. A psych re-evaluation note dated January 30, 2023 documented that resident displays partial response to treatment, though symptoms remain unstable as evidenced by irritability, frustration, anxiety, demanding, and verbally aggressive with staff. Resident is having a difficult time adjusting to new environment. Resident was noted as grieving previous life and autonomy. Under the plan portion of the notes, it indicated that resident will be monitored and evaluated for response and side effects in 3-4 weeks or as needed. A quarterly PHQ-9 (Patient Health Questionnaire-9) assessment dated [DATE] revealed a score of 3 indicating that the resident has minimal depression. A social service note dated July 27,2023 revealed that resident continues to have difficulty adjusting to being in long term facility. The note indicated that social services will request continued psych consult. A physician order dated August 20, 2023 prescribed Sertraline HCI oral tablet and directed to give 150 milligrams by mouth one time a day for depression as evidenced by verbalization of sadness. Review of a physician note dated August 23, 2023 indicated under the review of systems portion that resident's psych was stable and at baseline. It also noted under plan, the resident be on Sertraline, followed by in-house psychiatry. Review of a physician note dated August 30, 2023 indicated under the review of systems portion that resident's psych was stable and at baseline. The plan portion of the note, indicated Sertraline, followed by in-house psychiatry. During an interview with resident #33 conducted on September 5, 2023 at 9:09 am, he stated that his depression is worse. Resident #33 said he told the facility how he feels but no one has addressed his depression. Hospice was addressing it but he was being dropped from hospice so he is worried that the situation will get worse. A Pre-Admission Screening and Resident Review (PASRR) Level I Screening assessment dated [DATE] revealed that the resident has major depression and that referral for LL determination for MI (mental illness) only was needed. Further review of the resident's clinical record did not reveal any indication that resident #33 received psych follow-up, psych consult, or that he was followed by in-house psychiatry. Additionally, there was no mention that resident was referred for behavioral health consult as needed and as indicated on his care plan. Review of the August 2023 Medication Administration Record (MAR) revealed that the resident received medications as ordered. Review of the August 2023 Treatment Administration Record (TAR) indicated that resident received treatments as ordered. Review of the September 2023 MAR revealed that the resident received medications as ordered. Review of the September 2023 TAR indicated that the resident received treatments as ordered. An interview with the Social Services Director (SSD/staff #56) was conducted on September 7, 2023. Staff #56 stated that she does psych referrals but that case managers also does them. She said she was familiar with resident #33, and that the resident was unhappy where he is at and has a hard time adjusting to his current situation of being at the facility while his wife is at home. Staff #56 stated that the resident has had a change in psych provider since July 27, 2023 so she would have to check if he has been receiving continued psych consult. She also indicated that the facility had a change in psych providers around that time. Due to this she is unsure of whether resident #33 was being seen or not. Staff #56 indicated that according to resident #33, he is not depressed. She noted that resident #33 has been improving in the last two months. Initially, the resident was very guarded, defensive, easy to anger, and would find any excuse to get mad-he gets mad when he is not addressed by his title Doctor. Additionally, staff #56 noted that during an IDT (interdisciplinary team) meeting, it was brought up that resident #33 is verbally abusive. She said that she relayed to the previous Director of Nursing (DON) her recommendation that resident receive continued psych consult. This was also relayed to the previous psychiatrist. Staff #56 stated that psych is not an in-house service and that they come whenever there are enough residents that they need to see. She said psych is normally in the long-term care floor every once or twice a week. Staff #56 stated that resident #33 was for sure not currently being followed-up by the new psych provider. Resident #33 did not transfer to the new provider. Staff #56 stated that if he was receiving services in January, she is not sure why he was not transferred when the facility switched providers. She stated that maybe his info was not relayed to the new person in July. Staff #56 noted that it would have been the previous DON's responsibility to ensure the resident's information flowed to enable the transfer/continuity of care to happen. She indicated that the previous DON cut her off with certain processes so she is not sure if the new psych provider has a roster of residents who needs to be seen. An interview was conducted on September 8, 2023 at 11:49 am with a Certified Nursing Assistant (CNA/staff #52), who stated that whenever she notices something is off or the resident express sadness she informs the nurse immediately so they can follow-up on the resident. She indicated that she is familiar with resident #33 and that he was nice and pleasant. Staff #52 noted that resident #33 sometimes gets a little agitated but nothing major. She noted that she is not aware of any mood or emotional concerns regarding this resident. However, she stated that the resident told her today that he was depressed so she informed the nurse. Staff #52 indicated that the intervention for mood/emotional concern is that CNAs must inform the nurse about concerns so they can follow-up. When asked if she was trained in behavioral health, she replied that she was not a behavior technician. As a CNA she assists residents with ADLs (activities of daily living). An interview was conducted on September 8, 2023 at 11:23 am with a Licensed Practical Nurse (LPN/staff #7), who stated that she checks for emotional patterns like depression, anxiety, loneliness, and would monitor these symptoms during Med Pass. Staff #7 indicated that she is somewhat familiar with resident #33 since she has taken care of him a few times. She said that the resident does not present any concerning mood or emotional behavior. However, she did note that the resident expresses agitation when things do not go his way or if the food he receives is not what he ordered. Staff #7 stated that each time she administers his medications, the resident does inform him that he is depressed which has been an ongoing problem. She also said that as an intervention, she relays the information to the physician and she monitors and documents the resident's behavior on the MAR. Staff #7 stated that the resident is on medication for depression but she does not know which one off the top of her head. When asked if there are non-pharmacological interventions attempted, she indicated that she had not done any. Staff #7 said that she is not aware if resident #33 is monitored by Psych but indicated that he would benefit from it. During an interview with the Director of Nursing (DON/staff #5) conducted on September 8, 2023 at 11:57 am, he stated that residents with mood/emotional concerns should be monitored every shift. If any alterations are noted, then the physician should be notified, and interventions should be followed-up. When asked who tracks/audit residents recommended for psych consult, staff #5 indicated that it is either the DON or the Assistant Director of Nursing (ADON). The DON or ADON contacts the psych provider, who then conducts and evaluation on the resident, and provides recommendations for interventions. According to staff #5, if a resident has concerns and needs a psych consult, an order for psych eval is placed, and that is how they track who needs it. He stated that no one keeps a log of who needs psych evals/follow-ups/treatments. Staff #5 noted that he is familiar with resident #33, who he described as pleasant and does not cause anything of concern. When asked if he was aware that per a psych note dated January 30, 2023 that resident #33 was supposed to be monitored and reevaluated in 3-4 weeks or as needed, and if it was accomplished, the DON sated that there is an order for psych consult sent by the Social Services Director on September 7, 2023 but no follow-up has been completed prior to this survey. When asked about the Social Services Director's (SSD) note dated July 27, 2023 which indicated that the SSD will request continued psych consult for the resident and if it was accomplished, staff #5 sated that the resident has not been seen by psych since January and that he would follow-up right away. Review of the facility policy titled Comprehensive Care Plans revised July 18, 2023 indicated that the facility implements a comprehensive person-centered care plan for each resident to meet their needs which include mental and psychological needs as identified in the resident's comprehensive care plan. Additionally, the policy noted that alternative interventions will be added/revised, as needed. Review of the facility policy titled Abuse, Neglect and Exploitation revised August 8, 2023 stated that the facility will implement policies and procedures that achieves identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#201) was provided services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for residents. Findings included: Resident #201 was admitted on [DATE], diagnoses that included joint replacement aftercare, diabetes mellitus, chronic obstructive pulmonary disease, fibromyalgia, anxiety disorder, depression, and dorsalgia. Review of the care plan revealed no evidence of a focus for pain management. Review of physician orders revealed the following orders: -Gabapentin oral capsule 300mg four times a day for neuropathy -Diclonfenac Sodium External Gel 1% tropical. Apply to affected area topically every 8 hours as needed for pain. -Oxycodone HCL Oral Tablet 5mg tablet every 4 hours as needed for pain 6-10 -Doppler ultrasound to right lower leg due to increased pain and swelling. -Regarding Administration outside of pain level parameters: Review of the August 2023 MAR, revealed that the Oxycodone had been administered outside of parameters for a pain level of 5 on 4 occasions. Review of the September 2023 Medication Administration Record (MAR) revealed that Oxycodone HCL Oral Tablet 5mg, give 1 tablet by mouth every 4 hours as needed for pain 6-10, was administered for a pain level of 5 on 6 occasions. Continued review of the clinical record revealed no evidence that the provider was notified regarding the oxycodone being administered for a pain level outside of parameters (5) during the months of August 2023 - September 2023. -Regarding Administration of Oxycodone with less than 4 hours between doses: Review of the August and September 2023 MARs revealed that the oxycodone had been administered less than 4 hours between doses on 5 occasions. Further review of the August 2023 MAR, revealed that the Oxycodone was administered on August 28, 2023 at 5:30 AM, 8:31 AM and 10:30 AM. Further review of the September 2023 MAR revealed that on September 6, 2023 the oxycodone was administered at 5:20 PM and again at 8:42 PM. There was less than 4 hours between administration times. Review of the clinical record revealed no evidence that the provider had been notified that the oxycodone was administered less than 4 hours between doses on all 5 occasions. An interview was conducted on September 7, 2023 at 02:24 PM with a Licensed Practical Nurse (LPN/staff #33), who stated that the process for pain management/medication administration included assessing the resident's pain level, and location and document in the clinical record. He also stated that it is the facility policy to follow physician orders as directed, including any parameters. He further stated that that anytime a medication is administrated outside of the ordered parameters, the provider should be notified, and it should be documented in the progress notes. The LPN stated that the nurse should document that the provider was notified, why the medication was administered outside of parameters. He also stated that it is the facility policy to administer medications within the time-frame ordered by the provider. He further stated he would not expect oxycodone to be administered less than four hours apart. He stated that if this occurred, the nurse should notify the provider and get a one-time order, and document in progress notes. The LPN stated that when a resident is on opioids he would expect that it would be included in the care plan. He reviewed the clinical record and stated that in August 2023 and September 2023 MARs there were multiple occasions that oxycodone had been administered for a pain level of 5, which was outside of the ordered parameters, and also several times that the medication had been administered with less than 4 hours between doses. He also stated that the risk could result in over sedation, and constipation. An interview was conducted on September 7, 2023 with the Director of Nursing (DON/staff #5), who stated the facility process for pain management should be included in the care plan. He also stated that the facility policy is to follow physician orders as written, including parameters and time frames. He further stated that when a medication is ordered to be administered every 4 hours, that is should not be administered less than 4 hours apart, unless there is a onetime order. He stated that if this occurs there should be documentation in the clinical record of physician notification and orders. The DON reviewed the August 2023 and September 2023 MARs and stated that oxycodone had been administered outside of parameters on multiple occasions, and that oxycodone had also been administered less than the ordered 4 hours apart on multiple occasions. He stated that he was not concerned about the medication being administered less than 4 hours between doses, because for oxycodone can be administered every hour with an order for hospice residents. The DON reviewed the clinical record revealed and stated that there was no evidence that the physician was notified regarding the administration of the oxycodone outside of parameters and less than 4 hours between doses during August or September 2023. He also reviewed the care plan and stated that there is no care plan for pain management but is documented as Pressure ulcer -- but would suffice for pain management. He also stated that the provider should have been notified regarding the pain level of 5, and requested that the order/parameters be changed. Review of the facility policy titled, Physician/Practitioner Orders, revealed that Review of the facility policy titled, Medication Administration, revealed that medications are administered as ordered by the physician and in accordance with professional standards of practice. Identify resident by photo in the Medication Administration Record (MAR), review MAR to identify medication to be administered. Verify resident name. Review of the facility policy titled, Medication Errors, revealed that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. A medication error means the observed or identified preparation or administration of medications which is not in accordance with the prescriber's order, or accepted professional standards and principles which apply to professionals providing services. To prevent medication errors and ensure safe medication administration, nurses should verify the right medication, dose, route, and time of administration, right resident and right medication. Review of the facility policy titled, Documentation in the Medical Record, revealed that each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy.

Based on observations, clinical record review, staff interviews and policy reviews, the facility failed to ensure that services were provided to treat and follow-up a resident's (#33) diagnosed mental health condition. The census was 49. The deficient practice could result in residents not receiving individualized person-centered care and treatment, in order to reach their highest practicable well-being. Findings include: Resident #22 was admitted on [DATE] with diagnoses that included major depressive disorder and claustrophobia. A physician order dated December 22, 2022 directed for the resident's behavior to be monitored every shift in relation to the medication Sertraline for depression as evidenced by flat affect and self-isolation. It also indicated to monitor anti-depressant side effects every shift. Review of the admission Minimum Data Set assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident is cognitively intact. The assessment did not indicate that the resident was receiving psychological therapy. Review of a care plan initiated on January 5, 2023 revealed that the resident uses antidepressant medication. The interventions indicated to observe for/document/report to physician as needed ongoing signs/symptoms of depression that are unaltered by antidepressant medications. A care plan with a focus on the resident's mood problem was initiated on January 5, 2023. The interventions indicated for the resident to have behavioral health consults as needed, and to allow resident adequate time to talk, and encourage him to express his feelings. A psych re-evaluation notes dated January 30. 2023 documented that resident displays partial response to treatment, though symptoms remain unstable as evidenced by irritability, frustration, anxiety, demanding, and verbally aggressive with staff. Resident is having a difficult time adjusting to new environment. Resident was noted as grieving previous life and autonomy. Under the plan portion of the notes, it indicated that resident will be monitored and evaluated for response and side effects in 3-4 weeks or as needed. A quarterly PHQ-9 (Patient Health Questionnaire-9) assessment dated [DATE] revealed a score of 3 indicating that the resident has minimal depression. A social service note dated July 27,2023 revealed that resident continues to have difficulty adjusting to being in long term facility. The note indicated that social services will request continued psych consult. A physician order dated August 20, 2023 prescribed Sertraline HCI oral tablet and directed to give 150 milligrams by mouth one time a day for depression as evidenced by verbalization of sadness. Review of a physician note dated August 23, 2023 indicated under the review of systems portion that resident's psych was stable and at baseline. It also noted under plan, the resident be on Sertraline, followed by in-house psychiatry. Review of a physician note dated August 30, 2023 indicated under the review of systems portion that resident's psych was stable and at baseline. The plan portion of the note, indicated Sertraline, followed by in-house psychiatry. During an interview with resident #33 conducted on September 5, 2023 at 9:09 am, he stated that his depression is worse. Resident #33 said he told the facility how he feels but no one has addressed his depression. Hospice was addressing it but he was being dropped from hospice so he is worried that the situation will get worse. A Pre-Admission Screening and Resident Review (PASRR) Level I Screening assessment dated [DATE] revealed that the resident has major depression and that referral for LL determination for MI (mental illness) only was needed. Further review of the resident's clinical record did not reveal any indication that resident #33 received psych follow-up, psych consult, or that he was followed by in-house psychiatry which were services that were identified as needed by the resident. Review of the August 2023 Medication Administration Record (MAR) revealed that the resident received medications as ordered. Review of the August 2023 Treatment Administration Record (TAR) indicated that resident received treatments as ordered. Review of the September 2023 MAR revealed that the resident received medications as ordered. Review of the September 2023 TAR indicated that the resident received treatments as ordered. An interview with the Social Services Director (SSD/staff #56) was conducted on September 7, 2023. Staff #56 stated that she does psych referrals but that case managers also does them. She said she was familiar with resident #33, and that the resident was unhappy where he is at and has a hard time adjusting to his current situation of being at the facility while his wife is at home. Staff #56 stated that the resident has had a change in psych provider since July 27, 2023 so she would have to check if he has been receiving continued psych consult. She also indicated that the facility had a change in psych providers around that time. Due to this she is unsure of whether resident #33 was being seen or not. Staff #56 indicated that according to resident #33, he is not depressed. She noted that resident #33 has been improving in the last two months. Initially, the resident was very guarded, defensive, easy to anger, and would find any excuse to get mad-he gets mad when he is not addressed by his title Doctor. Additionally, staff #56 noted that during an IDT (interdisciplinary team) meeting, it was brought up that resident #33 is verbally abusive. She said that she relayed to the previous Director of Nursing (DON) her recommendation that resident receive continued psych consult. This was also relayed to the previous psychiatrist. Staff #56 stated that psych is not an in-house service and that they come whenever there are enough residents that they need to see. She said psych is normally in the long-term care floor every once or twice a week. Staff #56 stated that resident #33 was for sure not currently being followed-up by the new psych provider. Resident #33 did not transfer to the new provider. Staff #56 stated that if he was receiving services in January, she is not sure why he was not transferred when the facility switched providers. She stated that maybe his info was not relayed to the new person in July. Staff #56 noted that it would have been the previous DON's responsibility to ensure the resident's information flowed to enable the transfer/continuity of care to happen. She indicated that the previous DON cut her off with certain processes so she is not sure if the new psych provider has a roster of residents who needs to be seen. An interview was conducted on September 8, 2023 at 11:49 am with a Certified Nursing Assistant (CNA/staff #52), who stated that whenever she notices something is off or the resident express sadness she informs the nurse immediately so they can follow-up on the resident. She indicated that she is familiar with resident #33 and that he was nice and pleasant. Staff #52 noted that resident #33 sometimes gets a little agitated but nothing major. She noted that she is not aware of any mood or emotional concerns regarding this resident. However, she stated that the resident told her today that he was depressed so she informed the nurse. Staff #52 indicated that the intervention for mood/emotional concern is that CNAs must inform the nurse about concerns so they can follow-up. When asked if she was trained in behavioral health, she replied that she was not a behavior technician. As a CNA she assists residents with ADLs (activities of daily living). An interview was conducted on September 8, 2023 at 11:23 am with a Licensed Practical Nurse (LPN/staff #7), who stated that she checks for emotional patterns like depression, anxiety, loneliness, and would monitor these symptoms during Med Pass. Staff #7 indicated that she is somewhat familiar with resident #33 since she has taken care of him a few times. She said that the resident does not present any concerning mood or emotional behavior. However, she did note that the resident expresses agitation when things do not go his way or if the food he receives is not what he ordered. Staff #7 stated that each time she administers his medications, the resident does inform him that he is depressed which has been an ongoing problem. She also said that as an intervention, she relays the information to the physician and she monitors and documents the resident's behavior on the MAR. Staff #7 stated that the resident is on medication for depression but she does not know which one off the top of her head. When asked if there are non-pharmacological interventions attempted, she indicated that she had not done any. Staff #7 said that she is not aware if resident #33 is monitored by Psych but indicated that he would benefit from it. During an interview with the Director of Nursing (DON/staff #5) conducted on September 8, 2023 at 11:57 am, he stated that residents with mood/emotional concerns should be monitored every shift. If any alterations are noted, then the physician should be notified, and interventions should be followed-up. When asked who tracks/audit residents recommended for psych consult, staff #5 indicated that it is either the DON or the Assistant Director of Nursing (ADON). The DON or ADON contacts the psych provider, who then conducts and evaluation on the resident, and provides recommendations for interventions. According to staff #5, if a resident has concerns and needs a psych consult, an order for psych eval is placed, and that is how they track who needs it. He stated that no one keeps a log of who needs psych evals/follow-ups/treatments. Staff #5 noted that he is familiar with resident #33, who he described as pleasant and does not cause anything of concern. When asked if he was aware that per a psych note dated January 30, 2023 that resident #33 was supposed to be monitored and reevaluated in 3-4 weeks or as needed, and if it was accomplished, the DON sated that there is an order for psych consult sent by the Social Services Director on September 7, 2023 but no follow-up has been completed prior to this survey. When asked about the Social Services Director's (SSD) note dated July 27, 2023 which indicated that the SSD will request continued psych consult for the resident and if it was accomplished, staff #5 sated that the resident has not been seen by psych since January and that he would follow-up right away. Review of the facility policy titled Comprehensive Care Plans revised July 18, 2023 indicated that the facility implements a comprehensive person-centered care plan for each resident to meet their needs which include mental and psychological needs as identified in the resident's comprehensive care plan. Additionally, the policy noted that alternative interventions will be added/revised, as needed. Review of the facility policy titled Abuse, Neglect and Exploitation revised August 8, 2023 stated that the facility will implement policies and procedures that achieves identification, ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on observation, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during catheter care for one resident (#26). The deficient practice could result in transmission of infection. Findings include: Resident #26 was admitted on [DATE] with diagnoses that included dementia, traumatic brain injury, and (BPH) benign prostatic hyperplasia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The assessment also included the presence of a indwelling catheter. Review of a care plan initiated on September 16, 2022, revealed an area of focus that included potential for urinary tract infections related to indwelling catheter with interventions that included catheter care with soap and water every shift and as needed, and to flush catheter as ordered. Review of orders revealed the following: -Irrigate foley catheter with 60cc of normal saline every shift, dated March 24, 2023. -Enhanced barrier precautions: foley required - gloves, gowns, mask, face shield/goggles during maintenance, dated August 30, 2023. -Change indwelling catheter, 18 french 10 ml (milliliter), Foley bag as needed for dislodgement, leakage, clogged, dated August 3, 2023. Catheter care observation was conducted on September 6, 2023 at 9:59 AM with a Certified Nursing Assistant, (CNA/staff #41), the following was observed: -Enhanced barrier precautions notice posted outside the resident's room. -The CNA sanitized her hands, donned a gown, gloves, mask, and goggles. -She entered the resident's room and stated that she was there to conduct catheter care. -The CNA raised and positioned the bed using the remote. -Without changing gloves, she proceeded to remove the resident's the brief, then removed a wipe from the package, and proceeded to wipe from top to bottom starting at the glans penis, turning the wipe with each time. Then cleansed around scrotum, turned the resident and cleansed anal area with a clean wipe from front to back, turning the wipe. -The CNA applied zinc barrier to buttocks. -The CNA then removed one glove, and reapplied the brief (with the hand that had no glove), removed the other glove, and replaced the gown. -She then placed on clean gloves and removed the dirty linen, brief, and replaced the blanket. -She lowered the bed using the remote with the same gloves. An interview was conducted with the CNA (staff #41) on September 7, 2023 at 08:55 AM, who stated that it is the facility policy to change gloves prior to starting catheter care, and after positioning the resident/bed. She stated that she knew that she did not change the gloves during catheter care after positioning the resident, and prior to beginning the catheter care. She stated that the risk of using contaminated gloves for catheter care could result in cross contamination, and possible infection. An interview was conducted on September 7, 2023 at 09:05 AM with the Wound Care and Infection Preventionist (staff #30), who stated that for catheter care she expected the CNA to donn gloves, gown, mask, goggles prior to entering the resident's room. She then stated that the CNA should sanitize the bed side table, get supplies ready and explain the procedure to the resident. She stated that she expected the CNA to discard gloves after positioning the resident, sanitize hands, and donn a clean pair of gloves, then start the catheter care. She further stated that the risk of not changing gloves prior to starting catheter care, and after positioning the resident, could result in cross-contamination, infection and possible urinary tract infections. An interview was conducted on September 7, 2023 at 09:12 AM with the Director of Nursing (DON/staff #5), who stated that that catheter care is completed by CNAs every shift and as needed. He also stated that it was his expectation that a clean pair of gloves would be donned prior to starting catheter care, and after positioning the resident. He further stated that catheter care needs to be as clean as possible. He also stated that the CNA should donn a clean pair of gloves to prep for the treatment, and reposition the resident, would donn a 2nd pair of clean gloves prior to starting catheter care, and would donn a 3rd set of clean gloves to reposition the resident after catheter care. The DON stated that the risk of using contaminated gloves during catheter care could result in transmission of infection. Review of a facility policy titled, Catheter Care, revealed that it is the facility policy to ensure that resident's with indwelling catheters receive appropriate catheter care. Assist the resident to a lying position, perform hand hygiene, then don gloves. Review of a facility policy titled, Infection Prevention and Control Program, revealed that all staff shall assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

Based on clinical record reviews, staff and resident interviews, and review of facility policy, the facility failed to ensure two residents (#17 & #39) received medications according to professional standards of practice. The sample size was 5 residents. The deficient practice could result in residents experiencing negative impact from not receiving ordered medications. Findings include: -Resident #17 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan initiated on March 28, 2021 revealed the resident had the potential for injuries from seizures related to [CONDITION(S)]. The goal was that the resident would remain free from injury related to [CONDITION(S)] activity. Interventions included giving the [CONDITION(S)] medication as ordered. Review of the care plan revised on June 14, 2021 revealed the resident had the potential for alteration in comfort related to [CONDITION(S)], for adverse effects from the use of an antidepressant medication. Interventions included administering medications as ordered. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications included: -Acetaminophen for pain management; -[MEDICATION(S)] for [CONDITION(S)] prophylaxis; -[MEDICATION(S)] (Vitamin D), [MEDICATION(S)] (Vitamin B12), fish oil, and [MEDICATION(S)] (supplements); -[MEDICATION(S)] for [CONDITION(S)]; -[MEDICATION(S)] for seizures; and -[MEDICATION(S)] for depression. Review of the clinical record did not reveal any nursing progress note or physician communication related to the medications scheduled for administration on July 20, 2022 at 9:00 a.m. An interview was conducted on July 27, 2022 at 11:46 a.m. with a Licensed Practical Nurse (LPN/staff #6). He stated that a check mark in the administration box on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated if ordered medications were not given, the risk to the resident would depend on what the medication was being used for, but that there was a risk of adverse effects to the resident. An interview was conducted on July 27, 2022 at 12:28 p.m. with the Director of Nursing (DON/staff #2). She stated she expected staff to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimal Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. An interview was conducted on July 25, 2022 at 1:25 PM with resident #39. The resident stated that sometimes he does not get his ordered medications. The resident stated that he is ordered a lot of medications and has a very detailed regimen that he has gotten used to. The resident stated that he was not able to name the medications specifically however when he asked nursing staff about the medications they never told him specifically what was going on. Resident #39 stated that staff give him a general answer that the nurses are working on getting the medications from the pharmacy. Further, he explained that it is easy for him to tell when medications are missing because multiple times throughout the day there are three capsules missing at a time. The resident stated that he knows they have been missing on multiple occasions. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Regarding [MEDICATION(S)] Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The following dates and times indicated see nurses note: July 14, 2022 at 1:00 PM and 6:00 PM July 15, 2022 at 9:00 AM 1:00 PM July 16, 2022 at 1:00 PM and 6:00 PM July 18, 2022 at 9:00 AM, 1:00 PM, and 6:00 PM July 25, 2022 at 9:00 AM, 1:00 PM, and 6:00 PM Review of the nursing progress notes revealed no notes documented for the administration at 1:00 PM and 6:00 PM on July 14, 2022 or for scheduled times at 9:00 AM and 1:00 PM on July 15, 2022. Review of the clinical record revealed no evidence the medical provider was notified. A progress note regarding [MEDICATION(S)] dated July 16, 2022 at 12:33 PM stated prior authorization was needed, however there was no documentation the medical provider was notified. An administration progress note dated July 18, 2022 at 7:34 PM revealed the medication was on order from the pharmacy. Review of the clinical record revealed no evidence the medical provider was notified. An administration progress note dated July 25, 2022 at 11:57 AM stated [MEDICATION(S)] was not available and was reordered. A progress note dated July 25, 2022 at 5:25 PM stated the facility was waiting for the medication from the pharmacy. However, there was no evidence the medical provider was notified the resident had not received the medication as ordered. Regarding [MEDICATION(S)] Review of the MAR for July 2022 revealed [MEDICATION(S)] was scheduled three times per day at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. The following dates and times indicated see nurses note: July 15, 2021 at 8:00 PM July 18, 2022 at 8:00 AM and 12:00 PM July 25, 2022 at 8:00 AM, 12:00 PM, and 4:00 PM July 26, 2022 at 8:00 PM A progress note dated July 15, 2022 at 8:57 PM stated [MEDICATION(S)] was on order from the pharmacy. However, there was no documentation the medical provider was notified the resident did not receive the medication. A progress note dated July 18, 2022 at 7:28 PM stated [MEDICATION(S)] was on order from the pharmacy. There was no documentation the medical provider was notified the resident did not receive the medication. Review the care plan initiated on July 20, 2022 stated the resident has [CONDITION(S)] disease. The goal was that the resident would remain free of further signs/symptoms, discomfort or complications related to [CONDITION(S)] disease. Interventions included administering medications as ordered. Review of the progress note dated July 25, 2022 at 9:40 AM stated [MEDICATION(S)] was not available and the prescription was faxed to the pharmacy. Review of the administration progress notes dated July 25, 2022 at 10:06 AM regarding [MEDICATION(S)] stated awaiting from pharmacy. A progress note dated July 25, 2022 at 11:53 AM stated the nurse had spoken to the pharmacy and the medication will be sent out July 26, 2022. However, there was no documentation the medical provider was notified the resident did not receive the medication. A progress note dated July 25, 2022 at 11:57 AM stated the medication was not available and was reordered. A progress note dated July 25, 2022 at 4:13 PM stated the medication was not available. An interview was conducted on July 27, 2022 at 10:18 AM with an LPN (staff #13). The LPN stated for a newly admitted resident, usually their medications have already been ordered from the pharmacy so when the resident gets to the facility the medications are already there for them. She stated that if the nurse is unable to locate the medications, the nurse will contact the pharmacy. The LPN stated there had been some issues getting resident #39's medications from the pharmacy. She stated that when she called the pharmacy on July 25, 2022, the pharmacy told her they were out of [MEDICATION(S)]. She further stated she was out of the medication at the facility so the resident did not receive the medication. The LPN stated if a resident does not receive medications as ordered, the nurses will notify the medical provider. The LPN stated that she does not chart in the resident's record if she notified the medical provider, she deletes her messages, and she is unable to provide evidence that notification occurred. She stated she knows that every time the medication was unable to be administered to the resident there should be documentation the physician was notified. The LPN stated that she believes the resident has a right to receive their prescribed medications. An interview was conducted on July 27, 2022 at 1:46 PM with the DON (staff #2). The DON stated when a resident is going to be newly admitted , they order their prescribed medications through the pharmacy so that once the resident arrives the medications should be at the facility. She explained that if the orders are in the resident medical record by 8:00 PM then the medication should be on the last run for the day. She stated that if the orders are put in the resident record after 8:00 PM then the medications should be in by mid-morning. The DON stated that she expects the staff to refill the resident medications when there are approximately 7 pills left to avoid the resident running out of medications. The DON stated that she is not aware of any concern related to residents not getting their medications. Further, the DON stated that if the resident is completely out of their medications then she expects the nurse to call the pharmacy and get some answers. The DON stated that sometimes the pharmacy can do a stat run and get the medication to the facility even faster than normal. She stated that if there are difficulties that continue then the nursing staff should notify her so she can assist them. The DON stated whenever a resident does not get their prescribed medications they should notify the medical provider. The DON stated that she was unsure if the nurses document in the resident's record if the physician is notified when a resident does not get their medications but she thought they should. The DON stated she reviewed the record and there were multiple days where the resident did not receive their prescribed medications. The facility policy titled administering medications stated medications shall be administered in a safe and timely manner, and as prescribed. The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame.

Based on clinical record reviews, observations, resident and staff interviews, and review of policies and procedures, the facility failed to ensure care and services were provided to three residents (#'s 61, 96 and 156) with pressure ulcers. Findings include: -Resident #156 was admitted to the facility on [DATE] from a hospital, with [DIAGNOSES REDACTED]. A hospital wound care note dated October 5, 2016, included the resident had a suspected deep tissue injury on the left heel, which evolved into an unstageable pressure ulcer. The suspected deep tissue injury on the left heel is covered by eschar, which measures 1.2 centimeters (cm) in width by 1.2 cm in length, and surrounding skin has no [DIAGNOSES REDACTED] or induration. The note further included for [MEDICATION NAME] to be applied daily and leave open to air. Review of a nursing note dated October 5, 2016 revealed the resident was admitted on the evening shift and was alert and oriented x 4. Review of the facility's physician admission orders [REDACTED]. Further review revealed that there were no treatment orders for the pressure ulcer on the left heel. Review of the facility's standing physician orders [REDACTED]. According to the clinical record, there was no documentation that the physician had been notified regarding the left heel unstageable pressure ulcer. A Braden Scale for Predicting Pressure ulcers dated October 5, 2016, documented that the resident was at low risk. A nursing note dated October 6, 2016, documented the resident's left heel had an open area that was dark, black in color and that the resident had a protective boot in place. However, a weekly head to toe skin assessment signed by a licensed practical nurse (LPN/wound nurse/staff #85) dated October 7, 2016, revealed no documentation of an open area on the resident's left heel. A nutritional services progress note dated October 7, 2016, documented that the resident had a possible pressure ulcer to the left heel . The note included that staff would continue to monitor for further interventions. Review of the clinical record revealed there was no documentation that the resident's left heel was thoroughly assessed upon admission. Review of a skin monitoring comprehensive shower review form dated October 8, 2016 revealed instructions to perform a visual assessment of the resident's skin and report any abnormal looking skin to the nurse and to use the form to show the exact location and describe the skin abnormality. The documentation included that the resident did not have any skin problems. The form was signed by a licensed nurse. Further review of the clinical record revealed that a care plan for skin breakdown/pressure ulcers had not been developed upon admission. physician progress notes [REDACTED]. Review of the Treatment Administration Record (TAR) for October 2016 revealed there were no treatment orders for the left heel, nor was there documentation of any treatment which had been provided. Continued review of the clinical record revealed there was no documentation that a thorough assessment of the resident's left heel was done, which included measurements from the time of admission through October 11. An interview with a LPN (staff #136) who was working on the resident's unit was conducted on October 11, 2016 at 2:11 p.m. She stated the resident had an unstageable pressure ulcer on the left heel, which was present on admission. She also stated that the wound nurse (staff #85) had not yet seen the wound. According to the admission Minimum Data Set (MDS) assessment dated [DATE], the resident was cognitively intact and required extensive assistance of two persons with bed mobility and transfers. The MDS also identified that the resident had one unstageable pressure ulcer, due to being covered with slough or eschar and that it was present upon admission. An interview was conducted on October 12, 2016 at 1:00 p.m., with a LPN (staff #97) who was caring for the resident. Staff #97 stated that she did not know that the resident had a pressure ulcer and she could not locate any physician orders [REDACTED]. Following this interview, staff #97 inspected the resident's left heel and stated that an unstageable pressure ulcer was present. At this time, the resident stated that the left heel had not been treated since admission. An interview was conducted with the Director of Nursing (DON/staff #43) on October 12, 2016 at 1:45 p.m. Staff #43 stated the physician should have been been notified on October 6, when staff documented the left heel problem. Staff #43 stated that the head to toe skin assessment (conducted on October 8) was not accurate, as it did not include the left heel pressure ulcer. She further stated that physician's standing orders could have been implemented. At this time, staff #85 joined the interview. Staff #85 stated that she signed and dated the head to toe skin assessment from October 7, but she did not physically assess the resident's heels. An observation of the resident's left heel was then conducted with staff #85 on October 12, 2016 at 2:17 p.m. The resident was observed to have two areas on the left heel as follows: area #1 was located on the distal heel and was non-blanchable, dark purple in color, and measured 3/4 inch in length by 1/2 inch in width, with no depth; area #2 was located on the left lateral heel and was not open, the area was blanchable and measured 1 inch in length by 3/4 inch in width, with no depth. Staff #85 stated both were unstageable pressure ulcers and that area #2 was a possible blister with fluid or pus. Staff #85 stated she would immediately notify the physician of the pressure ulcers and obtain treatment orders. A physician's orders [REDACTED]. -Resident #96 was admitted to the facility on [DATE] and a readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 12, which indicated the resident had moderate cognitive impairment. Review of the skin condition section revealed the resident was at risk for the development of pressure ulcers but did not have any pressure ulcers at the time of the assessment. A Weekly Skin assessment dated [DATE] did not indicate that the resident had any pressure ulcers. A Wound Progress Note dated June 22, 2016 did not indicate that the resident had any pressure ulcers. A Nurses Progress Note dated June 24, 2016 indicated that while a Certified Nursing Assistant (CNA) was changing the resident, an open area was noted on the resident's coccyx. The note indicated the wound nurse would follow up with the resident. A Wound Progress Note dated June 24, 2016 indicated a wound to the right buttock area, which measured 0.5 x 0.5 cm. 0.1 cm in size with a red wound bed and barrier cream was applied. A physician's orders [REDACTED]. symptoms of infection every day and night and notify provider. The Weekly Skin assessment dated [DATE] indicated the resident had an open area on the coccyx. A Wound Progress Note dated July 3, 2016 indicated the left buttock ulcer was unchanged and measured 1 x 0.5 x 0.1, with no drainage and that barrier cream was applied. The Weekly Skin assessment dated [DATE] indicated the coccyx had an open area and barrier cream was applied with each brief change. Review of the TAR for July 2016 revealed the barrier cream was not completed on the night shift on July 22 and July 29. The TAR also included that the open area on the left buttocks was not monitored for signs and symptoms of infection on the day and night shift on July 10, or on the night shift on July 22 or July 29. A physician's orders [REDACTED]. The Weekly Skin assessment dated [DATE] indicated the left buttock open area was being followed by the wound nurse and cream is being applied with each brief change. A Wound Progress Note dated August 9, 2016 indicated the resident had a pressure injury to the right sacrum, with no exudate. The note included the stage 2 wound measured 2.2 x 2.3 x 0.1 cm with 100% granulation tissue, wound edges were defined but macerated, and the periwound was intact with tenderness. The Weekly Skin assessment dated [DATE] indicated the left buttock had an open area. Review of the August 2016 TAR revealed to cleanse the left buttocks ulcer with wound cleanser, pat dry, and apply Solosite gel to wound bed. However, the treatment was not competed on August 6 and August 22. In addition, the TAR indicated the open area on the left buttocks was not monitored for signs and symptoms of infection on the night shift on August 5, the day shift on August 8, the night shift on August 13, and the day shift on August 22. A Wound Progress Note dated August 25, 2016 indicated the wound to the coccyx is resolved. The documentation contained in the resident's clinical record as noted above described a pressure ulcer to four different locations (sacrum, coccyx, left buttocks and right buttocks). The clinical record documentation did not clarify if the resident had one pressure ulcer or if multiple pressure ulcers were present. In an interview with a Licensed Practical Nurse (wound nurse/LPN/staff #136) on October 12, 2016 at 9:03 a.m., staff #136 stated the difference in describing the location of the wound was because she has been told she was getting too specific with her descriptions and that she should be more general. She further stated that although the documentation appears as though the resident had four pressure ulcers because of the different locations described (sacrum, coccyx, left buttocks and right buttocks), the resident only had one pressure ulcer. -Resident #61 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the nurse's notes from April 13, through April 15, 2016 revealed no documentation that the resident had any pressure ulcers. However, a skin integrity care plan initiated on April 15, 2016 documented the resident had a right heel unstageable pressure ulcer. Interventions included to evaluate skin condition on a weekly basis, provide treatments per physician orders [REDACTED]. A physician's orders [REDACTED]. Review of the clinical record revealed there was no documentation regarding a thorough assessment of the resident's heels, which was completed upon admission. A nurse's note dated April 18, 2016 included the resident did not have any pressure ulcers. Review of the admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS also assessed the resident to be at risk for the development of pressure ulcers, however, did not have any pressure ulcers at the time of admission. Review of the functional section of the MDS revealed the resident required extensive assistance/total dependence for all ADLs (activities of daily living). According to two nursing notes dated April 29, 2016, the resident had a suspected deep tissue injury (SDTI) to the right heel which measured 7 x 6.5 cm and the depth was unable to be determined. The pressure ulcer was described as purple and maroon in color and the skin was intact. The second note indicated the resident had a SDTI to the left heel which measured 5.2 x 3.5 and the depth was unable to be determined and the skin was intact. Review of the Treatment Administration Record for April 2016 revealed the treatment for [REDACTED]. A nursing note dated May 4, 2016 included the SDTI to the right heel had drainage. The physician was called and a new order for treatment to the right heel was received. A physician's orders [REDACTED]. A Wound Progress Note dated May 17, 2016 indicated skin prep was applied and the dressing changed to the right heel, which measured 4.9 x 6.8 cm. The note indicated the left heel SDTI measured 2.3 x 4.7 cm and skin prep was applied. Both wounds were described as being dark in color. Review of a physician's note dated May 26, 2016 revealed the resident had bilateral heel decubitus ulcers with eschar caps and the left was larger than the right, and both were hard. Will continue [MEDICATION NAME] daily and off loading heels. A physician's orders [REDACTED]. A physician's note dated May 30, 2016 revealed the deep tissue injury to the right heel was opening and that the orders will be changed to [MEDICATION NAME], and Kerlix and the left heel decubitus treatment included [MEDICATION NAME]. A physician's orders [REDACTED]. Review of the TAR for May 2016 revealed skin prep to the left heel was not completed on two shifts, and the right and left heels were not monitored for signs of infection on six shifts. Further review of the clinical record revealed there was no additional assessment documentation of the resident's left heel from May 18-31, 2016. The right heel pressure ulcer continued to be assessed weekly. Review of a physician's note dated June 6, 2016 included the resident had a left heel decubitus with eschar. A physician's orders [REDACTED]. A Wound Progress Note dated June 15, 2016 indicated the presence of a SDTI to the right heel, which measured 2.5 x 2 cm and depth was UTD, with a scant amount of drainage. A physician's note dated June 16, 2016 documented the resident had a decubitus ulcer with eschar to the left heel. Continued review of the clinical record revealed there were no thorough assessments of the resident's left heel decubitus ulcer in June 2016. The right heel pressure ulcer continued to be assessed weekly. A physician's note dated July 1, 2016 included the resident had a decubitus ulcer with eschar to the left heel. A Wound Progress Note dated July 3, 2016 indicated the right heel wound continues to be scabbed over and measured 2.5 x 2 cm. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's note dated July 27, 2016 included the resident had a decubitus ulcer with eschar to the left heel. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. Review of the TAR for July 2016 revealed skin prep to bilateral heels was not completed on six shifts, floating heels was not documented as performed on two shifts, left heel ulcer care was not documented on nine shifts, and the right and left heels were not monitored for signs of infection on two shifts. Further review of the clinical record revealed there was no thorough assessment documentation of the resident's left heel decubitus ulcer in July 2016. The right heel pressure ulcer continued to be assessed weekly. A physician's note dated August 1, and 26, 2016 did not include any documentation regarding a left heel decubitus ulcer. There was also no clinical record documentation regarding the left heel decubitus ulcer in August 2016. The right heel pressure ulcer continued to be assessed weekly. In an interview with the Director of Nursing (registered nurse/DON/staff #43) on October 12, 2016 at 1:45 p.m., the DON stated there were problems identified with pressure ulcers over the past 4-6 weeks, such as incomplete documentation and follow-up. The DON stated that the wound nurses are supposed to evaluate the wounds as soon as possible after the wound is identified, and contact the physician for orders. She further stated that the physician should be called any time there is a change for the worse in the condition of the wound or when the wound is healed. A pressure ulcer treatment observation was conducted on October 13, 2016 at 9:01 a.m., with licensed staff present. The right heel was observed to be dried and without redness or drainage and was covered with eschar and measured 1 x 2 cm. The resident did not have a wound to the left heel. Review of the facility's policies regarding pressure ulcers revealed that a head to toe skin assessment should be done on all residents upon admission, then every shift for the first 24 hours. The policy included that the CNA's are to communicate skin integrity issues noted during daily care and to complete the form and ensure delivery to the licensed nurse. The licensed nurse then assesses the resident's skin issue and intervenes as necessary by documenting, communicating the findings to the physician and implementing appropriate interventions. The policies further included that the licensed nurse will monitor pressure ulcers daily to include status of the dressing, condition of the peri-wound, and presence of possible complications. Weekly, the treatment nurse will document wound location, measurements, characteristics, absence of odor, etc. Licensed nurse to provide treatment as ordered. Residents admitted with pressure ulcers will have appropriate preventive interventions, care plans with interventions, and physician orders [REDACTED]. When a new skin issue is identified the licensed nurse validates the observation by examining the resident and complete documentation on the wound tracking worksheet. Document only one area or site per form. Determine the stage of the pressure ulcer, measure the pressure ulcer and describe the pressure ulcer. Notify the physician and collaborate on a treatment order.

Based on clinical record review, review of hospital records, observations, staff interviews, and review of facility policies, the facility failed to ensure that appropriate care and services for pressure ulcers were provided to two residents (#s 147 and 2). Resident #147 sustained actual harm. The sample size was four. Findings include: -Resident #147 was readmitted to the facility on [DATE], with post acute [MEDICAL CONDITION] infarction, diabetes mellitus, [MEDICAL CONDITIONS], and pneumonia. The hospital continuing care information sheet revealed the resident had no pressure wounds present. The physician ordered, on the admitted , to conduct weekly skin assessments and to use the facility's skin protocol. The physician also order to apply [MEDICATION NAME] to perineal area and buttocks twice a day. Review of the clinical record revealed an admission evaluation dated October 31, 2011, a Braden skin assessment score of 14, which placed the resident at moderate risk for skin breakdown. Review of the admission nurses progress notes from October 31, 2011, revealed that the resident's skin was "clear of open areas". Review of the initial care plan, dated October 31, 2011, included that the resident was at risk for skin breakdown and was to be on a turning/repositioning program, the resident's heels were to be floated, and the resident was to be monitored regarding changes in skin integrity. The care plan also documented for staff to apply barrier cream. The November 2011 treatment administration records (TARs) revealed that there was no documentation that showed that the resident's skin had been assessed weekly. On November 2, the resident was admitted into hospice. On November 6, 2011, the nurse progress notes noted that the resident's perineal and buttock areas were excoriated. The November TAR revealed no documentation that the resident had received [MEDICATION NAME] treatment as physician ordered on the following evening shifts: November 3, 5, 6, 7, 10, 11, 16, 17, and 21, 29, and 30, 2011. Nor was there documentation on the TARs that the resident received [MEDICATION NAME] treatment on the morning shifts of November 16, 29, and 30, 2011. There were no TARs, in the clinical record, for the month of December 2011. Review of the nurse practitioner progress notes dated December 1, 2011, revealed that the hospice nurse had reported a pressure ulcer stage I. There was no location documented. Review of the hospice note dated December 6, 2011, revealed that the resident had an open sore on her bottom, and it looked like it was getting deep. Review of the nutrition at risk notes dated December 7, 2011, revealed a stage II pressure ulcer. The daily nursing assessments dated December 2, 3, 8, 9, 10, 13, 15, 2011, included documentation that the resident's skin was intact. On December 16, the nursing assessment stated that the resident's skin was not intact and was identified as unstageable. This assessment failed to include the location and site of the wound. The following daily nursing assessments for the remaining part of December only identified that the resident's skin was not intact. It was not until December 29, that the daily nursing assessments noted that the resident's right buttock had an "...unstageable area, yellow slough is covering depth of wound, approximately 60% slough, 40% pale pink wound bed-Induration noted to periwound, pink to wound edges..." The physician ordered, on this same date, Santyl ointment and to gently pack with calcium diginate to be applied daily. The hospice nurse documented the following: On December 14, 2011, the pressure ulcer was measured 4 centimeters (cm) X 2.5 cm X unable to be determined. The wound was described as 10 percent [MEDICATION NAME], 90 percent slough, moderate drainage with foul odor. The location was identified as the right buttocks. There was no documentation to show that the physician was notified of the wound's deterioration which would have provided the physician the opportunity to change treatment. On December 19, 2011, 4 cm X 2.2 cm X unable to be determined. Slough was 100 percent, red edges macerated, moderate amount of purulent draining with odor present. The physician ordered, on this same date, a wound culture to right buttocks. The ordered also stated to not change the wound until this culture was obtained on December 20, 2011. On December 21, 2011, revealed that the culture could not be obtained on December 20, since the resident received a bed bath and the area was cleaned. On December 30, 2011, the wound nurse reported to the hospice the the pressure ulcer was now unstageable due to the slough. On December 28, 2011, the facility pressure ulcer evaluation stated that the ulcer as a stage II and measured as 1.9 cm X 2.4 cm X 0.5 cm, with tunneling at one o'clock and 6 o'clock. Review of the January 2012 TARs revealed no documentation that weekly skin assessments were completed as physician ordered. Further review of the the facility's pressure ulcer evaluation sheet revealed on January 3, 2012, the wound was unstageable and measured 3 cm X 2.5 cm X depth was unable to determine, and had no tunneling documented. There was no documentation to show that the physician was notified. Per wound evaluation flow sheets, the following was documented: January 9, 2012, ulcer was 3 cm X 2 cm X 0.5 cm, with tunneling at 12:00 o'clock 3 cm. January 15, 2012, measurement 2 cm X 3 cm X 0.5 cm with 3 cm tunneling at 10 to 12 o'clock. January 19, 2012, measurements 2.5 cm X 2 cm X 0.3 cm with tunneling at 10 to 12 o'clock at 5.2 cm. Comments on sheet wound bed better tunneling worsening. Further review of the clinical record did not show that the physician was notified that the wound continued to deteriorate. During the wound observation conducted on January 19, 2012, with the registered nurse (RN), who provided wound care, stated that the tunneling had worsened. Later while reviewing the wound evaluation flow sheet she stated that the nurse that had documented the measurements on January 15, 2012, had transposed the length and width of the wound bed. -Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The physician's admission orders [REDACTED]. The admission nursing note entry dated August 19, 2011, included that the resident had chronic wounds on chest wall. There was no documented evidence that a pressure ulcer was present. A Braden skin assessment dated also August 19, 2011, identified that the resident was not a high risk for the development of pressure ulcers (score of 19 and per the guidelines a score of 12 or less represented a high risk). A review of the August 2011, treatment sheet revealed documentation that the weekly skin assessments would be completed every Wednesday, however, the treatment sheets did not include any documented evidence that any skin assessments had been completed in August. A review of the September 2012, treatment sheet revealed a physician's orders [REDACTED]. However, the order was transcribed as a, "FYI," and did not include documentation that the cream had been applied. A wound evaluation flow record dated September 8, 2011, now included documentation that a Stage 1 pressure ulcer, which measured 14 by 18 cm (centimeters), was identified on the resident's coccyx. A physician's orders [REDACTED]. A continued review of the wound evaluation flow record revealed documentation that on September 16, 2011, the Stage 1 pressure ulcer had deteriorated and now was a Stage 2 pressure ulcer, which measured 2.5 by 1.3 cm. According to the documentation, the prescribed treatment was to cover the area with a protective film or gauze. A hospice physician's orders [REDACTED]. However, a review of the September 2011, TAR revealed no documentation of that of newly prescribed treatment or any documentation that it had been administered. A review of a facility form titled, Weekly Skin Sweep, revealed documentation that the resident's skin was assessed on August 19, September 12, and 20, 2011. The documentation included that there were no new skin impairments since admission. However, as evidenced by the wound evaluation flow record, the resident had actually developed a Stage 1 pressure ulcer on the coccyx on September 8, which then had progressed to a Stage 2 pressure ulcer on September 16, 2011. In addition, neither an initial or comprehensive care plan, to address the pressure ulcer, was able to be located in the clinical record. An interview was conducted on January 20, 2011, with a RN/wound nurse. Following a review of the resident's clinical record, she stated that a care plan should have been developed when the pressure ulcer was a Stage 1 and then revised to reflect the deterioration of the pressure ulcer to a Stage 2. She also stated that according to the treatment record documentation, a weekly skin assessment had not been completed after admission (August 19, 2011) or prior to September 6, 2011. In addition, the nursing note entries from September 6 through 23, 2011, and the September treatment sheets were also reviewed at this time. Following this review, the RN/wound nurse, stated that the nursing note entries did not include documentation that a pressure ulcer had developed or that the physician order [REDACTED]. A second interview was conducted on January 24, 2012, with administrative nursing staff, who stated that the treatment sheets should have included all current treatment orders to be administered. She also stated that the weekly skin assessments should have been completed and documented and that care plans should have been developed and revised to address the pressure ulcer. A facility policy titled, Skin Integrity Oversight, included, "...Community staff will perform ongoing monitoring of residents' skin and obtain or provide care as indicated..." The policy also included, "...Caregivers will observe and report changes in the skin, for residents who are receiving bathing assistance...Update resident's Service Plan and implement treatment...Monitor treatment and progress...Document in resident's Service Notes..."