Haven Of Flagstaff

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to submit a 5-day written investigation summary regarding physical altercation between 2 residents (#1 and #2).

Findings include:

-Regarding resident #1

Resident #1 was admitted on December 30, 2020 with diagnosis including displaced intertrochanteric fracture of the right femur, low back pain, unsteadiness on feet, hypertension, unspecified glaucoma, major depressive disorder-recurrent, insomnia, type 2 diabetes with neuropathy, muscle wasting and atrophy, abnormalities of gait and mobility, osteoporosis, repeated falls and urinary tract infection.

A review of the admission MDS (minimum data set) dated January 6, 2021 revealed a BIMS (brief interview of mental status) score of 00, indicating severe cognitive impairment.

-Regarding resident #2

Resident #2 was admitted on January 2, 2021 with diagnosis including unspecified fracture of right femur, repeated falls, unspecified dementia, type 2 diabetes, monoplegia of upper limb, facial weakness, other cerebral infarction due to occlusion or stenosis.

A review of the progress notes revealed an entry, that on January 28, 2021 an altercation took place between resident #1 and #2. It was noted that both residents were sitting in their wheelchairs prior to the altercation. It was further noted that a PTA (physical therapy assistant) was maneuvering resident #2 around the dining table and upon passing resident #1, resident #2 starting hitting resident #1 with her left upper extremity. It was noted that resident #2 kept hitting resident #1 and then resident #1 starting hitting back in self-defense. Staff (PTA) alerted other staff to the incident and the residents were separated. It was noted that the residents were assessed for injuries and none were present. The progress notes further revealed that an LPN staff#22 notified the previous ADON and he called the Arizona State Board of Nursing, leaving a voicemail regarding the incident and that case managers and family members were notified; however, there is no documented evidence that the incident was reported to the state survey agency. Given that the incident occured in 2021, several of the staff members who witnessed the incident are no longer with the facility

An interview was conducted on October 22, 2023 at 2:15 P.M. with staff #18 CNA (certified nursing assistant). Staff #18 stated that abuse could be mental, financial, verbal, neglect or physical. She stated that the facility has annual training but also provides monthly training refreshers. Staff # stated that if abuse is observed between residents, the first thing that is done is to physically separate the residents and ensure their safety. Residents may need to be moved to another room, if they were sharing a room. She further stated that once residents are safe, notifications and an incident report would occur and that these are time sensitive and would need to happen right away.

A telephonic interview was conducted on October 22, 2023 at 2:50 P.M. with staff #22, LPN (licensed practical nurse). Staff # 22 stated that she had recollection of the incident, but given that it was in 2021, no longer recalled the specifics of what had occurred.

An interview was conducted on October 23, 2024 at 1:40 P.M. with staff #115 LPN (licensed pratical nurse). Staff #115 stated that if an altercation occurred between residents, they are immediately separated and she and other staff would check to make sure they are safe and not injured. If additional assistance was needed, staff know to call for help. Once residents are safe, the director of nursing is notified and the facility proceeds with notifications of family, physician, case manager as well as filling a complaint report. She stated that she believed that the notification window was a 2-hour time span for incidents of abuse. Staff #115 further stated that the facility conducts training regarding abuse at least annually, but usually more frequently. She stated that the risk for not reporting timely or conducting an investigation, could impact finding out what actually happened and requirements regarding timely reporting.

An interview was conducted on October 23, 2024 at 8:30 A.M. with staff #28 DON (director of nursing). Staff #28 stated that the facility is required to report incidents on a timely basis and follow-up with a thorough investigation. She stated that the facility was unable to locate the 5-day investigation of the incident regarding resident #1 and resident #2 and that these records might be in storage. She stated that she was fairly certain that a 5-day investigative report would have been completed and that she would look in the facilities storage facility for the investigative report. She stated that if the 5-day investigation was not completed then the risk would include not knowing what actually transpired and not meeting timely reporting guidelines.

On October 25, 2024 at 5:35 P.M. an email was received from the Executive Director, staff #42. The email noted that the facility was unable to find the 5-day investigative report regarding this incident.

There was no evidence that the 5-day investigative summary had been submitted to the state survey agency.

A review of the facility policy entitled Abuse with a copywrite date of 2022 version 0622 noted that the executive director will begin an investigation immediately and complete the incident investigation within 5-working days utilizing an abuse investigation packet. It was further noted that this summary is then sent to the state survey agency;

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#1 and #2) were free from physical abuse.

Findings include:

-Regarding resident #1

Resident #1 was admitted on December 30, 2020 with diagnosis including displaced intertrochanteric fracture of the right femur, low back pain, unsteadiness on feet, hypertension, unspecified glaucoma, major depressive disorder-recurrent, insomnia, type 2 diabetes with neuropathy, muscle wasting and atrophy, abnormalities of gait and mobility, osteoporosis, repeated falls and urinary tract infection.

A review of the admission MDS (minimum data set) dated January 6, 2021 revealed a BIMS (brief interview of mental status) score of 00, indicating severe cognitive impairment.

-Regarding resident #2

Resident #2 was admitted on January 2, 2021 with diagnosis including unspecified fracture of right femur, repeated falls, unspecified dementia, type 2 diabetes, monoplegia of upper limb, facial weakness, other cerebral infarction due to occlusion or stenosis.

A review of the progress notes revealed an entry, that on January 28, 2021 an altercation took place between resident #1 and #2. It was noted that both residents were sitting in their wheelchairs prior to the altercation. It was further noted that a PTA (physical therapy assistant) was maneuvering resident #2 around the dining table and upon passing resident #1, resident #2 starting hitting resident #1 with her left upper extremity. It was noted that resident #2 kept hitting resident #1 and then resident #1 starting hitting back in self-defense. Staff (PTA) alerted other staff to the incident and the residents were separated. It was noted that the residents were assessed for injuries and none were present. The progress notes further revealed that an LPN (Licensed Practical Nurse/ staff #22) notified the previous ADON (Assistant Director of Nursing) and he called the Arizona State Board of Nursing, leaving a voicemail regarding the incident and that case managers and family members were notified.

However, there is no documented evidence that the incident was reported to the state survey agency.

An interview was conducted on October 22, 2023 at 2:15 P.M. with CNA (certified nursing assistant/ Staff #18). Staff #18 stated that abuse could be mental, financial, verbal, neglect or physical. She stated that the facility has annual training but also provides monthly training refreshers. Staff #18 stated that if abuse is observed between residents, the first thing that is done is to physically separate the residents and ensure their safety. Residents may need to be moved to another room, if they were sharing a room. She further stated that once residents are safe, notifications and an incident report would occur and that these are time sensitive and would need to happen right away. Stated that she had received training on abuse and behavioral health.

A telephonic interview was conducted on October 22, 2023 at 2:50 P.M. with an LPN (Staff #22). Staff # 22 stated that she had recollection of the incident, but given that it was in 2021, no longer recalled the specifics of what had occurred.

An interview was conducted on October 23, 2024 at 1:40 P.M. with staff #115 (LPN). Staff #115 stated that if an altercation occurred between residents, they are immediately separated and she and other staff would check to make sure they are safe and not injured. If additional assistance was needed, staff know to call for help. Once residents are safe, the director of nursing is notified and the facility proceeds with notifications of family, physician, case manager as well as filling a complaint report. She stated that she believed that the notification window was a 2-hour time span for incidents of abuse. Staff #115 further stated that the facility conducts training regarding abuse at least annually, but usually more frequently.

An interview was conducted on October 23, 2024 at 8:30 A.M. with staff #28 , DON (director of nursing). Staff #28 stated that the expectation is that resident to resident abuse does not occur; however with certain diagnosis behaviors arent always predictable. She further stated that when an incident does occur, the facility is required to report incidents on a timely basis and follow-up with a thorough investigation. She stated that the risk of resident to resident abuse could result in injury to a resident.

A review of the facility policy entitled Abuse, with a copywrite date of 2022, version 0622 revealed that abuse is not condoned in Haven Health facilities.

Based on observation, interview, and record review the facility failed to ensure that one resident (#3) received care for pressure ulcers consistent with professional standards when observed wound care assessments were not completed on a weekly basis.

Findings include:

Resident #3 was admitted on January 6, 2021 with diagnosis including venous insufficiency (chronic-peripheral), pressure ulcer of the left heel (unstageable), pressure ulcer of the right heel (unstageable), acute posthemorragic anemia and cellulitis of the left lower limb.

A review of the discharge MDS (minimum data set) dated March 10, 2021 revealed no BIMS (brief interview of mental status) score.

A review of the physician orders revealed orders for daily wound care to both right/ left heels and posterior right/ left calf. Orders were further observed for physical and occupational therapy. An order dated March 10, 2021 was also observed for a consult for heel debridement.

A review of the care plan revealed that the resident had a DTI (deep tissue injury) to bilateral heels and had the potential for further pressure ulcer development due to decreased mobility. The noted intervention included to access, record and monitor wound healing weekly and as necessary. It further noted that length, depth and width would be measured when possible and that all assessments would be documented. The care plan further revealed that the resident had limited mobility due to right hand and bilateral lower extremity contractures. The intervention included referral to physical and occupational therapy as well as monitoring and documentation of contractures forming or worsening.

The electronic health record for the resident revealed a time span greater than 7-days for pressure ulcer documentation and assessment for the following assessments: January 25, 2021, February 4, 2021 and February 27, 2021.

An interview was conducted on October 22, 2024 with staff #115, LPN (licensed practical nurse). Staff #115 stated that that skin assessments are conducted weekly and documented in the electronic health record. She stated that the risk for not completing the assessment or not completing it timely would include not knowing what is going on with the resident in relationship to wound care or the wound worsening.

An interview was conducted on October 23, 2024 at 10:30 A.M. with staff #72 (ADON-assistant director of nursing and wound care nurse). Staff #72 stated that upon admission, residents with wounds are placed on weekly wound care rounds with the physician or nurse practitioner. She stated that assessments are conducted weekly but sometimes more often contingent on what is going on with the pressure ulcer. Staff #72 stated that the risk for not having assessments completed weekly would be contingent on the resident's comorbidities. She stated the facility now has a program in place called PUP (pressure ulcer prevention) and that this has been very helpful in reducing the number of facility acquired pressure ulcers.

An interview was conducted on October 23, 2024 at 10:40 A.M. with staff #28 DON (director of nursing). Staff #28 stated that the expectation is that pressure ulcer and skin assessments be completed weekly, as per policy. She stated that wound care and more specifically pressure ulcers were current QAPI (quality assurance and performance improvement) measures for the facility. Staff #28 reviewed the residents electronic health record and confirmed that the assessments were not consistent on a week to week basis for resident #3. She stated that the risk for not conducting weekly assessments timely could include a worsening of the pressure ulcer or wound.

A review of the facility policy entitled Skin/Wound Management: Pressure Injury Risk Assessment with an effective date of January 1, 2024 revealed that the resident is to be assessed at admission and that the risk assessment is to be completed weekly thereafter; however, facility documentation did not reveal evidence of consistent weekly assessments.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to provide evidence that the an allegation of abuse for one resident (#71) was thoroughly investigated and results of the investigation was reported to the State Agency within 5 working days of the incident.

Findings include:

Resident #71 was admitted on December 16, 2022 with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness.

The minimum data set (MDS) assessment dated February 5, 2023 include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact.

The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents.

-Resident #46 was admitted on December 27, 2022 with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism.

The MDS assessment dated December 28, 2022 revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment.

A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off.

Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night.

A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive.

A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents.

A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound.

A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on the nurse.

Despite documentation of resident #46 slapping or swatting resident #71, there was no evidence found in facility documentation that this incident was reported and thoroughly investigated by the facility.

In an interview conducted with a certified nursing assistant (CNA/staff #3) on December 14, 2023 at 2:21 p.m., the CNA stated that abuse can be verbal, emotional, physical, sexual, and financial. She stated that if a resident slaps another resident, it was abuse; and that, she would separate the residents and report the incident to the nurse.

During an interview with the Executive Director (ED/staff #1) conducted on December 14, 2023 at 2:47 p.m., the ED stated that abuse can be verbal, physical, sexual, seclusion, mental, neglect, and financial; and that, it was abuse, if a resident slaps another resident. The ED further stated that when there is an allegation of abuse, the staff and residents should be interviewed and an investigation should be completed within 5 days and submitted to the state agency. However, the ED stated that she does not have a 5-day investigation for incident between residents #46 and #71.

The facility's "Abuse Policy" stated that the facility strives to prevent the abuse of all their residents. The ED will begin investigation immediately and complete within 5 working days using the Abuse Investigation Packet. A minimum of three residents will be interviewed in order to determine if there is a trend. interviews may also include Alleged Perpetrator, witnesses and staff members as applicable. When the investigation is complete, the ED will submit a summary to the state survey agency.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#71) was free from abuse of another. The deficient practice could result on resident being physically and psychosocially harmed by other residents.

Findings include:

Resident #71 was admitted on December 16, 2022 with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness.

The minimum data set (MDS) assessment dated February 5, 2023 include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact.

The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents.

-Resident #46 was admitted on December 27, 2022 with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism.

The MDS assessment dated December 28, 2022 revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment.

A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off.

Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night.

A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive.

A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents.

A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound.

A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on the nurse.

In an interview conducted with a certified nursing assistant (CNA/staff #3) on December 14, 2023 at 2:21 p.m., the CNA stated that abuse can be verbal, emotional, physical, sexual, and financial. She stated that if a resident slaps another resident, it was abuse; and that, she would separate the residents and report the incident to the nurse.

An interview was conducted on December 14, 2023 at 2:36 p.m. with a registered nurse (RN/staff #8), who stated that she has received training on abuse and if a resident slaps another resident, it was abuse.

During an interview with the Executive Director (ED/staff #1) conducted on December 14, 2023 at 2:47 p.m., the ED stated that abuse can be verbal, physical, sexual, seclusion, mental, neglect, and financial; and that, it was abuse, if a resident slaps another resident.

The facility's "Abuse Policy" stated that the facility strives to prevent the abuse of all their residents. The facility recognizes that care is provided for residents with the diagnosis of dementia and other mental illnesses whose behaviors are not always predictable. The facility further recognizes that due to the proximity of residents to one another and an individual's freedom of choice, that situations may arise where it is not possible to completely prevent all incidents of abuse.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to provide evidence that the an allegation of abuse for one resident (#71) was thoroughly investigated and results of the investigation was reported to the State Agency within 5 working days of the incident. The deficient practice could result on further abuse of residents and appropriate actions not taken.

Findings include:

Resident #71 was admitted on December 16, 2022 with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness.

The minimum data set (MDS) assessment dated February 5, 2023 include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact.

The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents.

-Resident #46 was admitted on December 27, 2022 with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism.

The MDS assessment dated December 28, 2022 revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment.

A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off.

Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night.

A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive.

A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents.

A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound.

A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on the nurse.

Despite documentation of resident #46 slapping or swatting resident #71, there was no evidence found in facility documentation that this incident was reported and thoroughly investigated by the facility.

In an interview conducted with a certified nursing assistant (CNA/staff #3) on December 14, 2023 at 2:21 p.m., the CNA stated that abuse can be verbal, emotional, physical, sexual, and financial. She stated that if a resident slaps another resident, it was abuse; and that, she would separate the residents and report the incident to the nurse.

During an interview with the Executive Director (ED/staff #1) conducted on December 14, 2023 at 2:47 p.m., the ED stated that abuse can be verbal, physical, sexual, seclusion, mental, neglect, and financial; and that, it was abuse, if a resident slaps another resident. The ED further stated that when there is an allegation of abuse, the staff and residents should be interviewed and an investigation should be completed within 5 days and submitted to the state agency. However, the ED stated that she does not have a 5-day investigation for incident between residents #46 and #71.

The facility's "Abuse Policy" stated that the facility strives to prevent the abuse of all their residents. The ED will begin investigation immediately and complete within 5 working days using the Abuse Investigation Packet. A minimum of three residents will be interviewed in order to determine if there is a trend. interviews may also include Alleged Perpetrator, witnesses and staff members as applicable. When the investigation is complete, the ED will submit a summary to the state survey agency.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#71) was free from abuse of another.

Findings include:

Resident #71 was admitted on December 16, 2022 with diagnoses of Parkinson's disease, dementia, and generalized muscle weakness.

The minimum data set (MDS) assessment dated February 5, 2023 include a brief mental status (BIMS)score of 13 indicating the resident was cognitively intact.

The progress note dated December 27, 2022 at 11:30 p.m. revealed that the Director of Nursing (DON) was notified about an altercation between two residents. Per the documentation, resident #71 was slapped by another resident (#46); and that, skin assessment revealed no visible or apparent injury noted. The documentation also included that the nurse instructed staff to maintain one-to-one staffing with the other resident (#46) to ensure the safety of the other residents.

-Resident #46 was admitted on December 27, 2022 with diagnoses that included Parkinson's disease, Type II Diabetes, and hypothyroidism.

The MDS assessment dated December 28, 2022 revealed a BIMS score of 11 indicating the resident had a moderate cognitive impairment.

A progress note dated December 27, 2022 at 5:32 p.m. revealed that resident #46 was heard telling someone on the phone that the resident would blow her own fucking head off.

Another progress note dated December 27, 2022 at 5:52 p.m. revealed the resident's change of condition was reported to the nurse practitioner and the certified nursing assistants were asked to check on the resident frequently that night.

A progress note dated December 27, 2022 at 6:26 p.m. revealed that resident #46 was wandering, hitting others, and was verbally aggressive.

A progress note dated December 27, 2022 at 10:03 p.m. revealed that resident #46 got agitated, crawled out of bed into the hallway screaming for help. Per the documentation, resident #46 got close slapped, and tried to grab resident #7; and that, a certified nursing assistant (CNA) intervened. The documentation also included that resident #46 then aggressively grabbed the CNA and tried to bite the nurse. It also included that the behavior was reported to the physician who advised staff to continue monitoring resident #46 and to keep resident #46 away from other residents.

A progress note dated December 27, 2022 at 11:40 p.m. revealed that resident #46 swatted resident #71 and it made a slapping sound.

A progress note dated December 28, 2022 at 10:58 a.m. revealed that resident #46 was combative with and threatened to kill her roommate. Per the documentation, when the nurse asked resident #46 to refrain from threatening the roommate, resident #46 threw a glass of water on the nurse.

In an interview conducted with a certified nursing assistant (CNA/staff #3) on December 14, 2023 at 2:21 p.m., the CNA stated that abuse can be verbal, emotional, physical, sexual, and financial. She stated that if a resident slaps another resident, it was abuse; and that, she would separate the residents and report the incident to the nurse.

An interview was conducted on December 14, 2023 at 2:36 p.m. with a registered nurse (RN/staff #8), who stated that she has received training on abuse and if a resident slaps another resident, it was abuse.

During an interview with the Executive Director (ED/staff #1) conducted on December 14, 2023 at 2:47 p.m., the ED stated that abuse can be verbal, physical, sexual, seclusion, mental, neglect, and financial; and that, it was abuse, if a resident slaps another resident.

The facility's "Abuse Policy" stated that the facility strives to prevent the abuse of all their residents. The facility recognizes that care is provided for residents with the diagnosis of dementia and other mental illnesses whose behaviors are not always predictable. The facility further recognizes that due to the proximity of residents to one another and an individual's freedom of choice, that situations may arise where it is not possible to completely prevent all incidents of abuse.

1. Based on clinical record review, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I was updated appropriately for one resident (#47). The deficient practice could result in specialized services not being identified and provided to residents.

Findings include:

Resident #47 was admitted to the facility on August 12, 2023 with diagnoses including anxiety disorder, psychoactive substance dependence,, and chronic obstructive pulmonary disease with acute exacerbation.

A Level I PASRR screening completed on August 11, 2023 included the attending physician had certified, prior to admission, that the resident would require less than 30 calendar days of nursing facility services and that the nursing facility must update the Level I at such a time it appeared the resident's stay would exceed 30 days. However, review of the clinical record did not indicate an updated PASRR had been completed.

Review of the admission Minimum Data Set (MDS) assessment dated September 20, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

On October 4, 2023 at 08:30 AM, an interview was conducted with the Resident Relations (staff #8), she stated that the admission department will obtain a PASRR from the transferring facility and that she doesn't obtain or complete the PASRR for admission as she is still new to her role with the facility. Staff #8 stated that if the resident is admitted longer than 30 days then she will update the PASRR and that her assistant will complete an audit for any residents who would need an updated PASRR pass 30 days.

An interview was conducted with Vice President of Clinical Operations (staff #84), she stated that she and staff #8 went through the resident chart and reviewed the Level I PASRR completed on August 11, 2023. However, per staff #84, there is no updated Level I PASRR for the resident after the 30 days convalescent care.

On October 4, 2023 at 09:06 AM an interview was conducted with the Director of Nursing (staff #23), stated that admission will obtain the PASRR and if the resident has a new diagnosis of SMI or disability then a Level II PASRR will be sent to the state agency for the screening process. Staff #23 stated that from here on out they will invite social services in their Gradual Dose Reduction / Psychotropic medication regimen review as a plan of corrections in order to catch any new diagnoses that would prompt for a Level II PASRR or an updated Level I PASRR.

Review of the facility policy titled, Pre-Admission Screening and Resident Review (PASRR), revealed that the facility will strive to verify that a Level I PASRR Screening has been conducted, in order to identify Serious Mental Illness (MI) and/or an Intellectual Disability (ID) prior to initial admission of individuals to the facility. PASRR Level 1 Screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for MI or ID. If the resident is positive for a potential MI or ID, a Level II Screening referral must be submitted.


Surveyor: Chamness, Thomas

2. Based on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that a PASRR Level 2 referral was completed for one resident (#30). The deficient practice could lead to residents not receiving needed care and services.

Findings include:

Resident #30 was admitted to the facility on December 29, 2020 with diagnosis of Dementia, Unspecified severity with mood disturbance and Major Depressive Disorder, single episode, severe with psychotic features. The resident had a PASRR Level 1 and 2 at that time. A review of the resident record revealed that resident #30 readmitted to the facility with a new diagnosis of Schizoaffective Disorder, unspecified. Further review of the clinical record revealed a completed level 1 PASRR dated February 2, 2021. The level 1 PASRR revealed that the resident had serious mental illness and a level 2 PASRR should be completed.

No evidence of any further PASRR documentation was found in the resident clinical record. The facility has planned the level II PASRR dated December 22, 2020 with a revision on December 30, 2022 but not for the PASRR level II referral from February 2, 2021. The resident has a diagnosis of schizoaffective disorder, unspecified dated November 21, 2022 with no PASRR related for this diagnosis. The resident has a diagnosis of Major Depressive Disorder, single episode, severe dated October 30, 2020.

A review of the August 10, 2023 quarterly minimum data set (MDS) was conducted. Section C revealed that the resident was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 10. Section N revealed that the resident is receiving an antipsychotic and antidepressant and that antipsychotics were received on a routine basis. A progress note from the Nurse Practitioner dated August 8, 2023 revealed that the following problems were reviewed:Major Depressive Disorder, Single Episode, Severe with Psychotic Features and Schizoaffective Disorder.

An interview was conducted with a Registered Nurse (RN) (staff #23) and the Minimum Data Set (MDS) Coordinator, (staff #40) on October 3, 2023 at 3:18 PM. Staff #23 accessed the resident's medical record on PCC (point click care) and was not able to provide the PASRR level II for the resident.

An interview was conducted with the Administrator, staff #58 on October 4, 2023 at 12:55 PM. Staff #58 stated that the facility does not have any documentation for the PASRR level II.

Review of the facility policy Pre- Admission Screening and Resident Review (PASRR 2020, Version 0920) revealed that the facility was responsible to make referrals for a Level II PASRR. The policy further revealed that an updated PASRR Level I screening must be conducted for each resident in the facility who had a serious mental illness not less than annually.

Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure that alleged violations involving abuse were reported within required timeframe for one resident (#13). This resulted in the allegation of abuse not being investigated.

Findings Include:
Resident #13 admitted to the facility on 6/9/23 with diagnoses that included sepsis, scoliosis, osteoporosis, acute kidney failure, and acute respiratory failure.

In her current care plan there is a goal with appropriate interventions related to her limited physical mobility related to contracture. In a 30 day look back period Resident #13 needed extensive assistance from staff when transferring (moving from bed to wheelchair and vice versa for example) with one occasion of full staff performance 9/22/2023 at 16:00.

During an interview conducted on 10/02/23 at 01:56 PM, Resident #13 said she had dignity concerns, and stated that a Certified Nursing Assistant (CNA) had put her in her wheelchair despite her saying no. She was not able to recall the CNAs name, but stated that she had had to crawl back to bed. She could not recall the exact date, but stated it had been a few weeks, but her daughter and medical power of attorney would know more.

During an interview on 10/5/23 with Resident #13's daughter at 9:35 AM, she stated that the incident had happened several weeks ago and she considered it abuse. She stated she had spoken to the nurse on duty as well as the front desk about the incident due to her mother calling her frequently about the incident and seeming to be in distress. The daughter stated she completed a grievance form and submitted it to staff. The daughter stated she followed up with the same staff, Staff #42, several days later because she had not heard any updates. She stated she was told because the incident was considered abuse which needed to be reported immediately after the incident, it had been reported to the administrator and that is who would follow up with her. She was told the administrator and resident relations manager were aware of the situation and it was being handled.

During an interview at 10:45 AM on 10/5/23 with Staff #42, staff stated that she had spoken with Resident #13's daughter regarding and incident of a CNA being rough with her. She stated she asked the daughter if she had put in a grievance form, assisted her with completing one, and placing it in the submission box outside social services. Several days later the daughter followed up with her and stated she had not heard anything from the management team by way of an update on her mothers alleged abuse. Staff #42 touched bases with Staff #8 again who stated that the administrator was working on it as an abuse case. Staff #42 stated Staff #8 told her they would follow up with the resident's daughter. Staff #42 stated she did not recall the exact date, but this started the week of September 18th. She has not spoken with the daughter nor management regarding the incident since.

During an interview with the administrator on 10/5/23 at 10:25 AM, she stated she did not speak directly to resident #13 or her daughter about abuse concerns. She stated grievances go to resident relations/social services, and if it is abuse, then it is handed over to her. Grievances are submitted in a drop box outside of her and resident relations manager's offices. Staff #58 stated the policy for reporting and investigating abuse is to within a 2-hour window of learning of the incident and begin immediate investigation. Any involved staff will be immediately suspended.

During an interview on 10/5/23 at 10:29 AM with Staff #8, she stated that if anyone reports a grievance, the process is to get details, complete grievance form, and then bring it to either Staff #58 or whichever department is implicated. Even if a person does not specifically state they want to file a grievance, she treats all complaints as such and will follow grievance procedure. Regarding Resident #13, she stated that a staff member told her approximately 2 weeks ago that the daughter wanted to speak with her. When she went to talk to her, she stated that the daughter was visiting with Resident #13 and never stopped by to talk to Staff #8 afterwards. She has not had any reports of abuse or grievances directly from Resident #13.

During a follow up joint interview with administrator and resident relations manager, they mentioned the submission box was broken and in the process of being replaced during the time period of the allegation. However, when the box was broken there was a temporary "sleeve" there and it is checked every morning.

A review of the facility grievance binder did not show the form alleging abuse submitted by Staff #42 and resident's daughter.

A review of facility self-reports did not show submission of any abuse allegations for Resident #13 in the allegation time period.

Surveyor reported allegation of abuse to the administrator during the survey and the facility completed self-report within 2 hours. The actual allegation of abuse related to this tag was not substantiated.

Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure that a resident (#39) had been assessed to self adminster medications. The deficient practice could result in resident not receiving medications needed to maintain or improve their physical health.

Findings included:

The resident (#39) was admitted to the facility on September 13, 2023 with diagnoses that include: orthostatic hypotension, hypo-osmolality and hyponatremia, other specified diseases of blood and blood-forming organs, and acute kidney failure, unspecified.

A review of the physician's orders revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ Give 3 tablet by mouth two times a day for hypokalemia until 10/15/2023.
Review of the MDS (minimum data set) dated September 17, 2023 revealed a BIMS (brief interview of mental status) score of 14 indicating cognitive intactness.

On October 02, 2023 at approximately 2:18 PM during the initial screening process a small clear cup containing what appeared to be a tablet of medication that had been broken in half was observed on the bedside table of resident (# 39). The Director of Nursing (DON, staff# 23) entered to room and observed the medication. The DON asked the resident if he would like to have the medication crushed and put into some applesauce. The resident advised the DON that he had tried that once and will never eat applesauce again. A suggestion of crushing the medication and placing it in some pudding was made and the resident stated that he would give that a try. The DON then removed the cup containing the medication from the room. The DON returned a short time later with some chocolate pudding and mixed in the medication that had been crushed after the DON left the residents room. The DON then proceeded to spoon some pudding out and give it to the resident.

October 3, 2023 at approximately 10:25 AM an interview was conducted with DON (staff # 23). The DON was asked to explain the steps she took regarding the medication. The DON stated that upon entering the resident's room she saw the pills at beside. The DON stated that she took the medication directly to the nurse, Licensed Practical Nurse (LPN # 97), verified the drug and then crushed them. Brought medication back to the resident's room, mixed it with the pudding and administered to the resident. The DON states that their policy states that they do not leave medications at bedside. Protocol would be to conduct evaluation to determine self-administration.

On October 4, 2023 at 1:20 PM an interview was conducted with LPN (staff #97). The LPN was asked to take the surveyor through the morning med pass with resident (#39). She advised that she is aware of this resident from previous admissions to the facility and that he has low potassium levels and had been prescribed potassium tablets. She further stated that the resident had told her that he was having trouble swallowing medications. She added that the resident took one pill and had difficulty swallowing it. She then stated that she offered the resident to crush the medications and put them in applesauce and the resident stated that he tried that once and will never eat applesauce again. The resident was offered to have the medications crushed and put into pudding and he declined this as well. She stated that the resident refused to have his medications crushed. She added she advised the resident of the importance of taking his medications and that the resident stated that he wanted to take them on his own time frame. The LPN stated that she cut the tablet in two to make swallowing easier for the resident and against her better judgement she left the medication at the resident's bedside as he stated that he would take it.

Review of facility policy- Administering Medications-Policy Statement- Medications shall be administered in a safe and timely manner, and as prescribed. (2001 MED-PASS, Inc. (Revised December 2012)).

Review of facility policy on Self-Administration of Medications: Policy Statement- Residents have a right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. (2001 MED-PASS, Inc. (Revised December 2016))

The evaluation for self-administration was conducted after the fact in this situation.

Based on clinical record review, staff interviews and review of policy and procedure, the facility failed to ensure that alleged violations involving abuse were reported within required timeframe for one resident (#13). This resulted in the allegation of abuse not being investigated.

Findings Include:
Resident #13 admitted to the facility on June 9, 2023 with diagnoses that included sepsis, scoliosis, osteoporosis, acute kidney failure, and acute respiratory failure.

In her current care plan there is a goal with appropriate interventions related to her limited physical mobility related to contracture. In a 30 day look back period Resident #13 needed extensive assistance from staff when transferring (moving from bed to wheelchair and vice versa for example) with one occasion of full staff performance September 22, 2023 at 4:00 PM.

During an interview conducted on October 2, 2023 at 01:56 PM, Resident #13 said she had dignity concerns, and stated that a Certified Nursing Assistant (CNA) had put her in her wheelchair despite her saying no. She was not able to recall the CNAs name, but stated that she had had to crawl back to bed. She could not recall the exact date, but stated it had been a few weeks, but her daughter and medical power of attorney would know more.

During an interview on October 5, 2023 with Resident #13's daughter at 9:35 AM, she stated that the incident had happened several weeks ago and she considered it abuse. She stated she had spoken to the nurse on duty as well as the front desk about the incident due to her mother calling her frequently about the incident and seeming to be in distress. The daughter stated she completed a grievance form and submitted it to staff. The daughter stated she followed up with the same staff, Staff #42, several days later because she had not heard any updates. She stated she was told because the incident was considered abuse which needed to be reported immediately after the incident, it had been reported to the administrator and that is who would follow up with her. She was told the administrator and resident relations manager were aware of the situation and it was being handled.

During an interview at 10:45 AM on October 5, 2023 with Staff #42, staff stated that she had spoken with Resident #13's daughter regarding and incident of a CNA being rough with her. She stated she asked the daughter if she had put in a grievance form, assisted her with completing one, and placing it in the submission box outside social services. Several days later the daughter followed up with her and stated she had not heard anything from the management team by way of an update on her mothers alleged abuse. Staff #42 touched bases with Staff #8 again who stated that the administrator was working on it as an abuse case. Staff #42 stated Staff #8 told her they would follow up with the resident's daughter. Staff #42 further stated she did not recall the exact date, but this started the week of September 18th. She has not spoken with the daughter nor management regarding the incident since.

During an interview with the administrator (staff #58) on Octobder 5, 2023 at 10:25 AM, she stated she did not speak directly to resident #13 or her daughter about abuse concerns. She stated grievances go to resident relations/social services, and if it is abuse, then it is handed over to her. Grievances are submitted in a drop box outside of her and resident relations manager's offices. Staff #58 stated the policy for reporting and investigating abuse is to within a 2-hour window of learning of the incident and begin immediate investigation. Any involved staff will be immediately suspended.

During an interview on October 5, 2023 at 10:29 AM with Staff #8, she stated that if anyone reports a grievance, the process is to get details, complete grievance form, and then bring it to either Staff #58 or whichever department is implicated. Even if a person does not specifically state they want to file a grievance, she treats all complaints as such and will follow grievance procedure. Regarding Resident #13, she stated that a staff member told her approximately 2 weeks ago that the daughter wanted to speak with her. When she went to talk to her, she stated that the daughter was visiting with Resident #13 and never stopped by to talk to Staff #8 afterwards. She has not had any reports of abuse or grievances directly from Resident #13.

During a follow up joint interview with the administrator (staff #58) and resident relations manager (#8), they mentioned the submission box was broken and in the process of being replaced during the time period of the allegation. However, when the box was broken there was a temporary "sleeve" there and it is checked every morning.

A review of the facility grievance binder did not show the form alleging abuse submitted by Staff #42 and resident's daughter.

A review of facility self-reports did not show submission of any abuse allegations for Resident #13 in the allegation time period.

Surveyor reported allegation of abuse to the administrator during the survey and the facility completed self-report within 2 hours. The actual allegation of abuse related to this tag was not substantiated.

Based on review of clinical records, staff interviews and review of facility policy and procedure, the facility failed to ensure that a PASRR Level 2 referral was completed for one resident (#30). The deficient practice could lead to residents not receiving needed care and services.

Findings include:

Resident #30 was admitted to the facility on December 29, 2020 with diagnosis of Dementia, Unspecified severity with mood disturbance and Major Depressive Disorder, single episode, severe with psychotic features. The resident had a PASRR Level 1 and 2 at that time. A review of the resident record revealed that resident #30 readmitted to the facility with a new diagnosis of Schizoaffective Disorder, unspecified. Further review of the clinical record revealed a completed level 1 PASRR dated February 2, 2021. The level 1 PASRR revealed that the resident had serious mental illness and a level 2 PASRR should be completed.

No evidence of any further PASRR documentation was found in the resident clinical record. The facility has planned the level II PASRR dated December 22, 2020 with a revision on December 30, 2022 but not for the PASRR level II referral from February 2, 2021. The resident has a diagnosis of schizoaffective disorder, unspecified dated November 21, 2022 with no PASRR related for this diagnosis. The resident has a diagnosis of Major Depressive Disorder, single episode, severe dated October 30, 2020.

A review of the August 10, 2023 quarterly minimum data set (MDS) was conducted. Section C revealed that the resident was moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) of 10. Section N revealed that the resident is receiving an antipsychotic and antidepressant and that antipsychotics were received on a routine basis. A progress note from the Nurse Practitioner dated August 8, 2023 revealed that the following problems were reviewed:Major Depressive Disorder, Single Episode, Severe with Psychotic Features and Schizoaffective Disorder.

An interview was conducted with a Registered Nurse (RN) (staff #23) and the Minimum Data Set (MDS) Coordinator, (staff #40) on October 3, 2023 at 3:18 PM. Staff #23 accessed the resident's medical record on PCC (point click care) and was not able to provide the PASRR level II for the resident.

An interview was conducted with the Administrator, staff #58 on October 4, 2023 at 12:55 PM. Staff #58 stated that the facility does not have any documentation for the PASRR level II.

Review of the facility policy Pre- Admission Screening and Resident Review (PASRR 2020, Version 0920) revealed that the facility was responsible to make referrals for a Level II PASRR. The policy further revealed that an updated PASRR Level I screening must be conducted for each resident in the facility who had a serious mental illness not less than annually.

Based on clinical record review, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level I was updated appropriately for one resident (#47). The deficient practice could result in specialized services not being identified and provided to residents.

Findings include:

Resident #47 was admitted to the facility on August 12, 2023 with diagnoses including anxiety disorder, psychoactive substance dependence,, and chronic obstructive pulmonary disease with acute exacerbation.

A Level I PASRR screening completed on August 11, 2023 included the attending physician had certified, prior to admission, that the resident would require less than 30 calendar days of nursing facility services and that the nursing facility must update the Level I at such a time it appeared the resident's stay would exceed 30 days. However, review of the clinical record did not indicate an updated PASRR had been completed.

Review of the admission Minimum Data Set (MDS) assessment dated September 20, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

On October 4, 2023 at 08:30 AM, an interview was conducted with the Resident Relations (staff #8), she stated that the admission department will obtain a PASRR from the transferring facility and that she doesn't obtain or complete the PASRR for admission as she is still new to her role with the facility. Staff #8 stated that if the resident is admitted longer than 30 days then she will update the PASRR and that her assistant will complete an audit for any residents who would need an updated PASRR pass 30 days.

An interview was conducted on October 4, 2023 with Vice President of Clinical Operations (staff #84). She stated that she and staff #8 went through the resident's chart and reviewed the Level I PASRR completed on August 11, 2023. However, per staff #84, there is no updated Level I PASRR for the resident after the 30 days convalescent care.

On October 4, 2023 at 09:06 AM an interview was conducted with the Director of Nursing (staff #23), who stated that Admissions will obtain the PASRR and if the resident has a new diagnosis of serious mental illness (SMI) or disability then a Level II PASRR will be sent to the state agency for the screening process. Staff #23 stated that from here on out they will invite social services in their Gradual Dose Reduction / Psychotropic medication regimen review as part of the plan of corrections in order to catch any new diagnoses that would prompt for a Level II PASRR or an updated Level I PASRR.

Review of the facility policy titled, Pre-Admission Screening and Resident Review (PASRR), revealed that the facility will strive to verify that a Level I PASRR Screening has been conducted, in order to identify Serious Mental Illness (MI) and/or an Intellectual Disability (ID) prior to initial admission of individuals to the facility. PASRR Level 1 Screenings are used to determine whether the individual has a diagnosis or other presenting evidence that suggests the potential for MI or ID. If the resident is positive for a potential MI or ID, a Level II Screening referral must be submitted.

Based on personnel record review, staff interview, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in not providing activities that meet the physical and psychosocial needs of the residents.

Findings include:

Review of the personnel file for the Activity Manager (staff #95) revealed staff #95 was hired on July 30, 2021 as a CNA (Certified Nursing Assistant) and promoted to the Activity Manager on June 10, 2023. Continued review of the file did not reveal documentation that staff #95 met the qualifications for the Activity Manager.

Review of the 2016 Employee Job Description for Haven Health Group, version 0916 revealed the Activity Manager works under the direction of the Executive Director and is an active member of the Interdisciplinary Care Team. The Activity Manager directs the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion of the activity's component of the comprehensive assessment along with the comprehensive care plan goals and approaches. The Activity Manager oversees the direction of an activity program, which includes scheduling of activities; both individual and groups, and the implementation of such programs. The Activity Manager directs the monitoring of the residents' responses as-well as the evaluation of responses to the programs to determine if the activities meet the assessed needs. The minimum requirements are: background check, fingerprint clearance card, TB clearance, employee screening post hire and must be able to speak and understand English. However, the job description did not include the requirements for an Activity Manager.

During an interview conducted on 10/05/23 at 8:37 AM staff #95 stated that she has been with the facility for two years and has become the Activities Manager about four months ago further stating that she does not have the activities Manager certification but that she will be taking the class soon. During the interview staff #95 stated that she works five days a week, Monday through Friday, does not have an activity assistant and does not have coverage for activities over the weekend.

An Interview was conducted on 10/05/23 at 9:30AM with the Executive Director (ED, staff #58) the job description for Activity Manager was reviewed along with the resume for the Activities Manager (staff #95). Staff #58 agreed that the job description did not include minimum requirements, such as education/certification or experience, and staff #95's resume revealed no education/certification. Staff #58 agreed that staff #95 did not meet the requirements needed for the position as Activity Manager as per CMS regulation.

Based on personnel record review, staff interview, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in not providing activities that meet the physical and psychosocial needs of the residents.

Findings include:

Review of the personnel file for the Activity Manager (staff #95) revealed staff #95 was hired on July 30, 2021 as a CNA (Certified Nursing Assistant) and promoted to the Activity Manager on June 10, 2023. Continued review of the file did not reveal documentation that staff #95 met the qualifications for the Activity Manager.

Review of the 2016 Employee Job Description for Haven Health Group, version 0916 revealed the Activity Manager works under the direction of the Executive Director and is an active member of the Interdisciplinary Care Team. The Activity Manager directs the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion of the activity's component of the comprehensive assessment along with the comprehensive care plan goals and approaches. The Activity Manager oversees the direction of an activity program, which includes scheduling of activities; both individual and groups, and the implementation of such programs. The Activity Manager directs the monitoring of the residents' responses as-well as the evaluation of responses to the programs to determine if the activities meet the assessed needs. The minimum requirements are: background check, fingerprint clearance card, TB clearance, employee screening post hire and must be able to speak and understand English. However, the job description did not include the requirements for an Activity Manager.

During an interview conducted on 10/05/23 at 8:37 AM staff #95 stated that she has been with the facility for two years and has become the Activities Manager about four months ago further stating that she does not have the activities Manager certification but that she will be taking the class soon. During the interview staff #95 stated that she works five days a week, Monday through Friday, does not have an activity assistant and does not have coverage for activities over the weekend.

An Interview was conducted on 10/05/23 at 9:30AM with the Executive Director (ED, staff #58) the job description for Activity Manager was reviewed along with the resume for the Activities Manager (staff #95). Staff #58 agreed that the job description did not include minimum requirements, such as education/certification or experience, and staff #95's resume revealed no education/certification. Staff #58 agreed that staff #95 did not meet the requirements needed for the position as Activity Manager as per CMS regulation.

Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure rehabilitation services were provided for one resident (#16) as ordered by the physician. The deficient practice could result in resident not receiving rehabilitation services needed to maintain or improve their physical health.

Findings included:

Resident #16 was admitted to the facility on March 19, 2021 with diagnoses including non-insulin dependent diabetes mellitus, coronary artery disease, and left below knee amputation.

Review of record of Provider Progress Notes dated December 5, 2022 for resident #16 revealed "Patient has great difficulty walking and standing, requires wheelchair, difficult to leave assisted living for appointments so seen in assisted living today. Denies other pedal or ankle concerns at this time. Denies recent falls or trauma. Feeling well, denies nausea/vomiting/diarrhea/ ...."

Review of record of Provider Progress Notes dated June 22, 2023 for resident #16 revealed "Patient has great difficulty walking and standing, requires wheelchair, difficult to leave assisted living for appointments, so seen in assisted living today. Denies other pedal or ankle concerns at this time..."

Review of the resident #16 Care Plan Detail Review dated July 31, 2023 for impaired functional mobility revealed an intervention refer to therapy as necessary. For at risk for falls related to gait and balance problems revealed an intervention for physical therapy to evaluate and treat as ordered or as needed and physical therapy to evaluate for transfer training. For Activity of Daily Living Self Care Performance Deficit related to activity intolerance, impaired balance, and limited mobility revealed an intervention for physical therapy/occupational therapy evaluation and treatment as per physician orders.

Review of Minimum Data Set (MDS) Section G- Functional Status dated August 21, 2023 revealed that resident #16 required extensive assistance with one-person assist with bed mobility, transfer, locomotion on unit, locomotion off unit, toilet use, and personal hygiene.

Review of a physician order dated September 14, 2023 revealed an order for physical therapy evaluation and treat, occupational therapy evaluation and treat, speech evaluation and treat, and rehab potential - fair was created by Staff #17.

A review of record revealed no documentation that physical therapy, occupational therapy, and speech therapy evaluation and treatment was started for resident #16.

An interview was conducted with resident #16 on October 2, 2023 at 1:40 PM who stated "should be receiving therapy for leg amputation."

An interview was conducted on October 3, 2023 at 2:25 PM, with a Physical Therapy Assistant (PTA/Staff #102) stated resident received physical therapy 6 months ago, then restorative therapy took over for safe mobility and fall prevention.

An interview was conducted on October 4, 2023 at 8:25 AM, with a Certified Nursing Assistant (CNA/staff #75) stated resident #16 had a left leg amputation, and with turning, changing brief, getting resident out of bed and transfer require two-person assist. Staff #75 also stated resident #16 follows command like rolling in bed while staff is performing care. Staff #75 stated resident #16 is still working with rehab therapy. Staff #75 stated resident said, was going to therapy, still wants to do therapy, and wants to walk again. Staff #75 does not know what day and time they take resident to therapy. Staff #75 stated she does not do restorative therapy.

An interview was conducted with resident #16 on October 4, 2023 at 11:11 AM, who stated she has been in the facility for a year and a half, received therapy a while ago, and wanted to continue therapy. She stated the therapy department informed her that they had run out of funds. She stated her last therapy on her leg was last year. She also stated she had throat issues last year but never completed therapy. Resident stated she was supposed to learn how to walk but she is still in a wheelchair.

An interview was conducted on October 5, 2023 at 11:04 AM with the Director of Nursing (DON/Staff #23). Staff #23 stated a Licensed Practical Nurse (LPN) or a Registered Nurse (RN) are authorized to take orders and write in the medical record, also therapist are given access to take orders. Medical Record transcribes orders into PCC (Point Click Care). Medical Record creates the order into PCC and orders are confirmed and activated by an authorized licensed individual.

An interview was conducted on October 5, 2023 at 11:43 AM, Physical Therapist (PT/Staff #101) stated resident #16 received therapy services. Staff 101 was unable to recall dates resident #16 received the therapy services. Staff 101 stated therapy services are stopped if resident stop making progress, or if resident reach maximum potential, or resident met set goals. For instance, if resident is a minimal assist to stand, or the resident level is not improving, then the resident is taken off the therapy list. Staff 101 stated that quarterly screenings of residents are performed by talking to certified nursing assistant or nursing. If there is a decline from prior discharge from therapy services, then the resident is reengaged for another physical therapy evaluation. There is weekly meeting to discuss recommendation for discharge or for continue therapy based on resident plan of care and progress in resident plan of care.

An interview was conducted with resident #16 on October 5, 2023 at 2:37 PM during a Resident Council meeting who stated she just saw therapy and evaluated her leg.

The facility's policy on Medication and Treatment Orders, revised July 2016 included, "Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record."

Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure rehabilitation services were provided for one resident (#16) as ordered by the physician. The deficient practice could result in resident not receiving rehabilitation services needed to maintain or improve their physical health.

Findings included:

Resident #16 was admitted to the facility on March 19, 2021 with diagnoses including non-insulin dependent diabetes mellitus, coronary artery disease, and left below knee amputation.

Review of record of Provider Progress Notes dated December 5, 2022 for resident #16 revealed "Patient has great difficulty walking and standing, requires wheelchair, difficult to leave assisted living for appointments so seen in assisted living today. Denies other pedal or ankle concerns at this time. Denies recent falls or trauma. Feeling well, denies nausea/vomiting/diarrhea/ ...."

Review of record of Provider Progress Notes dated June 22, 2023 for resident #16 revealed "Patient has great difficulty walking and standing, requires wheelchair, difficult to leave assisted living for appointments, so seen in assisted living today. Denies other pedal or ankle concerns at this time..."

Review of the resident #16 Care Plan Detail Review dated July 31, 2023 for impaired functional mobility revealed an intervention refer to therapy as necessary. For at risk for falls related to gait and balance problems revealed an intervention for physical therapy to evaluate and treat as ordered or as needed and physical therapy to evaluate for transfer training. For Activity of Daily Living Self Care Performance Deficit related to activity intolerance, impaired balance, and limited mobility revealed an intervention for physical therapy/occupational therapy evaluation and treatment as per physician orders.

Review of Minimum Data Set (MDS) Section G- Functional Status dated August 21, 2023 revealed that resident #16 required extensive assistance with one-person assist with bed mobility, transfer, locomotion on unit, locomotion off unit, toilet use, and personal hygiene.

Review of a physician order dated September 14, 2023 revealed an order for physical therapy evaluation and treat, occupational therapy evaluation and treat, speech evaluation and treat, and rehab potential - fair was created by Staff #17.

A review of record revealed no documentation that physical therapy, occupational therapy, and speech therapy evaluation and treatment was started for resident #16.

An interview was conducted with resident #16 on October 2, 2023 at 1:40 PM who stated "should be receiving therapy for leg amputation."

An interview was conducted on October 3, 2023 at 2:25 PM, with a Physical Therapy Assistant (PTA/Staff #102) stated resident received physical therapy 6 months ago, then restorative therapy took over for safe mobility and fall prevention.

An interview was conducted on October 4, 2023 at 8:25 AM, with a Certified Nursing Assistant (CNA/staff #75) stated resident #16 had a left leg amputation, and with turning, changing brief, getting resident out of bed and transfer require two-person assist. Staff #75 also stated resident #16 follows command like rolling in bed while staff is performing care. Staff #75 stated resident #16 is still working with rehab therapy. Staff #75 stated resident said, was going to therapy, still wants to do therapy, and wants to walk again. Staff #75 does not know what day and time they take resident to therapy. Staff #75 stated she does not do restorative therapy.

An interview was conducted with resident #16 on October 4, 2023 at 11:11 AM, who stated she has been in the facility for a year and a half, received therapy a while ago, and wanted to continue therapy. She stated the therapy department informed her that they had run out of funds. She stated her last therapy on her leg was last year. She also stated she had throat issues last year but never completed therapy. Resident stated she was supposed to learn how to walk but she is still in a wheelchair.

An interview was conducted on October 5, 2023 at 11:04 AM with the Director of Nursing (DON/Staff #23). Staff #23 stated a Licensed Practical Nurse (LPN) or a Registered Nurse (RN) are authorized to take orders and write in the medical record, also therapist are given access to take orders. Medical Record transcribes orders into PCC (Point Click Care). Medical Record creates the order into PCC and orders are confirmed and activated by an authorized licensed individual.

An interview was conducted on October 5, 2023 at 11:43 AM, Physical Therapist (PT/Staff #101) stated resident #16 received therapy services. Staff 101 was unable to recall dates resident #16 received the therapy services. Staff 101 stated therapy services are stopped if resident stop making progress, or if resident reach maximum potential, or resident met set goals. For instance, if resident is a minimal assist to stand, or the resident level is not improving, then the resident is taken off the therapy list. Staff 101 stated that quarterly screenings of residents are performed by talking to certified nursing assistant or nursing. If there is a decline from prior discharge from therapy services, then the resident is reengaged for another physical therapy evaluation. There is weekly meeting to discuss recommendation for discharge or for continue therapy based on resident plan of care and progress in resident plan of care.

An interview was conducted with resident #16 on October 5, 2023 at 2:37 PM during a Resident Council meeting who stated she just saw therapy and evaluated her leg.

The facility's policy on Medication and Treatment Orders, revised July 2016 included, "Only authorized, licensed practitioners, or individuals authorized to take verbal orders from practitioners, shall be allowed to write orders in the medical record."

Based on clinical record review, resident and staff interviews and policy review, the facility failed to ensure that a resident (#39) had been assessed to self adminster medications. The deficient practice could result in resident not receiving medications needed to maintain or improve their physical health.

Findings included:

The resident (#39) was admitted to the facility on September 13, 2023 with diagnoses that include: orthostatic hypotension, hypo-osmolality and hyponatremia, other specified diseases of blood and blood-forming organs, and acute kidney failure, unspecified.

A review of the physician's orders revealed the following: Potassium Chloride ER Tablet Extended Release 20 MEQ Give 3 tablet by mouth two times a day for hypokalemia until 10/15/2023.
Review of the MDS (minimum data set) dated September 17, 2023 revealed a BIMS (brief interview of mental status) score of 14 indicating cognitive intactness.

On October 02, 2023 at approximately 2:18 PM during the initial screening process a small clear cup containing what appeared to be a tablet of medication that had been broken in half was observed on the bedside table of resident (# 39). The Director of Nursing (DON, staff# 23) entered to room and observed the medication. The DON asked the resident if he would like to have the medication crushed and put into some applesauce. The resident advised the DON that he had tried that once and will never eat applesauce again. A suggestion of crushing the medication and placing it in some pudding was made and the resident stated that he would give that a try. The DON then removed the cup containing the medication from the room. The DON returned a short time later with some chocolate pudding and mixed in the medication that had been crushed after the DON left the residents room. The DON then proceeded to spoon some pudding out and give it to the resident.

October 3, 2023 at approximately 10:25 AM an interview was conducted with DON (staff # 23). The DON was asked to explain the steps she took regarding the medication. The DON stated that upon entering the resident's room she saw the pills at beside. The DON stated that she took the medication directly to the nurse, Licensed Practical Nurse (LPN # 97), verified the drug and then crushed them. Brought medication back to the resident's room, mixed it with the pudding and administered to the resident. The DON states that their policy states that they do not leave medications at bedside. Protocol would be to conduct evaluation to determine self-administration.

On October 4, 2023 at 1:20 PM an interview was conducted with LPN (staff #97). The LPN was asked to take the surveyor through the morning med pass with resident (#39). She advised that she is aware of this resident from previous admissions to the facility and that he has low potassium levels and had been prescribed potassium tablets. She further stated that the resident had told her that he was having trouble swallowing medications. She added that the resident took one pill and had difficulty swallowing it. She then stated that she offered the resident to crush the medications and put them in applesauce and the resident stated that he tried that once and will never eat applesauce again. The resident was offered to have the medications crushed and put into pudding and he declined this as well. She stated that the resident refused to have his medications crushed. She added she advised the resident of the importance of taking his medications and that the resident stated that he wanted to take them on his own time frame. The LPN stated that she cut the tablet in two to make swallowing easier for the resident and against her better judgement she left the medication at the resident's bedside as he stated that he would take it.

Review of facility policy- Administering Medications-Policy Statement- Medications shall be administered in a safe and timely manner, and as prescribed. (2001 MED-PASS, Inc. (Revised December 2012)).

Review of facility policy on Self-Administration of Medications: Policy Statement- Residents have a right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. (2001 MED-PASS, Inc. (Revised December 2016))

The evaluation for self-administration was conducted after the fact in this situation.

Based on record review and staff interview, the facility failed to participate in a community based exercise in 2022-2023. Failure to provide policy and procedures for the training and testing program may lead to untrained staff in an emergency situation and may result in harm to the patients and/or staff during an emergency.

Findings include:

Based on record review and staff interview on October 10, 2023, revealed the facility failed to participate in the following;

1. Participate in a full-scale exercise (FSE) that is community-based.
2. Conduct an additional exercise that may include, but is not limited to the following: (A) A second FSE that is individual, facility-based. (B) A tabletop exercise.

During the exit conference on October 10, 2023, the above finding was again acknowledge by the management team.

Based on observation the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on October 10, 2023, revealed the following;

1) room 105 had a 1/2 gap on the upper handle side of the door
2) room 106 had a 1/2 gap on the upper handle side of the door
3) room 112 had a 1/2 gap on the upper handle side, 1/2 gap on the upper hinge side of the door. The door also failed to latch secure
4) the nourishment room door was split and delaminating
5) room 211 had a 1/2 gap on the upper handle side of the door
6) the staff lounge door was a 20 minute fire door which had excessive gap over 1/8 inch around the door

During the exit conference conducted on October 10, 2023, the above findings were again acknowledged by the management team.

Based on record review and interview, the facility failed to provide fire drill documentation for 2022-2023. Failing to conducted the fire drills in accordance with the life safety code to familiarize staff with conditions under an actual fire can result in harm to patients and staff during a an actual fire or emergency situation.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.

Findings include:

Based on record review and interview on October 10, 2023, revealed the facility was missing the following;

1) first quarter- first, second and third shifts 2023
2) second quarter- second and third shifts 2023
3) fourth quarter- first and second shifts 2022

During the exit conference conducted on October 10, 2023, the above findings were again acknowledged by the management team.

Based on record review and interview, the facility failed to document the required thirty minute (30) testing of the emergency generator under load once a month for several months since the last survey. Failure to test the emergency generator under load for thirty minutes once a month could result in harm to patients during emergency system failures.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.7.6 "Maintenance and Testing (See 4.6.12) Section 4.6.12.2 "Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99, HEALTH CARE FACILITIES, Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6", Section 8.4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly." NFPA 110, Chapter 8, Section 8.4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes..."

Findings Include:

Based on record review and interview on October 10, 2023, revealed the facility failed to provide monthly under load tests on the generator for the following months;

1) December 2022, January 2023, February 2023, March 2023, and April 2023

During the exit conference conducted on October 10, 2023, the above findings were again acknowledged by the management team.