Desert Peak Care Center

Based on a record review and staff interviews, the facility failed to participate in drills as required. Failure to participate in drills may lead to untrained staff in an emergency and may result in harm to the residents during an emergency.

Findings include:

During the document review on January 23, 2025, it was revealed the facility was missing documents proving participation in a full-scale exercise (FSE) that was community-based, tabletop drills or a facility based full scale exercise within the last year.

During the exit conference on January 23, 2025, facility management confirmed the facility could not provide proof of participation in a full-scale exercise that was community-based. or a facility based full scale exercise within the last year.

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." NFPA 80 2010 edition, Chapter 5 Section 5.2.14 Maintenance of Closing Mechanisms. 5.2.14.1 Self-closing devices shall be kept in working condition at all times. Chapter 19, Section 19.3.6.3 Corridor Doors Section 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1-3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Doors shall be provided with a means suitable for keeping the door closed.

Findings include:

Observations made while on tour on January 23, 2025, revealed the following:

1. Room 203 door is bowed from the handle to the top 1-inch gap.
2. Room 206 door \'bc inch gap at the top handle side.
3. Room 205 play in the door \'bd inch gap at the top.
4. Room 207 play in the door \'bc inch gap at the top.
5. Room 209 play in the door \'bc inch gap at the top.
6. Room 212 has gaps on both sides of the door as well as the top.
7. Room 211 play in the door 1/4/gap at the top of the door.
8. Room 213 has a gap at the top, can see light from the room.
9. Day room door at Victoria Lane missing door closure hardware as well gap at the top of the door, can see light from the room.
10. Room 216 has play in the door and \'bc in gap at the top.
11. Room 215 has a gap of \'bc inch at the top.
12. Room 218 the door drags at the bottom not allowing the door to close.
13. Room 222 play in the door, gap at the top and handle side of the door above the handle.
14. Room 306 gap at the top and side allowing light to come through.
15. Room 305 gap at the top and side allowing light to come through.
16. Room 308 the door frame is splitting top handle side.
17. Room 309 door will not close due to dragging on the floor.
18. Room 316 door handle coming apart will not secure.
19. Room 318 gap at the top handle side.
20. Room 31 gap along the top of the door.
21. Room 33 door will not close, drags on the floor.
22. Room 21 gap at the top handle side, allowing light to come through.
23. Room 101 gap at the top of the door allowing light to come through.
24. Room 107 gap at the top handle side, play in the door.
25. Room 109 gap at the top handle side, play in the door.
26. Room 112 gap at the top handle side, play in the door.
27. Room 111 gap at the top handle side, play in the door.

The management team acknowledged during the facility tour and exit conference on January 23, 2025, the door deficiencies.

Based on observation the facility failed to fill penetrations in four (4) of the smoke barriers in the facility. Failing to seal the penetrations, holes, and openings in the smoke barriers will allow smoke and heat to penetrate other wings or possibly the whole facility which could cause harm to the patients in the time of a fire.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.7.3 "Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a fire resistance rating of at least \'bd hour." Chapter 8, Section 8.5.6.2 Penetrations for cables cable trays, conduits, pipes, tubes, vents wires and similar items to accommodate electrical, plumbing and communications systems that pass through a wall, floor or /ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof /ceiling of a smoke barrier assembly shall be protected by a system or material capable of restricting the transfer of smoke.

Findings include:

Observations made during a facility tour conducted on January 23, 2025, revealed that the facility failed to maintain the fire/ smoke barrier in the following areas:

1. Penetrations along the wall at room 205 as well as large squares cut in the drywall ceiling above the ceiling tiles measuring approximately 12" x 12" on both sides of the 90-minute doors.
2. Penetration to the wall above the ceiling tile at room 222.
3. Penetration (large holes) to the drywall ceiling above the ceiling tile at room 318.
4. Penetration (large holes) to the drywall ceiling above the ceiling tile outside of the staffing office.
5. Penetration (large holes) to the drywall ceiling above the ceiling tile outside of the maintenance storage room.
6. Wall penetration from the hot water heater room into the laundry room.
7. Wall penetration wall penetration at the door magnet by room 32.

The management team acknowledged the wall/ceiling penetrations during the facility tour and during the exit conference on January 23, 2025.

Based on observation, the facility failed to provide a protective guard on light bulbs located throughout the facility and area with exposed wiring. Failure to keep light guards on the light bulbs and ensure all electrial wiring is covered could cause accidental damage or possibly a fire, which could cause harm to the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70, 2011 Edition, "National Electrical Code." NEC, 2011, Article 110, Section 110-27 (b) Prevent Physical Damage." In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage.

NFPA 70, 2011 Edition Chapter 1 General "110.27(A) Live Parts Guarded Against Accidental Contact. Except as elsewhere required or permitted by this Code, live parts of electrical equipment operating at 50 volts or more shall be guarded against accidental contact by approved enclosures or by any of the following means: (1) By location in a room, vault, or similar enclosure that is accessible only to qualified persons. (2) By suitable permanent, substantial partitions or screens arranged so that only qualified persons have access to the space within reach of the live parts. Any openings in such partitions or screens shall be sized and located so that persons are not likely to come into accidental contact with the live parts or to bring conducting objects into contact with them

Findings include:

During the facility tour conducted on January 23, 2025, it was revealed the light bulbs in the following areas were missing covers:

1. The soiled utility room in the Victoria Lane area is missing light covers.
2. The laundry room closet is missing light covers.
3. The social services storage room is missing light covers.
4. The soiled utility room in the Apache area is missing light covers.

The facility tour also revealed exposed wiring in the following locations:

1. The mechanical room across from the clean linen in the Rio unit had electrical equipment with exposed wiring.
2. The area above the ceiling tile at room 318, j-box missing cover.

The management team confirmed during the exit conference conducted on January 23, 2025, that the facility was missing the protective covers over the lights in various rooms throughout the facility and the exposed wiring.

Based on observation and staff interviews, the facility failed to ensure that a remote stop or kill switch for the generator was installed. This could affect the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop on the generator could cause a fire or harm the residents and staff.

Code reference: NFPA 110 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation, located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. A.5.6.5.6 For systems located outdoors, the manual shut-down should be located external to the weatherproof enclosure and should be appropriately identified.

Findings include:

During observations during a tour conducted on January 23, 2025, it was revealed that the facility's generator did not have the required remote stop or kill switch.

The management team acknowledged the deficiency on the facility tour and the exit conference on January 23, 2025.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident (#117) was transported to and from dialysis in a timely manner.

Findings include:

Resident #117 was admitted to the facility on November 7, 2023 with diagnoses that included Acquired absence of the right and left legs below the knee, type 2 diabetes mellitus with diabetic neuropathy, and end stage renal disease.

Review of the care plan revealed a focus initiated on November 8, 2023, indicating that Resident #117 needs dialysis, with interventions including to encourage the resident to go to scheduled dialysis appointments and that the resident may attend dialysis without an escort.

Review of the Minimum Data Set (MDS) dated November 6, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition.

The follow-up instruction sheets from the dialysis center were requested from the facility. Upon review of these sheets, there were multiple periods of time where there was no evidence of any sheets from the dialysis center. The follow-up instruction sheets indicate that the resident was dialyzed on November 6, 2024 and on November 11, 2024. There were no dialysis follow-up instruction sheets found for the dates between November 6, 2024 and November 11, 2024. As the resident's dialysis schedule indicates, the resident should have received dialysis on November 8, 2024. These sheets also indicate that the resident received dialysis on December 6, 2024 and again on December 13, 2024. With the resident's dialysis schedule, the resident should have received treatment on December 9, 2024 and December 11, 2024, but there were no dialysis follow-up instruction sheets found for the dates between December 6 , 2024 and December 13, 2024. Additionally, the resident received dialysis on December 27, 2024 and on January 3, 2025. There were no dialysis follow-up instruction sheets found for the dates between December 27, 2024 and January 3, 2025. The resident's dialysis schedule indicated that the resident should have received dialysis treatment on December 30, 2024 and January 1, 2025.

Further review of the dialysis follow-up instruction sheets revealed two dates, November 22, 2024 and November 29, 2024, where the dialysis center notated that the resident did not complete treatment due to late arrival, leaving the resident with a remaining time of 30 minutes.

The psychosocial progress note dated December 16, 2024 revealed that the social worker had reviewed most of the resident's reports and identified 1 missed dialysis treatment and 3 shortened dialysis treatments within the past 90 days.

Review of the transportation audit sheets from October 2024 to January 2025 revealed that the resident had reocurring Monday, Wednesday, and Friday appointments for dialysis. The sheets also revealed the following dates where transportation was late or did not show up:

- October 2, 2024
- November 1, 2024
- November 8, 2024
- November 24, 2024
- December 9, 2024
- December 22, 2024
- December 29, 2024

Review of the front desk appointment logs from October 2024 to December 2024 provided by the facility revealed the following dates and times that the resident had checked out at the front desk for an appointment to dialysis, which are after the resident's scheduled appointment times:

- October 3, 2024 at 12:50PM with facility driver, following a VA (Veterans Affairs) appointment in the morning.
- October 21, 2024 at 6:45AM with VA driver
- October 25, 2024 at 6:53AM with facility driver
- November 1, 2024 at 6:20AM with facility driver
- November 4, 2024 at 10:15AM with facility driver
- November 22, 2024 at 6:49AM with facility driver
- November 27, 2024 at 10:44AM with facility driver
- November 29, 2024 at 8:40AM with facility driver
- December 4, 2024 at 8:00AM with facility driver
- December 6, 2024 at 9:20AM with facility driver
- December 20 2024 at 6:26AM with facility driver

Interview was conducted on January 9, 2025 at 12:10PM with Resident #117, who explained that he has issues getting transportation to the dialysis centers. The resident stated that he receives dialysis on Monday, Wednesdays, and Fridays. He reported that the trasnportation is often late. He explained that he is supposed to be picked up by 6:15AM and be at the clinic by 6:45AM. The resident complained that sometimes the transportation does not show up until close to 8:00AM. The resident also added that when the trasnport shows up so late, the resident occasionally will tell them that there is no point in him going now, as he would only be able to get a little chair time and the dialysis clinic gets upset.

Interview was conducted on January 10, 2025 at 9:15AM with a Licensed Practical Nurse Unit Manager (LPN/staff #125), who stated that medical records staff are responsible for arranging transport. She also identified the risks of transportation being late to be that the resident may not be able to sit for the full chair time and therefore may not receive full dialysis treatment.

Interview was conducted on January 10, 2025 at 9:28AM with a Certified Nursing Assistant (CNA/Staff #32). The CNA stated that she had not worked with Resident #117 much, but knew that sometimes transportation for residents going to dialysis was late by about an hour. She stated that when this happens, she lets the nurse know so they can relay the message.

Interview was conducted on January 10, 2025 at 11:13AM with an employee from the dialysis center (Staff #222), who stated that Resident #117's transportation is unreliable, and described it as hit or miss. Additionally, due to transportation issues, the resident's dialysis chair time was changed from 5AM to 6:45AM on November 1, 2024. The employee identified risks associated with this to be that the resident cannot receive the full treatment, which means there is a threat for not cleaning the blood, which could cause issues such as cardiac arrest.

Interview was conducted on January 10, 2025 at 11:16AM with the Director of Medical Records (Staff #) who explained that Resident #117 has scheduled recurring outside transportation for dialysis, and they are scheduled for 5:30AM pickup, and that the resident needs to be at the dialysis center at 6:00AM. He stated that this transportation fails the facility all the time, and that they often cancel due to not having an available driver. The staff member further detailed that if the transportation does not show up, a staff member will call the dialysis center and notify them that the resident will be late. He explained that one of the staff members approved to drive arrives to the facility around 7:00AM, and that she will take the resident to the dialysis center at that time. This staff member stated that when the issues first began, the resident's dialysis sessions were being cut short due to him arriving late, but he stated that the dialysis center is now able to accomodate when the resident is late.

Interview was conducted on January 10, 2025 at 1:52PM with the Director of Nursing (DON/Staff #143), who stated that the facility is having issues with the transportation not showing up, so the facility hired a driver on October 5, 2023 to address this. She stated that if the transport does not show up, the facility driver will take the resident to dialysis. She states that the driver works 8AM to 4PM, but comes in early since Resident #117 has to be at dialysis early.

Review of the facility policy titled, "Dialysis, Pre and Post Care", revealed that facility staff should confirm chair time and days, and set up transportation to and from dialysis.

Based on clinical record review and staff interviews, the facility failed to ensure one resident (#93) with a diagnosis of a serious mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review.

Findings include:

Resident #96 was admitted to the facility on April 24, 2024 with diagnoses of Vascular Dementia Depression, and Anxiety.

Review of the Pre-Admission Screening and Resident Review (PASARR) Level I Screening dated February 9, 2024 completed prior to admission, revealed the resident did not have primary diagnosis of dementia and no diagnoses of a serious mental illness and mental disorder.

Further review of the Level I Screening revealed mental disorders include anxiety disorder and depression (mild or situational) which were not checked.

The quarterly Admission Minimum Data Set (MDS) assessment dated September 24, 2024 included an active diagnosis of Non-Alzheimer's Dementia, Anxiety Disorder, and Depression (other than bipolar).

A physician's order dated October 31, 2024, revealed an order for Ativan Oral Tablet 1 MG (Lorazepam) by mouth by mouth every 8 hours as needed Anxiety Disorder, Unspecified (F41.9) for 90 Days.

A Psych Follow up progress note dated November 12, 2024 revealed that history present illness includes anxiety disorder and Vascular Dementia.
A physician's order dated January 2, 2024, revealed an order for Olanzapine Oral Tablet 10 MG by mouth two times a day for aeb disorganized thinking related to Unspecified Psychosis not due to a Substance or known Physiological Condition.

An interview was conducted on January 10, 2025 at 9:30AM with Social Worker Director (SS/staff #158), who stated that he uploads the resident's information for PASARR into AHCCCS portal online and submits all the relevant documents for state determine if they need PASARR level 2 is required for the resident. Staff #158 also stated that if PASARR level 2 is not done then resident will have risk of not getting the help they need as well as medications.

Further interview was conducted on January 10, 2025 at 12:02PM with SS/staff#158 who stated that he did not complete the PASARR level 1 for resident #96 because he was not here that time, whoever did it, they did not mark Anxiety and Depression on the PASARR level 1 under the mental disorders, therefore it is not done correct.

An interview was conducted on January 10, 2025 at 01:21PM with the Resource Nurse (staff #144), who stated that the anxiety diagnosis should have been verified then put on the PASARR level 1. She stated that there is no risk to resident #96 behaviors are caused by dementia. Although, she confirmed that Dementia was not the resident's primary diagnosis.

An interview was conducted on January 10, 2025 at 02:20PM with the Director of Nursing (DON/staff #143) who stated that Dementia is not primary diagnosis for resident #96 and current PASARR is done incorrectly because mental Illness section (B) for mental disorder Anxiety Disorder and Depression (mild or situational) are not checked. She also stated this need to be corrected immediate and going do audit for all the resident's that reside in the facility. She further stated that risk to resident #96 behaviors are caused by dementia.

The facility's policy titled, "Admission Criteria" reveled that the facility conducts a Level 1 PASARR screen for all potential admission, regardless payer, source, to determine if the individual meet the criteria for mental disorder (MD), intellectual disabilities (ID), or related disorder (RD). if the level 1 screen indicates that the individual may meet the criteria for MD, ID, OR RD, he or she is referred to state PASARR representative for the level II (evaluations and determination) screening process. The social services director is responsible for making referrals to the appropriate state-designated authority.

Based on personnel file review, staff interview, and the job description, the facility failed to ensure that the activities program was directed by a qualified professional.

Findings include:

A review of the personnel file for the activities director (AD/Staff #1) revealed that she was hired on December 4, 2024 to be the full time AD. However, review of the personnel file did not reveal evidence that staff #1 possessed the qualifications to be the AD.

Review of the facility's job description for the activities director position revealed that an activities director certification was required. Further review of the requirements revealed that experience in a social or recreation program within the last five (5) years or must be a qualified occupational therapist or occupational therapy assistant licensed by the state and is eligible for certification as a recreation specialist or as an activity professional.

An interview was conducted on January 10, 2025 at 11:56 a.m. with the activities director (staff #1). Staff #1 stated she had been serving as the AD for a month and was still learning the role. The AD further verified that she does not have an activities director certification and was looking into starting a course soon.

An interview was conducted on January 10, 2025 at 1:20 p.m. with the Administrator (staff #10). The administrator stated that his expectations would be that all employees have the proper certifications necessary to fulfill the role. Staff #10 confirmed that staff #1 did not have an activities director certification. When asked if he could present any paperwork regarding her offer letter, the administrator stated he does not have any other documentation regarding the terms of the AD being hired.

Based on clinical record reviews, resident and staff interviews, and a review of policies and procedures, the facility failed to ensure insulin treatment was provided in accordance with professional standards of practice for one of six sampled residents (#89), as ordered by the physician.

Findings include:

Resident #89 was admitted on December 12, 2024, with diagnoses that included Dementia and Type 2 Diabetes Mellitus.

An order summary dated December 12, 2024, indicated that insulin should be administered per sliding scale: if 0-200 = 0; 201-250 = 2; 251-300 = 4; 301-350 = 6; 351-400 = 8; 401-450 = 10; 451-999 = 12 (Notified MD), subcutaneously before meals and at bedtime for DM. The order summary revealed that the resident should be administered Insulin Lispro per sliding scale.

A Medication Administration Record (MAR) dated December 18, 2024, revealed that the resident was not administered an 8 PM insulin dose for a blood sugar level of 280 and was coded with a code of 9, which referred to "Other/See Progress Notes."

Progress notes dated December 18, 2024, revealed no evidence of why the 8 PM insulin dose was not administered or whether the physician was notified.

Further review of the MAR dated January 5, 2025, and weights/vitals documented on January 5, 2025, revealed no evidence that the resident was administered a 5 PM insulin dose, and blood sugar levels were not recorded on the MAR.

Progress notes dated January 5, 2025, revealed no evidence of insulin administration at 5 PM or notification of the provider that the insulin had not been administered.

An interview was conducted on January 9, 2025, at 2:13 PM with a Registered Nurse (RN/Staff #140), who stated that insulin administration was based on physician ' s orders and a sliding scale. The RN reviewed the clinical record and stated that resident #89 was supposed to receive insulin before meals and before bed. She further stated that all medication administrations must be documented in the MAR. The RN also stated that when insulin is not administered due to blood sugar levels, the reason must be recorded in the progress notes, and that any blank entries in the MAR require a corresponding explanation in the progress notes. During the review, the RN found instances for resident #89 where insulin was omitted without documented reasons in the progress notes, deeming this unacceptable. The RN stated that the risk of missing insulin administration can lead to serious complications like Diabetic Ketoacidosis (DKA) and hospitalization.

An interview was conducted on January 9, 2025, at 3:28 PM with the Director of Nursing (DON/Staff #143), who emphasized the eight rules of safe medication administration and the importance of accurate documentation. The DON stated that nurses must check the blood sugar levels for all residents on a sliding scale, administer the correct dose, and document in the MAR. She further stated that a blank MAR entry is unacceptable, and missing insulin doses can lead to severe consequences, potentially death. The DON reviewed the MAR and progress notes for resident #89 and stated that there was no evidence that the insulin was administered per physician's order on a sliding scale, and there was no evidence in the progress notes that the physician had been notified.

A facility policy titled "Medication Orders" revealed that medications must be administered in accordance with the orders.

Based on clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that liquid diet order for one of two sampled residents (#23) was administered as ordered by the physician.

Findings include:

Resident #23 was readmitted to the facility on September 1, 2022 with diagnoses of dysarthria following other cerebrovascular disease, paralysis of bilateral vocal cords and larynx, dysphagia oropharyngeal phase, dysarthria and anarthria.

A physician order dated November 21, 2023 included for regular pureed texture with honey/moderate thick consistency.

A physician order dated November 23, 2023 revealed an order for the resident to be upright in chair for all meals, 1:1 assist with all oral intake, giving small bites; alternating bites/sips; and for resident to tolerate liquids via a teaspoon or managed sips by straw only to facilitate single sips and prevent silent aspiration.

Review of a quarterly Minimum Data Set (MDS) assessment dated August 1, 2024 revealed a Brief interview for Mental Status (BIMS) score of 11 indicating the resident had moderately impaired cognition. Further, the assessment revealed the resident required a mechanically altered diet.

A care plan initiated on August 6, 2024 revealed the resident had a nutritional risk related to a swallowing difficulty as exhibited by mild-moderate oropharyngeal dysphagia with low-moderate risk of aspiration per a study conducted on November 24, 2023; and required for a texture modified diet. The goal was that the resident would be monitored for aspiration. Interventions included 1:1 assist with all meals by mouth; providing and serving diet as ordered; and monitoring, documenting, and reporting as needed signs and symptoms of dysphagia; for the registered dietician to evaluate and make diet change recommendations as needed; and, for speech therapy to evaluate and treatment as ordered.

The chest x-ray result dated August 29, 2024 revealed aspiration of fluid as the cause of abnormal reaction of the patient, or of later complication, without mention of misadventure at the time of the procedure. Conclusion included that there no apparent acute cardiopulmonary process.

Further review of the clinical record revealed physician orders dated August 30 and August 31, 2024 for antibiotic for pneumonia.

The progress note dated September 3, 2024 included that the resident continued with antibiotics treatment for aspiration pneumonia.

Further review of the clinical record revealed no evidence of any changes in the diet order for resident #23.

A dining observation was conducted on September 12, 2024 at 11:39 a.m. The diet order slip for resident #23 read puree, honey thick liquids with divided plate. Resident #23 was positioned upright in a high back wheelchair and was being assisted with his lunch meal by a restorative nursing assistant (RNA/staff #40). The liquids that were served to resident #23 was prepared by a certified nursing assistant (CNA/staff #77) who stated that the resident should have a honey thick consistency for liquids. The RNA stated that the liquids were prepared for resident #23 had a honey-thick consistency. The resident was given 5 half teaspoons of mash potatoes with gravy and pureed meat with gravy, followed by six teaspoons of thickened grape juice. The resident then began to cough. The RNA then took the resident's drink to the area where the drinks were being prepared and began to add four teaspoons of thickener to the liquid; and stated that he was adding thickener to the resident's grape juice. He stated that when the resident starts to cough it was not safe to keep giving resident #23 honey thick liquid so they always make it into a pudding consistency. The RNA stated the resident had an order for a honey thick liquid consistency. The RNA then went back to the table where the resident was with the thickened liquid and checked the diet order slip for resident #23.

An interview with the registered nurse (RN/staff #52) was conducted on September 12, 2024 at approximately 11:57 a.m. The RN stated that resident #23 was at risk for aspiration and was currently prescribed antibiotics for aspiration pneumonia. She further stated the resident had been advised that he should not eat, was aware of the risks associated with eating and had been referred for Hospice. She stated the resident had not decided at that time and had also declined a feeding tube. The RN further stated that altering a resident's diet increase the risk of choking and/or aspiration; and, resident's diet should not be altered without a physician order.

An interview was conducted on September 12, 2024 at 12:04 p.m. with the Director of Nursing (DON/staff #68) who stated that resident #23 had a diet order for puree and honey moderate thick consistency liquids; and that, there were no orders for pudding thickened/consistency liquids. She stated that the only staff who were qualified to make those changes was the speech therapist (ST) who will conduct an evaluation; and, changing the resident's diet order without the recommendation/order by the physician/registered dietician and/or ST could result in resident risk for aspiration. Further, the DON stated that CNAs/RNAs should not alter the resident's diets in any way; and, if they had concerns with the resident's current diet they should inform her immediately.

In an interview with the administrator (staff #94) conducted on September 12, 2024 at 1:10 pm, the administrator stated she spoke with the RNA (staff #40) who admitted to adding the thickener with the intent of serving to resident #23. She stated she had an immediate in-service with all staff regarding residents' diets, precautions and risks associated with altering without an order or an evaluation.

The facility policy on Therapeutic Diets revealed that therapeutic diets are prescribed by the attending physician to support the residents treat and plan of care and in accordance with his or her goals and preferences. Overseeing nurse/physician can downgrade diet based on observation, tolerance and safety. Followed by a referral to speech therapist.

Based on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure two residents (# 8, 12) out of five sampled remained free from abuse.

Findings include:

-Regarding Resident # 8 and Resident # 26

Resident # 8 was admitted into the facility on July 05, 2024 with diagnoses that included bipolar disorder, unspecified dementia with agitation, depression, and unspecified mood disorder.

A review of the Admission MDS (minimum data set) assessment dated July 11, 2024 for Resident # 8 revealed a BIMS (brief interview of mental status) score of 3, which indicated the resident was severely cognitively impaired.

Resident # 26 was admitted into the facility on June 14, 2021 with diagnoses that included schizophrenia, secondary parkinsonism, major depressive disorder, and auditory hallucinations.

A review of the Admission MDS assessment dated May 22, 2024 for Resident # 26 revealed a BIMS score of 14, which indicated the resident was cognitively intact.

Review of electronic medical records (EMR) progress note dated July 10, 2024 with time of 09:49 AM, revealed Resident # 8 was intrusive with roommates' (Resident # 26) belongings; and that, was educated 3 times regarding room boundaries. Resident # 8 then became argumentative and verbally aggressive to the staff. Review of EMR revealed no other progress notes were written on that day for Resident # 8.

Review of documentation via reportable incident revealed that on July 10, 2024 at 09:20 PM, unnamed nurse witnessed Resident # 8 out of room, and stated that he had been hit by his roommate Resident # 26.

Review of EMR progress note dated July 10, 2024 with time of 10:24 PM, revealed Resident # 26 had a room change to a new unit within the facility. At 10:40 PM, EMR revealed that Resident # 26 was interviewed at 10:40 PM by the local police department. However, review of EMR revealed no other progress notes were written that day for Resident # 26.

An interview was conducted with the daughter of Resident # 8 on August 13, 2024 at 01:50 PM who stated that she had made efforts to communicate to the facility a possibility of behavior issues if Resident # 8 was placed with other residents upon admission. Moreover, the daughter confirmed that she had received a call and was notified that there was an altercation with another resident giving Resident # 8 a black eye.

An interview was conducted with Resident # 26 on August 13, 2024 at 02:45 PM who stated that while laying in the bed, resident #26 was approached by Resident # 8; and that, he believed Resident # 8 wanted to throw him out of the bed. Resident # 26 stated this is why, "I hit him in the face". Resident # 26 confirmed the name of Resident # 8 which he had swung and hit in the face. Resident # 26 stated that after the incident, an unnamed staff was, "pissed at me" and told the resident that it would have been best to scream. However, Resident # 26 stated screaming was not an option because, "he was going to put hands on me".

An interview was conducted with certified nursing assistant (CNA/Staff # 33) on August 13, 2024 at 02:57 PM, who stated she recalled the incident that had occurred between Residents (# 8 and # 26). Staff # 33 stated hearing a noise and Resident # 8 was bleeding above his right eye. Staff # 33 stated that she recalled being told by Resident # 8 that all he wanted was to see what Resident # 26 was doing and that's why he had approached his roommate.

-Regarding Resident # 12 & Staff # 1

Resident # 12 was admitted into the facility on May 24, 2024 with diagnoses that included anoxic brain damage, major depressive disorder, anxiety disorder, and borderline personality disorder.

A review of the Admission MDS (minimum data set) assessment dated May 31, 2024 for Resident # 12 revealed a BIMS (brief interview of mental status) score of 15, which indicated the resident was cognitively intact.

A care-plan initiated on June 05, 2024 revealed that the resident has a psychosocial well-being problem related to behaviors. The goal was for resident to have no indications of psychosocial well-being by/through review date. Interventions included when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. Furthermore, resident had behavior problems and interventions included approach/speak in a calm manner, divert attention, remove from situation and take to alternate location as needed.

A behavioral treatment plan initiated on July 08, 2024 revealed de-escalation techniques suggested a calm approach, redirect, offer a choice.

Review of EMR progress note dated July 31, 2024 with time of 01:05 PM, revealed an investigation of verbal abuse had been initiated for Resident # 12. At 01:14 PM, EMR revealed that Resident # 12 had been observed crying while in the hallway, had been assessed by psychiatry nurse practitioner, and had accepted referral for counseling services at that time.

An interview was conducted with social work assistant (SWA/Staff # 50) on August 13, 2024 at 10:24 AM, who confirmed that licensed practical nurse (LPN/Staff # 1) had uttered towards Resident # 12, "stop lying you bitch." SWA believed it was an oppositional driven response by Staff # 1 because of a recent discussion held between Staff # 1 and the Assistant Director of Nursing (aDON) concerning Resident # 12. SWA stated that while accompanying Resident # 12, observed Staff # 1 return to the nurses' station for her belongings, and walked by Resident # 12 and started calling her names. SWA stated there had been previous instances of verbal and physical aggression, from Resident # 12 towards Staff # 50, which had on one occasion prompted brief discussion by interdisciplinary team (IDT), in the morning meetings, to believe that they should not to be in the same unit. SWA could not explain why separation of unit of staff/resident was not in the care plan or progress notes, and why they were in the same unit at the time of the incident.

An interview was conducted with assistant Director of Nursing (aDON/Staff #10) on August 13, 2024 at 11:31 AM who confirmed was a part of the morning IDT meetings. Staff # 10 stated that the purpose of the meetings was to go over anything important from the day before and recalled that on one meeting Staff # 1 had mentioned feeling trapped at the nurse's station by Resident # 12. Staff # 10 stated the police had been involved at that time. Staff # 10 reviewed electronic medical records and stated that on July 31, 2024 after the recent verbal incident, Staff # 1 was removed to a different unit. Staff # 10 reviewed notes and stated could not recall if anything else was added to the care plan because there was so much going on -- although confirmed that Staff # 1 went home that day as she was mostly upset and had made comments on her way out; and that, it was a decision made by the team. A second interview was requested later by Staff # 10 at 12:07 PM who stated wanted to provide more details regarding changes made to the plan of care since admission of Resident # 12 which included cares in pairs and being placed on 1:1 as well as switching to different units whenever Resident became physically aggressive towards other residents.

An interview was conducted with director of human resources (dHR/Staff # 62) on August 13, 2024 at 12:59 PM, who confirmed the accuracy of documentation of resolution regarding the incident between Staff # 1 and Resident # 12 which revealed actions taken by the facility were to send Staff # 1 home. Staff # 62 confirmed that he interviewed Staff # 1 and in frustration Staff # 1 stated that the resident was acting like a brat; and that, "everyone has to bow down to the princess"; and that, had questioned why Resident # 12 was moved. Staff # 62 recalled that Staff # 1 was observed hyperven

Based on clinical record review, resident and staff interviews, and facility documentation and policy, the facility failed to ensure care and treatment according to professional standards of practice was provided to one resident (#1). The deficient practice resulted in the hospitalization of the resident and amputation of his leg.

Findings include:

Resident #1 was admitted on 03/06/2006 with diagnoses of borderline personality disorder, obsessive-compulsive disorder, epilepsy, and an anxiety disorder.

Review of the clinical record revealed documentation that the resident was in a car accident, had metal pieces in his left foot; and that, in October and November of 2019, he was again noted to be limping and complaining of pain to right lower leg.

The care plan initiated on 11/11/2022 revealed the resident had a goal related to his potential for impairment to skin integrity related to his potential for poor safety awareness. Interventions included following facility protocols for treatment of injury and identifying and documenting potential causative factors and eliminate and resolve where possible.

The care plan dated 03/08/2023 included that the resident had diabetes mellitus and had the potential for pressure ulcer development. The goals were that the resident will not have complications related to diabetes and the resident will have intact skin, free of redness, blisters or discoloration. Interventions included to check all body for breaks in skin and treat promptly as ordered by the doctor; and, to follow facility policies/protocols for the prevention/treatment of skin breakdown.

The follow-up encounter notes dated 04/04/2024 included that the resident had red/open areas to the right upper shoulder; and that, there was no edema noted on the extremities.

The skin observation dated 04/09/2024 revealed a red area; however, the documentation did not identify the location of the red areas observed.

The shower sheet dated 04/10/2024 included that the resident had swelling to his right leg.

The clinical record revealed no documentation whether the swelling to the resident's right leg was reported to the nurse or the provider; and that, it was assessed and interventions were put in place to address this.

The nursing weekly skin check dated 04/12/2024 revealed the resident had wound to the right bicep which was healing, scabbed and without drainage or swelling. However, there was no documentation of any redness or swelling to the resident's right leg. Per the documentation, the skin was expected color for ethnicity without lesions or rashes, was warm, dry with no edema, and had normal turgor with no tenting.

The follow-up NP (nurse practitioner) note dated 04/16/2024 included the resident had red and open areas to the right upper shoulder; and, had no edema on the extremities.

The nursing weekly skin check dated 04/18/2024 included the resident had a scab on the right shoulder and the rest of the skin was clean, dry and intact. It also included that the skin color was normal to ethnicity and skin turgor was good. The documentation did not include any redness or swelling to the resident's right leg.

The wound progress note dated 04/18/2024 revealed there was no edema or tenderness to the right and left lower extremities.

A progress note dated 04/25/2024 at 07:23am documented that a certified nursing assistant (CNA) alerted the nurse that the resident had redness to his right leg. The nurse completed an assessment and took the vitals:
-Temperature of100.4 degrees Fahrenheit;
-Pulse of 92 bpm (beats per minute);
-Respiration-breaths per minutes;
-Blood pressure-140/100; and,
Oxygen saturation-90%.
Per the documentation, these vital were reported to the NP who ordered a stat CBC (complete blood count), CMP (comprehensive metabolic panel), CRP (C-reactive proteins) labs and a chest -X-Ray.

The NP progress note dated on 04/25/2024 revealed that a leakage to the right lower extremity sweat pants at groin/leg/thigh was noted; and that, the resident's leg appeared red and swollen from ankle to calf with some open/yellow slough dime-sized areas noted to distal shin on right lower extremity. Per the documentation, when the resident's pants were removed, a variety of items including snacks, straws, and toys fell out; and, these hoarded items were next to the skin which might be a component of the irritation. The documentation included that the NP requested the wound nurse consult promptly for evaluation and treatment and expressed concern for the sudden onset of symptoms. Physical exam included had 2+ edema on the extremities, red/open areas to the right lower extremity from the ankle to the knee, and swelling but no redness to the left lower extremity. Diagnoses included edema bilateral lower extremities and cellulitis on the right lower extremity. Plan was to start Doxycycline (antibiotic) for 7 days and Lasix (diuretic) twice daily for 3 days. Further, the documentation included that the stat labs (CBC, CMP and CRP) and ultrasound were pending: and, an oral antibiotic was to be started for seven days and Lasix (diuretic) for edema to be given twice a day for three days.

The physician order dated 4/25/2024 included the following orders:
-two STAT (immediate) orders for ultrasounds to his bilateral lower extremities to evaluate for deep vein thrombosis (DVT) related to redness on his leg and cellulitis;
-Another STAT order for CBC, CMP and CRP labs; and,
-Doxycycline 100 milligrams (mg) tablet by mouth twice a day until 05/02/2024.

The Medication Administration Record (MAR) for April 2024 revealed documentation that Doxycycline was administered to the resident as ordered.

The clinical record revealed that the orders for physician-ordered laboratory tests were completed on 4/25/2024 at 3:14 p.m.

The following results from the STAT labs on 04/25/24 were flagged as high:
-White blood cell count (WBC) was 22.9 thousand per cubic millimeter (Normal range was 4.0 to 11.0);
-Absolute Neutrophil was 14.6 thousand per microliter (Normal range was 1.5 to 7.8);
-Absolute Monocyte 4.3 thousand per microliter (Normal range was 0.2 to 1.0);
-Absolute Immature Granulocytes 2.2 thousand per microliter (Normal range was 0.0 to 0.1);
-CRP was 173.6 milligrams per liter (mg/L) (Normal range was less than or equal to 4.9 mg/L).

The clinical record revealed no evidence that the provider was notified and had reviewed these lab results.

The shower sheet dated 4/28/2024 included the resident had swelling and reddened right leg.

A nursing progress note from 04/29/2024 revealed that the ultrasound was completed and results were pending.

A wound note from 04/30/2024 included that the wound care team was consulted due to the worsening cellulitis of unknown origin in his right leg; and that, the resident was started on Doxycycline by attending NP with no improvement. Wound assessment included an unhealed full thickness cellulitis on the right lower leg measuring 34 cm (centimeters) length x 34 cm width x 0.2 cm depth; had moderate amount of yellow drainage noted; wound bed had 1-25% pink granulation, 51-75% epithelialization; and, periwound skin was warm, had edema and erythema and presented with signs and symptoms of infection. Active problems included cellulitis of the right lower limb. Plan included wound treatment. recommendation was for a wound culture and possible intravenous (IV) antibiotics for severe worsening cellulitis.

The NP progress note dated 04/30/2024 revealed that the resident's right lower extremity appeared more swollen, red, and inflamed than previous exam. It also included that the ultrasound was negative and the stat labs were reviewed with concern for sepsis or osteomyelitis. Per the documentation, the NP discussed these concerns with the director of nursing (DON)

Based on clinical record review, resident and staff interviews, and facility documentation and policy, the facility failed to assist in maintaining the highest practicable well-being by failing to ensure care and treatment according to professional standards of practice was provided to one resident (#1) resulting in the hospitalization of the resident and amputation of his leg.

Findings include:

Resident #1 was admitted on 03/06/2006 with diagnoses of borderline personality disorder, obsessive-compulsive disorder, epilepsy, and an anxiety disorder.

Review of the clinical record revealed documentation that the resident was in a car accident, had metal pieces in his left foot; and that, in October and November of 2019, he was again noted to be limping and complaining of pain to right lower leg.

The care plan initiated on 11/11/2022 revealed the resident had a goal related to his potential for impairment to skin integrity related to his potential for poor safety awareness. Interventions included following facility protocols for treatment of injury and identifying and documenting potential causative factors and eliminate and resolve where possible.

The care plan dated 03/08/2023 included that the resident had diabetes mellitus and had the potential for pressure ulcer development. The goals were that the resident will not have complications related to diabetes and the resident will have intact skin, free of redness, blisters or discoloration. Interventions included to check all body for breaks in skin and treat promptly as ordered by the doctor; and, to follow facility policies/protocols for the prevention/treatment of skin breakdown.

The follow-up encounter notes dated 04/04/2024 included that the resident had red/open areas to the right upper shoulder; and that, there was no edema noted on the extremities.

The skin observation dated 04/09/2024 revealed a red area; however, the documentation did not identify the location of the red areas observed.

The shower sheet dated 04/10/2024 included that the resident had swelling to his right leg.

The clinical record revealed no documentation whether the swelling to the resident's right leg was reported to the nurse or the provider; and that, it was assessed and interventions were put in place to address this.

The nursing weekly skin check dated 04/12/2024 revealed the resident had wound to the right bicep which was healing, scabbed and without drainage or swelling. However, there was no documentation of any redness or swelling to the resident's right leg. Per the documentation, the skin was expected color for ethnicity without lesions or rashes, was warm, dry with no edema, and had normal turgor with no tenting.

The follow-up NP (nurse practitioner) note dated 04/16/2024 included the resident had red and open areas to the right upper shoulder; and, had no edema on the extremities.

The nursing weekly skin check dated 04/18/2024 included the resident had a scab on the right shoulder and the rest of the skin was clean, dry and intact. It also included that the skin color was normal to ethnicity and skin turgor was good. The documentation did not include any redness or swelling to the resident's right leg.

The wound progress note dated 04/18/2024 revealed there was no edema or tenderness to the right and left lower extremities.

A progress note dated 04/25/2024 at 07:23am documented that a certified nursing assistant (CNA) alerted the nurse that the resident had redness to his right leg. The nurse completed an assessment and took the vitals:
-Temperature of100.4 degrees Fahrenheit;
-Pulse of 92 bpm (beats per minute);
-Respiration-breaths per minutes;
-Blood pressure-140/100; and,
Oxygen saturation-90%.
Per the documentation, these vital were reported to the NP who ordered a stat CBC (complete blood count), CMP (comprehensive metabolic panel), CRP (C-reactive proteins) labs and a chest -X-Ray.

The NP progress note dated on 04/25/2024 revealed that a leakage to the right lower extremity sweat pants at groin/leg/thigh was noted; and that, the resident's leg appeared red and swollen from ankle to calf with some open/yellow slough dime-sized areas noted to distal shin on right lower extremity. Per the documentation, when the resident's pants were removed, a variety of items including snacks, straws, and toys fell out; and, these hoarded items were next to the skin which might be a component of the irritation. The documentation included that the NP requested the wound nurse consult promptly for evaluation and treatment and expressed concern for the sudden onset of symptoms. Physical exam included had 2+ edema on the extremities, red/open areas to the right lower extremity from the ankle to the knee, and swelling but no redness to the left lower extremity. Diagnoses included edema bilateral lower extremities and cellulitis on the right lower extremity. Plan was to start Doxycycline (antibiotic) for 7 days and Lasix (diuretic) twice daily for 3 days. Further, the documentation included that the stat labs (CBC, CMP and CRP) and ultrasound were pending: and, an oral antibiotic was to be started for seven days and Lasix (diuretic) for edema to be given twice a day for three days.

The physician order dated 4/25/2024 included the following orders:
-two STAT (immediate) orders for ultrasounds to his bilateral lower extremities to evaluate for deep vein thrombosis (DVT) related to redness on his leg and cellulitis;
-Another STAT order for CBC, CMP and CRP labs; and,
-Doxycycline 100 milligrams (mg) tablet by mouth twice a day until 05/02/2024.

The Medication Administration Record (MAR) for April 2024 revealed documentation that Doxycycline was administered to the resident as ordered.

The clinical record revealed that the orders for physician-ordered laboratory tests were completed on 4/25/2024 at 3:14 p.m.

The following results from the STAT labs on 04/25/24 were flagged as high:
-White blood cell count (WBC) was 22.9 thousand per cubic millimeter (Normal range was 4.0 to 11.0);
-Absolute Neutrophil was 14.6 thousand per microliter (Normal range was 1.5 to 7.8);
-Absolute Monocyte 4.3 thousand per microliter (Normal range was 0.2 to 1.0);
-Absolute Immature Granulocytes 2.2 thousand per microliter (Normal range was 0.0 to 0.1);
-CRP was 173.6 milligrams per liter (mg/L) (Normal range was less than or equal to 4.9 mg/L).

The clinical record revealed no evidence that the provider was notified and had reviewed these lab results.

The shower sheet dated 4/28/2024 included the resident had swelling and reddened right leg.

A nursing progress note from 04/29/2024 revealed that the ultrasound was completed and results were pending.

A wound note from 04/30/2024 included that the wound care team was consulted due to the worsening cellulitis of unknown origin in his right leg; and that, the resident was started on Doxycycline by attending NP with no improvement. Wound assessment included an unhealed full thickness cellulitis on the right lower leg measuring 34 cm (centimeters) length x 34 cm width x 0.2 cm depth; had moderate amount of yellow drainage noted; wound bed had 1-25% pink granulation, 51-75% epithelialization; and, periwound skin was warm, had edema and erythema and presented with signs and symptoms of infection. Active problems included cellulitis of the right lower limb. Plan included wound treatment. recommendation was for a wound culture and possible intravenous (IV) antibiotics for severe worsening cellulitis.

The NP progress note dated 04/30/2024 revealed that the resident's right lower extremity appeared more swollen, red, and inflamed than previous exam. It also included that the ultrasound was negative and the stat labs were reviewed with concern for sepsis or osteomyelitis. Per the documentation, the NP discussed t

1. Based on clinical record review, an interview, and policy, the facility failed to provide one resident (#13) and/or the resident's representative with bed-hold policy information before a transfer to the hospital.

Findings include:

Resident # 13 was initially admitted to the facility on June 29, 2010 and was re-admitted on September 28, 2023 with diagnoses that includes schizophrenia, bipolar disorder, dementia, anxiety disorder, personality disorder, and pseudobulbar affect.

Review of the annual Minimum Data Set (MDS) assessment dated September 18, 2023 indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment.

Review of nursing note dated September 22, 2023 revealed that the resident left with Emergency Medical Services (EMS) and that the resident was sent to the hospital.

A progress note dated September 23, 2023 indicated that the resident was admitted inpatient (to the hospital) for diagnosis of pna (pulmonary nodular amyloisosis) with possible aspiration. The progress note stated that "all parties made aware." However, it did not indicate who all parties were.

Continued review of the clinical record did not reveal documentation that the facility provided the resident and the resident representative written notice of the facility's bed-hold policy when the resident was transferred to the hospital on September 22, 2023.

Review of the entry MDS assessment dated September 28, 2023 indicated that the resident reentered the facility that day.

An interview with the Director of Nursing (DON/staff #80) was conducted on October 27, 2023 at 11:15 AM. Staff #80 stated that she is not sure that notification of bed hold policy is part of the transfer process. She said that residents are notified of the policy during admission-it is part of the admission packet. Staff #80 said that to her knowledge bed hold is automatic since residents are in long term care.

Review of the facility policy titled "Bed-Holds and Returns" revised March 2017 indicated that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Furthermore, the policy stated that prior to a transfer, written information will be given to residents and resident representatives that explains in detail the rights and limitations of the resident regarding bed holds; the reserve bed payment policy; the facility per diem rate required to hold a bed or to hold a bed beyond the state bed-hold period; and the details of the transfer.

2. Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was completed accurately and a level II was sent to the state for determination for one resident (#13).

Findings include:

Resident #13 was initially admitted to the facility on June 29, 2010 and was re-admitted on September 28, 2023 with diagnoses that includes schizophrenia, bipolar disorder, dementia, anxiety disorder, personality disorder, and pseudobulbar affect.

Review of the resident's facesheet revealed the following new diagnoses and date of onset: dementia, with other behavioral disturbance dated January 3, 2023 and undifferentiated schizophrenia dated January 15, 2023.

Review of the PASRR Level I Screening Tool dated March 5, 2023 revealed the form was not adequately filled out. Section B. Mental Illness pertaining to the question does the individual have any of the following mental disorders was left unanswered. The question does the individual have a substance related disorder was also left unanswered. The symptoms portion under the area interpersonal with the question has the individual exhibited interpersonal symptoms or behaviors was left unanswered. Additionally, the concentration/task related symptoms portion was left answered. Furthermore, Section D. Referral Determination was also left unanswered.

Review of the annual Minimum Data Set (MDS) assessment dated September 18, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating that the resident has severe cognitive impairment. Section I. Active Diagnoses indicated that the resident's diagnoses included Non-Alzheimer's Dementia, anxiety disorder, bipolar disorder, and schizophrenia.

A care plan initiated on September 28, 2023 indicated that the resident has a behavior problem related to undifferentiated schizophrenia. Interventions indicated to assist the resident to develop more appropriate methods of coping and interacting, encourage to express feelings appropriately, and ensure needs are met in order to reduce agitation.

A care plan initiated on September 28, 2023 revealed that the resident has impaired cognitive function/dementia or impaired thought process. Interventions include communicate with the resident/family/caregivers regarding resident's capabilities and needs.

Further review of the clinical record did not reveal a PASRR Level I after the PASRR Level I dated March 5, 2023.

An interview with the Social Services Director (staff #66) was conducted on October 26, 2023 at 11:32 AM. Staff #66 stated that the PASRR process entails reviewing existing PASRR for new admits to screen diagnoses, verify primary diagnoses, indicators of behavior to cause harm, and indicators that will prevent them from thriving. Staff #66 also noted that diagnoses such as schizophrenia and violent behaviors usually triggers level II. She stated that residents must have a level I PASRR. She said that she reviews level I from prior facility and if the form is complete then she takes it and uses it. If the resident have new updates then it prompts a new level I depending on the diagnoses or it can also be a level II. Staff #66 noted that they have a resource person that provides her guidance regarding PASRR so she can get better. She stated that it is a work in progress to get the facility's PASRR process solidified. She noted that there was an audit conducted by Corporate approx. 1 to 2 weeks ago. She stated that completed PASRR goes to medical records for then to upload into PCC (Point Click Care). When there is a level II she would send it to the state point of contact but she was informed that the individual is no longer there so there is an PASRR email it is sent to and that she can only send 2 a day. When asked about resident #13, she noted that looking at her PASRR it is not current. However, she does not need one since there is one on file from 2009. When asked if new diagnoses pertaining to mental illness or intellectual disability would have triggered a need for new PASRR, staff #66 then said that resident #13 should have a new level II PASRR. She admitted that resident #13 does not have a current level II. When asked to pull up resident #13's PASRR from March 2023, she said that looking at it, it was not complete. She said she was not properly trained at that time and that is why it was not completely filled out.

An interview with the Director of Nursing (DON/staff #80) was conducted on October 27, 2023 at 11:15 AM. Staff #80 stated that her expectation is that PASRR are completed in a timely manner and according to policy. She noted that PASRR is a work in progress with her social services still learning.

Review of the facility's policy titled "Behavioral Assessment, Intervention and Monitoring" revised March 2019 stated that all residents will receive a level I PASRR screen prior to admission. If the level I screen indicates that the individual may meet criteria for a mental disorder, intellectual disability or related condition then the resident will be referred to the state PASRR representative for the level II determination. Additionally,

Based on observations, staff interview, and policy reviews, the facility failed to ensure pharmaceutical services were adequately provided for medication administration for four residents.

Findings include:

During observation of medication pass with a Licensed Practical Nurse (LPN/staff #297) conducted on
October 24, 2023 at 7:00 AM, the LPN administered medications to four residents (#82, #28, #58, #127). In each medication prep on the cart, the LPN verified the right resident from the resident's electronic medial record photograph, right medication, right dose, and right route per the order. In each bedside encounter, the LPN kindly greeted each resident and assisted each resident in sitting in a fowlers or semi-fowlers position but the LPN did not verify each resident's identity by checking the identification band at bedside before giving the resident medications.

A review of each resident's face sheet, BIMS score, and orders revealed: Resident #82: Admission October 20, 2020 with the diagnosis of dementia, mood disorder, benign prostatic hyperplasia, human immunodeficiency (HIV) disease, and a brief interview of mental status (BIMS) score of 10 (moderate cognitive impairment). Resident #28: Admission March 02, 2023 with the diagnosis of acquired absence of right and left leg above knee, peripheral vascular disease, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, and a brief interview of mental status (BIMS) score of 15 (intact cognition). Resident #58: Admission February 24, 2023 with the diagnosis of multiple sclerosis, schizoaffective disorder, bipolar type, anxiety disorder, actinic keratosis, dorsalgia, Parkinson's disease without dyskinesia, and a brief interview of mental status (BIMS) score of 05 (severe cognitive impairment). Resident #127: Admission October 9, 2023 with the diagnosis of essential hypertension, benign prostatic hyperplasia, anemia, gout, and a brief interview of mental status (BIMS) score of 15 (intact cognition)

An interview with the Director of Nursing (DON) on October 25, 2023 at 12:15 PM, the DON stated that the facility verifies the identity of the resident with the photograph on the electronic medical record and verbally at bedside.

Review of the facility policy Administering Medication and revealed the paragraphs; "The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: (a) checking identification band; (b) checking photograph attached to medical record; and (c) if necessary, verifying resident identification with other facility personnel.", "The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication."

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that allegations of misappropriation of resident property were reported to the State Agency and that the results of the investigations were submitted to the State Agency within the required time frame for one resident (#123). The universe was 118 the sample was 1.

Findings include:

Resident (#123) was admitted to the facility on August 9, 2023 with diagnoses that included Type I Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Acquired absence of right leg below knee, Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs, End-stage renal disease

An admission MDS (Minimum Data Set) assessment dated August 15, 2023 revealed the resident scored 15 on a BIMS (Brief Interview for Mental Status) assessment, which indicated the resident was cognitively intact.

A progress note dated 09/30/2023 1:40 AM, revealed resident stated the last time he had seen his card was last night and it must have gone missing between last night and this morning. When he woke up for breakfast and his phone and wallet were no longer on the nightstand. The phone was found behind his roommate's TV and the credit cards were missing. When the resident called to report the missing cards and close the accounts the resident was informed a transaction was made in the amount of $321 dollars to an airline.

A progress note dated 10/01/2023 17:19 states the police came out to complete incident report. Report # 23-1493202. American Airlines also states they will not hold him liable and will issue refund.

A progress note dated 10/02/2023 1:28 PM, revealed social services interviewed the resident regarding his debit card being allegedly being used. The resident informed social services his phone/wallet (phone has a case on it where he can put his debit cards) on his night stand. The resident reported that sometimes he keeps it in his top drawer of his night stand but the previous night (Saturday 9/30) he believes it was on his nightstand. Resident reported to social services that he had not given consent for anyone to use his American Express card and had contacted the police. Social Services contacted the family who stated they did not have access to the resident's bank information.

A progress note dated 10/02/2023 2:41 PM revealed social services attempted to speak with Frontier Airlines as well as American Airlines with resident (#123) but resident was asleep and would attempt the following day to see if the airlines will provide the name of who purchased the ticket.

In an interview was conducted with the Executive Director (Staff #223) on October 25, 2023 at 09:20 AM, she stated that APS was notified regarding the incident, had investigated and provided a report number. Staff (#223) further stated that she was poorly advised and has since been educated on the process of reporting resident incidents. Staff (#223) stated she was the responsible party for notifying the state agency.

Review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating states All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on resident and staff interviews, the facility investigation report and documents, clinical record review, and policy review, the facility failed to ensure one resident (#123) was treated in a dignified manner. The deficient practice could negatively impact the psychosocial well-being of residents. The universe was 130 as all residents could be affected, the sample was one.

Findings include:

Resident (#123) was admitted to the facility on August 9, 2023 with diagnoses that included Type I Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Acquired absence of right leg below knee, Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs, End-stage renal disease.

During the initial part of the survey, an interview was conducted with resident (#123) on October 23, 2023 at 11:40 AM, who stated that CNA (certified nursing assistant) identified as (Staff #34) had come into his room, after he had turned on his call light. Resident (#123) stated the CNA turned off the call light and left without acknowledging him. The resident stated he turned his call light back on. Resident (#123) stated the same CNA, (Staff #34) came back into his room and proceeded to stare at him for a few minutes, without saying anything. Resident (#123) stated he asked the CNA why was she staring at him? Resident (#123) stated when he questioned her, the CNA started a high-pitched, cackling laugh sound directed at him. The resident stated she was near his bed, when she started staring and laughing at him. The resident stated he asked the CNA why was she laughing? The resident stated her reply was "it's not against the law to laugh." Resident (#123) stated there was no reason for her laughter and felt disrespected, afraid and now felt that "I have to keep one eye open when she works." Resident (#123) stated (LPN, Staff #355) was aware of the situation. Resident (#123) stated the CNA refuses to change him for hours and he will sometimes have to wait for the next shift to be changed. The resident stated the situation has stressed him out and has requested the Veterans Administration (VA) to locate another facility to reside in. Resident (#123) became tearful discussing the incident.

On October 23, 2023 at 12:13 PM, the Administrator (staff #223) was notified of the resident's allegations and stated that she would begin the investigation process.

Review of the comprehensive care plan dated August 9, 2023 and revision on August 10, 2023, revealed the following: ADL: requires extensive staff assistance with activities of daily living (ADL) with interventions that stated the resident is mostly dependent for all ADL with 1-2-person assistance due to self-care deficit related to right below the knee amputation.

A Medicare 5-day MDS (minimum data set) assessment dated May 16, 2022, revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The assessment also revealed the resident required extensive assistance with bed mobility, personal hygiene, and required 1-2-person assistance with transfer, dressing, toilet use, and bathing.

Review of nursing progress notes dated September 2023 through October 22, 2023, revealed no evidence that the resident or other staff had reported any concerns regarding the resident's care/treatment by the Certified Nursing Assistants (CNAs).

Review of the facility investigation report dated October 26, 2023, revealed that October 23, 2023 resident (#123) stated to a surveyor that a CNA was not answering his call light in a timely manner and refused to give him iced water. The report included the facility DON (Director of Nursing/staff #80), social services (staff #341) and Administrator (staff #223) were notified, and social services visited the resident to discuss how the resident felt and obtain feedback. The report was currently ongoing and did not have a resolution documented on the grievance/complaint report.

The investigation report included the following witness statements:

Staff #341 (LPN) reported that CAN (staff #34) has a negative attitude, complaining about staff and residents, has never seen staff #34 argue with resident (#123) or refuse to assist him, finds staff #34 argumentative with staff and others at times and does not like to follow directions.

Staff #297(LPN) reported that staff #34 does not answer call lights in a timely manner, is very negative, complaining and argumentative and refuses to follow nurses' directions at times.

Staff #221 (RN) reported staff #34 is not professional, argumentative, and antagonistic with staff and others, does not follow directions from nursing leaders.

Staff #136 (CNA) reported staff #34 is thorough and abrupt at times.

Staff #342 (CNA) reported staff #34 can provide good care, is argumentative and negative, takes a while to answer call lights.

The investigative report included staff #34's statement dated October 24, 2023 which included that she denied ever refusing to provide care for the resident or purposely not answering his call light. Hat she does not spend a lot of time with the resident and that resident (#123) will appear fine at the beginning of the shift then becomes rude, aggressive, and angry towards her so she has another CNA provide his care. She further stated she believed resident (#123) did not like her because she is African American.

Review of facility grievance documentation, revealed a formal Grievance/Complaint Report dated August 17, 2023 filed by resident (#123) and received by RN (Staff #221) revealed that resident (#123) had filed a formal grievance. The report states as follows: Resident reports that he doesn't like the CNA (Staff #34) laughs and doesn't seem to care for her. Actions taken to resolve grievance/complaint dated 08/21/23: Educate Staff (#34) about customer service; Not to assign staff (#34) to room unless absolutely necessary. Resolution of Grievance/Complaint checked yes states the following: Gave staff (#34) education in customer service, resident rights and giving care on time. Staff (#34) will not take care of the resident. The form was completed on August 18, 2023 and signed by the administrator (staff #223) and Director of Nursing (staff #80).

On October 26, 2023 at approximately 10 AM the Administrator (staff #223) delivered requested staff #34's employee records and stated, based on interviews with staff, residents and violation of workplace policies, CNA (#34) had been terminated October 26, 2023.

An interview was conducted on October 26, 2023 at 02:24 PM with the Administrator (staff #223 and Staff (RN Consultant #443) who stated that she was involved with Human Resources and thought CNA (staff#34) could be educated, but she could not. She stated that she did interview the CNA, and that staff #34 denied the allegations made. The Administrator stated nursing staff are responsible of making the room assignments, but had not been informed of any room restrictions for Staff (CNA#34). She further stated the understanding would be to keep Staff (CNA #34) on Victoria Lane, but she would not take care of the resident (#123) unless necessary. The Administrator reviewed the grievance/complaint formed dated August 17, 2023. The Administrator acknowledged it was her signature on the form stating CNA (#34) would not provide care for resident (#123). The Administrator stated she needed to pay closer attention when signing documents.

An interview was conducted on October 27, 2023 at approximately 10:00 AM with resident #123's roommate (resident #69), who stated that an unidentified CNA had treated him roughly, did not want to give him cleaning supplies and had accused him of playing in his feces. Resident stated he could not recall the date or the staff's name, but was not afraid or felt threatened in any w

Based on observations, and resident and staff interviews the facility failed to ensure a resident (#6) had the means to communicate with staff, by failing to ensure the call device was accessible to the resident. The deficient practice can result in residents' needs not being met in a timely manner. The universe was 130 and the sample was one.

The findings include:

Resident #6 was readmitted to the facility on August 23, 2023 with diagnoses that included coronary artery disease, hypertension, gastroesophageal reflux disease, anxiety disorder, and manic depression.

The admission Minimum Data Set assessment dated August 28, 2023 revealed a Brief Interview for Mental Status score of 12 which indicated the resident had moderate impaired cognition.

During the initial observation of resident #6 conducted on October 23, 2023 at 10:07 AM, the call device was observed on the top of the light fixture, and out of resident's reach.

During an interview with the resident #6 conducted on October 23, 2023 at 10:07 AM, he stated that the call device was placed on the light fixture when they painted his room two weeks ago.

An additional observation was conducted on October 25, 2023 at 8:34 AM. Staff was observed entering the resident's room and then shutting the door. After the staff left, the call device was observed still on top of the light fixture.

An interview was conducted with resident #6 on October 25, 2023 at 8:42 AM. The resident stated that he does not normally use it but that the device needs to be placed where he can reach it, in the event he needs to use it. Resident #6 stated that currently, if he needs assistance he gets on his wheelchair and goes to the nurse's station to get help. He said that the call device has been on top of the light fixture a few nights.

Another observation was conducted on October 26, 2023 at 1:09 PM. The call device was observed still up on the light fixture which was located on the wall on the left-hand side of the room by the foot of the bed. During the observation, the resident asked another surveyor to hand him the call device so he can place it where he can reach it.

An interview was conducted with a Certified Nursing Assistant Lead (CNA Lead/staff #342) on October 27, 2023 at 9:50 AM. Staff #342 stated that CNAs are supposed to place the call light where residents can reach them. She said at the beginning of the shift CNAs are to lay eyes on residents and ensure they can access the call light. Staff #342 noted that there should never be a time when the call light is out of the resident's reach. The call device is normally attached to the bed. If the CNA is changing the sheets on the bed, they need to make sure that the device is placed back within the resident's reach. When asked if she noticed that these past few days, resident #6's call device was not accessible, she stated she had not noticed. She said that resident #6's call device was normally placed on his bed or on the side of his pillow. Staff #342 stated that the call device should not have been placed on the light figure indefinitely and should have been placed where the resident could reach it. She stated that she last checked the call device this past weekend. She said that CNAs should check that call devices are within the residents reach. However, she also noted that resident #6 comes out of his room and into the hallway to ask for assistance.

An interview with a registry Licensed Practical Nurse (LPN/staff #125) was conducted on October 27, 2023 at 10:02 AM. Staff #125 noted that nursing staff makes sure that call light is within the residents' reach. She noted that she normally assigned to various units but was familiar with resident #6. When she was informed that resident #6's call device was stored on to of the light fixture, she stated that it was not supposed to be placed on the light fixture. Staff #125 stated that CNAs are supposed to ensure call device are within the residents' reach. She also noted that nurses are supposed to check as well that call devices are within resident's needs. However, she stated that resident #6 comes out of his room and lets the nurse know what he needs. She also stated that resident #6 had not mentioned anything about his call light.

During an interview with the Director of Nursing (DON/staff #80) conducted on October 27, 2023 at 11:15 AM, she noted that she expects her nursing staff to ensure that call devices are within residents' reach each time they go into the residents' room. If staff has to move the call device for any reason during care or services, they should make sure that it is placed back within the residents' reach afterwards. She stated that the call device should not be out of the residents' reach. However, she noted that when it comes to resident #6, he is very independent and is capable of letting the staff know of his care needs.

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#10) had the correct advance directive in place. The deficient practice could result in residents not being allowed to make their own medical decisions. The universe is 130 and the sample is one.

Findings include:

Resident #10 was admitted to the facility on May 5, 2021 with diagnoses that included atherosclerotic heart disease, chronic kidney disease, and unspecified protein-calorie malnutrition.

Review of the clinical record revealed an advanced directive statement dated February 26, 2022 for a do not resuscitate (DNR) status.

Review of the clinical record also revealed an advanced directive statement form that was not completed, signed or dated with documentation of refusal to sign.

Review of the order summary revealed an order dated August 5, 2022 for full code status.

The care plan dated May 12, 2023 revealed that the resident was a full code status. Interventions included to call for help immediately and begin basic life support sequence.

The minimum data set (MDS) dated August 10, 2023 revealed that the brief interview score of 10 indicating the resident has a moderate cognitive impairment.

Review of the advanced directive statement dated October 25, 2023 revealed that the resident did not want cardiopulmonary resuscitation and was (DNR) status.

An interview was conducted on October 25, 2023 at 12:38 PM, with the Social Services Director (staff #66), who stated that the facility is responsible for reviewing the advanced directive form with the resident/power of attorney (POA) and ensuring that it is completed, signed and dated. She reviewed the clinical record for the resident and located:

-an advanced directive dated 2022 documenting the resident was DNR, signed by the POA.

-an advance directive form that was not dated, signed or completed.

-an order for full code status dated August 5, 2022.

During the interview, staff #66 called the resident ' s POA, who stated that she and the resident had already discussed it and had agreed that he wanted to be DNR status. Staff # stated that there is risk of doing the wrong thing when the documentation is not correct and a very dangerous position to put the family in.

During an interview conducted on October 25, 2023 at 1:18 PM, with a licensed practical nurse (LPN/staff #341), she reviewed the orange binder labeled "Advanced Directives and DNR" located at the nurse station and said that she could not find the advanced directive for the resident. Then, she reviewed the electronic clinical record and stated that the resident was full code status.

An interview was conducted on October 26, 2023 at 2:22 PM, with the Director of Nursing (DON/staff #80), who do not have the staff list stated that the resident/POA should complete the Advanced Directive form and it should be placed in the clinical record. She reviewed the resident ' s clinical record showing that the resident had three advanced directive forms: February 26, 2022 was a DNR status, the second form was not completed, signed or dated, and the third form dated October 25, 2023 was a DNR status, and she agreed that the full code status was incorrect.

The facility's policy, "Advance Directives" date September 2022 states that the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.

Based on observations, staff interviews, and policy reviews, the facility failed to ensure that maintenance and comfortable interior was provided for 1 resident (#106). The deficient practice could result in resident rooms not having a homelike environment. The universe was 130 the sample was one.

Findings include:

An interview was conducted with resident #106 on October 23, 2023 at 11:42 AM. Resident # 106 stated that the baseboards in his room is coming off and that there is a huge cut out hole in his room where cockroaches are coming out.

An observation was conducted of resident #106's room on October 23, 2023 at 11:42 AM. An area approximately 2-feet in high and 1-foot wide was discovered on the wall by the foot of the A-side bed.

An additional observation was conducted of resident #106's room on October 25, 2023 at 8:24 AM. It revealed that the hole on the wall was still present. However, no evidence of pest coming out of the hole was found.

An interview with a Certified Nursing Assistant (CNA/staff #118) was conducted on October 25, 2023 at 8:24 AM. Staff # 118 stated that the hole has been there for a few days. She noted that the resident has not complained to her about the hole. However, she did verify that the resident is aware that there is a hole on the wall in the room. Staff #118 stated that the hole was caused by the bed hitting the wall when staff was moving the bed.

Review of work order log with a date range of October 1, 2022 thru October 22, 2023 did not reveal any work order regarding identifying the hole in the wall for resident's room.

During a surveyor walk around conducted on October 25, 2023 at approximately 9:50 AM, staff #118 notified the surveyor that the hole in resident #106's room has been fixed.

An interview was conducted with the Maintenance Director (staff #221) on October 25, 2023 at 9:54 AM. Staff #221 stated that work orders are normally placed by the nurse in TELS system to inform maintenance of issues that need to be resolved. Depending on the issue it is rated between low and critically high and transmitted to the maintenance team for resolution. He said that the maintenance team checks TELS often to check work orders. Staff #221 stated that nurses and staff are pretty vocal about building issues. Maintenance double checks with the staff to ensure issues are taken care. Alternatively, staff also contacts maintenance via phone call or text message. He indicated that a hole in the wall or a patch job is normally pretty high priority. Staff #221 stated that maintenance checks TELS daily to see what needs to be addressed depending on emergent status. When asked if he was aware of the hole in resident #106's room, he stated he is not sure and that he might not know if it was not on TELS. Staff #221 stated that the facility is pretty big so they relay on staff to report issues. During the interview the room in question was visited with staff #221. Staff #221 noted that since the hole was pretty big, it should have been fixed the same day as long as the supply is available and if not, the supply should have been obtained to fix the hole immediately.

An interview was conducted with Maintenance Assistant (staff #198) on October 25, 2023 at 10:06 AM. Staff #198 stated that a work order was placed on TELS yesterday for resident #106's room. He said that the wall was prepped yesterday and completed today.

An interview with a Licensed Practical Nurse (LPN/staff #125) was conducted on October 27, 2023 at 10:02 AM. Staff #125 stated that the facility utilizes a TELS system for work orders. She said that work order requests are normally completed within 24 hours and that if it was an emergency, it is fixed immediately. Staff #125 said that holes in the wall are normally fixed within 24 hours from when it was reported. She noted that part of the nursing staff's job when they do their rounds is to check the resident's room to make sure it is safe for the resident and that it is in good order.

An interview with the Director of Nursing (DON/staff #80) was conducted on October 27, 2023 at 11:15 AM. Staff #80 stated that her expectations with regards to work orders needs and turnaround time is that work order needs are inputted into TELS and that staff inform maintenance right away of any work order needs. She said that she expects the maintenance team to be on the message thread regarding work orders. She also noted that she expects maintenance to take care of work order needs within a reasonable amount of time.

The facility policy titled "Maintenance Service" revised December 2009 stated that maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy indicated that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. Additionally, it said that maintenance personnel should maintain the building in good repair and free from hazards.

Review of the facility policy titled "Work Orders, Maintenance" revised April 2010 stated that maintenance work orders shall be completed in order to establish a priority of maintenance service. Furthermore, it noted that in order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director. The policy also noted that the department directors are responsible for filling out and forwarding work orders to the Maintenance Director.

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that allegations of misappropriation of resident property were reported to the State Agency and that the results of the investigations were submitted to the State Agency within the required time frame for one resident (#123). The universe was 130 the sample was one.

Findings include:

Resident (#123) was admitted to the facility on August 9, 2023 with diagnoses that included Type I Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Acquired absence of right leg below knee, Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs, End-stage renal disease

An admission MDS (Minimum Data Set) assessment dated August 15, 2023 revealed the resident scored 15 on a BIMS (Brief Interview for Mental Status) assessment, which indicated the resident was cognitively intact.

A progress note dated 09/30/2023 1:40 AM, revealed resident stated the last time he had seen his card was last night and it must have gone missing between last night and this morning. When he woke up for breakfast and his phone and wallet were no longer on the nightstand. The phone was found behind his roommate's TV and the credit cards were missing. When the resident called to report the missing cards and close the accounts the resident was informed a transaction was made in the amount of $321 dollars to an airline.

A progress note dated 10/01/2023 17:19 states the police came out to complete incident report. Report # 23-1493202. American Airlines also states they will not hold him liable and will issue refund.

A progress note dated 10/02/2023 1:28 PM, revealed social services interviewed the resident regarding his debit card being allegedly being used. The resident informed social services his phone/wallet (phone has a case on it where he can put his debit cards) on his night stand. The resident reported that sometimes he keeps it in his top drawer of his night stand but the previous night (Saturday 9/30) he believes it was on his nightstand. Resident reported to social services that he had not given consent for anyone to use his American Express card and had contacted the police. Social Services contacted the family who stated they did not have access to the resident's bank information.

A progress note dated 10/02/2023 2:41 PM revealed social services attempted to speak with Frontier Airlines as well as American Airlines with resident (#123) but resident was asleep and would attempt the following day to see if the airlines will provide the name of who purchased the ticket.

In an interview was conducted with the Executive Director (Staff #223) on October 25, 2023 at 09:20 AM, she stated that APS was notified regarding the incident, had investigated and provided a report number. Staff (#223) further stated that she was poorly advised and has since been educated on the process of reporting resident incidents. Staff (#223) stated she was the responsible party for notifying the state agency.

Review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating states All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on closed record review and staff interviews the facility failed to ensure that all transfer/discharge notifications were made for one resident (#13). The deficient practice could lead to notifications of resident transfer/ discharge not being made to all required parties. The universe was 130 the sample was 1.

Findings include:

Resident #13 was initially admitted to the facility on June 29, 2010 and was re-admitted on September 28, 2023 with diagnoses that includes schizophrenia, bipolar disorder, dementia, anxiety disorder, personality disorder, and pseudobulbar affect.

A nurse practitioner order dated September 22, 2023 revealed an order to send the resident to the hospital immediately for hypoxia.

Review of the resident's clinical record did not reveal that a transfer to hospital form (e-Interact) was completed for the incident on September 22, 2023.

A progress note dated September 22, 2023 revealed that the resident was sent to the emergency room immediately and that the Director of Nursing and Administrator were notified of changes.

An additional progress note dated September 23, 2023 indicated that the resident was admitted inpatient (to the hospital) for diagnosis of pna (pulmonary nodular amyloisosis) with possible aspiration. The progress note stated that "all parties made aware." However, it did not indicate who all parties were.

Continued review of the clinical record revealed no further documentation related to this incident found.

There was no evidence found in the clinical record that the resident's representative/s or Ombudsman were notified of the resident's transfer to the hospital on September 22, 2023.

The discharge minimum data set (MDS) dated September 22, 2023 revealed that the resident's discharge was coded as an unplanned discharge, return anticipated.

During a document request for Ombudsman notification on October 24, 2023 at 9:01 AM, the Administrator (staff #223) stated that they do not have an ombudsman notification log. She said that the ombudsman is normally in the building every 2 weeks and that is when they inform her of discharge/hospital transfers. She said she will try her best to put one together from emails.

Review of the documents the facility put together as ombudsman notification equivalent revealed an Ombudsman visit log/sign in logs and a separate transfer/discharge log. The logs did not document that the transfer/discharge were discussed during the visits.

An interview with Licensed Practical Nurse (LPN/staff #125) was conducted on October 27, 2023 at 10:02 AM. The LPN stated that if a resident is sent to the hospital the provider, family, POA (power of attorney), and public fiduciary are notified. She stated that as a nurse she does not provide the family or ombudsman anything in writing but does call. Staff #125 sated that an e-Interact is completed for all transfers to the hospital. If the transfer is an emergency/911 event then the e-Interact is completed following the event and documented on PCC (Point Click Care). When asked what "all parties notified mean" she stated that she does not know what it means and that it is not sufficient documentation. Staff #125 said that documentation regarding the transfer notification should be specific and indicate that the family, physician, POA, Director of Nursing, and administrator were notified.

Review of the Social Services e-mail notification indicated that a notification was sent to resident #13's public fiduciary regarding her hospitalization but there was no evidence that a copy was sent to the Ombudsman.

During an interview with the Director of Nursing (DON/staff 80) conducted on October 27, 2023 at 11:15 AM, the DON stated that if a resident goes out to the hospital emergent, then the notification is conducted after the fact. If not then notification for the family and ombudsman is supposed to happen as the incident is going on. She indicated that nurse is supposed to notify the ombudsman and if not then Social Services should notify or email the ombudsman.

A policy regarding ombudsman notification was requested on October 25, 2023 at 12:20 PM but was not provided. Instead an Admission Handbook for the State of Arizona was provided which indicated that during transfer/discharge, the facility will notify the appropriate state agency. Additionally, it noted that if the resident was transferred because of an emergency situation, the facility will provide the required notice a soon as reasonable.

Based on clinical record review, an interview, and policy, the facility failed to provide one resident (#13) and/or the resident's representative with bed-hold policy information before a transfer to the hospital. The deficient practice could result in residents being unaware of their bed-hold rights. The universe is 130 the sample is one.

Findings include:

Resident # 13 was initially admitted to the facility on June 29, 2010 and was re-admitted on September 28, 2023 with diagnoses that includes schizophrenia, bipolar disorder, dementia, anxiety disorder, personality disorder, and pseudobulbar affect.

Review of the annual Minimum Data Set (MDS) assessment dated September 18, 2023 indicated that the resident had a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment.

Review of nursing note dated September 22, 2023 revealed that the resident left with Emergency Medical Services (EMS) and that the resident was sent to the hospital.

A progress note dated September 23, 2023 indicated that the resident was admitted inpatient (to the hospital) for diagnosis of pna (pulmonary nodular amyloisosis) with possible aspiration. The progress note stated that "all parties made aware." However, it did not indicate who all parties were.

Continued review of the clinical record did not reveal documentation that the facility provided the resident and the resident representative written notice of the facility's bed-hold policy when the resident was transferred to the hospital on September 22, 2023.

Review of the entry MDS assessment dated September 28, 2023 indicated that the resident reentered the facility that day.

An interview with the Director of Nursing (DON/staff #80) was conducted on October 27, 2023 at 11:15 AM. Staff #80 stated that she is not sure that notification of bed hold policy is part of the transfer process. She said that residents are notified of the policy during admission-it is part of the admission packet. Staff #80 said that to her knowledge bed hold is automatic since residents are in long term care.

Review of the facility policy titled "Bed-Holds and Returns" revised March 2017 indicated that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Furthermore, the policy stated that prior to a transfer, written information will be given to residents and resident representatives that explains in detail the rights and limitations of the resident regarding bed holds; the reserve bed payment policy; the facility per diem rate required to hold a bed or to hold a bed beyond the state bed-hold period; and the details of the transfer.

Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) level I was completed accurately and a level II was sent to the state for determination for one resident (#13). The deficient practice could result in specialized services not being identified and provided to residents. The Universe was 22 the sample was 1.

Findings include:

Resident #13 was initially admitted to the facility on June 29, 2010 and was re-admitted on September 28, 2023 with diagnoses that includes schizophrenia, bipolar disorder, dementia, anxiety disorder, personality disorder, and pseudobulbar affect.

Review of the resident's facesheet revealed the following new diagnoses and date of onset: dementia, with other behavioral disturbance dated January 3, 2023 and undifferentiated schizophrenia dated January 15, 2023.

Review of the PASRR Level I Screening Tool dated March 5, 2023 revealed the form was not adequately filled out. Section B. Mental Illness pertaining to the question does the individual have any of the following mental disorders was left unanswered. The question does the individual have a substance related disorder was also left unanswered. The symptoms portion under the area interpersonal with the question has the individual exhibited interpersonal symptoms or behaviors was left unanswered. Additionally, the concentration/task related symptoms portion was left answered. Furthermore, Section D. Referral Determination was also left unanswered.

Review of the annual Minimum Data Set (MDS) assessment dated September 18, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 4, indicating that the resident has severe cognitive impairment. Section I. Active Diagnoses indicated that the resident's diagnoses included Non-Alzheimer's Dementia, anxiety disorder, bipolar disorder, and schizophrenia.

A care plan initiated on September 28, 2023 indicated that the resident has a behavior problem related to undifferentiated schizophrenia. Interventions indicated to assist the resident to develop more appropriate methods of coping and interacting, encourage to express feelings appropriately, and ensure needs are met in order to reduce agitation.

A care plan initiated on September 28, 2023 revealed that the resident has impaired cognitive function/dementia or impaired thought process. Interventions include communicate with the resident/family/caregivers regarding resident's capabilities and needs.

Further review of the clinical record did not reveal a PASRR Level I after the PASRR Level I dated March 5, 2023.

An interview with the Social Services Director (staff #66) was conducted on October 26, 2023 at 11:32 AM. Staff #66 stated that the PASRR process entails reviewing existing PASRR for new admits to screen diagnoses, verify primary diagnoses, indicators of behavior to cause harm, and indicators that will prevent them from thriving. Staff #66 also noted that diagnoses such as schizophrenia and violent behaviors usually triggers level II. She stated that residents must have a level I PASRR. She said that she reviews level I from prior facility and if the form is complete then she takes it and uses it. If the resident have new updates then it prompts a new level I depending on the diagnoses or it can also be a level II. Staff #66 noted that they have a resource person that provides her guidance regarding PASRR so she can get better. She stated that it is a work in progress to get the facility's PASRR process solidified. She noted that there was an audit conducted by Corporate approx. 1 to 2 weeks ago. She stated that completed PASRR goes to medical records for then to upload into PCC (Point Click Care). When there is a level II she would send it to the state point of contact but she was informed that the individual is no longer there so there is an PASRR email it is sent to and that she can only send 2 a day. When asked about resident #13, she noted that looking at her PASRR it is not current. However, she does not need one since there is one on file from 2009. When asked if new diagnoses pertaining to mental illness or intellectual disability would have triggered a need for new PASRR, staff #66 then said that resident #13 should have a new level II PASRR. She admitted that resident #13 does not have a current level II. When asked to pull up resident #13's PASRR from March 2023, she said that looking at it, it was not complete. She said she was not properly trained at that time and that is why it was not completely filled out.

An interview with the Director of Nursing (DON/staff #80) was conducted on October 27, 2023 at 11:15 AM. Staff #80 stated that her expectation is that PASRR are completed in a timely manner and according to policy. She noted that PASRR is a work in progress with her social services still learning.

Review of the facility's policy titled "Behavioral Assessment, Intervention and Monitoring" revised March 2019 stated that all residents will receive a level I PASRR screen prior to admission. If the level I screen indicates that the individual may meet criteria for a mental disorder, intellectual disability or related condition then the resident will be referred to the state PASRR representative for the level II determination. Additionally, new onset or change in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a level II evaluation.

The facility policy titled "Admission Criteria" revised March 2019 noted that all new admissions and readmissions are screened for mental disorder, intellectual disabilities or related disorders per the Medicaid Pre-Admission Screening and Resident Review (PASRR). Additionally, it stated that the social worker is responsible for making referrals to the appropriate state-designated authority.

2. Based on observations, clinical record review and staff interviews the facility failed to ensure medications were administered by a physician for one resident. The census was 130. This deficient practice could result in adverse effects to the resident.

Findings include:

Resident #16 was admitted on May 9, 2022 with diagnosis that included dementia and unspecified hearing loss. The resident was edentulous.

The minimum data set (MDS) assessment dated September 21, 2023 revealed a brief interview of mental status (BIMS) score of 04 that indicated the resident had severe cognitive impairment. The MDS revealed the resident had no hearing aid used and the ability to hear is with a moderate difficulty. The MDS revealed the resident had no broken or loosely fitting full or partial denture.

The minimum data set (MDS) assessment dated September 28, 2023 revealed a brief interview of mental status (BIMS) score of 08 that included the resident had moderate cognitive impairment. The MDS revealed the resident used hearing aids and had a high hearing impairment. The MDS revealed the resident no broke or loosely fitting full or partial denture.

The baseline care plan dated September 5, 2022 revealed the resident was edentulous and coordinated arrangements for dental care are to be provided as ordered. The baseline care plan revealed monitoring, documentation, and reporting as needed of any signs and symptoms of oral dental problems needing attention. The baseline care plan revealed the facility did not address the resident's hearing difficulty or use of hearing appliances.

A review of the resident's dental notes revealed: June 16, 2022 states House call, no teeth, dentures soaking in glass - wiped mouth with [ineligible] rinse, brushed, wiped dentures, put in mouth with Fixodent. September 26, 2022 states, "rinsed and cleaned dentures, *needs upper dentures adjusted hurts". March 29, 2023 states, "Can someone help [resident] look everywhere for her dentures? She cannot find dentures." April 20, 2023 states, "Pt has [history] of dentures. She was not wearing them today." July 7, 2023 states, "Pt says her dentures are lost"

A review of the resident's progress note revealed: November 14, 2022 at 6:50 PM, Social Services Note Text: DENTAL VISIT: The resident was seen onsite by Coronado Dental on 11-14-22. The dental note was sent to Medical Records and a copy will be kept in the Social Services department. December 7, 2022 at 1:04 PM, Social Services Note Text: DENTAL VISIT: The resident was seen by the dental hygienist from Coronado Dental. The assessment notes have been sent to Medical Records to be uploaded to the record and a copy maintained in the Social Services office. March 29, 2023 at 12:56 PM, Social Services Note Text: ONSITE DENTAL VISIT: The resident was seen by Coronado Dental Services today, 03-29-2023. Dental Notes have been given to Medical Records to upload to the residents EMR through PCC. April 20, 2023 at 2:48 PM, Social Services Note Text: ONSITE DENTAL EXAM was completed with the resident on 04-20-23 by Coronado Dental. Dental Notes were given to Medical Records to be uploaded to the resident's chart in PCC and a copy maintained in Social Services for up to one (1) year. July 7, 2023 at 9:52 AM, Social Services Note Text: The resident was seen by Coronado Dental on July 7, 2023 by the dental hygienist. The hygienist will follow up regarding denture replacement for the resident once she gets back to the office. October 11, 2023 at 2:26 PM, Social Services Note Text: The resident was seen by Coronado Dental on October 10, 2023 by the dental hygienist. Dental notes were forwarded to Medical Records and a copy maintained in Social Services for up to one (1) year.

During an interview on conducted on October 25, 2023 at 3:45 PM with a Certified Nursing Assistant (CNA staff #342), she stated that the resident broke her lower dentures but didn't know when or how. The CNA presented a hand-held white plastic container that the resident's first name labeled on the lid. The CNA stated that the container contained the resident's upper denture. Inside the container, observed what appeared to be one denture for either the upper or lower mouth, the denture was immersed in a clear odorless liquid. The CNA also presented a hand-held gray container that she stated was the resident's hearing aids. Inside the container, observed what appeared to be a pair of hearing aids, one for a right ear and one for a left ear, they were neatly stored in the container's hearing appliance form.

During an interview on conducted on October 25, 2023 at 3:45 PM with Social Services Director (staff #66), she stated she was familiar with the resident (resident #16) and her physical needs in hearing impairment and memory deficit. For her dental needs, she stated that she is aware of the resident's dental needs based on the resident's complaints. For dental record reviews, the Social Services Director stated that her assistant reviews the dental examination notes and she is her assistant's direct supervisor. In regards to reviewing the resident's dental notes, she stated that she'll have to look at the notes and ask my assistant. After reviewing the resident's treatment notes, she stated "you are correct about the dental note statements documenting the resident's denture concerns". The Social Services Director stated, for the resident's July visit, I have a Social Services note in her electronic medical record that the Coronado Hygienist needs to replace her dentures and I haven't followed up. The Social Services Director stated that after reviewing her July note, this note is the last reference and I have to follow-up with Coronado dental about her dentures. I'll send them an email right now. When asked about the care plan for her hearing the Social Services Director stated, the care plan should address hearing appliances and it's not showing in her care plan, but I will correct her care plan as soon as possible.

Based on observations, staff interview, and policy reviews, the facility failed to ensure pharmaceutical services were adequately provided for medication administration for four residents. The census was 130. This deficient practice could result in adverse effects in the facilities residents.

Findings include:

During observation of medication pass with a Licensed Practical Nurse (LPN/staff #297) conducted on
October 24, 2023 at 7:00 AM, the LPN administered medications to four residents (#82, #28, #58, #127). In each medication prep on the cart, the LPN verified the right resident from the resident's electronic medial record photograph, right medication, right dose, and right route per the order. In each bedside encounter, the LPN kindly greeted each resident and assisted each resident in sitting in a fowlers or semi-fowlers position but the LPN did not verify each resident's identity by checking the identification band at bedside before giving the resident medications.

A review of each resident's face sheet, BIMS score, and orders revealed: Resident #82: Admission October 20, 2020 with the diagnosis of dementia, mood disorder, benign prostatic hyperplasia, human immunodeficiency (HIV) disease, and a brief interview of mental status (BIMS) score of 10 (moderate cognitive impairment). Resident #28: Admission March 02, 2023 with the diagnosis of acquired absence of right and left leg above knee, peripheral vascular disease, type 2 diabetes, hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, and a brief interview of mental status (BIMS) score of 15 (intact cognition). Resident #58: Admission February 24, 2023 with the diagnosis of multiple sclerosis, schizoaffective disorder, bipolar type, anxiety disorder, actinic keratosis, dorsalgia, Parkinson's disease without dyskinesia, and a brief interview of mental status (BIMS) score of 05 (severe cognitive impairment). Resident #127: Admission October 9, 2023 with the diagnosis of essential hypertension, benign prostatic hyperplasia, anemia, gout, and a brief interview of mental status (BIMS) score of 15 (intact cognition)

An interview with the Director of Nursing (DON) on October 25, 2023 at 12:15 PM, the DON stated that the facility verifies the identity of the resident with the photograph on the electronic medical record and verbally at bedside.

Review of the facility policy Administering Medication and revealed the paragraphs; "The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: (a) checking identification band; (b) checking photograph attached to medical record; and (c) if necessary, verifying resident identification with other facility personnel.", "The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication."

Based on clinical record review, resident and staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#10) received required specialized services. The deficient practice could result in residents not being able to obtain the services needed to achieve medical/therapy goals. The Universe was 130, the sample is 1.

Findings include:

Resident #10 was admitted to the facility on May 5, 2021 with diagnoses that included type 2 diabetes, chronic kidney disease, and acquired absence of left leg below the knee.

The minimum data set (MDS) dated August 10, 2023 revealed that the brief interview score of 10 indicating the resident has a moderate cognitive impairment. It also included that the resident used a wheelchair and received training on walking with prostheses for 3 days out of the 7-day look-back period.

Review of the order summary report revealed: September 2, 2022, cleanse right stump daily with \'bc Dakin's soaked gauze apply thin layer of medihoney to medial and lateral open areas cover with roller gauze every day. September 27, 2022, patient to wear bilateral lower extremities (BLE) prostheses for 4-6 hours per day as tolerated. August 14, 2023, physical therapy (PT) evaluation and treat as indicated. August 14, 2023, PT evaluation completed, resident is now receiving PT services, 24 visits over 8 weeks. October 10, 2023. Resident needs eval/treat for prosthetic fit-needs socket replacement for bilateral Trans-Tibial (TT) limbs due to volume and weight gains discontinued. October 25, Resident needs eval/treat for prosthetic fit-needs socket replacement for bilateral Trans-Tibial limbs due to volume and weight gains discontinued. One year to 6 visits.

Review of the notes dated September 18, 2023 from the certified/licensed prosthetist revealed that the patient was seen for follow-up on bilateral trans-tibial (TT) prostheses and reports excessive toe out on right lower extremity and pain when standing in both right and left prosthesis. The resident received new legs in October 2022, gained weight and limb volume increased drastically. The resident could not get into his legs and needs new sockets. The resident will need to be scheduled with the primary care physician at the facility to obtain an order for socket replacements for bilateral (TT) limbs due to volume and weight gain. Once an order and clinical notes are obtained from the primary care physician, the prosthetist can submit for insurance authorization. In the interim, temporary new castings were made for the resident, but are substantially too loose and the resident will need to be refitted with new castings for proper weight distribution and fit/function. Excessive pressure over bony prominence is consistent with poor socket fit and although a 5-ply sock was added to each side today, they are still too loose with poor pressure distribution.

The physical therapy discharge summary dated September 27, 2023 revealed a goal, once standing , the patient will improve ability to safely ambulate at least 10 feet in a room, corridor, or similar space with adequate toe clearance, functional posture and functional dynamic balance using a four-wheel walker. Resident needs new prosthetics and is unable to tolerate standing and walking at this time. Will continue with RNA until new ones are fitted and ready.

Review of a written statement from a Licensed Practical Nurse (LPN/staff #202), revealed that on October 9, 2023, the resident wanted to know the status of his legs. Staff #202 assisted the resident with calling the prosthetist and was told that the insurance authorization was still pending.

Review of a physician note dated October 10, 2023 revealed the resident was seen face to face for order of prosthetics. The resident has gained weight since getting the original prosthetic for bilateral legs and limb volume increased. He is not able to use current prosthetics. A new order for socket replacements for bilateral TT limbs was placed.

During an interview conducted on October 23, 2023 at 9:09 AM with resident #10, he stated that he is supposed to be working on walking in therapy and is not getting it regularly. He stated that he is given pain medication for the pain in the right knee due to the prosthetic rubbing, but doesn't always work and has told staff. Observed the resident in a wheelchair and that right prosthetic does not fit and moves from side to side. He stated that when it moves, the prosthesis rubs on the bone, knee area.

An interview was conducted on October 25, 2023 at 10:23 AM with the Director of Therapy (staff #516), who stated that the resident was evaluated on August 9, 2023 for physical therapy (PT) and was recommended for treatment, 24 times over an 8-week period. She stated that the resident did not meet his goal, to stand and walk because his prosthetics didn' t fit due to weight gain. The resident has temporary new castings, but they are too big. She stated that she called the prosthetic company to follow up on the prosthetic evaluation that was completed on September 18, 2023, the week of the evaluation or the following week after the evaluation, and was told that the evaluation was already sent to the facility and the resident would need an order to be fitted for new prosthetics. She stated that there is not a designated person who is responsible for getting the order and she has nothing to do with the process, she just relayed that an order was needed to the facility team members. She reviewed the clinical record and stated there was an order for new prosthetics dated was October 10, 2023.

An interview was conducted on October 25, 2023 at 11:19 a.m. with the unit clerk (staff #444), who stated that she was responsible for scheduling appointments for the residents. She stated that the Director of Nursing, Assistant Director of Nursing and Director of Therapy let her know when she needs to schedule an appointment for a resident, and she checks to see if there is an order for the resident and faxes it to the specialist. She stated that the resident saw the prosthetist on September 18, 2023 and needs the doctor to assess the resident for socket replacements with new liners and once the assessment is completed, the prosthetist will obtain the order. Then she reviewed the resident's clinical record and stated that the resident was seen by the doctor on October 10, 2023, but doesn't have an order for the resident's new prosthetics. She stated that the appointment has been delayed and should happened sooner and she was going to follow up with a nurse.

An interview was conducted on October 25, 2023 at 11:55 a.m. with a Licensed Practical Nurse (LPN/staff #297), who stated that medical records posts appointments on the bulletin board and she reviews it weekly, and she was not aware of an appointment needing to be scheduled with the prosthetist. She stated that the nurse would be responsible for getting the order from the physician. She reviewed the progress note dated October 10, 2023 and stated that the resident needs socket replacements for prosthetics and states an order was placed. Then, she reviewed the orders and stated there was not an order for the replacement of prosthetics and would follow up on the matter.

The facility's policy, "Physician Medication Orders" dated October 2021 states that verbal orders must be transcribed immediately in the resident's chart by the person receiving the order and must include the date and time of the order.

Based on closed record review and staff interviews the facility failed to ensure that all transfer/discharge notifications were made for one resident (#13).

Findings include:

Resident #13 was initially admitted to the facility on June 29, 2010 and was re-admitted on September 28, 2023 with diagnoses that includes schizophrenia, bipolar disorder, dementia, anxiety disorder, personality disorder, and pseudobulbar affect.

A nurse practitioner order dated September 22, 2023 revealed an order to send the resident to the hospital immediately for hypoxia.

Review of the resident's clinical record did not reveal that a transfer to hospital form (e-Interact) was completed for the incident on September 22, 2023.

A progress note dated September 22, 2023 revealed that the resident was sent to the emergency room immediately and that the Director of Nursing and Administrator were notified of changes.

An additional progress note dated September 23, 2023 indicated that the resident was admitted inpatient (to the hospital) for diagnosis of pna (pulmonary nodular amyloisosis) with possible aspiration. The progress note stated that "all parties made aware." However, it did not indicate who all parties were.

Continued review of the clinical record revealed no further documentation related to this incident found.

There was no evidence found in the clinical record that the resident's representative/s or Ombudsman were notified of the resident's transfer to the hospital on September 22, 2023.

The discharge minimum data set (MDS) dated September 22, 2023 revealed that the resident's discharge was coded as an unplanned discharge, return anticipated.

During a document request for Ombudsman notification on October 24, 2023 at 9:01 AM, the Administrator (staff #223) stated that they do not have an ombudsman notification log. She said that the ombudsman is normally in the building every 2 weeks and that is when they inform her of discharge/hospital transfers. She said she will try her best to put one together from emails.

Review of the documents the facility put together as ombudsman notification equivalent revealed an Ombudsman visit log/sign in logs and a separate transfer/discharge log. The logs did not document that the transfer/discharge were discussed during the visits.

An interview with Licensed Practical Nurse (LPN/staff #125) was conducted on October 27, 2023 at 10:02 AM. The LPN stated that if a resident is sent to the hospital the provider, family, POA (power of attorney), and public fiduciary are notified. She stated that as a nurse she does not provide the family or ombudsman anything in writing but does call. Staff #125 sated that an e-Interact is completed for all transfers to the hospital. If the transfer is an emergency/911 event then the e-Interact is completed following the event and documented on PCC (Point Click Care). When asked what "all parties notified mean" she stated that she does not know what it means and that it is not sufficient documentation. Staff #125 said that documentation regarding the transfer notification should be specific and indicate that the family, physician, POA, Director of Nursing, and administrator were notified.

Review of the Social Services e-mail notification indicated that a notification was sent to resident #13's public fiduciary regarding her hospitalization but there was no evidence that a copy was sent to the Ombudsman.

During an interview with the Director of Nursing (DON/staff 80) conducted on October 27, 2023 at 11:15 AM, the DON stated that if a resident goes out to the hospital emergent, then the notification is conducted after the fact. If not then notification for the family and ombudsman is supposed to happen as the incident is going on. She indicated that nurse is supposed to notify the ombudsman and if not then Social Services should notify or email the ombudsman.

A policy regarding ombudsman notification was requested on October 25, 2023 at 12:20 PM but was not provided. Instead an Admission Handbook for the State of Arizona was provided which indicated that during transfer/discharge, the facility will notify the appropriate state agency. Additionally, it noted that if the resident was transferred because of an emergency situation, the facility will provide the required notice a soon as reasonable.

Based on observations, staff interviews, and policy review, the facility failed to ensure staff followed infection control standards related to personal protective equipment (PPE). The deficit practice could result in transmission of infection. Universe was 130.

Findings include:

An observation was conducted on October 24, 2023 at 9:00 AM, of multiple resident rooms with enhanced barrier precautions. Observation revealed glove boxes and hand sanitizing stations were on walls in the hallway, but no PPE carts were outside of rooms. It was also observed that within these rooms were two washable PPE gowns hanging on hooks. However, some rooms had multiple gowns stacked on top of each other hanging from hooks. All gowns were touching each other in every room. Further observations showed that neither the hooks or the gowns were labeled. It was observed that a Licensed Practical Nurse (LPN staff# 297) told (CNA staff #342), to get a hazard bag and remove the gowns from the room.

An Interview was conducted on October 25, 2023 at 8:29 AM, with Regional Resource Nurse/Infection Control Preventionist, Registered Nurse (RN staff #443). She stated that enhanced barrier precautions were the only precautions within the building at that time. If someone was contact, or airborne precautions, PPE carts would be out in front of the room. There is not a need for a PPE cart for enhanced barrier precautions. She states this guidance of reusing the washable gowns came from the Centers for Disease Control (CDC). The facility's process is to label the hooks A and B, and to label the gown for who is using it for the day. One gown is for the CNA and the other gown is for the nurse. The same gown is to be used throughout the day for the same resident. At the end of shift, the gown is discarded, and it goes to laundry and new gowns are hung in the rooms. RN (staff #443) also stated that (staff #90), from central supply, checks the enhanced barrier precaution rooms in the mornings. She ensures new gowns have been placed. She also stated there should only be one gown per hook. Gowns should never be touching each other because that would be cross contamination.

An Interview was conducted on October 25, 2023 at 9:30 AM, with Director of Nursing, (DON staff #80). Enhanced barrier precaution signage is posted on the residents door. The expectation is no more than one staff member wearing the same gown. When a staff member begins there shift, if a gown is hanging, it should be considered dirty and replaced with a new gown. Gowns should be changed every shift, or immediately if they are soiled. She also stated if gowns are touching each other, it isn't an issue because the gowns are for the same resident. However, she also stated, that if the outside of a gown is touching the inside of another gown, that is an issue of cross contamination. She stated there should only be one gown per hook. If both residents in the room require gowns, they each have their own set. CNAs should remove the gowns from the room if a resident discharges or goes on a leave of absence to the hospital.

An interview was conducted on October 24, 2023 at 10:20 AM, with Lead Certified Nursing Assistant,
(CNA staff #342). She stated that the gowns are used by the CNA throughout the day when they provide care to the resident. At the end of the shift, the gowns are collected and sent to laundry, and new gowns are put in the resident's room. Since the gowns are washable, they may reuse them during the day for the same resident, unless they are visibly soiled. Gowns are hung on the side of the room depending on which resident they need them for.

Recommendations from the CDC for, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated July 28, 2021 are as follows:

Framework for Applying Enhanced Barrier Precautions in Skilled Nursing Facilities

Implementation Approaches: General implementation considerations for EBP are available from the CDC.20 The application of EBP to routine care of residents with wounds or indwelling medical devices requires that staff participate in initial and on-going training on the facility's expectations about hand hygiene and gown and glove use, along with proof of competency regarding appropriate use and donning and doffing technique for PPE. Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities. Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room). A trash can (or laundry bin, if applicable) large enough to dispose of multiple gowns should be available for each room. Facilities with rooms containing multiple residents should provide staff with training and resources to ensure that they change their gown and gloves and perform hand hygiene in between care of residents in the same room.

Neither extended use nor re-use of gowns and gloves is recommended for mitigating shortages in the context of EBP.

Based on resident and staff interviews, the facility investigation report and documents, clinical record review, and policy review, the facility failed to ensure one resident (#123) was treated in a dignified manner. The universe was 118 as all residents could be affected, the sample was one.

Findings include:

Resident (#123) was admitted to the facility on August 9, 2023 with diagnoses that included Type I Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Acquired absence of right leg below knee, Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs, End-stage renal disease.

During the initial part of the survey, an interview was conducted with resident (#123) on October 23, 2023 at 11:40 AM, who stated that CNA (certified nursing assistant) identified as (Staff #34) had come into his room, after he had turned on his call light. Resident (#123) stated the CNA turned off the call light and left without acknowledging him. The resident stated he turned his call light back on. Resident (#123) stated the same CNA, (Staff #34) came back into his room and proceeded to stare at him for a few minutes, without saying anything. Resident (#123) stated he asked the CNA why was she staring at him? Resident (#123) stated when he questioned her, the CNA started a high-pitched, cackling laugh sound directed at him. The resident stated she was near his bed, when she started staring and laughing at him. The resident stated he asked the CNA why was she laughing? The resident stated her reply was "it's not against the law to laugh." Resident (#123) stated there was no reason for her laughter and felt disrespected, afraid and now felt that "I have to keep one eye open when she works." Resident (#123) stated (LPN, Staff #355) was aware of the situation. Resident (#123) stated the CNA refuses to change him for hours and he will sometimes have to wait for the next shift to be changed. The resident stated the situation has stressed him out and has requested the Veterans Administration (VA) to locate another facility to reside in. Resident (#123) became tearful discussing the incident.

On October 23, 2023 at 12:13 PM, the Administrator (staff #223) was notified of the resident's allegations and stated that she would begin the investigation process.

Review of the comprehensive care plan dated August 9, 2023 and revision on August 10, 2023, revealed the following: ADL: requires extensive staff assistance with activities of daily living (ADL) with interventions that stated the resident is mostly dependent for all ADL with 1-2-person assistance due to self-care deficit related to right below the knee amputation.

A Medicare 5-day MDS (minimum data set) assessment dated May 16, 2022, revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The assessment also revealed the resident required extensive assistance with bed mobility, personal hygiene, and required 1-2-person assistance with transfer, dressing, toilet use, and bathing.

Review of nursing progress notes dated September 2023 through October 22, 2023, revealed no evidence that the resident or other staff had reported any concerns regarding the resident's care/treatment by the Certified Nursing Assistants (CNAs).

Review of the facility investigation report dated October 26, 2023, revealed that October 23, 2023 resident (#123) stated to a surveyor that a CNA was not answering his call light in a timely manner and refused to give him iced water. The report included the facility DON (Director of Nursing/staff #80), social services (staff #341) and Administrator (staff #223) were notified, and social services visited the resident to discuss how the resident felt and obtain feedback. The report was currently ongoing and did not have a resolution documented on the grievance/complaint report.

The investigation report included the following witness statements:

Staff #341 (LPN) reported that CAN (staff #34) has a negative attitude, complaining about staff and residents, has never seen staff #34 argue with resident (#123) or refuse to assist him, finds staff #34 argumentative with staff and others at times and does not like to follow directions.

Staff #297(LPN) reported that staff #34 does not answer call lights in a timely manner, is very negative, complaining and argumentative and refuses to follow nurses' directions at times.

Staff #221 (RN) reported staff #34 is not professional, argumentative, and antagonistic with staff and others, does not follow directions from nursing leaders.

Staff #136 (CNA) reported staff #34 is thorough and abrupt at times.

Staff #342 (CNA) reported staff #34 can provide good care, is argumentative and negative, takes a while to answer call lights.

The investigative report included staff #34's statement dated October 24, 2023 which included that she denied ever refusing to provide care for the resident or purposely not answering his call light. Hat she does not spend a lot of time with the resident and that resident (#123) will appear fine at the beginning of the shift then becomes rude, aggressive, and angry towards her so she has another CNA provide his care. She further stated she believed resident (#123) did not like her because she is African American.

Review of facility grievance documentation, revealed a formal Grievance/Complaint Report dated August 17, 2023 filed by resident (#123) and received by RN (Staff #221) revealed that resident (#123) had filed a formal grievance. The report states as follows: Resident reports that he doesn't like the CNA (Staff #34) laughs and doesn't seem to care for her. Actions taken to resolve grievance/complaint dated 08/21/23: Educate Staff (#34) about customer service; Not to assign staff (#34) to room unless absolutely necessary. Resolution of Grievance/Complaint checked yes states the following: Gave staff (#34) education in customer service, resident rights and giving care on time. Staff (#34) will not take care of the resident. The form was completed on August 18, 2023 and signed by the administrator (staff #223) and Director of Nursing (staff #80).

On October 26, 2023 at approximately 10 AM the Administrator (staff #223) delivered requested staff #34's employee records and stated, based on interviews with staff, residents and violation of workplace policies, CNA (#34) had been terminated October 26, 2023.

An interview was conducted on October 26, 2023 at 02:24 PM with the Administrator (staff #223 and Staff (RN Consultant #443) who stated that she was involved with Human Resources and thought CNA (staff#34) could be educated, but she could not. She stated that she did interview the CNA, and that staff #34 denied the allegations made. The Administrator stated nursing staff are responsible of making the room assignments, but had not been informed of any room restrictions for Staff (CNA#34). She further stated the understanding would be to keep Staff (CNA #34) on Victoria Lane, but she would not take care of the resident (#123) unless necessary. The Administrator reviewed the grievance/complaint formed dated August 17, 2023. The Administrator acknowledged it was her signature on the form stating CNA (#34) would not provide care for resident (#123). The Administrator stated she needed to pay closer attention when signing documents.

An interview was conducted on October 27, 2023 at approximately 10:00 AM with resident #123's roommate (resident #69), who stated that an unidentified CNA had treated him roughly, did not want to give him cleaning supplies and had accused him of playing in his feces. Resident stated he could not recall the date or the staff's name, but was not afraid or felt threatened in any way. Resident stated if he had any concerns he would tell his son.

An interview was condu

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#10) had the correct advance directive in place. The universe is 118 and the sample was one.

Findings include:

Resident #10 was admitted to the facility on May 5, 2021 with diagnoses that included atherosclerotic heart disease, chronic kidney disease, and unspecified protein-calorie malnutrition.

Review of the clinical record revealed an advanced directive statement dated February 26, 2022 for a do not resuscitate (DNR) status.

Review of the clinical record also revealed an advanced directive statement form that was not completed, signed or dated with documentation of refusal to sign.

Review of the order summary revealed an order dated August 5, 2022 for full code status.

The care plan dated May 12, 2023 revealed that the resident was a full code status. Interventions included to call for help immediately and begin basic life support sequence.

The minimum data set (MDS) dated August 10, 2023 revealed that the brief interview score of 10 indicating the resident has a moderate cognitive impairment.

Review of the advanced directive statement dated October 25, 2023 revealed that the resident did not want cardiopulmonary resuscitation and was (DNR) status.

An interview was conducted on October 25, 2023 at 12:38 PM, with the Social Services Director (staff #66), who stated that the facility is responsible for reviewing the advanced directive form with the resident/power of attorney (POA) and ensuring that it is completed, signed and dated. She reviewed the clinical record for the resident and located:

-an advanced directive dated 2022 documenting the resident was DNR, signed by the POA.

-an advance directive form that was not dated, signed or completed.

-an order for full code status dated August 5, 2022.

During the interview, staff #66 called the resident ' s POA, who stated that she and the resident had already discussed it and had agreed that he wanted to be DNR status. Staff # stated that there is risk of doing the wrong thing when the documentation is not correct and a very dangerous position to put the family in.

During an interview conducted on October 25, 2023 at 1:18 PM, with a licensed practical nurse (LPN/staff #341), she reviewed the orange binder labeled "Advanced Directives and DNR" located at the nurse station and said that she could not find the advanced directive for the resident. Then, she reviewed the electronic clinical record and stated that the resident was full code status.

An interview was conducted on October 26, 2023 at 2:22 PM, with the Director of Nursing (DON/staff #80), who do not have the staff list stated that the resident/POA should complete the Advanced Directive form and it should be placed in the clinical record. She reviewed the resident ' s clinical record showing that the resident had three advanced directive forms: February 26, 2022 was a DNR status, the second form was not completed, signed or dated, and the third form dated October 25, 2023 was a DNR status, and she agreed that the full code status was incorrect.

The facility's policy, "Advance Directives" date September 2022 states that the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.

Based on clinical record review, resident and staff interviews, and the facility policy and procedures, the facility failed to ensure one resident (#10) received required specialized services.

Findings include:

Resident #10 was admitted to the facility on May 5, 2021 with diagnoses that included type 2 diabetes, chronic kidney disease, and acquired absence of left leg below the knee.

The minimum data set (MDS) dated August 10, 2023 revealed that the brief interview score of 10 indicating the resident has a moderate cognitive impairment. It also included that the resident used a wheelchair and received training on walking with prostheses for 3 days out of the 7-day look-back period.

Review of the order summary report revealed: September 2, 2022, cleanse right stump daily with \'bc Dakin's soaked gauze apply thin layer of medihoney to medial and lateral open areas cover with roller gauze every day. September 27, 2022, patient to wear bilateral lower extremities (BLE) prostheses for 4-6 hours per day as tolerated. August 14, 2023, physical therapy (PT) evaluation and treat as indicated. August 14, 2023, PT evaluation completed, resident is now receiving PT services, 24 visits over 8 weeks. October 10, 2023. Resident needs eval/treat for prosthetic fit-needs socket replacement for bilateral Trans-Tibial (TT) limbs due to volume and weight gains discontinued. October 25, Resident needs eval/treat for prosthetic fit-needs socket replacement for bilateral Trans-Tibial limbs due to volume and weight gains discontinued. One year to 6 visits.

Review of the notes dated September 18, 2023 from the certified/licensed prosthetist revealed that the patient was seen for follow-up on bilateral trans-tibial (TT) prostheses and reports excessive toe out on right lower extremity and pain when standing in both right and left prosthesis. The resident received new legs in October 2022, gained weight and limb volume increased drastically. The resident could not get into his legs and needs new sockets. The resident will need to be scheduled with the primary care physician at the facility to obtain an order for socket replacements for bilateral (TT) limbs due to volume and weight gain. Once an order and clinical notes are obtained from the primary care physician, the prosthetist can submit for insurance authorization. In the interim, temporary new castings were made for the resident, but are substantially too loose and the resident will need to be refitted with new castings for proper weight distribution and fit/function. Excessive pressure over bony prominence is consistent with poor socket fit and although a 5-ply sock was added to each side today, they are still too loose with poor pressure distribution.

The physical therapy discharge summary dated September 27, 2023 revealed a goal, once standing , the patient will improve ability to safely ambulate at least 10 feet in a room, corridor, or similar space with adequate toe clearance, functional posture and functional dynamic balance using a four-wheel walker. Resident needs new prosthetics and is unable to tolerate standing and walking at this time. Will continue with RNA until new ones are fitted and ready.

Review of a written statement from a Licensed Practical Nurse (LPN/staff #202), revealed that on October 9, 2023, the resident wanted to know the status of his legs. Staff #202 assisted the resident with calling the prosthetist and was told that the insurance authorization was still pending.

Review of a physician note dated October 10, 2023 revealed the resident was seen face to face for order of prosthetics. The resident has gained weight since getting the original prosthetic for bilateral legs and limb volume increased. He is not able to use current prosthetics. A new order for socket replacements for bilateral TT limbs was placed.

During an interview conducted on October 23, 2023 at 9:09 AM with resident #10, he stated that he is supposed to be working on walking in therapy and is not getting it regularly. He stated that he is given pain medication for the pain in the right knee due to the prosthetic rubbing, but doesn't always work and has told staff. Observed the resident in a wheelchair and that right prosthetic does not fit and moves from side to side. He stated that when it moves, the prosthesis rubs on the bone, knee area.

An interview was conducted on October 25, 2023 at 10:23 AM with the Director of Therapy (staff #516), who stated that the resident was evaluated on August 9, 2023 for physical therapy (PT) and was recommended for treatment, 24 times over an 8-week period. She stated that the resident did not meet his goal, to stand and walk because his prosthetics didn' t fit due to weight gain. The resident has temporary new castings, but they are too big. She stated that she called the prosthetic company to follow up on the prosthetic evaluation that was completed on September 18, 2023, the week of the evaluation or the following week after the evaluation, and was told that the evaluation was already sent to the facility and the resident would need an order to be fitted for new prosthetics. She stated that there is not a designated person who is responsible for getting the order and she has nothing to do with the process, she just relayed that an order was needed to the facility team members. She reviewed the clinical record and stated there was an order for new prosthetics dated was October 10, 2023.

An interview was conducted on October 25, 2023 at 11:19 a.m. with the unit clerk (staff #444), who stated that she was responsible for scheduling appointments for the residents. She stated that the Director of Nursing, Assistant Director of Nursing and Director of Therapy let her know when she needs to schedule an appointment for a resident, and she checks to see if there is an order for the resident and faxes it to the specialist. She stated that the resident saw the prosthetist on September 18, 2023 and needs the doctor to assess the resident for socket replacements with new liners and once the assessment is completed, the prosthetist will obtain the order. Then she reviewed the resident's clinical record and stated that the resident was seen by the doctor on October 10, 2023, but doesn't have an order for the resident's new prosthetics. She stated that the appointment has been delayed and should happened sooner and she was going to follow up with a nurse.

An interview was conducted on October 25, 2023 at 11:55 a.m. with a Licensed Practical Nurse (LPN/staff #297), who stated that medical records posts appointments on the bulletin board and she reviews it weekly, and she was not aware of an appointment needing to be scheduled with the prosthetist. She stated that the nurse would be responsible for getting the order from the physician. She reviewed the progress note dated October 10, 2023 and stated that the resident needs socket replacements for prosthetics and states an order was placed. Then, she reviewed the orders and stated there was not an order for the replacement of prosthetics and would follow up on the matter.

The facility's policy, "Physician Medication Orders" dated October 2021 states that verbal orders must be transcribed immediately in the resident's chart by the person receiving the order and must include the date and time of the order.

-Resident #16 was admitted on May 9, 2022 with diagnosis that included dementia and unspecified hearing loss. The resident was edentulous.

The minimum data set (MDS) assessment dated September 21, 2023 revealed a brief interview of mental status (BIMS) score of 04 that indicated the resident had severe cognitive impairment. The MDS revealed the resident had no hearing aid used and the ability to hear is with a moderate difficulty. The MDS revealed the resident had no broken or loosely fitting full or partial denture.

The minimum data set (MDS) assessment dated September 28, 2023 revealed a brief interview of mental status (BIMS) score of 08 that included the resident had moderate cognitive impairment. The MDS revealed the resident used hearing aids and had a high hearing impairment. The MDS revealed the resident no broke or loosely fitting full or partial denture.

The baseline care plan dated September 5, 2022 revealed the resident was edentulous and coordinated arrangements for dental care are to be provided as ordered. The baseline care plan revealed monitoring, documentation, and reporting as needed of any signs and symptoms of oral dental problems needing attention. The baseline care plan revealed the facility did not address the resident's hearing difficulty or use of hearing appliances.

A review of the resident's dental notes revealed: June 16, 2022 states House call, no teeth, dentures soaking in glass - wiped mouth with [ineligible] rinse, brushed, wiped dentures, put in mouth with Fixodent. September 26, 2022 states, "rinsed and cleaned dentures, *needs upper dentures adjusted hurts". March 29, 2023 states, "Can someone help [resident] look everywhere for her dentures? She cannot find dentures." April 20, 2023 states, "Pt has [history] of dentures. She was not wearing them today." July 7, 2023 states, "Pt says her dentures are lost"

A review of the resident's progress note revealed: November 14, 2022 at 6:50 PM, Social Services Note Text: DENTAL VISIT: The resident was seen onsite by Coronado Dental on 11-14-22. The dental note was sent to Medical Records and a copy will be kept in the Social Services department. December 7, 2022 at 1:04 PM, Social Services Note Text: DENTAL VISIT: The resident was seen by the dental hygienist from Coronado Dental. The assessment notes have been sent to Medical Records to be uploaded to the record and a copy maintained in the Social Services office. March 29, 2023 at 12:56 PM, Social Services Note Text: ONSITE DENTAL VISIT: The resident was seen by Coronado Dental Services today, 03-29-2023. Dental Notes have been given to Medical Records to upload to the residents EMR through PCC. April 20, 2023 at 2:48 PM, Social Services Note Text: ONSITE DENTAL EXAM was completed with the resident on 04-20-23 by Coronado Dental. Dental Notes were given to Medical Records to be uploaded to the resident's chart in PCC and a copy maintained in Social Services for up to one (1) year. July 7, 2023 at 9:52 AM, Social Services Note Text: The resident was seen by Coronado Dental on July 7, 2023 by the dental hygienist. The hygienist will follow up regarding denture replacement for the resident once she gets back to the office. October 11, 2023 at 2:26 PM, Social Services Note Text: The resident was seen by Coronado Dental on October 10, 2023 by the dental hygienist. Dental notes were forwarded to Medical Records and a copy maintained in Social Services for up to one (1) year.

During an interview on conducted on October 25, 2023 at 3:45 PM with a Certified Nursing Assistant (CNA staff #342), she stated that the resident broke her lower dentures but didn't know when or how. The CNA presented a hand-held white plastic container that the resident's first name labeled on the lid. The CNA stated that the container contained the resident's upper denture. Inside the container, observed what appeared to be one denture for either the upper or lower mouth, the denture was immersed in a clear odorless liquid. The CNA also presented a hand-held gray container that she stated was the resident's hearing aids. Inside the container, observed what appeared to be a pair of hearing aids, one for a right ear and one for a left ear, they were neatly stored in the container's hearing appliance form.

During an interview on conducted on October 25, 2023 at 3:45 PM with Social Services Director (staff #66), she stated she was familiar with the resident (resident #16) and her physical needs in hearing impairment and memory deficit. For her dental needs, she stated that she is aware of the resident's dental needs based on the resident's complaints. For dental record reviews, the Social Services Director stated that her assistant reviews the dental examination notes and she is her assistant's direct supervisor. In regards to reviewing the resident's dental notes, she stated that she'll have to look at the notes and ask my assistant. After reviewing the resident's treatment notes, she stated "you are correct about the dental note statements documenting the resident's denture concerns". The Social Services Director stated, for the resident's July visit, I have a Social Services note in her electronic medical record that the Coronado Hygienist needs to replace her dentures and I haven't followed up. The Social Services Director stated that after reviewing her July note, this note is the last reference and I have to follow-up with Coronado dental about her dentures. I'll send them an email right now. When asked about the care plan for her hearing the Social Services Director stated, the care plan should address hearing appliances and it's not showing in her care plan, but I will correct her care plan as soon as possible.

Based on observations, staff interviews, and policy review, the facility failed to ensure staff followed infection control standards related to personal protective equipment (PPE).

Findings include:

An observation was conducted on October 24, 2023 at 9:00 AM, of multiple resident rooms with enhanced barrier precautions. Observation revealed glove boxes and hand sanitizing stations were on walls in the hallway, but no PPE carts were outside of rooms. It was also observed that within these rooms were two washable PPE gowns hanging on hooks. However, some rooms had multiple gowns stacked on top of each other hanging from hooks. All gowns were touching each other in every room. Further observations showed that neither the hooks or the gowns were labeled. It was observed that a Licensed Practical Nurse (LPN staff# 297) told (CNA staff #342), to get a hazard bag and remove the gowns from the room.

An Interview was conducted on October 25, 2023 at 8:29 AM, with Regional Resource Nurse/Infection Control Preventionist, Registered Nurse (RN staff #443). She stated that enhanced barrier precautions were the only precautions within the building at that time. If someone was contact, or airborne precautions, PPE carts would be out in front of the room. There is not a need for a PPE cart for enhanced barrier precautions. She states this guidance of reusing the washable gowns came from the Centers for Disease Control (CDC). The facility's process is to label the hooks A and B, and to label the gown for who is using it for the day. One gown is for the CNA and the other gown is for the nurse. The same gown is to be used throughout the day for the same resident. At the end of shift, the gown is discarded, and it goes to laundry and new gowns are hung in the rooms. RN (staff #443) also stated that (staff #90), from central supply, checks the enhanced barrier precaution rooms in the mornings. She ensures new gowns have been placed. She also stated there should only be one gown per hook. Gowns should never be touching each other because that would be cross contamination.

An Interview was conducted on October 25, 2023 at 9:30 AM, with Director of Nursing, (DON staff #80). Enhanced barrier precaution signage is posted on the residents door. The expectation is no more than one staff member wearing the same gown. When a staff member begins there shift, if a gown is hanging, it should be considered dirty and replaced with a new gown. Gowns should be changed every shift, or immediately if they are soiled. She also stated if gowns are touching each other, it isn't an issue because the gowns are for the same resident. However, she also stated, that if the outside of a gown is touching the inside of another gown, that is an issue of cross contamination. She stated there should only be one gown per hook. If both residents in the room require gowns, they each have their own set. CNAs should remove the gowns from the room if a resident discharges or goes on a leave of absence to the hospital.

An interview was conducted on October 24, 2023 at 10:20 AM, with Lead Certified Nursing Assistant,
(CNA staff #342). She stated that the gowns are used by the CNA throughout the day when they provide care to the resident. At the end of the shift, the gowns are collected and sent to laundry, and new gowns are put in the resident's room. Since the gowns are washable, they may reuse them during the day for the same resident, unless they are visibly soiled. Gowns are hung on the side of the room depending on which resident they need them for.

Recommendations from the CDC for, Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities dated July 28, 2021 are as follows:

Framework for Applying Enhanced Barrier Precautions in Skilled Nursing Facilities

Implementation Approaches: General implementation considerations for EBP are available from the CDC.20 The application of EBP to routine care of residents with wounds or indwelling medical devices requires that staff participate in initial and on-going training on the facility's expectations about hand hygiene and gown and glove use, along with proof of competency regarding appropriate use and donning and doffing technique for PPE. Facilities should develop a method to identify residents with wounds or indwelling medical devices, and post clear signage outside of resident rooms indicating the type of PPE required and defining high risk resident care activities. Gowns and gloves should be available outside of each resident room, and alcohol-based hand rub should be available for every resident room (ideally both inside and outside of the room). A trash can (or laundry bin, if applicable) large enough to dispose of multiple gowns should be available for each room. Facilities with rooms containing multiple residents should provide staff with training and resources to ensure that they change their gown and gloves and perform hand hygiene in between care of residents in the same room.

Neither extended use nor re-use of gowns and gloves is recommended for mitigating shortages in the context of EBP.

Based on observations, staff interviews, and policy reviews, the facility failed to ensure that maintenance and comfortable interior was provided for 1 resident (#106). The universe was 118 the sample was one.

Findings include:

An interview was conducted with resident #106 on October 23, 2023 at 11:42 AM. Resident # 106 stated that the baseboards in his room is coming off and that there is a huge cut out hole in his room where cockroaches are coming out.

An observation was conducted of resident #106's room on October 23, 2023 at 11:42 AM. An area approximately 2-feet in high and 1-foot wide was discovered on the wall by the foot of the A-side bed.

An additional observation was conducted of resident #106's room on October 25, 2023 at 8:24 AM. It revealed that the hole on the wall was still present. However, no evidence of pest coming out of the hole was found.

An interview with a Certified Nursing Assistant (CNA/staff #118) was conducted on October 25, 2023 at 8:24 AM. Staff # 118 stated that the hole has been there for a few days. She noted that the resident has not complained to her about the hole. However, she did verify that the resident is aware that there is a hole on the wall in the room. Staff #118 stated that the hole was caused by the bed hitting the wall when staff was moving the bed.

Review of work order log with a date range of October 1, 2022 thru October 22, 2023 did not reveal any work order regarding identifying the hole in the wall for resident's room.

During a surveyor walk around conducted on October 25, 2023 at approximately 9:50 AM, staff #118 notified the surveyor that the hole in resident #106's room has been fixed.

An interview was conducted with the Maintenance Director (staff #221) on October 25, 2023 at 9:54 AM. Staff #221 stated that work orders are normally placed by the nurse in TELS system to inform maintenance of issues that need to be resolved. Depending on the issue it is rated between low and critically high and transmitted to the maintenance team for resolution. He said that the maintenance team checks TELS often to check work orders. Staff #221 stated that nurses and staff are pretty vocal about building issues. Maintenance double checks with the staff to ensure issues are taken care. Alternatively, staff also contacts maintenance via phone call or text message. He indicated that a hole in the wall or a patch job is normally pretty high priority. Staff #221 stated that maintenance checks TELS daily to see what needs to be addressed depending on emergent status. When asked if he was aware of the hole in resident #106's room, he stated he is not sure and that he might not know if it was not on TELS. Staff #221 stated that the facility is pretty big so they relay on staff to report issues. During the interview the room in question was visited with staff #221. Staff #221 noted that since the hole was pretty big, it should have been fixed the same day as long as the supply is available and if not, the supply should have been obtained to fix the hole immediately.

An interview was conducted with Maintenance Assistant (staff #198) on October 25, 2023 at 10:06 AM. Staff #198 stated that a work order was placed on TELS yesterday for resident #106's room. He said that the wall was prepped yesterday and completed today.

An interview with a Licensed Practical Nurse (LPN/staff #125) was conducted on October 27, 2023 at 10:02 AM. Staff #125 stated that the facility utilizes a TELS system for work orders. She said that work order requests are normally completed within 24 hours and that if it was an emergency, it is fixed immediately. Staff #125 said that holes in the wall are normally fixed within 24 hours from when it was reported. She noted that part of the nursing staff's job when they do their rounds is to check the resident's room to make sure it is safe for the resident and that it is in good order.

An interview with the Director of Nursing (DON/staff #80) was conducted on October 27, 2023 at 11:15 AM. Staff #80 stated that her expectations with regards to work orders needs and turnaround time is that work order needs are inputted into TELS and that staff inform maintenance right away of any work order needs. She said that she expects the maintenance team to be on the message thread regarding work orders. She also noted that she expects maintenance to take care of work order needs within a reasonable amount of time.

The facility policy titled "Maintenance Service" revised December 2009 stated that maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy indicated that the maintenance department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times. Additionally, it said that maintenance personnel should maintain the building in good repair and free from hazards.

Review of the facility policy titled "Work Orders, Maintenance" revised April 2010 stated that maintenance work orders shall be completed in order to establish a priority of maintenance service. Furthermore, it noted that in order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director. The policy also noted that the department directors are responsible for filling out and forwarding work orders to the Maintenance Director.

Based on observations, and resident and staff interviews the facility failed to ensure a resident (#6) had the means to communicate with staff, by failing to ensure the call device was accessible to the resident. The universe was 118 and the sample was one.

The findings include:

Resident #6 was readmitted to the facility on August 23, 2023 with diagnoses that included coronary artery disease, hypertension, gastroesophageal reflux disease, anxiety disorder, and manic depression.

The admission Minimum Data Set assessment dated August 28, 2023 revealed a Brief Interview for Mental Status score of 12 which indicated the resident had moderate impaired cognition.

During the initial observation of resident #6 conducted on October 23, 2023 at 10:07 AM, the call device was observed on the top of the light fixture, and out of resident's reach.

During an interview with the resident #6 conducted on October 23, 2023 at 10:07 AM, he stated that the call device was placed on the light fixture when they painted his room two weeks ago.

An additional observation was conducted on October 25, 2023 at 8:34 AM. Staff was observed entering the resident's room and then shutting the door. After the staff left, the call device was observed still on top of the light fixture.

An interview was conducted with resident #6 on October 25, 2023 at 8:42 AM. The resident stated that he does not normally use it but that the device needs to be placed where he can reach it, in the event he needs to use it. Resident #6 stated that currently, if he needs assistance he gets on his wheelchair and goes to the nurse's station to get help. He said that the call device has been on top of the light fixture a few nights.

Another observation was conducted on October 26, 2023 at 1:09 PM. The call device was observed still up on the light fixture which was located on the wall on the left-hand side of the room by the foot of the bed. During the observation, the resident asked another surveyor to hand him the call device so he can place it where he can reach it.

An interview was conducted with a Certified Nursing Assistant Lead (CNA Lead/staff #342) on October 27, 2023 at 9:50 AM. Staff #342 stated that CNAs are supposed to place the call light where residents can reach them. She said at the beginning of the shift CNAs are to lay eyes on residents and ensure they can access the call light. Staff #342 noted that there should never be a time when the call light is out of the resident's reach. The call device is normally attached to the bed. If the CNA is changing the sheets on the bed, they need to make sure that the device is placed back within the resident's reach. When asked if she noticed that these past few days, resident #6's call device was not accessible, she stated she had not noticed. She said that resident #6's call device was normally placed on his bed or on the side of his pillow. Staff #342 stated that the call device should not have been placed on the light figure indefinitely and should have been placed where the resident could reach it. She stated that she last checked the call device this past weekend. She said that CNAs should check that call devices are within the residents reach. However, she also noted that resident #6 comes out of his room and into the hallway to ask for assistance.

An interview with a registry Licensed Practical Nurse (LPN/staff #125) was conducted on October 27, 2023 at 10:02 AM. Staff #125 noted that nursing staff makes sure that call light is within the residents' reach. She noted that she normally assigned to various units but was familiar with resident #6. When she was informed that resident #6's call device was stored on to of the light fixture, she stated that it was not supposed to be placed on the light fixture. Staff #125 stated that CNAs are supposed to ensure call device are within the residents' reach. She also noted that nurses are supposed to check as well that call devices are within resident's needs. However, she stated that resident #6 comes out of his room and lets the nurse know what he needs. She also stated that resident #6 had not mentioned anything about his call light.

During an interview with the Director of Nursing (DON/staff #80) conducted on October 27, 2023 at 11:15 AM, she noted that she expects her nursing staff to ensure that call devices are within residents' reach each time they go into the residents' room. If staff has to move the call device for any reason during care or services, they should make sure that it is placed back within the residents' reach afterwards. She stated that the call device should not be out of the residents' reach. However, she noted that when it comes to resident #6, he is very independent and is capable of letting the staff know of his care needs.

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 31, 2023, revealed the following;

1) room 101 had excessive gap on the upper handle side
2) room 102 had excessive gap on the lower handle side
3) room 110 had a 3/4 inch gap on the upper handle side
4) room 117 had a 1/2 inch gap on the upper hinge side
5) room 203 failed to latch secure
6) room 208 had excessive gap on the upper handle side
7) room 214 had a 1/2 inch gap on the upper handle side
8) room 219 had a 1/2 inch gap on the upper handle side
9) room 220 had damage to the door near the handle. It was partially delaminated
10) room 303 had a 1/2 inch gap on the upper handle side
11) room 304 had excessive gap on the lower handle side
12) room 309 had excessive gap on the upper handle side
13) room 311 had excessive gap on the upper hinge side
14) room 313 had excessive gap on the upper hinge side
15) room 315 had excessive gap on the upper handle side and across the entire upper door
16) room 316 had excessive gap on the lower handle side
17) room 317 failed to close and latch secure
18) Apache soiled utility room excessive gap on the upper hinge side and lower handle side of the door
19) Paradise Island soiled room excessive gap on the lower handle side of the door
20) Victoria Lane soiled room excessive gap 3/4 inch on the lower handle side of the door
21) dry storage door in kitchen failed to latch secure

Note: the facility had two (2) proposals to repair/replace the doors.

During the exit conference conducted on October 31, 2023, the above findings were again acknowledged by the management team.

Based on clinical record review, staff interviews, facility documentation and policy review, and the State Agency (SA) complaint tracking system, the facility failed to ensure one resident (#1) was provided with treatment and care related to shearing in accordance with professional standards of practice.

Findings include:

Resident #1 was re-admitted on October 7, 2022 with diagnoses of chronic kidney disease stage 5, dependence of renal dialysis, schizoaffective disorder bipolar type, and chronic obstructive disease.

Review of a care plan initiated on January 17, 2023, revealed the resident required extensive assistance of two with bathing, bed mobility, to turn/reposition and transfers related to chronic kidney disease, and schizoaffective disorder. It also included that the resident was frequently incontinent of bladder, occasionally incontinent with bowel and had potential for pressure ulcer development. Interventions included to administer medications as ordered, assist to shift weight in wheel chair every 15 minutes, follow facility policies/procedures for the prevention/treatment of skin breakdown, incontinence care when needed and to apply barrier cream as ordered.

Review of a quarterly Minimum Data Set (MDS) assessment dated July 11, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The assessment also revealed the resident required extensive two-person assist with for bed mobility, transfer, dressing, and personal hygiene; and that, the resident had no unhealed pressure ulcers, and had a pressure reducing device for the bed.

The provider note dated July 17, 2023 included the resident would benefit from modifications to her current wheelchair to enhance her quality of life by assisting her to maintain midline functional position when seated; and that this would enable the resident to self-propel on her own and reduce the risk of skin breakdown. Assessments included morbid obesity and ESRD (end stage renal disease).

The CNA (certified nurse assistant) shower/skin sheets dated July 27 and August 1, 2023 revealed no evidence of abnormal skin color or open areas.

The Weekly Skin Check Licensed Nurse assessment dated July 28, 2023 revealed no new findings, no unhealed pressure ulcer/injuries and skin was clean, dry and intact. Per the documentation, the resident was at risk of developing pressure ulcer/injuries and had no unhealed pressure ulcer/injuries.

Review of a nursing communication note dated August 2, 2023 revealed the resident was complaining of pain on her butt while seated on chair. Per the documentation, the resident had previously been asked to be assisted to bed to relieve the pressure felt but declined. The resident's skin had been assessed by several nurses and the skin was intact, no open areas or redness noted.

The bath/shower sheet dated August 3, 2023 revealed no skin breakdown or redness.

The Weekly Skin Check Licensed Nurse assessment dated August 4, 2023 revealed no new findings, no unhealed pressure ulcer/injuries and skin was clean, dry and intact. Per the documentation, the resident was at risk of developing pressure ulcer/injuries and had no unhealed pressure ulcer/injuries.

However, review of CNA tasks documentation from July 27, 2023 through August 4, 2023 revealed documentation of observations of skin discoloration and redness on multiple shifts.

Despite documentation that the resident had skin discoloration and redness, there was no evidence found in the clinical record that the affected area was assessed, and treatment was provided.

A health status note dated August 5, 2023 included that the resident was sent to the hospital from dialysis for complains of chest pain.

Review of emergency room provider note dated August 5, 2023 revealed an open area was identified on the resident's buttock.

Another hospital note dated August 5, 2023 included that the areas in the sacral region were caked with protective powder and cream. The documentation included it appeared to have a small area that is open, no ulcer or sign of decubitus; and that, powder and cream limits the exam. It also included that there was some note of mild skin breakdown.

Review of the SA complaint tracking system revealed that on August 5, 2023, the resident complained of having ulcerations for two weeks on her bottom that had not been treated by the facility.

The nursing note dated August 6, 2023 included the facility received a report from the hospital that the resident was returning to the facility with no new orders.

The nutrition/dietary note dated August 8, 2023 included that the nurse assessment dated August 4 revealed skin assessment of within normal limits.

Review of the clinical record revealed no physician orders for or treatment provided to the skin from August 5, 2023 through August 11, 2023.

The CNA documentation from August 5 through 11, 2023 revealed documentation that there was no new skin condition observed.

The bath/shower sheets from August 8 through 10, 2023 revealed no evidence of abnormal skin, color or any open areas.

However, the skin/wound note dated August 11, 2023 revealed new open area noted on the upper right buttocks that measured 0.3 x 0.2 x 0.1; and that, cream was applied on bilateral buttocks.

Review of the physician order dated August 11, 2023 revealed an order for a triad paste to sacral area daily and as needed.

The Weekly Skin Check Licensed Nurse assessment dated August 12, 2023 revealed no new findings, no unhealed pressure ulcer/injuries and the skin was clean, dry and intact.

Further review of the clinical record revealed no evidence of CNA POC Tasks that included to apply barrier and provide peri care in the clinical record.

A request for the POC Tasks of apply barrier and provide peri-care were requested, but the facility was not able to provide the documentation, stating that due to an electronic medical record (EMR) update in June 2023, the tasks had been "dropped" from the task list, and they were not aware until this week.

However, a skin wound note dated August 11, 2023, revealed a new open area noted on the right buttock with measurements of 0.3 x 0.2 x 0.1 cm (centimeters), and cream applied on bilateral buttocks.

An interview with a Licensed Practical Nurse (LPN/staff #106) was conducted on August 14, 2023 at 2:25 p.m. The LPN stated that skin evaluation/assessment by the licensed nurse was expected to be completed weekly, usually during showers, or on the skin check day.

An interview was conducted on August 14, 2023 at 2:35 p.m. with a certified nursing assistant (CNA/staff #105) who stated that documentation of skin observation should be completed every day; and, if they observe a rash or discoloration on the skin they would notify the nurse and write a note in the electronic record. She further stated the nurse would assess the area, a barrier cream would be applied, and if it was a new area the nurse would notify the provider. The CNA stated that continence care was provided every 2 hours and as needed. Regarding resident #1, she stated that she noticed a rash between the resident's legs two weeks ago and that, it was treated with ointment and improved. The CNA stated the resident complained of pain in her bottom after returning from dialysis; and, she observed the area was red but did not observe any open areas. The CNA said she notified the nurse and then placed barrier cream to the area, and was instructed to turn/reposition the resident every 2 hours. Further, the CNA said that resident #1 was not able to relieve pressure on her own while in the wheelchair.

In an interview conducted with another LPN (staff #106) on August 15, 2023 at 9:05 a.m., the LPN stated that the facility policy was to follow physician's orders as written, inclu

Based on clinical record review, staff interviews, facility documentation and policy review, and the State Agency (SA) complaint tracking system, the facility failed to ensure one resident (#1) was provided with treatment and care related to shearing in accordance with professional standards of practice. The deficient practice could result in non-healing of shearing and development of complications.

Findings include:

Resident #1 was re-admitted on October 7, 2022 with diagnoses of chronic kidney disease stage 5, dependence of renal dialysis, schizoaffective disorder bipolar type, and chronic obstructive disease.

Review of a care plan initiated on January 17, 2023, revealed the resident required extensive assistance of two with bathing, bed mobility, to turn/reposition and transfers related to chronic kidney disease, and schizoaffective disorder. It also included that the resident was frequently incontinent of bladder, occasionally incontinent with bowel and had potential for pressure ulcer development. Interventions included to administer medications as ordered, assist to shift weight in wheel chair every 15 minutes, follow facility policies/procedures for the prevention/treatment of skin breakdown, incontinence care when needed and to apply barrier cream as ordered.

Review of a quarterly Minimum Data Set (MDS) assessment dated July 11, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderately impaired cognition. The assessment also revealed the resident required extensive two-person assist with for bed mobility, transfer, dressing, and personal hygiene; and that, the resident had no unhealed pressure ulcers, and had a pressure reducing device for the bed.

The provider note dated July 17, 2023 included the resident would benefit from modifications to her current wheelchair to enhance her quality of life by assisting her to maintain midline functional position when seated; and that this would enable the resident to self-propel on her own and reduce the risk of skin breakdown. Assessments included morbid obesity and ESRD (end stage renal disease).

The CNA (certified nurse assistant) shower/skin sheets dated July 27 and August 1, 2023 revealed no evidence of abnormal skin color or open areas.

The Weekly Skin Check Licensed Nurse assessment dated July 28, 2023 revealed no new findings, no unhealed pressure ulcer/injuries and skin was clean, dry and intact. Per the documentation, the resident was at risk of developing pressure ulcer/injuries and had no unhealed pressure ulcer/injuries.

Review of a nursing communication note dated August 2, 2023 revealed the resident was complaining of pain on her butt while seated on chair. Per the documentation, the resident had previously been asked to be assisted to bed to relieve the pressure felt but declined. The resident's skin had been assessed by several nurses and the skin was intact, no open areas or redness noted.

The bath/shower sheet dated August 3, 2023 revealed no skin breakdown or redness.

The Weekly Skin Check Licensed Nurse assessment dated August 4, 2023 revealed no new findings, no unhealed pressure ulcer/injuries and skin was clean, dry and intact. Per the documentation, the resident was at risk of developing pressure ulcer/injuries and had no unhealed pressure ulcer/injuries.

However, review of CNA tasks documentation from July 27, 2023 through August 4, 2023 revealed documentation of observations of skin discoloration and redness on multiple shifts.

Despite documentation that the resident had skin discoloration and redness, there was no evidence found in the clinical record that the affected area was assessed, and treatment was provided.

A health status note dated August 5, 2023 included that the resident was sent to the hospital from dialysis for complains of chest pain.

Review of emergency room provider note dated August 5, 2023 revealed an open area was identified on the resident's buttock.

Another hospital note dated August 5, 2023 included that the areas in the sacral region were caked with protective powder and cream. The documentation included it appeared to have a small area that is open, no ulcer or sign of decubitus; and that, powder and cream limits the exam. It also included that there was some note of mild skin breakdown.

Review of the SA complaint tracking system revealed that on August 5, 2023, the resident complained of having ulcerations for two weeks on her bottom that had not been treated by the facility.

The nursing note dated August 6, 2023 included the facility received a report from the hospital that the resident was returning to the facility with no new orders.

The nutrition/dietary note dated August 8, 2023 included that the nurse assessment dated August 4 revealed skin assessment of within normal limits.

Review of the clinical record revealed no physician orders for or treatment provided to the skin from August 5, 2023 through August 11, 2023.

The CNA documentation from August 5 through 11, 2023 revealed documentation that there was no new skin condition observed.

The bath/shower sheets from August 8 through 10, 2023 revealed no evidence of abnormal skin, color or any open areas.

However, the skin/wound note dated August 11, 2023 revealed new open area noted on the upper right buttocks that measured 0.3 x 0.2 x 0.1; and that, cream was applied on bilateral buttocks.

Review of the physician order dated August 11, 2023 revealed an order for a triad paste to sacral area daily and as needed.

The Weekly Skin Check Licensed Nurse assessment dated August 12, 2023 revealed no new findings, no unhealed pressure ulcer/injuries and the skin was clean, dry and intact.

Further review of the clinical record revealed no evidence of CNA POC Tasks that included to apply barrier and provide peri care in the clinical record.

A request for the POC Tasks of apply barrier and provide peri-care were requested, but the facility was not able to provide the documentation, stating that due to an electronic medical record (EMR) update in June 2023, the tasks had been "dropped" from the task list, and they were not aware until this week.

However, a skin wound note dated August 11, 2023, revealed a new open area noted on the right buttock with measurements of 0.3 x 0.2 x 0.1 cm (centimeters), and cream applied on bilateral buttocks.

An interview with a Licensed Practical Nurse (LPN/staff #106) was conducted on August 14, 2023 at 2:25 p.m. The LPN stated that skin evaluation/assessment by the licensed nurse was expected to be completed weekly, usually during showers, or on the skin check day.

An interview was conducted on August 14, 2023 at 2:35 p.m. with a certified nursing assistant (CNA/staff #105) who stated that documentation of skin observation should be completed every day; and, if they observe a rash or discoloration on the skin they would notify the nurse and write a note in the electronic record. She further stated the nurse would assess the area, a barrier cream would be applied, and if it was a new area the nurse would notify the provider. The CNA stated that continence care was provided every 2 hours and as needed. Regarding resident #1, she stated that she noticed a rash between the resident's legs two weeks ago and that, it was treated with ointment and improved. The CNA stated the resident complained of pain in her bottom after returning from dialysis; and, she observed the area was red but did not observe any open areas. The CNA said she notified the nurse and then placed barrier cream to the area, and was instructed to turn/reposition the resident every 2 hours. Further, the CNA said that resident #1 was not able to relieve pressure on her own while in the wheelchair.

In an interview conducted with another LPN (staff #106) on August 15, 2023 at 9:05

Bases on clinical review, staff interviews, and policy and procedure, the facility failed to ensure consistent pressure ulcer treatments were provided to one of 3 sampled resident (#2) as ordered by the physician. The deficient practice could result in worsening of pressure ulcers and/or development of new pressure ulcers.

Findings include:

Resident #2 was admitted on May 9, 2022 with diagnoses of dementia, osteomyelitis of sacral-coccygeal region, stage IV pressure ulcer of sacral region, type 1 diabetes mellitus and stage III pressure ulcer of right and left buttocks.

The care plan initiated on September 15, 2022 included the resident had a stage IV pressure ulcer to sacrum. Interventions included low air loss mattress, monitor for progression and wound care treatments as ordered.

The skin care plan revised on March 28, 2023 included the resident had potential for impaired skin integrity. Interventions included to monitor/document location, size and treatment of skin, report abnormalities, failure to heal, signs/symptoms of infection to physician.

The Braden scale dated April 5, 2023 included a score of 13 indicating the resident had moderate risk for developing pressure ulcer/sore.

A physician order dated April 12, 2023 included to cleanse sacral wound with vashe wound cleanser (WC), pack with collagen with silver under calcium alginate, secure with foam every day shift and to change every day during night shift.

The skin/wound note dated June 1, 2023 included sacral wound present on admission. Assessment included a stage IV sacral pressure injury, a status of not healed, that measured 4.6 cm (centimeters) x 3.7 cm x 3.5 cm, bone exposed, undermining at 5:00 and ends at 7:00 with a maximum distance of 1.7 cm, moderate amount of serosanguineous drainage and wound bed with 76-100% pink granulation. Diagnoses included stage IV pressure ulcer of the sacral region, stage III pressure ulcer of the right buttocks, stage III pressure ulcer of left buttocks and stage III pressure ulcer of other site (with site not indicated). Plan was for daily collagen then cover with calcium alginate then dry protective dressing, offload wound, repositioning, and ROHO cushion to chair if available.

Review of a quarterly Minimum Data Set (MDS) assessment dated June 22, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The assessment included the resident required extensive assist with two persons for bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS included that the resident was at risk for developing pressure ulcer/injuries. Active diagnoses included stage IV pressure ulcer to the sacral area, stage III pressure ulcer to the right and left buttocks. However, the assessment only coded for one stage IV pressure ulcer that was present on admission.

The Braden scale dated June 23, 2023 included a score of 14 indicating the resident had moderate risk for developing pressure ulcer/sore.

The weekly skin check dated July 5, 2023 revealed a stage IV pressure wound to the sacrum, with slight drainage noted and no odor. Per the documentation, the skin was warm, dry and within normal limits; and that, there were no new skin check findings since the last documented skin check. The documentation included that the resident had a pressure ulcer/injury to the coccyx.

The weekly skin check dated July 11, 2023 revealed a stage IV pressure wound to the sacrum. Per the documentation, the skin was warm, dry and within normal limits; and that, there were no new skin check findings since the last documented skin check.

The skin/wound note dated July 11, 2023 included that wound care was performed by the wound care provider and wound nurse; and, wound culture was ordered.

The physician order dated July 11, 2023 revealed to cleanse sacral wound with wound cleanser, lightly soak gauze with vashe (Dakin's) \'bc strength, cover with foam dressing twice a day every day and night shift for wound care.

The weekly skin check dated July 18, 2023 revealed a stage IV pressure wound to the sacrum. Per the documentation, the skin was warm, dry and intact; and that, there were no new skin check findings since the last documented skin check.

The nutrition/dietary note dated July 18, 2023 included the RN (registered nurse) skin check dated July 11, 2023 included stage IV pressure wound to the sacrum.

The weekly skin check dated July 25, 2023 revealed the resident had open area to the coccyx. Per the documentation, the skin was warm, dry and within normal limits; and that, there were no new skin check findings since the last documented skin check.

The weekly skin check dated August 1, 2023 revealed a stage IV pressure wound to the sacrum with dressing clean, dry and intact. Per the documentation, there were no new skin issues noted.

The weekly skin check dated August 5, 2023 revealed a stage IV pressure wound to the coccyx; and skin within normal limits, dry and had a good turgor. Per the documentation, there were no new skin issues noted.

A physician order dated August 5, 2023 included to observe sacral wound for infection every shift.

The weekly skin check dated August 8, 2023 revealed a stage IV pressure wound to the coccyx; and skin within normal limits, dry and had a good turgor. Per the documentation, there were no new skin issues noted.

Review of the July and August 2023 Treatment Administration Record (TAR) revealed no evidence that the wound treatments had been completed on had been completed as ordered and the wound had been assessed for infection on multiple occasions, or, of resident refusal.

There was also no evidence of provider notification as to the reason the treatments were not completed as ordered, or that the resident had refused the treatments in July 2023 or August 2023.

Despite the inconsistencies in the documentation of the sacral and/or coccyx location of the pressure ulcer/injury, there was no evidence found that the location was clarified with the provider.

In an interview conducted with another LPN (staff #106) on August 15, 2023 at 9:05 a.m., the LPN stated that the facility policy was to follow physician's orders as written, including wound treatments; and, skin assessments should be completed weekly by a licensed nurse. She also stated that when a CNA observes any red or discolored areas on a resident's skin, the CNAs would bring it to the nurse's attention, and the nurse would then assess the area and document the findings in the clinical record. She stated that she would assess the area again prior to the end of her shift. The LPN stated that nurses do daily wound treatments and document when the treatment was completed on the TAR: and that, the expectation was to complete treatments as ordered, and to document on the TAR, if completed or if the resident refused. The LPN stated that when a treatment is not completed as ordered, the nurse should notify the provider, and document in the clinical record. During the interview, a review of the clinical record of resident #2 was conducted with the LPN who stated that in July and August 2023 there were seven occasions with no evidence that the treatment was completed as ordered; and, there was no evidence that the resident refused and the provider was notified. The LPN stated that the risk of not administering wound treatments as ordered could result in the wound becoming infected, and/or cause more skin breakdown. She also stated that the risk of not completing observations for wound infection as ordered could result in risk for infection and not healing.

An interview was conducted on August 15, 2023 at 9:45 a.m. with a certified nursing assistant (CNA/staff #103) who stated that she was familiar with resident #2 and she applied barrier cream to the resident'

Bases on clinical review, staff interviews, and policy and procedure, the facility failed to ensure consistent pressure ulcer treatments were provided to one resident (#2) as ordered by the physician.

Findings include:

Resident #2 was admitted on May 9, 2022 with diagnoses of dementia, osteomyelitis of sacral-coccygeal region, stage IV pressure ulcer of sacral region, type 1 diabetes mellitus and stage III pressure ulcer of right and left buttocks.

The care plan initiated on September 15, 2022 included the resident had a stage IV pressure ulcer to sacrum. Interventions included low air loss mattress, monitor for progression and wound care treatments as ordered.

The skin care plan revised on March 28, 2023 included the resident had potential for impaired skin integrity. Interventions included to monitor/document location, size and treatment of skin, report abnormalities, failure to heal, signs/symptoms of infection to physician.

The Braden scale dated April 5, 2023 included a score of 13 indicating the resident had moderate risk for developing pressure ulcer/sore.

A physician order dated April 12, 2023 included to cleanse sacral wound with vashe wound cleanser (WC), pack with collagen with silver under calcium alginate, secure with foam every day shift and to change every day during night shift.

The skin/wound note dated June 1, 2023 included sacral wound present on admission. Assessment included a stage IV sacral pressure injury, a status of not healed, that measured 4.6 cm (centimeters) x 3.7 cm x 3.5 cm, bone exposed, undermining at 5:00 and ends at 7:00 with a maximum distance of 1.7 cm, moderate amount of serosanguineous drainage and wound bed with 76-100% pink granulation. Diagnoses included stage IV pressure ulcer of the sacral region, stage III pressure ulcer of the right buttocks, stage III pressure ulcer of left buttocks and stage III pressure ulcer of other site (with site not indicated). Plan was for daily collagen then cover with calcium alginate then dry protective dressing, offload wound, repositioning, and ROHO cushion to chair if available.

Review of a quarterly Minimum Data Set (MDS) assessment dated June 22, 2023, revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The assessment included the resident required extensive assist with two persons for bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS included that the resident was at risk for developing pressure ulcer/injuries. Active diagnoses included stage IV pressure ulcer to the sacral area, stage III pressure ulcer to the right and left buttocks. However, the assessment only coded for one stage IV pressure ulcer that was present on admission.

The Braden scale dated June 23, 2023 included a score of 14 indicating the resident had moderate risk for developing pressure ulcer/sore.

The weekly skin check dated July 5, 2023 revealed a stage IV pressure wound to the sacrum, with slight drainage noted and no odor. Per the documentation, the skin was warm, dry and within normal limits; and that, there were no new skin check findings since the last documented skin check. The documentation included that the resident had a pressure ulcer/injury to the coccyx.

The weekly skin check dated July 11, 2023 revealed a stage IV pressure wound to the sacrum. Per the documentation, the skin was warm, dry and within normal limits; and that, there were no new skin check findings since the last documented skin check.

The skin/wound note dated July 11, 2023 included that wound care was performed by the wound care provider and wound nurse; and, wound culture was ordered.

The physician order dated July 11, 2023 revealed to cleanse sacral wound with wound cleanser, lightly soak gauze with vashe (Dakin's) \'bc strength, cover with foam dressing twice a day every day and night shift for wound care.

The weekly skin check dated July 18, 2023 revealed a stage IV pressure wound to the sacrum. Per the documentation, the skin was warm, dry and intact; and that, there were no new skin check findings since the last documented skin check.

The nutrition/dietary note dated July 18, 2023 included the RN (registered nurse) skin check dated July 11, 2023 included stage IV pressure wound to the sacrum.

The weekly skin check dated July 25, 2023 revealed the resident had open area to the coccyx. Per the documentation, the skin was warm, dry and within normal limits; and that, there were no new skin check findings since the last documented skin check.

The weekly skin check dated August 1, 2023 revealed a stage IV pressure wound to the sacrum with dressing clean, dry and intact. Per the documentation, there were no new skin issues noted.

The weekly skin check dated August 5, 2023 revealed a stage IV pressure wound to the coccyx; and skin within normal limits, dry and had a good turgor. Per the documentation, there were no new skin issues noted.

A physician order dated August 5, 2023 included to observe sacral wound for infection every shift.

The weekly skin check dated August 8, 2023 revealed a stage IV pressure wound to the coccyx; and skin within normal limits, dry and had a good turgor. Per the documentation, there were no new skin issues noted.

Review of the July and August 2023 Treatment Administration Record (TAR) revealed no evidence that the wound treatments had been completed on had been completed as ordered and the wound had been assessed for infection on multiple occasions, or, of resident refusal.

There was also no evidence of provider notification as to the reason the treatments were not completed as ordered, or that the resident had refused the treatments in July 2023 or August 2023.

Despite the inconsistencies in the documentation of the sacral and/or coccyx location of the pressure ulcer/injury, there was no evidence found that the location was clarified with the provider.

In an interview conducted with another LPN (staff #106) on August 15, 2023 at 9:05 a.m., the LPN stated that the facility policy was to follow physician's orders as written, including wound treatments; and, skin assessments should be completed weekly by a licensed nurse. She also stated that when a CNA observes any red or discolored areas on a resident's skin, the CNAs would bring it to the nurse's attention, and the nurse would then assess the area and document the findings in the clinical record. She stated that she would assess the area again prior to the end of her shift. The LPN stated that nurses do daily wound treatments and document when the treatment was completed on the TAR: and that, the expectation was to complete treatments as ordered, and to document on the TAR, if completed or if the resident refused. The LPN stated that when a treatment is not completed as ordered, the nurse should notify the provider, and document in the clinical record. During the interview, a review of the clinical record of resident #2 was conducted with the LPN who stated that in July and August 2023 there were seven occasions with no evidence that the treatment was completed as ordered; and, there was no evidence that the resident refused and the provider was notified. The LPN stated that the risk of not administering wound treatments as ordered could result in the wound becoming infected, and/or cause more skin breakdown. She also stated that the risk of not completing observations for wound infection as ordered could result in risk for infection and not healing.

An interview was conducted on August 15, 2023 at 9:45 a.m. with a certified nursing assistant (CNA/staff #103) who stated that she was familiar with resident #2 and she applied barrier cream to the resident's peri-area. The CNA also said that the resident's wounds had improved.

During an interview with the Director of Nursin