Tempe Post Acute

Based on clinical review, staff interviews, and facility policy, the facility failed to ensure that physician orders were followed according to professional standards regarding blood sugar monitoring for two out of five sampled residents (#215 and #46).

Findings Include:

-Regarding resident #215:

Resident #215 was admitted to the facility on November 8, 2024 with diagnoses that included Type II Diabetes Mellitus without complications.

The care plan for Diabetes Mellitus initiated on November 09, 2024 included an intervention of diabetes medication as ordered by doctor; monitor/document for side effects and effectiveness.

The Minimum Data Set (MDS) assessment dated November 14, 2024 included a brief interview for mental status (BIMS) score of 00 indicating severe cognitive impairment.

Review of the physician's order dated November 8, 2024, revealed an order for, Insulin Lispro solution 100 unit/milliliter (ml), inject as per sliding scale: if 0 - 60 =0 units asymptomatic or symptomatic blood sugar (BS) 60 and below; see as needed orders; 61 - 150 = 0 units; 151 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 12 units; 351 - 400 = 15 units; 401+ = 18 units recheck, if still elevated in 60 minutes call medical doctor (MD), subcutaneously before meals and at bedtime.

Review of the Medication Administration Record (MAR) dated November 2024 revealed the following:
-November 10, 2024, BS was 447 and 18 units of insulin was administered.
-November 12, 2024, BS was 463 and 18 units of insulin was administered.
-November 13, 2024, BS was 430 and 18 units of insulin was administered.
-November 16, 2024, BS was 491 and 18 units of insulin was administered.
-November 17, 2024, BS was 449 and 18 units of insulin was administered.
-November 18, 2024, BS was 415 and 18 units of insulin was administered.
-November 19, 2024, BS was 402 and 18 units of insulin was administered.
-November 20, 2024, BS was 401 and 18 units of insulin was administered.

A review of the clinical record revealed no evidence that the BS was rechecked or that the physician was notified for the above dates regarding blood sugar.

An interview was conducted on November 21, 2024 at 8:40 AM with a Certified Nursing Assistant (CNA/staff #17) who stated that blood sugar checks are done whenever they are scheduled. She also stated that the blood sugar results are given to the nurses and the nurses document the results in the electronic record. She further stated that she would notify the nurse about blood sugar results in any situation but especially if the resident is below 90 or over 250.

In an interview with a Licensed Practical Nurse (LPN/staff #82) on November 21, 2024 at 8:41 AM, who stated that the process for administering insulin included: checking the blood sugar, depending on the result the resident could have either a standard and/or sliding scale order to give insulin, wiping the resident area with an alcohol pad, and administering the medication. She also stated that she would follow the sliding scale as it was written in the order. The LPN (staff #82) reviewed the physician order of insulin lispro for resident (#215) and verified that if the blood sugar was above 401 it should be rechecked in 60 minutes and if it is still 400 to notify the physician. The LPN then reviewed the above dates and blood sugar results in the resident's clinical record and stated that the blood sugars should have been rechecked after the initial result but there was no evidence showing that it had been completed. She also stated that the physician should have been notified. The LPN (staff #82) stated that the risks to the resident of not rechecking the blood sugar or notifying the physician could result in the resident passing out. She further stated that not following the physician's order for insulin lispro did not meet facility expectations.

An interview was conducted on November 21, 2024 at 8:57 AM with the Director of Nursing (DON/staff #7) who stated that the process for administering insulin would be based off of the physician's order and nursing assessment. She stated that the physician orders regarding insulin would be followed. The DON (staff #7) reviewed the above dates and documented blood sugars in the resident's (#215) clinical record, and stated that the blood sugars should have been rechecked. She further reviewed the resident's clinical record and stated that there was no evidence of the blood sugars being rechecked after the initial result according to physician's orders, or that the physician was notified. The DON stated that the risks to the resident of not rechecking the blood sugar or notifying the physician could include that the resident's blood sugar could stay elevated and that they would not be addressing his diabetes. She further stated that not following physician orders did not meet facility expectations.

Based on observation the facility failed to provide a clear means of egress to exit to a public way. Failure to provide a clear and unimpeded means of egress could cause harm to the patients and staff in a fire emergency.

NFPA 101, Life Safety Code, 2012, Chapter 19, Section 19.2.1 "Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Section 7.1.10.1 " Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency." Section 7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto egress there from, or visibility thereof.

Observations made while on tour on November 25, 2024, the facility failed to maintain a clear path to the exit in the following areas.

1) Hall with rooms 515-522- 4 Hoyer lifts, laundry bin, and briefs cart in means of egress.
2) Hall with rooms 523-532- 4 med carts, Hoyer lift, briefs cart, and laundry bin in means of egress.

Management confirmed during the facility tour and the exit conference on November 25, 2025, that the above-listed exit pathways were restricted.

Based on observation the facility failed to ensure that all parts of the facility sprinkler system were properly installed. Failing to ensure proper installation in all areas of the facility could result in the sprinkler not controlling the fire which could cause harm to the residents and staff.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, 8.6.3.3 Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.

Findings include:

Observations made while on tour on November 25, 2024, revealed a ceiling-mounted sprinkler head in the Zone 1 Crash Cart room was 3 \'bc inches away from the wall.

The management team acknowledged during the walk-through and exit conference on November 25, 2024, that the ceiling-mounted sprinkler head in the Zone 1 Crash Cart room was to close to the wall.

Based on observation the facility failed to fill multiple penetrations in the smoke barriers of 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:

During a facility tour conducted on November 25, 2024, revealed the facility failed to maintain the smoke barriers in the fire/ smoke barrier above the ceiling tiles in the following areas:

1) The water heater room had seven plus areas of penetration (pipes not sealed, patches not sealed) in the walls and ceiling.
2) The westside storage room had penetrations in the ceiling.
3) The east therapy wall has three areas of penetration, a 4"x4" patch not sealed, a 4"x4" hole not sealed, and a 4"x6" patch not sealed.
4) The hallway outside of the therapy room above the 90-minute rated doors had penetrations as did the south wall.
5) The west wall outside room 505 had penetrations.
6) The west wall of room in 505 had penetrations.
7) The mechanical room across from Nursing Station 1 had penetrations above the door.

The management team acknowledged the above-listed deficiencies during the facility tour and exit conference on November 25, 2024.

Based on observations, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen. The deficient practice could result in a potential for food borne illness. The resident census is 51.

Findings include:

During an initial walk through of the kitchen conducted with the Kitchen Manager (staff #46).

On December 12, 2023 at 8:07 AM conducted initial kitchen tour with Staff #46, the Food Service Director. Logs for freezer, fridge, dishwasher, cleaning bucket, food temps, cleaning schedule, and sanitizing concentration were reviewed and revealed the log titled Cleaning List for Cook Daily hanging on clipboard nailed to wall was not completed for the Monday AM shift prior to morning food service. Additionally reviewed the Cleaning List for Dishwasher log hanging on clipboard nailed to wall and which revealed the Monday AM the cleaning list for dishwasher log was not completed prior to morning food service. Observed five empty crushed boxes stored near food prep area, food debris under enclosed refrigerator shelf with black sticky substance on the floor approximately six inches in diameter.

On December 13, 2023 12:25 AM Observed several empty crushed boxes stored near food prep area, and food debris under food prep table.

On December 14. 2023 at 10:16 AM, observed a live roach on door in Kitchen Manager's office, the Kitchen Manager (staff #46) stated that it was a roach and smashed it on the door with a floor duster. At approximately 10:35 AM conducted a tour of the kitchen and observed the following;

1) food debris under two food prep tables and near baseboards with a toaster above one food prep table,
2) five empty cardboard boxes with two open empty containers of processed mashed potatoes. The Kitchen Manager stated that this was trash and explained that the trash will be emptied right away because of the risk of cross contamination, this trash pile was observed 6 inches away from a push cart of prepared desert cakes,
3) thawing processed ham under running water while sitting on top of a metal strainer three inches away from a sheet of uncovered tray of desert cake, with water observed splashing near uncovered tray of desert cake,
4) a white bath towel under a mobile refrigerator and the kitchen manager pulled the white bath towel from under the refrigerator and stated that the risk of the towel could harbor bacteria and stated somebody must've spilled something here, the white bath towel appeared crusted dry with a brown stain,
5) one dead roach under canned food shelf and the kitchen manager stated it looks like a dead bug, and one live roach crawling across the floor and the kitchen manager stepped on the insect,
6) standing water under dry food storage shelf with vinyl baseboard partially peeled from the wall and crusted lifted floor tile from what appeared to be a water leak from the wall,
7) baseboards behind the ice machine in the resident dining room had three dead roaches and debris build up next to a floor drain sink that had black debris particles build-up caught in filter trap, the surrounding tile around the drain sink were broken and had exposed sub-floor.

Reviewed Maricopa County Food Inspection Report from October 2, 2023 and revealed a finding statement of: the floor drains under the hand wash sink in the cook line area under the prep table with excess soil residue/old food debris present. PIC stated that all areas would be cleaned.

Reviewed the pest service log from Burns Pest Elimination and revealed an invoice for Commercial Healthcare Program (December 2023) with no description of services.

Reviewed the pest service log from Atomic Pest Control, LLC and revealed services with locations (June 10, 2023 to September 21, 2023) with no service requests for the kitchen.

Reviewed the work orders for the kitchen (October 1 - December 13, 2023) with no service request for pest elimination or water leaks.

Based on observations, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen. The deficient practice could result in a potential for food borne illness. The resident census is 51.

Findings include:

During an initial walk through of the kitchen conducted with the Kitchen Manager (staff #46).

On December 12, 2023 at 8:07 AM conducted initial kitchen tour with Staff #46, the Food Service Director. Logs for freezer, fridge, dishwasher, cleaning bucket, food temps, cleaning schedule, and sanitizing concentration were reviewed and revealed the log titled Cleaning List for Cook Daily hanging on clipboard nailed to wall was not completed for the Monday AM shift prior to morning food service. Additionally reviewed the Cleaning List for Dishwasher log hanging on clipboard nailed to wall and which revealed the Monday AM the cleaning list for dishwasher log was not completed prior to morning food service. Observed five empty crushed boxes stored near food prep area, food debris under enclosed refrigerator shelf with black sticky substance on the floor approximately six inches in diameter.

On December 13, 2023 12:25 AM Observed several empty crushed boxes stored near food prep area, and food debris under food prep table.

On December 14. 2023 at 10:16 AM, observed a live roach on door in Kitchen Manager's office, the Kitchen Manager (staff #46) stated that it was a roach and smashed it on the door with a floor duster. At approximately 10:35 AM conducted a tour of the kitchen and observed the following;

1) food debris under two food prep tables and near baseboards with a toaster above one food prep table,
2) five empty cardboard boxes with two open empty containers of processed mashed potatoes. The Kitchen Manager stated that this was trash and explained that the trash will be emptied right away because of the risk of cross contamination, this trash pile was observed 6 inches away from a push cart of prepared desert cakes,
3) thawing processed ham under running water while sitting on top of a metal strainer three inches away from a sheet of uncovered tray of desert cake, with water observed splashing near uncovered tray of desert cake,
4) a white bath towel under a mobile refrigerator and the kitchen manager pulled the white bath towel from under the refrigerator and stated that the risk of the towel could harbor bacteria and stated somebody must've spilled something here, the white bath towel appeared crusted dry with a brown stain,
5) one dead roach under canned food shelf and the kitchen manager stated it looks like a dead bug, and one live roach crawling across the floor and the kitchen manager stepped on the insect,
6) standing water under dry food storage shelf with vinyl baseboard partially peeled from the wall and crusted lifted floor tile from what appeared to be a water leak from the wall,
7) baseboards behind the ice machine in the resident dining room had three dead roaches and debris build up next to a floor drain sink that had black debris particles build-up caught in filter trap, the surrounding tile around the drain sink were broken and had exposed sub-floor.

Reviewed Maricopa County Food Inspection Report from October 2, 2023 and revealed a finding statement of: the floor drains under the hand wash sink in the cook line area under the prep table with excess soil residue/old food debris present. PIC stated that all areas would be cleaned.

Reviewed the pest service log from Burns Pest Elimination and revealed an invoice for Commercial Healthcare Program (December 2023) with no description of services.

Reviewed the pest service log from Atomic Pest Control, LLC and revealed services with locations (June 10, 2023 to September 21, 2023) with no service requests for the kitchen.

Reviewed the work orders for the kitchen (October 1 - December 13, 2023) with no service request for pest elimination or water leaks .

Based on clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#10) received dialysis servicves as per physician's orders. The sample was 3. The deficient practice could result in residents not getting the required treatment to manage their condition.

Findings include:

Resident #10 was admitted to the facility on April 4, 2023 with diagnoses that included end stage renal disease (ESRD), dependence on renal dialysis, and chronic metabolic acidosis.

A Care Plan initiated April 5, 2023 and revised on April 17, 2023 revealed that the resident needed dialysis regarding renal failure and had a permacath to the right chest. Interventions noted included to encourage resident to go for the scheduled dialysis appointments and also included that the resident received dialysis on Monday/Wednesday/Friday.

Regarding dialysis orders:
The physician order dated April 5, 2023 included that the resident had dialysis on Monday/Wednesday/Friday.

Review of an undated document titled "Dialysis PT List - with schedules" revealed a list of residents on dialysis which included resident #10. The document indicated that resident #10 is scheduled for dialysis on Monday, Wednesday, and Friday.

However, dashboard section that was marked as special instructions on the resident's electronic record indicated that the resident received dialysis on Tuesday, Thursday, and Saturday.

During an interview with the Dialysis Center Administrator (staff #1) conducted on May 1, 2023 at 1:26 p.m., he stated that the resident was scheduled for dialysis three times a week (Tuesday, Thursday, and Saturday). Staff # 1 stated the resident missed his dialysis appointment on April 6, 2023 and April 15, 2023 and no reason was provided.

During an interview with a Licensed Practical Nurse (LPN/staff #48) conducted on May 2, 2023 at 3:02 p.m., she stated that the orders for dialysis should match the information on the dashboard under special instructions which stated where the dialysis takes place, the day/times for dialysis, and the pick-up times. Following the interview, resident #10's clinical record was reviewed with staff #48. The order for dialysis was compared to the special instructions on the dashboard. Staff #48 agreed that the information did not match. Staff #48 stated that if the information did not match then the resident would not be ready to go on their appointment, the resident would not get their vitals taken before and after the dialysis. Furthermore, the shunts/fistula would not be checked at the appropriate times. Staff #48 also noted that a staff member unfamiliar with the resident and the scheduled dialysis days would find the conflicting information between the orders and the dashboard confusing which can lead to the nurse erroneously doing monitoring on a different date.

An interview with the Medical Records Supervisor/Transportation (staff #25) was conducted on May 2, 2023 at 3:55 p.m. Staff #25 stated that the Admissions Department set up the special instructions on the dashboard. Medical records confirm with the dialysis center that the information on the dashboard is accurate since this is what they use to schedule transportation. Staff #25 also stated that the special instructions on the dashboard should match the orders. However, she stated that if the information between the orders and dashboard conflicts, that they follow the information on the special instructions since that information is what is verified with the dialysis center. Staff #25 stated that transportation did not look at orders since once they verify the days/times with dialysis center, they place that information on the excel sheet for quick reference of who goes where and when.

An interview was conducted on May 2, 2023 at 4:14 p.m. with the Director of Nursing (DON/staff #20). Staff #20 stated that dialysis information can be viewed under special instructions on the dashboard, communication board, and orders for site and dialysis. She stated that her expectation of her nurses when conflicting information between the dashboard and orders exist is for them to know which information is correct. The DON stated that the negative impact of the conflicting information is bad communication and confusion. Following the interview, the DON reviewed the resident's clinical record and agreed that the special instructions on the dashboard and the orders had conflicting information.

Regarding missed dialysis:

A rounding report from the dialysis center dated April 18, 2023 indicated under treatment history that the resident has had zero missed treatments in the last 30 and 60 days. However, the chart portion for the last 6 completed treatment did not contain information regarding pre/post blood pressure, dialytic weight loss, pre/post weight, average blood flow restriction, and actual treatment time for April 6 and April 15.

Review of resident #10's April 2023 Treatment Sheet for dialysis revealed that the resident received treatment on the following days:
April 8 (Saturday)
April 11 (Tuesday)
April 13 (Thursday)
April 18 (Tuesday)
April 20 (Thursday)

During an interview with the Dialysis Center Administrator (staff #1) conducted on May 1, 2023 at 1:26 p.m., he stated that the resident was scheduled for dialysis three times a week (Tuesday, Thursday, and Saturday). Staff # 1 stated that the resident missed his dialysis appointment on April 6, 2023 and April 15, 2023 and no reason was provided. Staff #1 stated that resident did not receive dialysis on April 22, 2023 because the resident declined treatment due to having a bowel movement. Staff #1 also stated that the resident was 1.5 hours late to the dialysis appointment, never made it to the treatment area and just wanted to go back home. Staff #1 noted that in the event that a resident arrived at the dialysis center soiled, they have gowns that the resident can change into. He stated the dialysis center can help clean up the resident and position them for isolation so they can receive their treatment.

Review of the resident's record revealed no documentation on the reason behind missed dialysis on April 6 and April 15, 2023.

A progress note dated April 22, 2023 documented that the resident was taken to dialysis center in the morning. The note stated when the resident #10 arrived at the dialysis center, it was noted that she had a bowel movement during transport and the dialysis center refused to have the resident sit for dialysis treatment due to bowel movement. The note further included that the resident was instructed per dialysis staff to return to facility and the transport driver was unable to assist resident with brief change. The progress note indicated that the dialysis staff refused to assist resident and had resident return to facility.

Review of the order summary revealed a physician order dated April 22, 2023 which indicated a change of condition for missed dialysis. It noted that provider, resident, and responsible party were notified/aware and agreeable to plan of care.

A progress note dated April 23, 2023 indicated that the resident presents with moderate weakness. Resident was noted to be alert with confusion after missing dialysis the day prior.

A progress note dated April 24, 2023 indicated that the resident missed dialysis on Saturday. It noted that a call was placed to the dialysis center to see if resident can do a make-up time. However, there were no spots open that day and resident was to resume regular schedule the next day.

Review of the order summary revealed an order dated April 25, 2023 which directed for orders to be on hold due to the resident being sent to the emergency department as a result of a change of condition for missed dialysis, altered mental status, lethargy, not alert and oriented to

Based on clinical record review, staff interviews and policy review, the facility failed to ensure one resident (#10) received dialysis servicves as per physician's orders.

Findings include:

Resident #10 was admitted to the facility on April 4, 2023 with diagnoses that included end stage renal disease (ESRD), dependence on renal dialysis, and chronic metabolic acidosis.

A Care Plan initiated April 5, 2023 and revised on April 17, 2023 revealed that the resident needed dialysis regarding renal failure and had a permacath to the right chest. Interventions noted included to encourage resident to go for the scheduled dialysis appointments and also included that the resident received dialysis on Monday/Wednesday/Friday.

Regarding dialysis orders:
The physician order dated April 5, 2023 included that the resident had dialysis on Monday/Wednesday/Friday.

Review of an undated document titled "Dialysis PT List - with schedules" revealed a list of residents on dialysis which included resident #10. The document indicated that resident #10 is scheduled for dialysis on Monday, Wednesday, and Friday.

However, dashboard section that was marked as special instructions on the resident's electronic record indicated that the resident received dialysis on Tuesday, Thursday, and Saturday.

During an interview with the Dialysis Center Administrator (staff #1) conducted on May 1, 2023 at 1:26 p.m., he stated that the resident was scheduled for dialysis three times a week (Tuesday, Thursday, and Saturday). Staff # 1 stated the resident missed his dialysis appointment on April 6, 2023 and April 15, 2023 and no reason was provided.

During an interview with a Licensed Practical Nurse (LPN/staff #48) conducted on May 2, 2023 at 3:02 p.m., she stated that the orders for dialysis should match the information on the dashboard under special instructions which stated where the dialysis takes place, the day/times for dialysis, and the pick-up times. Following the interview, resident #10's clinical record was reviewed with staff #48. The order for dialysis was compared to the special instructions on the dashboard. Staff #48 agreed that the information did not match. Staff #48 stated that if the information did not match then the resident would not be ready to go on their appointment, the resident would not get their vitals taken before and after the dialysis. Furthermore, the shunts/fistula would not be checked at the appropriate times. Staff #48 also noted that a staff member unfamiliar with the resident and the scheduled dialysis days would find the conflicting information between the orders and the dashboard confusing which can lead to the nurse erroneously doing monitoring on a different date.

An interview with the Medical Records Supervisor/Transportation (staff #25) was conducted on May 2, 2023 at 3:55 p.m. Staff #25 stated that the Admissions Department set up the special instructions on the dashboard. Medical records confirm with the dialysis center that the information on the dashboard is accurate since this is what they use to schedule transportation. Staff #25 also stated that the special instructions on the dashboard should match the orders. However, she stated that if the information between the orders and dashboard conflicts, that they follow the information on the special instructions since that information is what is verified with the dialysis center. Staff #25 stated that transportation did not look at orders since once they verify the days/times with dialysis center, they place that information on the excel sheet for quick reference of who goes where and when.

An interview was conducted on May 2, 2023 at 4:14 p.m. with the Director of Nursing (DON/staff #20). Staff #20 stated that dialysis information can be viewed under special instructions on the dashboard, communication board, and orders for site and dialysis. She stated that her expectation of her nurses when conflicting information between the dashboard and orders exist is for them to know which information is correct. The DON stated that the negative impact of the conflicting information is bad communication and confusion. Following the interview, the DON reviewed the resident's clinical record and agreed that the special instructions on the dashboard and the orders had conflicting information.

Regarding missed dialysis:

A rounding report from the dialysis center dated April 18, 2023 indicated under treatment history that the resident has had zero missed treatments in the last 30 and 60 days. However, the chart portion for the last 6 completed treatment did not contain information regarding pre/post blood pressure, dialytic weight loss, pre/post weight, average blood flow restriction, and actual treatment time for April 6 and April 15.

Review of resident #10's April 2023 Treatment Sheet for dialysis revealed that the resident received treatment on the following days:
April 8 (Saturday)
April 11 (Tuesday)
April 13 (Thursday)
April 18 (Tuesday)
April 20 (Thursday)

During an interview with the Dialysis Center Administrator (staff #1) conducted on May 1, 2023 at 1:26 p.m., he stated that the resident was scheduled for dialysis three times a week (Tuesday, Thursday, and Saturday). Staff # 1 stated that the resident missed his dialysis appointment on April 6, 2023 and April 15, 2023 and no reason was provided. Staff #1 stated that resident did not receive dialysis on April 22, 2023 because the resident declined treatment due to having a bowel movement. Staff #1 also stated that the resident was 1.5 hours late to the dialysis appointment, never made it to the treatment area and just wanted to go back home. Staff #1 noted that in the event that a resident arrived at the dialysis center soiled, they have gowns that the resident can change into. He stated the dialysis center can help clean up the resident and position them for isolation so they can receive their treatment.

Review of the resident's record revealed no documentation on the reason behind missed dialysis on April 6 and April 15, 2023.

A progress note dated April 22, 2023 documented that the resident was taken to dialysis center in the morning. The note stated when the resident #10 arrived at the dialysis center, it was noted that she had a bowel movement during transport and the dialysis center refused to have the resident sit for dialysis treatment due to bowel movement. The note further included that the resident was instructed per dialysis staff to return to facility and the transport driver was unable to assist resident with brief change. The progress note indicated that the dialysis staff refused to assist resident and had resident return to facility.

Review of the order summary revealed a physician order dated April 22, 2023 which indicated a change of condition for missed dialysis. It noted that provider, resident, and responsible party were notified/aware and agreeable to plan of care.

A progress note dated April 23, 2023 indicated that the resident presents with moderate weakness. Resident was noted to be alert with confusion after missing dialysis the day prior.

A progress note dated April 24, 2023 indicated that the resident missed dialysis on Saturday. It noted that a call was placed to the dialysis center to see if resident can do a make-up time. However, there were no spots open that day and resident was to resume regular schedule the next day.

Review of the order summary revealed an order dated April 25, 2023 which directed for orders to be on hold due to the resident being sent to the emergency department as a result of a change of condition for missed dialysis, altered mental status, lethargy, not alert and oriented to person, place, or time. The order noted that the nurse practitioner was advised.

During an interview with a Licensed Practica