Sante Of Mesa

Based on clinical record review, interview, review of policies and procedures, the facility failed to notify the ombudsman of transfer or discharge.

Resident # 70 was admitted to the facility on May 20, 2024 with diagnoses that include adult failure to thrive, HTN, BPH, Anemia. Resident # 70 was discharged 06/25/2024.

Resident # 70 needs supervision or touching assistance with: eating, oral hygiene, and personal hygiene. Resident # 70 needs substantial/maximal assistance with: upper body dressing, lower body dressing, putting on/taking on foot wear, roll left and right, sit to lying, chair/bed-to-chair transfer.
The care plan revealed Resident #70 was monitored for any change of conditions. If any change were to occur it would be reported to their provider. Resident # 70 is at risk for altered fluid balance r/t Poor intake, feeding tube. Resident # 70 has oral thrush and antifungal.

Progress notes on June 14, 2024 revealed Resident # 70 is progressing with their therapy and was going to be discharged to an acute rehab center. There was no date or time that resident discharge was completed in progress notes or that the ombudsman was notified.

Staff #66 Care Manager LPN said the resident was the main point of contact for plan of care and discharge plan. Resident # 70 was provided admission orders, baseline care plan and discussion held on Resident # 70 goals, expectation, and treatment. Resident #70 was informed of their treatment orders, dietary orders, medications, and therapy services. If there are any changes care plan will be notified to Resident # 70. Resident # 70 had verbalized in understanding their care plan and agreed to the care plan.

Interview with staff # 167 Care Manager Licensed Practical Nurse (LPN) on 09/05/2024 at 8:44AM revealed Resident # 70 was transferred to an acute rehab unsure of the reason. Since this was an emergency transfer there were no documents signed by resident or on the resident behalf of this transfer.

Interview with staff # 66 Care manager Licensed Practical Nurse (LPN) on 09/05/2024 at 9:17AM
revealed an Ombudsman would only be notified if there is a problem. Since this is not a discharge a discharge packet was not given to resident #70. This was a skilled nursing facility to a skilled nursing facility transfer. An email or fax of everything needed would have be given to the receiving facility.

On 09/06/2024 at 8:44AM the Administrator said the process of discharge would normally be if a resident had requested for a change in facility they would give the resident a list of facilities. With this list we will help residents pick out a facility that they would like. In this case this Resident # 70 wife wanted to go to a different facility prior to coming to this facility. At the time Resident # 70 was not qualified for that particular facility. Resident # 70 would start off with a lower level rehab to build on their strength like this facility. During Resident # 70 times here, they were recovering quite well. Resident # 70 wife requested this transfer and we had sent out a referral which was approved. During this process case managers and resource nurses are involved. There should have been a note that the patient was discharged in the progress notes. There was no discharge packet given.

On 09/05/2024 2:58PM documentation the ombudsman being notified of transfer and discharge was requested but the documentations was not provided. Social Services Staff # 172 stated they were not aware that the ombudsman needed to notify.

Review of the policy Transfer or Discharge facility revealed that the Ombudsman would be given a notice of transfer or discharge and resident and representatives.

Based on the reviewing of staff list, census, record review and interview facility failed to ensure that a Registered Nurse (RN) severed 8 consecutive hours in the day.The deficit practice would result resident care not being property given in need of a registered nurse.

Reviews of daily staff revealed that an RN was not present during the 8 hours in the day for 8 different dates. On May 19, 2024 the Census was 58 no RN coverage for day and night. On July 01, 2024 Census was 68 no RN coverage for the day for 8 hours. At the August 05, 2024 census there was 68 no RN coverage for the day for 8 hours. On August 06,2024 census was 66 for the day for 8 hours, August 12, 2024 the census was 69 and no RN coverage for 8 hours of the day. August 19,2024 census 67 no RN coverage for the day for 8 hours. August 27, 2024 census 64 no RN coverage for the day for 8 hours. September 01, 2024 census 59 no RN coverage for 8 of the day.

Upon further review of the daily staffing list provided to the surveyor, Director of Nursing or Assistant of Director of Nursing are not listed on the daily staffing list.

Interview with staff # 52 Certified Nurse Assistant CNA September 05, 2024 1:35PM. Typically I would get 11-12 residents under my care. I don't stay over time when working. If my coverage isn t here on time we would document and report our task and care that we have given to residents. This will help the next person taking over when we leave for the day. We can communicate with staff verbally and put reports within the chart. Call devices are given to residents and they can put them on their neck or they can have it near them on the table. We have in-service training and staff meetings to help us learn.

Interview with Staff # 34 Director of Nursing (DON) on September 06, 2024 at 2:29 PM, the DON stated if we don't have an RN 8 hours of the day, the Director of Nursing or Assistant Director of Nursing would cover during those days. The Director of Nursing would work Monday - Friday. Our coverage is not based on the census, and if someone calls off the Director of Nursing or Assistant Director of Nursing would cover. We do what we can with what we have.

Policy review of staffing had revealed 24 hours of the day a Licensed Nurses need to be able to provide direct resident services .

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure pain medications were administered in accordance with the physician's orders for one resident (#15). The deficient practice could result in the resident receiving unnecessary medication and being overmedicated.

Findings include:

Resident #15 was admitted to the facility on July 4, 2023 with diagnoses of a fracture of shaft of right fibula, fracture of shaft of right tibia, and acquired absence of left hip joint.

A review of the quarterly Minimum Data Set (MDS) assessment, dated June 20, 2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact.

A physician's order dated May 9, 2024 indicated Oxycodone HCI (narcotic analgesic) Oral Tablet 5 milligrams (mg) was to be given by mouth every 4 hours as needed for pain between 6-10 on a 0-10 pain scale.

A review of the July and August medication administration record (MAR) revealed that oxycodone was not being administered within the pain parameters established by the physician.

For the month of July 2024, oxycodone was administered below the required pain rating of 6-10 thirty-three times. For the month of August 2024, oxycodone was administered below the required pain rating of 6-10 thirty-two times.

The clinical record revealed no documentation of the reason why oxycodone was administered outside of the parameters established by the physician's orders and that the physician was not notified.

An interview was conducted with staff #110 (Registered Nurse) on September 6, 2024 at 9:58 AM. Staff # 110 indicated that pain medications are given to residents after a pain assessment is done. During the pain assessment a resident identifies how much pain they are having using a pain scale to determine if they are eligible to take the specific pain medication. Staff #110 explained that she will look at the medication order and it would specify when to give the medication to the resident. Staff #110 reviewed the August MAR for resident #15 and indicated that the oxycodone was not administered within parameters. When asked what the risk would be to the resident when administering oxycodone outside of parameters, staff #110 indicated that they would not be doing what would be best for the resident and they would not be treating the pain as prescribed by the physician.

An interview was conducted on September 6, 2024 at 10:31 AM with staff #34 (Director of Nursing). Staff #34 indicated that when a resident asks for pain medications, the nurse is to ensure there is an order then ask the resident what they rated their pain as, and then identify the symptoms that indicates the resident is in pain. When reviewing the August MAR for resident #15, staff # 34 stated they saw multiple administrations being done outside of the ordered parameters. Staff #34 indicated that the nurse did not administer pain medication according to her expectation as she expected staff to follow the orders. When asked what the risk to the resident would be when oxycodone is administered outside of the ordered parameters, staff #34 explained that it could make the resident sleepy and it would enhance their fall risk. Staff #34 continued by stating their "goal is not to make them dependent on narcotics".

A review of the facility policy titled "Administering Medications," revised on December 2012 indicated that medications are to be administered according to orders.

A review of the facility policy titled "Pain Assessment and Management," revised on March 2015 states "Addiction to narcotic analgesics is not likely if used appropriately for moderate to severe pain".

Based on observation, clinical record review, staff interview, and facility documentation, policy and procedure, the facility failed to ensure dialysis assessments were completed and transportation to dialysis appointments was arranged for one of three sampled residents (#4). The deficient practice could result in the resident missing dialysis treatment and developing renal complications.

Findings include:

The facility's contract with the Dialysis Facility, signed and dated 10/18/2023, it included that the facility shall be responsible for arranging transportation of residents to and from Dialysis Facility, including all transportation costs and expenses. Long term care facility shall be responsible for ensuring that residents are (i) medically stable to undergo such transportation, (ii) medically suitable to receive treatment at Dialysis Facility, and (iii) timely transported to and from Dialysis Facility.

Resident (#4) was admitted April 8, 2024 with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease (CKD), CKD with Heart Failure and Stage 5 CKD or end stage renal disease

A physician order dated April 8, 2024 included for dialysis three times a week on Mondays, Wednesdays, and Fridays; and, the chair time would be from 11:50am to 3:20pm with an arrival time of 11:30am.

Another physician order dated April 8, 2024 revealed an order to complete pre-dialysis and post-dialysis assessments every day shift on every Monday, Wednesday, and Friday.

A progress note dated April 9, 2024 included that the care manager met with the resident and family for an admission intake review that covered review of all medications, treatment orders, dietary orders, therapy services and all other interventions or services ordered at the time of admission.

A review of the Treatment Administration Record (TAR) for April 2024 included that a post dialysis assessment was documented as completed on April 10 and 12, 2024.

However, the documentation from the dialysis center revealed that the resident did not receive dialysis on April 10, 2024.

A progress note dated April 10, 2024 revealed that the resident was sent to the Emergency Room (ER) at 2:45 p.m.

The progress note dated April 11, 2024 revealed that the resident returned to the facility at 12:05 a.m. Per the documentation, the family were upset because resident #4 was not scheduled for dialysis on April 11, 2024. Further, the documentation included that the family took the resident to the dialysis center on April 11, 2024 at 5:00 a.m.; and that, the facility agreed to schedule transport to pick the resident from dialysis to return to the nursing facility.

Further review of the clinical record revealed no documentation of reason why transportation to dialysis appointment was not arranged for resident #4.

In an interview with the licensed practical nurse (LPN/staff #90) conducted on April 17, 2024 at 3:00 p.m., the LPN (#90) stated that they did not complete any post dialysis assessment for resident #4 even if it was on the TAR. LPN (#90) stated that pre- and post- dialysis assessments were completed in the assessment section of the electronic health record. A review of the clinical record was conducted with the LPN (#90) during the interview. The LPN stated that there were no dialysis assessments completed for resident #4.

An interview with the Director of Nursing (DON/staff #88) was conducted on April 17, 2024 at 4:31 p.m. The DON stated that the clinical record of resident #4 did not have dialysis assessments completed for resident #4.

During an interview with the unit clerk (staff #76) conducted on April 17, 2024 at 2:45 p.m., the unit clerk stated that they were responsible for scheduling transportation for all residents; and that, if they had already left for the day when a resident gets admitted, the care management or the transportation director will have to set it up the appointments. Staff (#76) said that if the facility were notified that a resident was not picked up at the facility, they will follow up immediately with the dialysis center to see if the resident person can still be seen for dialysis. They stated that if the center does not have any chairs available for later time that same day, they will schedule a special chair for the resident for the next day; and that, they would make the appointment for them to be seen outside their regularly scheduled time. Staff (#76) stated that if the facility was advised that it was an urgent case, the facility will take the resident to the hospital to be dialyzed. Regarding resident #4, staff (#76) stated that resident #4 did not have dialysis completed on April 10, 2024 at 11:30 a.m. because the staff who completed the resident's admission did not inform her that the resident needed transportation to dialysis. Staff (#76) said that they found out that the resident did not go to his dialysis appointment when they received a call from the resident's family at approximately 10:00 a.m. and reported that family was at the dialysis center but resident #4 was not. Staff (#76) said they called the dialysis center to see if the resident could be seen that day, but she was told no. Staff (#76) stated that the resident was then scheduled on April 11, 2024 at 5:00 a.m. and they notified the family. However, the unit clerk said that on April 10, the resident had an accident and was sent out to the ER. Further, Staff (#76) said that they cancelled the resident's transportation to dialysis for April 11, 2024 at 5 a.m. because she did not know if the resident would be back to the nursing facility from the ER. The Staff (#76) said that the resident returned at the facility on April 11, 2024 at 12:00 a.m.

In another interview with the LPN (staff #90) conducted on April 17, 2024 at 3:00 p.m., the LPN stated they were responsible for setting up transportation to dialysis appointments for residents; and that, the facility provided all transportation, so it is very unlikely for transportation not showing up. Staff (#90) said that if the transportation did not come, they would call the dialysis center to let them know and work to reschedule the resident for later time that day or as soon as possible. Further, Staff (#90) stated that the provider at the dialysis center will either say the resident was okay to skip that day's session and attend their next appointment as scheduled; or, they will need to come in as soon as possible.

In an interview with the nurse care manager (staff #65) conducted on April 17, 2024 at 3:12 p.m., they stated a 'meet and greet' with new admissions where they would go over things like transportation needs and dialysis appointments; but, the unit clerk or maintenance director will set up the actual transportation. Regarding resident (#4), staff (#65) said that after completing the intake with resident #4 and his family, they told the staff (#76) that resident (#4) would need transportation set up for his Monday, Wednesday, Friday dialysis appointments. Staff (#65) said that there was no transportation set up to take the resident to his April 10, 2024 11:30 a.m. appointment; and that, after the resident was sent out for his fall on April 10 (same day as the scheduled dialysis), an appointment was made for 5:00 a.m. on April 12, 2024. Staff (#65) further stated that she made sure transportation had been set up for that one as well as a return car for 10:00 a.m.

In an interview with the DON conducted on April 17, 2024 at 3:55 p.m., the DON stated that the expectation was for the facility to always offer to transport residents to dialysis appointments whether they use the facility driver or a third-party vendor to do so. The DON said that if transportation does not show up, staff were expected to check if they can get the resident's dialysis set up again immediately; and, for sta

Based on observation, clinical record review, staff interviews, and facility documentation, policy and procedure, the facility failed to maintian highest practicable well-being by failing to ensure dialysis assessments were completed and transportation to dialysis appointments was arranged for one of 3 sampled residents (#4).

Findings include:

The facility's contract with the Dialysis Facility, signed and dated 10/18/2023, it included that the facility shall be responsible for arranging transportation of residents to and from Dialysis Facility, including all transportation costs and expenses. Long term care facility shall be responsible for ensuring that residents are (i) medically stable to undergo such transportation, (ii) medically suitable to receive treatment at Dialysis Facility, and (iii) timely transported to and from Dialysis Facility.

Resident (#4) was admitted April 8, 2024 with diagnoses of type 2 diabetes mellitus with diabetic chronic kidney disease (CKD), CKD with Heart Failure and Stage 5 CKD or end stage renal disease

A physician order dated April 8, 2024 included for dialysis three times a week on Mondays, Wednesdays, and Fridays; and, the chair time would be from 11:50am to 3:20pm with an arrival time of 11:30am.

Another physician order dated April 8, 2024 revealed an order to complete pre-dialysis and post-dialysis assessments every day shift on every Monday, Wednesday, and Friday.

A progress note dated April 9, 2024 included that the care manager met with the resident and family for an admission intake review that covered review of all medications, treatment orders, dietary orders, therapy services and all other interventions or services ordered at the time of admission.

A review of the Treatment Administration Record (TAR) for April 2024 included that a post dialysis assessment was documented as completed on April 10 and 12, 2024.

However, the documentation from the dialysis center revealed that the resident did not receive dialysis on April 10, 2024.

A progress note dated April 10, 2024 revealed that the resident was sent to the Emergency Room (ER) at 2:45 p.m.

The progress note dated April 11, 2024 revealed that the resident returned to the facility at 12:05 a.m. Per the documentation, the family were upset because resident #4 was not scheduled for dialysis on April 11, 2024. Further, the documentation included that the family took the resident to the dialysis center on April 11, 2024 at 5:00 a.m.; and that, the facility agreed to schedule transport to pick the resident from dialysis to return to the nursing facility.

Further review of the clinical record revealed no documentation of reason why transportation to dialysis appointment was not arranged for resident #4.

In an interview with the licensed practical nurse (LPN/staff #90) conducted on April 17, 2024 at 3:00 p.m., the LPN (#90) stated that they did not complete any post dialysis assessment for resident #4 even if it was on the TAR. LPN (#90) stated that pre- and post- dialysis assessments were completed in the assessment section of the electronic health record. A review of the clinical record was conducted with the LPN (#90) during the interview. The LPN stated that there were no dialysis assessments completed for resident #4.

An interview with the Director of Nursing (DON/staff #88) was conducted on April 17, 2024 at 4:31 p.m. The DON stated that the clinical record of resident #4 did not have dialysis assessments completed for resident #4.

During an interview with the unit clerk (staff #76) conducted on April 17, 2024 at 2:45 p.m., the unit clerk stated that they were responsible for scheduling transportation for all residents; and that, if they had already left for the day when a resident gets admitted, the care management or the transportation director will have to set it up the appointments. Staff (#76) said that if the facility were notified that a resident was not picked up at the facility, they will follow up immediately with the dialysis center to see if the resident person can still be seen for dialysis. They stated that if the center does not have any chairs available for later time that same day, they will schedule a special chair for the resident for the next day; and that, they would make the appointment for them to be seen outside their regularly scheduled time. Staff (#76) stated that if the facility was advised that it was an urgent case, the facility will take the resident to the hospital to be dialyzed. Regarding resident #4, staff (#76) stated that resident #4 did not have dialysis completed on April 10, 2024 at 11:30 a.m. because the staff who completed the resident's admission did not inform her that the resident needed transportation to dialysis. Staff (#76) said that they found out that the resident did not go to his dialysis appointment when they received a call from the resident's family at approximately 10:00 a.m. and reported that family was at the dialysis center but resident #4 was not. Staff (#76) said they called the dialysis center to see if the resident could be seen that day, but she was told no. Staff (#76) stated that the resident was then scheduled on April 11, 2024 at 5:00 a.m. and they notified the family. However, the unit clerk said that on April 10, the resident had an accident and was sent out to the ER. Further, Staff (#76) said that they cancelled the resident's transportation to dialysis for April 11, 2024 at 5 a.m. because she did not know if the resident would be back to the nursing facility from the ER. The Staff (#76) said that the resident returned at the facility on April 11, 2024 at 12:00 a.m.

In another interview with the LPN (staff #90) conducted on April 17, 2024 at 3:00 p.m., the LPN stated they were responsible for setting up transportation to dialysis appointments for residents; and that, the facility provided all transportation, so it is very unlikely for transportation not showing up. Staff (#90) said that if the transportation did not come, they would call the dialysis center to let them know and work to reschedule the resident for later time that day or as soon as possible. Further, Staff (#90) stated that the provider at the dialysis center will either say the resident was okay to skip that day's session and attend their next appointment as scheduled; or, they will need to come in as soon as possible.

In an interview with the nurse care manager (staff #65) conducted on April 17, 2024 at 3:12 p.m., they stated a 'meet and greet' with new admissions where they would go over things like transportation needs and dialysis appointments; but, the unit clerk or maintenance director will set up the actual transportation. Regarding resident (#4), staff (#65) said that after completing the intake with resident #4 and his family, they told the staff (#76) that resident (#4) would need transportation set up for his Monday, Wednesday, Friday dialysis appointments. Staff (#65) said that there was no transportation set up to take the resident to his April 10, 2024 11:30 a.m. appointment; and that, after the resident was sent out for his fall on April 10 (same day as the scheduled dialysis), an appointment was made for 5:00 a.m. on April 12, 2024. Staff (#65) further stated that she made sure transportation had been set up for that one as well as a return car for 10:00 a.m.

In an interview with the DON conducted on April 17, 2024 at 3:55 p.m., the DON stated that the expectation was for the facility to always offer to transport residents to dialysis appointments whether they use the facility driver or a third-party vendor to do so. The DON said that if transportation does not show up, staff were expected to check if they can get the resident's dialysis set up again immediately; and, for staff to call the dialysis center and see if the resident can be a

Based on clinical record review, facility documentation, the State database, staff interviews, and policies review, the facility failed to ensure that an allegation of abuse for one resident (#45) was reported to the State within the required time frame.

Findings include:

Resident #45 was admitted to the facility on 10/16/2023 with diagnoses that included chronic kidney disease and pneumonia.

According to the Minimum Data Set assessment, he scored 13 on his Brief Interview for Mental Status (BIMS) which indicated cognitive intactness.

He had orders for 300 milligrams (mg) of Gabapentin one time a day for neuropathy dated 10/17/23. His hospital discharge paperwork reflected this same order for 300mg of Gabapentin once a day. He had a new order for Gabapentin dated 11/9/23 for 800 mg three time a day for neuropathy.

In a review of the grievance log for November 2023, the facility received a "Comment and Concern Form" from Resident #45 on 11/9/23. His concern was that he had been asking for Gabapentin since he cannot sleep due to the pain related to his neuropathy in his arms and legs. He stated he laid awake all night in pain and felt the staff did not take him seriously. He stated he had contacted an attorney due to not getting his medications being a form of abuse.

The Grievance log shows that the complaint was investigated by staff and resolved on 11/9/23 and the resident was informed the same day.

In an interview on 1/31/24 with the social services director at 11:25 AM, she stated that the Executive Director is the one who reports abuse to the Department of Health, and Social Services will report to the Ombudsman and Adult Protective Services. She stated she gets reports of abuse from a resident, staff, or comment/concern cards. She will then go an interview the patient and will write up a report which is given to the Director of Nursing and the Executive Director to follow up with.

During an interview with the Executive Director on 1/31/24 at 1:13 PM regarding Resident #45, she stated that she had had concerns with medication orders and how they were written and nursing had to get updated orders to manage the residents pain. The Executive Director reviewed the documentation of his grievance where Resident #45 specified he felt he was being abused. She stated that if the patient stated he felt he was abused it would be reportable.

Upon a request for self reports for November 2023, and a review of State databases, it was revealed this incident had not been reported by the facility. The Executive Director stated she would report the abuse to DHS immediately. DHS received the report on 1/31/24 at 01:47 PM.

In a facility policy titled "Grievances/Complaints, Recording and Investigating" last revised April 2017, it states "The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law."

Additionally, in the facility policy titled "Abuse Neglect, Exploitation or Misappropriation-Reporting and Investigating," last revised September 2022, it states "the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director ... "Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on clinical record review, facility documentation, the State database, staff interviews, and policies review, the facility failed to ensure that an allegation of abuse for one resident (#45) was reported to the State within the required time frame. The deficient practice could result in further incidents of abuse not being reported as required.

Findings include:

Resident #45 was admitted to the facility on 10/16/2023 with diagnoses that included chronic kidney disease and pneumonia.

According to the Minimum Data Set assessment, he scored 13 on his Brief Interview for Mental Status (BIMS) which indicated cognitive intactness.

He had orders for 300 milligrams (mg) of Gabapentin one time a day for neuropathy dated 10/17/23. His hospital discharge paperwork reflected this same order for 300mg of Gabapentin once a day. He had a new order for Gabapentin dated 11/9/23 for 800 mg three time a day for neuropathy.

In a review of the grievance log for November 2023, the facility received a "Comment and Concern Form" from Resident #45 on 11/9/23. His concern was that he had been asking for Gabapentin since he cannot sleep due to the pain related to his neuropathy in his arms and legs. He stated he laid awake all night in pain and felt the staff did not take him seriously. He stated he had contacted an attorney due to not getting his medications being a form of abuse.

The Grievance log shows that the complaint was investigated by staff and resolved on 11/9/23 and the resident was informed the same day.

In an interview on 1/31/24 with the social services director at 11:25 AM, she stated that the Executive Director is the one who reports abuse to the Department of Health, and Social Services will report to the Ombudsman and Adult Protective Services. She stated she gets reports of abuse from a resident, staff, or comment/concern cards. She will then go an interview the patient and will write up a report which is given to the Director of Nursing and the Executive Director to follow up with.

During an interview with the Executive Director on 1/31/24 at 1:13 PM regarding Resident #45, she stated that she had had concerns with medication orders and how they were written and nursing had to get updated orders to manage the residents pain. The Executive Director reviewed the documentation of his grievance where Resident #45 specified he felt he was being abused. She stated that if the patient stated he felt he was abused it would be reportable.

Upon a request for self reports for November 2023, and a review of State databases, it was revealed this incident had not been reported by the facility. The Executive Director stated she would report the abuse to DHS immediately. DHS received the report on 1/31/24 at 01:47 PM.

In a facility policy titled "Grievances/Complaints, Recording and Investigating" last revised April 2017, it states "The Grievance Officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse and/or misappropriation of property will be reported and investigated under guidelines for reporting abuse, neglect and misappropriation of property, as per state law."

Additionally, in the facility policy titled "Abuse Neglect, Exploitation or Misappropriation-Reporting and Investigating," last revised September 2022, it states "the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director ... "Immediately" is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 09/04/2023 and 09/10/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/28/2023 and 09/03/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.