Haven Health Sky Harbor, LLC

Based on clinical record review, interviews, and review of the facility policies, the facility failed to ensure that the care plan for one resident (#22) was updated according to the resident's preferences following a five-day investigation of a complaint. The deficient practice could result in suboptimal care planning to meet the resident's preferences.

Findings include:

Resident #22 was admitted to the facility on September 19, 2024 with a diagnosis of unilateral primary osteoarthritis to the right hip, epilepsy, mood affective disorder, psychosis and adjustment disorder.

Review of the Minimum Data Set (MDS) dated September 25, 2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12. Indicating that the resident has moderate cognitive impairment.

Resident #22 reported on October 7, 2024 at 6:00 PM that when a Certified Nursing Assistant (CNA) came to her room to provide incontinence care, she was "popped" in the "butt". Resident was not able to provide a date or time when the alleged incident occurred, but she did give a brief description of the CNA. The facility launched an investigation on October 7, 2024 through October 11, 2024 and it was determined that the allegation was unsubstantiated. In the investigation notes, it stated, "care plan has been updated to include 2 care givers for incontinent cares and per res request-female caregivers".

Review of the care plan dated September 19, 2024 with a revision on October 8, 2024, revealed the care plan was not revised to include the requested change in care regarding the resident was to have 2 female caregivers for incontinence care.

An interview was conducted on October 22, 2024 at 1:30 PM with Director on Nursing, (DON, staff #13). When asked if the care plan had been updated to 2 female care givers for incontinence care as was stated in the facility investigation report, staff #13 stated, no; and that, it was not in the care plan, it was an alert that was across her chart in the electronic medical records. "That's going to be a problem isn't it".

Review of State Operations Manual (SOM), Appendix PP (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17), revealed each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review and revision of his/her care plan. Residents also have the right to refuse treatment. The residents's care plan must be reviewed after each assessment, as required, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on clinical record review, interviews, and review of the facility policies, the facility failed to ensure that the care plan for one resident (#22) was updated according to the resident's preferences following a five-day investigation of a complaint. The deficient practice could result in suboptimal care planning to meet the resident's preferences.

Findings include:

Resident #22 was admitted to the facility on September 19, 2024 with a diagnosis of unilateral primary osteoarthritis to the right hip, epilepsy, mood affective disorder, psychosis and adjustment disorder.

Review of the Minimum Data Set (MDS) dated September 25, 2024 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12. Indicating that the resident has moderate cognitive impairment.

Resident #22 reported on October 7, 2024 at 6:00 PM that when a Certified Nursing Assistant (CNA) came to her room to provide incontinence care, she was "popped" in the "butt". Resident was not able to provide a date or time when the alleged incident occurred, but she did give a brief description of the CNA. The facility launched an investigation on October 7, 2024 through October 11, 2024 and it was determined that the allegation was unsubstantiated. In the investigation notes, it stated, "care plan has been updated to include 2 care givers for incontinent cares and per res request-female caregivers".

Review of the care plan dated September 19, 2024 with a revision on October 8, 2024, revealed the care plan was not revised to include the requested change in care regarding the resident was to have 2 female caregivers for incontinence care.

An interview was conducted on October 22, 2024 at 1:30 PM with Director on Nursing, (DON, staff #13). When asked if the care plan had been updated to 2 female care givers for incontinence care as was stated in the facility investigation report, staff #13 stated, no; and that, it was not in the care plan, it was an alert that was across her chart in the electronic medical records. "That's going to be a problem isn't it".

Review of State Operations Manual (SOM), Appendix PP (Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17), revealed each resident has the right to participate in choosing treatment options and must be given the opportunity to participate in the development, review and revision of his/her care plan. Residents also have the right to refuse treatment. The residents's care plan must be reviewed after each assessment, as required, except discharge assessments, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a safe and appropriate transfer of one resident (#1). The deficient practice could result in residents not receiving appropriate care and services during the transition of care.

Findings include:

Resident #1 was admitted on April 2, 2024 with diagnoses of cerebral palsy, chronic respiratory failure with hypoxia, polyneuropathy, dysphasia, and scabies.

The care plan dated April 2, 2024 included that the resident was ventilator dependent related to respiratory failure. Interventions included to assess for signs/symptoms of hypoxia such as altered level of consciousness, irritability, listlessness and cyanosis; chest physio-therapy as ordered; keep head of bed elevated above 30 degrees; maintain spare trach at bedside; maintain ventilator settings as ordered; to monitor oxygen saturation while resident was on mechanical ventilatory support and/or during weaning process; and trach care twice in a 24-hour period.

A care plan dated April 3, 2024 revealed the resident required tube feeding and was dependent with tube feeding and water flushes. Interventions included to check for and record tube placement and gastric contents/residual volume per facility protocol; and to see physician orders for current feeding orders

The Minimum Data Set (MDS) admission assessment dated April 8, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. The MDS revealed the resident was on special treatments such as high concentration continuous oxygen therapy, scheduled and as needed suctioning, tracheotomy care, and invasive mechanical ventilator.

The care plan dated April 15, 2024 included that the resident had impaired cognitive function, dementia or impaired thought processes. Interventions included to administer medications as ordered; communicate regarding resident's capabilities and needs; and to engage the resident in simple, structured activities that avoid overly demanding tasks.

Another care plan dated April 15, 2024 revealed that the resident had a communication problem related to confusion. Interventions included to anticipate and meet needs; and, to use effective strategies and communication techniques which enhance interaction.

The social service progress note dated May 6, 2004 revealed that the state insurance prescreens, benefits, covered services and application process for continued placement was discussed resident #1 who did not want the insurance and would like to return back to the out-of-state facility where he came from.

The social service progress note dated May 8, 2024 included resident #1 came from an out-of-state facility that was closed due to flooding. Per the documentation, the out of state facility where resident #1 transferred out from was still not in operation and had no plans to open until December 2024.

The social service progress note dated May 8, 2024 revealed the resident would like to go back to the state where he came from due to having his whole family residing there; and, he wanted to go to a "sister" facility of the old out-of-state facility where he came from.

The social service progress note dated June 28, 2024 included a discussion with the resident family about having resident #1 closer to home so family can visit.

The social service progress note dated June 28, 2024 revealed that social service reached out to the out-of-state facility for bed availability.

Another progress note dated June 28, 2024 revealed that social service reached out to another out-of-state facility for bed availability.

The social service progress note dated July 8, 2024 revealed that the social service reached out to the out-of-state facility (where the resident came from) via phone and through email asking for assistance to relocate the resident back.

Another social service progress note dated July 8, 2024 included that social service reached out to another out-of-state facility requesting any update on accepting resident #1; and that, social services was told that the out-of-state facility did not have an available bed for the resident.

Another social service progress note dated July 8, 2024 revealed that social service reached out to additional eight out-of-state facilities provided by resident's family. Per the documentation, three facilities were not accepting residents on vents or trachs (tracheostomy); one facility not taking admissions due to full capacity; one facility had no male beds available; and three facilities did not answer the call and a message to call back was left.

The interdisciplinary team (IDT) care plan conference note dated July 8, 2024 included that the family of resident #1 would like the resident to stay at the facility until the resident was able to be placed in the out-of-state facility where he came from.

The social service progress note dated July 18, 2024 included that social service reached out to another out-of-state facility. The documentation included that the out-of-state facility did not have a subacute rehab and were unable to take the resident.

The nurse practitioner (NP) note dated July 18, 2024 included that the resident looked chronically ill, was alert, nodded in response to questions, had nonlabored breathing and was on a ventilator via trach (tracheostomy). Assessments included cerebral palsy, quadriplegia and chronic respiratory failure s/p (status post) trach.

Another social service progress note dated July 18, 2024 revealed that case management discussed the transfer update with the resident. The documentation included that during the discussion, the resident moved his head up and down indicating "yes" confirmation to go back to the state where he came from; and when asked about state insurance application option, the resident moved his head from side to side indicating "no". Further, the documentation included that the resident was asked whether he would go back to a hospital out-of-state (where he came from) if no facilities would accept his transfer; and that, the resident moved his head up and down indicating a "yes" confirmation in response.

The physician progress note dated July 19, 2024 revealed that the resident had a known history of ventilator dependent respiratory failure, was tetraplegic with spasticity and cerebral palsy. Plan included adjust ventilator settings as needed, tracheostomy care twice daily, aspiration precautions and suction as needed

A daily skilled evaluation note dated July 20, 2024 revealed that skilled care services provided were wound care, respiratory therapy/services, respiratory aspiration, gastrostomy feeding, physical and occupational therapy services; and tracheostomy care. Per the documentation, the resident had shortness of breath while lying flat, oxygen and ventilator were in use and the resident had a Foley catheter in place.

The social service progress note dated July 22, 2024 revealed that all placement options were exhausted in the resident's home state. Per the documentation, to honor the resident wishes to go back to his home state, resident was willing to go to the hospital in his home state. It also included that the resident was asked one more time if he was willing to stay and apply for state insurance and the "resident signal 'NO' with the movement of his side to side." Further, the note included that to honor resident wishes the facility paid for the resident's transport to his home state; and that, the resident was aware and understood that he will be transported per his wishes to the hospital in his home state.

The skilled needs review note dated July 23, 2024 included that resident expected to be discharged to community; an

Based on closed record review, staff interviews, review of facility documentation and policy, and the State Agency (SA) complaint tracking system, the facility failed to ensure a safe and appropriate transfer of one resident (#1).

Findings include:

Resident #1 was admitted on April 2, 2024 with diagnoses of cerebral palsy, chronic respiratory failure with hypoxia, polyneuropathy, dysphasia, and scabies.

The care plan dated April 2, 2024 included that the resident was ventilator dependent related to respiratory failure. Interventions included to assess for signs/symptoms of hypoxia such as altered level of consciousness, irritability, listlessness and cyanosis; chest physio-therapy as ordered; keep head of bed elevated above 30 degrees; maintain spare trach at bedside; maintain ventilator settings as ordered; to monitor oxygen saturation while resident was on mechanical ventilatory support and/or during weaning process; and trach care twice in a 24-hour period.

A care plan dated April 3, 2024 revealed the resident required tube feeding and was dependent with tube feeding and water flushes. Interventions included to check for and record tube placement and gastric contents/residual volume per facility protocol; and to see physician orders for current feeding orders

The Minimum Data Set (MDS) admission assessment dated April 8, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was unable to complete the interview. The MDS revealed the resident was on special treatments such as high concentration continuous oxygen therapy, scheduled and as needed suctioning, tracheotomy care, and invasive mechanical ventilator.

The care plan dated April 15, 2024 included that the resident had impaired cognitive function, dementia or impaired thought processes. Interventions included to administer medications as ordered; communicate regarding resident's capabilities and needs; and to engage the resident in simple, structured activities that avoid overly demanding tasks.

Another care plan dated April 15, 2024 revealed that the resident had a communication problem related to confusion. Interventions included to anticipate and meet needs; and, to use effective strategies and communication techniques which enhance interaction.

The social service progress note dated May 6, 2004 revealed that the state insurance prescreens, benefits, covered services and application process for continued placement was discussed resident #1 who did not want the insurance and would like to return back to the out-of-state facility where he came from.

The social service progress note dated May 8, 2024 included resident #1 came from an out-of-state facility that was closed due to flooding. Per the documentation, the out of state facility where resident #1 transferred out from was still not in operation and had no plans to open until December 2024.

The social service progress note dated May 8, 2024 revealed the resident would like to go back to the state where he came from due to having his whole family residing there; and, he wanted to go to a "sister" facility of the old out-of-state facility where he came from.

The social service progress note dated June 28, 2024 included a discussion with the resident family about having resident #1 closer to home so family can visit.

The social service progress note dated June 28, 2024 revealed that social service reached out to the out-of-state facility for bed availability.

Another progress note dated June 28, 2024 revealed that social service reached out to another out-of-state facility for bed availability.

The social service progress note dated July 8, 2024 revealed that the social service reached out to the out-of-state facility (where the resident came from) via phone and through email asking for assistance to relocate the resident back.

Another social service progress note dated July 8, 2024 included that social service reached out to another out-of-state facility requesting any update on accepting resident #1; and that, social services was told that the out-of-state facility did not have an available bed for the resident.

Another social service progress note dated July 8, 2024 revealed that social service reached out to additional eight out-of-state facilities provided by resident's family. Per the documentation, three facilities were not accepting residents on vents or trachs (tracheostomy); one facility not taking admissions due to full capacity; one facility had no male beds available; and three facilities did not answer the call and a message to call back was left.

The interdisciplinary team (IDT) care plan conference note dated July 8, 2024 included that the family of resident #1 would like the resident to stay at the facility until the resident was able to be placed in the out-of-state facility where he came from.

The social service progress note dated July 18, 2024 included that social service reached out to another out-of-state facility. The documentation included that the out-of-state facility did not have a subacute rehab and were unable to take the resident.

The nurse practitioner (NP) note dated July 18, 2024 included that the resident looked chronically ill, was alert, nodded in response to questions, had nonlabored breathing and was on a ventilator via trach (tracheostomy). Assessments included cerebral palsy, quadriplegia and chronic respiratory failure s/p (status post) trach.

Another social service progress note dated July 18, 2024 revealed that case management discussed the transfer update with the resident. The documentation included that during the discussion, the resident moved his head up and down indicating "yes" confirmation to go back to the state where he came from; and when asked about state insurance application option, the resident moved his head from side to side indicating "no". Further, the documentation included that the resident was asked whether he would go back to a hospital out-of-state (where he came from) if no facilities would accept his transfer; and that, the resident moved his head up and down indicating a "yes" confirmation in response.

The physician progress note dated July 19, 2024 revealed that the resident had a known history of ventilator dependent respiratory failure, was tetraplegic with spasticity and cerebral palsy. Plan included adjust ventilator settings as needed, tracheostomy care twice daily, aspiration precautions and suction as needed

A daily skilled evaluation note dated July 20, 2024 revealed that skilled care services provided were wound care, respiratory therapy/services, respiratory aspiration, gastrostomy feeding, physical and occupational therapy services; and tracheostomy care. Per the documentation, the resident had shortness of breath while lying flat, oxygen and ventilator were in use and the resident had a Foley catheter in place.

The social service progress note dated July 22, 2024 revealed that all placement options were exhausted in the resident's home state. Per the documentation, to honor the resident wishes to go back to his home state, resident was willing to go to the hospital in his home state. It also included that the resident was asked one more time if he was willing to stay and apply for state insurance and the "resident signal 'NO' with the movement of his side to side." Further, the note included that to honor resident wishes the facility paid for the resident's transport to his home state; and that, the resident was aware and understood that he will be transported per his wishes to the hospital in his home state.

The skilled needs review note dated July 23, 2024 included that resident expected to be discharged to community; and that the resident needed long term care (LTC) placement. Per the documentation, application to state insurance for LTC pl

Based on staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee developed and implemented action plans on identified problem related to PRN (as needed) pain medication administration.

Findings include:

In an interview conducted on May 2, 2024 at 3:34 p.m., with the Director of Nursing (DON/staff #4558) and the Vice President of Clinical Operations (Staff #2908). Staff #4558 stated that pain medications prescribed on an as needed basis (PRN) need a pain scale and it is her expectation that nurses assess the pain level prior to administration and document the pain level. She also stated that there is a risk of over or under medicating a resident if the pain medication is administered outside to the pain scale. Staff #2908 stated that they have identified the administration of pain medication as a problem in the last couple of months, and it is being addressed through quality assurance and performance improvement (QAPI).


An interview was conducted on May 6, 2024 at 11:24 a.m., with the Acting Administrator (staff #3911), Operations Manager (staff #2910) and the Director of Nursing (DON/staff #4558).


Staff #3911 stated that during QAA committee meetings they discuss reviews, activities reports, clinical staff reports. Recently mock surveys and issues were also brought up. Medical parameters, specifically following parameters i.e. for insulin was a problem. He noted that it is a challenge to determine what should be prioritized. Criteria for prioritization can either be based on which can be resolved quicker or priority of importance that impacts care. In December 13, 2023, there was a mock survey and they started in-servicing for specifically for administration of pain medication and general parameters. Staff #3911 stated that monitoring varies from 4-6 weeks to see if it is addressed.


The Resource Registered Nurse (RN), Vice President of Clinical Operations (staff #2908) joined the interview on May 6, 2024 at 11:34 a.m. Staff #2908 stated that in early December they identified PRN pain meds, and administering pain medications outside of parameters. The findings were disclosed to the administrator and the DON. The education and audits were written up and tools were provided. The DON was responsible for educating the staff and was assigned on late December - early January. Education was completed by the previous DON, who left around mid-March. The info was then handed to the new DON. The ADON (staff #6833) was the interim DON. Audits were supposed to be done. The Medication Administration Report (MAR) was supposed to be audited to check if the parameters were met. The frequency of the audits were supposed to be followed-up. Once the audit was completed, the outcome was to be presented at the next QAPI (Quality Assurance and Performance Improvement) meeting. The reason for the review is to determine if the facility has improved and if there a need to improve or adjust. Staff #2908 stated that she would need to see if a PIP (Performance Improvement Plan) was instituted or if it was just an audit and education which is not an official plan. The decision to make it an official PIP or an internal audit (audit and education) is determined by the frequency of the errors.


In a follow-up interview with staff #2908 (Resource RN, Vice President of Clinical Operations) conducted on May 6, 2024 at 12:25 p.m., she noted that pain review had no other findings other than multiple residents were given PRN medications outside of parameters. She noted that commendation was to do staff education and audits. Staff #2908 stated that they cannot provide the mock survey. She indicated that she is unable to tell who determined the recommendation and how often since it all occurred during the previous administrator and DON. She also noted that they cannot provide documentation since the folks in-charge at the time did not submit the documents. Staff #2908 said she did not see a PIP and that the assumption is that it was an education and audit. She also indicated that she understands that this is a finding.


Review of the Quality Assurance and Performance Improvement (QAPI) policy version 0917, indicated that the primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of residents. It indicated that systems are in place to monitor care and services. The policy also indicated that care processes and outcomes are monitored using performance indicators. These are measured against quality benchmarks and targets that the facility has established.


The policy titled "Quality Assurance and Performance Improvement Action Steps" version 0917, indicated that one of the steps is taking systemic action targeted at the root causes of identified problems. This encompass the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply "do the right thing."

Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that one resident's (#48) communication deficit was appropriately care planned and implemented. The deficient practice could result in a plan of care that did not meet the resident's needs.

Findings include:

Resident # 48 was admitted on March 25, 2022 with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder.



Review of the annual Minimum Data Set (MDS) assessment dated February 22, 2024 revealed that the resident had highly impaired hearing and unclear speech. The MDS noted that the resident was rarely/never understood and rarely/never understands. Furthermore, the MDS indicated that the resident had severely impaired vision. The MDS assessment also noted that the resident was dependent for cares.


Further review of the annual MDS dated February 22, 2024 indicated that the resident's diagnoses included aphasia, Cerebrovascular Accident (CVA)/Transient Ischemic Attack (TIA)/stroke, anxiety disorder, schizophrenia, blindness, and deafness.


The communication care plan revised September 7, 2023 indicated that the resident has a communication problem regarding hearing deficit and impaired cognition. The care plan indicated a goal which noted that resident will be able to make basic needs known. Interventions included to anticipate and meet needs, be conscious of positioning when in groups, activities to promote communication with others.


A care plan pertaining to the resident's impaired visual function dated September 7, 2023 indicated a goal in which resident will have no indications of acute eye problems. Interventions included to have resident's room and things arranged to promote independence.


However, further review of the care plan did not indicate the resident's method of communication. Additionally, the care plan did not state how staff can communicate with resident in order to meet her needs.


Additionally, review of the resident's clinical record revealed that the last time an interpreter was used was for the October 10, 2023 Nurse Practitioner (NP) visit. The progress note for the visit indicated that the interpreter was available but that the resident does not respond.

However, further review of the care plan did not indicate any update to address communication deficits or identify that resident needs American Sign Language (ASL) - tactile services.


A telephonic initial interview was conducted with resident #48's mother on April 29, 2024 at 11:47 a.m. Resident #48's mother indicated that she had asked the facility numerous times to provide an interpreter for the resident so that the resident can communicate her needs. However, this has not been routinely accommodated. Resident #48's mother indicated that the resident communicates via tactile sign language. She noted that her daughter gets scared/startled when staff provides care without warning or communicating what is going on.


A telephonic interview was conducted on May 2, 2024 at 3:11 p.m. with a representative (Receptionist/Scheduler/staff #666) of a language access company (interpretation service). Staff #666 noted that in the last three months, there was a request for an interpreter in February that they were not able to fill. Prior to that the last two sessions was from December 12, 2023 and November 7, 2023. The representative noted that the only resident they service at the facility is resident #48. Staff #666 indicated that the resident requires American Sign Language (ASL) - tactile since she is deaf and blind. She noted that their company has a contract with the facility and that the facility pays when services are provided. Staff #666 indicated that they are should be contacted during the monthly Nurse Practitioner (NP) visits to provide interpretation services.


During a follow-up telephonic interview with resident #48's mother conducted on May 5, 2024 at 12:59 a.m., she noted that Medicare pays for interpreter so she does not understand why the facility refuses to get an interpreter for her daughter. She noted that without an interpreter her daughter is not able to communicate her needs and the facility is not able to accurately understand her needs.


A telephonic interview was attempted on May 5, 2024 at 1:34 pm with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989). Voice mail left.



An interview with a Licensed Practical Nurse (LPN/staff #8888) was conducted on May 6, 2024 at 9:18 a.m. The LPN indicated that for residents with communication deficits, especially for those that have specific communication deficit it is helpful for staff to know how to communicate with the resident. Sometimes, certain residents require staff to have specific training even by a professional in order for them to be able to communicated and meet needs. Staff #8888 indicated that if a resident needs an interpreter to facilitate communication then it should be part of the care planned. The LPN also noted that in the case of resident #48, since she communicates via American Sign Language (ASL) - tactile, then there should be a tactile interpreter and have staff learn basics in order to communicate with the resident. Staff #8888 noted that the impact of a care plan not addressing specific issues such as communication deficits can affect care if the care plan is not updated which means it is not appropriate and can cause problems for both the resident and the staff.



A telephonic interview was attempted on May 7, 2024 at 2:10 p.m. with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989). No response, voice mail left.



A telephonic interview with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989) was conducted on June 10, 2024 at 11:12 a.m. Staff #8989 indicated that she had known resident #48 for 8 years. She noted that resident #48 uses American Sign Language (ASL) - tactile to communicate since she is deaf and blind. She indicated that she had told the facility numerous times that resident needs ASL-tactile to communicate. Furthermore, she had indicated that she informed the facility that due to the resident not getting ASL-tactile communication services, the resident is losing her ability to communicate due to lack of her language use. The resident is not being communicated to in the language that she recognizes which causes the resident to forget and get stuck when she is communicating in ASL-tactile. Due to the lack of use of her language and isolation this is causing her not to understand and not be as responsive. She also indicated that it makes it hard for the resident when she is not familiar with the interpreter and it is important to have object that she can relate to the person in order for her to recognize and be familiar with an individual. Staff #8989 also indicated staff should communicate to resident via ASL-tactile to explain to her what is going on around her so she can understand and not be weary when she is being touched.


An interview was conducted with both the Director of Nursing (DON/staff #4558) and the Assistant Director of Nursing (ADON/staff # 6833) on May 6, 2024 at 10:08 a.m. The DON indicated that her expectation is that residents would have a way to communicate their needs and for staff to understand residents' needs. Staff #4558 indicated that the impact of residents not being able to communicate their needs is that staff would not understand what the resident is requesting. The DON also noted that the expectation regarding care plans is that it is targeted towards residents' needs and individualized towards them. Staff #4558 also noted that the car

Based on documentation, staff interviews, and facility policies the facility failed to ensure that staff were trained in communication skills needed to communicate with one resident (#48).

Findings include:

Resident # 48 was admitted on March 25, 2022 with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder.

A neurology note dated May 19, 2023 indicated that resident #48 is bed ridden and needs tactile sign language to communicate. The note revealed that the resident has a complex medical history. She was born deaf, and had been high functioning for many years. However, she developed Usher syndrome and retinal detachment and lost her vision in her 30's.

Review of the annual Minimum Data Set (MDS) assessment dated February 22, 2024 revealed that the resident had highly impaired hearing and unclear speech. The MDS noted that the resident was rarely/never understood and rarely/never understands. Furthermore, the MDS indicated that the resident had severely impaired vision. The MDS assessment also noted that the resident was dependent for cares. The MDS indicated "unable to determine" if resident need or want an interpreter to communicate with a doctor or health care staff.

Further review of the annual MDS dated February 22, 2024 indicated that the resident's diagnoses included aphasia, Cerebrovascular Accident (CVA)/Transient Ischemic Attack (TIA)/stroke, anxiety disorder, schizophrenia, blindness, and deafness.

The communication care plan revised September 7, 2023 indicated that the resident has a communication problem regarding hearing deficit and impaired cognition. The care plan indicated a goal which noted that resident will be able to make basic needs known. Interventions included to anticipate and meet needs, be conscious of positioning when in groups, activities to promote communication with others.

A care plan pertaining to the resident's impaired visual function dated September 7, 2023 indicated a goal in which resident will have no indications of acute eye problems. Interventions included to have resident's room and things arranged to promote independence.

However, further review of the care plan did not indicate the resident's method of communication. Additionally, the care plan did not state how staff can communicate with resident in order to meet her needs. There was no mention that the resident's form of communication/language is American Sign Language - tactile (ASL-tactile) due to her being blind and deaf.

Review of the resident's clinical record revealed that the last time an interpreter was used was back in October 10, 2023 for a Nurse Practitioner (NP) visit. The progress note for the visit indicated that the interpreter was available but that the resident did not respond.

However, further review of the resident's clinical record did not indicate any updates or interventions to address the resident's communication deficits or evaluate potential decline in communication skills. Additionally, the clinical record does not identify that the resident utilizes ASL-tactile to communicate.

A telephonic initial interview was conducted with resident #48's mother on April 29, 2024 at 11:47 a.m. Resident #48's mother indicated that she had asked the facility numerous times to provide an interpreter for the resident so that the resident can communicate her needs. However, this has not been routinely accommodated. Resident #48's mother indicated that the resident communicates via tactile sign language. She noted that her daughter gets scared/startled when staff provides care without warning or communicating what is going on.

During an interview with the Activities Manager (staff #8607) conducted on May 2, 2024 at 8:49 a.m., staff #8607 noted that when it comes to resident #48, she does not know if she knows sign language but was told but the resident's mother that this is how she communicates. Staff #8607 said she believes there was a care plan that included what she thought was ladies that came out to teach the resident sign language. However, she did not receive a report and was not taught any sign language. Staff #8607 said that she would like to learn sign language so she could communicate with the resident.

An interview was conducted with a Restorative Nursing Assistant (RNA/staff #2753) on May 3, 2024 at 12:04 p.m. Staff #2753 stated that when resident #48 first arrived at the facility, her mother showed them basic signs to communicate with the resident. The RNA indicated that the resident's mother shared how to signal pain or hungry. Staff #2753 indicated that they always have ring on so that resident #48 knows how to identify them. This is basically an object specific to them to help the resident know who it is. They then touch the resident's leg first then signs name. Staff #2753 noted that each day is different for resident #48. Lately resident #48 have not been responding and refuses cares. They believe that it is potentially due to approach or interaction that the resident has had that day. Additionally, staff #2753 indicated that they noticed that resident #48 had been sleeping a lot more lately in the last 2-months. The RNA noted that this might be because the mother was not in the facility as much and she was the one that the resident communicated in ASL-tactile regularly.

In a follow-up interview with the Activities Manager (staff #8607) conducted on May 5, 2024 at 8:32 a.m., she stated that she did not receive training on tactile sign language but was aware that this is how the resident could communicate. Staff #607 stated that the interpreters only came a few times and she never asked anyone if she could receive training on tactile sign language.

During an interview with a Certified Nursing Assistant (CNA/staff #7901) conducted on May 5, 2024 at 8:50 a.m., staff #7901 stated that they rub resident #48's hands to her know that they are there. They noted that they stroke her arm to let her know that they are changing her. Rubs spoon on lips to let the resident know that they are feeding her, and if the resident pushes away then that means she is refusing. Staff #7901 stated that in all honesty, they do not know how to communicate with resident #48 since they do not know sign language. The CNA noted that the resident's mom informed them that the resident understands sign language but they never received training from the facility on sign language. Staff #7901 said that the resident's mother said to rub the resident's arm/hands to let the resident know that they are there.

An interview was conducted with a CNA (staff #4901) on May 5, 2024 at 9:02 a.m. Staff #4901 noted that they communicate with resident #48 by talking to her and touching her blouse to let her know they are changing her blouse. The CNA noted that she touches her slowly so she does not scare her. Staff #4901 stated that resident #48 knows sign language. However, the facility did not offer training in sign language. The CNA noted that sometimes resident #48 is yelling but they do not know what she needs. Staff #4901 noted that they try to get the resident up but she sometimes sleep all day. The CNA noted that if they were taught some sign language, then they would be able to communicate with the resident. Furthermore, staff #4901 stated that sometimes resident #48 is having behaviors but they do not know the reason for the behavior. They noted that an interpreter have been brought in to communicate with her. However, they said that they are not aware of anyone in the facility knowing tactile sign language. Staff #4901 said that they do not know how staff communicates with the resident during activities or how they tell resident #48 about activities. When resident #48 is yelling, it i

Based on observations, clinical record review, family and staff interviews, and facility policy and procedure, the facility failed to provide care and services related to communication for one resident (#48) assessed with communication/language deficit. The deficient practice could result in residents not maintaining their communication abilities.

Findings include:

Resident # 48 was admitted on March 25, 2022 with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder.


A neurology note dated May 19, 2023 indicated that resident #48 is bed ridden and needs tactile sign language to communicate. The note revealed that the resident has a complex medical history. She was born deaf, and had been high functioning for many years. However, she developed Usher syndrome and retinal detachment and lost her vision in her 30's.


Review of the annual Minimum Data Set (MDS) assessment dated February 22, 2024 revealed that the resident had highly impaired hearing and unclear speech. The MDS noted that the resident was rarely/never understood and rarely/never understands. Furthermore, the MDS indicated that the resident had severely impaired vision. The MDS assessment also noted that the resident was dependent for cares. The MDS indicated "unable to determine" if resident need or want an interpreter to communicate with a doctor or health care staff.


Further review of the annual MDS dated February 22, 2024 indicated that the resident's diagnoses included aphasia, Cerebrovascular Accident (CVA)/Transient Ischemic Attack (TIA)/stroke, anxiety disorder, schizophrenia, blindness, and deafness.


The communication care plan revised September 7, 2023 indicated that the resident has a communication problem regarding hearing deficit and impaired cognition. The care plan indicated a goal which noted that resident will be able to make basic needs known. Interventions included to anticipate and meet needs, be conscious of positioning when in groups, activities to promote communication with others.


A care plan pertaining to the resident's impaired visual function dated September 7, 2023 indicated a goal in which resident will have no indications of acute eye problems. Interventions included to have resident's room and things arranged to promote independence.


However, further review of the care plan did not indicate the resident's method of communication. Additionally, the care plan did not state how staff can communicate with resident in order to meet her needs. There was no mention that the resident's form of communication/language is American Sign Language - tactile (ASL-tactile) due to her being blind and deaf.


Review of the resident's clinical record revealed that the last time an interpreter was used was back in October 10, 2023 for a Nurse Practitioner (NP) visit. The progress note for the visit indicated that the interpreter was available but that the resident did not respond.

However, further review of the resident's clinical record did not indicate any updates or interventions to address the resident's communication deficits or evaluate potential decline in communication skills. Additionally, the clinical record does not identify that the resident utilizes ASL-tactile to communicate.


Review of the facility assessment completed January3, 2024 indicated that the facility accepts residents with vision and hearing impairments. Additionally, the staff training/education and competencies section noted that education and training will include communication for effective communication for direct care staff.


A telephonic initial interview was conducted with resident #48's mother on April 29, 2024 at 11:47 a.m. Resident #48's mother indicated that she had asked the facility numerous times to provide an interpreter for the resident so that the resident can communicate her needs. However, this has not been routinely accommodated. Resident #48's mother indicated that the resident communicates via tactile sign language. She noted that her daughter gets scared/startled when staff provides care without warning or communicating what is going on.


During an interview with the Occupational Therapist (OT/staff #664) conducted on May 2, 2024 at 10:28 a.m., they noted that a sign language interpreter for resident #48 only comes out for serious things such as splinting and the interpreter noted that resident can communicate to an extent. Staff #664 noted that resident #48 is both deaf and blind. Due to this it is difficult to communicate with this resident.


A telephonic interview was conducted on May 2, 2024 at 3:11 p.m. with a representative (Receptionist/Scheduler/staff #666) of a language access company (interpretation service). Staff #666 noted that in the last three months, there was a request for an interpreter in February that they were not able to fill. Prior to that the last two sessions was from December 12, 2023 and November 7, 2023. The representative noted that the only resident they service at the facility is resident #48. Staff #666 indicated that the resident requires American Sign Language (ASL) - tactile since she is deaf and blind. She noted that their company has a contract with the facility and that the facility pays when services are provided. Staff #666 indicated that they are should be contacted during the monthly Nurse Practitioner (NP) visits to provide interpretation services.


An interview was conducted with a Restorative Nursing Assistant (RNA/staff #2753) on May 3, 2024 at 12:04 p.m. Staff #2753 stated that when resident #48 first arrived at the facility, her mother showed them basic signs to communicate with the resident. The RNA indicated that the resident's mother shared how to signal pain or hungry. Staff #2753 indicated that they always have ring on so that resident #48 knows how to identify them. This is basically an object specific to them to help the resident know who it is. They then touch the resident's leg first then signs name. Staff #2753 noted that each day is different for resident #48. Lately resident #48 have not been responding and refuses cares. They believe that it is potentially due to approach or interaction that the resident has had that day. Additionally, staff #2753 indicated that they noticed that resident #48 had been sleeping a lot more lately in the last 2-months. The RNA noted that this might be because the mother was not in the facility as much and she was the one that the resident communicated in ASL-tactile regularly.


During an interview with a Certified Nursing Assistant (CNA/staff #7901) conducted on May 5, 2024 at 8:50 a.m., staff #7901 stated that they rub resident #48's hands to her know that they are there. They noted that they stroke her arm to let her know that they are changing her. Rubs spoon on lips to let the resident know that they are feeding her, and if the resident pushes away then that means she is refusing. Staff #7901 stated that in all honesty, they do not know how to communicate with resident #48 since they do not know sign language. The CNA noted that the resident's mom informed them that the resident understands sign language but they never received training from the facility on sign language. Staff #7901 said that the resident's mother said to rub the resident's arm/hands to let the resident know that they are there.


An interview was conducted with a CNA (staff #4901) on May 5, 2024 at 9:02 a.m. Staff #4901 noted that they communicate with resident #48 by talking to her and touching her blouse to let her know they are changing her blouse. The CNA noted that she touches her slowly so she does not scare her. Staff #4901 stated that resident #48 knows sign language. However, the facility did not offer tr

Based on observations, clinical record review, staff interviews, and review of policy and procedure, the facility failed to ensure assistance with meals was provided to one resident (#48). The sample size was 20. The deficient practice could result in resident not receiving adequate nutrition.

Findings include:

Resident #48 was admitted on March 25, 2022 with diagnoses of aphasia, dysphagia, major depressive disorder-recurrent, schizophrenia, generalized anxiety disorder, deaf, and blindness-right eye.

The minimum data set (MDS) dated November 23, 2023 included a staff assessment for mental status score of 3 indicating the resident had a severe cognitive impairment.

The care plan dated September 7, 2023 included that the resident had communication problem related to hearing deficit and impaired cognition. Interventions included anticipating and meet resident needs; and to communicate regarding resident's capabilities and needs.

The care plan further revealed that the resident was at risk for functional self-care deficits, required assistance with meals, had a nutritional or potential nutritional problem requiring one on one assistance with dining.

The resident's plan of care (POC) response history/ CNA (certified nursing assistant) tasks for April 2024 revealed the following information:

-April 7 - No meal intake entry documented for lunch;
-April 20 - No meal intake entry documented for breakfast; and,
-April 28 - No meal intake entry documented for breakfast.

Further review of the POC also revealed no documentation that the resident refused meals on April 7, 20 and 28, 2024.

A review of facility's video recordings for the 2100 nurses' station was conducted on May 2, 2024 at 3:09 P.M. with assistant director of nursing (ADON/staff #6833). The video recording revealed the following:

-An unknown staff member entered the resident's room with a lunch tray on April 7, 2024 at 12:44 p.m. and exited the room right away. The video recording further showed that no one entered the resident room again until 1:14 p.m.

-On April 20, 2024, the facility video recording revealed that an unknown staff member delivered the breakfast tray to resident #48 at 7:29 a.m. and immediately exited the room. At 7:57 a.m., a certified nursing assistant (CNA/staff #7901) entered the room and exited the room approximately 30 minutes after.

-On April 28, 2024 at 7:39 a.m., the CNA (staff #4901) dropped off the breakfast tray for resident #48 and then immediately exited the room. The video revealed that there was no one who entered the resident's room until 8:00 a.m. On the same date at 12:33 p.m., a lunch tray was delivered to resident #48 by staff the same CNA (#4901) who entered the room with the tray and immediately came back out of the room without the tray. The video recording did not show anyone else entering the resident's room again until 1:11 p.m.

An interview was conducted on May 2, 2024 at 10:31 A.M. with CNA (staff #29010) who stated that resident #48 was blind and deaf; and, required assistance with eating.

A telephone interview with licensed practical nurse (LPN/staff #7840) was conducted on May 2, 2024 at 9:41 A.M. The LPN stated that resident #48 required assistance with meals, tends to not eat much and needed encouragement. The LPN said that on April 30, 2024 she assisted the resident with eating for lunch; and that, the LPN documented that the resident only ate about 25% of her meal on April 30, 2024.

An interview was conducted on May 5, 2024 at 8:41 A.M. with the Operations Manager (staff #2910) and the Acting Administrator (staff # 3911). The acting administrator stated that the expectations were for staff to deliver meal trays and provide assistance to residents at the time meal trays were delivered. The acting administrator also stated that meals should be provided to residents that were independently able to eat first and then to those residents requiring assistance next, to ensure that staff can take their time with those that needed help. Further, the acting administrator stated that the delay for meal assistance after meal delivery for resident #48 did not meet his expectations; and that, the risk could include that the food would be cold and not palatable and the resident's nutritional needs would not be met.

The facility policy titled The Dining Experience, dated 2020, revealed that residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care.

Review of the policy on Food Services: Assistance with Meals with effective date of January 1, 2024 revealed that staff are to serve resident trays and help residents who require assistance with eating; however, meal assistance was not consistently rendered at the time of meal tray delivery, in spite of the resident requiring meal assistance as documented in the plan of care.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide and ongoing program of activities designed to meet the interest and the physical, mental, and psychological well-being of two residents (#48 and #37). The deficient practice could result in a decline in physical and social skills.

Findings include:

Resident #48 was admitted to the facility on March 25, 2022 with diagnoses that included blindness in right and left eye, deaf non-speaking, aphasia following cerebral infarction.

The care plan dated September 7, 2023 revealed a communication problem related to a hearing deficit and impaired cognition include the goal that the resident will be able to make her basic needs known. Interventions included that the staff will anticipate and meet the needs of the resident, and staff will be conscious of the resident's position when in groups, activities, and the dining room to promote proper communication with others. and discuss with the resident/family concerns or feelings regarding communication difficulty.

Review of the Activities Data Collection and Review (assessment) dated September 8, 2023 revealed that the resident was assessed for one-to-one sensory activities and does not participate in group activities at this time.

The minimum data set (MDS) dated November 23, 2023 included a staff assessment for mental status score of 3 indicating the resident had a severe cognitive impairment.

Review of the transfer task sheet dated February 2024 revealed that the resident was not transferred out of bed for 11 days out of 29.

The task sheet for one-to-one activities dated February 2024 did not reveal documentation of activity participation from February 1, 2024 to February 14, 2024. When the resident did participate in a one-to-one activity, the specific activity was not documented and the activity is documented as passive. There was no documentation of group activities occurring.

Review of the transfer task sheet dated March 2024 revealed that the resident was not transferred out of bed for 22 days out of 31.

The task sheet for one-to-one activities dated March 2024 did not reveal documentation of activity participation from March 20, 2024 to March 31, 2024. When the resident did participate in a one-to-one activity, the specific activity was not documented and the activity is documented as passive. There was no documentation of group activities occurring.

Review of the transfer task sheet dated April 2024 revealed that the resident was not transferred out of bed for 18 days out of 30.

Review of the activity task sheet dated April 2024 did not reveal activity participation. `

Review of all the activity task sheets, such as one-to-one activities, exercise/sports, family/friend visits, arts and crafts, Bingo, group events, ice cream social, lunch to go, manicure, music, nourishment snack, outdoor activities, room visits, sensory stimulation, special events/parties, reminisce, and walking/wheeling club did not reveal documentation for the last 30 days.

On May 5, 2024 at 8:31 a.m., the resident observed in her wheelchair in her room. She was wearing a helmet and facing the television.

During an interview conducted on April 29, 2024 at 12:06 p.m. with the resident's mother stated that the facility doesn't provide the resident with anything and just lets the resident stay in bed. She stated that the resident is not provided a sign language interpreter.

An interview was conducted on May 2, 2024 at 8:49 a.m. with the Activities Manager (staff #8607), who stated that she completes an activities assessment for each resident annually. She reviewed the resident's assessment and stated that the resident participates in sensory activities and comes out of her room to play bingo. She recommended that the resident come out of her room to participate in group activities at least twice week. She stated that the most current assessment doesn't include group activities, but it was a mistake and the resident is appropriate for group activities. It is hard for her to understand what the resident needs because the resident communicates through hand sign language, but no one has taught her to sign with the resident and she would have liked to have been able to communicate with her. Staff #8607 stated that the purpose of the activities is to help the resident emotionally, mentally, physically and it helps with depression. She reviewed the April attendance for activities and stated that resident does a lot of one-to-ones in her room and didn't have any activities documented for March 2023.

An interview was conducted on May 2, 2024 at 10:28 a.m. with the Occupational Therapist (OT/staff #664), who stated that she is monitoring the activities program and it is her expectation that the Activities Manager documents activity participation of each resident. She stated that the resident make noises, but it doesn't really bother anyone, and there is no reason why the resident can't participate in group activities. Staff #664 stated that the resident could go outside, and might like to be present for Bingo, music, ice cream socials, snacks, and could possibly work with larger beads. She doesn't know why the resident is not attending group activities and stated that the purpose of group activities is socialization and it can be very isolating if the resident is staying in her room. She stated that the facility schedules a sign language interpreter to communicate with the resident for more serious things, such as splinting and the interpreter has stated that the resident does understand to a certain extent.

An interview was conducted on May 2, 2024 at 11:30 a.m. with the RN, Clinical Compliance Director (#4909) and the acting Administrator (staff #3911). During the interview, the Activity Manager's job description was reviewed and staff #4909 agreed that it was the Activity Manager's job to assess the residents' participation and appropriateness of the activities, which was not being done. Staff #3911 reviewed the activity task sheets and stated that there is no documentation for activities at this time and this issue can go to QAPI.

An interview was conducted on May 5, 2024 at 1:51 p.m. with a Staffing Coordinator/certified nursing assistant (CNA/staff #7750), who stated that the resident is able to open her hands and fingers and can sometimes hold a piece of bread, cup, and milk carton. The resident can put the milk carton to her mouth and will attempt to drink with assistance. She stated that the resident is able to hold a hair brush, but not brush her hair. Staff #7750 stated that the resident attended Bingo this morning and just sat there, staff did not provide hand-over-hand assistance to help the resident participate. She would have to see if the resident could handle large beads to participate in beading.

The facility policy, "Activities and Social Services" dated January 2011 states that the interdisciplinary Care Team will evaluate the individual's personal history and preferences, and will consider his/her medical condition and prognosis in identifying relevant recreational and cultural activities.

Based on record review, staff interviews, and the facility policy and procedures, the facility failed to provide documentation of nursing and non-nursing staff working hours. The deficient practice could result in a lack of sufficient staffing and impact the residents' treatment and care.

Findings included:

Review of the daily staff posting dated July 30, 2023 revealed that one registered nurse (RN), four licensed practical nurses (LPNs), and eight certified nursing assistants (CNAs) were scheduled to work a 12-hour shift on the day shift.

Review of the nursing and non-nursing schedule dated July 30, 2023 revealed that one RN, four LPNs, eight CNAs were scheduled to work 12 hours on the day shift, However, none of the staff signed in to indicate that they were present for the shift.

Review of the daily staff posting dated July 30, 2023 revealed that three LPNs, and five CNAs were scheduled to work 12 hours on the night shift, and one CNA was scheduled to work eight hours during the night shift.

Review of the nursing and non-nursing schedule dated July 30, 2023 revealed that three LPNs were scheduled to work a twelve-hour shift during the night shift, but only two LPNs signed in. Five CNAs were scheduled to work 12 hours and one CNA was scheduled to work 8 hours. Only five CNAs signed in and one of the CNAs didn't start her shift until 10:00 p.m.

The PBJ Staffing Data Report for the fourth quarter, July 1, 2023 through September 30, 2023, revealed that the facility triggered for excessively low weekend staffing.

A written statement by the Acting Administrator (staff #3911) revealed that the facility has no employee records, including punch cards prior to August, 1, 2023.

An interview was conducted on May 2, 2024 at 3:48 p.m. with the Staffing Coordinator (staff #7750), who stated that she schedules the number of nursing and non-nursing staff for a shift based on the census. She stated that she did not have any punch cards for July 30, 2023, so she had no way to verify that there was an RN for eight consecutive hours or to confirm the number of nurses or CNAs that worked.

An interview was conducted on May 2, 2024 at 4:26 p.m. with the Operations Manager (staff #2910), who stated that they don't have any personnel records prior to the acquisition, which occurred August 1, 2023, which includes time cards.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that a registered nurse (RN) worked at least 8 consecutive hours per day.

Findings included:

Review of the daily staff posting dated December 31, 2023 did not reveal that a RN was scheduled to work on the day or night shift.

Review of the nursing schedule dated December 31, 2023 did not reveal that a RN was scheduled to work the day or night shift.

Review of the punch cards dated December 31, 2023 did not reveal that a RN worked during the day or night shift.

The PBJ Staffing Data Report for the fourth quarter, October 1 through December 31, 2023 revealed that the facility had four or more days within the quarter with no RN hours.

An interview was conducted on May 2, 2024 at 3:48 p.m. with the Staffing Coordinator (staff #7750), who stated that one RN is needed to work in the facility at least one 12-hour shift daily.

An interview was conducted on May 2, 2024 at approximately 4:45 p.m. with Human Resources (staff # 9814), who stated that she starting inputting the staffing data for the PBJ in December 2023, and the facility did not have RN coverage on December 31, 2024.

An interview was conducted on May 5, 2024 at 11:21 a.m. with the Director of Nursing (DON/staff #4558), who stated that the facility is required to have a RN work 8 consecutive hours per day.

An interview conducted on May 5, 2024 at 10:55 a.m. with Human Resources (staff #9814), who stated that the facility doesn't have a policy regarding staffing to include RN coverage.

The Facility Assessment Tool, Staffing Plan dated January 3, 2024 includes 0 to 4 RNs during the day shift and 0 to 5 RNs during the evening shift.

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure pain medications were administered as ordered for one resident (#68). The deficient practice could result in resident receiving unnecessary medication and overmedicated.

Findings include:

Resident #68 was admitted on August 14, 2023 with diagnoses of acute respiratory failure, critical illness myopathy, and Type II Diabetes.

The care plan dated August 14, 2023 revealed that the resident was at risk for pain. Interventions included to anticipate the resident's need for pain relief and respond as soon as possible to any complaint.

A physician order dated November 2, 2023 included for Tramadol HCI (narcotic analgesic) oral tablet 50 mg give 25 mg enterally every 12 hours as needed for pain 6-10.

The minimum data set (MDS) assessment dated February 14, 2024 included a brief interview for mental status (BIMS) score of 14 indicating the resident had intact cognition.

Review of the medication administration record (MAR) for February through April 2024 revealed that Tramadol was administered on the following dates:
-February 1 and February 22 for a pain level of 5;
-March 3, 2024 for a pain level of 4;
-March 29, 2024 for a pain level of 5;
-April 7, 2024 for a pain level of 4; and,
-April 10, 2024 for a pain level of 5.

The clinical record revealed no documentation of the reason why Tramadol was administered outside of the physician ordered pain parameters; and that, the physician was notified.

An interview was conducted on April 30, 2024 at 3:26 p.m. with a licensed practical nurse (LPN/staff #6757) who stated that PRN (as needed) pain medications include a pain scale. The LPN stated that the residents were assessed for pain and she would review the PRN pain medication order to ensure the resident's pain level was within the ordered pain parameter. The LPN said that pain scales were used to ensure that the resident will not be not over or under medicated. During the interview a review of the clinical record was conducted with the LPN who stated that records showed that Tramadol was administered outside of the physician ordered pain parameter to resident #68.

During an interview conducted on May 2, 2024 at 3:34 p.m., with the Director of Nursing (DON/staff #4558) and Vice President of Clinical Operations (VPCO/staff #2908), the DON stated that pain medications prescribed on a PRN basis needed a pain scale; and that, it was her expectation that nurses assess the pain level prior to administration and document the pain level. The DON also said that there was a risk of over or under medicating a resident if the pain medication was administered outside of the physician ordered pain parameters. The VPCO stated that they have identified the administration of pain medication as a problem in the last couple of months; and, it was being addressed through quality assurance and performance improvement (QAPI).

The facility policy, "Pain Management: Administering Pain Medications" dated January 2024 included a purpose to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice. Further, the policy included a procedure to administer pain medications as ordered.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#14). The deficient practice could result in residents not receiving care and services for oral/dental conditions.

Findings include:

Resident # 14 was initially admitted to the facility on January 6, 2022 with diagnoses that included multiple sclerosis, chronic obstructive pulmonary disease, aphagia, dysphagia, and general anxiety disorder.

A physician order dated July 31, 2023 directed that resident may be seen by podiatrist, dentist, eye doctor, wound care consultant, psychiatrist, and audiologist of choice as needed.

Review of the annual Minimum Data Set (MDS) assessment dated November 23, 2023 indicated that the resident has "obvious or like cavity or broken natural teeth."

A care plan regarding oral/dental health revised on December 5, 2023 indicated that the resident had potential for oral/dental health problems. Interventions included to coordinate for dental care, transportation as needed/ordered, and observe/monitor/document/report to provider as needed sign and symptoms of oral/dental problems needing attention.

The quarterly Minimum Data Set (MDS) dated February 22, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact.

During the initial screening interview conducted on April 29, 2024 at 10:37 a.m., resident #14 indicated that he has rotten molars. These molars have not started giving him pain which started last night.

In a follow-up interview with resident #14 conducted on May 1, 2024 at 12:22 p.m., he noted that he had informed the Resident Relations Manager (staff #9773) regarding the issue and was told it will be taken care of. Resident #14 noted transportation is not provided by the state so it has to be coordinated. He also stated that he has never been provided a dental exam and had never refused a dental exam. Resident #14 stated that there had never been any conversation regarding dental examinations and he was never offered any dental care. If they had, then he would have gotten it.

Review of the resident's clinical record did not reveal documentation which stated that resident was offered dental care or that dental care had been scheduled.

An interview was conducted with a Care Coordinator (staff #4689) on May 1, 2024 at 12:53 p.m. Staff #4689 noted that once a month there is a dental provider that comes in to provide residents dental care. The scheduling is normally done by the Unit Coordinator/Unit Secretary (staff #9600). The Unit Coordinator schedules the appointment and the transportation. Tracking of appointments is also done by the Unit Coordinator.


During an interview with the Unit Coordinator/Unit Secretary (staff #9600) conducted on May 1, 2024 at 1:01 p.m., staff #9600 stated that she normally looks at orders every morning to see if anything is new. If there is a new order, she schedules it if it is with a dentist that they normally use. If not, then a referral is sent out. Staff #9600 stated that for long term care residents, they are normally seen twice a year or every six months. She looks over the orders and then once the provider comes in, then compiles a list of everyone that has been seen. Staff #9600 noted that since she has only been on the job for a month, she does not have access to information prior or the previous list. She noted that with regards to resident #14, she is not sure if he is scheduled or getting scheduled. She noted that she will not be able to schedule him unless there is an order or she has been told to schedule him. Staff #9600 stated that basically if someone lets her know that is when he can get scheduled. She also noted that the he will get scheduled based on the urgency of the need. Staff #9600 said that the last time dental services were in the facility was April 22, 2024. She noted that it can be mentally impactful on a resident if they are not receiving needed dental care since it affects their health and they would feel like they are not cared for.


In a follow-up correspondence with the Unit Coordinator/Unit Secretary (staff #9600) on May 1, 2024 at 5:03 p.m., staff #9600 stated that resident #14 had a standing order and had been placed on the list for the next dental visit.


An interview was conducted with a Certified Nursing Assistant (CNA/staff #7750) on May 5, 2024 at 4:27 p.m. Staff #7750 stated that if a resident complaints of tooth pain, then they let the nurse know and provide oral care for the resident. They encourage the resident to brush and rinse to see if there is something going on and see if there is something is there that is causing the pain. Oral/dental pain is addressed right away especially if it impacts chewing/eating.

In an interview with a Licensed Practical Nurse (LPN/staff #8888) conducted on May 6, 2024, staff #8888 said that typically there is a dentist that comes into the facility every couple of months. Long term care residents are seen routinely and some as needed if they are complaining of pain. Those that have oral/dental pain/concerns are seen depending on whether the issue is acute or routine care. If acute, then the facility is more proactive in getting the resident scheduled right away.

During an interview with the Director of Nursing (DON/staff #4558) and Assistant Director of Nursing (ADON/staff #6833) conducted on May 6, 2024 at 10:08 a.m., they noted that the expectation is that residents have the option to be seen by a dentist to address dental issues. The DON noted that some residents are able to go without and some need preventative care. Her expectation is that dental services is available to the residents. Additionally, she noted that going forward long-term care residents should be provided preventative dental services.

Review of the facility policy titled "Personal Care: Dental Services" effective January 1, 2024, indicated that routine and emergency dental services are available to meet the resident's oral health in accordance with the resident's assessment and plan of care. Additionally, it noted that social services representatives will assist residents with appointments and transportation arrangements.

Based on observations, interviews and policy review the facility failed to ensure a resident's (#48) food was served warm and palatable. The sample size was 20. The deficient practice has the potential for residents to refuse meals and or potentially impact the resident's nutritional intake as well as weight.

Findings include:

Resident #48 was admitted on March 25, 2022 with diagnoses of aphasia, dysphagia, major depressive disorder-recurrent, schizophrenia, generalized anxiety disorder, deaf, and blindness-right eye.

The minimum data set (MDS) dated November 23, 2023 included a staff assessment for mental status score of 3 indicating the resident had a severe cognitive impairment.

The care plan dated September 7, 2023 revealed that the resident was at risk for functional self-care deficits, required assistance with meals, had a nutritional or potential nutritional problem requiring one on one assistance with dining.

A review of facility's video recordings for the 2100 nurses' station was conducted on May 2, 2024 at 3:09 P.M. with assistant director of nursing (ADON/staff #6833). The video recording revealed the following:

-An unknown staff member entered the resident's room with a lunch tray on April 7, 2024 at 12:44 p.m. and exited the room right away. The video recording further showed that no one entered the resident room again until 1:14 p.m.

-On April 20, 2024, the facility video recording revealed that an unknown staff member delivered the breakfast tray to resident #48 at 7:29 a.m. and immediately exited the room. At 7:57 a.m., a certified nursing assistant (CNA/staff #7901) entered the room again and exited the room approximately 30 minutes after.

-On April 28, 2024 at 7:39 a.m., the CNA (staff #4901) dropped off the breakfast tray for resident #48 and then immediately exited the room. The video revealed that there was no one who entered the resident's room until 8:00 a.m. On the same date at 12:33 p.m., a lunch tray was delivered to resident #48 by staff the same CNA (#4901) who entered the room with the tray and immediately came back out of the room without the tray. The video recording did not show anyone else entering the resident's room again to assist until 1:11 p.m.

An interview was conducted on May 2, 2024 at 10:31 A.M. with CNA (staff #29010) who stated that resident #48 was blind and deaf; and, required assistance with eating.

A telephone interview with licensed practical nurse (LPN/staff #7840) was conducted on May 2, 2024 at 9:41 A.M. The LPN stated that resident #48 required assistance with meals, tends to not eat much and needed encouragement.

An interview was conducted on May 5, 2024 at 8:41 A.M. with the Operations Manager (staff #2910) and the Acting Administrator (staff # 3911). The acting administrator stated that the expectations were for staff to deliver meal trays and provide assistance to residents at the time meal trays were delivered. The acting administrator also stated that meals should be provided to residents that were independently able to eat first and then to those residents requiring assistance next, to ensure that staff can take their time with those that needed help. Further, the acting administrator stated that the delay for meal assistance after meal delivery for resident #48 did not meet his expectations; and that, the risk could include that the food would be cold and not palatable and the resident's nutritional needs would not be met.

The facility policy titled The Dining Experience, dated 2020, revealed that residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care.

-An observation was conducted on April 30, 2024 at 9:50 a.m. There were approximately 4 off-white particles measuring approximately 2 to 3 centimeters in length, stuck in between the round holes of the floor mat, directly in front of the food service area. There was also a personal cell phone found on the food preparation counter.

An interview was conducted on April 30, 2024 at 10:01 a.m. with the dietary manager (staff #2809 who stated that the cell phone should not be on the food preparation counter. The dietary manager then immediately removed the phone and placed it in the office area. The dietary manager stated that his expectation was that cell phones be put away and not stored on surfaces where food might be prepared; and that, the risk would be an infection control issue for the facility. Further, the dietary manager stated that the cell phone found on food preparation area belonged to a dietary aide (staff #7841).

An interview was conducted on April 30, 2024 at 10:11 a.m. with the dietary aide (staff #7841) who stated that the cell phone found on the food preparation counter belonged to her and that, it should not have been in the food service area. She stated that she had received training on not placing or storing personal items in the meal preparation areas in the kitchen, and that the risk was infection control.

In later observations conducted on April 30, 2024 at 11:53 a.m. and May 1, 2024 at 7:23 a.m., revealed that the off-white particles continued to be found in floor mat.

During the test tray observation conducted on April 30, 2024 at 12:54 p.m. there was a blue substance which was approximately 1 centimeter in length that was found on a meal tray.

In an interview with the dietary manager conducted on April 30, 2024 at 1:01 p.m., the dietary manager stated that the blue substance found the test tray appeared to be a piece from a plastic glove, and that it was the same color as the gloves currently utilized in the kitchen. The dietary manager also stated that this probably happened when the pork for lunch was being cut because staff wear gloves while touching the meat to slice it. The dietary manager also said that finding a foreign particle, such as this, in food did not meet his expectations and that the presence of non-food items on meal trays could cause potential health issues.

An interview conducted on May 1, 2024 at 8:06 a.m. with the operations manager (staff #2910) and the dietary manager (staff #2809). The dietary manager said that it was an expectation that no foreign objects are found in the food and that the risk to the residents could include getting the residents sick or a resident chocking. The operations manager stated that kitchen staff normally utilize clear gloves but they had run out and were utilizing the blue gloves at this time.

In an interview with the dietary manager (staff #2910) and acting administrator (staff #3911), conducted on May 1, 2024 at 8:15 a.m. the dietary manager stated that the expectation was that there would be no personal items kept in the kitchen area; and that, having a cell phone on the kitchen counter was an infection control issue. The acting administrator said that his expectation was that the kitchen floor-mat was raised every evening and the staff mop underneath the mat to ensure the floor was clean and that the risk for not doing this would be an infection control issue as well.

A review of the facility guideline and procedure manual on Cleaning Rotation revealed that items to be cleaned daily include the kitchen and dining room floors.

Review of the facility policy on Infection Control dated 2013, revealed that it is the facility's policy to maintain an active infection control program with the focus on a safe, and sanitary environment to help prevent the development and transmission of disease and infection.

Based on clinical record review, staff interviews, review of facility documentation, and policy, the facility failed to ensure that the electronic health record for resident #48 was complete and accurately documented. The sample size was 20. The deficient practice could result in incomplete and/or inaccurate clinical records.

Findings include:

Resident #48 was admitted on March 25, 2022 with diagnoses including aphasia, dysphagia, major depressive disorder-recurrent, schizophrenia, generalized anxiety disorder, deaf, and blindness-right eye.

A review of the quarterly MDS (minimum data set) dated November 23, 2024 revealed a BIMS (brief interview of mental status) score of 99, suggesting severe cognitive impairment.

A review of the plan of care (POC) response history, denoting the caregiver task of eating, for resident #48 on May 1, 2024 revealed that the resident had refused breakfast; however, the facility video revealed that staff #5901, had provided the meal tray and assisted with breakfast. The breakfast entry on the POC for May 1, 2024 was noted to have been made by staff #4901, CNA. Further documentation on May 1, 2024 for the lunchtime meal revealed documentation in the POC that the resident had eaten at 2:15 P.M.; however, per surveyor observation on the unit, resident #48 had not received her lunch tray at or before 2:15 P.M. on May 1, 2024.

Review of the POC response history for resident #48 on April 30, 2024 revealed that the resident had consumed between 26% to 50% for dinner, which was documented by staff #2691, LPN (licensed practical nurse); however, facility video documentation revealed that the dinner tray had been delivered by staff #2901, CNA and not staff #2691.

Review of the POC response history on April 20, 2024 for resident #48 revealed no evidence of any documentation for lunch intake and or refusal.

Review of the POC response history for April 16, 2024 for resident #48 revealed meal intake documentation for 2 entries at 4:57 P.M. and one for 5:00 P.M. The POC response history revealed no documentation for breakfast.

Review of the POC response history for April 14, 2024 revealed only 2 entries, one at 8:48 A.M and one at 2:09 P.M. The POC response history revealed no documentation for dinner.

An interview was conducted on May 1, 2024 with staff #2691, LPN at 2:30 P.M. Staff #2691 stated that all CNA related tasks are documented in the POC. She stated that she also documents on the POC, as she is the unit manager.

A follow-up interview was conducted with staff #2691, LPN on May 2, 2024 at 7:40 A.M. Staff #2691 stated that the documentation on May1, 2024 and on April 30, 2024 may have been made in error. She stated that she may have had another resident's information in front of her when she made the entries. She stated that the risk for not documenting accurately under the correct resident could include, not knowing what they had actually consumed.

An interview was conducted on May 2, 2024 at 10:31 A.M. with staff #2901, CNA in the presence of staff #6833 ADON (assistant director of nursing). Staff #2901 stated that resident #48 requires assistance with eating and that she has to be fed. He was unsure when the dinner tray arrived on April 30, 2024 but stated that he recalled that the resident had refused dinner that night when he delivered her tray. He stated that he does his own charting and is unsure why there was entry by someone else indicating that the resident had eaten, when she had not. He stated that he was not aware of anyone charting on behalf of other staff.

An interview was conducted on May 5, 2024 at 8:41 A.M. with staff #2910, Operations Director and staff #3911 Acting Administrator. Staff #3911 stated that the expectation is that documentation is accurate regarding residents and that the entries documenting resident care are made by those staff members providing the care or that entries, at minimum, are verified to ensure accuracy. Staff #3911 stated that the risk for entries being made by others and not verified could include inaccurate documentation in the resident's health record and that the facility can't follow-up clinically as needed when documentation is inaccurate.

A review of the facility policy entitled documentation, revised January 1, 2024 revealed that documentation in the medical record will be objective and not opinionated or speculative, complete and accurate; however, the POC response history was noted to be incomplete, inaccurate and speculative. Furthermore, it was noted that documentation will include the date and time of the service as well as the name and title of the individual providing the care; however, the POC revealed instances where the time of service was observed to be inaccurate or missing and instances where other staff had entered information incorrectly for staff who had actually provided resident care.

Based on staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee developed and implemented action plans on identified problem related to PRN (as needed) pain medication administration.

Findings include:

In an interview conducted on May 2, 2024 at 3:34 p.m., with the Director of Nursing (DON/staff #4558) and the Vice President of Clinical Operations (Staff #2908). Staff #4558 stated that pain medications prescribed on an as needed basis (PRN) need a pain scale and it is her expectation that nurses assess the pain level prior to administration and document the pain level. She also stated that there is a risk of over or under medicating a resident if the pain medication is administered outside to the pain scale. Staff #2908 stated that they have identified the administration of pain medication as a problem in the last couple of months, and it is being addressed through quality assurance and performance improvement (QAPI).


An interview was conducted on May 6, 2024 at 11:24 a.m., with the Acting Administrator (staff #3911), Operations Manager (staff #2910) and the Director of Nursing (DON/staff #4558).


Staff #3911 stated that during QAA committee meetings they discuss reviews, activities reports, clinical staff reports. Recently mock surveys and issues were also brought up. Medical parameters, specifically following parameters i.e. for insulin was a problem. He noted that it is a challenge to determine what should be prioritized. Criteria for prioritization can either be based on which can be resolved quicker or priority of importance that impacts care. In December 13, 2023, there was a mock survey and they started in-servicing for specifically for administration of pain medication and general parameters. Staff #3911 stated that monitoring varies from 4-6 weeks to see if it is addressed.


The Resource Registered Nurse (RN), Vice President of Clinical Operations (staff #2908) joined the interview on May 6, 2024 at 11:34 a.m. Staff #2908 stated that in early December they identified PRN pain meds, and administering pain medications outside of parameters. The findings were disclosed to the administrator and the DON. The education and audits were written up and tools were provided. The DON was responsible for educating the staff and was assigned on late December - early January. Education was completed by the previous DON, who left around mid-March. The info was then handed to the new DON. The ADON (staff #6833) was the interim DON. Audits were supposed to be done. The Medication Administration Report (MAR) was supposed to be audited to check if the parameters were met. The frequency of the audits were supposed to be followed-up. Once the audit was completed, the outcome was to be presented at the next QAPI (Quality Assurance and Performance Improvement) meeting. The reason for the review is to determine if the facility has improved and if there a need to improve or adjust. Staff #2908 stated that she would need to see if a PIP (Performance Improvement Plan) was instituted or if it was just an audit and education which is not an official plan. The decision to make it an official PIP or an internal audit (audit and education) is determined by the frequency of the errors.


In a follow-up interview with staff #2908 (Resource RN, Vice President of Clinical Operations) conducted on May 6, 2024 at 12:25 p.m., she noted that pain review had no other findings other than multiple residents were given PRN medications outside of parameters. She noted that commendation was to do staff education and audits. Staff #2908 stated that they cannot provide the mock survey. She indicated that she is unable to tell who determined the recommendation and how often since it all occurred during the previous administrator and DON. She also noted that they cannot provide documentation since the folks in-charge at the time did not submit the documents. Staff #2908 said she did not see a PIP and that the assumption is that it was an education and audit. She also indicated that she understands that this is a finding.


Review of the Quality Assurance and Performance Improvement (QAPI) policy version 0917, indicated that the primary purpose of the QAPI program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of residents. It indicated that systems are in place to monitor care and services. The policy also indicated that care processes and outcomes are monitored using performance indicators. These are measured against quality benchmarks and targets that the facility has established.


The policy titled "Quality Assurance and Performance Improvement Action Steps" version 0917, indicated that one of the steps is taking systemic action targeted at the root causes of identified problems. This encompass the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply "do the right thing."

Based on documentation, staff interviews, and facility policies the facility failed to ensure that staff were trained in communication skills needed to communicate with one resident (#48). The deficient practice could result in staff not understanding the medical and care needs of the residents.

Findings include:

Resident # 48 was admitted on March 25, 2022 with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder.

A neurology note dated May 19, 2023 indicated that resident #48 is bed ridden and needs tactile sign language to communicate. The note revealed that the resident has a complex medical history. She was born deaf, and had been high functioning for many years. However, she developed Usher syndrome and retinal detachment and lost her vision in her 30's.

Review of the annual Minimum Data Set (MDS) assessment dated February 22, 2024 revealed that the resident had highly impaired hearing and unclear speech. The MDS noted that the resident was rarely/never understood and rarely/never understands. Furthermore, the MDS indicated that the resident had severely impaired vision. The MDS assessment also noted that the resident was dependent for cares. The MDS indicated "unable to determine" if resident need or want an interpreter to communicate with a doctor or health care staff.

Further review of the annual MDS dated February 22, 2024 indicated that the resident's diagnoses included aphasia, Cerebrovascular Accident (CVA)/Transient Ischemic Attack (TIA)/stroke, anxiety disorder, schizophrenia, blindness, and deafness.

The communication care plan revised September 7, 2023 indicated that the resident has a communication problem regarding hearing deficit and impaired cognition. The care plan indicated a goal which noted that resident will be able to make basic needs known. Interventions included to anticipate and meet needs, be conscious of positioning when in groups, activities to promote communication with others.

A care plan pertaining to the resident's impaired visual function dated September 7, 2023 indicated a goal in which resident will have no indications of acute eye problems. Interventions included to have resident's room and things arranged to promote independence.

However, further review of the care plan did not indicate the resident's method of communication. Additionally, the care plan did not state how staff can communicate with resident in order to meet her needs. There was no mention that the resident's form of communication/language is American Sign Language - tactile (ASL-tactile) due to her being blind and deaf.

Review of the resident's clinical record revealed that the last time an interpreter was used was back in October 10, 2023 for a Nurse Practitioner (NP) visit. The progress note for the visit indicated that the interpreter was available but that the resident did not respond.

However, further review of the resident's clinical record did not indicate any updates or interventions to address the resident's communication deficits or evaluate potential decline in communication skills. Additionally, the clinical record does not identify that the resident utilizes ASL-tactile to communicate.

A telephonic initial interview was conducted with resident #48's mother on April 29, 2024 at 11:47 a.m. Resident #48's mother indicated that she had asked the facility numerous times to provide an interpreter for the resident so that the resident can communicate her needs. However, this has not been routinely accommodated. Resident #48's mother indicated that the resident communicates via tactile sign language. She noted that her daughter gets scared/startled when staff provides care without warning or communicating what is going on.

During an interview with the Activities Manager (staff #8607) conducted on May 2, 2024 at 8:49 a.m., staff #8607 noted that when it comes to resident #48, she does not know if she knows sign language but was told but the resident's mother that this is how she communicates. Staff #8607 said she believes there was a care plan that included what she thought was ladies that came out to teach the resident sign language. However, she did not receive a report and was not taught any sign language. Staff #8607 said that she would like to learn sign language so she could communicate with the resident.

An interview was conducted with a Restorative Nursing Assistant (RNA/staff #2753) on May 3, 2024 at 12:04 p.m. Staff #2753 stated that when resident #48 first arrived at the facility, her mother showed them basic signs to communicate with the resident. The RNA indicated that the resident's mother shared how to signal pain or hungry. Staff #2753 indicated that they always have ring on so that resident #48 knows how to identify them. This is basically an object specific to them to help the resident know who it is. They then touch the resident's leg first then signs name. Staff #2753 noted that each day is different for resident #48. Lately resident #48 have not been responding and refuses cares. They believe that it is potentially due to approach or interaction that the resident has had that day. Additionally, staff #2753 indicated that they noticed that resident #48 had been sleeping a lot more lately in the last 2-months. The RNA noted that this might be because the mother was not in the facility as much and she was the one that the resident communicated in ASL-tactile regularly.

In a follow-up interview with the Activities Manager (staff #8607) conducted on May 5, 2024 at 8:32 a.m., she stated that she did not receive training on tactile sign language but was aware that this is how the resident could communicate. Staff #607 stated that the interpreters only came a few times and she never asked anyone if she could receive training on tactile sign language.

During an interview with a Certified Nursing Assistant (CNA/staff #7901) conducted on May 5, 2024 at 8:50 a.m., staff #7901 stated that they rub resident #48's hands to her know that they are there. They noted that they stroke her arm to let her know that they are changing her. Rubs spoon on lips to let the resident know that they are feeding her, and if the resident pushes away then that means she is refusing. Staff #7901 stated that in all honesty, they do not know how to communicate with resident #48 since they do not know sign language. The CNA noted that the resident's mom informed them that the resident understands sign language but they never received training from the facility on sign language. Staff #7901 said that the resident's mother said to rub the resident's arm/hands to let the resident know that they are there.

An interview was conducted with a CNA (staff #4901) on May 5, 2024 at 9:02 a.m. Staff #4901 noted that they communicate with resident #48 by talking to her and touching her blouse to let her know they are changing her blouse. The CNA noted that she touches her slowly so she does not scare her. Staff #4901 stated that resident #48 knows sign language. However, the facility did not offer training in sign language. The CNA noted that sometimes resident #48 is yelling but they do not know what she needs. Staff #4901 noted that they try to get the resident up but she sometimes sleep all day. The CNA noted that if they were taught some sign language, then they would be able to communicate with the resident. Furthermore, staff #4901 stated that sometimes resident #48 is having behaviors but they do not know the reason for the behavior. They noted that an interpreter have been brought in to communicate with her. However, they said that they are not aware of anyone in the facility knowing tactile sign language. Staff #4901 said that they do not know how staff communicates with th

Based on clinical record review, staff interviews, and the facility policy and procedures, the facility failed to ensure pain medications were administered as ordered for one resident (#68).

Findings include:

Resident #68 was admitted on August 14, 2023 with diagnoses of acute respiratory failure, critical illness myopathy, and Type II Diabetes.

The care plan dated August 14, 2023 revealed that the resident was at risk for pain. Interventions included to anticipate the resident's need for pain relief and respond as soon as possible to any complaint.

A physician order dated November 2, 2023 included for Tramadol HCI (narcotic analgesic) oral tablet 50 mg give 25 mg enterally every 12 hours as needed for pain 6-10.

The minimum data set (MDS) assessment dated February 14, 2024 included a brief interview for mental status (BIMS) score of 14 indicating the resident had intact cognition.

Review of the medication administration record (MAR) for February through April 2024 revealed that Tramadol was administered on the following dates:
-February 1 and February 22 for a pain level of 5;
-March 3, 2024 for a pain level of 4;
-March 29, 2024 for a pain level of 5;
-April 7, 2024 for a pain level of 4; and,
-April 10, 2024 for a pain level of 5.

The clinical record revealed no documentation of the reason why Tramadol was administered outside of the physician ordered pain parameters; and that, the physician was notified.

An interview was conducted on April 30, 2024 at 3:26 p.m. with a licensed practical nurse (LPN/staff #6757) who stated that PRN (as needed) pain medications include a pain scale. The LPN stated that the residents were assessed for pain and she would review the PRN pain medication order to ensure the resident's pain level was within the ordered pain parameter. The LPN said that pain scales were used to ensure that the resident will not be not over or under medicated. During the interview a review of the clinical record was conducted with the LPN who stated that records showed that Tramadol was administered outside of the physician ordered pain parameter to resident #68.

During an interview conducted on May 2, 2024 at 3:34 p.m., with the Director of Nursing (DON/staff #4558) and Vice President of Clinical Operations (VPCO/staff #2908), the DON stated that pain medications prescribed on a PRN basis needed a pain scale; and that, it was her expectation that nurses assess the pain level prior to administration and document the pain level. The DON also said that there was a risk of over or under medicating a resident if the pain medication was administered outside of the physician ordered pain parameters. The VPCO stated that they have identified the administration of pain medication as a problem in the last couple of months; and, it was being addressed through quality assurance and performance improvement (QAPI).

The facility policy, "Pain Management: Administering Pain Medications" dated January 2024 included a purpose to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice. Further, the policy included a procedure to administer pain medications as ordered.

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#14).

Findings include:

Resident # 14 was initially admitted to the facility on January 6, 2022 with diagnoses that included multiple sclerosis, chronic obstructive pulmonary disease, aphagia, dysphagia, and general anxiety disorder.

A physician order dated July 31, 2023 directed that resident may be seen by podiatrist, dentist, eye doctor, wound care consultant, psychiatrist, and audiologist of choice as needed.

Review of the annual Minimum Data Set (MDS) assessment dated November 23, 2023 indicated that the resident has "obvious or like cavity or broken natural teeth."

A care plan regarding oral/dental health revised on December 5, 2023 indicated that the resident had potential for oral/dental health problems. Interventions included to coordinate for dental care, transportation as needed/ordered, and observe/monitor/document/report to provider as needed sign and symptoms of oral/dental problems needing attention.

The quarterly Minimum Data Set (MDS) dated February 22, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact.

During the initial screening interview conducted on April 29, 2024 at 10:37 a.m., resident #14 indicated that he has rotten molars. These molars have not started giving him pain which started last night.

In a follow-up interview with resident #14 conducted on May 1, 2024 at 12:22 p.m., he noted that he had informed the Resident Relations Manager (staff #9773) regarding the issue and was told it will be taken care of. Resident #14 noted transportation is not provided by the state so it has to be coordinated. He also stated that he has never been provided a dental exam and had never refused a dental exam. Resident #14 stated that there had never been any conversation regarding dental examinations and he was never offered any dental care. If they had, then he would have gotten it.

Review of the resident's clinical record did not reveal documentation which stated that resident was offered dental care or that dental care had been scheduled.

An interview was conducted with a Care Coordinator (staff #4689) on May 1, 2024 at 12:53 p.m. Staff #4689 noted that once a month there is a dental provider that comes in to provide residents dental care. The scheduling is normally done by the Unit Coordinator/Unit Secretary (staff #9600). The Unit Coordinator schedules the appointment and the transportation. Tracking of appointments is also done by the Unit Coordinator.


During an interview with the Unit Coordinator/Unit Secretary (staff #9600) conducted on May 1, 2024 at 1:01 p.m., staff #9600 stated that she normally looks at orders every morning to see if anything is new. If there is a new order, she schedules it if it is with a dentist that they normally use. If not, then a referral is sent out. Staff #9600 stated that for long term care residents, they are normally seen twice a year or every six months. She looks over the orders and then once the provider comes in, then compiles a list of everyone that has been seen. Staff #9600 noted that since she has only been on the job for a month, she does not have access to information prior or the previous list. She noted that with regards to resident #14, she is not sure if he is scheduled or getting scheduled. She noted that she will not be able to schedule him unless there is an order or she has been told to schedule him. Staff #9600 stated that basically if someone lets her know that is when he can get scheduled. She also noted that the he will get scheduled based on the urgency of the need. Staff #9600 said that the last time dental services were in the facility was April 22, 2024. She noted that it can be mentally impactful on a resident if they are not receiving needed dental care since it affects their health and they would feel like they are not cared for.


In a follow-up correspondence with the Unit Coordinator/Unit Secretary (staff #9600) on May 1, 2024 at 5:03 p.m., staff #9600 stated that resident #14 had a standing order and had been placed on the list for the next dental visit.


An interview was conducted with a Certified Nursing Assistant (CNA/staff #7750) on May 5, 2024 at 4:27 p.m. Staff #7750 stated that if a resident complaints of tooth pain, then they let the nurse know and provide oral care for the resident. They encourage the resident to brush and rinse to see if there is something going on and see if there is something is there that is causing the pain. Oral/dental pain is addressed right away especially if it impacts chewing/eating.

In an interview with a Licensed Practical Nurse (LPN/staff #8888) conducted on May 6, 2024, staff #8888 said that typically there is a dentist that comes into the facility every couple of months. Long term care residents are seen routinely and some as needed if they are complaining of pain. Those that have oral/dental pain/concerns are seen depending on whether the issue is acute or routine care. If acute, then the facility is more proactive in getting the resident scheduled right away.

During an interview with the Director of Nursing (DON/staff #4558) and Assistant Director of Nursing (ADON/staff #6833) conducted on May 6, 2024 at 10:08 a.m., they noted that the expectation is that residents have the option to be seen by a dentist to address dental issues. The DON noted that some residents are able to go without and some need preventative care. Her expectation is that dental services is available to the residents. Additionally, she noted that going forward long-term care residents should be provided preventative dental services.

Review of the facility policy titled "Personal Care: Dental Services" effective January 1, 2024, indicated that routine and emergency dental services are available to meet the resident's oral health in accordance with the resident's assessment and plan of care. Additionally, it noted that social services representatives will assist residents with appointments and transportation arrangements.

Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that one resident's (#48) communication deficit was appropriately care planned and implemented.


Findings include:


Resident # 48 was admitted on March 25, 2022 with diagnoses which included blindness, deafness, dysphasia, anxiety disorder, aphasia, schizophrenia, and major depressive disorder.


Review of the annual Minimum Data Set (MDS) assessment dated February 22, 2024 revealed that the resident had highly impaired hearing and unclear speech. The MDS noted that the resident was rarely/never understood and rarely/never understands. Furthermore, the MDS indicated that the resident had severely impaired vision. The MDS assessment also noted that the resident was dependent for cares.


Further review of the annual MDS dated February 22, 2024 indicated that the resident's diagnoses included aphasia, Cerebrovascular Accident (CVA)/Transient Ischemic Attack (TIA)/stroke, anxiety disorder, schizophrenia, blindness, and deafness.


The communication care plan revised September 7, 2023 indicated that the resident has a communication problem regarding hearing deficit and impaired cognition. The care plan indicated a goal which noted that resident will be able to make basic needs known. Interventions included to anticipate and meet needs, be conscious of positioning when in groups, activities to promote communication with others.


A care plan pertaining to the resident's impaired visual function dated September 7, 2023 indicated a goal in which resident will have no indications of acute eye problems. Interventions included to have resident's room and things arranged to promote independence.


However, further review of the care plan did not indicate the resident's method of communication. Additionally, the care plan did not state how staff can communicate with resident in order to meet her needs.


Additionally, review of the resident's clinical record revealed that the last time an interpreter was used was for the October 10, 2023 Nurse Practitioner (NP) visit. The progress note for the visit indicated that the interpreter was available but that the resident does not respond.

However, further review of the care plan did not indicate any update to address communication deficits or identify that resident needs American Sign Language (ASL) - tactile services.


A telephonic initial interview was conducted with resident #48's mother on April 29, 2024 at 11:47 a.m. Resident #48's mother indicated that she had asked the facility numerous times to provide an interpreter for the resident so that the resident can communicate her needs. However, this has not been routinely accommodated. Resident #48's mother indicated that the resident communicates via tactile sign language. She noted that her daughter gets scared/startled when staff provides care without warning or communicating what is going on.


A telephonic interview was conducted on May 2, 2024 at 3:11 p.m. with a representative (Receptionist/Scheduler/staff #666) of a language access company (interpretation service). Staff #666 noted that in the last three months, there was a request for an interpreter in February that they were not able to fill. Prior to that the last two sessions was from December 12, 2023 and November 7, 2023. The representative noted that the only resident they service at the facility is resident #48. Staff #666 indicated that the resident requires American Sign Language (ASL) - tactile since she is deaf and blind. She noted that their company has a contract with the facility and that the facility pays when services are provided. Staff #666 indicated that they are should be contacted during the monthly Nurse Practitioner (NP) visits to provide interpretation services.


During a follow-up telephonic interview with resident #48's mother conducted on May 5, 2024 at 12:59 a.m., she noted that Medicare pays for interpreter so she does not understand why the facility refuses to get an interpreter for her daughter. She noted that without an interpreter her daughter is not able to communicate her needs and the facility is not able to accurately understand her needs.


A telephonic interview was attempted on May 5, 2024 at 1:34 pm with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989). Voice mail left.



An interview with a Licensed Practical Nurse (LPN/staff #8888) was conducted on May 6, 2024 at 9:18 a.m. The LPN indicated that for residents with communication deficits, especially for those that have specific communication deficit it is helpful for staff to know how to communicate with the resident. Sometimes, certain residents require staff to have specific training even by a professional in order for them to be able to communicated and meet needs. Staff #8888 indicated that if a resident needs an interpreter to facilitate communication then it should be part of the care planned. The LPN also noted that in the case of resident #48, since she communicates via American Sign Language (ASL) - tactile, then there should be a tactile interpreter and have staff learn basics in order to communicate with the resident. Staff #8888 noted that the impact of a care plan not addressing specific issues such as communication deficits can affect care if the care plan is not updated which means it is not appropriate and can cause problems for both the resident and the staff.



A telephonic interview was attempted on May 7, 2024 at 2:10 p.m. with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989). No response, voice mail left.



A telephonic interview with the Program Coordinator of a Non-Profit Interpretation Service (staff # 8989) was conducted on June 10, 2024 at 11:12 a.m. Staff #8989 indicated that she had known resident #48 for 8 years. She noted that resident #48 uses American Sign Language (ASL) - tactile to communicate since she is deaf and blind. She indicated that she had told the facility numerous times that resident needs ASL-tactile to communicate. Furthermore, she had indicated that she informed the facility that due to the resident not getting ASL-tactile communication services, the resident is losing her ability to communicate due to lack of her language use. The resident is not being communicated to in the language that she recognizes which causes the resident to forget and get stuck when she is communicating in ASL-tactile. Due to the lack of use of her language and isolation this is causing her not to understand and not be as responsive. She also indicated that it makes it hard for the resident when she is not familiar with the interpreter and it is important to have object that she can relate to the person in order for her to recognize and be familiar with an individual. Staff #8989 also indicated staff should communicate to resident via ASL-tactile to explain to her what is going on around her so she can understand and not be weary when she is being touched.


An interview was conducted with both the Director of Nursing (DON/staff #4558) and the Assistant Director of Nursing (ADON/staff # 6833) on May 6, 2024 at 10:08 a.m. The DON indicated that her expectation is that residents would have a way to communicate their needs and for staff to understand residents' needs. Staff #4558 indicated that the impact of residents not being able to communicate their needs is that staff would not understand what the resident is requesting. The DON also noted that the expectation regarding care plans is that it is targeted towards residents' needs and individualized towards them. Staff #4558 also noted that the care plan is there to assist staff in providing care. The impact of a care plan not addressi

Based on observations, clinical record review, staff interviews, and review of policy and procedure, the facility failed to assist in maintaining the highest practicable well-being by failing to ensure assistance with meals was provided to one resident (#48).

Findings include:

Resident #48 was admitted on March 25, 2022 with diagnoses of aphasia, dysphagia, major depressive disorder-recurrent, schizophrenia, generalized anxiety disorder, deaf, and blindness-right eye.

A review of the quarterly MDS (minimum data set) assessment dated November 23, 2024 revealed a BIMS (brief interview of mental status) score of 99, indicating the resident had severe cognitive impairment.

The care plan revealed that the resident was at risk for functional self-care deficits, required assistance with meals, had a nutritional or potential nutritional problem requiring one on one assistance with dining.

The resident's plan of care response history for April 2024 revealed the following information:
-April 7 - No meal intake entry documented for lunch;
-April 20 - No meal intake entry documented for breakfast; and,
-April 28 - No meal intake entry documented for breakfast.
The documentation also revealed no documentation that the resident refused meals on April 7, 20 and 28, 2024.

A review of facility video recordings for the 2100 nurses' station was conducted on May 2, 2024 at 3:09 P.M. with assistant director of nursing (ADON/staff #6833). The video recording revealed the following:
-An unknown staff member entered the resident's room with a lunch tray on April 7, 2024 at 12:44 p.m. and exited the room right away. It also showed that no one entered the resident room again until 1:14 p.m.;
-On April 20, 2024, the facility video recording revealed that an unknown staff member delivered the breakfast tray to resident #48 at 7:29 a.m. and immediately exited the room. At 7:57 a.m., the certified nursing assistant (CNA/staff #7901) entered the room again and exited the room approximately 30 minutes after.; and,
-On April 28, 2024 at 7:39 a.m., the CNA (staff #4901) dropped off the breakfast tray for resident #48 and then immediately exited the room. The video revealed that there was no one who entered the resident's room until 8:00 a.m. On the same date at 12:33 p.m., a lunch tray was delivered to resident #48 by staff the same CNA (#4901) who entered the room with the tray and immediately came back out of the room without the tray. The video recording did not show anyone else entering the resident's room again until 1:11 p.m.

An interview was conducted on May 2, 2024 at 10:31 A.M. with another CNA (staff #29010 who stated that resident #48 was blind and deaf; and, required assistance with eating.

A telephone interview with licensed practical nurse (LPN/staff #7840) was conducted on May 2, 2024 at 9:41 a.m. The LPN stated that resident #48 required assistance with meals, tends to not eat much and needed encouragement. The LPN said that on April 30, 2024 she assisted the resident with eating for lunch; and that, the LPN documented that the resident only ate about 25% of her meal on April 30, 2024.

An interview was conducted on May 5, 2024 at 8:41 a.m. with the Operations Manager (staff #2910) and the Acting Administrator (staff # 3911). The acting administrator stated that the expectations were for staff to deliver meal trays and provide assistance to residents at the time meal trays were delivered. The acting administrator also said that meals should be provided to residents that were independently able to eat first and then to those residents requiring assistance next, to ensure that staff can take their time with those that needed help. Further, the acting administrator stated that the delay for meal assistance after meal delivery for resident #48 did not meet his expectations; and that, the risk could include that the food would be cold and not palatable and the resident's nutritional needs would not be met.

The facility policy titled The Dining Experience, dated 2020, revealed that residents will have an exceptional dining experience that enhances their quality of life and provides attention to the individual resident's plan of care.

Review of the policy on Food Services: Assistance with Meals with effective date of January 1, 2024 revealed that staff are to serve resident trays and help residents who require assistance with eating; however, meal assistance was not rendered at the time of meal tray delivery in spite of the resident requiring meal assistance as documented in the plan of care.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food items that were unsafe for resident consumption were discarded; and, the facility failed to ensure a clean and sanitary environment was maintained in the kitchen. The facility census was 98. The deficient practice could result in a potential for food borne illness and resident safety.

Findings include:

An initial tour of the kitchen was conducted with the dietary manager (staff #2809) on April 29, 2024 at 7:20 a.m. There was a 10-pound box of Romaine lettuce in an unsealed plastic bag in the walk-in refrigerator. There was also 10-pound box of snap peas that had white fuzzy growth on the snap peas. The dietary manager stated the bag was approximately one-third full; and, there was approximately two pounds of snap peas remaining in the box. The dietary manager stated that the lettuce leaves were wilted and some of the leaves were brown around the edges; and, the pea pods were no longer good because there was something growing on the pea pods. Further, the dietary manager stated that the lettuce should have been removed and should not be served to the residents; and that, the cook was supposed to check the produce to ensure food item was still fresh daily.

An interview was conducted with the Operations Manager (staff #2910) on May 2, 2024 at 4:08 p.m. She stated that it was her expectation that produce was checked daily and food with mold should be discarded. She also stated that mold spores create a risk of illness to the residents.

The facility policy titled, The Dining Experience: Objectives included that resident meals will be served in a sanitary environment with proper food handling procedures.

The facility policy, "Food Storage" dated 2018 included that sufficient storage facilities are provided to keep foods safe, wholesome, and appetizing. Food is stored in an area that is clean, dry, and free from contaminants.

Based on observation and staff interview the facility failed to provide a record of electrical equipment tests, repairs, and modifications. Failing to conduct maintenance on patient care appliances could cause harm to the residentt if the appliance malfunctions.

NFPA 101 Life Safety Code, 2012, Chapter 18, Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 10, Section 10.5.6 Record Keeping-Patient Appliances Electrical Equipment - Testing and Maintenance Requirements "The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training."

Findings include:

Observation, record review and staff interview on May 22, 2024, revealed the facility was unable to produce documentation to identify all electrical equipment tests, repairs, and modifications. The facility provided paper work for beds but not for blood pressure machines, suction units, or AED's

Facility management confirmed during the exit conference on May 22, 2024, the facilty failed to test some electrical equipment.

Based on observation, interviews and policy review, the facility failed to ensure that medications were administered as ordered by the physician for one resident (#400). The deficient practice could result in residents not receiving prescribed doses of medications.

Findings include:

Resident #400 was admitted on March 28, 2024 with diagnoses of cerebral infarction, myalgia, hyperlipidemia, polyneuropathy, and gastro-esophageal reflux disease.

A care plan initiated on April 1, 2024 revealed the resident had a history of stroke. Interventions included to give medications as ordered by the physician.

Review of the discharge Minimum Data Set (MDS) assessment dated April 2, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident had intact cognition.

The physician order dated March 28, 2024 revealed the following orders:
- Atorvastatin (anticholesterol) calcium oral tablet, give 40 mg (milligram) by mouth one time a day for hyperlipidemia; and,
- Gabapentin (anticonvulsant) oral capsule, give 400 mg by mouth three times a day for neuropathy

The physician order dated March 29, 2024 included for Methocarbamol (muscle relaxant) oral tablet, give 1000 mg by mouth three times a day for muscle spasms for 5 days 2 tabs.

Review of the eMAR (electronic MAR) progress notes for March 29, 2024 revealed the following:
- Atorvastatin was "awaiting pharmacy". This note was time stamped 9:04 p.m.;
- Gabapentin was "on order". This note was time stamped 11:00 p.m.; and,
- Methocarbamol was "on order awaiting pharmacy to deliver". This note was time stamped 11:00 p.m.

Review of the March 2024 Medication Administration Record (MAR) revealed the following medications were coded 9 on March 29, 2024.:
-Atorvastatin for the 8:00 p.m. administration;
-Gabapentin for 10:00 p.m. administration; and,
-Methocarbamol for the 10:00 p.m.
Per the documentation, code 9 indicated "Other/See Nurse Notes."

However, further review of the March 2024 MAR revealed that Gabapentin and Methocarbamol were administered on scheduled administration times of 8:00 a.m. and 2:00 p.m. on March 29; and,

The email correspondence from the pharmacy consultant (staff #10) and pharmacy director (staff #20) dated April 11, 2024 revealed that the order for medications for Gabapentin, Methocarbamol, and Atorvastatin was received by the pharmacy on March 28, 2024 at 9:53 p.m. It also included that the received time was after the cutoff for the 11:00 p.m. run, the medications were sent the next morning, March 29, 2024 on the 9:00 a.m. run. Further, the documentation included that to their records the medications were received and signed for by a facility staff member at 12:11 p.m. on March 29, 2024.

Review of the text message from the pharmacy consultant (staff #10) dated April 11, 2024 revealed that all the medications for resident #400 were delivered at the same time. It also included that she had seen gabapentin and methocarbamol in e-kits for the pharmacy in the past so she thought it could have been available; but that availability of these medications in the e-kits (emergency kit) were dependent on the facility's needs.

Review of the Pyxis machine's medication inventory list revealed that atorvastatin was listed as a medication in stock.

An interview was conducted with a licensed practical nurse (LPN/staff #30) on April 11, 2024 at 12:34 p.m. The LPN stated that the process to ensure that newly admitted residents get or have their medication at the facility, the staff check the e-kits for the medications and ensure that the orders for the medications have been sent to the pharmacy. She stated that between the e-kits and the pyxis machine the medication should be available; and that, if the resident's medications have not arrived, they will call the pharmacy and see about getting it STAT (immediately). The LPN said that the provider should be informed to see what needs to be done; or, staff should ask the DON (Director of Nursing) or ADON (Assistant Director of Nursing) for further instructions. She said that staff had to give scheduled medication as ordered unless it was refused by the resident. The LPN also said that it was weird that medication for a new admit to be available earlier in the day but later on be not available. Further, the LPN said that in instances that a medication was not available, there should be a detailed progress note and that provider should be informed.

An interview was conducted with another LPN (staff #40) on April 11, 2024 at 2:24 p.m. The LPN said that staff receives the paperwork approximately 2 hours prior to the arrival of the new admits. The staff will then fax the orders to the pharmacy to ensure that the medications will be on the next delivery run; and, if the medications have not arrived and there was a scheduled medication administration, staff were supposed to contact the pharmacy to find out the status of the medications and when it was expected to arrive. The LPN said that the staff was supposed to notify the provider that the resident's medication was not available or have not arrived so they can provide further instructions/orders. The LPN also said that when the medication is not available, staff was supposed to check the e-kits and the pyxis machine which contains common medications; and that, the pyxis machine can be accessed with pharmacy approval to obtain a medication. The LPN said that if the medication was not part of the inventory kept in the e-kits/pyxis machine, the medication will be ordered STAT which means that the medication should arrive within 2 hours. Further, the LPN said that it was rare that residents will miss medication since most medications were available in the e-kits/pyxis machine. The LPN stated that it was probably a registry who completed the resident's admission and was unfamiliar with the facility procedures. The LPN further stated that the facility normally had most medications handy; and that, there should be progress note regarding why the medication was still pending/awaiting pharmacy delivery. The LPN said that it can be a problem for a resident to not receive medications as ordered; and that, some medications were life sustaining and if it was not, then the medication can be placed on hold by the provider. However, the LPN said that the provider had to be informed so the provider can decide on what should be done. Regarding resident #400, the LPN said that it was weird to have the medication available for resident #400 earlier in the day and not available later on the same day. The LPN also said that it was hard to speculate what the impact of resident #400 missing the medications; but, there should have been more detailed notes documented to know what, why, and when the medication will be available and can be administered.

In an interview conducted with a Nurse Practitioner (NP/staff # 60) on April 11, 2024 at 2:54 p.m., the NP stated that his expectation was that medications are administered according to the order and facility protocols and documented in the MAR. The NP also said that his expectation was that he is notified if a resident's medications becomes unavailable to ensure that he knows if medications are on time or if unable to get it then to be able to get a different one that was similar to the unavailable drug. Further, the NP stated that medications not provided as scheduled can be problematic since these medications were there for a reason and were needed by the resident.

An interview was conducted on April 11, 2024 at 3:51 p.m. with the pharmacy consultant (staff #10) who stated that the facility had three delivery runs a day during the week and two on the weekends. Staff #10 said that during the week, the delivery leaves for the route at 9:00 a.m., 2:00 p.m., and 11:00 p.m.; and, on the w

Based on observation, interviews and policy review, the facility failed to ensure that medications were administered as ordered by the physician for one resident (#400).

Findings include:

Resident #400 was admitted on March 28, 2024 with diagnoses of cerebral infarction, myalgia, hyperlipidemia, polyneuropathy, and gastro-esophageal reflux disease.

A care plan initiated on April 1, 2024 revealed the resident had a history of stroke. Interventions included to give medications as ordered by the physician.

Review of the discharge Minimum Data Set (MDS) assessment dated April 2, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that the resident had intact cognition.

The physician order dated March 28, 2024 revealed the following orders:
- Atorvastatin (anticholesterol) calcium oral tablet, give 40 mg (milligram) by mouth one time a day for hyperlipidemia; and,
- Gabapentin (anticonvulsant) oral capsule, give 400 mg by mouth three times a day for neuropathy

The physician order dated March 29, 2024 included for Methocarbamol (muscle relaxant) oral tablet, give 1000 mg by mouth three times a day for muscle spasms for 5 days 2 tabs.

Review of the eMAR (electronic MAR) progress notes for March 29, 2024 revealed the following:
- Atorvastatin was "awaiting pharmacy". This note was time stamped 9:04 p.m.;
- Gabapentin was "on order". This note was time stamped 11:00 p.m.; and,
- Methocarbamol was "on order awaiting pharmacy to deliver". This note was time stamped 11:00 p.m.

Review of the March 2024 Medication Administration Record (MAR) revealed the following medications were coded 9 on March 29, 2024.:
-Atorvastatin for the 8:00 p.m. administration;
-Gabapentin for 10:00 p.m. administration; and,
-Methocarbamol for the 10:00 p.m.
Per the documentation, code 9 indicated "Other/See Nurse Notes."

However, further review of the March 2024 MAR revealed that Gabapentin and Methocarbamol were administered on scheduled administration times of 8:00 a.m. and 2:00 p.m. on March 29; and,

The email correspondence from the pharmacy consultant (staff #10) and pharmacy director (staff #20) dated April 11, 2024 revealed that the order for medications for Gabapentin, Methocarbamol, and Atorvastatin was received by the pharmacy on March 28, 2024 at 9:53 p.m. It also included that the received time was after the cutoff for the 11:00 p.m. run, the medications were sent the next morning, March 29, 2024 on the 9:00 a.m. run. Further, the documentation included that to their records the medications were received and signed for by a facility staff member at 12:11 p.m. on March 29, 2024.

Review of the text message from the pharmacy consultant (staff #10) dated April 11, 2024 revealed that all the medications for resident #400 were delivered at the same time. It also included that she had seen gabapentin and methocarbamol in e-kits for the pharmacy in the past so she thought it could have been available; but that availability of these medications in the e-kits (emergency kit) were dependent on the facility's needs.

Review of the Pyxis machine's medication inventory list revealed that atorvastatin was listed as a medication in stock.

An interview was conducted with a licensed practical nurse (LPN/staff #30) on April 11, 2024 at 12:34 p.m. The LPN stated that the process to ensure that newly admitted residents get or have their medication at the facility, the staff check the e-kits for the medications and ensure that the orders for the medications have been sent to the pharmacy. She stated that between the e-kits and the pyxis machine the medication should be available; and that, if the resident's medications have not arrived, they will call the pharmacy and see about getting it STAT (immediately). The LPN said that the provider should be informed to see what needs to be done; or, staff should ask the DON (Director of Nursing) or ADON (Assistant Director of Nursing) for further instructions. She said that staff had to give scheduled medication as ordered unless it was refused by the resident. The LPN also said that it was weird that medication for a new admit to be available earlier in the day but later on be not available. Further, the LPN said that in instances that a medication was not available, there should be a detailed progress note and that provider should be informed.

An interview was conducted with another LPN (staff #40) on April 11, 2024 at 2:24 p.m. The LPN said that staff receives the paperwork approximately 2 hours prior to the arrival of the new admits. The staff will then fax the orders to the pharmacy to ensure that the medications will be on the next delivery run; and, if the medications have not arrived and there was a scheduled medication administration, staff were supposed to contact the pharmacy to find out the status of the medications and when it was expected to arrive. The LPN said that the staff was supposed to notify the provider that the resident's medication was not available or have not arrived so they can provide further instructions/orders. The LPN also said that when the medication is not available, staff was supposed to check the e-kits and the pyxis machine which contains common medications; and that, the pyxis machine can be accessed with pharmacy approval to obtain a medication. The LPN said that if the medication was not part of the inventory kept in the e-kits/pyxis machine, the medication will be ordered STAT which means that the medication should arrive within 2 hours. Further, the LPN said that it was rare that residents will miss medication since most medications were available in the e-kits/pyxis machine. The LPN stated that it was probably a registry who completed the resident's admission and was unfamiliar with the facility procedures. The LPN further stated that the facility normally had most medications handy; and that, there should be progress note regarding why the medication was still pending/awaiting pharmacy delivery. The LPN said that it can be a problem for a resident to not receive medications as ordered; and that, some medications were life sustaining and if it was not, then the medication can be placed on hold by the provider. However, the LPN said that the provider had to be informed so the provider can decide on what should be done. Regarding resident #400, the LPN said that it was weird to have the medication available for resident #400 earlier in the day and not available later on the same day. The LPN also said that it was hard to speculate what the impact of resident #400 missing the medications; but, there should have been more detailed notes documented to know what, why, and when the medication will be available and can be administered.

In an interview conducted with a Nurse Practitioner (NP/staff # 60) on April 11, 2024 at 2:54 p.m., the NP stated that his expectation was that medications are administered according to the order and facility protocols and documented in the MAR. The NP also said that his expectation was that he is notified if a resident's medications becomes unavailable to ensure that he knows if medications are on time or if unable to get it then to be able to get a different one that was similar to the unavailable drug. Further, the NP stated that medications not provided as scheduled can be problematic since these medications were there for a reason and were needed by the resident.

An interview was conducted on April 11, 2024 at 3:51 p.m. with the pharmacy consultant (staff #10) who stated that the facility had three delivery runs a day during the week and two on the weekends. Staff #10 said that during the week, the delivery leaves for the route at 9:00 a.m., 2:00 p.m., and 11:00 p.m.; and, on the weekends, the delivery run leaves for the route at 2:00 p.m., and 8:00 p.m. Staff #10 said that t