ARBOR VIEW CARE CENTER

A complaint survey, prompted by CO42629, was completed on 7/14/26. No deficiencies were cited.

A revisit survey was completed on 5/4/26 for all previous deficiencies cited on 1/28/26. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO40159, was completed on 1/28/26. A deficiency was cited.

Based on observation, record review, and interview, the residence failed to have an effective pest control policy toensure the eradication of pests, including mice affecting 30 current residents. Findings include:1. Records ReviewThe residence's Pest Control Policy, developed on 11/23/2015 and last reviewed on 8/10/2023 stated the facility's policy is to prevent, eliminate, and/or control pests through an organization-wide program. The policy specified "Resident ' s Responsibility" include keeping food items in closed containers, throwing out old food, not accumulating garbage, trash and clutter, and reporting evidence and sightings of pests to staff. Review of an Orkin billing statement dated from 1/9/2025 to 1/23/2026 revealed a technician inspected the perimeter and exterior equipment. The technician documented "minor rodent traffic" in exterior bait stations and placed "Contract with Lumitrack" bait to target mice. 2. ObservationObservations on 1/28/2026 at 8:45 a.m. revealed mouse traps placed inside the residence's main entrance. Additional bait stations were observed surrounding the exterior of the facility 3. InterviewsResident #1 was interviewed on 1/28/2026 at 10:25 a.m. She stated she saw a mouse emerging from under her bed on 1/27/2026. She further stated she previously left food outside her door to feed squirrels but stopped after the door mesh was broken. She said maintenance placed a trap in her room. Resident #2 was interviewed on 1/28/2026 at 10:32 a.m. She stated she saw a mouse in her closet on 1/27/2026. She said she ate meals in her bedroom but did not feed wildlife. Staff #1 was interviewed on 1/28/2026 at 8:15 a.m. He identified that many residents attract mice by feeding squirrels through open windows and patio doors. While he was uncertain of the exact entry points, he noted that staff attempts to mitigate the issue by placing foam or steel wool in baseboard heaters. Staff #1 is aware that the rodent problem has existed for the three years he has been employed at the facility. He has seen mice in the residents rooms and has caught them on traps. Staff #3 was interviewed on 1/28/26 at 8:15 a.m. He stated the kitchen dumpster is picked up once a week. He said he has seen mice outside but not in the kitchen. Staff #2 was interviewed on 1/28/26 at 9:15 a.m. She said she has seen mice in the rooms and in mouse traps. She stated she believed mice were present because residents leave food, such as peanuts, by their doors for squirrels. She also noted the facility is surrounded by a large open field. The administrator was interviewed on 1/28/26 at 9:30 a.m. She said the facility had addressed feeding squirrels in resident council meetings and individually with residents on numerous occasions. However, the mice were still an ongoing problem even with current interventions in place.

A revisit survey was completed on 4/28/25 for all previous deficiencies cited on 2/18/25. The facility is in compliance with all deficiencies that were cited.

A relicensure survey was completed on 2/18/25. A deficiency was cited. A change of ownership occurred on 5/21/24.

Based on record review and interview, the residence failed to develop and implement an involuntary discharge grievance policy which included all required elements, affecting 34 current residents. Findings include:The residence's discharge criteria policy and the grievance policy, both dated 8/10/23, failed to include all required elements. On 2/18/25 at 2:00 p.m., the administrator stated she was unaware of the missing elements from the residence's discharge and grievance policies. She acknowledged the deficient practice and stated she would have the policy updated as soon as possible.

A licensure complaint revisit was completed on 2/18/25 for the previous deficiencies cited on 3/16/23. The residence is in compliance with all regulations surveyed.

PLEASE NOTE: The emergency rules regarding COVID-19 Vaccination were suspended effective 7/14/22. As such, a revisit could not be conducted for this event to determine compliance with the cited deficiency

A licensure complaint prompted by #CO31199 was completed on 3/16/23. Deficiencies were cited.

Based on record review and interview, the residence failed to have, readily available, a roster of current residents which contained emergency contact information along with a residence diagram showing room location, affecting 18 current residents. Findings include: On 3/16/23 at 8:03 a.m., the resident care coordinator (RCC) provided a current resident roster, dated 3/16/23. The resident roster contained room numbers, resident last names and first initials. Additionally, the roster contained three columns that identified which residents smoked, received external hospice services and who utilized oxygen. However, the resident roster did not contain resident first names, emergency contact information or a diagram that showed room location. On 3/16/23 at approximately 3:43 p.m., the RCC stated she was unsure what was required to be on a resident roster. She stated she believed it should have contained the resident's name, room number and the resident's responsible party. The RCC stated she believed she provided a roster with the correct information. She acknowledged the roster may not have contained the required elements. On 3/16/23 at approximately 4:22 p.m., the administrator was unable to identify the elements required to be on the resident roster. The administrator instead asked what elements should have been on the resident roster. The administrator stated the roster provided by the RCC was not the residence's current resident roster. She stated the resident roster had been provided to her through email by the regional health and wellness director. On 3/16/23 at approximately 4:52 p.m., the regional quality improvement specialist provided a second resident roster that had been provided by the administrator. However, the second resident roster only contained resident first and last names, resident number, room location and a column that read active status. The additional resident roster did not contain emergency contact information and a diagram that showed room location. On 3/16/23 at approximately 5:15 p.m., the administrator acknowledged the second provided resident roster did not contain emergency contact information or a diagram that showed room location.

Based on observation, interview and record review, the residence failed to discharge a resident that required more services than could be routinely provided, affecting one sample resident (#2). (Cross-reference Q1160)Findings include:Specifically, Resident #2 was admitted to the residence on 9/15/22 with diagnoses that included dysphagia, benign prostatic hyperplasia, constipation, chronic obstructive pulmonary disease and legal blindness. Upon admission Resident #2 was able to ambulate and transfer with the assistance of one staff member. The record for Resident #2 revealed the resident received external physical therapy services from 9/19 to 10/18/22 and from 1/9-3/9/23. Although the resident had received physical therapy, he continued to decline as a result of requiring a higher level of care. External physical therapy services began notifying the residence of the resident's needs for a higher level of care as early as 9/19/22, just four days after admission. However, the residence failed to discharge Resident #2 for 178 days. As of 3/16/23 Resident #2 was bed bound, unable to reposition independently and receiving all incontinence care and baths in bed. The practitioner for Resident #2 stated that the residence was unable to provide adequate services to the resident and confirmed Resident #2's condition had worsened since admission and would not improve at the current level of care. 1. Residence Policy and Referencesa. The residence's discharge policy, dated 1/2/22, read in part: A resident may be discharged for the following reasons: When the residence can no longer meet the resident's needs based on it's own admission criteria and discharge criteria. b. The residence's undated resident agreement read in part: The residence would assist with transferring to outside facilities and higher levels of care, as needed and prescribed by the practitioner. 2. Resident #2 was admitted to the residence on 9/15/22 with diagnoses that included dysphagia, benign prostatic hyperplasia, constipation, chronic obstructive pulmonary disease and legal blindness. a. Record ReviewA progress note, dated 9/15/22, read in part: Resident moved into assisted living today. Resident was observed in a hospital bed with two side bars for positioning. Resident #2 was standing at this time and required one person assistance with a gait belt and walker. The resident was able to take short steps with his walker and standby assistance. A progress note, dated 9/16/22, read in part: Orders were received for physical therapy and occupational therapy evaluation. A progress note, dated 9/18/22, read in part: Resident #2 could not walk to the restroom, he stated he was very weak. An external physical therapy note, dated 9/19/22, read in part: Resident #2 required a higher level of care than was appropriate and safe for an assisted living residence. A progress note, dated 10/4/22, read staff noticed a sore on the bottom of Resident #2's buttocks while showering the resident. A progress note, dated 10/6/22, read the resident had a wound forming under his buttocks, the practitioner for Resident #2 was notified. An external physical therapy note, dated 10/6/22, read in part: Meeting with the administrator held today and discussed progress to date, barriers and appropriateness for an assisted living setting. A progress note, dated 10/10/22, read in part: A meeting was held with Resident #2, the physical therapist director. The resident was "insistent that he needed (three) persons to get him on/off the bedside commode. Three person assist(ance) is not necessarily Assisted Living criteria." It was discussed that if he required three person assistance for transfers he would need a higher level of care. Resident #3 was advised that if he continued to insist on three person transfer assistance he could be given a discharge notice. It was agreed to focus on physical therapy and to meet in one week. An external physical therapy note, dated 10/11/22, read in part: It was discussed with the resident the level of care that he needs and the level of care that assisted living residence provided. The resident required a higher level of care. A progress note, dated 10/27/22, read in part: Resident #2 needed to use the commode, he was weak and unable to stand on his own. The resident required two staff to stand, when Resident #2 was walking. It took one staff member to hold the walker down and the other to support his weight. A progress note, dated 10/30/22 read in part: Resident #2 was very weak and it took three staff to lift him off the commode. A progress note, dated 11/2/22, read the resident received a bed bath with the assistance of two caregivers. A progress note, dated 11/4/22, read it took three staff to assist Resident #3 off the commode. A progress note, dated 11/10/22, read in part: Resident #2 requested staff to go into his room every 30 minutes to help him stand up for five minutes. "I let the resident know that we do not do therapy and to possib(ly) get with his therapist. Resident was not happy with what we were telling him."A progress note, dated 11/16/22, read in part: The external home health agency was waiting for insurance approval for more physical therapy visits. The external home health agency representative notified Resident #2 that his current physical therapist would not return due to his resistance with therapy. The external home health representative further stated that Resident #2 required a higher level of care. Progress notes dated 11/17 and 11/18/22, read Resident #2 requested assistance from staff to place him in a seated position and later requested assistance to lay down. A care conference, dated 11/19/22, read in part: Showers were discussed with Resident #2. It was agreed by the resident and staff that bed baths would be initiated every Wednesday evening due to the resident's weakness. Staff would assist with transfers for safety issues with a maximum of three people, two people to use gait belt to stand resident and one person to perform peri care after he uses the bedside commode. An assessment titled Change of Condition, dated 11/19/22, read in part: Resident #2 was alert and oriented, did not have a diagnosis of dementia and was able to make independent decisions. The resident was resistant to care and refused to follow directions from physical therapy. Resident #2 had no skin conditions, had a history of swallowing difficulties, a vision impairment, required two person assistance with transfers and bathing twice weekly via bed bath as the resident could not walk to the shower. Additionally, the assessment read the resident required one two person maximum assistance with dressing, three person assistance to use the restroom, required a bedside commode and had a catheter. Resident #2 required assistance from staff to empty the catheter twice a day. The assessment further read that the resident utilized external therapy and home health services. A progress note, dated 11/19/22, read in part: Resident #2 had a very small bowel movement on the bed with an absorbent bed pad underneath, as it was not safe to transfer the resident with three staff. "It was not easy to convince him to do so but (it) was the safest way."A progress note, dated 11/20/22, read in part: Resident #2 asked staff to transfer him to the commode. Staff explained to the resident that the other staff was currently with another resident and the staff was unable to transfer Resident #2 alone. Resident #2 stated he would wait for the second staff to come and provide assistance placing the absorbent bed pad underneath him. Resident #2 subsequently had a bowel movement, in bed on an absorbent bed pad. Staff assisted the resident to a seated position. An external physical therapy note, dated 11/22/22, read in part: Resident #2 moved into the Residence on 9/2022 from rehabilitation and according to his daughter, the resident was able to stand and required minimal assistance with ambulation. Today Resident #2 required three person assistance to stand and was only able to stand one minute without needing to sit down. Progress notes from 11/23/22 to 3/16/23 all read the resident was no longer transferring to the bedside commode for bowel movements and was using an absorbent bed pad when having a bowel movement. Additionally a progress note, dated 12/2/22, read Resident #2 requested staff to line his bed with absorbent pads for when he needed to have a bowel movement in bed. A progress note, dated 12/6/22, read the practitioner for Resident #2 was trying to find the resident with a higher level of care. A progress note, dated 12/7/22, read Resident #2 had been turned down by three higher level of care facilities. A progress note, dated 12/9/22, read Resident #2 was discharged from external home health nursing and therapy services. A progress note, dated 12/10/22, read the heater broke in Resident #2's room and the resident would have to move to a new room using three people for transfer assistance. A progress note, dated 12/15/22, read staff telephoned an external home heath and requested catheter care. External home health stated the case for Resident #2 had been closed and if the resident had not been moved to a higher level of care by 12/21/22 to notify external home health to see what could be done. An visiting urgent care practitioner's order dated, 12/29/22, read upon arrival Resident #2 was soiled with feces. The practitioner cleaned the resident up, started medications for a urinary tract infection. The order further read it would be faxed to the residence because they could not find any staff. Resident #2 required more care than what was provided at the residence. A progress note, dated 1/4/23, read Resident #2 was now requiring assistance from staff when in the supine position in order to get to a seated position. Resident #2 was very weak and unable to get himself up. A progress note, dated 1/5/23, read it took staff two attempts to assist the resident to a seated position as staff pushed down his knees while he tried to pull himself up. Progress notes, dated 1/6 and 1/8/23, read staff assisted Resident #2 to a seated position three times. An external physical therapy note, dated 1/9/23, read physical therapy started and recommended a higher level of care. An external physical therapy note, dated 1/23/23, read the physical therapist educated the resident about assistance and a higher level of care recommended long term care and spoke to the administrator about the residents functional abilities. A progress note dated 1/26/23, read a meeting was held with the resident about him requiring a higher level of care. The residence's sister facility was currently in the process of reviewing the resident. An external physical therapy note, dated 1/31/23, read the physical therapist communicated to the administrator that the resident required a mechanical lift shower chair and needed long term care placement. A care plan, dated 2/20/23, read in part: Resident #2 required two person assistance to use the restroom, had a bedside commode, required a visiting nurse for catheter care, had a bed cane, gait belt and walker. A progress note dated 3/2/23, read staff noted a red spot on Resident #2's right hip. The note further read the resident often laid in bed on his right side. A progress note, dated 3/6/23, read in part: Resident #2 was upset because his back was hurting from sitting too long. The resident laid down for 30 minutes before saying his back hurt and needed assistance to sit back up. An external physical therapy note, dated 3/6/23, read in part: Resident #2 asked the difference between assisted living and a long term care facility. The physical therapist educated the resident that his current level of care needs would have been better met in a long term care facility. A progress note, dated 3/8/23, read in part: Resident #2 requested assistance from staff to sit up as he was too weak. Staff put their hands on his knees in an attempt to sit him up; however, it did not work. Staff subsequently suggested that she have staff come up from the sister long term care facility to provide assistance and the resident declined. An external physical therapy note, dated 3/9/23, read in part: Physical therapy was discontinued and recommended the resident move to a long term care facility. A progress note, dated 3/14/23, read the resident had a rash on his inner thigh by his peri area.b. ObservationOn 3/16/23 at 2:53 p.m., Resident #2 was in his room in his bed, laying down on is left side, facing the wall. c. InterviewsOn 3/16/23 at 7:05 a.m., Staff #1 stated Resident #2 required two or more persons to assist with transfers. She further stated that Resident #2 was now bed bound and staff no longer transferred him out of bed. Staff #1 stated Resident #2 had a catheter which the staff emptied and the resident was changed in bed for bowel movements. She stated staff administered a bed bath once a week which required two person assistance. Staff #1 stated the resident had the start of a sore on his right side of his body and currently nothing was being done to prevent skin breakdown. She further stated that staff were doing everything they could to take care of Resident #2; however, she stated that Resident #2 should have been moved to a long term care facility. On 3/16/23 at 7:27 a.m., the sister facility nursing home administrator (NHA) stated that Resident #2 was waiting to transition to a long term care facility. He stated Resident #2 required a two person transfer assistance which did not work well in an assisted living setting. On 3/16/23 at 2:35 p.m., the practitioner for Resident #2 stated that when the resident moved into the residence he was ambulatory and was able to stand and transfer. She stated once insurance approved external physical therapy he began services with the sister facilities external physical therapy; however, she stated that since Resident #2 was not making progress on his physical therapy Resident #2 was denied continuation of external physical therapy. The practitioner stated once the external physical therapy services were terminated she began to reach out to insurance for approval for a long term care facility. The practitioner stated Resident #2 required more visits and assistance from an external physical therapist then would be approved and therefore required rehabilitation or a long term care facility. She stated Resident #2 was not receiving enough external therapy to get him back to where he was when he was first admitted. The practitioner stated Resident #2 required "round the clock care" and the residence was staffed to help people who could take care of themselves and stated his level of assistance was "more of a skilled nursing level." She stated that Resident #2 had toured the sister facility; however, the practitioner stated that the facility did not have any open beds. The practitioner confirmed that the residence had not issued a notice of discharge; although the residence was not able to meet his needs. On 3/16/23 at 2:53 p.m., Resident #2 stated he stayed in bed each day. He stated he wanted to get out of bed but was unable to, because of a previous diagnosis of polio. Resident #2 stated he had surgery in 2014 and it had caused a negative effect on his body due to his previous polio diagnosis, which resulted in limited movement. Resident #2 stated the staff "make me use the bathroom in my bed." Resident #2 declined to discuss his care at the residence any further and asked the surveyor to leave the room. On 3/16/23 at 3:43 p.m., the resident care coordinator (RCC) stated that she had been employed at the residence since 1/20/23. She stated she had been made aware of the decline Resident #2 had experience since his admission. The RCC stated that Resident #2 had been receiving external physical therapy services from the residence's sister long term care facility and stated those services had been terminated for a second time. The RCC confirmed that the residence had not issued a discharge notice for Resident #2 and stated the residence was currently meeting the basic needs for Resident #2. The RCC further stated that it would have been better for Resident #2 to get out of bed for showers and toileting; however, the residence was not able to meet those needs. The RCC confirmed that the sister long term care facility did not have any available beds for the resident. On 3/16/23 at 4:15 p.m., the administrator stated the residence had tried external physical therapy services since his admission. She stated Resident #2 "was aging in place and it is not working, he is not doing as well as he could be." The administrator further stated she had not yet issued a discharge notice and stated that a conversation would need to be done. On 3/16/23 at 4:52 p.m., the vice president of operations (VPO) confirmed that Resident #2 did not have the quality of life that he should have had as he was in bed all of the time. The VPO confirmed that Resident #2 was no longer at an appropriate level of care for an assisted living residence.

Based on observation, record review and interview, the residence failed to not keep a resident with a stage 3 pressure sore that did not have a terminal condition and was not receiving continuing care from an external service provider, affecting one sample resident (#3) with a stage 3 pressure sore. (Cross-reference Q1160)Specifically, Resident #3 was admitted to the hospital on 2/21/23 due to sepsis from a heel wound. On 3/9/23, a wound practitioner from her practitioner's office visited Resident #3 to assess her wounds. The wound practitioner diagnosed Resident #3 with a stage 3 pressure injury (sore) on her left heel. The wound practitioner recommended skilled wound care greater than what the residence could provide. The residence kept Resident #3 in the residence and did not discharge Resident #3, despite being aware she had a stage 3 pressure sore along with additional wounds on the same foot and were unable to get proper treatment. Subsequently, on 3/16/23, the wound practitioner identified Resident #3 had a second wound that had become infected. Findings include: 1. References and Residence Policies Chapter VII regulations governing assisted living residence defines, in part 2.21, "External services" means personal services and protective oversight services provided to a resident by family members or healthcare professionals who are not employees, contractors, or volunteers of the facility. External service providers include, but are not limited to, home health, hospice, private pay caregivers and family members. Chapter VII regulations governing assisted living residence defines, in part 2.37, "Pressure sore" (also called pressure ulcer, decubitus ulcer, bed-sore or skin breakdown) means an area of the skin or underlying tissue (muscle, bone) that is damaged due to loss of blood flow to the area. Symptoms and medical treatment of pressure sores are based upon the level of severity or "stage" of the pressure sore.(B) Stage 2 goes below the upper surface of the skin. Symptoms include pain, broken skin, or open wound that is swollen, warm, and/or red, and may be oozing fluid or pus.(C) Stage 3 involves a sore that looks like a crater and may have a bad odor. It may show signs of infection such as red edges, pus, odor, heat, and/or drainage. The residence's Discharge policy, revised 5/20/19, read in part: "A resident may be discharged for the following reasons: ... 2. When the community (residence) can no longer meet the resident's needs based on it's own admission criteria and discharge policy ..." The residence's undated Resident Agreement read in part: "... (the residence) will assist you with arranging needed appointments with professionals offering medical ... and other health care services and with accessing and transferring to outside facilities and higher levels of care, as needed and prescribed by you physician (practitioner) ..." 2. Observation On 3/16/23 at 3:07 p.m., Resident #3 was in her bed laying flat on her back with both feet on the bed. Resident #3 had tubi-grip stockings on both legs from her toes to underneath the knee. Both heels were flat on the mattress. 3. Resident #3 was admitted to the residence on 6/22/22 with diagnoses including Alzheimer's Disease, Parkinson's Disease and type II diabetes mellitus. a. A practitioner's note, dated 3/9/23, read the following:Resident #3 had three wounds on her left foot. Wound #3 was on her left medial heel and was diagnoses as stage 3. The wound measured at 2.5 centimeters (cm) in length and 2 cm in width. Resident #3's diagnosis read: "Pressure injury of left heel, stage 3." Treatment read: the wound practitioner performed wound care, sent message to practitioner office to prioritize getting external home health services for Resident #3. Resident was noted to have been at "very high risk for decline and complications without adequate wound care more frequent that (sic) (practitioner) wound provider can provide." The practitioner's note also read: "the following home health modalities are indicated based on medical need: SN (skilled nursing). Skilled Home Health is needed for the following: active wound care ... change (three) (times) week and PRN (as needed) soiled/dislodgement " The second and third distal toe wounds had notes that read: "will benefit from HH (home health) SN." b. The residence's assessment for Resident #3, dated 3/7/23, read the following:"ER (emergency room) visit on 2/22/23 due to Sepsis caused by wound in foot."Resident #3 had an "other" skin condition. Resident #3 required wound care monitoring or treatment. "(practitioner) temporarily coming out weekly. (Practitioner) sending referral over to a home health to take over wound care." Resident #3 had a stage 1 or 2 pressure injury. c. The residence's care plan for Resident #3, updated 3/16/23, read the following:Resident #3 received wound care through the practitioner's office on a weekly basis. "After obtaining physician (practitioner) order for services/equipment, make arrangements with required community resources to obtain." 4. Interviews On 3/16/23 at approximately 7:16 a.m., Staff #1 stated she was unaware Resident #3 had any open sores. On 3/16/23 at approximately 11:00 a.m., the resident care coordination (RCC) stated a nurse practitioner from the resident's practitioner's office came once weekly to provider wound care services for Resident #3. The RCC confirmed Resident #3 did not have external home health services in place prior to the onsite visit. The RCC stated she was not aware the wound on Resident #3's heel was a stage 3 pressure sore. She stated she believed the residence could admit residents with stage 1 and stage 2 pressure sores only but she was not aware of what stage pressure sore a resident was no longer able to remain at the residence. On 3/16/23 at 2:17 p.m., a nurse practitioner (NP) for Resident #3 stated Resident #3 had sores on her left foot since approximately December 2022. She stated Resident #3's pressure sore on her left heel had been diagnosed as a stage 3 pressure sore by her four to five weeks prior to the onsite visit. The NP stated Resident #3 did not have external home health services to provide wound care services as of the date of the onsite visit. The NP stated she was able to visit the residence once a week to provide wound care services for Resident #3 as a practitioner while Resident #3 did not have external home health services. She added that was not enough wound care for Resident #3. The NP state Resident #3 had been septic from her heel wound in February 2023 and was sent to the hospital for treatment. The NP stated she had visited Resident #3 on the date of the onsite visit (3/16/23) and identified that a second sore on Resident #3's foot had been infected. The NP stated the wound on Resident #3's left third toe had been identified as infected with redness and pus. She stated the resident's wounds on her foot would come and go and not properly heal due to lack of proper wound care. The NP stated the new infection in Resident #3's third toe was at risk of causing her to go septic again if not properly treated. She acknowledged the residence staff were unable to provide the wound care Resident #3 needed and were only able to preform basic first aid. The NP stated Resident #3 should have been considered for discharge to a higher level of care that could have provided the wound care services she required, which would have prevented further infection in Resident #3's foot. On 3/16/23 at approximately 3:07 p.m., Resident #3 stated she was unsure how long she had the wound on her left heel. She stated at times it had been painful. Resident #3 stated a nurse practitioner came once a week to clean her wound. She stated that because of her wound she tried to stay in bed as much as possible. She stated staff did not provide any additional care or support for her wounds. On 3/16/23 at approximately 4:22 p.m., the administrator stated she was aware Resident #3 had wounds on her left foot. She stated she was aware the pressure sore on Resident #3's left heel was a stage 3 pressure sore. The administrator stated she believed Resident #3 was provided external home health services for wound care three times weekly. The administrator stated, contrary to her previous statement, that the resident's practitioner had been working on initiating external home health services to provide wound care. The administrator stated she did not think the residence should have discharged Resident #3 from the residence due to her stage 3 pressure sore. She stated a stage 3 pressure sore was not an automatic discharge from the residence if the residence was able to provide the care the resident needed.

Based on observation, interview and record review the residence failed to coordinate care with known external service providers affecting two of two sample residents (#2, #3). (Cross-reference Q1060 and Q1124) Specifically, on 12/14/23 Resident #3's practitioner diagnosed her with a stage 2 pressure injury and ordered external home health services to provide wound care. The residence provided no assistance in coordinating care and services with external home health agencies to provide wound care services for Resident #3. The practitioner for Resident #3 attempted to obtain external home health services for Resident #3 and was unsuccessful. A wound practitioner from the practitioner's office subsequently provided minimal wound care services once weekly until an external agency could be contracted to provide the required services three times a week for Resident #3. Subsequently, Resident #3 went without the proper required wound care which resulted in Resident #3's wound developing an infection and Resident #3 becoming septic. Resident #3 required hospitalization and intravenous antibiotics to clear the infection. Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residence defines, in part 2.21, "External services" means personal services and protective oversight services provided to a resident by family members or healthcare professionals who are not employees, contractors, or volunteers of the facility. External service providers include, but are not limited to, home health, hospice, private pay caregivers and family members.b. Chapter VII regulations governing assisted living residence defines, in part 2.37, "Pressure sore" (also called pressure ulcer, decubitus ulcer, bed-sore or skin breakdown) means an area of the skin or underlying tissue (muscle, bone) that is damaged due to loss of blood flow to the area. Symptoms and medical treatment of pressure sores are based upon the level of severity or "stage" of the pressure sore.(B) Stage 2 goes below the upper surface of the skin. Symptoms include pain, broken skin, or open wound that is swollen, warm, and/or red, and may be oozing fluid or pus.(C) Stage 3 involves a sore that looks like a crater and may have a bad odor. It may show signs of infection such as red edges, pus, odor, heat, and/or drainage.c. According to the Centers for Disease Control and Prevention (CDC), "Sepsis is the body's extreme response to an infection. It is a life-threatening medical emergency. Sepsis happens when an infection you already have triggers a chain reaction throughout your body. Infections that lead to sepsis most often start in the lung, urinary tract, skin, or gastrointestinal tract. Without timely treatment, sepsis can rapidly lead to tissue damage, organ failure, and death ... Sepsis is a medical emergency. If you or your loved one has an infection that's not getting better or is getting worse, ACT FAST ... Treatment requires urgent medical care, usually in an intensive care unit in a hospital, and includes careful monitoring of vital signs and often antibiotics." CDC, What Is Sepsis (8/9/22), Retrieved from: https://www.cdc.gov/sepsis/what-is-sepsis.htmld. The residence's undated Resident Agreement read in part: "... (the residence) will assist you with arranging needed appointments with professionals offering medical ... and other health care services and with accessing and transferring to outside facilities and higher levels of care, as needed and prescribed by you physician (practitioner) ..." 2. Resident #3 was admitted to the residence on 6/22/22 with diagnoses including Alzheimer's Disease, Parkinson's Disease and type II diabetes mellitus. a. Observation On 3/16/23 at 3:07 p.m., Resident #3 was laying in flat on her back in her bed with tubi grip stockings on both feet and calves. Both heels were flat on the mattress. b. Practitioner documentation for Resident #3, dated 12/14/22-3/9/23, read the following: A practitioner's note for Resident #3, dated 12/14/22, read in part, Resident #3 was seen for an evaluation of a foot wound. The wound was noted to be on Resident #3's left heel and was noted as moderate severity. The diagnosis was open wound of left heel, initial encounter. The practitioner noted "Seems to have been a blister on her left heel which is now a stage 2 ulcer. All staff have been cleaning and dressing the wound but they do not have the resources to manage it on a regular basis. Will refer to (external) home health nursing for wound care." A wound care referral, dated 12/19/22, ordered an external home health nurse evaluation and treatment for wound care due to Resident #3's open wound of the left heel. A note on the order read "the (resident) needs a home health nurse to manage her left heel ulcer. (The residence) prefers (external home health agency)." A practitioner's note for Resident #3, dated 1/4/23, read in part, Resident #3 was seen for a wound focused visit. The practitioner noted an identified person had applied ointment to the wound the morning of the practitioner visit. The wound was noted to measure 1 centimeter (cm) in length and 2 cm in width. Treatment read non-pressure chronic ulcer of other part of left foot with fat layer exposed. "Unable to get HH (home health)- nurse at (residence) will continue to cleanse with soap and water, antibiotic ointment and a (bandage)." A referral order was written for wound care supplies to be ordered. A practitioner's note for Resident #3, dated 1/10/23, read in part, Resident #3 was seen for a wound focused visit. The practitioner noted external home health (HH) services had not been obtained and a residence nurse had provided wound care. Additionally, the note read, "unable to get HH, high risk for non healing and other complications without adequate wound care." The practitioner noted wound care supplies had not arrived at the residence after being ordered on 1/4/23. The practitioner noted 35 minutes of the visit was spent counseling Resident #3 and coordinating care, including discussing the plan of care with the residence. A practitioner's note for Resident #3, dated 2/2/23, read in part, Resident #3 was seen for a wound focused visit. The practitioner noted Resident #3 had "almost no sensation, bilateral feet." The practitioner noted an additional wound was identified on the left third distal toe. The wound was noted as healed by crust. Additionally the practitioner noted Resident #3 was at a high risk for additional wounds due to her diagnosis of type 2 diabetes. The practitioner noted to have reiterated the importance of daily foot inspections. The practitioner noted the plan of care was discussed with the residence. A practitioner's note for Resident #3, dated 2/21/23, read in part, Resident #3 was seen for an evaluation of nausea and vomiting. Resident #3 was diagnosed with systemic inflammatory response syndrome. The practitioner noted Resident #3 met the criteria for sepsis from the infection on her foot. Emergency responders were contacted and Resident #3 was transported to the hospital by ambulance. A hospital discharge note for Resident #3, dated 2/23/23, read in part, Resident #3 presented with a reported fever and mental status changes. Resident #3 was noted to have leukocytosis with a white blood cell count of 15. Initial concern of sepsis/infection were noted and Resident #3 was started on intravenous antibiotics. Resident #3 was noted to have sores on her left foot which may have contributed to a mild skin and soft tissue infection. Resident #3 was discharged with an order for oral antibiotics for two additional days. A practitioner's note for Resident #3, dated 2/24/23, read in part, Resident #3 was seen for a hospital post discharge visit. The practitioner noted Resident #3 was treated with antibiotics intravenously and ordered an oral antibiotic for a diagnosis of cellulitis. A practitioner's note for Resident #3, dated 2/28/23, read in part, Resident #3 was seen for a re-evaluation of cellulitis and treatment with antibiotics. The practitioner noted Resident #3 was still being followed by a wound practitioner from the practitioner's office in place of external home health services. A practitioner's note, dated 3/9/23, read in part, Resident #3 had three wounds on her left foot. Wound #3 was on her left medial heel and was diagnoses as stage 3. The wound measured at 2.5 centimeters (cm) in length and 2 cm in width. Resident #3's diagnosis read: "Pressure injury of left heel, stage 3." Treatment read: the wound practitioner performed wound care, sent message to practitioner office to prioritize getting external home health services for Resident #3. Resident was noted to have been at "very high risk for decline and complications without adequate wound care more frequent that (sic) (practitioner) wound provider can provide." The practitioner's note also read: "the following home health modalities are indicated based on medical need: SN (skilled nursing). Skilled Home Health is needed for the following: wound care." c. Interviews On 3/16/23 at approximately 7:05 a.m., Staff #1 stated she was unaware Resident #3 had sores on her feet. On 3/16/23 at approximately 11:00 a.m., the resident care coordinator (RCC) stated Resident #3 had re-started wound care a couple weeks prior to the onsite visit and added Resident #3's practitioner currently saw Resident #3 weekly for wound care. The RCC stated she had discussed Resident #3's wounds with the practitioner. She added she was unsure of what stage Resident #3's heel wound was. The RCC stated Resident #3's practitioner's office had a wound practitioner that only came to the residence once a week to provide wound care services. The RCC stated she read the practitioner notes for Resident #3. However, contrary to her previous statement, the RCC stated she was not aware Resident #3 required wound care three times weekly or that her heel wound was a stage 3 sore. The RCC stated Resident #3's practitioner had worked to find external home health services for Resident #3 to receive wound care services. She stated she had not attempted to assist the practitioner in obtaining external home health services. The RCC confirmed she was responsible for coordinating care for Resident #3. The RCC confirmed she had not coordinated care and external home health services for Resident #3. On 3/16/23 at 2:17 p.m., the wound care practitioner for Resident #3 stated she had provided wound care services for Resident #3 for approximately two months prior to the onsite visit. She stated the practitioner's office had tried to find an external home health agency to provide wound care services for Resident #3 and had been unsuccessful due to Resident #3's insurance. She stated Resident #3 should have received external home health services for wound care three times weekly since the wound was identified. However, because Resident #3 did not have external home health services she came to the residence once a week to provide wound care services and billed the visit as a practitioner visit. The wound care practitioner stated if Resident #3 had been receiving proper wound care three times weekly from an external home health agency it would have prevented the infection in her heel wound. She stated proper wound care would have prevented Resident #3 from becoming septic when she was hospitalized in February 2023. The wound care practitioner stated residence staff should have looked at her feet at least once daily and she was unsure if the residence staff monitored her feet as she had not been provided any notes. The wound care practitioner stated Resident #3 required external home health services for wound care approximately two month prior to the onsite visit. She stated the residence had not assisted in coordinating external home health services and added the practitioner's office had given up after five or six companies had denied the referral. On 3/16/23 at 3:07 p.m., Resident #3 stated she was unsure how long she had the wounds on her left foot. Resident #3 stated she went to the hospital in February 2023 due to an infection with a wound in her foot. Resident #3 confirmed she had a practitioner that came one time weekly to provide wound care services. She stated she did not have any other person that provided wound care services to her. On 3/16/23 at approximately 4:22 p.m., the administrator stated she was aware Resident #3 had wounds on her feet and that she believed a wound nurse provided routine wound care services to Resident #3. The administrator stated she was aware external home health services were ordered for Resident #3 in December 2022 for three times weekly. The administrator stated she believed Resident #3 had been receiving external home health services three times a week at the time of the onsite visit. The administrator was unaware that Resident #3 did not have external home health services three times weekly and a wound practitioner from the practitioner's office provided wound care one time weekly for Resident #3. Contrary to the practitioner notes and hospital discharge paperwork, dated 2/23/23, the administrator stated Resident #3's hospitalization was related to an untreated urinary tract infection and not related to the wound on her heel. Despite the administrator previous statement, Resident #3 did not have a diagnosis of a urinary tract infection. The administrator stated she was unsure if the residence staff had assisted in obtaining an external home health agency for Resident #3's wound care services. The administrator stated she was unaware that staff should have conducted routine inspections of Resident #3's foot and added she was unsure if staff were aware. The administrator stated it was the RCC's job responsibility to coordinate care and services for residents as needed. She added she was responsible for oversight of the RCC to ensure coordination of care and services was completed. The administrator stated "I think (the RCC) did what she should have," and "I don't think we did anything wrong with (Resident #3)." She stated she believed the practitioner for Resident #3 tried to coordinate external home health services for Resident #3. On 3/16/23 at approximately 4:52 p.m., the vice president of operations (VPO) stated it was the administrator's responsibility to ensure coordination of care occurred. She stated the administrator should have followed up and oversaw that external home health services had began as ordered. The VPO stated she was not aware that external home health services were ordered for Resident #3 in December 2022. 3. Resident #2 was admitted to the residence on 9/15/22 with diagnoses that included dysphagia, benign prostatic hyperplasia, constipation, chronic obstructive pulmonary disease and legal blindnessa. Record ReviewA progress note, dated 10/3/22, read in part: The practitioner for Resident #2 referred the resident to external home health for catheter care. The original external home health agency was unable to accept Resident #2 and staff left a message for the practitioner for Resident #2 regarding alternative plans for catheter change as the resident was due for a change within the week. A progress note, dated 10/5/22, read a second home health agency was contacted to evaluate resident #2 for catheter care. A progress note, dated 10/6/22, read Resident #2 refused services from the home health agency for catheter care as he preferred to have the residence's sister facility for physical therapy and insurance would not cover two external service agencies. A progress note, dated 10/12/22, read external home health evaluated the resident and Resident #2 was set up to receive services through them for catheter care and physical therapy. A progress note, dated 12/9/22, read Resident #2 was discharged from external home health nursing and therapy services. A progress note, dated 12/15/22, read staff telephoned external home home and requested catheter care. External home health stated the case for Resident #2 had been closed and if the resident had not been moved to a higher level of care by 12/21/22 to notify external home health. A second progress note, dated 12/15/22, read staff contacted a different external home health for catheter care; however, they were not accepting patients. A progress note dated 12/27/22, read a visiting urgent practitioner was telephoned for symptoms of a urinary tract infection and catheter care. An visiting urgent care practitioner's order dated, 12/29/22, read upon arrival Resident #2 was soiled with feces. The practitioner cleaned the resident up, started medications for a urinary tract infection. The order further read it would be faxed to the residence because they could not find any staff. A progress note, dated 1/27/23, read Resident #2 needed his catheter changed once a month. The residence was not receiving external home health services. Staff would assist the resident with coordinating with a urologist. A visiting urgent practitioner's order, dated 1/30/23 read a catheter change had not been done since 12/29/22. The residence was given a referral for external home health to complete routine changes. Resident declined and stated he would discuss it with his practitioner. The record for Resident #2 revealed no evidence of care coordination for catheter changes from 1/27/23 to 3/16/23, the day of the on-site investigation. b. ObservationOn 3/16/23 at 2:53 p.m., Resident #2 was laying in bed, his catheter tubing was located on the side of the bed. c. InterviewsOn 3/16/23 at 2:35 p.m., the practitioner for Resident #2 stated the resident required assistance from an external service provider for physical therapy and catheter care. She stated that Resident #4 chose to have external therapy services through the residence's sister long term care facility; however, the practitioner stated catheter care was not offered through the sister facility. The practitioner stated since the sister residence did not offer catheter services the resident could not obtain any further external services as insurance would not bill two companies. She stated that an urgent traveling practitioner had completed the previous catheter care. The practitioner stated she had hoped that the resident would have been discharged to a long term care facility before the next catheter change was needed; however, the practitioner stated it did not happen and stated the resident was overdue for his catheter to be changed. The practitioner stated the standard of practice was for catheters to be changed every thirty days and acknowledged it had been 48 days since his last catheter change. The practitioner further stated she had met with Resident #2 and the RCC on 3/14/23 and directed them to have the catheter changed as soon as possible by the urgent traveling practitioner. She stated the urgent traveling practitioner once telephoned would come the same day to change the catheter. On 3/16/23 at 2:53 p.m., Resident #2 stated he had different external service agencies that came into the residence and provided catheter care to him. Resident #2 refused to provide information regarding the last date he received catheter care. He stated "it has been well within the limits I am allowed to go." Resident #2 stated he believed he could go without catheter care for four to five weeks. Resident #2 stated he had a appointment for catheter care soon; however, he refused to provide the date. On 3/16/23 at 3:43 p.m., the RCC stated when the traveling practitioner had come out on 1/27/23, they had told her that Resident #2 needed to have external home health services complete catheter changes and they would not come back to the residence to complete the service. The RCC stated she thought Resident #2 would have been discharged from the residence to the sister long-term care facility; however, she stated on 3/10/23 the residence was notified there was no available beds for Resident #2. The RCC further stated she had not coordinated any further care regarding the catheter change for Resident #2. On 3/16/23 at 4:15 p.m., the administrator stated she was aware that Resident #2 had not had a catheter change. She stated that she was not sure how often the resident required a catheter change; however, she thought it needed changed as needed or if it was dirty. The administrator further stated she and the RCC discussed telephoning the urgent traveling practitioner to completed a catheter change for Resident #2 and thought it had been done.

Based on interview and record review the residence failed to ensure that only medication that has been ordered by a practitioner was administered to residents affecting one of four sample residents (#4). Findings include:The residence's medication administration policy, dated 1/1/22, read in part: The residence shall only administer medications upon the written order of a licensed practitioner or other authorized practitioner. Resident #4 was admitted to the residence on 10/22/22 with a diagnosis of hypertension. The February through March 2023 medication administration record for Resident #4 read the residence administered Lisinopril 5 mg once daily from 2/19-2/24 and 2/26-3/15/23 for a total of 35 doses administered in which there was no evidence of an authorized practitioner's order. On 3/16/23 at 11:32 a.m., The resident care coordinator stated the residence spoke with the practitioner for Resident #4 weekly. However, she stated the residence did not have an order from the practitioner in the record for Resident #4 as she was new to the residence administering medication.

Based on interview and record review the residence failed to comply with authorized practitioner's orders associated with medication administration affecting two of four sample residents (#2,#5). Findings include,1. Residence PolicyThe residence's medication administration policy, dated 1/1/22, read in part: Interventions would be used to avoid medication errors (staff education, audits, medication order clarifications). 2. Resident #2 was admitted to the residence on 9/15/22 with diagnoses that included dysphagia, benign prostatic hyperplasia, constipation, chronic obstructive pulmonary disease and legal blindness. a. Prevagen Written practitioner's orders, dated 1/24 and 3/8/23, directed the residence to administer Prevagen 10 mg once daily. However, the February and March 2023 medication administration records (MARs) read the medication was not administered on 2/28-3/5, 3/7 and 3/8/23 as the medication was not available for a total of eight missed doses. b. FamotidineWritten practitioner's order, dated 1/24 and 3/8/23, directed the residence to administer famotidine 20 mg once daily 30 minutes prior to breakfast. However, the March 2023 MAR read the medication was not administered from 3/12-3/13/23, as the medication was not available for a total of three missed doses. c. SennaWritten practitioner's orders, dated 1/24 and 3/8/23, directed the residence to administer Senna 8.6 mg once daily. However, the March 2023 MAR read the medication was not administered on 3/12-3/14/23 as the medication was not available for a total of three missed doses. On 3/16/23 at 3:43 p.m., the resident care coordinator (RCC) stated a private caregiver for Resident #2 purchased the over the counter medications for the resident. She stated when the medication was not given to the residence, the RCC went to the store and purchased the medication. However, she stated that she did not purchase the Prevagen as it was too expensive. She stated there was no current process in place to ensure compliance with over the counter medications. On 3/16/23 at 4:15 p.m., the administrator stated when she was informed that the over the counter medications for Resident #2 ran out of stock, she went and purchased the medication contrary to the RCCs statement that she purchased the medication. 3. Resident #5 was admitted to the residence on 5/1/19 with diagnoses including constipation, chronic pain, spinal stenosis, radiculopathy, pain in the left knee, pain in the lower leg and intervertebral disc degeneration. a. HydrocodoneA written practitioner's order dated 1/17/23, directed the residence to administer hydrocodone HCI 5 mg at 10:00 p.m. However, the March 2023 MAR read the medication was not administered on 3/15/23 as the resident already had the medication as needed. b. FlorastorA written practitioner's order, dated 2/7/23, directed the residence to administer Florastor 250 mg twice daily for 20 days. However, the February 2023 MAR read the medication was only administered from 2/8 p.m. through 2/25/23 a.m. for a total of 17 days. c. TylenolA written practitioner's order, dated 1/17/23, directed the residence to administer Tylenol Extra Strength 1000 mg three times daily. However, the February 2023 MAR the medication was not administered on 2/27/23 as the medication was out of stock for a total of one missed dose. d. SennaA written practitioner's order, dated 1/17/23, directed the residence to administer Senna 8.6 mg once daily. However, the February 2023 MARs read the medication was not administered as the medication was not available for a total of one missed dose. On 3/16/23 at 3:43 p.m., the RCC stated she was not aware about the above medications not being available. She stated she was aware that Florastor was not administered for 20 doses as prescribed. The RCC stated the medication was transcribed on the MAR incorrectly and therefore it was stopped at 17 doses.

Based on interview and record review the residence failed to ensure the residence had accurate medication administration records (MARs) affecting two of four sample residents (#2, #5). Findings include:1. Residence PolicyThe residence's medication administration policy, dated 1/1/22, read in part: For residents whose medications are monitored or administered by the residence staff, a current record shall be maintained of the resident's medications including name of drug, dosage, route of administration of medication and directions for administration of medication. The administration of medication shall be documented at the rime of administration 2. Resident #5 was admitted to the residence on 5/1/19 with diagnoses including constipation, chronic pain, spinal stenosis, radiculopathy, pain in the left knee, pain in the lower leg and intervertebral disc degeneration. A written practitioner's order dated 1/17/23, directed the residence to administer hydrocodone HCI 5 mg at 10:00 p.m. However, the February through March 2023 medication administration records (MARs) from 2/12-3/15/23 read the medication was to be administered at bedtime, 7:00 p.m. Additionally, the February 2023 MAR revealed no evidence that hydrocodone HCI 5 mg at 10:00 p.m., was administered on 2/11/23. A written practitioner's order, dated 1/17/23, directed the residence to administer Senna 8.6 once daily, atorvastatin 40 mg once daily, melatonin ER 5 mg once daily, hydrocodone 5 mg at 10:00 p.m., Tylenol Extra Strength 500 mg three times daily p.m. dose and MS contin ER 15 mg twice daily p.m. dose. However, the February 2023 MAR revealed no evidence of documentation on 2/28/23. 3. Resident #2 was admitted to the residence on 9/15/22 with diagnoses that included dysphagia, benign prostatic hyperplasia, constipation, chronic obstructive pulmonary disease and legal blindness. A written practitioner's order, dated 1/24/23, directed the residence to administer famotidine 20 mg once daily prior to breakfast. However, the February through March 2023 MARs from 2/1-3/16/23 revealed no evidence of the medication needing to be administered prior to breakfast. On 3/16/23 at 3:43 p.m., the resident care coordinator (RCC) stated she made the MARs. She stated she was not aware that Resident #5's hydrocodone was ordered at 10:00 p.m. and confirmed it should have been transcribed correctly on the MAR. The RCC further stated the resident was administered the medication at 10:00 p.m., although the MAR read 7:00 p.m. On 3/16/23 at 4:22 p.m., the administrator stated that a blank space in the MAR meant that staff did not check the box on the MAR which did not happen often. She confirmed staff should have documented medication administration at the time of the event.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised they must review and maintain the following processes in accordance with existing Assisted Living Residence program regulations. 12.14 A device that facilitates a resident's well-being and/or independence may be used only if all of thefollowing criteria are met:(A) The resident has the functional ability to alter his or her position;(B) The resident is able to remove the device to allow for normal movement;(C) The device improves the resident's physical or emotional state and allows the resident to participate in activities that would otherwise be difficult or impossible; and(D) There is an order from a practitioner for its use.(1) There shall also be interdisciplinary documentation from both the practitioner and a therapist describing the benefits and hazards associated with the device and information on its appropriate use.(2) A resident's continued use of such device shall be re-evaluated by both therapistand practitioner at least annually or whenever the resident experiences a significant change in status.(3) Documentation of compliance with this subpart (D) shall be retained in theresident's care plan. 12.16 Each assisted living residence shall direct staff to assist residents who have fallen or are otherwise unable to independently get up off the floor. The assisted living residence's policy on staff providing lift assistance shall be made available to its local emergency medical responders. 14.33 The assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of: (B) A resident's pattern of refusal.

A licensure revisit was completed on 3/16/23 for all previous deficiencies cited on 5/17/22. The residence is in compliance with all regulations surveyed.