Advanced Healthcare Of Mesa

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and record review, the facility failed to ensure that written abuse policy and procedures were followed and adhered to regulations regarding the alleged abuse of one resident (Resident #20). This deficient practice could result in allegations of abuse not being appropriately handled.Findings include:Resident #20 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of the pelvis, one rib, sacrum, and vertebra, bacterial infections of unspecified site, chronic kidney disease, depression, and insomnia.An initial pool interview was conducted with Resident #20 on September 2, 2025, at 10:15 AM. During the interview, the resident stated that some of the staff are strange. The resident said that when he was first admitted to the facility, an aide was rough with him while providing care, and that she held [his] cheeks in her hands and kissed [his] forehead. Resident #20 said he didn't want to be touched or kissed in that manner and felt uncomfortable with the gesture. The resident stated that he informed the aide's boss about the incident and that the aide was then told not to be in the same room as the resident.Following the interview with Resident #20, on September 2, 2025, at 10:33 AM, an alleged abuse incident was reported to the facility Administrator (Staff #51). The Administrator stated she had not received a report of suspected abuse regarding Resident #20 before this report.On September 2, 2025, at 3:31 PM, the State Agency (SA) database of facility self-reports was reviewed online. No reports from the facility were observed.On September 3, 2025, at 11:57 AM, the SA database of facility self-reports was reviewed online. No reports from the facility were observed.An interview was conducted with the DON (Staff #76) on September 3, 2025, at 1:29 PM. The DON stated that when she receives an allegation of abuse, she first goes to see the resident who made the claim. Following a discussion with the resident, she reports the alleged abuse to the facility Administrator, the ombudsman, and the transitional nurse, Staff #122. The DON stated that she would also report the incident to Adult Protective Services (APS) if she noted bruising, a black eye, or fingerprints on the resident. She then indicated these types of abuse claims should also be reported to the State Agency (SA).The DON then said that she had received a verbal report of alleged abuse for Resident #20 from the facility Administrator on September 2, 2025. She interviewed Resident #20, who told the DON that he was fearful of explaining what had occurred, but that he did not like his current aide and wanted to talk to the DON later in the day. The DON explained that she went to speak to Resident #20 later in the day, but he was asleep. The DON stated that she had not completed an official investigation at that time, as she was waiting for instructions from the facility Administrator.An interview was conducted with the facility Administrator (Staff #51) on September 4, 2025, at 8:25 AM. The Administrator explained that when a resident makes an allegation of abuse regarding a staff member, she expects her staff to report the allegation to her and the DON immediately. She stated she would then put the alleged perpetrator on leave, complete an investigation, and then report to the SA, APS, the ombudsman, and the police if needed. The Administrator stated she always files a report if it involves alleged abuse, whether it was witnessed or reported.The Administrator stated she had not reported the alleged abuse incident regarding Resident #20, which she was made aware of on September 2, 2025, at 10:33 AM. She indicated that the reason she did not report the alleged abuse to the SA was that the incident occurred in July 2025 and that they were not informed of it at that time. She also indicated that following the DON interview of the resident on September 2, 2025, the Administrator struggled to say it was abuse. The Administrator continued to explain that Resident #20 had issues with female aides of color and that it appeared he didn't like that particular aide. After further discussion of the incident with Resident #20, the Administrator then decided to report the incident to the SA on September 4, 2025.On September 4, 2025, at 10:19 AM, the DON stated that she discussed the incident with Resident #20 and that he indicated the aide involved was Certified Nurse Assistant (CNA/Staff #79). The DON called the CNA, who acknowledged that an incident had been reported by Resident #20 and stated that the Registered Nurse (RN/Staff #49) working that shift was made aware of the situation.An interview was conducted with RN (Staff #49) on September 4, 2025, at 10:53 AM. The RN stated that Resident #20 had reported to him that the CNA (Staff #79) was inappropriate with him, referring to the CNA kissing him on his forehead. The RN instructed the CNA not to enter the resident's room. The RN stated he did not report the alleged incident to anybody at that time because the CNA had denied that the incident occurred. The RN reported he had received training from the facility regarding reporting alleged abuse and that he had a lack of judgment by not reporting the incident.On September 4, 2025, at 10:58 AM, an interview was conducted with a CNA (Staff #84) regarding facility abuse policy and procedures. The CNA stated she did not know if she had received training regarding abuse and neglect. She left to ask her supervisor a question. She returned to the interview and stated she had received abuse and neglect training. The CNA stated that if an incident of alleged abuse were reported to her by a resident, she would report it to her supervisor. The CNA was unable to give the name of the facility's abuse coordinator.An interview was conducted with the facility Administrator (Staff #51) on September 4, 2025, at 1:16 PM. The Administrator acknowledged that RN (Staff #49) did not report the incident he was made aware of with Resident #20 in July 2025. The administrator did not state what the risk of the nurse not reporting was, but reiterated that this particular case did not seem to fall into the abuse category. The Administrator then acknowledged the finding of deficient practice and stated she would report all alleged abuse in the future, as well as perform in-service training to the facility staff.An interview was conducted with the RN (Staff #49) on September 5, 2025, at 10:24 AM. The RN stated that the resident had made an allegation of abuse in July 2025, but the RN did not report it at that time.A policy titled Abuse Policy and Procedure, Version E1107 was reviewed. The policy revealed that all patients have the right to be free from any form of verbal, sexual, physical. abuse. The policy stated that all personnel are required to immediately report incidents of suspected mistreatment or abuse to the facility administration. The policy further stated that an incident of patient abuse must be reported to a supervisor regardless of the time lapse since the incident occurred. The policy also instructed that should the investigation reveal 'reasonable cause to believe' that abuse. had occurred, the administrator and/or director of nursing would then report findings immediately to the required SA.Appendix PP of the State Operations Manual (SOM), issued August 8, 2024, was reviewed. Code 42 CFR 483.12(b)(5) instructs that all alleged violations involving abuse are to be reported immediately, but not later than 2 hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and record review, the facility failed to ensure that an allegation of abuse for one resident (Resident #20) was reported to the State Agency (SA) in a timely manner. This deficient practice could result in allegations of abuse not being reported and investigated.Findings include:Resident #20 was admitted to the facility on [DATE], with diagnoses that included multiple fractures of the pelvis, one rib, sacrum, and vertebra, bacterial infections of unspecified site, chronic kidney disease, depression, and insomnia.A Minimum Data Set (MDS) dated [DATE], indicated that Resident #20 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment.An initial pool interview was conducted with Resident #20 on September 2, 2025, at 10:15 AM. During the interview, the resident stated that some of the staff are strange. When asked to explain the statement, the resident said that when he was first admitted to the facility, an aide was rough with him while providing care, and that she held [his] cheeks in her hands and kissed [his] forehead. Resident #20 said he didn't want to be touched or kissed in that manner and felt uncomfortable with the gesture. The resident stated that he informed the aide's boss about the incident and that the aide was then told not to be in the same room as the resident. Resident #20 stated he currently felt safe in the facility, but was fearful of the staff finding out that he reported the incident.Following the interview with Resident #20, on September 2, 2025, at 10:33 AM, the surveyor reported the alleged abuse incident to the facility Administrator (Staff #51). The Administrator indicated that the aide that Resident #20 was referring to was most likely Staff #79. The Administrator stated she had not received a report of alleged abuse regarding Resident #20 before this report. The Administrator left her office to discuss with the staff.On September 2, 2025, at 11:08 AM, the Director of Nursing (DON/Staff #76) informed the surveyor that Resident #20 had been placed on 2-hour checks and that she ensured that the psychiatric nurse practitioner was following the resident's care. The DON stated that Resident #20 had not mentioned being mistreated by staff before the current date.On September 2, 2025, at 3:31 PM, the SA database of facility self-reports was reviewed online. No reports from the facility were observed.On September 3, 2025, at 11:57 AM, the SA database of facility self-reports was reviewed online. No reports from the facility were observed.An interview was conducted with the DON (Staff #76) on September 3, 2025, at 1:29 PM. The DON stated that when she receives an allegation of abuse, she first goes to see the resident who made the claim. Following a discussion with the resident, she reports the alleged abuse to the facility Administrator, the ombudsman, and the transitional nurse, Staff #122. The DON stated that she would also report the incident to Adult Protective Services (APS) if she noted bruising, a black eye, or fingerprints on the resident. She then indicated these types of abuse claims should also be reported to the State Agency (SA).The DON then said that she had received a verbal report of alleged abuse for Resident #20 from the facility Administrator on September 2, 2025. She interviewed Resident #20, who told the DON that he was fearful of explaining what had occurred, but that he did not like his current aide and wanted to talk to the DON later in the day. The DON explained that she went to speak to Resident #20 later in the day, but he was asleep. The DON stated that she had not completed an official investigation at that time, as she was waiting for instructions from the facility Administrator.An interview was conducted with the facility Administrator (Staff #51) on September 4, 2025, at 8:25 AM. The Administrator explained that when a resident makes an allegation of abuse regarding a staff member, she expects her staff to report the allegation to her and the DON immediately. She stated she would then put the alleged perpetrator on leave, complete an investigation, and then report to the SA, APS, the ombudsman, and the police if needed. The Administrator stated she always files a report if it involves alleged abuse, whether it was witnessed or reported.When the facility Administrator was asked if she had reported the alleged abuse incident regarding Resident #20, which she was made aware of on September 2, 2025, at 10:33 AM, she stated she had not. The Administrator indicated that the reason she did not report the alleged abuse to the SA was that the incident occurred in July 2025 and that they were not informed of it at that time. She also indicated that following the DON interview of the resident on September 2, 2025, the Administrator struggled to say it was abuse. The Administrator continued to explain that Resident #20 had issues with female aides of color and that it appeared he didn't like that particular aide. After further discussion of the incident with Resident #20, the Administrator then decided to report the incident to the SA on September 4, 2025.Attempts were made to contact the alleged perpetrator (Staff #79) on September 3, 2025, at 1:46 PM, September 4, 2025, at 9:59 AM, September 4, 2025, at 12:37 PM, and September 4, 2025, at 2:16 PM. All attempts were unsuccessful.On September 4, 2025, at 10:19 AM, the DON stated that she discussed the incident with Resident #20 and that he indicated the aide involved was Certified Nurse Assistant (CNA/Staff #79). The DON called the CNA, who acknowledged that an incident had been reported by Resident #20 and stated that the Registered Nurse (RN/Staff #49) working that shift was made aware of the situation.An interview was conducted with RN (Staff #49) on September 4, 2025, at 10:53 AM. The RN stated that Resident #20 had reported to him that the CNA (Staff #79) was inappropriate with him, referring to the CNA kissing him on his forehead. The RN instructed the CNA not to enter the resident's room. The RN stated he did not report the alleged incident to anybody at that time because the CNA had denied that the incident occurred. The RN reported he had received training from the facility regarding reporting alleged abuse and that he had a lack of judgment by not reporting the incident.On September 4, 2025, at 10:58 AM, an interview was conducted with a CNA (Staff #84) regarding facility abuse policy and procedures. The CNA stated she did not know if she had received training regarding abuse and neglect. She left to ask her supervisor a question. She returned to the interview and stated she had received abuse and neglect training. When asked what she would do if a resident reported an incident to her, the CNA stated that she would report it to her supervisor. The CNA was unable to give the name of the facility's abuse coordinator.An interview was conducted with the facility Administrator (Staff #51) on September 4, 2025, at 1:16 PM. The Administrator acknowledged that RN (Staff #49) did not report the incident he was made aware of with Resident #20 in July 2025. When asked what the risk of the nurse not reporting was, the Administrator did not comment, but reiterated that this particular case did not seem to fall into the abuse category. The Administrator then acknowledged the finding of deficient practice and stated she would report all alleged abuse in the future, as well as perform in-service training to the facility staff.An interview was conducted with the RN (Staff #49) on September 5, 2025, at 10:24 AM. The RN again stated that Resident #20 did make the report of alleged abuse in July 2025, but the RN did not report it at that time.A policy titled Abuse Policy and Procedure, Version E1107 was reviewed. The policy revealed that all patients have the right to be free from any form of verbal, sexual, physical. abuse. The policy stated that all personnel are required to immediately report incidents of suspected mistreatment or abuse to the facility administration. The policy also noted that abuse should be reported by the Administrator and/or the Director of Nursing immediately to the required state agency.Appendix PP of the State Operations Manual (SOM), issued August 8, 2024, was reviewed. Code 42 CFR 483.12(b)(5) instructs that all alleged violations involving abuse are to be reported immediately, but not later than 2 hours after the allegation is made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of facility documents and policy, the facility failed to provide written notice to the resident or resident representative that specifies duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility for one resident (#48). The deficient practice could result in residents not being able to exercise their right to return to the facility of choice. Number of residents sampled: 12Number of residents cited: 1 Findings include: Resident #48 was admitted to the facility on [DATE] with a diagnosis that included sepsis, anemia and hypertension.A review of Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15.0, cognitively intact.A review of care plan dated July 24, 2025 revealed resident has an alteration in respiratory function.A review of progress notes dated August 6, 2025 revealed resident was noted to be short of breath, febrile with a temperature of 101.4, has low blood pressure of 102 over 60, and a heart rate of 102 beats per minute. The staff notified the nurse practitioner and the staff received orders to start resident on intravenous push (IVP) Lasix 40 mg (milligram) every day for three days and to hold/not administer oral Lasix for four days due to resident have a large right pleural effusion. Resident was administered one gram of acetaminophen (APAP) for fever. The IVP Lasix was administered by the director of nursing (DON). Resident's laboratory blood work was pending. Resident's urine and stool samples were collected and were sent to lab for testing. The provider was updated about the Resident's condition and additional orders, CBC (complete blood count) and CMP (comprehensive metabolic panel) daily for three days, were received from the provider. The progress notes also revealed that resident and resident's family requested to be transferred to the hospital.Review of progress note dated August 6, 2025 at 8:43 PM revealed the date and time resident left facility: August 6, 2025 at 18:03 PM; Bed hold policy was given: Emergent transfer; and Family/Responsible party notified of transfer: Yes.Review of MDS discharge-Return Anticipated assessment revealed Resident #48 was discharged on August 6, 2025 to a short-term general hospital. An interview was conducted on September 4, 2025 at 9:28 AM with a Licensed Practical Nurse (LPN)/Staff #82. Staff #82 stated that when he transfers a resident out to a hospital, it could be due to an emergency such as chest pain, oxygen saturation dropping and not able to maintain even after titrating oxygen to keep the resident's oxygen saturation above 90 percent using a rebreather mask, and a resident looking diaphoretic. Before transferring a resident, Staff #82 notifies the provider and receives an order to call 911. Regarding a resident who was sent out to the hospital but end up not admitted to the hospital, the resident have within 24 hours and returns back to the facility. The hospital calls the facility that the resident is coming back and the facility arrange a transportation to pick resident up from the hospital. However, Staff #82 stated that if the resident is in the hospital for over 24 hours, the resident is offered a bed hold. The admission and or case manager calls the resident or resident's family regarding bed hold.An interview was conducted on September 4, 2025 at 10:00 AM in the case management office with case manager Registered Nurse (RN)/ Staff #106. Staff #106 stated that she does discharge planning, she assists with placement, help with home health resources, care giving, and transportation. Staff #106 stated that when a resident is discharged to a hospital, she does not do anything with residents that goes to the hospital, she does not do bed hold, and it is the nurse or business office that takes care of bed hold. And, their DON sent reports of discharges to the ombudsman. An interview was conducted on September 4, 2025 at 10:06 AM with Patient Account Coordinator/Staff #74. Staff #74 stated that she checks and verifies insurance and get authorization, checks resident's documentation for every resident in the facility so she and the case manager can plan a safe discharge for the resident. Staff #74 stated that she takes care of bed hold. She stated that if their resident is admitted in the hospital, she takes care of bed hold so the resident will not lose their room. She will offer the resident a bed hold either in person before going out to the hospital or she will speak or reach out to the resident's family member or Power of Attorney (POA). She stated that the cost is $600.00 per day and she will have the form ready for resident or family to sign. She sated that the Bed Hold acknowledgement form is provided each time a resident is send out. But if a resident is going home, going to an assisted living (AL), the bed hold is not offered because it is not needed. Furthermore, Staff #74 stated that if a resident was not able to consent, she would look in the resident's chart to see who the resident's POA or emergency contact. If the bed hold is not signed or was declined verbally, the resident might still be able to come back if a bed is available and that will be handled by admission and not her.On September 4, 2025 at 12:05 PM, a request was made for a bed hold document for Resident #48 and at 1:13 PM Regional Director of Clinical Resource/Staff #300 returned the form, CMS form 807, and wrote Document unavailable to provide.An interview was conducted on September 4, 2025 at 1:41 PM with DON/Staff #76. The DON stated that the process regarding bed hold, Staff #74 from the finance and the administrator handles bed hold and admission to make sure they can fill the bed. Furthermore, the DON stated that if a bed hold was not communicated to the resident, the risk is resident will not have a placed to be at and will be sent some place else.An interview was conducted on September 5, 2025 at 10:44 AM with the administrator/Staff #51 in her office. The administrator stated that their bed hold policy process is if a resident was sent out, there is a follow up with resident's family member so the resident will have the chance to hold the bed if that is what they like, and the process of bed hold starts after the resident is sent out. The administrator stated that her corporate is starting to create a packet to be given to nurses so if there is a resident who is send out, the nurses will know what to do, to always make sure that there is a bed hold when a resident is sent out, and that there is always a communication to resident and family regarding bed hold. The administrator stated that regarding Resident #48, her previous DON charted that a bed hold was given but she is not seeing the document while looking at Resident #48's electronic record. The administrator stated that during the day, the bed hold is handled by Staff #74. Despite the administrator stating that her previous DON charted that a bed hold was given, review of the progress note dated August 6, 2025 at 8:43 PM revealed a documentation Bed hold policy was given: Emergent transfer, and the documentation did not indicate whether a bed hold was given or not. Review of facility's admission packet, Section 14 Bed Holds, revealed If the Patient leaves the Facility for a temporary stay in an acute care hospital, the Patient and/or Legal Representative may request that the Facility hold a bed until the Patient returns. Determinations regarding bed hold requests will be made at the Facility's sole discretion.Review of facility's policy titled, Bed Hold, updated on April 22, 2024 revealed prior to discharge, or as soon as possible thereafter if discharge is emergent, a facility representative will provide the patient, a family member, or legal representative a written notice of the specific duration of the bed-hold and the charges included, if any.

Based on clinical record review, staff interview, the Resident Assessment Instrument (RAI) manual, and facility failed to properly complete a Discharge Minimum Data Set (MDS) assessment for Resident #31. The deficient practice could result in delayed identification of potential risks and care needs of the residents.
Findings include:
Resident #31 was admitted into the facility on July 05, 2024 with a diagnosis of surgical wound infections, peritoneal abscess, elevated white blood cell count, chronic obstructive pulmonary disease, and epigastric pain.
MDS revealed that the resident had been discharged to a short-term general hospital.
Progress notes for resident #31 revealed that residents had been discharged home with Home Health services with discharge summary, and medication review on July 19, 2024.
Resident #31 was discharged on July 05, 2024; however, MDS and progress notes there was a discrepancy between progress notes, and MDS.
An interview was conducted on October 17, 2024 at 1:19PM with RN/MDS Coordinator (Registered Nurse & Minimum Data Set) (Staff #9) review with progress notes and states that resident #31 was discharged to home health and that the resident never went to the hospital. RN MDS (Staff # 9) had reviewed resident MDS and stated that on the MDS it is revealed that resident has been discharged to a short term hospital. RN MDS Coordinator ( staff # 9) stated that the MDS was inaccurate and that this is not part of the facility expectation.
An interview was conducted on October 17 at 1:56 PM with DON ( Director of Nursing) staff # 48 stated that this resident came in here for rehab , and when resident # 31 was discharged and they went home. In the MDS it gives you 4 option to pick from in regard to the resident discharge in this case RN MDS coordinator (staff # 9) had selected option 1 instead of opinion 4. The facility expectation would be that they are supposed to follow the Medicare Guide that applies to all staff.
Review of the facility Policy titled, Patient Assessment revealed, that any individual who completes any part of the assessment on RAI will sign and certify the accuracy of that part of the assessment they have completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical review, staff interviews and the facility policy and procedures, the facility failed to ensure one resident (#86) was permitted to return to the facility after a hospitalization.
Findings include:
Resident #86 was admitted to the facility on [DATE] with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome.
The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact.
Review of a Covid-19 test dated November 14, 2023 revealed a positive result.
A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her.
A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status.
Review of the clinical record did not reveal a bed-hold policy signed and dated by the resident or a family member.
An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the the resident was transferred to the hospital because she tested positive for Covid, was symptomatic, and the physician wanted her transferred to the hospital. She stated that the facility did not keep residents who tested positive for Covid and would transfer them to the hospital or another facility. She stated that if the resident would have passed the quarantine period, she would have been able to come back to the facility. Then she reviewed the progress notes and stated that the daughter was told on November 14, 2021, that the resident could not return to the facility, which is the same day that the resident was transferred to the hospital. She acknowledged that on November 14, 2023, she did not know how long the hospital was going to keep the resident or if the resident was being admitted , but knew that the resident was in the incubation period, so was not admitted back to the facility. She stated that the facility was able to isolate residents with Covid-19 by room, but did not have staff to care for the residents. She wouldn't have hired registry staff to provide one to one care for residents with Covid-19 because it is not practical for financial reasons, but doesn't have any documentation of trying to find additional staff or telling AZDHS that this was not feasible.
An interview was conducted on November 8, 2023 at 9:04 AM with a Registered Nurse/Critical Nurse Manager (RN/staff #25), who stated that she was responsible for discharge planning and any family concerns. She stated that if a resident was Covid-19 positive in 2021 and symptomatic, the resident was transferred to the hospital if ordered by the physician. During the interview, she reviewed facility documentation and stated that she didn't have any notes regarding the resident's discharge. She stated that it was her understanding that the facility did not have a Covid unit and she followed facility protocol, which was to transfer the Covid-19 positive residents to the hospital or another facility.
During an interview conducted on November 8, 2023 at 9:12 AM with the Administrator (staff #90), she stated that resident #86 would not have been given the resident a bed-hold policy because the facility wasn't going to accept the resident back due to being Covid-19 positive.
An interview was conducted on November 8, 2023 at 10:20 AM with the Administrator (staff #90) and the Director of Nursing (DON/staff #81). Both staff stated that they developed a plan for Covid positive residents, but didn't implement the plan. Staff #90 stated that they were a Covid-19 free facility and wanted to remain that way.
The facility's Covid-19 Emergency Plan, Location of Confirmed Patients with SARS-CoV-2 states to identify space in the facility that could be dedicated to care for residents with confirmed Covid-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with Covid-19. Determine the location of the Covid-19 care unit and create a staffing plan before residents or HCP with Covid-19 are identified in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, the facility failed to ensure two residents (#86, #26) were notified in writing regarding the reason for transfer and a copy was sent to the ombudsman.
Findings include:
Resident #86 was admitted to the facility on [DATE] with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome.
The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact.
A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her.
A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status.
-Resident #26 was admitted to the facility on with diagnoses that included benign prostatic hyperplasia without lower urinary tract symptoms, hypertensive heart disease with heart failure, and an anxiety disorder.
The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident had a mild cognitive impairment.
During an interview conducted on November 6, 2023 at 9:24 AM with resident #26, he stated that he did not receive a written statement regarding the reason for going to the hospital or a bed hold policy when he was transferred to the hospital.
An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the nurse/charge nurse informs the resident and family verbally regarding the reason for transport to the hospital. She also stated that the ombudsman is notified of the transfer at the end of the month, but the reason for discharge is not included.
An interview was conducted on November 8, 2023 at 10:20 AM with the Administrator (staff #90) and the (DON/staff #81). , Interview with 1. Administrator and 2. DON, Staff #81 stated that the facility did not give the residents a written reason for being transferred to the hospital, so the ombudsman did not receive a copy. She stated that the facility has never been provided the resident with a reason for transfer in writing and is currently looking at how to develop a process. Staff #90 stated that when she was at a conference, she heard other facilities talking about notifying the ombudsman about the reason for the transfer, but didn't know what they were talking about.
The facility's policy Admission, Transfer, Discharge Rights (F-Tag) states that before a facility transfers or discharges a patient, the facility will notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. Subject to the resident's agreement, the facility must send a copy of the notice to a
representative of the Office of the State Long Term Care Ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, the facility failed to ensure two residents (#86, #26) were notified were made aware of the bed-hold policy upon transfer to the hospital.
Findings include:
Resident #86 was admitted to the facility on [DATE] with diagnoses that included periprosthetic fracture around internal prosthetic left knee joint, acute and chronic respiratory failure with hypoxia, and chronic pain syndrome.
The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 13 indicating the resident was cognitively intact.
A progress note dated November 14, 2021 at 4:17 PM revealed that the resident had a rapid Covid test and tested positive earlier today. The resident complained of shortness of breath, with wet cough. The physician was notified and the resident was transferred to the emergency department (ER) via ambulance for further medical management. The family was notified about the hospital transfer and the resident's belongings were sent along with her.
A progress note dated November 14, 2021 at 10:08 PM revealed that the resident's daughter called the facility to report on the resident regarding the ER admission and discharge. The daughter was notified about the facility Covid-19 positive patient protocol. Despite being educated, the concerned family member was audibly upset due to the fact the resident cannot be readmitted into this facility with a positive Covid-19 status.
Review of the clinical record did not reveal a bed-hold policy signed and dated by the resident or a family member.
-Resident #26 was admitted to the facility on with diagnoses that included benign prostatic hyperplasia without lower urinary tract symptoms, hypertensive heart disease with heart failure, and an anxiety disorder.
The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident had a mild cognitive impairment.
A progress note dated September 10, 2023 revealed that the resident was transported to the hospital as per physician's orders for possible sepsis at approximately 6:40 a.m. The vital signs were taken prior to transport and were as follows: 112/57 blood pressure, 121 heart rate, 72% oxygen on 1 liter., 102.7 temperature, and 22 respiratory rate. There was an attempt to contact the resident's daughter, but there was no answer. The nurse sent the face sheet and orders to transport.
Review of the clinical record did not reveal a bed-hold policy.
During an interview conducted on November 6, 2023 at 9:24 AM with resident #26, he stated that he did not receive a written statement regarding the reason for going to the hospital or a bed hold policy when he was transferred to the hospital.
An interview was conducted on November 8, 2023 at 8:27 AM with the Director of Nursing (DON/staff #81), who stated that the the resident is given a bed-hold policy when he/she is transported to the hospital if it is feasible. If the situation is emergent, the bed hold policy is discussed with a family member, who would decide if he/she wanted to pay the rate required. She stated that she was not sure if the conversation regarding the bed hold policy with the family member is documented in a progress note. She also, stated that if the bed-hold form was used, she would expect that it was signed and dated by the resident or family member.
During an interview conducted on November 8, 2023 at 9:12 AM with the Administrator (staff #90), she stated that resident #86 would not have been given the resident a bed-hold policy because the facility wasn't going to accept the resident back due to being Covid positive.
The facility's policy Admission, Transfer, Discharge Rights (F-Tag) states that before a patient is transferred to a hospital or goes on therapeutic leave, the facility will provide written information to the patient, a family member or resident representative specifying the duration of the bed-hold policy during which the patient is permitted to return and resume temporary residence in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record, staff interviews and the facility policy and procedures, the facility failed to use appropriate hand hygiene practices and PPE when providing wound care for one resident (#18). The deficient practice could result in infection.
Findings include:
Resident #18 was admitted to the facility on [DATE] with diagnoses that included dementia, fracture of left femur, and abnormalities of gait and mobility.
A care plan dated October 9, 2023 for an actual impaired skin integrity related to admitted with surgical incision left hip. admitted with deep tissue injury on (DTI) on right buttock and left heel. The resident admitted with a stage II pressure ulcer to sacrum.
-October 11, 2023 DTI right buttock is resolved.
-October 11, 2023, stage II sacrum is now an unstageable pressure ulcer on her sacrum.
-October 20, 2023, sacrum ulcer is resolved.
-November 6, 2023, left heel is now stage III.
Interventions include to treat left heel per order.
Wound order dated November 3, 2023 revealed skin prep, okay open to air daily, float heels in bed, offload wound, reposition per facility protocol, offloading mattress.
November 6, 2023 wound note revealed a facility acquired left heel non-blanchable redness
-October 9, 2023: 3 cm length x 3 cm width -November 6, 2023: 0.8 length cm x 0.5 cm width
On November 7, 2023 at 10:31 a.m. observed a Registered Nurse/Clinical Nurse Manager (RN/staff #1) clean a pressure ulcer on left heel. Staff #1 was observed:
-sanitzing hands
-donning gown and gloves
-placing a paper towel below resident's left foot (foot was elevated by a pillow and did not touch the paper towel
-removed the resident's sock and bandage/gauze
-bandage/gauze was placed on the paper towel
-cleansed the left heel with clean gauze and then placed gauze on the paper towel
-doffed dirty gloves and placed them on the paper towel
-reached under her gown and pulled out another pair of gloves from her pocket and did not sanitize hands prior to donning the gloves
-Collagen pad was applied and covered
-doffed gloves and washed hands
An interview was conducted on November 8, 2023 at 11:10 AM with (RN/staff #1), who stated that
she doesn't necessarily need to sanitize her hands after doffing soiled gloves and before donning the new gloves because she has already cleaned her hands prior to beginning wound care. She acknowledged that she didn't sanitize her hands after doffing the soiled gloves and donning a new pair of gloves when she cleaned the resident's wound on November 7, 2023. She also, stated that it would not be appropriate to take new gloves from her pocket beneath her gown because the gown could be contaminated and she acknowledged that she pulled her gloves from underneath her gown when providing wound care on November 7, 2023.
An interview was conducted on November 8, 2023 at 11:22 AM with the Director of Nursing (DON/staff #81), who stated that when wound care is provide, the nurse should doff her gloves after removing the bandage, sanitize hands, and don new gloves. She stated that the hands should be sanitized because the old gloves may be contaminated. She also stated that the inside of the gown has the potential to be contaminated because it is touching the staff's clothing, so reaching underneath the gown to get gloves from the pocket creates the potential for contamination.
The facility's policy Isolation Procedures and Universal Precautions states that hand washing is considered the single most important procedure for preventing infections. Hand washing is necessary before and after removal of gloves and barriers.