Every finding on record at Bloomfield Nursing and Rehabilitation Center

Based on interview and record review, the facility failed to ensure the Director of Nursing (DON) was not working the floor as a charge nurse when the facility census was over 60 residents. This deficient practice is likely to affect all 72 residents who reside in the facility (facility census provided by the Director of Nursing on 01/05/26). If the DON is working as a charge nurse, they may be unable to complete their DON responsibilities, indicating low staffing levels and impacting all residents. The findings are: A. Record review of the facility's census for 11/07/25 through 01/06/26 revealed the following: 11/07/25 the facility census was 78, 11/17/25 the facility census was 82, 11/28/25 the facility census was 78,12/13/25 the facility census was 81,12/26/25 the facility census was 72,12/27/25 the facility census was 74,12/30/25 the facility census was 72,01/03/26 the facility census was 72,01/06/26 the facility census was 72. B. Record review of the facility's staffing logs for 11/07/25 through 01/06/26 revealed the following: On 11/07/25 the DON worked the floor as a nurse/charge nurse. On 11/17/25 the DON worked the floor from 5:00 pm to 2:30 am as a nurse/charge nurse. On 11/28/25 the DON worked the floor as a nurse/charge nurse. On 12/13/25 the DON worked the floor as a nurse/charge nurse. On 12/26/25 the DON worked the floor as a nurse/charge nurse. On 12/27/25 the DON worked the floor as a nurse/charge nurse from 9:00 am to 5:00 pm. On 12/30/25 the DON worked the floor as a nurse/charge nurse. On 01/03/25 the DON worked the floor as a nurse/charge nurse from 12:00 pm to 3:45 pm. On 01/06/25 the DON worked the floor as a nurse/charge nurse. C. On 01/07/26 at 11:47 am, during an interview with the Director of Nursing (DON), she stated she worked the floor last night (01/06/25) for six hours because there was not enough nurse coverage. The DON stated when she works the floor as a nurse/charge nurse, it is hard for her to get her other tasks completed. She stated she lost three agency nurses in the last couple of weeks, and they are trying to get new contracts for the agency nurses. The DON confirmed she worked the floor as a nurse/charge nurse for the dates listed on the staffing log (finding B).

Based on record review and interviews, the facility failed to complete an annual performance review of Certified Nursing Assistants (CNAs) for 3 (CNAs #6, #7, and #8) of 5 (#6, #7, #8, #9, and #10) CNAs randomly reviewed. If the facility is not completing a performance review of every CNA at least once every 12 months, then residents are likely to not receive the appropriate care and services, and the CNAs may not meet the needs of all residents. The findings are: A. Record review of the facility's training transcripts for CNA's #6, #7, and #8 revealed the following hire dates. CNA #6 was hired on 10/01/18, and an annual performance review was not present. CNA #7 was hired on 10/01/18, and an annual performance review was not present. CNA #8 was hired on 09/15/22, and an annual performance review was not present. B. On 01/09/26 at 11:24 am during an interview with the Director of Nursing (DON), she stated she only had the training logs for the staff requested but CNAs #6, #7, and #8 did not have annual performance reviews completed. C. On 01/14/26 at 2:30 pm, during an interview with the DON, she stated she does not have performance reviews available for CNAs #6, #7, and #8. The DON confirmed CNA annual performance reviews should be completed as required, but that did not happen.

Based on observation, interview, and record review, the facility failed to ensure a resident's right to retain his personal property for 1 (R #16) of 1 (R #16) resident reviewed when: Facility staff removed containers, a backpack, a small box, and other reuseable bags filled with resident's items from his room. The facility did not give R #16 consistent access to his personal belongings stored in a conference room. If staff do not respect a resident's right to personal property, then the resident may become angry, frustrated, and feel disrespected. The findings are: A. Record review of R #16's face sheet revealed he was re-admitted to the facility on [DATE] with the following diagnoses: Epilepsy (a seizure disorder),Traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head),Intellectual disabilities (lifelong condition characterized by significant limitations in intellectual functioning and adaptive behavior, affecting everyday skills and learning),Alcoholic cirrhosis of the liver (alcohol-associated liver disease causes toxic fat to build up in your liver, which leads to inflammation and scarring). B. Record review of R #16's quarterly Minimum Data Set (MDS is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 10/20/25 revealed R #16 had a Brief Interview for Mental Status (BIMS checks the resident cognitive impairment and whether further intervention is required for dementia diagnosis) of a 15 (0-7 severely impaired cognition, 8-12 moderately impaired, 13 -15 intact cognition) indicating R #16 was cognitively intact. C. Record review of R #16's care plan dated 10/20/25 indicated R #16 had a tendency to collect and store things in his room including but not limited to perishable items, cleaning supplies, facility linens, silverware, toilet paper, towels, and wash rags. Interventions included the following: Educate R #16 and his family for safety reasons, there are certain things that are not allowed to be kept at the bedside.Educate staff about R #16's tendency to keep and collect things and this should be reported to the nurse or nurse management if there is a safety concern.Educate R #16's family that all cleaning is done by our housekeeping department and if R #16 needs something cleaned, he can speak to any staff member, and we can get it done. R #16 does not need to have his own cleaning supplies. D. Record review of R #16's nursing progress note dated 12/19/25 revealed, R #16 had been hoarding his belongings, and they have just begun to pile up. R #16 was told he was not allowed to have all his things packed under his bed. R #16 became upset and agitated. R #16 was required to sign a behavioral agreement as there had been other unknown issues that had been happening. E. Record review of R #16's behavioral agreement dated and signed on 12/19/25 indicated the following: Behavior expectations: 1. Uncooperative with care. 2. Inappropriately touching staff. 3. Hoarding. R #16 will receive verbal warning and documentation of incident will be recorded that any further escalation of the behavior observed or reported can and will result in further consequences including up to potential discharge from the facility.Police may be contacted to intervene in the situation.Referrals/transfers to other facilities (emergency room in-patient behavioral health) may be deemed appropriate for the safety of the resident and others.Discharge from the facility may be deemed appropriate and 30-day discharge notice may be issued. F. Record review of R #16's electronic health record (EHR) did not reveal orders for monitoring the behaviors noted in the behavioral agreement. G. On 01/06/26 at 8:30 am, during an interview with R #16, he stated the Administrator (ADM) came and took a lot of his stuff out of his room on 12/19/25. R #16 stated water bottles, shampoo bottles, soaps, snacks, pens, and other items were removed from his room. R #16 stated he had two containers with items in them behind his bed and those were taken from him, and they took some bags and other items. He stated the ADM told him he had too much stuff and moved his things into the conference room across the hall. R #16 stated he wanted his things and his snacks back, but he was told by the ADM that the containers he had were a fire hazard. R #16 stated he felt like he was being singled out and picked on, and he did not understand why. H. On 01/06/26 at 10:27 am, an observation was made of R #16's belongings stored in the conference room. There were two black containers exactly as described by R #16 with his backpack, a small box, and some bags sitting on top of the containers. Inside of the containers were snacks, pistachios, boxes of cookies, several 2-liter bottles of various drinks, colored pens, anime (Japanese art form) drawing book, a comic, and several socks wrapped up with a decorative ribbon. Most of his items were in the two containers. The conference room door was locked and could only be unlocked by facility staff. R #16 did not have access to his items in the conference room. I. On 01/08/26 at 8:35 am, during an interview with Certified Nursing Assistant (CNA) #8, she stated R #16 can at times be a little stubborn and he keeps to himself a lot. She stated R #16 likes to keep everything, even if the item is past the expiration date.J. On 01/08/26 at 3:01 pm, during an interview with the stand in Administrator, he stated R #16's behavioral contract (for hoarding items in his room), should not be in place. He stated, assisting R #16 with maintaining his items should be addressed if he is having issues, and putting R #16 on a behavioral contract for hoarding is not an appropriate reason for a behavioral contract. His understanding of the behavioral agreement was to address R #16 taking items from the facility, not hoarding items. K. On 01/08/26 at 12:50 pm, during an interview with Social Services Director (SSD), she stated R #16 is in constant need of his room being decluttered because R #16 had items on top of his wardrobe and under his bed. She stated he can be very combative and resistant. The SSD stated when they ask him to go through his things he becomes very upset, so she and the Administrator went through R #16's belongings while R #16 was present in the room. L. On 01/15/25 at 11:28 am during an interview with the ADM, she stated the items were removed from R #16 because they were all behind the headboard in his room and taking up too much space. He had two totes, a duffle bag, shopping bags and a brown box. She stated she implemented the behavior agreement so R #16 would cooperate with them around all of the items in his room. The ADM confirmed R #16 should have access to his belongings that are stored in the conference room whenever he wanted, but that was not happening.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #66) of 1 (R #66) resident reviewed for MDS accuracy. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs. The findings are: A. Record review of R # 66's Face Sheet revealed an admission date of 05/18/23 with the following diagnoses: Expressive language disorder (a condition where a person has trouble using words and sentences to communicate),Sensorineural hearing loss, bilateral (hearing loss in both ears caused by damage to the inner ear (cochlea) or auditory nerve, leading to reduced ability to hear and understand sounds, especially speech),Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease),Other drug induced secondary Parkinsonism (movement disorder caused by certain medications, resulting in symptoms similar to Parkinson's disease (tremor, rigidity, slow movements),Cognitive communication deficit (a communication disorder caused by impairments in cognitive processes). B. Record of R #66's Physicians Orders, dated 01/07/26 revealed a referral for speech therapy evaluation and treatment as recommended non-verbal, communication board. C. Record review of R #66's Psychiatric Notes, dated 05/08/25, revealed the following: Resident uses paper and pencil to answer questions on notebook,Due to resident being non-verbal in today's assessment, this note is completed per chart review and staff support. D. Record review of R #66's Care Plan, dated 05/16/25 revealed the following: Potential for impaired communication r/t (related to) impaired hearing,Resident will express needs through non-verbal communication as needed daily,Resident will use alternative methods of communication such as writing as needed daily,Speak facing the resident,Ensure availability and functioning of adaptive equipment,Resident is at risk or is experiencing adjustment issues related to communication challenges.E. Record review of R #66's Progress Notes, dated 05/18/25, revealed the following: Resident is primarily non-verbal communication board, pen and paper, Resident has the following needs for special adaptive equipment to participate in desired engagement opportunities, Communication board written instructions/gestures for hearing lost.No cognitive limitations. F. Record review of R #66's Psychiatric Notes, dated 10/23/25, revealed Due to resident being non-verbal in today's assessment, this note is completed per chart review and staff support.G. Record review of R #66' Speech Therapy evaluation, dated 11/14/25, revealed the following: Evaluation of speech with evaluation of language and comprehension and expression,Resident is nonverbal,Hearing details- None (uses notepad to communicate),Resident reports not knowing all the words but communicates through a notebook,Speech clarity (the degree to which spoken words are produced clearly and can be easily understood by a listener) no speech,Auditory Comprehension-Not indicated (profound hearing loss),Ability to hear: highly impaired (absence of useful hearing), Due to the documented physical impairments, without skilled therapeutic interventions, the resident is at risk for anxiety, general health, decreased leisure participation and social isolation. H. Record review of R #66's Psychiatric Notes, dated 11/20/25, revealed the following: Resident uses paper and pencil to answer questions on notebook,Due to resident being non-verbal in today's assessment, this note is completed per chart review and staff support. I. Record review of R #66's MDS assessments revealed the following: Quarterly MDS Section B (Hearing, Speech, Vision), dated 12/18/24, was coded as having adequate hearing and clear speech.Quarterly MDS Section B (Hearing, Speech, Vision), dated 03/18/25, was coded as having adequate hearing and clear speech,Annual MDS Section B (Hearing, Speech, Vision), dated 08/13/25, was coded as having adequate hearing and clear speech,Quarterly MDS Section B (Hearing, Speech, Vision), dated 08/13/25, was coded as having adequate hearing and clear speech,Quarterly MDS Section B (Hearing, Speech, Vision), dated 11/11/25, was coded as having adequate hearing and clear speech.J. On 01/06/26, at 11:06 AM, during an interview with R #66, the resident was nonverbal and used his notebook to communicate. K. On 01/07/26, at 3:19 PM, during an interview with the Activities Director (AD), she stated R #66 used a whiteboard or his notebook as his source of communication. L. On 01/07/2026, at 3:21 PM, during an interview with Certified Nurse Aide (CNA) #1, she stated R #66 is nonverbal and writes his questions on a piece of paper. CNA #1 stated since the admission of the resident, she had never heard him speak. M. On 01/07/26, at 3:26 PM, during an interview with Registered Nurse (RN) #1, she stated R #66 is nonverbal and communicates with a notebook. She stated the resident also has hearing loss. N. On 01/07/26, at 3:27 PM, during an interview with CNA #2, she stated R #66 doesn't speak and uses his notebook to communicate. She stated the resident has difficulty hearing. O. On 01/07/26, at 3:36 PM, during an interview with Certified Medication Assistant (CMA) #1, she stated R #66 doesn't speak and uses his notebook to communicate. She stated the resident also has a hearing impairment. P. On 01/08/26, at 10:20 AM, during an interview with the Activities Director (AD), she stated R #66 has been nonverbal since he admitted in 2023. Q. On 01/08/26, at 10:21 AM, during an interview with the MDS Coordinator (MDSC), she stated she was responsible for the completion of R #66's MDS assessments. She stated R #66's MDS dated [DATE], 05/16/25, 08/13/25, and 11/11/25 Section B (Hearing, Speech, Vision), were coded correctly, reflecting the resident had adequate hearing and speech. The MDSC confirmed R #66's MDS Section B should have been accurate, but it was not. R. On 01/08/2026, at 1:38 PM, during an interview with the Director of Rehab (DOR), she stated R #66 is nonverbal and uses a communication board to communicate. S. On 01/08/2026, at 1:44 PM during an interview with the Social Services Director (SSD), she stated R #66 is nonverbal and uses a pen and notebook to answer questions and communicate.

Based on observations and interviews, the facility failed to ensure the environment was free of accident hazards when a portable electric space heater was plugged in and operating in a common hallway accessible to residents.This deficient practice is likely to affect all residents that walk by the front entrance of the facility and could place residents at risk for burn injuries, particularly residents with impaired cognition or limited safety awareness (inability to recognize or avoid the hazard). The findings are: A. On 01/05/26 at 12:27pm, during an observation of the front entrance hallway, a portable electric space heater was positioned directly on the hallway floor next to the vending machine. The heater was plugged in and operating with a digital display reading 72 degrees Fahrenheit (F). The heater was placed against the wall and immediately next to the vending machine. The space heater was located in a common hallway area accessible to residents. B. On 01/08/26 at 2:30 pm, during an interview with substitute Administrator, he stated the space heater should not be plugged in and left in the hallway unattended. He stated the residents could burn themselves on the heater. C. On 01/13/26 at 11:28 am, during an interview with Maintenance Director, he stated the space heater should not be plugged in as a resident with dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) could get burned on the heater.

Based on observation and interview the facility failed to: Lock a medication cart (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medications) while staff were away from the cart.Ensure all medications were not expired in the medication storage room. These deficient practices are likely to result in resident injury, through dosing with medications that have been improperly stored, having access to medications not prescribed for them, and possible overdose. The findings are: Medication Carts: A. On 01/06/26 at 8:55 AM, during an observation of the 100 Hall, the medication cart was found unlocked and unattended. B. On 01/06/26 at 8:57 AM, during an interview with Licensed Practical Nurse (LPN) #1, he stated he stepped away for a moment and left the medication cart unlocked. He stated it was his expectation to lock the medication cart when it was unattended and not in use. LPN #1 stated if a resident ingests a medication not prescribed to them, the resident could have had an adverse drug interaction, resulting in the resident becoming ill. C. On 01/08/26 at 2:17 PM, during an interview with the Director of Nursing (DON), she stated staff should never leave a medication cart open and unattended. The DON stated it is her expectation all medication carts are locked when not in use and unattended. She stated if a medication cart was unlocked, residents could ingest a medication and have an adverse reaction, causing the residents to become ill. D. On 01/08/26 at 2:25 PM, during an interview with the Administrator (AD), he stated it was his expectation that all medication carts be locked when not in use. The AD stated if a resident were to have access to an unlocked medication cart, the resident could take a medication not prescribed to them, which could result in illness. Expired Medications: E. On 01/06/26 at 11:11 am, during a medication storage room observation, one sealed bottle of Aspirin 325 milligrams (mg) had an expiration date of 06/25. F. On 01/06/26 at 11:22 am, during an interview with LPN #3, she confirmed the Aspirin had expired and should have been removed. G. On 01/06/26 at 11:33 am, during an interview with the DON, she stated finding expired medications in the medications room does not meet her expectations and the medication should have been disposed of properly and immediately.

Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 4 (R #7, R #36, R #50, and R #62) of 10 (R #7, R #10, R #32, R #36, R #50, R #62, R#67, R #74, R#76,and R #77 ) residents reviewed for medication administration and infection prevention when: The facility stored R #7's oxygen (O2) concentrator (medical device that provides continuous O2) inappropriately on the floor. Facility nursing staff administered R #62's topical eye medication while touching the eyelid of R #62 with ungloved hands. Facility nursing staff did not sanitize their hands before and/or after medication administration for R #s 36, 50 and 62. These deficient practices are likely to place residents at risk of contracting infections, hospitalization, and death. The findings are: Respiratory Equipment: A. Record review of R #7's face sheet revealed R #7 was admitted into the facility on [DATE] with the following diagnoses: Acute and chronic respiratory failure with hypoxia (low oxygen levels), Pulmonary hypertension (high blood pressure that affects the arteries in the lungs and the right side of the heart), Chronic pulmonary embolism (blood clot that blocks blood flow to an artery in the lung), Dependence on supplemental oxygen. B. Record review of R #7's Physician Orders, dated 09/20/25, revealed the following: BIPAP (bilevel positive airway pressure) oxygen setting to 5 LPM (liters per minute) to keep oxygen saturations above 88% (percent), Oxygen at 2-5 LPM via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). C. Record review R #7's Care Plan, dated 10/10/25 revealed the following: Risk of respiratory complications related to history of respiratory failure with the need for oxygen, Observed for new or worsening cough, Administer oxygen as ordered/indicated. D. On 01/05/26 at 1:29 PM, during an observation of R #7's room, R #7's portable O2 concentrator was observed lying on the floor, next to the resident's dresser. E. On 01/05/26 at 2:18 PM, during observation of R #7's room, Certified Nursing Assistant (CNA) #3 removed R #7's portable O2 concentrator from the floor, to be filled in the facility's oxygen room. F. On 01/05/26 at 2:19 PM, during an observation of R #7's room, CNA #3 placed R #7's portable O2 concentrator directly on the floor of R #7's room, uncovered. G. On 01/05/26 at 2:15 PM, during an interview with CNA #4, she stated portable O2 delivery equipment and O2 tubing should not be placed on the floor. She stated the proper storage is behind the resident's wheelchair or in the O2 storage room. CNA # 1 stated if the portable O2 concentrator is not stored properly, the resident could become sick. H. On 01/05/26 at 2:21 PM, during an interview with CNA #3, she stated she placed R #7's portable O2 concentrator on the floor because the resident does not like the portable on the back of her wheelchair when not in use. I. On 01/14/26 at 2:02 PM, during an interview with the Director of Nursing (DON), she stated it was her expectation for all O2 delivery devices to be stored properly and not on the floor of the resident's room. She stated if portable O2 concentrators and tubing are placed on the floor, it becomes a possible accident and hazard, or the resident may develop a respiratory infection. Topical Eye Medication and Hand Hygiene: Licensed Practical Nurse (LPN) #2: J. On 01/06/26 at 9:02 am, during medication administration for R #50, LPN #2 was observed leaving R #50's room without sanitizing her hands prior to giving R #50 her medications or sanitizing her hands after medication administration. K. 01/06/26 at 9:05 am, during an interview with LPN #2, she confirmed she did not sanitize her hands between residents and stated she should have. L. On 01/06/26 at 3:03 pm, during an interview with the Director of Nursing (DON), she stated her expectation is for nursing staff to sanitize or wash their hands before and after medication administration. Licensed Practical Nurse (LPN) #3: M. On 01/06/26 at 8:47 am, during medication administration for R #36, LPN #3 was observed preparing medications without sanitizing his hands prior to giving R #36 her medications or after medication administration. N. On 01/06/26 at 9:24 am, during medication administration for R #62, LPN #3 was observed applying eyedrops to R #62's eye using his ungloved hand to hold R #62's eye open. LPN #3 did not sanitize his hands after completing R #62's medication administration. O. On 01/06/26 at 09:27 am, during an interview with LPN #3, he confirmed he should have sanitized his hands after touching each resident and administering their medications. P. On 01/06/26 at 3:03 pm, during an interview with the DON, she stated her expectation is for nursing staff to sanitize or wash their hands before and after medication administration, touching a resident, or touching environmental surfaces.

Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #43) of 1 (R #43) resident reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are: A. Record review of R #43's face sheet revealed an admission date of 10/14/25 with the following diagnosis: Huntington's disease (is a fatal neurodegenerative disease that is usually inherited). B. Record review of R #43's Electronic Health Record (EHR) revealed there was no advanced directive, medical orders for scope of treatment (MOST is a form outlining patients' wishes for medical interventions and end-of-life care when individuals have a serious or life-threatening illness) completed or available for R #43. C. On 01/07/26 at 1:16 pm, during an interview with the Director of Nursing (DON), she stated she looked for R #43's advanced directive, but she could not find it. The DON confirmed R #43 did not have an advanced directive/MOST form readily available and should have.

Based on record review, observations, and interviews, the facility failed to notify the physician and obtain appropriate medical orders for 1 (R #25) of 1 (R #25) residents reviewed who experienced a significant change in condition, requiring oxygen (O2) therapy. If the facility fails to notify the physician and obtain a medical order when a resident experiences a significant change in condition, it may result in delayed or inadequate treatment. The findings are: A. Record review of R #25's face sheet revealed R #25 was admitted into the facility on [DATE] with the following diagnoses: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination),Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),Epilepsy (a seizure disorder). B. On 01/05/26 at 9:35 a.m., during an observation of R #25, the resident sat in his wheelchair in his room with a portable oxygen concentrator (medical device that provides continuous O2) delivering oxygen at 2 liters per minute via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). C. Record review of R #25's oxygen levels dated 01/05/26 at 4:58 pm, revealed R #25's oxygen level was at 98 percent on O2. D. On 01/06/26 at 1:26 p.m., during an observation of R #25, he was observed lying in bed asleep with a nasal cannula in place and connected to an oxygen concentrator delivering oxygen at 2 liters per minute. E. On 01/07/26 at 3:00 p.m., during an observation of R #25, he was observed lying in bed asleep with a nasal cannula in place and connected to an oxygen concentrator delivering oxygen at 2 liters per minute. F. Record review of R #25's physician orders dated 01/07/26, revealed there was no order present for O2 use. G. On 01/07/26 at 3:05 p.m., during an interview with Licensed Practical Nurse (LPN) #1, he stated R #25 was very weak and had a diagnosis of Parkinson's disease. LPN #1 stated oxygen therapy was initiated on Monday (01/05/26) after staff noted R #25 was desaturating (decrease in oxygen saturation levels), with readings observed in the low 80 percent range (normal O2 saturation levels are 95 to 100 percent). LPN #1 stated R #25 appeared increasingly weak at the time oxygen was initiated. LPN #1 stated he provided O2 to R #25, but he did not observe a physician's order authorizing oxygen use. LPN #1 further stated staff were not consistently documenting R #25's O2 use, O2 saturation levels, or episodes of desaturation. LPN #1 confirmed he was unable to identify documentation reflecting ongoing monitoring, physician notification, or clinical follow-up related to the R #25's O2 needs. H. On 01/07/26 at 3:23 p.m., during an interview with the Assistant Director of Nursing (ADON), she stated she was not aware R #25 had been receiving O2 prior to 01/07/26. The ADON stated she was informed approximately 10 minutes earlier by LPN #1 that R #25 was receiving O2 therapy. The ADON confirmed she should have been made aware when O2 was initiated for R #25, as changes in respiratory status and the initiation of O2 therapy require nursing leadership oversight, physician notification, and appropriate documentation. The ADON was unable to identify documentation reflecting physician notification, a physician's order, or supervisory review related to the resident's O2 use prior to 01/07/26.I. On 01/07/26 at 3:36 p.m., during an interview with the Director of Nursing (DON), she stated the physician, or medical director, should have been notified on the first day O2 was initiated for R #25, but that did not happen. J. On 01/13/26 at 1:00 p.m., during an interview with the Medical Director (MD), he stated there should have been a standing order for O2 use (a pre-authorized physician order permitting nursing staff to initiate oxygen therapy when clinically indicated based on established parameters) for R #25, but there was not. The MD stated it was his expectation to be notified of any decrease in a resident's O2 saturation levels. The MD confirmed he would expect to be notified so that O2 therapy could be authorized and administered in response to the resident's change in condition, but he was not notified for R #25's required O2 use.

Based on record review and interview, the facility failed to create a Baseline Care Plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #25) of 1 (R #25) resident reviewed for Baseline Care Plans. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are: A. Record review of R #25's face sheet revealed R #25 was admitted into the facility on [DATE] with a diagnosis of: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination),Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),Epilepsy (a seizure disorder).B. Record review of R #25's care plan revealed the facility did not develop or implement a baseline care plan within 48 hours of admission as required. R #25's care plan initiation dates reflected 12/22/2025. C. On 01/14/26 at 2:00 p.m., during an interview with the Director of Nursing (DON), she stated nursing staff are responsible for initiating the baseline care plan and stated her expectation was that R #25's baseline care plan would be completed within 48 hours of admission, and it was not.

Based on record review, observations, and interviews, the facility failed to ensure nursing services were provided in accordance with professional standards of practice for 1 (R #25) of 1 (R #25) resident reviewed, when: The facility nursing staff administered oxygen (O2) without physician orders. The facility nursing staff did not document R #25's O2 use.The facility did not notify the physician when R #25 experienced O2 desaturation (a drop in a person's oxygen level in the blood below normal, meaning the body is not getting enough oxygen). If nursing staff initiate and continue O2 therapy for a resident without a physician order, fail to document oxygen use, and do not notify the physician when a resident experiences O2 desaturation, then residents are at risk for receiving unauthorized treatment without appropriate medical oversight. These deficient practices are likely to lead to delayed or inappropriate medical intervention, and potential adverse outcomes related to untreated or improperly managed medical conditions. The findings are: A. Record review of R #25's face sheet revealed R #25 was admitted into the facility on [DATE] with the following diagnoses: Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination),Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),Epilepsy (a seizure disorder). B. On 01/05/26 at 9:35 a.m., during an observation of R #25, the resident sat in his wheelchair in his room with a portable oxygen concentrator (medical device that provides continuous O2) delivering oxygen at 2 liters per minute via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). C. On 01/06/26 at 11:34 a.m., during an observation of R #25, he was observed seated in his wheelchair and being escorted to the dining area while receiving oxygen via nasal cannula. D. On 01/06/26 at 1:26 p.m., during an observation of R #25, he was observed lying in bed asleep with a nasal cannula in place and connected to an oxygen concentrator delivering oxygen at 2 liters per minute.E. On 01/07/26 at 3:00 p.m., during an observation of R #25, he was observed lying in bed asleep with a nasal cannula in place and connected to an oxygen concentrator delivering oxygen at 2 liters per minute.F. Record review of R #25's physician orders dated 01/07/26, revealed there was no order present for O2 use. G. On 01/07/26 at 3:05 p.m., during an interview with Licensed Practical Nurse (LPN) #1, he stated R #25 was very weak and had a diagnosis of Parkinson's disease. LPN #1 stated oxygen therapy was initiated on Monday (01/05/26) after staff noted R #25 was desaturating (decrease in oxygen saturation levels), with readings observed in the low 80 percent range (normal O2 saturation levels are 95 to 100 percent). LPN #1 stated R #25 appeared increasingly weak at the time oxygen was initiated. LPN #1 stated he provided O2 to R #25, but he did not observe a physician's order authorizing oxygen use. LPN #1 further stated staff were not consistently documenting R #25's O2 use, O2 saturation levels, or episodes of desaturation. LPN #1 confirmed he was unable to identify documentation reflecting ongoing monitoring, physician notification, or clinical follow-up related to the R #25's O2 needs. H. On 01/07/26 at 3:23 p.m., during an interview with the Assistant Director of Nursing (ADON), she stated she was not aware R #25 had been receiving O2 prior to 01/07/26. The ADON stated she was informed approximately 10 minutes earlier by LPN #1 that R #25 was receiving O2 therapy. The ADON confirmed she should have been made aware when O2 was initiated for R #25, as changes in respiratory status and the initiation of O2 therapy require nursing leadership oversight, physician notification, and appropriate documentation. The ADON was unable to identify documentation reflecting physician notification, a physician's order, or supervisory review related to the resident's O2 use prior to 01/07/26.

Based on record reviews and interviews, the facility failed to ensure the accuracy and completeness of the electronic health record (EHR) for 1 (R #66) of 1 (R #66) resident reviewed for accuracy of resident information by: Inaccurately documenting R #66's communication and hearing impairments. This deficient practice is likely to create the potential for inaccurate or incomplete documentation within the electronic health record, which may negatively impact the resident's ability to receive the care and services needed. The findings are: A. Record review of R # 66's Face Sheet revealed an admission date of 05/18/23 and the following diagnoses: Expressive language disorder (a condition where a person has trouble using words and sentences to communicate),Sensorineural hearing loss, bilateral (hearing loss in both ears caused by damage to the inner ear (cochlea) or auditory nerve, leading to reduced ability to hear and understand sounds, especially speech),Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease),Other drug induced secondary Parkinsonism (movement disorder caused by certain medications, resulting in symptoms similar to Parkinson's disease (tremor, rigidity, slow movements),Cognitive communication deficit (a communication disorder caused by impairments in cognitive processes). B. Record review of R #66's Psychiatric Notes, dated 05/08/25, revealed the following: Resident uses paper and pencil to answer questions on notebook,Due to resident being non-verbal in today's assessment, this note is completed per chart review and staff support.C. Record review of R #66's Care Plan, dated 05/16/25 revealed the following: Potential for impaired communication r/t (related to) impaired hearing,Resident will express needs through non-verbal communication as needed daily,Resident will use alternative methods of communication such as writing as needed daily,Speak facing the resident,Ensure availability and functioning of adaptive equipment,Resident is at risk or is experiencing adjustment issues related to communication challenges. D. Record review of R #66's Progress Notes, dated 05/18/25, revealed the following: Resident is primarily non-verbal communication board, pen and paper, Resident has the following needs for special adaptive equipment to participate in desired engagement opportunities- Communication board written instructions/gestures for hearing lost. No cognitive limitations. E. Record review of R #66's Psychiatric Notes, dated 10/23/25, revealed Due to resident being non-verbal in today's assessment, this note is completed per chart review and staff support.F. Record review of R #66' Speech Therapy evaluation, dated 11/14/25, revealed the following: Evaluation of speech with evaluation of language and comprehension and expression,Resident is nonverbal,Hearing details- None (uses notepad to communicate),Resident reports not knowing all the words but communicates through a notebook,Speech clarity: no speech,Auditory Comprehension-Not indicated (profound hearing loss),Ability to hear- highly impaired (absence of useful hearing),Due to the documented physical impairments, without skilled therapeutic interventions, the resident is at risk for anxiety, general health, decreased leisure participation and social isolation. G. Record review of R #66's Psychiatric Notes, dated 11/20/25, revealed the following: Resident uses paper and pencil to answer questions on notebook,Due to resident being non-verbal in today's assessment, this note is completed per chart review and staff support. H. Record of R #66's Physicians Orders, dated 01/07/26, revealed the facility is to provide a speech therapy evaluation and treatment as recommended. Resident is non-verbal (unable to speak or use words to communicate) and uses a communication board.I. Record review of R #66's Provider Documentation revealed the following: Clear speech (intelligible articulation and pronunciation, with appropriate voice quality, rhythm, and fluency, allowing speech to be easily understood by listeners) and resident is deaf (partial or complete inability to hear sounds) 08/13/25,Speech is clear 08/19/25,Resident has clear speech 09/23/25, Resident has clear speech 12/01/25. J. On 01/07/26 at 3:19 PM, during an interview with the Activities Director (AD), she stated R #66 used a whiteboard or his notebook as his source of communication. K. On 01/07/2026 at 3:21 PM, during an interview with Certified Nurse Aide (CNA) #1, she stated R #66 is nonverbal and writes his questions on a piece of paper. CNA #1 stated since the admission of the resident, she had never heard him speak. L. On 01/07/26 at 3:26 PM, during an interview with Registered Nurse (RN) #1, she stated R #66 is nonverbal and communicates with a notebook. She stated the resident also has hearing loss. M. On 01/07/26 at 3:27 PM, during an interview with CNA #2, she stated R #66 doesn't speak and uses his notebook to communicate. She stated the resident has difficulty hearing. N. On 01/07/26 at 3:36 PM, during an interview with Certified Medication Assistant (CMA) #1, she stated R #66 doesn't speak and uses his notebook to communicate. She stated the resident also has a hearing impairment. O. On 01/08/26 at 10:20 AM, during an interview with the Activities Director (AD), she stated R #66 has been nonverbal since he admitted in 2023. P. On 01/08/2026 at 1:38 PM, during an interview with the Director of Rehab (DOR), she stated R #66 is nonverbal and uses a communication board to communicate. Q. On 01/08/2026 at 1:44 PM during an interview with the Social Services Director (SSD), she stated R #66 is nonverbal and uses a pen and notebook to answer questions and communicate. R. On 01/14/26, at 2:45 PM, during an interview with the Director of Nursing (DON), she stated R #66 was non-verbal and had profound hearing loss. The DON confirmed R #66's EHR should reflect R #66 being nonverbal with hearing loss, but it did not due to R #66's provider documentation indicating R #66 could speak without limitations (finding I).

Based on observation, interview, and record review the facility failed to provide wound care as ordered by the physician for 1 (R #25) of 1 (R #25) resident reviewed for wound care. This deficient practice could likely cause wounds to worsen or become infected which could lead to sepsis (a serious condition in which the body responds improperly to an infection) and hospitalization. The findings are: A. Record review of R #25's face sheet revealed R #25 was admitted to the facility on [DATE]. She was admitted with the following diagnoses: Atrial Fibrillation (A-Fib; irregular heart rhythm), Type II diabetes (a disease in which the body cannot make or properly use insulin), Chronic venous hypertension with ulcer and inflammation of the left lower extremity (venous ulcers are open skin lesions that occur in an area affected by venous hypertension caused by poor blood flow and circulation), Pulmonary hypertension (condition characterized by high blood pressure in the arteries of the lungs, leading to various symptoms and potential heart complications). B. Record review of R #25's physician orders indicated the following, wound care to left lower extremity (LLE), cleanse entire foreleg (front of the leg) with generic wound cleanser and pat dry with sterile gauze. Apply silver collagen sheet (used to assist in the wound healing process). Cover with Hydrogel dressing (moist wound care products that provide hydration, pain relief and infection prevention) secure in place with kerlix (used in wound care applications) and tape, dated/initialed. Every day shift for LLE Venous Stasis Ulcers for 2 Weeks. Notify wound team of any +/- (positive or negative) wound changes. Start 11/20/25. C. On 12/04/25 at 11:05 am, during an interview and observation with R #25, she stated that everything at the facility was going well except her wound dressing had not been changed recently. R #25 stated she thinks that she is supposed to get wound care every day. R #25 revealed the wound dressing on her LLE was dated 11/26/25 and it had initials and a date of who completed the wound care. D. Record review of R #25's Treatment Administration Record (TAR) from 11/25/25 to 12/03/25 indicated the following: 11/25/25 the TAR did not have any documentation for wound care being completed, 11/26/25 to 11/29/25 wound care was marked as completed, 11/30/25, 12/01/25, 12/02/25 the TAR did not have any documentation of wound care being completed, 12/03/25 wound care was marked as completed. E. On 12/04/25 at 11:15 am during an observation and interview with the Director of Nursing (DON) she confirmed the dressing on R #25's LLE was dated 11/26/25 with initials. The DON also confirmed the TAR for November 2025 indicated wound care was completed for R #25 on 11/27/25, 11/28/25, 11/29/25 and for December on 12/03/25 but stated the documentation was not accurate because wound care was not provided on those days. The DON stated the order was to do wound care daily and it was not completed daily. F. On 12/04/25 at 11:20 am, during an interview with Licensed Practical Nurse (LPN) #8, she stated the nurses are responsible for the wound care except on Wednesdays when the wound care team rounds (all the wounds in the building are assessed) and does wound care and assessments for all the wounds. She stated that the last time she performed wound care for R #25 was on Saturday 11/29/25. She was off on Sunday, Monday and Tuesday and wasn't able to do it yesterday. LPN #8 was not able to explain why the dressing date for R #25's LLE wound was dated 11/26/25, when her initials on the TAR indicated she performed wound care for R #25 on 11/27/25, 11/28/25, 11/29/25 and on 12/03/25. G. On 12/04/25 at 11:45 am, during an interview with the Wound Care Nurse, he stated the last time he performed wound care for R #25 was on 11/26/25. He stated Wednesday are wound assessment days and he and the wound care team do assessments and wound care for the whole building. The wound nurse stated he was the last nurse to have completed wound care for R #25 according to the wound dressing. The wound nurse stated, staff know and are aware if they are needing help with anything they can always ask him for help. He stated none of the nurses on the floor have asked for assistance from him and he was not aware there were issues with the wound care being completed. H. Record review of R #25's wound assessment completed on 12/04/25 revealed the wound had not deteriorated (gotten worse) since the last wound care completed on 11/26/25.

Based on observation, interview, and record review; the facility failed to accurately record (document what actually occurred) the wound care for 1 (R #25) of 1 (R #25) resident reviewed for wounds. This deficient practice is likely to cause confusion about wound care, when wound care documentation is inaccurate and indicates wound care treatments as being completed when they were not. The findings are: A. Record review of the R #25's face sheet revealed R #25 was admitted to the facility on [DATE]. She was admitted with the following diagnoses: Atrial Fibrillation (A-Fib; irregular heart rhythm), Type II diabetes (a disease in which the body cannot make or properly use insulin), Chronic venous hypertension with ulcer and inflammation of the left lower extremity (venous ulcers are open skin lesions that occur in an area affected by venous hypertension caused by poor blood flow and circulation), Pulmonary hypertension (condition characterized by high blood pressure in the arteries of the lungs, leading to various symptoms and potential heart complications). B. Record review of R #25's physician orders dated 11/20/25 revealed the following: - Wound care to left lower extremity (LLE), cleanse entire foreleg with generic wound cleanser and pat dry with sterile gauze. Apply silver collagen sheet (a type of wound dressing) to open areas. Cover with Hydrogel (wound dressing designed to provide a moist environment for wound healing) dressing, secure in place with kerlix (bandage roll) and tape, dated/initialed. Every day shift for LLE Venous Stasis Ulcers (wounds caused by a lack of blood circulation to the lower extremities) for 2 Weeks. Notify wound team of any +/- (positive or negative) wound changes. C. On 12/04/25 at 11:05 am, during an interview and observation with R #25, she stated that everything at the facility was going well except her wound dressing had not been changed recently. R #25 stated she thinks that she is supposed to get wound care every day. R #25 revealed the wound dressing on her LLE was dated 11/26/25 and it had initials and a date of who completed the wound care. D. Record review of R #25's Treatment Administration Record (TAR) from 11/27/25 to 12/03/25 indicated the wound care to the LLE was completed, and marked with the nurses' initials that completed the wound care on the following dates: - 11/20/25 through 11/24/25. - 11/26/25 through 11/29/25. - 12/03/25. E. On 12/04/25 at 11:15 am during an observation and interview with the Director of Nursing (DON) she confirmed the dressing on R #25's LLE was dated 11/26/25 with initials. The DON also confirmed the TAR for November 2025 indicated wound care was completed for R #25 on 11/27/25, 11/28/25, 11/29/25 and for December on 12/03/25 but stated the documentation was not accurate because wound care was not provided on those days. The DON stated the order was to do wound care daily and it was not completed daily. F. On 12/04/25 at 11:20 am, during an interview with Licensed Practical Nurse (LPN) #8, she stated the nurses are responsible for the wound care except on Wednesdays when the wound care team rounds (all the wounds in the building are assessed) and does wound care and assessments for all the wounds. She stated that the last time she performed wound care for R #25 was on Saturday 11/29/25. She was off on Sunday, Monday and Tuesday and wasn't able to do it yesterday. LPN #8 was not able to explain why the dressing date for R #25's LLE wound was dated 11/26/25, when her initials on the TAR indicated she performed wound care for R #25 on 11/27/25, 11/28/25, 11/29/25 and on 12/03/25.

Based on interviews and record review, the facility failed to ensure a resident's Level 1 Preadmission Screening and Resident Review (PASRR; a federal requirement to help ensure individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) were reviewed for accuracy and completion for 1 (R #1, R #2 and R #3) of 3 (R #1, R #2 and R #3). If the facility fails to review PASRR screenings for accuracy and completion, then residents with serious mental illness or intellectual disability may receive inappropriate placement and care. The findings are: A. Record review of R #1's admission Record, dated 05/12/15, revealed an admission date of 05/12/15 with the following diagnoses:- Dementia. (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment)- Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). B. Record review of R #1's New Mexico PASRR Level 1 Identification Screen, dated 05/08/15 and completed by the previous facility, revealed staff documented the resident did not have a diagnosis or suspected mental illness. Further review revealed the New Mexico PASRR Level 1 Identification Screen listed depression as a mental illness example. C. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment completed by facility staff), dated 02/04/25, revealed the following: -The resident had a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).-The resident received an antidepressant (medication to relieve the symptoms of depression). D. On 09/29/25, at 1:27 PM, during an interview, the Marketing Director stated the sending facility completed the resident's Level 1 PASARR, if the resident came from another facility. The Marketing Director stated it was the responsibility of the Marketing Director and the Social Services Department (SSD) to check the accuracy of the residents' PASARR for correct diagnoses. The Marketing Director stated if the diagnoses did not match the PASARR I Screening, then they sent it back to the sending facility for correction. The Marketing Director stated R #1's PASARR did not have the resident's diagnosis of depression, which made the PASARR incorrect. She stated it was her expectation all resident PASARRs were screened before the admission of the resident. The Marketing Director stated she was new to her position, and she did not review R #1's Level 1 PASARR. E. On 09/29/25, at 1:35 PM, during an interview, the Director of Social Services stated it was the responsibility of the Social Services Department and the Director of Marketing to check the accuracy of the residents' Level 1 PASARR. The Social Services Director stated if a resident had a condition listed on the New Mexico PASARR Level 1 Identification Screen, then SSD would submit the PASARR II to the State Agency for review. The SSD stated if the residents were not properly screened, then they may not receive the care or services needed. The SSD stated it was her expectation all PASARR were accurate and had the correct resident information. The Social Services Director stated she was new to her position, and she did not review R #1's Level 1 PASARR.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #5) of 5 ( R #'s 1, 2, 3, 4 and 5) residents when they failed to administer anti-seizure medication (medication used to prevent or stop seizures [sudden burst of electrical activity in the brain]) as ordered. This deficient practice likely resulted in the resident experiencing seizures requiring hospitalization . The findings are: A. Record review of R #5's face sheet revealed an admitted [DATE] and included a diagnosis of epilepsy (seizure disorder). B. Record review of Prepare to Admit document dated 11/20/24 for R #5 revealed that R #5's current medications included Lacosamide (medication used to prevent or treat seizures) 200 milligrams (mg). C. Record review of Minimum Data Set (MDS - federally mandated assessment instrument completed by facility staff) dated 12/04/24 for R #5 revealed the following: - Section I - Active Diagnoses: Seizure Disorder or Epilepsy. - Section N - Medications: Anticonvulsant (medication used to prevent and manage seizures) was included. D. Record review of Care Plan dated 11/25/24 for R #5 revealed, Focus: Risk for seizure activity related to diagnosis of epilepsy. Goal: There will be no complications from seizure activity over the next ninety days. Interventions . 4) Medicate as ordered assessing the effectiveness and for any adverse effects. E. Record review of physicians admission medication orders for R #5 included the following order: - Lacosamide oral tablet, 200 mg. Give 200 mg orally every 12 hours for epilepsy. Start date: 01/16/24. [no end date] F. Record review of medication administration record (MAR), dated November 1 through 30, 2024 for R #5 revealed no documentation that R #5 received Lacosamide Oral Tablet 200 mg from 11/21/24 through 11/30/24. G. Record review of the Facility Hospital Transfer form dated 11/25/24 for R #5 revealed that he was transferred to the hospital due to seizures. H. Record review of the hospital discharge paperwork dated 11/25/24 for R #5 revealed that R #5 was admitted to the hospital for seizure activity. Documentation confirmed that the nursing facility did not have lacosamide on formulary and therefore R #5 had not received this medication over the past four days. Documentation also revealed R #5 was noted to have generalized tonic-clonic seizures (type of seizure that causes loss of consciousness and violent muscle contractions) this afternoon; when emergency medical services (EMS) arrived, R #5 was actively seizing. Per the hospital H&P revealed his [R #5] seizures had been stable over the course of the last year. I. On 04/03/25 at 3:53 pm during an interview with the Director of Nursing (DON), the Administrator (ADM), and Nurse Educator/Unit Manager (NE/UM) revealed the following: DON stated that R #5 arrived in the evening on 11/21/24 and all his medications were received except for the seizure medication; R #5 had several seizures in a row and was sent out to the hospital. DON stated that no one was aware that the seizure medication had not come in until R #5 was sent to the hospital. DON also stated that the nurse on duty was supposed to call and follow up with the pharmacy. NE/UM stated that R #5 was transferred from another facility and the prescription was not sent to the new facility. She stated that R #5's insurance was not going to pay for the medication because the prior facility had already received the prescription. She stated that they contacted the prior facility and requested that the facility either return the medication to the pharmacy or send it to this facility. DON stated that the nurse on duty is supposed to contact the physician to reconcile the resident's admission medications to make sure the physician agrees with the medications. He stated that the order for lacrosamide was listed on the medication list but was not on the hard copies that arrived with the resident. J. On 04/03/25 at 4:14 pm during an interview, the Nurse Practitioner (NP) confirmed that she reconciled/verified the admission medications, for R #5, with Registered Nurse (RN) #1 which included the orders for Lacosamide. The NP confirmed that she was not aware that R #5 was not receiving this medication until he was sent to the hospital on 11/25/24. K. On 04/03/25 at 4:31 pm during an interview, RN #2 stated that when she reached out to the the pharmacy regarding R #5's Lacosamide she was told that the medication would be delivered to the facility by the evening on 11/22/24. The facility was later informed by the pharmacy that they could not fill the prescription because it had been filled by the previous facility from which R #5 transferred. The facility reached out to the prior facility requesting that the medication be sent to them or returned to the pharmacy to which the prior facility refused. Based on record reviews and interviews, an Immediate Jeopardy (IJ) was identified. The facility administrator was notified on 04/03/25 at 5:45 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The Plan of Removal was approved on 04/04/25 at 12:15 pm. Plan of removal: All residents have the potential to be affected by this alleged deficient practice. The following identification/corrections will be completed by 04/03/25. - Audit all residents with a diagnosis of seizures to ensure medication therapy is in place as ordered. - A 14 day look back audit of recent admissions to ensure accurate medication reconciliation, review and continuation of medications and treatments. - All licensed staff education to include medication transcription/medication reconciliation upon admission with documentation in the residents chart and steps to follow for medication availability with an emphasis on: validating with the pharmacy on arrival time, pulling from Ekit (emergency kit - contains a small quantity of medications that can be dispensed when pharmacy services are not available) if available, notification of provider for additional orders or medication adjustments, requesting medications from backup pharmacy if needed. - DON/Designee during morning clinical meetings, medication reconciliation audits occur for all new admissions and medication order changes. - DON/Designee to review medications not available during morning clinical meetings. - Nurse Practice Educator/Designee will begin education on 04/03/2025 and continue until all licensed nursing staff have been educated prior to their next shift. Any licensed staff member on leave of absence (FMLA- family medical leave act), vacation, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires will be educated on this process upon hire. - The Director of Nursing/designee will audit 5 random residents 3 x (times) week to ensure all medications reconciliation have occurred. - DON and/or designee will bring results of audits to QAPI (quality assurance and performance improvement) committee for further recommendations based on tracking and trending presented monthly for the next 2 months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator. Implementation of the POR was verified onsite on 04/04/25 by record reviews, and staff interviews. Scope and Severity was reduced to Level 2, D. Implementation was verified through: Record review of the facility's new admissions audit from 03/21/25 through 04/04/25 to ensure accurate medication reconciliation, review and continuation of medications and treatments. Record review of the facility's audit of all current residents with a diagnosis of seizures to ensure medication therapy was in place as ordered. Record review of staff signature sheets for the education provided to the licensed staff, to include medication transcription/medication reconciliation upon admission with documentation in the residents' chart and steps to follow for medication availability with an emphasis on: validating with the pharmacy on arrival time, pulling from Ekit if available, notification of provider for additional orders or medication adjustments, requesting medications from backup pharmacy if needed. Interviews of two nurses verified the in-service they received on 04/03/25 and 04/04/25 included medication transcription/medication reconciliation upon admission with documentation in the residents' chart and steps to follow for medication availability with an emphasis on: validating with the pharmacy on arrival time, pulling from Ekit if available, notification of provider for additional orders or medication adjustments, requesting medications from backup pharmacy if needed. Interview with the Administrator and DON regarding POR, audits new admissions audit from 03/21/25 through 04/04/25 to ensure accurate medication reconciliation, review and continuation of medications and treatments; audit of all current residents with a diagnosis of seizures to ensure medication therapy was in place as ordered; and education provided to the licensed staff, to include medication transcription/medication reconciliation upon admission with documentation in the residents' chart and steps to follow for medication availability with an emphasis on: validating with the pharmacy on arrival time, pulling from Ekit if available, notification of provider for additional orders or medication adjustments, requesting medications from backup pharmacy if needed.

Based on interview and facility policy review, the facility failed to ensure they had a certified infection prevention nurse hired at least part time onsite. This failure has the potential to increase infection rates due to the lack of active surveillance and staff education. Findings include: Review of the facility's policy titled, Infection Prevention and Control Program Description, and dated 01/09/04 with a revision date of 07/01/24 indicated, The IP [Infection Preventionist] must work at least part time. Under the Goals section the following was documented: The IPCP [Infection Prevention Control Policy] has been developed to provide staff with a coordinated organizational structure, technical procedures, comprehensive work practices, and guidelines to reduce the risk of transmission of infection or communicable disease. During an interview on 09/18/24 at 2:08 PM, Registered Nurse (RN)1 stated her last day of employment at the facility was 09/13/24. RN1 stated she received a text message from the Director of Nursing (DON) informing her that was her last day due to the facility hiring another RN for the IP role. RN1 stated she was working on completing infection control data for the month of July and August when she was notified of her termination. RN1 stated she quit working full time at the facility in April 2024 and began working remotely on an as needed basis (PRN) from April 2024 until September 2024. Since April 2024 RN1 had only been onsite four or five times to deliver completed work. RN1 stated she would provide verbal education on those facility visits to the staff present and leave written documentation for other staff to read. During an interview on 09/18/24 at 2:41 PM, the Medical Director (MD) stated he reviewed infections monthly. He stated the new IP nurse was RN5. During an interview on 09/18/24 at 3:43 PM, the Administrator stated RN 5 had literally worked at the facility for four days and was not currently certified as an IP. The Administrator stated she was aware the July and August infection control data was not complete. The Administrator was not aware the previous IP nurse was told to stop working on any of the IP work for the facility. The Administrator stated the DON told RN1 to stop working because the facility hired a new IP nurse. During an interview on 09/18/24 at 4:34 PM, the DON stated RN1's last day was on 09/13/24. The DON stated RN1 was the previous IP nurse at the facility, and she began working PRN in April 2024. He stated the new IP they hired was only going to be a floor nurse at this time. She told the facility she no longer wanted to be in a management role. The DON stated he was not aware the facility had to have a part time or full-time IP onsite until 09/17/24.

Based on interview, record review, and facility policy review, the facility failed to provide one of two residents (Resident (R)79) reviewed for hospital transfers out of a total sample of 30 residents a written bed hold when R79 was transferred to the hospital. Findings include: Review of the facility's policy titled Bed-Holds revised date 01/12/23, read in part .When a resident/patient (resident) is transferred out of the service location to a hospital or on therapeutic leave, the designee will provide the resident and his/her representative, if applicable with the written Bed Hold Policy and Authorization form. If the resident representative is not present to receive the written notice upon transfer, the notice is delivered via e-mail, fax or hard copy via mail. Review of R79's Admission Record located in the electronic medical records (EMR) section titled Profile revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, dementia and hypothyroidism. Review of the EMR, under the Progress Notes tab, revealed R79 was discharged to the hospital on 09/01/24 due to altered mental status. The EMR lacked evidence the facility provided R79 a copy of the facility's bed hold policy at the time of transfer to the hospital. Interview with the Business Office Manager (BOM) on 09/19/24 at 10:03 AM confirmed the facility failed to provide the facility's bed hold policy to R79 upon transfer to the hospital. BOM stated the nurses were responsible for initiating bed holds and had not been doing it. BOM stated they held an in-service a couple of weeks prior with nursing staff regarding bed holds and they still were not being done. BOM stated they had not received any written bed hold notices since they became employed at the facility, February 2024. Interview with the Licensed Practical Nurse (LPN) 1 on 09/19/24 at 10:07 AM they confirmed they knew about the bed hold form, but they did not use it. LPN stated they would ask they did would normally ask the resident or resident representative if they want a bed home and let the BOM know. Interview with the Registered Nurse (RN) 3 on 09/19/24 at 12:11 PM, RN 3 stated they would document when a resident transfers to the hospital and the BOM does any bed hold information.

Based on observations, record review, and interview, the facility failed to provide services based on acceptable standards of practice by specifically failing to accurately check a finger stick glucose level for three of three residents (Resident (R)14, R49, and R 52) reviewed for professional standards of 30 sample residents. This failure had the potential to affect the blood glucose levels for three of three residents reviewed. Findings include: Review of the revised facility's policy titled, Procedure: Fingerstick Blood Glucose Monitoring dated 06/15/22 did not address discarding the first drop of blood prior to obtaining the blood sample. 1. Review of R52's Face Sheet, located under the Resident tab of the electronic medical record (EMR), documented R52 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus with hyperglycemia. Review of R52's annual Minimum Data Sheet (MDS) with an Assessment Reference Date (ARD) of 08/07/24, located under the MDS tab of the EMR, documented R52 had a Brief Interview for Mental status (BIMS) of one out of 15 indicating, R52 had severe cognitive impairment. Review of R52's care plan, dated 08/08/24 and located under the Care Plan tab of the EMR, documented R52 had diabetes mellitus and had the potential for hypo/hyperglycemia and other complications. Review of R52's active orders for September 2024, located under the Orders tab of the EMR, indicated to notify the physician if the blood glucose was above 400 and if the blood sugar is less than 70 to initiate the hypoglycemia blood sugar protocol. Blood sugars were to be checked before meals. During an observation on 09/17/24 at 3:55 PM, Licensed Practical Nurse (LPN) 2 checked R52's blood sugar. LPN 2 cleaned R52's finger with an alcohol wipe prior to sticking R52's finger with the lancet. LPN 2 did not wipe away the first drop of blood prior to obtaining the blood sample. 2. Review of R14's Face Sheet, located under the Resident tab of the EMR, documented R14 was admitted to the facility on [DATE] with a diagnosis of type two diabetes without complications. Review of R14's annual MDS with an ARD of 07/09/24, located under the MDS tab of the EMR, documented R14 had a BIMS of 12 out of 15 indicating, R14 was cognitively intact. Review of R14's care plan, dated 07/10/24 and located under the Care Plan tab of the EMR, documented R14 had diabetes mellitus and would remain free of all signs and symptoms of hypo/hyperglycemia such as: sweating, trembling, thirst, fatigue, weakness, [and] blurred vision for 90 days. Review of R14's active orders for September 2024, located under the Orders tab of the EMR, indicated to check blood sugar before bedtime. During an observation on 09/17/24 at 4:08 PM, LPN2 checked R14's blood sugar. LPN2 cleaned R14's finger with an alcohol wipe prior to sticking R14's finger with the lancet. LPN2 did not wipe away the first drop of blood prior to obtaining the blood sample. During an interview on 09/17/24 at 4:21 PM, LPN2 stated she was taught to wipe away the first drop of blood but, she does not routinely do this. LPN2 was not sure if that was a facility policy or not. 3. Review of R49's Face Sheet, located under the Resident tab of the EMR, documented R49 was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus with hyperglycemia. Review of R49's annual MDS with an ARD of 06/24/24, located under the MDS tab of the EMR, documented R49 had a BIMS of nine out of 15 indicating, R49 had mild cognitive impairment. Review of R49's care plan, dated 06/26/24 and located under the Care Plan tab of the EMR, documented R49 had diabetes mellitus and would remain free of all signs and symptoms of hypo/hyperglycemia such as: sweating, trembling, thirst, fatigue, weakness, [and] blurred vision for 90 days. Review of R49's active orders for September 2024, located under the Orders tab of the EMR, indicated to check blood sugar levels before meals and administer sliding scale insulin as needed. During an observation on 09/17/24 at 4:14 PM, LPN2 checked R49's blood sugar. LPN2 cleaned R49's finger with an alcohol wipe prior to sticking R49's finger with the lancet. LPN2 did not wipe away the first drop of blood prior to obtaining the blood sample. During an interview on 09/17/24 at 5:02 PM, the Director of Nursing (DON) stated the proper steps for obtaining a blood sugar were as follows: clean the work surface, place a protective barrier on it, and then place your clean supplies on the barrier. He stated you cleanse the finger, let the alcohol dry and use a lancet to poke the finger. The DON went on to say you should discard the first drop of blood and use the second for the test sample. He was not sure if the facility's policy specifically stated to discard the first drop of blood but stated it was a professional standard.

Based on interview and record review, the facility failed to send a referral for a barium swallow study within an appropriate time frame for one of 30 sampled residents (Resident (R) 76). This failure placed the resident at risk of not having pleasurable items. Finding include: Review of R76's undated Admission Record, located in the resident's electronic medical record (EMR) under the Resident Summary tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included aftercare following surgery on nervous system, post-traumatic hydrocephalus and encephalitis and encephalomyelitis. Review of R76's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/13/24 located in the resident's EMR under the MDS tab revealed the resident did not have a Brief Interview for Mental Status (BIMS) and was rarely/never understood. Review of R76's Medication Order Summary located under the Orders tab of the EMR, dated 09/13/24, revealed an order for R76 to the hospital for a barium swallow study. Review of Nursing Progress Note, located under the Notes tab of the EMR, dated 09/07/24, documented R76's family was requesting a swallowing evaluation as R76 wants to drink fluids, juice and ice-chips. Family was notified that therapy (Speech Therapy (ST)) will follow up next week and discuss the next steps. Family members noted giving resident orange juice and sips of water today. The family was educated on swallowing precautions. Review of R76's Nursing Progress Note, located under the Notes tab of the EMR, dated 09/11/24 documented R76 was awaiting a barium swallow at the hospital to determine if he is able to take oral intake. Interview on 09/16/24 at 1:27 PM R76's Family Member (FM) stated they had been trying to get a swallow study done for the last two weeks and had not been able to get it done. FM stated they did not know what the holdup was, but they wanted to be able to give R76 different items and were not able to due to waiting on the swallow study. Interview on 09/17/24 at 11:28 AM with Rehabilitation Director (RD), RD stated they notified the receptionist that R76 needed a referral. RD stated they normally follow up on their referrals within a few days, but confirmed they had not followed up on R76. Interview on 09/17/24 at 11:34 AM with Receptionist, the Receptionist stated the Rehabilitation Director told her that R76 needed an appointment a swallow study. The Receptionist confirmed she had not gotten around to scheduling the referral for R76 yet. The receptionist stated they schedule their appointments and referrals within 24 to 48 hours. Interview on 09/18/24 at 8:56 AM with the Director of Nursing (DON), DON stated the receptionist is responsible for scheduling appointments for residents. DON stated their expectation is for appointments to be scheduled within 24 to 48 hours.

This is a past noncompliance. Based on record review and interview, the facility failed to ensure nursing staff demonstrated competency in skills and techniques necessary to safely administer medications to residents for 1 [Licensed Practical Nurse (LPN #1)] of 4 [LPN #1, LPN #2, Registered Nurse (RN) #1, and Certified Medication Assistant (CMA) #1] employees sampled for training. This deficient practice likely resulted in R #1 receiving another resident's medication, which resulted in R #1 being admitted to the hospital on 03/22/24 for accidental overdose and hypotension (low blood pressure). The findings are: A. Record review of the facility's Medication Management Clinical procedures, undated, revealed safe practices for giving medicines. Clinicians are required to follow policies and standards of practice when giving medicines. Staff directed to review the five rights of administering medicine: 1. The right person, 2. The right medicine, 3. The right dose, 4. The right route, 5. The right time. B. Record review of the facility's Complaint Narrative Investigation: A Follow-up Report (5 day), undated, revealed upon interview with LPN #1, she reported having pre-poured the medications in a cup, become distracted, and handed the medications to R #1 instead of R #2. LPN #1 reported she immediately realized she handed the medications to the wrong resident. Resident #1 did not ingest all of the medications, so she retrieved the remaining medications in the Sharp's container. RN #1 did not report the medication error to the physician or the Director of Nursing (DON). During a follow-up interview several days later, LPN #1 said she gave R #1 Prilosec (medication used for heart burn) and lisinopril (a medication used to lower blood pressure). C. Record review of the R #1's change of condition for medication error, dated 3/22/24, revealed the following: 1. On 03/22/24 at 5:46 am, staff documented R #1's blood pressure as 117/65 mmHG (millimeters of mercury; Normal blood pressure is 120/80 mmHG.) 2. On 03/22/24 at 10:37 am, staff documented R #1's blood pressure as 80/46 and sent the resident out to the emergency room (ER). D. Record review of R #1's hospital records, dated 03/22/24, revealed: 1. On 03/22/24 at 3:58 pm, R #1 was evaluated at the ER. 2. Chief Complaint: LPN accidentally gave the patient the wrong medications, hypotensive. 3. History of Present Illness: Patient is a [AGE] year-old-male in a nursing home with no significant past medical history besides dementia. Patient came in the Emergency Department (ED) after he was accidentally provided with the wrong patient medication. Medication list from R #2 included lisinopril (used to lower blood pressure), isosorbide (used for heart related chest pain, heart failure, and esophageal spasms), Lasix (used to treat fluid retention and high blood pressure), prazosin (used to treat high blood pressure), metformin (used to treat diabetes type 2). Patient was found to be hypotensive as a result, and he was transferred to the ED here. Patient did not have any other complaints, falls, or pain. Patient denied any complaint. He denied any headache, blurred vision, abdominal pain, chest pain, or shortness of breath. Telemetry (vital sign machine) showed normal blood pressure, normal saturation on room air (oxygen in the blood), ED reached out to Poison Control who recommended the addition of comprehensive metabolic panel (CMP; a blood test that measures 14 substances in the blood) and an electrocardiogram (EKG; a test that records the electrical signals in the heart, helps detect heart problems, and monitors heart health) later in the evening. Patient admitted for observation to monitor for many medication side effects that might arise. 4. At 3:58 pm, R #1's blood pressure was 115/55 mmHG. 5. Assessment: Medication overdose, hypotension. Patient noted to be hypotensive after receiving home medication of another patient. 6. Plan: Repeat CMP and EKG per Poison Control recommendations. Get physical therapy to evaluate the patient in the morning. 7. On 03/23/24 at 1:12 pm, R #1 was admitted overnight for observation to monitor of any medication side effects. He remained stable without any overnight events. He will be discharged to the nursing home. E. Record review of LPN #1's competency assessment record revealed the following: 1. Initial training and competency (the application and demonstration of appropriate knowledge, skills, behaviors, and judgment in a clinical setting) on medication administration completed on 03/24/2022. 2. Re-education competency completed on 01/26/24. F. On 05/07/24 at 2:37 pm, during an interview with the DON, he stated LPN #1 confused R #1 and R #2, who sat in two different places in the dining room. The DON stated the LPN #1 handed R #1 the medication and then she saw R #2 who was supposed to receive the medication. He stated R #1 was ambulating between the 100 and 200 hall towards the front office, on 03/22/24 at approximately 10:30 am, when he got dizzy and fell . He said a housekeeper saw the resident trying to get up from the floor by using the handrails in the hallway. The DON stated staff kept R #1 on the floor, because the resident was still dizzy. He said the housekeeper ran to his nurse, and his nurse evaluated R #1. The DON stated LPN #1 went to Unit Manager (UM) #1 and reported the medication error that occurred at breakfast in the dining room, and LPN #1 reported she gave R #1 a multivitamin and that was all. He said staff called Emergency Medical Services (EMS). He said by the time EMS arrived R #1's vital signs were back to his baseline, and R #1 went to the hospital for an overnight observation. The DON stated, during the facility's investigation, LPN #1 reported R #1 only received a multivitamin. Further investigation revealed she had given a Prilosec and lisinopril. The DON stated LPN #1 has been written up for pre-pouring medications on a previous occasion. G. On 05/08/24 at 8:26 am, during an observation with RN #1 while she passed medications, RN #1 reviewed the medications for R #3, asked R #3 his name, checked the medication, the route, the dosage, and time. RN #3 watched R #3 take his medication. RN #1 documented the medication she gave to R #3. H. On 05/08/24 at 3:31 am, during observation and interview, RN #1 passed medication to R #4. RN #1 asked the resident his name, checked the medication, the route, the dosage, and time. RN #3 stated R #4 had a crush medication order. RN #3 watched R #4 take his medication. RN #3 stated if the resident was unable talk or give his name then she could compare the resident to the photo that was in the resident's medical record. RN #3 said she did not go off the name on the door of a resident's room, because another resident might be in there and answer to the name. RN #3 said if she was unsure about the right resident she would ask another nurse or teammate that might know who the resident was before she gave the medications. RN #1 stated they had an in-service on the seven rights of medication administration on 03/25/24. I. On 05/08/24 at 11:56 am, during an observation and interview with CMA #1 during a medication pass, CMA #1 checked medication with the order on the computer, identified the right resident, the right medication, right route, right dose, and right time. CMA watched R #5 take her medication. CMA #1 stated if she was unsure of the identity of a resident then she would ask another nurse or look at the resident photo that was in the resident's medical record. CMA #1 stated she attended an in-service recently on the rights of medication administration on 03/25/24. J. On 05/08/24 at 12:17 pm, during an interview with the DON, he stated new staff shadow a senior nurse (a nurse in the facility longer than others.) During this time, it would depend on the new nurse's knowledge of the system and how comfortable they were using the electronic medical record program. The DON stated new staff shadow for a maximum of three days on the medication cart, in order to allow them to get to know the residents and the electronic medical record program. The DON stated staff complete a competency annually, and the facility had one in early 2024 for medication pass. The DON stated staff have not reported any other medication errors since he became DON on 01/12/24, and he was not aware of any other medication errors. K. On 05/09/24 at 830 am, during observation and interview with LPN #2 during a medication pass, the LPN checked the medication to the order, confirmed the right route, right dose, right time, and asked the resident his name. LPN #2 stated if this was a resident that he did not know then he would ask the resident to say their name and date of birth. LPN #2 stated if the resident could not tell him the information, then he would take the resident back to his cart to look at the picture in the resident's medical record. LPN #2 stated he could also get another staff who knew the resident to confirm the resident's identity. LPN #2 stated they have been getting in-serviced on the right of medication administration, and the education was in March 2024. Based on the facility's investigation of the medication error the following interventions were implemented and placed in an Improvement Action Plan: 1. LPN #1 was immediately suspended pending investigation for delayed notification of medication error. Completed 03/22/24. 2. All residents on LPN #1's assignment for 03/22/24 were evaluated for changes in status and screened for concerns related to their medication to rule out the potential of other medication errors. All resident audits were completed by nursing staff. The residents did not have changes from their baseline. 3. All nurses and CMAs to be educated on the five rights of medication administration related to resident identification. In-service on 03/24/24 and ongoing. 4. Random medication administration observations to be completed by DON or Designee three times per shift for four weeks. Evaluate and bring results to Quality Assurance Performance Improvement (QAPI; this is a data driven and proactive approach to quality improvement) monthly until determination of stop. Start date 03/22/24 and ongoing. 5. LPN #1 was terminated from the facility on 03/22/24 and turned into the New Mexico Board of Nursing on 03/24/24.

This is past noncompliance. Based on record review, observation, and interview, the facility failed to ensure residents are free of any significant medication errors for 1 (R #1) of 7 (R #1, R #3, R #4, R #5, R #6, R #7, and R #8) residents reviewed for neglect, when nursing staff failed to administer medication to the correct resident. This deficient practice likely resulted in R #1 experiencing adverse (unwanted, harmful, or abnormal) side effects and admission to the hospital. The findings are: A. Record review of the facility's Complaint Narrative Investigation: A Follow-up Report (5 day), undated, revealed upon interview with LPN #1, she reported having pre-poured the medications in a cup, become distracted, and handed the medications to R #1 instead of R #2. LPN #1 reported she immediately realized she handed the medications to the wrong resident. Resident #1 did not ingest all of the medications, so she retrieved the remaining medications in the Sharp's container. RN #1 did not report the medication error to the physician or the Director of Nursing (DON). During a follow-up interview several days later, LPN #1 said she gave R #1 Prilosec (medication used for heart burn) and lisinopril (a medication used to lower blood pressure). B. Record review of R #1's face sheet revealed the following diagnosis: - Unspecified dementia, unspecified severity, with other behavioral disturbance (characterized by a general decline in cognitive abilities that impacts a person's ability to perform everyday activities). - Vascular dementia, unspecified severity, with other behavioral disturbances (a condition caused by a lack of blood that carries oxygen and nutrients to the brain. It causes problems with reasoning, planning, judgement, and memory). - Benign prostatic hyperplasia with lower urinary tract symptoms (known as an enlarged prostate. Created the frequent and urgent need to urinate). C. Record review of R #1's electronic Medication Administration Record (eMAR) revealed staff administered the following medication to the resident on 3/22/24 in the morning: 1. Tobrex ophthalmic solution (eye antibiotic), 0.3%. Instill two drops in left eye, four times a day, for conjuntivits for seven days. Order started on 03/18/24. 2. Zrytec (allergy medication) oral tablet, 10 milligrams (MG). Give one tablet once a day for itching. D. Record review of the Change of Condition form (CIC) dated 10/22/24 revealed the following: 1. On 03/22/24 at 10:36 am, Licensed Practical Nurse (LPN) #1 called R #1's daughter to report R #1 would be going to the emergency room (ER) for an evaluation due to R #1 received another resident's medications along with his own during morning medication pass. 2. R #1 was hospitalized for one day and placed under observation. E. Record review of R #1's nursing notes, written by LPN #1, revealed: 1. On 03/22/24 at 10:42 am, R #1 had a drop in vital signs and was sent to the Emergency Department (ED) for evaluation. The resident's vital signs were: - At 9:45 am, blood pressure (B/P; normal B/P is 120/80) was 83/49, respiratory rate (RR; normal rate is 12 to 20) was 17, heart rate (HR; normal rate 60 to 100) was 66, temperature (normal rate 97 to 99 degrees) was 97.7 degrees, oxygen saturation (sats; oxygen in the blood. Normal range is above 88%.) was 97% on room air (RA). - At 10:30 am, B/P was 80/46, RR 12, HR 80, temperature 97.7, and sats 96% on RA. 2. On 03/22/24 at 11:20 am, staff checked the medications left in the cup that was handed to R #1 against medications cards to determine if any were given. Only Prilosec was missing from the medication cup. Due to low blood pressures R #1 had later, staff suspected hypertensive medication was ingested. R #1 was sent to the ER. Medications handed to resident in the medication cup were carvedilol (heart failure), 12.5 Milligrams (MG); furosemide (help with water retention/ blood pressure), 40 MG; isosorbide mononitrate extended release (used for heart related chest pain, heart failure, and esophageal spasms), 30 MG; lisinopril (reduces blood pressure), 5 MG; metformin (used to treat diabetes type 2), 500 MG; multivitamin with minerals, Prilosec (medication to reduce stomach acid), 20 MG; Steglatro (Diabetes Management), 5 MG. F. Record review of R #1's hospital records, dated 03/22/24, revealed: 1. On 03/22/24 at 3:58 pm, R #1 was evaluated at the ER. 2. Chief Complaint: LPN accidentally gave the patient the wrong medication, hypotensive. 3. History of Present Illness: Patient is a [AGE] year-old-male in a nursing home with no significant past medical history besides dementia. Patient came in the Emergency Department (ED) after he was accidentally provided with the wrong patient medication. Medication list from R #2 included lisinopril, isosorbide, Lasix (used to treat fluid retention and high blood pressure), prazosin (used to treat high blood pressure), metformin. Patient was found to be hypotensive as a result, and he was transferred to the ED here. Patient did not have any other complaints, falls, or pain. Patient denied any complaint. He denied any headache, blurred vision, abdominal pain, chest pain, or shortness of breath. Telemetry (vital sign machine) showed normal blood pressure, normal saturation on room air (oxygen in the blood), ED reached out to Poison Control who recommended the addition of comprehensive metabolic panel (CMP; a blood test that measures 14 substances in the blood) and an electrocardiogram (EKG; a test that records the electrical signals in the heart, helps detect heart problems, and monitors heart health) later in the evening. Patient admitted for observation to monitor for many medication side effects that might arise. 4. At 3:58 pm, R #1's blood pressure was 115/55 mmHG. 5. Assessment: Medication overdose, hypotension. Patient noted to be hypotensive after receiving home medication of another patient. 6. Plan: Repeat CMP and EKG per Poison Control recommendations. Get physical therapy to evaluate the patient in the morning. 7. On 03/23/24 at 1:12 pm, R #1 was admitted overnight for observation to monitor of any medication side effects. He remained stable without any overnight events. He will be discharged to the nursing home. G. On 05/07/24 at 2:37 pm, during an interview with the DON, he stated LPN #1 confused R #1 and R #2, who sat in two different places in the dining room. The DON stated the LPN #1 handed R #1 the medication and then she saw R #2 who was supposed to receive the medication. He stated R #1 was ambulating between the 100 and 200 halls towards the front office, on 03/22/24 at approximately 10:30 am, when he got dizzy and fell . He said a housekeeper saw the resident trying to get up from the floor by using the handrails in the hallway. The DON stated staff kept R #1 on the floor, because the resident was still dizzy. He said the housekeeper ran to the resident's nurse, and the nurse evaluated R #1. The DON stated LPN #1 went to Unit Manager (UM) #1 and reported the medication error that occurred at breakfast in the dining room, and LPN #1 reported she gave R #1 a multivitamin and that was all. He said staff called Emergency Medical Services (EMS). He said by the time EMS arrived R #1's vital signs were back to his baseline, and R #1 went to the hospital for an overnight observation. The DON stated, during the facility's investigation, LPN #1 reported R #1 only received multivitamin. Further investigation revealed she had given R #1 Prilosec and lisinopril. The DON stated LPN #1 has been written up for pre-pouring medications on a previous occasion. The DON stated his expectation for any medication error was for staff to report it to the DON. He said he also expected staff would report what medications were given to a resident in error. H. On 05/08/24 at 8:26 am, during an observation with RN #1 while she passed medications, RN #1 reviewed the medications for R #3, asked R #3 his name, checked the medication, the route, the dosage, and time. RN #3 watched R #3 take his medication. RN #1 documented the medication she gave to R #3. I. On 05/08/24 at 3:31 am, during observation and interview, RN #1 passed medication to R #4. RN #1 asked the resident his name, checked the medication, the route, the dosage, and time. RN #3 stated R #4 had a crush medication order. RN #3 watched R #4 take his medication. RN #3 stated if the resident was unable talk or give his name then she could compare the resident to the photo that was in the resident's medical record. RN #3 said she did not go off the name on the door of a resident's room, because another resident might be in there and answer to the name. RN #3 said if she was unsure about the right resident she would ask another nurse or teammate that might know who the resident was before she gave the medications. RN #1 stated they had an in-service on the seven rights of medication administration on 03/25/24. J. On 05/08/24 at 11:56 am, during an observation and interview with CMA #1 during a medication pass, CMA #1 checked medication with the order on the computer, identified the right resident, the right medication, right route, right dose, and right time. CMA watched R #5 take her medication. CMA #1 stated if she was unsure of the identity of a resident then she would ask another nurse or look at the resident photo that was in the resident's medical record. CMA #1 stated she attended an in-service recently on the rights of medication administration on 03/25/24. K. On 05/08/24 at 12:17 pm, during an interview with the DON, he stated new staff shadow a senior nurse (a nurse in the facility longer than others.) During this time, it would depend on the new nurse's knowledge of the system and how comfortable they were using the electronic medical record program. The DON stated new staff shadow for a maximum of three days on the medication cart, in order to allow them to get to know the residents and the electronic medical record program. The DON stated staff complete a competency annually, and the facility had one in early 2024 for medication pass. The DON stated staff have not reported any other medication errors since he became DON on 01/12/24, and he was not aware of any other medication errors. L. On 05/09/24 at 830 am, during observation and interview with LPN #2 during a medication pass, the LPN checked the medication to the order, confirmed the right route, right dose, right time, and asked the resident his name. LPN #2 stated if this was a resident that he did not know then he would ask the resident to say their name and date of birth. LPN #2 stated if the resident could not tell him the information, then he would take the resident back to his cart to look at the picture in the resident's medical record. LPN #2 stated he could also get another staff who knew the resident to confirm the resident's identity. LPN #2 stated they have been getting in-service on the right of medication administration, and the education was in March 2024.

Based on observation, interview, record review, and facility policy review, the facility failed to 1. provide adequate monitoring and supervision for a resident that was smoking while using oxygen (Resident (R)167). This failure of allowing a resident to smoke while using oxygen resulted in an Immediate Jeopardy due to the increased likelihood to cause serious harm or death in the event R167 being exposed to [CONDITION(S)]. 2. The facility also failed to provide adequate monitoring and supervision for residents in the smoking area while oxygen was in use (R6, R31, R34, R46, R117, and R218). 3. The facility further failed to provide adequate monitoring and supervision for eight (R117, R218, R46, R34, R6, R31, R13, and R7) of 15 residents that required supervision per the smoking evaluation. 4. The facility also failed to assess three (R13, R34, R218) of 15 residents who smoke. On 03/29/22 at 7:25 PM, the Center Executive Director (CED), Interim Center Executive Director (ICED), Director of Nursing (DON), and the Regional Administrator (RA) was notified of the Immediate Jeopardy (IJ) at F689-J Accidents. The Immediate Jeopardy began on 03/29/22 when the survey team identified R167 smoking while using oxygen. The facility provided an acceptable removal plan on 03/31/22 at 8:29 AM. The removal plan included education to residents and staff on the dangers of smoking while using oxygen, education on the smoking policy, review of smoking assessments, alarm to the door to the smoking area, revision of smoking times to have staff available, and collaboration with Ombudsman to assist with safe smoking in the facility. Through interviews with facility staff, observation of supervised smoking, clinical record review of revised smoking assessment, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan and therefore removed the IJ. On 03/31/22, during the exit conference, the survey team notified the Center Executive Director, and the facility staff present at the exit conference that the IJ was removed and reduce to level, E. The survey team exited the facility on 03/31/22 at 3:15 PM. Findings include: 1. Review of the facility's policy titled, Smoking, reviewed 11/04/19, indicated, Oxygen use is prohibited in smoking areas. Review of the list of residents who smoke, provided to the survey team by the facility, revealed a list 14 residents. R167 was not listed. During an observation on 03/29/22 at 11:58 AM, R167 was observed, in the smoking area, smoking while using oxygen via nasal cannula. Resident R167 was observed to be supervised by Certified Nursing Assistant (CNA)1. During an observation on 03/29/22 at 12:02 PM, R167 was observed entering the facility from the smoking area. At the time of observation, R167's nasal cannula was dragging on the floor behind her wheelchair. R167 removed her oxygen concentrator from the back of her wheelchair and put it on the floor near the beginning of the hallway and proceeded to return to the designated smoking area. Review of R167's Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included [CONDITION(S)] and [CONDITION(S)] (weakness and paralysis) following cerebral infarction (stroke) and nicotine dependence. Review of R167's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 03/07/22, revealed R167's Brief Interview for Mental Status (BIMS) score was not assessed. Review of R167's Physician Orders, dated 03/03/22 and located in the EMR under the Orders tab revealed, Oxygen via N/C [nasal cannula] to titrate to 90%. DX: oxygen dropping with exertion. Review of R167's Smoking Evaluation, dated 03/01/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: Supervised smoking is required per facility policy, however resident has been counseled not to smoke d/t [due to] recent [CONDITION(S)] [Cerebral Vascular Accident]/CHF [congestive heart failure]; resident unable to locate designated smoking area; resident unable to smoke safely without use of smoking apron. During an interview on 03/29/22 at 12:10 PM, CNA1 stated that staff supervised residents that smoke about once per day. CNA1 stated the residents do not use aprons and she was unsure of which residents needed aprons. CNA1 stated she was supervising R6, R31, R167, R117, and R218 at the time of interview. CNA1 stated the facility kept smoking supplies in a lockbox, which was kept in the medication room. CNA1 stated smoking supplies for R31, R117, and R218 are kept in the lockbox. CNA1 stated R6 keeps his own supplies because he is an independent smoker. CNA1 stated R167 did not have her own personal cigarettes and would borrow cigarettes from other people. As the interview ended, CNA1 was heard saying, Who has a lighter so I can light her cigarette for her? During an interview on 03/29/22 at 12:17 PM, R46 stated he had just come from outside smoking and stated R167 was smoking while using her oxygen. R46 stated CNA1 did not say anything to R167, so he told R167 that she could not smoke while using oxygen and to go back inside the facility. During an interview on 03/29/22 at 12:56 PM, CNA1 stated she was supervising the designated smoking area while R167 was smoking while using oxygen via nasal cannula. CNA1 stated she did not know who lit the cigarette for R167. CNA1 further stated R46 brought to her attention that R167 was smoking while using oxygen and CNA1 instructed R167 to go inside the facility. During an interview on 03/29/22 at 12:30 PM, Licensed Practical Nurse (LPN) 1 stated on 05/03/21, R117 was smoking in his room while using nasal cannula oxygen and set his face on fire. LPN1 stated the nasal cannula melted and R117 received [CONDITION(S)] to his nose and face. LPN1 stated the facility then started monitoring all residents who smoke and kept the residents' smoking materials. LPN1 stated after some time, the facility became relaxed, residents were allowed to keep their cigarettes and lighters, and facility stopped monitoring the residents that smoke. Review of R117's Progress Notes, dated 05/03/21, located in the EMR under the Notes tab, revealed: Resident was wearing his oxygen and lit a cigarette in his room. Recommendations: Monitor. Clean [CONDITION(S)] and apply antibiotic. A review of the unfinished incident report provided by the Infection Preventionist revealed, Describe the circumstances of the event and immediate actions taken: wasn't thinking and lit a cigarette. Part of the resident's mustache is burned off, and he has [CONDITION(S)] above his lip, on his cheeks and nose. Resident gave this LN [Licensed Nurse] his cigarettes and gave his lighter to the other nurse. During an interview on 03/29/22 at 5:05 PM, the Center Executive Director (CED) revealed that the potential risk of smoking while wearing oxygen, is that the oxygen could combust or cause a fire. During an interview on 03/29/22 at 5:05 PM, the DON stated, The possible risks of smoking with oxygen on are they could get burnt real easily because oxygen and fire don't mix; then there is a possible harm for others around the oxygen if a fire started; a lot of potential damage to the person's lungs, face and any other body parts that may be exposed to the fire; and then there is the possibility of falls and subsequent injuries from trying to get away from the fire. When asked what the possible risks were of residents having lighters in their rooms, the DON stated, they might be tempted to light a cigarette in their room - then it opens up all the risks I just said. During an interview on 03/30/22 at 9:12 AM, CNA42 stated there was an incident last year with R117. CNA42 stated R117 was smoking in his room. He didn't want to wait until his scheduled smoking time. He had oxygen on. He caught his face on fire. During an interview on 03/30/22 at 8:46 PM, LPN19 stated there had been an incident in 2010 where a resident received third degree [CONDITION(S)] while smoking using oxygen. LPN19 stated a second incident happened in 2021, when R117 received facial [CONDITION(S)] while smoking in his room while using oxygen. LPN19 stated residents should never smoke while using oxygen. Review of the facility's policy titled, Smoking, reviewed 11/04/19, indicated, Patients will be assessed on admission, quarterly, and with change in condition for the ability to smoke safely and, if necessary, will be supervised. The policy also indicated, Supervised smoking is defined as The observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. During an observation on 3/29/22 at 11:58 AM, R167 was observed in the smoking area, in the presence of staff and other residents, to be smoking while using oxygen via nasal cannula. At the time of this observation, R6, R31, R34, R46, R117, and R218 were also observed to be smoking. Residents were observed to be supervised by CNA1. During an interview on 03/29/22 at 12:56 PM, CNA1 stated she was supervising the designated smoking area while R167 was smoking while using oxygen via nasal cannula. CNA1 confirmed R6, R31, R34, R46, R117, and R218 were also in the designated smoking area while R167 was smoking. Review of the facility's policy titled, Smoking, reviewed 11/04/19, indicated, The admitting nurse will perform a Smoking Evaluation on each patient who chooses to smoke. The facility policy also indicated, Smoking supplies (including, but not limited to, tobacco, matches, lighters, lighter fluid, etc.) will be labeled with the patient's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station. The policy indicated, Patients will not be allowed to maintain their own lighter, lighter fluid, or matches. Review of R117's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included [CONDITION(S)] and dementia with behavioral disturbance. Review of R117's annual MDS located in the EMR under the MDS tab with an ARD of 12/20/21, revealed R117's BIMS score was six out of 15, indicating severe cognitive impairment. Review of R117's Smoking Evaluation, dated 11/04/21, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervision is required due to resident uses oxygen and is unable to keep a lighter due to history of setting himself on fire.; res uses oxygen, has dementia, has poor memory, history of setting fire/arson, history of unsafe smoking habits, history of sharing/selling cigarettes. Review of R117's Care Plan, dated 01/15/22, located in the EMR under the Care Plan tab revealed: may smoke with supervision per smoking assessment; Intervention: Ensure that there is no oxygen use in smoking area(s). Review of R218's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included [CONDITION(S)] and dementia without behavioral disturbance. Review of R218's admission MDS located in the EMR under the MDS tab was incomplete and R218's BIMS had not been assessed. R218's EMR revealed no evidence of a completed Smoking Evaluation. Review of R218's Care Plan, dated 03/16/22, located in the EMR under the Care Plan tab revealed: may smoke with supervision per smoking assessment; Interventions: Monitor patients' compliance to smoking policy; Ensure that there is no oxygen use in smoking area(s). Review of R46's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included heart failure and diabetes. Review of R46's quarterly MDS located in the EMR under the MDS tab with an ARD of 02/16/22, revealed R46's BIMS score was 15 out of 15, indicating R46 was cognitively intact. Review of R46's Smoking Evaluation, dated 01/05/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervision is required. No reason was given as to why R46 required supervision during smoking. Review of R46's Care Plan, dated 11/02/21, located in the EMR under the Care Plan tab revealed: May smoke per facility smoking policy; Interventions: Ensure that there is no oxygen use in smoking area(s); Maintain patients smoking materials at nurses' station; Monitor patients [sic] compliance to smoking policy. Review of R34's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included [CONDITION(S)] disorder and nicotine dependence. Review of R34's admission MDS located in the EMR under the MDS tab with an ARD of 11/03/21, revealed R34's BIMS score was seven out of 15, indicating severe cognitive impairment. R34's EMR revealed no evidence of a completed Smoking Evaluation. Review of R34's Care Plan, dated 02/08/22, located in the EMR under the Care Plan tab revealed no evidence of a care plan that addressed smoking. Review of R6's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included nicotine dependence and [CONDITION(S)]. Review of R6's quarterly MDS located in the EMR under the MDS tab with an ARD of 03/10/22, revealed R6's BIMS score was 11 out of 15, indicating R6 had moderate cognitive impairment. Review of R6's Smoking Evaluation, dated 03/04/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervision is required Per facility policy; Resident has a history of sharing/selling cigarettes or smoking material. Review of R6's Care Plan, dated 02/24/22, located in the EMR under the Care Plan tab revealed: may smoke with supervision per smoking assessment; Interventions: Educate patient/health care decision maker on the facility's smoking policy; Inform of and reinforce smoking restriction. Review of R31's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included [CONDITION(S)] and [CONDITION(S)]. Review of R31's quarterly MDS located in the EMR under the MDS tab with an ARD of 10/18/21, revealed R31's BIMS score was 13 out of 15, indicating R31 was cognitively intact. Review of R31's Smoking Evaluation, dated 01/14/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervised smoking Resident puts the butts in her bra, she takes others cigarettes & puts the cigarettes out on her leg; poor memory, unsafe smoking habits, sharing/selling cigarettes; does not properly dispose of ashes/butts. Review of R31's Care Plan, dated 09/13/21, located in the EMR under the Care Plan tab revealed: May smoke with supervision per smoking assessment; Interventions: Ensure that there is no oxygen use in smoking area(s). Review of R13's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included [CONDITION(S)] (seizures) and diabetes. Review of R13's quarterly MDS located in the EMR under the MDS tab with an ARD of 03/18/22, revealed R13's BIMS score was 14 out of 15, indicating R13 was cognitively intact. R13's EMR revealed no evidence of a completed Smoking Evaluation. Review of R13's Care Plan, dated 01/14/22, located in the EMR under the Care Plan tab revealed: May smoke with supervision per smoking assessment; Interventions: Monitor patients [sic] compliance to smoking policy; Inform and remind patient of location of smoking areas and times; Educate patient/health care decision maker on the facility's smoking policy. Review of R7's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included [CONDITION(S)] (paralysis of all four limbs) and nicotine dependence. Review of R7's quarterly MDS located in the EMR under the MDS tab with an ARD of 12/10/21, revealed R7's BIMS score was 15 out of 15, indicating R7 was cognitively intact. Review of R7's Smoking Evaluation, dated 02/04/22, located in the EMR under the Assessments tab, revealed the following: Smoking decision: supervision per facility policy; res has history of selling/sharing cigarettes or smoking materials; does not dispose of ashes/butts properly. Review of R7's Care Plan, dated 02/25/22, located in the EMR under the Care Plan tab revealed: May smoke with supervision per center protocol; Interventions: Maintain patients smoking materials at nurses' station. During an interview on 03/28/22 at 11:26 AM, R6 was observed to be in his bedroom and stated he keeps his lighter and cigarettes in his shirt pocket. R6 showed the survey team his cigarettes and lighter in his top left shirt pocket. During an interview on 03/28/22 at 12:54 PM, the Infection Preventionist (IP) and DON stated there were about 15 residents in the facility that smoke. The DON stated the cigarettes and lighters are kept in a box that is locked in the medication room. The IP stated there were four residents that were assessed to be independent for smoking and kept their lighter and cigarettes in their room. The IP stated R7, R46, R34, and R6 were assessed to be independent with smoking. Review of the medical records for R7, R46, and R6 revealed none of these residents were assessed as independent smokers but required supervision. Review of R34's medical record revealed no smoking assessment had been completed. During an interview on 03/28/22 at 1:41 PM, R34 stated she kept her lighter and cigarettes in her room. R34 stated the facility used to keep her cigarettes and lighter but she was allowed to keep them when some of her cigarettes went missing. During an observation and interview on 03/28/22 at 2:15 PM, R6 was observed smoking in the designated smoking area. R46 was also observed smoking in the designated smoking area at this time. R46 and R6 stated they both keep their cigarettes and lighters on their person and in their rooms. R46 and R6 stated they were assessed to be independent smoking residents. R6 stated he and R46 were independent, since we haven't did [sic] anything bad, we can keep it. During this time of observation, there were no staff supervising residents in the designated smoking area. During an observation on 03/28/22 at 4:30 PM, R6, R46, and R167 was observed smoking in the designated smoking area. No staff was present at this time of observation. During an interview on 03/29/22 at 12:17 PM, R46 stated he was an independent smoker and kept his lighter and my cigarettes. R46 showed the survey team his lighter and cigarettes in his pocket. R46 stated that he kept his cigarettes and lighter in the bedside drawer at night. R46 stated the facility has some wanders that go in and out of residents' room. R46 stated R167 is one of the wanderers. R46 stated there used to be staff that supervised the residents that smoke but lately there had not been staff supervising residents. During an interview and observation on 03/29/22 at 12:20 PM, the DON stated the box with material for residents that smoke was kept locked in the medication room. When asked to see where the box where kept, the DON found the clear container with residents' cigarettes on the desk at the nurses' station. The container was not in a locked area at the time of observation. In the container of supplies, there were cigarettes for the following residents: R117, R218, R52, R15, R27, and R62. There were no lighters in the box at the time of observation. The DON stated she was unsure how residents lit their cigarettes. During an interview on 03/29/22 at 12:24 PM, Certified Medical Assistant (CMA) 1 stated there were four residents that were assessed to be independent for smoking and were allowed to keep their own lighter and cigarettes in their rooms. CMA1 stated those residents were R6, R7, R34, and R46. CMA1 stated R167 received cigarettes from other residents. During an interview on 03/29/22 at 12:42 PM, the DON stated, No residents should have lighters in their room. During an interview on 03/29/22 at 12:44 PM, when asked about the smoking assessments, the IP stated that a resident that was assessed as supervised meant the cigarettes and lighters should be kept in the smoking box, should say the reason the resident was considered supervised, and should list if the resident should wear an apron. The IP stated a resident that was assessed as independent meant the resident could smoke without supervision and were allowed to keep their cigarettes and lighters in their rooms. During an interview on 03/29/22 at 12:49 PM, the RA stated the policy is generally that residents are not allowed to keep their cigarettes and lighters, but he would defer to the administrator. During an interview on 03/29/22 at 12:51 PM, the ICED stated the facility should keep lighters and cigarettes. The ICED state the predecessor allowed independent smokers to keep their lighters and cigarettes. During an interview on 03/29/22 at 1:17 PM, the IP confirmed there was no smoking evaluation completed for R34, R218, nor R13. During an observation on 03/29/22 at 2:16 PM, R46, R31, R117, R15, R7, R34, R6, R27, and R13 were observed smoking in the designated smoking area. The residents were supervised by CNA44 at the time of observation. During an observation on 3/29/22 at 3:47 PM, R7 was observed smoking in the designated smoking area. There was no staff in the designated smoking area at the time of observation. The DON confirmed R7 was smoking without supervision. During an interview on 03/30/22 at 8:26 AM, R167 stated R34 gives her cigarettes when they are outside in the designated smoking area. R167 stated no other residents give her cigarettes. 4. Reviewed smoking evaluations for each resident. There were no residents that were assessed as independent with smoking on their evaluations. All residents that were evaluated were deemed to need supervision. There were three residents that did not have a smoking evaluation completed: R13, R34, and R218. During an interview on 03/30/22 at 8:46 PM, LPN19 stated there was no such thing as a resident independent with smoking in the facility. LPN19 stated she completed all smoking evaluations that were on file and all residents were assessed to need supervision.

The facility failed to ensure that residents were assessed and evaluated for the use of physical restraints. Two residents were identified as having full side rails on their beds without having documentation of a medical condition that would warrant the use of physical restraints, physician orders, signed consent forms, and accurate and updated care plans for the use of full side rails. This deficient practice resulted in an Immediate Jeopardy (IJ) at a Scope and Severity of L being identified on 08/03/17 at 4:11 pm. The Administrator, Assistant Administrator, and Director of Nursing (DON) were notified at this time and a Plan of Removal was requested. The facility took corrective action by providing an acceptable Plan of Removal on 08/04/17 at 1:08 pm. The Plan of Removal included the following: 1. Resident #1 (R #118) the facility has assessed her and removed SR (side rails) and placed resident on low bed. Care Plan was updated to reflect current condition. 2. Resident #2 (R #15) was assessed and he is appropriate for use for mobility and he wants to keep them. A consent was gotten (sic) and physician was notified. 3. The Administrator and Director of Nurses were in-serviced by RQM (Regional Quality Manager) via phone on proper side rail usage on August 4, 2017 and will be in-serviced again on Friday August 4, 2017 by the Divisional Quality Manager. 4. The Director of Nursing, Administrator, and Nurse Managers will complete nursing staff in-services on the Side Rail Assessment, and appropriate and safe use of side rails. In-service for all staff will be completed by 08/04/17. Any staff member unable to attend the in-service will not be allowed to work until they have completed the in-service nursing (sic). Staff in-service consisted of and will consist of: a. Licensed Nurses will be re-educated on properly completing the Side Rail Assessment. b. New residents will be assessed for safe use of side rails. c. All staff in-serviced will be able to report any signs of potential hazard to resident related to side rails. 5. In-service began with nursing staff in facility concerning facility standard of practice for side rail usage on Thursday, August 3, 2017 by DON and designee. 6. A 100% audit of all residents in facility was initiated August 3, 2017 by DON and/or ADON (Assistant Director of Nursing) and completed on Friday August 4, 2017. 7. Any resident with a side rail was re-assessed for side rail appropriateness; family members were contacted and physician was notified for consents and orders where applicable. 8. Any resident assess to have a side rail that is inappropriate and not meeting any of the standards of practice for a side rail will have the side rail removed immediately. 9. Residents will have a side rail assessment completed upon admission, readmission and with any significant change of condition. 10. Re-education of all nursing staff on the side rail standard of practice will be done prior to starting work on their shift beginning Thursday August 3, 2017. No staff will be allowed to start work without receiving the side rail standard of practice. 11. If an unsafe side rail is identified the staff member will immediately notify the charge nurse and they will assign one to one monitoring until the side rail can be removed or replaced to meet standard of practice based on the side rail assessment. 12. DON or designee will review assessment of new residents or any resident that has side rails or mobility bars applied to their bed, and will conduct a visual inspection of the beds with device applied to ensure it is not a safety or entrapment risk. 13. Therapy will screen current residents with side rails for bed mobility and repositioning needs, and prior to any new application of any device. 14. (Name of Medical Director) was notified of the IJ situation by telephone on August 3, 2017 at 5:00 pm. 15. Physician orders [REDACTED]. 16. Mattresses are checked by maintenance for appropriateness. 17. Policy and procedure will be strictly adhered to by DON and/or designee and staff. 18. Process will be followed by DON and/or designee and staff. 19. An off cycle QAQI (Quality Assurance/Quality Improvement) committee meeting will be held on Friday, August 4, 2017 to discuss our plan. Based on the Plan of Removal provided by the Administrator, the IJ was lifted on 08/04/17 at 1:08 pm. This resulted in the scope and severity being reduced from level L to level F. Based on observation, record review, and interview, the facility failed to ensure residents were free from physical restraints for 2 (R #s 15 and 118) of 2 (R #s 15 and 118) residents reviewed for accident hazards. This deficient practice has the potential for serious injury from falls, suffering a decrease in ambulation and a diminished quality of life due to feelings of humiliation, loss of dignity, depression, anger, and frustration. The findings are: Findings for R #118: A. On 08/01/17 at 10:13 am, during initial observation of R #118's room revealed R #118's bed had bilateral (two sides; left and right) upper and lower half side rails, with a tall head board and foot board. There were two bed bolsters (large cushions used to prevent falls out of bed), on the bed, covering the gap between the upper and lower side rails. It was also observed that the mattress (regular size) was too small for the bed frame, leaving a gap at the foot of the bed. B. Record review of R #118's Face Sheet, revealed he was admitted on [DATE], with the following medical Diagnoses: [REDACTED]. of potassium in the blood), [MEDICAL CONDITION] (one side paralysis) [MEDICAL CONDITION]([MEDICAL CONDITION], a stroke) affecting the left side, major [MEDICAL CONDITION], dysphagia (difficulty swallowing), [MEDICAL CONDITION] (difficulty in understanding or expressing speech), and Type II diabetes (high blood sugar). The Face Sheet also indicated that R #118 was his own responsible party. C. Record review of the Resident Incident Reports for R #118 indicated the following; 1. 05/15/17 at 10:01 pm, Resident was found on floor by CNA (certified nursing assistant) resident had manage (sic) to squeeze between his side rails and fall to the floor. Bedrails were present and up at the time of R #118's fall, bed was not in low position. Immediate post-incident action: pads placed (sic) on bed between the side rails to prevent fall. 2. 05/16/17 at 12:15 pm, Therapy department parked resident in room unattended, resident fell out of wheelchair forward and hit head on bed frame, resident did point to head when asked if he hit his head. Immediate action: discussed with therapist that resident is unable to be left alone (sic) in wheelchair by self, that resident is not safe. 3. 05/17/17 at 8:38 am, Resident in room this am, this nurse walked by room and noted resident was sitting on floor, asked resident why he crawled out of bed, resident mumbled but was unable to understand, all bed rails were up .resident brought to nurses station for closer observation, then resident after being placed by nurses station began trying to get out of wheelchair. No other action taken after incident. D. Record review of the Nursing Progress Notes dated 05/17/17, revealed Resident found sitting on floor next to bed by this nurse, resident climbed over bed rails. E. Record review of the Physician order [REDACTED]. F. Record review of R #118's Medical Record, did not show that R #118 had signed a consent form or was educated on the risks and benefits of using side rails or a specialized bed frame. G. Record review of R #118's Medical Record, revealed he was not care planned for the use of side rails, bed bolsters or a specialized bed frame. H. Record review of the Admission Fall Risk (MDS) data set [DATE], revealed R #118 is at high risk for falls. Under comments it indicates, Resident has side rails on bed. Further review of R #118's medical record did not indicate fall risk assessments were completed after his falls on 05/15/17, 05/16/17, and 05/17/17. I. Record review of the Safety Device assessment dated [DATE], indicated no under emergency application. The assessment was not completed. J. Record review of the Admission Minimum Data Set ((MDS) dated [DATE], indicated R #118 was total dependent for bed mobility and transfers with the physical assist of two staff members. The MDS listed [MEDICAL CONDITION], TIA ([MEDICAL CONDITION], a mini stroke) with [MEDICAL CONDITION] or [MEDICAL CONDITION] (weakness or partial loss of movement on one side of the body) under medical conditions. The MDS also indicated that bed rails were not used. K. On 08/02/17 at 9:40 am, during an interview with Licensed Practical Nurse (LPN) #3, stated that when R #118 was admitted in May (2017), he was constantly trying to get out of bed. She stated that he had poor cognition and safety awareness. She stated that he can make his needs known, he understands when he is spoken to, and he has better safety awareness. LPN #3 confirmed that R #118 has left sided weakness due to a [MEDICAL CONDITION]. She also stated that he requires extensive assist for transfers and is able to grab the bed rail using his strong arm. LPN #3 was asked what the medical reason was for R #118 to be in that bed, she stated, I would assume because we have him on the air mattress (air flows under resident to prevent skin breakdown), he was falling out of the bed. Or maybe he had an air mattress and he was falling and they put him in that bed with a regular mattress. LPN #3 confirmed that R #118 does not have an air mattress. During a later interview at 10:14 am, LPN #3 stated that if R #118 wanted to, he could sit up in the bed, but if he attempted to get out of the bed he couldn't stand or walk away. L. On 08/02/17 at 10:15 am, during interview, Physical Therapist (PT) #1, stated that they initially put R #118 in that bed because he was not moving around and for pressure ulcer (skin breakdown creating an open wound) relief. PT #1 stated that as he became more alert, he was a fall risk. She stated that R #118 still has the bed because he is not safe to transfer independently, so it deters him from falling out. She also stated that the bolsters were put on the bed for safety and protection of his lower legs. PT #1 confirmed that there should be an order from the doctor to put a resident in that type of bed. PT #1 also stated, that R #118 would attempt to get out of bed himself, which he is not able to do safely and he would probably fall. M. On 08/02/17 at 10:27 am, during interview, the Assistant Director of Nursing (ADON), confirmed that R #118 had a stoke prior to coming to the facility and that he was a high fall risk. The ADON stated, I know when he first came in he would fling himself, we had to get him something and we don't have side rails. These are new beds so it helps with moving. The ADON was not able to provide a medical reason as to why R #118 was given the specialty bed, she stated, Just for boundaries. I don't know exactly why they gave him that one bed. The ADON did not know if physician orders [REDACTED]. The ADON confirmed that there was no consent for the use of side rails and that she didn't know if she needed consent if they were used for positioning. The ADON also confirmed that side rails would be expected to be on R #118's care plan. N. On 08/02/17 at 10:44 am, during interview, the Medicare MDS Coordinator confirmed that R #118's side rails and bed bolsters were not updated on his care plan. She stated, I updated his side rails today, because I forgot to put it on the care plan. When he came in, his family said they wanted him to have side rails. O. On 08/02/17 at 11:22 am, during interview, LPN #5 stated that she admitted R #118 to the facility. She stated, When he (R #118) came in, he had a bed with no side rails. His daughter requested a bed with side rails. She (the daughter) said that he was a very high fall risk and that he had several falls while at the hospital. LPN #5 stated, That was one of the beds at the time with side rails. That was the only available bed. LPN #5 stated, I would consider them full side rails, there is only a small open area. LPN #5 confirmed that the night R #118 was admitted , he fell out of the bed by sliding out of the opening between the upper and lower side rails. She stated that she put the bolsters on his bed to close the gaps at the daughters request. LPN #5 stated she notified the doctor about R #118's fall by text message, but she did not write an order for [REDACTED].#5 also confirmed that at the time she did not consider the bed a restraint and that she did not try using a low bed or fall mats next to the bed before putting him in a bed with side rails, stating, we didn't have low beds at the time. During the interview, LPN #5 provided the text messages between her and R #118's doctor, (with permission) it indicates, May 15, 2017 at 10:34 pm, LPN #5 texted, Just to let u know new guy wiggled out of his bed even with the side rails up added more rails to try and keep him in. No injury R #118's doctor at 10:35 pm, responded, K. P. On 08/03/17 at 9:14 am, during interview, the Medical Director, when asked why R #118 was in the specialty bed with side rails, he stated, I don't know exactly. When he arrived, he had possible sundowning (a state of confusion occurring in the late afternoon and spanning into the night). In order to prevent self harm they do require some bed rails. He had issues trying to get up. The Medical Director stated that he has at least 60 residents to over see in the facility and he was not familiar with the type of bed R #118 was in. The Medical Director stated that he wasn't sure if an order was required for using side rails. Q. On 08/03/17 at 9:27 am, during interview, R #118, stated that he does not like his bed because of the side rails and that he would like a bed like his roommates. R #118 also stated that he feels trapped in his bed, saying I can't get out of it. R #118 confirmed that staff put both side rails up and the bolster cushions on the bed. R. On 08/03/17 at 11:49 am, during interview, the Maintenance Director (MD) stated that he does a monthly check of resident beds. He checks for gaps, makes sure the mattress fits correctly, properly installed hand rails (side rails) and equipment. He stated that he checked all the beds on 01/27/17. During observation of R #118's bed, the MD stated, The mattress is too short on that bed. Somebody switched out the mattress, because it was fine in January. The MD also stated, If they (staff) don't have orders, they better get them. The MD stated that if the resident can't remove the cushion and open the gap, then he would consider the bed a restraint. The MD also stated that he will not put side rails on a bed without a physician order. S. On 08/03/17 at 12:40 pm, during interview, the Director of Nursing (DON), when asked if R #118 is at high risk for falls, she stated, I believe so, but only from what I've heard in the last couple of days. When asked why R #118 is in the bed he's in, the DON stated, I don't know and then asked what bed is he in. The DON stated she didn't know what bed R #118 was in and left the room to check, then stated, Apparently he was a high fall risk at the hospital. (Name of LPN #5) added bumpers because he wiggled out of the side rails and fell on the floor. The DON was asked if an assessment was done to see if the bed was appropriate for R #118, she stated, I don't know. It hasn't come up in risk management, because it hasn't been a problem. The DON stated that she was not familiar with R #118's fall on 05/17/17 when he climbed over the side rails. The DON was asked if climbing and falling over the side rail counted as getting out of bed, the DON stated, I would think that's one way of getting out of bed. The DON stated that orders were not needed because the doctor was notified and because he needed a bed upon arrival. The DON stated that she did not need to get consent from the resident, because the daughter knew about the bed, but doesn't know if the daughter is able to make those decisions on R #118's behalf. The DON was asked if R #118 had a medical reason for the bed, she stated that he could have had problems from [MEDICAL CONDITION] other than that, no. When asked why R #118 does not have a regular bed, she stated, Fine with me. The DON stated that she did not know if a pre-restraining assessment was completed prior to bed placement. The DON confirmed that a fall risk assessment should be completed after each fall and stated that the safety device assessment should be done quarterly. The DON stated that she would think the whole process would have to be re-done if the resident fell out of bed with side rails. She stated that after a fall, the therapist (physical or occupational) would make their recommendations and they would talk about it in Interdisciplinary Team (IDT). The DON stated that she doesn't know if R #118's two falls were discussed in the IDT meetings, stating, I would have to look. The DON stated that she does not consider the bed a restraint because he is able to get out and because LPN #5 said he was able to remove the bumpers. T. On 08/03/17 at 1:22 pm, during interview, the Certified Medication Aid (CMA) #1, confirmed that he has heard that staff strap the bolsters to the bed at night because R #118 tries to get out of bed. U. On 08/03/17 at 1:22 pm, during interview, Certified Nursing Assistant (CNA) #3 confirmed that at night they tie down the bolster to the bed to prevent him from removing them so he doesn't fall out of bed. CNA #3 also stated that when R #118 first came in he was falling a lot, so they put the bolster to stop him from falling. V. On 08/03/17 at 1:33 pm, during interview, CNA #4 confirmed that R #118 has blue cushions (bolsters) and side rails on his bed. CNA #4 stated that they have to put the bolsters on his bed because he can wiggle and move out of the bed. CNA #4 confirmed that she has had to untie the bolster from the right side of the bed to get him out of the bed in the morning. She stated that she was told they have to tie the cushions while he's in bed because he will fall out. CNA #4 confirmed that she has had to tie the cushion to the bed frame or else R #118 will pull it off. W. On 08/03/17 at 1:58 pm, during interview, the Central Supply Manager (CSM) confirmed that R #118's bed was owned by the facility. The CSM stated that according to what she knows the reason for using side rails has to be documented. She stated, We hardly ever have to use side rails unless there's a reason for it, because it's a restraint. A lot of times they don't have side rails because the restriction for restraints. I don't know who put those on, those are bolsters and they should be documented. If they need it, they (staff) let me know in the meeting. I don't remember if it was discussed in a meeting. They (staff) are supposed to let me know. I need to know, because it's a restraint. I get the beds when they ask me to, so if there is anything like the bolster, I need to know why. You can't just slap something on without a reason. There has to be a reason for everything. The CSM stated that the bolsters come with a strap to tie them to something and she stated that R #118 would have to go under the bed to untie the strap because that's where the connection is. Findings for R #15: X. Record review of R #15's Face Sheet indicated he was admitted on [DATE] and readmitted on [DATE], with a medical [DIAGNOSES REDACTED]. Y. On 08/01/17 at 12:01 pm, during observation of R #15's room, observed full side rails on both sides of R #15's bed. Z. On 08/03/17 at 10:14 am, during observation of R #15, observed him in bed asleep. Bed has full side rails on both sides of his bed, they are in the up position. Resident also has an air mattress in place. R #15 is laying on his left side in the fetal position with his head facing the left side rail. There was a visible gap on the left side between the side rail and the air mattress. AA. On 08/03/17 at 9:45 am, during interview, the ADON stated that R #15 has bad spasms and years ago they were so bad they threw him out of bed. The ADON confirmed that R #15's spasms were the reason for the use of full side rails. She stated that he cannot lower the side rails himself, due to his medical condition. The ADON stated that there were physician orders [REDACTED].#15 was recently readmitted to the facility and the doctor would either resume previous orders or prescribe new orders. The ADON confirmed that R #15 has an air mattress due to his wound, he cannot reposition himself in bed without assistance and the side rails are raised at all times while he is in bed. The ADON stated that she doesn't know if R #15 has cushion or padding to his side rails. BB. On 08/03/17 at 9:34 am, during interview, LPN #4 confirmed that R #15 has an air mattress due to a wound on his right hip. She stated that he is contracted on both arms and requires a mechanical lift for transfers and assist for bed mobility. She stated that R #15 has rails that he uses to help reposition, he puts his arm threw the side rail and helps staff during care. LPN #4 stated that R #15 was alert and makes his needs known. When asked if R #15 has had [MEDICAL CONDITION] or spasms, she stated, not that I know of. She stated that she has not heard in report or from any other nurses that R #15 has had any spasms. LPN #4 stated that R #15 does not have any padding on his rails because there was no signs of him hurting himself. LPN #4 confirmed that R #15 has full side rails on both sides of his bed. CC. On 08/03/17 at 9:56 am, during interview, the MDS Coordinator stated, He (R #15) has an air mattress and its for stabilization. The MDS Coordinator stated that R #15 does not reposition himself much and he requires assistance for activities of daily living (ADLs). Regarding spasms or [MEDICAL CONDITION], she stated that she could not recall him having any recently. The MDS Coordinator stated that if a resident had [MEDICAL CONDITION] or spasms it would be care planned. The MDS Coordinator stated side rails would be care planned if they fell under restraints. She confirmed that R #15 does not have padded side rails. The MDS Coordinator stated that the biggest accident hazard for R #15 is him sliding out of the bed because he has an air mattress. DD. On 08/03/17 at 11:41 am, during interview, R #15 stated that he did not request the side rails, they came with the bed. R #15 was asked if the dangers of having full side rails on his bed was explained to him, he stated, no. R #15 also stated that he has had one spasm while in the facility and it happened when he first got to the facility. EE. On 08/03/17 at 12:40 pm, during interview, the DON when asked what was the reason that R #15 has full side rails, she stated, I'm fixing to find out. He has been here a long time. The DON stated in the past he has had [MEDICAL CONDITION], but did not know if he had a [DIAGNOSES REDACTED]. The DON stated that the side rails are an enabler because he does hook his arm on the rails. The DON was asked why not half or quarter side rails, she stated, I don't know. I would have to look. The DON confirmed that the facility would need a physician order [REDACTED].#15s full side rails were considered a restraint. The DON stated that a consent would only be required if the side rails were deemed a restraint. The DON was asked if he was assessed to determine if he still needs side rails, she stated, Well, he is a paraplegic. It's not going to remedy itself, so I would think he still needs them. The DON was not able to provide an answer when asked why R #15 has full side rails if he cannot get out of bed on his own. When asked if R #15 has had any [MEDICAL CONDITION] in the last year, she stated, I don't know. When asked if R #15 has spasms, she stated, I don't know. I'm not on the floor. The DON stated that she does not believe a low bed or fall mats have been tried before using the side rails. The DON stated that she will have to look through R #15's old medical record to find the order for the side rails. FF. On 08/03/17 at 4:05 pm, during interview, LPN #5 confirmed that there was no signed consent for R #15 for the use of full side rails. GG. On 08/03/17 at 5:45 pm, during interview, the Nurse Practitioner (NP) confirmed that the nursing staff was supposed to call and verify the orders when residents were readmitted . She stated that if side rails were in his orders when he left, the staff should have called and asked if they want to keep the orders, and they will say yes. The NP confirmed that the side rails would carry over and be on the current orders. HH. Record review of the Physician order [REDACTED]. II. Record review of R #15's Medical Record, did not indicate that R #15 signed a consent form or was educated of the risks and benefits of using the full side rails. JJ. Record review of R #15s Care Plan dated 02/17/14, revealed that R #15 was at risk for injury related to falls with an intervention of Padded S/R (side rails) up times 2 while in bed with air mattress. KK. Record review of the MDS dated [DATE], indicated, restraints used in bed: bed rail .Not used. LL. Record review of the Use of Restraints policy and procedure dated 12/2008, indicated the following: 1. Physical restraints are defined as any manual method or physical or mechanical device or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement; 2. Restraints may only be used if/when the resident has a specific medical symptoms that cannot be addressed by another less restrictive intervention; 3. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints; 4. Restraints shall only be used upon written order of a physician and after obtaining consent; 5. Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction. MM. Record review of Bed Safety policy and procedure dated 12/2017, indicated the following: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical condition, and freedom of movement; 2. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative; 3. The staff shall obtain consent for the use of side rails from the resident or resident's legal representative prior to their use; 4. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails; 5. The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals.

The facility failed to ensure that residents received appropriate supervision by a Registered Nurse (RN) for at least eight (8) consecutive hours a day for seven (7) days a week. A complete review of the licensed staffing schedules from the date of the last recertification survey of [DATE] through [DATE], revealed noncompliance with the RN staffing numbers to meet federal regulation standards. This deficient practice of the systemic problem resulted in an Immediate Jeopardy (IJ) at a Scope and Severity of L being identified on [DATE] at 9:10 am. The Administrator and Director of Nursing (DON) were notified at that time and a Plan of Removal was requested to include the following: a list of residents who had expired in the facility on a weekend from [DATE] through [DATE], documented proof of Current Licensure, Cardiopulmonary Resuscitation (CPR) status and Intravenous (IV) Certification for all Licensed Practical Nurses (LPN's). The Facility took corrective action by providing an acceptable Plan of Removal on [DATE] at 2:47 pm. The Plan of Removal dated [DATE], included the following: 1. The Administrator and Director of Nurses were in-serviced by RQM (Regional Quality Manager) via phone on providing RN coverage 7 days a week on [DATE]. In servicing also included requirement of LPNs to provide proof of IV certification prior to providing treatment or care to IV's and CPR Certification and validation of licensure for LPNs. 2. Effective immediately the (sic) all LPNs will provide CPR Certification and the facility will validate current licensure for LPNs, also LPNs will no longer provide IV care or treatment until they provide proof of IV certification, and they will sign an acknowledgement stating they understand this directive. 3. Administrator and Director of Nurses in-serviced consisted of and will consist of - Federal Regulation F354. The facility is required to provide an RN for 8 consecutive hours a day, 7 days a week. Determination of sufficient staff will be based on the staff's ability to provide needed care to residents that enable them to reach their highest physical, mental, and psychosocial well-being. - Federal Regulation F281, provide services to meet professional standards. 4. A 100% audit of the current nursing schedule will take place to identify days when we are lacking RN coverage. 5. Schedules will reflect RN coverage on a Daily basis. 6. A 100% audit of personal files of all current LPNs on staff has been completed to identify those without proof of IV certification, Current Licensure and CPR certification for LPNs. 7. The facility will ensure that there is at least 1 CPR Certified staff member in house per shift. 8. Mandatory CPR Certification class is scheduled for Wednesday [DATE] for uncertified LPNs. 9. Effective immediately, the RN MDS (Minimum Data Set) Coordinator will be scheduled for a minimum of 8 consecutive hours per day on weekends to provide RN coverage if there is not an RN staff available to provide the coverage. 10. The Administrator will actively recruit Registered Nurses to ensure the facility has appropriate coverage per regulation. 11. DON/Designee will review Nursing Schedule with Administrator in daily stand up meeting to ensure RN coverage. 12. All LPNs will provide proof of IV certification prior to providing IV care and treatments to include administration of medications. 13. DON/Designee will verify proof of CPR Certification, validation of Licensure and IV certification upon hire of LPNs. If proof of IV certification cannot be verified, the LPN will sign acknowledgement that they are not to provide care or treatment to IVs. 14. (Name of the Medical Director) was notified of the IJ situation by telephone on [DATE]. An off cycle QAQI (Quality Assessment Quality Improvement) committee meeting will be held on Friday, [DATE] to discuss our plan. Based on receipt of the acceptable Plan of Removal for the documentation and verification that there will be RN coverage for 8 consecutive hours, 7 days a week, including weekends, all 14 (fourteen) LPNs verification of their licensure, documentation of the LPNs IV certifications and CPR certifications of compliance, the IJ was removed on [DATE] at 4:20 pm. This resulted in the scope and severity being reduced from a level L to level F. Based on record review and interview, the facility failed to provide RN coverage for at least 8 consecutive hours a day for 7 days a week. The facility also failed to provide the necessary documentation that would indicate that all Licensed Practical Nursing staff (LPN's) were certified in Intravenous Administration (the infusion of liquid substances and medications directly into a vein and throughout the body), had current active professional licenses issued by the State of New Mexico and had a valid CPR certification. This deficient practice resulted in the increased risk for avoidable clinical negative outcomes while directly impacting the health and well being of all 90 residents as documented on the Resident Census List provided by the Administrator on [DATE]. The findings are: A. Record review of June, July and August, 2017 staffing schedules, indicated no RN coverage during the weekend shifts. B. On [DATE] at 8:30 am, during interview, LPN #5 (staff development) confirmed that there was no RN coverage during the weekends. C. On [DATE] at 9:10 am, during interview, when the IJ was called regarding insufficient RN staffing, the Director of Nursing (DON) stated, Well .I guess I will just have to come in and work. The DON was reminded that she could not work as a charge nurse if the facility's census was 60 or greater. The DON was asked how many Licensed Practical Nurses (LPN's) were IV Certified? The DON stated, all of them. When asked how she could prove their IV certification, the DON stated, They tell me or show me. After reviewing the CMS regulation, the DON stated, They will not meet your standard. When asked what the protocol for a death was, the DON stated, I can pronounce .I'm a RN. D. On [DATE] 9:54 am, during interview, LPN #4 stated that she had been IV certified since 2006. When asked if any RN's work on the units, LPN #4 stated, We have the DON .I can start IV's but haven't done them here yet because they (meaning residents) usually come here from the hospital with them in .If something happened we can call Emergency Medical Services (EMS) or I would call the doctor and we would send them out (meaning to the hospital) to get checked. LPN #4 was then asked how long she had been working at the facility and what competencies she had completed? LPN #4 stated that she had been at the facility for about a year and had not seen any competencies or competencies specific for IV's or IV administration. E. On [DATE] 10:16 am, during interview, LPN #2 stated that she was IV certified and when asked if anyone had requested to see her certification at the facility? LPN #2 stated, No .I just told them and that was that. LPN #2 was then asked if she had to complete any competencies on IV's or IV administration when hired, LPN #2 stated, No. LPN #2 then added that she works three 12 hour shifts and does every other weekend and has been working at this facility since [DATE]. LPN #2 was asked if there were any RN's in the facility when she worked weekends? LPN #2 stated, No .but if we needed one to pronounce (meaning a death) there would be someone we can call. F. Record review of the Licensed Nursing staffing sheets revealed the following: 1. For RN coverage, dated [DATE] (last recertification survey date) through [DATE] revealed the following weekend days with no RN coverage: a. ,[DATE] - Four weekend days with no coverage b. ,[DATE] - Eight weekend days with no coverage c. ,[DATE] - Four weekend days with no coverage d. ,[DATE] - Three weekend days with no coverage * Total weekend days with no RN coverage = 19 2. For RN coverage, dated [DATE] through [DATE] revealed the following weekend days with no RN coverage: a. ,[DATE] - Four weekend days with no coverage b. ,[DATE] - Five weekend days with no coverage c. ,[DATE] - Six weekend days with no coverage d. ,[DATE] - Ten weekend days with no coverage e. ,[DATE] - Six weekend days with no coverage f. ,[DATE] - Eight weekend days with no coverage g. ,[DATE] - Ten weekend days with no coverage * Total weekend days with no RN coverage = 49 G. On [DATE] at 10:15 am, during interview, the administrator stated that the Medicare MDS (minimum data set) coordinator) an RN will be working the following weekend. She then stated that they (the facility) will be using agency RN staff to fulfill the weekend RN coverage for the rest of the month. At this time a request was made for a policy addressing the staffing schedule. As of 3:30 pm at the exit conference, a policy had not been produced by the facility. H. On [DATE] at 11:40 am, during interview, LPN #5 stated that since she was hired in 2013, there was never an RN on staff during a weekend, that she was aware of. LPN #5 was unaware that an RN was required to work 8 consecutive hours, 7 days a week. I. On [DATE] at 12:50 pm, during interview, the DON stated that we (as surveyors) will not see the LPNs IV certifications in their records. She stated, We don't ask for that (the IV certification document). The nurses just tell me that they are IV certified. When asked if there were any IV therapy competencies that are given at the facility? She stated, No. When asked what was her perception if a LPN working the weekend requested her presence? She stated, I would come over at any given time. When reminded again that as the DON, she can not work as a charge nurse, as long as the facility's census was above 60. She stated, I didn't quite understand that. She stated that on staff there were 2 (two) RNs that worked , one was full-time and the other was part-time, who lived across the street from the facility. She stated that as the DON, she reads the referrals of residents who are to be admitted to the facility. She stated that the physicians were real good about if there was a resident who had a [MEDICATION NAME] (diuretic) IV medication to push, the physician would change the order as an oral medication. The DON stated that as an LPN, they can not discontinue a PICC (peripherally inserted central catheter, a long plastic tube inserted into a vein in the arm where the line is guided up into a large vein near the heart where it can deliver medications) line nor can the LPN pronounce (to declare officially that a person has ceased respirations) someone if they expire. J. Record review of the facility's document titled Detail Admission/Discharge Report, dated [DATE] to [DATE], indicated the Residents who had passed away in the facility on a weekend. That document was compared to the staffing schedule dated [DATE] to [DATE], revealed that there were 3 (three) times out of 9 (nine) deaths that an RN was not scheduled for a weekend shift. There was a part-time RN that lived across the street that came into the facility to pronounce the resident. At one (1) time, the physician pronounced a resident when there was no RN coverage on the weekend shift. K. Record review of the facility's Position Descriptions, (undated) revealed the following: 1. Registered Nurse - Work with physicians, implementing orders for medications, treatments and special tests. Supervise LPNs, LVNs (licensed vocational nurses) and CNAs (certified nursing assistants), providing them support in order that they may provide total nursing care for residents. Essential Functions of Position: Utilize the nursing process to assess resident care plans, implement interventions, and evaluate outcomes related to nursing care. Initiate and lead team conferences to develop individualized nursing care plans; assess and document residents's condition and nursing needs; assign team members who have the capabilities and qualifications to meet resident's needs. Implement physicians' orders; administer medications, start IVs, perform treatments, procedures and special tests and document treatment as required by company policy and local/state/federal rules and regulations. Assist or institute emergency measures for sudden adverse developments . 2. LVN/LPN - Unit Manager - Be in charge of a group of dedicated clinical staff, ensuring they are able to provide the highest quality of care for residents .Working with doctors, obtaining medications, and maintaining accurate records of treatment. Essential Functions of Position: Supervise nursing unit including scheduling and directing nursing staff .Contact physicians as necessary and ensure physician interventions are timely and appropriate; ensure appropriate documentation of resident care. Review staffing patterns and census of nursing units; reassign personnel when necessary to ensure residents needs and budgetary controls are met. Investigate complaints and take necessary action to resolve problems. Responsible during the shift for the total nursing care of residents in the assigned unit. Assumes responsibility for compliance with Federal, State, Local and company regulations .Administers prescribed medications and treatments in accordance with approved nursing techniques .Follows established procedures for charting and reporting all reports of incident/accidents for residents and employees .Observes resident, records significant conditions and reactions, and notifies supervisor or Physician of resident's condition and reaction to drugs, treatments, and significant incidents .Responds to emergency situations based upon nursing standards, policies, procedures, and protocol .

The facility failed to ensure that hot water in resident bathrooms was maintained at a safe temperature. A survey of resident bathrooms on the 100-unit found that hot water exceeded 110 degrees Fahrenheit (F), temperatures with the potential to cause significant resident burns. This deficient practice resulted in a determination of Immediate Jeopardy (IJ) at a scope and severity of K being identified on 07/18/16. The Administrator was notified on 07/18/16 at 5:38 pm. The facility took corrective action by providing an acceptable Plan of Removal on 07/18/16 at 6:25 pm. Based on the Plan of Removal, interventions included: 1. Immediate reduction of the setting of the water heater thermostat to 100 degrees F. 2. Signage placed on the 100-unit shower room door stating Out of Order until the issue was resolved. 3. Immediate consultation by a local plumbing firm to assess the hot water system for mechanical failure. 4. Repair of the hot water system by 07/19/16. 5. Daily checks and logging of hot water temperatures once the repair has been made. 6. Assessment of the hot water system on the 200-unit to prevent a recurrence. Based on the Plan of Removal and interview, the IJ was lifted on 07/18/16 at 6:25 pm. This resulted in the scope and severity being reduced from level K to level G. Based on observation, interview and record review, the facility failed to maintain bathroom water temperatures at a safe level below 110 degrees F, for the 35 residents on the 100-unit, as identified on the Resident Census list provided by the Administrator on 07/18/16, and failed to provide adequate supervision, identify new interventions and implement existing interventions to prevent avoidable falls for 1 (R #131) of 2 (R #92 and 131) residents reviewed for accidents. If hot water temperatures are not maintained at a safe level, residents are likely to experience thermal burns while using restroom sinks. If resident falls are not adequately evaluated and interventions are not implemented, residents can experience avoidable falls and sustain injuries. The findings are: A. On 07/18/16, during observation of resident bathrooms on the 100-unit: 1. At 4:04 pm, the hot water in the bathroom shared by rooms 102 and 104 was noted to be at 122.7 degrees F. 2. At 4:05 pm, the hot water in the bathroom of room 110 was noted to be at 123.2 degrees F. 3. At 4:06 pm, the hot water in the bathroom shared by rooms 101 and 103 was noted to be at 122.5 degrees F. 4. At 4:08 pm, the hot water in the bathroom shared by rooms 105 and 107 was noted to be at 122.3 degrees F. 5. At 4:12 pm, the hot water in the bathroom shared by rooms 109 and 111 was noted to be at 122.5 degrees F. 6. At 4:20 pm, the hot water in the bathroom shared by rooms 116 and 118 was noted to be at 121.5 degrees F. B. On 07/18/16 at 4:35 pm, during interview with the Maintenance Director, he stated that he had just checked water temperatures on the 100-unit, after being notified of the problem. He stated that temperatures were 121 degrees F in the bathroom of room 101, 120.9 degrees F in the bathroom of room 115, and 120.1 degrees F in the bathroom of room 116. He stated that a mixing valve in the hot water tank room might be malfunctioning. He stated that the water temperatures were checked weekly, and daily if there was a problem. C. On 07/18/16 at 4:54 pm, during interview with the Maintenance Director, he stated that he had checked water temperatures that morning, and obtained readings of 108 degrees F. He stated that it would be repaired the following day. D. On 07/18/16 at 5:12 pm, during interview with the Maintenance Director, he provided copies of his logs of hot water temperature checks. The most recent entries were dated 07/14/16. The Maintenance Director stated that he had checked the water temperatures on 07/18/16, but had not logged his findings. E. On 07/20/16 at 10:00 am, during interview with the Maintenance Director, he stated that the water circulator on the 200-unit had been replaced four years previously. He stated that there had been no discussion of also replacing the 100-unit valve at that time, because it wasn't giving me any problems. He stated that the 100-unit valve had not been replaced during his [AGE] years as Maintenance Director. F. Record review of a completed Resident Census and Conditions of Residents (CMS-672) form, provided by the Director of Nursing on 07/18/16 and dated 07/18/16, found that 28 residents were listed as having dementia (a disease of judgement and memory impairment), which would increase the likelihood of their sustaining burns if excessively hot water was available to them. G. Record review of a Urine Output Report form, dated 07/17/16 and provided by the Director of Nursing on 07/18/16, found that it indicated which residents used the bathrooms on the 100-unit (did not have conditions rendering them unable to use bathroom facilities). Highlighting indicated that 24 residents used the bathroom facilities. H. Record review of the facility's undated Policy & Procedure document titled Water Temperature Log found the statements: 1. Temperatures of all domestic hot water systems must be checked every day and logged for that day. 2. Temperatures must be checked daily at patient room lavatories, at shower room, faucets and lavatories . I. On 07/22/16 at 10:29 am, during an interview with the Director of Nursing (DON), she stated that whenever a resident has a fall, an incident report is made regardless of whether an injury was sustained or not. The DON stated that R #131 had a fall without injury on 06/27/16 and a second fall on 06/30/16 which did result in a head injury and a subsequent trip to the hospital. The DON stated that an incident report was completed for the fall on 06/30/16 but not for the one on 06/27/16. She stated she was not sure why one was not made. She stated that it may have been a computer error while entering the information into the software. She stated that the bulk of what was included in the incident report is listed in a nurse's note on that same day (06/27/16). J. Record review of the nurse's note dated 06/27/16 indicated that a nurse aide reported that she saw resident (R #131) walking with stocking feet to the restroom. When she got to resident, resident slid to floor . Resident stated she was going to the bathroom. K. On 07/22/16 at 11:02 am, during an interview with the DON, she stated that they determined the root cause of the fall on 06/27/16 was that the resident would attempt to ambulate and use the restroom on her own instead of asking for help. The DON stated that the resident did have interventions in place since admission such as a wanderguard and personal alarm however no new interventions were attempted or put in place between the time the first fall occurred on 06/27/16 and when the second fall happened on 06/30/16. L. Record review of the incident report of the second fall on 6/30/16 stated Resident was attempting to go into the restroom by herself and did not call for assistance. fell and hit her head on the floor. Laceration/skin tear to right forehead with raised hematoma (a collection of blood outside a blood vessel). Laceration approximately 3 cm (centimeters) in length. The incident report indicated the fall occurred at 8:46 a.m. on 06/30/16. M. Record review of the Bowel and Bladder Training assessment dated [DATE] indicated that R #131 was a Candidate for Toileting (timed voiding). N. Record review of R #131's care plan dated 6/30/16 indicated that one of the interventions in place to prevent falls was assist to toilet q (every) 2 hrs (hours). O. Record review of R #131's record of Activities of Daily Living (ADL) for 06/30/16 revealed that R #131 was not assisted to toilet at all the morning of the second fall on 06/30/16. It also revealed the first toileting entry was at 6:45 p.m. the evening of 06/30/16. P. On 07/25/16 at 1:05 pm, during an interview with the DON, she stated that sometimes the nurse aides document the toileting ADL's on paper when the computer system is down. After several hours of searching, the DON verified that there was no paper or electronic documentation that R #131 was toileted at all the morning of 06/30/16. Also, the DON could not verify that R #131 was toileted every two hours in accordance with her care plan interventions.

The facility failed to ensure that fluids were thickened to the prescribed consistency for residents prescribed thickened fluids due to aspiration risk. During meal observations, Residents #54, 64, 65, 84, 85 and 94, were each prescribed thickened fluids. They were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 09/20/12 at 3:30 pm. The facility Administrator and Director of Nursing (DON) were notified on 09/20/12 at 3:30 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all kitchen staff and Certified Nursing Assistants (CNAs) in provision of thickened fluids and the implementation of a monitoring system to ensure that fluids were being thickened as prescribed. Based on the Plan of Removal and the information provided, the IJ was lifted on 09/21/12 at 1:15 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope E. Based on observation, interview and record review, the facility failed to follow physician orders [REDACTED].#54, 64, 65, 84, 85 and 94) of 6 (#54, 64, 65, 84, 85 and 94) sampled residents with physician's orders [REDACTED]. Residents #54, 64, 65, 84, 85 and 94 were each prescribed thickened fluids, and were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. This deficient practice had the potential to expose the 6 residents with orders for thickened fluids to the risk of aspiration, a condition in which the individual inadvertently takes fluids into the lungs. The findings are: A. On 09/20/12, between 12:00 pm and 12:40 pm, observation of the dining service in the facility's main dining room revealed Certified Nursing Assistant (CNA) #1 and CNA #2 serving meals to residents. Residents #54, 64, 65, 84, 85 and 94 were among the residents being served in the room. Each of the 6 residents were served beverages including an 8 ounce glass of thickened water with a 1 inch layer of thin water on top of the thickened water. B. Review of the physician orders [REDACTED]. 1. physician's orders [REDACTED]." A Speech Therapy Discharge Summary dated 04/07/12 recommended nectar thick liquids. 2. physician's orders [REDACTED]." 3. physician's orders [REDACTED]." A Speech Language Dysphagia Evaluation dated 07/07/10 recommended nectar thick liquids. 4. Record review of resident #84 revealed a Telephone Order dated 07/07/12 ordering, "Mech. soft (mechanical soft) c (with) nectar liq. (liquids)" and a second Telephone Order dated 08/31/12 ordering, "Regular diet, puree consistency, nectar thick liquids..." 5. Record review of resident #85 revealed a Telephone Order dated 08/22/12 ordering, "Liquids to be thickened. See Dietary Notes 8/21/12 (sic)" Review of the 08/21/12 Dietary Notes revealed, "Family feels res (resident) has problems swallowing thin liquids. Res did require thickened liquids at another nursing home. ..." 6. Record review of Resident #94 revealed physician's orders [REDACTED]." C. On 09/20/12 at 1:30 pm, during an interview, Cook #3 was asked about the kitchen's preparation of thickened fluids. She stated, "The dietary aide who prepares the beverages prepares them the day before. In other words they were poured yesterday for today. Of course the thickening agent always settles, and its only common sense that you would stir it." When asked who in the kitchen had set beverages on the trays for the 09/20/12 lunch meal service, she identified Dietary Aide #4. D. On 09/20/12 at 1:50 pm, during an interview, Dietary Aide #4 was asked if she had set fluids on the trays for the 09/20/12 lunch meal service. She stated, "Yes, sir." When asked if some of the fluids she handled were thickened, she stated, "Yes, sir." When asked how she normally handled thickened fluids, she stated, "When I set the drinks out, I check them. If I feel they're not ready, I swish them, but the thickener does separate from the drinks by the time the resident gets them." When asked if she had stirred the thickened fluids prior to placing them on the tray for the lunch meal, she stated, "No, I did not." When asked if she had observed that the thickened fluids were separated, she stated, "No, I didn't. I didn't notice." When asked about the usual process for thickening fluids, she stated, "We have a dietary aide that does the drinks the day before, so today's drinks were set out yesterday." When asked again if she had stirred the fluids, she stated, "No, I didn't." Based on observation, interview and record review, the facility failed to follow physician's orders [REDACTED].#1, 4, 7, 8, 13, 14, 26, 31, 40, 41, 51, 55, 56, 62, 64, 65, 68, 80, 82, 84, 85, 89, 94, 116, 120, 132, 135 and 136) evaluated for care. Residents #41 and #80 were observed to receive nectar-thick water during meal observation. Neither resident had physician orders [REDACTED]. Failure to provide the prescribed fluid texture had the potential to result in the two residents taking in less fluid, increasing risk of dehydration. The findings are: A. On 09/20/12, between 12:00 pm and 12:40 pm, observation of dining service in the facility main dining room revealed Certified Nursing Assistant (CNA) #1 and CNA #2 serving meals to residents. Residents #41 and 80 were among the residents being served in the room. For both residents, CNA #1 and CNA #2 served beverages including an 8 ounce glass of thickened water. During the meal, Resident #80 drank none of his thickened water. B. Review of the record of Resident #41 revealed the following: 1. On 08/01/12 Resident Admission Record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. 2. On 09/20/12 dining room diet card revealed a diet of, "Pureed/nectar thick liquids." 3. Review of physician's orders [REDACTED]. There were no orders for nectar thickened liquids. 4. On 09/18/12 a Nutritional Assessment documenting a regular pureed diet with no thickened liquids indicated. Under, "Recommendations," there was no recommendation for changing liquid texture. C. Review of the record of Resident #80 revealed the following: 1. On 08/10/12 Resident Admission Record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. 2. On 09/20/12 dining room diet card revealed a diet of, "Mech. soft/nectar thick liquids." 3. On revealed no orders for nectar thick liquids. Review of physician's orders [REDACTED]. 4. On 08/21/12 a Nutritional Assessment documenting a regular pureed diet with no thickened liquids indicated. Under, "Recommendations," there was no recommendation for changing liquid texture. 5. On 08/09/12 Speech Therapy Discharge Summary documented the resident had been discharged from speech/language services for dysphagia due to meeting his goal; it documented, "At time of speech therapy discharge, the pate (patient - Resident #80) is able to upgrade to 'thin' liquids." D. On 09/21/12 at 10:30 am, during an interview, the Director of Nursing was asked to review the records of Residents #41 and #80. She acknowledged they did not have orders for thickened liquids.

The facility failed to ensure that fluids were thickened to the prescribed consistency for residents prescribed thickened fluids due to aspiration risk. During meal observations, Residents #54, 64, 65, 84, 85 and 94, were each prescribed thickened fluids. They were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 09/20/12 at 3:30 pm. The facility Administrator and Director of Nursing (DON) were notified on 09/20/12 at 3:30 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all kitchen staff and Certified Nursing Assistants (CNAs) in provision of thickened fluids and the implementation of a monitoring system to ensure that fluids were being thickened as prescribed. Based on the Plan of Removal and the information provided, the IJ was lifted on 09/21/12 at 1:15 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope E. Based on observation, interview and record review, the facility failed to provide fluids thickened to the consistency prescribed by the residents' physicians to prevent aspiration for 6 (#54, 64, 65, 84, 85 and 94) of 6 (#54, 64, 65, 84, 85 and 94) sampled residents with physician's orders [REDACTED]. Residents #54, 64, 65, 84, 85 and 94 were each prescribed thickened fluids, and were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. This deficient practice had the potential to expose the 6 residents with orders for thickened fluids to the risk of aspiration, a condition in which the individual inadvertently takes fluids into the lungs. The findings are: A. On 09/20/12, between 12:00 pm and 12:40 pm, observation of the dining service in the facility's main dining room revealed CNA #1 and CNA #2 serving meals to residents. Residents #54, 64, 65, 84, 85 and 94 were among the residents being served in the room. Each of the 6 residents were served beverages including an 8 ounce glass of thickened water with a 1 inch layer of thin water on top of the thickened water. B. Review of the physician orders [REDACTED]. 1. physician's orders [REDACTED]." A Speech Therapy Discharge Summary dated 04/07/12 recommended nectar thick liquids. 2. physician's orders [REDACTED]." 3. physician's orders [REDACTED]." A Speech Language Dysphagia Evaluation dated 07/07/10 recommended nectar thick liquids. 4. Record review of resident #84 revealed a Telephone Order dated 07/07/12 ordering, "Mech. soft (mechanical soft) c (with) nectar liq. (liquids)" and a second Telephone Order dated 08/31/12 ordering, "Regular diet, puree consistency, nectar thick liquids..." 5. Record review of resident #85 revealed a Telephone Order dated 08/22/12 ordering, "Liquids to be thickened. See Dietary Notes 8/21/12 (sic)" Review of the 08/21/12 Dietary Notes revealed, "Family feels res (resident) has problems swallowing thin liquids. Res did require thickened liquids at another nursing home. ..." 6. Record review of Resident #94 revealed physician's orders [REDACTED]." C. On 09/20/12 at 1:30 pm, during an interview, Cook #3 was asked about the kitchen's preparation of thickened fluids. She stated, "The dietary aide who prepares the beverages prepares them the day before. In other words they were poured yesterday for today. Of course the thickening agent always settles, and its only common sense that you would stir it." When asked who in the kitchen had set beverages on the trays for the 09/20/12 lunch meal service, she identified Dietary Aide #4. D. On 09/20/12 at 1:50 pm, during an interview, Dietary Aide #4 was asked if she had set fluids on the trays for the 09/20/12 lunch meal service. She stated, "Yes, sir." When asked if some of the fluids she handled were thickened, she stated, "Yes, sir." When asked how she normally handled thickened fluids, she stated, "When I set the drinks out, I check them. If I feel they're not ready, I swish them, but the thickener does separate from the drinks by the time the resident gets them." When asked if she had stirred the thickened fluids prior to placing them on the tray for the lunch meal, she stated, "No, I did not." When asked if she had observed that the thickened fluids were separated, she stated, "No, I didn't. I didn't notice." When asked about the usual process for thickening fluids, she stated, "We have a dietary aide that does the drinks the day before, so today's drinks were set out yesterday." When asked again if she had stirred the fluids, she stated, "No, I didn't." Based on observation, interview and record review, the facility failed to provide supervision needed to prevent a fall for 1 (#40) of 3 (#26, 40 and 135) residents evaluated for fall prevention. Resident #40 was seated in a shower chair, being showered by Certified nursing Assistant (CNA) #5. CNA #6 was assisting another resident in a neighboring stall, and requested assistance. CNA #5 went to assist CNA #6, leaving resident #40 unattended. When CNA #5 returned, she found resident #40 had fallen from the shower chair during her absence. Review of the resident's care plan and facility showering policies revealed no instruction to provide continuous supervision during showers. This failed practice had the potential to effect resident 40, putting her at risk for a severe injury due to falling from a chair in the shower. The findings are: A. Review of resident #40's Resident Admission Record dated 09/12/12, revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. B. Review of resident #40's record revealed an Assessment of Fall Risk dated, 09/01/12; the Assessment documented a fall risk score of 21 and documented, "total score of 15 or above represents high risk." C. Review of resident #40's Nurses Notes for the period of 07/01/12 through 8/30/12 revealed one injury of unknown origin on 07/17/12 - a blackened left eye - and falls on 08/25/12 and 08/27/12. Review of the Nurse's Notes dated 08/27/12 at 5:00 pm revealed, "Res (resident) fell from shower chair to floor @ (at) 1615 (4:15 pm) while waiting for shower. Obtained lg (large) goose egg to L (left) FH (forehead) + (and) sml ST (small skin tear) to L elbow ... " D. On 09/19/12 at 4:10 pm, during an interview, the Director of Nursing (DON) was asked about the 08/27/12 fall. She stated, "She slid off the bath chair. There were two residents in the shower room and two aides giving them showers." When asked how the resident had fallen from the chair, she stated, "I don't know; she just slid off the wet chair." When asked who was with the resident in the shower at the time of the fall, she identified CNA #5. When asked if CNA #5 had been working with the resident at the time of the fall, she stated, "The other CNA (CNA #6) said, 'I need your help for a second.' She (CNA #5) said, 'Wait right there.' She (CNA #5) went around the curtain not farther than you are from me now (3 feet), and boom, down she (resident #40) went." When asked what the facility's policy was on showering, she stated, "There should be an aide per person in there, no more than two people getting showers." When asked whether there were any guidelines to the aide on how they handle the resident, she stated, "I'm sure there is; I'm not familiar with those. That's an HRSDC (Human Resources Staff Development Committee) thing." When asked what action she'd taken afterward, she stated, "I told the CNA (CNA #5) never, never, never leave; if anything else put on a call light and have somebody come in to help." When asked if that instruction had been added to the resident's care plan, she stated, "I don't know, I'd have to ask the MDS Coordinator." The DON summoned the MDS coordinator, who reported the issue of shower supervision had been discussed at the resident's care plan meeting but had not been added to the plan, stating, "I can update her to say that, but its common sense to stay close." E. On 09/20/12 at 5:01 pm, during ain interview, CNA #5 was asked about resident #40's fall in the shower. She stated, "We went in to give them a shower. It was (name of CNA #6) and me; (name of CNA #6) was showering (name of resident #23) on one side and I had (name of resident #40) on the other, and I had her sitting on the chair, getting ready to take her shower, and (name of CNA #6) was getting ready to finish dressing her (resident #23) when she (resident #23) just, whoosh, her legs gave out, and (name of CNA #6) couldn't hold her, and (name of CNA #6) said, '(name of CNA #5), come help me,' and I went around to help her with (name of resident #23), picked her up, put her in the chair, and by the time I went back to (name of resident #40) , she was already on the floor." F. On 09/21/12 at 9:20 am, during an interview, CNA #6 was asked about resident #40's fall in the shower. She stated, "She (resident #23) has her days when she doesn't want to help us with anything, she just flops around. She didn't want to stand; I didn't want to chance transferring her alone. We were trying to get her transferred. I was trying to get her transferred (from the shower chair to the wheelchair) to get her britches (pants) up." When asked if resident #23 required one or two persons for transfer, she stated, "Most times she's just a one-person, but she has her days when she doesn't want to help us with anything." When asked if she was holding resident #23 at the time she called for help, CNA #6 stated, "No, she was sitting in the shower chair." When asked if resident #23 was at risk of fall when she called for help, she stated, "No." When asked who the other CNA in the shower room was, she stated, "The other staff member in the shower room was (name of CNA #5)." When askef if CNA #5 was with a resident, she stated, "Yes, she had (name of resident #40) in there." When asked the usual process when a CNA needed assistance in the shower, she stated, "(Name of CNA #5) or I will step back where we can see both shower stalls, and the other gets the nurse or CNA." When asked whether there was a call bell available in the shower, she stated, "Yes, there is, but a lot of times people don't realize where that light's coming from." When asked if she had ever used the call bell, she stated, "Yes." When asked if someone had responded, she stated, "Sometimes. Sometimes it takes a while. I have to step out in the hallway for somebody." When asked if she had done that before resident #40's fall, she stated, "That's what we did. I had my foot in the shower door, and I was trying to get the nurse's attention to come and help us." When asked if CNA #5 was watching the two residents while she did that, she stated, "Yes." When asked about CNA #5's statement about helping her, she stated, "She stepped away to help me with (name of resident #23) when I couldn't get anyone to help us. (Name of CNA #5) stepped into the shower stall to help me, because there was no staff out there available, they were all busy taking care of their residents." When asked if there had been anyone with resident #40 while CNA #5 was assisting her, she stated, "No." When asked if resident #40 had fallen during that time, she stated, "Yes. We had no other help; everybody was busy." G. Review of the facility Shower policy, undated, revealed no instruction to staff to not leave residents by them selves. H. Review of resident #40's Care Plan for Falls dated 12/23/11 revealed no approach or plan addressing the need to not leave the resident unattended during showering. No update of the approaches had been performed. A handwritten entry dated 09/17/12 documented, "Has had 2 falls in past month. Continue goal x (for) 90 days."

This is a repeat deficiency The facility failed to ensure that fluids were thickened to the prescribed consistency for residents prescribed thickened fluids due to aspiration risk. During meal observations, Residents #54, 64, 65, 84, 85 and 94, were each prescribed thickened fluids. They were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. These deficient practices resulted in an Immediate Jeopardy (IJ) being identified at the facility on 09/20/12 at 3:30 pm. The facility Administrator and Director of Nursing (DON) were notified on 09/20/12 at 3:30 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included retraining of all kitchen staff and Certified Nursing Assistants (CNAs) in provision of thickened fluids and the implementation of a monitoring system to ensure that fluids were being thickened as prescribed. Based on the Plan of Removal and the information provided, the IJ was lifted on 09/21/12 at 1:15 pm. This resulted in the scope and severity being reduced from a scope and severity of K to Level 2, Scope E. Based on observation, interview and record review, the facility administration failed to coordinate training and supervision of staff to assure that fluids thickened to the consistency prescribed by the residents' physicians were provided to 6 (#54, 64, 65, 84, 85 and 94) of 6 (#54, 64, 65, 84, 85 and 94) sampled residents with physician orders [REDACTED]. Residents #54, 64, 65, 84, 85 and 94, each were prescribed thickened fluids, and were served thickened water in which the thickener had settled prior to service, leaving 1 inch of thin fluid visible at the top of the glass. When interviewed, the Administrator stated she was unaware of the change and would have implemented training and monitoring had she known. The Diet Manager stated that the facility had switched to powdered thickener six months ago and that the Administrator had been informed at the time. This deficient practice had the potential to expose the 6 residents with orders for thickened fluids to the risk of aspiration, a condition in which the individual inadvertently takes fluids into the lungs. The findings are: A. On 09/20/12, between 12:00 pm and 12:40 pm, during an observation of the dining service in the facility's main dining room, Certified Nursing Assistant (CNA) #1 and CNA #2 served meals to residents. Residents #54, 64, 65, 84, 85 and 94 were among the residents being served in the room. Each of the 6 residents received an 8 ounce glass of water with a 1 inch layer of thin water on top of the thickened water. B. Review of the physician orders [REDACTED]. 1. physician's orders [REDACTED]." A Speech Therapy Discharge Summary dated 04/07/12 recommended nectar thick liquids. 2. physician's orders [REDACTED]." 3. physician's orders [REDACTED]." A Speech Language Dysphagia Evaluation dated 07/07/10 recommended nectar thick liquids. 4. Record review of resident #84 revealed a Telephone Order dated 07/07/12 ordering, "Mech. soft (mechanical soft) c (with) nectar liq. (liquids)" and a second Telephone Order dated 08/31/12 ordering, "Regular diet, puree consistency, nectar thick liquids..." 5. Record review of resident #85 revealed a Telephone Order dated 08/22/12 ordering, "Liquids to be thickened. See Dietary Notes 8/21/12 (sic)" Review of the 08/21/12 Dietary Notes revealed, "Family feels res (resident) has problems swallowing thin liquids. Res did require thickened liquids at another nursing home. ..." 6. Record review of Resident #94 revealed physician's orders [REDACTED]." C. On 09/20/12 at 1:30 pm, during an interview, Cook #3 was asked about the kitchen's preparation of thickened fluids. She stated, "The dietary aide who prepares the beverages prepares them the day before. In other words they were poured yesterday for today. Of course the thickening agent always settles, and its only common sense that you would stir it." When asked who in the kitchen had set beverages on the trays for the 09/20/12 lunch meal service, she identified Dietary Aide #4. D. On 09/20/12 at 1:50 pm, during an interview, Dietary Aide #4 was asked if she had set fluids on the trays for the 09/20/12 lunch meal service. She stated, "Yes, sir." When asked if some of the fluids she handled were thickened, she stated, "Yes, sir." When asked how she normally handled thickened fluids, she stated, "When I set the drinks out, I check them. If I feel their not ready, I swish them, but the thickener does separate from the drinks by the time the resident gets them." When asked if she had stirred the thickened fluids prior to placing them on the tray for the lunch meal, she stated, "No, I did not." When asked if she had observed that the thickened fluids were separated, she stated, "No, I didn't. I didn't notice." When asked about the usual process for thickening fluids, she stated, "We have a dietary aide that does the drinks the day before, so today's drinks were set out yesterday." E. On 09/22/12 at 3:57 pm, during an interview, the Administrator was asked how the facility monitored dining. She stated, "We have a dining room monitor sheet. I can assure you thickened liquids was not on it. It was on how the staff treated the residents, the service, if they were assisting people." When asked if the facility had a system to monitor the provision of thickened fluids, she stated, "That's primarily handled out of dietary. I will tell you ... we were using the pre-mixed, the prepared, (fluids purchased pre-thickened) and then we went back to the mixing ourselves (thickening fluids prior to service by use of a powdered thickener), and we're going back to the mixed." When asked why the facility had changed, she stated, "I don't know. That would be healthcare services group, they run the dietary, they're a contract service ..." When asked if she had been informed before the change, she stated, "No." When asked if she had inquired about the change after it had occurred, she stated, "No, I didn't notice. I knew we were using the pre-mixed because I was signing the bill." When asked if she'd noticed the changes on the bills, she stated, "I'd like to say yes, but I think it's just been in the last month or two. I hadn't noticed they'd really changed to the cans until all this came up (the incident involving the separated fluids)." When asked if the Dietary Manager attended management meetings, she stated, "Absolutely, yes." When asked if the Dietary Manager had reported a change in the thickened liquids from pre-mixed preparations to use of thickening powder, she stated, "No." When asked what she would have done if she had known about the change before the incident, she stated, "I would have wanted to know what the difference between the two products were. When you buy something you have to mix, you have to make sure the staff is adequately trained to do that, and there probably would have been monitoring." F. On 09/22/12 at 4:34 pm, during an interview, the Dietary Manager was asked about the transition from premixed thickened fluids to the use of powdered thickener. When asked if the facility had been using a premixed thickened fluid, she stated, "Yes, for everything but the milk. We were doing that (thickening the milk) ourselves manually." When asked when the facility had switched to use of powdered thickener, she stated, "I'd say it's probably been about six months." When asked if she'd informed the Administrator at the time of the change, she stated, "Yes." When asked how she had informed the Administrator, she stated, "We have stand-up meetings everyday. We discuss what goes on in our meetings and stuff." When asked if there had been a letter or written notification, she stated, "I don't know if it's been put in a letter to the Administrator. I know our corporate office and (name of facility's corporate owner)'s corporate office were the ones that came to this decision before it came to us in a Dietary Manager's meeting."