Every finding on record at Desert Springs Health Care LLC

Based on record review and interview, the facility failed to prevent an accident for 1 (R #81) of 3 (R #4, R #37, and R #81) residents reviewed for falls when staff failed to provide the required assistance during personal care resulting in R #81 falling from her bed. This deficient practice resulted in R #81 sustaining a fractured (broke) femur (thigh bone) and a fractured finger. The findings are:A. Record review of R #81's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Chronic, systolic (congestive) heart failure (impaired heart function),2. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),3. Morbid (severe) obesity (severely overweight),4. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),5. Muscle weakness generalized (reduction in the power exerted by muscles).B. Record review of R #81's care plan revised on 06/03/25 revealed R #81 needs two-person assistance (assistance by two staff members) for the following activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating):1. Bathing and showering,2. Bed mobility,3. Dressing,4. Toilet use,5. Transfers, using a Hoyer lift (a device designed to help staff move a resident from one place to another within a room or from one position to another).C. Record review of R #81's progress notes dated 12/27/25 revealed R #81 was in her room with her husband and requested a bed bath. R #81 fell from her bed while getting a bed bath, had a laceration (a wound produced by tearing) on her left pinky finger and complained of pain to her left arm, leg, and hip. R #81 was sent via ambulance to a local hospital for evaluation where she was diagnosed with a displaced oblique fracture (where the bone breaks at an angle) along the distal aspect of the femur (the lower end of the bone) and a displaced fracture (a break where the bone fragments have moved and are not aligned) of the middle phalanx of the fifth finger (pinky finger).D. On 01/29/26 at 1:18 pm, during an interview with Certified Nurse Aide (CNA) #2, he stated that on 12/27/25 he was called to R #81's room where she was lying in her bed demanding a bed bath. CNA #2 stated he greeted R #81 and R #81's husband and then assisted R #81 with a bed bath. During this bed bath, CNA #2 stated he was on one side of the bed, completing the bed bath when R #81 rolled to the opposite side of the bed and he was unable to stop her from rolling out of the bed and she fell to the floor. CNA #2 stated that he assisted R #81 without a second staff because he was unaware that R #81 required two-person assistance.E. On 01/29/26 at 1:37 pm, during an interview with the Director of Nursing (DON), she stated she expects residents who require two-person assistance to receive assistance from two staff members, following the care plan. The DON stated CNA #2 should have been told that R #81 requires two-person assistance when he received report from the nurse at the beginning of his shift.F. Record review of R #81's hospital documentation dated 01/05/26 revealed the following:1. R #81 was admitted to the hospital for femoral fracture and left fifth digit fracture.2. R #81 underwent surgery to repair the fractures on 12/29/25.G. On 01/29/26 at 2:30 pm, during an interview with the Administrator (ADM), she confirmed that R #81 was transferred to a rehabilitation facility (a facility designed to help people recover and regain abilities after an injury or surgery) after being discharged from the hospital and has not returned to the facility yet.

Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 3 (R #3, R #39, and R #91) of 4 (R #1, R #3, R #39, and R #91) residents reviewed for respiratory care when staff failed to:1. Ensure medical orders indicated when to administer supplemental oxygen (extra oxygen required to support the body's vital functions) needed to R #3 and R #39.2. Ensure a medical order was in place for R #91's supplemental oxygen use. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions. The findings are: R #3A. Record review of R #3's admission record revealed R #3 was admitted into the facility on [DATE] with the following diagnoses:1. Chronic Obstructive Pulmonary Disease (COPD; a progressive lung condition causing airflow blockage and breathing difficulties),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),3. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),B. Record review of R #3's physician record revealed an order dated 08/14/25 for oxygen through nasal canula (a small, flexible tube that delivers oxygen to the nose through soft prongs) at two liters (L) to keep oxygen saturation (measures the percentage of oxygen-carrying hemoglobin in the blood) above 90% (percent).C. On 01/28/26 at 1:42 pm an interview and observation of R #3 in his room revealed an oxygen concentrator (medical device that delivers supplemental oxygen) next to the bed. R #3 was not wearing her oxygen cannula, and the machine was not on R #3 stated she only wears her oxygen when she needs it.D. On 01/30/26 at 4:26 pm during an interview with the Director of Nursing, she confirmed R #3 only wears oxygen as needed. She confirmed the order does not specify when R #3 should wear oxygen and it should.R #39F. Record review of R #39's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Congestive heart failure (CHF; impaired heart function),2. Chronic respiratory failure with hypoxia (an inability to exchange oxygen and carbon dioxide in the body),3. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),4. Unspecified atrial fibrillation (A-Fib; irregular heart rhythm),5. Sleep apnea (sleep disorder that occurs when a person's breathing is interrupted during sleep).6. Atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls).G. Record review of R #39's current medical orders revealed an order dated 10/21/24 for R #39 to receive two liters of oxygen via nasal cannula, may titrate to maintain oxygen level at 92% (percent).H. On 01/28/26 at 1:42 pm, during an interview with the DON, she confirmed that R #39's order for oxygen does not specify when to administer (continuous or PRN) oxygen to R #39 and it should.R #91I. Record review of R #91's admission record revealed R #91 was admitted into the facility on [DATE] with the following diagnoses:1. Hypertension (high blood pressure),2. Kidney failure (loss of kidney function),3. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),4. Cellulitis (deep inflammation of the tissues just under the skin; caused by infection) of right lower limb,5. Metabolic encephalopathy (non-traumatic brain dysfunction).J. On 01/29/25 at 12:43 pm, a random observation of R #91's room revealed R #91 was lying in bed wearing a nasal canula connected to an oxygen concentrator.K. On 01/29/26 at 12:48pm during an interview with the Assistant Director of Nursing (ADON), she confirmed R #91 was wearing oxygen.L. On 01/30/26 at 4:26 pm during an interview with the DON, she confirmed R #91's should have an order for use of oxygen prior to use and did not.

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring medications have an adequate indication of use and ensuring indication of use is based off of the residents' current diagnosis for 2 (R #7 and R #11) of 5 (R #2, R #3, R #6, R #7, and R #11) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are: R #7A. Record review of R #7's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Atherosclerotic heart disease (the build-up of fats, cholesterol, and other substances in and on the artery walls),2. Alzheimer's disease (progressive mental deterioration due to generalized degeneration of the brain),3. Atherosclerosis of coronary artery bypass grafts (plaque containing cholesterol and lipids that build up on artery walls),4. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),5. Chronic kidney disease (CKD; impaired kidney function). B. Record review of R #7's current medical orders revealed an order dated 08/06/25 for Apixaban (a medication used to lower the risk of a stoke) oral tablet, 2.5 milligrams (mg) to be given twice daily for atrial fibrillation (A-Fib; irregular heart rhythm).C. On 01/30/26 at 4:21 pm, during an interview with the Director of Nursing (DON), she confirmed R #7 does not have a diagnosis of A-Fib. The DON stated this does not meet her expectations because medications should be ordered and administered for diagnoses the resident has and this is not.R #11D. Record review of R #11's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),2. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),3. Essential (primary) hypertension (HTN; high blood pressure),4. Chronic obstructive pulmonary disease (COPD; lung disease),5. Rheumatoid arthritis (RA; chronic joint disease that causes pain and swelling).E. Record review of R #11's current medical orders revealed the following:1. An order dated 10/24/25 for Memantine HCl Oral Tablet 10 MG (a medication used to treat Alzheimer's disease), give two tablets by mouth at bedtime for Alzheimer's disease.2. An order dated 10/24/25 for Aricept Oral Tablet 10 MG (a medication used to treat Alzheimer's disease), give one tablet by mouth at bedtime for Alzheimer's disease.F. On 01/30/26 at 4:18 pm, during an interview with the DON, she confirmed R #11 does not have a diagnosis of Alzheimer's disease. The DON stated this does not meet her expectations because medications should only be ordered and administered for diagnoses the resident has.

Based on observation, record review, and interview, the facility failed to implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by not ensuring Enhanced Barrier (EBP) signs are posted outside of rooms with Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) readily available for 2 (R #37 and R #91) of 7 (R #2, R #5, R #8, R #9, R #10, R #37 and R #91) residents reviewed. These deficiencies place residents at risk of contracting infections, hospitalization, and death. The findings are:R #37A. Record review of R #37's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Focal traumatic brain injury (an external force causes localized damage to an area of the brain),2. Zoster (shingles),3. Elevated white blood cell count (typically means the body is responding to some form of stress or infection).B. Record review of R #37's current medical orders revealed an order dated 01/13/26 for this resident to be on contact precautions (used for individuals with infections that can spread through direct or indirect contact with the patient or their environment) due to shingles. The order stated Resident has active infection with highly transmissible/epidemiologically significant pathogens (easily spread from person to person) acquired by physical contact.C. On 01/28/26 at 1:49 pm, an observation of R #37's room revealed R #37 did not have a sign indicating contact precautions were required on her door. There was no PPE readily accessible.R #91D. Record review of R #91's admission record revealed R #91 was admitted into the facility on [DATE] with the following diagnoses:1. Hypertension (high blood pressure),2. Kidney failure (loss of kidney function),3. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),4. Cellulitis (deep inflammation of the tissues just under the skin; caused by infection) of right lower limb,5. Metabolic encephalopathy (non-traumatic brain dysfunction).E. Record review of R #91's physician orders revealed the following:1. An order dated 01/23/26 for wound care to the left hip, unstageable (a full-thickness, serious wound covered by necrotic tissue that obscures the depth, making it impossible to determine if it is stage 3 (full thickness skin loss that extends into deeper tissue and fat but not into muscle, tendon, or bone) or stage 4 (a deep wound that may impact muscle, tendons, ligaments, and bone), cleanse with wound cleanser, pat dry, apply honey to wound, cover with border gauze, change daily/as needed (PRN).2. An order dated 01/23/26 for wound care to the right ischium (lower-back bone of the pelvis), unstageable, cleanse with wound cleanser, pat dry, apply honey to wound, cover with border gauze, change daily/as needed (PRN).3. An order dated 01/23/26 for wound care to the left ischium, stage 3 (wound extending through the skin into the subcutaneous fat tissue, often appearing as a deep, crater-like crater), cleanse with wound cleanser, pat dry, apply honey to wound, cover with border gauze, change daily/as needed (PRN).4. An order dated 01/23/26 for wound care to the left heal, deep tissue injury (DTI; a serious form of pressure injury where damage occurs to underlying soft tissue (muscle/fat) beneath intact skin), cleanse with wound cleanser, pat dry, apply skin prep to wound, keep open to air daily/as needed (PRN).5. An order dated 01/23/26 for wound care to the right heal, unstageable, cleanse with wound cleanser, pat dry, apply betadine to wound, cover with border gauze, change daily/as needed (PRN).6. An order dated 01/23/26 for wound care to the sacrum (a large flat bone in the lower part of the spine, forming the rear section of the pelvis), unstageable, cleanse with wound cleanser, pat dry, apply honey to wound, cover with border gauze, change daily/as needed (PRN).7. An order dated 01/23/26 for wound care to the right big toe, unstageable, cleanse with wound cleanser, pat dry, apply betadine to wound, cover with border gauze, change daily/as needed (PRN).F. On 01/28/25 at 1:29 pm a random observation of R #91's room revealed R #91 did not have an EBP sign.G. On 01/30/26 at 11:28 am during an interview with the Certified Nurse Aide (CNA) #1, she confirmed R #91 did not have EBP sign posted.

Based on record review, observation and interview, the facility failed to ensure residents were provided with a choice about aspects of his/her life that are significant to the residents for 1 (R #27) of 3 (R #3, R #27 and R #91) residents by not having a choice to refuse dietician orders. If the facility does not honor residents' choices, then residents are likely to experience a loss of independence and self-worth leading to feelings of frustration and depression.The findings are:A. Record review of R #27's admission record revealed R #27 was admitted into the facility on [DATE] with the following diagnoses:1. Traumatic subdural hemorrhage (SDH; often life-threatening brain injury involving bleeding typically caused during head trauma),2. Anemia (low red blood cell count),3. Retention of Urine (the inability to fully empty the bladder),4. Repeated falls.B. Record review of R #27's Quarterly [NAME] Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 01/12/26 revealed R #27's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) is 12 (8-12 suggests moderate impairment).C. Record review of R #27's dietician orders dated 01/09/26 revealed an order for R #27 to be on a regular diet, soft and bite-sized texture and thin liquid consistency. D. On 01/28/26 at 12:52 pm, during a random observation of the dining room, R #27 asked for a tortilla. R #27 was informed that he could not have a tortilla due to his diet order. R #27 pushed his plate away and did not eat his meal.E. On 01/28/26 at 3:59 pm during an interview with R #27, he stated he really wants to eat a tortilla. He stated that he was told he could not have a tortilla because he might choke. R #27 stated he understands the risks and still wants a tortilla.F. On 01/30/26 at 4:26 pm, during an interview with the Director of Nursing (DON), she confirmed R #27 is on a soft, bite-sized diet. She confirmed R #27 has the right to refuse his dietary orders. She stated the staff should have communicated with the nurse or dietician to provide the opportunity for R #27 to refuse his dietary orders so he could have a tortilla.

Based on record review and interview, the facility failed to ensure the resident's current advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law and relating to the provision of health care when the individual is incapacitated) and New Mexico Orders for Scope of Treatment (MOST) form (a document which provides an individual's wishes for emergency and lifesaving care) matched the order in the electronic health record (EHR) for 2 (R #5 and R #39) of 7(R #5, R #6, R #8, R #9, R #10, R #12, and R #39) residents reviewed for advance directives when staff failed to update the resident's code status. This deficient practice is likely to result in confusion, delay, and residents not having their wishes honored if a life-threatening event occurred. The findings are:R #5A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. Record review of R #5's physician orders dated [DATE], revealed R #5 is a Full Code [attempt cardiopulmonary resuscitation (CPR; full code, an emergency procedure that combines chest compression with artificial ventilation)] for his advanced directive code status.C. Record review of R #5's current advance directive and the MOST form signed on [DATE] revealed R #5 chose a do not resuscitate (DNR; does not want to have CPR attempted on them if their heart or breathing stops) for his advanced directive code status.D. On [DATE] at 4:30 pm during an interview with the Director of Nursing (DON), she stated R #5's code status should be DNR and not full code, confirming the inaccuracy. R #39E. Record review of R #39's admission Record revealed she was admitted to the facility on [DATE].F. Record review of R #39's current medical orders revealed an order dated [DATE] to not attempt resuscitation due to DNR status.G. Record review of R #39's MOST form dated [DATE] revealed R #39 chose to be a full code and wants CPR performed if needed.H. On [DATE] at 4:23 pm, during an interview with the DON, she stated this does not meet her expectations because R #39's order should match her MOST form and it does not.

Based on record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #42) of 3 (R #2, R #3, and R #42) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.The findings are: A. Record review of R #42's admission record revealed he was admitted on [DATE].B. Record review of R #42's physician record revealed the following:1. An order dated 07/04/25 for Zoloft Oral Tablet (antidepressant medication) 100 milligrams (MG). Give 1.5 tablet by mouth one time a day for depression.2. An order dated 09/10/25 for Depakote Sprinkles (anticonvulsant medication) Oral Capsule 125 milligrams (MG). Give two capsules by mouth two times a day for dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with behaviors.3. An order dated 12/20/24 for Gabapentin capsule (anticonvulsant medication) 300 milligrams (MG). Give one capsule by mouth two times a day for anxiety (feelings of fear or apprehension).4. An order dated 12/20/24 for Aspirin oral tablet (antiplatelet medication) 81 milligrams (MG). Give one tablet by mouth one time a day for prophylactic measures related to history of stroke. Start date 12/20/24.5. An order dated 12/20/24 for Clopidogrel Bisulfate Oral Tablet (antiplatelet medication) 75 milligrams (MG). Give 1 tablet by mouth one time a day for prophylactic (intended to prevent) measures related to history of stroke (sudden interruption of blood flow to the brain).C. Record review of R #42's MDS dated [DATE], revealed Section N-Medications indicated R #27 does not take antidepressant medications, anticonvulsant medications or antiplatelet medications.D. On 01/30/26 at 4:40 pm during an interview with the MDS coordinator, she confirmed the assessment for R #42 was inaccurate and should include the use of antidepressant, anticonvulsant and antiplatelet medications but it does not.

Based on record review and interview, the facility failed to develop and implement a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours for 1 (R #11) of 6 (R #1, R #2, R #7, R #8, R #9, and R #11) residents reviewed for baseline care plans. If the facility fails to develop and implement a baseline care plan, then residents might not get the care and services they need. The findings are: A. Record review of R #11's admission Record revealed she was admitted to the facility on [DATE].B. Record review of R #11's Electronic Health Record (EHR) revealed no evidence of a baseline care plan.C. Record review of R #11's care plan revealed the care plan was developed and implemented on 10/27/25.D. On 01/30/26 at 4:16 pm, during an interview with the Director of Nursing (DON), she confirmed the facility failed to develop and implement a baseline care plan for R #11. The DON stated that she expects every resident to have a baseline care plan developed and implemented within 48 hours of being admitted to the facility.

Based on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 1 (R #91) of 4 (R #2, R #3, R #42, and R #91) residents reviewed for care plans when staff failed to: 1. Develop a care plan to include interventions for R #91's use of oxygen.2. Develop a care plan to include interventions for R #91's use of floor mat.This deficient practice could likely result in proper care not being provided to residents.The findings are: A. Record review of R #91's admission record revealed R #91 was admitted into the facility on [DATE].B. Record review of R #91's care plan dated 01/25/26 revealed the following:1. There was no care plan to include intervention for the use of supplemental oxygen (extra oxygen required to support the body's vital functions),2. There was no care plan to include interventions for the use of a floor mat.C. Record review of R #91's current medical orders revealed the following:1. An order dated 01/29/26 for this resident to use supplemental oxygen via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs).2. There was no order for this resident's use of a fall mat.D. On 01/29/25 at 12:43 pm, during a random observation of R #91's room revealed R #91 was lying in bed wearing a nasal canula connected to an oxygen concentrator (a medical device that provides supplemental oxygen). There was a floor mat on the floor next to the right side of the bed.E. On 01/29/26 at 12:48 pm during an interview with the Assistant Director of Nursing (ADON), she confirmed R #91 was wearing oxygen and had a floor mat placed on the floor next to the bed.F. On 01/30/26 at 4:26 pm during an interview with the Director of Nursing (DON), she confirmed R #91's use of oxygen and floor mat and confirmed both should be included in a care plan with interventions prior to use and was not.

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 1 (R #3) of 5 (R #2, R #3, R #27, R #34 and R #55) residents reviewed when staff failed to revise the care plan to include the current use of oxygen interventions. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #3's admission record revealed R #3 was admitted into the facility on [DATE] with the following diagnoses:1. Chronic Obstructive Pulmonary Disease (COPD; a progressive lung condition causing airflow blockage and breathing difficulties),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),3. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),B. Record review of R #3's physician record revealed an order dated 08/14/25 for oxygen through nasal canula (a small, flexible tube that delivers oxygen to the nose through soft prongs) at two liters (L) to keep oxygen saturation (measures the percentage of oxygen-carrying hemoglobin in the blood) above 90% (percent).C. Record review of R #3's care plan revised on 12/31/25 revealed R #3 uses oxygen through nasal cannula at two liters continuously.D. On 01/28/26 at 1:42 pm, an observation and interview with R #3 in her room revealed R #3 had an oxygen concentrator next to the bed. R #3 was not wearing an oxygen cannula, and the machine was not on. R #3 she stated she only wears her oxygen when she needs it.E. On 01/30/26 at 4:26 pm during an interview with the Director of Nursing she confirmed R #3 only wears her oxygen as needed. She confirmed the care plan was not accurate and should have been revised.

Based on observation, interview, and record review, the facility failed to provide adequate foot care services for 1 (R #77) of 1 (R #77) resident reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections. The findings are: A. Record review of R #77's face sheet indicated she was admitted on [DATE] with the following diagnoses: 1. Metabolic encephalopathy (brain dysfunction caused by metabolic disturbances in the body, leading to symptoms such as confusion, memory loss, and altered consciousness),2. Chronic kidney disease (a condition characterized by the gradual loss of kidney function over time, leading to the accumulation of waste and excess fluid in the body),3. Muscle weakness (generalized),4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),5. Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain),6. Repeated falls.B. On 01/30/26 at 11:30 am, during an observation of wound care to R #77's right ankle, Licensed Practical Nurse (LPN) #1 removed R #77's sock revealing an overgrown toenail to right great toe that was curving in slightly to the second toe.C. On 01/30/26 at 11:45 am, during an interview with LPN #1, she confirmed quarterly podiatry (the treatment of the feet and their ailments) appointments are made to provide nail care and would expect Certified Nurse Aides (CNA's), nurses or the providers to trim nails in between podiatry appointments. She also confirmed R #77's appointment with podiatry is scheduled for 02/09/26.D. On 01/30/26 at 4:30 pm, during an interview with the Director of Nursing (DON), she stated CNA's nurses, or the providers, should ensure nails do not become overgrown because the condition of R #77's toenail does not meet her expectation.

Based on record review and interview, the facility failed to ensure medical records were updated and accurate for 1 (R #6) of 5 (R #1, R #3, R #6, R #27, and R #55) residents reviewed, when the facility failed to document an updated consent ordered by physician. This deficient practice is likely to result in residents having an inaccurate medical record, which could result in the residents receiving less than optimal care and treatment. The findings are:A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE] with the following diagnoses:1. Type 2 Diabetes Mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),2. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),3. Anxiety (feelings of fear or apprehension),4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).B. Record review of R #6's Medication Regimen Review Recommendations form pharmacist dated 11/26/25 stated a consent could not be found for this resident's Risperidone (an antipsychotic medication used to treat various mental health disorders) for a diagnosis of dementia with behavior disturbance, and to update the resident records to reflect when consent is obtained.C. Record review of R #6's current consent for Risperidone dated 08/26/24 is for the diagnosis of schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly).D. Record review of physician orders dated 10/20/25, revealed the indicated use for Risperidone is dementia, unspecified severity, without other behavioral disturbance.E. On 01/30/25 at 4:00 pm, during an interview, the MDS (Minimum Data Set) regional coordinator confirmed that the consent does not match the physician's orders and stated the consent should be updated to match the current order.

Based on record reviews and interview, the facility failed to ensure staff assessed residents who utilized bed rails for 5 (R #21, R #25, R #27, R #31, and R #39) residents review for risk of entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) for bedrails. If the facility fails to assess the resident's risk for entrapment, then residents are likely to experience injury by becoming trapped between the mattress and the bedrail. The findings are: A. Record reviews for the five residents who utilized bed rails revealed staff reviewed the risks and benefits of bed rails but did not complete bedrail assessments for the residents. B. Record reviews for the five residents who utilized bed rails revealed staff did not attempt to use appropriate alternatives to bed rails or determine if the alternatives met the residents needs by not completing bed rail assessments for the residents. B. On 11/20/24 at 12:16 pm, during an interview with the Director of Nursing (DON), she stated staff did not complete bedrail assessments. The DON stated consent forms for the use of bedrails were completed, but she did not realize staff had to complete a separate bedrail assessment.

Based on observation and interview, the facility failed to post nurse staffing data on a daily basis that included the following: a. Facility name. b. The current date. c. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered nurses. ii. Licensed practical nurses. iii. Certified nurse aides. iv. Resident census. This deficient practice could likely result in resident not knowing the staf working. The findings are: A. On 11/16/2024 at 1:15 pm, during an observation there was no nurse staff posting for the day at the main nurses station. Observation of the nurses station in the 100 hall, staff posting available at nurses station was dated 09/26/2024. B. On 11/16/2024 at 1:19 pm, during an interview, LVN (licensed vocational nurse) # 1 she attempted to find the posting display frame located at the nurses station and it was empty. She stated staff did not post the nurse staffing information for that day at the main hall nurses station in the display as they should be doing. B. On 11/16/2024 at 1:22 pm, during an interview, RN (registered nurse)#1 stated the nurse staffing information in the 100 hall was outdated with a date of 09/26/2024. 50207

Past Noncompliance: Compliance Date was 04/06/24. Based on record review and interview, the facility failed to prevent an accident for 1 (R #1) of 1 (R #1) residents reviewed for falls, when the facility failed to: 1. Ensure beds were fully locked. 2. Ensure staff was familiar with equipment. These deficient practices resulted in R #1 falling and sustaining injuries that required treatment at the hospital. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. Type 2 Diabetes. 2. Hyperlipidemia (high cholesterol). 3. Anxiety. 4. Heart Failure. B. Record review of R #1's nursing progress notes revealed the following: - On 03/21/24, staff documented the resident had a witnessed fall and landed face down. The resident fell out of bed while receiving a bed bath. Witness stated the resident did not lose consciousness when she landed on the floor. - On 03/22/24, staff documented that staff gave the resident a bed bath. When staff turned the resident to the left side, the resident braced herself against the wall. The bed moved, and the resident fell to the ground between the wall and the bed. The wheels at the top of the bed did not lock, but the brakes at the bottom of the bed were locked. Staff replaced bed, and all brakes lock. C. Record review of R #1's Investigation Report (5 day report), dated 03/21/24, revealed a staff member gave R #1 a bed bath. The staff member turned the resident for the bed bath, and the resident got close to the edge of the bed. The resident fell off the bed to the ground and landed face first. The resident had pain to right arm and right eye swelling and bruising. An order was obtained to send R #1 to the emergency room for evaluation. The resident was transported to the hospital via Emergency Medical Services (EMS). Future preventative/corrective action for the resident's health and safety included the following: - The staff member who gave R #1 the bed bath was in-serviced on proper use of the bed, proper use of bed brakes, and proper positioning of residents during a bed bath for safety. - Staff completed a building wide sweep on residents' beds to ensure brakes were in proper condition for use, and all bed brakes were determined to be in proper working order. - Certified Nursing Assistants (CNAs) were in-serviced on the use of the bed brakes used for all resident beds in the facility. - R #1 returned from the hospital on 03/25/24 and was on therapy services for the fractured humerus (arm). - Trauma assessment was completed for R #1. D. Record review of R #1's care plan, initiated on 11/02/23 and revised on 03/26/24, revealed the following: - Focus: R #1 was at risk for falls related to weakness and history of falls. - Interventions: Replace bed (updated on 03/26/24). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Remove any potential causes if possible. Educate resident/family/caregivers as to causes. Transfers: Requires total physical assistance with 2 staff. E. Record review of R #1's Minimum Data Set (MDS) Section GG (Functional Abilities and Goals), dated 04/26/24, revealed the following: -R #1 requires maximal assistance to roll between her left and right side. -R #1 requires maximal assistance when moving from sitting on the side of the bed to lying flat on the bed. - R #1 requires maximal assistance when moving from lying flat on the bed to sitting on the side of the bed. F. On 05/16/24 at 4:12 pm during an interview with R #1, she stated she was in her bed and not all of the bed wheels were locked. R #1 also stated the bed started to move, and she fell to the floor and broke her arm. R #1 confirmed her bed was replaced when she returned from the hospital. G. On 05/16/24 at 5:03 pm during an interview with CNA #1, she stated she gave R #1 a bed bath, and she made sure all the brakes on the bed were locked. She stated she had R #1 roll over to the side, so she could put the new bed sheet on while R #1 held onto the wall. CNA #1 also stated R #1's bed was in a higher position due to the bed bath. She stated R #1's bed slid toward her (CNA #1), causing R #1 to fall on the floor. H. On 05/17/24 at 12:34 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated CNA #1 told her that not all of R #1's bed wheels were locked on 03/21/24. LPN #1 also stated when CNA #1 had R #1 roll onto her side, the bed started moving, and this caused the bed to slide out from under R #1. She stated R #1 fell to the ground. LPN #1 stated this had never happened before. She said R #1 was assessed and sent to the emergency room . I. On 05/17/24 at 1:04 pm during an interview with the Administrator (ADM), she stated the bed wheels were not aligned on R #1's bed, causing the bed wheels to not lock. The ADM confirmed the facility educated all nursing staff, checked every bed, and replaced the style of bed R #1 previously used. J. On 05/17/24 at 1:05 pm during an interview with the Director of Nursing (DON), she stated R #1's bed wheels did lock on the top; however, CNA #1 did not have R #1's bed wheels aligned properly so the top brakes did not lock at the time of the incident.

Based on observation and interview, the facility failed to label food in accordance with professional standards of food service safety. This failure had the potential to affect all 74 residents in the facility who eat food prepared in the kitchen. Residents were identified by the Resident Matrix provided by the Administrator on 01/22/24. If the facility fails to adhere safe food storage, residents are likely to be exposed to foodborne illnesses. The findings are: A. On 01/22/24 at 3:37 PM, during an observation of the kitchen revealed the following: 1. Yellow cake mix opened and not dated. 2. Original cheesecake filling opened and not dated. 3. Strawberry gelatin mix opened and not dated. 4. Graham cracker crumbs opened and not dated. B. On 01/22/24 at 3:44 PM, during an interview with the Dietary Manager, she stated the food items did not have open dates. The Dietary Manager stated the food should have opened dates to determine expiration dates.

Based on interview and record review, the facility failed to provide quarterly statements for resident's personal funds entrusted to the facility for 1 (R #23) of 2 (R #23, and R #54) residents sampled for personal funds. If residents are not provided quarterly statements for their personal funds accounts, then residents could experience unnecessary anxiety or depression, because they are unaware of their finances. The findings are: A. On 01/23/24 at 12:29 PM, during an interview with R #23, she stated she did not receive any statements for her personal funds account that the facility handled. B. Record review of R #23's medical record revealed she was admitted on [DATE] and she did not have a designated power of attorney (legal authorization that gives authority to someone to act on behalf of the resident). C. On 01/26/24 at 11:51 AM, during an interview with the contracted business office manager, she confirmed that she did not send the quarterly statement to R #23. The BOM stated that she sent the statements to R #23's daughter. The BOM was not aware of any reason R #23 would not be able to receive the quarterly statement.

Based on record review and interview, the facility failed to ensure residents, resident representatives, and Ombudsman received a written notice of transfer as soon as practicable for 2 (R #50 and R # 72) of 2 (R #50 and R #72) residents reviewed. This deficient practice could likely result in the resident and/or representatives not knowing the reason or location the resident was transferred or discharged or their options to appeal the transfer or discharge. The findings are: R #50 A. Record review of R #50's Electronic Medical Record (EMR) revealed the following: 1. R #50 was transferred to the emergency department on 12/03/23 for shortness of breath and returned to the facility the same day. 2. R #50 was transferred back to the hospital on 12/04/23 for altered mental status and returned to the facility on [DATE]. 3. The record did not contain documentation staff provided a written transfer notice to R #50 or to the Ombudsman. B. On 01/25/24 at 8:45 am, during an interview with the Social Services Director (SSD), she confirmed R #50 discharged to the hospital. The SSD also confirmed a written notice was not provided to the Ombudsman, resident, or resident representative. R #72 C. Record review of R #72's medical record revealed the following: 1. R #72 was transferred to the emergency department on 12/27/23 due to increased agitation. The resident did not return to the facility. 2. The medical record identified that the Power of Attorney was verbally notified of the transfer; however, the record did not contain documentation staff provided a written transfer notice or notice to the Ombudsman of the transfer. D. On 01/23/24 at 4:22 pm during interview with the Social Services Director (SSD), she confirmed R #72 discharged to the hospital. The SSD also confirmed a written notice was not provided to the Ombudsman, resident, or resident representative. 49827

48960 Based on record review and interview, the facility failed to provide a written notice to the resident or resident representative that specified the bed-hold policy and the number of days the facility would hold a bed for the resident at the time of the transfer for 2 (R # 50, R # 72) of 2 (R # 50, R # 72) residents sampled for hospitalization s. This deficient practice could likely result in the resident and/or representatives being unaware of the resident's ability to return to their previous bed or the next available bed upon return from the hospital. The findings are: R #50 A. Record review of R #50's electronic medical record (EMR) revealed R#50 was transported to the hospital on 12/04/23. The medical record did not contain evidence to show the resident or legal representative received notice of the bed-hold policy in writing at the time of transfer. R #72 B. Record review of R # 72's EMR revealed he was sent to the emergency roiagnom on [DATE] due to agitation. C. On 01/25/24 at 11:48 AM, during an interview, the Regional Nurse Consultant stated the facility staff have not provided written notice of the facility's bed hold policy to the residents at the time of transfer. She stated staff did not provide written notice to R #50 or R #72. 49827

Based on record review and interview, the facility failed to ensure the MDS accurately reflected the resident's status at the time of the assessment for 1 (R #37) of 3 (R #11, R #23, and R #37) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need. The findings are: A. Record review or R #37's physician's orders revealed a prescription for corrective lenses, dated 05/18/22. B. Record review of R #37's quarterly MDS, dated [DATE], revealed the record did not contain documentation R #37 had vision impairments or corrective lenses. C. On 01/23/24 at 10:19 AM, during an interview with R #37, he said he had problems with his right eye. R #37 said his right eye was blurry. R #37 said he went to the doctor for his eyes. D. On 01/25/24 at 4:42 PM, during an interview with SS, she said R #37 had a prescription for glasses. E. On 01/25/24 at 4:52 PM, during an interview, the MDS Nurse stated staff did not document in R #37's MDS that the resident had a vision impairment and corrective lenses. The MDS Nurse said R #37's vision and corrective lenses should have been documented in the quarterly MDS.

The following deficiency was a result of a QIS (Quality Indicators Survey) recertification survey that was initiated on 11/28/16. An Immediate Jeopardy was identified on 12/01/16 and a plan of removal was accepted on 12/06/16. Based on record review, observation and interview, the facility failed to ensure that care plans were reviewed, revised, updated and/or implemented as necessary for 2 (R #42, and R #29) of 2 (R #42, and R #29) residents reviewed for accidents. This failed practice likely resulted in: 1. Resident #42 having 11 falls, 6 with injury as follows: 06/16/16 - fall resulted in a skin tear to the right elbow; 07/21/16 - fall resulted in a skin tear to the right elbow and left index finger; 09/04/16 - fall resulted in a knot to the head; 09/09/16 - fall resulted in a skin tear to the right forehead, a skin tear to the right wrist, a skin tear to the right forearm and bruising and swelling to the scalp; 11/06/16 - fall resulted in a left temple contusion, a laceration to the left brow and a skin tear to the left hand; and 11/30/16 - fall resulted in a cervical fracture. 2. Resident #29 having 5 falls, 2 with injuries as follows: 05/26/16 - fall resulted in raised abrasion to left side forehead and pain to left ribs; 06/26/16 - fall resulted in redness noted to right wrist, left hand and left shoulder. These deficient practices resulted in an Immediate Jeopardy, at a scope and severity of K, being identified at the facility on 12/01/16 at 4:55 pm. The facility administrator was notified at this time. The facility provided an acceptable Plan of Removal on 12/06/16 at 1:40 pm. Based on the Plan of Removal, Interventions included: 1. Staff inservice on the process for monitoring falls and immediate interventions that included Incident and Accident Process, Fall Committee intervention and Recommendation Sheet, Fall Assessment/Intervention Process, Clinical Quality Assessment and Performance Indicator (QAPI) Daily review Process, Interdisciplinary/Risk Meeting and Care Plans. 2. Fall Risk Assessment was completed for R #29 with a referral for an evaluation by therapy. R #29's care plan was updated to reflect the referral to therapy and the recommendations made by the therapist, per the evaluation. The Nursing and Certified Nursing Assistant (CNA) notebook was implemented and updated. 3. Fall Risk Assessment was completed for R #42, noting a fall risk increase. Immediate interventions were made: bed in lowest position; bed alarm in place when in resident is in bed with fall mat on floor; a referral was made to therapy for a positioning device as R #42 is unable to sit up in wheelchair; R #42 is to be turned and repositioned every 2 hours; referral to therapy for evaluation and positioning for safety; Physical therapy recommended geri-chair. R #42's care plan was updated and the Nursing and CNA notebook updated. 4. Fall risk assessments for 50 residents were completed with 22 being identified to have had falls within the last 6 months. Care plans were reviewed and 6 residents had care plans updated with new interventions. 5. Unwitnessed falls will be investigated by the Interdisciplinary Team (IDT) and reported according to regulatory guidelines. Morning rounds will be made before stand-up meetings to ensure interventions are in place. Any identified falls and/or risks will be corrected and addressed in morning stand-up meetings. Falls will be placed on the 24 hour report and the Director of Nursing (DON) or designee will complete a QAPI report and report findings at the following stand-up meeting. 6. Care Plans will be updated with new interventions during daily morning meetings and reviewed weekly at the risk meeting. A red communication notebook will be kept at the nursing stations and all care plan changes will be made and placed in the notebook by the DON or designee. All direct care staff will be required to review the notebook at the beginning of each shift and sign off on changes. DON or designee will communicate changes to staff on duty. 7. The Nursing Management Team will review each incident report on occurrence and ensure interventions are implemented and care plans are updated. The DON, or designee will complete a 10% random weekly chart audit and visual observation for 6 consecutive weeks and review all fall incident reports to ensure interventions are in place and care plans are updated. If another fall occurs and/or care plans have to be changed, chart audits will continue for another 6 weeks. The Regional Quality manager will conduct a 10% random weekly chart audit for 6 weeks and will report to the Administrator. 8. Audited records will be reviewed by the Risk/Quality Assurance committee until a substantial compliance has been achieved as determined by the committee. Based on the Plan of Removal and observations, the Immediate Jeopardy was lifted on 12/06/16 at 1:40 pm. This resulted in the scope and severity being reduced from a K to a scope and severity of an H. Based on record review, observation, and interview, the facility failed to ensure that care plans were reviewed, revised, updated and/or implemented as necessary for 3 (R #42, R #29 and R # 46) of 3 (R #42, R #29 and R # 46) residents reviewed for accidents and [MEDICAL TREATMENT] care by: 1) failed to provide a chair alarm, supervision and proper positioning (R #42), 2) failed to provide therapy and a chair alarm (R #29), and 3) failed to revise the care plan for new [MEDICAL TREATMENT] nutritional interventions (R #46). If residents' care plans are not being revised and implemented with the most recent information, residents are likely to not receive the care and services that they need. The findings are: FINDINGS FOR RESIDENT #42 A. Record review of the facility face sheet for R #42, dated 12/05/16, revealed R #42 was initially admitted to the facility on [DATE], with a readmission on 12/03/16. Admission [DIAGNOSES REDACTED]. B. Record review of the Fall Risk Data Set for R #42, dated 08/17/16, revealed resident had a score of 12. The Fall Risk Data Set, dated 11/09/16 revealed resident had a score of 13. Per the assessment Score of 7-18 indicates resident is high risk. Regardless of score, any resident with previous falls should be considered high risk until fall free for 6 months. C. Record review of nursing notes for R #42 revealed: 1. Nursing note dated 05/17/16 - Resident found on floor lying on right side .No visible injuries. 2. Nursing note dated 06/16/16 - Resident is found lying on floor noted small skin tear to right elbow. 3. Nursing note dated 07/25/16 - Found resident lying on the floor next to bed in room, no apparent injuries noted. 4. Nursing note dated 07/28/16 - Found on floor beside bed, no injury . 5. Nursing note dated 08/14/16 - Resident had fall at 6:20 am this morning. Resident slipped out of wheelchair, no injuries noted. 6. Nursing note dated 09/04/16 - found on the floor beside bed. States hit back of head no signs of abrasions or tears. has knot to back of head. 7. Nursing note dated 09/09/16 - .resident was lying in fetal position on her right side with a skin tear to right side of forehead and left medial (area of wrist by the thumb) wrist also noted bruise and swelling to right top of scalp. 8. Nursing note dated 11/07/16 - Resident was found on floor at 5:15 am on 11/06/16 found a laceration to brow that was bleeding profusely and a skin tear to left hand wrists that was also bleeding. R #42 was transported to the hospital 9. Nursing note dated 11/18/16 - Resident found on floor in front of wheelchair in resident room .no apparent injury noted. 10. Nursing note dated 11/30/16 - Late entry occurrence was approximately 7:35 am .heard residents yell, turned to observe (Name of resident) falling forward from wheelchair and hitting the vinyl floor resident continued to lean to the right and forward .cleansed skin tear to left forearm cleansed laceration to forehead .Emergency Medical Services (EMS) called for transport .Resident responded to name but could not verbalize anything. D. Record review of Care Plans for R #42, dated 05/20/16, revealed the resident is at risk for injury related to falls as evidenced by previous falls and below knee amputation (BKA), right leg. Intervention for 07/24/16 was low bed and fall mat on floor. There is no evidence that interventions were made for falls on 08/14/16, 09/04/16. Intervention for 09/09/16 was chair alarm. Intervention for 11/06/16 was continue plan of care. There is no evidence of a new intervention. Intervention for 11/18/16 was do not leave resident up in wheelchair in room unattended. E. On 12/01/16, at 4:20 pm, during an interview with the Restorative Aide (RA), the RA stated that R #42 does not have a chair alarm. I have never seen a chair alarm on her chair. F. On 12/01/16, at 4:27 pm, during an interview with LPN #1 , LPN #1 stated (Name of resident) has trouble repositioning when in the wheelchair. (Name of Resident) has lower extremity contractures and is almost always in a somewhat fetal position and it makes repositioning difficult. When asked if R #42 has a chair alarm, LPN stated Yes. G. On 12/01/16 at 4:48 pm, during an observation of R #42's room, the RA confirmed that there was no chair alarm on R #42's wheelchair. There was no fall mat on the floor or visible to the surveyor. H. On 12/02/16 at 10:59 am, during an interview with the Minimum Data Set Coordinator (MDSC), the MDSC stated she did not know why the chair alarm was not placed on R #42's wheelchair. When asked if the resident was being monitored in the dining room while in the wheelchair, the MDSC stated, I do not know, I was not in the dining room. When asked if the resident's contracted extremity created difficulties for the resident to re-position independently in the wheelchair, the MDSC stated that it was a possibility. When asked if this was addressed in the care plan, the MDSC stated, No, I guess it wasn't. I. On 12/01/16 at 11:22 am, during an interview with the Director of Nursing (DON), the DON stated that interventions after a fall are placed on the care-plan and then it is communicated to the staff during morning meetings. When asked if updated interventions had been added to R #42's care plan after each fall, the DON reviewed the care plan and said, No, I guess we missed a few. When asked why the chair alarm was not placed on R #42's wheelchair after the 09/09/16 fall, the DON replied I really don't know. Findings for Resident #29 J. Record review of R #29's Face Sheet revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. K. Record Review of R #29's care plan dated 05/16/16 revealed, Problem onset: 05/16/16. Risk for injury r/t (related to) falls AEB (as evidenced by) history of falls. Goal & Target Date: Will transfer safely to and from all surfaces with extensive level of assist x 90 (times) days. Resident will have no significant injury related to r/t falls x 90 days. Falls and interventions include: 1. Fall 05/26/16, sent to hosp (hospital) 2. Fall 05/31/16 bed in low position 3. Fall 06/26/16 refer to physical therapy (PT) 4. Fall 11/07/16 bed low, mat on floor 5. Fall 11/17/16 w/c (wheelchair) alarm & bed alarm L. Record review of facility's Physician order [REDACTED]. M. During an interview on 12/05/16 at 2:15 pm, Director of Rehabilitation said there was no referral for R #29 to physical therapy. N. During an interview on 12/05/16 at 4:00 pm and on 12/06/16 at 7:45 am, Administrator (ADM) was asked why R #29 did not receive physical therapy. ADM did not answer the question by exit date. O. On 12/01/2016 at 8:46 am, observation of R #29 sitting in the wheelchair revealed no alarm was on the wheelchair. P. On 12/01/16 at 8:46 am, CNA #2 was asked if R #29 had an alarm on the chair and CNA #2 stated, (name of R #29) has no wheel chair alarm and has never had one. Q. On 12/01/2016 at 8:49 am, CNA #3 was asked to locate the alarm on R #29's bed. CNA #3 moved the bedding around on the bed, looked under and around the bed and said there was no alarm. R. On 12/06/16 at 2:35 pm, during an interview with R #29, R #29 was asked what interventions were put into place for (R #29) falls. R #29 stated, That's a $64.00 question. They don't know and I don't know. They don't tell me nothing. Findings for Resident #46 S. Record review of facility facesheet dated 08/10/16 revealed R # 46 was admitted on [DATE] with the current admitted d 08/30/16. Admission [DIAGNOSES REDACTED]. T. Care plans dated 08/17/16 with problem, measurable goal and interventions include, risk for alteration in nutrition, self care deficit, impaired cognition. There is no evidence of a revision to the nutritional care plan to include the fluid restriction. U. Record review of the [MEDICAL TREATMENT] Registered Dietician order dated 10/11/16 revealed a 960 milliliters (mls) per day fluid restriction. There is no evidence this restriction was entered onto the nutrition care plan nor the information passed onto the staff. V. On 11/29/16 at 1:55 pm, during an interview with the Minimum Data Set Coordinator (MDSC), the MDSC when asked about a nutrition care plan stated, After looking at his care plan there is not a revision for his fluid restriction. W. On 12/05/16 at 4:30 pm, during an interview with the Assistant Director of Nursing Services (ADON), the ADON when asked how the staff is made aware of orders such as fluid restrictions the ADON stated, As you have already identified all communication is an issue. So all I can say is there was no communication to the staff that the resident was on a fluid restriction.

The following deficiency was a result of a QIS (Quality Indicators Survey) recertification survey that was initiated on 11/28/16. An Immediate Jeopardy was identified on 12/01/16 and a plan of removal was accepted on 12/06/16. Based on record review observation and interview, the facility failed to identify and implement the measures necessary to reduce the number of falls, with injury for 2 (R #42 and R #29) of 3 (R #42, R #29 and R #85 ) residents reviewed for accidents. This failed practice likely resulted in: 1. Resident #42 having 11 falls, 6 with injury as follows: 06/16/16 - fall resulted in a skin tear to the right elbow; 07/21/16 - fall resulted in a skin tear to the right elbow and left index finger; 09/04/16 - fall resulted in a knot to the head; 09/09/16 - fall resulted in a skin tear to the right forehead, a skin tear to the right wrist, a skin tear to the right forearm and bruising and swelling to the scalp; 11/06/16 - fall resulted in a left temple contusion, a laceration to the left brow and a skin tear to the left hand; and 11/30/16 - fall resulted in a cervical fracture. 2. Resident #29 having 5 falls, 2 with injuries as follows: 05/26/16 - fall resulted in raised abrasion to left side forehead and pain to left ribs; 06/26/16 - fall resulted in redness noted to right wrist, left hand and left shoulder. These deficient practices resulted in an Immediate Jeopardy, at a scope and severity of K, being identified at the facility on 12/01/16 at 4:55 pm. The facility administrator was notified at this time. The facility provided an acceptable Plan of Removal on 12/06/16 at 1:40 pm. Based on the Plan of Removal, Interventions included: 1. Staff inservice on the process for monitoring falls and immediate interventions that included Incident and Accident Process, Fall Committee intervention and Recommendation Sheet, Fall Assessment/Intervention Process, Clinical Quality Assessment and Performance Indicator (QAPI) Daily review Process, Interdisciplinary/Risk Meeting and Care Plans. 2. Fall Risk Assessment was completed for R #29 with a referral for an evaluation by therapy. R #29's care plan was updated to reflect the referral to therapy and the recommendations made by the therapist, per the evaluation. The Nursing and Certified Nursing Assistant (CNA) notebook was implemented and updated. 3. Fall Risk Assessment was completed for R #42, noting a fall risk increase. Immediate interventions were made: bed in lowest position; bed alarm in place when in resident is in bed with fall mat on floor; a referral was made to therapy for a positioning device as R #42 is unable to sit up in wheelchair; R #42 is to be turned and repositioned every 2 hours; referral to therapy for evaluation and positioning for safety; Physical therapy recommended geri-chair. R #42's care plan was updated and the Nursing and CNA notebook updated. 4. Fall risk assessments for 50 residents were completed with 22 being identified to have had falls within the last 6 months. Care plans were reviewed and 6 residents had care plans updated with new interventions. 5. Unwitnessed falls will be investigated by the Interdisciplinary Team (IDT) and reported according to regulatory guidelines. Morning rounds will be made before stand-up meetings to ensure interventions are in place. Any identified falls and/or risks will be corrected and addressed in morning stand-up meetings. Falls will be placed on the 24 hour report and the Director of Nursing (DON) or designee will complete a QAPI report and report findings at the following stand-up meeting. 6. Care Plans will be updated with new interventions during daily morning meetings and reviewed weekly at the risk meeting. A red communication notebook will be kept at the nursing stations and all care plan changes will be made and placed in the notebook by the DON or designee. All direct care staff will be required to review the notebook at the beginning of each shift and sign off on changes. DON or designee will communicate changes to staff on duty. 7. The Nursing Management Team will review each incident report on occurrence and ensure interventions are implemented and care plans are updated. The DON, or designee will complete a 10% random weekly chart audit and visual observation for 6 consecutive weeks and review all fall incident reports to ensure interventions are in place and care plans are updated. If another fall occurs and/or care plans have to be changed, chart audits will continue for another 6 weeks. The Regional Quality manager will conduct a 10% random weekly chart audit for 6 weeks and will report to the Administrator. 8. Audited records will be reviewed by the Risk/Quality Assurance committee until a substantial compliance has been achieved as determined by the committee. Based on the Plan of Removal and observations, the Immediate Jeopardy was lifted on 12/06/16 at 1:40 pm. This resulted in the scope and severity being reduced from a K to a scope and severity of an H. Based on record review observation and interview, the facility failed to identify and implement the measures necessary to reduce the number of falls, with injury for 2 (R #42 and R #29) of 3 (R #42, R #29 and R #85 ) residents reviewed for accidents by: 1) failed to provide a chair alarm, supervision and proper positioning for R #42, and 2) failed to provide therapy and a chair alarm for R #29. These failed practices likely resulted in R #42 sustaining 3 separate head injuries and a neck fracture and R #29 to continue to have falls, with injuries. FINDINGS FOR RESIDENT #42 A. Record review of the facility face sheet for R #42, dated 12/05/16, revealed R #42 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of the facility Resident Incident Report dated 11/30/16 at 7:30 am revealed that Licensed Practical Nurse (LPN) #2 was out side of the dining room and heard residents yelling. LPN #2 turned to observe R #42 falling forward from the wheelchair hitting the floor. LPN #2 and CNA #4 assessed R #42 and assisted back into the wheelchair. Vital signs were taken and Emergency Medical Services were called for transport to (Name of Hospital). C. Record Review of (Name of Hospital) History and Physical/Admission notes, dated 11/30/16, revealed [AGE] year old presents as a level 2 trauma after a fall from the wheelchair at the nursing home .a Computed Tomography (CT) (a diagnostic imaging test) scan demonstrated a C1 (first vertebrae in the neck) fracture D. Record review of the Fall Risk Data Set for R #42, dated 08/17/16, revealed resident had a score of 12. The Fall Risk Data Set, dated 11/09/16 revealed resident had a score of 13. Per the assessment Score of 7-18 indicates resident is high risk. Regardless of score, any resident with previous falls should be considered high risk until fall free for 6 months. E. Record review of nursing notes for R #42 revealed: 1. Nursing note dated 05/17/16 - Resident found on floor lying on right side .No visible injuries. 2. Nursing note dated 06/16/16 - Resident is found lying on floor noted small skin tear to right elbow. 3. Nursing note dated 07/25/16 - Found resident lying on the floor next to bed in room, no apparent injuries noted. 4. Nursing note dated 07/28/16 - Found on floor beside bed, no injury . 5. Nursing note dated 08/14/16 - Resident had fall at 6:20 am this morning. Resident slipped out of wheelchair, no injuries noted. 6. Nursing note dated 09/04/16 - found on the floor beside bed. States hit back of head no signs of abrasions or tears. has knot to back of head. 7. Nursing note dated 09/09/16 - .resident was lying in fetal position on her right side with a skin tear to right side of forehead and left medial wrist (area of wrist near thumb) also noted bruise and swelling to right top of scalp. 8. Nursing note dated 11/07/16 - Resident was found on floor at 5:15 am on 11/06/16 found a laceration to brow that was bleeding profusely and a skin tear to left hand wrists that was also bleeding. 9. Nursing note dated 11/18/16 - Resident found on floor in front of wheelchair in resident room .no apparent injury noted. 10. Nursing note dated 11/30/16 - Late entry occurrence was approximately 7:35 am .heard residents yell, turned to observe (Name of resident) falling forward from wheelchair and hitting the vinyl floor resident continued to lean to the right and forward .cleansed skin tear to left forearm cleansed laceration to forehead .Emergency Medical Service (EMS) called for transport .Resident responded to name but could not verbalize anything. F. Record review of Care Plans for R #42, dated 05/20/16, revealed the resident is at risk for injury related to falls as evidenced by previous falls and below knee amputation (BKA), right leg. Intervention for 07/24/16 was low bed and fall mat on floor. There is no evidence that interventions were made for falls on 08/14/16, 09/04/16. Intervention for 09/09/16 was chair alarm. Intervention for 11/06/16 was continue plan of care. There is no evidence of a new intervention. Intervention for 11/18/16 was do not leave resident up in wheelchair in room unattended. G. On 12/01/16, at 4:20 pm, during an interview with the Restorative Aide (RA), the RA stated that R #42 does not have a chair alarm. I have never seen a chair alarm on her chair. H. On 12/01/16, at 4:27 pm, during an interview with LPN #1 , LPN #1 stated (Name of resident) has trouble repositioning when in the wheelchair. (Name of Resident) has lower extremity contractures and is almost always in a somewhat fetal position and it makes repositioning difficult. (Name of resident) does not sit at an assisted dining table; (Name of resident) eats on her own. When asked if R #42 has a chair alarm, LPN stated Yes. I. On 12/01/16 at 4:48 pm, during an observation of R #42's room, the RA confirmed that there was no chair alarm on R #42's wheelchair. There was no fall mat on the floor or visible to the surveyor. J. On 12/02/16 at 10:59 am, during an interview with the Minimum Data Set Coordinator (MDSC), the MDSC stated she did not know why the chair alarm was not placed on R #42's wheelchair. When asked if the resident was being monitored in the dining room while in the wheelchair, the MDSC stated, I do not know, I was not in the dining room. When asked if the resident's contracted extremity created difficulties for the resident to re-position independently in the wheelchair, the MDSC stated that it was a possibility. When asked if this was addressed in the care plan, the MDSC stated, No, I guess it wasn't. K. On 12/07/16, at 11:32 am, during an interview with LPN #2, LPN #2 stated, I was not in the dining room when the fall occurred. I turned just in time to see the resident hit the floor. When asked who or how many CNA's were in the dining room when the fall occurred, LPN #2 replied, I cannot answer that. L. On 12/07/16, at 11:43 am, during an interview with the Assistant Director of Nursing (ADON), the ADON stated that all CNA's are assigned to the dining room, unless they are the ones who are delivering room trays. The morning of R #42's fall, CNA #4 was in the dining room because the other CNA's were still transporting residents into the dining room for breakfast. M. On 12/07/16, at 3:13 pm, during an interview, CNA #4 stated that she was in the dining room during the fall on 11/30/16. CNA #4 stated she brought the resident into the dining room and once the resident was at the table, CNA #4 went to get R #42's tray. While CNA #4 was getting the tray, she heard someone yell and when she turned around, R #42 was on the floor. LPN #2 who was on duty came and assisted CNA #4 with the resident while they waited for the resident to be transported to the hospital. FINDINGS FOR RESIDENT #29 N. Record review of the facility's Face Sheet dated 12/01/16 revealed, R #29 was admitted on [DATE]. Admission [DIAGNOSES REDACTED]. O. Record review of facility's Resident Incident Reports revealed: 1. Incident report dated 05/26/16, 7:41 am. Narrative of incident and description of injuries: Resident sitting in chair fell to floor and yelled oh[***] damn that hurt. Resident states, I do this all the time and laugh at myself. Resident assisted up x 3 (times 3 staff) back into wheelchair noted raised abrasion to the left side forehead. After breakfast resident complained of pain to left ribs order received for chest x-ray. Resident taken by facility transportation to local hospital for x-rays. 2. Incident report dated 05/31/16, 3:27 am. Narrative of incident and description of injuries: Aide walked into room doing her rounds and found resident on the floor by bed. 3. Incident report dated 06/26/16, 9:35 pm. Narrative of incident and description of injuries: Resident found sitting down on the floor at bedside Redness noted to right wrist, left hand and left shoulder. 4. Incident report dated 11/07/16, 7:30 pm. Narrative of incident and description of injuries: Resident found sitting on floor beside bed. 5. Incident report dated 11/17/16, 7:30 pm. Narrative of incident and description of injuries: Res (resident) found on floor sitting beside wheelchair. P. Record Review R #29's care plan dated 05/16/16 revealed, Risk for injury r/t (related to) falls AEB (as evidenced by) history of falls. Goal & Target Date. Will transfer safely to and from all surfaces with extensive level of assist x 90 days. Resident will have no significant injury r/t falls x 90 days. Falls and interventions are as follows: 1. Fall 05/26/16, sent to hosp (hospital) 2. Fall 05/31/16 bed in low position 3. Fall 06/26/16 refer to physical therapy (PT) 4. Fall 11/07/16 bed low, mat on floor 5. Fall 11/17/16 w/c (wheelchair) alarm & bed alarm. Q. Record review of Physician order [REDACTED]. R. On 12/05/16 at 2:15 pm, during an interview, Director of Rehabilitation stated there was no referral for R #29 to physical therapy. S. On 12/05/16 at 4:00 pm and on 12/06/16 at 7:45 am, during an interview, Administrator (ADM) was asked why R #29 did not receive physical therapy. ADM did not answer the question by exit date. T. On 12/01/2016 at 8:46 am, observation of R #29 sitting in the wheelchair revealed no alarm was on the wheelchair. U. On 12/01/16 at 8:46 am, CNA #2 was asked if R #29 had an alarm on the wheelchair and she stated, (name of R #29) has no wheelchair alarm and has never had one. V. On 12/01/2016 at 8:49 am, CNA #3 was asked to locate the alarm on R #29's bed. CNA #3 moved the bedding around on the bed, looked under the bed and around the bed and stated there was no alarm. W. On 12/06/16 at 2:35 pm, during an interview, R #29 was asked what interventions were put into place. R #29 stated, That's a $64.00 question. They don't know and I don't know. They don't tell me nothing.