Every finding on record at Fort Bayard Medical Center

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #1 & R #16) of 6 (R #1, R #2, R #3, R #16, R #17, and R #18) residents reviewed for abuse and neglect when staff failed to:1. Document accurately about an incident that occurred with R #1 on 07/03/26.2. Document discussions with R #16's family members.These deficient practices could likely cause staff to not be aware of situations that occur or changes in care decisions, which could adversely impact the care staff provides. The findings are: A. Record review of the facility Charting and Documentation policy, dated 09/30/20, revealed the following: --All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record shall facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. --The following information is to be documented in the resident medical record: - Objective observations (the practice of recording and describing events, behaviors, or situations based solely on factual, observable evidence, without personal bias, interpretation, or opinion). - Events, incidents or accidents involving the resident. R #1 B. Record review of R #1 admission Record, no date, revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1's diagnoses included: a. Unspecified dementia, severe with other behavioral disturbance (a severe cognitive impairment where the specific type of dementia cannot be determined. It is characterized by memory loss, confusion, disorientation, impaired judgment, and difficulty with problem-solving, and the behavioral component can include agitation and aggression). b. Anxiety disorder unspecified (a diagnosis for clinically significant anxiety that causes distress or impairment but does not meet the full criteria for any specific anxiety disorder). C. Record review of the facility's five-day follow-up report (a written report submitted to the State Agency within five working days following an alleged violation or incident, and it details the investigation findings and actions taken), dated 07/17/26, revealed the following: 1. Subsequent review of the documentation and verbal reports determined that facility staff did not accurately reflect on the events of the incident. 2. Video footage of the date and time of the incident were reviewed and facility management agreed that the incident met criteria for abuse, neglect, restraint, and involuntary seclusion. 3. Video did not show resident attacking or kicking other residents prior to restraint; contradicting written statements from staff. 4. RN #1 repeatedly made shushing and circular hand motions near her head. 5. R #1 was physically restrained multiple times by three staff members. 6. Staff placed the resident in her room, closed the door and physically held the door shut, preventing the resident from exiting. 7. In conclusion, the facility abuse, neglect, and exploitation (ANE) investigator concluded that the documentation in R #1's medical record and the verbal reports obtained through the investigation did not accurately reflect the actual events that occured on 07/03/26. D. On 08/11/26 at 4:40 PM, during an observation and interview of R #1 the following was revealed: 1. R #1 was observed seated in her wheelchair exiting her room and closing the door behind her. 2. R #1 stated she did not recall the incident on 07/03/26 and she was happy to be at the facility. E. Record review of R #1's nursing progress note, dated 07/03/26, and written by LPN #1 revealed the following: Resident noted to be sitting in sunroom. Activities staff said hi to resident and resident began calling him names. CMA tried to redirect resident, and resident became verbally and physically aggressive. Resident attempted to kick another resident. Staff began to remove resident from sunroom. Resident began grabbing, kicking, pinching, punching, scratching, slapping, and biting staff. Staff placed resident in her room. Resident picked up chair and threw it at resident's window. Staff removed chair. Resident tore apart her dresser. Resident threw picture frames and broke them. Resident used picture frame to threaten staff. Resident grabbed shower extension and was swinging around with water on. Resident attempted to kick other residents as they walked by in the hallway. Resident verbally attacking other residents and staff in hallway. One staff member outside resident's door to monitor resident. This nurse contacted physician about behavior. Physician put in order for medication. Before medication could be administered, this nurse contacted physician about sending resident out to hospital for evaluation. Physician advised to send resident out for eval. This nurse called supervisor, and POA was informed. Resident will be sent out via emergency medical services (EMS) for evaluation. F. On 08/13/26 at 11:19 AM during a phone interview with LPN #1 she stated the following: 1. She was passing medication in the sunroom. R #1 and several other residents were sitting in the sunroom. 2. A male staff walked in and said Hi to R #1. R #1 started cussing and yelling and got mad. 3. LPN #1 stated that she was not aware that R #1 was her assigned resident. There were other staff present so she left the area to continue her medication pass. 4. A few minutes later, staff, CNA's, and the other nurse, were coming around the nurses' station taking R #1 to her room, she was hitting and kicking, and they were trying to wheel her facing forward but the resident kept putting her foot down. That's when they turned her wheelchair around and wheeled her to her room backwards. 5. LPN #1 stated she did not believe any staff were holding her arms down at that point. Another resident came down the hall, R #1 tried to hit that resident so that is when they held her arms down. 6. LPN #1 stated she was busy behind the nurses' station calling the doctor, getting the paperwork ready, and calling the ambulance to send R #1 out. 7. Staff final got R#1 into her room, and a staff member was holding R #1's door shut. LPN #1 thinks that the staff holding the door shut was a CNA but was not sure and didn't recall the staff member's name. 8. The police arrived first and spoke with R #1 first until the ambulance arrived and then they took R #1 to the hospital. The doctor wanted her to be evaluated for a UTI. 9. LPN #1 stated she initially charted what she was told by the other staff because she didn't observe the whole incident. G. On 08/12/26 at 2:48 PM, during an interview, the DON stated her expectation is that staff will document their factual observations rather than other people's accounts of an incident. R #16 H. Record review of R #16's admission Record, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 was discharged from the facility on 06/22/26. 3. R #16 had the following diagnoses: a. Malignant neoplasm of unspecified part of bronchus or lung (cancerous tumor in the air tube leading to the lung or the lung). b. Chronic obstructive pulmonary disease (COPD, a long-term lung condition that damages the airways and air sacs, making it progressively harder to breathe) c. Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a person has a medical diagnosis of cognitive and memory decline, but they do not show disruptive, aggressive, or psychotic behavior) . d. Chronic respiratory failure with hypoxia (a long-term medical condition where the lungs develop a slow, ongoing inability to take in enough oxygen, resulting in chronically low blood oxygen levels). e. Dyspnea (difficulty breathing). I. Record review of R #16's Palliative Care Protocol, dated 06/17/26, revealed the provider signed the orders on 06/17/26. J. Record review of R #16's progress notes revealed the following: 1. On 06/17/26, staff documented R #16 was receiving morphine for palliative care. 2. On 06/18/26, staff documented they talked to R #16's POA about R #16's change in condition, palliative care, and medications that were provided under palliative care. Staff documented that R #16's POA asked to speak to the provider. 3. On 06/22/26, staff documented that they spoke to R #16's POA regarding concerns of not being notified about R #16's decline in condition and R #16 being placed on palliative care without notifying them. Staff documented that they believed the provider had talked to R #16's POA about R #16's decline prior to placing R #16 on palliative care. K. On 08/10/26 at 5:27 PM, during an interview, Unit Manager #16 (UM #16) stated the following: 1. R #16 was placed on palliative care on 06/17/26. 2. Provider #16 was supposed to talk to R #16's POA to notify them about R #16's worsening condition and his recommendation for palliative care. 3. On 06/18/26, provider #16 spoke with R #16's POA about R #16's worsening condition and the decision to place her on palliative care on 06/17/26. L. On 08/12/26 at 2:15 PM, during an interview, provider #16 stated the following: 1. He had spoken to R #16's family member (not POA) approximately two weeks prior to placing R #16 on palliative care (did not give a date). 2. He discussed R #16's worsening condition and the need to place her on palliative care in the near future (did not give a date). 3. He did not discuss this plan with R #16's POA prior to placing her on palliative care on 06/17/26. 4. He spoke to R #16's POA about placing R #16 on palliative care on 06/18/26. 5. He should have contacted R #16's POA prior to placing her on palliative care on 08/17/26. 6. He did not document his discussion with R #16's family member two weeks prior to placing her on palliative care. 7. He did not document his discussion with R #16's POA on 06/18/26. 8. He should have documented discussions that were held with residents and/or their family members regarding care and treatment decisions. M. On 08/12/26 at 3:42 PM, during an interview, the DON stated the provider was expected to document discussions that were held with residents and their family members regarding care and treatment decisions.

Based on record review and interview, the facility failed to notify the resident's Power of Attorney (POA, the authority to act for another person in specified or all legal or financial matters) about a change in resident condition and decision to place resident on palliative care (specialized medical care focused on providing relief from the symptoms, pain, and stress of a serious illness to improve the quality of life for both the patient and their family) for 1 (R #16) of 3 (R #16, R #17, and R #18) residents reviewed for neglect. This deficient practice could likely result in residents' families not being aware of a change in residents' conditions and not being able to make informed decisions regarding the residents' care. The findings are:A. Record review of the facility Non-Hospice Palliative Care policy, dated 08/09/26, revealed the following:1. Medical staff must discuss and educate the resident or power of attorney about Palliative Care and Screening/Recognition for appropriateness. a. If the resident or representative disagrees with the initiation of palliative care, routine care continues. b. If they agree, palliative care will be initiated. B. Record review of R #16's admission Record, no date, revealed the following:1. Resident was admitted to the facility on [DATE].2. Resident was discharged from the facility on 06/22/26.3. Resident had the following diagnoses: a. Malignant neoplasm of unspecified part of bronchus or lung (cancerous tumor in the air tube leading to the lung or the lung). b. Chronic obstructive pulmonary disease (COPD, a long-term lung condition that damages the airways and air sacs, making it progressively harder to breathe) c. Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a person has a medical diagnosis of cognitive and memory decline, but they do not show disruptive, aggressive, or psychotic behavior). d. Chronic respiratory failure with hypoxia (a long-term medical condition where the lungs develop a slow, ongoing inability to take in enough oxygen, resulting in chronically low blood oxygen levels). e. Dyspnea (difficulty breathing). C. Record review of R #16's Palliative Care Protocol, dated 06/17/26, revealed the provider signed the orders for R #16 to be placed on palliative care on 06/17/26. D. Record review of R #16's progress notes revealed the following:1. On 06/17/26, staff documented R #16 was receiving morphine for palliative care.2. On 06/18/26, staff documented they talked to R #16's POA about R #16's change in condition, palliative care, and medications that were provided under palliative care. Staff documented that R #16's POA asked to speak to the provider.3. On 06/22/26, staff documented that they spoke to R #16's POA regarding concerns of not being notified about R #16's decline in condition and being placed on palliative care without their knowledge. Staff documented that they believed the provider had talked to the POA about R #16's decline prior to placing R #16 on palliative care. E. On 08/10/26 at 5:27 PM, during an interview, UM #16 stated the following:1. R #16 was placed on palliative care on 06/17/26.2. Provider #16 was supposed to talk to R #16's POA to notify them of R #16's worsening condition and recommendation for palliative care before placing her on palliative care.3. On 06/18/26, the provider spoke with R #16's POA about R #16's worsening condition and placing her on palliative care on 06/17/26. F. On 08/12/26 at 2:15 PM, during an interview, provider #16 stated the following:1. He had spoken to R #16's family member (not R #16's POA) approximately two weeks prior to placing R #16 on palliative care.2. He discussed R #16's worsening condition and the need to place her on palliative care in the near future and R #16's family member (not R #16's POA) agreed with the plan.3. He did not discuss this plan with R #16's POA prior to placing her on palliative care on 06/17/26.4. On 06/18/26, he spoke to R #16's POA about his decision to place R #16 on palliative care on 06/17/26. 5. He should have contacted R #16's POA prior to placing her on palliative care on 06/17/26. G. On 08/12/26 at 3:42 PM, during an interview, the DON stated the provider was expected to talk to the resident and/or their POA to notify them about a resident's worsening condition and determine if they want the resident to be placed on palliative care.

Based on interview, observation, and record review, the facility failed to keep residents free from involuntary seclusion (separation of a resident from other residents or from his or her room or confinement to his or her room) for 1 (R #1) of 1 (R #1) residents sampled for involuntary seclusion, when staff placed R #1 in her room and held the door shut not allowing her to exit the room. This deficient practice could likely result in residents experiencing anger, anxiety, and depression. The findings are: A. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program Policy, dated 02/06/26, revealed the following:- Involuntary seclusion is defined as a separation of a resident from other residents or from his or her room or confinement to his or her room (with or without roommates) against the resident's (or representative's) will. - Examples of involuntary seclusion include: a. any attempt to keep a resident confined to a certain area by blocking the exit with furniture or a closed door. b. placing a resident in an area without access to a call light or other method of direct communication with staff. c. confining a resident to his or her room as a form of punishment or for staff convenience. d. Secluding or confining a resident against his or her will is prohibited. B. Record review of R #1 admission Record, no date, revealed the following: 1. R #1 was admitted to the facility on [DATE]. 2. R #1's diagnosis included: a. Unspecified dementia, severe with other behavioral disturbance (a severe cognitive impairment where the specific type of dementia cannot be determined. It is characterized by memory loss, confusion, disorientation, impaired judgment, and difficulty with problem-solving, and the behavioral component can include agitation and aggression). b. Anxiety disorder unspecified (a diagnosis for clinically significant anxiety that causes distress or impairment but does not meet the full criteria for any specific anxiety disorder). C. Record review of R #1's provider progress notes revealed an Encounter visit note, dated 06/19/26, revealed R #1's BIM score was 0-3. Baseline severe cognitive impairment with BIMS 0-3, short-term memory loss, and disorganized thought process. Currently redirectable and calm. D. Record review of the facility's five-day follow-up report (a written report submitted to the State Agency within five working days following an alleged violation or incident, and it details the investigation findings and actions taken), dated 07/17/26, revealed the facility staff placed R #1 in her room, closed the door and physically held the door shut, preventing R #1 from exiting. E. On 08/11/26 at 4:40 PM, during an observation and interview of R #1 the following was revealed: 1. R #1 observed seated in her wheelchair exiting her room and closing the door behind her. 2. R #1 stated she did not recall the incident on 07/03/26 and she was happy to be at the facility. F. On 08/12/26 at 2:48 PM, during an interview with the DON, she stated the following: 1. CNA #1 and CMA #1 attempted to remove R #1 from the sunroom, R #1 was resistant and became agitated. 2. CMA #2 and RN #1 assisted CNA #1 and CMA #1 in holding R #1 down by her limbs and wheeled R #1 into her room. 3. Once in her room CNA #1 held R #1's room door shut and did not allow her out of the room. 4. CNA #2 walked into R #1's room and removed the bedside table, bringing it into the hallway and then shut the door but did not hold it shut. 5. The DON stated she did consider this to be involuntary seclusion.

Based on record review and interview, the facility failed to effectively manage pain (use of different techniques and medication to reduce and control the amount of pain a person experiences) for 1 (R #16) of 3 (R #16, R #17, and R #18) residents reviewed for pain, when the facility failed to ensure that physician ordered morphine (strong opioid pain medication used to treat severe pain when other treatments do not work) was available. This deficient practice could likely result in residents experiencing unnecessary pain causing residents to experience a decline in physical and emotional health. The findings are:A. Record review of facility Pain Management policy, dated 09/16/25, revealed the following:1. The purpose of this procedure is to observe, report, assess, and/or manage Residents' pain consistent with a comprehensive assessment and plan of care, current clinical standards of practice, and the Resident's goals and preferences.Residents will attain or maintain their highest practicable level of comfort through timely recognition, assessment, treatment and management of pain.2. Pain medication will be administered according to providers orders per pain regimen and pain goals. B. Record review of R #16's admission Record, no date, revealed the following:1. R #16 was admitted to the facility on [DATE].2. R #16 was discharged from the facility on 06/22/26.3. R #16 had the following diagnoses: a. Malignant neoplasm of unspecified part of bronchus or lung (cancerous tumor in the air tube leading to the lung or the lung). b. Chronic obstructive pulmonary disease (COPD, a long-term lung condition that damages the airways and air sacs, making it progressively harder to breathe) c. Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a person has a medical diagnosis of cognitive and memory decline, but they do not show disruptive, aggressive, or psychotic behavior). d. Chronic respiratory failure with hypoxia (a long-term medical condition where the lungs develop a slow, ongoing inability to take in enough oxygen, resulting in chronically low blood oxygen levels). e. Dyspnea (difficulty breathing). C. Record review of R #16's physician's orders revealed the following orders:1. Dated 06/17/26 and discontinued on 06/22/26, morphine sulfate (concentrate) solution 20 MG/ML Give 0.25 ml by mouth every 2 hours as needed for pain/dyspnea for moderate pain from 6-7 dose=5mg.2. Dated 06/17/26 and discontinued on 06/22/26, morphine sulfate (concentrate) solution 20 MG/ML, give 0.5 ml by mouth every 30 minutes as needed for pain/dyspnea prn for severe pain from 8-10 dose=10mg.3. Dated 06/19/26 and discontinued on 06/21/26, lorazepam (a prescription medication used to treat anxiety disorders, short-term anxiety, and insomnia related to anxiety) oral tablet 0.5 MG, give 1 tablet by mouth every 4 hours as needed for restlessness, anxiety, insomnia.4. Dated 06/21/26 and discontinued on 06/22/26, lorazepam oral tablet 0.5 MG, give 1 tablet by mouth every 2 hours as needed for restlessness, anxiety, insomnia. D. Record review of R #16's progress notes revealed the following:1. On 06/17/26, staff documented R #16 was receiving morphine for palliative care.2. On 06/21/26 at 5:44 PM, staff documented R #16 was given PRN pain medication every 1-2 hours and it had been effective. 3. On 06/21/26 at 8:30 PM, staff documented that R #16 was having Cheyne-Stokes breathing (an abnormal breathing pattern marked by gradual increases and decreases in depth and speed, separated by temporary pauses where breathing stops completely) and her family was requesting for R #16 to have morphine to help relax her breathing. Staff notified R #16's family that morphine was not available for R #16 at that time and that the provider gave orders to give her lorazepam every two hours to ease her respirations.4. On 06/22/26 at 6:37 AM, staff documented that resident's breathing had smoothed out since morphine administration. E. Record review of R #16's MAR, dated June 2026, revealed staff administered morphine as follows:1. 06/21/26 at 11:37 AM, 0.5 mL2. 06/21/26 at 12:19 PM, 0.25 mL3. 06/21/26 at 1:47 PM, 0.5 mL4. 06/21/26 at 2:39 PM, 0.5 mL5. 06/21/26 at 3:44 PM, 0.5 mL6. 06/21/26 at 4:44 PM, 0.5 mL7. 06/22/26 at 12:40 AM, 0.5 mL (approximately 8 hours since previous dose)8. 06/22/26 at 1:10 AM, 0.5 mL9. 06/22/26 at 1:40 AM, 0.5 mL10. 06/22/26 at 2:20 AM, 0.5 mL11. 06/22/26 at 2:58 AM, 0.5 mL12. 06/22/26 at 5:07 AM, 0.5 mL13. 06/22/26 at 6:12 AM, 0.5 mL14. 06/22/26 at 6:55 AM, 0.5 mL F. On 08/11/26 at 4:03 PM, during an interview, UM #16 stated the following:1. R #16 had orders to receive morphine for pain.2. On 06/21/26, the facility ran out of R #16's morphine at 12:20 PM.3. Staff got morphine from the backup electronic medication dispensing system to administer to R #16.4. The backup electronic medication dispensing system only had enough morphine for four (4) 0.5 mL doses to be administered to R #16.5. R #16 received the last dose of morphine from the backup electronic dispensing system at 4:44 PM on 06/21/26.6. Staff received an order for morphine from the on-call provider in the morning of 06/21/26 and sent it to the contract pharmacy at approximately 8:52 AM.7. Orders that are placed on the weekend before 2:00 PM do not arrive until between 7:00 PM to 10:00 PM. 8. The pharmacy driver arrived at approximately 8:30 PM on 06/21/26 but did not have R #16's ordered morphine.9. The pharmacy delivered R #16's morphine order at approximately 12:00 AM on 06/22/26, which was approximately eight (8) hours after her last dose.10. Pharmacy technicians at the facility were expected to ensure there was at least a seven (7) day supply of all medications. G. On 08/12/26 at 2:15 PM, during an interview, provider #16 stated the following:1. Staff called him on 06/21/26 around 8:30 PM and notified him that R #16 was out of morphine but that the pharmacy was expected to arrive any minute with the morphine.2. Staff did not notify him prior to the phone call at 8:30 PM that the facility had ran out of morphine to treat R #16's pain.3. Staff did not notify him when the pharmacy did not have R #16's ordered morphine at approximately 8:30 PM.4. If staff had notified him that the facility ran out of morphine to treat R #16's pain, he would have either ordered another opioid pain medication or placed an order for morphine at the local pharmacy. H. On 08/12/26 at 3:42 PM, during an interview, the DON stated the following:1. The facility did not have enough morphine to administer to R #16 for her pain on 06/21/26.2. The amount of medication in the electronic dispensing system was low.3. The pharmacy didn't deliver R #16's morphine when they arrived at the facility around 8:30 PM on 06/21/26, which caused R #16 to have to wait longer.4. Staff were expected to notify the provider if the facility did not have the ordered pain medication to treat resident pain.5. Pharmacy staff were expected to look at medications to ensure they didn't run out.

Based on observation, interview, and record review, the facility failed to ensure a resident was free from abuse for 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for abuse when facility staff made derogatory hand gestures towards R #1, held R #1's arms down, and forcefully placed R #1 in her room and held R #1's door shut. This deficient practice could likely lead to residents experiencing physical injury and psychological harm, including fear or distress related to staff interactions. The findings are: A. Record review of the facility's Abuse, Neglect, Exploitation and Misappropriation PreventionProgram Policy, dated 02/06/26, revealed the following:- Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.- Mental abuse is the use of verbal or non-verbal conduct which causes (or has the potential to cause) the resident to experience humiliation, intimidation, fear, shame, agitation or degradation.- Verbal abuse may be a type of mental abuse. Verbal abuse includes the use of verbal, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability. B. Record review of R #1 admission Record, no date, revealed the following:1. R #1 was admitted to the facility on [DATE].2. R #1's diagnoses included: a. Unspecified dementia, severe with other behavioral disturbance (a severe cognitive impairment where the specific type of dementia cannot be determined. It is characterized by memory loss, confusion, disorientation, impaired judgment, and difficulty with problem-solving, and the behavioral component can include agitation and aggression). b. Anxiety disorder unspecified (a diagnosis for clinically significant anxiety that causes distress or impairment but does not meet the full criteria for any specific anxiety disorder). C. Record review of R #1's provider progress notes revealed the following:1. Encounter visit note dated 06/19/26 revealed R #1's BIM score was 0-3. Baseline severe cognitive impairment with BIMS 0-3, short-term memory loss, and disorganized thoughtprocess. Currently redirectable and calm. D. Record review of R #1's initial incident report (written report submitted to the State Agency to report potential abuse) dated 07/13/26, revealed the following:1. On 07/03/26 at approximately 4:00 PM, R #1 was having an episode of resident-to-resident and resident-to-staff behavior. 2. Law enforcement reported to the facility for reports of a combative resident, but no action was required by law enforcement.3. The facility provider was notified, and the resident was sent out to the local emergency room (ER) for evaluation. E. Record review of R #1's nursing progress notes revealed R #1 returned from the ER on [DATE] at 10:00 PM with no new orders. F. Record review of the facility's five-day follow-up report (a written report submitted to the State Agency within five working days following an alleged violation or incident, and it details the investigation findings and actions taken), dated 07/17/26, revealed the following:1. Subsequent review of the documentation and verbal reports determined that facility staff did not accurately reflect on the events of the incident. 2. Video footage of the date and time of the incident were reviewed and facility management agreed that the incident met criteria for abuse, neglect, restraint and involuntary seclusion. 3. Video did not show resident attacking or kicking other residents prior to restraint; contradicting written statements from staff. 4. RN #1 repeatedly made shushing and circular hand motions near her head. 5. R #1 was physically restrained multiple times by three staff members.6. Staff placed R #1 in her room, closed the door and physically held the door shut, preventing R #1 from exiting. 7. In conclusion, the facility abuse, neglect and exploitation (ANE) investigator substantiated the incident and believed abuse, neglect, improper restraint, and involuntary seclusion occurred. G. On 08/11/26 at 4:40 PM, during an observation and interview of R #1 the following was revealed:1. R #1 was observed seated in her wheelchair exiting her room and closing the door behind her.2. R #1 stated she did not recall the incident on 07/03/26 and she was happy to be at the facility. H. On 08/12/26 at 3:09 PM, during an interview with the ADON he stated the following:1. The house supervisor (RN on duty during the night and/or weekend shifts when the Administrator, Director of Nursing, and Assistant Director of Nursing are not present) called him to report that R #1 was being sent out to the local ER for evaluation due to being aggressive towards staff and residents. 2. The staff reported that R #1 was hitting and kicking other residents and staff.3. The house supervisor reported that police were at the facility. I. On 08/12/26 at 2:48 PM, during an interview with the DON, she stated the following:1. The ANE investigator reported that he was concerned with the incident that occurred with R #1 on 07/03/26 after reviewing video footage.2. He reviewed the footage due to the police being dispatched to the facility. 3. Per the DON, the process for sending residents out due to behavioral concerns has changed and the police respond to assist as necessary. 4. Staff did not report the incident to reflect what occurred as seen on the video.5. Upon review of the video RN #1 was seen making hand gestures toward the resident more than once indicating that R #1 was crazy. 6. R #1 was not observed to be hitting or kicking other residents or staff. 7. CNA #1 and CMA #1 attempted to remove R #1 from the sunroom, R #1 was resistant and became agitated. 8. CMA #1 then folded and crossed R #1's arms across her chest and held R #1's arms down. 9. R #1 attempted to bite CMA #1, that is when CMA #1 pulled R #1's head back by placing her hand on R #1's forehead. 10. CNA #1 and CMA #1 then turned R #1's wheelchair around, tilted the wheelchair back so her feet were off the ground, and wheeled her backwards towards her room while holding her arms and legs down. 11. CMA #2 and RN #1 assisted CNA #1 and CMA #1 in holding R #1 down by her limbs and wheeled R #1 into her room.12. Once R #1 was in her room, CNA #1 held R #1's room door shut and did not allow R #1 out of the room. 13. CNA #2 walked into R #1's room and removed the bedside table bringing it into the hallway and then shut the door but did not hold it shut. 14. LPN #1 did not document accurately in the resident's chart, she documented what was reported to her by other staff even though she did not witness the entire incident. 15. The DON stated that she did consider this to be abuse, restraints, and involuntary seclusion. J. On 08/13/26 at 1:19 PM, during an interview with the DON, she stated the following:1. R #1 would not likely remember the incident.2. If the same incident were to occur with another resident that did not have a cognitive decline there are multiple possible outcomes, but most likely they could possibly become fearful of staff or have anxiety related to the incident.

Based on record review and interview, the facility failed to ensure a resident was treated with respect and dignity for 1 (R #13) of 1 (R #13) resident reviewed for neglect when staff failed to stay with the resident until she felt comfortable. This deficient practice could likely create a feeling of frustration, anxiety, and disappointment. The findings are:A. Record review of the Facility's Initial Incident Report dated 03/11/26, revealed R #13 needed her portable oxygen tank to be refilled. CNA #8 filled R #13's oxygen tank and returned it to R #13. R #13 stated that the oxygen was not working properly. R #13 stated that CNA #8 left without ensuring that the oxygen was working properly. B. Record review of R #13's admission record, no date, revealed R #13 was admitted to the facility on [DATE]. C. Record review of R #13's nursing progress notes, dated 04/05/26, revealed R #13 passed away on 04/05/26. D. On 04/08/26 at 11:39 AM, during an interview, CNA #8 stated R #13 had pushed her call light because she was ready to go to an activity. CNA #8 stated R #13's portable oxygen tank needed to be refilled. CNA #8 refilled R #13's oxygen and returned it to the resident. CNA #8 stated R #13 reported that the oxygen was not flowing. CNA #8 stated she confirmed the oxygen was flowing. However, R #13 was still insisting the oxygen was not flowing. CNA #8 stated she left R #13 to inform the nurse that R #13 was concerned her oxygen was not flowing. CNA #8 stated that she did not return to the resident's room after she spoke with the nurse to ensure the resident was comfortable and the issue was resolved. E. On 04/08/26 at 1:42 PM, during an interview with the DON, she stated her expectation is CNA #8 should have stayed with R #13 until she was comfortable that her oxygen was flowing properly.

Based on record review and interview, the facility failed to submit direct care staffing information to the federal agency overseeing certification for long term care facilities for February 10, 2025, through February 22, 2025. This has the potential to affect all 117 residents in the facility, (residents were identified by the Resident Matrix provided by the Administrator on 09/15/25). This deficient practice could likely result in inaccurate direct care staffing information for residents/facility. The findings are: A. Record review of Payroll Base Journal (PBJ) Staffing Data Report (report from the data base of the federal agency overseeing certification for long term care facilities) dated February 10, 2025, through February 22, 2025, revealed there was no RN coverage for 8 consecutive hours, or 24 hour licensed nurse coverage. B. On 09/19/2025 at 10:41 AM, during an interview, the Staffing Scheduler (SS) stated there was RN coverage and 24 hour licensed nursing coverage. SS stated he did not know why the PBJ did not document the correct staffing. C. On 09/25/25 at 11:16 AM, during an interview with the Administrator, he stated in February 2025 there was two weeks showing no coverage on the PBJ report. The Administrator said they had the data for the two weeks that were missing, but the data didn't transmit. The Administrator stated that they were not able to go back in and correct it once it was submitted the data had been submitted.

Based on record review and interview, the facility failed to assist a resident in gaining access to vision services when staff failed to make appointments and arrange for transportation to the appointment for 1 (R #59) of 4 (R #2, R #9, R #59 and R #112) residents reviewed for vision and hearing. This deficient practice could likely result in residents losing some independence if they cannot see adequately or lead to an increase in the risk of missing early signs of serious eye diseases which could compromise their quality of life. The findings are: A. On 09/16/25 at 12:04 PM, during an interview, R #59 said he needed new bifocals (eyeglasses with two distinct optical powers correcting vision at both long and short distances) because he was having difficulty reading some materials. B. Record review of R #59's Progress notes revealed the following: 1. Clinical admission note dated 01/24/25: resident wears glasses. 2. Encounter note dated 03/28/25: R #59 would like to be seen by an ophthalmologist (branch of medicine that deals with the diagnosis, treatment, and surgery of eye diseases and disorders) as he feels his vision is getting worse. An order was placed for ophthalmology to further evaluate the resident's declining vision. 3. Encounter note dated 04/09/25: R #59's vision has been declining, and he reports having difficulty reading his Bible. Ophthalmology referral placed for declining vision and difficulty reading. C. On 09/22/2025 at 1:05 PM, during an interview with the scheduler, she confirmed she did receive an ophthalmology referral in April 2025, but the resident has not been seen by an ophthalmologist yet and is not currently scheduled for an appointment.

Based on interview, the facility failed to ensure residents were treated with respect and dignity for 3 (R #1, R #21, and R #87) of 5 (R #1, R #21, R #35, R #51 and R #87) residents sampled for dignity, when the staff failed to: 1. Refer to residents in a dignified manner to R #1 and R #87. 2. Maintain a calm and kind tone, avoid interrupting, or condescension for R #1, R #21, and R #87. These deficient practices could likely to result in residents feeling embarrassed, angry, and that their feelings and preferences are unimportant to the facility staff. The findings are:Dignified manner R #1 A. On 09/17/25 at 1:56 PM, during an interview, R #1 stated staff is rude and are smart asses. R #1 said staff don't address them correctly. R #1 stated staff will say, Hey you, [last name]. R #1 stated he has asked to be called Mr. [last name], and they do not do it. R #1 said he has addressed in resident council and has told staff on his unit that staff are not addressing him the way he wants to be addressed. R #87 B. On 09/17/23 at 1:58 PM, during an interview, R #87 said staff do not address residents in a respectful way. R #87 said staff will just call them by their last name. R #87 stated that he has told staff that it is rude to just yell out their last name. C. On 09/18/25 at 1:41 PM, during an interview, Unit Manager (UM) #9 stated she had recently been made aware of staff being rude to residents. UM #19 stated staff should address resident's the way the resident wants to be addressed. UM #9 stated residents should always be addressed in a respectful manner. The UM stated that she will reeducate staff when she is made aware of staff being rude. Speak in a respectful manner R #21 D. On 09/15/25 at 1:54 PM, during an interview, R #21 stated staff is rude. R #21 stated there is a staff member that will tell R #21 that she is not the only resident that needs help. R #21 stated that there is a staff member that doesn't like her and when that staff member is working, she won't help her in a timely manner and makes her wait.R #21 stated that she told the UM #8. E. On 09/18/25 at 1:35 PM, during an interview with UM #8, she stated she had been made aware that staff is rude to residents. UM #8 said that if she is made aware of someone specific, that she will reeducate and counsel them on how to communicate with residents

Based on interview, observation, and record review, the facility failed to keep residents free from involuntary seclusion (separation of a resident from other residents) for 1 (R #101) of 1 (R #101) resident sampled for elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) risk, when staff failed to implement and document the following: 1. The clinical criteria (rules or standards on which a decision or judgment is made to determine medical necessity) met for placement of R #101 in the secured/locked area by the R #101's physician along with information provided by members of the interdisciplinary team (IDT team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). 2. Whether placement in the secured/locked area was the least restrictive approach that was reasonable to protect R #101 and assure her health and safety. 3. The IDT consideration of the impact and reaction of R #101, if any, regarding placement on the unit. 4. Ongoing review and revision of R #101's care plan as necessary, including whether he/she continues to meet the criteria for remaining in the secured/locked area, and if the interventions continue to meet the needs of the resident. 5. Obtain consent from R #101's representative for placement in the secured/locked area. 6. Develop clinical criteria for the placement of residents in the secured/locked area that ensures residents are not placed in the secured/locked area for the convenience of staff, discipline, or based on diagnosis alone. These deficient practices are likely to result in residents being placed in seclusion involuntarily causing anxiety and depression. The findings are: A. Record review of R #101's admission documents, no date, revealed the following: 1. R #101 was admitted to the facility on [DATE]. 2. R #101 had the following diagnoses: a. Dementia with psychotic disturbance (a condition characterized by cognitive decline (dementia) accompanied by psychotic symptoms, such as hallucinations and delusions). b. Depression (a treatable mental health condition causing persistent sadness, loss of interest, and changes in sleep, appetite, and energy that affect daily life). c. Generalized anxiety disorder (a common mental health condition characterized by excessive and persistent worry, often about everyday events). d. Insomnia (a sleep disorder characterized by difficulty falling or staying asleep, resulting in daytime fatigue and impaired functioning). B. On 09/16/2025 at 8:29 AM, during an interview and observation of R #101 revealed the following: 1. R #101's family member (FM) pushed R #101 in her wheelchair around the secured unit. 2. R #101's FM stated R #101 had been unable to walk since before she was admitted to the facility. 3. R #101's FM stated R #101 was unable to transfer herself into a wheelchair. 4. R #101 was unable to push herself in a wheelchair. 5. R #101 FM stated R #101 had been in the same unit of the facility since she arrived. 6. FM was not aware R #101 was in a secured/locked area, he thought all the units required visitors to use a card to get on and off the unit. 7. FM did not know why R #101 was housed in a secured/locked unit. C. Record review of R #101's elopement risk evaluation, multiple dates, revealed the following: 1. On 01/30/25, staff documented R #101 was not an elopement risk and R #101 was located in the secured/locked unit. 2. On 05/05/25, staff documented R #101 was not an elopement risk and R #101 was located in the secured/locked unit. 3. On 08/05/25, staff documented R #101 was not an elopement risk and R #101 was located in the secured/locked unit. D. Record review of R #101's entire medical record, no date, revealed R #101's medical record did not contain the following: 1. The clinical documentation by R #101's physician and Interdisciplinary Team (IDT) about clinical need for placement of R #101 in the secured/locked unit. 2. Documentation if placement in secured unit was the least restrictive approach for R #101. 3. Documentation of a consent from R #101's representative for the placement of R #101 in the secured/locked unit. 4. The record did not contain documentation from the IDT of R #101's impact or reaction to being placed in secured/locked unit. 5. The record did not contain documentation of ongoing review and revision of R #101's care plan to indicate whether R #101 continued to meet criteria to remain in the secured/locked unit. 6. A physician's order for R #101 to be placed in the secured/locked unit. E. Record review of R #101's care plan, revised 08/04/25, revealed the following: 1. Staff did not document on R #101's care plan the clinical criteria that was met for R #101 to be housed in the secure unit upon admission. 2. Staff did not document whether R #101 continued to meet the criteria for remaining in the secured/locked area. F. On 09/18/2025 at 12:12 PM, during a joint interview with unit manager (UM) #16 and the ADON, revealed the following: 1. When a resident is referred to be admitted to the facility, the DON determines which unit they think will be best for the resident. 2. Referral packets for residents who have a diagnosis of dementia are given to the UM for the secure/locked unit. 3. The UM and therapist meet the resident wherever they are (hospital, home, etc) to complete a pre-admission assessment. 4. The IDT team discusses the resident's admission, unit placement, and what the resident will need prior to their admission. 5. The provider is not part of the IDT discussion regarding resident's unit placement. 6. Any resident with a diagnosis of Alzheimer's Disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to perform daily activities) or dementia automatically gets placed in the secured/locked unit. 7. R #101 had been housed in the secured/locked unit since her admission on [DATE]. 8. R #101 had a diagnosis of dementia. 9. R #101 was not an elopement risk. 10. R #101 did not have an order to be housed in the secured/locked unit. 11. They were unable to find documentation in R #101's medical record that the IDT team discussed R #101's criteria for placement on the secured/locked unit. 12. R #101 did not have consent for being placed in the secured/locked unit. 13. R #101's medical record did not have documentation that the IDT team reassessed R #101's continued need for placement in the secured/locked unit. G. Record review of the facility's policy Placement of Residents on Secured Neighborhoods, dated 08/16/22, revealed the following criteria for being placed on the secured/locked unit: 1. Psychiatric diagnosis or symptoms and meet the serious of illness of at least one of the following: a. Self-destructive behavior b. Assaultive behavior c. Destructive to property d. Medication noncompliance (failure to act in accordance with a wish or command) e. Disorientation or memory impairment causing change in daily living activities f. Psychiatric (relating to mental illness) symptoms such as: hallucinations (sensory experiences that occur without external stimuli), delusions (false, fixed beliefs that persist despite clear evidence to the contrary), panic reaction (a sudden and intense surge of fear or anxiety that can trigger a variety of physical and psychological symptoms), anxiety, agitation (an emotional state of unease and heightened arousal, marked by a mix of restlessness, irritability, tension, and potentially hostile or confused behaviors like pacing, excessive talking, and poor impulse control), depressions. g. Behavior which is life threatening, destructive, or disabling to self or others. h. Serious risk taking or any self-endangering behavior. i. Serious risk taking or any self-endangering behavior. j. Psychosis (symptoms that happen when a person is disconnected from reality) that presents a danger to self or ex-command auditory hallucinations (a specific type of hallucination in which a person hears voices that instruct them to perform certain actions). k. Significant deterioration (process of becoming progressively worse) of usual level of function. l. The resident is experiencing severe and acute (sudden) deterioration as evidenced by: m. The resident has symptoms which hinders (create difficulties) the residents ability to function in daily life. The level of functioning is so impaired that the resident cannot maintain adequate nutrition, shelter, safety, or other essentials n. Severe memory loss o. Extensive confusion p. Behaviors that are potentially dangerous to self or others. H. On 09/22/2025 at 3:02 PM, during an interview, the DON confirmed the following: 1. The criteria for being placed in the secured/locked unit are: a. A diagnosis of cognitive or memory issues. b. Resident's having behaviors. 2. R #101 was not an elopement risk. 3. R #101 had behaviors of yelling out and residents on other units wouldn't like that behavior.

Based on interview, and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status) was accurate for 3 (R #4, R #59, and R #101) of 4 (R #4, R #21, R #59, and R #101) residents reviewed for pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin). This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: R #4 A. Record review of R #4's admission documents, no date, revealed R#4 was admitted to the facility on [DATE]. B. Record review of R #4's physician's order dated 06/18/25 and discontinued on 09/11/25, revealed an order to wrap R #4's left ankle with gauze and bandages. C. Record review of R #4's wound care measurement dated 08/12/25, revealed R #4 had a stage three (3) pressure ulcer (a full-thickness skin loss that extends into the subcutaneous tissue but does not expose muscle, tendon, or bone) to her left lateral (outer) ankle. D. Record review of R #4's administration record, dated August 2025, revealed R #4 received wound care for her left ankle as ordered for the month of August 2024. E. Record review of R #4's quarterly MDS dated [DATE], revealed staff did not document R #4 had a stage three (3) pressure ulcer. F. On 09/17/2025 at 1:18 PM, during an interview, MDS coordinator #16 confirmed the following: 1. R #4 had a stage three (3) pressure ulcer on her left lateral ankle. 2. R #4's quarterly MDS on 08/22/25, did not include a stage three (3) pressure ulcer. 3. R #4's stage three (3) pressure ulcer should have been included on the quarterly MDS on 08/22/25. R #59 G. Record review of R #59's admission Record (no date) revealed R #59 was admitted to the facility on [DATE]. H. Record review of R #59's Comprehensive (Significant change in condition; completed when there is a significant decline or improvement) MDS, dated [DATE], revealed staff documented R #59 had one venous or arterial ulcer. I. Record review of R #59's medical record revealed R #59 did not have a venous ulcer (slow healing open wounds that develop on the lower legs due to poor blood circulation in the veins) or arterial ulcer (open wound caused by poor circulation to the lower limb). J. On 09/22/2025 at 1:44 PM, during an interview with the MDS Nurse, she confirmed the following: 1. R #59 did not have a venous or arterial ulcer while at the facility. 2. She documented R #59's comprehensive MDS dated [DATE], inaccurately because R #59 does not have a venous or arterial ulcer. R #101 K. Record review of R #101's admission documents, no date, revealed R #101 was admitted to the facility on [DATE]. L. Record review of R #101's quarterly MDS, dated [DATE], revealed staff documented that R #101 had one (1) venous or arterial pressure ulcer M. Record review of R #101's entire medical record, no date, revealed R #101 did not have a venous ulcer (chronic open wounds that develop on the lower legs due to poor blood circulation) or arterial ulcer (due to a reduced arterial blood supply to the lower limb). N. On 09/18/2025 at 9:43 AM, during an interview with unit manager (UM) #16, she confirmed R #101 never had a venous or arterial pressure ulcer while at the facility. O. On 09/18/2025 at 10:09 AM, during an interview, MDS coordinator #16 confirmed the following: 1. R #101 did not have a venous or arterial pressure ulcer. 2. Staff documented on R #101's quarterly MDS dated [DATE] that R #101 had one (1) venous or arterial pressure ulcer. 3. R #101's quarterly MDS dated [DATE] was inaccurate and staff should not have documented that R #101 had a venous or arterial pressure ulcer.

Based on observation, record review and interview, the facility failed to ensure care plan revisions occurred for 7 (R #2, R #5, R #7, R #13, R #17, R #21, and R #59) of 21 (R #2, R #3, R #4, R #5 R #7, R #10, R #12, R #13, R #17, R #21, R #22, R #33, R #49, R #59, R #71, R #74, R #75, R #87, R #101, R #104, and R #123) residents when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #2 A. On 09/16/25 at 11:38 AM, during an interview, R #2 stated she has a catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) because she can't go to the bathroom on her own. B. Record review of R #2's care plan, dated 01/03/24, revealed R #8's catheter interventions were not documented on the care plan. C. On 09/18/25 at 12:05 PM, during an interview with the DON, she stated R #2 has had a catheter for urinary retention. The DON confirmed R #2's care plan does not document goals for the catheter or bladder retraining (behavioral therapy used to improve urinary control and reduce urinary incontinence). The DON stated R #2's treatment and interventions should be documented on her care plan. R #5 D. Record review of R #5's admission documents, no date, revealed R #5 was admitted to the facility on [DATE]. E. Record review of R #5's physician's order dated 07/2/25 revealed the following: 1. An order for Olanzapine (an antipsychotic medication used to treat mental disorders, including schizophrenia and bipolar disorder) intramuscular (IM, administered into a muscle) every eight (8) hours as needed (PRN) for severe agitation/Dementia with Psychotic Disturbances. 2. Olanzapine order was completed on 08/10/25. F. Record review of R #5's care plan dated 07/08/25 revealed staff did not revise R #5's care plan when her order for PRN Olanzapine was discontinued. G. On 09/22/2025 at 2:52 PM, during an interview with the DON, she confirmed the following: 1. R #5's Olanzapine order was completed on 08/10/25. 2. Staff did not revise R #5's care plan after Olanzapine was completed. 3. Staff should have revised R #5's care plan when her order for Olanzapine was completed. R #7 H. Record review of R #7's admission Record (no date) revealed the following: 1. R #7 was admitted to the facility on [DATE]. 2. R #7's primary diagnosis; secondary malignant neoplasm of the brain (cancer that has spread to the brain from another part of the body). I. Record review of R #7's Progress notes revealed the following: 1. Restorative Program (a formal, planned and organized program of care aimed at restoring or maintaining a potentially deteriorating function) note dated 06/27/25: After several attempts this week and last week resident is refusing to get weighed. Resident stated he was on palliative (medical care that provides symptom relief, comfort and support to individuals living with serious or chronic illness) and does not want to get weighed. 2. Encounter (documentation by physician or nurse practitioner) note dated 08/06/25: Plan: Goals of Care Discussion. Ongoing discussion regarding transition to hospice (medical care designed for individuals nearing the end of life typically when curative treatment is no longer pursued) versus continuing palliative care, patient is already on palliative care. 3. Encounter note dated 08/12/25: Medications, morphine concentrated oral solution (narcotic medication used to treat pain severe enough to require daily, around-the-clock, long-term opioid treatment when other pain medicines did not work well enough or cannot be tolerated) new order for palliative care. J. Record review of R #7's Care Plan dated 06/06/25 revealed no plan in place for palliative care related to his primary diagnosis of brain cancer. K. On 09/22/2025 at 1:36 PM, during an interview with the MDS Nurse, she confirmed there was documentation in R #7's medical record regarding palliative care but the care plan was not updated to include palliative care. R #13 L. Record review of R #13's admission documents, no date, revealed R #13 was admitted on [DATE]. M. Record review of R #13's progress notes, revealed R #13 fell on [DATE] and 09/16/25. N. On 09/19/2025 at 8:38 AM, during an observation of R #13 in the hall, R #13 sat in her wheelchair near CNA #16. O. On 09/19/2025 at 8:40 AM, during an interview, CNA #16 stated the following: 1. On 09/15/25, R #13 fell because she tried to get out of her bed without assistance. 2. After her fall on 09/15/25, close supervision was implemented, and staff were supposed to keep an eye on R #13 at all times. 3. On 09/16/25, R #13 fell because she tried to get out of her wheelchair without assistance. Her and another CNA were watching R #15, but they were unable to get to her before she fell. 4. After her fall on 09/16/25, staff were instructed to keep R #13 near them in the hall when she was out of bed and they moved R #13's bed closest to the door. P. Record review of R #13's care plan dated 08/27/25 revealed the following: 1. After R #13's fall on 09/15/25, staff did not revise R #13's care plan to include that staff were to keep a constant eye on R #13. 2. After R #13's fall on 09/16/25, staff did not revise R #13's care plan to include she was moved to the bed closest to the door and staff were expected to keep R #13 with them in the hall when she was out of bed. Q. On 09/19/2025 at 8:46 AM, during an interview, unit manager (UM) #16 confirmed the following: 1. R #13's care plan did not include that staff were to keep a close eye on R #13. 2. R #13's care plan did not include R #13 was moved to the bed closest to the door. 3. R #13's care plan did not include staff were to keep her in the hall near them when R #13 was out of bed. 4. Staff should have revised R #13's care plan with new interventions after each fall. R #17 R. Record review of R #17's progress note dated 09/01/25 revealed R #17 had weight loss. S. Record review of R #17's physician orders revealed the following: 1. On 05/19/25 a milkshake supplement two times a day for supplementation. 2. On 08/11/25 boost (ready-to-drink, nutrient-fortified beverage designed to supplement a person's diet and provide essential nutrients like protein, vitamins, and minerals to support energy, muscle health) three times a day for supplement. T. Record review of R #17's care plan dated 02/25/16 revealed R #17's current interventions for weight loss are not documented. R #17's milkshake and boost are not documented on her care plan. U. On 09/17/25 at 10:37 AM, during an interview withUM #8, she stated R #17 has a history of weight loss. UM #8 stated R #17 has supplements that she gets daily. UM #8 said they will give R #17 extra boost drinks when she asks for them. UM # 8 confirmed the supplements are not documented in R #17's care plan. UM #8 stated she did not know they should be on R #17's care plan. V. On 09/18/25 at 12:00 PM, during an interview, the DON stated R #17 has had weight loss. The DON stated staff is providing R #17 snacks and supplements as ordered, and that they will provide her more when she asks for them. The DON confirmed the supplements are not documented on R #17's care plan. The DON stated the resident's interventions for weight loss should be on her care plan. R #21 W. On 09/15/25 at 2:20 PM, during an observation of R #21's room, R #21's used oxygen. There was no date on the nasal cannula (medical device with two prongs that sit in a patient's nostrils to deliver supplemental oxygen) documenting when it was changed. X. Record review of R #21's physician order dated 09/18/24 revealed an order for oxygen 2 liters continuous every shift. Y. Record review of R #21's care plan, dated 01/29/23, revealed that changing R #21's nasal cannula weekly was not documented. Z. On 09/22/25 at 11:09 AM, during an interview, the DON stated the nasal cannulas are supposed to be changed once a week, and the date should be documented on the cannula tubing. The DON stated the care plan should document that the nasal cannulas should be changed weekly and dated when done. R #59 AA. Record review of R #59's admission Record (no date) revealed R #59 was admitted to the facility on [DATE]. BB. Record review of R #59's Progress notes revealed the following: Clinical admission note dated 01/24/25: resident has dentures. 2. Nursing note dated 05/29/25: R #7 had his dentures in his jacket pocket, R #7 stated he needed some help with them to put them in and by the way there is a small piece missing from the back right side which is kinda sharp. 3. Social Work note dated 05/30/25: spoke with resident regarding his broken dentures, will send him to dental to see if they can fix them. 4. Nursing note dated 06/09/25: R #7 reported he lost bottom dentures. 5. Encounter note dated 07/26/25: R #7 reports difficulty eating due to missing bottom dentures. 6. Nutrition/Dietary noted dated 08/29/25: R #7 said that he is missing his lower dentures and that makes it hard to chew and sometimes gives him pain (his upper is fine). CC. Record review of R #59's Care Plan dated 02/12/25 revealed the following: 1. Focus: Dental care- edentulous (without natural teeth). Goal: Resident will not have any oral infections, difficulty chewing, or nutritional issues related to being edentulous through this review period. Interventions (actions taken by staff): monitor/document/report any s/s of oral/dental problems needing attention. 2. R #7's care plan was not updated when his bottom dentures went missing. DD. On 09/22/2025 at 1:42 PM, during an interview with the MDS Nurse, she confirmed R #7's care plan was not updated when his bottom dentures went missing.

Based on interview and record review, the facility failed to ensure appropriate treatment and services for Foley catheter (a thin, flexible tube inserted into the bladder to drain urine) for 1 (R #2) of 4 (R #2, R #3, R #11 and R #123) residents reviewed for catheter use when staff failed the to do the following: 1. Ensure R #2 has a clinical condition that demonstrates catheterization (the action or process of inserting a catheter into a body cavity) was necessary. 2. Ensure R #2 was assessed for the removal of the catheter as soon as possible. 3. Ensure R #2 received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible. These deficient practices could likely result in residents getting infections and having the Foley catheter longer than needed. The findings are: A. On 09/16/25 at 11:38 AM during an interview, R #2 stated she has had the catheter for a long time. R #2 said she has had urinary tract infections (UTI an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra). R #2 stated she has the catheter because she cannot get up to go to the bathroom on her own. R #2 stated she does not know when the catheter will be removed. B. Record review of R #2's admission record, no date, revealed an admission date of 12/22/2023. C. Record review of R #2's physicians order dated 08/08/25, revealed the following: 1. On 08/08/25 Change indwelling catheter every 30 days and as needed for urinary retention. 2. On 08/24/25 Macrobid (used to treat and prevent urinary tract infections) give 1 oral capsule 100 mg 2 times daily for a UTI. 3. On 04/03/25 Macrobid give 1 oral capsule 100 mg 2 times daily for UTI. D. On 09/18/25 at 12:05 PM, during an interview, the DON stated R #2 has a catheter for urine retention (inability to empty the bladder completely). The DON stated R #2 has had the catheter since shortly after admission. The DON stated that residents should be reassessed for catheters quarterly. The DON stated that it is not documented that R #2 has been reassessed for the catheter. The DON stated she did not see documentation that bladder retraining (a behavioral therapy used to improve urinary control and reduce urinary incontinence) has been attempted. E. On 09/19/25 at 9:00 AM, during an interview, the Unit Manager (UM) stated that R #2 has had a catheter since she was admitted for bladder retention. The UM stated that R #2 does have a history of UTI's. UM stated that R #2 has not been reevaluated for the catheter and bladder training has not been attempted. F. On 09/19/25 at 11:27 AM, during an interview, the Doctor (DR) stated that R #2 has not been reevaluated and bladder retraining has not been attempted since the resident has had the catheter. The DR stated that it is not good to have a catheter for almost 2 years and not be reassessed. The DR stated that residents should be reassessed.

Based on observation and interview, the facility failed to properly store medications in the treatment cart for all 19 residents (residents were identified by the resident matrix provided by the Administrator on 09/15/25) randomly sampled, when staff failed to secure the medication carts on the East Unit 100 hall. This deficient practice could likely result in residents obtaining medication not prescribed to them and residents having adverse side effects. The findings are: A. On 09/15/25 at 2:15 PM, during observation of the East Unit 100 hall, the treatment cart was unlocked. The following medications were in the treatment cart: 1. Arthritis hot ointment (fast-acting relief from minor aches, pains, and stiffness associated with arthritis). 2. Muscle rub cream (relief of minor aches and pains in muscles and joints). 3. Hibiclens skin cleanser (pre-surgical preparation, wound care, hand hygiene, and daily skin cleansing in both hospital and home settings). 4. Nystop ointment (used to treat fungal skin infections caused by the yeast). 5. Calmoseptine ointment (multi-purpose moisture barrier ointment used to treat and prevent minor skin irritations). 6. Cold and Hot ointment (relief of minor aches and pains in muscles and joints). 7. Minerin ointment (used to soothe and moisturize extremely dry, sensitive, and irritated skin). 8. Moisture barrier antifungal cream (treat and prevent fungal skin infections while simultaneously creating a protective, moisture-repelling layer on the skin). 9. Baby powder (absorbs moisture, reduces friction to prevent rashes and chafing). B. On 09/15/25 at 2:33 PM, during an interview, the Wound Care Nurse (WCN), confirmed the treatment cart was not locked, and the cart was supposed to be locked. C. On 09/22/25 at 2:31 PM, during an interview with the DON, she confirmed staff should not leave treatment carts unlocked when they are not in site of the cart.

Based on record review 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 when staff failed to: 1. Ensure R #21's nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was labeled with the date that it was changed. 2. Have a system of surveillance with data analysis to properly identify possible communicable diseases and infections. This failure could potentially affect all (15) residents who had infections (residents were identified by the Resident Matrix provided by the DON on 09/15/25). If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are: R #21 A. On 09/15/25 at 2:20 PM, during an observation of R #21's room, R #21 wore a nasal cannula attached to the oxygen tank. The nasal cannula was not dated with a date that indicated a date the nasal cannula was changed. B. On 09/17/25 at 11:09 AM, during an interview, CNA #8 confirmed staff did not date R #21's tubing. CNA #8 confirmed that there should be a date on it indicating when the cannula was changed. [Facility practice is to change the nasal cannulas weekly and date the cannulas for tracking purposes.] C. On 09/22/25 at 2:29 PM, during an interview, the DON confirmed that nasal cannulas should be changed once a week and the date that they are changed should be documented on the nasal cannula tubing. D. Record review of the facility Infection Prevention and Control Program policy, dated 06/28/22, revealed the following: 1. Surveillance a. Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness. b. Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infection, monitoring adherence to infection prevention and control practices, and detecting unusual pathogens with infection control implications. c. The information obtained from infection control surveillance activities is compared with that from other facilities and with acknowledged standards (for example, acceptable rates of new infections), and used to assess the effectiveness of established infection prevention and control practices. d. Standard criteria are used to distinguish community-acquired or facility-acquired infections. 2. Data Analysis a. Data gathered during surveillance is used to oversee infections and spot trends. 3. The Infection Prevention and Control Program policy did not have evidence that it had been reviewed annually. E. On 09/22/2025 at 12:47 PM, during an interview, the Infection Preventionist (IP) stated the following: 1. He was unable to state which residents had infections or were on precautions. 2. He did not have a document that he used to track resident or staff infections. 3. He did not have a document or method that he used to track individuals who were on precautions. 4. He stated he should use some type of mapping or line list to track infections and precautions, but he hadn't started that yet. F. On 09/22/2025 at 3:12 PM, during an interview, the DON confirmed the IP was expected to keep a line list (is a table used in epidemiology to organize key information about each case during an outbreak investigation) for tracking staff and resident infections in the facility.

Based on record review and interview, the facility failed to ensure staff implemented a comprehensive Antibiotic Stewardship Program (ASP, a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This failed practice has the potential to affect the following: 1. All eight (8) residents in the facility that were taking antibiotics. Residents identified using the list of residents taking antibiotics provided by the Administrator on 09/24/25. 2. R #59 who was taking antibiotics from 9/08/25 through 09/20/25. This deficient practice could likely result in the inappropriate use of antibiotics and lead to resistance of Multi-Drug Resistant Organisms (MDRO; a germ that is resistant to many antibiotics). The findings are: Antibiotic Monitoring A. Record review of the facility's Antibiotic Stewardship policy, dated 09/27/22, revealed the facility did not have a proper and adequate ASP that included: 1. Protocols to monitor/review response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made (e.g., antibiotic time-out). 2. A process for a periodic review of antibiotic use by prescribing practitioners to determine whether an infection or communicable disease has been documented and whether an appropriate antibiotic has been prescribed for the recommended length of time. 3. A system for the provision of feedback reports on antibiotic use, antibiotic resistance (the ability of microorganisms, such as bacteria, to withstand the effects of antibiotics that were designed to kill or inhibit their growth) patterns based on laboratory data, and prescribing practices for the prescribing practitioner. R #59 B. Record review of R #59's progress notes revealed the following: 1. On 09/07/25 Skin/wound note, wound #3 right inner gluteal fold (crease formed between the buttocks and the upper thigh) wound is new. Bloody yellow and white pus draining from wound. Significant amount of drainage noted. C. Record review of R #59's physician's orders revealed the following: 1. An order dated 09/07/25 sulfamethoxazole-Trimethoprim 800-160 mg (Bactrim; combination antibiotic used to treat a variety of bacterial infections) give 1 tablet by mouth every 24 hours for soft tissue infection (infection that affects the skin and the underlying tissue often caused by bacteria) for 14 Days. D. Record review of R #59's medication administration record (MAR; form used by nurses to document when medication is given to residents) dated September 2025 revealed the following: 1. Bactrim dose for 09/07/25 was blank. 2. Bactrim was documented as given for thirteen days instead of fourteen days. E. On 09/22/2025 at 12:47 PM, during an interview, the Infection Preventionist (IP) stated the following: 1. He reviewed antibiotic orders right after they were placed and compared the order with the culture and sensitivity (laboratory test that identifies a specific microorganism, like bacteria or fungi, causing an infection and determines which medications are most effective against it) reports to determine if the antibiotic ordered should be effective. 2. He stated he didn't utilize any data collection tool or have a system to monitor antibiotic use after he checked the order with the laboratory results. 3. He stated he didn't have a method for monitoring whether the antibiotic was effective for treating the resident's infection. 4. He confirmed staff were not completing an antibiotic time out (a structured process designed to ensure appropriate and judicious use of antibiotics. It involves a healthcare professional reviewing and reassessing an antibiotic prescription at a predetermined time after the initiation of therapy). 5. He confirmed he did not conduct any type of periodic review on antibiotic use. 6. He confirmed that R #59 missed a dose of his antibiotic. 7. He was unaware of R #59 missing the first dose of his antibiotic 8. Nursing staff should have notified the provider that R #59 missed a dose and changed the order so that the resident receives the full fourteen days of his antibiotic as ordered. F. On 09/22/2025 at 3:12 PM, during an interview, the DON confirmed the following: 1. The IP was expected to monitor antibiotic use. 2. Staff should be completing a time out for antibiotic usage and ensuring residents receive all doses of their antibiotic medication.

Based on interview and record review the facility failed to update a resident care plan to reflect changes in the resident's treatments or interventions for 1 (R #3) of 2 (R #3 and R #101) residents reviewed for care plan accuracy. This inaccuracy has the potential of harm to a resident if the medical record does not provide correct indwelling catheter (a tube inserted into and left in the bladder to drain urine) information for staff to respond to the resident needs if the catheter had already been removed. The findings are: A. On 09/16/25 at 1:57 PM, during an interview, R #3 stated her indwelling catheter was removed about 1 month ago. B. Record review of R #3's PCP (primary care physician) orders dated 8/16/25 revealed R #3's indwelling catheter was to be removed. C. Record review of R #3's current care plan dated 09/18/25 indicated that R #3 has an indwelling catheter. D. On 09/18/25 at 11:10 AM during an interview, the nurse supervisor #1 verified R #3's indwelling catheter was listed on the care plan. She stated R #3 does not have an indwelling catheter, and this documentation should have been removed. E. On 09/18/2025 at 11:30 AM, during an interview, the DON (Director of Nursing) stated the residents care plans are updated by the MDS coordinator and/or the nurse supervisor within 30 days.

Based on a review of records, the facility failed to ensure residents were free from unnecessary medications and properly manage psychotropic medications for two (R #5 and R #101) of 5 (R #4, R#5, R #10, R #22, and R #101) residents reviewed for unnecessary medications when staff failed to ensure psychotropic medications for R #5 and R #101 were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: R #5 A. Record review of R #5's admission documents, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE]. 2. R #5 had the following diagnoses: a. Alzheimer's Disease with late onset (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to perform daily activities) b. Dementia with psychotic disturbance (a condition characterized by cognitive decline (dementia) accompanied by psychotic symptoms, such as hallucinations and delusions). c. Dementia with agitation (a condition where a person with dementia experiences excessive restlessness, pacing, irritability, and sometimes aggression). d. Major Depressive Disorder (a common and debilitating mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). e. Anxiety Disorders (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can interfere with daily life). B. Record review of R #5's physician's orders, dated 07/21/25, revealed the following: 1. An order for Seroquel (an atypical antipsychotic prescription medication used to treat mental health conditions characterized by psychosis, such as schizophrenia and bipolar disorder) 75 mg at bedtime for Dementia with psychotic disturbance. 2. A black box warning (the most serious warning the U.S. Food and Drug Administration (FDA) can issue on drug and device labeling, alerting healthcare providers and patients to the risk of death or serious injury associated with the product) attached to the Seroquel order in the EMR system that stated Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Quetiapine (Seroquel) is not approved for the treatment of patients with dementia-related psychosis. C. On 09/22/2025 at 2:52 PM, during an interview, the DON confirmed the following: 1. R #5 had an order for Seroquel for Dementia with psychotic disturbance. 2. R #5's Seroquel order had a black box warning indicated that Seroquel was not approved for dementia related psychosis. 3. Staff were expected to ensure that residents were not given psychotropic medications if they did not have an appropriate diagnosis. R #101 D. Record review of R #101 admission record dated 09/23/25, revealed the following: 1. R #101 was admitted to the facility on [DATE]. 2. R #101 had psychiatric diagnoses for dementia with psychotic disturbances (a decline in cognitive function alongside the onset of psychotic symptoms such as delusions or hallucinations), depression (a low mood where a person is not able to enjoy activities that he or she usually enjoys), and anxiety (a feeling of worry, nervousness or unease, typically about an imminent event or something with an uncertain outcome). E. Record review of R #101's physician's orders dated 01/30/25 revealed an order for the following: 1. Mirtazapine (medication used to treat depression) 7.5 mg (milligrams) by mouth at 6:00 PM daily for depression and dementia. 2. Trazadone (medication used to treat depression) 150 mg by mouth at bedtime for insomnia. 3. Ativan (medication used to treat anxiety disorders, panic attacks and social phobia) 0.25 mg by mouth as needed every 12 hours for dementia with aggression. F. Record review of R #101's Medication Administration Record (MAR) dated September 2025 revealed the following medications for psychiatric (having to do with disorders of the mind) diagnoses: 1. Lorazepam (medication used to treat anxiety) 0.5 mg (milligrams) Monday, Friday every shift. 2. Quetiapine (medication used to treat mental health conditions such as schizophrenia, bipolar disorder and major depressive disorder) 12.5 mg twice a day. 3. Trazadone (medication used to treat depression) 150 mg before bed. G. Record review of R #101 psychotropic (medication used to exert an effect on the chemical makeup of the brain and nervous system) medication consent form dated 02/28/25 indicated R #101 was prescribed Quetiapine for Dementia with psychotic disturbances. H. Record review of the Quetiapine Blackbox warning (medications that carry risks of death or serious injury) indicated a contraindication (a condition or circumstance that suggests or indicates that a particular technique or drug should not be used) for patient diagnoses of Dementia with Psychotic disturbances. I. Record review of R #101's pharmacist's recommendation dated 02/28/25 revealed the following: 1. The PCP (primary care physician) review the appropriateness for R #101's continued use of Quetiapine. 2. The PCP indicated the continued use of Quetiapine for behavioral symptoms that present a danger to the resident or others and symptoms identified due to mania or psychosis. (This surveyor found no documentation the facility had determined that other treatments have been deemed clinically contraindicated). J. Record review of 101's Psychopharmacological Behavior Committee progress notes dated 03/26/25, revealed the following: 1. Psychiatric diagnoses of unspecified dementia, unspecified severity, with psychotic disturbance and depression. 2. Behaviors of verbal aggression (controlling and manipulating through language) and physical aggression (intentional use of force to harm another person or property manifesting in various forms and often driven be emotional or psychological factors). 3. Psychiatry visit note from 03/17/25 recommended R #101 to continue current medications and plan of care. 4. Committee review notes indicated R #101 has history of physical and verbal aggression but no recent aggression and is doing better and has shown some progress from hallucinations. (when a person sees things that are not present in reality). K. Record review of R #191's Psychopharmacological Behavior Committee progress notes dated 06/25/25, revealed the following: 1. Psychiatric diagnoses of unspecified dementia, unspecified severity, with psychotic disturbance and depression. 2. Behaviors of verbal aggression, physical aggression, yelling out mama during care, and visual hallucinations (when a person sees things that are not present in reality). 3. Psychiatry visit note from 05/19/25 stated staff has said there is no recent aggression and R #101 is doing good. 4. Committee review notes indicated R #101 is being monitored for verbal and physical aggression, yelling out during care and visual hallucinations. R #101 has had less physical and verbal aggression, stays with her husband and does 1:1 (with one person) activities. No change in medications at this time. L. Record review of R #101's pharmacist's recommendation dated 08/23/25, does not indicate recommendations for the appropriateness of Quetiapine.

Based on record review, observation, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 2 (R #4 and R #10) of 7 (R #4, R #5, R #10, R #21, R #22, R #59, and R #101) residents reviewed for medication regimen and pressure injuries when staff failed to: 1. Follow facility protocols when a new wound was identified for R #4. 2. Monitor for adverse effects of antipsychotic medication for R #10. If the facility is not identifying new wounds and following facility protocols for newly developed wounds and monitoring for adverse effects of antipsychotic medications, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not recognizing changes in the resident's condition. The findings are: R #4 A. Record review of R #4's admission documents, no date, revealed R#4 was admitted to the facility on [DATE]. B. Record review of R #4's wound evaluations, dated 09/03/24, revealed the following: 1. R #4 had an unstageable pressure wound (a type of pressure injury where the depth of tissue damage cannot be determined due to the presence of slough or eschar) on her right heel that started on 07/26/25. 2. R #4 had an unstageable pressure ulcer to her left lateral (outer) malleolus (ankle) that started on 08/19/25. 3. R #4 had a wound on her left inner ankle that the provider was notified about on 08/28/25. C. Record review of R #4's wound evaluations, dated 09/16/25, revealed the following: 1. R #4 had an unstageable pressure wound (a type of pressure injury where the depth of tissue damage cannot be determined due to the presence of slough or eschar) on her right heel that started on 07/26/25. 2. R #4 had an unstageable pressure ulcer to her left lateral (outer) malleolus (ankle) that started on 08/19/25. 3. R #4 had an unstageable pressure ulcer to her left lateral foot that started on 08/05/25. D. Record review of R #4's wound photographs, dated 09/16/25, revealed the following: 1. R #4 had two wounds to the left outer foot, one was dark brown/red and one was almost skin colored and appeared like dry skin. 2. R #4 had one wound on her left ankle which was skin colored and appeared like dry skin. 3. R #4 had one wound on her right heel that appeared brown with yellowish white skin around it. E. On 09/17/2025 at 12:19 PM, during an interview with RN #16, the following was revealed: 1. R #4 had one (1) wound on her right heel. 2. R #4 had one (1) wound on her left outer ankle. 3. R #4 had two (2) wounds on her left outer foot. 4. Wound care was completed daily for all wounds. F. On 09/17/2025 at 12:38 PM, during an interview with the wound care nurse, he stated the following: 1. R #4 had 3 wounds, one on her right heel, one on her left outer ankle, and one on the left outer foot. 2. After reviewing the photographs taken on 09/16/25, he confirmed R #4 had four total wounds, including two wounds on her left outer foot. 3. He stated he was unaware that R #4 had a new wound on her left outer foot. 4. He confirmed he took the pictures of R #4's wounds on 09/16/25. 5. He stated that R #4's old wound had healed so much that he didn't realize the new wound was not the same wound R #4 had before. 6. He stated he was not sure when R #4 developed the new wound on her left lateral foot. G. Record review of R #4's entire medical record, no date, revealed staff did not document that R #4 had a new wound on her left outer foot, if the wound care nurse or provider were notified to assess the wound, or what was being done to care for R #4's new wound on her left outer foot. H. On 09/18/2025 at 9:18 AM, during a joint interview, RN #16 and unit manager (UM) stated the following: 1. UM #16 stated that she evaluated R #4's wounds on 09/03/25 and she only had one wound on her left outer foot that was almost completely healed. 2. UM #16 stated she didn't document the wound on R #4's left lateral foot on 09/03/25 because it didn't appear to be a wound anymore. 3. RN #16 stated she did not know when R #4 developed the new wound on her left lateral foot. 4. Both stated that when a new wound is identified staff were expected to complete a wound screen form and the unit clerk emails it to leadership and wound care nurse. 5. Both stated that staff were expected to enter documentation in the non-emergency provider notification binder so the providers can assess the resident. 6. Both confirmed that they could not find a wound screen form for R #4's new wound on her left outer foot. 7. Both confirmed staff did not document that R #4 had a new wound on her left outer foot in the non-emergency provider notification binder. 8. Both confirmed that staff did not document in R #4's medical record that R #4 had a new wound on her left outer foot. 9. Both stated they were unable to determine when R #4 developed the new wound on her left outer foot. I. On 09/18/2025 at 11:16 AM, during an observation of R #4's wound care on her left foot, the following was observed: 1. R #4 had one (1) wound on her left outer ankle that was almost healed. 2. R #4 had two (2) wounds on her left outer foot. One (1) wound was closer to the back of the foot and was almost healed. The second wound was about an inch in front of the other wound and was reddish/brown. J. On 09/22/2025 at 2:46 PM, during an interview, the DON confirmed the following: 1. If staff identify that a resident had a new wound, staff were expected to complete a wound screening form and give it to the unit clerk to email to leadership and wound care nurse. 2. Staff were also expected to notify the provider in the non-emergent notification binder. 3. If the wound needed urgent attention, staff were expected to call the in-house or on-call provider. K. Record review of the facility wound policy and procedure, dated July 2015, revealed staff were expected to do the following when a new wound was identified: 1. Complete a Wound Nurse Screen Request 2. Notify the provider about the wound in the pink book (non-emergent provider notification binder). 3. For wounds that require treatment orders immediately- initiate Physician's Standing Orders based on best wound description, Or request in house provider assessment and treatment orders . R #10 L. Record review of R #10's admission Record (no date) revealed the following: 1. R #10 was admitted to the facility on [DATE]. 2. R #10 had the following diagnoses: Unspecified dementia (cases where the specific type of dementia cannot be clearly identified despite the present of cognitive decline and memory loss) with psychotic disturbance (serious mental illnesses characterized by abnormal thinking and perceptions, often resulting in a loss of contact with reality). M. Record review of R #10's physician's orders revealed the following: 1. an order dated 09/19/24 for ziprasidone (antipsychotic medication; used to treat severe mental health disorders which affect the ability to distinguish reality from fantasy) 20 mg give 1 capsule orally in the morning for dementia with psychotic features. 2. an order dated 09/19/24 for ziprasidone 80 mg give 1 capsule orally at bedtime for dementia with psychotic features. N. Record review of the facility policy Use of psychotropic medications, dated 08/21/25, revealed the following: 1. the effects of psychotropic medication on a resident's physical, mental and psychosocial well-being will be evaluated on an ongoing basis such as: a. upon physician evaluation, routine and as needed. b. during the pharmacist's monthly medication regimen review. c. during MDS review, quarterly, annually, significant change. O. Record review of R #10's assessments revealed the following: 1. Quarterly abnormal involuntary movement scale (AIMS; standardized tool used to assess involuntary movement side effects often associated with long-term use of antipsychotic medications) evaluations were completed on 11/11/24, 01/30/25, and 04/30/25. 2. There was no AIMS assessment completed for July 2025. P. On 09/22/2025 at 2:36 PM, during an interview with the DON, she confirmed the following: 1. R #10's quarterly AIMS assessment was not completed for July 2025. 2. her expectation is that AIMS assessment be completed quarterly.

Number of residents sampled: 2Number of residents cited: 2S483.10(f) Self-DeterminationThe resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the rights specified in paragraphs (f)(1) through (11) of this section.S483.10(f)(1) The resident has a right to choose activities, schedules (including sleeping and waking times), health care and providers of health care services consistent with his or her interests, assessments, and plan of care and other applicable provisions of this part.S483.10(f)(2) The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident.S483.10(f)(3) The resident has a right to interact with members of the community and participate in community activities both inside and outside the facility.S483.10(f)(8) The resident has a right to participate in other activities, including social, religious, and community activities that do not interfere with the rights of other residents in the facility.This REQUIREMENT is NOT MET as evidenced by:Based on record review and interview the facility failed to ensure residents were provided a choice about aspects of his/her life that are significant to the resident for 2 (R #3 and R #74) of 2 (R #3 and R #74) residents approved to self-administer medications by having a choice to keep medications in their room. These deficient practices could likely result in residents feeling a loss of humanity (the quality of being human) by not having a right to make choices about aspects of their life and feelings of despair (complete loss or absence of hope). The findings are: R#3 A. Record review of R #3's face sheet dated 09/23/25, revealed an admission to the facility on [DATE]. B. On 09/15/25 at 1:57 PM during an interview, R #3 revealed the following: 1. The facility removed R #3's Albuterol Inhaler (used to treat conditions by relaxing the muscles in the airways making it easier to breathe) and (Brand) mouthwash (a liquid used for rinsing the mouth which contains an antiseptic) from her room about 2 months ago and stated the facility told her it wasn't us but Santa Fe that directed the facility to remove the inhaler and mouthwash. 2. R #3 stated she feels like her humanity has been taken away. C. Record review of R #3's self-administration of medications assessment dated [DATE], revealed a physician note that R #3 is approved for self-administration of medications and can keep medications at her bedside. D. Record review of R #3's progress note dated 04/30/25, revealed the following: 1. R #3 is capable of storing medications in a secure location. 2. R #3 is capable of opening/closing medication containers. 3. R #3 can accurately tell time to know when medications need to be taken. 4. R #3 understands that skipping/choosing not to take a medication dose is a refusal of medication and she must notify staff when refusal has occurred. 5. R #3 is capable of administering eye drops/ointments. 6. R #3 is capable of administering topical medications. (including patches) 7. R #3 Is capable of administering inhalants or inhalers. 8. R #3 is capable of administering oral medications. 9. R #3 is capable of administering nasal sprays or drops. 10. R #3 can name her medications and their prescribed use. 11. R #3 can read the labels for her medication prescriptions. 12. R #3 can identify common side effects of her medications. 13. R #3 can state the time to take her medications. 14. R#3 Can state the proper dosage of her medications. 15. R #3 can dispense the proper amount of medication. 16. R #3 can document self-administration of medications. 17. R #3 can identify situations requiring the administration of PRN medications. 18. R #3 is approved for self-administration of medications. 19. R #3 may keep medications at her bedside. R #74 A. Record review of R #74's face sheet, dated 09/23/25, revealed an admission to the facility on [DATE]. B. On 09/16/25 at 09:27 AM during an interview, R #74 stated the facility took away his saline nasal spray (a mixture of salt and water that is used to moisturize, lubricate and flush the nose) and (brand) mouthwash from his bedside a month or so ago and he is not happy. C. Record review of R 74's self-administration assessment, dated 04/23/25, revealed R #74 is approved for self-administration of medications and may keep medications at his bedside. D. Record review of R #74's progress notes, dated 04/23/25, revealed the following: 1. R #74 is fully capable of storing medications in a secure location. 2. R #74 is fully capable of opening/closing medication containers. 3. R #74 can accurately tell time to know when medications need to be taken. 4. R #74 Understands that skipping or choosing not to take a medication dose is refusal of medication and he must notify staff when refusal occurs. 5. R #74 is fully capable of administering oral medications. 6. R #74 is fully capable of to name medications and their prescribed use. 7. R #74 is fully capable to read labels for medications. 8. R #74 is fully capable of identifying common side effects of medications. 9. R #74 is fully capable to state the time a medication is taken. 10. R #74 is fully capable to dispense the proper amount of medication. 11. R #74 is fully capable to document self-administration of medication. 12. R #74 is fully capable of identifying situations requiring PRN administration of medications. 13. R #74 is fully capable of administering one application of (brand) mouthwash as needed for mouth care. 14. R #74 is approved for self-administration of medications and may keep medications at his bedside. E. Record review of R #74's MAR (Medication Administration Record), dated September 2025, revealed the following: 1. R #74's (brand) mouthwash may be kept at his bedside. 2. R #74's saline nasal spray may be kept at his bedside. F. On 09/17/25 at 11:05 AM, during an interview, Charge Nurse #1 revealed the following: 1. A few months ago, there was a recommendation received by (name of facility pharmacy) to remove all medications from resident bedsides in the facility. 2. Removal included any mouthwash which contained alcohol. 3. All residents were assessed to determine if medication or mouthwash was permitted to be left at the bedside. G. On 09/17/25 at 11:30 AM during an interview, the DON revealed the following: 1. The recommendation was received by (name of facility pharmacy) 2. The DON does not have a copy of the recommendation from the (name of pharmacy) to present to the surveyor. 3. Charge Nurse #1 was directed to perform written assessments on all residents to determine if medications and mouthwashes may be permitted to remain at a resident's beside and these written assessments are kept in a binder on the unit. H. On 09/17/25 at 11:50 AM during an interview, Charge Nurse #1 revealed the following: 1. The written assessments were not completed or kept in a binder on the unit. 2. Documentation of the assessments should be located in a resident's progress notes. I. On 09/18/25 at 12:50 PM, during an interview, R #3 stated she has no recollection of agreeing to the removal of her Albuterol inhaler and (brand) mouthwash and has asked several times to have them returned to her bedside. J. On 09/18/25 at 1:00 PM, during an interview, R #74 stated he did not agree to have his saline nasal spray or (brand) mouthwash) removed from his bedside and the facility just took it.

Based on record review and interview, the facility failed to provide quality of care for 1 (R #4) of 3 (R #3, R #4, and R #5) residents reviewed for diabetes (chronic condition that happens from persistently high blood sugar levels) when staff did not administer diabetic medications to R #4 upon admission to the facility and did not monitor the resident's blood glucose when exhibiting symptoms of high blood sugar. This deficient practice likely resulted in R #4 being admitted to the hospital for diabetic ketoacidosis (DKA; a serious complication of diabetes that can be life-threatening. Occurs when blood sugar is very high, and ketones [acids your body makes when it's using fat instead of sugar for energy] build up in the body, causing symptoms of increased thirst, frequent urination, weakness and fatigue) and could likely result in other diabetic residents not starting their diabetes medications leading to complications, DKA, and potentially death. The findings are: A. Record review of R #4's admission record, no date, revealed she was admitted to the facility on [DATE] from the local hospital. B. Record review of the R #4's hospital discharge summary, dated 02/29/24, revealed a discharge plan: 1. Continued medications: a. Januvia (oral diabetes medication used to help lower blood sugar), 100 milligrams (mg; strength of medication) by mouth daily. b. Jardiance (oral diabetes medication used to help lower blood sugar and helps protect the kidneys), 10 mg by mouth daily. c. Glipizide (oral diabetes medication that helps control blood sugar levels by helping your pancreas produce insulin), 5 mg by mouth twice daily. d. Insulin glargine/Lantus (long-acting insulin that helps control blood sugar and starts to work several hours after injection and keeps working evenly for 24 hours), 20 units (measurement of insulin medication) subcutaneously (injected under the skin) twice daily. C. Record review of R #4's admission physician's orders (handwritten orders), dated 02/29/24, revealed the following: 1. Jardiance, 10 mg tablet. One tablet by mouth daily for diabetes type 2 (condition resulting from insufficient production of insulin, causing high blood sugar). 2. Other diabetic medications were not ordered. D. Record review of R #4's physician's order (order placed in computer), dated 02/29/24, revealed the following: 1. Accu-Check as needed for symptoms high or low, as needed for hyperglycemia (high blood sugar) symptoms or hypoglycemia (low blood sugar) symptoms. 2. Physician did not document orders for Januvia, Glipizide, and Insulin glargine/Lantus. E. Record review of R #4's admission nursing assessment, completed by RN #13 and dated 02/29/24, revealed the resident had blood glucose which measured 241 (If blood sugar over 240 mg/dL, you may be at risk for ketoacidosis (when your body produces high levels of blood acids called ketones) (normal non-fasting blood sugar level is 150 or less) on admission. F. Record review of R #4's progress notes revealed the following: 1. Medical Doctor note, dated 03/01/24, Note type: History and Physical. Diagnosis, Assessment and Plan: Type 2 diabetes mellitus with diabetic neuropathy (type of nerve damage caused by diabetes), unspecified whether long term insulin use. 2. Medical Doctor note, dated 03/03/24, on admission, the patient was continued on her oral diabetes medications (Januvia, glipizide and Jardiance). 3. Therapy note, dated 03/03/24, resident fatigued during task and required max assistance with clothing management and toilet hygiene from two CNAs. Resident verbalized she needed to drink a lot of water but it goes through me. 4. Therapy note, dated 03/04/24, resident struggled to perform stand, pivot, and transfer to commode. Resident verbalized I can't after two steps. Resident made five attempts to perform sit-to-stand from commode to front wheeled walker with failed attempts. Resident was provided time to rest and calm down but got more frustrated with each attempt. Resident began to cry. Certified Occupational Therapy Assistant (COTA) then called CNA for assistance. Resident required a two person assist for transfer to wheelchair from commode. 5. Therapy note, dated 03/05/24, resident fatigued very easily with activity and had noted desaturation (low blood oxygen) during limited ambulation. 6. Therapy note, dated 03/06/24, therapy arrived at resident's room for scheduled physical therapy (PT) visit. Resident reported she just got into bed and was tired. Resident refused to participate with PT today. 7. Therapy note, dated 03/07/24, resident fatigued easily with activity. 8. Nursing note, dated 03/08/24, staff did not administer Jardiance to the resident because it was not available. It will be delivered on 03/09/24. 9. Therapy note, dated 03/09/24, resident tolerated all activities well; however, she fatigued easily. 10. Therapy note, dated 03/10/24, resident was rescheduled for the occupation therapy (OT) session, because the resident was laying down and refused to get out of bed for scheduled time. The COTA observed R #4 in the dining area for the lunch meal, but the resident already completed her meal. The COTA observed the resident, and the resident did not make an attempt to self-propel (move on own) despite spouse leaving the table. The CNA assisted the resident, and she accepted. The COTA intervened and encouraged the resident to self-propel. R #4 used her right lower extremity (leg) and bilateral upper extremities (arms) to get down Hallway 3. R #4 made it to the double door and required extended amount of time, approximately 20 minutes. The CNA and RN were notified to encourage the resident to self-propel if time permitted. Resident complained of fatigue and requested assistance down Hallway 4 to return to her room. 11. Therapy note, dated 03/11/24, resident complained of fatigue and refused to get out of bed for the rescheduled OT session for lunch meal. Resident stated she ate a large breakfast and did not want to attend lunch meal today. 12. Nursing note, dated 03/12/24, resident refused to get up for lunch and stayed in bed to rest and sleep. 13. Therapy note, dated 03/12/24, resident fatigued easily with activity. R #4 had more difficulty with extending knees and picking up feet during transfers when fatigued. 14. Therapy note, dated 03/12/24 at 3:11 PM, resident lay in bed, sleeping. Therapy asked R #4 how she was doing. The resident responded with resting but did not open her eyes. The resident did not want to participate with PT and requested visit be rescheduled for 03/13/24 after lunch. 15. Therapy note, dated 03/12/24 at 7:26 PM, resident complained of being tired but agreed to working with PT initially. The resident appeared more fatigued over the past week, with limited endurance to activities. The resident did not appear highly motivated to work towards gaining strength, endurance, and improved mobility. Therapy planned to discontinue skilled PT and submit referral for the restorative nursing program (nursing care designed to improve or maintain the functional ability of residents). 16. Nursing note, dated 03/19/24 at 2:40 PM, resident's POA (power of attorney) came and took resident out on pass at approximately 2:20 pm. He stated that he felt comfortable transferring her. At 5:10 PM, the resident returned. The POA stated he did not take her out of the vehicle. He stated he drove her around and let her dogs come to the car. He said he did notice she was weaker. 17. Nursing note, dated 03/20/24, resident refused to get up for supper and stated, I am tired and not hungry. 18. Nursing note, dated 04/02/24, staff did not administer Jardiance to R #4, because it was not available. 19. Nursing note, dated 04/04/24, the resident had complaints of pain and not able to use right hand and fingers. The resident's grip strength was weak in bilateral hands, but it was weaker on right. book, and Therapy evaluation sent. 20. Nursing note, dated 04/07/24, resident sent out to emergency room due to being unresponsive and with a blood sugar of 529. 21. Nursing note, dated 04/08/24 at 2:00 AM, resident was admitted to hospital for management of DKA. 22. The record did not contain documentation staff reported R #4's thirst, increased urination, or fatigue to the physician or nurse practitioner. G. Record review of R #4's Electronic Medical Record revealed: 1. Staff did not check R #4's blood sugar when she had complaints of thirst, increased urination, fatigue, or when she missed doses of her Jardiance. 2. R #4's lab work, completed on 03/01/24, documented an A1C level of 8.8 percent (%) (an average A1C is below 5.6%). H. Record review of R #4's hospital history and physical, dated 04/08/24, revealed insulin was ordered upon discharge, both Lantus insulin and Accu-checks with sliding scale coverage (blood sugar checks with a scale indicating how much insulin is needed dependent on blood sugar reading). Assessment and Plan: DKA Accu-checks with sliding scale, Lantus, and gentle intravenous (IV) hydration (fluid through the vein). I. On 06/05/24 at 12:42 AM, during an interview with the Assistant Unit Manager, she confirmed staff did not start R #4 on all of her diabetes medications. The Assistant Unit Manager stated there was confusion with the resident's hospital discharge paperwork, and the facility was not sure if R #4 was to be on insulin. The Assistant Unit Manager confirmed no one from the facility contacted the hospital to clarify R #4's diabetes medications. J. On 06/05/24 at 3:22 PM, during an interview with RN #1, she stated she admitted R #4, and the provider directed staff to monitor the resident only if she had symptoms of high or low blood sugar. RN #1 stated there were not any specific symptoms for which staff were to monitor the resident. L. On 06/11/24 at 3:21 PM, during an interview, the DON stated R #4 had an order for Jardiance upon admission to the facility, even though the admitting provider reviewed and signed off on the hospital discharge paperwork. She also stated staff did not report R #4's symptoms of elevated blood sugar to a provider and staff did not check R #4's blood sugar levels and they should have. J. Record review of facility's diabetes policy, Nursing Care of the Older Adult with Diabetes Mellitus, revision date November 2020, revealed: 1. Symptoms associated with diabetes include: a. Hyperglycemia: Uncontrolled diabetes from lack of insulin or inadequate insulin results in hyperglycemia (blood sugar above target levels). Signs and symptoms of hyperglycemia include the following: increased thirst, frequent urination, fatigue. b. Diabetic ketoacidosis (DKA; diabetic coma). Ketoacidosis occurs when hyperglycemia is untreated and the cells begin to metabolize fat for energy (use fat for energy). The byproduct of fat metabolism is ketones, which build up quickly in the blood. Diabetic ketoacidosis is a life-threatening emergency that needs immediate medical attention. Symptoms include high blood sugar, weakness, and fatigue. The above findings resulted in Immediate Jeopardy that was called on 06/06/22 at 12:39 PM. A final Plan of Removal was submitted and approved on 06/07/24 at 2:24 PM. Implementation of the POR was verified on 06/11/24 at 4:15 PM. The Immediate Jeopardy was lifted on 06/11/24 and scope and severity was reduced to D. Plan of Removal New Protocols implemented 6/11/24 1. Identification of Residents Affected or Likely to be Affected: -The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome: -Residents demonstrating signs and symptoms of hyperglycemia were immediately transferred to the hospital. -Thirty-five (35) residents with the diagnosis of diabetes mellitus have potential to be effected. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring: -Identified residents with diabetes mellitus will be audited to ensure orders are in place to reduce and/or prevent risk of severe adverse outcomes. Audits including blood sugar monitoring are included as part of the resident medication and/or treatment record. -All applicable policies and procedures regarding admission assessment, physician orders and diabetic management were reviewed and revised when indicated by supporting professional references. -The DON and Nursing Supervisors implemented an post admission checklist for all admissions. Admission Checklist is completed following completion of provider assessment and physician orders entry. Checklist includes review to ensure proper order transcription, correct medication administration, instruction for appropriate physician notification when residents demonstrate symptoms of hyperglycemia/hypoglycemia, review of necessary medical information and that the physician contact was properly documented. Checklist includes double checks by admitting nurse and unit manager. -Admission checklist is completed following provider assessment at time of admission. Unit Manager/Nurse Supervisor will verify variances from documented treatment history to ensure orders are in agreement with treatment plan. -The DON or designee re-educated licensed nurses on facility policies regarding admission procedures and diabetic management as well as medication reconciliation guidelines. -Facility has secured additional providers to ensure that a provider is available in-house for all admissions. The provider will complete accurate review and completeness of admission assessments through reconciliation of all related admission documents. -Medical providers have been trained on facility protocols regarding review of all related admission documents prior to or at time of admission. Providers shall document agreement with and/or changes with treatment history. -Medical providers shall communicate with discharging entities to clarify any discrepancies in provided documentation. -Direct care staff will be in-service regarding signs and symptoms of hypoglycemia and hyperglycemia and proper procedure to notify appropriate nursing staff. -Direct care staff will be in-service on documenting all pertinent conversations in the electronic medical record. -Licensed nursing staff will document communication with the provider through SBAR process. Evidence of notification will be included in the electronic health record. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 6/7/2024

Based on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #21) of 3 (R #21, R #22, & R #23) residents reviewed for falls, when staff failed to: 1. Identify the cause of R #21's onset of fatigue and weakness. 2. Evaluate R #21's ability to safely use a wheelchair independently. This deficient practice likely resulted in R #21 falling multiple times and sustaining an intracranial hemorrhage (bleeding in the skull or brain tissue). The findings are: A. Record review of R #21's face sheet revealed she was admitted to the facility on [DATE]. B. Record review of R #21's care plan, dated 12/26/23, revealed the following: 1. R #21 had a functional abilities deficit (decreased capability to engage in one's surroundings and carry out desired physical and mental activities). a. R #21 was independent but may require supervision with ambulation (ability to walk without the need for any assistance). She may require greater assistance at times. b. R #21 may use a wheelchair during times of illness or unsteadiness. The care plan did not state the level of assistance for staff to provide when R #21 used a wheelchair. 2. R #21 was at risk for falls a. Monitor for any acute illness or any other changes, including level of consciousness which could increase resident's risk for falls. b. Note any decline in ADL (activities of daily living; all the basic skills you need in regular daily life, including walking and activities to maintain personal hygiene, such as toileting, dressing, and eating) performance or change in gait (a person's manner of walking), and notify nurse or provider PRN (as needed). c. PT (Physical Therapy; the treatment of disease, injury, or deformity physical methods with methods such as massage, heat treatment, and exercise rather than by drugs or surgery)/OT (Occupational Therapy; help residents relearn their daily living activities, like dressing or eating) evaluate and treat as ordered or PRN (as needed). C. Record review of R #21's Fall risk assessment, dated 03/22/24, revealed R #21 had a high risk for falling. D. Record review of R #21's PT Narrative Note, dated 10/23/23, revealed the following: 1. R #21 reported difficulty walking, fatigue, weakness, and dizziness. 2. R #21 requested a wheelchair. 3. PT recommended that R #21 ask for a wheelchair when she needed it (No evaluation for R #21's ability to use the wheelchair was done). 4. PT recommended that the wheelchair not be left in R #21's room. E. Record review of R #21's OT evaluation, dated 06/04/24, revealed the following: 1. R #21 reported symptoms of being lethargic (an unusual decrease in consciousness) and weakness starting in November or December 2023. 2. R #21 started using the unit wheelchair (wheelchair not assigned to any resident but was available to use for any resident on the unit) on 04/20/24. F. Record review of R #21's PT Narrative note, dated 05/21/24, revealed the following: 1. On 05/08/24, PT received a referral from nursing to evaluate R #21 due to unsteadiness in gait which the nurse believed would cause a fall. 2. On 05/14/24, PT met with R #21, and she stated she felt weaker and had been using the unit wheelchair. PT encouraged the resident to get out of bed for activities (No PT assessment or evaluation for R #21's ability to use the wheelchair was completed). 3. On 05/17/24, PT met with R #21 after she fell during a transfer to the wheelchair. a. R #21 reported pain to her right knee when she extended her knee. b. PT submitted a work order to get R #21 a wheelchair (R #21 was using the unit wheelchair) that she was able to self-propel (move herself) using her feet (No PT assessment or evaluation for R #21's ability to use the wheelchair was done). 4. On 05/20/24, R #21 was provided her own wheelchair (No PT assessment or evaluation for R #21's ability to use the wheelchair was done). G. Record review of R #21's nursing progress note, dated 05/17/24, revealed R #21 had an unwitnessed fall when she transferred self from her bed to the wheelchair. R #21 denied pain or injury to her head. H. Record review of R #21's provider note, dated 05/17/24, revealed the provider saw R #21 after her fall that day (05/17/24) and the resident reported pain in her right knee. I. Record review of the Acute Care Plan Fall Risk dated 05/17/24, revealed the following: 1. Problem: Has increase fall risk due to: weakness. 2. Staff did not document any other causes for R #21 fall or increased fall risk. J. Record review of R #21's nursing progress note revealed the following: 1. 05/18/24, revealed she was very weak and unable to sit straight up in bed. 2. 05/19/24, revealed R #21 reported being weak. Nurse told the resident if she did not get out of bed then she would get pneumonia. K. Record review of R #21's provider progress note, dated 05/20/24 (prior to the fall), revealed the following: 1. R #21 did not have breakfast in the morning and did not get up for lunch since her fall on 05/17/24. 2. R #21 reported she was very fatigued, lethargic, slept a lot, was not hungry, and did not feel good. 3. R #21 reported pain to her left leg and had a bruise on her right tibia (bone in the lower part of the leg). L. Record review of R #21's nursing progress note, dated 05/20/24, revealed the following: 1. Staff found R #21 sitting on the bathroom floor. 2. The resident reported she missed the toilet. 3. Staff transferred R #21 to the wheelchair. 4. The resident's pupils (round opening in the center of the eye) were unequal and unreactive to light. The right pupil was larger than the left (may be a sign of a very serious condition). 5. Staff contacted the provider, and the provider ordered for R #21 to go to the emergency department. M. Record review of R #21's Emergency Department Notes, dated 05/21/24, revealed the following: 1. The resident's right pupil was dilated (larger than usual). 2. The residents right and left pupils were not reactive to light. 3. The resident's visual fields (the portion of space in which objects are visible at the same moment during steady fixation of the gaze in one direction) were not intact. 4. The computed tomography scan (CT; a medical imaging technique used to obtain detailed internal images of the body) of the head and neck showed R #21 had a hematoma (bad bruise), a hemorrhage (an emergency condition in which a ruptured blood vessel causes bleeding inside the brain), and a midline shift in the brain (a shift of brain tissue across the center line of the brain). 5. R #21 was transferred to another hospital that had a neurosurgeon (a specially trained medical doctor who diagnoses and treats conditions that affect the brain, spinal cord and nerves) on 05/21/24. N. On 06/11/24 at 2:29 PM, during an interview with CNA #21, she stated the following: 1. R #21 currently needed assistance to get out of bed or to transfer out of a wheelchair. 2. R #21 was aware of how to use the call bell to call for assistance. 3. R #21 did not get up without assistance. O. On 06/11/24 at 2:32 PM, during an interview with RN #21, he stated the following: 1. Prior to her falls: a. RN #21 stated R #21 was too weak to go to the main dining room so she ate in the unit dining room (R #21's weakness had been going on for sometime prior to the falls). b. R #21 was independent with all activities. 2. He referred R #21 to therapy on 05/09/24 due to her weakness, unsteady gait, and inability to walk outside the confines of her room. P. On 06/11/24 at 4:57 PM, during an interview with CNA #22, she stated the following: 1. Prior to R #21's falls on 05/17/24 and 05/20/24, R #21 was independent with all ADLs, except she needed some assistance for showers. 2. R #21 would use the wheelchair when she felt dizzy or weak. 3. R #21 would notify staff when she needed assistance. 4. CNA #22 was never told R #21 needed assistance to transfer into or out of the wheelchair. 5. CNA #22 did not notice R #21 was weaker or used the wheelchair prior to R #21's falls on 05/17/24 or 05/20/24. Q. On 06/11/24 at 4:15 PM, during an interview with PT #11 she stated the following: 1. Staff provided R #21 with a unit wheelchair. 2. Staff asked for R #21 to be evaluated for her own wheelchair. PT #11 said she talked to R #21 (but did not assess), and R #21 said she felt weaker than normal. 3. R #21 was given her own wheelchair. 4. PT #11 said she did not assess R #21 for the use of the wheelchair. PT #11 said R #21 had used a wheelchair before in the past, and she knew how to use it. R #21 used the wheelchair for mobility. R #21 transferred on her own without any problems [in the past]. 5. PT #11 confirmed that R #21 fell on [DATE], and the resident used the unit wheelchair at that time. PT #11 said she did not assess the resident to confirm the resident knew how to safely transfer at that time. PT confirmed that she should have assessed R #21 for the use of the wheelchair. 6. PT #11 confirmed that R #21 fell on [DATE], and she used her own wheelchair at that time. 7. PT #11 said staff evaluated R #21 after the second fall, and it was determined R #21 needed the assistance of one person. 8. PT #11 said an assessment was not done to confirm R #21 knew how to safely transfer after the second fall, because she was to be assisted with transfers. 9. PT #11 said she should have done an assessment to make sure R #21 knew how to transfer safely to and from the wheelchair prior to R #21 using the wheelchair. R. On 06/12/24 at 11:32 AM, during an interview with UM #22, the following was revealed: 1. One wheelchair was designated for each unit. 2. There was not a process for a resident to use the wheelchair. Anyone could grab the wheelchair and use it. 3. Staff used the wheelchair if a resident was weak. 4. Staff would notify the nurse that the resident needed a wheelchair, and the nurse would put in a screening for therapy. 5. If the resident needed the wheelchair for a prolonged period of time, the unit wheelchair would remain with the resident until the facility was able to get them their own personal wheelchair (R #21 had the unit wheelchair for a prolonged time). 6. The decision to leave the wheelchair with a resident was determined by nursing and therapy (they made the decision to leave the wheelchair with R#21 for extended period of time without an assessment). 7. UM #22 thought therapy did the evaluation for a resident to have their own personal wheelchair (therapy only met with R #21 and did not evaluate her before putting in work order for her to have her own wheelchair). 8. She was not aware if the unit wheelchair was left with the R #21 unsupervised (R #21 used unit wheelchair during the fall on 05/17/24). 9. A wheelchair should not be left with a resident who was not assessed for their ability to transfer safely. 10. UM #22 confirmed that on 05/17/24, R #21 fell trying to transfer from her bed to her wheelchair. 11. The fall on 05/17/24 was an unwitnessed fall. 13. The wheelchair was left in R #21's room for her use 14. It was common for a resident to use the unit wheelchair without staff assessing the resident's ability to use the wheelchair and transfer to and from the wheelchair safely. 15. UM #22 confirmed that on 05/20/24, R #21 was given her own wheelchair. 16. PT should have assessed R #21's ability to use and transfer in and out of the wheelchair prior to being given her own wheelchair. 17. R #21 had an unwitnessed fall in the bathroom on 05/20/24 that resulted in R #21 obtaining an intracranial hemorrhage. 18. R #21 returned from the hospital on 06/03/24. S. On 6/12/24 at 12:03 PM, during an interview with the DON, she confirmed the following: 1. The unit wheelchair was to be used if a resident had a change in condition like pain or weakness. 2. If a resident needed the unit wheelchair long term, they should be evaluated by the provider and a referred to PT. 3. Nurses can use their judgement to leave the unit wheelchair with a resident in their room without a therapy evaluation. 49313

Based on record review, interview, and observation, it was determined that: 1) 4 staff members failed to use proper infection control practices of wearing appropriate PPE (personal protective equipment) for 2 residents, R #7 and R #114, who were on contact precautions for infectious disease when they failed to wear gowns when they were in close contact with the residents and their environment. 2) 2 staff members failed to use proper infection control practice of washing their hands after removing gloves after caring for R #7 and R #114. 3) RN checking fingerstick blood sugar for R #7 failed to ensure she followed the manufacturer instructions for disinfecting the blood sugar machine by using Hydrogen Peroxide Wipes. 4) Staff failed to follow manufacturers instructions for disinfecting a community bath tub used by 6 residents, 2 with previously identified with multi-drug resistant organisms. An Immediate Jeopardy was called on 06/15/17 at 9:10 am and the DON and Administrator were notified at that time. The final Plan of Removal from the facility's administration was accepted on 06/16/17 at 3:00 pm. The summary of the plan: 1) Hand hygiene retrained with competencies and return demonstrations, surveillance was begun with 15 staff members daily for 2 weeks, then continue surveillance at decreasing intervals with any deficient practice corrected immediately. Results to be review by infection control committee. 2) Contact precautions training with a quick identification process implemented. All staff trained in use of personal protective equipment and reasons for precautions. Quick identification process included dates of implementation and when precautions are to be discontinued. Audits of the process began and will follow the time frame/schedule in #1 and will reported to infection control committee. 3) IP Nurse to plan, organize, develop, coordinate, monitor and direct IP program as directed by DON to ensure an effective plan is maintained. DON will maintain supervision. 4) The disinfection procedure was updated in facility for use of Quat-256, staff retrained and audits have begun and will follow schedule in #1. Signs have been posed in Tub Room with instructions on how to use the disinfectant and the process of cleaning the tub. 5) The staff development power point used during new employee orientation and annual training has been updated to include proper and safe handling of disinfectants including dwell time. Return demonstrations will be included in the orientation. 6) Communication during shift to shift report by charge nurses to staff will include any isolation information regarding the residents. All audit finds will be discussed, as they become available in the Department head meetings. The plan of correction (sic) (removal) will be integrated in the Quality Assurance Performance Improvement program. The responsible party is the DON. Staff members for failing to follow policy for fail to complete required training will be subject to progressive discipline. 7) The facility will use cleaning products for equipment that are recommended by the manufacturer or CDC (Center for Disease Control) guidelines, including Accu-Check glucometers. All residents that have been in contact with facility glucometers will be monitored for signs and symptoms of infection. All nurses responsible for glucometers have been inserviced. Audits are scheduled and have begun. Results will be reported in infection control meetings. Upon confirmation by record review and observation of the implementation of the Plan of Removal, the IJ was lifted on 06/20/17 at 2:00 pm. This reduced the severity level to Level 2, E. Based on record review, interview, and observation, the facility failed to ensure infection control practices were followed when they failed to: 1) Ensure isolation gowns were worn when in close contact with residents on contact isolation precautions (measures intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) and perform hand hygiene after removing gloves after caring for 2 (R #7 and R #114) of 2 (R #7 and R #114) residents reviewed for contact precautions and having been identified with multi-drug resistant organisms; 2) Follow manufacturer instructions for disinfecting the community bathtub used by 6 (R #6, R #35, R #37, R #114, R #123, and R #135) of 6 (R #6, R #35, R #37, R #114, R #123, and R #135) residents who utilize the bathtub on E wing (per list provided by the DON on 06/20/17); 3) Follow manufacturer instructions for disinfection of a multi-resident use glucometer (a machine used to blood sugar) used for 15 residents residing in E wing (per list provided 06/20/16 by the DON of residents requiring finger stick blood sugar testing); and 4) Ensure effective infection control surveillance (refers to the ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks, to try to reduce morbidity and mortality and to improve resident health status), coordinate information, verify effective practice, and make timely interventions. These deficient practices could likely result in residents being exposed to potentially infectious agents that could result in illness, debility, and death. The findings are: PPE R #7 A. On 6/13/17 at 10:00 am, during observation of care for R #7, CNA # 2 was observed to have gloves on and to be in close contact with resident who was up in her electric wheelchair. CNA #2's bare arms and scrubs were touching the resident and the wheelchair. CNA #2 removed her gloves, and stated she needed to get a washcloth and towel. CNA #2 removed her gloves and left the room, pushing the door open with her bare hands on the door opener. She returned almost immediately with the items, put her gloves and resumed care of the resident. There is a sign on the resident's door stating, Contact Precautions and PPE (personal protective equipment like gowns, gloves, and masks) are in an [MEDICATION NAME] on the door. B. On 06/13/17 at 10:05 am, during an interview, RN #3 confirmed R #7 is on contact precaution for a drug resistant organism. She confirmed the staff should be wearing a gown if they are going to have contact with the resident and her surroundings, and that hand hygiene should be done immediately when gloves are removed. C. On 06/13/17 at 10:07 am, during an interview, CNA #2 stated, (Name R #2) is on precautions for something in her urine. They (other CNAs) gown when they change her brief. I don't have to gown, but I glove. I don't need to gown. D. Record review of physician orders [REDACTED].MDRO (multi-drug resistant organism). R #114 E. On 06/14/17 at 12:30 am, during observation, CNA #4, CNA #5, and CNA #6 were providing care for R #114. All the CNAs wore gloves, but no gowns. The CNAs were in close contact with the R #114, turning and repositioning her and were observed to be in close contact with bare arms and scrubs touching the resident and her bed. CNA #4 removed her gloves, and exited the room without performing hand hygiene. There is a sign on the resident's door stating, Contact Precautions and PPE (personal protective equipment like gowns, gloves, and masks) are in an [MEDICATION NAME] on the door. F. On 06/14/17 at 12:35 am, during an interview, CNA # 4 and CNA #6, CNA #4 stated, We glove but we do not need to gown because she (R # 114) has been on an antibiotic. We were just in there briefly. CNA #6 stated, She is not on isolation, just precautions. She has been on an antibiotic, so we just glove. G. On 06/14/17 at 1:40 pm, during an interview with LPN #1, when asked what type of precaution R #114 was on, she stated, I don't know but I'll check the chart . It might be contact precaution. After several minutes, LPN #1 stated she could not find the information in the chart and went to the medication room and after referring to note on the wall stated, She is on contact precautions. The CNAs should have been gowned to give care. They should do the alcohol rub (an alcohol based hand hygiene product) or wash their hands before they leave the room. H. On 06/15/217 at 11:10 am, during observation, it was observed that CNA #3 was providing care to R #114. CNA #3 had an isolation gown on that was completely untied and hanging down off his lower chest. CNA #3 assisted the resident in blowing her nose, and giving her a drink from a cup with straw and holding the straw to her mouth. The inside of the top of the isolation gown contacted the resident's bed and bedside table. CNA #3 shrugged upwards and pulled the gown over his scrubs as he finished caring for the resident. RN #4 was present in the doorway during this observation. I. On 06/15/27 at 11:20 am, during an interview, CNA #3 stated, I usually gown up better, but I thought she just wanted me to blow her nose, but then she asked me to do more stuff. Yes, I do think I cross contaminated (where organisms can be carried from one place to another). They have told us about that. I should have tied it up. J. On 06/15/17 at 2:17 pm, during an interview, RN #4 stated, I did see (name CNA #2) had has gown not tied and it had fallen partly off when he was taking care of R #114. I did not address it this morning. I figured everyone should know the right way (and chose not to redirect CNA #2). K. Record review of the physician's orders [REDACTED]. (contact) precautions due to wound coccyx/ischium (tailbone). L. Review of the undated facility procedure statement Infection Prevention and Control, Procedure Number: IP 01.06 Transmission Based-Precautions (precautions for residents with suspected or identified pathogen and its mode of transmission revealed: Procedure: 1. f. Gloves and hand hygiene: 2) remove gloves before leaving the isolation room and disinfect hands immediately. 1. g. Gown: Wear a gown to enter the room or for any interaction that may involve contact with the resident/patient or any surfaces in the resident/patient environment. M. Review of the Center for Disease Control 2007 Publication Guidelines for Isolation Precautions Preventing Transmission of Infections Agents in Healthcare Settings 1985-88, 870, 896 revealed: Handwashing recommended immediately after glove removal. II.E.1. Gloves. Gloves are used to prevent contamination of healthcare personnel hands when 1. anticipating direct contact with blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material; 2. having direct contact with patients who are colonized or infected with pathogens (a bacteria, virus or other organism that can transmit disease) that can be transmitted by the contact route II.E.2. Isolation gowns. Isolation gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW's (health care workers) arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material 24, 88, 262, 744-746. Tub Disinfection N. On 6/14/17 at 12:00 pm, during an interview and observation, CNA #1 stated, (Name R #114) gets a tub bath. I use the multiclean machine (a disinfection system designed for use with the Parker Bathtub) after every bath. It has its own chemicals. I use the spray (bottle) after I brush after I run the system. I don't know the name of the spray. I spray it (the tub) then pick up my dirty towels (it takes just a minute or two) and rinse it off. I don't think it (the spray) has to stay on any special length of time. CNA #1 showed me the spray bottle and had a hand-written sticker marked as Quat. CNA #1 took me to the housekeeping storeroom room where she said she refills the spray bottle. The bag of solution in the room is labeled Quat 256 (a disinfectant, germicidal detergent and deodorant used in health care settings). O. On 06/14/17 at 12:20 pm, during an interview, the Housekeeping Manager affirmed the Quat 256 is (W)hat housekeeping used to clean the floors, but it would be ok for a shower or bathtub. It has to sit (on the surface) for 30 seconds. P. Record review of the manufacturer's disinfection instructions and facility's policy and procedures revealed: 1. For the Buckeye Quat 256 revealed: Let the solution remain on surface for a minimum of 10 minutes. Rinse or allow to air dry. 2. For the Parker Bath hygiene/disinfection system revealed: 6. Allow the disinfected areas to stand for at least 10 minutes to give the disinfectant time to work. 9. After 10 minute contact or longer, drain the bath of residual disinfectant solution. 9. Rinse the bath .using clean cold water . 3. An undated facility document titled, Infection Prevention 01.10 Equipment Cleaning, Disinfection and Obtaining Environmental Cultures Procedure revealed: 8. a Disinfect the tub before and after resident use. e. Turn on the disinfectant hygiene system. g. Direct disinfectant spray to bottom of tub. i. Spray tub and accessories with disinfectant thoroughly. j. secure sprayer to injection point and squeeze trigger for 30 seconds. l. using long handled brush, clean tub and accessories. m. Wait 10 minutes, n. Drain disinfectant form tub. Q. Rinse tub and accessories thoroughly with clean water. S. use pre-mixed disinfectant spray on outside surfaces of tub; leave to air dry. Q. On 06/16/17 at 11:50 am, during an interview, the IP acknowledged that staff using disinfectants should know the amount of time they have to be left to be effective. She stated, If they don't wait the right amount of time, the germs might not be killed and someone could get sick. Glucometer Disinfection R. On 06/15/17 at 11:07 am, during observation of a medication pass for R #114, RN #4 was observed to check the resident's blood sugar with a multi-patient use glucometer. RN #4 then used Clorox Hydrogen Peroxide Disinfectant Cleaner Wipes to wipe down the machine and case. When asked if those wipes were recommended by the manufacturer for disinfection, RN #4 replied, Yes, they are. S. On 06/16/17 at 11:05 am, during an interview, UM #2 stated, We use Saniwipe Bleach wipes for glucometers. But both those wipes, the Clorox hydrogen peroxide wipes and Saniwipe Bleach, are both available in the medication room (where glucometers are kept). T. On 06/16/17 at 11:50 am, during an interview with the Infection Preventionist regarding the use of Hydrogen Peroxide wipes on the glucometer, she stated, Hydrogen Peroxide wipes are wrong wipe - that doesn't kill the germs right (sic). They (the residents) can get an infection. U. On 06/20/17 at 9:28 am, during an interview, RN #1 stated, I use bleach wipes on the glucometer. I have used the hydrogen peroxide wipes before on the glucometer, but now I know to use the bleach wipes. V. On 06/20/17 at 12:10 pm, during an interview, the Nurse Aide Program Coordinator stated, I also do training for new nurses or agency nurses on the equipment, reporting accidents and injury, things like that. I do teach about the glucometer. I had been using the hydrogen peroxide wipes in training, I had them return demonstrate (disinfection) with the hydrogen peroxide wipes. W. Review of the Center for Disease Control recommendations in Infection Prevention during Blood Glucose Monitoring and Insulin Administration: If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. X. Review of Accu-Check Inform 11 In-service Facilitation Guide (glucometer manufacturer instructions) revealed: Cleaning/Disinfection of Meter: Hospital-approved product is Clorox Germicidal Wipe (bleach) or Super Sani-Cloth Wipes. Y. Review of the undated facility document Infection Prevention and Control Procedure Statement, Policy Number: IP 01 revealed: Equipment of Supplies Procedure: 2. J. Equipment with manufacturer's instructions: 1) Select appropriate agent from facility approved disinfectants according to manufacturer's instructions. Facility Infection Control Program Z. On 06/14/17 at 9:12 am, during an interview, the IP stated, Either the provider (doctor or mid-level practitioner who cares for the resident) or myself decides if resident goes on contact precautions. I tell the nurses that if they have doubts they can put it on, then I'll evaluate. Any nurse could write it as an order to start the precautions. The unit managers and providers decide who cohorts (placing a resident in a multi-patient room when at least one of the residents has or had had an infection disease). If there is a question, they might ask me; but they don't have to. To come off isolation, I make the decision. I might speak with the DON or providers, but it can be just me. AA. On 06/16/17 at 11:50 am, during an interview, the IP stated, Facility-wide, our hand hygiene rates are 75-78 % Our hand hygiene at the 70's concerns me. We should be at 100%. No, we did not make a new goal or a plan about the percentage rate. We discussed it in the Infection Control Committee. The committee is me, all the directors, and a performance improvement person. Usually between 5 and 12 attends, no staff lower than director level. The managers could come if they wanted. Our medical director cannot attend, I send him a report. If there are breeches in infection control, I correct staff on the spot. I think we lack communication, but it depends on who the nurse is. If she (a nurse) sees a breech in infection control (by the CNAs), she should intervene. I don't know if it is part of the nurses' orientation. The managers are responsible for the handling and storage of linen. I am not involved in that. Not much comes though me, I am not the decision maker. I keep a log of all infections. I do not do investigations. BB. On 06/13/17 at 8:53 am, during a random observation of R #12 and interview with CNA #7, CNA #7 was asked which resident(s) in the two bed room were on contact precautions. CMA #7 looked at the Contact Precaution Sign on the door and the PPE supplies on the door and stated, I am not sure which one is on isolation. CC. On 06/13/17 at 8:55 am, during an interview, CMA #1 stated, (Name of R #12) is on isolation for impetigo (a skin infection). CMA #1 left and returned in just a few minutes to state that the isolation had been discontinued. DD. On 06/13/17 at 9:00 am, during an interview, CNA #7 as he returned, stated, I did clarify with the nurse, the resident is not on precautions anymore. EE. On 06/13/17 at 9:07 am, during an interview, RN #2 stated, (name R #12) came off precautions yesterday. (Name UM # 2) took her off. The techs (CNAs) were worried and the techs put it back up (the door signage and PPE supplies). I believe the IP confirmed she no longer needs it. It (the signage and supplies) has not been removed yet. The techs should know from the report. We (nurses) give them report. This morning I did not report anything about isolation precautions to them because I assumed she was off. FF. On 06/20/17 at 8:58 am, during an interview, UM #2 stated, I do hand (hygeine) audits monthly. The audits have been OK. They (staff) know you are watching. For the most part, they do their hand wash or use hand sanitizer. Educating the CNAs, as far as infection control--they go through orientation. I try and correct them at the time it (when they make a mistake in precautions) happens. The nurses should supervise (the CNAs) and direct care. I would want a nurse to stop, correct and educate them (the CNAs) if they see any infection control problem. I do not go to Infection Control meetings. It is the DON and ADON who go--and they relay the information to us. I don't meet with Infection Control nurse unless there is an issue. GG. On 06/20/17 at 10:21 am, during an interview, the Nurse Educator stated, (Name of the IP) does the new employee orientation for infection, and does the yearly updates. I don't usually have a role in that. We teach proper peri-care, handwashing--depending on the situation. It was known we were having UTI (urinary tract infection) issues. I have been doing training for peri-care (cleansing of the area that would be covered by a disposable brief) and other initiatives. The CNA trainer/coordinator would do most of the nurse training--contract (nurses on temporary assignment and under a contract for a specified period) and our own (nurses). They spend at least one day with her. HH. On 06/20/17 at 11:07 am, during an interview, the IP stated, UTIs are on the 2016-1017 goals for Infection Control. The Nurse Educator has been doing random peri-care observations. I don't necessarily get her surveillance of what she is doing. I haven't gotten peri-care results. She tracks her stuff and I track mine. When the IP was asked about the wrong type of disinfecting wipes used on the glucometers, she stated, I don't teach that. II. On 06/20/17 at 12:10am, during an interview the Nurse Aide Program Coordinator stated, I do the CNA training and Nurse orientation for a new nurse, or an agency (temporarily contracted through an agency) nurse. I work closely with the nurse educator; we work on projects together. If the infection control nurse needs me to do something, she will tell me. We work together very occasionally. It would be helpful to know what the infection control issues are. Occasionally, I will get an email to tell me something. I know they do yearly competencies for the CNAs; another person in education does that. I don't know if nurse supervision responsibilities of the CNAs are addressed by others, it is not something I do in nurse orientation.

Based on record review and staff interview, the facility failed to conduct a comprehensive assessment after knowing of a fall for 1 (R #999) of 3 (R #24, R #119, and R #999) residents sampled for fall with injuries; after it was reported that R #999 had a fall and had a swollen right knee and she was no longer walking or putting weight on that leg. This failed practice failed practice resulted in the facility not knowing of or treating a broken right femur. The findings are: A. Record review of R #999's Progress Notes dated 05/12/17 revealed the nurse's note that read, (Resident) did not get OOB (out of bed) today, c/o (complained of) pain to right swollen knee, reported she fell , fall was not noted or witnessed, staff and doctor aware of her claim, discharged home @ (at) 13:30 (1:30 pm). B. On 06/08/17 at 11:15 am, during an telephone interview, R #999 daughter stated that her brother was at the facilty early in the moring on 05/12/17 and R #999's right knee was swollen. He told her that she would not get out of bed and she was complaining of pain. When she got to the facility, R #999 would not get out of bed and was complaining of pain. When she asked R #999 whaat had happened, she could not provide an answer. C. On 06/15/17 at 4:45 pm, during an interview, RN #5 confirmed that she remembered R #999. She stated that she ambulated during her short stay without any assistance of a cane or walker and she complained of pain of one leg, but could not remember which leg. She further stated that on the day of discharge, she was told that R #999 had fallen, but it was not witnessed. She stated that she assessed R #999 and she had a swollen knee, but no bruising. She was in so much pain that she did not walk. She stated that when she talked to the doctor about the knee, the doctor stated that it was probably R #999's arthritis. When asked, she confirmed that no orders were given for x-rays or to treat the area. D. Record review of R #999's X-ray report from the hospital that she had her repair surgery dated 05/13/17 at 2:05 am revealed that her right thigh bone (femur) was broken right above her knee. The fracture is oblique (at an angle) and comminuted (broken into many pieces) and the proximal shaft (upper portion of the bone) is displaced laterally (shifted to the side) on the distal segment (lower portion of the bone). This required surgery on 05/13/17 to repair the fracture. E. On 06/20/17 at 1:30 pm, during an interview, the DON confirmed no incident report was filled out, no investigation was completed, and the incident was not reported to the SA. She further confirmed no orders to treat or to further examine the area were obtained before the resident was discharged .

§483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: This REQUIREMENT is Not Met as evidenced by: Based on record review and staff interview, the facility failed to provide a comprehensive assessment and treatment for 1 (R #999) of 3 (R #24, R #119, and R #999) residents sampled for fall with injuries, after it was reported that R #999 had a fall and had a swollen right knee and she was no longer walking or putting weight on that leg. This failed practice resulted in the facility not treating a broken right femur (thigh bone) The findings are: A. Record review of face sheet dated 05/09/17 for R #999 revealed a [DIAGNOSES REDACTED]. B. Record review of R #999's Progress Notes dated 05/12/17 revealed the nurse's note that read, (Name of Resident #999) did not get OOB (out of bed) today, c/o (complained of) pain to right swollen knee, reported she fell , fall was not noted or witnessed, staff and doctor aware of her claim, discharged home @ (at) 13:30 (1:30 pm). C. On 06/08/17 at 11:15 am, during a telephone interview, R#999's daughter stated that her brother was at the facility early in the morning on 05/12/17 and R #999's right knee was swollen. Her brother told her (R#999's daughter) that she (R #999) would not get out of bed and she was complaining of pain. When she got to the facility, R #999 would not get out of bed and was complaining of pain. When she asked R #999 what had happened, she could not provide an answer. The daughter stated staff were aware that R#999 was in pain, as they were in and out of the room throughout the morning. Daughter further stated that R#999 had surgery on 05/13/17 and continues with rehabilitation for the injury. D. On 06/15/17 at 4:45 pm, during an interview, RN #5 confirmed that she remembered R #999. She stated that she ambulated without any assistance of a cane or walker and she complained of pain of one leg, but could not remember which leg. She further stated that on the day of discharge (05/12/17), she was told that R #999 had fallen on her date of discharge, but it was not witnessed. She stated that she assessed R #999 and she had a swollen knee, but no bruising. She was in so much pain that she did not walk. She stated that when she talked to the doctor about the knee, the doctor stated that it was probably R #999's arthritis. When asked, she confirmed that no orders were given for x-rays or to treat the area. No documentation was found showing pain medication was provided. E. Record Review of R#999 Emergency Report (ER) dated 05/12/17 showed she arrived (was transported by family) at 6:30 pm at the ER for severe pain in the right knee with swelling. F. Record review of R #999's X-ray report from the hospital indicated that her surgery occurred on 05/13/17 at 2:05 am. This report revealed that her right thigh bone (femur) was broken above her knee. The fracture is oblique (at an angle) and comminuted (broken into many pieces) and the proximal shaft (upper portion of the bone) is displaced laterally (shifted to the side) on the distal segment (lower portion of the bone). This required surgery on 05/13/17 to repair the fracture. G. On 06/20/17 at 1:30 pm, during an interview, the DON confirmed no orders to treat or to further examine the area were obtained before the resident was discharged .

Based on observation, record review and interview, the facility failed to follow the care plan for 1 (#9) of 2 sampled residents (#9 and #89) evaluated for implementation of fall prevention care plans, resulting in the resident sustaining a fracture. Resident #9's care plan required transportation by staff members in a wheelchair when traveling long distances off the unit. On 02/27/11, during a smoke break, Resident #9 ambulated with a staff escort from the unit to a covered patio, 217 feet from the unit. On the return trip, the resident fell and broke his right humerus (upper arm). The findings are: A. Review of the Admission Record dated 03/01/11 revealed Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. B. Review of a Comprehensive Care Plan dated 04/10/10 revealed, "Self Care Deficit r/t (related to) hx (history) [MEDICAL CONDITION], displaced fracture of femoral neck... gait imbalance previous to [MEDICAL CONDITION] difficulty with ambulation related to [MEDICAL CONDITION] on 12/30/09, ataxic (lack of coordination of muscle movement) gait." 1. A handwritten entry dated on 09/08/10 instructed, "W/c (wheelchair) for off unit activities/long distances. Once at destination, may ambulate..." 2. A handwritten entry dated on 02/27/11 documented, "Fall in main hallway dx (diagnosis) R (right) humerus proximal (near) fx (fracture)..." C. Review of Nurse's Notes dated on 02/27/11 at 11:20 am revealed, "Notified by staff that Rs (resident) fell in main hallway. Found Rs outside of unit in main hallway near chapel, lying supine on floor. Rs c/o (complained of) R (right) shoulder pain. 'Hurts a lot,' he stated, ...while assessing Rs, noted he was in significant pain. EMS (Emergency Medical Services) called by (Physician #33). Rs was on his way back from smoking outside the lab area due to weather conditions. Rs was c/ (with) staff (CMA (Certified Medication Aide)) who took group of smokers out. Activities CNA (Certified Nursing Assistant) witnessed Rs fall. She stated he fell forward and he put out his arms to break his fall. She said she heard a thump and he rolled to his R side then to his back. ...Rs had tennis shoes on, laces were tied, floor was not wet or slick, it just seemed Rs lost his balance due to his chronic leaning forward gait and possibly walking too fast. Rs did not utilize w/c to go off unit to smoke at this time." D. Review of a Post-Fall Report dated 02/27/11 revealed, "Rs was to have w/c for long distances while off unit and this did not occur. Was accompanied by CMA while off unit." Under, "Why did interventions not work?" a handwritten entry revealed, "Care Plan was not followed." E. Review of hospital records revealed the following information: 1. A Consultation report dated on 02/27/11 revealed, "Right upper extremity has an obvious deformity of his shoulder. He has tenderness to palpation at the shoulder and with attempted range of motion... x-rays show that he has a shoulder dislocation with appears to be anterior (the front)... It is inferior (lower) as well. This does also show that he has some fracture fragments involving the greater tuberosity (lateral area of the head of the humerus)... the procedure as well as the risks and complications including loss of life, loss of limb, infection, neurovascular damage as well as the fact that we may not be able to reduce (reset) it, that he could still end up with problems with his shoulder, or that he may not regain his function were discussed with the patient ...will go ahead and try a closed reduction of his shoulder." 2. A Procedure note dated on 02/27/11 revealed, "presented with a right shoulder fracture dislocation for which he has undergone a reduction. At this time he was placed in a shoulder immobilizer." F. On 03/01/11 at 9:33 am, during an observation, Resident #9 was observed sitting in his room with a sling on his right arm. His right hand and wrist were swollen and larger than his left. Resident #9 was approached by Physician #33 and asked what his pain level was on a scale of 1 to 10, with 1 being no to little pain and 10 being a lot of pain. Resident #9 responded that his pain level was at an 8. G. During an interview on 03/01/11 at 10:00 am, Resident #9 was asked what happened to his arm. He reported that he had fallen and broken his arm. H. On 03/03/11 at 11:26 am, during an interview, CMA #32 reported that it had snowed the morning of 02/27/11 and since there was no covered area close by for residents to smoke under, they were taken through the lab area to a covered patio. "While coming back... I was keeping an eye on the rest of the people, five altogether ...(Resident #9) was even with me and, in front of the chapel, he just fell . I heard someone yell, and (I) turned around, and he was on the floor." When asked if Resident #9 had trouble walking, the CMA replied, "His feet kind of turn inside and sometimes he walks fast." When asked if he was supposed to be in a wheelchair to go out and smoke, she replied, "I did not know he was supposed to be in a wheelchair for long distances." When asked if that was in his care plan, she replied, "Yes, I think so." She was then asked if she had reviewed the resident's care plan before working on the floor that day, and she reported, "No, I deal with medications most of the time." I. On 03/03/11 at 2:14 pm, during an interview, Physician #33 was asked what was meant by "long distance" in Resident #9's care plan. He replied, "Where he was at was long distance (the patio behind the lab). What I understand happened, they had to pull staff from another floor and took him out for a smoke and the care plan wasn't communicated very well. As you go out, the first door to the left is the normal smoking area. That day was windy and snowy and so they will take them by my office where there is a covered area. It would be okay to walk out this door (the one to the normal smoking area) but when they went to where he was going, he was supposed to have been in a wheelchair. He has a funny shuffle-gait and gets going fast, and when he is going faster he leans forward, and that's what happened." J. On 03/03/11 at 2:15 pm, during an interview, Registered Nurse (RN) #12 reported that any area beyond the unit's normal smoking area would be considered long distance for Resident #9. She stated she had not given a report to CMA #32 regarding any special instructions to place Resident #9 in a wheelchair on that day. When asked how staff were made aware of the Care Plans, she replied, "I try to emphasize when giving or getting report that we don't forget we have to do this or that, but I did not do that that morning." K. On 03/03/11 at 3:30 pm, during an interview, the Assistant Director of Nursing (ADON) was asked to describe Resident #9's fall. She reported Resident #9, "... was taken out for smoking and taken out through the lab area to protect them (Resident #9 and other residents accompanying him) from the wind and snow, which is farther than he is used to going to smoke. He has a strange gait..." When asked what happened after the fall, she stated the fall had been referred for investigation. When asked how staff would be aware of special care instructions on the Care Plan, she stated, "We have a CNA worksheet that should mirror the Care Plan." When asked how a CMA would know, she stated, "On the cigarette box, we have a list of people with special equipment and special needs that is right on the box." When asked if that was present on the day of Resident #9's accident, she reported she could not answer the question. When asked if the accident was avoidable, she replied, "If they had followed the Care Plan, yes." L. On 03/03/11 at 3:49 pm, during an interview, Maintenance Staff Member #34 was asked to measure the distance between the door to the covered patio by the lab and the door to the unit. He measured 217 feet. When asked to measure the distance between the door to the unit's usual smoking area and the unit door, he measured 23 feet. M. On 03/03/11 at 4:57 pm, during an interview, the Director of Nursing stated that the CNA that usually took the residents out was busy so the CMA volunteered to assist. She further reported that there had been nothing taped to the outside of the cigarette box on the day of the accident regarding Resident #9's mobility Care Plan.

Based on observation, record review and interview, the facility failed to provide care planned assistive devices necessary to prevent an avoidable fall for 1 (#9) of 2 (#9 and #89) residents evaluated for fall prevention. Resident #9's care plan required staff to transport Resident #9 in a wheelchair when traveling long distances off the unit. On 02/27/11, during a smoke break, Resident #9 ambulated with a staff escort from the unit to a covered patio 217 feet from the unit. On the return trip, the resident fell and broke his right humerus (upper arm). The findings are: A. Review of the Admission Record dated 03/01/11 revealed Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. B. Review of a Comprehensive Care Plan dated 04/10/10 revealed, "Self Care Deficit r/t (related to) hx (history) hip fracture, displaced fracture of femoral neck... gait imbalance previous to hip fracture... difficulty with ambulation related to hip fracture on 12/30/09, ataxic (lack of coordination of muscle movement) gait." 1. A handwritten entry dated on 09/08/10 instructed, "W/c (wheelchair) for off unit activities/long distances. Once at destination, may ambulate..." 2. A handwritten entry dated on 02/27/11 documented, "Fall in main hallway dx (diagnosis) R (right) humerus proximal (near) fx (fracture)..." C. Review of Nurse's Notes dated on 02/27/11 at 11:20 am revealed, "Notified by staff that Rs (resident) fell in main hallway. Found Rs outside of unit in main hallway near chapel, lying supine on floor. Rs c/o (complained of) R (right) shoulder pain. 'Hurts a lot,' he stated, ...while assessing Rs, noted he was in significant pain. EMS (Emergency Medical Services) called by (Physician #33). Rs was on his way back from smoking outside the lab area due to weather conditions. Rs was c/ (with) staff (CMA (Certified Medication Aide)) who took group of smokers out. Activities CNA (Certified Nursing Assistant) witnessed Rs fall. She stated he fell forward and he put out his arms to break his fall. She said she heard a thump and he rolled to his R side then to his back. ...Rs had tennis shoes on, laces were tied, floor was not wet or slick, it just seemed Rs lost his balance due to his chronic leaning forward gait and possibly walking too fast. Rs did not utilize w/c to go off unit to smoke at this time." D. Review of a Post-Fall Report dated 02/27/11 revealed, "Rs was to have w/c for long distances while off unit and this did not occur. Was accompanied by CMA while off unit." Under, "Why did interventions not work?" a handwritten entry revealed, "Care Plan was not followed." E. Review of hospital records revealed the following information: 1. A Consultation report dated on 02/27/11 revealed, "Right upper extremity has an obvious deformity of his shoulder. He has tenderness to palpation at the shoulder and with attempted range of motion... x-rays show that he has a shoulder dislocation with appears to be anterior (the front)... It is inferior (lower) as well. This does also show that he has some fracture fragments involving the greater tuberosity (lateral area of the head of the humerus)... the procedure as well as the risks and complications including loss of life, loss of limb, infection, neurovascular damage as well as the fact that we may not be able to reduce (reset) it, that he could still end up with problems with his shoulder, or that he may not regain his function were discussed with the patient ...will go ahead and try a closed reduction of his shoulder." 2. A Procedure note dated on 02/27/11 revealed, "presented with a right shoulder fracture dislocation for which he has undergone a reduction. At this time he was placed in a shoulder immobilizer." F. On 03/01/11 at 9:33 am, during an observation, Resident #9 was observed sitting in his room with a sling on his right arm. His right hand and wrist were swollen and larger than his left. Resident #9 was approached by Physician #33 and asked what his pain level was on a scale of 1 to 10, with 1 being no to little pain and 10 being a lot of pain. Resident #9 responded that his pain level was at an 8. G. During an interview on 03/01/11 at 10:00 am, Resident #9 was asked what happened to his arm. He reported that he had fallen and broken his arm. H. On 03/03/11 at 11:26 am, during an interview, CMA #32 reported that it had snowed the morning of 02/27/11 and since there was no covered area close by for residents to smoke under, they were taken through the lab area to a covered patio. "While coming back... I was keeping an eye on the rest of the people, five altogether ...(Resident #9) was even with me and, in front of the chapel, he just fell . I heard someone yell, and (I) turned around, and he was on the floor." When asked if Resident #9 had trouble walking, the CMA replied, "His feet kind of turn inside and sometimes he walks fast." When asked if he was supposed to be in a wheelchair to go out and smoke, she replied, "I did not know he was supposed to be in a wheelchair for long distances." When asked if that was in his care plan, she replied, "Yes, I think so." She was then asked if she had reviewed the resident's care plan before working on the floor that day, and she reported, "No, I deal with medications most of the time." I. On 03/03/11 at 2:14 pm, during an interview, Physician #33 was asked what was meant by "long distance" in Resident #9's care plan. He replied, "Where he was at was long distance (the patio behind the lab). What I understand happened, they had to pull staff from another floor and took him out for a smoke and the care plan wasn't communicated very well. As you go out, the first door to the left is the normal smoking area. That day was windy and snowy and so they will take them by my office where there is a covered area. It would be okay to walk out this door (the one to the normal smoking area) but when they went to where he was going, he was supposed to have been in a wheelchair. He has a funny shuffle-gait and gets going fast, and when he is going faster he leans forward, and that's what happened." J. On 03/03/11 at 2:15 pm, during an interview, Registered Nurse (RN) #12 reported that any area beyond the unit's normal smoking area would be considered long distance for Resident #9. She stated she had not given a report to CMA #32 regarding any special instructions to place Resident #9 in a wheelchair on that day. When asked how staff were made aware of the Care Plans, she replied, "I try to emphasize when giving or getting report that we don't forget we have to do this or that, but I did not do that that morning." K. On 03/03/11 at 3:30 pm, during an interview, the Assistant Director of Nursing (ADON) was asked to describe Resident #9's fall. She reported Resident #9, "... was taken out for smoking and taken out through the lab area to protect them (Resident #9 and other residents accompanying him) from the wind and snow, which is farther than he is used to going to smoke. He has a strange gait..." When asked what happened after the fall, she stated the fall had been referred for investigation. When asked how staff would be aware of special care instructions on the Care Plan, she stated, "We have a CNA worksheet that should mirror the Care Plan." When asked how a CMA would know, she stated, "On the cigarette box, we have a list of people with special equipment and special needs that is right on the box." When asked if that was present on the day of Resident #9's accident, she reported she could not answer the question. When asked if the accident was avoidable, she replied, "If they had followed the Care Plan, yes." L. On 03/03/11 at 3:49 pm, during an interview, Maintenance Staff Member #34 was asked to measure the distance between the door to the covered patio by the lab and the door to the unit. He measured 217 feet. When asked to measure the distance between the door to the unit's usual smoking area and the unit door, he measured 23 feet. M. On 03/03/11 at 4:57 pm, during an interview, the Director of Nursing stated that the CNA that usually took the residents out was busy so the CMA volunteered to assist. She further reported that there had been nothing taped to the outside of the cigarette box on the day of the accident regarding Resident #9's mobility Care Plan.