Every finding on record at Gallup Nursing & Rehabilitation LLC

Based on record reviews and interviews, the facility failed to follow physician orders for 2 (R #50 and R #51) of 2 (R #50 and R #51) residents reviewed when: Facility staff failed to administer or withhold blood pressure medications as directed by blood pressure parameters (boundary or limit defining scope of particular activity or process) per R #50 and R #51's physician's order. If the facility does not follow physician orders for the management of a resident's blood pressure, then it is likely to result in the resident not maintaining optimal health outcomes as established by the medical provider. The findings are: R #50: A. Record review of R #50's physician's order dated 07/16/25 revealed, R #50's lisinopril (medication used to treat high blood pressure) medication was ordered to be held for systolic blood pressure (the pressure in the arteries when the heart beats, represented as the first (top) number in a blood pressure reading) less than 110 millimeters of mercury (mmHg). B. Record review of R #50's Medication Administration Record (MAR) dated 01/01/26 to 01/21/26, revealed R #50's lisinopril was administered on 01/05/26 with a systolic blood pressure of 105 mmHg. R #51: C. Record review of R #51's physician's orders dated 11/20/25 revealed, R #51's carvedilol (medication used to treat chronic heart failure, left ventricular dysfunction following heart attack, and high blood pressure) administration for hypertension (HTN; high blood pressure) to be held for systolic blood pressure of less than 110 mmHg or a heart rate less than 60 beats per minute. D. Record review of R #51's MAR dated 01/01/26 to 01/21/26, revealed the administration for carvedilol on 01/01/26 was documented as not administered, to see progress note. E. Record review of R #51's MAR dated 01/01/26 (for blood pressure and heart rate) revealed R #51 had a systolic blood pressure of 118 mmHg and heart rate of 70 beats per minute, which was within stated parameters of order for administration. F. Record review of R #51's progress notes dated 01/01/26 to 01/02/26 revealed the progress note did not document withholding administration of carvedilol for R #51. G. Record review of R #51's MAR dated 01/01/26 to 01/21/26, revealed R #51's evening systolic blood pressure on 01/01/26 was 118 mmHg and a heart rate of 70 beats per minute, same as the morning measurements. The evening dose of carvedilol is documented as administered to R #51. H. Record review of R #51's MAR dated 01/01/26 to 01/21/26, regarding administration of evening dose of carvedilol on 01/16/26, revealed R #51 was not administered the medication, and it was documented to see nurse's note. I. Record review of R #51's MAR vital signs (body temperature, pulse rate, respiration rate [rate of breathing], oxygen saturation [amount of oxygen in the blood], and blood pressure) dated 01/16/26, revealed R #51's systolic blood pressure was 156 mmHg and a heart rate of 60 beats per minute. J. Record review R #51's nursing notes dated 01/16/26 to 01/17/26 revealed a nursing note was not entered regarding withholding administration of carvedilol for R #51 with vital signs within parameters to administer medication. K. On 01/22/26 at 9:25 AM, during an interview with Director of Nursing (DON), she stated it is her expectation for resident's vital signs to be monitored and documented in the electronic MAR, and for medications to be administered or held according to parameters within the provider's order. The DON reviewed the MARs for R #50 and R #51, and stated her expectation is to hold lisinopril for R #50 on 01/05/26 as order states to hold for systolic blood pressure less than 110 mmHg, and R #50's systolic blood pressure was 105 mmHg. The DON stated the carvedilol for R #51 should have been administered on 01/16/26 as the systolic blood pressure and heart rate were within parameters written by provider to administer medication. The DON stated it is her expectation that nursing staff follow physician orders.

Based on observation and interview, the facility failed to maintain a safe environment and protect the residents from the potential for accidents and hazards by: Failing to ensure adhesive tape (is a strip of material with a sticky surface on one side that is used to hold, fasten, or secure items in place) applied to resident room floors remained secured and flat to the surface in Room (RM) #41, Failing to ensure a water hose connected to the ice machine remained secured within its protective case, allowing water to drip onto the floor in a hall that is accessible to all residents. This deficient practice is likely to affect all 57 residents listed on the facility census by creating a tripping and slipping hazards, which can put the residents at risk for falls and potential injury. The findings are: A. On 01/21/26 at 10:31 a.m., during an observation of RM #41, multiple strips of adhesive tape were applied directly on the bedroom floor near the bedside area. Several strips of tape appeared worn, partially detached, and curling upward at the edges. Dark adhesive residue remained on the floor where tape had deteriorated (worn out, damaged, or in worse condition than before, often from age, use, or lack of maintenance) or been removed, creating uneven and sticky surface areas which were a potential hazard for the room occupants. B. On 01/21/26 at 11:00 a.m., during an observation of the hallway leading to the dining room, a hose was connected to a wall-mounted water source next to the ice machine and it was actively dripping water onto the floor, creating a small puddle. The hose was intended to be secured within a clear plastic protective case; however, the clear plastic case did not securely hold the hose in place. C. On 01/23/26 at 10:30 a.m., during an interview with the Maintenance Supervisor (MS), he stated it was his expectation that tape applied to floors should be flat to the ground to prevent a tripping hazard. He further stated the water hose nozzle should be secured inside the clear plastic case to prevent dripping water onto the floor, which could cause a resident to fall. D. On 01/23/26 at 10:31 a.m., during an interview with the Administrator (ADM), she stated the hose should be always secured to prevent water from dripping onto the floor, as this could cause a fall. She also stated tape placed on the floor should remain flat with the surface to prevent residents from tripping or falling.

Based on observation and interview, the facility failed to ensure residents had a safe and functional environment for 7 (Rooms: RM's #15, 31, 33, 34, 36, 37, 43, 44 ) of 13 (RM's #15, 16, 17, 21, 25, 31, 33, 34, 36, 37, 43, 44, 45 and 49) rooms observed when the facility failed to: Repair walls with intact, smooth, and cleanable surfaces (scuff marks, chipped paint, uneven paint, visible putty).Repair windowsills and surrounding tiles.Repair fixtures and building components (heating vent and electrical outlet). These deficient practices are likely to expose residents to an unsafe and uncomfortable environment. The findings are: A. On 01/21/26 at 3:12 pm during an observation of RM #15, the windowsill closest to Bed B was unpainted and separating from the wall with a gap approximately 0.5 inches. B. On 01/23/26 at 9:50 am, during an observation of RM # 31, the bathroom walls had scuff marks and chipped paint. C. On 01/23/26 at 9:51am, during an observation of RM #33, the windowsill closest to Bed B had a loose tile. D. On 01/23/26 at 9:53 am, during an observation of RM #34, the windowsill closest to Bed B had a loose tile. E. On 01/23/26 at 9:55 am, during an observation of RM #36, observation revealed the residents heating vent had three horizontal broken slats (vent was damaged and could not properly control the flow of warm air). Further observation revealed the bathroom had scuff marks and chipped paint on the walls. F. On 01/23/26 at 9:57 am, during an observation of RM #37, observation revealed scuff marks on bathroom walls. G. On 01/21/26 at 10:13 am and 11:46 am, during an observation of RM #44, observation revealed the following: The interior bathroom door had visible wood putty (soft material used to fill holes, cracks, or gaps in wood to make the surface smooth before painting or finishing) that was not painted. The bathroom door and multiple walls had uneven paint coverage. Scuffed walls were present behind Bed-B. The windowsill beside of Bed-B was separating from the wall with an approximate one-inch gap. The electrical outlet housing (protective cover or casing that surrounds an electrical outlet and holds it securely in place) behind Bed A was separated from the wall. H. On 01/21/26 at 10:13 am and 11:46 am, during an observation of RM #43, the windowsill near Bed-B was separating from the wall. I. On 01/23/26 at 9:21 am, during an interview with the Maintenance Supervisor (MS), he stated all the scuff marks should be painted evenly. The MS also stated all the windowsills should be in good repair and not separating from the wall, as it could cause a draft or a resident could hurt themself. He stated it is his expectation the resident's rooms would all be in good repair, so they feel like they are at home.

Based on record review and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #67) of 1 (R #67) resident reviewed for baseline care plans. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are: A. Record review of the facility's Care Plans- Baseline policy dated December 2016 revealed, to ensure resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. B. Record review of R #67's face sheet revealed R #67 was admitted into the facility on [DATE]. C. Record review of R #67's baseline care plan revealed R #67's care plan was initiated on 01/12/26 (initiated and completed after 48 hours of admission). D. On 01/23/26 at 9:31 am, during an interview with Director of Nursing (DON), she stated it is her expectation R #67's baseline care plan should have been completed on 01/11/26. E. On 01/23/26 at 10:58 am, during an interview with the Administration (ADM), she stated it is her expectation resident's baseline care plans be completed within 48 hours.

Based on a record review and interviews, the facility failed to ensure medical records were complete for 1 (R #51) of 1 (R #51) resident reviewed when staff failed to: Document accurately and completely when R #51 was not administered medication per physician's orders. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents. The findings are: A. Record review of R #51's physician's orders dated 11/20/25 revealed, R #51's carvedilol (medication used to treat chronic heart failure, left ventricular dysfunction following heart attack, and high blood pressure) administration for hypertension (HTN; high blood pressure) to be held for systolic blood pressure (the pressure in the arteries when the heart beats, represented as the first (top) number in a blood pressure reading) of less than 110 mmHg or a heart rate less than 60 beats per minute. B. Record review of R #51's Medication Administration Record (MAR) dated 01/01/26 to 01/21/26 revealed the administration for carvedilol on 01/01/26 was documented as not administered, to see progress note. C. Record review of R #51's MAR dated 01/01/26 (for blood pressure and heart rate) revealed R #51 had a systolic blood pressure of 118 mmHg and heart rate of 70 beats per minute, which was within stated parameters of order for administration. D. Record review of R #51's progress notes dated 01/01/26 to 01/02/26 revealed no progress note documented withholding administration of carvedilol for R #51. E. Record review of R #51's MAR dated 01/01/26 to 01/21/26, revealed R #51's evening systolic blood pressure on 01/01/26 was 118 mmHg and a heart rate of 70 beats per minute, same as the morning measurements. The evening dose of carvedilol is documented as administered to R #51. F. Record review of R #51's MAR dated 01/01/26 to 01/21/26 revealed the evening dose of carvedilol on 01/16/25 was not administered to R #51, and it was documented as see nurses note. G. Record review of R #51's MAR vital signs (body temperature, pulse rate, respiration rate [rate of breathing], oxygen saturation [amount of oxygen in the blood], and blood pressure) dated 01/16/26, revealed R #51's systolic blood pressure was 156 mmHg and a heart rate of 60 beats per minute. H. Record review R #51's nursing notes dated 01/16/26 to 01/17/26 revealed a nursing note was not entered regarding withholding administration of carvedilol for R #51 with R #51's vital signs being within parameters to administer the medication. I. On 01/22/26 at 9:45 AM, during an interview with Director of Nursing (DON), she stated it is her expectation if a nurse is entering a medication as held and to see nurse's note or progress note, then a nurse's note or progress note should be documented stating the reasoning for holding medication. The DON confirmed R #51's medical record, regarding medication administration, was not accurate and should have been.

Based on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 1 (R #34) of 1 (R #34) resident reviewed for infection control when: The facility did not ensure R #34's urinary catheter (a thin, sterile tube inserted into the bladder to drain urine) drainage bag had a privacy bag (bag that covers urination drainage bag) present. The facility did not ensure R #34's urinary catheter tubing (is the flexible tube that carries urine from the catheter (inside the bladder) to the drainage bag outside the body) remained off the floor to prevent contamination. These deficient practices are likely to result in repeated and ongoing exposure of residents to increased risk of infection, cross-contamination, and injury. The findings are: A. Record review of the facility's Catheter Care Procedure (steps to maintain the catheter and drainage system), last revised June 2020, revealed the accepted procedure was to secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor. Policy revealed privacy bags will be placed over drainage bags when resident it out of bed. B. Record review of R #34's Face Sheet, revealed R #34 was originally admitted to the facility on [DATE] with diagnoses of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and Bladder neck obstruction (bladder neck becomes narrowed or blocked, leading to difficulty urinating). C. Record review of R #34's minimum data set (MDS, which was part of the federally mandated process for clinical assessment of all residents in nursing homes) completed on 10/20/25, indicated R #34 had a brief interview for mental status (BIMS; screening for cognitive impairment) score of 6 (00-07 is severe impairment). D. Record review of R #34's physician orders dated 08/15/25 revealed R#34 required an Indwelling Foley catheter (soft tube placed into the bladder that stays in place to continuously drain urine into a collection bag) PRN (as needed) for chronic urinary retention (bladder does not empty completely). E. On 01/20/26 at 12:04 pm, during a dining room lunch observation, R #34's catheter bag did not have a privacy bag present while R #34 was sitting in his wheelchair. F. On 01/20/26 at 12:56 pm, during an interview with Certified Nursing Aid (CNA) #5, she stated all residents should have a privacy bag covering their urinary drainage bags. G. On 01/22/26 at 1:00 pm, during an observation of the common tv area, R #34 sat in his wheelchair with his catheter tubing touching the ground. H. On 01/22/26 at 1:25 pm, during an interview with CNA #6, she stated the last CNA forgot to attach R #34's urinary catheter bag to his chair. She stated the catheter tube for R #34 should not be dragged onto the floor, as it could cause infection. CNA #6 also stated R #34's catheter tube could become caught and pulled out of the resident, causing discomfort. I. On 01/23/26 at 10:33 pm, during an interview with Director of Nursing (DON), she stated urinary catheter tubing should not be dragged on the floor. The DON stated if the catheter tube is touching the ground, it could cause an infection. The DON also stated the urinary catheter tube could get caught on something and pull the tube out of the resident. She confirmed there should always be a privacy bag on all the residents' catheter bags when they are out of their room. J. On 01/23/26 at 10:58 am, during an interview with the Administrator (ADM), she stated resident's catheter tubing should not be dragged across the ground, as it could get snagged and pull on the resident's appendage. The ADM also stated it is her expectation urinary catheter tubing for residents would be properly secured under the residents' chair. She confirmed residents should always have a private bag to cover the resident's catheter bag.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #'s 1, 2 and 3) residents when they failed to properly assess a resident following an unwitnessed fall that resulted in injury. If the facility fails to properly assess residents who have an unwitnessed fall with an injury, then the residents may experience unidentified life-threatening conditions such as a brain bleed. This deficient practice likely contributed to the hospitalization and passing of R #1. The findings are: A. Record review of Face Sheet for R #1 revealed an admitted [DATE] and a discharge date of [DATE] and included the following diagnoses: - Lack of Coordination - Muscle Wasting and Atrophy (wasting away) - Depression (mood disorder that causes a persistent feeling of sadness and loss of interest) - Generalized Muscle Weakness (muscle weakness that affects the whole body) - Dysphagia (difficulty swallowing) - Difficulty in Walking - Parkinson's Disease (a brain disorder that affects movement such as shaking, stiffness, and difficulty with balance and coordination) - Hypertension (high blood pressure) B. Record review of R #1's nursing progress note, dated 07/14/24, revealed he was admitted to the facility for skilled nursing services related to frequent falls. C. Record review of R #1's care plan initiated on 07/15/24 revealed resident was at risk for falls related to history of multiple falls, poor safety awareness, poor vision, Parkinson's, hypotentsion, new environment, deficit to his left side, decline in condition and needs assistance with ADLs (activities of daily living). D. Record review of R #1's nursing progress note, also dated 07/14/24, revealed that R #1 was found laying on the floor between the two beds. E. Record review of R #1's nursing progress note, dated 07/15/24, revealed that R #1 is a very high fall risk, having had one fall. Daughter stated he has very poor safety awareness and had multiple falls in the community with injury. Staff to continue to monitor. F. Record review of R #1's nursing progress note, dated 09/03/24, revealed that R #1 has poor safety awareness due to dementia and will attempt self-transfer/ambulation without assistance. Therapy informed of fall and care plan updated. Progress note did not provide any information on a recent fall. G. Record review of R #1's nursing progress note, dated 09/10/24, revealed that R #1 is impulsive and requires assistance with Activities of Daily Living (ADLs). Resident is not safely able to transfer or ambulate independently. Therapy notified of fall and care plan updated. Progress note did not provide any information on a recent fall. H. Record review of R #1's nursing progress note, dated 09/13/24 at 3:50 am, revealed that R #1 was found on the floor in his room laying on his stomach at the foot of the bed about one foot from the floor safety mat. Upon assessment resident noted to have a cut about 4 centimeters (cm - unit of measure) long over his right eye and that neuro checks (an evaluation used to assess the mental status of individuals with head injuries) were initiated. I. Record review of R #1's nursing progress note, dated 09/14/24, revealed the following vital signs were taken on 09/13/24: Blood pressure (BP) - 93/52 Temperature - 98.0 Pulse - 70, regular Respirations - 18 Oxygen (O2) - 97 percent (%) on room air (not using supplemental oxygen) J. Record review of R #1's nursing progress note, dated 09/15/24, revealed the following vital signs were taken on 09/14/24: Blood pressure (BP) - 104/44 Temperature - 97.9 Pulse - 64, regular Respirations - 24 Oxygen (O2) - 95% K. Record review of R #1's nursing progress note, also dated 09/15/24, revealed that R #1 had a change in condition of altered mental status and included the following vital signs: Blood pressure (BP) - 124/61 Temperature - 97.5 Pulse - 73, regular Respirations - 20 Oxygen (O2) - 93% This nursing note also revealed that R #1 was alert and oriented x1 (times one), began mumbling words, slowly responding to his name. Send to emergency room (ER) for CT scan (computed topography - medical imaging technique used to obtain detailed internal images of the body). L. Record review of R #1's Neuro Evaluations revealed that no neuro evaluations were completed or documented following R #1's unwitnessed fall on 09/13/24. M. Record review of R #1's Fall Risk Evaluations revealed no fall risk evaluation was completed following R #1's unwitnessed fall on 09/13/24. N. Record review of facility reportable incidents revealed no documentation of R #1's unwitnessed fall with injury on 09/13/24. O. Record review of facility Response to Falls policy revealed: Post-Fall Assessment and Monitoring - a. Following each resident fall, the Licensed Nurse will complete an incident report and perform a post-fall assessment and investigation. b. The Licensed Nurse will also complete the Neurological Flow Sheet for any un-witnessed fall, or witnessed fall with known head injury for 72 hours following the fall. c. Nursing staff, with the attending physician's guidance, will follow up on any fall associated with an injury until the resident is stable, and delayed complications like that of a late fracture or a subdural hematoma (bleeding of or near the brain) have been ruled out or resolved. i.) Delayed complications such as late fractures and major bruising may occur hours or several days after a fall. ii.) Signs of subdural hematoma or other intracranial bleeding (bleeding in the brain) can occur up to several weeks after a fall. P. Record review of R #1's hospital documentation dated 09/15/24, revealed that patient presented with altered mental status; his baseline is awake and alert x 3 (times three), however here he is awake and alert x 0; per nursing, this patient had a couple of falls over the last few days with 1 possibly as recently as last night; he is not moving his left lower extremity; he has bruising around the right orbital rim and around the right eye; the degree at onset was severe, the degree at present is severe. Patient was intubated (the process of inserting a tube into the mouth or nose and then into the airway). Patient has periorbital ecchymosis (dark purple or blue bruises under the eyes); was found to have a large left temporal lobe bleed (sudden bleeding in the brain); patient is greatly deconditioned (decline in physical fitness due to inactivity) and only exhibits limited movement in each of the limbs. I think that this bleed is probably the result of one of his falls. Patient was accepted by the triage physician at [name of hospital], he is now intubated, sedated (to make calm) on fentanyl (pain medication) and precedex (sedating medication used for patients who are intubated); awaiting transfer, flight team on their way. Q. Record review of R #1's radiology report dated 09/15/24 for CT scan of head, revealed the following: 1. Temporal parenchymal hemorrhage (bleeding in the brain) - this could represent an evolving hemorrhagic infarction (stroke) or a direct contusion (bruise) to the brain parenchyma (brain tissue). 2. Subdural (area between the brain and the skull) and subarachnoid (area between the brain and the tissue covering the grain) hemorrhage (blood loss). 3. Small intraventricular hemorrhage (type of bleeding that occurs within the ventricles of the brain). R. Record review of R #1's nursing progress note, dated 09/16/24, revealed that R #1 was admitted to [name of hospital]. S. Record review of R #1's care plan initiated 09/19/24 revealed At risk for abnormal bleeding or hemorrhage due to antiplatelet (medications that prevent blood clots from forming) use. T. On 12/17/24 at 11:01 am during an interview with the Director of Nursing (DON) and the Administrator (ADM), the DON stated that she would expect there to be neuro checks done for 72 hours and that a resident would only be sent out if there was an identified change in condition. DON further stated that R #1 had falls in July and then he was doing good with not having any and then it changed and he started having falls and the falls got closer together. She stated that she would have expected there to be neuro checks and verified that there were none done for R #1 following his unwitnessed fall on 09/13/24. DON stated that rounds are done each shift but that they are not documented. U. On 12/17/24 at 12:32 pm during an interview, Assistant Director of Nursing (ADON) stated that when she began her day shift on 09/13/24, the night shift nurse relayed the information about R #1 being found laying on the floor and that he had a laceration to the right side of his forehead and that the night nurse had began neurological checks for him, however there were none documented. ADON further stated that she was the only nurse on the floor on 09/15/24 because the other nurse had called out of work and that she remembers that R #1 was taking his medications and was verbally responding to her and was able to stand for her on 09/13/24 and 09/14/24, but that on 09/15/24 she noticed that he was choking on his medications (medications were administered crushed and with thickened liquids) and that he was also having weakness and was not responding to her. The ADON confirmed that the resident was sent out to the hospital. V. Record review of the complaint intake received by the State Survey Agency on 11/20/24 identified that R #1 passed away in the hospital. Based upon the evidence, immediate jeopardy was identified. The facility Administrator was notified on 12/17/24 at 2:43 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 12/18/24 at 12:11 pm. Implementation of the POR was verified onsite on 12/18/24 by conducting record reviews and staff interviews. Plan of removal: Resident was discharged to the hospital. Resident had an unwitnessed fall and neurological checks were incomplete. Residents who reside at the facility that have experienced an unwitnessed fall or a fall in which the resident hit their head have the potential to be affected by this alleged deficient practice. Review of the last seventy-two hours of fall occurrence were reviewed to validate, if any resident experienced unwitnessed fall and that neuro checks and vital signs were completed as scheduled, any issues identified to be addressed upon discovery. This audit was completed by the Director of Nursing by 12/17/24. Neurological Checks and Obtaining/Completing Vital Signs re-education for Licensed Nurses were initiated on 12/17/24 by Director of Nursing. If omissions noted within neurological checks and/or vital signs, Director of Nursing/designee to conduct a neurological assessment of the resident to ensure no neurological changes are noted, any issues identified to be addressed upon discovery. Director of Nursing and/or designee was re-educated by the Clinical Consultant on 12/17/24 on the following: - Fall documentation related to neurological checks and vital sign obtaining/completion as scheduled. Director of Nursing and/or designee will re-educate Licensed Nurses including agency personnel on the following: - Fall documentation related to neurological checks and vital sign obtaining/completion as scheduled. The above education will be completed by the Director of Nursing/designee, this education will be initiated on 12/17/24, all other licensed nurses will be educated prior to their next scheduled shift. This information will be presented in new hire orientation. The above audits to be completed daily for two weeks, then three times a week for two weeks, then twice a week for two weeks, then weekly for four weeks, then bi-monthly for additional two weeks, then randomly thereafter, any concerns identified to be addressed upon discovery. Facility Administrator will be responsible for the overall implementation and validation of this plan. Facility Medical Director will be informed of this plan and given progress updates. The Medical Director was notified of the Immediate Jeopardy on 12/17/24.

Based on record review and interview, the facility failed to provide facility Initiated Reports (mandatory self-initiated facility report of an incident) to the State Survey Agency (SSA) for 1 (R #1) of 3 (R #'s 1, 2 and 3) residents reviewed for incidents when staff failed to report an unwitnessed fall with an injury for R #1. The findings are: A. Record review of R #1's nursing progress notes dated 09/13/24 revealed that R #1 was found on the floor in his room laying on his stomach at the foot of the bed about 1 foot from floor safety mat. Upon assessment, resident was noted to have a cut about 4 centimeters long over his right eye. The wound was cleansed with normal saline, antibacterial ointment (topical medication used to prevent infections) was applied, and the wound was covered with a bandage which was used to reinforce and keep the resident from touching it. B. Record review of R #1's nursing progress note, also dated 09/15/24, revealed that R #1 had a change in condition of altered mental status. This nursing note also revealed that R #1 was alert and oriented x1 (times one), began mumbling words, slowly responding to his name. Send to emergency room (ER) for CT scan (computed topography - medical imaging technique used to obtain detailed internal images of the body). C. Record review of facility's Incident Report Log, received on 12/16/24 from the Administrator (ADM), revealed that no incident for R #1 having an unwitnessed fall with an injury had been reported. D. Record review of facility Response to Falls policy revealed: Post-Fall Assessment and Monitoring - a. Following each resident fall, the Licensed Nurse will complete an incident report and perform a post-fall assessment and investigation. b. The Licensed Nurse will also complete the Neurological Flow Sheet for any un-witnessed fall, or witnessed fall with known head injury for 72 hours following the fall. c. Nursing staff, with the attending physician's guidance, will follow up on any fall associated with an injury until the resident is stable, and delayed complications like that of a late fracture or a subdural hematoma (bleeding of or near the brain) have been ruled out or resolved. i.) Delayed complications such as late fractures and major bruising may occur hours or several days after a fall. ii.) Signs of subdural hematoma or other intracranial bleeding (bleeding in the brain) can occur up to several weeks after a fall. E. On 12/17/24 at 12:09 am during an interview, the Administrator (ADM) verified that the facility had not filed an incident report for R #1 for the unwitnessed fall with injury that occurred on 09/13/24 and further stated that she [Administrator] is the one responsible for filing the incident reports with the SSA but that she can only report an incident if she is made aware of it. She stated that the unwitnessed fall with injury had not been reported to her and that it should have been reported by the nurse. She stated that the nurse who wrote the progress note regarding the fall was an agency nurse who is no longer employed with the facility.

Based on interview and record review, the facility failed to ensure their binding arbitration agreement included a provision for convenient venue (a location in which to carry out arbitration proceedings which should be agreed upon and suitable for both parties) selection. Failure to include this provision in the agreement could likely result in residents who choose to seek arbitration experiencing frustration and difficulty deterring them from exercising their rights. This deficient practice has the potential to affect 56 of the 57 facility residents who signed the binding arbitration agreement. The findings are: A. Record review of the facility's Voluntary Arbitration Agreement, undated, revealed it did not contain a provision for the selection of a convenient venue should arbitration become necessary. B. On 10/10/24 at 1:00 pm during an interview with the facility Administrator, she confirmed the binding arbitration agreement did not include a provision for a convenient venue selection and added the provision was stated in the facility's Admission Guide. C. Record review of the facility's Admission Guide revealed a provision for convenient venue selection in cases of arbitration. Further review revealed the guide did not include a signed acknowledgement that the resident received it, understood it, and that it was to be included as a part of the Voluntary Arbitration Agreement.

Based on observation, record review, and interview, the facility failed to promote care with dignity and respect for 1 (R #35) of 1 (R #35) residents reviewed for residents' rights when staff closed the resident's room door against his wishes and without communicating why to the resident. This deficient practice is likely to result in residents feeling disrespected and as if they were kept in their room against their will. The findings are: A. On 10/07/24 at 1:35pm during at interview, R #35 stated the Housekeeping Manager (HM) #1 angrily slammed his door shut last week while he was listening to his music, which made him feel like the staff did not respect or care about his feelings. B. On 10/07/24 at 2:00pm, during an observation, R #35 listened to music. The volume was loud enough to be heard in the immediate hallway. Other residents in the hallway did not appear to be affected by the music. C. On 10/10/24 at 12:47pm, during an interview with HM #1, she recalled the incident in which she shut the resident's door and stated R #35's music was playing loudly while the staff had a meeting in the nearby conference room. She stated she was asked by the facility Administrator to close the resident's door. She stated she informed the resident that she would close his door. She stated she did not wait for a response from the resident, because she could tell he was agitated. D. On 10/10/24 at 1:00pm, during an interview and record review with the Administrator, she stated she was aware of the incident. The Administrator provided a written statement from HM #1, dated 10/04/24, which revealed HM #1 informed R #35's roommate rather than R #35 that she was closing the door.

Based on record review and interview, the facility failed to create a Baseline Care Plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #108) of 3 (R #15, #25 and #108) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents' condition due to staff not being aware of the care residents' need and residents not being able to attain or maintain their highest practical level of well-being. The findings are: A. Record review of the Face Sheet for R #108 revealed an admitted [DATE] and included the following diagnoses: - Acute respiratory failure with hypoxia (when there is not enough oxygen in your blood/body tissue).- Type 2 diabetic mellitus with neuropathy (high blood sugar with nerve damage). - Hyperlipidemia (high blood fat levels).- Obstructive sleep apnea (repeated breathing interruptions during sleep). - Hypertension (high blood pressure). - Atherosclerotic heart disease (build up of fats, cholesterol and other substances in and on the artery walls). - Congestive heart failure (when your heart can't pump blood well enough to meet the body's needs). - Pneumonia due to coronavirus disease (infection in the lungs). - Asthma (condition that affects the lungs and makes breathing difficult). - Muscle wasting and atrophy (loss of muscle mass and strength). - Overactive bladder. - Difficulty in walking. - Post COVID-19 condition [any medical condition that continues for more than 3 months linked to Covid-19 (contagious respiratory infection)] . B. Record review of baseline care plan for R #108 revealed it was created on 09/30/24, which was more than 48 hours after the resident's admission. C. One 10/10/24 02:31 PM during an interview with the Administrator, she stated staff should have created the baseline care plan for R #108 within 48 hours. She verified staff did not complete a baseline care plan for R #108 until three days after the resident was admitted to the facility.

Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #208) of 1 (R #208) residents reviewed for medication administration, when staff did not administer R #208's lactulose [a medication used to prevent and treat complications of hepatic encephalopathy (liver disease) by decreasing the amount of ammonia in the blood] as ordered by the medical provider. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered. The findings are: A. Record review of R #208's Physician orders revealed the following: Lactulose. Give 45 milliliters (ml) by mouth three times a day for enchphalopathy with a start date of 08/30/24. B. Record review of R #208's Medication Administration Record (MAR), dated September 2024, revealed staff did not administer the lactulose midday dose to the resident due to hold/see nursing notes on 9/3/24. C. Record review of R #208's nurse progress note, dated 09/03/24, revealed the resident had three loose stools since the morning. Staff did not administer the lactulose. D. On 10/10/24 at 3:33 PM, during an interview, the DON stated staff should not have held R #208's lactulose due to loose stools. The DON stated R #208's lactulose was ordered to address encephalopathy not constipation, and the medication helped to decrease ammonia levels in the blood. The DON stated loose stools would be indicative of the medication having the desired outcome.

Based on observations and interviews, the facility failed to: 1. Ensure that opened and accessed (has been opened or accessed) for a flex pen weren't dated as to when they were initially opened/accessed, by nursing staff. 2. Ensure that undated medications (not dated when opened) were not stored with dated medications that are available for use 3. Ensure that expired supplies are not stored with unexpired supplies in the storage rooms 4. To properly store medications in medications carts. 5. Ensure treatment/medication carts were kept locked when not in use. These deficient practices have the likelihood to result in 57 (fifty-seven) residents that were identified on the census list provided by Center Executive Director (CED) on 06/12/23, to receive medications that had either lost their potency or effectiveness. The findings are: Regarding Opened and Un-labeled Medications: A. On 06/12/23 at 10:45 am, during observation of the Hall A Medications Cart, three (3) medications were found to be undated as to when they were opened: 1. Senna Plus (a stool softener/laxative) in a bottle was opened with no open date. Upon inspection the bottle was noted to be about 1/4 full and this was confirmed with CMA (Certified Medication Aide) #1. 2. Omeprazole (used to treat stomach and esophagus problems such as acid reflux and ulcers) 20 mg (milligram) capsules were open and was 1/4 the way full a bottle. This was confirmed with CMA #1 that no open date was found. 3. Mucus Relief Guaifenesin (used to relieve chest congestion) Extended tablets 600 mg. These were house stock (medications used by residents in the facility). There was about 1/2 left in the bottle as confirmed by the CMA #1 and there was no open date located on the bottle. B. On 06/12/23 at 10:53 am, during observation of the Hall B Medication Cart, two (2) medications that were found to be undated as to when they were opened. 1. Famotidine (used to prevent and treat heartburn and acid indigestion) tablets 10 mg. The bottle was open with no open date. Confirmed this with CMA #1 that the bottle was open and that 18 tablets remained out of 30 tablets. 2. Loperamide Hydrochloride (is used to treat diarrhea) 2 mg tablets were not in the box they originated in. Two (2) tablets were found to be stored in a small plastic bag on the top shelf of the medications cart. No open date was found. C. On 06/12/23 at 11:03 am, during observation of Hall D Medication Cart revealed one (1) opened medications that had not been dated. 1. Aspercreme lidocaine patches (a cream to relieve minor muscle pain) came in a box of five (5) with four (4) left in the box. The box had no open date listed on the box. Findings related to Insulin Flex Pens D. On 06/12/23 at 11:03 am, during observation of the Hall D Cart revealed: 1. One (1) Insulin Glargine (a long-acting type of insulin) flex pen (is prefilled with insulin you don't have to load it) for R #15. This flex pen showed there were 140 units left out of 300 units. There was no open date and no use by date. It was confirmed by Licensed Practicing Nurse (LPN) #2 that there was no open date, and no use by date. 2. One (1) Insulin Glargine flex pen for R #8. The flex pen showed there were 140 units left out of 300 units. There was no open date and no use by date. It was confirmed by LPN #2 that there was no open date and no use by date. Findings related to Medication Storage Room: E. On 06/14/23 at 9:04 am, during observation of the medication storage room for the entire facility revealed fourteen (14) clear needleless connectors (devices that allow quick access to the infusion line). Two (2) expired 04/12/23, two (2) expired on 05/01/23, and five (5) expired on 05/18/23, and five (5) expired on 06/02/23. All were found in a drawer mixed in with needleless connectors (devices that allow quick access to the infusion line) that had not expired. F. On 06/14/23 at 9:07 am, during an interview with Licensed Practical Nurse (LPN) #2, she was unsure of the process on how expired supplies or medications are handled, but said that the Center Nursing Executive (CNE) and the Assistant Director of Nursing (ADON) do come in and pick at things (supplies or medications) checking them for expirations dates. LPN #2 also stated that when she is obtaining a medication or supply, she checks the expirations date to ensure it is not expired. G. On 06/14/23 at 9:20 am during an interview with the CNE, she was asked what the process was to discard expired supplies from the medication storage room. CNE stated,every month when I am preparing the medication for destruction, I looked at the OTC's (over the counter medications) and the supplies for expirations. What I will do is take the ones that expire first and place it to be used first. If I find they are expired. I will throw them away. When asked how CNE discards expired medications that are over the counter and not prescription, or narcotics they get thrown away. Supplies get thrown away. Findings related to treatment/medication carts kept locked when not in use: H. On 06/14/23 at 8:24 am, during observation, the medication cart for Hall D was noted to be unlocked with no staff near or observing it. I. On 06/4/23 at 8:26 am, during an interview with LPN #2, she stated, I did get nervous. I usually always lock it. This is my first week on the floor. 45426 J. On 06/12/23 at 4:47 pm, a medication cart was observed unlocked and unattended across hall from the therapy room. LPN #2, was observed to exit a resident's room at the end of the hall. The cart was observed to be unlocked for approximately 2 minutes. LPN #2 returned to the cart and was observed and heard to lock (with an audible click) the medication cart by pushing in the lock, which locks the cart. K. On 06/12/23 at 4:52 pm during an interview, LPN #2 confirmed the medication cart was unlocked and that it should be locked when unattended. She stated she had gone to give a resident medications. When she got back to the cart, she observed that it was unlocked, and locked it.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring: 1. Freezer units' temperatures were taken daily, 2. Proper handling techniques were used when handling cups and glasses when drinks were distributed to residents served in the dining room 3. Hands were not sanitized prior to handling residents' meals after handling resident's adaptive equipment during a meal. These deficient practices are likely to affect all 57 residents listed on the resident census list provided by the Administrator on 06/16/23; and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to. The findings are: A. On 06/12/23 at 10:42 am during an observation during the initial tour of the kitchen, the reach-in freezer's (located on the back wall of the kitchen) temperature log was observed to have missing temperatures for the for the evening dates of 6/9/23, 06/10/23, and 6/11/23. The temperature for the day shift of 6/10/23 was also missing. The chest freezer's (deep freezers shaped like a trunk with the door that opens up rather than to the side) temperature log was observed to have missing evening temperatures for 06/06/23, 06/07/23, 06/08/23, 06/09/23, and 6/11/23. The temperature was also missing for the day shift of 06/10/23. B. On 06/12/23 at 10:51 am, during an interview, with Dietary Cook (DC #1) confirmed that the dates were missing from the temperature logs for the dates observed. She stated that she was only responsible for the day temperatures and did not know why the evening temperatures were missing for those dates. She reported that the dietary manager was currently out on leave. C. On 06/12/23 at 12:17 pm during a dining observation, several facility staff, Licensed Pratical Nurse (LPN) #12, Certified Nursing Assistants (CNA) and unidentified facility staff were observed handling residents' cups and glasses by the rim of the cups as they distributed residents drinks throughout the meal. D. On 06/16/23 at 9:53 am during an interview, the Director of Nursing stated glasses and cups should be held around the outside of the cup, not on the top when serving residents. 47899 E. On 06/12/23 at 12:30 pm, during an observation of meal services, Medical Record's staff (MR #1) brought an unknown female resident into the dining room. As she was assisting the resident to her seat, MR #1 had to move another unknown female resident so that her legs would go over the legs of the table. MR #1 leaned over, moved the unknown resident's resident feet. Then, without washing or sanitizing her hands, MR #1 handled a meal tray and served it to the unknown resident she had just brought into the dining room. F. On 06/12/23 at 12:49 pm, during an observation, MR #1, rubbed an unknown male resident on the back, then without washing or sanitizing her hands, went and got another unknown resident some fry bread which was on a plate, and gave it too him. G. On 06/16/23 at 9:53 am, during an interview with the Center Executive Nurse (CNE), she confirmed that staff should be performing hand hygiene (hand washing) between each resident and after touching a resident. 40671 H. On 06/12/23 at 12:16 pm during a lunch meal observation, Certified Nurse Aide (CNA) #1 was observed to be handling the cups/bowls by the rim of the dish, with her bare hand covering the opening of the dish, as she was serving meals to residents. I. On 06/12/23 at 1:31 pm during a random lunch meal observation revealed, CNA #3 was observed to be handling the cups of beverages and bowls of soup by the rim of the dish, with her bare hand covering the opening of the dish as she was serving meals to residents. J. On 06/14/23 at 11:55 am during a random lunch meal observation revealed, CNA #3 was observed to be handling the cups of beverages and bowls of stew, with her bare hand covering the opening of the dish, as she was serving meals to residents.

Based on record reviews, interviews and observations, the facility failed to provide proper infection control practices by: 1. Not performing hand hygiene between residents, and 2. Providing resident care, not removing used gloves before entering the hallway. These deficient practices could likely affect all 57 residents in the facility on the census provided by the Center Executive Director (CED) on 06/12/23. Failure to practice infection control standards could likely cause the spread of infection and illnesses to residents and staff within the facility. The findings are: A. On 06/12/23 at 4:04 pm, during observation, Registered Nurse (RN) #1 walked from R #47's room with her gloves on. RN #1 then went into the treatment cart with the dirty gloves on, going through wound treatment items. RN #1 then walked down the hallway to the nurse's station, still wearing her dirty gloves, discarded her gloves and performed hand hygiene using hand alcohol gel. B. On 06/12/23 at 4:05 pm, during an interview with R #47's regarding wound care. R #47 stated, Nurses had been changing her dressing when she remembered she needed to get something she had forgotten. C. On 06/12/23 at 4:05 pm, during an observation of R #47's wound care revealed the wound was open, and the old dressing was sitting on the residents bed. D. On 06/12/23 at 4:06 pm, during an interview with RN #1, she stated, We should be performing hand hygiene before going into resident's room. After we do any type of care. We should not wear gloves in the hallway. E. On 06/16/23 at 9:45 am, during an interview with the Center Nurse Executive (CNE) she stated, Hand hygiene should be done before and after resident care, if they are exposed to any splashes (to scatter liquid or to cause liquid to scatter through the air or onto something) from the resident, or before entering and after the resident's room, after they touch anything dirty, they should do hand hygiene. D. Record review of the facility's policy titled: Infection Control Policy and Procedures regarding Hand Hygiene, Purpose: To improve hand hygiene practices and reduces the transmission of pathogenic microorganisms: Process: 1.1 Before patient/resident (hereinafter patient) care 1.2 Before an aseptic procedure 1.3 After any contact with blood or other body fluids, even if gloves are worn 1.4 After patient care 1.5 After contact with the patient's environment

Based on record review and interview, the facility failed to ensure that the resident's responsible party, Power of Attorney (POA) and/or family was notified of a resident's change in condition for 1 (R #49) of 1 (R #49) resident reviewed for weight decline. This deficient practice could likely result in the resident's responsible party, POA, and/or family not participating in important decisions regarding the resident's health and well-being. The findings are: A. Record review of R #49's nutrition progress notes dated 05/16/23, indicated the following: Current weight 124.4 lbs (pounds) triggers for 90-day weight loss -7.5% (percent) change comparison weight 2/20/23 150.2 Lbs, -17.2%, -25.8 lbs. B. Record review of R #49's Change in Conditions reports (CIC) for the dates of 04/07/23 through 05/19/23 revealed that no CIC reports had been completed for R #49's significant weight loss. The change of condition was not reported to POA. C. On 06/13/23 at 10:15 am, during an interview with the POA/daughter of R #49, she stated that she was not called or informed of R #49's decrease in weight documented on 05/16/23 in R #49's nutrition progress notes. POA/Daughter was never notified of any weight loss. D. On 06/16/23 at 9:45 am, during an interview with the Center Nursing Executive (CNE), she confirmed that Nursing staff should be notifying residents' responsible party, Power of Attorney (POA), or family members regarding weight loss. The CNE stated that a CIC report should be completed to show that the residents' responsible party, Power of Attorney (POA) and/or family was notified. CNE confirmed that a CIC wasn't in the chart for R #49. E. Record review of the facility's policy and procedure titled: Weights and Heights, under Significant weight change management: 2.1.1 Significant weight change is defined as: 2.1.1.1 5% in one month 2.1.1.2 10% in six months 2.3 The licensed nurse will notify: 2.3.2 Patient representative of weight changes and Dietitian recommendations. Notification will be documented.

Based on record review and interview, the facility failed to report an Injury of Unknown Origin to the State Survey Agency, for 1 (R #11) of 3 (R #s 11, 28, and 35) residents reviewed for Injury of Unknown Origin. This deficient practice is likely to result in the State Survey Agency not being aware of facility incidents, and unable to assure residents a safe and hazard free environment. The findings are: A. Record review of Face Sheet dated 10/01/15 for R #11 revealed this as an initial admitted and included the following diagnoses: Age-Related Osteoporosis (weakened bones due to the aging process), Weakness, Dementia (a group of symptoms that affect memory and thinking and interfere with daily life), Cognitive Communication Deficit (difficulty with thinking, understanding, and speaking), Personal History of Healed Traumatic Fracture (break in a bone), Pain, and Presence of Left Artificial Hip Joint. B. Record review of the Minimum Data Set (assessment tool used to assess the health and needs of residents) dated 04/14/23 revealed in Section C - Cognitive (how a person thinks, learns and remembers) Patterns - Brief Interview for Mental Status (an assessment used to determine cognitive ability in the elderly) revealed a score of 9 (scores are as follows: 0-7 = Severe cognitive impact; 8-12 = Moderate impairment; and 13-15 = cognitively intact). C. Record review of Progress Notes dated 09/24/22 at 00:37 (12:37 am) revealed, CNA (Certified Nurse Aide) alerted this nurse to bruising to Resident's (R#11) left knee and right hip. When asked, Resident reports she fell between the bed and wall in the evening (09/23/22) and they helped. Resident did not specify who or what day; however NOC (night shift) CNA reports Resident did not have bruising during night shift of 09/22/22 . Bruising is purple/blue in color, surrounded by erythema (redness of the skin) . D. Record review of Facility Incidents Log, as provided by the Administrator (ADM)on 06/14/23, revealed no documentation regarding an injury of unknown origin for R #11 for 09/24/22. E. On 06/16/23 at 10:13 am during an interview, the ADM and Corporate Administrator (CADM) verified that there was no incident report filed for R #11 for an Injury of Unknown Origin for 09/24/22. CADM stated that if there is an injury of unknown origin, she would expect it to be reported to the State Agency.

Based on observation, record review, and interview, the facility failed to implement an ongoing one-to-one, resident-centered activities program for 1 (R #52) of 3 (R #s 14, 20 and 52) residents looked at for activities. This deficient practice does not encourage stimulation for residents who have a physical condition; as it does not allow them to attend the regularly scheduled activities programs. This could potentially cause depression and an overall decline of the resident's well-being. The findings are: A. Record review of R #52's Face Sheet revealed that he was admitted to the facility on [DATE] with the following diagnoses: Severe Protein Calorie Malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and is being fed with a feeding tube (medical device to provide nutrition to people who cannot obtain nutrition by mouth) for all nutrition, Cerebral Palsy (a group of disorders that affect movement, muscle tone, balance, and posture and is caused by abnormal brain development or damage to part of the brain that controls muscles), Cachexia (a wasting disorder that causes extreme weight loss and muscle wasting), Dysphagia (a condition with difficulty in swallowing food or liquid and may interfere in a person's ability to eat and drink), Profound Intellectual Disabilities (require round-the-clock support and care. They depend on others for all aspects of day-to-day life and have extremely limited communication ability), Contractures all four limbs (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), Adolescent Idiopathic Scoliosis (a condition in which the spine is curved sideways in one or more areas with no known cause), Adult Failure to Thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). This is not all inclusive list of diagnoses. B. On 06/12/23 at 2:30 pm, an observation was made of R #52. He was lying in bed with eyes opened. There was no TV or music on for stimulation or background noise. C. On 06/13/23 at 8:59 am, an observation was made of R #52. He was awake, lying in bed with no music or TV on for stimulation or background noise. D. On 06/13/23 at 10:22 am, during an interview with Family Member (FM) #10, she stated that R #52 can sit up in a chair and likes to wear a hat. He likes music and that if a TV is on, it needs to be closer to him so he can see it. When asked about phone calls with her son (R #52) or a video visit, FM #10 was told by a staff member (name not recalled) that they are too busy to do that. E. On 06/14/23 at 8:29 am, during an interview with Activities Director (AD), she stated that it takes time to work with R #52 and he will respond to you with his eyes. AD stated that she does talk to FM #10, who told her [the AD] that she [FM #10] speaks with him in Navajo, so she [the AD] also speaks to R #52 in Navajo. AD will turn on music for him (R #52) and most of the time, she will turn it on a local Navajo station. AD stated that FM #10 has a wheelchair for him, but hasn't brought it in [to the facility] yet. There is also a hat that he likes to wear, but FM #10 hasn't brought it in [to the facility] either. FM #10 told her about a game she plays with R #52, where she has a handkerchief and plays peek a boo with him. The AD stated that she isn't comfortable with that game at this time; so she is waiting for FM #10 to come in so she [the AD] can see how she [FM #10] does it. F. On 06/16/23 at 11:44 am, during an interview with the AD Assistant and the AD, the AD Assistant stated that R #52 doesn't really know her [the AD Assistant] voice and he won't engage with her. When asked about reading to R #52, the AD stated that they had not tried that yet. G. Record review of the Recreation Assessment Care Plan initiated on 03/03/23 indicated the following interventions in activities summary: Resident is admitted on [DATE] from hospital. He is alert, resident unable to make needs known, unable to communicate. [R #52's] mother states he enjoys listening to native radio station, if TV is closer, he is able to watch TV, enjoys wearing cap by observing color, plays with handkerchief. Resident will be receiving one to one room visits 3 x (times)/week, working with sensory activities and hand massage. Resident will be encouraged to participate with activities of choice. Will monitor resident to next assessment period.

Based on record review, interview, and observation, the facility failed to ensure that restorative services (person-centered and designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) were being provided for 1 (R #15) of 1 (R #15) resident reviewed for mobility capabilities (ability to move purposely as you go throughout your day). This deficient practice could likely result in resident joints feeling contracted (when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) or weakened. The findings are: A. Record review of R #15's physician order dated 05/15/22 revealed Resident was to wear a left functional hand splint (a supportive device that helps prevent moving the affected body part while it is healing) in the AM, off at PM as tolerated. Staff to remove splint for hygiene, PROM (passive range of motion) and skin check. Every Shift (6 am to 6 pm). Order stated that the hand splint should be on during the AM shift, and taken off during the PM shift. B. Record Review of R #15's care plan revised 04/21/23 revealed that R #15 is at risk for contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and skin integrity (breakdown of skin tissue) due to cerebral vascular accident (CVA) and contracture to left hand. C. On 06/12/23 at 2:36 pm, during interview, R #15 stated that she was supposed to have a splint on her left hand, and that they (facility staff) never put it on her anymore. D. On 06/12/23 at 2:36 pm, during an observation, the resident didn't have a splint on the left hand. E. On 06/14/23 at 9:46 am, during an observation, the resident didn't have a splint on her left hand. F. On 06/14/23 at 12:05 pm, during an observation, the resident didn't have a splint on her left hand. G. Record review of the administration record of the ETAR (Electronic Treatment Record) was documented that the splint was on June 1 through June 15, 2023 during the AM shift and off during the PM shift. H. On 06/16/23 at 9:45 am, during an interview, the Center Executive Nurse (CNE) stated nurses are responsible for placing the splint on the resident. She confirmed that they are to put it in place during the morning, and then remove it during the night.

Based on record review and interview, the facility failed to ensure that 1 (R #110) of 1 (R #110) resident reviewed for behavioral health concerns, was receiving necessary behavioral health care to meet the resident's needs. This deficient practice could likely cause the resident to not receive the mental health care and assistance that they may need. The findings are: A. Record review of the Face Sheet for R #110 indicated that resident was admitted on [DATE] to the facility and was discharged on [DATE]. She had a mental health diagnosis of Bi-Polar Disorder (mental health condition that causes extreme mood swings that include emotional highs and lows, and depression). B. Record review of the Admission nursing note dated 02/10/23 at 12:00 pm indicated in the Mental Health/Behavior section: Pt. (patient) has expressed/verbalized sadness or symptoms of depression. C. Record review of the physician orders dated 02/24/23 indicated that a referral to (name of company that provides comprehensive behavioral care via video, and in-person psychology and psychiatry health services) was ordered. D. Record review of a nursing note dated 02/26/23 at 14:48 (2:48 pm) indicated in the Mental Health/Behavior section: Pt. has expressed/verbalized sadness or symptoms of depression. E. On 06/16/23 at 9:15 am, during an interview with Social Services Director (SSD), she confirmed that no appointment was made for mental health services for R #110. The SSD stated that her new assistant put in the order for mental health services on 02/24/23, but forgot to let her [the SSD] know about it, so the appointment was not made.

This is a repeat deficiency from a survey completed on [DATE]. The facility failed to provide the necessary treatment to residents with pressure ulcers (an injury to skin and underlying tissue resulting from prolonged pressure on the skin) to promote wound healing and the prevention of infection for 4 (R #1, 2, 3, and 6) of 6 (R #1, 2, 3, 4, 5 and 6) residents who were reviewed for receiving wound care for pressure ulcers, in which one of the resident was hospitalized [MEDICAL CONDITION] (infection in the blood stream), expiring in the hospital. This was indicated by: 1. Nursing staff not following physician's orders [REDACTED]. 2. Nursing staff were unable to complete the wound care treatments on their shift; 3. Nursing staff not notifying the physician of the resident's symptoms that included: an increased temperature, a low blood pressure and having a wound odor; providing the physician with the resident's assessment, to make a medical decision of possibly ordering an antibiotic (medication used to treat an infection). 4. Nursing staff providing the same wound care treatment for [REDACTED]. 5. Wounds not being evaluated to identify progress or decline and appropriate communications with the physician(s); 6. Nursing staff not following standards of practice for wound care by not documenting on the dressings as to the time, date and initials as to when the dressing was changed last; 7. Nursing staff not providing wound treatments completed as ordered and wound care treatments not being documented in the Treatment Administration Record (TAR) and validated wound treatments thru observations or visualization of the wound and wound dressings. The facility failed to provide the necessary treatment and services to prevent the development of pressure ulcers for residents in which a resident was not recognized as having an infection, likely resulted in for an unknown period of time, resulting in the resident becoming septic (having an infection in the blood), being hospitalized , and eventually contributing to the resident's death. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity of K being identified on [DATE]. The facility was notified on [DATE] at 5:55 pm. The facility took corrective action by providing a Plan of Removal on [DATE] at 9:45 am, and was accepted on [DATE] at 10:00 am. Based on the Plan of Removal the interventions included: 1. Resident #6 current treatment orders were reviewed and wound was assessed to identify need to revise treatment order on [DATE]. A call was placed to MD to discuss updating wound treatment orders and new orders were received. Completion date: [DATE]. 2. Beginning [DATE], re-education will be provided to licensed nursing staff that when they are unable to complete the wound care on their shift a call should be made to the CNE (Center Nurse Executive) to discuss a plan to have wound care completed and adjusting of scheduled time for wound care. Completion date: [DATE]. 3. Beginning [DATE], an audit was conducted by CNE/designee to identify other residents who could potentially be affected by not having their wound evaluated to identify progress or decline and appropriate communication to MD/practitioners. Current residents with wounds will be evaluated by CNE/designee to ensure current treatment is appropriate and refer to the MD/practitioner if revisions are needed to current wound treatment/interventions. Completion date: [DATE]. 4. Beginning [DATE], an audit was conducted by CNE/designee to identify other residents who could potentially be affected by not having their treatment completed as ordered and wound care documented on the TAR. Current residents with wounds will be audited to ensure wound treatment is performed per MD's orders, documented by nurse who performed the treatment on the TAR and validated treatment thru observation or visualization of the wound dressings. Completion date: [DATE]. 5. Re-education to licensed nurses on completing wound care as ordered, documenting the treatment provided on the TAR and reporting any complication noted when performing wound care to MD/practitioner. If nurse is unable to perform wound treatment as ordered prior to the end of shift, Nurse is to contact the CNE or supervisor. Re-education began on [DATE] by the CNE/designee and nurses not currently trained will be re-educated prior to beginning of their next scheduled shift. Completion date: [DATE]. 6. Re-education to licensed nurses with regards to weekly wound evaluations and document status of wound and to report if wound is significantly improving or showing decline and communicate to MD/practitioners for further interventions or revision in treatment if indicated. Re-education began on [DATE] by CNE/designee and nurses not currently trained will be re-educated prior to beginning of their next scheduled shift. Validation of retention of re-education will be measured by each nurse passing a post-test beginning [DATE]. Completion date: [DATE]. 7. Wound rounds will be conducted weekly by the Skin Integrity Coordinator and member/s of the Interdisciplinary Team. During the weekly Clinical Meeting, CNE/designee will review the weekly Skin Integrity Report wound evaluation note, treatment documentation to monitor wound progress or decline. Any changes to wound status will be reviewed to ensure communication to the Medical practitioner for further interventions or revision in treatment as needed. Completion date: Ongoing. 8. CNE and the Nursing Management Team will monitor and review weekly to ensure residents receive the care they require to prevent the development of pressure ulcers, wound evaluation, wound treatment is provided as ordered and promote the healing of pressure ulcers. Completion date: Ongoing. 9. On [DATE], the CED (Center Executive Director) held an Ad Hoc (a solution developed for a specific purpose) Quality Assurance and Performance Improvement (QAPI) meeting with the Performance Improvement Team to review the Skin Integrity policy/procedure and the Performance Improvement measures outlined in this document. The Committee reviewed results of the audits in which compliance is achieved on [DATE] and appropriate corrective measures were put in place. CNE/designee will report findings of audits in the monthly QAPI meeting. Committee will continue with the performance improvement audits for monitoring of compliance and report on the next meeting monthly for three months or until compliance is achieved as determined by the Committee. The plan will be updated, reviewed and revised as needed monthly in the QAPI meeting. Completion date: Ongoing for the next 3 months. Based on the acceptable Plan of Removal, the IJ was lifted on [DATE] at 10:30 am. This resulted in the scope and severity being reduced from level K to a level H. Based on record review, interviews, and observations, the facility failed to ensure that a resident was provided the necessary treatment and services, that are consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing for 6 (R #1, 2, 3, 4, 5, and 6) of 6 (R #1, 2, 3, 4, 5 and 6) residents who were reviewed for receiving wound care for pressure ulcers and one resident who was hospitalized . This was indicated by: 1. Nursing staff not following physician's orders [REDACTED]. 2. Nursing staff not notifying the physician of R #1's symptoms that included: an increased temperature, a low blood pressure and having a wound odor. These symptoms would indicate to the physician, that R #1 had the potential of a possible blood and wound infection. R #1 was hospitalized , and eventually expiring in the hospital; 3. Nursing staff were providing the same wound care treatment for [REDACTED]. 4. Wounds were not being evaluated to identify progress or decline, by not having appropriate communications with the physician(s); and 5. Nursing staff not following standards of practice for wound care by the deficient practice of not documenting on the dressings as to the time, date and initials as to when the dressing(s) were changed. The findings are: Findings related to R #1: A. Record review of R #1's medical record indicated the following: 1. Review of the face sheet indicated that R #1 was admitted to the facility on [DATE], from a long hospital stay from [DATE] through [DATE]. 2. Review of the R #1's Discharge Summary from the hospital, dated [DATE], revealed the following: a. R #1 was admitted to the facility with the following Diagnoses: [REDACTED]. or mass of dead tissue separated from surrounding living tissue as in a wound, sore, or inflammation) and measured 2.5 x 3.5 x 0.8 cm, dementia (a group of thinking and social symptoms that interferes with daily functioning), volume depletion (or extracellular fluid volume that occurs as a result of loss of total body sodium, causes by vomiting, diarrhea, burns, kidney failure), lactic acidosis (when lactic acid buildsup when there is not enough oxygen in the muscles to break down glucose (too much sugar in the blood). It is caused when the blood pressure is low and too little oxygen is reaching the body's tissue), hypomagnesium (there is a low level of serum magnesium in the blood, caused by a chronic disease, renal losses and gastrointestinal losses), CKD ([MEDICAL CONDITION], means the kidneys are damaged and can't filter blood as they should), diabetes (a group of diseases that result in too much sugar in the blood), [MEDICAL CONDITION] (a disorder if the central nervous system that affects movement, often including tremors) and hypertension (having high blood pressure), and [MEDICATION NAME] (having a low [MEDICATION NAME] are seen in inflammation, shock, and malnutrition} laboratory results dated [DATE], indicated a level of 2.8 (normal range is 3.5 to 5.0). b. R #1 was discharged from the local hospital on [DATE], with the following physician orders: [MEDICATION NAME] (antibiotic, used to treat infections) 875 mg (miligram) by mouth twice a day, with a stop date of [DATE]; a sports bed (an air mattress used for residents that spend long amounts if time in bed and who are unable to turn themselves and are subject to getting skin ulcers); sacral decubitus care: Dakin's solution (used in pressure ulcers with necrotic tissue (dead tissue) to help control infection) wet to dry dressings two times a day and left Iliac crest (hip) decubitus ulcer care: Normal saline wet to dry dressings two times a day. B. On [DATE] at 7:45 am, during an interview, R #1's daughter stated that she noticed the smell right away on [DATE], she was concerned. She told RN #3, who told her, Don't worry about it, we will take care of it. She stated that she knew that smell. She knew that her mother had another wound infection. She stated that the facility was slow with everything, like ordering antibiotics. She stated that they treated her mother like she was on hospice, but she wasn't on hospice while she was at that facility. She felt like her mother didn't get enough care. C. On [DATE] at 10:15 am, during an interview, R #1's daughter stated that she was upset about the care her mother received at the facility. She stated that when she brought it up that in her mother's room, there was an odor, which was on a Sunday ([DATE]). She thought that her mother had another infection from her wound. She stated, I talked to the nurses, but they didn't do anything about it. D. Record review of the Skin Integrity Report dated [DATE] through [DATE], for the sacral wound, (which is a stage 3), revealed the following: a. The report initiated on [DATE], indicated the sacral wound measured 7.5 x 5.5 x 3.5 cm, with no U undermining (occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wounds edge) or T tunneling (wounds that reach through layers of tissue, often including deeper skin layers and muscle, forming tracts, or tunnels). b. The next wound measurement occurred on [DATE], which indicated the wound measured 7.5 x 5.5 x 3.0 cm, and there was either U or T (not indicated) at the 12:00 position (Face of the clock), that measured 2.0 cm, on the wound. c. The next wound measurement occurred on [DATE], which indicated the wound measured 7.5 x 5.5 x 3.0 cm, and there were two areas either U or T (not indicated), one at the 12:00 position, that measured 2.8 cm, and another area at the 9:00 position, that measured 1.5 cm, on the wound. d. The next wound measurement occurred on [DATE], which indicated the wound measured 7.5 x 5.0 x 3.0 cm, and the two areas either U or T (not indicated), measured 2.5 cm at the 12:00 position and 1.2 cm at the 9:00 position. R #1 was transferred to the local hospital on [DATE]. E. Record review of the Skin Integrity Report dated [DATE] through [DATE], for the left hip wound, (which is unstageable), revealed the following: a. The report initiated on [DATE], indicated the left hip wound was unstageable and measured 2.5 x 3.5 x 0.8 cm, with no U or T being indicated. b. The next wound measurement occurred on [DATE], the left hip wound was unstageable and measured 2.5 x 3.5 x 1.3 cm, with no U or T being indicated. c. The next wound measurement occurred on [DATE], the left hip wound was unstageable and measured 3.0 x 4.0 x 1.0 cm, with 2 areas either U or T (not indicated), measured 1.5 cm between the 9:00 o'clock and 11:00 o'clock positions and 2.5 cm at the 12:00 o'clock position. d. The next wound measurement occurred on [DATE], the left hip wound was unstageable and measured 4.0 x 4.5 x 0.6 cm, with the 2 areas either U or T (not indicated), measured 1.5 cm between the 9:00 o'clock and 11:00 o'clock positions and 2.4 cm at the 12:00 o'clock position. R #1 was transferred to the local hospital on [DATE]. F. Record review of the Treatment Administration Record (TAR) dated [DATE] - [DATE], indicated the following: 1) physician order [REDACTED].) two times a day for left hip wound. Times were indicated as the day shift and the evening shift. a. On [DATE] for the pm (evening shift), there was no indication or documentation in the TAR or the nursing progress notes that wound care had been completed either for the sacral wound care or the left hip wound care. There was no further documentation in the Nursing Progress notes on this date to indicate if the wounds were treated or not. b. On [DATE] at 2:20 pm, during an interview, Licensed Practical Nurse (LPN) #1, stated that she works the evening shift 3 pm to 11 pm, Monday through Friday. She stated, We need a treatment nurse for the evening shift. She stated in regards to the documentation in the treatment notes, she stated, If I can't get to the treatments, I document an NN, which indicates documentation in the nurses notes or I did not do the treatment. G. Record review of the Nursing Progress notes, revealed the following: a. On [DATE] at 5:58 am, (Registered Nurse, RN #1) indicated that the Dakin's Solution was not available in the facility, (R #1 was admitted to the facility on [DATE], R #1 was a new admission); b. On [DATE] at 2120 (9:20 pm), LPN #1 documented, Did not get a chance to do it (the dressing changes either to the sacral wound or the left hip wound); c. On [DATE] at 2216 (10:16 pm), LPN #1 documented, Did not get a chance to do it (the dressing changes either to the sacral wound or the left hip wound); d. On [DATE] at 2216 (10:16 pm), LPN #1 documented, Did not get a chance to do it (the dressing changes either to the sacral wound or the left hip wound); There was no further documentation of wound care being completed in the TAR for the dates [DATE] through [DATE]. e. On [DATE] at 10:12 am, RN #1 documented, Med (medication, being the Dakin's Solution) not available. Will follow up; f. On [DATE] at 5:55 am, LPN #1 documented, Wound care was not performed during noc (night) shift. AM nurse notified of situation.; g. On [DATE] at 10:57 am, the Wound Care (RN) nurse documented, Rsd (resident) c/o (complains of) pain in her sacral wound. No pain scale number was indicated. Tylenol 325 mg 2 tablets given for pain was administered; h. On [DATE] at 12:47 pm, the Wound Care nurse documented, Tylenol ineffective, the follow-up pain scale (a scale that measures a person's pain intensity or other features, 0 is no pain, where an 8 is considerate moderate pain) was 8 out of 10; i. On [DATE] at 12:48 pm, the Wound Care nurse documented, [MEDICATION NAME]-[MEDICATION NAME] (a combination narcotic pain reliever for moderate to severe pain) 5 mg-325 mg 1 tablet was given (for the pain 8 out 10); j. On [DATE] at 2159 (9:51 pm), RN #2 documented, Woke (R #1) while sleeping to do dressing change - res (resident) refused, went to sleep; k. On [DATE] at 12:21 pm, RN #3 documented the following: RSD's (resident's) family stated to this nurse that RSD was warm to touch w (with)/possible fever. CNA obtained temp (temperature) (97.0) per this nurse and CNA was advised to monitor RSD for increase in temp, offer fluids throughout shift and keep blankets off RSD for cooling measures. l. There was no indication or documentation regarding an odor from the wound, that was mentioned by the family nor was the physician notified of the resident's family concerns. m. On [DATE] at 1725 (5:25 pm), RN #3 documented the following: General, Daily Skilled Note, skilled care includes: Wound Care Management of Diabetes Long Term Care - vital signs included: Temperature 97.0, pulse, 82, respirations 18, oxygen saturation was 95% on room air, and blood pressure was ,[DATE]. n. On [DATE] at 2121 (9:21 pm), RN #3 documented the following: Tylenol 325 mg 2 tabs (tablets), Assisted with 650 mg Tylenol after CNA (Certified Nursing Assistant) reported to this nurse that the oral temperature is 99.9 (normal is 98.6). Will continue to monitor RSD (resident) for fever, further interventions, PM (evening/night) nurse notified of situation; o. On [DATE] at 2305 (11:05 pm), RN #3 documented the following: prn (as necessary) (medication) administration was effective, follow-up pain scale was 0, Temp (temperature) 98.8; p. On [DATE] at 1603 (4:03 pm), the evening nurse documented the following: Cleanse left hip with cleansing solution, apply wet to dry normal saline. There was no indication or documentation in R #1's nursing note that indicated an odor from the wound. q. On [DATE] at 0019 (12:19 am), the evening/night nurse documented, (Wound care) not done.'' r. On [DATE] at 7:56 am, the wound nurse completed a Braden Scale Assessment (a tool that helps nurses to assess a resident's risk of developing a pressure ulcer), R #1's score was a 13, indicating a moderate risk. s. On [DATE] at 1836 (6:36 pm), LPN #1 documented, Tylenol 325 mg 2 tablets given by mouth for a temperature of 101.3. There was no indication or documentation of notifying the physician of the increased temperature. t. On [DATE] at 2114 (9:14 pm), LPN #1 documented that R #1's temperature as 98.8; u. On [DATE] at 8:12 am, RN #4 documented the following: Resident c/o (complains of) pain in wound. No indication or documentation of a number for the pain score; v. On [DATE] at 23:44 (11:44 pm), LPN #1 documented the following: Nursing Documentation Note .PU (pressure ulcer) on left hip swabbed for C&S (culture and sensitivity, which would indicate an infection in the wound) by (name of wound nurse), sent to (Name of local hospital) lab (laboratory). Started on [MEDICATION NAME] (antibiotic) 150 mg .Infection(s) present/suspected: Skin/Soft Tissue newly identified .VS (vital signs) included: (temperature) 97.0, (pulse) 81, (respirations) 20, (oxygen saturation) was 92% on room air and (blood pressure) was ,[DATE]. (A blood pressure reading lower than 90 for the top number or 60 for the bottom number is generally considered a low blood pressure). There was no indication/reason of documentation in the nurses notes or a physician order [REDACTED].> w. On [DATE] at 15:34 (3:34 pm), RN #1 documented the following: Rsd (resident's) daughter came to check as resident was not responding. Obtained rsd's (resident's) vital signs: (blood pressure) ,[DATE], (pulse) 86, (oxygen saturation) 87% (normal is anything greater than 88% and above), (respirations) 23 and (temperature) 98.2. Installed the oxygen concentrator at 3 liters, Rsd (Resident) oxygen level was up to 96%. Rsd (Resident) was staring in one direction but eyes moved when her name was called. Notified (Name of physician), he ordered to send her out to (Name of local hospital) ER (emergency room ). Acting Director of Nursing gave [MEDICATION NAME] (an antibiotic) 1 Gm (gram) IM (intramuscular) in the left deltoid. Gave morning scheduled crushed meds only half as rsd (resident) was not swallowing. Rsd (resident) sent out to (local hospital ER ) at 10:15 am. H. Record review revealed no documentation by the nursing staff informing the physician until [DATE], when he was notified of the R #1's change in condition. I. On [DATE] at 4:00 pm, during an interview, the Medical Director stated that he only assumed care of being the Medical Director of the facility in February. He was familiar with R #1 as she was his patient. He stated that he was not made aware by the nursing staff that R #1 had a temperature of 101.3 on [DATE], nor was he aware that R #1's pressure ulcers were not improving, and even increased from a stage 3 to a stage 4. He stated that the only phone call that he remembers was on [DATE], when R #1's condition had changed. When asked if he had ever seen R #1's wounds, he replied, No. J. Record review of the Physician Clinical Report from the Emergency Department dated [DATE], revealed the following: Arrival: [DATE] at 10:32 am, Chief Complaint: DECREASED MENTAL STATUS. This started today last normal unknown (sic) . The patient was found unresponsive. The patient was found unresponsive (by family member. Would not eat this morning per nursing staff). Nursing home resident .(History of decubitus ulcers antibiotic started yesterday. Was given [MEDICATION NAME] today and was started on [MEDICATION NAME] (an antibiotic) 150 mg 3 times daily yesterday [DATE]) .At 13:47 (1:47 pm), Previously while in ER (emergency room ) patient had a generalized tonic-clonic [MEDICAL CONDITION] (a person loses consciousness, muscle stiffen, and jerking movements are seen) that aborted after milligram of [MEDICATION NAME] ( a medication used to treat [MEDICAL CONDITION]) and started on [MEDICATION NAME] [MEDICATION]) .Clinical Impression: New onset generalized [MEDICAL CONDITIONS], Stage 4 pressure ulcer (Large stage IV decubitus ulcer over sacrum and is all over left hip posteriorly (situated behind or at the rear)). K. Record review of the Nurses Clinical Report from the Emergency Department dated [DATE], revealed the following: Physical Assessment: Skin: Stage II pressure ulcer (Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wounded (sic) bed, without slough. Intact or open /ruptured serum-filled blister) noted on the left hip; present on arrival (9 cm x 4.5 cm). (This is in contrast to the facility's last assessment dated [DATE], when the facility assessed the left hip wound as unstageable, due to wound being covered with 100 % slough and measured 4.0 x 4.5 x 0.6 cm, with the 2 areas either U or T (not indicated), measured 1.5 cm between the 9:00 o'clock and 11:00 o'clock positions and 2.4 cm at the 12:00 o'clock position); Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Exposed bone/tendon is visible or directly palpable) noted on the coccyx; present on arrival (9 cm x 6 cm). (This is in contrast to the facility's last wound assessment [DATE], which indicated the wound measured 7.5 x 5.0 x 3.0 cm, and the two areas either U or T (not indicated), measured 2.5 cm at the 12:00 position and 1.2 cm at the 9:00 position). L. Record review of the Discharge Summary from the hospital dated [DATE], revealed the following: Hospital Course: Pt (patient) admitted for [MEDICAL CONDITION]ly as a result of Decubitus Ulcer stage IV. Pt was treated aggressively without much improvement. Pt had been very lethargic (sluggish, lack of energy). She is not responding to stimulus (no reaction or excitement or energy). Her daughter POA (power of attorney) decided on inpatient hospice care. M. Record review of the death certificate indicated that R #1 died [MEDICAL CONDITION] (potentially life-threatening condition caused by the body's response to an infection), Pressure ulcer Stage IV (full-thickness tissue loss with exposed bone, tendon or muscle) and [MEDICAL CONDITION] (is a progressive nervous system disorder that affects movement) on [DATE]. N. Record review of R #1's the physician's Discharge Summary from the local hospital, dated [DATE], revealed the following: .R #1 having an infection for an unknown period of time, causing R #1 to become septic (having an infection in the blood), resulting in being hospitalized , and eventually contributing to (name of R #1) death. O. On [DATE] at 3:45 pm, during an interview , LPN #1 stated that she does not do wound care, the wound care nurse does the wounds. The wound nurse does most of the treatments in the morning and will have the night nurse do them in the evening. She stated that she does remember R #1. She had two wounds that she stated she only saw a few times. She remembers that at some point the wound care became twice daily. She also remembered the smell in the room and stated that both of them (R #1 and R #2) had wounds. She stated that she wasn't sure which one the smell was coming from. LPN #1 stated she remembers the daughter stating she felt like her mom needed an antibiotic. She stated that the daughter brought it up again a few days later and the physician was called and an antibiotic was ordered (antibiotic was not given until EMT's (emergency medical technicians) came to take resident to the emergency room the next day). During a follow up interview on [DATE], LPN #1 stated that she did some wound care a few times, and sometimes when she signed off on the TAR that it was done, it was due to the wound care falling on her shift but that another nurse on the night shift was doing the wound care, along with the treatment nurse. P. On [DATE] at 9:00 am, during an interview, the Wound Care Nurse stated that R #1 had two wounds; one on her left hip and one on her sacral area. The left hip was 100% slough (a layer or mass of dead tissue) and on her sacrum there was eschar (dead tissue) and slough. She indicated that the wounds were not really healing. She stated that part of it was do to her diet, she wasn't eating that well and she was diabetic. She stated that she did do a wound culture of her wound and it came back positive for, some sort of bacteria. She remembered that there was a smell and said, eschar and slough will start to smell. Cause its dead tissue. Q. On [DATE] at 11:00 am, during an interview, Certified Nursing Assistant (CNA) #1 stated that she did take care of R #1, explaining that she changed and turned her every 2 hours. She stated that R #1 could not feed herself, so the CNA's would assist her while she was in bed. She did not remember any odor or smell in the room. R. On [DATE] at 11:15 am, during an interview, CNA #2 stated that R #1 was a screamer. She stated that if R #1 was touched, she would scream, indicating she was in pain. She further stated that R #1 stayed in bed 24 hours a day, 7 days a week, the staff never assisted her out of bed. CNA #2 stated that she would turn R #1 every now and then. S. On [DATE] at 11:28 am, during an interview, RN #1 stated that she has done some wound care and has learned a lot from the Wound Care Nurse. She stated that she does remember the room smelling and it was hard to tell if the smell was coming from R #1 or R #2. They both had very bad wounds. She stated that she remembers R #1's daughter, (she didn't want to use the word pleading ) requested that her mother (R #1) receive more wound care treatment and an antibiotic. This was passed along to the Wound Care Nurse. T. On [DATE] at 3:04 pm, during an interview, the Interim CNE (Certified Nursing Executive, a Graduate Nurse (GN)) stated, the wound care could have been better, and that the wound care was not getting done as often as it should have. He further stated that the nursing staff depend on the treatment nurses too much and she isn't always here to do it. The CNE confirmed that there was a smell in the room, that was either coming from R #1 or R #2. He did remember while he was walking down the hall and you could smell something, he wasn't sure if it was every day or every other day. He stated that this was a concern. The CNE stated that he was not sure why if the room smelled for days and days and no one knew exactly which resident the smell was coming from, or if it was a wound or the wound vac (vacuum) for R #2; why nothing was done sooner. The CNE stated that it was likely due to the smell, that the wound for R #1 was cultured. He stated that he did remember speaking with R #1's daughter and that she was not happy with the care her mother received. U. On [DATE] at 5:14 pm, during an interview, the interim Center Nurse Executive (CNE) stated that he had not noticed R #1's moaning, or any facial grimacing during the day that he saw her. He stated that he was never aware of R #1's moaning or complaining like she was in pain. The family when they came to see him on [DATE] did not state that there was a problem. He stated that he was not sure about the family meeting and why they were bringing up the pain issue. He stated that when R #1 was having a [MEDICAL CONDITION] (involuntary muscle jerks or spasms), R #1 would be staring off with her eyes open. He stated to the family that day, if they would give us the opportunity to make things right. The family was not happy with the wound care. He said that the daughter was not happy, she noticed a smell in her mother's room and suspected that something was wrong. He said that the facility thought hat it could have been the wound vac (vacuum) (a wound therapy to assist in the closure of a wound). (Record review, R #1 was not admitted to the facility with a [DEVICE]). The interim CNE stated that the only time if a wound smells is if there is drainage or infected. He further stated that due to the smell, it was likely what prompted the culture to get done. V. On [DATE] at 11:20 am, during an interview, Registered Nurse (RN) #1, who works the day shift stated in regards to R #1, that her daughter had been taking care of her (R#1) mother while she was at home. She (RN#1) recalled that on [DATE], she was attempting to administer medications to R #1, but that R #1's jaw was locked and rigid. Her medications were crushed, but that R #1 was still unable to take her medications. Do to those reasons was why it was (TRUNCATED)

Based on record review and interview, the facility failed to notify the physician of changes in resident status for 2 (R #34 and #21) of 2 (R #34 and #21) residents reviewed for notification of change. The facility failed to notify the physician of R #34's high and low blood glucose readings and failed to notify the physician timely of R #21'[MEDICAL CONDITION] lump that had been observed to be there for an unknown period of time prior to 04/25/17. The findings are: Findings Related to R #34: A. Record review of R #34's physician order [REDACTED]. B. Record review of R #34's physician order [REDACTED]. C. Record review of R #34's Nurse's note dated 06/11/17 indicated his blood glucose was 43 that day. D. Record review of R #34's Medication Administration Record [REDACTED]. E. On 08/09/17 at 11:14 am, during an interview with LPN (Licensed Practical Nurse ) #1, she stated that when they notify the physician regarding high or low blood glucose levels they document in a nurse's note that they notified the physican. F. Record review of R #34's Nurse's note for June 2017 revealed no entries to indicate the physician was contacted regarding any of the high or low blood glucose readings. G. On 08/09/17 at 12:03 pm, during an interview with the Corporate Regional Nurse, she verified that the facility had not notified the physician regarding any of R #34's high or low blood glucose readings for the month of June 2017. Findings Related to R #21: H. On 08/07/17 at 3:30 pm, during an interview with R #21's POA (Power of Attorney), he stated that his mother had a [PROCEDURE] on 06/05/17 because she [MEDICAL CONDITION] in her breast. He was upset, because he never understood why, if the lump had been observed to be there previously, (before 04/25/17) why the doctor was not notified sooner. I. On 08/10/17 at 4:32 pm, during an interview with Physician, she stated that the first time she heard about a lump on R #21's breast was on 04/25/17. She spoke with the nurse that day, the nurse informed her of the lump on R #21's breast and stated that she had been told that it (the lump) had been there a long time and that it was a Sebaceous Cyst (sebaceous cyst are common noncancerous cysts of the skin). When asked why the nurse called her on that day 04/25/17 if it had been there for so long; the physician stated that someone different had seen it and was concerned about it. The Physician stated that when she saw the lump on R #21's breast she knew that it was not a Sebaceous Cyst. J. On 08/10/17 at 4:35 pm, during an interview with an ex-employee of the facility, RN (Registered Nurse) #5, she stated that R #21 was getting a shower when CNA (Certified Nursing Assistant) #2 saw the lump on R #21's breast. CNA #2 went and got RN #5 to see the lump. She stated that she went down and examined R #21. After she examined R #21, she was told by LPN (Licensed Practical Nurse) #1 that it (the lump) had been there awhile. She stated that LPN #1 called it something, but she does not remember what that was. She stated that she also notified the son who was R #21's POA. She stated that the son was very upset when she notified him. She had told him that she wasn't sure how long it had been there but it had been there awhile from the information she got from other nurses. RN #5 was unable to find any other information in R #21's medical chart about the lump on her breast. K. On 08/10/17 at 5:52 pm, during an interview with LPN #1, she stated that she does not recall who told her that the lump on R #21's breast was a Sebaceous Cyst, but it was another nurse. She stated that the lump had been for a while, before 04/25/17 but she couldn't recall how long. She stated that she thought a Physician had been notified prior to 04/25/17 of the lump in R #21's breast but she couldn't be sure. She stated that she didn't remember what staff member asked her about it on 04/25/17 but that all she told that nurse was that she thought it (the lump) had been there awhile. L. Record review of the progress note dated 4/22/17, indicated that R #21 was given a shower and during the shower, CNA #2 stated that there was a presence of a lump to R #21's right chest wall. Resident was checked and there was a 2.5 cm X 2.5 cm square feeling lump to right chest wall. Lump is hard. Does not move. No bruising to area. M. Record review of the progress note dated 4/25/17, indicated that a note was written; 1435 a message was left for the Physician regarding lump on pt's right anterior chest wall. There was no previous (before 04/25/17) documentation of a lump in R #21's breast prior to this entry. N. Record review of the progress note dated 4/26/17, indicated that POA for R #21 called and was upset about why this lump was not noted earlier and wanted to know how long it had been there. O. Record review of the physician progress notes [REDACTED].#21's right breast. The note also indicated that it is unclear how long it has been present home (the facility)notified me last month; described a cyst like structure on chest that was not new, discussed options with son just watch or get mammogram and decide then how to proceed. He would like to get mammogram. P. Record review of a progress note dated 5/26/17 indicated that resident was seen for diagnostic Mammogram at (name of hospital), Mammogram and physical exam consistent with [MEDICAL CONDITION], will discuss with guardian (Son) Q. Record review of a progress noted dated 5/31/17 indicated that the surgical clinic called to give the facility a report for R #21's scheduled surgery appointment. pt is scheduled for possible R (right) breast [PROCEDURE] on 6/5/17 @ 0630.

Based on record review and interview, the facility failed to prevent misappropriationof resident funds by a CNA (certified nurse aide), for 1 resident (R #55) of 4 residents (R #'s 48, 55, 56 and 63) reviewed for exploitation. Former CNA #1 accepted money from the resident for the purposes of purchasing jewelry on the resident's behalf, and for helping with the CNA's car payment. This deficient practice caused the resident to suffer a financial loss. The findings are: A. On 08/11/17 at 8:50 am, during interview with the facility administrator, she stated that Former CNA #1 had been a CNA at the facility for a long time. She indicated that R #55 reported that she had given Former CNA #1 money for a car payment and hadn't been paid back yet. It turned out that Former CNA #1 had, some time previously, been wearing a silver bracelet. R #55 admired it and wanted one. Former CNA #1 and a silversmith met R #55 at a restaurant when she was out on pass with her auntie. R #55 and the aunt had visited the bank before the meeting and had withdrawn money. R #55 gave Former CNA #1 $1000 to give to the silversmith, as an initial payment towards the $2500 total cost. R #55 acquired the bracelet at some point, and the silversmith began to press Former CNA #1 for the rest of the money. Former CNA #1 paid an additional $1000 when R #55 didn't. Former CNA #1 missed her car payment because of having given money to the silversmith, and she told R #55, who gave her $600 for the car payment. The administrator stated that when she found out about it, she considered it to be a case of exploitation, and called the police.The police, however, couldn't do anything because R #55 told them she willingly gave Former CNA #1 the money. R #55 hadn't wanted her family to know about the situation, stating that her brothers would kill Former CNA #1 if they knew. The sale is now off, but R #55 is out $1600. Former CNA #1 is supposed to bring in the money and she hasn't yet. The administrator confirmed that Former CNA #1's employment was terminated. She stated that R #55 had the money because she had sold a property she owned. B. On 08/11/17 at 10:00 am, during interview with R #55, she stated that Former CNA #1 had received a total of $4000 from her. She stated that she had given Former CNA #1 $3000 for the bracelet, and $1000 for a car payment. She stated her car got repo'd and she asked me for the money so I gave it to her. She indicated that she received the bracelet at some point, but that Former CNA #1 ultimately took it back again. She stated that she had never been reimbursed any of the $4000 that she had given Former CNA #1. She confirmed that Former CNA #1 has not worked at the facility since she (R #55) reported the incident on 07/15/17, though she had seen her on 3 occasions when she came in to try to get her job back. C. On 08/11/17 at 11:44 am, during interview with the facility administrator, she stated that a police report was never done, as the responding officer had not found a crime to have occurred. D. Record review of R #55's medical record did not find any [DIAGNOSES REDACTED]. E. Record review of Former CNA #1's employee record indicated that she had been a certified nurse aide since 03/07/91, and had been employed at the facility since 2006. Her employment was terminated on 07/19/17 due to gross misconduct, with a notation of misappropriation of resident property. F. Record review of the facility's Policy and Procedure document related to Abuse Prohibition, dated 06/01/96 and last revised 04/07/17, found statements indicating: 1. (name of facility's parent corporation) will prohibit abuse, mistreatment, neglect, misappropriation of resident property, and exploitation for all residents 2. Federal Definitions: . Misappropriation of patient property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a patient's belongings or money without the patient's consent.

§483.25 Quality of care F309 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: Based on interview and record review, the facility failed to seek out a more immediate medical opinion and/or medical care for a lump in residents breast, for an un-identified period of time, for one resident (R #21) of one (R #21) looked at for quality of care issues. This deficient practice resulted in the lump in R #21's going unidentified as [MEDICAL CONDITION] and without treatment for [REDACTED].#21 having a [PROCEDURE]. The findings are: A. On 08/07/17 at 3:30 pm, during an interview with R #21's POA (Power of Attorney), he stated that his mother had a [PROCEDURE] on 06/05/17 because she [MEDICAL CONDITION] in her breast. He was upset, because he never understood why, if the lump had been observed to be there previously, (before 04/25/17) why the doctor was not notified sooner. B. On 08/10/17 at 4:32 pm, during an interview with Physician, she stated that the first time she heard about a lump on R #21's breast was on 04/25/17. She spoke with the nurse that day, the nurse informed her of the lump on R #21's breast and stated that she had been told that it (the lump) had been there a long time and that it was a Sebaceous Cyst (sebaceous cyst are common noncancerous cysts of the skin). When asked why the nurse called her on that day 04/25/17 if it had been there for so long; the physician stated that someone different had seen it and was concerned about it. The Physician stated that when she saw the lump on R #21's breast she knew that it was not a Sebaceous Cyst. C. On 08/10/17 at 4:35 pm, during an interview with an ex-employee of the facility, RN (Registered Nurse) #5, she stated that R #21 was getting a shower when CNA (Certified Nursing Assistant) #2 saw the lump on R #21's breast. CNA #2 went and got RN #5 to see the lump. She stated that she went down and examined R #21. After she examined R #21, she was told by LPN (Licensed Practical Nurse) #1 that it (the lump) had been there awhile. She stated that LPN #1 called it something, but she does not remember what that was. She stated that she also notified the son who was R #21's POA. She stated that the son was very upset when she notified him. She had told him that she wasn't sure how long it had been there but it had been there awhile from the information she got from other nurses. RN #5 was unable to find any other information in R #21's medical chart about the lump on her breast. D. On 08/10/17 at 5:52 pm, during an interview with LPN #1, she stated that she does not recall who told her that the lump on R #21's breast was a Sebaceous Cyst, but it was another nurse. She stated that the lump had been for a while, before 04/25/17 but she couldn't recall how long. She stated that she thought a Physician had been notified prior to 04/25/17 of the lump in R #21's breast but she couldn't be sure. She stated that she didn't remember what staff member asked her about it on 04/25/17 but that all she told that nurse was that she thought it (the lump) had been there awhile. E. Record review of the progress note dated 4/22/17, indicated that R #21 was given a shower and during the shower, CNA #2 stated that there was a presence of a lump to R #21's right chest wall. Resident was checked and there was a 2.5 cm X 2.5 cm square feeling lump to right chest wall. Lump is hard. Does not move. No bruising to area. F. Record review of the progress note dated 4/25/17, indicated that a note was written; 1435 a message was left for the Physician regarding lump on pt's right anterior chest wall. There was no previous (before 04/25/17) documentation of a lump in R #21's breast prior to this entry. G. Record review of the progress note dated 4/26/17, indicated that POA for R #21 called and was upset about why this lump was not noted earlier and wanted to know how long it had been there. H. Record review of the physician progress notes [REDACTED].#21's right breast. The note also indicated that it is unclear how long it has been present home (the facility)notified me last month; described a cyst like structure on chest that was not new, discussed options with son just watch or get mammogram and decide then how to proceed. He would like to get mammogram. I. Record review of a progress note dated 5/26/17 indicated that resident was seen for diagnostic Mammogram at (name of hospital), Mammogram and physical exam consistent with [MEDICAL CONDITION], will discuss with guardian (Son) J. Record review of a progress noted dated 5/31/17 indicated that the surgical clinic called to give the facility a report for R #21's scheduled surgery appointment. pt is scheduled for possible R (right) breast [PROCEDURE] on 6/5/17 @ 0630.

Based on observation, record review and interview the facility failed to provide the necessary care and services to maintain the highest practicable well-being for 1 (R #83) of 1 (R #83) sampled residents who had a fall, was experiencing continuous pain, and not getting an X-ray until twelve days later which indicated Resident #83 had sustained a [MEDICAL CONDITION] hip. The facility also failed to ensure documentation of the effectiveness of pain medication being administered to the resident was effective or not. This deficient practice caused the resident to remain in pain, experience an adverse change in condition, and resulting in a fracture. The findings are: A. Review of the Medical Record for Resident #83 revealed the following: 1. Face Sheet (no date) indicated [DIAGNOSES REDACTED]. 2. Nursing assessment dated [DATE], indicated Resident #83 is alert, with clear speech, and ambulates with one to two person assistance. It further indicated that Resident #83 has an impairment to the lower extremity (hip, knee, ankle, foot) on one side of the body. 3. Fall Risk Evaluation dated 07/08/14, indicated Resident #83 had a fall in the last 2-6 months prior to admission to the facility. 4. Pain Screening and Evaluation Tool dated 07/08/14 indicated, Resident #83 had experienced pain over the last five days, and displayed non-verbal symptoms of pain. At the time of evaluation on 07/08/14, Resident #83 scored his pain at a 4 and at it's worst a 10. The location was to the Right Leg, Pain Frequency was indicated as Frequent, and the Pain Description was Sharp, aching, gnawing, worse on movement, and worse in morning. 5. Interdisciplinary Progress Notes dated 07/08/14, indicated "Res (resident) has right leg/thigh pain. States pain is only present during ambulation." 6. A Change of Condition Document dated 07/14/14, indicated Resident #83 had a "Unwitnessed fall, found lying on the floor with w/c (wheelchair) at the foat (sic)." Found resident lying on Left lat. (lateral) side...Complaints of leg and buttocks with dull pain." 7. Risk Management System Incident Report dated 07/14/14 indicated Resident #83 fell . It further indicated Injury was a Fracture, c/o (complained of) right side back pain...Pt. (patient) did c/o pain on right side of back when he was being assisted up by three person assist. 8. Interdisciplinary Progress Notes revealed the following: a. On 07/15/14, "Noted bruise area on R (Right) lower quad (quad) quadrant of abdomen. Possibly related to incident on 07/14/14." b. On 07/16/14, "Resident c/o (complained of) pain after PT (physical therapy) services. Will cont. (continue) to monitor and assess for pain. c. On 07/17/14, "Spoke with (name of Physician) about sending pt (patient) for X-ray. Has been c/o (complaining of) rt (Right) leg pain since fall. (Name of Doctor) stated that pt (patient) has had rt (right) leg pain since before fall, and would not make referral." 9. Physician's progress notes dated 07/17/14, indicated that Resident #83 had "Increased pain in right upper leg." 10. Interdisciplinary Progress Notes revealed the following: a. On 07/20/14, "Rsd (resident) has c/o (complained of) right leg pain w (with) walking during PT (physical therapy). Cont (continue) to monitor. b. On 07/25/14, "Pt (patient) sent to (name of emergency room ) for CT (cat scan) (a type of special X-ray test)...revealed a fracture to right hip." c. A total of twelve days went by (from 07/14/14 to 07/25/14) in which Resident #83 had a fall, been experiencing pain, and experienced a decline in activities of daily living. When Resident #83 did have an X-ray completed on 07/25/14, it indicated "Femoral neck fx (fracture)" B. Review of Emergency Department Progress Notes dated 07/25/14, indicated "Pt (patient) fell on ,[DATE] (while at home) and since that time has not been able to bear weight effectively on his right leg. He states he has pain that he localized to his right hip that is worse with movement. He (Resident #83) was sent today to have a ct (Cat scan) done of his right hip which showed a femoral neck fx (fracture)." C. On 09/08/14 at 4:05 pm, during interview Registered Nurse (RN) #2 stated, that Resident #83 was found on the floor (September 16, 2014) with no injuries. D. On 09/10/14 at 10:59 am, during interview, the Director of Nursing (DON) confirmed that Resident #83 had a fall (referring to the fall that occurred on 07/14/14) and "He had a hip fx." E. On 09/10/14 at 2:35 pm, during interview Resident #83 stated that his leg hurts bad." When Resident #83 was asked if he could rate his pain, he stated, "It's a 9" (referring to a pain scale of 1 to 10). Resident #83 further stated, "When it really hurts, nothing helps." F. On 09/10/14 at 3:03 pm, during interview regarding Resident #83, DON stated, "He (Resident #83) fell here (at the facility) on 07/14 and at that time, we called the doctor because he (Resident #83) had a decreased ability to walk. The doctor was saying he (Resident #83) came in with hip pain and that was his base line. The doctor was also very adamant that we don't send him (Resident #83) out to the hospital. We called him (the same doctor) multiple times. On 07/17 the doctor came in and we had set it up that when he (the doctor) came in, he would get us a referral to send the resident out. We and the physical therapist were concerned that he (the doctor said no). The Doctor said he (Resident #83) was admitted with pain, and there was no reason to send him out. But we continued to call him (the doctor) and he continued to say no. When we asked for a reason for not sending the resident out, it was always the same, that he (Resident #83) was admitted and it was his base line. He (Resident #83) used to be able to walk and now he can't." The DON further stated, that the doctor was convinced he (Resident #83) did not receive the fracture here at the facility and that is why he did not want to send him out. When he was originally admitted to the facility, he did not have any fracture or dislocation of his right hip. So on 07/14 he fell in his room. The Doctor was notified that he (Resident #83) was complaining of hip pain and had declined orders for and X-ray. He (the doctor) was called again on 07/17 due to the pain the resident was having. Now on 07/25, he was sent to the emergency room and the cat scan revealed a fx (fracture) of his right hip." The DON then stated stated currently he (Resident #83) is not able to ambulate anymore as he was before. When we did sent him out, it was determined he had a right [MEDICAL CONDITION]. He did have a decline in his Activities of Daily Living (ADL's)." G. On 09/10/14 at 5:00 pm, during interview regarding Resident #83's fall that occurred on 07/14/14, the Facility Medical Director stated that what was told to him by the staff was that they (staff) had contact him (Resident #83's Physician) a number of times and he felt there was no indication to re-image him. The Medical Director further stated, "As far as my expectations, this is a major adverse event that the patient (Resident #83) experienced. He was injured and there was a delay in care which could ultimately lead to worse outcomes and that is not want we want." As the Medical Director, it would have been my expectation for the staff to contact me if they are not being able to reach the physician and it is a bad scenario in which the patient (Resident #83) had a bad injury and this needs to be corrected." H. On 09/10/14 at 5:15 pm, during interview the Senior Administrator stated, "I agree with you (meaning there was a delay in care regarding Resident #83) and we see Resident #83 was having issues with pain and there was a delay in care and treatment." I. On 09/11/14 at 1:55 pm, during interview the Senior Administrator stated, "It appears he (Resident #83) got the fracture here. I looked through this and it indicated the fracture happened here. Prior to coming here, it shows no fracture." J. On 09/11/14 at 2:21 pm, during interview the Manger of Clinical Operations stated, "It was an impacted fracture on the 25th. It might have been missed on the X-ray before coming into the facility and when he (Resident #83) fell (referring to 07/14/14), it might have exasperated it."

Based on observation, record review and interview, the facility failed to ensure 1 (R #83) of 1 (R #83) sampled residents medical records was complete and accurate. The facility failed to ensure consistent documentation regarding when/if pain medication was being administered, and the effectiveness of the medication. This deficient practice has potential to mislead staff as to when/if pain medication was administered as well as unsure if the medication was effective to relieve the residents pain or not. The findings are: A. Review of the Medical Record for Resident #83 revealed the following: 1. Face Sheet (no date) indicated [DIAGNOSES REDACTED]. 2. Pain Screening and Evaluation Tool dated 07/08/14 indicated, Resident #83 had experienced pain over the last five days, and displayed non-verbal symptoms of pain. At the time of evaluation on 07/08/14, Resident #83 scored his pain at a 4 and at it's worst a 10. The location was to the Right Leg, Pain Frequency was indicated as Frequent, and the Pain Description was Sharp, aching, gnawing, worse on movement, and worse in morning. 3. Interdisciplinary Progress Notes dated 07/08/14, indicated "Res (resident) has right leg/thigh pain. States pain is only present during ambulation." 4. Risk Management System Incident Report dated 07/14/14 indicated Resident #83 fell . It further indicated Injury was a Fracture, c/o (complained of) right side back pain...Pt. (patient) did c/o pain on right side of back when he was being assisted up by three person assist. 5. Interdisciplinary Progress Notes revealed the following: a. On 07/15/14, "Noted bruise area on R (Right) lower quad (quad) quadrant of abdomen. Possibly related to incident on 07/14/14." b. On 07/16/14, "Resident c/o (complained of) pain after PT (physical therapy) services. Will cont. (continue) to monitor and assess for pain. c. On 07/17/14, "Spoke with (name of Physician) about sending pt (patient) for X-ray. Has been c/o (complaining of) rt (Right) leg pain since fall. (Name of Doctor) stated that pt (patient) has had rt (right) leg pain since before fall, and would not make referral." 6. Physician's progress notes dated 07/17/14, indicated that Resident #83 had "Increased pain in right upper leg." 7. Interdisciplinary Progress Notes revealed the following: a. On 07/20/14, "Rsd (resident) has c/o (complained of) right leg pain w (with) walking during PT (physical therapy). Cont (continue) to monitor. b. On 07/25/14, "Pt (patient) sent to (name of emergency room ) for CT (cat scan) (a type of special X-ray test)...revealed a fracture to right hip." c. A total of twelve days went by (from 07/14/14 to 07/25/14) in which Resident #83 had a fall, been experiencing pain, and experienced a decline in activities of daily living. When Resident #83 did have an X-ray completed on 07/25/14, it indicated "Femoral neck fx (fracture)" 8. Review of the PRN Pain Management Flow Sheet dated July 2014, revealed the form to be completely blank. There was no documentation when/if pain medication had been administered to Resident #83, and no documentation of the effectiveness of pain if it was effective or not was being documented. B. On 09/10/14 at 3:55 pm, during interview the Director of Nursing (DON) stated, that the nurses did not document his (Resident #83's) pain on the pain management flow sheet. The DON further indicated, "I don't see where they (staff) even had his pain being rated and that would have been the expectation to be documenting it." The DON further stated, "We (staff) assess for pain every shift, and if someone is being treated with a PRN (as needed) pain medication, then we are supposed to check the patient again in an hour." When the DON was asked about the effectiveness of a pain medication where that is documented, the DON stated, "In the nurses notes mainly and it should be in the MARs as well. (At this time the DON was referring to the PRN Pain Management Flow Sheet). When the DON was reviewing the PRN Pain Management Flow Sheet, she stated, "I can't find anything here. Normally it's a q (every) shift check. When the DON was asked if the effectiveness was being documented each time in August when Resident #83 received pain medication, she stated, "No, not for each time and that would have been the expectation every time to do so." C. On 09/11/14 at 7:55 am, during interview regarding the PRN Pain Management Flow sheet documentation, Licensed Practical Nurse (LPN) #1 stated, "You are supposed to write it out and document when a PRN is given and the effectiveness." LPN #1 then stated that Resident #83 did receive PRN medication in July and he received medication on 07/24, 07/25, 07/26, 07/28, 07/29 and on 07/31. When the LPN was asked where is that documented, the LPN stated, "O the PRN sheet. Usually we write it on here (referring to the PRN sheets), but it looks like it wasn't filled out." LPN #1 confirmed that the effectiveness of the prn medication Resident #83 was receiving, "Should be documented on the sheet and if they are effective or not."

Based on record review and interview, the facility failed to follow the care plan by not ensuring that the calf board (foot rest) was in place while the resident was in the wheelchair for 1 (#1) of 7 (#1-7) residents identified as a fall risk. This deficient practice likely caused Resident #1 to fall and suffer a laceration to her forehead and a neck fracture. The findings are: A. Review of Resident #1's care plan dated 05/07/13 revealed the intervention "Use calf board while in wheelchair." B. On 09/05/13 at 12:25 pm, during interview, Certified Nursing Assistant (CNA) #1 stated, "I took (Name of Resident #1) into her room. I took off her oxygen cannula and clothing to put her to bed. I undid her foot rest as well. I was preparing her for when the float CNA came in because this was a 2 person transfer. The float was not walking by. I left the room with (Name of Resident #1) in it and found the float in another resident's room. I asked her if she could help me with the transfer. We walked back to (Name of Resident #1's) room. We heard someone asking for help in Navajo. We walked into the room and saw (Name of Resident #1) on the floor. I didn't think the foot rest was part of her balancing. I was familiar with the transfer part of the care plan. I didn't realize that there was a part that said not to remove the foot rests." C. On 09/05/13 at 10:45 am, during interview, the Director of Nursing Services (DNS) stated, "I received a call from the RN (Registered Nurse) who informed me that (Name of Resident #1) had fallen out of her wheelchair in her room. It surprised me because she hadn't fallen for over a year. She does not walk and was in her wheelchair often. I had her sent to the hospital because she had a laceration to her forehead. If there is an injury and we send patients out for treatment, we report the incident. She was not alert before this injury or now. She is not conversant (able to express herself). A head CT (computerized tomography scan) showed a fracture in her neck. I investigated and found that the CNA who was caring for her was out of the room to get assistance in transferring her from her wheelchair to her bed. This was a 2-person assist. During the CNA's absence, the patient fell out of her wheelchair. The problem was that the CNA had removed the foot rest. The CNA should not have left the patient alone in the wheelchair under any circumstances and should have obtained assistance prior to removing the calf board for transfer. The CNA was aware that the calf board was supposed to be in place. I think this incident was a case of negligence."

Based on record review and interview, the facility failed to ensure that the calf board (foot rest), an assistive device, was in place while the resident was in the wheelchair for 1 (#1) of 7 (#1-7) residents identified as a fall risk. This deficient practice likely caused Resident #1 to fall and suffer a laceration to her forehead and a neck fracture. The findings are: A. On 09/05/13 at 12:25 pm, during interview, Certified Nursing Assistant (CNA) #1 stated, "I took (Name of Resident #1) into her room. I took off her oxygen cannula and clothing to put her to bed. I undid her foot rest as well. I was preparing her for when the float CNA came in because this was a 2 person transfer. The float was not walking by. I left the room with (Name of Resident #1) in it and found the float in another resident's room. I asked her if she could help me with the transfer. We walked back to (Name of Resident #1's) room. We heard someone asking for help in Navajo. We walked into the room and saw (Name of Resident #1) on the floor. I didn't think the foot rest was part of her balancing. I was familiar with the transfer part of the care plan. I didn't realize that there was a part that said not to remove the foot rests." B. On 09/05/13 at 10:45 am, during interview, the Director of Nursing Services (DNS) stated, "I received a call from the RN (Registered Nurse) who informed me that (Name of Resident #1) had fallen out of her wheelchair in her room. It surprised me because she hadn't fallen for over a year. She does not walk and was in her wheelchair often. I had her sent to the hospital because she had a laceration to her forehead. If there is an injury and we send patients out for treatment, we report the incident. She was not alert before this injury or now. She is not conversant (able to express herself). A head CT (computerized tomography scan) showed a fracture in her neck. I investigated and found that the CNA who was caring for her was out of the room to get assistance in transferring her from her wheelchair to her bed. This was a 2-person assist. During the CNA's absence, the patient fell out of her wheelchair. The problem was that the CNA had removed the foot rest. The CNA should not have left the patient alone in the wheelchair under any circumstances and should have obtained assistance prior to removing the calf board for transfer. The CNA was aware that the calf board was supposed to be in place. I think this incident was a case of negligence." C. Review of Resident #1's care plan dated 05/07/13 revealed the intervention "Use calf board while in wheelchair." D. Review of Resident #1's MDS (Minimum Data Set) dated 08/20/13 revealed under Section G, Functional Status, that the resident requires total dependence on staff and a two-person physical assist when transferring. E. Review of the Incident Follow Up report prepared by the DNS dated 08/20/13 revealed that the DNS "Counseled (Name of CNA #1) for not following protocol."