Every finding on record at Grants Wellness & Rehabilitation LLC

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #1) of 1 (R #1) resident reviewed for MDS accuracy. This deficient practice is likely to result in a failure to provide adequate care and treatment of the residents' needs. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: Aphasia (inability or difficulty communicating),Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease),Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). B. Record review of R # 1's Quarterly MDS, dated [DATE], revealed R #1 had clear speech and did not have difficulty communicating. C. Record review of R # 1's Comprehensive MDS, dated [DATE], revealed R #1 had clear speech and did not have difficulty communicating. D. Record review of R # 1's Comprehensive MDS, dated [DATE], revealed R #1 had clear speech and did not have difficulty communicating. E. On 04/29/2026 at 12:37 PM, during an interview, R #1's daughter stated her mom has been non-verbal and unable to speak since 2024. F. On 04/30/26 at 11:08 AM, during an interview, Licensed Practical Nurse #1 (LPN) stated R #1 is non-verbal and cannot speak clearly. G. On 05/08/2026 at 10:59 AM, during an interview, the MDS Coordinator stated she was responsible for completing R #1's MDS assessments. She stated it was her expectation the MDS assessments reflect the resident's current healthcare information. The MDS Coordinator stated if the MDS assessments are not completed accurately, the facility is not capturing the resident's needs. The MDS Coordinator stated R #1's MDS assessments were inaccurate and should reflect R #1's non-verbal status.

Based on observation, record review, and interviews, the facility failed to ensure the appropriate treatment and services related to a Foley catheter (indwelling catheter; a thin, flexible tube inserted into the bladder to drain urine) for 1 (R #1) of 1 (R #1) resident, when staff failed to: Maintain free urine flow through a Foley catheter by positioning the catheter collection bag (also called a drainage bag; a device connected to the catheter tubing to collect urine) below the level of the bladder (hollow organ in the human body that collects urine) so urine can flow freely.This deficient practice is likely to increase the risk of infection and compromises the quality of catheter care. The findings are:A. Record review of the facility's catheter care policy, dated 06/2020, revealed the following: Residents receive the appropriate care and services to prevent infections to the extent possible.Position the catheter, drainage system, and bag utilizing gravity to facilitate drainage.The catheter collection bag will be kept below the level of the bladder. B. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: Obstructive Uropathy (a blockage in the urinary tract that impedes the normal flow of urine, potentially causing kidney damage),Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). C. Record review of R #1's physician orders, dated 01/13/2026, revealed an order for an indwelling urinary catheter. D. Record review of R #1's care plan, dated 02/02/2026, revealed the following: R #1 has an indwelling catheter related to obstructive uropathy.Position R #1's catheter collection bag and tubing below the level of the bladder. E. On 04/29/2026 at 11:01 AM, during an observation, R #1's catheter collection bag was attached to the footboard of the resident's bed, in a position higher than R #1's bladder. Urine flow was observed to be returning toward the resident instead of draining into the collection bag as required. F. On 04/30/2026 at 12:27 PM, during an observation, R #1's catheter collection bag was attached to the footboard of the resident's bed, in a position higher than R #1's bladder. Urine flow was observed to be returning toward the resident instead of draining into the collection bag as required. G. On 04/30/2026 at 12:32 PM, during an interview, Licensed Practical Nurse #1 (LPN) stated the catheter collection bag should never be positioned above the level of the resident's bladder. LPN #1 stated if the drainage bag is placed above the bladder, urine may not drain properly, which could place the resident at risk for infection. LPN #1 stated R #1's catheter collection bag was not positioned correctly and should have been for proper urine flow. H. On 04/30/2026 at 2:53 PM, during an interview, the Director of Nursing (DON) stated it is her expectation all residents with a urinary catheter collection bag have the bag positioned below the level of the bladder to ensure proper urine flow. The DON stated if the catheter drainage bag is not kept below the bladder, urine may not drain properly, which could increase the risk of infection.

Based on record reviews, observations, and interviews, the facility failed to provide a homelike environment for 5 (R #1, #2, #3, #5, and #8) out of 5 (R #1, #2, #3, #5, and #8) residents reviewed by not: Maintaining comfortable and safe temperature levels for R #1, #2, #3, and #5. Providing R #8 bed linens. If the facility fails to maintain a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues. The findings are: Temperature: A. On 01/22/26 at 8:39 am, during an observation of R #1's room, R #1 was lying in bed sleeping with two blankets present. One small blanket was over her upper body and head, and another blanket was covering her feet. R #1's room was colder than the common area and the other rooms on the unit. The thermostat in R #1's room was set to 59 degrees Fahrenheit (F). A large wall furnace was present, but not operational. When R #1's room thermostat was set to a higher temperature, the furnace did not activate. B. On 01/22/26 at 8:45 am, during an observation and interview with R #3, R #3's room was observed to be cold with the room thermostat set to 78 degrees F. R #3 confirmed it is often cold in his room. C. On 01/22/26 at 8:51 am, during an observation of R #2's room (R #1's roommate), she moaned in discomfort. R #2 was taken to the restroom by Certified Nursing Assistant (CNA) #1, but R #2 continued to moan in discomfort. D. On 01/22/26 at 8:55 am, during an interview with CNA #1, she stated R #2 was moaning in discomfort because R #2 was cold, and R #2 does not like to be cold. She stated she does not think the thermostats in resident's rooms work often. CNA #1 stated R #1 and R #2's room is often cold, but the facility is aware. E. On 01/22/26 at 9:05 am during an interview with Maintenance Supervisor (MS), he stated there had been some issues with it being cold on the 300 unit in the past. The MS stated he was aware of recent resident complaints regarding the temperature of the 300-unit. The MS confirmed the room thermostats do not work, because the rooms temperature was controlled by the thermostat at the nurse's station. He stated he had not kept any logs of the temperature readings he had been taken on the 300 unit, but confirmed residents had recently complained about the room temperatures. F. On 01/22/26 at 12:30 pm, during an interview with CNA #1, she stated it was colder on the 300-unit more than anywhere else in the building. CNA #1 confirmed residents have recently complained about the room temperatures. G. On 01/22/26 at 12:36 pm, during an interview with Registered Nurse (RN) #1, she stated the vent at the 300-unit nursing station constantly blows cold air. RN #1 confirmed R #3 complained about the cold temperatures several weeks prior, and R #5 complained about the cold room temperature earlier today. RN #1 stated the nursing station thermometer was set to 72 degrees F, but the common area (of the 300-unit) has had recent temperatures of 68 degrees F, when checked. H. On 01/22/26 at 1:19 pm, during an interview with Director of Nursing (DON), she stated some of the residents have complained about it being cold on the 300-unit and some rooms are cooler than others. She stated the radiant heaters on the walls work throughout the building except on the 300 unit. The DON confirmed resident rooms should not be cold, and maintenance should be made aware of cold rooms so the temperatures can be adjusted. R #8 Bed Linens: I. Record review of R #8's face sheet revealed R #8 was admitted into the facility on 08/07/08 and the following diagnoses: Atopic dermatitis (chronic itchy skin rash or eczema), Type 2 diabetes mellitus with diabetic neuropathy (a condition where high blood sugar causes nerve damage, often leading to numbness, tingling, or pain), Varicose veins of unspecified lower extremity with inflammation (a condition in which enlarged, twisted veins in the leg become inflamed, causing pain, swelling, redness, or tenderness), Unspecified dementia, unspecified severity, without behavioral (condition involving a decline in memory and thinking abilities that affects daily functioning, without associated behavioral problems such as aggression or agitation). J. On 01/22/26 at 10:07 AM, during an observation of R #8's room, R #8 was observed lying on her mattress without linens. K. On 01/22/26 at 12:02 PM, during an observation of R #8's room, R #8 was observed lying on her mattress without linens. L. On 01/22/26 at 1:09 PM, during an observation of R #8's room, R #8 was observed lying on her mattress without linens. M. On 01/22/26 at 2:10 PM, during an observation of R #8's room, R #8 was observed lying on her mattress without linens. N. On 01/22/26 at 1:27 PM, during an interview with CNA #1, she stated all facility CNAs are responsible for making resident beds. She stated once the linen is removed, the bed should be re-made right away. O. On 01/22/26 at 1:30 PM, during an interview with the RN #1, she stated resident beds should be made without unnecessary delay. She noted residents should not be lying in bed without linens, as the material is plastic and prolonged contact could disrupt the resident's skin. RN #1 also stated the residents can be cold without a blanket. RN #1 confirmed R #8's bed should have been provided linens once the soiled ones were removed. P. On 01/22/26, at 2:40 PM, during an interview with the DON, she stated it is her expectation all residents' beds be made immediately after the linen is removed. She stated residents cannot rest comfortably without linens on their beds and noted delays in making beds could contribute to worsening skin issues.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #8) of 1 (R #8) resident reviewed for MDS accuracy. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs. The findings are: A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE] with the following diagnoses: Type 2 diabetes mellitus with diabetic autonomic neuropathy (a condition in which high blood sugar from diabetes causes damage to the nerves that control automatic body functions, such as heart rate, digestion, blood pressure, and bladder control), Personal history of transient ischemic attack (TIA; a brief blockage of blood flow to the brain that causes stroke-like symptoms), and cerebral infarction without residual deficits cerebral infarction (Stroke; in which blood flow to the brain was temporarily or briefly interrupted, with no lasting neurological deficits remaining), Cognitive communication deficit (condition in which a person has difficulty understanding, processing, or expressing information due to impaired cognitive functions such as memory, attention, problem-solving, or executive functioning, often affecting effective communication), Depression (a mood disorder characterized by persistent feelings of sadness or low mood, loss of interest or pleasure in activities, and changes in thinking, behavior, or physical functioning that interfere with daily life). B. Record review of R # 8's MDS, dated [DATE], Section C (Cognitive Patterns) revealed the following: Should brief interview for mental status Brief Interview for Mental Status (BIMS; screening for cognitive impairment) be conducted? (Section C 0100) was coded as: unanswered, Brief Interview for Mental Status (Section C0200) was unanswered, Brief Interview for Mental Status (Section C0300) was unanswered, Brief Interview for Mental Status (Section C0400) was unanswered, Brief Interview for Mental Status (Section C0500) was unanswered, resulting in the absence of a BIMS score, Should the Staff Assessment for Mental Status be Conducted? (Section C0600) was dashed (unanswered), Short-term memory (Section C0700) coded as: memory ok, Cognitive skills for daily decision making (Section C1000) coded as: modified independence. C. Record review of R # 8's MDS, dated [DATE], Section C (Cognitive Patterns) revealed the following: Should brief interview for mental status Brief Interview for Mental Status (BIMS; screening for cognitive impairment) be conducted? (Section C 0100) was coded as: yes, Brief Interview for Mental Status (Section C0200) was dashed (unanswered), resulting in the absence of a BIMS score, Should the Staff Assessment for Mental Status be Conducted? (Section C0600) was dashed (unanswered), Short-term memory (Section C0700) coded as: dashed (unanswered).D. Record review of R # 8's MDS, dated [DATE], Section C (Cognitive Patterns) revealed the following: Should brief interview for mental status Brief Interview for Mental Status (BIMS; screening for cognitive impairment) be conducted? (Section C 0100) was coded: unanswered, Brief Interview for Mental Status (Section C0200) was coded as: unanswered, Should the Staff Assessment for Mental Status be Conducted? (Section C0600) was dashed (unanswered), Brief Interview for Mental Status (Section C0200) was unanswered, Brief Interview for Mental Status (Section C0300) was unanswered, Brief Interview for Mental Status (Section C0400) was unanswered, Brief Interview for Mental Status (Section C0500) was unanswered, resulting in the absence of a BIMS score, Should the Staff Assessment for Mental Status be Conducted? (Section C0600) was dashed (unanswered). E. Record review of R # 8's MDS, dated [DATE], Section C (Cognitive Patterns) revealed the following: Should brief interview for mental status Brief Interview for Mental Status (BIMS; screening for cognitive impairment) be conducted? (Section C 0100) was coded as: yes, Brief Interview for Mental Status (Section C0200) was dashed (unanswered), Brief Interview for Mental Status (Section C0300) was dashed (unanswered), Brief Interview for Mental Status (Section C0400) was dashed (unanswered), Brief Interview for Mental Status (Section C0500) was dashed (unanswered), Should the Staff Assessment for Mental Status be Conducted? (Section C0600) was dashed (unanswered), resulting in the absence of a BIMS score, Short-term memory (Section C0700) coded as: dashed (unanswered), Long-term memory (Section C0800) coded as: dashed (unanswered). F. Record review of R # 8's MDS, dated [DATE], Section C (Cognitive Patterns) revealed the following: Should brief interview for mental status Brief Interview for Mental Status (BIMS; screening for cognitive impairment) be conducted? (Section C 0100) was coded as: yes, Brief Interview for Mental Status (Section C0200) was dashed (unanswered), Brief Interview for Mental Status (Section C0300) was dashed (unanswered), Brief Interview for Mental Status (Section C0400) was dashed (unanswered), Brief Interview for Mental Status (Section C0500) was dashed (unanswered), Should the Staff Assessment for Mental Status be Conducted? (Section C0600) was dashed (unanswered), resulting in the absence of a BIMS score, Short-term memory (Section C0700) coded as: dashed (unanswered), Long-term memory (Section C0800) coded as: dashed (unanswered). G. On 01/22/26 at 4:08 PM, during an interview with the MDS Coordinator (MDSC), she stated she was responsible for the completion of R #8's MDS assessments. She stated it was her expectation that R #8's MDS assessments be fully completed, including Section C, and not dashed or left unanswered.

Based on record review and interview, the facility failed to ensure physician-ordered diabetic foot care was provided for 1 (R #8) of 1 (R #8) resident reviewed for foot care. This deficient practice is likely to result in foot related complications, including infection, injury, or worsening foot conditions. The findings are: A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE] with the following diagnoses: Type 2 diabetes mellitus with diabetic autonomic neuropathy (a condition in which high blood sugar from diabetes causes damage to the nerves that control automatic body functions, such as heart rate, digestion, blood pressure, and bladder control), Paraplegia (paralysis of the lower half of the body, typically affecting both legs, usually caused by injury or disease of the spinal cord), Cognitive communication deficit (trouble understanding, remembering, or expressing ideas because of problems with thinking skills, often due to brain injury or illness), Reduced mobility (having difficulty moving or limited ability to move independently, often due to illness, injury, or aging), Unsteadiness on feet (difficulty maintaining balance while standing or walking, which increases the risk of falls). B. Record review of R # 8's Care Plan dated 08/05/25 revealed diabetic foot care was not included in the care plan. C. Record review of R #8's Physician Orders, dated 09/11/25 revealed the following: Diabetic Foot Care/Check Daily Observation of feet, toes, ankles, and soles (undersurface of a person's foot). Noting any alteration in skin integrity, color, temperature, and cleanliness. Inspect shoes for proper fit and excessive wear, check Pedal Pulses (rhythmic throbbing sensation felt in the arteries of the foot) every night shift. D. Record review of R #8's Treatment Administration Record (TAR) dated 09/11/25 through 01/14/26 revealed diabetic foot care was not completed by the facility nursing staff for the following dates: 09/11/25 through 09/30/25, 10/01/25 through 10/31/25, 11/01/25 through 11/01/25, 12/01/25 through 12/31/25, 01/01/26 through 01/14/26. E. Record review of R #8's Podiatry Consultation dated 01/14/26 revealed the following: Diagnosis of Type 2 Diabetes Mellitus with hyperglycemia (high blood sugar), Diagnosis of Onychogryphosis (a thickening and deformity of the toenails, often called ram's horn nails), Nail dystrophy (abnormal nail growth or appearance), Pain in right and left toes, Localized edema (swelling) in a specific area, Range of motion in foot and ankle joints is slightly diminished but without pain, Consent was given for debridement (removal) of the thickened, painful toenails (#1 refers to the big toes), Nails #1 and #2 through 5 on both feet were trimmed and cleaned using nail nippers and an electric grinder to reduce pain and improve hygiene, Recommended daily foot checks to monitor for infection or other problems, Suggested wearing supportive shoes while walking, Recommended moisturizing lotions every 2 to 3 months, but cautioned against putting lotion between the toes to avoid maceration (softening and breakdown of the skin), Painful thickened nails with fungal or other infections, treated with nail trimming and care, Ongoing diabetic foot care is important due to the resident's underlying diabetes. F. On 01/22/26 at 2:55 PM, during an interview with the Director of Nursing (DON), she stated it was her expectation that physician orders, including diabetic foot care, were followed for R #8. She stated if residents who are diabetic did not receive the recommended footcare, it could lead to diabetic complications. The DON confirmed R #8's foot care was not followed per physician orders and should have.

Based on record reviews and interview, the facility failed to:Demonstrate its measures to minimize the risk of Legionella (bacteria naturally found in water that can cause a severe type of lung infection called legionnaires' disease when people inhale tiny water droplets containing the bacteria) in the building's water system, when the Water Management Program (WMP) team failed to develop and implement an adequate Legionnaires Water Management Program (LWMP). If the facility does not have a an adequate LWMP, then residents can be at risk of legionellosis (legionnaires' disease and Pontiac fever, a milder flu-like illness).These failures had the potential to affect all residents in the facility. The findings are:A. Record review of the facility's LWMP, last revised on 06/2020, showed the following: - The policy did not have a procedure on how to use the control measures to control the introduction and/or spread of Legionella in the building water system. - The policy did not include control limits (the maximum value, minimum value, or range of values that are acceptable for the control measures that you are monitoring to reduce the risk for legionella growth and spread) and parameters. - The policy did not have monitoring procedures to include specified and documented environmental testing protocols for legionella and established control limits acceptable for the control measures the facility monitored to reduce the risk for Legionella growth and spread. - The policy did not have established ways to intervene when control limits were not met or when there was a case of healthcare-associated legionellosis in the facility. B. On 11/18/25 at 11:00 am, during an interview with the facility's Administrator, Director of Nursing, Corporate Nurse, Corporate Maintenance Director, and the Infection Control Preventionist, they stated they were not aware the LWMP was inadequate to prevent the growth and spread of legionella in the building water system. They stated they were not aware the plan did not have procedures to explain how to use the control measures, what were the acceptable control limits and parameters, what were the monitoring procedures, what were the testing protocols, and what were the established ways to intervene when control limits were not met or when there was a case of healthcare-associated legionellosis in the facility.

Based on observation, record review, and interview, the facility failed to promote care with dignity and respect for 1 (R #33) of 1 (R #33) residents when R #33 was found sitting in the dining room during lunch with an active bleeding wound on his hand, which included blood on his clothing, face, and both hands. This deficient practice is likely to result in residents feeling unimportant to facility staff and an increased risk of infection due to being around other residents in the dining room. The findings are: A. Record review of R #33's face sheet revealed a re-admission date of 08/18/25 and included a diagnoses of cognitive communication deficit (difficulties in communication that arise from impaired cognitive functions, such as attention, memory, reasoning, and problem solving) and degenerative disease of nervous system (conditions that gradually damage and destroy parts of your nervous system, especially areas of the brain). B. Record review of R #33's annual Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 05/29/25, revealed R #33 had a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) of 2 (severe impairment).- Scores range from 00 to 15, with 15 - 13 is cognitively intact, 12 - 8 is moderately impaired, 7 - 00 is severe impairment.C. On 09/30/25 at 12:14 pm, an observation (approximately 30 minutes) revealed the following:- R #33 had blood on the top of his right hand; staff served his tray and then walked away.- R #33 had blood on his left hand and clothing.- R #33 had a wound on his right hand that was actively bleeding.- R #33 was feeding himself with his hands while they were still bloody.- R #33 was picking butter out of the single-serve butter cups with his bloody hands.D. On 09/30/25 at 12:45 pm during an interview, the Director of Nursing (DON) verified R #33 had an open actively bleeding wound, and he had blood on both hands and clothing. The DON stated it was not an acceptable practice for R #33 to be seated in the dining room in that condition. She stated the active bleeding wound on his right hand should have been cleansed and covered, and the staff who served his meal should have cleaned R #33's wound instead of walking away.

Based on record review and interview, the facility failed to ensure residents or their guardians were aware of the medications they received including the reasons, risks, and benefits of each medication for 2 (R #10 and #13) of 3 (R #10, #13 and #44) residents reviewed for unnecessary medications. If residents and/or their guardians are not informed of the risks and benefits of each medication, then they are not able to make informed decisions. The findings are: R #10A. Record review of R #10's physicians' orders revealed the following:- 07/11/25: Escitalopram Oxalate oral tablet (antidepressant), 20 mg by mouth one time a day for depression.- 10/02/25: Depakote oral tablet (anticonvulsant), delayed release, 500 milligrams (mg) by mouth two times a day for anxiety related to traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head). Start date: 10/02/25.- 10/11/25: Quetiapine Fumarate oral tablet (antipsychotic), 150 mg by mouth at bedtime for anxiety related to TBI and anxiety.- 11/17/25: Hydroxyzine HCI oral tablet (antianxiety), 25 mg by mouth every 6 hours as needed for agitation and anxiety.B. Record review of R #10's electronic medical record (EMR) revealed the record did not contain a consent form from the resident/responsible party for Depakote 500 mg, Escitalopram 20 mg, Hydroxyzine 25 mg, and Quetiapine 150 mg. C. On 11/18/25 at 1:50 pm during an interview, the Director of Nursing (DON) stated there should be a signed consent form for R #10's anticonvulsant, antidepressant, antianxiety and antipsychotic medications.R #13D. Record review of R #13's physicians' orders revealed the following: - 10/03/25: Citalopram Hydrobromide (increases the amount of serotonin in the brain and helps maintain mental balance) oral tablet, 20 mg by mouth one time a day for depression. - 10/13/25: Hydroxyzine Pamoate Please define oral capsule, 25 mg by mouth two times a day for anxiety related to dementia. E. Record review of R #13's Electronic Medical Record (EMR) revealed the record did not contain a consent form from the resident/responsible party for Citalopram 20 mg and Hydroxyzine 25 mg. F. On 11/18/25 at 1:50 pm during an interview, the Director of Nursing (DON) stated there should be a signed consent form for R #13's anticonvulsant, antidepressant, antianxiety and antipsychotic medications.

Based on record review and interview, the facility failed to develop and implement an adequate 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 2 (R #10 and #44) of 3 (R #2, #10 and #44) residents reviewed for baseline care plans. If the facility fails to develop and implement an adequate baseline care plan within 48 hours of admission for residents, then staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident due to medical care or lack of medical care). R #10A. Record review of R #10's face sheet revealed an admission date of 07/05/25 and included the following diagnoses: - Urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra).- Type 2 diabetes (DM2, a condition which results from insufficient production of insulin, causing high blood sugar).- Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).- Anxiety disorder (feelings of fear or apprehension).- Polyneuropathy (a condition that damages multiple peripheral nerves in the body).- Blindness, both eyes.- Hypertension (HTN; high blood pressure).- Esophageal varices (abnormal veins that usually develop when the blood to the liver is blocked).- Constipation (bowel movements either occur less often than expected or the stool is hard, dry, and difficult to pass).- Alcoholic cirrhosis of liver (the most advanced form of liver disease related to excessive alcohol consumption).- Muscle wasting and atrophy (loss of muscle mass and strength).- Reduced mobility.- Traumatic Brain Injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head). B. Record review of R #10's baseline care plan dated 07/09/25 revealed there was no baseline care plan in place within 48 hours, as it was developed four days after R #10's admission date. C. On 11/18/25 at 1:50 pm during an interview, the Director of Nursing (DON) stated R #10's baseline care plan should have been completed within 48 hours.R #44D. Record review of R #44's face sheet revealed an admission date of 09/16/25 and include the following diagnoses:- Sequelae of cerebrovascular disease (residual effects of a stroke).- Klebsiella pneumoniae (type of bacteria that can cause pneumonia, UTIs, wound infections and more).- Anemia (low red blood cell count).- Type 2 diabetes mellitus (DM2, a condition which results from insufficient production of insulin, causing high blood sugar).- Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol).- Dementia with psychotic disturbance (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment with disconnection from reality).- Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).- Blindness, both eyes.- Hypertension. (HTN; high blood pressure).- Stage 3 Chronic kidney disease (CKD; impaired kidney function).- Urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra).E. Record review of R #44's baseline care plan dated 09/17/25, revealed the care plan did not address the following:- Dementia with psychotic disturbance.- Klebsiella pneumoniae. - Blindness.- Sequelae of cerebrovascular disease. F. On 11/18/25 at 1:50 pm during an interview, the DON stated dementia, blindness and any type of serious infection should be addressed in the baseline care plan for R #44. She stated it is her expectation that baseline care plans be completed timely and should include anything that would affect resident's health and safety.

Based on record review, observations, and interview, the facility failed to ensure the comprehensive care plan was complete for 1 (R #10) of 3 (R #10, #13 and #44) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for residents. The findings are: A. Record review of R #10's face sheet revealed an admission date of 07/05/25 and included diagnoses of blindness and depression. B. Record review of R #10's comprehensive care plans 07/09/25 revealed there was no care plan addressing activities for R #10. C. On 09/30/2025 at 2:48 pm, during an interview, R #10 stated he listens to music and the tv for entertainment but would participate in bingo if someone would help him. He stated he walks throughout the hallway to keep busy sometimes. D. On 11/18/25 at 1:50 pm during an interview, the Director of Nursing (DON) stated it is the Activities Department's responsibility to create a care plan addressing activities and wasn't sure why one had not been developed. She stated R #10 uses his phone for entertainment. She stated that facility staff download audio files to R #10's cell phone, and he also enjoys sitting next to the television when there is a football game on. E. On 11/18/25 at 2:13 pm during an observation, R #10 walked into the small dining room where residents were playing bingo; he asked what was going on in the room, staff advised him it was bingo and then R #10 walked out of the room back into the hallway.

Based on observation and interview the facility failed to ensure essential equipment was in safe operating condition by not replacing a broken plastic light covering for a light located directly over the cooking area of the stove. This deficient practice has the potential to affect all 33 residents on the facility census that was provided by the administrator on 07/08/24. The findings are: A. On 07/08/24 at 10:13 am during the initial tour of the kitchen, there was a light in the stove hood that had a broken plastic light cover which had tape holding part of the cover together. Pieces of tape hung off of the cover; and a piece of the plastic cover was completely missing. B. On 07/11/24 at 11:07 an during an interview, the dietary manager stated that the light cover on the oven hood had been broken since he started working at the facility in September of 2023. He also stated that he had not put in a paper work order to repair or replace the light cover but that he has verbally requested this to be fixed. He further stated that he was unsure as to if or when this light cover will be repaired and confirmed that there was loose and old/dirty tape used to hold the light cover together that was hanging loosely off of the light cover.

Based on record review, observation, and interview, the facility failed to provide reasonable accommodations of resident needs for 1 (R #10) of 1 (R #10) resident reviewed for care when the facility failed to ensure that the resident call light was within the resident's reach and signs were in the preferred language (Navajo-Dine). This deficient practice could likely result in the residents' needs not being met, leaving them at risk of accidents and falls. The findings are: A. During observations of R #10 the following was revealed: 1. On 07/08/24 at 10:24 am, R #10 laid in bed and the call light was under the bed. 2. On 07/08/24 at 12:15 pm, R #10 laid in bed and the call light was under the bed. 3. On 07/09/24 at 09:13 am, R #10 laid in bed and the call light was under the bed. 4. On 07/09/24 at 12:30 pm, R #10 laid in bed and the call light was under the bed. B. On 07/09/24 at 12:36 pm, during an interview with Certified Medical Assistant (CMA) #1, she confirmed the following: 1. R #10 does need occasional assistance getting out of bed. 2. R #10 does need to have his call light within reach due to having multiple falls in the past. C. Record review of R #10's care plan revised on 11/27/23, revealed that the call bell and personal items are within resident's reach. Encourage resident to use the call bell to request assistance PRN (as needed). Record Review of the care plan for R # 10, revised 11/27/23, revealed place a chair at the nurses' station with signage in English and Navajo with a picture of a person sitting. Add signage to the chair in 400 hall lounges. Upon observation there was no signage anywhere on the 400 hall that was in Navajo/Dine', so the residents that speak or read Navajo/Dine'. D. On 07/12/24 at 11:32 am, during an interview with Social Services, she confirmed that the sign should be on the 400 hall.

Based on observation and interview, the facility failed to provide a comfortable and home-like environment for all 33 residents (residents were identified by the census provided by the Administrator on 07/08/24) when they failed to clean mice dropping on the floor in multiple areas of the facility. This deficient practice could likely cause residents to feel like they are not living in a comfortable, home-like environment and are not valued. The findings are: A. On 07/08/24 at 11:30 am, during an observation of the main conference room, mice dropping were along the walls and behind the trash can. B. On 07/09/24 at 1:22 pm, during an observation of the main dining area, mice droppings were along the walls and behind the door that enters the dining area. C. On 07/09/24 at 1:32 pm, during an observation of the secondary dining area, mice droppings were along the walls and behind the bookshelf. D. On 07/11/24 at 11:30 am, during an observation of multiple rooms in the 400 halls the following were revealed: 1. Room # 410- mice dropping on the north wall floor under the window along the wall. 2. Room # 402- mice dropping on the north wall floor under the window where the fall pad was located. 3. Room # 401- mice dropping on the north wall under the window along the wall. E. On 07/12/24 at 11:30 am, during an interview, Certified Medical Assistant (CMA) #1 stated, staff have seen mice in the dining area and the rooms. She stated that she and other staff, along with housekeeping, had let the management know. F. On 07/15/24 at 12:13 pm, during an interview with the Administrator, he stated that the main conference room was used for the resident council meetings and the Care Plan meeting. He stated that housekeeping cleans the conference room daily Admin confirmed that the mice issue was being addressed with maintenance. G. On 07/15/24 at 12:22 pm, during an interview with the housekeeper, she stated that she sees mice dropping around the building but does her best to sweep and mop daily. She states that the housekeeping does deep cleaning when they have extra time.

Based on observation and interview, the facility failed to treat residents with respect and dignity for 2 (R #10 and R # 31) of (R #10 and R # 31) residents randomly identified when the staff failed to knock on the resident's bedroom door before they entered the resident's room. This deficient practice could likely result in residents feeling unimportant and not having privacy. The findings are: A. On 07/09/24 at 12:37 pm, during an observation of staff interaction, Registered Nurse (RN) #1 entered R #10's room, RN did not knock on R #10's door prior to entering the room. R #10 was asleep on his bed. B. On 07/09/24, at 12:38 pm, during an observation of staff interaction, RN #1 entered multiple empty room (residents were in the recreation room socializing), without knocking, . RN #1 found Certified Medical Assistant (CMA) #1 and asked for help. Both staff proceeded back into the R #10 room again without knocking. C. On 07/09/24 at 12:40 pm, during an observation of staff interaction, RN #1 entered R # 31's room without knocking to perform personal care. D. On 07/09/24 at 12:41 pm, during an interview, CMA #1 stated that it is call light policy for staff to knock on the residents' door and announce why staff are entering the room. CMA #1 stated that they were in a hurry looking for wipes for another resident.

Based on observation and interview, the facility failed to maintain infection control practices for 1 (R #31) of 1 (R #31) residents reviewed for catheter care (the practice of properly utilizing a Foley catheter and catheter bag. The Foley catheter is a tube that is inserted into a patient's bladder to remove urine. The catheter bag is where the urine is drained into). This deficient practice could likely result in the resident being susceptible to infection. A. On 07/08/24 at 10:55 am, during an observation, R #31 was resting in bed, with the bed in the lowest position. R #31's urine catheter bag was attached to the bottom rail of his bed. Due to the position of the bed, the catheter bag was resting on the floor. B. On 07/09/24 at 2:10 pm, during an observation, R #31 was resting in bed, with the bed in the lowest position. R #31's urine catheter bag was attached to the bottom rail of his bed. Due to the position of the bed, the catheter bag was resting on the floor. C. On 07/09/24 at 2:12 pm, during an interview with Registered Nurse (RN) #1, she confirmed the catheter bag was on the floor. She also confirmed that the catheter bag should not be resting on the floor.

Based on observation, record review, and interview the facility failed to protect 1 (R #1) of 1 (R #1) resident from the potential of elopement (when a resident leaves the facility without the knowledge of the staff) and accidents. If the facility fails to properly supervise residents for elopement, serious injury or death may occur if they leave the facility unannounced. The findings are: A. Record review of R #1's face sheet, dated 01/24/24, revealed he was admitted to the facility on [DATE] with multiple diagnoses including: - Dementia (a chronic persistent condition, decline of mental abilities) unspecified severity with other behavioral disturbance, - History of falls, - Muscle wasting and atrophy (loss of muscle mass), - Unspecified injury of head. B. Record review of R #1's Elopement Risk Assessment, dated 11/02/23, revealed R #1 had a history of wandering, because he wanted to be with his dog. C. Record review of R #1's Brief Interview for Mental Status (BIMS, a screening for cognitive impairment), dated 11/03/23, revealed a score of 99, because the resident could not complete the interview. This indicated significant cognitive impairment and/or severe end stage dementia. D. Record review of R #1's baseline care plan, dated 11/02/23, revealed R #1 had a behavior symptom in which he wandered around the facility looking for his dog and tried to leave the facility to find his dog. The care plan also revealed R #1 was at risk for falls related to weakness, as evidenced by a history of falls. E. Record review of R #1's medication review report, dated 11/05/23, revealed staff to check R #1's WanderGuard's (device that sounded an alarm and locked doors if it came near a WanderGuard equipped exit) placement and functioning every day and evening shift for elopement precautions. Further review revealed staff checked R #1's WanderGuard twice a day and found it to be in working order each time. F. Record review of the WanderGuard exit door alarms inspection forms, dated December 2023 and January 2024, revealed all exits equipped with WanderGuard alarm functioned properly. Further review of the forms revealed staff performed the inspections daily. G. Record review of the facility's five day follow-up report, not dated, regarding R #1's elopement, stated R #1 wore a WanderGuard. A security camera revealed R #1 eloped from the facility on 01/17/24 at 3:44 am, through a door in the kitchen that was not part of the WanderGuard system. Staff found R #1 to be missing on 01/17/24 at approximately 7:30 am as other residents were headed to breakfast. The Infection Preventionist (IP) nurse called the Administrator at 7:55 am, and staff searched the building. The Administrator called the Director of Nursing (DON) at 7:56 am and the Environmental Services Director (EVS) at 7:57 am. The EVS immediately implemented the facility's elopement protocol, which included an expanded search of the immediate surroundings. The Administrator called 911 to report the elopement at 8:51 am. Police, emergency medical technicians (EMTs), and Fire Rescue arrived to assist with the search. Facility staff located R #1 at the baseball field behind the center on 01/17/24 sometime between 9:00 am and 9:30 am. The resident was conscious and responsive. Staff calmed the resident until Fire Rescue and EMTs arrived. The resident had visible injuries to his elbows from a fall and was taken to the emergency room . H. Record review of R #1's hospital record, dated 01/17/24, revealed hospital staff assessed the resident for hypothermia (low body temperature) and cared for the resident's elbow and knee skin tears (a wound that happens when the layers of skin separate or peel back). R #1 was also diagnosed with frostbite (freezing of tissue under the skin) to his fingertips on both hands. R #1 was stable and returned to the facility on [DATE] at 6:37 pm. I. Record review of R #1's wound care at the facility, dated 01/18/24, revealed the following injuries: - Second degree (skin will begin to turn from a reddish color to a paler color and in some cases, it may appear blue) frostbite to multiple digits of both hands. Will treat with silvadine cream (burn cream), dressings daily, and close monitoring. Currently with good capillary (blood vessels) refill, stable at this time. - Multiple cuts, scrapes, and bruising to the lower extremities. Will need staff assistance with frequent checks. Gait (walking) is unsteady at this time. Will consider physical therapy. J. Record review of the work schedule for medical staff, dated 01/16/24 through 01/17/24, revealed the following staff worked at the time R #1 eloped: - One Registered Nurse, - One Medication Assistant, - Two Certified Nursing Assistants (CNA). K. Record review of CNA #3's written statement, dated 01/17/24, concerning R #1's elopement on 01/17/24, revealed she started her shift on 01/16/24 at 6:00 pm and was scheduled to work until 01/17/24 at 6:00 am. The CNA stated, When I looked at the clock it was a little after 3:00 am. So after CNA #5 left, I was on 300 hall myself and the medication tech: (employee name) was in the nurses station. Again, on my downtime, I started back-up on my charting. To my best knowledge, I trusted my intuition that (name of R #1) was in bed, so I didn't think anything of it. Here and there, some call lights were going off so I was going to certain rooms to check on a couple residents. Around 3:45 (am), I went to 400 (hall) because one resident was on their call light, so I assisted him by putting him back to bed, change his linens, and his clothes. I made sure he was covered with his heavy blankets. Then, off and on I tried to go back to my charting to make sure everything was documented. At 3:59 am (employee name) asked me, 'Did (employee name) do the dressing change? Or has (employee name) give (resident name) her morphine?' And I said 'I saw her go in (resident name) room.' And she asked me, 'What time are you starting?' I said, 'As soon as (employee name) gets down here, if not at 4:30 (am).' We started the wound dressing a little after 4:00 am and then after we started doing rounds on 300 (hall) first and we went over to 400 (hall.) To my best knowledge, I saw R #1 wander the halls a little after 4:00 am, but I wasn't too sure on the time. We were approaching our last set of rounds, we were pacing ourselves getting residents up in their wheelchairs, providing am (morning) care, and getting them dressed for day shift. After we completed our last set of rounds, (employee name) told me she was going to go back to 200 (hall) to finish her set of rounds. Later on, after she finished she came to 300 (hall) and asked if I was ready, which meant to toss out our trash. She had got the keys from (employee name) and we went out the back door from 300 (hall) to throw out the trash. I led first and she came after, to and from. After I finally settled in, I made sure charting was done on both halls. I do best believe to my knowledge I've done everything I could to finish my charting on time. It was a busy night as the residents kept me busy with just one CNA to take care of 300/400 halls (300 hall R #1 resided on) and one CNA on 200 (hall). That just leaves one medication tech and one nurse. I did do the charting ahead of time because I trusted myself that R #1 was in his room at the time. Throughout the night/morning he does and he did wander the premises. I physically saw him wander the halls, and I thought 'Okay, he should be fine.' L. On 01/24/24 at 9:45 am, during an interview with the DON, she stated CNA #3 was responsible for the hall on which R #1 resided on the morning he eloped. The DON further verified staff did not check on R #1 between the hours of 3:30 am and 7:15 am on 1/17/23, when staff recognized the resident was missing. The DON stated the facility policy was for staff (CNAs) to check hourly on everyone that was an elopement risk and had a WanderGuard. M. On 01/24/24 at 2:10 pm, during an interview with CNA #1, she stated it was expected that she checked on residents who wore WanderGuards every hour, but she tried to check every 15 minutes. N. On 01/24/24 at 2:15 pm, during an interview with CNA #2, he stated he was required to check on residents who wore WanderGuards hourly, but he tried to check on them every 15 minutes. O. On 01/24/24 at 2:30 pm, during an observation of R #1 in his room, the resident was asleep and resting. He woke up, but he was unable to answer question about his elopement due to his advanced dementia.

Based on record review and interview, the facility failed to provide a Facility Initiated Report (mandatory self-initiated facility report of an incident) within 24 hours from the date of the incident to the State Survey Agency, for 1 (R #1) of 3 (R #1, R #2, R #3) residents reviewed for incidents. If the facility fails to provide a Facility Initiated Report to the State Agency then the State Agency will be unable to assure residents are safe and have a hazard free environment. The findings are: A. Record review of New Mexico Health Facility Licensing and Certification (NMHFL&C) report revealed the facility did not successfully send a Facility Initiated Report to the state reporting system within 24 hours of a resident elopement (when a resident leaves the facility without the knowledge of the staff) that occurred on 01/17/24. B. On 01/24/24 at 9:45 am, during an interview with the Director of Nursing (DON), she stated the facility administrator sent the Facility Initiated Report on 01/17/24 but said they received an error message when it was sent.

Based on observation, interview, and record review the facility failed to provide quality care for 1 (R #18) of 2 (R #18 and 30) residents reviewed for death, by not monitoring R #18 oxygen saturation levels and ensuring that R #18 had his nasal cannula in place, after a change in condition was identified (needing supplemental oxygen) due to low oxygen saturation measurements the evening before. These deficient practices likely resulted in resident's passing. The findings are: A. Record review of the facility's policy titled INTERACT- Change in Condition Evaluation- CICE, last reviewed 12/02/2021, revealed the following procedure for a change in condition: Purpose: To improve communication between nurses and a provider when nursing is monitoring a change in condition. To enhance the nursing evaluation of and documentation of a resident who has a change in condition. To provide a standard format to collect pertinent clinical data prior to contacting the provider when there is a change in condition. To standardize shift to shift communication about a resident change in condition. If the resident is receiving skilled services and condition change requires monitoring . complete the CICE [Change in Condition Evaluation]. Notify the provider if the change in condition . Use the Change in Condition Evaluation to guide the change of shift report . B. Record review of R #18's face sheet revealed that R #18 was admitted to the facility on [DATE] with the following pertinent diagnosis: previous fall with traumatic subarachnoid hemorrhage (bleeding within the spaces of the brain, resulting in a traumatic brain injury), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), and dysphagia, unspecified (swallowing difficulties). C. Record review of physician orders, dated 10/23/22, Monitor O2 [oxygen] sat [saturation] and temp [body temperature] every shift. Notify MD [physician] if O2 sat is less than 85% or if temp is greater than 100.0 D. Record review of R #18's care plan revealed the following: Focus, date initiated: 11/22/22, Alteration in cardio-vascular status [conditions that affect your heart and blood vessels]. Hypertension, Hyperlipidemia [blood pressure that is higher than normal], CAD [Coronary artery disease- plaque buildup in the wall of the arteries that supply blood to the heart], History of NSTEMI [a type of heart attack that usually happens when your heart's need for oxygen can't be met], Traumatic and non-traumatic Subarachnoid Hemorrhages [Bleeding in the space between the brain and the tissue covering the brain]. Goal, date initiated: 11/22/22, [name of R #18] will remain free from complications related to Cardio-Vascular status, through next review date. Intervention, date initiated: 11/22/22, Monitor 02 Sats [oxygen saturation] and temp Q [every] Shift and prn [as needed], per provider's orders and call provider for 02 Sat <85% [oxygen saturation below 85%] and Temp >100 [body temperature more than 100 degrees Fahrenheit]. E. Record review of R #18's standing orders, dated 06/10/22, revealed the following Oxygen via nasal cannula 1-4 liters per minute as needed for dyspnea, hypoxia (O2 [oxygen] saturation less than 88% or acute angina. Immediately call provider/practitioner with nursing report. F. On 02/19/23 at 11:52 am, during an observation, R #18 was observed sleeping in bed with his oxygen cannula, misplaced, resting on his chest. Staff entered his room and placed his lunch tray at bedside. His cannula remained on his chest. G. On 02/19/23 at 2:03 pm, during an observation, R #18 was observed sleeping in bed with his oxygen cannula resting on his chest. His respirations were noted to be labored [difficulties breathing] with a crackle sound accompanied by occasional coughing. H. On 02/19/23 at 2:03 pm, during an interview with Med Tech #1, when asked to measure R #18's oxygen saturation (the amount of oxygen in blood- the normal range is 95%-100%), R #18's oxygen saturation was found to be 77%. I. Record review of R #18's vitals for 02/19/23 [time not documented] revealed his oxygen to be documented as 78% RA [while on room air- without supplemental oxygen] and 89 O2 4L [89% with 4 liters of supplemental oxygen]. There were no previous or additional recorded oxygen saturations taken on the day of 02/19/23. J. On 02/19/23 at 3:44 pm, during an interview with License Practical Nurse(LPN) #1, when asked for an update of R #18's status, she explained that he was declining and he passed. K. Record review of R #18's nursing notes revealed . Time of death pronounced at 15:15 [3:15 pm] on 02/19/2023 L. On 02/22/23 at 10:52 pm, during an interview with Registered Nurse (RN) #4, she explained, That night [02/18/22] his [R #18] oxygen saturation dropped and so we put him on oxygen, his oxygen saturation was 85. We put him on 2 liters and he went up to 92 When asked if the physician was notified of his change oxygen needs, she explained It was in the middle of the night so I passed it on to the day shift to notify the physician. In his profile is the protocol to put him on oxygen if he needed it [as a standing order] When asked to explain what she found upon assessing R #18, she explained He was aware and he was responsive. I listened to his lungs. I didn't hear any wheezes and his lower bases were diminished meaning the lower lobes, lung sounds were not as strong. That was baseline for him. M. Record review of R #18's nursing notes revealed that his recent need for oxygen was not documented for 02/18/22 or 02/19/22. N. On 02/22/23 at 12:03 pm, during an interview with the Social Services Coordinator, when asked to explain R #18's stay, she stated He was admitted as a skilled patient. He was here for therapy . and he was expected to go home and about halfway during his stay he let us know that he was going to transition to Long-Term Care. When asked if hospice was discussed, she stated Yes, they [him, his wife and facility staff] talked about it last Friday [02/17/23]. He didn't seem to fond of hospice and the wife said maybe O. On 02/22/23 at 1:44 pm, during an interview with the Director of Nursing (DON), when asked to explain the typical procedures if you find a resident with low oxygen levels, she explained We look at the chart, make sure they have oxygen, check MOST (Medical Orders for Scope and Treatment- a form that provides treatment directives for patients who are in a terminal state) form. Call the doctor, let him know of the situation. Do an assessment, check heart rate, blood pressure, history, check breathing, eyes, and pulse. This may include options to send to the hospital. It depends on their MOST status. P. Record review of R #18's MOST form, dated 07/12/22, revealed the following: (Section A): Do not attempt resuscitation/DNR (Section B): Comfort measures: Do not transfer to hospital unless comfort needs cannot be met in current location. Use medication by any route, positioning, wound care and other measures to relieve pain and suffering. Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. (Section C): Long-term artificial nutrition/hydration. Q. On 02/23/23 at 11:46 am, during an interview with the facility's physician, when asked if he was notified of R #18's need for oxygen, he explained I was notified at 2:30 pm on Sunday (02/19/23) however; they [staff] might of notified the on-call coverage. When asked if he would expect to be notified of R #18's new need of oxygen, he explained The way the standing order was written, I would expect to be notified when that oxygen requirement went beyond 4 liters. When asked if he would expect R #18's need for oxygen to be documented in his chart, he replied I would expect that they document the need for oxygen in his chart. It's a change in condition that should be documented. R. On 02/23/23 at 1:17 pm, during an interview with License Practical Nurse (LPN) #1, when asked to explain R #18's need for oxygen, she stated, When I came to work on Sunday (02/19/23), I got a report that his oxygen was in the 80's so she put oxygen on him and he was taking it [nasal cannula] off. He was on 2 liters of oxygen. The standing orders are for 2-4 liters. When asked if he needed oxygen before, she confirmed no. When asked if she notified the physician of R #18's oxygen needs, she explained Initially, it was the night nurse and I can't speak for her, if she notified him. S. On 03/16/23 at 2:14 pm, during an interview with the DON, when asked if the nurse who initially applied oxygen to R #18 should have documented this occurrence, the DON confirmed yes. When asked if the nurse should have created a Change In Condition assessment when he initially needed oxygen, she confirmed yes. She also explained that a Change In Condition should have been documented and an assessment should have been completed which would allow the nurse to provide an update for the doctor. When asked if she would expect the nurse on the shift of 02/19/23 to notify the doctor when she became aware that R #18 recently needed oxygen, she confirmed yes. When asked if additional monitoring should have occurred, she confirmed yes and explained that if the Change In Condition assessment was initiated, then it would have prompted the nurses to continue to monitor him closely. When asked if additional vital signs were taken for R #18 on 02/19/23, prior to being requested by the surveyor, she confirmed no. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J which was announced on 03/16/23 at approximately 3:15 pm to the administrator, in-person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 03/17/23 at 2:45 pm. Implementation of the POR was verified onsite at 11:46 pm on 03/20/23 by conducting record reviews and staff interviews. Plan of Removal: Resident #18 is no longer at the facility. Education of nurses by DON/designee regarding monitoring and reporting Change in Condition to physicians before next shift. The DNS [DON] or designee will conduct a head to toe assessment utilizing PCC [Point Click Care- software platform for Electronic Health Record] Daily Skilled UDA [User-Defined Assessment] that includes a review of all body systems, if Change in Condition is noted, DNS and/or designee will utilize PCC eINTERACT Change in Condition Evaluation tool and a full set of vital signs on each resident to determine any other residents having the potential to be affected by deficient practice. DNS or designee will utilize eINTERACT reference guide for Change in Condition: When to report to the MD/NP/PA, to report any immediate notification needs (examples include but not limited to) any symptom, sign or apparent discomfort that is Acute or Sudden in onset, a marked change in relation to usual symptoms and sign and/or unrelieved by measure already prescribed. Each resident will be asked, 'Have you felt any recent changes or concerns in your health?' Nurse or CNA currently assigned to resident will be asked, 'Have you observed any changes recently in the residents' health or functional ability?' 24 hr/72 hr [hour] summary report to be incorporated into clinical review meetings to ensure physician notification of change in conditions. Change in Condition process will be included in agency and new hire onboarding Describe any review and changes (if applicable) of policies and procedures: Change in Condition policy Education of staff: Education of nurses by DON/designee regarding Change in Condition policy and procedure, eINTERACT Change in Condition: When to report to the MD/NP/PA, and eINTERACT Change in Condition Evaluation UDA. Change in Condition process will be included in agency and new hire onboarding.

Based on record review, observation, and interview, the facility failed to: 1. Discard refrigerated food when it met its 7-day shelf life; 2. Date refrigerated food; and 3. Discard dented cans These deficient practices are likely to affect all 30 residents listed on the census provided by the Director of Nursing (DON) on 02/20/23 and could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. Record review of facility policy Date Marking- Food and Nutrition, last revised 05/03/22, revealed the following: Leftovers- Food items prepared for service that were not served and subsequently stored for use within seven days per food code . a. Ready-to-eat TCS [Time/temperature control for safety foods- a food that requires time/temperature control to limit pathogenic microorganism growth or toxin formation] foods prepared at the location and held in refrigeration for more that 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. Employees: 2) Count the day of preparation as day 1. At no time can a TCS prepared food be held more than seven days in a non-frozen state. B. On 02/19/23 at 10:08 am, during an observation of the dry food storage, the following canned food items were noted to be dented: 1. Blueberry pie filing 2. Apple sauce 3. Seasoned beef stalk C. On 02/19/23 at 10:11 am, during an observation of the walk-in refrigerator, the following food items were noted to be on the shelf: 1. A bag of cilantro, dated 2/2 [02/02/23], opened 2. A bag of diced red potatoes, undated and opened 3. A bag of leaf lettuce, undated and opened 4. A bag of Diced tomatoes, dated 2/9 [02/09/23] with a use by date of 2/17 [02/17/23] D. On 02/19/23 at 10:15 am, during an interview with the Dietary Manager, when asked how food is stored in the walk-in fridge (refrigerator), she explained We keep open produce on the shelf for less than a week. We come in on Wednesdays and clean it out. The food should be dated when we received it and it should have a use by date. When asked if the bag of cilantro, and tomatoes should remain on the shelf, she confirmed no. When asked if the potatoes and leaf lettuce should be dated, she confirmed yes. When asked how she stores canned food, she explained We date them and file fill the shelves [older cans are placed in the front to be used sooner]. When asked what is done with a dented can, she explained We just toss them. If someone dropped a can and doesn't say something, I may not be aware of the dented can on the shelf. She then confirmed that the 3 observed dented cans should be disposed of.

Based on observation and interview, the facility failed to follow infection control practices by; 1. Not doffing (removing personal protection equipment) gloves prior to exiting a room that was occupied by a resident on Transmission Based Precautions (infection control practices that help to stop the spread of germs); 2. Not washing or sanitizing hands in-between assisting residents; 3. Not developing a comprehensive surveillance plan (a plan and process to identify whether staff comply with established prevention and infection control procedures to prevent and reduce the spread of infection) These deficient practices could likely effect all 30 residents in the facility as identified on the census provided by the Director of Nursing (DON) on 02/20/23, Failure to plan, implement and monitor an infection control program could likely result in the spread of infections and illness to residents and staff within the facility. The findings are: A. On 02/19/23 at 11:53 am, during an observation of Certified Nursing Assistant (CNA) #1 while exiting R #26's room that was on contact Transmission Based Precautions for MRSA (Methicillin-resistant Staphylococcus aureus-a difficult to treat type of bacteria). It was observed that he removed his gloves after exiting the room. B. On 02/19/23 at 3:03 pm, during an observation of the Certified Medical Assistant (CMA) #1 while administering medications, it was noted that she did not wash her hands in between assisting residents. She prepared a medication to administer, adjusted the oxygen cannula (a device that sits on a resident's nostrils and is used to deliver supplemental oxygen) on a different resident, then proceeded to administer the medication without sanitizing or washing her hands after adjusting the nasal cannula. C. On 02/19/23 at 3:06 pm, during an interview with CMA #1, when asked how often hand washing should occur, she explained that you should wash or sanitize in between helping patients. When asked if she washed her hands or sanitized her hands in between adjusting the oxygen cannula for unknown and administering a medication to unknown resident she confirmed No I didn't, I didn't stop to wash my hands [between residents]. I probably was just thinking about getting the oxygen on the patient. There are some [residents] who remove their oxygen and its a force of habit [for me] to put the oxygen on. D. On 02/21/23 at 3:40 pm, during an interview with the DON, when asked if staff should remove their gloves before exiting a room on Transmission Based Precautions, she confirmed yes. When asked if staff should wash their hands or sanitize in-between helping residents, she confirmed yes. E. On 02/23/23 at 2:27 pm, during an interview with the DON, when asked if she had a comprehensive surveillance plan in place, she explained that she does surveillance everyday as she is working however; a formal surveillance plan has not been established and the only results form her daily surveillance was a training on hand hygiene that occurred in January of 2023. When asked if she has a checklist of observations to make that are included in her surveillance, she confirmed no. When asked if she documents her daily surveillance, she confirmed no. F. Record review of the facility policy Surveillance, AL [Assisted Living], Rehab/Skilled, Home Health, Hospice- Enterprise, last revised 03/30/22, revealed the following: Surveillance is an activity that a healthcare institution employs to find, analyze, control and prevent nosocomial [infection that occurs within 48 hours after admission] infections. It's definition can further include; collection, collation, analysis of data and passing of information to those who need to know and take action. Once a baseline is established, it can then be determined where control is needed. Components of surveillance are the following: -Definitions of infections -Data collection procedures -Forms and reports -Analysis by using cultures, changes in prevalent organisms and increase in rates - Results, which are given to appropriate persons Uses of the surveillance data may be the following: -Establish baseline -Identify problems -Evaluate control measures -Evaluate policies and procedures

Based on record review and interview, the facility failed to provide necessary care for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed for wound care by not: 1. Conducting accurate wound measurements 2. Updating the treatment plan and 3. Not implementing interventions related to R #1's refusal to eat, and 4. Not notifying the physician when the wound began to smell (evidence of infection). These deficient practices likely resulted in the resident becoming septic and contributing to her death. The findings are: A. Record review of R #1's EMR (Electronic Medical Record) revealed that the resident was admitted to the facility on [DATE] with the following pertinent Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Symptoms usually include delusions, hallucinations, hearing voices, incoherent speech, or negative symptoms, such as a flattening of emotions), [CONDITION(S)] (inflammation of the bone caused by infection), and paranoid personality disorder (a group of conditions which involves odd ways of thinking accompanied by excess paranoia). B. Record review of care plan revealed the following: 1. Focus: The resident has a behavior symptom R/T [related to] psychiatric condition. Goal: Resident will have fewer episodes of refusing care, rude behavior, yelling. Intervention: Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Deviert attention. Remove from situation and take to alternate location as needed. Date initiated: [DATE]. 2. Focus: The resident has actual impairment to skin [skin injury] R/T [related to] pressure. Goal: Resident's skin injury stage 4 [a skin injury that is deep enough to reach the muscles, tendons and ligaments] on sacrum [the bottom of the spine] will be healed by review date (date initiated: [DATE], target date: [DATE]). Intervention: . Monitor location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to health care provider. Date initiated: [DATE]. 3. Focus: The resident has Stage 4 pressure ulcer [a skin injury that is deep enough to reach the muscles, tendons and ligaments]. Goal: Resident's pressure ulcer will show signs of healing and remain free from infection by/through review date (date initiated: [DATE], target date: [DATE]). Intervention: . Notify nurse immediately of any new areas of skin breakdown: redness, blister, bruises, discoloration, etc. noted during bath or daily care . Date initiated: [DATE]. C. Record review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE], Chief complaint: sacral decub (Pressure ulcers). History of present illness: stage 4 to sacrum- refusing wound care- psychotic- not in touch with reality or understanding consequences of decisions. Plan: Needs guardian- I believe she lacks the decision making capacity- wants to go to wound care facility but refuses care . On [DATE], Chief complaint: [CONDITION(S)] [CONDITION(S)]. History of present illness: On a long talk today with no failure discussing all of her concerns and issues. I did look at her wound which is improved compared to previously on her sacrum though still stage III-IV but surrounding tissue is now pink and there is minimal slough [necrotic tissue]. She basically just wants to argue for a while. D. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Pack wound [apply special dressing to the wound to absorb any drainage to help in healing from the inside out] with wet to dry dressing or [MEDICATION(S)] [gel like substance used to aid in wound healing] as required. Cover with [MEDICATION(S)] [silicone dressing], then cover buttock with ABD [antibiotic] and secure with [MEDICATION(S)] [a soft non-woven polyester tape] tape. Change 3x/week [three times per week] (Tuesday/Thursday/Saturday) and PRN [as needed]. Every day shift, every Tue, Thu, Sat for wound care for pressure injuries. E. Record review of Wound Data Collection-V2 revealed that the resident's wound dressing was changed sparingly [infrequent] in the months of April (2021) and May (2021), however; consistent assessments occurred during the month of June (2021). Further review of the Wound Data Collection- V2 revealed that the only wound measurements were done on the following dates: [DATE], [DATE], [DATE], [DATE], and [DATE]. Further record review of Wound Data Collection- V2 revealed the following: On [DATE], the initial documentation of the wound states Upper wound, stage 4. Healing evidence: new epithelial tissue. Deterioration evidence: very rancid [unpleasant odor as a result of decomposition] large exuding from wound, saturated dressing and pad of bed. Physician notified. Lower wound, stage 3 [a skin injury where the thickness of the skin is diminished and it potentially extends into the subcutaneous tissue layer]. Healing process- evidence by new epithelial tissue [the outer layer of the skin that grows to close wounds]. Deterioration of wound- evidence by wound is concave [deeper into the tissue] in, though shows s/s [signs or symptoms] of healing. Physician was notified. On [DATE], wound documentation states Unable to assess measurement of the ulcer. Takes too long to just change the dressing and the last time dressing was changed on Friday. On [DATE], the initial measurements of the wound describe the wound as 5.5 X 5 X 4.5 cm [centimeters]. Draining present. Dressing intact. Drainage on dressing. Drainage around dressing. Increased drainage. 70% epithelialized [a process where epithelial cells migrate upwards and repair the wounded area], 20% granulation [the primary type of tissue that will fill in a wound], 10% slough [necrotic tissue], 0% eschar [dead tissue]. Moderate drainage, serosanguineous [blood and clear yellow liquid] in color, no odor. Macerated [exposed to moisture]. No undermining [a separation of the fibrous septae that connect the skin to the underlying fascia]. On [DATE], wound documentation describes the wound as Dressing intact with drainage. Surrounding tissue- white & moist. Drainage: heavy, purulent [a type of fluid that is released form the wound], foul odor. Surrounding skin: macerated. On [DATE] and [DATE], the resident refused wound care. On [DATE], the wound was described as Dressing intact with drainage. Surrounding skin: pink & macerated. Surrounding skin: pink, intact & macerated. On [DATE] and [DATE], the resident refused wound care. F. Record review of nursing notes revealed that the resident expired in the facility on [DATE]. G. On [DATE] at 12:18 pm, during an interview, the niece of R #1 stated She had been having some problems a few months before her passing and they [the facility] had informed the family that things were getting worse and she was not taking her meds, at that point we were told to expect the worse and she was not going to make it. We went to visit her and she seemed fine. Then, we didn't hear from the nursing home often at all. We were told she was fine. When asked to confirm the cause of death according to her death certificate. She stated The death certificate says that her cause of death was [CONDITION(S)] . H. Record review of R #1's death certificate, dated [DATE], revealed the resident's date of death to be [DATE]. Further review of the death certificate revealed the resident's cause of death to be [CONDITION(S)], certified by the facility's physician. I. On [DATE] at 1:46 pm, during an interview with CNA (Certified Nursing Assistant) #1, when asked to describe R #1, she stated She wasn't happy . She was saying that the food was poison. We tried to give her a variety of food, but she didn't want to eat. She didn't want us to help her with care. She was verbally abusive when we tried to help. We saw a decline when she was refusing her meds and she stopped eating. She started to refuse to eat, I don't know why. She would only take a few bites. She refused weights so I don't know if she was actually losing weight. J. On [DATE] at 11:18 am, during an interview with Dietary Manager, when asked if she was made aware of intake changes for R #1, she stated I did receive notification about three or four days before she passed away. This was unusual to me as she was eating everything and would ask for seconds [an additional serving]. When asked what was done to remedy her decreased intake, she replied We looked at her chart. With her, we discussed her a lot in clinicals [daily meeting] . we discussed her behaviors. K. On [DATE] at 2:14 pm, during an interview with the DON (Director of Nursing) when asked to explain the wound documentation, she replied, It looks like her wounds were not measured, only her admitting wounds were measured. It's hard to tell if they [the wounds] were getting better or worse since it was not tracked well. The descriptions [assessment of the wound, i.e.: the drainage, color, and odor] are typically signs of infection. When asked to describe the process to complete a wound assessment, she replied, We're supposed to measure them weekly. Report any changes, foul smell or drainage, to the doctor. He would then put them on antibiotics or order wound cultures. When asked what may occur if the wounds do not receive proper treatment, she replied, If not treated, they [the patient] can get septic or die. L. On [DATE] at 1:58 pm, during an interview with the facility physician, the physician explained that he was familiar with R #1 as she was a resident at another facility that he is also employed at. During her time at the previous facility, she displayed the same behaviors. When asked if hospice was considered he confirmed that she was on hospice before, while residing at the previous facility but was discharged from hospice due to her behaviors. He continued to state Her non-compliance would of directly contributed to her demise [death]. She was sent to the previous facility on hospice in the same condition months before. It was clear that she was going to die. Given that I had her for months and months and she was clinically stable, I was not convinced that she met a 6 month prognosis [the likely course of a disease or ailment]. When asked what can happen for a patient who has chronic ostemilitis [a continous infection found in boney prominences], he replied The infection can spread to the blood and get septic and the patient can die, or it will erode [gradually destroy] and eat into a blood vessel. Usually, the next step is to make sure they have decision making capacity [cognitively able to make decisions on their own behalf]. You can't force people that have capacity to do what they don't want to do. When asked if she had decision making capacities, he replied I talked to her regularly about her resistance. She would argue with me for about a half an hour and become fixated about things and have a very lucid argument about how she wanted to go home. The goal was for her to go home. She felt that she knew what was best for her and she didn't feel like she needed it [medications]. When asked if a psychiatric evaluation was considered, he confirmed that he did not consult in those services for her as he did not expect her to participate. When asked what are his expectations if a wound is not improving he replied If treatment plans are being adhered to, I would reassess and try to decide of something different needs to be done. The first thing that needs to be done is consistent wound care. Her immobility prevents healing. When asked if he was notified of decreased meal intake, he replied I don't recall being notified of meals. If I was notified, I would do more frequent weights. M. On [DATE] at 2:22 pm, during an interview with RN (Registered Nurse) #1, when asked to explain R #1, she stated Yes, I remember her, she was a heavy-set lady and she had a very bad wound on her coccyx. She would sometimes refuse treatment or repositioning. She refused medications. The wound was big and tunneled to the left. It was deep, about ,d+[DATE] fingers. You had to pack it and cover it, to try to get it to heal . She allowed wound care but sometimes refuse. She proceeded to mention how the staffing level was low, and this made it hard for the DON to complete her tasks because she was forced to work as an aid or sometimes a floor nurse. During that time the census was low however the acuity [complexity] of care was higher as the facility was caring for multiple residents with wounds and behaviors. When asked to explain the condition of the wound, she stated I don't think it looked infected but maybe she needed a wound VAC [a device that decreases the pressure in the wound to aid in healing], I was concerned that she would get septic. It wasn't necrotic but it was open and red and it was very deep. The drainage that came out was horrible and foul smelling. When asked if the physician was notified of her concerns, she replied, I would try to text the doctor or talk to the DON but she couldn't do a lot because of administration [administration's directive for the DON to work as an aid or floor nurse] and lack of staff. She continued to explain that although there were concerns for infection the doctor didn't change treatment plans or provide additional orders.

Based on observation, record review and interview, the following was revealed: 1. Facility allowed a staff member who had symtpoms of COVID-19 (new strain of coronavirus that has not been previously identified in humans, resulting in mild to severe illness) symptoms to work with non-positive residents and staff even after alerting the facility of possible COVID-19 symptoms prior to the beginning of the shift. The staff member test positive for COVID-19 after working this shift. This resulted in Immediate Jeopardy being called on 12/02/20 at 1:23 pm. The Administrator (ADM) and Director of Nursing (DON) were notified at this time. A first plan of removal was received on 12/02/20 at 3:35 pm and was rejected at 5:56 pm with the ADM notified. A second plan of removal was received on 12/02/20 at 6:30 pm. The second plan of removal was rejected on 12/02/20 at 7:06 pm, with the ADM notified. A third plan of removal was received on 12/02/20 at 7:46 pm. The third plan of removal was accepted on 12/03/20 at 8:45 am and implementation was verified. The ADM was notified. The plan of removal included: 1. Staff member, Certified Medication Aide (CMA) #2 was removed from work on 12/01/20. 2. Facility audited to verify that no other staff members had new onset of symptoms. The facility screening log was reviewed and no additional staff were found any new onset of symptoms. The areas of the facility that were potentially affected were changed to a yellow zone (potential exposure area). Facility completed the COVID 19 User Defined Assessment screening tool on residents currently residing in the facility. 3. Facility will follow procedure on COVID 19 work guide lines and the employee screening tool for new onset of symptoms. Staff will be educated using the (Name of facility society) Employee Screening Application. Including the following resources available within the application: Frequently Asked Questions, Website Job Aid and Decision Tree for Employee Screening (links to COVID-19 Work Guidelines). Staff supervisors will be trained on how to identify the work status of employees with symptoms, so that, if an employee exhibits symptoms, the staff supervisor will contact the Administrator or designee for final decision. Staff currently working will be educated before end of shift and remainder of staff will be educated prior to their next shift. 4. The Administrator/designee will audit the COVID 19 work guidelines and screening tool, daily X2 (for two) weeks, weekly X4 (for four), monthly X3 (for three), and quarterly X3. Audits will be reviewed by the Quality Assurance Performance Improvement (QAPI) Committee for compliance and make recommendations or changes as needed. 5. The facility will be in substantial compliance by December 2, 2020. Based on observation, record review, and interview, the facility failed to maintain infection prevention measures by 1) Allowing staff who was exhibiting symptoms of Covid 19 to continue to work and assist residents that did not have COVID-19. 2) Not conducting infection surveillance. This deficient practice is likely to result in the spread of potentially deadly infectious diseases to other residents and staff. The findings are: A. Record review of facility screening History dated 11/28/20 to 12/01/20 revealed Certified Medication Aide (CMA) #2 arrived for work and was screened at 14:09 (2:09 pm) for COVID-19 symptoms. CMA #2 screening indicated that she had answered yes to being symptomatic (sore throat and watery eyes), but she did not have a fever. B. On 12/01/20 at 3:33 pm during observation of medication administration, CMA #2 was observed to appear to be ill, she appeared to have a raspy voice and watery eyes. CMA #2 was wearing full PPE (personal protective equipment) which included N95 (respiratory) mask, gown and faceshield but no gloves. C. On 12/01/20 at 3:33 pm during interview with CMA #2, she was observed to be preparing medications for R #4. Prior to pouring medications, she stated that she was not feeling well and that she had a sore throat, cough and runny nose and that she called in and informed the Assistant Director of Nursing (ADON) of her symptoms, but was told by ADON to come to work. CMA #2 stated that she arrived for her shift at 3:00 pm and still had symptoms of sore throat, cough and runny nose. CMA #2 confirmed that she recorded her screening online and indicated that she was positive for symptoms. D. On 12/01/20 at 4:53 pm during interview with the ADON, she confirmed that she had received a call from CMA #2 and had been informed of symptoms of a sore throat. ADON stated that she informed CMA #2 to plan to come to work at 3:00 pm, CMA #2 arrived for work and was screened. ADON also stated that she informed Licensed Practical Nurse (LPN ) #1 that CMA #2 was fit for work and cleared her (CMA#2) to enter and begin her (CMA #2) shift. ADON stated that she only reported a sore throat and no other symptoms. She did not have fever, change of taste or smell. Per the ADON, those (fever and change in taste and smell) are the only symptoms that would warrant her to not be cleared for work and if they had any of the symptoms noted then staff are not cleared to work. E. On 12/01/20 at 5:13 pm during interview with Licensed Practical Nurse (LPN) #1, she stated that she had screened CMA #2 upon her arrival for her shift today (12/01/20) at 3:00 pm. LPN #1 stated that she observed that CMA #2 had indicated positive symptoms. LPN #1 also stated the ADON was standing next to them at that time, and the ADON informed CMA #2 that she was clear to work. F. On 12/01/20 at 5:19 PM during interview with CMA #2, she stated that she had been tested on [DATE] for COVID-19 and she had no symptoms at the time of the test. CMA #2 stated the COVID-19 test she received would require several days to receive a result. CMA #2 further stated that she had not been tested for Covid 19 upon arrival at work. G. On 12/01/20 at 5:25 pm during interview with the DON, she stated that in the past few days, they have received equipment to conduct rapid testing of COVID-19, but the facility has not begun to use this as a testing method for staff or residents. H. On 12/01/20 at 5:42 pm during interview with CMA #2, she confirmed that she continued to pass her medications and had passed medications to a total of 24 residents before being sent home. I. On 12/02/20 at 12:41 pm during an interview with the DON, she stated, I sent her (CMA #2) to the hospital to get a rapid test and her results came back positive. I got a verbal from the lab. Findings related to infection surveillance: J. Record review of Facility Infection Surveillance Binder revealed no evidence of infection surveillance (tracking of infections) since April 2020. K. On 12/03/20 at 10:06 am during an interview, ADON/ Infection Preventionist, verified that there is no documented infection surveillance since April 2020 and stated that she cannot say whether there was any infection surveillance done since then because she wasn't here. She confirmed that they have positive cases of covid in the facility however she was unsure how many residents have tested positive for COVID or when the first case was.

Based on record review and interview the facility failed to prevent resident neglect for 1 (R #1) of 3 (R #s 1, 2 and 3) residents looked at for falls, mechanical lifts and staffing. This deficient practice caused R #1 to have a more serious leg fracture, pain, and potentially caused psychosocial harm, due to the facility neglecting to have the resident seen by a physician, causing the fracture to become an external fracture (the bone is now penetrating through the skin) over the weekend. The facility also identified on two separate occasions that staff moved R #1 without the appropriate equipment and without the appropriate amount of people. The findings are: [NAME] Record review of R #1's [DIAGNOSES REDACTED].#1 had Alzheimer disease, Diabetes Mellitus Type II, [MEDICAL CONDITION], Chronic [MEDICAL CONDITION] Disease [MEDICAL CONDITION], asthma, pressure sores, and other conditions. R #1 was also Navajo and only spoke Navajo. While R #1 was in the facility there were staff members that spoke Navajo to her. Residents care plan indicated that she was a two person assist with a Hoyer lift. Resident needed assistance with bed mobility, dressing, toleiting, set up assitance with eating and personal hygiene assistance. B. Record review of R #1's nursing progress notes dated 04/07/19 indicated the following, called to resident's room by staff; resident c/o (complaints) generalized; just touching/moving her legs appears to cause discomfort/pain. prn Tylenol (treat minor aches and pains) to be offered. resident repositioned in bed . C. Record review of R #1's nursing progress notes dated 04/07/19 indicated the following, Tylenol given earlier today was partially effective and is being repeated at this time as resident shows s/s (signs and symptoms) of increased pain with movement in and out of bed and may need something scheduled or stronger at this point as she continues to decline . D. Record review of the physician's orders [REDACTED]. R #1 received [MEDICATION NAME] 0.5 ML from 04/11/19 to 05/22/19, 37 times with documented effective results. E. Record review of R #1's nursing progress notes dated 04/09/19 indicated the following, Translated for Nurse on 300/400 in Navajo I asked resident if she hurting? Does she know where she is? Do you want medicine to help the pain? Does it feel better when you lay down? Can we do anything for you? Your daughter wants us to ask you if you are in pain? She did not respond verbally, she blinked and started crying. F. Record review of R #1's nursing progress notes dated 04/10/19 indicated the following, Resident has swelling to left leg compared to her right leg Resident denies constant pain, but stated certain positions it aches. Certified Nurses Aide (CNA) x2 has a statement for observation of resident complaining of left knee discomfort, Supervisor notified that resident stated she hit her knee while in the wheelchair on her bed two days ago. G. Record review of a statement written on 04/10/19 by CNA #1 indicated that R #1 was complaining of pain in her left leg, knee area, while the CNA #1 was getting R #1 ready for breakfast. The written statement also stated that R #1 had told the CNA that a couple of days ago someone, during transfer, hit her leg aganist the bed. CNA #1 told the charge nurse about residents pain. H. Record review of R #1's nursing progress notes dated 04/12/19 indicated the following, Nurse in to give resident morning medication and observed left foot and ankle with swelling, ted hose (compression stockings) applied. Director of Nurses (DON) notified and I was instructed to check for pedal pulses. This nurse unable to palpate for pedal pulses in left foot. DON called to assess and unable to as well. Power of Attorney (POA) with additional family here and agreeable to move resident to (room number). Resident #1 transferred to room (number). Resident #1 transferred to room (room number) @ 10:20 AM medications transferred to (hall number) nurse to report. I. Record review of R #1's nursing progress notes dated 04/17/19, 04/21/19, 05/01/19 and 05/16/19 indicated that R #1 had swelling, or her left knee was inflamed. [NAME] Record review of R #1's physician progress notes [REDACTED]. Due to language barrier, patient cannot tell me much about it, but she does seem to indicate the same thing when I examined her. In the Diagnosis, Assessment and Plan section: Primary [MEDICAL CONDITION] of left knee Try BenGay (treat minor aches and pains of muslces and joints) 3 times a day and monitor for effect. K. Record review of the MAR indicated [REDACTED]. L. Record review of R #1's medication administration note dated 05/10/19, indicated that R #1 complained of knee pain and was administered [MEDICATION NAME] 0.5 ML. M. Record review of R #1's medication administration note dated 05/11/19 [MEDICATION NAME] was given two different times to R #1 for pain (Patient is grimacing and yelling out.) On 05/12/19 [MEDICATION NAME] was given again due to R #1 crying and grimacing. It is marked as an [NAME] for being effective on the MAR. N. Record review of R #1's nursing progress notes dated 05/16/19 indicated the following, resident has swelling to her left knee. Also noted a bony prominence on the inner aspect of same knee with redness and irritation noted. The bony piece looks anomalous (deviating from what is standard, normal, or expected), gave her [MEDICATION NAME] and am waiting for callback from provider to formulate a treatment plan. O. Record review of R #1's nursing progress notes dated 05/17/19 indicated the following, Spoke with provider, advised of X-ray results positive for fracture of distal (situated away from the center of the body) femoral shaft (thigh bone) above a total knee prosthesis. Order to splint for comfort as resident is not a candidate for surgery at this time. Provider suggested discussing Hospice options with the family. P. Record review of R #1's nursing progress notes dated 05/17/19 indicated the following, discussed the positive fracture results from today's x-ray. Discussed the P[NAME], (plan of care) and (name of family) voiced understanding, agreeing her mother was not a candidate for surgery. Requested to be notified of the outcome of the investigation. Q. Record review of R #1's nursing progress notes indicated no progress notes were made on 05/18/19 or 05/19/19. R. Record review of R #1's nursing progress notes dated 05/20/19 indicated the following, Notified by CNA dressing to [MI] Knee was bleeding; sanguous (sic) (relating to, or containing blood) drainage quarter size drainage noted. Notified / notified DON of findings; Open fracture with bone protrusion, and vital signs. DON stated is aware of findings and provider will see her in the morning. Noted previous note by RN on 16th of open fx; 'protruding bone' xrays taken, orders for soft knee brace. Reapplied clean dressing ABD (thick wound dressing), [MEDICATION NAME] (a bandage that provides fast-wicking action, superior aeration, and excellent absorbency), [MEDICATION NAME] given for pain. Will continue to monitor. S. Record review of R #1's nursing progress notes dated 05/20/19 indicated the following, called TeamHealth and left a message to notify (name of physician) of increased severity of leg fracture, waiting for call-back. T. Record review of R #1's nursing progress notes dated 05/20/19 indicated the following, Received a call from ( name of physician) He orders to call orthopedics to see if they will evaluate the resident's leg prior to sending her out . U. Record review of R #1's nursing progress notes dated 05/20/19 indicated the following, Explained the situation: fracture has become an external fracture and our options were to keep her in house and keep her as comfortable as possible or send her to (Name of nearby city) to a trauma center to see what can be done to secure the fracture in place and hope it heals. (name of family) will contact her siblings and call back with a decision. V. Record review of R #1's physician progress notes [REDACTED]. In the History of Present Illness section: 04/22/19: Nurse recently noted patient pointing to or holding her left knee, as if it was hurting her. Since then it became apparent that there was a [MEDICAL CONDITION] femur, Director of Nursing is investigating whether there was any incident with transfers. There is no known fall out of bed or from a height. I advised to keep the patient comfortable in line with family wishes, and splinting was attempted. However this morning was told that the bone was protruding from the skin above the left knee. I found the patient lying in bed on her left side, and a bulky dressing around the left knee had strike through of bloody fluid just above the knee. Patient appeared somewhat uncomfortable but was resting quietly in bed. Multiple conversations were held with Director of Nursing, family and one daughter will visit tomorrow and consult with her other daughter before deciding whether to send the patient for orthopedic evaluation. An orthopedist in Gallup was consulted by phone and advised to send the patient to the trauma service at (name of hospital), (name of hospital) PALS (Physician Access Line Service) line was contacted, they said that they were overwhelmed with cases and referred the patient to (name of hospital) One Call. 1:09 PM I spoke with (name of person and phone number) who offered to contact orthopedics if the family wanted patient transferred. W. Record review of R #1's physician progress notes [REDACTED]. Family unable to decide by phone, reportedly will visit tomorrow. X. Record review of R #1's nursing progress notes dated 05/22/19 indicated that R #1 passed away on 05/22/19 at 1903 (7:03 PM). Y. On 09/18/19 at 12:45 PM, during an interview with the DON she stated that she started an investigation into the left knee fracture for R #1 on 05/20/19. She had concerns that something might have happened. She stated that either before the investigation started, or during the course of the investigation she was told that CNA #1 had transferred R #1 alone, and did not use a Hoyer lift. Upon the DON questioning CNA #1 about this incident, it was revealed that CNA #1 did admit to transferring R #1 by herself and without a Hoyer Lift on 05/14/19, CNA #1 was placed on suspension. During the investigation CNA #1 told DON that another CNA, (CNA #2) had previously transferred R #1 alone and without a Hoyer lift a few days prior to 04/10/19. The DON stated that she spoke to CNA #2 and she did admit to transferring the resident alone and without a Hoyer lift. When questioned about the left knee pain that seemed to increase for R #1 on 04/07/19; she stated that R #1 had pain all the time in her lower extremities and she didn't feel like her pain level had become worse. The DON also stated that an x-ray was not considered before the protruding bone was discovered on 05/16/19. The DON stated that she had provided a Hoyer lift demonstration during the CNA meeting and that new hires are trained on Hoyer lifts although she did not have documentation of that demonstration. The DON also stated that after the fracture was discovered, and the physician and family were called, it was agreed to just keep R #1 comfortable. The DON stated that a physician did not see the resident until 05/20/19 and the only intervention that had been put into place was a soft splint. She stated that she was receiving pain medications and they were effective. She stated that staff were not getting R #1 up in her wheelchair from (MONTH) 16th through the 20th, but they (staff) were re-positioning her in bed. The DON also stated that she wasn't sure about the soft splint being enough support for R #1's fracture. The DON stated that from 05/16/19 to 05/20/19 R #1 was not seen by a physician, or sent to the hospital to be assessed. She stated that R #1 would have just sat in the emergency room for hours being uncomfortable and in pain anyway. She stated that she, the physician via phone, and the family all felt that she (R #1) was not a candidate for surgery, so they decided to put a soft splint on her and were going to keep her comfortable. She stated that on 05/20/19, when it was discovered that she now had an external fracture (an open/external fracture involves a break in the skin, which is caused by the protrusion of a broken bone) the facility physician did see R #1 on 05/20/19 and had concerns. They did call for an ortho consult, but the family wasn't sure what they wanted to do; so we made her comfortable and she passed on 05/22/19. Z. On 09/18/19 at 2:20 PM, during an interview with a staff nurse, it was stated that R #1 did have pain in her lower extremities and she was known to grimace in pain and point to her left knee. She did hurt a lot consistently but towards the end, her pain had increased a lot. Staff nurse #1 stated that when it was discovered that R #1 had a displaced fracture, many questions were asked. Like, why wasn't R #1 sent out to the hospital? Why is there no documentation? It was stated by another nurse that she was told to not send out R #1 by the DON. Initially it was thought that the displaced fracture had just occurred but was shocked to find out that it had happened days prior and R #1 had not been seen by a physician. Then it became an external fracture on the 20th (May) and the DON was contacted, and the DON stated that there was no point to send R #1 out to sit in the ER. At that time an ortho consult was sought out. The staff nurse stated that this fracture should have been looked at by a physician before Monday, (MONTH) 20th (2019). She (R #1) could have been seen Friday (05/17/19) or Saturday (05/18/19). At least there would have been information on whether or not her fracture was even stable. The staff nurse stated that the physician was not able to see the fracture so he would have been unable to know if it was stable or not. The staff nurse also stated that R #1 should have been sent out regardless of what the DON had said. The staff nurse stated that R #1 would have been transferred by ambulance out to the hospital, and with a protruding bone, would have been seen right away {and not waited in ER like DON had thought). It is our duty as nurses to seek out a higher level of care when it is needed, and in this case it wasn't done.

Based on record review the facility failed to ensure that residents were free from repeated falls with injury for 1 (R#2) of 4 (R #s 1, 2, 3 & 4) residents reviewed for falls. This deficient practice has the potential for residents to be at risk for bruising, skin tears and other [MEDICAL CONDITION] if staff are unable to identify the cause of repeated falls. The findings are: A. Record review of the facility's admission notes indicate R#2 was admitted [DATE] to facility for rehabilitation after surgical repair of fracture of femur (thigh bone) from a fall. B. Record review of R #2's nursing services notes dated 09/08/17 at 2:20 am indicate, Resident was found sitting on floor leaning against bed trying to get up note then indicates, bruise apparent to bilateral (having or relating to two sides; affecting both sides) hips. red abrasions to back. bruise to left hand . right forehead has some discoloration .resident attempted to get up again, scooting self to edge of bed. There was no documentation available to indicate how the incident occurred and what interventions could be implemented to prevent further falls. C. Record review of R #2's nursing services notes dated 09/13/17 at 9:39 am, indicate a fall resulting in, small skin tear noted to bridge of nose. Bleeding stopped. The documentation further indicates that the fall was a result of the resident, leaning too far forward pulling herself out of the chair (a wheelchair). D. Record review of R #2's nursing services notes dated 09/14/17 at 10:53 pm, indicates a fall resulting in, skin tear to left elbow. red and bruising apparent . bruise to bilateral arms. There was no documentation available to indicate how the incident occurred and what interventions could be implemented to prevent further falls. E. On 12/27/17 at 3:30 pm, during interview with the Director of Nurses (DON) in response to query of the facility's practice responding to resident falls he replied that, every morning they review falls and they identify why a resident fell and immediately make changes to the care plan to prevent another fall.

Based on record review and interview, the facility failed to ensure residents were free from pain, for 1 (R #1) of 4 (R #'s 1, 2, 3, 4) residents reviewed during a complaint investigation. This deficient practice likely resulted in R #1 experiencing pain. The findings are: A. Record review of the Complaint Intake Information revealed, 11/15/17 at proxy (approximately) 8:30 am, resident reports to activity director that her leg was hurting and was screaming in pain. The activity director reported it to the charge nurse (Licensed Practical Nurse, LPN #1). He stated that he was too busy and would look at it later. At approx 2:45 pm the activity director readdressed the concern with (LPN #1) and he stated that he was still busy and would look at it later. In addition, later in the day (LPN #1) brought (R #1) out to the common area to the activities staff and made a statement of here is your resident, I am done babysitting. On 11/16/17 at approx 8:30 am, the activity director saw the resident was still in pain and reported to a nursing (sic) staff that (sic) and they advised the activity director to report to the charge nurse. The activity director attempted to address the concern with the Director of Nursing (DON) who was not in the center at the time. B. Record review of a physician progress notes [REDACTED]. Patient seemed uncomfortable with right knee tender to touch and moderately swollen. There is also some redness. No history of trauma is reported. Pain medication and antibiotics ordered along with CBC (complete blood count). Further review of the progress notes did not show any evidence that R #1 was complaining of pain or documentation showing that pain medications were offered and R #1 refused. There is also no documentation from nursing staff indicating R #1's knee pain was assessed or reports of redness, pain, or bruising. C. Record review of R #1's Electronic Medical Record, did not indicate R #2 had a recent pain assessment completed after she was complaining of pain in her right knee. The last documented pain assessment was done on 10/27/17. D. Record review of physician's orders [REDACTED]. [MEDICATION NAME] ([MEDICATION NAME]) 800 mg (milligrams) one tab po TID (three times a day) prn. E. Record review of the Medication Administration Record [REDACTED]. The documentation showed R #1 did not receive any pain medications, other than Aspirin that was ordered for [MEDICAL CONDITION] (a group of conditions that affect blood supply to the brain) disease. F. Record review of Certified Nurses Aide (CNA) Shift Pass Down Sheets for (MONTH) (YEAR), revealed the following: 1. On 11/1417, states c/o (complains of) R (right) leg pain. CN (charge nurse) notified. 2. Date unavailable, states R leg and knee is swollen. 3. On 11/17/17, states R knee is swollen and red (hot to touch). Crying in pain due to knee. CN notified. Refused to get up. Additional sheet states, In bed all day. Knee still swollen. 4. Date unavailable, states R knee still bothers her. In pain. 5. On 11/18/17, states R knee red and sensitive to touch, in pain, CN notified. 6. Date unavailable, states c/o pain, down all day due to R leg. 7. Date unavailable, states R leg bruised. Very sensitive. 8. Date unavailable, states R leg is bruised; yelling every movement mb (maybe) fracture?? idk (I don't know). 9. Date unavailable, states Showered. Screaming during change. Refused to get up. 10. On 11/21/17, states Down all day. Knee/thigh (yellow, bruise) hot to touch. 11. On 11/21/17, states Bottom is turning red. Down, leg still looks bad. 12. Date unavailable, states Hospital (emergency). Possible R leg fracture or broken. Flown her to (name of hospital). Fracture fibula (calf bone ). G. Record review of Written Staff Statements, revealed the following regarding R #1: 1. I (name of CNA #1) was working the day of 11/15, 11/16. This is regarding (R #1). I was on orientation (sic). (R #1) with (CNA #2 and #3). (R #1) was as complaining of her leg hurting. Her son wanted her to lay down. (CNA #2 and #3) changed her. The two girls (CNAs) changed her and said she was in a lot of pain to the point where she was crying. We reported it to the nurse right-o-way (sic). 2. CNA # 2 stated, I worked with (R #1) on 11/16/17 and 11/17/17. Both days she was in bed. She was sleeping most of the day. When we went to give her care and moved her right leg, she was in pain. Whenever we touched her knee she cried of pain. She didn't eat much. 3. Statement dated 12/05/17, stated The 15th, 16th, and 17th when caring for the resident she would be in so much pain and cry when we change and reposition her. I had reported to (LPN #2) if there is something that can be done but I was told she's on antibiotics. H. Record review of R #1's Care Plan initiated on 03/13/17, revealed Resident has chronic pain/discomfort r/t (related to)[MEDICAL CONDITION], decreased mobility, PAD (peripheral artery disease) e/b (evidenced by) need for PRN pain medications: [REDACTED]. Observe/record/report to nurse any s/s (signs or symptoms) of non-verbal pain: changes in breathing,; mood/behavior; eyes, face, and body. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increase agitation, restlessness, confusion, hallucinations, dysphoria (a state of unease or generalized dissatisfaction with life); nausea; vomiting; dizziness and falls. Report occurrences to the healthcare provider. I. On 12/27/17 at 9:30 am, during interview the Activity Director stated, that on 11/15/17, R #1 told her that her knee was really hurting. She stated that she looked at R #1's knee and it was red and warm to the touch and that she let LPN #1 know. She stated that LPN #1 told her he would look at it later and that to her knowledge LPN #1 still had not looked at R #1 at 3 pm that same day. The Activities Director stated that when she came in the next day, on 11/16/17, R #1 was not eating breakfast again and when she asked how her knee was, R #1 stated that it was hurting. The Activities Director stated when she looked, her knee was a little redder. She stated that around 12:00 pm, R #1 was crying so she took her to the Medical Directors office to have him look at R #1's knee. She stated the Medical Director wrote orders to give LPN #1. J. On 12/27/17 at 9:57 am, during interview LPN #1 verified that the Medical Director wrote orders for prn pain medication for R #1. Later at 10:50 am, LPN #1 confirmed that he did not inform the Medical Director of R #1's complains of pain on 11/15/17, stating that there was nothing to report. K. On 12/27/17 at 10:38 am, during a phone interview the Medical Director stated, he examined R #1 (date unknown) and there was redness and swelling to her knee. The Medical Director stated that R #1 looked uncomfortable during the examination and that it was the first time he was aware of her pain. L. On 12/27/17 at 2:00 pm, during interview CNA #6 stated that when R #1 was moved she yelled in pain. CNA #6 stated that he was told in report (date unknown) about the bruising to her leg and stated that when he looked at her knee it was swollen and the bruising was old and it was turning yellow. M. On 12/27/17 at 2:55 pm, during interview the DON verified that there was a pain issue with R #1's leg. He stated that there were orders for prn [MEDICATION NAME] and a standing prn order for Tylenol. The DON stated that R #1 was left in pain, because he could not find documentation that pain medications were given. The DON also confirmed that a pain assessment had not been after 10/27/17, stating that he would expect one to be done since then. N. Record review of the Pain Management Policy revised on 5/17, revealed The registered nurse will assess current pain levels and develop with the physician and interdisciplinary team interventions that may be non-pharmacological, as well as pharmacological. The registered nurse will review response to medication intervention and work closely with the physician to assist in the individualized pain management plan. The nurses working directly with residents must continually monitor and observe the resident for success of the pain management plan and report to the nurse manager and prescribes as necessary to keep the resident comfortable .Complete the Pain Data Collection UDA (user defined assessment), which will be triggered from the Nursing Admit Re-Admit Data Collection UDA (if the resident experienced pain in the past five days) .The Pain Assessment UDA will be triggered from the Pain Data Collection .Follow prescribed orders for pain, documenting results in the eMAR (electronic medication administration record) and eAdmin (electronic administration) notes as needed .Residents with a history of pain or a [DIAGNOSES REDACTED].