Every finding on record at Las Cruces Wellness & Rehabilitation LLC

Based on observation and interview, the facility failed to keep residents free from accidents for all 16 residents who reside on the South Unit (residents were identified by the resident matrix provided by the Administrator on 11/26/25) when they failed to secure a treatment cart (cart with medical supplies and equipment for treatment) when they left it unlocked on the South Unit. This deficient practice could likely result in residents obtaining equipment from the unsecured treatment cart and injuring themselves or others. The findings are: A. On 11/26/25 at 9:08 am, during an observation of the South Unit revealed a treatment cart unlocked with the keys in the cart. No staff were present. B. On 11/26/25 at 9:09 am, during an interview CNA #1 confirmed it was unlocked and attempted to secure the treatment cart. C. On 11/26/25 at 9:09 am, during an interview, the Wound Care Nurse confirmed the treatment cart was unlocked with the keys in it. D. On 11/26/25 at 11:28 am, during an interview the DON confirmed that if there are no staff present the treatment cart should be locked.

Based on record review and interview the facility failed to develop a complete baseline care plan for 1 (R #1) of 3 (R #1, R #2, and R #3) residents sampled for enhanced barrier precautions, (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). This deficient practice could likely result in staff being unaware of the residents' needs. The findings are: R #1 A. Record review of R #1's medical record no date revealed se was admitted [DATE]. B. Record review of R #1's physician's orders dated 11/21/25 revealed R #1 was on enhanced barrier precautions for a surgical wound to right hip and IV (intravenous therapy is a medical process that administers fluids, medications and nutrients directly into a person's vein) access. C. Record review of R #1's baseline care plan dated 11/23/25 revealed staff did not document R #1 was on enhanced barrier precautions for a surgical wound to right hip and IV access. D. On 11/26/25 at 11:28 am during an interview the DON confirmed the following: 1. R #1 did not have the enhanced barrier precautions on her baseline care plan 2. The facility team should be care planning the EBP for residents.

Based on record review and interview the facility failed to develop a complete comprehensive care plan for 2 (R #2 and R #3) of 3 (R #1, R #2, and R #3) residents sampled for enhanced barrier precautions, (an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes). This deficient practice could likely result in staff being unaware of the residents' needs. The findings are: R #2 A. Record review of R #2's medical record no date revealed he was admitted [DATE]. B. Record review of R #2's physician's orders dated 11/03/25 revealed R #2 was on enhanced barrier precautions for a wound to left leg and IV (intravenous therapy is a medical process that administers fluids, medications and nutrients directly into a person's vein) access. C. Record review of R #2's Care Plan dated 11/04/25 revealed staff did not document R #2 was on enhanced barrier precautions for a wound to left leg and IV access. D. On 11/26/25 at 11:28 am during an interview the DON confirmed the following: 1. R #2 did not have the enhanced barrier precautions on his care plan 2. The facility team should be care planning the EBP for residents. R #3 E. Record review of R #3's medical record no date revealed he was admitted [DATE]. F. Record review of R #3's physician's orders dated 10/31/25 revealed R #3 was on enhanced barrier precautions for a wound to right foot and IV access. G. Record review of R #3's Care Plan dated 10/31/25 revealed staff did not document R #3 was on enhanced barrier precautions for a wound to right foot and IV access. H. On 11/26/25 at 11:28 am during an interview the DON confirmed the following: 1. R #3 did not have the enhanced barrier precautions on his care plan 2. The facility team should be care planning the EBP for residents.

Based on record review and interview, the facility failed to report an allegation of abuse from CNA #28 to the State Survey Agency regarding CNA #28. This has the potential to affect all 25 of 25 residents in Hallway 1 where CNA #28 worked with (residents were identified by the Census List provided by the DON on 08/04/25). If the facility fails to report incidents of possible abuse to the State Agency, then the State Agency is unable to ensure residents have a safe environment. The findings are: A. Record review of the facility's Human Resources complaint investigation report, dated 04/18/25, revealed the following:1. Staff Member (SM) stated there were several people complaining of CNA #28's quality of work, and SM doesn't think anything is being done.2. On 04/16/25 SM found CNA #28 sleeping on the couch in the nurse's station.3. On 04/18/25 SM found CNA #28 eating a resident's (the report was not sure which resident was mentioned in allegation) breakfast.4. On 04/18/25 CNA #28 was seen approximately around 04/01/25 to be using a resident's breathing machine to administer medication to herself. B. On 07/23/25 at 1:02 PM, during an interview with the DON, she confirmed the following:1. The Administrator met with CNA #28 on 04/22/25 regarding allegations from the complaint investigation report submitted to Human Resources from SM on 04/18/25.2. The findings were unsubstantiated, and no disciplinary action was carried out for CNA #28 from the complaint investigation report submitted to Human Resources from SM on 04/18/25.3. No incident report was sent out to State Agency regarding allegations from the complaint investigation report submitted to Human Resources from SM on 04/18/25.C. On 08/08/25 at 9:25 AM, during an interview with the Administrator, she confirmed she completed an investigation on CNA #28 about a report that came into Human Resources on 04/18/25 regarding abuse allegations. The Administrator stated that CNA #28 did use the breathing machine to administer herself medication. The breathing machine was changed out and CNA #28 was educated on Abuse. The administrator stated the films of the cameras were reviewed, and there was no evidence of CNA #28 sleeping, and no food was taken. The anonymous report doesn't state what equipment she used, and there were no reports from the residents. The Administrator stated the report could have come from someone who didn't like CNA #28, and she did not submit a report to state agency.D. On 08/08/25 at 9:54 AM, during an interview with SM, she stated it was reported to her and someone else that CNA #28 a long time ago used a resident's breathing treatment (SM could not recall the name of the staff who reported it). SM stated that on the day of the Easter Egg Hunt CNA #28 was seen by SM sleeping. CNA #28 had a [NAME] cart in front of her on the couch in the dining area by nursing station. CNA #28's eyes were closed. SM told CNA #28 to get up because call lights were going off. CNA #28 woke up and told SM to close the door leading to the outside courtyard because it was too loud. SM stated at a different time she witnessed CNA #28 eating a resident's meal tray. SM stated that a resident stated to her he was hungry, upset and had been waiting for his food. SM stated that when she asked CNA #28 about her eating the food CNA #28 stated a resident refused his food. SM assumed it was the resident's food tray she had talked too about not getting their food because the meal tickets were on table. SM stated that the Administrator called her once about the incidents she reported to HRD. SM stated she missed the call because she was out sick, and after that SM forgot about the incident. SM stated she does know to report abuse to the ADM, and she reported this to HR.E. Record review of the facility's Abuse Prevention and Prehabilitation Program, policy and procedure review, dated 10/24/22, revealed the following:1. Immediately, but no later than 2 hours after forming the suspicion - if the alleged violation involves abuse or results in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman.2. No later than 24 hours after forming the suspicion - if the alleged violation (e.g., misappropriation of property, neglect) does not involve abuse and does not result in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman.

Based on record review and interview, the facility failed to have evidence that a thorough investigation of an allegation of abuse was conducted and preventive measures to keep residents safe. This has the potential to affect all 25 of 25 residents in Hallway 1 where CNA #28 worked with (residents were identified by the Census List provided by the DON on 08/04/25) residents sampled for abuse, when staff failed to do the following: 1. Staff did not document the facility action, future preventive/corrective action, or conclusion.2. Staff did not document any other witness statements of the events surrounding the allegation's occurrence.3. Staff did not report complaint investigation to State agency. This deficient practice could likely result in residents being at risk of continued abuse if allegations are not thoroughly investigated and preventative measures are not implemented. The findings are: A. Record review of CNA #28's personal file revealed a human resources complaint investigation report dated 04/18/25, with the following: 1. Staff Member (SM) stated there were several people complaining of CNA #28's quality of work, and SM doesn't think anything is being done. 2. On 04/16/25, SM found CNA #28 sleeping on the couch in the nurse's station. 3. On 04/18/25 SM found CNA #28 eating a resident's (the report was not sure which resident was mentioned in allegation) breakfast. 4. On 04/18/25 CNA #28 was seen approximately around 04/01/25 to be using a resident's breathing machine to administer medication to herself. B. On 07/23/25 at 1:02 PM, during an interview with the DON, she confirmed the following:1. The Administrator met on 04/22/25 with CNA #28 regarding allegations from the complaint investigation report submitted to Human Resources from SM.2. The findings were unsubstantiated, and no disciplinary action was carried out for CNA #28 from the complaint investigation report submitted to Human Resources from SM on 04/18/25.3. No incident report was sent out to State Agency, and a through investigation was not completed. C. On 08/08/25 at 9:25 AM, during an interview with the Administrator, she confirmed she completed an investigation on CNA #28 about a report that came into Human Resources on 04/18/25 regarding abuse allegations. The Administrator stated that CNA #28 did use the breathing machine to administer herself medication. The breathing machine was changed out and CNA #28 was educated on Abuse. The administrator stated the films of the cameras were reviewed, and there was no evidence of CNA #28 sleeping, and any food was taken. The anonymous report doesn't state what equipment she used, and there were no reports from the residents. The Administrator stated the report could have come from someone who didn't like CNA #28, and she did not submit a report to state agency. D. On 08/08/25 at 9:36 AM, during an interview with Human Resources Director (HRD), she stated that SM reported abuse allegation of CNA #28 to the HRD and wanted to speak to the Administrator. The Administrator wasn't in the office. SM never came back to speak to the HRD or the Administrator to discuss this allegation. The HRD stated this was first issue regarding this CNA #28. E. On 08/08/25 at 9:54 AM, during an interview with SM, she stated it was reported to her and someone else that CNA #28 a long time ago used a resident's breathing treatment (SM could not recall the name of the staff who reported it). SM stated that on the day of the Easter Egg Hunt CNA #28 was seen by SM sleeping. CNA #28 had a [NAME] cart in front of her on the couch in the dining area by nursing station. CNA #28's eyes were closed. SM told CNA #28 to get up because call lights were going off. CNA #28 woke up and told SM to close the door leading to the outside courtyard because it was too loud. SM stated at a different time she witnessed CNA #28 eating a resident's meal tray. SM stated that a resident stated to her he was hungry, upset and had been waiting for his food. SM stated that when she asked CNA #28 about her eating the food CNA #28 stated a resident refused his food. SM assumed it was the resident's food tray she had talked too about not getting their food because the meal tickets were on table. SM stated that the Administrator called her once about the incidents she reported to HRD. SM stated she missed the call because she was out sick, and after that SM forgot about the incident. SM stated she does know to report abuse to the ADM, and she reported this to HR. F. Record review of the facility's Abuse Prevention and Prehabilitation Program, policy and procedure review, dated 10/24/22, revealed the facility promptly and thoroughly investigates reports of resident abuse, mistreatment, neglect, injuries of an unknown source, or criminal acts.

Based on record review and interview, the facility failed to provide quality of care for resident needs for 1 (R #44) of 3 (R #6, R #43, R #44) residents reviewed for abuse when the facility:1. Failed to ensure call-lights were answered when a resident needed assistance for R #44. This deficient practice could likely result in the residents' needs not being met, leaving them at risk for accidents, incontinence (lack of voluntary control over urination or defecation) and falls. The findings are:A. Record review of R 44's face sheet revealed an admission date of 07/02/25. B. Record review of R #44's admission MDS dated [DATE] revealed a BIMS (The Brief Interview for Mental Status is a structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 15 (Scores closer to 0 indicate severe cognitive impact and scores closer to 15 indicate an intact cognitive response). C. On 08/04/25 at 1:52 PM, during an interview with R #44 she stated it takes 35 minutes or longer for staff to answer my call light. R #44 couldn't recall dates. D. Record review of the facility's call history (log time staff took to answer call lights), dated 07/18/25-07/25/25 for R #44's call light revealed the following:1. 07/18/25 at 7:05 AM, staff answered call light in 19 minutes.2. 07/18/25 at 7:18 AM, staff answered call light in 53 minutes.3. 07/19/25 at 10:04 AM, staff answered call light in 24 minutes.4. 07/20/25 at 10:21 AM, staff answered call light in 18 minutes.5. 07/20/25 at 1:00 PM, staff answered call light in 20 minutes.6. 07/21/25 at 5:49 AM, staff answered call light in 17 minutes.7. 07/22/25 at 7:10 AM, staff answered call light in 20 minutes.8. 07/22/25 at 4:16 PM, staff answered call light in 18 minutes.9. 07/23/25 at 7:48 AM, staff answered call light in 18 minutes.10. 07/23/25 at 11:13 AM, staff answered call light in 20 minutes.11. 07/24/25 at 7:29 AM, staff answered call light in 19 minutes.12. 07/24/25 at 1:36 PM, staff answered call light in 20 minutes.13. 07/25/25 at 7:42 AM, staff answered call light in 23 minutes. E. On 08/06/25 at 9:56 AM, during an interview with the DON, she stated her expectation for call lights being answered is with a reasonable time of around 15 minutes.

Based on record review and interview, the facility failed to implement the comprehensive care plan for 1 (R #25) of 3 (R #25, R #26, and R #27) residents reviewed for falls. This deficient practice could likely result in residents not receiving the care they need for safety, and result in residents being at risk of serious harm or injury when staff failed to identify and implement interventions to prevent R #25 from falling. The findings are: A. Record review of R #25's face sheet dated 12/31/2024, revealed R #25 was admitted to the facility on [DATE]. B. Record review of R # 25's order summary report dated 12/31/24, revealed the following diagnoses: 1. Alzheimer's Disease. 2. Blindness with right eye. 3. Unspecified hearing loss, unspecified ear. 4. Muscle weakness, generalized. 5 Difficulty walking. 6. Lack of coordination. 7. Need for assistance with personal care. C. Record review of R #25 5-day MDS assessment dated [DATE], revealed the following functional abilities: 1. Toileting hygiene: (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). R #25 requires substantial/maximal assistance. (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) 2. Toilet transfer: The ability to get on and off a toilet or commode. R #25 requires substantial/maximal assistance. 3. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. R #25 requires substantial/maximal assistance. D. Record review of R #25 care plan dated 01/01/25 revealed the following: 1. R #25 is at risk for falls related to gait/balance and cognitive deficits. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible . 2. Care plan updated date 01/03/25, R #25 had an actual fall without injury . Continue interventions on the at-risk plan . 3. Care plan updated date 01/04/25 R #25 had impaired cognitive function with impaired thought processes . Use task segmentation (breaking up the task) to support short term memory deficits. E. Record review of R #25's nursing progress notes dated 01/02/25 revealed the following: 1. R # 25 has unsteady gait requiring supervision. 2. R # 25 has impaired balance. 3. R # 25 has weakness. 4. R # 25 does not have a change in functional ability, and uses wheelchair, with staff assistance required when ambulating (walk; move about). F. On 03/18/25 at 9:45 AM, during an interview, the CNA #28 confirmed the following: 1. CNA #28 assisted R #25 to the restroom just prior to R #25 being found on the floor (CNA #28 was not specific about the time or date). 2. CNA #28 told R #25 that she was going to help another resident and advised R #25 to call for assistance when he was finished using the restroom, and left R #25 with call light to go answer another call light. CNA #28 returned after 5-6 minutes, and R #25 was on the floor of the restroom. 3. CNA #28 stated she does not review resident care plan and receives report at the beginning of the shift and knows what to do. 4. CNA #28 stated she does not have Kardex (is used to record important patient information). G. On 03/19/25 at 9:15 AM, during an interview, the DON stated the following: 1. R #25 fell in the restroom on 01/03/25 and should have not been left alone on the toilet by staff. 2. Staff have access to see the care plan and that it populates in the Kardex. 3. DON stated staff should follow care plans when working with residents.

Based on record review, and interview, the facility failed to keep residents free from accidents for 1 (R #25) of 3 (R #25, R #26, and R #27) residents reviewed for falls, when staff left R #25 (a cognitively impaired resident who required assistance) unattended in the bathroom to help another resident. This deficient practice could likely result in residents being at risk of serious harm or injury. The findings are: A. Record review of R #25's face sheet dated 12/31/24, revealed R #25 was admitted to the facility on [DATE]. B. Record review of R # 25's order summary report dated 12/31/24, revealed the following diagnoses: 1. Alzheimer's Disease. 2. Blindness with right eye. 3. Unspecified hearing loss, unspecified ear. 4. Muscle weakness, generalized. 5 Difficulty walking. 6. Lack of coordination. 7. Need for assistance with personal care. C. Record review of R #25 physicians orders revealed on 01/02/25, an order to have R #25's bed low bed and place mat when resident is in bed. D. Record review of R #25 5-day MDS assessment dated [DATE], revealed the following functional abilities: 1. Toileting hygiene: (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). R #25 requires substantial/maximal assistance. (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) 2. Toilet transfer: The ability to get on and off a toilet or commode. R #25 requires substantial/maximal assistance. 3. Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. R #25 requires substantial/maximal assistance. E. Record review of R #25 care plan dated 01/01/25 revealed the following: 1. R #25 is at risk for falls related to gait/balance and cognitive deficits. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible . 2. Care plan updated date 01/03/25, R #25 had an actual fall without injury . Continue interventions on the at-risk plan . 3. Care plan updated date 01/04/25 R #25 had impaired cognitive function with impaired thought processes . Use task segmentation (breaking up the task) to support short term memory deficits. F. Record review of R #25's nursing progress notes dated 01/02/25 revealed the following: 1. R # 25 has unsteady gait requiring supervision. 2. R # 25 has impaired balance. 3. R # 25 has weakness. 4. R # 25 does not have a change in functional ability, and uses wheelchair, with staff assistance required when ambulating. G. On 03/18/25 at 9:45 AM, during an interview, the CNA #28 confirmed the following: 1. CNA #28 assisted R #25 to the restroom just prior to R #25 being found on the floor (CNA #28 was not specific about the time or date). 2. CNA #28 told R #25 that she was going to help another resident and advised R #25 to call for assistance when he was finished using the restroom, and left R #25 with call light to go answer another call light. CNA #28 returned after 5-6 minutes, and R #25 was on the floor of the restroom. 3. CNA #28 stated she does not review resident care plan and receives report at the beginning of the shift and knows what to do. 4. CNA #28 stated she does not have Kardex (is used to record important patient information). H. On 03/19/25 at 9:15 AM, during an interview the DON confirmed the following: 1. R # 25 BIMS (brief interview for mental status) score was 6 (BIMS score with lower scores indicating a decline in cognitive performance. 0-7 severe impairment) 2. CNA #28 should not have left R #25 alone on the toilet. 3. Staff have access to see the care plan and that it populates in the Kardex. 4. Staff should follow care plans when working with residents.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #25) of 3 (R #25, R #26, and R #27) residents reviewed for documentation accuracy. This deficient practice has the potential to have a negative impact on the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: A. Record review of R #25's face sheet dated 12/31/2024, revealed R #25 was admitted to the facility on [DATE]. B. Record review of R # 25's order summary report dated 12/31/24, revealed the following diagnoses: 1. Alzheimer's Disease. 2. Blindness with right eye. 3. Unspecified hearing loss, unspecified ear. 4. Muscle weakness, generalized. 5 Difficulty walking. 6. Lack of coordination. 7. Need for assistance with personal care. C. Record review of R #25's Situation-Background-Assessment-Recommendation (SBAR) form dated 01/04/25 revealed the following: 1. R #25 had a fall on 01/03/25. 2. The SBAR was not signed and complete. D. Record review of R #25 care plan dated 01/03/25 revealed R #25 had an actual fall without injury . Continue interventions on the at-risk plan . E. Record review of R #25's progress notes revealed LPN #5 did not document R #25 fall in the progress notes. F. On 03/18/25 at 3:21 PM, during an interview LPN #5 confirmed that he was working with R #25 the night of his fall 01/03/25. LPN #5 confirmed that he did not document R #25's fall in the progress notes. G. On 03/18/25 at 2:40 PM, during an interview the DON confirmed the following: 1. Staff did not complete the SBAR note for R #25's fall. 2. Staff did not document a progress note after R #25's fall.

Based on record review and interview, the facility failed to notify the provider of missed medication doses for 1 (R #59) of 2 (R #59 and R #96) residents reviewed for urinary tract infection (UTI), when they failed to notify the provider that R #59 missed 10 doses of cefuroxime (prescription medication that treats bacterial infections throughout the body) antibiotic. This deficient practice could likely result in residents not receiving necessary care or worsening of medical condition due to lack of treatment. The findings are: A. Record review of R #59's face sheet revealed she was admitted to the facility on [DATE]. B. Record review of R #59's hospital follow-up instructions (orders to facility after hospitalization ) dated 06/19/24 revealed: 1. Diagnosis; urinary tract infection (UTI). 2. New medications, start taking: cefuroxime 500 mg twice daily for 10 days for UTI. C. Record review of R #59's Physician's Orders revealed: Order date 06/19/24, cefuroxime oral tablet give 500 mg by mouth two times a day for UTI for 10 days. D. Record review of R #59's medication administration record (MAR) dated June 2024 revealed R #59 did not receive her cefuroxime on the following dates: 1. 06/20/24 at 8:00 AM 2. 06/21/24 at 8:00 PM 3. 06/22/24 at 8:00 AM and 8:00 PM 4. 06/23/24 at 8:00 AM and 8:00 PM 5. 06/24/24 at 8:00 AM and 8:00 PM 6. 06/25/24 at 8:00 AM and 8:00 PM E. Record review of R #59's Nurse Progress Notes revealed the record did not contain any documentation that the provider had been notified regarding the resident missed doses of the prescribed antibiotic. F. On 06/28/24 at 3:54 PM, during an interview, the DON confirmed R #59's missed 10 doses of the prescribed antibiotic because the facility did not receive it from the pharmacy, and was unable to confirm that the provider was notified.

Based on record review and interview the facility failed to report the results of the investigation within 5 days of the incident to the State Agency for 2 (R #270 and R #271) of 2 (R #270 and R #271) residents sampled for abuse. If the facility fails to report the results of the investigations to the State Agency within five days, then corrective action may not be taken and residents could likely suffer serious bodily injury. The findings are: R #270 A. Record review of the facility's 5-day report (no date) revealed the following: 1. R #270 fell on [DATE], that resulted in an emergency room (ER) visit with a diagnosis of acute displacement of the left hip, that required surgery on 03/05/24. 2. The record did not contain any documentation that the follow up report was submitted to the state agency. R #271 B. Record review of the facility's 5-day report (no date) revealed the following: 1. R #271 sustained a fall on 03/05/24, that resulted in an ER visit and R #271 did not have a serious injury. 2. The record did not contain any documentation that the follow-up report was submitted to the state agency. C. On 07/01/24 at 9:53 AM, during an interview with the Administrator, she confirmed the following: 1. She does not know when the 5-day follow-up reports for R #270 and R #271 were sent to the state agency. 2. She was not able to provide proof of when the 5-day follow-up reports for R #270 and R #271 were sent to the State Agency. D. Record review of the State Agency Reporting system, revealed the system did not have any record that the 5-day reports for R #270 or R #271 were received by the State Agency.

Based on record review and interview, the facility failed to notify the resident and resident's representative(s) of the transfer in writing for 4 (R #15, R #109, R #266, and R #269) of 4 (R #15, R #109, R #266, and R #269) residents sampled for hospitalization s when they failed to: 1. Notify the resident's representative(s) of the transfer to the hospital in writing and in a language and manner they understand for R #15, R #109, R #266, and R #269. 2. Include the name, phone number, and address (mailing and email) of the Office of the State Long-Term Care Ombudsman on the transfer notification form. 3. Send a written copy of the Transfer Notices for R #15, R #266, and R #269 to the Ombudsman. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer, and their rights to advocate and make informed decision regarding their healthcare. The findings are: R #15 A. Record review of R #15's medical record revealed R #15 was transferred to the hospital on 06/21/24. B. Record review of R #15's transfer notice revealed the following: 1. Staff did not document that a copy of the transfer notice was provided to the resident representative. 2. Staff did not document the name, phone number, or address (mailing and email) of the Office of the State Long-Term Care Ombudsman. 3. Staff did not document that a written copy of the Transfer Notice was sent to the Office of the State Long-Term Care Ombudsman. R #109 C. Record review of R #109's medical record revealed R #109 was transferred to the hospital on 04/14/24. D. Record review of R #109's transfer notice revealed staff did not document that a transfer notice was completed and provided to the resident or the resident representative. E. On 07/02/24 at 10:34 AM, during an interview, the Administrator confirmed that there was not a transfer notice documented for R #109 on 04/14/24. The administrator said that her expectation is that every time a resident is sent out of the facility for an unanticipated reason, a transfer notice should be done. R #266 F. Record review of R #266's medical record revealed R #266 was transferred to the hospital on 06/24/24. G. Record review of R #266's transfer notice revealed the following: 1. Staff did not document that a copy of the transfer notice was provided to the resident representative. 2. Staff did not document the name, phone number, or address (mailing and email) of the Office of the State Long-Term Care Ombudsman. 3. Staff did not document that a written copy of the Transfer Notice was sent to the Office of the State Long-Term Care Ombudsman. R #269 H. Record review of R #269's medical record revealed R #269 was transferred to the hospital on 06/17/24. I. Record review of R #269's transfer notice revealed the following: 1. Staff did not document that a copy of the transfer notice was provided to the resident representative. 2. Staff documented the name and phone number of the Volunteer Ombudsman. 3. Staff did not document the name, phone number, or address (mailing and email) of the Office of the State Long-Term Care Ombudsman. 4. Staff did not document that a written copy of the Transfer Notice was sent to the Office of the State Long-Term Care Ombudsman. J. On 06/27/24 at 4:52 PM, during an interview with the State Long-Term Care Ombudsman, she confirmed the following: 1. Staff email her a list of the residents that were transferred. 2. Staff should be including her name and contact information on the transfer notification forms. K. On 07/01/24 at 9:44 AM, during an interview with the Social Worker, she confirmed the following: 1. She emails the Ombudsman a weekly list of the residents who transferred or discharged from the facility. 2. If a resident is sent to the hospital, the nurses are expected to call the family at the time of the resident's transfer to notify them of the resident's condition and need to be transferred to the hospital. 3. She does not provide a copy of the transfer notices to the resident's family. L. On 07/01/24 at 9:55 AM, during an interview with LPN #21, she revealed the following: 1. When a resident is transferred to the hospital the nurse must notify the resident's family by phone that the resident is being transferred to the hospital. 2. The nurse must complete a transfer notification in the electronic medical record and provide a copy of the form to the resident or their representative if they are with the resident at the time of the transfer. 3. The nurse must include the name and phone number of the ombudsman on the transfer notification form. 4. The nurses have a binder at the nurse's station that includes the name and phone number for the Ombudsman. 5. The nurses do not mail a copy of the transfer notification form to the resident's family. M. Record review of the binder at the nurse's station, revealed the following: 1. The name and phone number listed as the Ombudsman, was the name and phone number for the Volunteer Ombudsman. 2. The binder did not include the name, phone number, or address of the Office of the State Long-Term Care Ombudsman.

Based on record review and interview, the facility failed to ensure that residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 4 (R #15, R #109, R #266, and R #269) of 4 (R #15, R #109, R #266, and R #269) residents reviewed for hospitalization . This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital. The findings are: R #15 A. Record review of R #15's medical record revealed R #15 was transferred to the hospital on 06/21/24. B. Record review of R #15's bed hold notice revealed the following: 1. Staff did not document how many days a bed would be held for the resident. 2. Staff did not document who was notified about the bed hold notice. 3. Staff did not document that the Bed Hold Notification was provided to the resident. 4. Staff did not document that the Bed Hold Notification form was provided to the resident's family. R #109 C. Record review of R #109's medical record revealed the following: 1. R #109 was transferred to the hospital on 04/14/24 for respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). 2. R #109's medical record did not contain a written notice of bed hold policy for the transfer on 04/14/24. R #266 D. Record review of R #266's medical record revealed R #266 was transferred to the hospital on 06/24/24. E. Record review of R #266's bed hold notice revealed the following: 1. Staff did not document how many days a bed would be held for the resident. 2. Staff did not document who was notified about the bed hold notice. 3. Staff did not document that the Bed Hold Notification was provided to the resident. 4. Staff did not document that the Bed Hold Notification form was provided to the resident's family. R #269 F. Record review of R #269's medical record revealed R #269 was transferred to the hospital on 06/17/24. G. Record review of R #269's bed hold notice revealed the following: 1. Staff did not document how many days a bed would be held for the resident. 2. Staff did not document who was notified about the bed hold notice. 3. Staff did not document that the Bed Hold Notification was provided to the resident. 4. Staff did not document that the Bed Hold Notification form was provided to the resident's family. H. On 07/01/24 09:55 AM, during an interview with LPN #21, she revealed the following: 1. When a resident is transferred to the hospital, the nurses creates the bed hold notice document in the resident's medical record, but do not document on it, the Business Office is supposed to fill out the the bed hold notice form. 2. The nurses do not notify the resident or family about the bed hold notification. 3. The business office handles the bed hold notification form. I. On 07/01/24 at 10:10 AM, during an interview with the Business Office Manager, she revealed that the business office does not do anything with the Bed Hold Notification Forms. J. On 07/02/24 at 10:34 AM, during an interview, the Administrator confirmed that there was not a bed hold documented for R #109 on 04/14/24. The administrator said that her expectation is that every time a resident is sent out of the facility for an unanticipated reason, a bed hold should be signed by the resident or resident representative as soon as practicable. 49313

Based on record review and interview, the facility failed to create a baseline care plan (healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours, that accurately reflected the resident's current condition for 4 (R #59, R #96, R #110, and R #163) of 5 (R #59, R #96, R #110, R #163 and R #266) residents sampled for baseline care plan when staff failed to: 1. Include physician's orders for R #59's antibiotic and use of oxygen. 2. Complete all sections of the baseline care plan and did not include physician's orders for R #96's antibiotic. 3. Complete all sections of the baseline care plan and did not include R #163's dementia (term used to describe a group of symptoms affecting memory, thinking and social abilities)-mild (stage of dementia where cognitive impairment starts to become more noticeable to the patient, as well as friends and family members) diagnosis and physician's orders for R #163 taking an antipsychotic medication (medication that works by changing the effects of chemicals in the brain often used manage the symptoms of mental health conditions). 4. Include physician's orders for R #110's Plaquenil and Lispro medication. These deficient practices could likely result in residents not receiving the appropriate care and services and may place residents at risk of an adverse event (an event, preventable or nonpreventable, that caused harm to a patient as a result of medical care or lack of medical care) or worsening of current condition after admission. The findings are: R #59 A. Record review of R #59's face sheet revealed R #59 was admitted to the facility on [DATE]. B. Record review of R #59's hospital discharge instructions dated 06/19/24 revealed: 1. Diagnosis; urinary tract infection (UTI). 2. New medications, start taking: Cefuroxime (prescription medication that treats bacterial infections throughout the body) 500 mg twice daily for 10 days for urinary tract infection. C. Record review of R #59's Physician's Orders revealed: Order date 06/19/24 oxygen at three (3) liters per minute per nasal cannula (tubing that delivers oxygen into the nose) via O2 (oxygen) concentrator and/or tank continuous (used at all times). D. Record review of R #59's medical record revealed NM (New Mexico) Person Centered Baseline Care Plan dated 06/20/24 did not have a plan in place for R #59's UTI and for the continuous use of oxygen. E. On 06/28/24 at 3:54 PM, during an interview, the DON confirmed that R #59's baseline care plan was not customized and did not include R #59''s use of continuous oxygen and R #59 received antibiotics for a UTI. R #96 F. Record review of R #96's face sheet revealed: 1. R #96 was admitted to the facility on [DATE]. 2. Diagnosis of a urinary tract infection (UTI). G. Record review of R #96's Physician's Orders revealed: Order date 05/24/24 cefdinir oral capsule (antibiotic taken orally that is used to treat many different types of infections caused by bacteria) 300 mg, give 1 capsule by mouth two times a day for UTI for seven (7) days. H. Record review of R #96's medical record revealed NM Person Centered Baseline Care Plan dated 05/28/24 was not completed within 48 hours and did not have a plan in place for R #96's UTI. I. On 06/28/24 at 3:37 PM, during an interview, the DON confirmed that R #96's baseline care plan did not have all sections completed within 48 hours of admission and did not include R #96's physician's order for antibiotic treatment for a UTI. R #110 J. Record review of R #110's orders revealed the following: 1. R #110 was admitted to the facility on [DATE]. 2. An order dated 05/03/24 for Plaquenil (used in the treatment of arthritis) oral tablet two (2) times a day for Rheumatoid arthritis (a chronic inflammatory disorder). 3. An order dated 05/03/24 for Insulin Lispro [NAME] KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (to control high blood sugar in people with diabetes). K. Record review of R #110's Baseline Care Plan dated 05/04/24 revealed that R #110's Plaquenil and Lispro were not documented. L. On 07/01/24 at 2:20 PM, during an interview, Social Services said that R #110's Plaquenil and Lispro were not documented in the care plan. R #163 M. Record review of R #163's face sheet revealed: 1. R #163 was admitted to the facility on [DATE]. 2. Diagnoses: a. Dementia with anxiety (feeling of worry, nervousness, or unease, typically about something with an uncertain outcome). b. Major depressive disorder (MDD, mood disorder that causes a persistent feeling of sadness and loss of interest). N. Record review of R #163's Physician's Orders revealed: Order date 06/24/24 risperidone oral tablet (antipsychotic medicine taken orally, that works by changing the effects of chemicals in the brain often used to treat schizophrenia and bipolar disorder) 0.5 mg, give 1 tablet by mouth two times a day for MDD and dementia. O. Record review of R #163's medical record revealed NM Person Centered Baseline Care Plan dated 06/27/24 was not completed within 48 hours and did not have a plan in place for dementia diagnosis and use of antipsychotic medication. P. On 06/28/24 at 3:43 PM, during an interview, the DON confirmed that R #163's baseline care plan did not have all sections completed within 48 hours of admission and did not include the diagnosis of dementia and the physician's order for R #163 taking an antipsychotic medication. 47510

49313 Based on record review, observation, and interview, the facility failed to ensure care plans were complete for 3 (R #106, R #108, and R #265) of 3 (R #106, R #108 and R #265) residents reviewed for care plans. This deficient practice could likely result in staff being unaware of the needs of the residents. The findings are: R #106 A. Record review of R #106's medical record revealed R #106 was admitted on [DATE]. B. Record review of R #10's care plan dated 06/11/24, revealed the care plan did not address R #10's discharge plan and any referrals to the local contact agency. C. On 07/01/24 at 2:20 PM, during an interview, Social Services confirmed that if it is not documented on R #10's care plan for discharge she did not do it. R #108 D. Record review of R #108's medical record revealed R #108 was admitted on [DATE]. E. On 06/25/24 at 10:56 AM, during an interview with R #108, he revealed the following: 1. He had a urinary tract infection (UTI, an infection in any part of the urinary system) and was receiving antibiotics (medication used to fight bacterial infections) through his Midline catheter (an 8-12 cm long soft, thin tube that is placed into a large vein in the upper arm, with the tip located just below the axilla (armpit).) 2. He completed his antibiotic treatment on 06/23/24. 3. He was unsure if the midline catheter was going to be removed. F. Record review of R #108's physician's orders, dated 06/12/24, revealed an order to change dressing weekly and orders to flush (inject saline into) peripherally inserted central catheter (PICC line, thin tube that's inserted through a vein in your arm and passed through to the larger veins near the heart)/Midline/Central line every shift. G. Record review of R #108's care plan, dated 06/23/24, revealed the following: 1. Staff did not document that R #108 had a Midline catheter on the Care plan. 2. Staff did not document instructions for how to care for R #108's midline. H. On 06/27/24 at 10:47 AM, during an interview with the Minimum Data Set (MDS) Nurse, she confirmed the following: 1. R #108 had a midline in his right arm. 2. R #108's care plan indicated that R #108 had an intravenous catheter (IV, short small tube that is placed into a vein). 3. R #108's care plan did not indicate that R #108 had a midline catheter. 4. R #108's care plan did not indicate how staff should care for R #108's midline catheter. 5. Care plan's should be resident specific and indicate specific information for providing care for each resident. R #265 I. Record review of R #265's medical record revealed R #265 was admitted on [DATE]. J. On 06/25/24 at 10:25 AM, an interview and observation of R #265, revealed the following: 1. R #265 stated that he received antibiotics through a catheter in his arm. 2. R #265 stated that he was unsure why he was taking antibiotics. 3. R #265 had redness to both of his lower legs. 4. R #265 stated that the redness on his legs was due to him having problems with swelling and infections in his lower legs. K. Record review of R #265's medical record revealed he had the following diagnoses: 1. Primary diagnosis was cellulitis (a deep infection of the skin caused by bacteria) of the left lower limb (lower leg). 2. Cellulitis of the right lower limb. 3. UTI. L. Record review of R #265's physician's orders, dated 06/16/24, revealed an order for Ertapenem (antibiotic used to treat certain infections including pneumonia, urinary tract, and skin) IV every night for 10 days for UTI, and an order to change dressing weekly and to flush PICC/Midline/Central line every shift. M. Record review of R #265's physician's orders, dated 06/17/24, revealed an order to cleanse two open wounds on right lower leg, three times weekly and as needed. N. Record review of R #265's care plan, dated 06/25/24, revealed the following: 1. Staff did not document interventions that were in place to care for R #265's diagnosis of cellulitis. 2. Staff did not document R #265's two wounds to the right leg. 3. Staff did not document that R #265 had a peripherally inserted central catheter (PICC line, thin tube that's inserted through a vein in your arm and passed through to the larger veins near the heart). 4. Staff did not document instructions for caring for R #265's PICC line. O. On 06/27/24 at 10:28 AM, during an interview with the MDS Nurse, she confirmed the following: 1. R #265 had a PICC line. 2. R #265 care plan indicated that R #265 had an IV. 3. R #265's care plan did not indicate that R #265 had a PICC line. 4. R #265's care plan did not indicate how staff should care for R #265's PICC line. 5. R #265's care plan did not include information for caring for R #265's diagnosis of cellulitis other than providing ordered medications for pain. 6. R #265's care plan should have included what staff should be observing for regarding R #265's cellulitis and any interventions that were being implemented to improve or prevent worsening of R #265's cellulitis in both of his legs. 7. R #265's care plan did not include R #265's two wounds to his right leg.

49313 Based on record review, and interview, the facility failed to ensure care plan revision and care plan meeting requirements occurred for 5 (R #1, R #2, R #5, R #74, and R #266) of 5 (R #1, R #2, R #5, R #74, and R #266) when the staff failed to: 1. Revise the care plan with the most current resident information for R #2, R #5, R #74, and R #266. 2. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities, and includes other appropriate staff or professionals in disciplines as determined by the resident's needs) members participate in the care plan meeting for R #1 and R #2. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #1 A. Record review of R #1's admission record revealed R #1 was admitted on [DATE]. B. On 06/26/24 at 9:34 AM, during an interview, R #1 said that she wasn't sure if she had participated in her care plan meeting. C. Record review of R #1's medical record revealed the record did not contain any documentation of a care plan meeting. D. On 07/02/24 at 12:01 PM, during an interview, Social Services (SS) said that she has never had a care plan meeting with R #1. SS said she knows what R #1 likes and what her needs are. R #2 E. Record review of the admission record, R #2 was admitted to the facility on [DATE]. F. On 06/25/24 at 2:36 PM, during an interview with R #2's Family Member (FM) revealed the following: 1. FM stated she never attended any meetings in the facility since R #2 was discharged from the hospital. 2. FM did not know she could attend meetings for the residents care plan meetings and was not invited. G. On 06/27/24 at 10:23 AM, during an interview with SS revealed the following: 1. Confirmed R #2 admission to the facility was on 04/26/24. 2. She was provided information by the FM for R #2 on 05/01/24 and 05/10/24 through phone call for the care plan. 3. Care plan was not completed with the the IDT members since the facility is short-term. H. Record review of the care plan dated 04/26/24 revealed R #2 FM was not invited to the meeting. R #5 I. On 06/25/24 at 10:15 AM, during an interview with R #5, she stated she receives dialysis three times a week and the facility transports her and has fluid restriction (diet which limits the amount of daily fluid consumption each day). J. Record review of the dialysis communication forms dated 05/27/24 and 06/17/24 revealed the following: 1. R #5 needs to be in fluid restriction 1 liter per day. 2. R #5 needs to be limited on fluid intake to 0.8 Liter (L) (the basic unit of liquid volume or capacity in the metric system equal to 1.06 quart or 2.12 pints) to 1 Liter (L). K. Record review of R #5 medical orders revealed the following: 1. R #5 receives Hemodialysis (HD) (process of filtering the blood of a person whose kidneys are not working normally) Monday, Wednesday, and Friday at 9:00 AM at local clinic. 2. R #5 was on fluid restriction of 1L on the following days Tuesday, Thursday, Saturday, Sunday as ordered on 06/01/24 by physician. L. Record review of R #5 activities of daily living (ADL) sheet for the month of June 2024 revealed R #5 was over on her fluid intake thirteen times during the month. M. Record review of R #5 care plan dated 05/23/24, revealed fluid intake restriction was not documented. N. On 06/26/24 at 2:21 PM, during an interview, with CNA #31 revealed the following: 1. The RN's had not told her about R #5 fluid restrictions and R #5 eats and drinks everything. 2. R #5 is on dialysis and attends Monday, Wednesday and Friday. 3. CNA's don't have access to the care plan and only follow RN's orders. 4. CNA #34 stated if the resident had a fluid restriction order she would only provide the necessary Cubic Centimeters (CC) (unit used to quantify the flow rate of liquid) of water during the day. O. On 06/27/24 at 8:50 AM, during an interview with RN #32 revealed: 1. There was a dialysis communication form dated 06/17/24 for R #5 which indicated R #5 needs to be on a 0.8L to 1L fluid restriction. 2. Hemodialysis was documented but fluid restriction was not documented on the care plan. P. On 06/27/24 at 2:00 PM, during an interview with the DON revealed the following: 1. The order of the fluid restriction should be care planned for. 2. Confirmed fluid restriction was not care planned for R #5 since it began in the middle of her stay and stated we probably forgot to document it. R #74 Q. Record review of R #74 of admission record revealed: R #74 was admitted to the facility on [DATE]. R. Record review of the physician's orders dated 04/29/24 revealed the following: 1. Gravity flush percutaneous endoscopic gastrotomy tube (PEG) (endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate), with 30mL (Milliliters) (unit is used to measure fluid volume of liquid) every shift. 2. Enteral tube site care: cleanse with soap and water, pat dry and observe skin health. Notify the provider of any changes. 3. Apply split sponge dressing as needed for drainage every shift. 4. Change enteral irrigation syringe, graduated cylinder (narrow laboratory container made of glass or plastic used to measure the volume of liquid) daily. Initial and date. S. Record review of R #74 care plan revealed the following: 1. R #74 care plan did not indicate frequencies or times PEG tube is supposed to be cleaned. 2. R #74 care plan did not specify what type of care was ordered for the cleaning of the PEG tube except local care as ordered. T. On 06/25/24 at 1:46 PM, during an interview with LPN #33 she stated the following: 1. R #74 arrived at the facility with a PEG tube. 2. R #74 was no longer being fed through PEG tube and eats a regular diet since admitted . 3. R #74 PEG-tube gets it flushed out daily. U. On 06/27/24 at 1:52 PM, during an interview with the DON she stated the following: 1. R #74 arrived at the facility with a PEG tube. 2. R #74 eats a regular diet. 3. Provided care of the PEG-tube flushing was completed by wound care nurse. Confirmed there was an order for the PEG tube's care and cleaning from the time of admission to time she was transferred to hospital on 06/25/24. Care plan did not specify what type of care was ordered for the PEG tube. R #266 V. Record review of R #266's Admission record revealed R #266 was admitted to the facility on [DATE]. W. Record review of R #266's nursing progress note, dated 06/24/24, revealed R #266 was sent to the hospital after being found with white cream on her teeth and tongue. X. On 06/28/24 at 10:34 AM, during an interview with CNA #21, he revealed the following: 1. R #266 had ingested creams that were in her bedside table. 2. After that incident, R #266's creams are to be kept out of her reach in the bathroom. Y. Record review of R #266's care plan, dated 06/17/24, revealed the following: 1. R #266 has behavior problems. 2. R #266 had removed her midline three times and unplugged her call light and placed a spoon in the outlet. 3. R #266's care plan was not revised to include information that she had ingested cream on 06/24/24 or any interventions that the facility initiated to prevent R #266 from ingesting cream again. Z. On 06/28/24 at 10:19 AM, during an interview with the DON, she confirmed the following: 1. R #266's has impulsivity and poor safety awareness. 2. R #266's care plan was not updated to include that she had ingested cream on 06/24/24. 3. R #266's care plan should have been updated to include keeping creams in the bathroom, out of R #266's reach 50497

Based on interview and record review, the facility failed to ensure that a resident who enters the facility with diagnosis of urinary tract infection (UTI) received appropriate treatment for 1 (R #59) of 2 (R #59 and R #96) residents reviewed for UTI when they failed to ensure that a resident received all doses of antibiotic as prescribed to treat the UTI. This deficient practice could result in residents being susceptible to worsening of infection or becoming septic (potentially life-threatening when the body responds to infection by damaging its own tissues) The findings are: A. On 06/25/24 at 10:31 AM, during an interview, R #59 laid in bed and reported she was discharged to the facility about a week ago due to being in the hospital for a urinary infection. B. Record review of R #59's face sheet revealed R #59 was admitted to the facility on [DATE]. C. Record review of R #59's hospital discharge instructions dated 06/19/24 revealed: 1. Diagnosis; urinary tract infection (UTI). 2. New medications, start taking: cefuroxime (prescription medication that treats bacterial infections throughout the body) 500 mg twice daily for 10 days for urinary tract infection. D. Record review of R #59's Physician's Orders revealed: Order date 06/19/24, cefuroxime oral tablet give 500 mg by mouth two times a day for UTI for 10 days. E. Record review of R #59's medication administration record (MAR) dated June 2024 revealed she did not receive her cefuroxime on the following dates: 1. 06/20/24 at 8:00 AM 2. 06/21/24 at 8:00 PM 3. 06/22/24 at 8:00 AM and 8:00 PM 4. 06/23/24 at 8:00 AM and 8:00 PM 5. 06/24/24 at 8:00 AM and 8:00 PM 6. 06/25/24 at 8:00 AM and 8:00 PM F. Record review of R #59's progress notes revealed the following: 1. 06/20/24 at 8:37 AM cefuroxime on order 2. 06/21/24 at 11:35 PM cefuroxime on order 3. 06/22/24 at 8:52 AM cefuroxime on order has not been delivered, none in e kit (emergency kit where medication that has not been delivered from pharmacy can be obtained.) 4. 06/22/24 at 10:07 PM cefuroxime not in cart (medication cart that holds residents' medications) or pyxis (machine where medication can be obtained prior to delivery from pharmacy) 5. 06/23/24 at 9:33 AM cefuroxime on order from pharmacy 6. 06/23/24 at 8:16 PM cefuroxime awaiting arrival from pharmacy 7. 06/24/24 at 9:32 AM cefuroxime on order from pharmacy 8. 06/24/24 at 11:14 PM cefuroxime awaiting arrival from pharmacy 9. 06/25/24 at 09:01 PM cefuroxime not available G. On 06/28/24 at 3:54 PM, during an interview, the DON confirmed that R #59 missed 10 doses out of 13 doses of the antibiotic medication ordered to treat her UTI because the facility did not receive the medication from the pharmacy.

Based on record review and interview, the facility failed to ensure residents have a written, signed, and dated progress note from the provider (physician or nurse practitioner) at the time of each visit for 1 (R #15) of 1 (R #15) residents reviewed for physician's visits This deficient practice could likely result in the resident's needs not being met due to facility staff being unaware of resident's status related to lack of written, signed, and dated progress notes at the time of the visit. A. Record review of R #15's Electronic Medical Record (EMR) revealed R #15 was admitted to the facility on [DATE]. B. Record review of R #15's physician's progress notes revealed the following: 1. History and Physical (H&P), dated 04/14/24, revealed the H&P note was a late entry entered on 06/20/24. 2. Provider progress note, dated 04/15/24, revealed the note was a late entry entered on 06/20/24. 3. Provider progress notes dated 04/16/24, revealed the note was a late entry entered on 06/20/24. 4. Provider progress notes dated 04/17/24, revealed the note was a late entry entered on 06/20/24. 5. Provider progress notes dated 04/18/24, revealed the note was a late entry entered on 06/20/24. 6. Provider progress notes dated 05/01/24, revealed the note was a late entry entered on 06/20/24. 7. Provider progress notes dated 05/02/24, revealed the note was a late entry entered on 06/20/24. 8. Provider progress notes dated 05/03/24, revealed the note was a late entry entered on 06/20/24. 9. Provider progress notes dated 06/01/24, revealed the note was a late entry entered on 06/20/24. 10. Provider progress notes dated 06/02/24, revealed the note was a late entry entered on 06/20/24. 11. Provider progress notes dated 06/03/24, revealed the note was a late entry entered on 06/20/24. C. On 07/01/24 at 1:36 PM, during an interview with Nurse Practitioner #21, he revealed the following: 1. He sees residents at the facility almost daily. 2. He is behind on entering progress notes into the medical records. 3. He entered several late entries for R #15 on 06/20/24. 4. He waits to get a collection of notes on residents before he enters them. D. On 07/01/24 at 2:35 PM, during an interview with the Administrator, she confirmed that her expectation is for the providers to enter their notes timely (she did not specify what timely meant).

Based on record review and interview, the facility failed to ensure that residents had a physician visit at least every 30 days for the first 90 days after admission for 1 (R #15) of 1 (R #15) residents reviewed for physician's visits. This deficient practice could likely result in residents not receiving the required medical assessment which could cause a delay in care and treatment of medical conditions. The findings are: A. Record review of R #15's Electronic Medical Record (EMR) revealed R #15 was admitted to the facility on [DATE]. B. Record review of R #15's entire EMR revealed the medical record did not contain any documentation that R #15 was seen by the physician. C. On 07/01/24 at 2:35 PM, during an interview with the Administrator, she confirmed the following: 1. There was no documentation in R #15's medical record from the physician. 2. She was unable to determine if R #15 was seen by a physician. 3. She was unsure how frequently R #15's physician sees residents in the facility. 4. Her expectation is for physicians to see their residents at least once every 30 days for the first 90 days.

Based on observation, record review, and interview, the facility failed to store medications properly for all 17 residents in rooms 135-151 (residents were identified by the Resident Matrix provided by the Administrator on 06/25/24), when they failed to ensure the medication cart did not contain loose medications. This deficient practice could likely result in residents obtaining or being administered medication not prescribed to them, receiving medications that are less effective and may result in adverse side effects. The findings are: A. On 06/29/24 at 2:55 PM, during an observation of the medication cart assigned to room's 135-151, one white oval tablet was loose between the medication cards (cardboard and foil packaging prefilled with prescription medication) in the second drawer of the medication cart. B. On 06/29/24 at 2:57 PM, during an interview with LPN #34, he confirmed there was a loose white tablet stating, I will remove it. C. Record review of the facility's Storage of Medication Policy dated September 2018, revealed Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication storage should be kept clean, well lit, organized and free of clutter.

Based on interview and record review, the facility failed to keep residents free from abuse and neglect for 2 (R #46 and R #247) of 2 (R #46 and R #247) residents reviewed for abuse neglect, when they failed to: 1. Keep R #247 free from verbal abuse and sexual harassment from LPN #13 when she made inappropriate comments to him in front of his family, and 2. Provide R #46 dinner on the day she was admitted into the facility This deficient practice likely resulted in R #247 having anger, fear, and anxiety as a result. The findings are: R #247 A. On 03/09/23 at 1:59 PM, during an interview with R #247, he stated that he was not sure of the date, but while visiting with his daughter, a nurse made a comment about making a baby with him. R #247 gave the physical attributes of LPN #13 and gave a name very similar to LPN #13 (as he was unsure of her name). He responded to LPN #13 that he already had his kids and she replied that they could practice making a baby. R #247 was asked how the comments made him feel and he put his head down and said he was angry, embarrassed, and upset that LPN #13 said that and that he was just there to recover. During observation, R #247 was visibly upset, concerned and his eyes were watering. He said he was afraid that staff were going to do something to hurt him because he was stepping on toes. B. On 03/09/23 at 4:20 PM, during an interview with the Administrator, it was revealed the facility was not aware of the allegation of abuse and confirmed they were going to investigate and report it as abuse. The Administrator confirmed that LPN #13 matched the description and likeness in name given by R #247's description. C. On 03/10/23 at 10:27 AM, during an interview with LPN #13 confirmed that if R #247 said she said it [statement about making a baby with R #247], that she probably said it. She said she doesn't recall saying that statement specifically but does remember saying something similar. She said she is always in trouble, and she isn't politically correct. D. On 03/10/23 at 11:12 AM, during an interview with R #247's Family Member it was confirmed that LPN #13 did make a comment about making a baby to R #247. She also stated that R #247 was visibly upset at the time. R #46 E. Record review of R #46's face sheet revealed an admitted [DATE]. F. On 03/10/23 at 11:34 AM, during an interview, R #46 stated that she was not provided dinner on the evening she was admitted to the facility after 5:00 pm. She revealed that when the driver wheeled her to her room he stated that the kitchen staff will bring her dinner. R #46 continued to state that when the nursing staff came to her room to get her settled in, she was told again that the dietary staff will be bringing her dinner and then left. R #46 confirmed that she never got dinner. G. Record review of R #46's Electronic Medical Records (EMR) revealed: 1. No documentation of a meal intake on 01/24/23. 2. BIMS (BIMS a test for cognition) score of 15 (A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) . H. On 03/14/23 at 11:32 AM during an interview with the Dietary Manager revealed: 1. When any resident is admitted after 5:00 PM, the kitchen staff leave extra food plates in the refrigerator for late admissions. 2. kitchen staff are in the facility until 7:00 PM. 3. Dietary Manager (DM) is notified of late admissions through a phone app. The DM is new to his position and he was not the DM when R #46 was admitted and could not confirm what occurred on the evening R #46 was admitted . I. On 03/14/23 at 11:58 AM during an interview with the Administrator revealed: 1. An Admission notice for R #46 was provided to the Kitchen at 4:40 PM on 01/24/23 via a phone APP. 2. The Administrator could not confirm if a meal was provided to R #46 because she was not the Administrator at the time, but confirmed that there was no documentation or evidence a meal was provided. 3. The Administrator confirmed that her expectation is for meals to be provided to new residents that arrive after 5:00 PM. 47510

Based on record review and interview, the facility failed to ensure residents received care consistent with professional practices to prevent a pressure wound from worsening and to receive necessary treatment to promote healing for 2 (R #12 and R #130) of 2 (R #12 and R #130) residents reviewed for pressure wounds when they: 1) failed to have the R #12's physician assess R #12's before LPN #1 requested Santyl (non-recommended treatment) to treat R #12's closed pressure wound, and 2) failed to implement orders to reposition R #130. This deficient practice likely resulted in the delay of appropriate treatment and interventions to prevent further wounding and for healing. The findings are: R #12 A. Record review of facility record revealed R #12 was admitted [DATE] with Diagnoses: [REDACTED]. B. Record review of MDS (Minimum Data Set) for R #12 dated [DATE]. Section MO150 indicated the R #12 was at risk for developing pressure ulcers. Section M0210 revealed no indication the resident had pressure ulcers. C. Record review of the care plan for R #12, dated [DATE] revealed: Has potential for pressure ulcer development related to immobility and incontinence with dementia. Interventions: Instruct and assist to shift weight in W/C (wheelchair) q (every 15 minutes), Pressure relieving devices on bed and wheelchair. D. Record review of the Total Body Skin Assessment for #12, dated [DATE], [DATE], [DATE] all revealed: 0 new wounds. E. Record review of the Skin and Wound Evaluation for R #12 dated [DATE] revealed: Type of wound: Pressure, Stage: Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Wound Measurements: Length 4.5 cm (centimeter a metric unit of measure), Width 3.5 cm, Depth Not Applicable, Length of Time: one month, present of admission F. Record review of the physician order [REDACTED]. G. On [DATE] at 1:32 PM, during observation, R #12 sitting in wheelchair, head is forward, and she is snoring. She has socks on and her right foot is off the foot rest and on the floor, left heel on the foot rest with heel in contact with the foot rest. H. On [DATE] at 10:08 am, during observation, R #12 was observed to be in her room sitting in a wheelchair. She had socks on her feet are on the hard, plastic foot rests. Her left heel is sitting on the footrest. I. Record review of the physician order [REDACTED]. J. Record review of physician progress notes [REDACTED].#12, dated [DATE] revealed: Left heel wound measures 3.8 x 2.1 x 0.1 cm (centimeter, a metric unit of measure) wound bed with soft light brown eschar (dry, dark scab or falling away of dead skin), moderate purulent (pus) drainage. Surrounding tissue macerated (by soaking). Impression/recommendations: 84 y/o female with h/o (history of) left ORIF has pressure injury of left heel-unstageable (a full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. These ulcers are unstageable until enough slough and/or eschar are removed to expose the base of the wound), unknown duration. 1. Left heel wound =recommend stopping Santyl and start TheraHoney (a medication used to treat pressure wounds), cover with [MEDICATION NAME] (a type of dressing). Change 3 x (three times) a week and prn (as needed). 2. Offloading - frequent change of position while in bed or chair. Offload heels with boots when in bed. K. On [DATE] at 10:43 am, during an interview, LPN #1 stated, I did the admission for (Name of R #12) and on admission she only had a surgical incision that was healing, no pressure wounds. About 2 to 3 weeks ago ([DATE]), one of the CNAs said she (R #12) had a spot on her left heel. It looked like a blood blister. It was squishy when I touched it, but it was not open. I called the doctor who was on call and asked for an order for [REDACTED]. He did not come in and see the wound. I just said what I wanted, and I got the order and started Santyl that same afternoon. Technically I can't stage (determine the extent) of a wound because I am an LPN, but I knew we had to get the blood blister off. It (the wound) opened up 2 or 3 days later. I did not care plan her for the wound. We use heel protectors just when she is in bed at night and the CNAs turn her every 2 hours. She is mostly up in her wheelchair. We try not to let her stay in bed. She is not putting pressure on her heel in the wheelchair because she cannot move, and we put her foot on the footrest, so the heel is off the foot rest. I know the CNAs turn her because we communicate. I don't know how to look at CNAs task list and see if they are turning her, I just communicate with them I want it done. When asked what training she has had regarding wound assessments and wound treatments, LPN #1 stated, I saw a video, I don't remember when. When asked if she has had training about care of SDT (Suspected Deep Tissue-a type of pressure wounding) of the heels, she said she did not know there was anything special about the heels. L. On [DATE] at 12:30 pm, during an interview, CNA #3 stated, She (R #12) does have some wound on her left heel. It does smell bad. The nurses change the dressing. I keep her in socks. She is up in her wheelchair during the day. She has booties for at night; when she is bed. We change her position every 2 hours when she is in bed. We don't have to do position changes if she is up in her wheelchair. M. On [DATE] at 1:10 pm, during observation, R #12 was sitting in the wheelchair, small fluffy lined boots were in place. LPN # 3 was in the room and I asked her if this resident has ever had or has suspension boots (boots designed so heel is suspended and does not come in contact with any surface under the foot). LPN #3 responded, No, she does not have any suspension boots and has never had them. We just put here on the regular booties when she is in bed. N. On [DATE] at 11:05 am, during an interview, MDS Coordinator #1 stated she has just started the MDS job in this facility and was not aware of R #12's heel wound. She reviewed R #12's care plan and stated, There is nothing here about a wound or interventions, just that she (R #12) is at risk for wounds. O. On [DATE] at 12:13 pm, during an interview, the DON stated, The wound and interventions should have been care planned for (Name of R #12). The nurse should not have asked for or used Santyl --it eats up the skin. The heel should be off loaded (pressure taken off the heel) even when up in her wheelchair. All of our nurses go through a training video for wounds. We have wound protocols in a notebook on top of the treatment cart and each pressure wound is referenced to a treatment. For wound care technique, we have nurses do a return demonstration. It is done on orientation. We do not have competencies on wound assessment. P. Review of the PUAP (Pressure Ulcer Advisory Panel) Prevention and treatment of [REDACTED]. 12. Do not debride stable, hard, dry eschar in ischemic limbs. Shannon (2013) 42 conducted a retrospective review in a nursing home population of heel pressure ulcers (n = 179) with entire eschar (67.8% of the sample) or blister coverage (31.8% of the sample). Of the 155 patients not lost to follow up, 154 of the wounds (99.3%) healed. Of the heel pressure ulcers covered with eschar, 100% of wounds healed with an average healing time of 11 weeks (range 2 to 50 weeks). Q. Review of Nursing 2005: (MONTH) 2005 - Volume 35 - Issue 1 -p 68, Treating Heel Pressure Ulcers, Joyce Black RN, PHF revealed: If the patient has heel blisters, don't break them. Elevate the heel or place the leg in a splint or boot that suspends the heel. If the ulcer has broken the skin (Stage II to IV), use a [MEDICATION NAME] dressing, such as a [MEDICATION NAME], impregnated gauze, and gauze wrap, to keep it clean and moist. You may also use [MEDICATION NAME] dressings to manage drainage and promote a moist healing environment. But don't use occlusive dressings if you suspect infection; they trap bacteria in the wound and encourage invasion into normal tissues. Instead, use gauze dressings and change them twice a day. treatment for [REDACTED]. Although this is a controversial area that needs more research, the current standard is to avoid removing stable eschar on the heel, as recommended by both the 1994 Agency for Health Care Policy and Research (AHCPR) and the 2003 Wound, Ostomy, and Continence Nurses Society practice guidelines. (AHCPR is now the Agency for Healthcare Research and Quality.) Because the heel has no vascular tissue beneath the eschar (only a fat pad), even a clean open wound can quickly become infected, leading to osteo[DIAGNOSES REDACTED] (an infection in the bone). Instead, protect the heel by wrapping it with gauze and using elevating devices that keep it off the bed. Check the heel daily for bogginess around the eschar, [MEDICAL CONDITION], redness, drainage, or overt signs of infection, which would require a change in the treatment plan. R #28 R. Record review of face sheet for R #28 revealed admission to the facility on [DATE]. S. Record review of MDS dated [DATE] revealed: Unhealed Pressure Ulcers/Injuries: Does this resident have one or more unhealed pressure ulcers/injuries? 1. Yes. *Current Number of Unhealed Pressure Ulcers/Injuries at each stage? 1. Number of stage 2 pressure Ulcers/Injuries at each stage: One 2. Number of these stage 2 pressure Ulcer that were present upon admission/entry or reentry? One 3. Skin and Ulcer/injury treatments: a). Pressure reducing device for chair b). Pressure reducing device for bed c). Pressure ulcer/injury care d). Applications of ointments/medications other than feet. T. Record review of R #28's orders dated [DATE] revealed, Turn Q2 hrs (turn every two hours). U. Record review of (name of hospital) progress notes dated [DATE] revealed: Wounds: 1. Sacrum - non-blanchable skin area measuring 5.5 x 3 x 0 cm, skin intact. No drainage. No surrounding [DIAGNOSES REDACTED] (superficial reddening of the skin, usually in patches, as a result of injury or irritation causing dilatation of the blood capillaries). Impression/Recommendations: [AGE] year-old Male with pressure injury stage II to sacrum. 2. Sacrum - Improving, skin currently intact. Continue with Silicone boarder dressing, change 3x weekly or PRN.2. Offloading - Frequent position change while in bed or chair, Silicone boarder to protect boney prominence. 3. Nutrition - Discussed and educated to improve wound care out comes. Receiving liquid protein daily. V. On [DATE] 10:26 am during an interview, CNA #1, when ask if R #28 had a Pressure Ulcer, she stated, Not that I'm aware of. W. On [DATE] at 10:38 am, during an interview, RN #5 revealed that he was not aware of an order for [REDACTED]. X. On [DATE] at 11:07 am during an interview, the DON revealed that R #28 developed a pressure Ulcer prior to admission into the facility. She also said that all CNAs and nurses should be aware of R #28's pressure ulcer and all nurses should be checking the TAR prior to their shift. When asked if an order for [REDACTED].