Every finding on record at Las Estancias by Pure Health

Based on record review and interviews, the facility failed to ensure psychotropic medication (medication used to treat mental health conditions) consent forms were signed by the resident or resident representative prior to medication administration for 1 (R #14) of 5 (R #1, 4, 6, 14, and 15) residents reviewed for unnecessary psychotropic drugs. This deficient practice is likely to put residents at an increased risk for undesirable side effects (including but not limited to; increased thoughts of suicide, insomnia, fatigue, sexual dysfunction) associated with the use of these medications.The findings are: A. Record review of R #14's face sheet indicated an admission date of 04/01/25 with the following diagnoses:Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with psychotic disturbance (experiences hallucinations or delusions).Anxiety disorder (feelings of fear or apprehension). B. Record review of R #14's physician orders revealed the following:Dated 05/01/25, Buspirone (antianxiety medication) tablet 7.5 milligrams (MG). Give 1 tablet by mouth three times a day for dementia with agitation. This order was discontinued on 11/06/25. Dated 11/06/25, Buspirone tablet 15 MG. Give 1 tablet by mouth three times a day for dementia with agitation. This order was discontinued on 11/06/25.Dated 12/19/25, Quetiapine Fumarate (antipsychotic medication) 25 MG. Give 1 tablet by mouth at bedtime for dementia with aggressive behaviors. R #14 is still receiving this medication. Dated 01/20/26, Buspirone tablet 10 MG. Give 1 tablet by mouth three times a day for dementia with agitation. R #14 is still receiving this medication. C. Record review of R #14's pharmacist recommendations indicated, dated 12/29/25 and 04/27/26, both revealed a recommendation was made to obtain psychotropic medication consent at admission, prior to the initiation of psychotropic, or prior to increasing a dose of a psychotropic medication. Consent forms for R #14 could not be located in R #14's electronic health record (EHR) during the pharmacist review. D. Record review of R #14's EHR, dated 05/22/26, revealed the following: Dated 04/01/25, only the initial psychotropic consent form Buspirone 7.5 MG was present. Additional psychotropic consent forms reflecting Buspirone dosage changes was not present. A psychotropic consent form was not available for the initiation of Quetiapine Fumarate on 12/19/25. E. On 05/22/26 at 11:00 am, during an interview, the Director of Nursing (DON) stated psychotropic consent forms should be completed for every new psychoactive medication and for any dosage changes. The DON stated R #14's psychotropic consent forms were not completed as required for the use of Buspirone and Quetiapine Fumarate. F. On 05/22/26 at 12:45 pm, during an interview, the Unit Manager (UM) #3 stated she is responsible for overseeing the completion of psychotropic medication consent forms. The UM #3 stated she was not sure why the psychotropic medication consent forms were not being completed and believed the facility's nursing staff was completing them.

Based on record review and interviews, the facility failed to ensure residents were free from unnecessary medications, in accordance with professional standards of practice, for 1 (R #14) of 5 (R #1, 4, 6, 14, and 15) residents, when: A psychotropic medication (medication used to treat mental health conditions) gradual dose reduction (tapering of a medication dose to determine if symptoms, conditions, or risks can be managed by a lower dose) was not attempted or supported by documentation indicating it was clinically contraindicated. An abnormal involuntary movement scale (AIMS is a tool that assesses and monitors for the risk of tardive dyskinesia) was not completed as required. This deficient practice is likely to result in residents being administered psychotropic medications that are unnecessary resulting in possible sedation and other unwanted side effects. The findings are: GDR: A. Record review of R #14's face sheet indicated an admission date of 04/01/25 with the following diagnoses:Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with psychotic disturbance (experiences hallucinations or delusions).Anxiety disorder (feelings of fear or apprehension). B. Record review of R #14's physician orders revealed the following:Dated 04/03/25, Sertraline (antidepressant) 100 milligrams (MG). R #14 is still receiving this medication.Dated 05/01/25, Buspirone (antianxiety medication) tablet 7.5 MG. Give 1 tablet by mouth three times a day for dementia with agitation. This order was discontinued on 11/06/25. Dated 11/06/25, Buspirone tablet 15 MG. Give 1 tablet by mouth three times a day for dementia with agitation. This order was discontinued on 11/06/25.Dated 01/20/26, Buspirone tablet 10 MG. Give 1 tablet by mouth three times a day for dementia with agitation. R #14 is still receiving this medication. C. Record review of R #14's pharmacist recommendations, dated 05/22/26, revealed the following:The last GDR attempt for Sertraline occurred on 11/24/24. Documentation was not available indicating whether a GDR was attempted or determined not to be needed for Sertraline after 11/24/24.Documentation was not available indicating whether a GDR was attempted or determined not to be needed for Buspirone use from April 2025 through April 2026. D. On 05/22/26 at 11:00 am, during an interview, the Pharmacist stated R #14's physician made changes to R #14's Buspirone dosages, but those recommendations were not conducted through the formal GDR process. E. On 05/22/26 at 11:03 am, during an interview, the Director of Nursing (DON) stated GDRs should be documented and that she would provide R#14's GDR documentation for Buspirone and Sertraline. The facility did not provide R#14's GDR documentation for Buspirone or Sertraline during the survey as requested. AIMS Score: F. Record review of R #14's physician orders, dated 12/19/25, revealed R #14 is prescribed Quetiapine Fumarate (antipsychotic medication) 25 MG. Give 1 tablet by mouth at bedtime for dementia with aggressive behaviors. G. Record review of R #14's pharmacist recommendations revealed the following:Dated 12/29/25, the pharmacist recommended that an AIMS test be completed initially within 30 days and then at least every six months while the resident continues on antipsychotic therapy.Dated 01/30/26, the pharmacist recommended that an AIMS test be completed.Dated 03/31/26, the pharmacist recommended the completion of an AIMS test, noting the last documented AIMS test occurred in 09/2023. H. On 05/22/26 at 11:00 am, during an interview, the DON stated that an AIMS should be completed upon a resident's admission, at the initiation of any antipsychotic medication, and every six months while the resident continues taking the medication. The DON stated that R#14 should have had an AIMS completed as recommended by the pharmacist but did not.

Based on record review and interviews, 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) for 2 (R #92 and 111) of 2 (R #92 and 111) residents, when: R #'s 92 and 111 baseline care plans were incomplete and inaccurate due to the baseline care plans failing to include multiple diagnoses with interventions. 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). The findings are: R #92: A. Record review of R #92's face sheet revealed an admission date of 04/30/26 and included the following diagnoses:Infectious gastroenteritis and colitis (inflammation caused by an infection in the gastrointestinal tract and the large intestine).Perforation of intestine (a hole in the digestive tract).Protein-calorie malnutrition (when the body does not receive enough protein and calories to maintain proper health and functionality).Acute respiratory failure (a life-threatening condition where the lungs cannot deliver enough oxygen to the blood) with hypoxia (low oxygen levels in body tissue).Sepsis (a serious condition in which the body responds improperly to an infection).Colostomy status (a surgical procedure in which the colon is connected to the abdominal wall and an opening [stoma] is created in the abdominal wall created to allow waste to leave the body).Generalized muscle weakness (reduction in the power exerted by muscles throughout the body).Abnormalities of gait and mobility.Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol).Hypo-osmolality (low levels of electrolytes and other fluids in the blood) and hyponatremia (low sodium level).Hypokalemia (low levels of potassium in the blood).Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Anxiety disorder (feelings of fear or apprehension).Hypertension (HTN; high blood pressure).Disorders of peritoneum (the tissue that lines your abdominal wall and covers most of the organs in your abdomen). B. Record review of R #92's baseline care plan, dated 05/01/26, revealed the baseline care plan did not include multiple diagnoses that were listed on R #92's face sheet that require interventions. C. On 05/22/26 at 3:18 pm, during an interview, the Assistant Director of Nursing (ADON) stated the expectation is that baseline care plans be completed within 48 hours of a resident's admission and should include basic healthcare information, which varies based on each resident's diagnoses. The ADON stated if a resident is taking high-risk medications such as an antidepressant or anti-anxiety medications, upon admission, these diagnoses and treatments should be included in the baseline care plan. The ADON stated R #92's baseline care plan was not inclusive of pertinent diagnoses and should have been. R #111: D. Record review of R #111's face sheet revealed an admission date of 05/02/26 and included the following diagnoses:Spinal stenosis, cervical region (the narrowing of one or more spaces within the spinal canal in the neck area).Age-related osteoporosis (bones become extremely porous and are subject to fracture and slow healing).Polymyalgia rheumatica (inflammatory disorder that causes muscle pain and stiffness).Right femur fracture (upper part of the thigh bone). E. Record review of R #111's baseline care plan, dated 05/04/26, revealed the baseline care plan did not include multiple diagnoses that were listed on R #111's face sheet that require interventions. F. On 05/22/26 at 3:22 pm, during an interview, the ADON stated the expectation is for baseline care plans to be completed within 48 hours of resident's admission. The ADON stated the facility has a list of things that should be included in a baseline care plan, which nursing staff follow. She stated pain should be included in a baseline care plan if the resident is admitted with pain. The ADON stated R #111's baseline care plan was not inclusive of pertinent diagnoses and should have been.

Based on observation, record review, and interviews, the facility failed to maintain a safe and sanitary environment to prevent the transmission of infectious agents and communicable diseases for residents, when the facility: Failed to ensure a water pitcher on a medication cart was dated which had the potential to affect all residents on the 200-unit,Failed to prevent a urinary catheter (a thin, flexible tube which drains urine from the bladder) bag and tubing from touching the floor for 4 (R #6, R#16, R #74, and R #87) of 4 (R #6, R#16, R #74, and R #87) residents reviewed for catheter care. These deficient practices have the potential to expose staff and other residents to infectious diseases. The findings are: Dated Water Pitcher: A. On 05/20/26 at 8:29 am, during an observation, the water pitcher on the 200 unit medication cart was not dated and was used to administer medications to R #16, R #66, and R #121. B. On 05/20/26 at 8:57 am, during an interview, Licensed Practical Nurse (LPN) #3 stated the water pitchers used for medication administration should be dated when the water is placed into the pitcher. The LPN #3 stated if water was used after 24 hours, there would be a risk of infection to residents. C. On 05/22/26 at 1:15 pm, during an interview, the Director of Nursing (DON) stated it is her expectation for the water pitchers used for medication administration to have the current date of when the water pitcher was filled. The DON stated the water in the water pitcher should be discarded at the end of the day and should not be carried over for use the following day. The DON stated if water is used past the approved timeframe, there is a risk of infection to the resident. Urinary Catheters: D. Record review of the facility's Urinary Catheter Care policy, revised on 08/2022, revealed the facility staff were expected to ensure catheter tubing and drainage bags were kept off the floor. R #6: E. Record review of R #6's face sheet revealed an admission date of 01/14/26. F. Record review of R #6's physician orders, dated 01/15/26, revealed R #6 utilized a urinary catheter. G. On 05/18/26 at 12:28 pm, during an observation, R #6's catheter bag was attached to his wheelchair and dragging on the floor in the main dining room. H. On 05/18/26 at 2:47 pm, during an observation, R #6's catheter bag was attached to his wheelchair and dragging on the floor in the hallway near the activity room. I. On 05/19/26 at 12:17 pm, during an observation, R #6's catheter bag was attached to his wheelchair and lying on the floor in the main dining room while R #6 ate lunch. R #16: J. Record review of R #16's face sheet revealed R #16 was originally admitted into the facility on [DATE]. K. Record review of R #16's physician orders, dated 05/10/26, revealed the following: Urinary catheter, change the foley catheter monthly and as needed for occlusion or leakage. L. On 05/18/26 at 11:56 am, during an observation, R #16's urinary catheter drainage bag was lying on the floor under her wheelchair. R #74: M. Record review of R #74's face sheet revealed R #74 was originally admitted into the facility on [DATE] with the following diagnoses: Obstructive and reflux uropathy (a blockage in the urinary tract that prevents normal urine flow). Hydronephrosis (swelling of the kidneys caused by a backup of urine). Acute kidney failure. N. Record review of R #74's physician orders, dated 11/19/25, revealed the following: Urinary catheter, change the foley catheter monthly and as needed for occlusion or leakage. O. On 05/18/26 at 11:56 am, during an observation, R #74's urinary catheter drainage bag was lying on the floor underneath his wheelchair. R #87: P. Record review of R #87's face sheet revealed R #87 was originally admitted into the facility on [DATE]. Q. Record review of R #87's physician orders, dated 03/19/26, revealed the following: Urinary catheter, change the foley catheter monthly and as needed for occlusion or leakage. R. On 05/18/26 at 2:36 pm, during an observation, R #87 propelled herself down the common area hallway in her wheelchair with the urinary catheter drainage bag dragging along the floor. S. On 05/21/26 at 12:13 pm, during an interview, the Infection Preventionist (IP) #1 stated the facility staff should keep urinary catheter drainage bags below the resident's bladder and off the floor at all times. The IP #1 stated the facility staff are responsible for ensuring urinary catheter drainage bags do not touch or drag on the floor. The IP #1 stated the risks include urine spillage and bacteria entering the catheter system. T. On 05/22/26 at 1:15 pm, during an interview, the DON stated per policy, urinary catheter drainage bags should be kept off the floor. The DON stated it is the responsibility of the facility staff to ensure urinary catheter drainage bags remained secured and off the floor. The DON stated R #6's, #16's, #74's, and #87's urinary catheter drainage bags should not have been on the floor.

Based on observation, record review, and interviews, the facility failed to develop and update a comprehensive, person-centered care plan for 1 (R #121) of 4 (R #6, #92, #111, and #121) residents reviewed for care planning, when staff failed to:Update R #121's care plan to include oxygen (O2) use. This deficient practice is likely to result in residents not having needs met, decreased quality of life, and avoidable decline in physical and psychosocial well-being. The findings are: A. Record review of R #121's face sheet revealed an admission date of 05/14/26 and included the following diagnoses: Congestive heart failure (CHF; impaired heart function).Pulmonary hypertension (a type of high blood pressure that affects the arteries in the lungs and the right side of the heart). B. Record review of R #121's physicians orders revealed the following: Dated 05/18/26, obtain blood oxygen levels as needed for signs and symptoms of cyanosis (a bluish discoloration of the skin resulting from poor circulation or inadequateoxygenation of the blood), shortness of breath, or dyspnea (shortness of breath). Dated 05/18/26, obtain blood oxygen levels every shift. Dated 05/18/26, oxygen at two liters per minute (LPM) per nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs) to treat and prevent hypoxia (low levels of oxygen in body tissue), every shift.Dated 05/21/26, clean oxygen filter every night shift, every Thursday. C. Record review of R #121's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/18/26, revealed R #121 receives oxygen. D. Record review of R #121's care plan, dated 05/19/26, revealed R #121's respiratory diagnoses and oxygen use was not included in R #121's care plan. E. On 05/22/26 at 3:24 pm, during an interview, the Director of Nursing (DON) stated the expectation is for all of a resident's medical needs and concerns to be addressed in a comprehensive care plan. The DON stated R #121's care plan should have included each respiratory diagnosis and the use of oxygen, but it did not.

Based on record review and interview, the facility failed to provide quality care that meets professional standards for 1 (R #10) of 1 (R #10) resident reviewed, when: The facility failed to obtain a physician's order for the use of a Foley catheter (indwelling catheter; a thin, sterile tube inserted into the bladder to drain urine).This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:A. Record review of R #10's face sheet revealed R #10 was admitted into the facility on [DATE] with the following diagnoses:Neuromuscular Dysfunction of Bladder (occurs when nerve or brain problems disrupt the normal control of bladder muscles, leading to difficulty storing or emptying urine).Quadriplegia (paralysis of all four limbs).Polyneuropathy (the breakdown of peripheral nerves that typically affects multiple nerves symmetrically throughout the body). B. Record review of R #10's care plan, dated 01/17/25, revealed R #10 required the use of an indwelling urinary catheter. Interventions included to document oral intake and urine output as per facility policy, monitor for pain and/or discomfort related to catheter use, and monitor for signs and symptoms of a urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra). C. Record review of R #10's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/17/26, revealed the facility staff documented R #10 required the use of an indwelling urinary catheter. D. Record review of R #10's physician orders R #10, dated 05/05/26, revealed an active order for Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) related to chronic indwelling catheterization. E. Record review of R #10's physician orders, dated 05/21/26, revealed a physician order for indwelling catheter use was not present for R #10. F. On 05/21/26 at 2:02 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated R #10 currently has a urinary catheter in place. LPN #1 stated there should be a physician's order for the use of the urinary catheter, and the expectation is to keep the catheter clean and follow the physician's orders regarding routine urinary catheter care. G. On 05/22/26 at 1:15 PM, during an interview, the Director of Nursing (DON) stated urinary catheter use begins with orders received from the hospital upon admission, and the orders are entered into the electronic health record (EHR) by the Assistant Director of Nursing (ADON). H. On 05/22/26 at 1:16 PM, during an interview, the ADON stated a physician's order should always be present for the use of a urinary catheter. The ADON stated R #10 should have a physician's order for urinary catheter use.

Based on observation, record review, and interviews, the facility failed to complete a change in condition (CIC; sudden decompensation or clinically significant shift from a resident's baseline cognitive, behavioral, physical, or functional abilities) assessment for 1 (R #39) of 1 (R #39) resident reviewed after R #39 hit her head and sustained an injury. If the facility fails to complete a change in condition assessment after a resident experiences an injury, then residents are unlikely to receive care that promotes their highest practicable physical, mental, and psychosocial well-being. The findings are: A. Record review of R #39's face sheet revealed R #39 was admitted into the facility on [DATE] with the following diagnoses:Parkinson disease (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination).Schizoaffective disorder (a mental condition that causes both psychosis and mood problems).Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).Anxiety (feelings of fear or apprehension).Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). B. Record review of R #39's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment), dated 04/14/26, shows a score of 3, which indicated severe cognitive impairment C. Record review of R #39's nursing progress notes, dated 05/18/26 at 9:03 am, revealed R #39 was agitated in bed. A Certified Nursing Assistant (CNA) was trying to provide care when R #39 pulled away and hit herself on the siderail. An injury was not included in the progress note. D. On 05/18/26 at 10:24 am, during an observation, R #39 sitting was observed sitting in her wheelchair on the 100-unit, with bruising beginning around her left eye. E. Record review of R #39's nursing progress notes, dated 05/20/26 at 9:09 am, revealed R #39 was observed having a small amount of redness to the left eye. The facility provider was notified. F. Record review of R #39's electronic health record (EHR), dated 05/20/26, revealed staff did not document a completed CIC assessment after R #39's injury on 05/18/26. G. On 05/20/26 at 1:59 pm, during an observation, R #39 was observed sitting in her bed with significant bruising around her left eye. H. On 05/20/26 at 2:56 pm, during an interview, the Director of Nursing (DON) stated she was aware of R #39's incident with injury. The DON stated the facility nursing staff should have completed a change in condition assessment for R #39, but that was not done. I. On 05/20/26 at 2:58 pm, during an interview, the Unit Manager (UM) #3 stated R #39 was resistant and combative. She stated R #39 threw her head back and hit her face on the bed rail. The UM #3 stated she did not complete a CIC assessment after R #39's injury because she witnessed the incident, but she did notify the provider.

Based on observation, record review, and interviews, the facility failed to properly store medications located in the 100-unit medication storage room refrigerator for 1 (R #6) of 1 (R #6) residents, when:R #6's diabetic medication was expired and stored in the medication refrigerator. This deficient practice is likely to result in expired medication being administered to residents, creating the risk of medications becoming unusable for administration and preventing residents from receiving the full therapeutic benefit of their medications.The findings are: A. Record review of R #6's face sheet revealed R #6 was admitted into the facility on [DATE] with the following diagnosis:Type 2 Diabetes Mellitus (DM2; a disease in which the body cannot make or properly use insulin) with Diabetic Neuropathy (a type of nerve damage that occurs as a complication with diabetes). B. Record review of R #6's physician orders, dated 09/28/25, revealed R #6 was prescribed Trulicity (medication in the form of an injection to treat type 2 diabetes). R #6's Trulicity medication was discontinued on 11/13/25. C. On 05/21/26 at 1:38 PM, during an observation of the medication refrigerator in the 100-unit medication storage room, a box of R #6's Trulicity injection pens with the expiration dates of 03/2026 and 04/2026 was present. D. On 05/21/26 at 1:41 PM, during an interview, the Unit Manager (UM) for the 100-unit stated R #6 brought the medications from home. The UM stated R #6's expired medications should not be kept in the refrigerator and should have been removed. The UM stated the box of R #6's Trulicity should have been checked for expiration dates when it was brought into the facility. E. On 05/22/26 at 1:15 PM, during an interview, the Director of Nursing (DON) stated it is her expectation the medications in the medication storage room refrigerator have their expiration dates checked, and the expired medications are removed. The DON stated if a resident is bringing medications from home, each bottle or injectable pen should be checked, and any expired medication should be returned to the family. The DON stated R #6's expired Trulicity medication should not have been left in the medication storage room refrigerator.

Based on observation, record review, and interviews, the facility failed to ensure a resident had access to dental services and was seen for routine and emergency dental care for 1 (R #15) of 1 (R #15) residents reviewed for routine dental services. This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing. The findings are:A. Record review of R #15's face sheet revealed R #15 was admitted into the facility on [DATE] with the following diagnosis:Osteoporosis (bones become extremely porous and are subject to fracture and slow healing). B. Record review of R #15's physician orders, dated 11/13/25, revealed R #15 may be evaluated by dental services as needed. C. Record review of R #15's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/17/25, revealed staff documentation indicating R #15 is missing the bottom front of her teeth. D. Record review of R #15's care plan, dated 11/20/25, revealed R #15 has missing teeth, with interventions that include coordinating arrangements for dental care. E. Record review of R #15's electronic health record (EHR), dated 11/13/25 through 05/20/26, revealed documentation is not present indicating R #15 received a dental consultation or dental appointment during that timeframe. F. On 05/19/26 at 9:14 AM, during an observation and interview, R #15 pulled down her front lip and showed she was missing her front bottom teeth. R #15 stated she would like a dental appointment to see if she qualifies for dentures, but she has not been seen by a dentist. G. On 05/21/26 at 2:02 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated he is not sure whether R #15 has had a recent dental appointment. H. On 05/22/26 at 9:37 AM, during an interview, LPN #2 stated residents should be assessed for dental care. If missing teeth are noted upon admission, the facility staff will contact the family to determine whether any dentures were left at home. If the family does not have dentures to bring to the facility, the facility staff should schedule a dental appointment for the resident to be assessed. LPN #2 stated a notification will be sent to the provider, and the Assistant Director of Nursing (ADON) will assist with scheduling the dental appointment for the resident. I. On 05/22/26 at 10:37 AM, during an interview, the Social Work Appointment Scheduler (SWAS) stated new facility admissions undergo a clinical assessment. If needed, orders are placed and brought to her to schedule a dental appointment. She stated any current residents may also speak with her directly to schedule a dental appointment. The SWAS stated R #15 has not received any dental services while at the facility. J. On 05/22/26 at 1:15 PM, during an interview, the ADON stated R #15 has only two teeth but is able to eat a regular diet, and her family did not request a dental consult. The ADON stated R #15 should have been seen by a dentist if she wanted. The ADON stated the risks of not receiving proper dental care include infections, pain, and potential hospital admissions.

Based on interview and record review, the facility failed to coordinate vision services for 1 (R# 1) of 1 (R #1) resident reviewed for outside vision services, when:The facility did not adhere to the care plan and failed to schedule a vision appointment for approximately three months. This deficient practice is likely to result in residents being unable to achieve their full visual potential, thereby diminishing their quality of life.The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE].B. Record review of R #1's care plan dated 09/07/25 revealed R #1 was diagnosed with Hyperopia (a common vision condition in which distant objects are clear, but close objects look blurry). A facility intervention was to arrange consultation with eye care practitioner as required. C. Record review of R #1's electronic health record (EHR) dated 07/07/26, revealed there was no documentation indicating R #1 had a vision appointment completed or was scheduled for a vision consultation. D. On 01/07/26 at 11:37 am, during an interview, R #1 stated he has not been to the eye doctor in over two years and the facility was aware that he had not gone to the eye doctor. R #1 confirmed one of his major concerns was he has not had a vision appointment, and he wanted one. E. On 01/07/26 at 5:11 pm, during an interview, the Scheduler (SCH) stated she is responsible for making appointments for residents in the facility. The SCH stated R #1 has not had a vision consultation since he was admitted into the facility, and his next appointment is scheduled for July 2026. F. On 01/08/26 at 10:14 am, during an interview, the SCH stated R #1's next vision consultation was scheduled for 07/01/26, and she did not call to schedule this appointment until 12/16/25. The SCH confirmed R #1's vision appointment should have been scheduled sooner than 12/16/25 since his care plan was updated on 09/07/25, indicating R #1 needed a vision appointment scheduled. G. On 01/08/26 at 11:27 am during an interview, the Social Services Assistant (SSA) stated the facility no longer has an in-house vision provider. The SSA confirmed R #1 should have had a vision appointment scheduled sooner than 12/16/25 since his care plan was updated on 09/07/25.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. All items were labeled and dated in the kitchen refrigerator. 2. The counter tops and shelves were clean. 3. The floors throughout the kitchen were clean. 4. The heated plate dispenser (a device used to heat and store plates prior to use) was clean. These deficient practices are likely to affect all 115 residents listed on the resident census provided by the Administrator on 02/17/25 and are likely to lead to foodborne illnesses in residents. The findings are: A. On 02/17/25 at 10:15 am, observation of the kitchen revealed the following: 1. Two liquid pitchers, one was full of red liquid, and one was full of white liquid, on the bottom shelf in the refrigerator was not labeled to indicate the type of contents and not dated with the date the liquid was made. 2. The counter tops and shelves throughout the kitchen had food particles, spilled liquid, and dust on them. 3. The floors throughout the kitchen had food particles, spilled liquid, trash, and dust on them. 4. The heated plate dispenser had food particles, spilled liquid, and dust on the top and in the inserts that hold the plates. B. On 02/17/25 at 11:17 am, during an interview with the Culinary Manager (CM), he stated that all food and drink items should be labeled and dated. The CM confirmed that counter tops, shelves, floors, and heated plate dispenser did not meet his expectations. He stated his expectations are for the kitchen and everything in it to be clean.

Based on observation, record review, and interview, the facility failed to develop and implement an accurate, person-centered comprehensive care plan for 4 (R #4, R #72, R #109, and R #164) of 9 (R #3, R #4, R #8, R #37, R #46, R #62, R #72, R #109 and R #164) residents reviewed for care plans. This deficient practice is likely to result in staff being unaware of the current and actual needs of the residents. The findings are: R #4 A. Record review of R #4's face sheet revealed R #4 was admitted to the facility on [DATE] with the following diagnoses: 1. Acute osteomyelitis (a bone infection that develops rapidly and is characterized by inflammation and destruction of bone tissue), right ankle and foot, 2. Abnormalities of gait and mobility (a deviation from the normal pattern of walking), 3. Lack of coordination, 4. Chronic pain syndrome (a condition characterized by persistent pain that lasts for at least three months and significantly impacts daily life), 5. Muscle wasting and atrophy (a condition where muscles lose mass and strength), 6. Age-related physical debility (a gradual decline in physical function and overall health that occurs with advancing age), 7. Acquired absence (the loss of a limb, organ, or body part due to injury, disease, or surgery) of right leg below knee, 8. Rheumatoid arthritis (a chronic inflammatory autoimmune disease that primarily affects the joints). B. Record review of R #4's bed rail assessment dated [DATE] revealed the following: 1. R #4 consented to bed rails for safety and comfort. 2. Bilateral (horizontal metal bars that attach to the side of a bed, extending a quarter of the length of the bed) rails indicated to serve as an enabler for independence. C. Record review of R #4's care plan dated 6/22/24 revealed there was not a care plan for bed rail use. D. On 02/18/25 at 11:21 am during an observation of R #4's bed revealed quarter side rails on each side of the bed. E. On 02/18/25 at 11:33 am during an interview, R #4 stated she was aware she had bed rails on each side of the bed and used the rails to help with repositioning herself and bed mobility. F. On 02/21/25 at 12:16 pm during an interview with the DON, she stated R #4 did not have a care plan for bed rails and should have. R #72 G. Record review of R #72's face sheet revealed R #72 was admitted to the facility on [DATE] with the following multiple diagnoses: 1. Muscle wasting and atrophy (a condition where muscles lose mass and strength), 2. Abnormalities of gait and mobility (a deviation from the normal pattern of walking), 3. Muscle weakness, 4. Pain in left hip, 5. Pain in right knee, 6. Lack of coordination. 7. Age-related osteoporosis (a condition that weakens bones and increases the risk of fractures) H. Record review of R #72's bed rail assessment dated [DATE] revealed the following: 1. R #4 consented to bed rails for safety and comfort. 2. Bilateral (having or relating to two sides) rails indicated to serve as an enabler for independence. I. Record review of R #72's care plan dated 07/15/24 revealed there was not a care plan for bed rail use. J. On 02/18/25 at 11:03 AM, during an observation of R #72's bed revealed quarter side rails on each side of the bed. K. On 02/18/25 at 11:03 AM during an interview, R #72 stated she was aware she had bed rails on each side of the bed to help reposition herself and bed mobility. L. On 02/21/25 at 12:16 pm during an interview with the DON, she stated R #4 did not have a care plan for bed rails and should have. R #109 M. Record review of R #109's face sheet revealed R #109 was admitted to the facility on [DATE] with the following diagnoses: 1. Malignant neoplasm of the tongue (cancer of the tongue), 2. Unspecified; dysphagia (difficulty swallowing), 3. Unspecified; otitis media (inflammation of the ear), 4. Other lack of coordination (poor muscle control); 5. Dehydration (lack of total body water); 6. Malignant neoplasm of the head, neck and face (cancer that has spread to the neck, head and face); 7. Cognitive communication deficit (brain's inability to communicate effectively). N. Record review of R #109's care plan dated 02/07/25, revealed the antibiotic was not care planned. O. Record review of the Minimum Data Set (MDS) dated [DATE] (Entry MDS) shows the antibiotic was a hospital physician's order upon admission to the facility. P. Record review of R #109's progress note dated 02/07/25 at 3:20 pm, revealed the antibiotic was entered on the electronic medical record (EMR) for his admission. The antibiotic did not have a stop date. Q. On 02/21/25 at 12:55 PM, during an interview, the DON confirmed R #109's care plan did not contain any documentation of antibiotics. DON stated her expectations are the care plan would include all aspect of antibiotic management and monitoring. R #164 R. Record review of R #164's face sheet revealed R #164 was admitted to the facility on [DATE] with the following diagnoses: 1. Fracture of sacrum (a break in the sacrum bone, located at the base of the spine and forming the back wall of the pelvis), 2. Abnormalities of gait (a person's manner of walking) and mobility (a deviation from the normal pattern of walking), 3. Lack of coordination, 4. Polyosteoarthritis (a condition where multiple joints experience osteoarthritis, a form of degenerative joint disease), 5. Spinal stenosis (a condition where the spinal canal, the space within the spine that houses the spinal cord and nerve roots, becomes narrowed), cervical (neck) region. S. Record review of R #164's bed rail assessment dated [DATE] revealed the following: 1. R #164 consented to bed rails for safety and comfort. 2. Bilateral rails indicated to serve as an enabler for independence. T. Record review of R #164's care plan dated 02/13/25, revealed there was not a care plan for bed rail use. U. On 02/18/25 at 1:27 PM, during an observation of R #164's bed revealed quarter sized rails on each side of the bed. V. On 02/18/25 at 1:27 PM, during an interview, R #164 stated she was aware she had bed rails on each side of the bed and used them for bed mobility. W. On 02/21/25 at 12:16 PM, during an interview with the DON, she stated R #164 did not have a care plan for bed rails and should have. 51616 51657

Based on interview, record review, and observation, the facility failed to ensure staff served meals that were attractive and palatable (pleasant to taste) for 8 (R #'s 4, 12, 37, 46, 99, 105, 108, and 165) of 10(R #'s 4, 8, 12, 37, 46, 48, 99, 105, 108, and 165) residents reviewed for meal quality. This deficient practice reduces residents' ability to eat and enjoy meals, may decrease their quality of life, and could likely lose weight. The findings are: A. On 02/17/25 at 11:17 am, during an interview, R #108 stated the food does not taste good, it is overcooked. R #108 stated that the food is not palatable. R #108 stated that they are not getting vegetables very often either and when they do they are usually overcooked. B. On 02/17/25 at 11:22 am, during an interview, R #46 stated the food is not hot, always cold, is poor quality of food, not abiding by national diets. Every time they change managers the food gets worse. There have been three managers in three years. C. On 02/17/25 at 11:55 am, during lunch observation, residents were served shredded pork roast, oven fried potatoes, yellow squash medley, a wheat dinner roll, an iced brownie and a drink for lunch. The food was served to residents on an dinnerware that was the same neutral coloring as the food. The food was not appealing to the eye and lacked color. D. On 02/17/25 at 12:43 pm, during an interview, R #12 stated the eggs are tough and we had pasta yesterday with one big noodle and a bowl of peas. R #12 also stated for breakfast I had biscuits and gravy and I was not quite sure what it was until I poked it. E. On 02/18/25 at 11:21 am during an interview, R #4 she stated the food is not very good. F. On 02/18/25 at 11:49 am during an interview, R #99 stated the food is horrible, it is not like home cooking at all and lacks flavor. G. On 02/18/25 at 11:55 am, during a lunch observation, staff asked R #99 if she was going to eat lunch, R #99 declined to got to lunch. Staff then asked R #99 if someone was bringing her food as usual which R #99 replied a friend is bringing her food. H. On 02/18/25 at 12:34 pm during an interview, R #165 stated the food is awful, the food does not have any flavor, and the potatoes are really dry. R #165 also stated the food does not look good most days. I. On 02/18/25 at 2:33 pm, during an interview, R #105 stated she doesn't like the food it doesn't taste good and doesn't eat it very often. J. On 02/18/25 at 3:08 pm, during an interview, R #37 stated he does not like the food, the food is horrible. He stated he has food delivered to facility and keeps his own butter and cinnamon for his toast in his room. He stated the food has no flavor. K. Record review of the facility's policies and procedures for Dietary Management revised July 2017 under Assistance with Meals revealed Hot foods shall be held at a temperature of 136 degrees or above until served. L. Record review of Resident Council minutes revealed the following: 1. On 09/06/24 dietary was requested to attend the next meeting due to food concerns. 2. On 10/04/24 residents talked about what they like to eat and what food they want. 3. On 11/01/24 residents complained about cold food being cold. The concern form was filled out and given to the DON to discuss with dietary staff. 4. On 02/07/25 residents complained about cold food and being unappetizing; food is always the same and does not taste good; same food all the time, always chicken and pork. Concern form filled out and given to dietary. M. On 02/21/25 at 9:38 am during an interview, the Culinary Supervisor (CS) confirmed the prepared menu offers a lot of foods that lack color and appeal. He stated he will ask residents about food choices when there is a complaint, otherwise he will make changes to meals for the residents when they arrive in the dining area on an as needed basis. 50207 51616 51657

Based on observation, interview, and record review, the facility failed to provide respiratory care (health care discipline specializing in the promotion of optimum cardiopulmonary (promotion of health and wellness in the respiratory system (lungs)) function, that was consistent with professional standards of practice for 2 (R #46 and R #62) of 5 (R #4, R #8, R #46, R #62 and R #72) resident sampled for respiratory care when staff failed to change R #46's and R #62's nasal cannula (medical device to provide supplemental oxygen therapy to through the nose) within seven days of the previous change. This deficient practice could likely cause the nasal cannula to become obstructed, non-functional, and unsanitary and not provide the resident with the oxygen needed. The findings are: R #46 A. On 02/17/25 at 11:35 AM, during an observation of R #46's room, revealed R #46 had an oxygen concentrator (a device that removes nitrogen from the air to provide oxygen-enriched air) by his bed and nasal cannulas (a thin, flexible tube that delivers oxygen through the nose) hanging on his bed. The nasal cannula was not dated with a date indicating the date the cannula had been changed. B. Record review of R #46's Physicians Orders dated 02/20/22, revealed oxygen at 2 Liters administered via nasal cannula every shift. C. On 02/17/25 at 11:16 AM, during an interview, the Assistant Director of Nursing-Facility Wide (ADON-FW) stated the oxygen cannulas are changed once a week, usually on Sundays. The ADON said there should be a piece of tape on the tubing with a date to document when the tubing was changed. The ADON stated that the tape on the tubing is how they document when the cannulas were changed. The ADON confirmed that R #72's cannula does not have a date indicating when the cannula was changed, and she could not confirm if R #72's cannula had been changed. D. On 02/17/25 at 1:55 PM, during an interview, CNA #6 confirmed R #46's nasal cannula does not have a date indicating when the nasal cannula was changed. CNA #6 said that the nasal cannulas are usually changed on Sundays, and she could not confirm if R #46's nasal cannula had been changed. R #62 E. On 02/17/25 at 11:05 AM, during an observation of R #62's room, revealed R #62 had an oxygen concentrator and nasal cannula next to her bed. The nasal cannula was not dated with a date indicating the date the cannula had been changed. F. Record review of R #62's Physicians Order dated 01/17/25 revealed oxygen at 2 Liters administered via nasal cannula every shift.

Based on record review and interview, the facility failed to offer COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations to 1 (R #8) of 5 (R #3, R #4, R #8, R #15, and R #46) residents reviewed for COVID-19 vaccinations. This deficient practice could likely result in residents getting COVID-19. The findings are: A. Record review of R #8's Electronic Health Record (EHR) revealed the record did not contain any COVID-19 vaccine forms which indicated staff offered or administered the COVID-19 vaccine to the resident. B. On 02/21/25 at 11:15 am, during an interview with the DON, she confirmed R #8's EHR does not contain any evidence that the facility offered the COVID-19 vaccination to R #8.

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of 12 hours per year for 3 (CNA #1, CNA #2, and CNA #3) of 5 (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents. The findings are: CNA #1 A. Record review of CNA #1's personnel file revealed CNA #1's Caregiver Criminal History Screening (background check for employment at the facility) was cleared on 07/31/22. B. Record review of CNA #1's in-service training Transcript Report, dated 02/21/25, revealed CNA #1 did not complete any training past 08/07/23. C. On 02/21/25 at 1:23 pm, during an interview with the Administrator (ADM), she confirmed the facility does not have any evidence of CNA #1 completing any training past 08/07/23. The ADM confirmed CNA #1 continued to work shifts providing care for residents in the facility even though the facility has no proof of ongoing training. The ADM stated she expects all CNAs to complete at least 12 hours of training per year. CNA #2 D. Record review of CNA #2's personnel file revealed CNA #2's Caregiver Criminal History Screening was cleared on 12/13/22. E. Record review of CNA #2's in-service training Transcript Report, dated 02/21/25, revealed CNA #2 did not complete any training past 08/16/23. F. On 02/21/25 at 1:23 pm, during an interview with the ADM, she confirmed the facility does not have any evidence of CNA #2 completing any training past 08/16/23. The ADM confirmed CNA #2 continued to work shifts providing care for residents in the facility even though the facility has no proof of ongoing training. CNA #3 G. Record review of CNA #3's personnel file revealed CNA #3's Caregiver Criminal History Screening was cleared on 04/09/21. H. Record review of CNA #3's in-service training Transcript Report, dated 02/21/25, revealed CNA #3 did not complete any training past 08/07/23. I. On 02/21/25 at 1:23 pm, during an interview with the ADM, she confirmed the facility does not have any evidence of CNA #3 completing any training past 08/07/23. The ADM confirmed that CNA #3 continued to work shifts providing care for residents in the facility even though the facility has no proof of ongoing training.

Based on record review and interview, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #3) of 4 (R #3, R #8, R #37, and R #112) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the residents not receiving the services they need. The findings are: A. Record review of R #3's Admission Record revealed R #3 was admitted into the facility on [DATE] with multiple diagnoses including: 1. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 2. Unspecified psychosis (mental disorder) not due to a substance or known condition, 3. Schizoaffective disorder (a mental condition that causes both psychosis and mood problems), 4. Other specified anxiety (feelings of fear or apprehension) disorder, 5. Delusional disorders (condition in which a person can't tell what's real from imagined), 6. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). B. Record review of R #3's PASRR, dated 11/06/15, revealed staff documented R #3 does not have a diagnosis or suspected mental illness. C. On 02/21/25 at 2:11 pm, during an interview with the [NAME] President of Clinical Services,she confirmed R #3's PASRR was not correct.

Based on record reviews and interviews, the facility failed to ensure staff revised the care plan for 1 (R # 21) of 1 (R # 21) resident reviewed when staff failed to: 1. Update R 21's plan of care to include fall prevention and interventions. 2. Update R #21's plan of care to include oxygen therapy. 3. Update R #21's plan of care to include vision loss under ADL (activities of daily living) self-care performance deficit. This deficient practice is likely to result in staff not being aware of residents' care needs and preferences, and residents not receiving the needed care. The findings are: A. Record review of R #21's Admission Record revealed R #21 was admitted to the facility on [DATE] with the following multiple diagnoses: 1. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar) with diabetic chronic kidney disease (CKD; impaired kidney function), and polyneuropathy (a type of neuropathy (general diseases or malfunctions of the nerves) that affects many peripheral nerves in the body), 2. End Stage Renal Disease (ESRD; chronic irreversible kidney failure), 3. Major Depressive Disorder, a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 4. History of falling, 5. Osteoporosis without current pathological fracture (bones become extremely porous and are subject to fracture and slow healing). B. Record review of R #21's care plan dated 08/10/23 revealed the following: 1. Focus are of The resident is at risk for falls AEB (as evidenced by) actual falls. 2. Follow facility fall protocol. R #21's care plan does not list specific interventions that are in place to assist R #21 with his fall risk. C. Record review of R #21's medical orders revealed an order dated 01/14/25 for continuous oxygen at two liters per nasal canula (a small, flexible tube that delivers oxygen to the nose through soft prongs). D. Record review of R #21's care plan dated 11/07/23 revealed R #21 has as needed (PRN) order for oxygen therapy that is not consistent with current order for continuous oxygen therapy. E. Record review of R #21's progress note dated 01/09/25, revealed R #21 had acute vision loss after dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) and was sent to emergency room for evaluation. F. Record review of R #21's care plan dated 08/10/23, revealed R #24 had an ADL (activities of daily living) self-care performance deficit. This care plan did not include interventions to assist R #21 with his recent vision loss. G. On 02/21/25 at 11:15 AM, during an interview with the DON, she confirmed R #21's care plan was not accurately revised because of the following: 1. The DON was not able to produce a facility fall protocol and stated there was not individualized fall protocol for R #21 [fall protocol is listed on care plan but does not include what fall protocol include. Example: wear non-skid socks, non-skid shoes, fall mat etc ]. 2. R #21's care plan for the use of oxygen does not match with R #21's current order for the continuous use of oxygen. 3. R #21's care plan for ADL self-care performance deficit and impaired visual function do not include specific interventions that R #21 needs to deal with his recent visual impairment.

Based on record review and interview, the facility failed to adequately monitor for the stop on the antibiotic for 1 (R #109) of 1 (R #109) resident reviewed for stop date on an antibiotic. This deficient practice could likely lead to overuse of an antibiotic and lead to multi-drug-resistant infections, antibiotic resistance and poor patient outcomes. The findings are: A. Record review of the facility's resident dashboard (an overview of the electronic health record) dated 02/07/25 revealed R #109 was admitted on this date. Admission diagnosis includes, malignant neoplasm of the tongue (cancer of the tongue), unspecified; dysphagia (difficulty swallowing), unspecified; otitis media (inflammation of the ear) of the ear; other lack of coordination (poor muscle control); dehydration (lack of total body water); malignant neoplasm of the head, neck and face (cancer that has spread to the neck, head and face); and cognitive communication deficit (brain's inability to communicate effectively). B. Record review of R #109's Progress Note dated 02/18/25 at 11:33 am, revealed the physicians order for Ofloxacin otic solution 0.3% instill 5 drops in the right ear one time a day for ear infection, was to be continued. There was no stop date given for the antibiotic physician's order. C. Record review of R #109's history and physical dated 02/19/25, revealed the order to continue antibiotic and does not have a recommended stop date. D. On 02/21/25 at 12:55 pm, during an interview, the DON confirmed there was no care plan for the use of an antibiotic. The DON's expectations were that the care plan would include the reason for the antibiotic use, the start and stop dates, and all interventions to help prevent infection (harmful bacteria entering the body). E. Record review of R #109's progress notes from the Medical Director (MD) dated 02/18/25 at 11:33 am, revealed the antibiotic was given for otitis media (inflammation of the ear) and the physician was not sure if the infection was related to his cancer diagnosis. According to policy and procedure for antibiotic stewardship, all antibiotics require a stop and require reassessment. F. On 02/19/25 at 1:00 pm, during an interview, the DON stated according to the policy and procedure for antibiotic stewardship, all antibiotics must have a stop date and be reassessed for any changes. The DON would have expected the nurse to ask the Certified Nurse Practitioner (CNP) for a stop date. The DON stated the administration team completes a review of all antibiotics during the morning clinical meeting and they must have overlooked there was no stop date.

Based on record review and interview, the facility failed to offer the influenza (for Flu virus, a highly contagious viral respiratory infection that affects the nose, throat, and sometimes the lungs) vaccine for 1 (R #8) of 5 (R #3, R #4, R #8, R #15, and R #46) residents reviewed for immunizations. If residents are not given the opportunity to consent or decline the vaccine as appropriate against the flu, then they have a higher likelihood of contracting the illness and spreading it to other residents in the facility. The findings are: A. Record review of R #8's Electronic Health Record (EHR) revealed staff failed to offer the influenza vaccination to R #8. B. On 02/21/25 at 11:15 am, during an interview with the DON, she confirmed R #8's EHR does not contain any evidence that the facility offered the influenza vaccination to R #8.

Based on record review and interview, the facility failed to provide pain management for 1 (R #1) of 1 (R #1) resident reviewed by: Not recognizing, responding to, and treating a significant injury in a timely manner. This deficient practice likely resulted in R #1 experiencing undo and prolonged discomfort from the pain caused by a fracture (broken bone) of her leg. The findings are: A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses including but not limited to: History of Falling Unspecified Fracture (break) of Right Femur (long bone of upper leg) Dementia (a chronic progressive condition that results in diminished mental capacity) B. Record review of daily care notes revealed the following: 1. 05/14/23 6:51 pm (the date and time when the note was entered) Nursing Incident Note: Resident (R #1) reportedly fell per care attendant. Resident found sitting on the floor in the bathroom. Resident assessed no injuries observed, moves all extremities. Resident complained of mild discomfort in (L) hip, no deformities observed 2. 05/14/23 8:24 pm Nursing Note: Post Fall Evaluation was completed. Per note: fall occurred 05/14/23 at 6:00 pm. (The fall was witnessed in R #1's bathroom by a private in-room caregiver. Residents was found in a sitting position on the floor .The note included information regarding pain as follows: Pain: indicators of pain: Vocal complaints of pain. Pain Issue: #001: New. Location: Left Thigh-Generalized. Pain Note: Resident complains of pain in left hip. 3. 05/15/23 2:06 pm Nursing Note Health Status Note-Pt. (patient) (R #1) experienced a fall on 05/14/23 and states she is having severe left hip pain and a 2 view left femur x-ray is ordered and result is negative (there is no date or time given for when this x-ray was done or when results were returned). [name of Nurse Practitioner] is notified and sees patient this AM. Pt family requested her to be sent to ER (emergency room ) for MRI (Magnetic Resonance Imaging-a medical test that produces an image of an internal area of the body) and physical therapy does an assessment and does not recommend discharge r/t (related to) severe pain and now pt. declines with ADL's (Activities of Daily Living-those daily care needs necessary to maintain health and movement) regarding bed mobility. Provider gives the order to send pt. to ER for severe uncontrolled left hip pain. [Name of ambulance service] is called and notified and they set up transport for 3:45 pm and family is notified of transport time. C. Record review of Nurse Practitioner (NP) #1 note revealed the following: 1. 05/14/23 I (NP #1) was called today by nursing staff in relation to this patient (R #1): Nursing staff called to report patient with a fall earlier today which was initially known injury. Patient is now complaining of severe left-sided hip pain that is worsening. Nurse states that the patient (R #1) is in severe pain, concern for fracture. 2 view hip x-ray ordered. Results came back showing no acute fracture. Nurse states that the patient is still in significant pain, yelling out in agony. I (NP #1) reviewed the patient's (R #1) vital signs with the patient's nurse, and reviewed the patient's medical record. Assessment: Severe Pain Plan of Care: Oxycodone (a narcotic pain relieving drug) 5 mg (milligrams) one-time dose now Oxycodone 2.5 mg P.O. (by mouth) every 6 hours as needed x 3 days (available for the next 3 days) Document e-signed (electronic signature) by (name of NP #1) Internal Medicine May 15, 2023 at 1:06 AM PDT (pacific daylight time) D. Record review of R #1's physician orders revealed no order to provide or administer Oxycodone of any dose at any time. E. Record review of R #1's Medication Administration Record (MAR) dated May 2023 revealed: 1. No Oxycodone was available to be administered to R #1 and therefore none was given to R #1. 2. Ativan (a prescribed medication to help reduce anxiety) 0.5 MG (milligrams) was administered as scheduled on 05/14/15 at 5:00 pm 3. Ativan 0.5 MG was administered again on 05/15/23 at 14:42 (2:42 pm) 4. Tylenol (tradename for Acetaminophen-a anti-inflammatory medication that can provide mild pain relief) 325 mg tablets give 2 tablets by mouth as needed for pain was given at 1240 (1:40 pm). The MAR notes that R #1's pain was a '4' (on a scale of 0-10) and the medication was not effective. F. Record review of hospital medical records dated 05/15/23 with X-ray and MRI results and physician recommendations revealed the following physician notes: 1. MRI Hip w/o Contrast (an injected medication to assist in visualizing structures during an MRI exam) Performed 05/15/23 2320 (11:30 pm) Narrative: Clinical history/Indication for Exam: Fall, severe left hip pain, cannot range of motion or ambulate, films from earlier today negative for fracture per POA (Power of Attorney-Daughter) 2. This is an [AGE] year old female with Alzheimer's Dementia who presents following a fall at her rehab (rehabilitation) facility. She had a recent right hip ORIF (open reduction internal fixation-a surgical procedure that repairs broken bones) and was undergoing therapy for this. She presented to the emergency department with left hip pain and was found to have a fracture on MRI . 3. Intertrochanteric (bony protrusions located at the head of the femur-that portion of the bone that attaches to the pelvic hip bones) fracture of the left femur .My (physician) recommendation was for intramedullary (middle cavity of a long bone) nail (a long metal rod) fixation (surgical procedure that forces a long metal rod into the cavity of a long bone to help stabilize and repair breaks). 4. (This medical record did not indicate any pain assessment nor did it indicate whether pain medication was administered. The medical record did indicate that Morphine (a narcotic drug administered to control pain) was ordered, but no notes indicate the Morphine was administered.) G. Record review of R #1's Minimum Data Set (MDS-a standardized test administered to all long-term care residents of a nursing home to help establish resident care needs and strengths) section C (mental capacity) revealed R #1 BIMS (Brief Interview for Mental Status-a standardized test that reveals a score that indicates a resident's mental capacity that ranges from 0-unable to understand or complete the exam to 15-considered to have clear cognitive [NAME]) score of 8 (indicates a mostly limited capacity to understand and respond mentally). H. Record review of R #1 daily pain assessment revealed the following daily notes: 1. 05/13/23 at 12:51 am: pain level 0 (pain level assessed by using a 0-10 scale with 0 being no pain and 10 being the most extreme pain level) 2. 05/14/23 at 12:43 am: pain level 0 3. 05/15/23 at 1:21 pm: pain level 2 4. 05/15/23 at 1:40 pm: pain level 4 5. 05/15/23 at 2:08 pm: pain level 0 I. On 07/07/23 at 10:07 am during interview with R #1's daughter (D), she provided the following information: She described her mother as demented and often confused. On 05/14/23 her mother was being monitored by a person who was hired by family to sit with R #1. In late afternoon, she was called and informed that her mother had fallen and daughter went to the facility to be with her mother. D noted her mother was indicating pain by moaning but that she had been given Ativan and D felt this helped her to relax and rest. D was informed that an x-ray had been completed and there was no indication of a fracture from the fall. D informed the facility staff that the Resident's last fall required an MRI to recognize her fracture and she asked if this could be done. Staff attempted to contact an on-call provider with no response. D left the facility that evening and returned early the next morning about 8:00 am, and found her mother still in a great deal of pain. R #1 was restless and moaning. D asked about further testing and was told by staff nothing would be done until a physical therapist would arrive and assess her mother. At 1:00 pm, the physical therapist arrived and assessed R #1 and she yelled out in pain. By 2:30 pm, R #1 was being transported to the local hospital. D stated that she felt R #1 was in significant pain for 24 hours without any relief. D stated she had asked that her mother (R #1) be taken to hospital on Sunday (05/14/23) evening and again on Monday (05/15/23) morning, but this did not occur until mid-afternoon on 05/15/23. J. On 07/07/23 at 3:35 pm during interview with the facility interim Director of Nursing, reviewed the medical record of R #1 and confirmed that R #1 had a fall. She stated that R #1 had a caregiver who was provided by the family to sit and monitor R #1. DON confirmed that R #1 fell on [DATE] during the later afternoon hour. DON confirmed that R #1 was assessed, she confirmed there was a note from a provider to prescribe and administer Oxycodone to R #1. She confirmed this plan was not implemented-no order was entered and no Oxycodone was administered. DON could not offer any explanation as to why this medication was not provided. DON stated that Ativan 0.5 mg was administered at a scheduled time around 5:00 pm on 05/14/23 and another dose given on 05/15/23 at 2:42 pm. DON also noted that Tylenol was given on 05/15/23 at 1:40 pm only. K. On 07/10/23 at 9:45 am during interview with interim DON, she stated that she had met with and discussed R #1's fall and after care with the nurse on duty during the night 05/14/23 to 05/15/23. DON stated that the nurse was a reliable and experienced nurse. DON stated that the nurse had confirmed his awareness of the fall and that he felt R #1 was not experiencing any significant pain. DON stated this nurse spoke with the on-call provider late 05/14/23 and per the nurse, there was no mention of provider's plan to prescribe Oxycodone and there was no order received by phone or electronically to administer Oxycodone. DON could not explain why this provider's note indicated R #1 was in extreme pain. DON stated the nurse [when questions about the incident later] did not recall any discussion with R #1's daughter to send R #1 to hospital for an MRI. DON stated that the next morning, 05/15/23, the unit nurse manager could not recall that R #1 was experiencing significant pain or discomfort. DON confirmed that when R #1 was assessed by the Physical Therapist. R #1 was in pain and the provider present at the time was notified and that Nurse Practitioner (NP #1) gave order for R #1 to be taken to hospital. L. On 07/10/23 at 10:08 am during interview with NP #2, she stated she arrived at the facility for her normal rounds in the morning of 05/15/23. NP #2 stated that she was asked to assessed R #1 following a fall and pain. NP #2 reviewed R #1's x-ray and her medical record. NP #2 stated that she then asked for a Physical Therapist to assess R #1. NP #2 stated that after this exam, it was noted that R #1 had significant pain and the decision was then made to send R #1 to hospital for assessment. NP #2 reviewed the provider note of 05/14/23 and confirmed the note indicated a plan of Oxycodone for immediate administration and Oxycodone for as needed administration. NP #2 confirmed that this order had not been entered by on call [NP#1] provider. NP #2 stated that this should have been entered electronically by the practitioner [NP #1] and this would be the standard procedure. NP #2 also stated that with a negative x-ray, she would not have suspected a fractured femur, she stated that when she met with R #1 on the morning of 05/15/23 that she felt it was best for R #1 to be assessed by a Physical Therapist before determining that R #1 should be transferred to hospital. NP #2 stated this occurred during the early afternoon of 05/15/23 after which NP #2 directed that R #1 be transported to hospital.

Based on record review, observations and interviews, the facility failed to prevent avoidable accidents by: 1) not reassessing the risks and hazards of the alternating pressure mattress allowing the resident to move her legs over to the edge of the mattress, resulting in R #2 rolling over the side rails and falling on the floor face down; 2) the lack of communication between the licensed nurses not listening to the Certified Nursing Aides (CNAs) about their concerns regarding a special mattress the resident was laying on; 3) not ensuring adequate supervision for 1 (R #2) of 2 (R #s 1 and 2) residents who were reviewed for falls. These deficient practices likely caused R #2 to move her legs to the edge of the mattress, rolling herself over the side rails of the bed and falling face down on the floor next to the bed. This resulted in R #2 sustaining a [MEDICAL CONDITION] orbital floor (a fractured eye socket), a large intercerebral hemorrhage (a ruptured blood vessel causing bleeding inside the brain), [MEDICAL CONDITION] fifth rib, left tibial plateau fracture (a break of the upper part of the tibial (shinbone) that involves the knee joint) and multiple facial lacerations needing sutures (a stitch or row of stitches holding together the edges of a wound or surgical incision). The findings are: Findings related to R #2: A. Record review of R #2's (admitted [DATE]) history and physical dated 09/28/17 revealed the following: This is a [AGE] years (sic) old female with prior medical history of [REDACTED].-related [MEDICAL CONDITION] (disease that weakens the bones), [MEDICATION NAME] degeneration (eye disorder that causes blurred vision or the loss of vision in the center of the visual field), TIA ([MEDICAL CONDITION], a temporary blockage of blood flow to the brain), muscle weakness, lack of coordination, unsteadiness on feet, dysphagia (difficulty swallowing foods or liquids), a recent syncopal ([MEDICAL CONDITION]) episode in (MONTH) (YEAR), and status [REDACTED]. B. Record review of R #2's Nurses Notes dated 09/28/17, revealed the following: (Name of R #2) was observed laying on the floor next to the right side of the head of the bed, the day shift CNA (#3) who took over from the night CNA (#5), states, 'I enter the resident room to get her ready for breakfast and saw the resident on the floor with her face down.' This Nurse informed, resident was observed on the floor bleeding from the laceration injury on her forehead (sic) and face. Resident turned, physical injury assessed, VS (vital signs) assessed BP (blood pressure) 164/118, 86 P (pulse), 20 R (respirations), 99.7 (Temperature), 91 O2 sat (oxygen saturation) via nc (nasal cannula) 2L (liter). Neck collar in placed, resident was transferred back to her bed by the nursing staff. On call physician (name of physician) notified. Order to send to ER (emergency room ) received. Emergency service called immediately. Daughter notified via phone, who prefers (name of local hospital). Resident transported to (name of local hospital) by emergency service ambulance by 0650 (6:50 am). DON (name of Director of Nursing) notified. Administrator notified. C. Record review of the Order Summary Report with a date range of 05/01/17 - 03/31/18, revealed the following: MA85 Mattress (an alternating pressure of air cushions that continue to inflate or deflate .half of the air cushions remain at a constant pressure when an alternating pressure time has been selected) order date 09/13/17, Hoyer lift (a mechanical device used for transfers when a person requires 90 - 100% assistance to get into and out of bed) for all transfers order date 05/31/17, Both Upper side rails for mobility and to assist patient in turning themselves order date 05/29/17, Cervical collar to be donned for all mobility and transfers, especially hoyer lift due to unstable odontoid process (a peg-like part of the second bone in the neck) date order 05/30/17. D. Record review of R #2's Braden Scale (the scale is to help health professionals, especially nurses, assess a patient's risk of developing a pressure ulcer) dated 09/04/17, revealed the following: .Activity - degree of physical activity, Chairfast was indicated: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. Mobility- ability to change and control body position, Very Limited was indicated: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently .Friction & Shear- Problem was indicated: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. [DIAGNOSES REDACTED], contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) or agitation leads to almost constant friction. E. Record review of R #2's Quarterly MDS dated [DATE], revealed the following: Section G - Functional Limitation in Range of Motion - Upper extremity, Impairment on both sides; Lower extremity, Impairment on both sides. F. Record review of the Neurology Consultation Notes dated 09/28/17, revealed the following: .patient was found by nursing home staff on the floor next to her bed, according to the daughter the nurse was trying to move her for cleaning and she fell off the bed and hit her right (eye) orbit (the cavity or socket of the skull in which the eye is situated in) over the disc beside the bed and injured her hands and legs. When I ask the patient she stated that she was aware that she is falling and she did not lose consciousness .According to the daughter the patient is an elderly female .with past medical history of [REDACTED].On my exam, the patient is asleep but arouses with verbal stimulation .Neglecting the left side. Right gaze preference, left facial droop . G. On 03/20/18 at 3:00 pm, during an interview, the Administrator stated that R #2 was on a LAL (low air loss) mattress, which alternated air flow from side to side. She stated, If (name of R #2) was too close to the side of the bed, (name of R #2) would not be able to help herself if she was rolling off the mattress. H. On 03/21/18 at 9:35 am, during an interview, the Administrator and the Wound nurse (who orders the specialty mattresses for the facility), stated that R #2 was on a MA85 mattress. The wound nurse was asked if R #2 was positioned very close to the edge of the bed and not centered in the bed and was completely immobile, could she fall out of the bed. The Wound nurse stated, Yes, the resident could fall off the bed. He stated that there were 8 settings for the bed, and that it depends on the weight of the resident (R #2 weighed 170 pounds). He also stated that the settings are first set up by the company and that there is a lock/unlock button. When asked how was the bed justified, he answered that it was given [MEDICATION NAME] (A preventive measure) for skin issues and that R #2's daughter requested it. He stated that there were half-side rails and that in order for R #2 to have fallen off the bed she would have had to have been positioned toward the foot of the bed. I. On 03/21/18 at 10:40 am, during an interview the roommate of R #2 was asked if she could remember anything the morning when R #2 was found on the floor. She stated that R #2 couldn't holler for help, but the staff found her. J. On 03/21/18 at 11:00 am, during an interview, with CNA #2, who worked the day shift on 09/28/17, she stated at the beginning of shift change (6:00 am) that morning CNA #3 stated that she needed help, and I told the nurse. She stated that when she went into the room, she saw the blood on the floor and on the resident, laying on the floor towards the head of bed close to the bedside stand. She said, I believe that the side rails were up, and she did not remember what position the bed was in. CNA #2 stated that there was quite a bit of blood on the floor, and that R #2 was not wearing her neck collar .the resident was crying a little bit and was confused .R #2 didn't remember trying to get up. CNA #2 stated that there had been times that the resident tried to get up out of bed and get up out of her wheelchair. She stated that R #2 was able to move her legs to the side of the bed .that there were days that R #2 was stronger than other days .she thought that R #2 had more strength in her legs than her arms. CNA #2 stated, I honestly thought it could have been the mattress, they are slippery even with the sheets on them. K. On 03/21/18 at 11:35 am, during an interview, Licensed Practical Nurse (LPN) #2, who worked the day shift on 09/28/17 stated the following: When she came on her shift about 6:25 (am) in the morning, she walked on the floor, the night nurse was not on the floor. She stated that there was a commotion in room [ROOM NUMBER] B, where she found RN #2 (night shift RN), CNA #3 (day shift CNA) and CNA #5 (night shift CNA). R #2 was back in bed, pressure dressing was applied to R #2. Registered Nurse (RN) #2 was assessing R #2 neurochecks (which includes mental status, pupil reactions, reflexes, and vital signs), notifying the physician, the DON and the Administrator. LPN #2 stated that she was continuously assessing R #2, and cleaning up the lacerations on R #2's face. L. On 03/21/18 at 1:35 pm, during an interview, CNA #3, who worked the day shift on 09/28/17, stated that CNA #5 was giving her a walking report of the residents that morning, when they heard yelling. They found R #2 moaning out loud, it looked like it could have just happened. We called the nurse, the side rails of the bed were up and the bed was in a high position. She said that R #2 had her neck brace on, which she was supposed to have the neck brace on at all times. CNA #3 stated that R #2 was on the floor towards the top of the bed. She also stated that R #2 would put her legs over the side of the bed, that she was able to move, it wasn't a lot but she was able to move her legs. She said that there was a lot of blood on the floor, R #2 was awake and telling the nurse that she was in pain. CNA #3 stated that it was the first time for her to follow CNA #5. She said that CNA #5 had told her that he had just changed her and that he was charting when CNA #3 walked on the floor. She stated that R #2 had a little movement and that she thought that R #2 was a fall risk. CNA #3 stated that she thought that R #2 was moving in bed and fell off the bed. She said that R #2 was someone that needed to be watched in bed .and that there were many people who thought that the mattress was unsafe for the resident. When asked if she had told that to the nurse on duty, she said, Yes. She stated that R #2 required a hoyer lift (a mechanical device used for transfers when a person requires 90 - 100% assistance to get into and out of bed) to transfer and that they would never be allowed to transfer a resident by themselves. M. On 03/21/18 at 4:00 pm, during interview, CNA #4, who works the day and night shifts on the 400 hall, stated the she worked the day shift on 09/28/17. She stated that R #2 was a 2 (two) person transfer with the hoyer lift, when R #2 first got to the nursing home, she could not move. She said that since R #2 has been here awhile that she can move herself now a little bit. CNA #4 stated that she was the person that brought the towels into the room that morning to clean up the blood on the floor. She thought that the bed, wasn't too high or too low. She said the air mattress was not a very smart idea for R #2, she continued that any movement with the mattress would turn R #2 to the side, that it would happen with her legs. She said, I would position (name of R #2's) legs in bed and would turn-around and her legs would be in another position. When R #2 was moved in bed, the mattress would be inflated, she thought that the bed was inappropriate for R #2 in retrospect. When asked if she remembers talking to the nurse about her concerns regarding R #2's mattress, she said, Yes. N. On 03/21/18 at 4:55 pm, during an interview, the wound care nurse stated that there were no staff members that came to tell him that R #2's mattress, was not appropriate for her regarding the safety reasons that R #2 was unable to move herself. O. On 03/22/18 at 8:00 am, during an interview, RN #2 who worked the night shift 09/27/18, stated that it was around 5:45 (am) in the morning, when I was passing medications. She said that CNA #5 had changed R #2 and was coming out of her room with a laundry bag and a trash bag. She said that LPN #2 came in late that morning on 09/27/18. At 6:25 am, R #2 was laying on the floor face down. Her roommate R #12 didn't even put on her call light for R #2. RN #2 stated that CNA #5 did his job, and that when she went into R #2's room, her side rails were up .she stated that when she called R #2's daughter, the daughter stated, Whoever took care of my mother is in trouble. RN #2 had used her personal cell phone, so that R #2's daughter could talk with R #2, and asked her if she was ok. P. Record review of the microAir MA80 Series and MA85 (with Alternating Pressure) Series, User Manual dated (YEAR), revealed the following: 1 General 1.1 Symbols: DANGER! -Danger indicates an imminently hazardous situation which, if not avoided, will result in death or serious injury. WARNING! -Warning indicates a potentially hazardous situation which, if not avoided, could result in death or serious injury. 2 Safety 2.1 DANGER! Risk of Death, Injury or Damage - Conditions such as restlessness, mental deterioration and dementia or [MEDICAL CONDITION] disorders (uncontrolled body movement), sleeping problems, and incontinence can significantly impact a patient's risk of entrapment .Monitor patient with these conditions frequently . WARNING! Risk of Death, Injury or Damage To avoid risk of death, injury or damage from product misuse or entrapment: .Proper patient assessment and monitoring is required. Work with therapist, physician and other medical staff to perform assessment and patient monitoring. Q. Record review of facility policy titled Falls and Fall Risk, Managing, (undated) indicated, If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.

The facility failed to ensure that resident and family allegations of neglect and mistreatment were investigated and acted upon. Without follow-up, the facility could not ensure that residents remained free of retaliation or harm. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of K being identified on 11/10/15. The facility was notified on 11/10/15 at 11:34 am. The facility took corrective action by providing an acceptable Plan of Removal on 11/10/15 at 4:41 pm. Based on the Plan of Removal, interventions included: 1. A complete review of outstanding grievances. 2. A review of the grievance log to verify that all grievances were included. 3. Re-education of all Department Managers on grievance and abuse/neglect policies and procedures. 4. Daily review of grievances/concerns in the morning stand-up meeting. 5. Review of the grievance log weekly by the Administrator to validate timeliness of investigations and resolutions. 6. Review of grievances and grievance logs weekly in a Quality Assurance meeting. Based on the Plan of Removal and interview, the IJ was lifted on 11/10/15 at 4:55 pm. This resulted in the scope and severity being reduced from level K to level H. Based on record review and interview, the facility failed to follow up on written complaints from residents and family members regarding mistreatment and neglect, for 7 (R #s 7, 17, 81, 129, 153, 164, & 211) of 10 (R #s 7, 17, 81, 129, 153, 164, 168, 178, 211 & 239) residents reviewed for grievances. This deficient practice is likely to have resulted in resident feelings of fear, frustration and dissatisfaction, and a failure to substantiate reports of mistreatment and neglect and take action to prevent further occurrences. The findings are: A. Record review of a Grievance/Complaint Report filed by R #81 on 06/19/15 found the statement (Name of Staff Member #1) stated that I owed them thousands of dollars. I told her I was not able to pay that. She then said 'Do you like to eat? Do you like to have electricity?' (Name of Former Director of Nursing) (illegible word) follow it up with 'This is a business we are running. A business. Do you get it?' I felt threated (sic), humiliated, and bullyed (sic) by both women . An attached Documentation of Facility Follow-Up form was blank. B. Record review of a Grievance/Complaint Report filed by R #17 on 06/21/15 found the statement At 7:00 (am, the posted dining room breakfast time) I went to the dining room for breakfast. I had to get my own coffee & milk then wait. No one was in the room. No one took my order. The mean lady who is rude keeps telling me my tray is coming but it does not come It was 8:30 (am) when they brout (sic) my tray. It was cold eggs, no cereal, they said they ran out, and 1 mighty shake. I was the last one served in the dining room. They said if I have to complain it is (name of Former Director of Nursing)'s fault. No documentation of facility follow-up was found attached to this grievance. C. Record review of a Grievance/Complaint Report filed by a family member of R #211 on 06/25/15 found the statement This is the third time I have had to personally wash my mother because the nurses are not washing her hair or bathing her. If I have to wash her that is fine, but I need to know so I can understand what is being paid for. I think I shouldn't have to put up signs to do this but will if this is what it takes for her to get bathed 2x (twice) a week. Imagine sitting in your own filth for weeks its not right. Please let the nurses know she is to be showered on Wednesdays and Saturdays. An attached Documentation of Facility Follow-Up form was blank. D. Record review of a typed document dated 06/26/15, without record of the author, found: 1. The statement, (R #129) reported during care conference yesterday, 06/27/15 (sic) that he has some concerns in the treatment he was receiving from the nursing staff. 2. The statement, He has stated that the girls are in the habit of telling him that they will return to help him and they never come back. There is a nurse that does this as well, but he was unable to recall the nurses (sic) name. 3. The statement, Another incident, was resident has dropped his reacher and just needed someone to pick it up for him, but he said no one answered his call light. 'They just kept walking by.' 4. The statement, The wife (of R #129) shared that one evening (could not remember the specific day or date) another resident was in her room yelling for help. She noticed that 4 staff members were by the nurses station and no one was addressing the woman's cry for help. 5. An attached Documentation of Facility Follow-Up form was blank. E. Record review of a Grievance/Complaint Report filed by R #153 on 07/15/15 found: 1. The statement, Since I have been moved to 400 hall I have been totally forgotten - CNAs (Certified Nurse Aides) don't answer the call button sometimes for over an hour. Most are rude - mean and hateful. 2. The statement, (Saturday) (name of Assistant Director of Nursing #1) was nurse and she never came in to take my blood sugar or give me my meds, one of which is my 30 units of insulin . 3. The statement, I was upset and crying - I told (name of Assistant Director of Nursing #1): you never brought my meds last night or checked my blood sugar. 4. No documentation of facility follow-up was found attached to this grievance. F. Record review of a Grievance/Complaint Report filed by a family member of R #7 on 07/29/15 found the statement Mom pushed the call button; she needed help to the restroom. She went to the bathroom. She pushed the call button various times. No one came. She waited 45 minutes . There has been various times that she has used the call button and no one comes. She has even gotten out and walked to the nurse station. The CNAs just looked at her. Review of the attached Documentation of Facility Follow-Up form found no evidence of follow-up. G. Record review of a Grievance/Complaint Report filed by R #164 on 07/29/15 found the statement I was in the doorway and (name of CNA #6) then said 'Excuse me, in a rude tone, stating get out of the way. She then continued her business and she got me very upset. I then went to my room and flipped her off, slamming my door because she got me extremely upset by her rudeness. This behavior has happened many times before and made me so uncomfortable. I chose not to press my call light all night. The nurse agreed with me as well, saying that was not right or proper manners toward residents. Review of the attached Documentation of Facility Follow-Up form found no evidence of follow-up. H. Record review of a Grievance/Complaint Report filed by R #153 on 08/31/15 found the statement I have had a UTI (urinary tract infection) for months. Now it [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus, a kind of infection) and (Physician #1) is upset that lab work was done and antibiotics are being asked for AGAIN. Actually upset is not correct. Angry is more appropriate. And he is prescribing an antibiotic not on the list to treat a UTI [MEDICAL CONDITION]. He acts like it is an inconvience (sic) to do anything No documentation of facility follow-up was found attached to this grievance. I. On 09/29/15 at 10:00 am, during interview with the Director of Social Services, she was asked about the facility's resident/family grievance process. She stated that The way it's supposed to work is that when a grievance comes in, I log it, and attach a follow-up form, and pass it on to the appropriate person for follow up. She stated We know the process is broken, and that there has not been follow-up because there has been so much turnover in department heads over the past year. J. On 09/28/15 at 10:10 am during interview with the Administrator, he stated that when he started at the facility (in July 2015), grievances were scattered all over the Director of Social Services' desk. None of them had been responded to. Around 2-3 weeks ago they were collected from the Director of Social Services. About one week ago a book for grievances was put together. They administrator stated that he was concerned that some of the grievances might have needed to be reported to the state. He also stated that staff are supposed to talk about them in stand-up meeting. He said that the grievances were passed out to the department heads but never discussed with other staff.

The facility failed to implement its policies and procedures that prohibit mistreatment and neglect of residents, through failing to act on grievances. Without follow-up, the facility was unable to ensure that residents remained free of retaliation or harm. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of K being identified on 11/10/15. The facility took corrective action by providing an acceptable Plan of Removal on 11/10/15 at 4:41 pm. Based on the Plan of Removal, interventions included: 1. A complete review of outstanding grievances. 2. A review of the grievance log to verify that all grievances were included. 3. Re-education of all Department Managers on grievance and abuse/neglect policies and procedures. 4. Daily review of grievances/concerns in the morning stand-up meeting. 5. Review of the grievance log weekly by the Administrator to validate timeliness of investigations and resolutions. 6. Review of grievances and grievance logs weekly in a Quality Assurance meeting. Based on the Plan of Removal and interview, the IJ was lifted on 11/10/15 at 4:55 pm. This resulted in the scope and severity being reduced from level K to level H. Based on record review and interview, the facility failed to implement its policies and procedures that prohibit mistreatment and neglect of residents, for 7 (R #s 7, 17, 81, 129, 153, 164, & 211) of 10 (R #s 7, 17, 81, 129, 153, 164, 168, 178, 211 & 239) residents reviewed for grievances. Resident and family grievances regarding mistreatment and neglect were not investigated or acted upon, for 8 of 18 grievances pulled at random. This deficient practice is likely to have resulted in a failure to substantiate reports of mistreatment and neglect and take action to prevent further occurrences. The findings are: A. Record review of the facility's (undated) Policy and Procedures document related to Abuse Investigations found the statements: 1. All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 2. The individual in charge of the investigation will consult daily with the Administrator concerning the progress/findings of the investigation. 3. The Administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. 4. The results of the investigation will be recorded on approved documentation forms. 5. The Administrator will inform the resident and his/her representative (sponsor) of the results of the investigation and corrective action taken within five (5) days of the completion of the investigation. B. Record review of facility Grievance/Complaint Report documents found: 1. A statement from R #81 dated 06/19/15 indicating I felt threated (sic), humiliated, and bullyed (sic) by both (staff members). An attached Documentation of Facility Follow-Up form was blank. 2. A statement from R #17 dated 06/21/15 stating The mean lady who is rude keeps telling me my tray is coming but it does not come. He indicated that he had to wait 90 minutes for his breakfast tray. No documentation of facility follow-up was found attached to this grievance. 3. A statement from the family member of R #211 dated 06/25/15 indicating This is the third time I have had to personally wash my mother because the nurses are not washing her hair or bathing her . Imagine sitting in your own filth for weeks its not right. Please let the nurses know she is to be showered on Wednesdays and Saturdays. An attached Documentation of Facility Follow-Up form was blank. 4. A typed, unsigned document dated 06/26/15, related that during a care conference, a family member of R #129 had stated another resident was in her room yelling for help. She noticed that 4 staff members were by the nurses' station and no one was addressing the woman's cry for help. An attached Documentation of Facility Follow-Up form was blank. 5. Statements from R #153 dated 07/15/15 indicating I was upset and crying - I told (name of Assistant Director of Nursing #1): you never brought my meds last night or checked my blood sugar. No documentation of facility follow-up was found attached to this grievance. 6. A statement from R #164 dated 07/29/15 indicating . she got me extremely upset by her rudeness. This behavior has happened many times before and made me so uncomfortable. I chose not to press my call light all night. Review of the attached Documentation of Facility Follow-Up form found no evidence of follow-up. 7. A statement from a family member of R #7 dated 07/29/15 indicating that her mother had frequently had no response to pressing her call light button, and had on occasion gotten out of bed by herself when she needed to use the bathroom. Review of the attached Documentation of Facility Follow-Up form found no evidence of follow-up. C. On 09/29/15 at 10:00 am, during interview with the Director of Social Services, she was asked about the facility's resident/family grievance process. She stated that The way it's supposed to work is that when a grievance comes in, I log it, and attach a follow-up form, and pass it on to the appropriate person for follow up. She stated We know the process is broken, and that there has not been follow-up because there has been so much turnover in department heads over the past year. D. On 09/28/15 at 10:10 am during interview with the Administrator, he stated that when he came on board at the facility (in July 2015), grievances were scattered all over the Director of Social Services' desk. None of them been had been responded to. Around 2-3 weeks ago they were collected from the Director of Social Services. About one week ago a book for grievances was put together. They administrator stated that he was concerned that some of the grievances might have needed to be reported to the state. He also stated that staff are supposed to talk about them in stand up meeting. He said that the grievances were passed out to the department heads but never discussed with other staff.

The facility failed to ensure that the physician's comprehensive plan of care was acted upon for 5 residents with new medication orders written on pharmacist monthly review documents. Orders modified on the documents were never transferred to residents' electronic medical records or medication administration records (MARs), and medication doses continued to be delivered as originally ordered. This deficient practice, as well as a failure of the facility to ensure action on pharmacist recommendations, resulted in an Immediate Jeopardy at a scope and severity of K being identified at the facility on 09/25/15 at 3:50 pm. The facility administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal on 09/25/15 at 5:25 pm. Based on the Plan of Removal, interventions included: 1. Review of outstanding pharmacist recommendations by 09/28/15. 2. New review of all residents' medication regimens by a corporate pharmacist by 09/28/15. 3. Completion of physician review of new recommendations by 09/29/15. 4. Initiation of a tracking log to ensure completion of the review process. 5. Initiation of a process whereby the Medical Director is advised of reviews not completed by practioners within 5 days. 6. The administrator's personal assurance of safety in medication administration through the weekend of 09/25/15 to 09/27/15. Based on the Plan of Removal and interview, the IJ was lifted on 09/25/15 at 5:25 pm. This resulted in the scope and severity being reduced from level K to level E. Based on record review and interview, the facility failed to implement the physician's comprehensive plan of care for 5 (R #s 23, 51, 69, 75 and 152) of 7 (R #s 23, 37, 51, 69, 75, 152 and 165) residents for whom new orders were written as a result of pharmacy monthly reviews provided by the Corporate Compliance Officer on 09/25/15. Orders written by prescribers were never transferred to the electronic medical records, and residents continued to be dosed with medications that had been discontinued or reduced. This deficient practice has the potential to result in negative resident outcomes related to drug interactions and side effects of unnecessary medications. The findings are: A. On 09/25/15 at 4:43 pm, the Corporate Compliance Officer provided copies of 14 Note to Attending Physician/Prescriber documents, which had been signed by prescribers. 7 of these documents were found to contain new medication orders. B. Record review of the active medication orders of the residents for whom new orders had been written on 7 signed Note to Attending Physician/Prescriber documents found that: 1. An order dated 08/31/15 for R #75 stating d/c (discontinue) [MEDICATION NAME].[MEDICATION NAME](a sleep aid) 10 mg (milligrams) hs (at bedtime) had not been enacted in R #75's electronic medical record as of 09/25/15. [MEDICATION NAME] remained among active medications in her medication regimen, [MEDICATION NAME] dosed at 5 mg. 2. An order dated 08/31/15 for R #23 stating Reduce [MEDICATION NAME] (an antidepressant medication) to 20 mg had not been enacted in R #23's electronic medical record as of 09/25/15. [MEDICATION NAME] continued to be dosed at 40 mg. 3. An order dated 08/31/15 for R #51 stating Reduce [MEDICATION NAME] (an antianxiety medication) to 0.5 mg BID (twice daily) had not been enacted in R #51's electronic medical record as of 09/25/15. [MEDICATION NAME] continued to be given every 6 hours. 4. An order dated 08/31/15 for R #69 stating Reduce [MEDICATION NAME] to 2 mg PO (by mouth) TID (3 times daily) for muscle spasm had not been enacted in R #69's electronic medical record. [MEDICATION NAME] continued to be given 4 times daily. 5. An order dated 08/31/15 for R #152 stating d/c [MEDICATION NAME]/APAP ([MEDICATION NAME]) had not been enacted in R #152's electronic medical record. This medication combination remained among active medications in his medication regimen.

The facility failed to ensure that action was taken on pharmacist recommendations related to medication irregularities identified on monthly medication regimen reviews. No documentation was found to indicate that prescribers had received or reviewed 368 of 382 recommendations listed on the consultant pharmacist's monthly reports for June 2015, July 2015 or August 2015. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of K being identified at the facility on 09/25/15 at 3:50 pm. The facility administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal on 09/25/15 at 5:25 pm. Based on the Plan of Removal, interventions included: 1. Review of outstanding pharmacist recommendations by 09/28/15. 2. New review of all residents' medication regimens by a corporate pharmacist by 09/28/15. 3. Completion of physician review of new recommendations by 09/29/15. 4. Initiation of a tracking log to ensure completion of the review process. 5. Initiation of a process whereby the Medical Director is advised of reviews not completed by practioners within 5 days. 6. The administrator's personal assurance of safety in medication administration through the weekend of 09/25/15 to 09/27/15. Based on the Plan of Removal and interview, the IJ was lifted on 09/25/15 at 5:25 pm. This resulted in the scope and severity being reduced from level K to level E. Based on record review and interview, the facility failed to ensure that pharmacy reviews were acted upon as evidenced by (1) No evidence was found of physician review of pharmacist recommendations for 368 of the 382 recommendations (2) Of the 14 recommendations which had been reviewed, 7 had resulted in physician changes to medication orders, but for 5 of these, the ordered changes had not been enacted, for 135 of 163 residents identified by the Director of Nursing on 09/25/15 at 1:40 pm in the Consultant Pharmacist's Medication Regimen Review documents for June 2015, July 2015 and August 2015. This deficient practice is likely to result in negative resident outcomes related to inappropriate dosing of medications, inappropriate administration of medications, medication interactions, and delivery of medications without appropriate indications. The findings are: A. On 09/25/15 at 1:40 pm, during interview with the Director of Nursing (DON), she provided copies of the Consultant Pharmacist's Medication Regimen Reviews dated 06/28/15, 07/19/15 and 08/17/15. She stated that none of the pharmacist's recommendations had been forwarded to the prescribers during this three month period, and that no action had been taken on them. B. Record review of the Consultant Pharmacist's Medication Regimen Review documents dated 06/28/15, 07/19/15 and 08/17/15 found: 1. A total of 382 recommendations had been made by the Consultant Pharmacist during the three reviews. None of the Notes to Attending Physician/Provider in the file showed evidence of physician review, agreement or disagreement with the recommendation, or a corresponding medication order change. 2. A recommendation for R (resident) #69 dated 07/19/15 stated This resident is receiving Prazosin (a blood pressure medication) for 'Mental Disorder.' This is not an FDA approved indication for this medication. 3. A recommendation for R #69 dated 07/19/15 stated This resident is receiving Tizanidine (an anti[DIAGNOSES REDACTED] medication) 2 mg (milligrams) four times daily for anxiety. This medication does not have an indication for anxiety. 4. A recommendation for R #143 dated 08/17/15 stated This resident is receiving three different antidepressants, none of which are maximally dosed. Both Nortriptyline and Mirtazapine are given at bedtime. Please consider increasing the Mirtazapine dose to 15 mg and discontinuing the Nortriptyline. 5. A recommendation for R #1 dated 07/19/15 stated This resident is receiving three different PRN (as needed) narcotic orders: Morphine 15 mg ER (extended release), Oxycodone 5 mg, and Hydrocodone/APAP (acetaminophen) 10/325 mg. These orders do not have specific administration instructions. R #1 is also receiving scheduled Methadone (a pain medication) 5 mg twice daily, Baclofen (an anti[DIAGNOSES REDACTED] medication) and Gabapentin (an anticonvulsant medication) for pain. This combination of narcotics can result in extreme sedation and respiratory depression. 6. A recommendation for R #152 dated 07/19/15 stated This resident has PRN orders for Oxycodone/APAP (acetaminophen) 5/325 mg and Oxycodone 5 mg. This is duplicate therapy. Please discontinue one of the PRN orders. 7. A recommendation for R #75 dated 07/19/15 stated Per the Ambien (a sleep aid) order, both the Trazodone (an antidepressant medication) and Ambien should not be given together. Please consider increasing the Ambien dose and discontinuing the Trazodone order. C. Record review of active MEDICATION ORDERS FOR [REDACTED]Note to Attending Physician/Prescriber documents was still current in the Medication Administration Record, [REDACTED]. D. On 09/25/15 at 2:35 pm, during interview with the Consultant Pharmacist, she stated that as of 09/01/15, her company was no longer working with the facility. Regarding her medication regimen reviews, she stated There wasn't much in the way of follow through. There wasn't much in the way of response from the first DON, and the second one was even worse. I never met the current one - we only overlapped for one week. I don't know what ever happened to the Letters to Physician that I wrote, but I never saw any kind of response. E. On 09/25/15 at 4:43 pm, during interview with the Corporate Compliance Officer, she provided copies of 14 Note to Attending Physician/Prescriber documents, which had been signed by prescribers. The Corporate Compliance Officer stated that many of the Notes to Attending Physician/Prescriber, had been sent to prescribers, but that many had not been received back. She stated Some of them they never looked at, some of them they refused to look at. We are going to have to work through those issues with the physician. F. Record review of the 14 signed Note to Attending Physician/Prescriber documents provided by the Corporate Compliance Officer found that: 1. 2 of the letters contained the notation he has been discharged . 2. 2 of the letters did not contain a notation of agreement or disagreement with the recommendation or any new orders. 3. 3 of the letters indicated that the practitioner disagreed with the recommendation and declined to amend the orders. 4. 7 of the letters indicated that the practitioner agreed with the recommendation and included new medication orders. G. Record review of the 7 signed Note to Attending Physician/Prescriber documents with new orders, and comparison with current orders in the resident's electronic medical records, indicated that 5 of the new orders had never been enacted: 1. An order dated 08/31/15 for R #75 stated d/c (discontinue) trazodone and Ambien (a sleep aid) 10 mg hs (at bedtime) had not been enacted in R #75's electronic medical record as of 09/25/15. Trazodone remained among active medications in her medication regimen, and Ambien remained dosed at 5 mg. 2. An order dated 08/31/15 for R #23 stated Reduce fluoxetine (an antidepressant medication) to 20 mg had not been enacted in R #23's electronic medical record as of 09/25/15. Fluoxetine continued to be dosed at 40 mg. 3. An order dated 08/31/15 for R #51 stated Reduce clonazepam (an antianxiety medication) to 0.5 mg BID (twice daily) had not been enacted in R #51's electronic medical record as of 09/25/15. Clonazepam continued to be given every 6 hours. 4. An order dated 08/31/15 for R #69 stated Reduce tizanidine to 2 mg PO (by mouth) TID (3 times daily) for muscle spasm had not been enacted in R #69's electronic medical record. Tizanidine continued to be given 4 times daily. 5. An order dated 08/31/15 for R #152 stated d/c oxycodone/APAP had not been enacted in R #152's electronic medical record. This medication combination remained among active medications in his medication regimen.

Administration failed to ensure that the facility was operated in a manner that maximized resident health, safety, comfort, and quality-of-life. One deficient practice, the failure to act on pharmacist medication recommendations, resulted in an Immediate Jeopardy at a scope and severity of K being identified at the facility on 09/25/15 at 3:50 pm. The facility administrator was notified at that time. The facility took corrective action by providing an acceptable Plan of Removal on 09/25/15 at 5:25 pm. Based on the Plan of Removal, interventions included: 1. Review of outstanding pharmacist recommendations by 09/28/15. 2. New review of all residents' medication regimens by a corporate pharmacist by 09/28/15. 3. Completion of physician review of new recommendations by 09/29/15. 4. Initiation of a tracking log to ensure completion of the review process. 5. Initiation of a process whereby the Medical Director is advised of reviews not completed by practioners within 5 days. 6. The administrator's personal assurance of safety in medication administration through the weekend of 09/25/15 to 09/27/15. Based on the Plan of Removal and interview, the IJ was lifted on 09/25/15 at 5:25 pm. This resulted in the scope and severity being reduced from level K to level E. Based on observation, interview and record review, the administration of the facility failed to manage and coordinate resident care in a manner that would enable each resident to attain or maintain his or her highest practicable physical, mental and psychosocial well being, for 108 of the 108 residents listed on the alphabetical census provided by the Administrator on 09/21/15. Findings indicate: 1. A failure to ensure that residents were treated with respect and dignity. 2. A failure to acknowledge, investigate and resolve grievances lodged by residents and family members. 3. A failure to act on monthly pharmacist reports of medication irregularities. 4. A failure to ensure that residents were free of unnecessary medications. 5. A failure to ensure timely delivery of appetizing and nutritious meals. 6. A failure to provide nursing staff sufficient to attend to resident needs in a timely manner. These deficient practices likely contributed to poor resident outcomes with respect to quality-of-life, quality-of-care, health, safety and comfort. The findings include: See F166, F241, F311, F329, F353, F364, F367, and F428 for additional details. Findings relating to failure to treat residents treatment with respect and dignity, and to resolve resident/family grievances: A. Record review of Grievance/Complaint Report documents found grievances filed by R #s 17, 81, 153 and 164 detailing occasions when they had not been treated by staff with respect and dignity. B. Interviews with residents produced statements by residents R #150, 153, and 164 detailing occasions when they had not been treated by staff with respect and dignity. C. Observations on the 400 unit noted occasions with R #s 46, 150 and 211 where dignity or privacy had been violated. D. Interviews with the Director of Social Services indicated that few resident/family grievances had received any investigation, follow-up, or resolution. See F166 and F241 for additional details. Finding related to the failure to act on pharmacist reviews: E. Record review of pharmacist monthly review documents found that for 368 of 382 reviews, action was not taken on irregularities found in resident's drug regimens. These findings resulted in a declaration of Immediate Jeopardy at the facility on 09/25/15. See F428 for additional details Finding related to the use of unnecessary medications: [REDACTED] F. Record reviews of 5 residents (R #s 17, 18, 39, 144 and 190) found the use of unnecessary medications. See F329 for additional details. Findings related to meal service: G. Interviews with residents produced statements by R #s 7, 59, 150, 196, 213 and 220 indicating that meal quality was poor or that meal trays had been served late or insufficiently heated. An interview with R #153 found that she was not routinely served meals appropriate for a diabetic resident. H. Record review of Grievance/Complaint Report documents found food quality concerns raised by residents R #7, 17 and 81. See F364 and F367 for additional details. Findings related to failure to provide sufficient nursing staffing: I. Interviews with residents produced statements by residents R #s 7, 59, 146, 150, 153, 164, 168, 196 and 213 indicating staffing was insufficient to meet their needs. See F311 and F428 for additional details.