Every finding on record at Life Care Center of Farmington

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 #1) of 1 (R #1) resident, when: A medication consent form was not completed as required before administration of a psychotropic medication (medication used to treat mental health conditions).A psychotropic medication gradual dose reduction (GDR; 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 a clinically contraindicated reason likely to impair function or cause psychiatric instability in the resident.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: A. Record review of the facility's psychotropic medication use policy, revised on 03/01/25, revealed the following: Facility staff should inform the resident and/or representative of the initiation, reason for use, and the risks associated with the use of psychotropic medications, per facility policy or applicable state regulations. Physician/prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would likely to impair the resident's function or increase distressed behavior. B. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), revealed R #1 was admitted on [DATE] with a diagnosis of cerebrovascular accident (CVA; stroke) and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). R #1's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) showed a score of 02, indicating R #1 had severe cognitive impairment. C. Record review of R #1's physician orders revealed the following: Dated 09/20/24, R #1 was prescribed trazodone (antidepressant and sedative), 50 milligrams (mg), give two tablets by mouth at bedtime for depression. This medication was discontinued on 07/07/26. Dated 07/07/26, R #1 was prescribed trazodone, 50 mg, give 1.5 tablets by mouth at bedtime for depression for 14 days. This medication was discontinued on 07/20/26. Dated 07/23/26, R #1 was prescribed trazodone, 50 mg, give 1.5 tablets by mouth at bedtime for depression for 14 days. D. Record review of R #1's medication informed consent form, dated 03/03/25, revealed a medication consent was obtained for R #1's trazodone 50 mg use, which began on 09/20/24. A medication consent form was not obtained prior to this form. E. Record review of R #1's pharmacist consultation reports, revealed the following: Dated 04/23/26, the pharmacist recommended a GDR for R #1's use of trazodone to 75 mg by mouth every night at bedtime. The facility provider declined the pharmacist's recommendation, and the rationale provided by the provider for why a GDR attempt was likely to impair function or cause psychiatric instability in the resident was documented as Family routinely declines GDRs.Dated 06/30/26, the pharmacist recommended a GDR for R #1's use of trazodone to 75 mg by mouth every night at bedtime. The facility provider accepted the pharmacist's recommendation. F. Record review of R #1's medication administration record (MAR), dated 01/01/26 through 07/29/26, revealed R #1 was administered trazodone per physician orders each day he was in the facility. G. On 07/28/26 at 2:43 pm, during an interview, R #1's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) stated there were times she was not contacted by the facility for a medication consent before R #1 received the medication. The POA stated whenever a medication consent form is required, she should be contacted immediately rather than months later, after the medications have already been administered. H. On 07/29/26 at 3:50 pm, during an interview, Registered Nurse (RN) #1 stated the nurse responsible for entering the medication order is required to obtain a medication consent from the resident, the resident's POA, or family before administering the medication. I. On 07/29/26 at 4:23 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated after the provider ordered the medication, nursing staff were required to obtain a medication consent from the resident, the resident's POA, or family before administering the medication. LPN #1 stated it was the nurse's responsibility to obtain a completed medication consent form prior to administering a psychotropic medication. J. On 07/30/26 at 1:31 pm, during an interview, the pharmacist stated medication consent forms are required before administering psychotropic medications. The pharmacist stated the resident's family is included in discussions about the resident's medications, but the provider is ultimately responsible for a GDR and determining what is best for the resident. K. On 07/30/26 at 2:05 pm, during an interview, the Director of Nursing (DON) stated a medication consent form is required before administering medication. The DON stated R #1's medication consent form for trazodone was not completed before administration and should have been. The DON stated a GDR was implemented at a later date for R #1's trazodone use due to R #1's family. The DON stated documenting family routinely declines GDRs as the reason for not attempting a GDR on the pharmacist recommendation dated 04/23/26 did not indicate whether the decline was based on a concern the recommendation was likely to impair function or cause psychiatric instability in the resident, as required.

Based on observation, record review, and interviews, the facility failed to meet professional standards of quality for 1 (R #1) of 1 (R #1) resident, when staff failed to follow the physician orders for placement of R #1's urinary catheter (a thin, flexible tube which drains urine from the bladder) collection bag (also called a drainage bag; a device connected to the catheter tubing and collects 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 the facility's physician order policy, revised on 02/11/26, revealed a physician, physician assistant, or nurse practitioner must provide orders for the resident's immediate care and ongoing care of the resident. The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. B. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), revealed R #1 was admitted on [DATE] with a diagnosis of cerebrovascular accident (CVA; stroke), dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and neurogenic bladder (the bladder does not empty properly due to a neurological condition). R #1's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) showed a score of 02, indicating R #1 had severe cognitive impairment. C. Record review of R #1's physician order, dated 03/10/25, directed staff to check R #1's urinary catheter tubing and drainage bag placement every shift to ensure proper placement below the knee for optimal gravity drainage. D. Record review of R #1's care plan, dated 12/22/25, revealed R #1 used a urinary catheter and directed staff to educate the resident and the resident's family regarding the urinary catheter and its' care. E. On 07/29/26 at 3:44 pm, during an observation, R #1's urinary catheter drainage bag was secured to his right thigh (upper portion of the leg between the hip and the knee) and positioned above his knee while R #1 sat in a wheelchair. F. On 07/29/26 at 3:54 pm, during an interview, Registered Nurse (RN) #1 stated R #1's urinary catheter drainage bag was supposed to be secured below his knee, but R #1's spouse wanted the drainage bag secured above his knee, so staff followed her instructions. G. On 07/29/26 at 4:29 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated R #1's urinary catheter drainage bag was supposed to be secured below his knee, but during the day, nursing staff placed it on his thigh. H. On 07/30/26 at 9:33 am, during an interview, RN #2 stated staff kept R #1's urinary catheter drainage bag above the knee and positioned on his thigh each shift. I. On 07/30/26 at 2:16 pm, during an interview, the Director of Nursing (DON) stated R #1's physician order states R #1's urinary catheter drainage bag should be positioned below R #1's knee, but R #1's spouse wants it secured above R #1's knee. The DON stated nursing staff should follow physician orders as written and not follow instructions from a resident's family member if those instructions contradict the physician order.

Based on record review and interview, the facility failed to provide the required transfer information to the residents' and the residents' representatives for 1 (R #3) of 3 (R #1, #2 and #3) residents, when staff failed to: Notify R #3 and/or R #3's representative in writing, and in a language and manner they understand, of the resident's transfer to the hospital.Send a written copy of R #3's transfer notice to the State Long Term Care Ombudsman (a government advocate for residents of long-term care facilities, such as nursing homes and assisted living facilities, working to protect their rights and improve the quality of care they receive) before or after R #3's hospitalization. These deficient practices could likely result in residents and/or their representatives not knowing the reason for the transfer, the location of the transfer or discharge, or their rights to advocate for and make informed decisions regarding the residents' healthcare.The findings are:A. Record review of R #3's face sheet revealed an initial admission date of 08/26/20 and a readmission date of 02/25/26. B. Record review of R #3's nursing progress notes, dated 02/14/26, revealed the following: A Certified Nursing Aide (CNA) reported R #3 was on the floor in the bathroom. R #3 reported he was finished using the restroom when he tripped on his shoes. The resident was assessed for injuries, and redness was noted to the resident's right shoulder blade, with a documented self-inflicted scratch to the resident's right lower back. R #3 complained of pain when attempting to pick up his right arm and there is slight swelling to his right elbow. R #3 was able to move his arm earlier today during a shower. R #3's fall and injury reported to on-call physician who advised sending the resident to the emergency room to be evaluated. R #3 was sent to the hospital via Emergency Medical Services (EMS). C. Record review of R #3's facility census revealed R #3 was discharged to the hospital on [DATE] and was readmitted into the facility on [DATE]. D. Record review of R #3's electronic health record (EHR), dated 06/03/26, revealed documentation was not available indicating the facility staff completed and provided a formal written transfer notice or written bed hold notification to R #3 or R #3's representative before or after R #3's hospitalization. R #3's EHR did not contain documentation indicating the facility staff notified the State Long Term Care Ombudsman before or after R #3's hospital discharge. E. On 06/03/26 at 11:00 am, during an interview, the Director of Nursing (DON) stated the facility staff did not provide a written transfer notice or bed hold notification to R #3, R #3's representative, or the State Long Term Care Ombudsman before or after R #3's hospitalization on 02/14/26, but they should have. The DON stated it is her expectation that, even during emergency hospitalizations, the facility nursing or admissions staff must complete and issue the written transfer and bed hold notices to the family and the Ombudsman as soon as practicable following the transfer.

Based on record review and interviews, the facility failed to notify the resident representative of a medication change for 1 (R #2) of 1 (R #2) residents reviewed, when:R #2's Parkinson's (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination) medication management was altered and the facility failed to notify R #2's representative of the medication change per R #2's care plan. Failure to notify the resident representative of a medication change is likely to result in delayed awareness of the change and may contribute to delayed or inadequate treatment. The findings are: A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] with the following diagnosis:Parkinson's disease. B. Record review of R #2's comprehensive care plan, dated 02/28/24, revealed an instruction at the top of care plan directing staff to notify R #2's son regarding medication changes and behaviors. C. Record review of R #2's physician orders dated 12/09/25, revealed an order for carbidopa-levodopa (Parkinson's disease medication) 25 to 100 milligrams (mg), give two tablets by mouth, four times daily for Parkinson's disease. D. Record review of R #2's nursing progress notes revealed the following: Dated 11/10/2025: Staff placed R #2's carbidopa-levodopa on hold (not administered) for 7 days to assess for improvement in R #2's behaviors.Dated 11/11/2025: R #2 developed weakness and upper extremity (arm) shaking after the medication was held. The progress note documented the physician ordered the medication be administered at 0.5 mg, four times daily due to the worsening symptoms.Dated 11/25/2025: Meeting with R #2, R #2's son, Administrator, and Director of Nursing. R #2's son expressed concerns about not being made aware of a recent medication change (carbidopa-levodopa) and the side effects after the medication was discontinued. E. On 03/02/26 at 2:25 pm, during an interview, R #2 stated he was unaware the facility stopped giving him the medication carbidopa-levodopa until his hands began to shake aggressively and that bothered him. F. On 03/02/2026 at 3:45 pm, during an interview, R #2's son who identified himself as R #2's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) stated the facility stopped R #2's Parkinson's medication, which R #2 had been taking four times daily. R #2's son stated he contacted the facility after learning the medication had been stopped and asked the staff why the medication was discontinued. He stated staff informed him they stopped the medication to determine if discontinuing it would improve R #2's behaviors. R #2's son confirmed the facility knew to notify him prior to any medication changes, and he was not contacted by the facility and made aware of R #2's carbidopa-levodopa being stopped. G. On 03/03/2026 at 3:50 pm, during an interview, the Administrator (ADM) stated if R #2's care plan directs staff to notify R #2's son regarding medication changes or behaviors, the staff should follow the care plan and notify R #2's son prior to any changes. The ADM confirmed R #2's son was not notified prior to R #2's Parkinson's medication management change and should have been per R #2's care plan.

Based on observation, interview, and record review, the facility failed to ensure staff administered and secured medications for all 112 residents listed on the facility census when: Medication carts were not secured and left unattended during medication pass. Medications were pre-poured (the practice of preparing and storing medications in advance of their scheduled administration) and left unattended without supervision. These deficient practices increased the risk of unauthorized access, medication diversion, contamination, and administration of medications to the wrong resident. Failure to ensure facility nursing staff do not pre-pour medications, do not leave medications unattended, and consistently secure medication carts is likely to create a substantial likelihood that residents, staff members, and/or visitors could access or remove medications that were not prescribed to them. The finding are: Medication Carts Unattended: A. Record review of the facility's Administration of Medications policy dated 09/09/25 stated only certified or licensed staff may administer medications and must adhere to the 10 Rights of Medication Administration, including verifying the right drug, right resident, right dose, right route, and right time immediately before administration. The policy requires staff to compare the medication label with the Medication Administration Record (MAR) three times: Before removing the medication from the drawer, as the drug is removed from the container, and at the bedside before administration to the resident. The policy further stated medications must be administered safely and appropriately and in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards. Staff must verify the resident's identity with two identifiers and confirm accuracy directly against the MAR before each administration. B. On 11/17/25 at 2:43 p.m., observation of the B-unit revealed the medication cart remained unlocked and unattended in the hallway, allowing unsupervised access to resident medications. C. On 11/17/25 at 2:43 p.m., during an interview with Register Nurse (RN) #1 stated the medication cart was her responsibility and she is required to keep it locked at all times. She stated an unsecured cart permits unauthorized individuals to access medications. RN #1 reported the cart contained all B- and C-Unit medications, including narcotic (opioid) medications. Rolling Table with Pre-Poured Medications: D. On 11/18/25 at 11:27 AM, during an observation in the 200 Hall on A-unit, revealed an unattended table containing multiple pre-poured medications in unlidded plastic medication cups. Several cups contained tablets and capsules labeled with resident names. Additional supplies on the table included open over the counter medication boxes labeled for specific residents, multiple plastic spoons and cups, and personal-use items. A licensed nurse was not present at or supervising the table. During the same observation, a Certified Medication Aide (CMA) walked out of a resident occupied room after leaving the cart for approximately one minute. E. On 11/18/25 at 4:00 p.m., during an interview, Certified Medication Aide (CMA) #1, she stated she prepared and pre-poured medications into cups prior to administration. She stated she pre-pours medications for residents who attend activities and prefer to receive medications in the activity room. She confirmed she left the pre-poured medications unattended on a table in the hallway while she entered room [ROOM NUMBER] to assist a resident who had spilled a drink, and the medications were left unattended for approximately five seconds. CMA #1 confirmed she is responsible for supervising medications at all times and acknowledged the facility's policy does not allow pre-pouring medications or leaving medications unattended. She stated the policy requires staff to ask a nurse or another CMA to monitor medications if they must step away during medication administration. She further stated the medications were not secured in the locked medication cart because she pre-poured them to transport to the activity room. CMA #1 stated leaving medications unattended creates a risk because a resident or visitor could take or ingest the medications. She confirmed this practice occurs once or twice a week and stated she typically pre-pours medications for multiple residents when transporting them to the activity area. F. On 11/18/25 at 4:45 p.m., during an interview, the Director of Nursing (DON) stated the facility does not permit pre-pouring medications and requires medications to remain secured and attended at all times during medication administration. She stated medications are not allowed to be left in open areas, such as hallway tables, and must remain locked unless actively being dispensed to a resident. She stated if a staff member must step away during a medication pass, medications must be secured in the locked medication cart. The DON stated Certified Nurse Aides (CNAs) are not permitted to hold, monitor, or supervise medications. She stated the licensed individual administering medications is responsible for ensuring medications are administered safely and in accordance with facility policy. The DON confirmed that leaving multiple residents' pre-poured medications unattended is not acceptable and creates a significant risk because staff would not know whose medications they were and because residents or visitors could access the medications. On 11/19/25 at 12:12 pm the facility was notified of a finding of Immediate Jeopardy (IJ). On 11/19/25 at 4:22 pm an acceptable plan of removal was approved with the following evidence for compliance. Medication Administration Corrective Action Plan Implemented: 11.18.25 Identified Deficiency- The facility left multiple pre-poured medications unattended in an open hallway accessible to residents and visitors for Unit A and B. The unattended medication cart on two separate days contained all unit medications, including narcotic controlled substances, and remained unlocked and unsupervised in a resident-care hallway. Immediate Corrective Actions The Regional Director of Quality Services (RDCS) is working with the facility via telephone and directing the corrective actions with the Executive Director (ED) and Director of Nursing (DON). The RDCS will continue to provide support until immediate corrective action complete.The identified CMA will not pass medications until further determination is made.The DON/designee checked all other medication carts to determine if there were any other pre-poured medications. No other instances of pre-poured medications were observed.The DON/designee checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified.The DON/designee monitored residents on identified hall who received pre-poured medications within the past 24 hours, no concerns were identified. They were monitored for potential adverse medication reactions, such as a significant change in vital signs. No concerns were identified. Education was provided to all nurses and CMAs on-site regarding: Medications are to only be prepared for one resident at a time, using a 3-way-check (comparing the medication to the MAR and to the prescription label) [see facility policy General Dose Preparation and Medication Administration].No pre-poured medications are allowed.Medications are not to be left unsecured and unattended. Medication carts will be locked at all times when out of site or unattended.Nurses and CMAs that are coming in as scheduled, will receive education prior to passing any medications. Additional Nurses and CMAs that are not onsite will receive education via telephone and a signed acknowledgement of education will be obtained prior to their next working shift. The facility Medical Director was called on 11/19/25 to notify of the Immediate Jeopardy. He agreed with the plan for removal of the Immediate Jeopardy. As need Quality Assurance Performance Improvement (QAPI) team meeting was held to review the plan for removal on 11/19/25. Implementation of the plan of removal was verified onsite on 11/19/25 by conducting observations, record reviews, and staff interviews. Scope and Severity was reduced to Level I. Implementation was verified through: Record review of new admissions audit from 11/18/25 through 11/19/25 to ensure accurate medication reconciliation, review and continuation of medications and treatments.Record review of staff signature sheets for checked all other medication carts to determine if there were any issues with the Narcotic counts. No discrepancies were identified. No pre-poured medications are allowed. Medications are not to be left unsecured and unattended. Medication carts will be locked at all times when out of site or unattended.Interviews with nurses regarding in-services and on pre-pouring medication and leaving medications unsecure.Interview with the Administrator and DON regarding plan of removal, audits, and medication reconciliation processes.

Based on interview and record review, the facility failed to implement and maintain an effective Infection Prevention and Control Program during a COVID-19 (a viral respiratory disease) outbreak affecting all 58 residents residing on Unit A, when: The facility failed to exclude symptomatic staff from resident contact. The facility did not effectively identify and control the spread of infection. The facility failed to prevent unit-wide clustered transmission consistent with uncontrolled spread. This deficient practice like resulted in residents acquiring COVID-19 infections with prolonged isolation precautions. The findings are: A. Record review of the facility's Infection Prevention and Control Program (IPCP) Policy, revised 06/02/25, revealed the facility is required to: Prevent, identify, report, investigate, and control infections. Maintain a system of surveillance to identify infections before they spread. Implement standard and transmission-based precautions; Exclude staff with communicable diseases from resident contact; Maintain a system for staff to report illness and remain off work while symptomatic. B. On 11/18/25 at 12:50 p.m., during an interview with the Infection Preventionist (IP), she stated the COVID-19 outbreak began when a Certified Nurse Aide (CNA) worked while sick, and a housekeeper had worked while symptomatic before testing positive. She stated the outbreak started on 08/20/25 through 09/04/25, and the facility conducted testing every three days until the entire facility tested negative for COVID-19. She stated many residents became symptomatic. The IP stated, one hall would get better, and another would start getting positives [with COVID-19], and the facility isolated all residents in their rooms due to ongoing spread. C. On 11/20/25 at 11:45 a.m., during an interview with the Administrator (ADM), he confirmed he was aware of the COVID-19 outbreak affecting Unit A from 08/20/25 through 09/04/25. He stated residents and staff were tested repeatedly as new positive cases occurred. The ADM confirmed it was his expectation staff would not work while experiencing COVID-19 symptoms.

Based on record review and interviews, the facility failed to ensure 1 (R #3) of 1 (R #3) residents reviewed received the appropriate pharmacy services when: R #3 did not receive prescribed medications as ordered. A follow-up and coordination with the pharmacy and prescribing providers was completed when R #3's ordered medications were unavailable. The facility did not obtain nor administer the complete provider-ordered taper of Venlafaxine (antidepressant) during a cross-taper process (a process used when switching antidepressants. It involves gradually reducing the dose of one antidepressant while simultaneously increasing the dose of another) resulting in an unintended interruption of therapy. This deficient practice is likely to place residents at risk for withdrawal symptoms, worsening mental health symptoms, and delayed treatment. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses: Anxiety disorder (a medical condition in which a person experiences ongoing, excessive fear or worry interfering with daily life). Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Attention Deficit Hyperactivity Disorder (ADHD) (a neurodevelopmental condition involving persistent patterns of inattention, hyperactivity, or impulsivity that interfere with daily functioning or development. B. Record review of R #3's Physician Orders Summary Report dated 11/19/24 revealed the following: Venlafaxine oral tablet 75 mg (milligram), extend release -2 capsules by mouth for depression. May increase to 225 mg if patient tolerates well for one week. Methylphenidate (central nervous system stimulant medication used primarily to treat attention-deficit/hyperactivity disorder (ADHD) and narcolepsy) 20 mg 1 tablet by mouth 2 times daily. C. Record of review of R #3's Care Consultant Report dated 6/23/25 revealed the following: Gradual Dose Reduction (GDR; the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) of Methylphenidate. Dose reduction should occur in the modest increments over adequate period of time to minimize withdrawal symptoms and to monitor symptom recurrence. GDR is attempted in 2 separate quarters, with at least 1 month initiated such medications. DON accepted the recommendation, implement as written, working with psychiatric care (branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) to slowly taper Methylphenidate. D. Record review of R #3 Medication Administration Record (MAR), dated 07/01/25 through 07/07/25 revealed the following: R #3 did not receive Venlafaxine for the dates of 07/01/25 through 07/07/25. E. Record review of R #3's provider visit notes dated 07/08/25 revealed the following: R #3 was out of her Venlafaxine for several days and had thoughts of suicide. R #3 is now back on her medication and no further suicidal ideations, still struggling with depression. Will change Venlafaxine to 150 mg every morning, if tolerating after one week increase to 225mg. F. On 11/18/25 at 8:38 a.m., during an interview with the Director of Nursing (DON), she stated R #3 went approximately one week without receiving the prescribed Venlafaxine taper medication during a cross-taper process from a previous antidepressant to Wellbutrin (bupropion-antidepressant). The DON stated the pharmacy provided only the first week of the Venlafaxine taper capsules and failed to send the second week due to insurance-related issues, resulting in the medication not being available in the facility. The DON stated this resulted in the abrupt discontinuation of Venlafaxine, a medication known to cause withdrawal symptoms if stopped without an appropriate taper. The DON stated R #3 experienced increased anxiety and distress related to the interruption in her medication regimen, and the facility holds responsibility for ensuring residents receive all prescribed medications regardless of insurance or pharmacy barriers. G. On 11/18/25, at 8:55 AM, during an interview with R #3's Medical Doctor (MD), he stated he expected all residents to receive the full ordered taper, meaning the complete provider-prescribed tapering schedule, including all ordered doses and duration. The MD confirmed he relied on the facility to notify him if medications were unavailable. He stated he was contacted after the facility learned the second week of medication had not been supplied and confirmed he had not been previously informed the resident missed multiple doses. H. On 11/19/25 at 1:27 PM, during an interview with R #3's Psychiatric Provider (PP), he stated on July 14, 2025, R #3 reported she had not received her prescribed Venlafaxine. He stated R #3 described experiencing joint pain, urinary difficulties, emotional distress, including crying during the therapy session, and reported contacting the physician and working with the New Mexico State Ombudsman (a government official who investigates and tries to resolve complaints, usually through recommendations (binding or not) or mediation) regarding her medication concerns. The PP stated R #3 was undergoing a GDR of another medication, and her Venlafaxine was part of a cross-taper process (gradually withdraw the first antidepressant). The PP confirmed R #3 could have experienced depression, anxiety, and/or tearful episodes when she did not receive Venlafaxine as ordered.

Based on record reviews and interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long-term care) was accurate for 1 (R #3) of 1 (R #3) resident reviewed for PASARR accuracy when the facility did not properly screen for mental disorders or intellectual disabilities prior to admission. This deficient practice is likely to result in the facility not providing the specialized services and support needed by residents. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses: Anxiety disorder (a medical condition in which a person experiences ongoing, excessive fear or worry interfering with daily life). Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Attention Deficit Hyperactivity Disorder (ADHD: a neurodevelopmental condition involving persistent patterns of inattention, hyperactivity, or impulsivity that interfere with daily functioning or development. B. Record review of R #3's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/13/25, revealed the resident received antidepressant medication (medication to relieve the symptoms of depression). C. Record review of R #3's base line Care Plan, dated 11/19/2024, revealed R #3 used an antidepressant for depression. D. Record review of R #3's most recent PASARR, dated 01/17/25, revealed the following: Section A (Type of Review) was left blank. Section A identifies the type of PASRR review conducted (e.g., preadmission, annual review, significant change, or readmission) and establishes the purpose of the screening. Section C, which identifies mental illness evaluation criteria including diagnoses such as Schizophrenia (serious mental health condition that affects how people think, feel, and behave including hallucinations, delusions, and disorganized thinking and behavior, leading to a distorted sense of reality), disorders of mood, panic, anxiety, personality, psychotic, and substance-related disorders (this list is not all-inclusive), was answered No. E. On 11/18/25 at 9:52 AM, during an interview with the Admissions Director (AD), she stated R #3's PASARR dated 01/17/25 was incorrect. She stated Section A should not have been left blank, which meant that section had not been completed. The AD also stated Section C was inaccurate because R #3's mental illness section did not include her diagnoses and was marked No, despite her having major depressive disorder, anxiety disorder, and cognitive issues. The AD confirmed R #3's PASARR must reflect all relevant diagnoses and align with the information on the medical orders, but it did not. F. On 11/18/25 at 10:05 a.m., during an interview with the Social Services Assistant (SSA), she stated current PASARR responsibilities involve completing Level I screenings (a federal requirement designed to ensure that individuals with serious mental illness or intellectual disabilities are appropriately assessed before admission) and coordinating Level II evaluations (aims to determine the most appropriate placement and whether specialized services are needed) when indicated. The SSA stated she is familiar with the PASARR form but has not received formal PASARR training and receives instruction from the Social Services Director (SSD), who also addresses PASARR questions from Admissions. The SSA stated she did not complete R #3's PASARR dated 01/17/25 and was not involved in the completion or review of that PASARR. G. On 11/20/25 at 11:45 AM, during an interview with Administrator (ADM), he stated PASARR responsibilities are divided between Admissions and Social Services. Admissions handle PASARRs at intake, while Social Services manages post-admission updates for residents. The AD stated it is his expectation for all PASARRs to be screened properly for accuracy. H. On 11/20/25, at 1:27 PM, during an interview, the SSD stated the admission Department, and the Social Services Department complete the PASARR process together. She stated R #3's PASARR was incorrect because Section A was left blank and R #3's diagnosis was not listed in Section C. The SSD stated it is her expectation for all PASARRs to be screened properly to ensure residents who triggered the PASARR received the necessary services and support.

Based on record review and interviews, the facility failed to notify the Medical Director (MD) of missed antidepressant doses for 1 (R #3) of 1(R #3) resident reviewed for medications when: The facility did not administer medications according to the prescribed schedule, including not following proper tapering protocols for an antidepressant medication. The facility failed to provide timely (immediate) communication with the Medical Director. These deficient practices are likely to result in untreated or worsening depression, delayed treatment, and adverse reactions for the residents. The findings are: A. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses: Anxiety disorder (a medical condition in which a person experiences ongoing, excessive fear or worry interfering with daily life). Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Attention Deficit Hyperactivity Disorder (ADHD) (a neurodevelopmental condition involving persistent patterns of inattention, hyperactivity, or impulsivity that interfere with daily functioning or development. B. Record review of R #3's Physician Orders Summary Report dated 11/19/24 revealed the following: Venlafaxine oral tablet 75 mg (milligram), extend release -2 capsules by mouth for depression. May increase to 225 mg if patient tolerates well for one week. Methylphenidate (central nervous system stimulant medication used primarily to treat attention-deficit/hyperactivity disorder (ADHD) and narcolepsy) 20 mg 1 tablet by mouth 2 times daily. C. Record of review of R #3's Care Consultant Report dated 6/23/25 revealed the following: Gradual Dose Reduction (GDR; the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether) of Methylphenidate.Dose reduction should occur in the modest increments over adequate period of time to minimize withdrawal symptoms and to monitor symptom recurrence.GDR is attempted in 2 separate quarters, with at least 1 month initiated such medications.DON accepted the recommendation, implement as written, working with psychiatric care (branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders) to slowly taper Methylphenidate. D. Record review of R #3 Medication Administration Record (MAR), dated 07/01/25 through 07/07/25 revealed the following: R #3 did not receive Venlafaxine for the dates of 07/01/25 through 07/07/25. E. Record review of R #3's provider visit notes dated 07/08/25 revealed the following: R #3 was out of her Venlafaxine for several days and had thoughts of suicide.R #3 is now back on her medication and no further suicidal ideations, still struggling with depression. Will change Venlafaxine to 150 mg every morning, if tolerating after one week increase to 225 mg. F. On 11/18/25 at 8:38 a.m., during an interview with the Director of Nursing (DON), she confirmed the Medical Director (MD) was not notified of R #3 missing multiple doses of Venlafaxine or not having the medication readily available, and the MD should have been notified. G. On 11/18/25, at 8:55 AM, during an interview with the Medical Director (MD), he stated he relied on the facility to notify him if medications were unavailable. The MD confirmed he was not contacted by the facility regarding R #3's missed Venlafaxine doses until the second week R #3 had not received that medication. The MD confirmed he should have been notified sooner and stated he would have written a hard copy prescription and arranged for it to be filled at a local pharmacy.

Based on record reviews and interviews, the facility failed to provide access to medical records for 1 (R #3) of 1 (R #3) resident reviewed for access to medical records. If the facility fails to provide residents with access to their medical records upon request, then residents' rights to review, obtain, and understand their own health information is compromised.This deficient practice is likely to result in delays involving care, lack of informed decision-making, and unnecessary barriers to exercising their rights. The findings are: A. Record review of the facility's Health Information Management Manual dated 02/28/24 revealed the following: Each resident has the right to access his or her protected health information contained in the medical record. Residents are notified of their right to access Protected Health Information (PHI) in the Notice of Privacy Practices given upon admission to the facility. When a request is made by a current resident or another party to view or copy the medical record, those requests should be directed to the Health Information Management Director/Privacy Official. The resident or personal representative has the right to review his or her records under federal law. Requested copies should be provided within two working days (excluding weekends and/or holidays) if the resident currently resides at the facility unless state law mandates a shorter period. The facility must provide a timely, written denial to the individual, which includes the basis for the denial and, if applicable, a statement of the individual's review rights. B. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE] with the following diagnoses: Anxiety disorder (a medical condition in which a person experiences ongoing, excessive fear or worry interfering with daily life).Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life).Attention Deficit Hyperactivity Disorder (ADHD: a neurodevelopmental condition involving persistent patterns of inattention, hyperactivity, or impulsivity interfering with daily functioning or development). C. Record review of an email dated 07/01/25 at 4:45 PM, revealed the New Mexico (NM) State Ombudsman (a government official who investigates and tries to resolve complaints, usually through recommendations (binding or not) or mediation) requested medical records on behalf of R #3. D. Record review of an email dated 07/08/25 at 12:19 PM, from the Director of Nursing (DON) to the Pharmacist Consultant revealed the following: -Venlafaxine (antidepressant) was reordered by a facility Registered Nurse (RN) on 06/16/25. DON's request to the Pharmacy Consultant regarding documentation of R #3's medication delay. Documentation requested by NM State Ombudsman on behalf of R #3. E. Record review of an email dated 07/24/25 revealed a follow-up request from the NM State Ombudsman for R #3's medical records. F. Record review of an email dated 08/05/25 revealed the following: NM State Ombudsman's initial request on behalf of R #3's medical records occurred on 07/01/25. Request to be processed within 24 hours, per resident rights. G. Record review of an email dated 08/11/25 at 12:18 PM, revealed the Administrator (ADM) had requested the Medical Records Director (MRD) to hand-deliver R #3's medical records to R #3. H. On 11/18/25 at 8:34 AM, during an interview with the DON, she stated R #3 requested information regarding her medications the first week of July 2025. The DON stated R #3 wanted to know what had occurred with her (R #3) medications and how to prevent future delays. She stated pharmacy communication and records are not part of the resident's medical records and no medical records release form had been provided to R #3. I. On 11/18/25, at 10:25 AM, during an interview with R #3, she stated she had requested her medical records in the first week of July 2025. R #3 stated she requested the records from several facility nurses, the DON, MRD, and the ADM. R #3 also stated she has not received any records and was not given a reason for the lack of documentation and has not received anything in writing from the facility regarding her request for the delay. R #3 confirmed she has not been given any part of her medical records, which she states was also requested by the NM State Ombudsman on behalf of her request. J. On 11/18/25, at 11:32 AM during an interview with the MRD, she stated R #3's request for her medical records was initially received via email from the NM State Ombudsman on August 5, 2025. The MRD stated she spoke with R #3 on August 11, 2025, to clarify the request, and R #3 stated she wanted records regarding her medications. The MRD informed R #3 that her pharmacy information was not a part of the medical record request. The MRD confirmed emails were exchanged regarding R #3's medications between herself, the DON, and the Pharmacy Consultant, with the first discussion involving the medical records request occurring on 08/12/25. K. On 11/20/25, at 11:32 AM during an interview with the ADM, he stated he had not been aware of R #3's request for medical records in June 2025. He explained medical records staff handled requests for residents with a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) of 15 (alert and oriented) and no Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care), although he had not reviewed the specific written policy. The ADM stated it was his expectation all residents receive their medical records easily and as quickly as possible. The ADM confirmed there was no reason the facility could not print and provide the records requested by R #3.

Based on record review and interview, the facility failed to promote resident choices for 1 (R #2) of 1 (R #2) resident reviewed for choices, when an outside individual entered the resident's room and removed a religious item without obtaining authorization from the resident's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care). If the facility does not honor residents' choices, then residents are likely to experience a loss of independence and self-worth leading to feelings of frustration and depression. The findings are: A. Record review of R #2's face sheet revealed he was admitted into the facility on [DATE] with the following diagnoses: Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors, difficulty with walking, movement and coordination), Nontraumatic Intracerebral Hemorrhage (is a type of stroke). B. Record review of R #2's Quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 09/28/25 revealed R #2's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) is 03 (00 to 7 is severe impairment). C. On 11/17/25 at 11:39 a.m., during an interview with the facility's Ombudsman (a government official who investigates and tries to resolve complaints, usually through recommendations (binding or not) or mediation), she stated R #2's POA, reported a priest entered R #2's room and removed a statue containing a sacramental wafer (sacred element used in Christian rituals) on 06/18/25. The Ombudsman stated she informed the Director of Nursing (DON) during a face-to-face meeting on 06/27/25, and R #2's family believed the item should not have been removed. The Ombudsman also expressed concern that the camera in R #2's room had been turned off for approximately eight minutes around the time of the incident. D. On 11/17/25 at 12:07 p.m., during an interview with R #2's POA, she stated the religious item was a statue containing a consecrated wafer (a small piece of unleavened bread used in Christian (especially Catholic) communion that has been blessed by a priest). She stated volunteers from the Catholic Church photographed the statue and later a priest entered R #2's room and took the item without informing her. R #2's POA stated the priest claimed he asked R #2 for permission, but R #2 has dementia and could not reliably provide informed consent. R #2's POA stated she believed the removal of the item constituted theft and stated she expected to be notified before any personal belongings were removed. E. On 11/19/25 at 10:48 a.m., during an interview with the Director of Nursing (DON), she stated she was aware of the item being removed from R #2's room, but she was not aware of who turned off R #2's camera during the time of the priest being in the room. The DON stated it is her expectation that no one, regardless of their status, would enter R #2's room and turn off a camera or take anything from the resident's room without permission from the resident and/or the POA. F. On 11/20/25 at 10:45 a.m., during an interview with Medical Records (MR), she stated the priest spoke to R #2 before removing the wafer and then notified R #2's family. She stated she had notified the family on 06/18/25. G. On 11/20/25 at 2:26 p.m., during an interview with the Administrator (ADM), he stated the priest entered the facility, declared the item sacrilegious (an inappropriate or disrespectful use of a consecrated religious object), and removed it from R #2's room without notifying the POA. The ADM stated R #2 has dementia and is not consistently oriented, but the facility did not permit any outside individual regardless of clergy status to enter a resident's room and remove personal items without authorization from the legal decision maker and/or resident. The ADM confirmed the situation should have been addressed through a care conference with the R #2's POA, but it was not.

Based on observation, record reviews, and interview, the facility failed to store food under sanitary conditions when staff failed to ensure: 1. Food items were labeled, dated, and protected in the kitchen dry storage and refrigerator. 2. The kitchen was clean and free of stains, spatters, and food debris. 3. Single use items were covered and protected. 4. Staff wore hairnets and beard guards while working in the kitchen. 5. The ice machine drained through an air gap. These deficient practices are likely to affect all 110 residents listed on the resident census list provided by the Administrator on 05/12/25. These failures are likely to lead to foodborne illnesses in residents if food is not stored properly and if staff do not adhere to safe food handling practices. The findings are: Food Storage A. Record review of the facility's Food safety Policy, dated 05/01/24, revealed the following: - Pre-packaged food should be placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container should be labeled with the name of the contents and date (when the item was transferred to the new container). 'Use by Date' should be noted on the label or product when applicable. - Food should be labeled with the date received if not already indicated on the item. - Leftovers should be dated properly and discarded after 72 hours unless otherwise indicated. - Food should be stored and maintained in a clean, safe, and sanitary manner following Federal, State, and local guidelines to minimize contamination and bacterial growth. B. On 05/13/25 at 9:19 am, observations of the dry storage in the kitchen revealed the following: - One container of granulated garlic opened and undated, - Prepared fruit cups undated, - Several pizza slices undated, - One bag of bread opened, unsealed, and undated, - One bag of taco seasoning opened and undated, - One bag of steak seasoning opened and undated, - One box of baking soda open to air and undated, - One bag of breaded rectangles open to air and undated, - One bag of pasta open to air and undated, - One bag of pasta opened and undated, - Two bags of corn chips opened and undated, - One bag of Macaroni noodles undated, - One bag of Frosted Flakes opened and undated, - One box of [NAME] Krispies opened and undated, - One box of Froot Loops opened and undated, - One bag of cheesecake mix opened and undated, - One bag of whole grain bread opened and undated. C. On 05/13/25 at 9:19 am, observations of the refrigerator in the kitchen revealed the following: - Two, 2 liter root beer bottles opened and undated, - One strawberry jam container opened and undated, - One whipped topping container opened and undated, - One bottle of Med Pass (a nutritional supplement drink) opened and undated, - One bag of brown bread opened and undated, - Three pies open to air and undated, - Thirteen cereal cups unlabeled, - One sweet and sour sauce opened and undated. D. On 05/13/25 at 10:25 am, during an interview, the Dietary Manager (DM) stated all food items should be labeled, dated, and stored protected from air and other contaminations. Cleanliness E. Record review of the kitchen cleaning schedule, dated 05/12/25 through 05/18/25 revealed staff were to do the following areas daily: - Clean stove, - Clean beverage station, - Clean hand sink and check the paper towels, - Sweep and mop, - Send mops and aprons to housekeeping to wash them. F. On 05/13/25 at 9:19 am, observations of the kitchen revealed the following: - The kitchen wall contained stains and spatters by food. - Microwave had food particles on top. - The stove had black debris around the burners, and the oven had white splashes on the front and side. - The kitchen baseboard, located near the cooking equipment, had black buildup. - A lower shelf on the food preparation table held pans and had white splatter and crumbs. - A sugar container had a lid which did not fit the container and brownish debris inside the container on the sugar. G. On 05/13/25 at 10:25 am, during an interview, the facility's DM stated kitchen floors, walls, surfaces and appliances should be cleaned according to the cleaning schedule. Single Use Items H. Record review of the facility's Food Safety Policy, dated 05/01/24, revealed the policy did not address the storage of single use items. I. On 05/13/25 at 9:19 am, observations of the kitchen revealed the following: - A stack of cloth napkins sat by the hand washing sink and exposed to water splashes. - A stack of Styrofoam plates and a stack of plates were exposed and not protected. J. On 05/13/25 at 10:25 am, during an interview, the facility's DM stated single use items should be protected and stored away from the sink. Hairnet and Beardguards K. Record review of the facility's Food Safety Policy, dated 05/01/24, revealed the following: - Physical contaminants are foreign objects that may inadvertently enter the food. Examples include, but are not limited to, staples, fingernails, jewelry, hair, glass, metal shavings from can openers, and pieces or fragments of bones from fish or chicken for example. - The policy did not address the use of hairnets or beardguards. L. On 05/13/25 at 9:19 am, observations of the kitchen revealed the following: - [NAME] #1 did not wear a hairnet in a manner to cover all her hair. [NAME] #1's hair hung out of the hairnet two inches around her face. - A dietary staff had facial hair which measured greater than 1/4 inch. Further observation revealed the staff washed dishes but did not wear a beard guard. M. On 05/13/25 at 10:25 am, during an interview, the DM stated staff should wear hairnets and beard guards in a manner to cover all their hair when working in the kitchen. Ice Machine N. Record review of the facility's Food Safety Policy, dated 05/01/24, revealed ice machines must be of a type that eliminates contamination during ice manufacture, storage, and dispensing. The policy did not address the placement of the ice machine drain pipe or the hand washing sink drain pipe. O. On 05/13/25 at 9:19 am, observation of the kitchen revealed the ice machine did not drain through an air gap. The drain pipe from the ice machine drained below the surface of the floor. Further observation revealed the hand washing sink drained on top of the ice machine drain pipe, which caused a black substance around the end of the ice machine drain pipe. P. On 05/13/25 at 10:25 am, during an interview, the facility's DM stated she was not aware the ice machine did not drain through an air gap. She did not know the drain pipe from the ice machine drained below the surface of the floor. The DM was not aware the hand washing sink drained on top of the ice machine drain pipe. She stated the drain pipes should have been built in a way that prevents ice contamination due to dirty water coming into contact with the drain pipe and bacteria growing up into the ice machine.

Based on observations, interviews, and record review, the facility failed to ensure Nurses and Certified Medication Aides (CMAs) dated opened insulin (a medication prescribed to help the body turn food into energy and manages blood sugar levels) pens and discarded them within 28 days of opening date for 3 (R #44, R #45, and an unidentified R) of 3 (R #44, R #45, and an unidentified R) residents reviewed. This deficient practice is likely to result in all 3 residents receiving medications that are less effective or expired in the facility. The findings are: A. Record review of the facility's Medication Storage Policy, dated 2025, revealed if a multidose vial of an injectable medication has been opened or accessed, then the vial should be dated and discarded within 28 days, unless the manufacturer specifies a different date. B. On 05/14/25 at 1:09 pm, observation of the 100 Hall medication cart revealed the following: - Insulin Lispro (a short-acting insulin),100 units/milliliter (ml) multiple-dose pen was opened, not dated, and was labeled with R #45's last name only. The insulin pen belonged to R #45. - Insulin Lispro,100 units/ml multiple-dose pen was opened and dated 03/27/25. The insulin pen belonged to R #44. - Insulin Lispro,100 units/ml multiple-dose pen was opened and not dated or labeled. The owner of the pen could not be verified, because the pen did not have a resident's name on it. C. Record review of the manufacturer's instructions for Insulin Lispro multiple dose vial, dated 2023, revealed staff were instructed to throw away all opened vials after 28 days of use, even if there was insulin left in the pen. D. Record review of R #45's Physician Orders, dated 02/04/24, revealed R #45 had an order to receive Insulin Lispro. E. Record review of R #44's Physician Orders, dated 04/15/25, revealed R #44 had an order to receive Insulin Lispro. F. On 05/14/25 at 1:09 pm, during an interview, Nurse #1 stated she should have discarded the opened insulin pens within 28 days of the opening date. She stated she did not know one pen did not have an owner. G. On 05/15/25 at 10:24 am, during an interview, the Director of Nursing (DON) stated staff must date the opened insulin pens and discard them within 28 days of the opening date. She stated staff should also label insulin pens with the resident's name when they open the pen for the first time. H. On 05/15/25 at 1:20 pm, during an interview, the facility's Consultant Pharmacist (CP) #1 stated she expected Nurses and CMAs to date the opened insulin pens and discard them within 28 days of the opening date. She stated staff should label insulin pens with the resident's name when they first use them.

Based on observations, record reviews and interviews, the facility failed to ensure the facility was free of the potential for accidents and hazards for residents in B unit, when staff failed to ensure the following: 1. The Emergency Cart (E-cart, a mobile unit that contains essential supplies, and equipment needed to respond to life-threatening emergencies in hospitals and other medical facilities) was locked to prevent access to scissors and other medical supplies. 2. Shower room was locked to prevent access to shaving razors and hazardous cleaning materials. These deficient practices are likely to affect all the 37 residents in B Unit listed on the resident census list provided by the Administrator on 05/12/25 and are likely to lead to residents experiencing avoidable accidents. The findings are: A. Record review of the facility's E-cart Policy, dated 07/22/24, revealed Emergency Carts should be in a central and convenient location and used only during emergencies. The policy did not address locking the E-cart to prevent unauthorized access. B. On 05/12/25 at 2:30 pm, observation of B Unit revealed the following: - Shower room in the B Unit was unlocked and unattended. Staff stored shaving razors and a Cloralen (bleach cleaner) bottle in an unsecured vanity inside the shower room. Further observation revealed several residents walked by the shower room and were not accompanied by staff. - An E-cart in the B unit Day Room was unlocked and contained one pair of scissors, several intravenous (IV) catheters, and oxygen tubing. All items were accessible to residents. Further observation revealed five residents sat unattended by staff in the day room where the E-cart was stored. C. Record review of Cloralen's Manufacturer recommendations, dated 6/19/2024, revealed the following precautions for safe handling: - Ensure good ventilation of the workstation. - Wear personal protective equipment. - Do not eat, drink or smoke when using this product. - Always wash hands after handling the product. D. On 05/14/25 at 8:09 am, during an interview, Nurse #1 stated she did not know if the E-Cart should be locked. E. On 05/14/25 at 8:28 am, during an interview, Certified Nursing Assistant (CNA) #4, CNA #5, and CNA #6 stated they should have locked the shower room while not in use. F. On 05/14/25 at 10:17 am, during an interview, the Director of Nursing (DON) stated staff should always lock the E- Cart, except for restocking it or in case of emergency. She stated the IV catheters and oxygen tubes can pose risks to residents in B Unit if left accessible to them. The DON also stated staff should lock the shower room in B Unit when not in use.

Based on record review and interview, the facility failed to provide care that met professional standards for 1 (R #105) of 1 (R #105) resident when the facility failed to obtain and administer carvedilol (used to treat high blood pressure and certain heart conditions) as ordered by the physician. This deficient practice could likely result in a resident having an adverse reaction due to not receiving medications as ordered. The findings are: A. Record review of R #105's face sheet indicated an admission date of 04/02/25 with the following diagnoses: - Type II diabetes (DM2, a condition which results from insufficient production of insulin, causing high blood sugar), - Dementia (affects memory, thinking and social abilities), - Hypertension (high blood pressure). B. Record review of R #105's physician orders, dated 04/02/24, revealed an order for carvedilol tablet 3.125 milligram (mg). Give one tablet by mouth two times a day for hypertension. C. Record review of R #105's Medication Administration Record (MAR) revealed staff did not administer carvedilol 3.125 mg tablet to R #105 at 5:00 pm on 05/10/25, 05/13/25, 05/14/25, 05/15/25, and 05/18/25. D. Record review of R #105's nursing progress notes, dated 05/13/25, 05/14/25 and 05/15/25, indicated staff did not administer the carvedilol to R #105, because the medication was not available. E. On 05/16/25 at 9:00 am, during an interview, Certified Medication Technician (CMT) #3 stated the pharmacy did not send R #105's carvedilol medication. She stated the carvedilol was ordered on 05/08/25. She stated she checked on the status of the medication almost everyday. She stated she did not have access to the emergency kit (eKit; holds medications to use during an emergency), so she asked the nurse on duty to get the medication from the eKit for her. She stated the nurse called the pharmacy to get an access code to the eKit to get her the carvedilol for R #105. She stated the nurse called the pharmacy every morning to get access to the eKit for the carvedilol. She stated staff would also have to accessed the eKit at night to give the evening dose of carvedilol, but it did not appear that was happening. F. On 05/16/25 at 9:08 am, during an interview, Nurse #12 stated she went to the eKit to pull the carvedilol for R #105. She stated all nurses had access to the eKit, and they could also call the DON for access to it. G. On 05/16/25 at 9:35 am, during an interview, the Medical Director stated R #105 received carvedilol for hypertension. The MD stated if R #104 did not receive carvedilol as ordered, then she could develop high blood pressure. He stated R #105 should receive her medication as ordered. H. On 05/16/25 at 10:14 am, during an interview, the Director of Nursing (DON) stated all nurses did not have access to the eKit. She stated if the nurses did not log in after a period of time, then they lost access to the eKit. The DON stated if a nurse lost access, then the nurse should have asked another nurse to pull the medication. The DON stated any nurse could pull the medication out of the eKit.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for 1 (R #57) of 3 (R #16, #41 and #57) residents when staff failed to ensure R #57 received showers timely. This deficient practice could likely result in residents being at a higher risk for infection and to feel unimportant, embarrassed, and undignified. The findings are: A. Record review of R #57's Face Sheet, dated 05/15/25, revealed an initial admission date of 08/13/21. B. Record review of R #57's Care Plan, last reviewed on 05/15/25, revealed the resident required the assistance of one staff for activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). C. Record review of R #57's shower tracking revealed the resident's scheduled shower days were Wednesday and Saturday evening. Further review revealed R #57 did not receive a shower from 05/07/25 through 05/14/25. D. Record review of R #57's medical record, dated May 2025, revealed staff did not document why R #57 did not receive a shower from 05/07/25 through 05/14/25. E. Record review of R #57's progress notes, dated 05/14/25, revealed the Director of Nursing (DON) returned a phone call to R #57's daughter regarding the daughter's concerns R #57 did not receive a shower in five days. F. On 05/16/25 at 9:36 am during an interview, the DON stated R #57's shower tracking indicated the resident did not have a shower for seven days. The DON the resident's record did not contain documentation as to why R #57 did not receive a shower for seven days. She stated the resident's record should contain a follow-up with notes regarding the reason why R #57 did not receive her shower.

Based on record review and interview, the facility failed to revise the care plan for 1 (R #105) of 1 (R #105) resident reviewed for care plans. If the facility is not updating the care plan to reflect the resident's current care areas and treatment, then the facility may not be providing the appropriate care and treatment to meet the residents' needs. The findings are: A. Record review of R #105's face sheet indicated an admission date of 04/02/25 with the following diagnoses: - Type II diabetes (DM2, a condition which results from insufficient production of insulin, causing high blood sugar), - Dementia (affects memory, thinking and social abilities), - Hypertension (high blood pressure). B. Record review of R #105's physician orders, dated 05/08/25, indicated an order for oxygen at 2 liters/minute continuously per nasal cannula. Keep oxygen saturation above 90 percent (%). C. Record review of R #105's care plan revealed the care plan did not address the resident's use of oxygen. D. On 05/16/25 at 10:15 am during an interview, the Director of Nursing (DON) stated that if a resident received oxygen, then it should be addressed in the resident's care plan.

Based on observation, interview, and record review, the facility failed to ensure a resident wore her oxygen, and the oxygen ran continuously for 1 (R #105) of 1 (R #105) resident reviewed for oxygen. If the facility is not following orders for oxygen use then the resident may be low on oxygen, which had the potential to cause health concerns such as headache, difficulty breathing or rapid heart rate. The findings are: A. Record review of R #105's face sheet indicated an admission date of 04/02/25 with the following diagnoses: - Type II diabetes (DM2, a condition which results from insufficient production of insulin, causing high blood sugar), - Dementia (affects memory, thinking and social abilities), - Hypertension (high blood pressure). B. Record review of R #105's physician orders, dated 05/08/25, indicated an order for oxygen at 2 liters (L)/minute continuously per nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). Keep oxygen saturation (the amount of oxygen in blood) above 90 percent (%). C. Record review of R #105's oxygen saturations, dated 05/09/25, revealed the following: - On 05/09/25 at 12:14 am and 12:17 am, 87% on room air. - On 05/09/25 at 6:39 am, 90% on 2 L of oxygen. D. On 05/14/25 at 10:14 am, during an observation, R #105 wore her nasal cannula, but the oxygen concentrator (a medical device that provides supplemental oxygen by concentrating oxygen from ambient air) was not on. E. On 05/14/25 at 3:00 pm, during an observation, R #105 participated in activities in the dining area without her oxygen. F. On 05/15/25 at 3:09 pm, during an interview, Nurse #11 stated residents should wear their oxygen nasal cannula at all times if the resident had an order for continuous oxygen . G. On 05/16/25 at 10:00 am, during an interview, the Medical Director stated if a resident had an order for continuous oxygen, then they should wear the oxygen at all times. He stated he can change the resident's order if a resident did not need supplemental oxygen or did not use the supplemental oxygen as ordered.

Based on record review and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #14) of 1 (R #14) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are: A. Record review of R #14's face sheet revealed an admission date of 07/25/24 with the following diagnoses: - Chronic respiratory failure with hypoxia (low levels of oxygen in the blood), - Chronic obstructive pulmonary disease (COPD; lung disease), - Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), - Paroxysmal atrial fibrillation (a type of irregular heartbeat.) B. Record review of R #14's MDS, dated [DATE], indicated R #14's primary language was English. C. Record review of R #14's MDS, dated [DATE] indicated R #14's primary language was English. D. Record review of R #14's MDS, dated [DATE], indicated R #14's primary language was English. E. On 05/15/25 at 12:13 pm, during an interview, Nurse #10 stated when R #14 spoke, she spoke in Navajo. Nurse #10 stated R #14 understood some English. She stated the facility had staff that spoke Navajo so they will find a staff member to translate as needed. F. On 05/15/25 at 12:19 pm, during an interview, Certified Nursing Assistant (CNA) #9 stated R #14 spoke primarily Navajo. CNA #9 stated she will find a staff member who speaks Navajo to translate when R #14 spoke to her in Navajo. CNA #9 stated R #14 answered yes or no questions in English. She stated R #14's primary language was Navajo, and the resident understood Navajo better than English. G. On 05/15/25 at 11:30 am, during an interview, the Social Services Director (SSD) and the Social Services Assistant (SSA), the SSA stated she spoke Navajo fluently, and R #14 spoke primarily Navajo. The SSA stated she completed R #14's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) on 01/23/25 in English, and the resident scored 8 out of 15, which indicated moderate cognitive impairment (scores 8 to 12 indicate moderate cognitive impairment). The SSA stated she completed R #14's BIMS on 04/24/25 in Navajo, and the resident scored 12 out of 15. The SSD stated she believed the discrepancy in the resident's BIMS score likely had to do with which language staff conducted the interview. She stated R #14's MDS should reflect R #14's primary language which was Navajo.

Based on observation and interview, the facility failed to identify quality deficiencies through their Quality Assurance and Performance Improvement Plan (QAPI; a structured framework used in healthcare to enhance the quality of care provided to patients) when staff were unaware the exit doors in the Memory Unit did not function as they were supposed to when the fire alarm was activated. This deficient practice is likely to affect all 118 residents, per census list provided by the Administrator (ADM) on 05/12/25. This deficient practice could likely result in staff and residents not able to safely evacuate the facility in case of emergency. The findings are: A. On 05/15/25 at 1:56 pm during an observation, staff activated the fire alarm, and all three exit doors on the Memory Unit failed to unlock when the fire alarm was activated. B. On 05/16/25 at 10:29 am during an interview, the Administrator stated he was not aware the exit doors in the Memory Unit did not function correctly. He stated he became aware of this issue on 05/15/25 when staff tested the fire alarm. He stated his expectation was for facility staff to recognize the failure before the fire alarm test on 05/15/25.

Based on interview and record review, the facility failed to ensure that nursing staff had the competencies required to ensure 2 (R #1 and R #12) out of 2 (R #1 and R #12) residents received care that met the health and safety needs of the residents when staff failed to: - Prevent R #12 from rolling off the bed, causing a serious head injury that resulted in death. - Position R #1's catheter leg bag (a bag that is attached to the leg and catches urine) below his catheter (tube placed in the bladder to drain urine from the bladder) while he was in bed, which could cause urine to back up into the bladder and cause an infection. - Properly assist R #1 with standing, which caused him pain. The findings are: Findings for R #12 A. Record review of the face sheet for R #12 indicated the resident was admitted on [DATE] with the following diagnoses: - Muscular dystrophy (a group of diseases that cause progressive muscle weakness and loss of muscle mass), - Obesity (overweight), - Chronic pain, - Cardiac pacemaker (regulates the heart), - Disc degeneration (disk in your spine start to wear out and cause and pain). B. Record review of the medical record for R #12 revealed the resident's weight was 285 pounds (lbs) as of 05/14/24. C. Record review of the quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for R #12, dated 03/28/24, indicated the resident was dependent (two or more staff do all of the effort, and the resident does none of the effort to complete the activity) in the following areas: - Roll left and right: The ability to roll from lying on back position to the left and right sides and return to lying on back position on the bed. - Sit to lying: The ability to move from sitting position on the side of bed to lying flat on the bed. - Lying to sitting on side of bed: The ability to move from lying on the back position to sitting on the side of the bed and with no back support. D. Record review of the care plan intervention for R #12, dated 12/27/23, indicated the resident required the assistance from one or two staff with all activities of daily of living (ADLs; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). E. Record review of the nursing progress notes for R #12, revealed the following: - On 05/16/24 at 1:56 pm, late entry note, R #12 had a witnessed fall from the bed onto the floor. Certified Nursing Assistant (CNA) #3 notified the nurse on the unit of the fall that occurred during peri-care. R #12 rolled out of bed onto her left side, as staff assisted her with a brief changed. R #12 was alert and oriented. R #12's left toe was bent backwards and bleeding. R #12 had abrasions on her left back shoulder, left temple, and left elbow. She required four staffs' maximum assistance to roll onto back, and staff assisted her off the floor with a mechanical lift (a device which assists care givers to transfer residents). Staff notified the provider, started the paperwork to transfer R #12 to the hospital, and notified emergency medical services (EMS). - On 05/16/24 at 2:14 pm, CNA #3 called for the nurse to report the resident rolled out bed during a brief change. Nurse assessed R #12. The resident was able to follow every direction and answer questions appropriately. The resident's arms were strong equally, but she was only able to bend the right leg without issues. The resident was not able to bend the left leg without issues. The resident's third toe on her left foot was bent backward, and R #12 stated it was really painful to the touch. The resident's left shoulder was painful, and R #12 had a hematoma (bruise: localized bleeding outside of blood vessels, due to either disease or trauma) on top of her left eye with a small abrasion. F. Record review of the hospital medical records for R #12, dated 05/16/24 at 3:58 pm, indicated the following: - An acute large subdural hemorrhage (bleeding that occurs in the membranes surrounding the brain) resulting in uncal herniation [life threatening trauma causing the brain to shift and herniate (an organ or fatty tissue squeezes through a weak spot in a surrounding muscle or connective tissue )] and midline shift (pressure from the hematoma pushes the brain off-center) measuring 1.4 centimeter (cm). There was trace subarachnoid hemorrhage [bleeding within the subarachnoid space (the area between the brain and the tissue covering the brain)] present with the left frontal lobe (the front part of the brain) and no intraventricular extension [bleeding into the brain's ventricular system (an interconnected series of cavities filled with cerebrospinal fluid (CSF) that cushions the brain.)] - Medical decision making: R #12 was prepped for transport to a different hospital in another city. R #12 was going to be intubated and placed on a ventilator for the transport. R #12's father had a conversation with the physician about comfort measures. The physician did a repeat of the exam, and R #12's pupils (the black opening in the middle of the colored part of your eye) bilaterally (both pupils) were dilated (open) and non-reactive [did not get smaller with light; a sign of severe traumatic brain injury (TBI), usually considered a sign of irreversible brain damage and strongly associated with a very poor outcome (death, vegetative state, or severe disability) in most patients.] The physician told the father he did not think R #12 would survive the transfer. She was placed on comfort measures. G. Record review of the hospital nursing progress note for R #12, dated 05/16/24 indicated R #12 arrived at the hospital unit from the emergency room and was obtunded (diminished responsiveness to stimuli), including painful stimuli. R #12's heart rate was 120 to 130 beats per minute (bpm) range (normal heart rate is 70 to 90 bpm), and her oxygenation (amount of oxygen in the blood) was in the 50 to 70 range (normal range is between 90 and 100%). R #12 passed away on 05/16/24 at 19:49 (7:49 pm). H. On 07/09/24 at 10:45 am during an interview with the Director of Nursing (DON), she stated a CNA went to change R #12. The CNA pulled the bed away from the wall and asked R #12 to roll herself onto her side. CNA #3 started to clean the resident, and R #12 rolled off the bed. The DON stated pulling the bed away from the wall was not standard practice. The DON stated CNA #3 asked R #12 if she was able to roll, and the resident stated yes. The DON stated she did not think the CNA should have moved the bed away from the wall unless there was another person present on the other side. I. On 07/09/24 at 2:25 pm, during an interview with CNA #3, she stated she worked with R #12 on 05/16/24 . She stated she was doing her last rounds, and it was shift change. CNA #3 stated she checked R #12, and the resident needed to be changed. She stated that one side of R #12's bed was against and the wall and before she started to change her she moved the bed away from the wall, raised the bed up higher, and locked the bed wheels. CNA #3 stated that if she needed to access to the other side of the bed, then she will pull the bed away from the wall. She said she asked R #12 if she could hold herself on her side, and the resident said yes. CNA #3 stated she cleaned R #12 up and went around the bed to the other side to continue to clean her up. CNA #3 stated R #12 started to roll over (forward from her side), and she could not stop her. CNA #3 stated R #12 fell to the ground and hit her head. CNA #3 stated she notified the nurse immediately. CNA #3 stated she typically changed R #12 with another person; however, it was shift change, and everyone was busy. CNA #3 stated she decided to change the resident alone. J. On 07/11/24 at 10:25 am, during an interview with CNA #5, she stated she always used two people when she did pericare (cleaning the private areas) on a resident. She stated she would never move the bed away from the wall, unless there was another person with her to stand on the other side with the resident. She stated she worked with R #12 before, and the resident would not provide assistance when she was changed. CNA #5 stated R #12 was a heavier lady and did not have much strength. CNA #5 stated she would never change R #12 alone, because the resident absolutely required two people to change her. K. On 07/11/24 at 10:37 am, during an interview with CNA #4, she stated if there was a larger resident who was not very strong and unable to assist with pericare, then she would not change them alone. She stated she would always ask someone for help. She stated she never did pericare alone for safety reasons. CNA #4 also stated if she did not have another person to be on the other side of the resident's bed, then she would not move the bed away from the wall. L. On 07/11/24 at 10:43 am, during an interview with CNA #6, she stated she would not move the resident's bed away from the wall if it was just her doing pericare. She stated she worked with R #12 before, and she would not change her alone. She stated there was always someone [staff] available to assist if you needed help, such as the nurses. M. On 07/10/24 at 2:13 pm, during an interview with the Nursing Educator (NE), she stated that when she stepped into the Educator role, she was told she needed to do a training on two person assist. She stated she was not sure what the issue was exactly. She stated she did not find issues with two person or Hoyer lift transferring. NE stated she was aware of the incident with CNA #3 and R #12 however she stated she was going to do training with everyone regarding brief changes, because she did not want to single out CNA #3 (who was the CNA involved in the fall with R #12). The Educator stated she training did not occur because she stepped down from the position. Findings for R #1's catheter leg bag. N. Record review of the medical record face sheet for R #1 revealed he was admitted on [DATE]. He was admitted with the following diagnoses: - Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) - Difficulty walking, - Communication deficit, - Intracerebral hemmorrhage (a brain bleed and a type of stroke. It causes blood to pool between the brain and skull and prevents oxygen from reaching the brain. It is life-threatening), - Type II diabetes (the body does not use insulin properly), - Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) - Neuromuscular dysfuntion of bladder (a problem in the brain, spinal cord, or central nervous system which creates a loss of bladder control). - This is not an all inclusive list. O. Record review of the physician orders for R #1 indicated orders to change catheter bag as needed for infection, obstruction, or when the closed system is compromised. Keep catheter placed below the level of the bladder. Start date: 06/13/24. P. On 07/09/24 at 5:18 pm, during an interview with R #1's Power of Attorney (POA)/Family Member, she stated she saw numerous recordings from a video camera in R #1's room of staff putting the catheter leg bag on the resident. The POA stated staff come and put the leg bag on him early in the morning. She stated R #1 did not get out of bed for hours, so he lay there with the leg bag at the same height as the catheter. The POA stated the resident's catheter leg bag must be below the catheter, so it drained into the leg bag. She said if the leg bag was level with the catheter then it will drain back into his bladder and cause an infection. Q. Record review of a video from the video camera in R #1's room indicated the following: - On 06/02/24 at 5:54 am, the resident transferred from his bed to the reclining chair and had on his catheter leg bag. - On 06/19/24 at 4:42 am, a Nurse (N) #9 placed a catheter leg bag on R #1. The resident lay in bed and slept. R #1 did not get out of bed at this time. - On 06/19/24 at 8:35 am, R #1 lay in bed and had on his catheter leg bag. R. On 07/11/24 at 1:42 pm, during an interview with CNA #2, she stated there were two nights last week, sometime between 07/01/24 and 07/07/24, when R #1 had his catheter leg bag on while he was asleep in bed. She stated she did not think staff took it off him the day before. S. On 07/11/24 at 3:30 pm the Director of Nursing (DON) stated she thought it was the CNAs who did not remove the catheter leg bag when they put R #1 to bed at night, but it was a nurse who did not remove it. The DON stated the catheter leg bag should be removed and connected to the bag hanging off of the bed. Findings for R #1 standing assistance. T. Record review of the medical record face sheet for R #1 revealed he was admitted on [DATE]. He was admitted with the following diagnoses: - Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life) - Difficulty walking, - Communication deficit, - Intracerebral hemmorrhage (a brain bleed and a type of stroke. It causes blood to pool between the brain and skull and prevents oxygen from reaching the brain. It is life-threatening), - Type II diabetes (the body does not use insulin properly), - Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) - Neuromuscular dysfuntion of bladder (a problem in the brain, spinal cord, or central nervous system which creates a loss of bladder control). - This is not an all inclusive list. U. On 07/09/24 at 5:18 pm, during an interview with Power of Attorney (POA)/Family Member, she stated she was very upset when she saw a video on 06/17/24 where staff assisted R #1 with getting up by pulling his right arm. She stated she called the facility immediately told them to stop pulling the resident by his right arm to get him up. She stated she could tell the resident was in pain on the video, and she could hear him speaking in Spanish that he was in pain. She stated when she got back into town on 06/22/24, she took R #1 to get a new set of x-rays on his right shoulder and ribs, because the resident complained of pain. The POA stated R #1 had extensive bruising over his right side. She stated R #1's shoulder was not asymmetrical (same), because his right shoulder had a bump on top. She stated she was concerned that it was a fracture. V. Record review of R #1's x-rays, dated 07/23/24, revealed the following: - R #1's right shoulder: a communicated fracture (fracture refers to a bone that is broken in at least two places), of the distal clavicle (break in the collarbone, one of the main bones in the shoulder) with adjacent soft tissue swelling. - R #1's right ribs and chest area: an oblique lucency (fracture across the width of the bone with low density) is in the fourth rib. Cortical irregularity (constant traction of the soft tissue attachments) of the lateral third rib. Displaced lateral fifth rib fracture (a rib bone breaks and becomes misaligned or shifts from its normal position, leading to significant chest pain and potential breathing difficulties) and cortical step-off in the sixth lateral rib (minimally displaced fracture). Displaced second rib fracture. W. Record review of the pain scale (zero meant no pain, and 10 meant the worst possible) for R #1 indicated the following: - The resident did not typically report pain, with staff documenting R #1's pain to be 0, no pain. - On 06/14/24, the resident reported pain four times from 1:15 pm to 11:47 pm. - On 06/17/24, the resident reported his pain to be a 5. - On 06/18/24, the resident reported his pain to be a 2. - On 06/20/24, the resident report his pain to be a 3. X. Record review of the orthopedic physician notes, dated 06/26/24, indicated R #1 complained of right clavicle pain, right side rib pain, and elbow pain due to multiple falls. Y. Record review of the orthopedic physician orders, dated 06/26/24, indicated R #1 should remain in a sling, with no pulling or lifting using right side due to fracture at right clavicle and elbow and no using right upper extremity. The resident would be non-weight bearing with right upper extremity (right arm), and staff were to have R #1 lean more to the left side. Z. Record review of a video from the video camera in R #1's room revealed the following: - On 06/19/24 at 8:35 am, R #1 was in pain (evident by grimacing and did not want to get out of bed.) CNA #2 encouraged the resident to get up and pulled on R #1's right arm to assist him to get up. R #1 indicated he did not want to get up and was in pain. R #1 told CNA #2 that he was in pain. CNA #2 encouraged R #1 to get into his wheelchair so they could go to the nurse's station to get pain medication. - On 06/20/24 at 10:15 pm, Nurse #9 pulled on R #1's right arm to get him out of bed and told him to get up. AA. On 07/11/24 at 1:42 pm, during an interview with CNA #2, she stated she was aware R #1 had fallen on 06/14/24 and 06/17/24. She stated she was told he fell but was not given any other information. CNA #2 stated the resident had a sling on his right arm, but he did not keep the sling on much. She stated she was not aware of the extent of R #1's injuries at that time. CNA #2 stated she tried to pull R #1 up by his arm on 06/19/24 and the next day 06/20/24 she was told to stop pulling on his arm by the nurse. CNA #2 stated R #1's POA called the nursing station to report she saw CNA #2 pull R #1 up by his arm on the video. CNA #2 stated R #1 was very bruised on 06/19/24. She stated that they do use gait belts to assist with getting residents up but it didn't work well with him (she did not clarify why it was hard). BB. Record review of photos taken by the POA/Family Member of R #1, taken on 06/22/24, indicated extensive bruising on R #1's right side. He had dark purple bruising on his right side shoulder blade area, top of his shoulder, under his arm. The back of his arm had dark purple bruising, yellow bruising on his shoulder and rib/chest area, and had yellow bruising on his right temple. He had scabs and both yellow and purple bruising on his right elbow. CC. On 07/11/24 at 2:03 pm, during an interview with Nurse #3, she stated that there was not any specific training given to the CNAs or nurses around R #1's bruising and concerns to his right side. She stated R #1 still used his right arm and did not seem to be in any pain. Nurse #3 stated they did not receive any specific training on how to assist with transferring of R #1 after they found out about his broken clavicle (shoulder) and broken ribs. Based on interview and record review, Immediate Jeopardy (IJ) was identified on 07/11/24 at 3:15 pm to the administrator and the Director of Nursing, in person. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 07/12/24 at 8:00 am. Implementation of the POR was verified onsite on 07/12/24 with ongoing trainings for staff around issues of competent nursing staff. Scope and severity was reduced to E. Plan of removal: Resident #1 was discharged to the hospital on May 16, 2024. Resident #12 was reassessed by therapy to review level of assist for transfers. Staff working with Resident #2 were educated to follow the individual care plan that was updated on how to transfer safely with regards to his current fracture. Resident #2 was also reassessed regarding his catheter bag needs and the care plan was updated. Staff working with Resident #2 were educated to follow catheter needs as directed by care plan. Identification of others having the potential to be affected: - An audit was completed on July 11, 2024 by the DON and Infection Preventionist (IP) Nurse to ensure that all residents who require peri-care are care planned for level of assistance required with peri-care. All changes will be reflected in the Kardex for CNAs. - An audit was completed on July 11, 2024 by the DON and IP Nurse to ensure that all residents with current fractures are care planned for level of assistance required due to their injury. All changes will be reflected in the Kardex for CNAs. - An audit was completed on July 11, 2024 by the DON and IP Nurse to ensure that all residents with urinary catheter bags are care planned with catheter bag change instructions. All changes will be reflected in the Kardex for CNAs. Measures / systemic changes to ensure the deficient practice does not recur: - Policies and procedures related to person centered care planning and resident rights were reviewed and utilized for education. - Education of licensed nursing staff and CNAs related to providing peri-care per individual care planned needs will be completed starting on July 11, 2024. These staff will not be allowed to work until they have received the education which will be provided prior to the start of their shift. - Education of licensed nursing staff and CNAs related to how to transfer a resident appropriately who have current fractures will be started on July 11, 2024. These staff will not be allowed to work until they have received their education and will receive education prior to the start of their shift. - Education of licensed nursing staff and CNAs related to a resident's individualized catheter bag change needs will be completed to educate to follow the resident's care plans with regards to bag change needs. Medical Director was notified of the IJ on July 11, 2024. Root cause analysis completed on July 11, 2024 and taken to QAPI. QAPI to be conducted on July 11, 2024.

Based on record review and interview the facility failed to prevent an accident when staff did not provide appropriate care for 1 (R #12) out of 1 (R #12) resident looked at for accidents. This deficient practice caused R #12 to fall out of bed, hitting her head, and passing away at the hospital hours later. The findings are: A. Record review of the face sheet for R #12 indicated the resident was admitted on [DATE] with the following diagnoses: - Muscular dystrophy (a group of diseases that cause progressive muscle weakness and loss of muscle mass), - Obesity (overweight), - Chronic pain, - Cardiac pacemaker (regulates the heart), - Disc degeneration (disk in your spine start to wear out and cause and pain). B. Record review of the medical record for R #12 revealed the resident's weight was 285 pounds (lbs) as of 05/14/24. C. Record review of the quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for R #12, dated 03/28/24, indicated the resident was dependent (two or more staff do all of the effort, and the resident does none of the effort to complete the activity) in the following areas: - Roll left and right: The ability to roll from lying on back position to the left and right sides and return to lying on back position on the bed. - Sit to lying: The ability to move from sitting position on the side of bed to lying flat on the bed. - Lying to sitting on side of bed: The ability to move from lying on the back position to sitting on the side of the bed and with no back support. D. Record review of the care plan intervention for R #12, dated 12/27/23, indicated the resident required the assistance from one or two staff with all activities of daily of living (ADLs; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). E. Record review of the nursing progress notes for R #12, revealed the following: - On 05/16/24 at 1:56 pm, late entry note, R #12 had a witnessed fall from the bed onto the floor. Certified Nursing Assistant (CNA) #3 notified the nurse on the unit of the fall that occurred during peri-care. R #12 rolled out of bed onto her left side, as staff assisted her with a brief change. R #12 was alert and oriented. R #12's left toe was bent backwards and bleeding. R #12 had abrasions on her left back shoulder, left temple, and left elbow. She required four staffs' maximum assistance to roll onto back, and staff assisted her off the floor with a mechanical lift (a device which assists care givers to transfer residents). Staff notified the provider, started the paperwork to transfer R #12 to the hospital, and notified emergency medical services (EMS). - On 05/16/24 at 2:14 pm, CNA #3 called for the nurse to report the resident rolled out bed during a brief change. Nurse assessed R #12. The resident was able to follow every direction and answer questions appropriately. The resident's arms were strong equally, but she was only able to bend the right leg without issues. The resident was not able to bend the left leg without issues. The resident's third toe on her left foot was bent backward, and R #12 stated it was really painful to the touch. The resident's left shoulder was painful, and R #12 had a hematoma (bruise: localized bleeding outside of blood vessels, due to either disease or trauma) on top of her left eye with a small abrasion. F. Record review of the hospital nursing progress note for R #12, dated 05/16/24 indicated R #12 arrived at the hospital unit from the emergency room and was obtunded (diminished responsiveness to stimuli), including painful stimuli. R #12's heart rate was 120 to 130 beats per minute (bpm) range (normal heart rate is 70 to 90 bpm), and her oxygenation (amount of oxygen in the blood) was in the 50 to 70 range (normal range is between 90 and 100%). R #12 passed away on 05/16/24 at 19:49 (7:49 pm). G. On 07/09/24 at 10:45 am during an interview with the Director of Nursing (DON), she stated a CNA went to change R #12. The CNA pulled the bed away from the wall and asked R #12 to roll herself onto her side. CNA #3 started to clean the resident, and R #12 rolled off the bed. The DON stated pulling the bed away from the wall was not standard practice. The DON stated CNA #3 asked R #12 if she was able to roll, and the resident stated yes. The DON stated she did not think the CNA should have moved the bed away from the wall unless there was another person present on the other side. H. On 07/09/24 at 2:25 pm, during an interview with CNA #3, she stated she worked with R #12 on 05/16/24 . She stated she was doing her last rounds, and it was shift change. CNA #3 stated she checked R #12, and the resident needed to be changed. She stated that one side of R #12's bed was against the wall, and she moved the bed away from the wall, raised the bed up higher, and locked the bed wheels before she started to change the resident. CNA #3 stated if she needed to access to the other side of the bed, then she will pull the bed away from the wall. She said she asked R #12 if she could hold herself on her side, and the resident said yes. CNA #3 stated she cleaned R #12 up and went around the bed to the other side to continue to clean her up. CNA #3 stated R #12 started to roll over (forward from her side), and she could not stop the resident. CNA #3 stated R #12 fell to the ground and hit her head. CNA #3 stated she notified the nurse immediately. CNA #3 stated she typically changed R #12 with another person; however, it was shift change, and everyone was busy. CNA #3 stated she decided to change the resident alone. I. On 07/11/24 at 10:25 am, during an interview with CNA #5, she stated she always used two people when she did pericare (cleaning the private areas) on a resident. She stated she would never move the bed away from the wall, unless there was another person with her to stand on the other side with the resident. She stated she worked with R #12 before, and the resident would not provide assistance when she was changed. CNA #5 stated R #12 was a heavier lady and did not have much strength. CNA #5 stated she would never change R #12 alone, because the resident absolutely required two people to change her. J. On 07/11/24 at 10:37 am, during an interview with CNA #4, she stated if there was a larger resident who was not very strong and unable to assist with pericare, then she would not change them alone. She stated she would always ask someone for help. She stated she never did pericare alone for safety reasons. CNA #4 also stated if she did not have another person to be on the other side of the resident's bed, then she would not move the bed away from the wall. K. On 07/11/24 at 10:43 am, during an interview with CNA #6, she stated she would not move the resident's bed away from the wall if it was just her doing pericare. She stated she worked with R #12 before, and she would not change her alone. She stated there was always another staff available to assist if needed help, such as the nurses.

Based on record review and interview the facility failed to thoroughly assess the pain level of 2 (R #1 and #11) of 2 (R #1 and #11) residents looked at for an injury of unknown origin and pain, when staff: 1. Pulled on R #1's arm to assist him to get out of bed after complained of pain in his arm. 2. Allowed R #11 to sit in severe pain for several hours before the physician saw the resident and sent her to the emergency room for x-rays. The findings are: Findings for R #1 A. Record review of the medical record face sheet for R #1 revealed he was admitted on [DATE]. He was admitted with the following diagnoses: - Dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), - Difficulty walking, - Communication deficit, - Intracerebral hemmorrhage (a brain bleed and a type of stroke. It causes blood to pool between your brain and skull and prevents oxygen from reaching your brain it is life-threatening), - Type II diabetes (when the body does not use insulin properly) - Parkinson's disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves) - Neuromuscular dysfuntion of bladder (is when a problem in your brain, spinal cord, or central nervous system makes you lose control of your bladder). - This is not an all inclusive list. B. On 07/09/24 at 5:18 pm, during an interview with Power of Attorney (POA)/Family Member, she stated she was very upset when she saw a video on 06/17/24 where staff assisted R #1 with getting up by pulling his right arm. She stated she called the facility immediately told them to stop pulling the resident by his right arm to get him up. She stated she could tell the resident was in pain on the video, and she could hear him speaking in Spanish that he was in pain. She stated when she got back into town on 06/22/24, she took R #1 to get a new set of x-rays on his right shoulder and ribs, because the resident complained of pain. The POA stated R #1 had extensive bruising over his right side. She stated R #1's shoulder was not asymmetrical (same), because his right shoulder had a bump on top. She stated she was concerned that it was a fracture. C. Record review of a video from the video camera in R #1's room revealed the following: - On 06/19/24 at 8:35 am, R #1 was in pain (evident by grimacing and did not want to get out of bed.) CNA #2 encouraged the resident to get up and pulled on R #1's right arm to assist him to get up. R #1 indicated he did not want to get up and was in pain. R #1 told CNA #2 that he was in pain. CNA #2 encouraged R #1 to get into his wheelchair so they could go to the nurse's station to get pain medication. - On 06/20/24 at 10:15 pm, Nurse #9 pulled on R #1's right arm to get him out of bed and told him to get up. D. Record review of photos taken by the POA/Family Member of R #1 taken on 06/22/24 indicated extensive bruising on R #1's right side. He had dark purple bruising on his right side shoulder blade area, top of his shoulder, under his arm. The back of his arm had dark purple bruising, yellow bruising on his shoulder and rib/chest area, and had yellow burising on his right temple. He had scabs and both yellow and purple bruising on his right elbow. E. Record review of the pain scale (zero meant no pain, and 10 meant the worst possbbile) for R #1 indicated the following: - The resident did not typically report pain, with staff documenting R #1's pain to be 0, no pain. - On 06/14/24, the resident reported pain four times from 1:15 pm to 11:47 pm. - On 06/17/24, the resident reported his pain to be a 5. - On 06/18/24, the resident reported his pain to be a 2. - On 06/20/24, the resident report his pain to be a 3. F. Record review of the orthopedic physician notes, dated 06/26/24, indicated R #1 complained of right clavicle pain, right side rib pain, and elbow pain due to multiple falls. G. Record review of the orthopedic physician orders, dated 06/26/24, indicated R #1 should remain in a sling, with no pulling or lifting using right side due to fracture at right clavicle and elbow and no using right upper extremity. The resident would be non-weight bearing with right upper extremity (right arm), and staff were to have R #1 lean more to the left side. H. Record review of R #1's x-rays, dated 07/23/24, revealed the following: - R #1's right shoulder: a communicated fracture (fracture refers to a bone that is broken in at least two places), of the distal clavicle (break in the collarbone, one of the main bones in the shoulder) with adjacent soft tissue swelling. - R #1's right ribs and chest area: an oblique lucency (fracture across the width of the bone with low density) is in the fourth rib. Cortical irregularity (constant traction of the soft tissue attachments) of the lateral third rib. Displaced lateral fifth rib fracture (a rib bone breaks and becomes misaligned or shifts from its normal position, leading to significant chest pain and potential breathing difficulties) and cortical step-off in the sixth lateral rib (minimally displaced fracture). Displaced second rib fracture. I. On 07/11/24 at 1:42 pm, during an interview with CNA #2, she stated she was aware R #1 had fallen on 06/14/24 and 06/17/24. She stated she was told he fell but was not given any other information. CNA #2 stated the resident had a sling on his right arm, but he did not keep the sling on much. She stated she was not aware of the extent of R #1's injuries at that time. CNA #2 stated she tried to pull R #1 up by his arm on 06/19/24 and the next day 06/20/24 she was told to stop pulling on his arm by the nurse. CNA #2 stated R #1's POA called the nursing station to report she saw CNA #2 pull R #1 up by his arm on the video. CNA #2 stated R #1 was very bruised on 06/19/24. She stated that they do use gait belts to assist with getting residents up but it didn't work well with him (she did not clarify why it was hard). J. On 07/11/24 at 2:03 pm, during an interview with Nurse #3, she stated there was not any specific training given to the CNAs or nurses around R #1's bruising and concerns to his right side. She stated R #1 still used his right arm and did not seem to be in any pain. Nurse #3 stated they did not receive any specific training on how to assist with transferring of R #1 after they found out about his broken clavicle (shoulder) and broken ribs. Findings for R #11 K. Record review of the Face Sheet for R #11 indicated R #11 was admitted on [DATE]. She had the following diagnoses: - Dementia, - Heart disease, - Cardiac pacemaker (small, battery-powered device that prevents the heart from beating too slowly), - Diabetes, - Long term use of anticoagulants (medicines that increase the time it takes for blood to clot). - This is not an all inclusive list. L. Record review of the quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for R #11, dated 04/18/24, indicated R #11 required maximum assistance (helper does more than half the effort) with most of her activities of daily living (ADLs; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating), to include showering and bathing. R #11 was always incontinent (can not control urine or feces) of bowel and most of the time incontinent of bladder. M. On 07/09/24 at 8:52 am, during an interview with the daughter of R #11, she stated she received a call from facility staff about 1:30 pm on 06/26/24 that something happened with her mother in the shower. She stated staff told her that her mother was fine, and there was not anything wrong with her. She stated staff told her since R #11 did not want the staff to touch her, they were going to send her mother out to the emergency room . She stated the physician from the hospital called her around 3:30 pm. The daughter stated when she got to the hospital, the hospital staff told her they needed to do surgery on her mother, because both of her mother's legs were fractured. The daughter stated she spoke to her mother in Navajo R #11, and her mother told her the guy (unknown staff) who took care of her was not careful and dropped her. The daughter said her mother had a stroke at some point while in the hospital and passed away on 06/30/24. N. Record review of the nursing progress notes for R #11, dated 06/26/24 at 11:50 am, indicated R #11 complained of severe pain to both knees, and the left was worse than the right. Resident cried out and yelled out. Resident had a history of bilateral knee surgeries. Unable to assess knees as resident pushed nurse hands away to check for swelling. Asked if she would try Bengay for pain, and the resident did not want nursing staff to touch her knees. Resident wanted to have a towel under her feet as her feet dangled down. The resident would not let staff put her feet on footrest because of increase pain with movement. Resident was left sitting near nurses station and did not want to be wheeled in her wheelchair sinced it caused increase pain in her knees. The resident did not want to be taken into the dining room for lunch. Physician would be in and assess pain medication. O. Record review of the nursing progress notes for R #11 indicated the resident was sent to the hosptial after the physician assessed her. Director of Nursing (DON) was notified at 1:19 pm, and emergency medical services was notified at 1:20 pm. P. Record review of the Medical Records from the hopsital, dated 06/27/24, indicated R #11 had bilateral femur fractures (broken bones in both legs). Resident was admitted to the hopsital on 06/26/24 at 14:01 (2:01 pm). Q. On 07/09/24 at 2:10 pm, during an interview with DON, she stated she was not sure of when staff notified her of R #11's pain. She stated if R #11 was in a lot of pain, she wished staff notified her sooner. The DON stated she knew the Medical Director (MD) was in the building and told the nurse the MD needed to see R #11. The DON stated the nurse wrote a progress note in reference to R #11, and it indicated R #11 was in a lot of pain. R. Record review of the physician orders for R #11 revealed the following orders: - An order for acetaminophen, 325 mg start date 12/13/23, two tablets every four hours by mouth. - An order for Tramadol, 50 mg. Give one tablet by mouth every eight hours as needed for moderate to severe pain, dated 06/26/24 at 12:52 pm. S. Record review of the medication administration record (MAR) for R #11, dated 06/01/24 to 06/26/24, revealed the following: - Staff administered a dose of acetaminophen to R #11 on 06/26/24 at 12:21 am, 8:59 am, and 12:59 pm. - Staff did not administer a dose of the Tramadol before resident left to go to the hosptial. T. On 07/10/24 at 8:20 am, during an interview with Nurse #10, she stated Certified Nursing Assistant (CNA) #9 and CNA #10 transferred R #11 back into the wheelchair after her shower. The nurse stated when the CNAs brought the resident out of the shower, R #11 complained of knee pain. Nurse #10 stated R #11 was in a lot of pain, and the resident told her the pain was in both knees, with one of them hurting more than the other. Nurse #10 stated she could not give the resident any more Tylenol, because R #11 already received it that morning. Nurse #10 stated she called the physician. She said he was in a meeting, but she knew he was in the building that day. She stated the physician saw R #11, and she was in a lot of pain. The physician ordered Tramadol for R #11, but R #11 was sent out and did not receive the Tramadol. U. On 07/10/24 at 8:45 am, during an interview with CNA #9, he stated he came to work on 06/26/24 around 8:30 am. He said he immediately looked at the shower list, and R #11 was on it. He said the resident was complaining of pain when he arrived that day so the nurse gave R #11 a Tylenol for the pain. He said he gave R #11 a shower around 9:00 am. He stated the resident required two people for transferring in the shower. He stated another CNA (he did not know who) helped him get R #11 into the shower chair. CNA #9 stated after the shower, he turned on the call light, and CNA #10 helped him get R #11 dressed and back into her wheelchair. CNA #9 stated he worked with R #11, and she never complained of pain. He said R #11 was in a lot of pain, and the nurse told the resident she could not give her anything else for the pain. CNA #9 stated the nurse told R #11 the physician would be in to see her. He said R #11 cried out in pain and got really loud. CNA #9 stated they sent the resident out to the hospital hours later, but she was in a lot of pain that whole time. CNA #9 stated R #11 did not fall in the shower. V. On 07/10/24 at 11:40 am during an interview with the Physician, he stated he could not remember what time he saw (it was around lunch time, maybe 12:30 pm) R #11 on 06/26/24, but she was complaining of knee pain. He said R #11 was in severe pain, cried, and pointed to her knee. The Physician stated R #11 spoke Navajo, and he had a staff member translate for him. He stated the resident did not say anything other than she was in pain. He stated he sent R #11 out to get x-rays, and she had a fracture. He said he suspected the resident fell , but staff did not report a fall to him. He stated a fall or a twisting motion might have caused that kind of femur fracture. W. On 07/10/24 at 11:31 am, during an interview with the Director of Rehabilitation (DOR), she stated that she heard R #11 crying and screaming out out in pain on 06/26/24, and she went to check on the resident. The DOR stated R #11 pointed to her leg but did not want anyone to touch her leg or to look at it. She said the timeframe was between 9:00 am and 11:00 am.

Based on record reviews and interviews, the facility failed to notify the residents Healthcare Power of Attorney (POA)/sister and the facility physician when abnormal vital signs were identified during the first 23 hours of her stay for 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for short stay admissions. This deficient practice likely resulted in the death of R #1. The findings are: A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: diabetes type II (an impairment in the way the body regulates and uses sugar/glucose as a fuel), chronic obstructive pulmonary disease (a lung disease that causes obstructed airflow from the lungs), chronic respiratory failure with hypoxia (a lung disease characterized by low levels of oxygen in your body tissues), gastro-esophageal reflux disease (when stomach acid repeatedly flows back into the tube/esophagus connecting your mouth and stomach), hypertension (high blood pressure), hypothyroidism (a condition in which your thyroid gland doesn't produce enough of certain crucial hormones) and weakness. B. Record review of R #1's Admission/Readmission Collection Tool dated [DATE] revealed that R #1 was admitted to the facility on [DATE] at 3:00 pm. C. Record review of nursing progress notes dated [DATE] 18:00 (6:00 pm) Report not received from hospital. Called ER to get report .The nurse stated she did not know how resident took her meds as no meds were given while at the hospital Note further identified that no fasting blood sugars (FSBS) were taken at the hospital. Resident confirmed that she was not given any medication and her FSBS were no taken at anytime while she was in the ER nor did she eat d/t (due to) diarrhea as she was afraid to eat. D. Record review of R #1's Order Summary Report dated [DATE] revealed Hyperglycemia (the medical term for a high blood sugar/glucose level) protocol - notify MD (medical doctor) as needed if blood sugar is greater than 400. E. Record review of R #1's Pulse Summary revealed the following: [DATE] 16:11 (4:11 pm) - 131 bpm [DATE] 23:08 (11:08 pm) - 109 bpm [DATE] 6:39 am - 122 bpm [DATE] 10:07 am - 122 bpm [DATE] 14:49 (2:49 pm) - 148 bpm [DATE] 15:35 (3:35 pm) - 148 bpm F. Record review of the following website www.mayoclinic.org/healthy-lifestyle/fitness/expert-answers/heart-rate on [DATE] revealed A normal resting heart rate (pulse) for adults ranges from 60 to 100 beats per minute. G. Record review of R #1's Respiration (respiratory rate is the number of breaths taken per minute) Summary revealed the following: [DATE] 16:11 (4:11 pm) - 22 breaths/minute (b/m) [DATE] 23:08 (11:08 pm) - 20 b/m [DATE] 14:49 (2:49 pm) - 36 b/m [DATE] 15:35 (3:35 pm) - 36 b/m H. Record review of the following website www.verywellhealth.com/tachypnea-function-and-treatment-914914 on [DATE] revealed The normal respiratory rate for an adult ranges from 12 to 18 breaths per minute. If you take more than 20 breaths per minute for at least a few minutes, you would be described as having tachypnea (a medical condition causing a respiratory rate greater than normal, resulting in abnormally rapid and shallow breathing). I. Record review of R #1's Blood Sugar Summary revealed the following: [DATE] 18:49 (6:49 pm) - 334 mg/dL (milligrams per deciliter) [DATE] 7:57 am - 400 mg/dL [DATE] 12:23 pm - 495 mg/dL J. Record review of the following website www.webmd.com/diabetes/normal-blood-sugar-levels-chart-adults on [DATE] revealed Target Blood Sugar Level for (Adults with) Diabetes: Fasting less 100 mg/dL, Before a meal ,d+[DATE] mg/dL, After a meal (,d+[DATE] hrs.) less than 180 mg/dL, Before exercise, if taking insulin at least 100 mg/dL and Bedtime ,d+[DATE] mg/dL. K. Record review of R #1's Temperature Summary revealed the following: [DATE] 6:39 am - 102.4 degrees [DATE] 10:04 am - 102.4 degrees [DATE] 12:09 pm - 99.4 degrees [DATE] 14:49 pm (2:49 pm) - 101.9 degrees [DATE] 15:35 (3:35 pm) - 101.9 degrees L. Record review of the following website www.webmd.com/first-aid/normal-body-temperature on [DATE] revealed For a typical adult, body temperature can be anywhere from 97 F (degrees Fahrenheit-temperature scale at which pure water freezes was defined as 32 F and the boiling point of water was defined to be 212 F) to 99 F. M. Record review of R #1's nursing progress notes dated [DATE] and morning of [DATE] revealed no outreach made to Facility Physician (FP) #1 regarding abnormal vitals. N. Record review of R #1's nursing progress note dated [DATE] at 11:50 am revealed Resident had a large emesis (episode of vomiting) after breakfast .BS (blood sugar) was 400 this morning. No s/s (signs or symptoms) of hypo/hyperglycemia noted .she is very weak .she is running a lowgrade fever right now of 99.4. O. Record review of R #1's nursing progress notes [DATE] at 6:00 pm revealed that the Physician was contacted at 3:30 pm on [DATE] regarding abnormal vitals at which time, the physician advised the staff to send R #1 to the emergency room as he suspected she may be septic (an infection in the blood stream). P. On [DATE] at 10:20 am, during an interview, Facility Physician (FP) #1 reported that the nursing staff should notify him if blood sugar readings are over 400 and that he would expect a call, if a blood sugar reading was 495 as the resident could be at risk for DKA (diabetic ketoacidosis-a life threatening problem that affects people with diabetes and occurs when the body starts breaking down fat at a rate that is much too fast; then the liver processes the fat into a fuel called ketones, which causes the blood to become acidic) or HSS (hyperglycemic hyperosmolar syndrome-is a serious complication of diabetes and occurs when a person's blood glucose/sugar levels are too high for a long period of time leading to severe dehydration/extreme thirst and confusion). FP #1 reported that weakness, vomiting, resting pulse rate of over 100 and a fever are symptoms associated with hyperglycemia. FP #1 reported that a consistent at rest pulse rate of 120 or over is considered high and of concern. FP #1 reported that he does not recall being contacted by the nursing staff at the facility about R #1 prior to him telling them (staff) to send her (R #1) to the ER due to abnormal vitals late afternoon on [DATE]. Q. On [DATE] at 11:59 am, during an interview, the Interim Director of Nursing (IDON) reported that if a residents' blood sugar reading is consistently 400 or above, the resident could be at risk of diabetic neuropathy (a type of nerve damage that can occur throughout the body, if you have diabetes and your blood sugar/glucose runs high). The IDON reported I would consider (a blood sugar reading of) 495 high, you could have a silent MI (myocardial infarction, otherwise known as a heart attack), because it kills a lot of the nerves off. If I happened upon (a blood sugar reading of) 495 I would not do anything unless the (residents') orders say to, because some doctors only write to recheck (a blood sugar reading) at 500. The symptoms listed (in nursing progress note dated [DATE] at 11:50 am) and the (blood sugar reading of) 400 would not be of concern, but I would check with someone else like it's hard to tell what to do, if you have no history like her (R #1) coming from the hospital. The IDON reported that a resting pulse rate of anything above 100 would be considered high and the nursing staff should monitor the resident closely. R. On [DATE] at 1:45 pm, during an interview, LPN (Licensed Practical Nurse) #1 (worked with R #1 afternoon [DATE] and afternoon [DATE]) reported that she notified the Assistant Director of Nursing (ADON) at the time, who is now the IDON about the abnormal vitals she took for R #1 on [DATE] shortly after her shift began at 2:00 pm. LPN #1 reported the vitals of concern to her were R #1's fever (high temperature), rapid heart rate (pulse) and breathing (respirations). LPN #1 reported that 99.4 or higher is considered a high temperature or fever, a pulse rate of 115 or higher is considered a high heart rate and anything over 200 is considered a high blood sugar reading. LPN #1 reported that as R #1 was being sent out to the ER late afternoon on [DATE], she was declining fast, she was moaning instead of talking or responding to questions asked of her, she was sweating a lot, she had a fever and her breathing was Kussmaul breathing (deep, labored breathing that is seen when the body or organs have become too acidic). S. On [DATE] at 1:55 pm, during an interview, LPN #2 (worked with R #1 in the morning of [DATE]) reported that she figured R #1 had a large emesis after breakfast on [DATE], because she had a diagnosis of acid reflux (also known as gastro-esophageal reflux disease) and a fever. LPN #2 reported that R #1 was also very weak the morning of [DATE]. LPN #2 reported that the blood sugar reading of 400 that was taken on [DATE] at 7:57 am was high and the blood sugar reading taken on [DATE] at 12:23 pm of 495 was really high. LPN #2 reported (On [DATE]) for me, I did not think there was anything alarming, because she (R#1) was talking to me and she ate breakfast and then threw up. LPN #2 reported we changed the sheets (after R #1 threw up) and her (R #1's) clothing and then everything was fine except her pulse rates were high too ([DATE] 6:39 am & 10:07 am pulse rate was 122 and [DATE] 2:49 pm pulse rate was 148). LPN #2 confirmed that she did not make outreach to the Physician regarding R #1's vitals. T. On [DATE] at 12:30 pm, during an interview, FP #1 reported that a respiration rate of ,d+[DATE] would be considered normal and he would definitely be concerned and would want to be notified by the nursing staff, if the respiration rate of a resident was over 20. U. Record review of R #1's Power of Attorney for Healthcare document dated [DATE] revealed [full name of R #1's Healthcare Power of Attorney (POA)/Sister] is listed as the designation of agent (a person that has been legally empowered to act on behalf of another person or entity). V. Record review of the facility policy titled Changes in Resident's Condition or Status issued [DATE] and reviewed [DATE] revealed This facility will notify the resident, his/her primary care provider, and resident/resident representative of changes in the residents condition or status (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration-process of becoming progressively worse in health, mental, or psychosocial status in either life threatening conditions or clinical complications). W. On [DATE] at 11:56 am, during an interview, the Interim Director of Nursing (IDON) reported we (staff) did not call her (R #1's) POA when she (R #1) was declining (deteriorating) and going to be transported to the emergency room (ER) as we went with (contacted) who was listed first on her (R #'s) face sheet under Emergency Contacts, which was her son [first name of R #1's son), but it looks like her (R #1's) sister [first name of Healthcare POA/sister], should have been contacted per the POA paperwork. X. Record review of R #1's Emergency Documentation/ED (Emergency Department) Provider Note dated [DATE] 15:43 (3:43 pm) revealed Chief Compliant: coming from [name of facility] .Pt (patient) is typically alert and oriented. This morning, pt unresponsive and heart rate of 150 with a fever of 103.5 (degrees), bgl (blood glucose level) reads high .History of Present Illness: brought to the emergency department today from [name of facility] nursing home by EMS (emergency medical services) with chief of unresponsiveness. The patient was last seen at her baseline (an observation that represents the normal state of medical being) around 10 AM today. She was transported to the emergency department after she was found unconscious and unresponsive by staff later in the afternoon. She was febrile (having or showing symptoms of a fever) for EMS at 103.5 (degrees). Patient was noted to be tachypneic (rapid and shallow breathing) but O2 (oxygen) sat (saturation-the measure of how much oxygen is traveling through your body in your red blood cells) stable on her baseline oxygen. Critical Care Indication: Patient was critically ill with a high probability of imminent or life-threatening deterioration (immediate threat of great bodily harm or death). Patient was immediately intubated (a procedure involving a tube being placed into the airway that can help save a life when someone can't breathe) for airway protection. BGL greater than 400 .hyperkalemia (elevated level of potassium) .Concern for possible DKA (diabetic ketoacidosis-a life threatening problem that affects people with diabetes and occurs when the body starts breaking down fat at a rate that is much too fast; then the liver processes the fat into a fuel called ketones, which causes the blood to become acidic) given elevated blood sugar, hyperkalemia, and patient tachypneic with respiratory rate into the 40's low 50's .patient was noted to become more bradycardic (slow heart rate less than 60 beats per minute) with heart rate in the 40's .she continued to bradycardia down into the 20's and lost pulses. She did undergo immediate CPR (Cardiopulmonary Resuscitation-a series of emergency lifesaving actions performed in an effort to manually resuscitate or bring back to life) .but never regained pulses. Time of death called at 1808 (6:08 pm). Y. On [DATE] at 6:41 pm, during an interview, R #1's Healthcare POA/sister reported that she was R #1's Healthcare POA, but she was not contacted by the facility staff when the resident experienced a change in condition that lead to R #1 being taken to the hospital via ambulance on [DATE]. R #1's POA reported that her nephew (R #1's son) told her that when he went to visit R #1 (his mother) at the facility on [DATE] at around noon, she (R #1) had vomit all over her, was breathing funny like fast, short breaths, was losing her level of consciousness and declining quick. R #1's POA reported that when she got home from work on [DATE], she contacted the hospital to speak to her sister (R #1) and she was advised by the ER doctor that she (R #1) had coded (Cardiopulmonary Arrest or other emergency requiring resuscitation) and they tried CPR for 20 minutes, but it was unsuccessful and R #1 passed away. The ER doctor advised R #1's POA that R #1 had to be intubated as soon as she arrived to the hospital and that R #1 appeared to be in respiratory distress (is a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs) and the facility failed to recognize that. The ER doctor advised R #1's POA that when R #1 arrived at the ER, she also had a blood sugar reading of over 400 and her potassium level was very high. Z. On [DATE] at 10:34 am, during an interview, R #1's son reported that when he arrived on [DATE], she (R #1) had throw up all over her face and side of her body, she could not open her eyes and she was breathing funny like panting. R #1's son reported that he immediately went to the Nurses' Station and told them that they needed to tend to his mother (R #1). R #1's son reported that he observed 3 staff clean his mother (R #1) up and change her clothing. R #1's son reported it took all 3 staff to do this, because my mom (R #1) had no strength and they literally had to hold her up. R #1's son reported that he told the staff that his mother needed to be transported to the hospital as soon as possible. R #1's son reported that R #1's death certificate revealed the date and time she was pronounced deceased was [DATE] at 6:08 pm while in the hospital and that the cause of death was listed as Cardiopulmonary Arrest (the abrupt loss of heart function, breathing and consciousness), complications of diabetes and hyperkalemia. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J being called on [DATE] at 3:45 pm with the following staff members being advised: the Administrator (in-person), the Interim Director of Nursing/IDON (in-person) and the Divisional Clinical [NAME] President (telephonically/conference call). The facility took corrective action by providing an acceptable Plan of Removal (POR) on [DATE] at 11:23 am. Implementation of the POR was verified by conducting record reviews and interviews and approved onsite at 12:30 pm on [DATE]. Plan of Removal Corrective Action for Those Found to Have Been Affected by the Deficient Practice: Identified resident no longer resides at the facility. Education was provided and documented with the nurse on [DATE]. Identification of Other Residents Having the Potential to be Affected: Current residents with changes in status were evaluated and need for physician notification. No other residents were identified. Current residents with a diagnosis of Diabetes were evaluated to ensure physician orders were present for blood sugar monitoring to include when the physician is to be notified. No residents found to have been affected. Current residents with a diagnosis of Diabetes and blood sugar monitoring were evaluated to ensure blood sugar checks were performed as ordered and physician notification made and documented as ordered. Three additional residents were identified- the physician's were informed of the occurrence and the nurses involved will receive additional education. Measures/Systemic Changes to Ensure the Deficient Practice does Not Recur: The facility will begin immediate inservicing of current licensed staff on the following: -Notification of changes in resident condition or status - Signs and Symptoms of Hypo/Hyperglycemia and nursing interventions Current licensed staff will not be allowed to begin their shift until they have received the education as noted. Ongoing Monitoring: Residents with changes in status will be reviewed daily during the Grand Rounds process Monday thru Friday. A modified clinical Grand Rounds process will occur on the weekends and holidays. This review during the Grand Rounds process will include ensuring timely physician notification. Blood sugar results will be reviewed during the Grand Rounds process for nurse follow up as ordered by physician to include documentation of nurse follow up. Weekly audits of clinical records for residents with changes in status including blood sugar monitoring will be completed. Findings from the weekly audits will be immediately addressed with the nurse. The facility will continue to provide the inservicing as noted above to newly hired licensed staff, annually and as needed. All components of this plan of correction will be submitted to the facility QAPI meeting and additional recommendations will be made if needed. The Medical Director was notified and agrees with the plan of correction. The interim Director of Nursing and/or designee is responsible for the corrections and continued monitoring.

Based on record review and interview, the facility failed to prevent two facility acquired pressure ulcers for 1 (R #37) of 2 (R #s 37 and 112) reviewed for pressure sores. This deficient practice caused R #37 to develop a pressure sore on her right and left heels causing the resident to have to undergo debridement (the removal of damaged tissue or foreign objects from a wound) of both pressure sores on both heels, pain, and being uncomfortable. The findings are: A. Record review of R #37's nursing progress notes dated 05/23/18, indicated the following, resident complained of right foot pain after being laid down after supper . B. Record review of R #37's nursing progress notes dated 05/25/18, indicated the following, resident cooperative with care. Medications taken without difficulty. Good appetite and fluid intake. Received in report this morning that resident has redness to bilateral (both sides) heels. Upon assessment, 4 cm (centimeter) x (by) 4 cm blood blisters were noted to bilateral (both sides) heels. New orders (date unknown): Apply bilateral soft heel boots when in bed or wheelchair for pressure relief. Remove boots for transfers and showers only. Float heels while in bed. Place on regular Q2 (every 2) hour turning schedule for left buttock pressure relief . C. Record review of R #37's nursing progress notes dated 05/30/18, indicated the following, . Right heel dark purple narcotic (sic, necrotic, old dead tissue cells) tissue noted, very light purple soft tissue to the left heel noted. Changed coccyx (tailbone) wound dressing noticed 1 cm x 0.8 cm open area with yellow slough (is a non-viable fibrous yellow tissue) to wound bed, 0.3 cm redness surrounding area. D. Record review of the nursing progress notes dated 05/30/18, indicated the following, physical therapy to perform MIRE (Monochromatic Infrared Energy, a therapy used to reduce pain and increase circulation) to both heels. Both heels are floating using Podus Boots (a boot that helps in the healing and prevention of heel and toe ulcers and safeguards against foot drop) for pressure relief. Repositioned every two hours, using pillows between legs. Heel remains red and purple to both heels, swelling decreasing. Unit C supervisor in to see resident, and to do a total skin check, assisted by nursing staff and CNAs (Certified Nursing Assistants). E. Record review of R #37's nursing progress notes dated 06/04/18, indicated the following, . Removed Podus boots and socks to bilateral heels and noted two blisters. Measured the longest height and width of the blisters. Right heel measured 5.3 cm x 4.3 cm. Left heel measured 4.5 cm x 3.8 cm. Bilateral blisters are filled with blood and noted slight redness surrounding the blisters. No drainage, no discomfort while cleansing wound . F. Record review of R #37's physician's progress notes dated 06/05/18, indicated that (Name of resident) now has pressure injuries on both heels. (Name of resident) also has a new sacral (a large wedge shaped vertebra at the end of the spine) wound, which is a stage III (sore extends into the tissue beneath the skin, forming a small crater) -not seen- yellow slough according to nursing. Wound care and pressure unloading. G. Record review of R #37's nursing progress notes dated 06/09/18, indicated the following, physical therapy brought resident back to unit saying they wanted a nurse to look at her heel as her sock had dried blood on it. Removed sock from left heel, wetting it with DWC ([MEDICATION NAME] Wound Cleanser, a gentle skin and wound cleanser) first to discover open area on formerly closed pressure ulcer on heel. Very superficial, 1.5 cm circle. Wound bed yellow with dots of red tissue. H. Record review of R #37's nursing progress notes dated 06/18/18, indicated the following, heel measurements are right heel 3.0 cm x 3.0 cm left heel measured 2.5 cm x 3.0 cm. Small amount of drainage noted. I. Record review of R #37's nursing progress notes dated 06/24/18, indicated the following, unstageable (Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.) deep pressure injury 3.0 cm x 2 cm to right heel no blood blister noted large dry dark area noted. Removed dry scab around edges granulating tissue surrounding the edges of the wound. Left plantar calcaneus (the heel bone) 3.0 cm x 3.0 cm. Outer edge of the wound has granulating tissue and noted a small scab over the middle section of the wound. No s/s (sign/symptoms) infection noted light drainage. J. Record review of R #37's nursing progress notes dated 07/12/18, indicated the following, wound care to Buttocks D/C'd (discontinued), healed. Wound care and debridement to bilateral heels now being done by therapy. Nursing staff to change bilateral heel dressings PRN (as needed) . K. Record review of R #37's physician's progress notes dated 07/11/18, that right side heel pressure ulcer has eschar (a dry, dark scab or falling away of dead skin) on it and left side heel has slough. L. Record review of R #37's physician's progress notes on 07/17/18, follow up on pressure ulcers both heels doing better. Physical therapy (PT) was doing debridement on the pressure sores. M. Record review of R #37's physician's progress notes on 07/24/18, indicated that pressure injuries right heel to left heel being monitored by PT and improving. Right heel wound was clean and deep and left was superficial. N. Record review of R #37's physician progress notes [REDACTED]. O. Record review of R #37's physician's progress notes indicated that on 10/02/18, that the pressure ulcer injuries on the heels, right was almost healed and left was not nearly healed. P. On 10/18/18 at 2:15 pm, during an interview with the Director of Nursing (DON), she stated that she thinks that R #37 did not get her pressure ulcer here at the facility but that when she came back from the hospital she had boggy (painful, firm, mushy) heels. She stated that the nurses are supposed to do a head to toe assessment on all residents when they come back from the hospital and she thought it was noted on that assessment. During a second interview with the DON she stated that she looked and confirmed that the pressure sore was facility acquired. Q. On 10/18/18 at 2:37 pm, during an interview with the Physical Therapist (PT), he stated that he initially started working with R #37 when she broke her hip. He stated that he got involved with R #37 and her heel pressure wounds when they became necrotic (dead tissue). He stated that nursing had been taking care of them but when there is necrotic tissue and it needs to be taken off they will usually do the debridement of the wounds. He stated that after they started to improve and no longer had necrotic tissue, the care went back to the nursing staff. R. On 10/18/18 at 2:46 pm, during an interview RN (Registered Nurse) #4, stated that she used to be the Unit Manager for hall C. She stated that she did not come back from the hospital with those wounds. She stated that R #37 was getting showers, but they weren't looking at her heels. They weren't taking off her socks and pulling her feet up to look underneath. She stated that she went back and did some education for the staff about how to do skin sweeps.

Based on observation, record review, and interview the facility failed to ensure that residents were served food under sanitary conditions. The facility's dishwasher was not reaching the final rinse temperature of 180 degrees (?) Fahrenheit (F) to sanitize dishware, which resulted in an Immediate Jeopardy (IJ) being identified on 09/27/12 at 3:35 pm. The Administrator and corporate nurse were notified of the IJ on 09/27/12 at 3:45 pm. The facility took corrective action by providing an acceptable Plan of Removal on 09/27/12 at 7:18 pm and the IJ was removed. The scope and severity was lowered to an F. The Plan of Removal included the following: 1. The facility removed all dishware from resident rooms, dining rooms, resident nourishment rooms and medication carts. The facility ordered out food for resident's and served the evening meal using paper/styrofoam dishware. 2. All kitchen staff were inserviced regarding use of an alternative chlorine based dishwashing method to sanitize dishware while the high temperature dishwasher was out of order. 3. Arrangements were made by the facility to have the dishwasher repaired and kitchen staff were then inserviced on how to properly monitor/document dishwasher temperatures. 4. The facility appointed the Dietary Manager, or another designee, to perform audits of the dishwasher temperature logs three times daily and randomly by the Executive Director. This deficient practice presents a risk for the spread of foodborne illness to all 111 residents in the facility, listed on the Census List provided by the Administrator on 09/24/12. The findings are: A. On 09/27/12 at 1:50 pm. during observation, the maximum temperature reached by the facility's dishwasher rinse cycle, while staff were operating it, was 165?F. Observation of the dishwasher rinse cycle temperature at 1:55 pm revealed the temperature to still be at 165?F. B. On 09/27/12 at 2:50 pm during an interview with Dietary Cook (DC) #1, she stated that she had used the dishwasher in the past but was unaware of the proper temperature the wash/rinse cycle needed to be. C. On 09/27/12 at 2:54 pm, during an interview with Dietary Aide (DA) #1, she stated that she understood the proper temperature for the dishwasher wash and rinse cycles to be 170?F. DA #1 was asked what she does when the dishwasher temperatures are out of range; DA #1 stated that she writes them down on the daily log, but that she does not inform management. D. Review of the dishwashing machine temperature logs from 07/03/12 to 09/26/12 noted that all of the documented 215 rinse cycle temperature readings were recorded below 180?F. E. On 09/27/12 at 3:14 pm during an interview with the dietary manager (DM), he stated that the proper temperatures for the dishwasher were 160?F-165?F for the wash cycle and 180?F for the rinse cycle. The DM stated that if the dishwasher temperatures are not within range that kitchen staff are to notify him immediately and that staff had not notified him of any out of range temperatures during the months of July 2012, August 2012 and September 2012. The DM confirmed that none of the rinse cycle temperatures on the logs for July 2012, August 2012 and September 2012 had reached 180?F. F. On 09/27/12 at 4:25 pm during an interview with Eco-Lab (EL) Employee #1, he stated that he performs routine maintenance on the facility's high temperature dish washer. EL #1 confirmed that he uses the temperature gauge on the dishwasher to measure cycle temperatures and that he replaced the rinse cycle thermometer approximately 3 weeks prior to 09/27/12. EL #1 stated that the facility had hard water and it often solidifies inside of the dishwasher's heating element resulting in the dishwasher producing lower than ideal hot water temperatures. EL #1 stated that he had previously recommended to the facility that they purchase a water softener to prolong the life of dishwasher parts and potentially stop the loss of hot water temperature.