Every finding on record at Montezuma Specialty Care

Based on observation, clinical record review, policy review, and staff interview, the facility failed to maintain adequate kitchen sanitation for 2 of 2 observations of the kitchen. The facility reported a census of 31 residents. Findings: Observations on 4/21/2026 at 10:29 a.m. revealed the following concerns:a. Small plates and dishes placed face down in a cupboard covered with heavy crumbs.b. Cabinets on the left side and back wall of the kitchen sticky to the touch. The cabinets were partially covered with red and dark colored splatters and food debris.c. Styrofoam plates sat in a cupboard on a coating of heavy dust.d. Twelve large serving scoops sat in a layer of heavy crumbs and food debris in the 3rd drawer on the right of the entry door.e. Seven serving scoops sat in a layer of heavy crumbs and food debris in the 4th drawer on the right of the entry door.f. Multiple serving scoops sat in a layer of heavy crumbs in the 5th drawer on the right of the entry door.g. Fifteen plus slotted serving spoons sat in crumbs and red droplets in the 7th drawer on the right of the entry door. h. Eight serving ladles sat in a layer of crumbs in the bottom right drawer of the row of cabinets. i. Three muffin tins, 2 cookie sheets and other pans sat in a layer of crumbs and black debris in a cupboard below and to the right of the microwave. A small, dead, winged insect also sat on the floor of the cupboard near the cookie sheets.j. Various kitchen tools including a pizza cutter, egg slicer, and a basting brush sat in a layer of crumbs and what appeared to be a black human hair in a drawer to the right of the coffee maker. k. Multiple pitchers sat on bare wood in a cupboard below the coffee maker. The wood was stained black.On 4/22/2026 at 9:50 a.m., the drawers and cupboards remained unchanged from the previous observation.The facility policy Sanitation, revised October 2008, stated staff would maintain a clean and sanitary food service area. The policy directed staff to clean surfaces such as shelves frequently enough to prevent the accumulation of grime. On 4/23/26 at 9:20 a.m., the Dietary Manager (DM) stated she expected staff to wipe down drawers and cupboards. When asked if she thought that the staff had cleaned the cupboards and drawers recently, she stated she guessed not. She stated they were supposed to do this daily.

Based on clinical record review, policy review, and staff and resident interviews, the facility failed to update the care plan to reflect a resident's exit seeking behavior for 1 of 12 residents reviewed for care plans (Resident #6). The facility reported a census of 31 residents. Findings included: The Minimum Data Set (MDS) assessment tool, dated 12/19/25, listed diagnoses for Resident #6 which included non-Alzheimer's dementia, bipolar disorder, and depression. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 11 out of 15, indicating moderately impaired cognition. The facility policy Care Plans, Comprehensive Person-Centered, revised December 2016, stated the care plan would incorporate risk factors associated with identified problems.An 8/8/25 Encounter Note stated the resident expressed a strong desire to leave the care facility.A 2/17/26 Nurses Note stated the resident reported to a family member that she tried to remove the window in her room so she could get out. Inspection of the window revealed the resident removed a screw from the window track in order to open the window fully. A 3/2/26 Encounter Note stated the resident's family reported her cognition was worsening. The resident recently removed screws from the screen in her room because she wanted to try to climb out her window. On 4/20/26 at 12:56 p.m., the resident stated that she wanted to be released from the facility. She stated she wanted to leave and maybe she would just go out the window.As of 4/21/26, the resident's Care Plan did not include information regarding the resident's desire to leave the facility nor her history of removing a part of the window. On 4/21/26 at 3:28 p.m., the Maintenance Director stated he received a report that Resident #6 attempted to take a screw out of the window. He stated he replaced the screw with a torx screw (a screw that offered superior durability and required a specialized tool to remove). The Maintenance Director then pointed out the screw that he installed in the resident's room. The resident was present at the time and stated don't take that screw out, I got in trouble for taking it out. On 4/22/26 at 10:10 a.m., the Director of Nursing (DON) stated the resident did not make an attempt to leave but had told multiple staff members she would like to leave. She stated the resident removed the screw to her window but the screen was intact. She stated she was surprised this information was not on the care plan but she would have staff add this.

Based on observation, clinical record review, staff interviews and policy review, the facility staff failed to administer oxygen in accordance with physician orders for 1 of 2 residents reviewed (Resident #5). The facility reported a census of 31 residents.The Minimum Data Set (MDS) dated [DATE] for Resident #5 revealed a diagnosis of an irregular heart beat and identified the use of continuous oxygen therapy. Resident #5 had a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. During an observation on 4/20/2026 at 2:18 pm, Resident #5 was in her recliner with oxygen (O2) tube in her nose, the oxygen concentrator was set on 1-liter, and she took deep breaths while relaxing in her recliner.During an observation on 4/21/2026 at 9:05 am, Resident #5 sat in the dining room for breakfast and the portable oxygen tank level indicator not to be in red area, which indicated the tank had an inadequate to no supply of oxygen. Resident #5 was unaware that the O2 tank was not administering oxygen. On 4/21/26 at 9:26 am, the Director of Nursing (DON) notified by the State Agency that Resident #5 did not appear to be receiving oxygen per the portable oxygen tank. The DON assessed Resident #5's oxygen saturation at 91%. The Administrator checked the portable oxygen tank and stated it looked pressurized. Staff C, Certified Medication Aide (CMA) responded with an O2 Key used to open the portable oxygen tank to the valve to deliver oxygen through the valve and meter. Staff C placed the key on top of the O2 tank and turned it and the O2 pressure released O2 around the connection to the valve that caused a high hiss sound and quickly turned it closed. The DON educated Staff C that the valve seal was not lined up with the tank correctly and demonstrated how to connect it properly. When it was connected correctly, then the DON turned the key, the valve dial moved into the green and O2 was being delivered through the meter and tubing cannula to Resident #5's nose. The DON stated she will provide education for the nursing staff. During an interview on 4/21/26 at 9:35 am, Staff C, Certified Nursing Assistant (CNA) stated she put Resident #5's portable O2 on, turned it on to 1 Liter and she felt that it was working. Staff C stated the nurse regulated the oxygen. During an interview on 4/21/2026 at 12:24 pm, Staff A, Registered Nurse (RN) stated the CNA's had not brought any residents who used portable O2 to her. When asked who adjusted oxygen, Staff A stated the nurses regulate and administer O2. The Policy titled Oxygen Administration provided guidelines for the procedure to deliver safe oxygen to the resident, adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered.

Based on observation, clinical record review, resident and staff interviews, the facility staff failed to hold the anticoagulant (blood thinning) medication as ordered by the surgeon that resulted in the delay of a scheduled surgery for 1 of 1 resident's reviewed (Resident #31). The facility reported a census of 31 residents.The Minimum Data Set (MDS) for Resident #31 revealed a diagnosis of atrial fibrillation (a dysrhythmia of the heart) and received an anticoagulant. The Physician Orders for Resident #31 revealed an order for Apixaban (Eliquis) 5 milligram (mg) twice a day, Obtain X-ray of right knee and a referral to orthopedic doctor for a follow up on right knee pain and swelling. The X-ray results dated 3/30/26 for Resident #31revealed a dislocation of the knee joint and a bone fragment concerning for a fracture.A document titled Orthopedic Surgeons dated 4/3/26 for Resident #31 revealed the following:a. A surgical intervention would be necessary for the right dislocated knee.b. The blood thinner must be stopped five days before surgery or the patient can't have anesthesia.c. The surgery scheduled date was 4/22/26. The Medication Administration Record (MAR) for Resident #31 revealed: a. Apixaban 5mg (blood thinner) 1 tablet two times a day initiated on 3/21/26, with a hold date 4/19/26 to 4/21/26. b. Apixaban administered twice a day every day and on the morning of 4/19/26. A review of Progress Notes in the electronic health record revealed:a. On 4/3/26, Resident #31 had an appointment with the Orthopedic (bone) doctor. A surgery date was scheduled for 4/22/26. Resident #31 to be evaluated by the Cardiologist (heart doctor) on 4/14/26 prior to surgery. b. On 4/14/26, the Pharmacist requested to place a note on Resident #31's medication to hold the blood thinner for 3 days prior to surgery date on 4/22/26.c. On 4/21/26 at 2:44 pm, Staff A, Registered Nurse (RN) documented the night shift nurse Staff B, Licensed Practical Nurse (LPN) gave 6 am report that Resident #31 was to have surgery for knee on 4/21/26. Resident #31 was administered the morning dose of her blood thinner on 4/20/26 and the evening dose from 4/19/26 was not in the medication card. Resident #31 was to have the blood thinner held for 3 days prior to surgery on 4/22/26. Staff A notified the surgical team. d. On 4/21/26 at 3:02 pm Staff A, RN received an order to reschedule Resident #31's right knee surgery for April 27th and to hold the blood thinner after the evening dose on 4/23/26. The Director of Nursing (DON) notified the daughter.During an interview on 4/22/26 at 1:12 pm, the Medical Director stated he was notified Resident #31's surgery was delayed but was not aware of the reason. The Medical Director stated he did not feel that due to holding the blood thinner, then restart and hold again would increase Resident #31's risk for an adverse outcome in the surgical area. During an interview on 4/22/26 at 1:50 pm, Staff C, Certified Medication Aide (CMA) stated she was aware that Resident #31 was to have a surgery to her right knee as she was applying an ordered wash to her leg. Staff C stated she was not aware that the blood thinner was to be held and the MAR on the computer would have lite up red if it was held or cancelled and it was yellow on 4/19/26. Staff C stated the medication card was in the medication cart without a note but today it had an H on it and she had to clarify with the nurse on duty if it was to be administered. Staff C stated she was informed the surgical date was changed but was unaware of the reason. During an interview on 4/22/26 at 2 pm, Staff D, RN stated she had received the order to hold Resident #31's blood thinner on 4/15/26 and place the order into the computer which should have turned red on 4/19/26 to 4/22/26. Staff D stated the DON made her aware of the medication error on 4/21/26 and notified the surgical team. Staff D stated the procedure was for the nurse to immediately notify the DON if they discover a medication error, even over the night shift and notify the provider on call. Staff D stated that did not occur. Staff D stated the surgery for Resident #31 was postponed until 4/27/26 due to the error. During an interview on 4/23/2026 at 8:04 am, The DON stated a medication error occurred for Resident #31 on 4/19/26 as her blood thinner was on hold on 4/19/26 to 4/22/26 due to the scheduled surgery for her right knee. The DON stated she was made aware of the medication error on 4/21/26 in the afternoon and immediately contacted the surgical team to notify the surgeon who rescheduled the surgery. The DON stated Staff A, RN reported that the night nurse Staff B, LPN discovered the error on 4/20/26. The DON stated her expectation was that the nurses remove a medication from the medication cart if it was on hold and if an error was found, to report it immediately. The DON stated there was a scheduled care plan conference today, 4/23/26, that the resident and family would attend. They would be notified of the medication error.

Based on clinical record review, written staff statements, policy review, and staff and resident interviews, the facility failed to ensure residents were treated with respect and dignity for 4 out of 12 residents reviewed for dignity(Residents #6, #8, #11, #12). The facility reported a census of 28 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 8/21/24, listed diagnoses for Resident #8 which included heart failure, diabetes, and anxiety. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 8/18/22, stated the resident had impaired cognitive function/dementia or impaired thought processes related to schizophrenia and directed staff to face her when speaking and keep her routine consistent in order to decrease confusion. 2. The MDS assessment tool, dated 7/15/24, listed diagnoses for Resident #12 which included non-Alzheimer's dementia, anxiety, and depression. The MDS listed the resident's BIMS score as 12 out of 15, indicating moderately impaired cognition. Care Plan entries, dated 6/8/24, stated the resident cried, was tearful, and wanted to die related to recent life changes of learning she would not return home. The Care Plan directed staff to provide opportunities for positive interaction and attention and to stop and talk to the resident when passing by. 3. The MDS assessment tool, dated 7/24/24, listed diagnoses for Resident #11 which included depression, anxiety, and paraplegia (paralysis from the waist down). The MDS listed the BIMS score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 11/20/23, directed staff to speak to him in a calm manor. A 1/25/24 Care Plan entry stated the resident became anxious at times. On 10/2/24 at approximately 4:00 p.m., Resident #11 stated Staff F Certified Nursing Assistant (CNA) made him feel bad when he fell because he told him this seems to be a recurring thing with you. 4. The MDS assessment tool, dated 7/31/24, listed diagnoses for Resident #6 which included morbid obesity, lymphedema (a chronic condition that causes swelling due to a buildup of fluid in the body), and hypertension (high blood pressure). The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. An 8/19/24 Grievance/Concern Investigation Form stated Staff F did not provide care for Resident #6. A follow-up interview with the resident, conducted by Staff E former DON stated Staff F stated she was resisting him while rolling her and she wasn't. Resident #6 stated she did not have any problem with Staff F and it was not a big deal. A Care Plan entry, dated 9/23/24, stated the resident required the assistance of two staff for bed mobility. On 10/2/24 at approximately 3:30 p.m., Resident #6 stated one night Staff F rolled her and told her she was resisting. She told him she was not and he stormed out. He did not return to her room for 3 weeks and other staff assisted her. The facility lacked further documentation regarding the concern that Staff F did not care for Resident #6 for 3 weeks after the incident. The facility policy Residents Rights-Dignity and Respect dated June 2012, stated each resident had the right to considerate and respectful care to be treated with honest, dignity, and respect. Written statements, dated 7/6/24, by Staff D CNA revealed the following: a. Staff F was upset at dinnertime and when a resident asked him something, he yelled at her. When another resident joined in, Staff F started yelling at them for getting into business that wasn't theirs. He told them the needed to quit talking. b. A resident slid out of his bed and Staff F walked in and stated that his co-workers were incompetent because the bed was not all the way to the floor. The resident became upset thinking it was his fault that the bed was not all the way to the floor. On 10/2/24 at 10:22 a.m., Staff A CNA stated that Staff F CNA did not want to go into Resident #6's room because he was afraid she would accuse him of something. Staff A stated Resident #6 didn't understand why he would not go in there. Staff F stated she talked to Staff E former DON about him not going in her room. On 10/2/24 at 10:57 a.m., Staff B CNA stated Staff F would refuse to go in Resident #6's room for about a week and then began taking care of her again. On 10/2/24 at 11:10 a.m. Staff C CNA stated that Resident #6 did not understand why Staff F would not go in her room. Staff C stated she talked to Staff E about this and toward the end of his employment Staff F began to go in her room again. On 10/2/24 at 2:35 p.m. Staff D CNA stated that Staff F yelled at Resident #8 at the dining table and told her what he was talking about was none of her business. He then said the same thing to Resident #12. She stated he told Resident #6 that her pillows could not be a certain way because she peed the bed. She stated when Resident #11 fell , Staff F stated that the bed should have been all the way to the floor. Staff D stated Resident #11 felt that Staff F was mad at him about it and started to tear up. Staff D stated she placed written statements regarding the above concerns in the Administrator's mail box but did not hear anything further about the concerns. On 10/2/24 at 3:43 via phone, Staff E former DON stated she was aware of the situation with Resident #6 when Staff F assisted her with rolling. She stated she couldn't recall any other concerns reported regarding Staff F. On 10/3/24 at 9:04 a.m., the Administrator stated he did not have additional documentation related to any grievances or staff concerns submitted. He stated if a staff member turned in a concern related to another staff member, he would start an investigation and talk to the residents and staff. He stated he would provide coaching and education. He stated staff should treat residents how they would want to be treated and stated the way Staff F spoke to residents (in the above examples) was not ok.

Based on clinical record review, written staff statements, policy review, and staff and resident interviews, facility administration failed to follow-up on concerns with staff treatment of residents for 4 out of 12 residents reviewed for dignity (Residents #6, #8, #11, #12). The facility reported a census of 28 residents. Findings: 1. The Minimum Data Set (MDS) assessment tool, dated 8/21/24, listed diagnoses for Resident #8 which included heart failure, diabetes, and anxiety. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 8/18/22, stated the resident had impaired cognitive function/dementia or impaired thought processes related to schizophrenia and directed staff to face her when speaking and keep her routine consistent in order to decrease confusion. 2. The MDS assessment tool, dated 7/15/24, listed diagnoses for Resident #12 which included non-Alzheimer's dementia, anxiety, and depression. The MDS listed the resident's BIMS score as 12 out of 15, indicating moderately impaired cognition. Care Plan entries, dated 6/8/24, stated the resident cried, was tearful, and wanted to die related to recent life changes of learning she would not return home. The Care Plan directed staff to provide opportunities for positive interaction and attention and to stop and talk to the resident when passing by. 3. The MDS assessment tool, dated 7/24/24, listed diagnoses for Resident #11 which included depression, anxiety, and paraplegia (paralysis from the waist down). The MDS listed the BIMS score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 11/20/23, directed staff to speak to him in a calm manor. A 1/25/24 Care Plan entry stated the resident became anxious at times. On 10/2/24 at approximately 4:00 p.m., Resident #11 stated Staff F Certified Nursing Assistant (CNA) made him feel bad when he fell because he told him this seems to be a recurring thing with you. 4. The MDS assessment tool, dated 7/31/2, listed diagnoses for Resident #6 which included morbid obesity, lymphedema (a chronic condition that causes swelling due to a buildup of fluid in the body), and hypertension (high blood pressure). The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. An 8/19/24 Grievance/Concern Investigation Form stated Staff F did not provide care for Resident #6. A follow-up interview with the resident, conducted by Staff E former DON stated Staff F stated she was resisting him while rolling her and she wasn't. Resident #6 stated she did not have any problem with Staff F and it was not a big deal. A Care Plan entry, dated 9/23/24, stated the resident required the assistance of two staff for bed mobility. On 10/2/24 at approximately 3:30 p.m., Resident #6 stated one night Staff F rolled her and told her she was resisting. She told him she was not and he stormed out. He did not return to her room for 3 weeks and other staff assisted her. The facility lacked further documentation regarding the concern that Staff F did not care for Resident #6 for 3 weeks after the incident. The facility policy Residents Rights-Dignity and Respect dated June 2012, stated each resident had the right to considerate and respectful care to be treated with honest, dignity, and respect. Written statements, dated 7/6/24, by Staff D CNA revealed the following: a. Staff F was upset at dinnertime and when a resident asked him something, he yelled at her. When another resident joined in, Staff F started yelling at them for getting into business that wasn't theirs. He told them the needed to quit talking. b. A resident slid out of his bed and Staff F walked in and stated that his co-workers were incompetent because the bed was not all the way to the floor. The resident became upset thinking it was his fault that the bed was not all the way to the floor. The facility lacked documentation members of administration followed up with the above concerns. On 10/2/24 at 10:22 a.m., Staff A CNA stated that Staff F CNA did not want to go into Resident #6's room because he was afraid she would accuse him of something. Staff A stated Resident #6 didn't understand why he would not go in there. Staff F stated she talked to Staff E former DON about him not going in her room. On 10/2/24 at 10:57 a.m., Staff B CNA stated Staff F would refuse to go in Resident #6's room for about a week and then began taking care of her again. On 10/2/24 at 11:10 a.m. Staff C CNA stated that Resident #6 did not understand why Staff F would not go in her room. Staff C stated she talked to Staff E about this and toward the end of his employment Staff F began to go in her room again. On 10/2/24 at 2:35 p.m. Staff D CNA stated that Staff F yelled at Resident #8 at the dining table and told her what he was talking about was none of her business. He then said the same thing to Resident #12. She stated he told Resident #6 that her pillows could not be a certain way because she peed the bed. She stated when Resident #11 fell , Staff F stated that the bed should have been all the way to the floor. Staff D stated Resident #11 felt that Staff F was mad at him about it and started to tear up. Staff D stated she placed written statements regarding the above concerns in the Administrator's mail box but did not hear anything further about the concerns. On 10/2/24 at 3:43 via phone, Staff E former DON stated she was aware of the situation with Resident #6 when Staff F assisted her with rolling. She stated she couldn't recall any other concerns reported regarding Staff F. On 10/3/24 at 9:04 a.m., the Administrator stated he did not have additional documentation related to any grievances or staff concerns submitted. He stated if a staff member turned in a concern related to another staff member, he would start an investigation and talk to the residents and staff. He stated he would provide coaching and education. He stated staff should treat residents how they would want to be treated and stated the way Staff F spoke to residents (in the above examples) was not ok.

Based on review of Quality Assurance and Performance Improvement (QAPI) meeting documentation, policy review, and staff interview, the facility failed to carry out Quality Assurance (QA) activities to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. The facility reported a census of 28 residents. Findings: The Centers for Medicare and Medicaid Services (CMS) 2567, dated 5/9/24, listed, in part, the following concern: F550. The current survey, conducted 10/1/24-10/3/24 also identified the above concern. Review of QAPI/QA documentation from 1/1/24 to 10/3/24 revealed the facility lacked documentation of QAPI/QA program activities related to resident treatment or dignity concerns. The facility lacked evidence of an ongoing QAPI program related to the above areas including a process of addressing how the committee would conduct the activities necessary to identify and correct quality deficiencies. The facility lacked documentation of monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revision as needed. The facility policy QAPI Program Governance and Leadership, revised March 2020, stated the responsibilities of the QAPI committee were to to identify and help to resolve negative outcomes and to coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals. On 10/3/24 at 10:56 a.m., the Administrator stated in QA meetings, the facility should discuss citations from previous surveys. He stated since he started at the facility, they had not talked about past citations.

Based on observation, interviews, resident and staff interviews, the facility failed to provide the diet as ordered for 1 of 2 residents reviewed for nutrition (Resident #28). The facility did not provide double the protein for Resident #28 as recommended by the Registered Dietitian (RD) and as per the physician order. The facility reported a census of 31 residents. Findings include: The Annual Minimum Data Set (MDS) dated [DATE] for Resident #28 revealed a diagnosis of hyponatremia, chronic obstructive pulmonary disease (COPD), pulmonary embolism (blood clot in lung), and osteoarthritis. The MDS identified Resident #28 was at risk for the development of pressure injuries, and was on a therapeutic diet. Resident #28 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated an intact cognition. The Care Plan for Resident #28 directed staff to provide and serve the diet as ordered for a Nutritional Interventions Program (NIP) with double protein two times a day (BID) with initiated date of 1/24/24. On 5/28/24 at 11:14 A.M. Resident #28 stated that she was to be receiving double the protein at lunch and supper as she had skin injuries to her buttocks. She reported she had been receiving a large amount of starches. Resident #28 reported that she had seen the dietitian one time, and since she is on the blood thinner, Resident #28 reported she had to watch the vitamin K level, They keep giving me broccoli and green leafy foods that I can't eat. The Clinical Physician Orders reveal a regular, small portion diet with extra protein source at lunch and supper with start date of 7/5/23. The Dietary Progress Note dated 1/24/24 at 9:50 A.M. for Resident #28 revealed: a. Small portion diet, level 7, regular texture, level 0 thin consistency. b. Extra protein source at lunch and supper per diet directions. c. By mouth (po) intakes with mostly 26-100% two meals daily (appears to refuse breakfast). d. Notify RD of nutritional concerns. During an observation on 5/28/24 at 12:15 P.M. Resident #28 had 1 small portion of fish, rice, peas, pineapple juice, tomato juice and chocolate milk. The lunch lacked evidence of a second portion of protein. A document titled [NAME] Specialty Care Lunch Week 1 Wednesday May 29, 2023 for Resident #28 revealed Level 7 Regular thin fluids, small protein, with Alert: Extra protein lunch & supper. During an observation on 5/29/24 at 12:05 P.M. Resident #28 had 1 single protein source, turkey served at lunch. During an interview on 5/29/24 at 1:13 P.M., Staff A, Certified Dietary Manager (CDM) stated for a double portion of protein, the cook serving would give an extra serving of meat. Staff A stated Resident #28 picked out what she wanted and had the extra protein diet order. Staff A stated that the dietary staff were aware, and double the protein meant that the resident receives extra meat. During an interview on 5/29/24 at 1:32 P.M., Staff B, Registered Dietitian (RD) described small portions for diabetics and it was for carbohydrate control, therefore the resident received a small serving of the desert. Staff B described the double the protein as double the protein portion source of the meal. Staff B stated she had reviewed Resident #28's diet order and the menu, and found the menu directed the dietary staff to provide double the protein. Staff B stated she will meet with the CDM.

Based on observation, staff interview, resident interview and Facility Assessment the facility failed to ensure safe transport of resident in a wheelchair for 1 of 3 resident reviewed. (Resident #18). The facility reported a census of 31. Findings include: The Admission Minimum Data Set (MDS) for Resident #18 dated 4/10/24 revealed resident scored 13 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS revealed diagnoses of arthritis, osteoporosis, cerebrovascular accident (CVA) referring to stroke and fracture of right humorous. The MDS documented the resident normally used a manual wheelchair for a mobility device, with dependence on staff to operate the wheelchair. The Care plan initiated 4/6/24 documented resident continued to work with therapy, recent fall with fractured humorous. Resident #18 to use a wheel chair for mobility, non-weight bearing to right upper extremity, sling to right upper extremity at all times and required assist of one related to recent fracture. Observation on 5/28/24 at 10:45 AM revealed Staff#C, Certified Nursing Assistant (CNA) pushed resident in a wheelchair down the hall, both feet of the resident on one-wheel chair pedal. Staff C voiced, wish we could find the other wheel chair pedal and directed resident to keep your feet up. On 05/28/24 at 11:07 AM The Assistant Director of Nursing (ADON) relayed expectation is to have both food pedals on the wheelchair when pushed, for safety. On 05/28/24 at 1:55 PM Resident #18 reported she had only one (1) wheel chair pedal since she arrived at the facility and it did upset her that they can't find the another one. On 5/29/24 at 5:00 PM the Administrator acknowledged a resident should have both wheel chair pedals on when being pushed by staff. The Facility Assessment identified resident with abnormalities of gait and mobility. The Facility Assessment documented resident footing assessed upon admission and ongoing, proper transfer equipment provided as needed included cane, walker and wheelchair.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to treat 2 of 9 residents reviewed for resident rights with dignity (Resident #5 and #11) by failing to assist residents with the bedpan and/or incontinent care and instructing them to urinate/defecate in their incontinent briefs. The facility reported a census of 31 residents. Findings include: 1. The Admission Minimum Data Set(MDS) assessment tool, dated 4/24/24, listed diagnoses for Resident #5 which included tibia(a lower leg bone) fracture, weakness, and difficulty walking, and stated the resident required substantial/maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The MDS listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, which indicated intact cognition. Care Plan entries, dated 4/18/24, stated the resident required the assistance of 1 staff for toileting and personal hygiene. A 4/19/24 1:38 p.m., Nurses Note documented the resident admitted to the facility following a right ankle fracture and would complete therapy. The note stated the resident was incontinent of bladder but was aware of when she was incontinent and called promptly to request staff to change her. On 5/8/24 at 1:15 p.m., Resident #5 stated she had trouble with a night shift staff member who told her that she was not wet and she should defecate in her incontinent brief. She stated this happened several times and the staff member would reach into her brief and tell her she was not wet enough and to go in her brief. The resident stated she had had a suppository and really needed to use the bedpan but because the staff member would not provide this to her, she had to go in her brief. She stated this made her feel dirty. 2. The MDS assessment tool, dated 4/17/24, listed diagnoses for Resident #6 which included heart failure, respiratory failure, and morbid obesity. The MDS listed the resident's BIMS score as 15 out of 15, which indicated intact cognition. On 5/8/24 at 1:15 p.m. Resident #6, who is Resident #5's roommate was present during Resident #5's interview. Resident #6 stated the staff member who told Resident #5 to defecate in her pants was Staff A Certified Nursing Assistant (CNA). Resident #6 stated she heard her say that to Resident #6 2 times on 2 separate shifts. Resident #6 stated they reported it but she could not remember who it was they reported it to. Resident #6 stated this happened about 2 weeks ago and the next day someone came into talk to them about it and they had to sign a paper regarding the complaint. Resident #6 stated she was shocked when she heard Staff A state this to Resident #5 and stated this treatment was treating them like they were not human. 3. The Annual MDS assessment tool, dated 2/5/24, listed diagnoses for Resident #3 which included arthritis, morbid obesity, and high blood pressure. The MDS listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. On 5/8/24 at 1:45 p.m., Resident #3 stated about a year ago she heard Staff A tell Resident #11 to urinate in her pants. 4. The Quarterly MDS assessment tool, dated 5/11/23, listed diagnoses for Resident #11 which included heart failure, hip fracture, and weakness. The MDS stated the resident required extensive assistance of 1 staff for toilet use and personal hygiene and listed her BIMS score as 13 out of 15, which indicated intact cognition. Care Plan entries, dated 11/21/22, stated the resident required the assistance of 1 staff for toileting and personal hygiene related to limited mobility due to a hip fracture. On 5/8/24, the facility provided all reported grievances from 12/1/23 to 5/8/23 listed on the Resident/Family/Staff Grievance Concern Investigation Log. The form did not contain any concerns related to staff failing to change residents or provide a bed pan or directing them to urinate/defecate in their briefs. On 5/8/24 at 1:08 p.m. Staff B CNA stated Resident #5 reported to her that Staff A would not provide her the bed pan and instructed the resident to go in her brief. Staff B stated she reported this to Staff E, former Director of Nursing (DON). On 5/8/24 at 1:16 p.m. Staff C CNA stated Resident #5 reported to her that Staff A refused to provide her the bed pan and instructed her to urinate in her pants. On 5/8/24 at 3:23 p.m. via phone Staff D Registered Nurse (RN) stated that he administered a suppository to Resident #5 and asked her to call when she needed help. Staff D heard later from Resident #5's roommate, Resident #6 that Staff A came in and told Resident #5 to go in her brief. Staff D stated he reported the concern to the Assistant Director of Nursing (ADON). He stated Staff A should have provided the resident with a fracture pan (a smaller bed pan which was easier to move on and off of). On 5/8/24 at 4:08 p.m., the ADON stated she worked the night shift around 4/23/24 and on 4:00 a.m. rounds Residents #5 and #6 told her that Staff A told Resident #5 to just soil herself and she would change her rather than giving her a bed pan. The ADON stated she reported this to Staff E, former DON. On 5/9/24 at 9:36 a.m. via phone, Staff E, former DON stated staff reported to her that Staff A did not round on residents who were sleeping and she educated Staff A about making sure resident's were not wet. Staff E stated she did not think anyone reported to her that Staff A instructed residents to urinate in their briefs. She stated if she did hear that she would investigate it and report it because that was wrong. On 5/9/24 at 12:01 p.m., the Administrator stated that she found out yesterday about a staff member who told a resident to go to the bathroom in her brief and she would change her. She stated they called Staff A and suspended her and were currently completing their investigation. She stated she did not hear about this until yesterday and stated she would want this investigated and reported right after it occurred. The facility policy Dignity, revised February 2021, stated staff would care for each resident in a manner that promoted and enhanced well-being, level of satisfaction with life and feelings of self-worth and self-esteem.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to report an allegation of abuse (a staff member allegedly failed to assist a resident with the bedpan and/or incontinent care and instructed her to urinate/defecate in her incontinent brief) for 1 of 1 residents reviewed for an allegation of abuse(Resident #5). The facility reported a census of 31 residents. Findings included: 1. The Admission Minimum Data Set (MDS) assessment tool, dated 4/24/24, listed diagnoses for Resident #5 which included tibia (a lower leg bone) fracture, weakness, and difficulty walking, and stated the resident required substantial/maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The MDS listed her Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 4/18/24, stated the resident required the assistance of 1 staff for toileting and personal hygiene. A 4/19/24 Nurses Note stated the resident admitted to the facility following a right ankle fracture and would complete therapy. The note stated the resident was incontinent of bladder but was aware of when she was incontinent and called promptly to request staff to change her. On 5/8/24 at 1:15 p.m., Resident #5 stated she had trouble with a night shift staff member who told her that she was not wet and she should defecate in her incontinent brief. She stated this happened several times and the staff member would reach into her brief and tell her she was not wet enough and to go in her brief. The resident stated she had had a suppository and really needed to use the bedpan but because the staff member would not provide this to her, she had to go in her brief. She stated this made her feel dirty. 2. The Annual MDS assessment tool, dated 4/17/24, listed diagnoses for Resident #6 which included heart failure, respiratory failure, and morbid obesity. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. On 5/8/24 at 1:15 p.m. Resident #6, who is Resident #5's roommate was present during Resident #5's interview. Resident #6 stated the staff member who told Resident #5 to defecate in her pants was Staff A Certified Nursing Assistant (CNA). Resident #6 stated she heard her say that to Resident #6 2 times on 2 separate shifts. Resident #6 stated they reported it but she could not remember who it was they reported it to. Resident #6 stated this happened about 2 weeks ago and the next day someone came into talk to them about it and they had to sign a paper regarding the complaint. Resident #6 stated she was shocked when she heard Staff A state this to Resident #5 and stated this treatment was treating them like they were not human. On 5/8/24, the facility provided all reported grievances from 12/1/23 to 5/8/23 listed on the Resident/Family/Staff Grievance Concern Investigation Log. The form did not contain any concerns related to staff failing to change residents or provide a bed pan or directing them to urinate/defecate in their briefs. On 5/8/24 at 1:08 p.m. Staff B CNA stated Resident #5 reported to her that Staff A would not provide her the bed pan and instructed the resident to go in her brief. Staff B stated she reported this to Staff E, former Director of Nursing (DON). On 5/8/24 at 1:16 p.m. Staff C CNA stated Resident #5 reported to her that Staff A refused to provide her the bed pan and instructed her to urinate in her pants. On 5/8/24 at 3:23 p.m. via phone Staff D Registered Nurse (RN) stated that he administered a suppository to Resident #5 and asked her to call when she needed help. Staff D heard later from Resident #5's roommate, Resident #6 that Staff A came in and told Resident #5 to go in her brief. Staff D stated he reported the concern to the Assistant Director of Nursing (ADON). He stated Staff A should have provided the resident with a fracture pan (a smaller bed pan which was easier to move on and off of). On 5/8/24 at 4:08 p.m., the ADON stated she worked the night shift around 4/23/24 and on 4:00 a.m. rounds Residents #5 and #6 told her that Staff A told Resident #5 to just soil herself and she would change her rather than giving her a bed pan. The ADON stated she reported this to Staff E, former DON. On 5/9/24 at 9:36 a.m. via phone, Staff E, former DON stated staff reported to her that Staff A did not round on residents who were sleeping and she educated Staff A about making sure resident's were not wet. Staff E stated she did not think anyone reported to her that Staff A instructed residents to urinate in their briefs. She stated if she did hear that she would investigate it and report it because that was wrong. On 5/9/24 at 12:01 p.m., the Administrator stated that she found out yesterday about a staff member who told a resident to go to the bathroom in her brief and she would change her. She stated they called Staff A and suspended her and were currently completing their investigation. She stated she did not hear about this until yesterday and stated she would want this investigated and reported right after it occurred. The facility provided the survey team with a policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program with revised date of April 2021. The policy documented the following under the heading Policy Interpretation and Implementation; The resident abuse, neglect and exploitation program consists of a facility-wide commitment and resource allocation to support the following objectives: (which included the following directives) -Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property. -Protect residents from abuse, neglect, exploitation or misappropriation of property. -Establish and maintain a culture of compassion and caring for all residents -Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property -Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior -Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. -Investigate and report any allegations within timeframes required by federal requirements. The facility policy Dignity, revised February 2021, stated staff would care for each resident in a manner that promoted and enhanced well-being, level of satisfaction with life and feelings of self-worth and self-esteem.

Based on clinical record review, policy review, and resident and staff interviews, the facility failed to investigate an allegation of abuse (a staff member allegedly failed to assist a resident with the bedpan and/or incontinent care and instructed her to urinate/defecate in her incontinent brief) and ensure protection from further abuse for 1 of 1 residents reviewed for an allegation of abuse(Resident #5). The facility reported a census of 31 residents. Findings include: 1. The Minimum Data Set(MDS) assessment tool, dated 4/24/24, listed diagnoses for Resident #5 which included tibia(a lower leg bone) fracture, weakness, and difficulty walking, and stated the resident required substantial/maximal assistance for toilet transfers and was dependent on staff for toileting hygiene. The MDS listed her Brief Interview for Mental Status(BIMS) score as 15 out of 15, indicating intact cognition. Care Plan entries, dated 4/18/24, stated the resident required the assistance of 1 staff for toileting and personal hygiene. A 4/19/24 Nurses Note stated the resident admitted to the facility following a right ankle fracture and would complete therapy. The note stated the resident was incontinent of bladder but was aware of when she was incontinent and called promptly to request staff to change her. On 5/8/24 at 1:15 p.m., Resident #5 stated she had trouble with a night shift staff member who told her that she was not wet and she should defecate in her incontinent brief. She stated this happened several times and the staff member would reach into her brief and tell her she was not wet enough and to go in her brief. The resident stated she had had a suppository and really needed to use the bedpan but because the staff member would not provide this to her, she had to go in her brief. She stated this made her feel dirty. 2. The MDS assessment tool, dated 4/17/24, listed diagnoses for Resident #6 which included heart failure, respiratory failure, and morbid obesity. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. On 5/8/24 at 1:15 p.m. Resident #6, who is Resident #5's roommate was present during Resident #5's interview. Resident #6 stated the staff member who told Resident #5 to defecate in her pants was Staff A Certified Nursing Assistant(CNA). Resident #6 stated she heard her say that to Resident #6 2 times on 2 separate shifts. Resident #6 stated they reported it but she could not remember who it was they reported it to. Resident #6 stated this happened about 2 weeks ago and the next day someone came into talk to them about it and they had to sign a paper regarding the complaint. Resident #6 stated she was shocked when she heard Staff A state this to Resident #5 and stated this treatment was treating them like they were not human. On 5/8/24, the facility provided all reported grievances from 12/1/23 to 5/8/23 listed on the Resident/Family/Staff Grievance Concern Investigation Log. The form did not contain any concerns related to staff failing to change residents or provide a bed pan or directing them to urinate/defecate in their briefs. On 5/8/24 at 1:08 p.m. Staff B CNA stated Resident #5 reported to her that Staff A would not provide her the bed pan and instructed the resident to go in her brief. Staff B stated she reported this to Staff E, former Director of Nursing(DON). On 5/8/24 at 1:16 p.m. Staff C CNA stated Resident #5 reported to her that Staff A refused to provide her the bed pan and instructed her to urinate in her pants. On 5/8/24 at 3:23 p.m. via phone Staff D Registered Nurse(RN) stated that he administered a suppository to Resident #5 and asked her to call when she needed help. Staff D heard later from Resident #5's roommate, Resident #6 that Staff A came in and told Resident #5 to go in her brief. Staff D stated he reported the concern to the Assistant Director of Nursing(ADON). He stated Staff A should have provided the resident with a fracture pan(a smaller bed pan which was easier to move on and off of). On 5/8/24 at 4:08 p.m., the ADON stated she worked the night shift around 4/23/24 and on 4:00 a.m. rounds Residents #5 and #6 told her that Staff A told Resident #5 to just soil herself and she would change her rather than giving her a bed pan. The ADON stated she reported this to Staff E, former DON. On 5/9/24 at 9:36 a.m. via phone, Staff E, former DON stated staff reported to her that Staff A did not round on residents who were sleeping and she educated Staff A about making sure resident's were not wet. Staff E stated she did not think anyone reported to her that Staff A instructed residents to urinate in their briefs. She stated if she did hear that she would investigate it and report it because that was wrong. On 5/9/24 at 12:01 p.m., the Administrator stated that she found out yesterday about a staff member who told a resident to go to the bathroom in her brief and she would change her. She stated they called Staff A and suspended her and were currently completing their investigation. She stated she did not hear about this until yesterday and stated she would want this investigated and reported right after it occurred. The facility provided the survey team with a policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program with revised date of April 2021. The policy documented the following under the heading Policy Interpretation and Implementation; The resident abuse, neglect and exploitation program consists of a facility-wide commitment and resource allocation to support the following objectives: (which included the following) -Protect residents from abuse, neglect, exploitation or misappropriation of property. -Establish and maintain a culture of compassion and caring for all residents -Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property -Provide staff orientation and training/orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior -Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. -Investigate and report any allegations within timeframes required by federal requirements. The facility policy Dignity, revised February 2021, stated staff would care for each resident in a manner that promoted and enhanced well-being, level of satisfaction with life and feelings of self-worth and self-esteem.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to create interventions based on root cause analysis of falls in order to prevent future falls for 1 of 4 residents reviewed for falls(Resident #4). The facility reported a census of 31 residents. Findings include: The Admission Minimum Data Set(MDS) assessment tool, dated 2/9/24, listed diagnoses for Resident #4 which included pelvic fracture, non-Alzheimer's dementia, and heart failure, and stated the resident depended on staff for transfers and toilet transfers but did not walk due to a medical condition or safety concerns. The MDS documented the resident had a fracture related to a fall within the last 6 months and stated the resident's cognition was severely impaired. The MDS stated the resident was admitted to the facility on [DATE]. An untitled Hospital Report, dated 2/4/24, documented the resident sustained a fracture of the left greater trochanter(the upper part of the thigh bone) and a fracture of the pubic ramus (a part of the pelvic bone) from a ground-level fall. A 3/4/24 10:35 p.m. untitled Fall Incident Report stated staff found the resident on the floor after he took a couple of steps. The resident sustained 3 small skin tears to the left elbow. A 3/5/24 Fall Risk Evaluation stated the resident was at high risk for falls. A 3/9/24 untitled Fall Incident Report stated staff found the resident on the floor after he got up to use the bathroom. There was blood on the floor and running down the right side of his head. The resident transferred to the hospital. A 3/10/24 3:41 a.m. Nurses Note stated the resident returned from the ER with 5 staples to a right scalp laceration(cut) and multiple skin tears, blood blisters, and bruises to the right and left upper extremities. A 3/17/24 10:30 p.m. untitled Fall Incident Report stated staff observed the resident slide forward out of his electric recliner and the resident stated he had to go to the bathroom. A 4/11/24 2:00 a.m. untitled Fall Incident Report stated staff found the resident on the floor near the window. The resident stated he rolled over and caught the wall. He sustained a laceration to the right leg. The resident's Care Plan lacked interventions related to the above falls and the clinical record lacked documentation of a facility analysis of the root causes of each fall and interventions implemented to prevent future falls. Observation on 5/8/24 at 8:03 a.m. two staff transferred the resident from his wheelchair to his recliner a gait belt was used with the transfer. The facility policy Assessing Falls and Their Causes, revised March 2018, stated the facility would identify possible or likely causes of the incident. The facility policy Falls and Fall Risk, Managing, revised March 2018, stated staff would identify interventions related to the resident's specific risks to try to prevent the resident from falling. On 5/9/24 at 9:48 a.m., the Director of Nursing (DON) reported for each resident fall, they tried to come up with a root cause analysis and an intervention that fit the cause. She stated with regard to Resident #4, his lack of Care Plan interventions was not what was expected.

Based on observation, record review, staff and family interviews, the facility failed to provide adequate assessment and timely intervention for 1 of 4 residents reviewed (Resident #3). On 9/2/22 at 12:15 a.m. Resident #3 had an unwitnessed fall to the floor and was found face down with a hematoma (a mass of blood that forms in tissue as a result of a broken blood vessel) on the left side of her forehead and swelling to the left eye. Facility staff initiated Neurological checks but failed to complete as scheduled and failed to notify the provider. Resident #2 had a Neurological check at 4:00 a.m., but staff failed to complete the next check scheduled at 12 Noon. The next Neurological assessment was completed at 6:00 p.m., 14 hours after the 4:00 a.m. check. When assessed at 6:00 p.m., Resident #3 displayed altered mental status changes, was lethargic and weak, with nausea and was dry heaving. The Provider was notified at this time, resident was transferred to the local emergency room (ER) and was diagnosed with a subdural hematoma (collection of blood on the brain's surface) with brain bleed and required transfer to a larger hospital for care and treatment. The facility reported a census of 59 residents. Findings Include: The Minimum Data Set (MDS) Assessment with a reference date of 8/23/22 for Resident #3 identified intact cognitive skills for decision making. The MDS further revealed the resident independent for transfer, walking, and hygiene. The MDS identified the resident with adequate hearing. The resident had diagnoses that included atrial fibrillation, muscle weakness, hypertension, and anemia. Observation and interview on 12/28/22 at 12:40 p.m. Resident #3 seated at the dining room table in wheelchair. Resident noted to not be able to hear conversation, white board was provided for communication. Resident stated that she lost her hearing after the fall with head injury. Does not recall the fall or injury. An un-witnessed Fall Report initiated on 9/2/22 at 12:15 a.m., by Staff A, Licensed Practical Nurse (LPN) documented Resident #3 had been found on the floor face down beside her electric recliner which was tilted in the highest position. Resident #3 stated that she was trying to get up from the recliner and her leg gave out and she fell to the floor. The resident was assessed for injuries which included an abrasion to the right (in error) forehead. Neurological (Neuro) Checks were initiated. The report further documented the Associate Director of Nursing (ADON) and the Administrator were notified of the fall A Progress Note dated 9/2/22 at 12:15 a.m., documented Staff A was called to Resident #3's room and resident was on the floor face down, noted abrasion above left eye. Neuro's started. Active range of motion to all extremities without difficulties. A fax was made out to the Provider. The facility was unable to produce record of a fax being sent to the Provider at that time by Staff A. A Progress Note dated 9/2/22 at 2:59 p.m., documented Staff B, LPN documented the Provider was faxed and informed of the fall. The facility is unable to produce record of a fax being sent to the provider at this time by Staff B. Additionally, the clinical record lacked documentation of an assessment or Neuro Checks by Staff B. Review of a Progress Note dated 9/2/22 at 6:00 p.m., titled as a Summary for Providers initiated by the ADON described a change in condition which included the following: abnormal vital signs (BP 90/40), altered mental status, nausea and vomiting, resident on an anticoagulant, lethargic, unable to eat or drink, alert and oriented to self only, confused, unable to complete full sentences, and swelling to the left eye increased. Primary Care Provider responded with recommendation to send to local emergency room (ER) to evaluate and treat. A Progress Note dated 9/2/22 at 6:45 p.m., initiated by the ADON documented the Provider was notified via phone of the recent fall with bruising to the left forehead and shoulder and the left eye was swollen. Informed that resident now displayed altered mental status (AMS), nausea and dry heaving, lethargic and weak. Order received to send to the local ER for a CT scan and evaluation. 911 was notified and resident transported to local hospital ER. In a Progress Note dated 9/2/22 at 9:23 p.m., the ADON received an update from an ER Nurse that the resident was being transferred to a larger hospital due to a subdural hematoma with a brain bleed. Review of an electronic document titled Neurological Eval for Resident #3 included Neuro assessments directed to be completed at the following scheduled times: a. 15 minute checks x 4: 12:15 a.m., 12:30 a.m., 12:45 a.m., 1:00 a.m., 1:15 a.m. b. 30 minute checks x 2: 1:45 a.m., 2:15 a.m. c. 1 hour checks x 2: 3:00 a.m., 4:00 a.m. d. 8 hour checks x 9: No checks documented as completed During an interview on 12/29/22 at 2:14 p.m., Staff A, LPN confirmed she had worked the night of the fall. Confirmed that she had not contacted the Provider of the head injury and she had passed on the information to the next shift. During an interview on 12/28/22 at 2:59 p.m., Staff B, LPN had been informed of the fall at the start of her shift, but didn't feel it was her responsibility to notify the provider. She had no recall of why she failed to complete Neurological Checks as scheduled, or why she had not completed an assessment. Staff B verified that had she assessed she would have documented in the Clinical Record. In an interview on 12/28/22 at 2:24 p.m., a Facility Provider stated she would expect staff to notify of an unwitnessed fall that had resulted in an obvious head strike, to use the on-call service to report immediately and talk to a Provider and would not expect a fax notification. The Provider added that the resident was on a blood thinner which made her more at risk for a bleed. Additionally, would have expected all neurological checks to be completed as per protocol and would have expected staff to monitor for symptoms. The Provider recalled that the ADON had notified her that evening when she had arrived and assessed that resident had a mental status change and experienced nausea. In an interview on 12/28/22 at 2:44 p.m., the Administrator stated that staff are expected to follow the protocols identified for Neurological Checks in the electronic record after a fall with a head strike. The checks are prompted at every 15 minutes x 4, every 30 minutes x 2, every 1 hour x 2 and every 8 hours x 9. The Administrator stated would expect to be completed even if the resident was sleeping. Additionally, would expect staff to monitor for changes as they provided care to the resident. The Administrator stated she felt the facility had failed to send notification to the Provider, as could not find any faxes that had been sent. The Administrator indicated she would expect staff to complete assessments and provide timely intervention. In an interview on 12/28/22 at 1:05 p.m., Resident #3's sister listed as #1 contact and Power of Attorney (POA) stated that she felt she should have been notified immediately, that is what they are supposed to do. Had she been contacted she would have advocated for her sister to be sent to the local ER for evaluation right away. Prior to the fall Resident #3 had been independent, competent, and could hear a pin drop, now can't hear anything. A CT Scan (medical imaging technique) dated as completed 9/2/22 revealed a subdural hematoma and left frontal scalp hematoma. Review of a hospital document titled Trauma Surgery History and Physical dated 9/3/22 revealed the resident was evaluated for a subdural hematoma and altered mental status after sustaining a ground level fall with head contusion. Review of a Major Injury Determination Form signed by the Medical Director on 9/3/22 determined that as a result of a fall resulting in a brain bleed on 9/2/22 at 12:15 a.m. the injury sustained was a major injury. Review of a facility Corrective Action Form dated 9/12/22 documented Staff A received a written final warning for failing to: follow fall protocol, notify the Provider and family, and completing an assessment.

Based on record review and staff interview the facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage seven days a week as per regulations. The facility reported a census of 59 residents. Findings Include: The Administrator reviewed actual staffing schedules for 7/1/22-present and identified the following dates that the facility failed to provide eight consecutive hours of Registered Nurse coverage for the following months: a. In July 2022 - 7/2, 7/3, 7/4 and 7/24/22. b. In August 2022 - 8/6, 8/9, 8/11, 8/21, 8/23, 8/24 and 8/31/22. c. In September 2022 - 9/1, 9/2, 9/3, 9/4, 9/11, 9/18, 9/25, 9/26, 9/28 and 9/29/22. In an interview on 12/29/22 at 11:00 a.m., the Administrator confirmed that she was aware of the responsibility of the facility to provide 8 hours of Registered Nurse (RN) coverage 7 days a week. She stated that they had been trying to hire nurses, and had been using Agency Staff ,but had been very difficult to secure RN coverage for the facility. The Administrator reported coverage has improved, and when reviewed staffing sheets provided with surveyor confirmed no RN coverage on the dates identified.

Based on observation, record review, staff and family interviews the facility failed to promptly report a resident's emergent hospital transfer to family/resident representative (Resident #2) and a fall with head strike to the family/resident representative and the Physician (Resident #3) for 2 of 4 residents reviewed. The facility identified a census of 59 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment with a reference date of 8/16/22 for Resident #2 identified intact cognitive skills for decision making. The MDS further revealed the resident required extensive assistance for bed mobility, transfer, dressing, and toilet use. The resident had diagnoses that included Post Traumatic Stress Disorder (PTSD), anxiety, depression, noncompliance with medical treatment and regimen, and diabetes. A Progress Note dated 9/14/22 at 4:28 p.m., Staff B, Licensed Practical Nurse (LPN) documented resident found with low blood glucose level, and altered mental status changes, usually alert and oriented. Provider in facility notified and order received to send to local emergency room (ER) for evaluation and treatment. Resident departed facility by ambulance at 4:24 p.m. The Progress Note lacked documentation of family notification. Review of the Resident's Electronic Face Sheet revealed Resident #2 identified as her own responsible party. Comments identified that the Resident's family should be notified only at transfer or death. In an interview on 12/21/22 at 2:00 p.m., the Assistant Director of Nursing (ADON) stated the directive for family notification on Resident #2's Face Sheet directed staff to notify family of transfer and death. The ADON confirmed that facility had not notified the family at the time of her transfer and would have expected family notification as directed by the residents wishes. 2. The MDS Assessment with a reference date of 8/23/22 for Resident #3 identified intact cognitive skills for decision making. The MDS further revealed the resident was independent for transfer, walking, and hygiene. The MDS identified the resident with adequate hearing. The resident had diagnoses that included atrial fibrillation, muscle weakness, hypertension, and anemia. Observation and interview on 12/28/22 at 12:40 p.m., Resident #3 seated at the dining room table in wheelchair. Resident noted to not be able to hear conversation, white board was provided for communication. Resident stated that she lost her hearing after the fall with head injury. Sister is very involved in care. An un-witnessed Fall Report initiated on 9/2/22 at 12:15 a.m. by Staff A, LPN documented that Resident #3 found on the floor face down beside her electric recliner which was tilted in the highest position. Resident #3 stated that she was trying to get up from the recliner and her leg gave out and she fell to the floor. Resident was assessed for injuries which included an abrasion to the right (in error) forehead. Neurological (Neuro) checks were initiated. The report further documented the Associate Director of Nursing (ADON) and the Administrator were notified of the fall A Progress Note dated 9/2/22 at 12:15 a.m., documented Staff A was called to Resident #3's room and resident was on the floor face down, noted abrasion above left eye. Neuro's started. Active range of motion to all extremities without difficulties. A fax was made out to the provider. The facility was unable to produce record of a fax being sent to the provider at that time by Staff A. No documentation of family notification noted. A Progress Note dated 9/2/22 at 2:59 p.m., documented Staff B, LPN documented the provider was faxed and informed of the fall. The facility unable to produce record of a fax being sent to the provider at this time by Staff B. Additionally, the clinical record lacked documentation of family notification. Review of a Progress Note dated 9/2/22 at 6:00 p.m., titled as a Summary for Providers initiated by the ADON described a change in condition which included the following: abnormal vital signs (BP 90/40), altered mental status, nausea and vomiting, resident on an anticoagulant, lethargic, unable to eat or drink, alert and oriented to self only, confused, unable to complete full sentences, and swelling to the left eye increased. Primary care provider responded with recommendation to send to local ER to evaluate and treat. A Progress Note dated 9/2/22 at 6:45 p.m., initiated by the ADON documented the Provider was notified via phone of the recent fall with bruising to the left forehead and shoulder and the left eye was swollen. Informed that resident now displayed altered mental status (AMS), nausea and dry heaving, lethargic and weak. Order received to send to the local ER for a CT scan and evaluation. 911 was notified and resident transported to local hospital ER. The note further documented that the Power of Attorney (POA) was notified at 6:20 p.m. of the fall and recent change of condition. POA agreed resident should be sent out for evaluation. In a Progress note dated 9/2/22 at 9:23 p.m., the ADON received an update from an ER nurse that resident was being transferred to a larger hospital due to a subdural hematoma with a brain bleed. During an interview on 12/29/22 at 2:14 p.m., Staff A, LPN confirmed she had worked the night of the fall. Confirmed that she had not contacted the family or the provider of the head injury, had passed on to the next shift. During an interview on 12/28/22 at 2:59 p.m., Staff B, LPN had been informed of the fall at the start of her shift, but didn't feel it was her responsibility to notify the provider. She had no recall of why she had not completed neurological checks as scheduled, or why she had not completed an assessment. Staff B verified that had she assessed she would have documented in the clinical record. In an interview on 12/28/22 at 2:24 p.m., a facility provider stated she would expect staff to notify of an unwitnessed fall that had resulted in an obvious head strike, to use the on-call service to report immediately and talk to a provider, would not expect a fax notification. The provider added that the resident was on a blood thinner which made her more at risk for a bleed. Additionally, would have expected all neurological checks to be completed as per protocol and would have expected staff to monitor for symptoms. Recalled that the ADON had notified her that evening when she had arrived and assessed that resident had a mental status change and experienced nausea. In an interview on 12/28/22 at 1:05 p.m., Resident #3's sister listed as #1 contact and POA stated that she felt she should have been notified immediately, that is what they are supposed to do. Had she been contacted she would have advocated for her sister to be sent to the local ER for evaluation right away. Prior to the fall Resident #3 had been independent, competent, and could hear a pin drop, now can't hear anything. In an interview on 12/28/22 at 2:44 p.m., the Administrator stated that staff are expected to notify the provider urgently with a head strike. The Administrator stated she felt the facility had failed to send notification to the provider, as could not find any faxes that had been sent. Additionally, would expect the family representative to be notified immediately unless there is documentation to do otherwise. Confirmed would have expected to notify the family representative immediately for Resident #2 and #3. Review of a facility Corrective Action Form dated 9/12/22 documented Staff A received a written final warning for failing to: follow fall protocol, notify the Provider and family, and complete an assessment.

Based on observation, clinical record review, policy review and staff interview the facility failed to ensure that Oxycodone, a Schedule II opioid narcotic was destroyed as directed by facility policy for 1 of 3 residents reviewed (Resident #5). (Schedule II-V controlled medications have a potential for abuse and may also lead to physical or psychological dependence).The facility reported a census of 59 residents. Findings Include: 1. Observation on 12/19/22 at 4:37 p.m., revealed narcotics were double locked. All of the as needed (PRN) narcotics are stored in the cart assigned to a nurse. Medications are to be destroyed in the medication room, a drug buster container was identified by contracted staff who responded that destruction of a controlled medication must be witnessed by another staff member, who must initial the Narcotic Record. Further observation on 12/20/22 at 6:00 p.m. shift count was observed. Review of the Individual Narcotic Record for Resident #5 documented an order dated as received on 1/31/22 for Oxycodone HCL 5 milligrams (mg), administer 1 tablet by mouth every 8 hours as needed. 5 tablets were received by the facility. On 2/26/22 one tablet is signed out in error by Staff C, Registered Nurse (RN), on 3/4/22 3 tablets are signed out in error by Staff D, Licensed Practical Nurse (LPN) and on 3/16/22 the remaining tablet is destroyed by Staff E, LPN via the disposal bottle. The narcotic record failed to document a witness to the destruction of the wasted Oxycodone by Staff C, D, or E. During an interview on 12/20/22 at 3:15 p.m., the Administrator and the Assistant Director of Nursing (ADON) revealed that on 2/26/22 Staff C failed to document the Oxycodone that was removed in error was destroyed or that there was a witness to the destruction as was expected. On 3/4/22 Staff D stated that she had destroyed the 3 Oxycodone that had been removed in error but failed to have a witness to the destruction as expected. On 3/16/22 the medication was destroyed due to non-use. Staff E destroyed the remaining Oxycodone but failed to have a witness to the destruction. Staff E was counseled that a witness was required when destroying controlled medications. Education was provided to the staff of the expectation for counting and wasting narcotics. Review of facility policy titled Controlled Substance Record Book: Protocol last revised on 2/14/22 included the following directive for the expiration, discharge or medication is discontinued: a. Complete the date the medication was destroyed. b. The number of pills that were destroyed. c. Write in how the medication was destroyed i.e. drug [NAME] and the reason the medication was destroyed. d. The nurse and the other staff member will then sign at the bottom of the Narcotic Record Sheet.

Based on observation, staff interview and facility policy review, the facility failed to ensure the spread of potential infections with stained cutting boards with deep grooves; food in refrigerator and freezer, uncovered, not labeled nor dated. The facility reported a census of 17 at the time of the survey. Findings include: During initial tour of the kitchen on 8/23/21 at 11:00 AM the following items were discovered: 1. 6 cutting boards (green, blue, red, white, brown, yellow) approximately 18 x 12 inches, all had grooves; not sanitizable. 2. 2 pureed cake desserts in refrigerator, not covered nor dated. 3. approximately 1# diced chicken not labeled, not dated in refrigerator. 4. approximately 2# turkey not labeled nor dated in freezer. 5. 20 frozen biscuits not sealed, labeled nor dated. During an interview on 8/23/21 at 11:10 AM Staff A (cook) acknowledged the items not labeled nor dated in the refrigerator and freezer, along with the 20 biscuits not sealed properly. Acknowledged the cutting boards with deep grooves. During interview on 8/24/21 at 3:06 PM the Dietary Manager acknowledged the items in refrigerator and freezer and stated their expectations are for staff to follow the facility policies and procedures; properly sealing, covering, labeling and date items in refrigerators and freezers. During interview on 8/25/21 at 12:52 PM the facility Administrator acknowledged the items and stated all staff are to be following facility policies and procedures. The facility policy dated February 2016, Sanitation directed staff : 2. All frozen products will be sealed, labeled, and dated. Including items removed from the original packaging. 5. Refrigerated foods will be covered, labeled and dated (month, day, year)

Based on clinical record review, observations and interviews, the facility failed to implement Care Plan interventions related to smoking for one of two residents reviewed who smoked (Resident # 20).The facility reported a census of 25. Findings include: The Minimum Data Set ((MDS) dated [DATE] revealed Resident #20 with a Brief Interview for Mental Status score of 4 out of 15 which indicated severe cognitive impairment. The MDS revealed that resident required supervision for dressing and toileting. [DIAGNOSES REDACTED]. The facility provided a list entitled Resident's That Smoke and the list included Resident #20. During an observation on 1/13/20 at 9:30 a.m., Resident #20 went outside supervised by staff to smoke cigarettes. Record review done on 1/13/20 at 1:25 p.m. of Resident #20's Care Plan with an admission date of [DATE] does not reveal that resident smokes and no safety interventions related to smoking listed. During an interview on 1/13/20 at 1:26 p.m., the Director of Nursing stated that smoking should be addressed on the Care Plan for Resident #20.

Based on observations, record review, and staff interview the facility failed to ensure each resident received necessary respiratory care and services in accordance with professional standards of practice for one of one residents reviewed (Resident #21). The facility reported a census of 25 residents. Findings include: A Minimum (MDS) data set [DATE] for Resident #21, included [DIAGNOSES REDACTED]. During an observation on 1/12/20 at 10:43 a.m., the resident lying in bed with oxygen being administered per nasal cannula, noting the oxygen tubing undated. During an observation on 1/14/20 at 9:42 a.m., the resident lying in bed with oxygen being administered per nasal cannula, noting the oxygen tubing undated. Review of physician's orders [REDACTED]. Review of resident's Care Plan with admitted [DATE], documented focus of oxygen therapy related to stage 4 [MEDICAL CONDITION] with intervention to change tubing per protocol. Review of resident's Treatment Administration Record (TAR) dated 1/1/20 - 1/31/20, lacks documentation of oxygen tubing change. During an interview on 1/14/20 at 10:41 a.m., the Director of Nursing stated the facility's protocol is to change the oxygen tubing every Saturday night on the night shift, date the tubing, and document on the TAR. She stated her expectation would be to follow the facility protocol.

Based on clinical record review and interviews with a pharmacist, physician, staff and resident, the facility failed to administer a resident's medication as ordered by the physician for 6 days (Resident #4). The sample consisted of 5 residents and the facility reported a census of 37 residents. 1. According to the admission Minimum Data Set (MDS) assessment with a reference date of 1/17/2011, Resident #4 had [DIAGNOSES REDACTED]. Resident #4 could repeat 3 words to staff and had recall of the 3 words later in the assessment. The resident made decisions independently but exhibited disorganized thinking with [MEDICAL CONDITION]. Resident #4 required extensive assistance of 1 staff for transfers, walking about the facility, dressing, toilet use, personal hygiene as well as bathing and utilized a wheelchair and walker. The resident utilized antipsychotic medications daily. According to the Care Plan, Resident #4 was admitted into the facility on [DATE] with a [DIAGNOSES REDACTED]. The residential facility (where the resident lived prior to the hospitalization ) nurse ' s notes dated 1/9/2011 at 9:45 a.m. indicated the hospital pharmacy requested the resident ' s [MEDICATION NAME] (antipsychotic) be brought to the hospital since the resident would be admitted to the hospital. A Release of Pass Medications indicated the residential facility provided the hospital with 24 tablets of [MEDICATION NAME] 100 milligrams tablets. The residential facility Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The admission orders [REDACTED]. Review of the Medication Admission Record for January 2011 revealed the facility staff administered [MEDICATION NAME] 600 milligrams daily at bedtime from 1/10-1/18/11 but failed to administer the medication from 1/19-1/24/11. The nursing staff indicated the facility did not have the medication available to give to Resident #4. Review of the physician's orders [REDACTED].#4 on 1/17, 1/18, 1/21 and 1/22/11. According to a pharmacy policy titled Distribution of [MEDICATION NAME] (not dated) revealed the medication, [MEDICATION NAME], required monitoring of a resident's white blood cell levels. The levels must be obtained before the pharmacy could dispense [MEDICATION NAME]. The policy indicated the pharmacy would not dispense the medication without the receipt of the blood levels test results. Review of a local laboratory report indicated Resident #4 had white blood counts drawn on 1/17 and 1/24/11. The Nurses Notes dated either 1/20 or 1/21/2011 (unable to read accurate date) at 4:00 p.m. indicated the laboratory faxed the results of the white blood count to the pharmacy. The note indicated the white blood count results were within normal range and the laboratory would fax the report to the facility. The Nurses Notes further reflected the laboratory arrived at the facility to draw Resident #4's white blood count on 1/24/11. Review of a late entry dated 1/28/11 revealed the facility staff called the pharmacy and requested Resident #4's [MEDICATION NAME] on 1/24/11. The Pharmacy informed the facility they had not received the laboratory test results in order to dispense the medication. During an interview with the Director of Nurses (D.O.N.) on 2/9/11 at 2:10 p.m., the D.O.N. stated the required white blood count level for Resident #4 could be found in the resident's clinical record but the staff failed to send it to the pharmacy to obtain the [MEDICATION NAME] medication for the resident. The D.O. N. stated she/he could not lie to the surveyor stating they could not find documentation the staff requested additional [MEDICATION NAME] for Resident #4 and that the physician had knowledge of the medications not being administered. The D.O.N. stated she/he were unable to locate a fax that indicated the pharmacy received the required laboratory work to obtain the [MEDICATION NAME] for Resident #4. The staff failed to give the [MEDICATION NAME] to Resident #4 as directed by the physician due to not being available for a period of 6 days. The Nurses Notes dated 1/24/2011 at 10:00 p.m. indicated Resident #4 began to use abusive profanity with another resident. The resident continued to use profanity with nursing assistants and nurses about leaving the facility. The staff could not reorient the resident. The nurses note dated 1/25/2011 at 12:10 a.m. revealed the resident used the call light and then urinated in the trash can next to the bed side. The resident voiced " I just did it because I wanted to. " The resident requested something to help relax. The nurse administered [MEDICATION NAME] medication and the resident was reminded to use the toilet for further bathroom urgencies. The note of 1/25/2011 at 9:00 a.m. indicated a new order that the resident could return to a residential care facility level of care. A Resident Transfer Form indicated the resident transferred to the previous residential living facility on 1/25/2011. On 2/9/11 at 2:45 p.m., the resident ' s attending physician was interviewed and confirmed he/she had no knowledge Resident #4 did not receive the [MEDICATION NAME] from 1/19-1/24/11. The physician stated on 2/24/11, he/she gave an order for [REDACTED].#4. The residential facility told the physician the resident exhibited physical symptoms as well as unstable psychiatric symptoms. The residential facility notes indicated the resident experienced behaviors and activity of living changes upon re-admission into their facility. The resident had not been able to dress self until 1/25/2011. The resident would drop a cigarette and could not pick it up. The staff notified the attending physician. The staff reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 2/9/11 at 1:30 p.m. Staff A (Licensed Practical Nurse) was interviewed and stated she/he gave Resident #4 the last dose of [MEDICATION NAME] on 1/18/11. Staff A did not return to work again until 1/24/11. While administering medications on 1/24/11, she/he attempted to administer the [MEDICATION NAME] to Resident #4 and found no medication available. Staff A stated she/he called the pharmacy and the pharmacy stated they could not dispense [MEDICATION NAME] for Resident #4 until they received the appropriate blood level results. Staff A stated the staff noted behavioral changes in Resident #4 from 1/18-1/24. The resident exhibited an increase in delusional ideations and staff had more problems reorienting the resident. On 2/10/11 at 8:45 a.m. the pharmacist was interviewed and stated on Tuesday 1/18/11 when reviewing the follow up folder for Resident #4's medications identified the pharmacy needed the required white blood cell count. The pharmacy representative contacted the facility and stated the pharmacy needed the blood count in order to dispense the medication. On 1/20/11 the pharmacy again contacted the facility to obtain the lab work as they did not receive the lab work on their first request. The pharmacist stated the [MEDICATION NAME] is not a medication that is automatically refilled. The pharmacy did not dispense the medication as they did not receive the required lab work. On 2/10/11 at 10:30 a.m. the resident ' s psychiatrist was interviewed. The psychiatrist stated Resident #4 had been making progress working towards the goal of returning to his/her home town. The resident had an apartment ready to move into. The Psychiatrist stated Resident #4 had success on the medication, [MEDICATION NAME]. The resident had started the medication on a required low dose and had worked up to a therapeutic dose. [MEDICATION NAME] required close monitoring of the white blood cell levels as it could cause blood disorders. Upon return to the Residential Care Facility the staff called the psychiatrist and informed her/him of the lack of the medication from 1/19-1/24/11. The psychiatrist directed the staff to restart the low dose of [MEDICATION NAME] and slowly increase the dosage. The psychiatrist started the dose at 12.5 milligrams. The psychiatrist stated the progress for the resident to return home now has been delayed by about 2 months due to the lack of [MEDICATION NAME] experienced at the nursing facility. The Drug Information Handbook for Nursing 2007 identified the initial dose began at 12.5 milligrams twice daily and increased as tolerated in increments of 25-50 milligrams day to a target dose of 300-450 milligrams per day after a 2-4 weeks. The source indicated doses may be required as high as 600-900 milligrams each day (page 294). During an interview with Resident #4 on 2/10/11 at 12:00 p.m., the resident stated had felt better on the [MEDICATION NAME] but the nursing home had stopped the medication. Resident #4 voiced the desire to return home to own apartment in home town.