Every finding on record at Red Rocks Care Center

Based on observation and interview, the facility failed to ensure residents had a safe and functional environment throughout the facility and for 18 (RM's # 20, 22, 27, 41, 43, 46, 49, 50, 51, 54, 64, 65, 66, 67, 68, 70, 71, and 76) of 19 (RM's #4, 20, 22, 27, 41, 43, 46, 49, 50, 51, 54, 64, 65, 66, 67, 68, 70, 71, and 76) rooms observed when the facility failed to: Ensure the facility entrance wall was even and pain all facility walls that were unpainted.Repair broken trim around the heating/cooling unit and damaged floor tiles between resident beds, in room [ROOM NUMBER], 66.Repair seal around heating/cooling unit in room [ROOM NUMBER],66.Repair broken and uneven floor tiles in rooms 22, 41, 43, 45, 49, 50 and 51.Repair bathroom door frame trim in rooms 50, 54, 67, 68, 70 and 71.Repair baseboards in room [ROOM NUMBER].Ensure there were no lingering unpleasant odors throughout the facility.Repair of yellow expanding foal sealant in room [ROOM NUMBER].Repair of bathroom door with puncture hole in room [ROOM NUMBER]. These deficient practices are likely to expose residents to an unsafe and uncomfortable environment.The findings are:A-Hall: A. On 12/01/25, at 10:17 AM, during the initial tour of the facility and immediately upon entrance to the facility revealed a strong odor of urine and feces throughout the building including the A hall. B. On 12/01/25 at 12:46 PM during an observation of A-hall, a strong odor of feces revealed throughout the entire hall. C. On 12/04/25 at 11:45 AM during an observation of room [ROOM NUMBER], a strong odor of urine throughout this room; the dresser was broken; baseboard trim separated from walls and presence of a black substance behind and along the detached areas. D. On 12/04/25 at 12:15 PM during an observation of room [ROOM NUMBER] revealed the floor was uneven; broken floor tiles and baseboard trim separated from walls and presence of a black substance behind and along the detached areas. B-Hall: E. On 12/04/25 at 2:23 pm, observation revealed a wardrobe (a large cabinet used for storing clothes) in room [ROOM NUMBER] with the bottom left side of the door off its hinge. F. On 12/04/25 at 2:25 pm, observation in room [ROOM NUMBER] restroom revealed a cracked tile beside the toilet. Further observation revealed a black, dirt-like substance around back of toilet and splattered on the wall behind the toilet. G. On 12/05/25 at 12:20 pm, during interview with MD, he stated the wardrobe door in room [ROOM NUMBER] should not have the door off its hinge and should be repaired. MD stated the restroom in room [ROOM NUMBER] should not have any cracked tiles and should be in good repair. MD stated the facility served as the residents' home and the current environmental conditions did not support a homelike environment. C- Hall: H. On 12/01/25 at 10:17 AM during the initial tour of the facility and immediately upon entrance to the facility revealed a strong odor of urine and feces throughout the building including the C-hall. I. On 12/02/2025 at 8:46 AM during an observation of C-hall, revealed a strong odor of feces carried throughout the entire hall. J. On 12/03/2025 at 1:35 PM during an observation of room [ROOM NUMBER] revealed a strong odor of urine throughout this room; frame on bathroom door appeared dirty and had scratches. K. On 12/03/2025 at 1:40 PM during an observation of room [ROOM NUMBER], the heating/cooling unit was not completely sealed and daylight from the outside was visible; the wall next to the heating/cooling unit is cracked; the baseboard in the corner by the heating/cooling unit is broken; and there were cracked floor tiles by entry way. L. On 12/03/2025 at 1:43 PM during an observation of room [ROOM NUMBER], the floor was uneven and there were broken floor tiles. M. On 12/03/2025 at 1:45 PM during an observation of room [ROOM NUMBER], there were broken and uneven floor tiles throughout room; the bathroom door frame is broken; and the chair in this resident's room had torn upholstery on the seat. N. On 12/03/2025 at 1:48 PM during an observation of room [ROOM NUMBER], the dresser was broken; the hallway floor next to room [ROOM NUMBER] has uneven broken/bubbling flooring. O. On 12/03/2025 at 1:49 PM during an observation of room [ROOM NUMBER], cracked and uneven floor tiles were present throughout the room. P. On 12/03/2025 at 1:50 PM during an observation of room [ROOM NUMBER], a hole was present located on the bathroom door, and the dresser/drawer was broken with missing and loose handles. Q. On 12/03/2025 at 1:52 PM during an observation of the hallway near room [ROOM NUMBER], unpainted patchwork was present on the wall. R. On 12/03/2025 at 1:54 PM during an observation of room [ROOM NUMBER], broken floor tiles were present throughout the room. S. On 12/03/2025 at 2:00 PM during an observation of room [ROOM NUMBER], the trim for the heating/cooling unit was broken and there were black build-up or scratches on the floor between resident beds. T. On 12/03/2025 at 2:03 PM during a C-Hall observation, the wall at the entrance to C-Hall had unpainted and uneven patchwork. U. On 12/03/2025 at 2:05 PM during an observation of the main dining room revealed there was a broken light, missing pieces of the plastic light covering, and there was clear tape hanging off of it directly over a resident dining table. The wall and ceiling by the piano were cracked, there was a dirty ceiling vent directly over a resident table, the exit door (to outside) had scratches and black scuff marks over the bottom half of the door; and the ceiling vent by the entrance door to dining room appears dirty with black mold-like build-up. V. On 12/05/2025 at 12:20 PM during an interview with the Maintenance Director (MD), he stated he was aware of the issues throughout the facility, and he acknowledged that some of the doors need to be replaced. He further stated he was aware of the broken floor tiles throughout the facility, and they have been working on this. The MD stated the cracking on the walls, ceilings and floors were related to issues with the building's foundation, and the building should be in better condition. He stated they are in the process of replacing all of the heating/cooling units in resident rooms and acknowledged most of the resident furniture was in disrepair and he will be ordering new furniture for resident rooms. Regarding the lighting in the main dining room, he stated he was aware of the broken light fixture as well as the cracks in the walls and floors and further stated they were in the process of getting new lighting and again reiterating the cracks are due to issues with the building's foundation. Regarding the laundry room, he stated the damage to the wall was from water damage from water heaters that malfunctioned. He stated it was his expectation the drywall be repaired D-Hall: W. On 12/02/25 at 10:09 a.m. to 10:35 a.m., observation of D Hall revealed the following environmental concerns in occupied resident rooms: room [ROOM NUMBER], visible yellow expanding foam sealant was noted along the area where the baseboard meets the floor. The foam was uneven, excess material protruded outward, and the area had not been trimmed or finished. Rooms #67, #68, #70, and #71 revealed each bathroom door was missing trim along the lower portion of the door frame, resulting in an unfinished and irregular surface. room [ROOM NUMBER] revealed dresser/drawer was broken, lose drawer handle. room [ROOM NUMBER] revealed the bathroom door had a small, punctured hole located on the lower panel of the door. The hole contained rough and splintered edges and exposed interior material of the door surface. room [ROOM NUMBER] had a visible gap along the right-side perimeter of the unit where daylight was visible entering the room. The exposed opening showed deterioration of the wall surface, including a vertical crack extending upward from the top right corner of the unit. Observation further revealed the upper vertical plastic grill on the unit was bent and displaced. Sixth fluorescent light fixtures down the D-hall were broken and cracked. X. On 12/05/25 at 11:30 a.m., during an interview with the Maintenance Director (MD), he stated several doors need to be painted and that some doors are old. He stated the bathroom doors in Rooms 67, 68, 70, and 71 should not remain scuffed and the missing trim should be repaired. The Maintenance Director further stated the puncture hole in the bathroom door in room [ROOM NUMBER] should not be there and should be fixed because it does not look good for the residents. He stated room [ROOM NUMBER] should have had the yellow foam sealant should have been taken off.

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR; 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 5 (R #5, R #27, R #55, R #66, and R #94) of 5 (R #5, R #27, R #55, R #66, and R #94) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents who are identified in the screening process for additional care and services. The findings are: R #5 A. Record review of R #5's face sheet revealed the resident was admitted into the facility on [DATE] with the following diagnoses: Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety). Unspecified Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). Anxiety. B. Record review of R #5's PASARR Level I dated 02/19/25 revealed the section titled 1. Is there a diagnosis or suspected mental illness? did not have Yes or No selected. The form section intended to identify mental-illness-related diagnoses remained incomplete. C. On 12/05/25 at 11:18 AM during an interview, the admission Director (AD), she stated R #5's diagnosis of major depressive disorder was a mental illness. She stated the admission department was responsible for the completion of the PASRR screening and the screening was incorrect for R #5 because Section C, question 1, was not answered. R #27: D. Record review of R #27 Face Sheet revealed R #25 was admitted on [DATE] to the facility with the following diagnosis: Major depressive disorder. (major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment) E. Record review of R #27's PASRR Level 1 Screening, dated 05/19/25 revealed the following: Section C, identification of mental illness evaluation criteria, including diagnoses such as schizophrenia, or disorders of mood, panic, anxiety, personality, psychotic, somatoform, substance related. (this list is not all-inclusive; contact the PASRR office for questions on a particular diagnosis), was unanswered. F. Record review of R #27's Base Line Care Plan dated 11/03/25 revealed R #27 uses an antidepressant for depression. G. Record review of R #27 Physician Orders, dated 12/05/25 revealed the following: Monitor for signs or symptoms of increased depression or possible suicidal ideation, Medi telecare- (company that provides mental health care using telehealth) to evaluate and treat psychiatric and psychological health depression, Sertraline 100 mg (milligram) give 1 tablet by mouth, one time a day for depression. Resident exhibits or is at risk for distressed/fluctuating mood symptoms related to sadness/depression caused by diagnosis of Major Depressive Disorder. H. Record review of R #27's PHQ-2 to 9 Evaluation (PHQ-9 is a 9-question tool used to screen for depression and measure how severe the symptoms are) dated 10/17/25 revealed the resident feeling down, depressed or feeling hopeless. R #27's PHQ-2 to 9 evaluation was incomplete and without a score reported by the facility. I. On 12/05/25 at 11:24 AM during an interview, the admission Director (AD) stated R #27's diagnosis of major depressive disorder was a mental illness. She stated the admission department was responsible for the completion of the PASRR screening and the screening was incorrect for R #27 because it lacked the resident's diagnosis of major depressive disorder. R #55: J. Record review of R #55's face sheet revealed R #55 was admitted into the facility on [DATE] without a diagnosis or history of mental illness. K. Record review of R #55's PASRR Level 1 Screening, dated 11/11/25, revealed the following: Section C, identification of mental illness evaluation criteria, including diagnoses such as schizophrenia, or disorders of mood, panic, anxiety, personality, psychotic, somatoform, substance related. (this list is not all-inclusive; contact the PASRR office for questions on a particular diagnosis), was unanswered. L. On 12/05/25 at 11:29 AM during an interview, the admission Director (AD) she stated R #55's diagnosis of major depressive disorder was a mental illness. She stated the admission department was responsible for the completion of the PASRR screening and the screening was incorrect for R #55's because Section C, question 2, was not answered. R #66: M. Record review of R #66 Face Sheet revealed R #66 was admitted into the facility on [DATE] with the following diagnoses: Diagnosis of major depressive disorder. Diagnosis of anxiety disorder. N. Record review of R #66's PASRR Level 1 Screening, dated 01/23/24, revealed the following: Section C, identification of mental illness evaluation criteria, including diagnoses such as schizophrenia, or disorders of mood, panic, anxiety, personality, psychotic, somatoform, substance related. (this list is not all-inclusive; contact the PASRR office for questions on a particular diagnosis), was answered as not identified. O. Record review of R #66's Base Line Care Plan, dated 07/04/24 revealed the following: Resident uses an antidepressant for depression, Resident exhibits or is at risk for distressed/fluctuating mood symptoms related to sadness/depression caused by diagnosis of Major Depressive Disorder. P. Record review of R #66's Physician Order Summary Report, dated 12/05/25 revealed the following: Monitor for signs and symptoms of increased depression, Fluoxetine (antidepressant) 20 mg tablet by mouth for depression. Q. On 12/05/25 at 11:35 AM during an interview, the admission Director (AD), she stated the admission department was responsible for the completion of the PASRR screening and the screening was correct for R #66. AD was unaware of R #66's diagnosis of major depressive disorder. R #94: R. Record review of R 94's Face Sheet revealed R #94 was admitted into the facility on [DATE] with the following diagnosis: Diagnosis of anxiety disorder. S. Record review of R #94's PASRR Level 1 Screening, dated 03/12/24, revealed Section C, identification of mental illness evaluation criteria, including diagnoses such as schizophrenia, or disorders of mood, panic, anxiety, personality, psychotic, somatoform, substance related. (this list is not all-inclusive; contact the PASRR office for questions on a particular diagnosis), was answered as not identified. T. Record review of R #94's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 06/06/25 revealed Section I- (Active Diagnosis) was coded as anxiety disorder. U. On 12/05/25 at 11:42 AM during an interview, the admission Director (AD) she stated the admission department was responsible for the completion and accuracy R #94's PASRR screening and the screening was correct. AD was unaware of R #94's diagnoses of major depressive disorder and anxiety disorder.

Based on record review and interviews, the facility failed to revise the plan of care following a confirmed change in condition for 1 (R #77) of 1 (R #77) resident reviewed for care plan revision when:R #77's care plan was not updated to include an orthopedic follow-up (evaluation and ongoing management by a bone and joint specialist to assess healing, treatment needs, and potential complications) and monitoring for safety and pain after R #77 returned from the hospital with a documented fracture requiring immobilization. This deficient practice likely to result in staff not having instructions to direct care, monitor changes, or implement safety interventions after a resident's injury or change in condition. The findings are: A. Record review of the facility's Person-Centered Care Plan Policy revised 09/15/25 revealed that residents have the right to be informed in advance of changes to the care plan, and the care plan must be revised after each assessment and upon changes in the resident's condition. The policy stated that a comprehensive person-centered care plan must include services to be furnished, measurable goals, timeframes, and individualized interventions based on identified needs. The policy further directs that the interdisciplinary team (IDT; includes but is not limited to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of the food and nutrition services staff, resident or resident representative, and other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident) must review and revise the care plan after a change in condition to ensure safe and appropriate delivery of care. B. Record review of R #77's face sheet revealed he was admitted into the facility on [DATE]. C. Record review of R #77's hospital discharge paperwork dated 11/19/25 revealed diagnostic imaging confirmed a right scapular spine (shoulder blade) fracture with nonunion a fracture that failed to heal properly, resulting in incomplete or absent bone healing), and directed the resident return wearing a sling, receive orthopedic follow-up on 11/26/25, and receive monitoring for pain and mobility changes. D. Record review of R #77's care plan dated 12/02/25 revealed the care plan was not revised to indicate the diagnosed fracture, no interventions for immobilization, no instructions directing staff to assist with transfers or mobility, and no pain-specific interventions related to the fracture. E. On 12/05/25 at 9:09 a.m., during an interview with Certified Nurse Aide (CNA) #4, she stated R #77 was supposed to use a sling, but R #77 did not consistently wear it and continued pushing himself up with the injured arm. She stated she had not been provided with any care plan direction or training regarding sling use or mobility precautions. F. On 12/05/25 at 9:51 a.m., during an interview with the Administrator (ADM), he stated the care plan should be revised when a resident returns from the hospital with new diagnoses and treatment requirements. He stated he was unaware of the fracture and stated the Director of Nursing (DON) was responsible for ensuring care plan updates. The ADM stated R #77's plan of care was not revised and stated monitoring did not occur and it is his expectation the revision of the care plan and the monitoring would have been performed. G. On 12/05/25 at 12:32 p.m., during an interview with the Medical Director (MD), he stated he was aware R #77 had suffered a broken scapula. The MD also stated it was his expectation the facility would of follow the recommendations from the hospital and care plan all interventions.

Based on observation, and interviews, the facility failed to properly store medications in the facility medication cart and storage room by not: Ensuring the medication refrigerator (fridge) temperature log is being monitored routinely.Ensuring insulin (insulin is a natural hormone that turns food into energy and manages your blood sugar level) pens are dated when they are first used and dated 28 days after first use.These deficient practices are likely to result in expired medications and medical supplies being used in resident care resulting in residents being at risk of possible infections and not receiving the full benefits of medication. The findings are: A. On 12/01/25 at 11:38 am, observation of the locked medication room, the fridge temperature log form for the months of September through November 2025 were not complete. B. On 12/01/25 at 11:42 am, observation of the nurse medication cart revealed the insulin pens for R #'s 21, 36, 53, 56, and 72 were not dated with the date of first use and no date for when to discard after 28 days. C. On 12/01/25 at 11:42 am, during an interview with Registered Nurse (RN) #1, she confirmed the insulin pens are not dated when the pens were first used and dated for to discard after 28 days and it did not happen. RN #1 stated that undated insulin pens are considered expired and should be disposed appropriately. RN #1 confirmed that the fridge temperature logs were not complete and checked routinely as they should be. D. On 12/01/25 at 12:36 pm, during an interview with Director of Nursing (DON), she confirmed that nurses are expected to complete the fridge temperature log once a shift and it did not happen. DON also confirmed that undated insulin pens are considered expired and should not be in the carts.

Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 4 (R #3, R #55, R #71, and R #84) of 4 (R #3, R #55, R #71, and R #84) residents reviewed for infection control when: The facility failed to ensure staff performed hand hygiene during medication administration. The facility failed to ensure urinary catheter tubing remained off the floor to prevent contamination. The facility did not implement Enhanced Barrier Precautions (EBP) as required for residents with indwelling devices (inside the body) and wounds. The facility did not have biohazard bins or trash cans available for staff to discard used/soiled PPE (personal protective equipment). These deficient practices are likely to result in repeated and ongoing exposure of residents to increased risk of infection, cross-contamination, and injury. The findings are: Hand Hygiene: A. On 12/02/25 at 7:58 am, during a medication administration observation, Certified Medication Aide (CMA) #1 administered R #71's morning medications. Immediately afterward, CMA #1 proceeded to the medication cart to document her actions and started pouring the next residents without performing hand hygiene. B. On 12/02/25 at 7:58 am, during an interview with CMA #1, she confirmed that she forgot to perform hand hygiene after giving R #71's morning medications. CMA #1 stated that she is to perform hand hygiene after each medication administration as part of the facility infection control policy but did not happen. Catheter Tubing: R #3: C. Record review of the facility's Catheter Care Procedure (steps to maintain the catheter and drainage system - a thin, sterile tube inserted into the bladder to drain urine), last revised on 02/01/23, revealed procedure was to secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor. D. Record review of R #3's Face Sheet, revealed R #3 was originally admitted to the facility on [DATE] with diagnoses of Malignant Neoplasm (cancerous tumor) of Unspecified Kidney and Benign Prostatic Hyperplasia (enlarged prostate) with Lower Urinary Tract Symptoms. E. Record review of R #3's minimum data set (MDS, which was part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) completed on 07/08/25 indicated R #3 had a brief interview for mental status (BIMS; screening for cognitive impairment) score of 6 (00-07 is severe impairment). F. Record review of R #3's physician orders revealed an active order, dated 08/15/25, for Indwelling Foley catheter PRN (as needed) for chronic urinary retention or incontinence with discomfort. G. On 12/01/25 at 12:47 pm, during a dining room observation, R #3's catheter tubing dragged across the floor as he wheeled himself out of the dining room. H. On 12/02/25 at 12:25 pm, during an interview with Licensed Practical Nurse (LPN) #5, he stated the catheter tube for R #3 should not be dragged on the floor, as it could cause infection or the catheter tube could become caught and pulled out of the resident, causing discomfort. I. On 12/02/25 at 2:53 pm, during an interview with Director of Nursing (DON), she stated no catheter tubing should ever be dragged on the floor. The DON stated if the catheter tube is touching the ground, it could cause an infection, or the tube could get caught on something and pull the tube out of the resident. J. On 12/04/25 at 12:40 pm, during a hallway observation, R #3's catheter tubing dragged across the floor as he wheeled himself in the hallway. K. On 12/05/25 at 11:58 am, during an interview with the Administrator (ADM), he stated resident catheter tubing should not be dragged across the ground, as it could get snagged and pull on the resident's appendage. The ADM also stated it is his expectation catheter tubing for residents would be properly secured under the residents' chair. R #84: M. Record review of R #84's face sheet revealed he was admitted to the facility 10/31/25 with diagnoses of: Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement), History of traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head), Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others.) N. Record review of R #84's Quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 02 (00- 07 is severe impairment). O. On 12/02/25 at 12:05 p.m., during a room observation, R #84 was observed to be seated in a wheelchair with the urinary drainage bag secured in a blue privacy bag off the floor; the catheter tubing between the resident and the bag extended was under the wheelchair and dragging across the floor surface. P. On 12/02/25 at 12:25 p.m., during an interview with Licensed Practical Nurse (LPN) #5, he stated the catheter tube should not be dragging on the floor as it could cause, and infection or the catheter tube could become caught and be pulled out of the resident causing discomfort for the residents. Q. On 12/02/25 at 2:53 p.m. during an interview with DON, she stated no catheter should ever have catheter tubing dragging on the floor. She stated if the tube is touching the ground, it could cause an infection, or the tube could get caught on something and pull the tube out of the resident. R. On 12/05/25 at 12:38 p.m., during an interview with the ADM, he stated all catheter tubes should be properly secure for the residents below the bladder, without dragging the ground. He stated if the tube is dragging the ground, it could be pulled out and cause the residents' pain. EBP and Biohazard Bins: S. Record review of the facility's Enhance Barrier Policy, dated 01/06/20 revealed the following: EBP are an infection control intervention designed to reduce the transmission of novel or MRDO (multi-drug-resistant organisms) Enhanced barrier precautions are infection control intervention designed to reduce the transmission of novel or MDRO. It employs targeted personal protective equipment (PPE) use during high contact resident activities, To reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect contact, EBP expands on the use of gown and gloves beyond anticipated blood and body exposures, focusing on use of gown and gloves only during high contact resident care activities that have been demonstrated to result in transfer of MDRO's to hands and clothing of healthcare personnel, even if blood and body exposure is not anticipated, Post the appropriate EPB sign of the resident's room door, EBP are to be utilized for the duration of the resident's stay, All residents with any of the following require EPB: Wounds and/or indwelling medical devices such as urinary catheter, EPB required during dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, urinary catheter, Gown and gloves are used prior to high contact care, Change PPE before caring for another resident. R #3: T. On 12/05/25, at 9:09 AM, during an observation of R #3' s room, EBP signage was present on the outside of the room indicating staff are to utilize PPE when performing resident care. There was not a biohazard bin present (to throw away contaminated PPE) and there was only one trash can present in the room for R #3 and the roommate. U. On 12/05/25, at 9:13 AM, during an interview with Certified Nursing Assistant (CNA) # 1, she stated the red biohazard, or designated bin should be in the resident's room who are on EBP. She stated the two staff members providing care to R #3 should have PPE on while providing care to R #3. CNA #1 confirmed R #3 does not have a red biohazard bin, or designated trash can in the resident's room and should. V. On 12/05/25, at 9:14 AM during an observation of R #3 in his room, the Assistant Director of Nursing (ADON) and Medical Records (MR) were observed transferring R #3 from his wheelchair to his bed. No observation of PPE used by staff while providing care. W. On 12/05/25 at 9:17 AM, during an interview with the ADON, she stated she was unsure what the facility's policy was regarding Enhanced Barrier Precautions (EBP) and was not certain whether she was following EBP when providing care to R #3. She confirmed she had performed hand-to-hand contact (refers to direct physical contact between one person's hand and another person's hand) with the R #3 and acknowledged she should have been practicing EBP. She stated she was unsure if the care provided to R# 3 was consistent with EBP and was uncertain whether EBP needed to be followed when laying the resident down in bed. The ADON further stated if she was wearing PPE, she believed she would dispose of it in the trash located in the resident's room, but she was not sure. She stated residents on Active Isolation (deliberate separation of a patient with a contagious disease from others to prevent the spread of infection) require a red bin and room down the hall is where the facility's biohazard or designated bin is located. She noted there was only one trash can available for both residents in the shared room where she was providing care for R #3. The ADON stated it was her expectation all staff follow EBP to prevent the residents from declining or infection. R #55: X. Record review of R #55's face sheet revealed R #55 was admitted into the facility on [DATE] with the following diagnoses: Neuromuscular dysfunction of bladder (bladder doesn't work properly because of nerve or muscle problems, causing issues like leakage or trouble emptying), Retention of urine (a condition that occurs when a person is unable to empty their bladder, either partially or completely), Fracture of vertebra (break or crack in one of the bones of the spine, with routine healing (process by which a bone or tissue repairs itself after injury without complications). Y. Record review of R # 55's Care Plan, dated 11/12/25, revealed the following: Resident has surgical wound on his back, Enhanced Barrier Precautions: Use gowns and gloves when performing high-contact activities: dressing, bathing and showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (urinary catheter, wound care (any skin opening requiring a dressing), Enhanced Barrier Precautions: Change PPE before caring for another resident, Enhanced Barrier Precautions: Educate patient/family and visitors regarding precautions, Resident is at risk for Multidrug-Resistant Organism (MDRO) colonization/infection due to: foley catheter. Z. Record review of R #55's Treatment Administration Record (TAR), dated 11/11/25 revealed the following: Change Indwelling Catheter when occluded or leaking as needed, Empty catheter drainage bag at least once every eight hours to when it becomes 1/2 to 2/3 full as needed, Perform Indwelling Catheter Care as needed, Wound(s): Monitor site(s) Daily for status of surrounding tissue and wound pain, Staple(s) removal on 11/18/25 one time only for Thoracic Lumbar (middle-to-lower back) incision. AA. On 12/02/25 at 8:24 AM, during an observation of R #55's room, EBP signage was present on the outside of the room indicating staff are required to utilize PPE when performing care. BB. On 12/02/25 at 9:27 AM, during an observation of R #55's room, there was no biohazard bin to dispose of PPE. CC. On 12/02/25 at 9:45 AM, during an observation of A-Hall, it was revealed no biohazard bin to dispose of PPE DD. On 12/03/25 at 12:02 PM, during an observation of A-Hall, reusable gowns for EBP use were observed to be available for staff use. EE. On 12/03/25 at 2:30 PM, during an observation of R #55's room, Registered Nurse (RN) #1 not wearing personal protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) while providing care to R #55. FF. On 12/04/25 at 11:31 AM, during an observation of A-Hall, no biohazard bins were observed to be available for staff use. GG. On 12/04/25, at 11:33 AM, during an observation of R #55's s room, there was not a red biohazard bin for staff use available. HH. On 12/05/25, at 7:50 AM during an observation of R #55's room, RN #2 was observed providing care to R #55 and was not wearing PPE as required. II. On 12/03/25, at 2:39 PM, during an interview with RN #1, she stated R #55 was on EBP for a foley catheter. She stated she was not using the proper PPE when providing care. RN #1 stated staff should use PPE and dispose after resident use in the biohazard bin or the trash bin. RN#1 stated there was no biohazard bins located in R #55's room. RN #1 confirmed it is her expectation for all staff to follow EBP standards of practice to prevent infections. JJ. On 12/05/25, at 7:52 AM, during an interview with RN #2, she stated she provided hand to hand contact with R #55 while checking his blood pressure. RN #2 stated R #55 was on EPB and her understanding of the EBP Policy required staff to gel in and gel out (use of hand sanitizer) and wear a gown, mask, and gloves. RN #2 stated she was not following enhance barrier precautions, and there was not a red biohazard bin in R #55's room. The RN #2 stated she has received training (organized medical training for healthcare staff). She stated if enhance barrier precautions are not followed, the resident could get an infection. RN #2 stated it is her expectation there should be a red biohazard bin and trash located in R #55's room. KK. On 12/05/25, at 8:51 AM, during an observation of A-Hall, a red biohazard bin was not available for staff use.

Based on record review and interview, the facility failed to ensure a resident or their representative were aware of a medication taken by the resident, which included the risks and benefits associated with that medication for 1 (R #14) of 1 (R #14) resident reviewed for unnecessary medications. If residents and/or their representative is not informed of the risks and benefits of each medication, then they are likely not able to make informed decisions. The findings are: A. Record review of the facility's Behaviors: Management of Symptoms policy, last revised on 09/15/25, revealed residents exhibiting behavioral symptoms will be individually evaluated to determine the behavior. Further review revealed when medication is ordered for behavioral symptoms, consent (from the resident or resident representative) is to be obtained. B. Record review of R #14's Face Sheet, revealed R #14 was originally admitted to the facility on [DATE] with the diagnosis of unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with agitation. C. Record review of R #14's minimum data set (MDS, which was part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) completed on 11/10/25 indicated R #14 had a brief interview for mental status (BIMS; screening for cognitive impairment) score of 0 (0-7 is severe impairment.) D. Record review of R #14's nursing progress notes revealed the following: 08/04/25: 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) meeting note stated the primary care physician (PCP) determined the GDR was contraindicated due to R #14 still exhibiting behaviors. 08/04/25: Note of PCP order to start Risperdal (antipsychotic) 1 milligram (MG). E. Record review of R #14's physician orders revealed the following orders: 08/05/25: Risperdal 1MG, order was discontinued on 11/13/25.11/14/25: Risperdal 1MG for delusions and mood changes was started. Order was discontinued on 12/02/25.12/03/25: Risperdal 1MG for unspecified dementia, severe, with agitation was started. Order status was active. F. Record review of R #14's medication administration record (MAR) for September October, and November 2025 revealed Risperdal was administered to R #14 every day for all three months reviewed. G. Record review of R #14's psychotropic medication consent forms revealed the following:Consent for Quetiapine (antipsychotic) medication dated 11/20/24.Consent for Quetiapine medication dated 01/10/25.Consent for Seroquel (antipsychotic) medication dated 02/05/25.A consent form for Risperdal was not present. H. On 12/05/2025 at 10:58 am, during interview with the Director of Nursing (DON), she stated if a resident was determined to need psychotropic medication, staff had the resident complete a consent form within 24 hours. The DON stated if a resident could not sign the consent form, staff called the resident's family to obtain verbal consent, and all nurses were responsible for obtaining consent forms. The DON confirmed R#14 did not have a consent form for the medication Risperdal and should have.

Based on record review and interviews, the facility failed to submit the required five-day follow-up investigation results to the State Agency (SA) for 1 (R #77) of 1 (R #77) resident reviewed for incidents. If the facility is not submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation. The finding are: A. Refer to F0610 for related findings.B. Record review of the facility's policy titled Abuse Prohibition, revised on 11/14/25, revealed, the Administrator or designee is responsible for reporting findings of all completed investigations within five working days to the State Agency using the state online reporting system. The policy states the facility will report findings of all completed investigations within five working days to the State Agency using the state on-line reporting system or state-approved forms and further requires that subsequent reports be provided as often as necessary to inform the State Agency significant changes in the status of affected individuals or material facts originally reported. C. On 12/05/25 at 9:00 a.m., during an interview with the Director of Nursing (DON), she stated she had submitted the follow-up and confirmed the date of submission as 12/02/25 at 4:09 p.m. She stated the 5-day follow up was late. D. On 12/05/25 at 9:51 a.m., during an interview with the Administrator (ADM), he stated it was his expectation that all five-day follow-up reports be submitted to the State Agency within five days.

Based on record review and interview, the facility failed to complete a thorough investigation for injuries of unknown origin and report the investigation findings within five working days for 1 (R #77) of 1 (R #77) resident reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation.The findings are: A. Record review of the facility's Abuse Prohibition policy revised 11/14/25, revealed the facility prohibits neglect and requires immediate reporting, investigation, documentation, and follow-up of alleged injuries including injuries of unknown source. The policy defines neglect as failing to provide care or services necessary to prevent harm and directs the center to: Initiate an investigation within twenty-four hours when the facility receives information about an injury or suspected neglect,Document interviews and findings in the facility tracking system,Notify the physician and resident representative, Submit findings of completed investigations within five days to the State Agency. B. Record review of R #77's face sheet revealed he was admitted into the facility on [DATE]. C. Record review of R #77's nursing progress note dated 11/19/25 at 5:49 pm, revealed R #77 was discharged to the hospital (on 11/19/25) due to him experiencing uncontrolled pain. D. Record review of R #77's nursing progress note dated 11/20/25 revealed the facility received notification from the hospital that R #77 sustained a fracture to the right scapula (a broken shoulder blade), returned to the facility with his right arm placed in a sling (a supportive medical device used to immobilize and protect the injured extremity), and required orthopedic follow-up (evaluation and ongoing management by a bone and joint specialist to assess healing, treatment needs, and potential complications). E. Record review of the facility's state-reportable records revealed no evidence the facility initiated an investigation for R #77 within twenty-four hours of notification of the fracture diagnosis, submitted a report to the State, or completed a five-day follow-up that identified diagnosis, treatment needs, and monitoring requirements. F. On 12/05/25 at 9:00 a.m., during an interview with the Director of Nursing (DON), she stated she was not aware of R #77 returning from the hospital with a broken scapula. She stated she did not know how he fractured his scapula and stated the injury should have been investigated thoroughly and reported to the State Agency as an injury of unknown origin. G. On 12/05/25 at 9:51 a.m., during an interview with the Administrator (ADM), he stated he was not aware of the fracture diagnosis when R #77 returned to the facility. He stated injuries of unknown origin must be reported within twenty-four hours and must include a completed thorough investigation with a five-day follow-up. The ADM confirmed R #77's fracture should have been included with the original skin-related injury reported to the State.

Based on record reviews and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #4) of 1 (R #4) resident reviewed for MDS assessments. This deficient practice is likely to result in the facilities failure to provide adequate care and treatment of the resident's needs. The findings are: A. Record review of R #4's face sheet revealed R #4 was admitted into the facility on [DATE] with the following diagnoses: Diagnosis of blindness, one eye,Diagnosis of acquired absence of eye (complete loss of the eyeball due to injury, disease, surgery, or other medical conditions). B. Record review of R #4's Quarterly MDS Section B: Hearing, Speech and Vision dated 10/27/25 was coded as the resident having adequate vision. C. Record review of R #4's Care Plan, dated 10/15/25 revealed the following: Resident is at risk for falls related to blindness in one eye,Arrange residents' environment to enhance vision and maximize independence,Reposition items as needed to location within visual field,Impaired vision,Monitor conditions that may contribute to ADL (activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) decline, including vison impairment. D. Record review of R #4's Physician Orders, dated 12/05/25 revealed the following: Referral to Ophthalmology (branch of medicine concerned with the study, diagnosis, treatment, and prevention of diseases and disorders of the eye and visual system) for loss of vision to left eye,Transfer to Emergency Department for evaluation of blindness in left eye. E. On 12/05/25, at 11:45 AM, during an interview with the MDS Coordinator (MDSC), she stated R #4's MDS assessment dated [DATE] was inaccurate. The MDSC stated the information entered was incorrect because R #4 is legally blind and does not have adequate vison. The MDSC stated it is her expectation every MDS is completed with the residents correct medical history and diagnosis for proper treatment.

Based on record review and interview, the facility failed to develop and implement an adequate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 2 (R #1 and #42) of 3 (R #1, #42 and #48) residents reviewed for baseline care plans, when: R #1's baseline care plan was incomplete and inaccurate due to the baseline care plan failing to include multiple diagnoses with interventions for R #1. A baseline care plan was not developed within 48 hours of admission for R #42. If the facility fails to develop and implement an adequate baseline care plan within 48 hours of admission for residents, then staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident due to medical care or lack of medical care). The findings are: R #1: A. Record review of R #1's face sheet revealed an admission date of 08/27/25 and included the following diagnoses: Hepatic encephalopathy (a serious brain dysfunction caused by liver failure).Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease).Gastro-esophageal reflux disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining).Alcoholic cirrhosis of liver (the most advanced form of liver disease related to excessive alcohol consumption).Dementia with behavioral disturbance (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment).Pneumonia (infection and inflammation of the lung).Secondary thrombocytopenia (is excess platelets in the bloodstream that develops as a result of another disorder).Vitamin D deficiency (low levels of vitamin D).Sequelae of cerebral infarction (the long-term effects and complications that can occur after a stroke).Chronic obstructive pulmonary disease (COPD; lung disease).Contracture (a shortening of muscles around joints causing joint stiffness and immobility) of right upper arm muscle, contracture of left upper arm muscle, contracture of right lower leg muscle, and contracture of left lower leg muscle.Cognitive communication deficit (a condition where a person's ability to communicate effectively is compromised by an underlying impairment in mental processes). Epileptic seizures (a brain condition that causes recurring seizures).History of suicidal behavior. B. Record review of R #1's baseline care plan dated 08/27/25 revealed the following health care needs were not addressed in the baseline care plan: Dysphagia.Alcoholic cirrhosis of liver.Pneumonia.Secondary thrombocytopenia.Chronic obstructive pulmonary disease.Muscle contractures in all four limbs.Epileptic seizures.History of suicidal behavior. C. On 12/04/25 at 1:02 PM during an interview with the Director of Nursing (DON), she stated she was unsure why R #1's baseline care plan did not include dysphagia, alcoholic cirrhosis of liver, pneumonia, thrombocytopenia, COPD, Seizures, muscle contractures, and history of suicidal behaviors but confirmed those diagnoses should have been included in R #1's baseline care plan. The DON also stated it is the responsibility of the admitting nurse to review all documents for new admissions and include all relevant diagnoses in a baseline care plan. R #42: D. Record review of R #42's face sheet revealed an admission date of 10/17/25 and included the following diagnoses: Major depressive disorder with psychotic features (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life, accompanied by a loss of touch with reality).Brief psychotic disorder (the sudden onset of psychotic behavior that lasts less than 1 month followed by complete remission with possible future relapses).Suicidal ideations (thoughts or considerations about ending one's life).Insomnia (a sleep disorder that can make it hard to fall asleep or stay asleep).Anxiety disorder (a group of mental health conditions characterized by excessive fear, dread, or apprehension).Pain.Generalized muscle weakness (reduction in the power exerted by muscles throughout the entire body).Lack of coordination.Abnormalities of gait and mobility (deviations from normal walking patterns).Cognitive communication deficit. E. Record review of R #42's baseline care plan dated 10/27/25, revealed the care plan was developed ten days after admission and not within 48 hours as required. F. On 12/04/25 at 1:03 PM during an interview with the DON, she stated she expects care plans to be created within 48 hours. The DON confirmed the admission date for R #42 was 10/17/25 and the baseline care plan for R #42 was not created until 10/27/25.

Based on observation, interviews, and record review, the facility failed to ensure an environment free from accident hazards and failed to provide adequate supervision to prevent accidents for 2 (R #5 and R #38) of 2 (R #5 and R #38) residents reviewed for accidents and supervision when: The facility did not ensure staff maintained a safe room temperature, exposing R #5 and R #38 to 32-degree Fahrenheit (F) outside temperatures, when staff opened a window without consent and left the window open for an extended period of time. This deficient practice is likely to lead to residents experiencing avoidable accidents and/or injuries. The findings are: R #5: A. Record review of R #5's face sheet revealed R #5 was admitted to the facility on [DATE] with diagnosis of unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). B. Record review of R #5's Quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) revealed R #5's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score was 01 (00-07 is severe impairment) multiple mobility items coded as dependent, including Lying to sitting, Sit to stand, and Bed-to-chair transfer; indicating R #5 required complete staff assistance for all mobility. Additionally, (Walking 50 feet) and (Walking 150 feet) not attempted due to medical/safety concerns. R #38: C. Record review of R #38's face sheet revealed R #38 was admitted to the facility on [DATE] with the diagnosis having a lack of coordination (impaired ability to control voluntary muscle movements, which may affect balance, gait, transfers, and the ability to safely perform activities of daily living). D. Record review of R #38's Quarterly Minimum Data Set (MDS) revealed the following: R #38 had a Brief Interview for Mental Status (BIMS) score of 05 (defined as severe cognitive impairment, with scores of 00–07 indicating severe impairment). The MDS Section GG – Functional Abilities and Goals revealed R #38 was coded as dependent for the following activities: lying to sitting on side of bed, sit to stand, and bed-to-chair transfers, indicating staff were required to perform more than half of the effort necessary to complete these activities. The MDS further revealed walking activities were not attempted due to medical or safety concerns, indicating the resident was not clinically safe to ambulate at the time of the assessment. E. On 12/04/25 at 10:32 a.m., during an interview with R #5 and R #38, both residents were observed lying in their beds, while the room window remained open, and the curtain blew inward from the wind. The outside temperature measured 32 degrees F at the time of the observation, as verified using a mobile weather application. R #38's bed was placed right beneath the open window. Both residents stated they wanted the window closed because they were freezing. Neither resident demonstrated the physical ability to get up or close the window independently. F. On 12/04/25 at 10:37 a.m., during an interview with Licensed Practical Nurse (LPN) #4, she stated neither R #5 nor R #38 was physically strong enough to close the window. She stated she did not know who opened the window in R #5's and R #38's room. G. On 12/04/25 at 10:38 a.m., during an interview with Certified Nursing Assistant (CNA) #4, she stated she opened the window approximately five minutes earlier to air out the room. She stated she did not request permission from either R #5 or R #38 before opening the window and stated she did not realize the temperature outside was 32 degrees F. CNA #4 stated she left the room after opening the window and confirmed neither of the residents were strong enough to close it. H. On 12/04/25 at 10:45 a.m., during an interview with the Director of Nursing (DON), she stated her expectation is that all resident windows remain closed unless a resident requests otherwise, and staff must educate the resident on the outside temperature before the resident makes an informed decision to open a window. She stated the residents could become sick with how cold the weather is and the window being left open. The DON confirmed the CNA should not have opened R #5's and R #38's window without their consent. I. On 12/05/25 at 11:15 a.m., during an interview with the Administrator (ADM), he stated it is his expectation all windows in the resident room would stay closed at all times.

Based on record review and interviews, the facility failed to ensure ongoing communication and coordination with the resident's dialysis provider for 1 (R #4) of 1 (R #4) residents reviewed for dialysis. If the facility does not ensure consistent two-way communication with the dialysis center for every dialysis treatment, then the facility cannot ensure appropriate monitoring of the resident's dialysis-related condition, recognition of complications, or implementation of timely interventions. The findings are: A. Record review of the facility's Dialysis Policy dated 08/07/23 revealed facility nursing staff are required to complete ongoing assessments for the residents' condition and monitoring before and after dialysis treatments. B. Record review of R 4's face sheet revealed R #4 was admitted into the facility on [DATE] with the following diagnoses: Diagnosis of end stage renal disease,Dependence on renal dialysis. C. Record review of R #4's Care Plan, dated 04/22/23, revealed the following: Monitor dialysis labs.Monitor external hemodialysis catheter (tube placed in a vein that stays partly outside the body to allow temporary dialysis when kidneys aren't working properly). D. Record review of R #4's Order Summary Report, dated 12/05/25 revealed dialysis days Monday, Wednesday and Friday. E. Record review of R #4's Electronic Health Record (EHR) Hemodialysis Communication forms dated 06/01/25 through 12/06/25 revealed only three dialysis communication forms were available for that timeframe (08/20/25, 08/25/25, and 09/15/25). R #4's EHR did not contain any other dialysis communication forms. F. On 12/07/25 at 11:51 am during an interview with Medical Records (MR), she stated all dialysis communication notes have been uploaded into the resident's chart and there is no outstanding documentation that is not scanned into R #4's medical record. G. On 12/06/25, at 11:44 AM, during an interview with the Director of Nursing (DON), she stated the facility uses a dialysis communication sheet which must accompany each resident from every dialysis appointment to ensure facility staff receive current clinical information from the dialysis clinic and the facility is updated on any changes with the residents. She stated dialysis communication was not consistent for R #4 and failure to communicate could result in missed information about episodes during treatment, irregular vital signs, or other issues which could lead to resident complications. The DON stated it is her expectation there is communication between the facility and the dialysis every appointment for the resident.

Based on interviews and record review, the facility failed to provide a diet in accordance with physician orders for 1 (R #4) of 1 (R #4) resident reviewed for nutrition when:The facility did not ensure therapeutic dysphagia care (the clinical treatment of swallowing disorders using rehabilitative and compensatory interventions to improve swallowing function and reduce the risk of aspiration) was followed and sent R #4 to dialysis with food items (sandwich) inconsistent with his ordered renal/dysphagia advanced diet.Dietary staff and nursing leadership lacked awareness of and oversight over the contents of dialysis sack lunches, placing the resident at risk for aspiration and inadequate nutritional management. These deficient practices are likely to negatively impact a resident's ability to eat, causing difficulty with swallowing during mealtimes. The findings are:A. Record review of R 4's face sheet revealed R #4 was admitted into the facility on [DATE] with the following diagnoses: End stage renal disease (ESRD; chronic irreversible kidney failure),Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease),Dependence on renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys are not able to function properly). B. Record review of R #4's Care Plan, dated 04/22/23, revealed the following: Provide Dysphagia Advanced (soft-textured diet for patients with swallowing disorders that includes foods requiring chewing but that are easy to swallow safely, helping reduce the risk of choking or aspiration) consistency, diet as ordered,Provide thin liquid consistency liquids as ordered,Monitor for sign/symptoms of aspiration i.e. coughing, watery eyes, choking, moist sounding voice, if coughing occurs, no food/liquids until coughing resolves, Resident will be free from signs/symptoms of aspiration. C. Record review of R #4's Physician Order Summary Report, dated 12/18/24 revealed an order for a renal diet with dysphagia advanced texture (therapeutic diet prescribed for patients with kidney disease and swallowing disorders that provides soft, easy-to-chew foods while restricting nutrients such as sodium, potassium, phosphorus, and fluids, to support safe swallowing and proper renal management and reduce the risk of aspiration) standard thin liquids consistency. D. On 12/04/25 at 11:05 AM, during an interview with R #4, he stated he leaves the facility at 9:15 AM for dialysis and returns around 2:45 PM on Mondays, Wednesdays, and Fridays. R #4 stated the facility sends him with a sack lunch containing a sandwich that he cannot eat because he could choke.E. On 12/04/25 at 11:15 AM, during an interview with the Dietary Manager (DM), she stated the facility sends a sack lunch with all dialysis residents. The DM stated R #4 receives a turkey or peanut butter sandwich, graham crackers, and applesauce in his sack lunch. She stated it is her responsibility to look at residents' diet orders, and it is her expectation for all diet orders to be followed. F. On 12/04/25 at 12:13 PM, during an interview with the Director of Nursing (DON), she stated R #4's diet was a renal/dysphagia advanced diet and confirmed he has a diagnosis of dysphagia. The DON stated R #4 is sent to dialysis on Mondays, Wednesdays, and Fridays. She stated she was unaware of what is included in the sack lunches sent with dialysis residents. She stated residents with a dysphagia/renal diet can eat a peanut butter sandwich but cannot eat a turkey sandwich due to sodium content and the potential for choking. She stated it is her expectation dysphagia diets are followed, and anything outside the dysphagia diet can cause a choking hazard.

Based on record review and interview, the facility failed to maintain accurate resident records for 5 of (R #'s 8, 37, 42, 90 and 95) of 5 (R #'s 8, 37, 42, 90 and 95) residents reviewed for accuracy of records by not: Ensuring weights were accurately documented for R #'s 8, 37, 42, and 90. Ensuring discharge documentation was updated and accurate for R #95. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care, and services to residents. The findings are: R #8: A. Record review of R #8's face sheet revealed an admission date of 11/08/23. B. Record review of R #8's weight tracking revealed the following: 11/01/2025, the resident weighed 214.5 pounds (lbs.). 12/01/2025, the resident weighed 253.5 lbs. C. On 12/04/2025 at 1:02 PM during an interview with the Director of Nursing (DON), she confirmed the documented weights for R #8 and stated R #8's one month weight gain appears to be an error and R #8 should be re-weighed immediately. The DON stated it is her expectation that staff correctly document resident weights. R #37: D. Record review of R #37's face sheet revealed an admission date of 05/10/21. E. Record review of R #37's weight tracking revealed the following: 11/01/25, the resident weighed 125.0 lbs. 11/21/25, the resident weighed 63.0 lbs. F. On 12/04/2025 at 1:04 PM during an interview with the DON, she confirmed the documented weights for R #37 and stated R #37's significant weight loss in 20 days appeared to be a documentation error. She stated it is her expectation that staff correctly document resident weights. R #42: G. Record review of R #42's face sheet revealed an admission date of 10/17/25. H. Record review of R #42's weight tracking revealed the following: 11/01/2025, the resident weighed 126 lbs. 11/21/2025, the resident weighed 725.4 lbs. I. On 12/04/2025 at 1:05 PM during an interview with the DO, she stated R #42's 599.4-pound weight gain in 20 days appeared to be a documentation error. She stated it is her responsibility to ensure the nurses are accurately documenting weights for residents. R #90: J. Record review of R #90's face sheet revealed an admission date of 03/28/25. K. Record review of R #90's weight tracking revealed the following: 10/15/25, the resident weighed 71 lbs. 11/01/25, the resident weighed 72 lbs. 12/01/25, the resident weighed 127.5 lbs. L. On 12/04/2025 at 1:08 PM during an interview with the DON, she stated R #90's documented weight gain within one month appears to be a documentation error. She stated it is her expectation that staff correctly document resident weights. R #95: M. Record review of R #95's face sheet revealed R #95 was admitted to facility on 08/26/25. N. Record review of R #95's progress notes revealed a physician note, dated 11/16/2025, for R #95's discharge summary. Further review revealed R #95's discharge date was on 09/04/25. O. Record review of R #95's physician orders revealed an order, dated 09/04/25, for a referral to the hospital for a wound follow-up. P. Record review of R #95's minimum data set (MDS, which was part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) completed on 09/04/25 indicated R #95 was discharged to home/community. Q. On 12/05/2025 at 10:58 am, during an interview with Director of Nursing (DON), she stated R #95 was transferred out of the facility on 09/04/25 to the hospital. The DON stated she did not know why the physician discharge summary note was entered on 11/16/25 in R #95's progress notes, and she did not know why R #95's MDS showed R #95 was discharged to home/community. The DON stated she expected staff to complete R #95's discharge documentation accurately and consistently. The DON also stated it was the responsibility of the nurses to make sure assessments were accurate and the responsibility of the MDS coordinator to make sure the MDS was accurate. R. On 12/05/25 at 11:31 am, during an interview with the Administrator (ADM), he stated R #95 was originally scheduled to discharge home on [DATE]. The ADM stated staff noticed a change in condition for R #95 and he was sent out to the hospital on [DATE]. The ADM stated R #95's MDS should have reflected a discharge to the hospital rather than home. The ADM confirmed he expected all discharge documentation for R #95 to have been completed in an accurate and timely manner.

Based on observation, record review, and interviews, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 5 (1B, 25A, 26A, 27A, and 29A) of 5 (1B, 25A, 26A, 27A, and 29A) resident rooms observed for call light functionality. If the facility does not have a functioning communication system, then residents are unlikely to get their immediate needs met by facility staff.The findings are: A. Record review of the facility's Call Lights policy, last revised on [DATE], revealed residents will have a call light or alternative communication device at each patient's bedside, toilet, and bathing room to allow residents to call for assistance when unattended. Further review of policy revealed staff will report problems with a call light or call system immediately to the supervisor and/or Maintenance Director and will provide immediate or alternative solutions until the problem can be remedied (examples include replacing call light, providing a bell or whistle, increasing frequency of rounding, etc.). B. On [DATE] at 1:20 pm, observation revealed Call Lights above occupied resident room for 29A and unoccupied resident rooms, 27A, 26A, and 25A did not turn on when call buttons were pressed. C. On [DATE] at 12:20 pm, during an interview with the Maintenance Director (MD), stated call lights for Rooms 29A, 27A, 26A, and 25A should have worked. MD stated residents need to have call lights functioning in case they need any assistance. MD stated nurses may also tell maintenance directly of a repair needed and they will repair it right away. D. On [DATE] at 1:10 PM, during an observation of room [ROOM NUMBER]B, revealed the resident attempting to use her call light. E. On [DATE], at 1:37 PM, during an observation of room [ROOM NUMBER]B, CNA #1 was observed switching out the broken call light with a working call light. F. On [DATE], 12:20 PM, during an interview with the Maintenance Director (MD), stated call lights for Rooms 1B should have worked but it did not. The MD confirmed room [ROOM NUMBER]B's call light should have been replaced sooner but it was not.

Based on observation and interview, the facility failed to safeguard residents' personal health information when the facility mailed a notice of involuntary discharge to an unauthorized entity for 2 (R #3 and #4) of 3 (R #3, #4 and #7) residents. If the facility fails to ensure the confidentiality, security, and proper management of resident records, then residents are at risk of unauthorized persons accessing their personal and medical information. The findings are: A. Record review of R #3's Notice of Involuntary Discharge, dated 03/06/25, revealed the facility sent the resident's notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice to the State Long-Term Care Ombudsman in New Mexico. B. Record review of R #4's Notice of Involuntary Discharge, dated 03/05/25, revealed the facility sent the resident's notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice to the State Long-Term Care Ombudsman in New Mexico. C. On 06/12/25 at 10:31 am during an interview, the New Mexico State Ombudsman (SO) stated she was made aware the facility sent R #3's and R #4's discharge information to the wrong state ombudsman when the ombudsman from the other state reached out to her. She stated the ombudsman from the other state reported they received two New Mexico Notices of Involuntary Discharge. The SO stated she reached out to the facility Administrator, because she had concerns with resident information being shared with unauthorized persons. She stated there was not a resolution to ensure discharge notices would be sent to the correct state ombudsman. The SO stated she was concerned residents might not realize they could appeal the involuntary discharge, and the resident would not have the correct contact information for the SO who could assist residents in the process. D. On 06/12/25 at 12:46 PM during an interview, the Social Services Director (SD) stated she sent R #3's and R #4's Notice of Involuntary Discharge to the State Ombudsman in another state. She stated her Corporate Social Services Director (CSSD) provided her with a template for the notice that included ombudsman contact information, and the CSSD advised her to use the template. She stated she was not aware she sent the Notice of Involuntary Discharge to the incorrect state ombudsman.

Based on record review and interview, the facility failed to complete and submit a Five Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of neglect (the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for 1 (R #5) of 1 (R #5) residents. If the facility does not submit follow-up reports, then the State Agency cannot assure the residents are safe and free of neglect. The findings are: A. Record review of the facility's Reportable Incidents and Conditions policy, dated 06/01/15, revealed the following: - Staff will report, review, and investigate all reportable incidents and conditions which occurred, or allegedly occurred, on the property and involved, or allegedly involved, a resident who received services. - The Executive Director, Resident Care Director, or designee will review all reportable incidents and conditions to determine if: -Required documentation has been completed; and -Interventions to prevent further incident have been identified and implemented. - When conduction and investigation, the Executive Director, Resident Care Director, or designee will: - Monitor that all aspects of the reportable incident or condition and investigation are documented; - Complete the investigation within five working days. - The progress and outcome of investigation is communicated to appropriate leadership and to State Agencies, as indicated. B. Record review of R #5's face sheet revealed an initial admission date of 07/21/22 with the following diagnoses: - Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), - Dysphagia (difficulty or discomfort in swallowing). C. Record review of the facility's Facility Reported Incident, dated 05/05/25, revealed R #5 sat across from the nursing station after activities concluded. A nurse noticed R #5 was unable to speak and had a flushed face and watery eyes. The nurse went to assist the resident and observed the crumbs of a sandwich on the floor around the chair of R #5. D. Record review of the facility's records revealed the records did not contain documentation to show the facility submitted a Five Day Follow-Up Report to the State Survey Agency. E. On 06/13/25 at 1:34 pm during an interview, the Director of Nursing (DON) stated staff were to investigate and start initial reporting for all reportable incidents within two hours and to complete the investigation in five days. She stated she expected for staff to complete the investigations of reportable incidents by the fifth day, to include the completion of the Five Day Follow-Up Report. The DON stated staff completed the investigation for R #5 within five days, but the facility failed to submit the Five Day Follow-Up Report to the State Survey Agency.

Based on record review and staff interview, the facility failed to provide a copy of the planned Involuntary Discharge Notice to the State Long-Term Care Ombudsman for 2 (R #3 and #4) of 3 (R #3, #4 and #7) residents. This deficient practice could result in residents being discharged without necessary advocacy or support from the Ombudsman's office. The findings are: R #3 A. Record review of R #3's Notice of Involuntary Discharge, dated 03/06/25, revealed the facility sent the resident's Involuntary Discharge Notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice to the New Mexico Long-Term Care Ombudsman. B. On 06/12/25 at 10:31 am during an interview, the New Mexico Long-Term Care Ombudsman stated she did not receive R #3's Notice of Involuntary Discharge, dated 03/06/25. C. On 06/12/25 at 12:46 pm during an interview, the Social Services Director (SSD) stated she sent R #3's Notice of Involuntary Discharge, dated 03/06/25, to the Long-Term Care State Ombudsman in the wrong state. R #4 D. Record review of R #4's Notice of Involuntary Discharge, dated 03/05/25, revealed the facility sent the resident's Involuntary Discharge Notice to the State Long-Term Care Ombudsman in another state. The facility did not send the discharge notice tot he New Mexico Long-Term Care State Ombudsman. E. On 06/12/25 at 10:31 am during an interview, the New Mexico Long-Term Care Ombudsman stated she did not receive R #4's Notice of Involuntary Discharge, dated 03/05/25. She stated she had concerns residents did not receive the correct information to receive advocacy services should they appeal the discharge. F. On 06/12/25 at 12:46 pm during an interview, the Social Services Director (SSD) stated she sent R #4's Notice of Involuntary Discharge, dated 03/05/25, to the Long-Term Care State Ombudsman in the wrong state. She stated she was not aware she sent the notice to the wrong entity. She stated she followed the instructions she received from the Corporate SSD,who advised her to use a template which included the contact information for an Ombudsman in a different state.

Based on record review and interview, the facility failed to ensure residents or the guardians were aware of and understood the reason they took a medication, the risks, and the benefits of the medication for 2 (R #19 and R #66) of 2 (R #19, R #66) residents reviewed for unnecessary medications. If the residents or their guardians are not informed of the risks of benefits of the medication, they are not able to make informed decisions. The findings are: R #19 A. Record review of R #19's physician's orders revealed an order for quetiapine fumarate oral tablet (used to treat certain mental/mood disorders), 50 mg (milligrams). Give one tablet orally at bedtime for agitation. Start date: 05/09/24. B. Record review of R #19's medical record revealed the record did not contain a consent form for quetiapine fumarate oral tablet, 50 mg. C. On 08/29/23 at 2:30 pm, during an interview, the Director of Nursing (DON) stated R #19's medical record did not contain consent forms for quetiapine fumarate oral tablet, 50 mg, and staff did not monitor R #19's behaviors while taking the quetiapine from 05/09/24 thru 07/02/24. 40671 R #66 D. Record review of face sheet for R #66 revealed an admitted [DATE] and included the following diagnoses: Dementia (decline in cognitive abilities that affect memory, thinking, language, and behavior) and drug induced subacute dyskinesia (movement disorder that causes involuntary, repetitive body movements caused by long term use of certain medications). E. Record review of Physicians Orders for R #66 revealed the following:- Buspirone HCI oral tablet (medication used to treat anxiety), 5 mg. Give one tablet by mouth two times a day for anxiety. Start date: 03/25/24. - Risperdal (medication used to treat certain mental/mood disorders) Oral Tablet 1 mg. Give one tablet by mouth two times a day for dementia/behaviors. Start date: 06/24/24. F. Record review of medication administration records for R #66, dated 03/25/24 through 07/21/24, revealed staff administered buspirone and risperdal to R #66 daily. G. Record review of electronic medical record for R #66 revealed the record did not contain a signed consent by R #66 or R #66's Power of Attorney (POA) to receive psychotropic medications. H. On 07/24/24 at 10:15 am during an interview with the Director of Nursing, she stated R #66 or the resident's POA should have signed a consent for psychotropic medications on 03/25/24 or within a couple of days of his admitted , if the resident was admitted to the facility with orders for psychotropic medications. She verified a consent form was not completed until 07/22/24, when facility staff did a full sweep of residents who took psychotropic medications.

Based on observation, interview, and record review, the facility failed to provide a homelike environment for 4 (R # 21, 63, 67 and 201) out of 4 (R # 21, 63, 67 and 201) residents reviewed when staff failed to replace the shower bed mattress that had a large hole all the way through the mattress which exposed the white pipe frame; to replace the curtain rods for multiple rooms; and to fix a broken door into the shower room. If residents do not have a homelike environment, they may become depressed and anxious about things in disrepair. The findings are: Shower bed mattress findings: A. On 07/22/24 at 2:02 pm, during an interview with R #67, she stated the shower bed she used for showers had a large hole in it. She stated the bed hurt her back when she lay on it, and the hole kept getting bigger. She stated it has been like that for months. B. On 07/24/24 10:41 am, during an interview with Certified Nursing Assistant (CNA) #5, she stated the shower bed has been like this for probably a couple of months. She stated R #67 complained about the hole in the mattress. She stated that everyone (nurses and management) were aware of the condition of the shower bed mattress. C. On 07/24/24 at 10:55 am, during an observation of the shower room, the shower bed had multiple cracks on the shower bed mattress. The shower bed also had a large hole that went all the way through the mattress and exposed the pipe frame. D. On 07/24/24 at 11:10 am, during an interview with Administrator, he stated he was not aware the shower bed had a large hole in the mattress. He stated that it was not acceptable for residents to use the shower bed as it was. The Administrator stated the bed should not be used. 40671 Curtains E. On 07/22/24 at 9:50 am, a random observation of resident rooms revealed the following: - room [ROOM NUMBER] - curtains were inappropriately hanging and were falling off the curtain rods. - room [ROOM NUMBER] - curtain were inappropriately hanging and were falling off the curtain rods. F. On 07/22/24 at 9:54 am during an interview, the Housekeeper stated that housekeeping staff reported the broken curtain rods several times and requested the rods be fixed, but it never gets done. G. On 07/24/24 at 10:02 am, random observations of resident rooms revealed the window curtains in resident rooms 43, 46, 47, 51, 64, 66 and 70 were falling off the rods and were missing clips that held the curtains in place. Further observation revealed curtains could not be closed. H. On 07/24/24 at 12:08 pm during an interview and record review with the Administrator, he stated he was aware of the issue with the curtains, and they purchased extra clips to replace as needed. He stated he was not aware whether or not there were any maintenance requests for the curtain issues. He stated he expected all staff who were aware of any issues to put in maintenance requests. He stated he was not sure why the curtains in the resident rooms were not addressed. The Administrator provided one maintenance request for room [ROOM NUMBER] curtain issues. I. Record review of facility maintenance requests for repairs to curtains in resident rooms revealed one work order, dated 07/22/24, for resident room [ROOM NUMBER] - window curtain rail was bent. Shower room door findings: J. On 07/24/24 at 10:55 am, during an observation of the shower room, the shower room door was broken. A large chunk of the door, which measured approximately 12 inches () by 3 at the widest part, was missing around the handle area, the door did not lock, and the keypad on the door did not work. Further observation revealed a handle on the inside of the door so staff and residents could get out of the shower room. K. On 07/24/24 at 12:07 pm, during an interview with Administrator, he stated initially the door had an issue with latching, and then there was another issue with the door which he could not recall what it was. He stated measurements were taken for a new door, and a new door was ordered. The Administrator stated the issue with the shower room door had been like that for many months. He said it was a long process to get it replaced. He said they relied on outside companies, and it took a long time to get things done. L. On 07/25/24 at 12:30 pm, during an interview with the Maintenance Director, he stated the door sagged, and he put a piano hinge on it to help with the sagging. He stated he was not sure how the door became so damaged, but he was aware the door had been sticking. The Maintenance Director stated it took a little bit of force to open the door. He stated he started to work on the door issue in May 2024. He said the facility tried to get someone local to replace the door, but it took too long for the vendor to get paid. He stated they now have to go through an outside company to get the door replaced.

Based on record review and interview, that facility failed to ensure residents were free from abuse for 1 (R #4) of 7 (R #'s 4, 6, 7, 8, 9, 10, and 11) residents reviewed for allegations of abuse, when the facility failed to act on a reasonable suspicion of an intoxicated employee that had been accused of physically assaulting R #4. This deficient practice likely resulted in R #4 experiencing physical and psychosocial harm when the Nurse Assistant (NA) attempted to put the resident to bed and change her clothes while R #4 resisted. The findings are: A. Record review of a facility self report, dated 10/13/22, revealed that R #4, who has a history of fluctuating mood and false allegations of neglect and 'rough' treatment, informed the nurse that she was attacked by the NA (Nurse Assistant) when asked to be laid down in bed. In her allegation, she (R #4) claims that the NA threw her onto the bed and was rough with her. She also said that the NA put her hand over her nose and she couldn't breath. The resident was then appropriately assisted by her nurse and sent to the ER (emergency room ) to be evaluated. Further review revealed Conclusion: [name of NA], the nurse aide (NA) entered into [name of resident] (resident) room on October 10, 2022 to put the resident to bed. [name of resident], the resident, alleged that NA physically abused her. She has a history of mood changes and making false allegations. The NA alleged that the resident was not cooperative when she tried to assist her. The nurse met the resident soon after and provided the necessary nursing care. The hospital noted that the resident had a red mark on right collarbone with no other specific evidence of trauma found. The allegation is not confirmed. B. Record review of R #4's hospital documentation, dated 10/10/22, revealed the following; . You were seen in the Emergency Department for reported assault. Your heart rate was elevated but improved after fluid [a sterile solution containing isotonic concentrations of electrolytes in water] and Tylenol [a medication used to treat fever and mild to moderate pain]. You have what appear to be a bruise on your skin over left collar bone [the bone that joins the breast bone and shoulder blades] . C. Record review of the facility's investigative interviews with the staff members who worked on the night of the incident (10/10/22) revealed the following: 1. Investigative interview dated 10/10/22, . [name of alleged NA] was pushing one of the residents [in wheelchair] too fast and she was talking too loud. 2. Investigative interview dated 10/10/22, . [name of alleged NA] was in the restorative room with a resident, [name of resident], stating the resident's weight was more than hers, talking loud . 3. Investigative interview dated 10/10/22, . I saw [name of alleged NA] who worked in C hall, pushing resident, [name of resident], through D hall. She was asking him questions that I didn't understand . 4. Investigative interview dated 10/14/22, . [name of alleged NA] was very happy and loud, was wearing heavy perfume. D. Record review of the police report, dated 10/10/22 at 21:53 (9:53 pm), revealed that On October 10, 2022 at about 2153 hours (9:53 pm) I was dispatched to [address of facility] in reference to possible elderly abuse. Upon arrival at 2205 (10:05 pm) I made contact with the Registered Nurse [name of RN #1] who reported the following. [name of RN #1] stated that [name of R #4] one of the residents was complaining of shoulder pain and was being prepared for transport to [name of hospital] further review revealed that after R #4 had asked the alleged NA to help her to bed, that the alleged NA pushed her onto bed and then put her hand over her nose and squeezed it until she could not breath and placed her hands over her neck, holding it. RN #1 then explained that R #4 requires assistance from 2 people as she is paralyzed from the waist down. RN #1 noticed that when she checked R #4 she saw redness around her nose, her forehead, and to the left side of her neck R #4 also complained about pain in her right shoulder. RN #1 also noted blood in her hand but she could not find where it was coming from as she did not see any open cuts, and she checked [name of R #4's] nose, mouth, and ears but saw no indication of blood. Further review revealed that the alleged NA was sent home prior to law enforcement being contacted and therefor an interview was not conducted. E. Record review of nursing notes, dated 10/10/22, revealed the nurse was notified to check on R #4 by her roommate and when she tended to her, she found, Upon entering the room, resident became emotionally upset, crying, shaking and stating (in Navajo) 'I was attacked by the lady working when I asked her to lay me down and change me and she threw me into bed and did not change me. She was being rough with me. Put her hand over my nose and squeezed it and I couldn't breath. Then she choked me. She tied up my light string.' Resident appeared very disheveled, red markings apparent to face under eyes and around nose. Scratches and redness around neck right side. Blood observed on resident's hands R [right] hand on 3 knuckles and L [left] hand on knuckles and palm of hand that resident reports is from her nose. Redness to middle of forehead. redness to R [right] shoulder that resident reports 'it hurts from when the lady threw me into bed' Resident's undergarment brief heavily saturated with urine and BM [bowel movement] that spread from abdomen to her back. Sweatpants were also saturated with urine. Tank top that resident was wearing was backwards and inside out with both straps on L [left] shoulder. Further review of nursing notes, dated 10/13/22, revealed Visit with [name of R #4] , she said she is doing ok, sore on L [left] shoulder. F. On 02/01/22 at 1:24 pm, during an interview with RN (Registered Nurse) #1, when asked to describe the night of the incident (10/10/22), she explained I remember coming onto night shift and the alleged NA was driving round with a male resident [pushing a resident in a wheel chair around the halls] and she was being loud and different than what we would know [different from usual]. We [other staff and I] noticed her being different, I didn't recognize her . Later that evening, the NA went into see a resident who was in room [ROOM NUMBER] and she [the NA] was crying and having an emotional outburst. We asked the NA what was going on and she said 'They are all fine' and she said that she was worried about [name of R #4's roommate]. I didn't receive any issues for [name of R #4's roommate] during report [exchange of information regarding resident status]. I was confused and I asked why. She said 'Her condition is getting worse.' I again asked if everything was OK, she said 'yea, I am just feeling really bad.' We said OK, well it happens when you get attached to the people you work with. We told her to go get a breath of fresh air and come back when ready. She went out the back door of C wing which was odd because the door is locked for resident safety and the alarm was blaring. [Name of R #4's roommate] was at the nurse's station and asked me to go check on [name of R #4]. She said something was not right. I went to check on [name of R #4] and she (R #4) had a very scared look on her face. I noticed that her tank top was inside out and backwards, and I believe it was a spaghetti strap where both straps were on one side of her head, and she looked very disheveled. What I could gather form her Navajo was that she was saying 'The woman who works here attacked me.' There were red markings on her neck, chin, jaw area and ear. She had dry blood on her fingers. Her call light was tied up and away. She wasn't dressed for bed. She is usually very particular about how she likes things, and she explained that the lady didn't change her [change her brief]. When she (R #4) asked to get into bed, she (the NA) threw her. RN #1 found a translator and the translating CNA said that R #4 said that the NA had attacked her by putting her hand on R #4's nose and mouth and then placed the call light button out of reach by rolling up the call light cord. RN #1 then explained that the The alleged NA was saying 'who did it' all the CNAs did not know what she was talking about . The NA said that [name of R #4] was mad at her, and she [the NA] felt bad. Another nurse helped me do a skin assessment and change her. We found that that she was completely soaked with BM [bowel movement]. She was crying and scared. The NA was coming back inside, and we decided to send her home . I asked her to leave since she was having a hard time in emotional distress. She went home . Everyone noticed that she (the NA) was displaying odd behavior. Her (the NA's) mom then called and asked if she had gone to work and I told her that she did go into work but I had to send her home and her mom said 'Ugh, I know why, she has fallen off the wagon' we called the police and sent [name of R #4] to the hospital, she said that her nose felt like she was swelling and it was red and seemed likely swollen. When asked to explain the NA's behavior, she explained She is typically quiet. I have worked with her only a few times and she is usually very quiet and does her work. When asked if the NA had a particular smell or odor, she confirmed no. When asked if R #4 has made similar allegations in the past, she explained Yea, she would make allegations that people weren't changing her or not answering her call light or generally being mean to her. She was rooming with another resident who would have the same behaviors and they would say claims of neglect but I don't think there was any full report on it and it was never proven but I know that the CNAs would say that she would say things like that or that people were rough with her but she hasn't made claims like that in a very long time. When asked to explain the blood that was found on R #4's hands, she explained It was on her fingertips, and it was dry, and I wiped her face to see if there was any source but I didn't notice anything and I asked her where the blood came from and she just kept saying that she was attacked. She then explained that in the past, she thinks the CNAs were encouraged to provide care for R #4 with another CNA present to provide a witness for any type of allegation. G. On 02/01/23 at 2:59 pm, during an interview with the roommate of R #4, when asked if she remembers the night of the incident, she replied, no. H. On 02/01/23 at 3:56 pm, during an interview with R #4, When asked to recall the incident that occurred on 10/10/22, she stated Ever since that happened my mind is not the same as it used to be. My memory is not as good as it used to be . She [the alleged NA] didn't say anything she just grabbed my neck . I had a bloody nose maybe from when she chocked me. I stated bleeding because it [the blood] was on my hand. When asked if she feels safe, she explained Sometimes I do not feel safe. I'm afraid sometimes of my old roommate and the NA. She then explained that this is why she wants to transfer to another facility. I. On 02/02/23 at 9:39 am, during an interview with CNA #2, when asked to explain the night of the incident, he explained The nurse asked me to be a translator because I'm bilingual. She [R #4] said that the young lady who was taking care of her threw her in bed and tried to choke her. Her tank top was halfway taken off, she had some scratches or red areas on her neck and a bloody nose. She had wiped it down on her face. She was crying, she was shook up. When asked to recall if the alleged NA seemed different that night, he explained I do remember, the minute I walked in I noticed that she was loud, this NA is usually quite. J. On 02/02/23 at 10:27 am, during an interview with CNA #3 (the alleged NA), when asked to explain what occurred during the night of the incident, she explained She [R #4] said that I was trying to break her neck and throwing her around. I'm not too sure what was happening, I was trying to put her to bed and she was being really stubborn. She has to be lifted with a gait belt [an assistive device used to transfer residents form one surface to another] to be put in bed. I put the gait belt around her and I was trying to lift her and she was holding onto the wheelchair and I told her to let go and I put her in the bed and she probably thought I threw her on the bed. I tried to change her clothes and she wouldn't let me change her clothes. I kind of speak Navajo and I heard her saying 'damn you' in Navajo. She is usually cooperative. I've never had a problem with her at all. It threw me off and I got really emotional about it because she was nice and we got along. I laid her down and tried to cover her with her blanket. When asked if she often refuses care, she explained Her roommate had already told me before when I went into the room that she was being stubborn all day. That she has done this in the past with other CNAs. When asked if the CNA from the previous shift reported this behavior to her that day, she explained She didn't say anything about her being stubborn. When asked what she was wearing, she explained She wasn't in her pajamas and she needed a brief change but she wouldn't let me help her. When asked if she was upset about anything, she explained No, I tried to talk to her the way I usually do, and she wouldn't talk to me. She just kept nudging me away, like she just kept shrugging her shoulders. It was like she didn't even recognize me or something. When asked if she touched her neck or nose, she explained No. I don't know why she would say that. I asked the other CNAs if I did anything wrong, I usually don't get bad comments from the elders and they said that other CNAs have been accused by her for being thrown around and being talked badly about by her. When asked if she consumed any alcoholic beverages before coming to work, she stated, no. K. On 02/02/23 at 11:08 am, during an interview with CNA #'s 4 and 5, when asked to explain how R #4 is transferred from wheelchair to bed, they explained We use the sit-to-stand [a mechanical device that assist a patient from a sitting position to a standing position] with her. She is a full assist. To get into bed she needs 2 people. Sometimes she can stand, sometimes she cannot. It's different everyday. When asked how staff are aware when to use 2 people for her transfers, they explained with the sit-to-stand, someone has to hold her in the back and someone else has to help her in the front. Sometimes she will stand but it all depends on her knees. We will ask if its ok for her to stand and she will say yes or no but she doesn't stand for long. It's usually 2 people to transfer because you need 2 people to use the sit-to-stand. When asked if a gait belt is used for her, they explained Yes, we do use a gait belt, when we put her to bed if were not using the sit-to-stand. Her preferred method of transfer is 50/50 [between using the sit-to-stand or the gait belt]. When asked if she is able to make her needs known, they confirmed yes. When asked if they have noticed her make false allegations, they explained Sometimes she tells the truth, sometimes she lies . It's better to have 2 people with her so that someone can be a witness. We always go in at the same time to have 2 people. When asked how often does she make allegations, they explained Before, she would say things everyday. She would say things about with the young and new staff or if she just doesn't like certain ones. When asked if she has ever made a claim about a staff member being rough and placing their hands on her neck or nose, they explained She was telling us 'A lady put her hand on my neck' and threw her in bed. It was a new claim, it was the first time she said that. When asked if they were present during the night of the incident, they explained That NA would usually come in quiet but that day she was really happy. We were ready to give report and she came in happy and acting different. When asked if R #4 was refusing care that day, they explained No, she didn't refuse anything, she was still sitting in the wheelchair [at the end of shift] and we passed that on to the next shift. Then the next morning she was saying that that happened last night. She doesn't normally refuse When asked if she is able to dress herself, they explained that she can help get herself dressed but is not able to dress herself alone. L. On 02/02/23 at 11:37 am, during an interview with CNA #6, when asked if she remembers the night of the incident, she explained That NA, she's normally quiet and she doesn't say a lot. That night when she came in she was loud and heavily scented with perfume. She was very loud and happy. I thought it was weird. I came back the next day and they said what happened with [name of R #4]. When asked if she recalled any red markings on R #4, she explained She did have red marks on her upper nose [on the next day after the incident]. I worked with her that day and they were not there when I left at 7 pm. When asked if R #4 refuses care, she stated not normally. M. On 02/02/23 at 11:57 am, during an interview with CNA #7, when asked if she was familiar with the claims that R #4 makes against staff, she explained I think she has her favorites because with the senior CNAs, she's really nice to them. The younger ones or the ones who just came on board, she's mean to them. A lot of them don't speak Navajo, and that's a communication barrier. When asked of she was familiar with the incident, she explained About a couple of days after it happened, I was giving her a shower and she told me that a couple nights ago one of the girls came in, she said I don't know her name but she is a new one who is heavier set and she came in and threw me on the bed and shocked her and put her hands around her neck and put a pillow on her head and she said she tried to scream and almost lost her breath. When asked if she was familiar with the alleged NA, she explained One night [a different night] she came in different. When we work with her on day shift, she was usually really quiet, she only spoke when you spoke to her but on this particular night . December 24th. I saw her briefly at the nurses station and she was being really loud and I didn't know what she was saying but later on that night she got really wild. She was skipping down the hall and waiving her hands. She said she got a new phone and she was showing it off and she was taking pictures of us without permission. I was thinking that maybe she was more comfortable with a smaller crew but later in the night she was passed out [asleep] in the D wing in one of the vacant resident rooms. When asked if a nurse was aware of her behavior, she explained, Nobody said anything to the nurse but that the DON was made aware of it on the next day. N. On 02/02/23 at 12:20 pm, during an interview with CNA #8, when asked to explain the type of help R #4 usually needs, she explained She is cooperative, she usually likes to lay down at about 8 pm. She needs assistance from the bed to the chair and the back. We usually check on her throughout the night. She likes to get up at about 5 am. She likes a certain way to dress at night. She tells us that she likes to wear a tank top and a night gown. She is usually a 2 person assist. Sometimes in the morning if I can't find somebody to help me I will tell her to stand with me and she will do it but only for a couple seconds. When asked if she refuses, she explained No, by the time we come on shift, she likes to lay down. If she's up, then I will usually lay her down between 7:30 and 8 pm. When asked if R #4 ever shrugs her away, she responded No, she has never shrugged me away. She's usually happy to lay down. When asked if she could recall the night of the incident, she explained She [the alleged NA] was hyper, running around, and I don't know, she's usually quite but this time she was over happy and jumping up and down. She just looked happy and almost excited. It was off because she's usually quiet. When asked if she has displayed this behavior on additional nights, she explained It was just that one night. The other rest of the nights she has been working on another wing. O. On 02/02/23 at 5:01 pm, during an interview with the facility DON (Director of Nursing), when asked if she was aware of the alleged NA (CNA #3) acting differently and sleeping in a vacant bed on December 24th, she explained A CNA told me [the next day] that she had suspicions of her being intoxicated and I said, hey, why didn't you tell me when she was working. If I knew about it when it was happening, I would of confronted her and dealt with it. I would of took it to HR [Human Resources]. I had nothing in writing, so I didn't confront her about it. I didn't have any substantial information, it was just hearsay at the time. If I knew about it at the time, then I could of done something about it. She then confirmed that no investigation was conducted regarding her suspicious behaviors. P. On 02/03/23 at 8:33 am, during an interview with the Administrator, when asked to explain the incident, he explained Generally, from what I was told, she came into the building, they [staff] said that she [the alleged NA] was happy, talking out loud and then an incident happened with the resident. She was trying to change the resident's clothes and the resident was not happy with it so she left the resident with her clothes partially taken off. The roommate came to the nurse, before she [the NA] did. The nurse went there and calmed the resident down, she was upset about how the lady treated her. The nurse made a report. I talked to the resident but it was difficult to get the information from her so I had to depend on other staff to translate. She complained that the staff member was rough with her. She told the nurse that she was attacked by the NA. She said that the NA threw her and was rough with her. I think I collected the information the next day or maybe even in the same night. When asked to explain how the alleged NA explained the incident, he explained She told me that she was trying to change her [R #4's] clothes, but she was not cooperating and she was not able to calm her down. She was trying to change her clothes and the resident pushed her away and the resident landed on the bed, and she [the alleged NA] was feeling stressed because she was not able to calm her down. She then left the room and the nurse talked with her and later she was sent home. When asked if she was intoxicated, he explained She said she had taken [consumed] alcohol the day before but not that day. She was sent home because we wanted to protect the resident. When asked if the police officer interviewed the alleged NA, he confirmed no, as she had left the building prior to the arrival of the officer. When asked if it is expected that the police officer interview the alleged NA, he confirmed yes. When asked if he felt as though this incident would be considered abuse, he confirmed, yes. Q. On 02/06/23 at 3:40 pm, during an interview with the Administrator, when asked how R #4 developed a bruise on her left collarbone that was noted by the ER staff, he explained We thought it was her clothes that were causing redness because there was a struggle between the NA and [name of R #4] trying to get the clothes changed. When asked how a clothes change would cause redness on the jawline, he explained They were trying to pull the clothes with the arm in the neck and it caused the clothes to become tight on her neck. The NA explained to me that the resident was pulling the clothes. She pulled them half way before she had to leave the resident. And that is how the resident was found. She said that the resident was being difficult but she didn't know why. When asked to explain how the NA transferred the resident to bed, he explained I would say most likely the resident was not cooperating with her to be transferred. When asked, why did the NA proceeded with the transfer, he explained That is what I tried to let the NA know, the residents have their rights- If you are having difficulty with the residents then the supervisor should be informed. When asked if when the NA transferred the resident into bed even though the resident was refusing, that the transfer was an act of abuse, he explained She didn't respect the rights of the resident. The resident has the right to say no. When asked why he was not able to substantiate this allegation of abuse, he explained At that time, I couldn't confirm that she was drunk even though they [staff] said she was shouting and happy but none of them could tell if she smelled like alcohol and no one could confirm if she was drunk. Also, the resident has had incidents of false allegations. When asked if the NA was penalized as a result of the incident on 10/10/22, he explained that she received training and was suspended and asked to earn her NA certificate and was not allowed to return until she was certified. When asked if he was aware of the suspicious behavior on 12/24/22, he confirmed that he was not aware.

Based on record review and interview the facility failed to provide quality of care when staff failed to notify the Director of Nursing (DON), the Administrator and residents emergency contacts, failed to investigate, and address the temperature of the coffee for safety and put interventions/preventions in place in a timely manor for 1 (R #70) out of 1 (R #70) resident that got burned from a coffee spill. This deficient practice caused harm to R #70 and had the potential to cause harm to other residents by the facility never investigating what caused the burn, and how to prevent other residents from burning themselves with coffee. The findings are: A. Record review of R #70's nursing progress notes dated 12/09/18, indicated that a Certified Nursing Assistant (CNA) informed this nurse that RDS (resident) spilt coffee on her thighs during dinner time. RSD (resident) brought back to room, changed pants and cool washcloths placed on inner thighs. Bilaterally inner thighs has redness and shear to both inner thighs. Skin cooled down, dressing and triple antibiotic cream placed on thighs . B. Record review of R #70's physician orders [REDACTED]. C. Record review of R #70's Wound Assessment Report dated 12/19/18, indicated that the left thigh measurements were Length 5.5 x 2 cm (centimeters). The wound was 100% red, the wound type was a broken blister and there was serous (serum in the human body is a watery, clear fluid) scant drainage. The right thigh measurements were Length 2.5 x 2 cm on the top and 1.5 x 0.8 cm on the bottom. 100% red, the wound type was a broken blister and there was serous, scant drainage. Both wounds were being treated with wound cleanser, cover with dry dressing daily. D. Record review of R #70's physician orders [REDACTED]. E. Record review of R #70's Medication Administration Record [REDACTED]. F. Record Review of the Burn Exposure Chart on Antiscald dated (YEAR) indicated the following: 1. 120 degrees Fahrenheit (F) would take 8 minutes to cause a second degree burn 2. 131 degrees F it would take 17 seconds to cause a second degree burn 3. 140 degrees F would take 3 seconds to cause a second degree burn. G. Record Review of the(NAME)Children's Hospital Website indicated the following: 1. First-[MEDICAL CONDITION] only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Long-term tissue damage is rare and usually consists of an increase or decrease in the skin color. 2. Second-[MEDICAL CONDITION](also known as partial thickness burns) involve the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful. 3. A third-degree burn is referred to as a full thickness burn. This type of burn destroys the outer layer of skin (epidermis) and the entire layer beneath (the dermis). H. Record review of Diet Order and Communication Form and a Physician order [REDACTED].#70. I. On 04/25/19 at 10:56 am, during an interview with the Assistant Director of Nursing (ADON) and the DON, the ADON stated that they implemented the sippy cup/no spill before (MONTH) 2019, but could not be sure, and had no documentation to support that it wasn't implemented until 03/15/19. She stated that it wouldn't have required a speech evaluation or even a physician's orders [REDACTED]. The ADON confirmed that nothing was assessed after this incident for hot liquids, there was not a facility investigation on how she got burned, they did not ever test the coffee to see how hot it was, they did not report the incident. R #70 was not taken to the hospital because [MEDICAL CONDITION] not require it. J. On 04/25/19 at 1:36 pm, during an interview with Wound Care Nurse #1, she stated that R #70 had a coffee burn. She started to apply a silverdine dressing on her daily. The measurements when it initially happened were on her right thigh 4.5 x 2 cm and left thigh was 5.5 x 3 cm. It was red when she first saw it. Wound Care Nurse #1 stated that [MEDICAL CONDITION] fluid filled blisters. The entire burn area was a blister on both sides. She said she did treat [MEDICAL CONDITION] two months. She stated that she still has light scars on both sides. K. On 04/25/19 at 2:32 pm, during a follow up interview with the DON she stated that she was not told about this incident. Even though the progress note indicated that she was made aware of the incident, she stated that she never knew it happened. L. On 04/25/19 at 2:32 pm, during an interview with the Administrator he stated that he was not notified of this incident. Yes, he should have been notified. M. On 04/25/19 at 5:01 pm, during an interview with Family Member #1 she stated she was not informed of the coffee burn. She stated that she was in facility in (MONTH) (2018) as well and no one mentioned it to her. She stated that her mother has Dementia and doesn't really do much for herself anymore, she doesn't really enjoy activities and doesn't complain about being in any pain. N. On 04/25/19 at 5:43 pm, during an interview with Family Member #2, he stated that no one notified him of his mother burning herself with coffee back in (MONTH) (YEAR). He stated that he is the Healthcare Power of Attorney. He stated that sometimes they do notify, sometimes they don't and sometimes they call his sister. O. On 04/25/19 at 10:31 am, during an interview, Cook #1 stated she was in charge for the day. She stated they log the coffee temperatures daily at 8:00 am, but they only document the date not the time. She also stated the temperatures range from 84 degrees-89 degrees F. Dietary Manager #2, arrived as I took the temperature of the coffee in the cup poured from the coffee machine. Dietary Manager #2 stated she would be in charge for the rest of the day. Cook #1 and Dietary Manager #2 were present, as the coffee temperature was being taken. The temperature reached 149 degrees F in the cup. Dietary Manager #2 stated that the coffee was very hot to be serving to the residents. Dietary Manager #2 and Cook #1 agreed that the coffee needed to cool down for resident safety. P. On 04/26/19 at 7:32 am, during an interview, CNA #1 (Certified Nursing Assistant) had just poured coffee in a cup from an urn. The coffee that was poured, had the temperature taken before being given to the resident with my thermometer. The temperature read 149 degrees F. CNA #1 stated she does not know if the temperature is safe for the residents. She stated she normally does coffee in the morning for breakfast. She also stated the kitchen gets the coffee ready for the residents, she just pours it for them from the coffee urn. Q. On 4/26/19 at 7:39 am, during an interview, Dietary Manager #1 stated she thinks the temperature of 149 degrees (F) of the coffee for the residents is safe. She stated she does not know what time temperatures are taken for the coffee, but it is done once a day.

This is a repeated deficiency from the annual survey that identified substandard quality of care and therefore extended the survey on 09/15/17. The facility failed to ensure that residents who were identified as high fall risk received the appropriate supervision and had safety interventions in place to prevent reoccurring falls. During the recertification survey 3 (R #s 64 and 34) of 7 residents were identified as high fall risks and were observed with the following concerns: R #64 sustained a fall on 06/03/18, resulting in a laceration to the back of the head and a subarachnoid hemorrhage (bleeding within the subarachnoid space, which is the area between the brain and the tissues that cover the brain). During the days of the survey, from 06/18/18 to 06/21/18 there were multiple observations of high risk for fall resident being left unsupervised. On 06/20/18 R #64 was observed to be left unsupervised in the facility dining room and was attempting to stand up. R #34 sustained a fall from the wheelchair after being left in the hallway unsupervised on 06/09/18. Facility investigation revealed the staff failed to implement fall prevention interventions at the time of the fall. Observations during the survey revealed the positioning of the night stand close to the resident's bed which posed a safety hazard to the resident when in bed. It was determined during the survey the above findings had caused, or were likely to cause, serious injury, harm, impairment, or death to resident(s). An immediate jeopardy situation was determined to exist on 06/20/18 at 5:20 pm. The facility Administrator and the Director of Nursing (DON) were immediately notified by the contracted survey team. The facility Administrative Management submitted a corrective action plan during the on-site survey which was reviewed and approved by the survey team. The immediate jeopardy concern was abated on 06/20/18 at 10:45 pm and was lowered to the scope/severity of E. Facility Corrective Action Plan Statement: The facility took corrective action by providing an acceptable Plan of Removal on 06/20/18 at 10:45 pm The Plan of Removal included the following: 1. Therapy department will re-screen all residents who had a fall or who are at high risk for a fall since 1/1/18 to recommend appropriate interventions and implementation of any needed safety awareness changes that have not already been implemented. 2. Promoting activities and appropriate exercises: As of 06/07/18 (Name of Facility) implemented humming bird hour, this is a social hour after lunch to help with supervision of frequent fallers and those identified as high fall risk residents. The intervention will be implemented at other times that have been identified with occurrence of high falls risks. This intervention will be continuous, and the Activities Director will be responsible for overseeing the program. 3. Addressing supervision issues with the following: All Management staff will assist in monitoring residents during meal services. All management team will be responsible for periodic daily rounding assignments to help supervise residents who are high risk for falls. They will ensure that residents risk is decreased while in rooms, at nurses' stations, and other low traffic areas. 4. In-Service was completed by Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 6/20/18 at 8:00 p.m. with all management team regarding supervision and importance of observation of resident during rounds. A member of the management team will be present throughout the duration of the meal. 5. Staff will be re-educated by DON and ADON on 6/21/18 at 06:30 a.m. on not leaving high risk residents unattended in the dining room, encourage residents to participate in activities, and appropriate exercises. 6. The Center will enact a Falls Committee immediately. The facility will review incidents daily in morning meeting to ensure appropriate interventions and supervision is occurring on a routine basis. The team will consist of Administrator/DON/ADON/Activities/Restorative/Social Services/Therapy. Meeting will occur every Thursday on or about 11:00 a.m., to review falls and implement plan of actions. 7. Room assessment will be conducted immediately on residents who have been identified as high risks residents for environmental hazards. Residents rooms will be free of clutter. 8. Staff members will be positioned in the dining rooms immediately 6/21/18 at 7:30 a.m. to ensure residents are monitored and supervised while other staff transport residents out of the dining rooms. This will be an ongoing endeavor. 9. Maintenance and/or Therapy teams will immediately inspect and service all durable medical equipment (DME) related to falls. Based on record review and interview, the facility failed to ensure that residents received adequate supervision and interventions to prevent falls for 2 (R #s 64 and 34) of 7 residents reviewed for accidents. The facility's failure as evidenced by: failing to provide high fall risk residents with adequate supervision, complete fall risk assessments after falls, implementing and update the resident's plan of care with new interventions to prevent falls/injury, and failing to complete a thorough investigation to determine the root cause of resident falls likely resulted in residents suffering multiple falls resulting in injuries such as, abrasions, skin tears, lacerations (cut), hematomas (an abnormal collection of blood outside of a blood vessel), and pain. The findings are: Resident #64 A. Record review of Facility Reported Incident dated 06/04/18, revealed R #64 attempted to stand up from his wheelchair unassisted and sustained a fall with a laceration to the back of the head and a subarachnoid hemorrhage (bleeding within the subarachnoid space, which is the area between the brain and the tissues that cover the brain) on 06/03/18. The resident was sent to the emergency room for evaluation and treatment. The resident was diagnosed with [REDACTED]. B. Record review of R #64's medical record revealed R #64 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. that interferes with daily functioning) with Behavior Disturbances. C. Record review of R #64's admission Minimum Data Set ((MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 indicating the resident had a severely impaired cognition status. The resident was assessed as requiring extensive assistance of 1 person physical assistance with activities of daily living (ADLs). The resident was coded with an unsteady gait and requiring staff assistance for stabilization; no impairment of upper and lower extremities; and utilized a wheelchair for mobility. The resident did not experience any falls prior to admission into the facility. A review of the Care Area Assessment (CAAs) for the this MDS revealed the resident triggered for falls related to the resident's unsteady balance and diagnoses. D. The facility was unable to provide an admission fall risk assessment, which was part of their process when a resident is newly admitted . E. Record review of R #64's comprehensive care plan dated 06/01/18 identified that the resident sustained [REDACTED]. Interventions included: 1. rule out medical complications [REDACTED]. 2. notify the physician and family of falls or injuries as necessary (PRN); periodic medication review; 3. ensure safe environment free of clutter; neurological checks per facility protocol; 4. attempt to identify root cause; 5. extensive transfer assistance with one person assistance; 6. fall assessment on admission, quarterly, and with the changes or falls; 7. encourage resident to use call light and keep call light within reach; 8. provide adequate lighting and keep wheel chair within reach. The care plan interventions did not address providing supervision and ensuring the brakes on the resident's wheelchair were engaged to prevent the wheelchair from rolling backwards if the resident attempted to stand up. F. On 6/19/18 at 2:15 pm, during an interview with the MDS Coordinator revealed the MDS Coordinator had just developed the comprehensive care plan. The MDS Coordinator stated the comprehensive care plan was due 05/30/18. G. Record review of the facility's Incident Report dated 05/22/18 revealed R #64 was observed sitting on the floor inside the bathroom. The resident was unable to state how he came to be on the floor. The resident was assessed for injuries and no injuries noted. Interventions for this fall included assessing the resident for pain and injuries and encourage the resident to call for assistance for toileting. H. On 6/20/18 at 11:45 am, during an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) concerning the facility's fall program, revealed if a resident sustains a fall without injuries, then staff does not complete an investigation into the cause of the fall. The Interdisciplinary Team (IDT) team will meet and make recommendations or the nurse identifying the resident's fall will develop an intervention. After R#64's fall on 05/23/18, an investigation was not completed since the resident did not sustain an injury. An intervention was put in place to encourage the resident to use the call light for assistance when getting up. Both DON and the ADON (Administrative Nurses) were asked since R #64 was assessed with [REDACTED]. The DON admitted this was not an appropriate intervention. I. Record review of the R #64's Fall Risk assessment dated [DATE], indicated the resident scored a 10 indicating, high risk for falls. J. Record review of R #64's physician's progress notes dated 06/05/18 documents that R #64 fell on [DATE], sustained a laceration on the back of head and was sent to the emergency room . Computerized axial tomography (CT) (Pictures of structures within the body created by a computer that takes the data from multiple X-ray images and turns them in pictures) scan was performed, and the resident was found to have a small arachnoid hemorrhage (SAH) which did not change with a repeat CT scan performed hours later. K. Record review of the facility's investigation of the fall that occurred 06/03/18 documents R #64's was sitting at the nurses' station in a wheel chair (dressed and wearing shoes) apparently stood up and fell sustaining a laceration to the back head along with a small hematoma. Investigation included a statement from Licensed Practical Nurse (LPN) #2 documenting the resident was sitting across from the nurses' station in his wheelchair. LPN #2 also documents while working at the nurses' station that she heard a crash/thud and observed the resident laying on the floor partially on his right side. The staff Registered Nurse (RN) provided first aid to the resident and 911 was called to transport the resident to the emergency room . The investigation did not determine the underlying causes of the fall through a root cause analysis to prevent future falls. L. On 06/21/18 at 12:52 pm, during an interview with RN #2, who was on duty the day of R #64's fall, stated the resident was placed at the entrance of A hall in front of the nurse's station in his wheelchair. RN #2 was busy training a new nurse when she suddenly heard a loud thud and notice the resident was on floor. RN #2 did not observe the resident trying to stand up and was not sure if the resident was asleep and fell from the wheel chair. RN #2 noticed the resident was bleeding from the back of his head, was awake and talking unable to explain what happened. RN #2 stated that she immobilized and assessed and applied pressure dressing to the resident's wound. The resident's responsible party, and Medical Doctor were notified and 911 was called. RN #2 stated she did not check the resident's wheelchair to determine if the brakes were in place. M. On 06/19/18 to 06/20/18 during observations of R #64 at different times throughout the survey the following was observed: 1. On 06/19/18 at 9:30 am, R #64 was positioned at nurses' station next to a medication cart. The resident was observed sleeping with head resting on his chest, slightly leaning forward. Staff members passing by resident made no attempt to reposition resident in the wheelchair. 2. On 06/19/18 at 10:45 am, resident remains at nurses' station sitting in wheelchair sleeping head down towards chest, elbows on the arms of the wheelchair and feet resting on leg rest. Resident leaning forward slightly. No attempts by staff to awaken resident and reposition in the wheel chair. LPN #5 was sitting at nurses' station. 3. On 06/19/18 at 11:20 am, R#64 was positioned at the entrance to nurses' station still sleeping with head down towards chest slightly leaning forward. Staff passing by the resident made no attempt to reposition the resident in the wheelchair. 4. On 06/20/18 at 9:20 am, R #64 was positioned in his w/c (wheelchair) in front of the Humming Bird dining room out of sight of the nurse's station and staff in the dining room. The resident was awake and looking down the hall. 5. On 06/20/18 at 1:33 pm, R #64 was observed attempting to standup from his wheelchair while positioned at the dining room table. The resident's wheelchair was observed to roll slightly back and forth as the resident attempted to stand. R#64 attempted twice to stand up unassisted. No staff members were observed in the dining room to supervise R #64 or several other cognitively impaired residents. The Administrator entered the dining room and the surveyor advised the Administrator of the R # 64's attempts to stand unassisted. The Administrator went immediately to R#64's side and instructed him to sit down and then transported the resident to the Humming Bird hour where high risk fall residents are to be closely supervised. N. On 06/20/18 at 3:33 pm, during an interview with the Administrator, he revealed while assisting R #64 he noticed the wheelchair brakes were in place however, the table was moving as the resident attempted to get up. The Administrator stated there were three other Certified Nursing Assistants (CNAs) in the back of the dining room. The Administrator acknowledged the CNAs did not get up to assist the resident but felt they couldn't assist since they were feeding other residents. The Administrator identified Restorative Aide #1 and Certified Nursing Assistant #7 as being in the dining at the time of the incident. O. On 06/20/18 at 3:50 pm, during an interview with Restorative Aide (RA) #1 and CNA #7, CNA #7 stated that she was not in the dining room when the incident occurred and when she returned to the dining room she started feeding the residents. RA #1 states that she was the only one in the dining room and she was feeding two residents when she observed the resident attempting to stand but could not stop feeding the residents. RA #1 stated she didn't think to call for help but then noticed the Administrator was going over to help R #64. P. On 06/20/18 at 4:15 pm, during an observation of R #64 revealed the resident sitting in the Humming Bird dining room with two other residents and the Activities Assistant who was positioned with her back partially turned towards the resident. R #64 was sitting in a wheelchair with the brakes not applied. An interview during this observation with the Activities Assistant revealed she was familiar with the resident and his fall history and that the resident required close supervision. The Activities Assistant was asked if the resident's wheelchair brakes should be in place to prevent the wheelchair from rolling. The Activities Assistant stated the brakes were in place. When asked to verify the wheelchair brakes were in place, the Activities Assistant discovered the brakes were not in place to prevent the wheelchair from rolling. Resident #34 Q. Record review of the Facility Reported Incident dated 06/11/18, revealed on 06/09/18, R #34 was observed on the floor with her body on the right lateral side in a fetal position in front of the wheelchair with the brakes on. The resident sustained [REDACTED]. The resident was sent to the emergency room for evaluation and treatment. R. Record review of R #34's medical record revealed the resident was admitted into the facility with [DIAGNOSES REDACTED]. S. Record review of R #34's annual Minimum Data Set ((MDS) dated [DATE], assessed the resident with severe cognition impairment and no behaviors during the assessment period. The resident required extensive assistance of one person with transfer and all activities of daily living; incontinent of bowel and bladder and with functional range of motion limitation of upper and lower extremities. The resident did not experience any falls during this assessment period. T. Record review of R # 34's most recent quarterly ((MDS) dated [DATE] documents the resident was coded with severe cognition impairment and required extensive assistance with 1-person assistance with activities of daily living (ADLs), transfers, and mobility. The resident did not experience any falls during this assessment period. U. Record review R#34's fall risk assessment dated [DATE] assessed the resident with a fall risk score of 12 indicating the resident was at high risk for falls. The facility was unable to provide a fall risk assessment completed after the resident's fall on 06/09/18. V. Record review of R #34's care plan with a revision date of 06/09/18, revealed the resident was at risk for injury related to falls related to poor safety awareness and dementia. The interventions included: 1. rule out medical complications [REDACTED]. 2. ensure safe environment, free of clutters, adequate lighting, clean spills promptly; 3. low bed with mats, high back wheelchair with calf board (provides support for the users' calfs, aiding in the prevention of dragging feet); 4. ensure appropriate footwear when out of bed; 5. call light within reach; and fall risk assessments with admission, quarterly and with changes and falls. W. Record review of the facility's investigation for R #34's fall revealed on the night of 06/09/18, CNA #8 had gotten the resident dressed and placed her in the high back wheelchair around 6:00 am. The resident was in her wheelchair and placed in the hallway next to her room and left unsupervised. CNA #8 left to assist in getting the other residents up. A few minutes later a thud was heard and a nurse calling for assistance. The resident was found in a fetal position on the floor with a laceration to the right side of her head. The resident was assessed and sent to the emergency room for evaluations and treatment. The facility's investigation revealed the resident's Roho cushion ( wheelchair cushion provides optimal skin protection as well as positioning) was improperly place in the bottom of the wheelchair titling the resident forward in the w/c instead of backwards. Also, the resident's calf board was not in place to prevent the resident from falling forward. X. On 06/18/18 to 06/19/18 during observations of R #34 at different times throughout the survey the following was observed: 1. On 06/18/18 at 9:59 am, revealed R#34 was observed in a low bed pushed against the wall. Fall mat at the left of the resident's bed but not completely align with the resident's bed. Night stand close to resident's bed, potentially if the resident rolls out of the bed could possibly sustain a head injury from the night stand. 2. On 06/18/18 at 3:00 pm, the resident was observed in bed in low position, push against the wall and floor mat in place but still not aligned with bed. The bed was close to night stand. If the resident were to roll out of bed she could strike her head on the night stand. 3. On 06/19/18 at 2:00 pm, observed resident in bed in low position, bed pushed against the wall and floor mat on left side of the bed. Floor mat not positioned to the full length of the bed. Resident's night stand remains close to the resident's bed. Y. On 06/20/18 at 11:20 am, during an Interview CNA #7 stated she was aware of the R #34's fall last week and stated apparently the night CNA did not put the calf board in place and the Roho seat cushion was old and worn. CNA #7 also stated since the resident was not positioned properly on the cushion and the resident has tendency to rock in the wheelchair she pitched forward and fell striking her head. The CNA further stated that's why it is important to make sure the resident chair is tilted back and make sure the resident has the calf board in place. Z. On 06/20/18 at 4:30 pm, during an interview with the DON and ADON concerning R #34's recent fall, both the DON and the ADON explained the CNA had just gotten the resident out of bed, the CNA failed to properly place the resident's Roho seat cushion in the wheelchair correctly and it caused the resident to tilt forward. Also, the CNA failed to apply the resident's calf board to the leg rest of the wheelchair which would support the resident legs. It was also identified the CNA failed to place the resident's wheelchair in a reclining position. The resident was placed in the hallway by her room and left unsupervised and then the next thing the staff heard a thud and someone calling for help and found the resident on the floor. They further stated that they started training staff on falls investigations and holding the staff accountable for not ensuring the safety of the residents. They both stated the staff have been trained on safe transfers but unsure of the last time the staff was trained on positioning. They also stated that staff are expected to inspect the resident's rooms for environmental hazards that could contribute to a resident's fall. AA. On 06/20/18 at 8:00 pm, during an interview the Administrative staff was given a list of several facility specific policies requested by survey team. BB. On 06/21/18 at 2:00 pm, an interview was conducted with the Director of Nursing(DON) and Assistant Director of Nursing(ADON) concerning the lack of policies. The ADON stated that the facility has not had any policies onsite since she has been here. She was asked if she could access them electronically, she stated no. The ADON and DON were asked if the staff has the ability to access polices on the computer and they both stated no. The ADON stated that the DON has limited access to some polices. The DON stated that the facility was receiving policies by a corporate person who was sitting at the airport. CC. Both the DON and ADON were asked to accompany the surveyors (no date or time given) to inspect the resident room. Both administrative nurses observed the arrangement of furniture in the resident's room then placed the floor mat down along the bed and acknowledged the mat did not align to the full of the resident's length of bed and if the resident rolled out of bed the resident had a chance of striking her head on the night stand. The DON agreed this was a potential hazard and stated they need to look at rearranging the resident's room and furniture to avoid potential injury. DD. On 6/21/18 at 6:15 pm, during an interview with CNA #8 she confirmed she was assigned to R #34 the day of her fall. CNA #8 stated that R #34 likes to get up early. CNA# 8 admitted that she had placed the Roho cushion in the wheelchair the wrong way and that she could not find the calf board to place on the wheelchair leg rest. CNA #8 placed the resident in the hallway thinking the staff could visualize the resident as they carry on with their duties. While the CNA was getting linen she heard one of the nurses calling for help and discovered the resident on the floor.

Based on interview and record review, the facility failed to ensure that a resident was free from neglect, for 1 (R #1) of 4 (R #s 1, 2, 3 and 4) residents reviewed during a complaint investigation. Failure to communicate the termination of hospice services to facility staff resulted in R #1 not receiving needed care at the facility after her hospice services ended. The resident suffered bilateral leg fractures (broken bones in both legs) while under the facility's care, which the facility failed to prevent or identify, despite visible signs of injury. The facility's assertion that the injuries may have occurred when the family transferred the resident between bed and wheelchair, or during a family trip off-grounds, was not supported by any documentation that the family was noncompliant with safety measures or had taken the resident off-grounds. This deficient practice resulted in significant injuries to the resident, and likely contributed to the resident's sudden decline and death, through decreased mobility resulting in respiratory compromise and collapse. The findings are: A. Record review of a complaint intake dated [DATE] related to R #1 found statements from the complainant, R #1's family member (FM #1), indicating: 1. that on [DATE], FM #1 found the resident to be visibly dirty, with unclean hair and an odor emanating from her body. FM #1 stated that, when she inquired about the resident's showers, she was told by facility staff that only hospice staff was bathing the resident. 2. that on [DATE], FM #1 filed a grievance about the resident's care with management at the facility, though she didn't recall specifically who she spoke with. 3. that the family had been informed by the hospice provider (no date given) that the resident had been terminated from hospice services on [DATE]. Facility nursing staff were not made aware of the termination of hospice services until [DATE], resulting in lapses in care, as facility staff failed to assume the duties previously provided by hospice. 4. that on [DATE], FM #1 received a telephone call from a facility nurse, stating that the resident was experiencing breathing problems and decreased responsiveness, and FM #1 gave authorization to send the resident to a local hospital. The patient was transferred to the hospital's emergency department, and was admitted to an inpatient unit. 5. that on [DATE] and [DATE], a physician noted yellow and blue bruising on each of the resident's legs, and x-rays were ordered, which showed fractures of both legs. 6. that the resident was placed on hospice care at the hospital on [DATE], and died on [DATE]. B. Record review of a state Ombudsman report, dated [DATE], found a statement indicating that the Ombudsman received a phone call from FM #1, who was very concerned about R #1's care at the facility. FM #1 had reported that the resident's legs were found to be bruised at the hospital, and that X-rays had found a [MEDICAL CONDITION] leg, and that the right leg was due to be X-rayed that day. FM #1 had also stated that R #1 had not been getting bathed at the facility. FM #1 had indicated that she would not allow R #1 to be returned to the facility, due to significant concerns with the quality of her care there. C. Record review of a facility report to the Department of Health regarding R #1's injuries, filed by the Former Assistant Director of Nursing on [DATE], and updated by the Former Director of Nursing on [DATE], found statements indicating: 1. records from (facility) show no reports of falls or other injury to resident. 2. resident's primary physician (Physician #1) discussed pathology of fractures with (the Former Director of Nursing) and it was determined the fractures did not come from moving the resident inappropriately but from a possible fall. 3. Resident Factors that may have Impacted Occurrence: Resident's family members frequently took resident on walks, were observed several times transferring resident to bed from wheelchair without facility staff present to help . Family had also taken resident out on pass from facility. 4. Resident is non-weight bearing and is dependent for transfers to and from bed and wheelchair. D. Record review of R #1's medical record found that she was [AGE] years old, and that her [DIAGNOSES REDACTED]. E. Record review of R #1's care plan found: 1. A section dated [DATE] stating (R #1) has risk of injury r/t (related to) falls AEB (as evidenced by) extensive assistance with all ADLs (Activities of Daily Living) d/t (due to) stroke. 2. An undated section stating (R #1) has Self Care Deficit AEB: Need for total dependence with all ADLs d/t stroke. 3. A section dated [DATE] stating (R #1) has impaired communication AEB [MEDICAL CONDITION] (loss of ability to speak or understand speech) r/t cerebral infarction (stroke) . 4. A section dated [DATE] stating Resident has terminal/end stage ([DIAGNOSES REDACTED]. Highlighted and dated sections of this focus area indicated discontinuation of hospice services on [DATE]. 5. Nothing in the care plan to indicate that R #1's family had been noncompliant with safety measures, such as attempting to transfer the resident into a wheelchair without staff assistance. F. Record review of Interdisciplinary Team progress notes for the duration of R #1's stay at the facility found: 1. No notes under the Accident/Injury category. 2. No notes under the Change in Condition category. 3. A Certified Nurse Aide (CNA) note dated [DATE] stating Resident's (family member) wanted to know if they've been showering (R #1) as scheduled. 4. A Certified Nurse Aide note dated [DATE] stating Resident received a shower during day shift . 5. A note from the Social Services Director dated [DATE] stating (resident) was discharged from Hospice for over a week. Family wants aggressive treatment. 6. A physician's progress note dated [DATE] stating Acute problem: [MEDICAL CONDITION] (poor oxygenation of the blood) noted today . Patient has difficulty swallowing. Was on hospice but just learned of its discontinuation. (Family Member) would like evaluation and care of (patient) but still no intubation (breathing tube placement) or (illegible). 7. No notes to indicate that the facility had identified or assessed the wounds on R #1's legs at any point prior to transfer to the local hospital. 8. No notes to indicate that R #1's family was noncompliant with safety guidelines requiring staff assistance with transfers at any point during the resident's stay at the facility. G. Record review of R #1's CNA - ADL Tracking form, dated (MONTH) (YEAR), found notations indicating: 1. that R#1 was totally dependent on the assistance of 2 staff members for transfers between bed and wheelchair. 2. that Walk in Room and Walk in Corridor activities did not occur. 3. that R #1 received 4 baths/showers during the month, on [DATE], [DATE], [DATE] and [DATE]. No notations were found to indicate that the resident had refused showers on any date in September. H. Record review of R #1's Bath/Shower completion forms for (MONTH) (YEAR) found that 4 baths/showers were received by the resident during the month: 1. a bedbath on [DATE]. 2. an unspecified bath or shower on [DATE]. 3. a bedbath on [DATE]. 4. an unspecified bath or shower on [DATE]. I. Record review of the facility's Abuse Prohibition Standards of Practice document, dated (MONTH) (YEAR), found a definitions page, which identified Neglect as The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. J. Record review of R #1's hospital records found: 1. an Emergency Department note, dated [DATE], indicating that a urinary tract infection and possible pneumonia were the acute diagnoses. 2. an Internal Medicine History and Physical note, dated [DATE], indicating that the resident was hypoxic (inadequate oxygenation of the blood) and entirely nonverbal upon arrival at the Emergency Department. The note indicated that the resident's family member had reported that her condition marked a rapid decline from a few days earlier, when she had been able to propel her own wheelchair and had been attempting to form words. 3. a Diagnostic Imaging note dated [DATE] stating that the reason for X-rays was bruising of both legs, which was concerning for possible fractures. Findings included osteopenia (bone density loss of lesser severity than [MEDICAL CONDITION]), tibia (leg bone) [MEDICAL CONDITION] leg, tibia and fibula (two leg bones) fractures of the right leg. The conclusion section of the note indicates comparison of the resident's X-rays with earlier films, and states It is likely these occurred at (facility) from an undocumented fall. She did not have these fractures prior to her being sent to their facility. K. On [DATE] at 8:38 am, during interview with the wound care nurse, she stated that, due to her stroke, R #1 hadn't been mobile at all during her stay at the facility. She stated that R #1 never tried to get out of bed on her own, and that transfers were accomplished with the assistance of 2 staff. She verified that yellow coloration of a bruise wound indicate that it was not a new injury, but that it had started to fade. L. On [DATE] at 9:25 am, during interview with CNA #1, she indicated that R #1 had been unable to move very much on her own. Facility staff was moving her with two staff members, and when she declined further, with the use of a mechanical lift device. She did not recall any instances of the family attempting to transfer the patient unassisted, stating, They usually would call and ask for her to be put back down. M. On [DATE] at 9:30 am, during interview with RN #1, she recalled that R #1 had required two staff to transfer her, and then had been transitioned to the use of a mechanical lift. She confirmed that, had R #1 fallen when alone, she would not have been able to return to bed unassisted. She didn't recall R #1 having had any falls, or occasions when the family had attempted to transfer her unassisted. N. On [DATE] at 12:35 pm, during interview with the Social Services Director, she stated that R #1's family had not been happy with hospice services, and that they had wanted more aggressive treatment of [REDACTED]. She was aware of the family's decision to remove R #1 from hospice care, and stated that the physician had been notified right away, but she was unable to state whether or not nursing staff had been informed. She did not have direct observation of R #1's family attempting to transfer the resident without assistance, and had not been asked by anyone on staff to intervene with the family regarding unsafe transfers. O. On [DATE] at 1:10 pm, during interview with the Interim Administrator, he indicated that he had only been at the facility for 2 weeks, and had no direct knowledge of R #1's care at the facility. He confirmed that if a family were noncompliant with safety measures, he would expect it to be documented in the medical record and addressed in the resident's care plan, but that he had found no such documentation when reviewing the resident's medical record. P. On [DATE] at 1:10 pm, during interview with the Regional Nurse Administrator, she indicated that she was aware that there had been a gap in R #1's care after hospice services had been discontinued. She stated that she did not know where the breakdown in communication had occurred. Q. On [DATE] at 3:00 pm, during interview with the Regional Nurse Administrator, she indicated that she had reviewed R #1's care plan and had not found any entries about the family having been noncompliant with transfers or other safety measures. She had also reviewed the resident sign-out sheets and had not found any indication that the family had signed R #1 out for trips off-grounds, as suggested in the facility's investigation of the injuries. She stated that she believed that the gap in the resident's care had resulted from the hospice provider failing to notify the facility of the termination of R #1's hospice services. R. On [DATE] at 3:00 pm, during interview with RN #1, she stated that R #1's family would frequently take her outside in her wheelchair, but that she had never known them to take her off of the facility's grounds.

This is a repeat deficiency from a recertification survey dated 08/30/16. Based on record review and interview, the facility failed to update care plans after resident falls, or when residents received multiple medications for treatment of [REDACTED].#s 16, 64, 82 and 100) of 7 (R #s 16, 37, 38, 62, 64, 82 and 100) residents reviewed for accidents and pain management. The efficacy of various interventions was not communicated in the care plans. This deficient practice likely contributed to additional resident falls, and to a resident receiving haphazard treatment for [REDACTED]. The findings are: Findings related to R #16 A. On 09/11/17 at 3:24 pm, during interview with R #16, he stated, I have horrible pain. I fell at home and had 2 or 3 broken ribs. He indicated that his pain is on the left side of his torso and his left leg. He also stated that he receives [MEDICATION NAME] (a medication for nerve pain) for pain to his face. He stated that, on occasion, one of the nurse's aides will let the nurse know that he needs pain medication, but that he isn't sure how effective it is, because I don't move. B. Record review of R #16's medical record found that his [DIAGNOSES REDACTED]. C. Record review of physician's orders [REDACTED]. 1. An order dated 06/18/17 for [MEDICATION NAME] (an anti-[MEDICAL CONDITION] drug) 400 mg (milligrams) by mouth every four hours as needed for pain. 2. An order dated 06/18/17 for [MEDICATION NAME] (an anti-[MEDICAL CONDITION] drug) 500 mg every six hours as needed for pain. 3. An order dated 06/23/17 for [MEDICATION NAME] (a narcotic pain medication) 50 mg every 12 hours as needed for pain. 4. An order dated 07/31/17 for [MEDICATION NAME] 300 mg three times daily. D. Record review of a care plan section for R #16, dated 08/26/16, found a focus area stating, (R #16) is at risk for alteration in level of comfort aeb (as evidenced by) T11-12 vertebra (two [MEDICATION NAME] spine segments) fracture and multiple left rib fractures with additional risk of history of fecal impaction and bowel obstruction. A goals section stated, Pain will not interfere with daily routine, pain will be reported at acceptable level to resident, and free from constipation related to narcotic [MEDICATION NAME] as goals for the next 90 days. Nothing in the care plan was noted to specify which approaches should be used for different locations or severity of the resident's pain. E. Record review of Medication Administration Records (MARs) found that: 1. In July 2017, R #16 received 8 PRN (as needed) doses of [MEDICATION NAME], and 1 PRN dose of [MEDICATION NAME]. 2. In August 2017, R #16 received PRN doses of [MEDICATION NAME] and [MEDICATION NAME] once each. 3. In September 2017 to date, R #16 received one PRN dose of [MEDICATION NAME] and one PRN dose of [MEDICATION NAME]. F. On 09/15/17 at 5:22 pm, during interview with the Assistant Director of Nursing, she confirmed that the orders and care plan for R #16 did not specify when to use each pain medication option. She stated that nurses would have to use their nursing judgment in selecting an intervention, but conceded that a consistent approach to treating the resident's pain could not be assured with this approach. Findings for R #100: G. Record review of the Resident Incident Reports revealed R #100 had falls on, 06/19/17, 07/08/17, 09/08/17, and 09/11/17. H. Record review of R #100's Care Plan (no onset date) revealed, At risk for injury r/t (related to) falls AEB (as evidenced by): high fall risk with additional risk r/t [MEDICAL CONDITIONS] ([MEDICAL CONDITION], and muscle weakness .09/08/17 fall, 12:20 am, in rm (room) while self transferring from bed to restroom. 09/11/17-hematoma with laceration L (left) side of forehead. Interventions are: rule out medical complication with increased falls, notify MD and family of falls or injuries PRN (as needed), periodic medication review, ensure safe environment, free of clutter, adequate lighting, clean spills promptly, transfer with assist of limited x 1 person, neuro checks per facility protocol for any/suspected head injury, attempt to identify root cause for falls, fall assessment on admission, quarterly and with changes or falls, ensure proper footwear when OOB (out of bed), call bell in reach, provide adequate lighting, assistive device (wheelchair) within reach, bowel and bladder x 1 week, dycem (non-slip mat), orthostatic BP (blood pressure when standing) x 3 days, labs as ordered:UA (urine analysis). There is no evidence that R #100's care plan was updated with new interventions after the falls on 06/19/17 and 07/08/17. I. On 09/15/17 at 10:59 am, during interview with the Director of Nursing (DON), he stated that the care plan should be updated after each fall with new interventions and confirmed that the care plan was not updated after the falls on 06/19/17 and 07/08/17. Findings for R #64: J. Record review of the Resident Incident Reports revealed R #64 had falls on, 08/23/17, 08/20/17, 08/12/17, 08/03/17, and 06/25/17. K. Record review of R #64's Care Plan dated 01/05/17, revealed risk for injury r/t falls AEB: self transferring without assistance, attempting to ambulate without assistance, unsteady gait, non compliant with safety devices, with additional risk r/t dementia, DM (diabetes mellitus), difficulty in walking. Fall: 08/23/17 at 11:15 am dining room trying to stand but fell , scrap to R hand, abrasion to R middle side of back. Fall 8/20/17, from bed w/out assist to wc no injuries. Interventions: rule out medical complication with increased falls, notify MD and family of falls or injuries PRN, periodic medication review, ensure safe environment, free of clutter, adequate lighting, clean spills promptly, high low bed, bed to be placed against wall, transfer with extensive x 1 person, bed changed to a bed with no wheels, dycem to w/c, anti-brakes (sic) to wheel chair, floor mats on floor when resident is in bed, fall assessment on admission, quarterly and with changes or falls, ensure appropriate footwear when OOB (out of bed), call bell in reach, provide adequate lighting, PT eval/tx (evaluate/treat) as indicated, pt eval for fall, PCP (primary care physician) visit. Review of the care plan does not show evidence of updated interventions for falls on 08/03/17 and 08/12/17. L. On 09/15/17 at 11:19 am, during interview with the DON, he stated that R #64 cannot be educated regarding safety measures, because he will not retain the information. The DON confirmed that R #64's care plan was not updated with new interventions after the two falls in August 2017. Findings for R #82: M. Record review of Resident Incident Report revealed R #82 had falls on 08/24/17 and 09/08/17. N. Review of Resident #82's Care Plan dated 12/28/16, revealed At risk for injury r/t falls AEB: Hx falls, attempting to self transfer, non-compliant with safety measures with additional risk r/t Demetia, CAD, HTN; shuffling gait and [MEDICAL CONDITION] to left eye, 8/24/17 fall in room, dycem pad to wheelchair, room change to B28a for safety. Interventions: Rule out medical complication with increased falls, notify md and family of falls or injuries PRN, periodic medication review, ensure safe environment, free of clutter, adequate lighting, clean spills promptly, transfer with assist of extensive one person, educate for safe transfers with use of call light, low bed, toilet before and after meals as needed, helmet to be used for safety, fall assessment on admission quarterly and with changes or falls, ensure appropriate footwear when oob, call bell in reach, provide adequate lighting, assistive device wheelchair within reach, pt eval.tx as indicated. The care plan does not include fall mat or evidence of interventions added after the fall on 09/08/17. O. Record review of the Comprehensive Care Plans Standard of Practice dated 11/16, revealed Develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive, significant change of condition and quarterly minimum data set assessment.

Based on record review and interview, the facility failed to ensure that each resident received adequate supervision and interventions to prevent falls for 3 (R #s 64, 82, and 100) of 6 (R #s 37, 62, 64, 81, 82, and 100) residents reviewed for accidents. The facility's failure is evidenced by: failing to provide high fall risk residents with adequate supervision, complete neurological evaluations for falls with head injury and unwitnessed falls, complete fall risk assessments after falls, update the resident's plan of care with new interventions to prevent falls/injury, and failing to complete a thorough investigation to determine the root cause of resident falls. This deficient practice likely resulted in residents suffering multiple falls resulting in injuries such as, abrasions, skin tears, lacerations (cut), hematomas (an abnormal collection of blood outside of a blood vessel), and pain. The findings are: Findings for R #100: A. Record review of R #100's Face Sheet revealed an admission date of [DATE], with the following medical Diagnosis: [REDACTED]. B. Record review of the Admission Fall Risk (MDS) data set [DATE], revealed R #100 is a fall risk with a score of 12, indicating a high risk for falls. She is incontinent daily, her cognition is mild to moderately impaired, and is partial weight bearing. C. Record review of the Resident Incident Reports revealed the following: 1. On 06/19/17, R #100 had an unobserved fall in bath. No apparent injury. States res (resident) was found sitting on the floor next to toilet facing east. Res states I missed the rail next to toilet in Navajo language. Res states I landed on my butt. Res alert and talking to writer about incident. Res complained of pain 2/10 scale to legs. ROM (range of motion) within norm (normal) limits for res. No bruises or open areas noted. Rt (right) ankle with mild edema but that was noted earlier in the pm. Immediate actions taken: assessed res for injuries and initiated neuro checks, vital signs. Then assist res back into wheelchair. Documentation did not reveal that new interventions were put in place. 2. On 07/08/17, R #100 had an unobserved fall in hallway on unit. Injury: skin tear, unknown injury. Resident observed lying on floor with eyes closed more on right side by nurse's station. w/c (wheelchair) at feet. Resident c/o (complained of) pain to right side of face, arm, and leg. Swelling noted to R (right) cheek and skin tear right hand. Resident rolled on sheet and transferred with sheet to bed. Resident cries in pain when ROM attempted to right leg. Neuro checks started. 3 cm (centimeter) x (by) 4 cm skin tear right hand. Swelling to right cheek. Immediate actions taken: Assessed for injuries and pain. Neuro checks started. MD (medical doctor) notified and ordered to send up to ER (emergency room ) for evaluation of right cheek and right hip. Resident sent out via nonemergent ambulance. Documentation did not reveal that new interventions were put in place. 3. On 09/08/17, R #100 had an unobserved fall in room. Injury: other. States was called to room, rsd was sitting on her buttocks on the floor next to her bed at her left side. Actions taken: assessed rsd for any apparent injury-none were found. Placed legs out in front of her and the abnormal rotation of the lower ext with the assist of two and a gait belt we stood up and sat onto the bed. Once on the bed completed her assessment. Review of the post-incident actions revealed, re-instructed her to use her call light when she wants to get up. Documentation did not reveal that new interventions were put in place. 4. On 09/11/17, R #100 had an unwitnessed fall in hallway on unit. Injury: head injury, hematoma, laceration. States During assessment CNA (certified nursing assistant), stated I was talking to PT (physical therapy) at nurses station regarding rsd and that's when I saw rsd get up from her w/c and get on her knees and she went forward hitting her head on the floor. That's when I notified the nurse, (RN #2). I got to her and ask if she was okay, she tried to hit me. Hematoma with small opening to left side of forehead. Actions taken: assessment, first aide, neurochecks, notification of doctor, family and supervisor .ER. Review of the post-incident actions revealed, Education provided to rsd regarding use of call light and asking for assistance. Education provided to CNA to ensure hourly rounding is completed. Documentation did not reveal that new interventions were put in place. D. Record review of R #100's Care Plan (no onset date) revealed, At risk for injury r/t (related to) falls AEB (as evidenced by): high fall risk with additional risk r/t Parkinson's, DVT (deep vein thrombosis), and muscle weakness .09/08/17 fall, 12:20 am, in rm (room) while self transferring from bed to restroom. 09/11/17-hematoma with laceration L (left) side of forehead. Interventions are: rule out medical complication with increased falls, notify MD and family of falls or injuries PRN (as needed), periodic medication review, ensure safe environment, free of clutter, adequate lighting, clean spills promptly, transfer with assist of limited x 1 person, neuro checks per facility protocol for any/suspected head injury, attempt to identify root cause for falls, fall assessment on admission, quarterly and with changes or falls, ensure proper footwear when OOB (out of bed), call bell in reach, provide adequate lighting, assistive device (wheelchair) within reach, bowel and bladder x 1 week, dycem (non-slip mat), orthostatic BP (blood pressure when standing) x 3 days, labs as ordered:UA (urine analysis). There is no evidence that R #100's care plan was updated with new interventions after the falls on 06/19/17 and 07/08/17. E. Record review of R #100's Medical Record revealed fall risk assessments were not completed after the falls on 06/19/17, 09/08/17, and 09/11/17. Further review of the record, did not show evidence that R #100 was put on a bowel and bladder program for one week after her fall on 09/08/17. F. Record review of the Neurological Evaluation Flow Sheet dated 06/19/17, revealed it was incomplete. There were no responses for, eyes open, best verbal response, best motor response, pupil size, reflexes, or extremity movement. Further review revealed neurological checks were not initiated for the fall on 09/08/17. G. Record review of the Nursing Progress Notes revealed the facility had one documented IDT (interdisciplinary team) meeting for one (06/19/17) out of 4 falls. The note stated, Resident fell [DATE] at 5:00 am in the restroom. Plan is to educate the resident to use the call light to call for assistance. Maintenance will also procure appropriate-size wheelchair for the resident. There is no other documentation showing an IDT meeting was done after the falls on 07/08/17, 09/08/17, and 09/11/17. H. On 09/14/17 at 2:19 pm, during interview with the Regional Quality Manager (RQM), she stated the facility identified issues with falls during their mock survey in late April, and stated they were concerned by the number of falls and with the number of falls with injury. The RQM stated that the IDT comes together to look at the incidents and talk about it the next day to put new interventions in place. She stated that depending on the root cause of the fall, they will put appropriate interventions in place, for example if they fell in the bathroom, they will look at a possible toileting schedule. She stated that for the residents that continue to fall, they are looking to lesson the injuries by adding more activities, a low bed or a fall mat. The RQM stated that the facility also has weekly IDT meetings and will discuss interventions again to see if the interventions are working. She stated that they are also looking at the root cause of why the resident is falling. The RQM stated that they should be reporting any fall with injury with outside attention, a fall with a significant injury and unwitnessed falls that were sent out to the ER. She stated that R #100's fall on 09/11/17, should have been reported to the State, because she was sent to the ER. The RQM confirmed that fall risk assessments should be done after falls. The RQM also stated that after her fall on 09/08/17, the intervention was to put her on a bowel and bladder program for a week to try to anticipate her toileting needs. I. On 09/14/17 at 2:22 pm, during interview with the Assistant Director of Nursing (ADON), stated that if residents have an unwitnessed fall they always implement neurochecks and stated that it is up to the nurses and CNAs to fill out the form. The ADON stated that fall risk assessments are done at the time of admission or readmission, quarterly, change in condition, or after a fall. The ADON confirmed that fall risk assessments were not completed after R #100's falls on 06/19/17, 09/08/17, and 09/11/17. The ADON stated that the IDT team will discuss falls from the day before. She stated that after R #100's fall on 06/19/17 the plan was to educate resident on using the call light and to get her a new wheelchair. The ADON could not remember if R #100 received a new wheelchair. The ADON confirmed that neuro checks were not done for R #100's unwitnessed fall on 06/19/17. The ADON also stated that R #100 was put on a bowel and bladder program for a week after she fell trying to go to the bathroom on 09/08/17. The ADON verified that this was not done, she stated that it was communicated with the CNAs but there was not a form to document on. The ADON also confirmed neuro checks were not completed for the unwitnessed fall on 09/08/17. On 09/15/17 at 10:54 am, during interview, the ADON stated that she reported R #100's fall on 09/11/17. She stated the initial report was sent to the state agency on 09/14/17 and the 5 day investigation was sent to the state agency on 09/15/17. The ADON stated that the initial report was late, but the five day was on time. J. On 09/15/17 at 10:59 am, during interview with the Director of Nursing (DON), he stated that they try to look at the details of the falls and determine what the resident was doing at the time so they can better understand how to fix it. The DON stated that R #100's falls are sporadic and they don't understand the reasoning behind her falls. He stated that R #100 is able to make some of her needs known, but that she is not a reliable historian. The DON stated that they added a dycem mat to her wheelchair and most recently interventions was to do orthostaic blood pressure checks. The DON stated that the care plan should be updated after each fall with new interventions and confirmed that the care plan was not updated after the fall on 07/08/17. The DON also that R #100's bowel and bladder program was initiated on 09/14/17, confirming it was not after her fall on 09/08/17. The DON also confirmed that the IDT did not have a meeting to discuss the fall on 07/08/17 due to personnel. The DON stated that staff are not following R #100's care plan. Findings for R #64: K. Record review of R #64's Face sheet, revealed admitted [DATE], with a [DIAGNOSES REDACTED]. L. Record review of the Fall Risk (MDS) data set [DATE], indicated R #64 was at high risk for falls with a score of 9, mild-moderately cognitively impaired, transfers with minimum assist, and incontinent daily. On 08/23/17 and 09/04/17, scored a 9 indicating high fall risk. M. Record review of the Resident Incident Reports revealed the following: 1. On 08/23/17, R #64 had an unwitnessed fall in the dining room. Injury: abrasion. States Writer was paged to dining room. Upon assessment, rsd was laying on right side next to window. Rsd told CNA that he was trying to stand up and he fell . Rsd was assessed for injuries. Rsd has a scrape to the mid section on right side of back. Rsd denies pain to the site. There is also a scrape to right hand on pinky side. Rsd assisted to w/c x2 assist. Abrasion to right mid section of back an abrasion to right hand on pinky side. Cleansed and not dressed. Actions taken: assess, vs (vital signs), wound care, appropriate calls and notify appropriate individuals. 2. On 08/20/17, R #64 had an unwitnessed fall in room. No injury. States resident was trying to transfer self, from his bed to wheel chair, slipped and sat on the floor mate (sic) by his bedside. Assessed, no visible injury noted. Resident alert and verbally responsive. No change in level of consciousness. Resident denied pain or discomfort at this time. Actions taken: assess for injury and vital signs taken. 3. On 08/12/17, R #64 had an unwitnessed fall in room. No injury. States was in next door room when CNA advised me rsd was on floor. Arrived to room to find rsd sitting on fall pad with his back to bed, stating he slid when he was trying to get out of bed. Denied any urinary urgency. Voiced no complaints, no pain upon palpitation of c/t/l (cervical, thoracic, lumbar) spine and pelvic girdle. No pain to hips upon palpation. Denied dizziness and chest pain. Assisted rsd to wc and obtained v/s. initiated neurochecks; per (doctor) continue with neurochecks (no transport indic). 4. On 08/03/17, R # 64 had an unwitnessed fall in room. No injury. states Resident observed lying on lateral side of body between w/c and bed. Resident states he tried to stand up to get in bed when w/c moved back and he slipped to floor. Resident denies pain and denies hitting his head. No apparent injuries noted ROM WNL (within normal limits). Neuro checks started per facility protocol. Resident assisted from floor to w/c by 2 person assist. 5. On 06/25/17, R #64 had an unwitnessed fall in room. Injury: fall with head injury, laceration. States Resident went to the restroom without calling for help, as was standing, he fell backward. Resident alert and verbally responsive. Had occipital (back of head) swelling, laceration with bleeding. Area cleaned, 4 x 4 and kerlex (bandage) applied. Patient transported to (hospital) for evaluation per MD's order. N. Record review of R #64's Care Plan dated 01/05/17, revealed risk for injury r/t falls AEB: self transferring without assistance, attempting to ambulate without assistance, unsteady gait, non compliant with safety devices, with additional risk r/t dementia, DM (diabetes mellitus), difficulty in walking. Fall: 08/23/17 at 11:15 am dining room trying to stand but fell , scrap to R hand, abrasion to R middle side of back. Fall 8/20/17, from bed w/out assist to wc no injuries. Interventions: rule out medical complication with increased falls, notify MD and family of falls or injuries PRN, periodic medication review, ensure safe environment, free of clutter, adequate lighting, clean spills promptly, high low bed, bed to be placed against wall, transfer with extensive x 1 person, bed changed to a bed with no wheels, dycem to w/c, anit-brakes (sic) to wheel chair, floor mats on floor when resident is in bed, fall assessment on admission, quarterly and with changes or falls, ensure appropriate footwear when OOB (out of bed), call bell in reach, provide adequate lighting, PT eval/tx (evaluate/treat) as indicated, pt eval for fall, PCP (primary care physician) visit. Review of the care plan does not show evidence of updated interventions for falls on 08/03/17 and 08/12/17. O. Record review of the Nurses Notes dated 06/28/17, stated June 26, 2017 IDT Meeting: Resident had a fall 6.25.17 while in the restroom. Intervention: Resident re-education on using the call light and waiting for assistance when using the restroom. On 06/30/17, ADDENDUM to note dated for 6/26/17 IDT: Resident to be toileted as least 2 hours as needed. P. Record review of R #64's Medical Record, revealed neurological assessment dated [DATE] was initiated but not complete. The neurological assessment for the fall on 08/13/17, was a continued from 08/12/17, but is is still incomplete. A neurological assessment for the fall on 08/20/17 was initiated, but not complete. There were no responses for, eyes open, best verbal response, best motor response, pupil size, reflexes, or extremity movement. Fall on 08/23/17, a neurological assessment was not initiated. Further review of the record, showed fall risk assessments were not completed after each fall. Q. On 09/15/17 at 11:19 am, during interview with the DON, he stated that R #64 would not be reliable if asked what happened after a fall. He stated that R #64 requires extensive assistance of one person physical assist and that he can stand, but he can't walk. The DON stated that R #64 can not be educated regarding safety measure, because he will not retain the education. The DON confirmed that R #64's care plan was not updated with new interventions after each fall. He verified that neuro checks should be done for all unwitnessed falls and confirmed that they were not done on 08/20/17 and 08/12. The DON also confirmed that fall risks were not done for all R #64's falls and they should have been. The DON stated that the care plan is not being followed or updated by staff. Findings for R #82: R. Record review of R #82's Face Sheet revealed admitted [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. S. Record review of Resident Incident Report revealed R #82 had two falls; 1. On 08/24/17, unwitnessed fall in resident's room, no injury. States, was called to room, found res sitting beside bed on his buttocks. Actions taken: assessed for injuries, when none were found he was assisted up with 2 person and a gait belt. He back (sic) to bed. Review of the Post incident actions, stated resident was moved closer to nurses station. 2. On 09/08/17, unwitnessed fall in resident room, no injury. States 19:25 (7:25 pm) CNA reported that rsd was on the floor. This nurse and (RN) went to assess rsd for injuries. Rsd was found to be lying beside bed on his back on the floor. Rsd was wearing his helmet when the fall took place. Rsd stated I was gonna sit down but the bed moved in Navajo. The bed was not in it's original place. It could be easily moved. Dysum pads were placed at the bottom corners of the bed to prevent it from slipping. Rsd did not have any obvious open areas, redness, or bruising to his back. Actions taken: assessment of injuries and prevention of further falls. Rsd was instructed to use call light if he needs help. Review of the post-incident actions, stated dysum pads were placed at the floor of the bed to prevent movement of bed. T. Record review of R #82's Medical Record revealed neurological assessment on 09/08/17 was initiated,but not complete.There were no responses for, eyes open, best verbal response, best motor response, pupil size, reflexes, or extremity movement. No neurological assessment was found for unwitnessed fall on 08/24/17. Further review, did not show R #82 had fall risk assessments completed after both falls. U. Review of Resident #82's Care Plan dated 12/28/16, revealed At risk for injury r/t falls AEB: Hx falls, attempting to self transfer, non-compliant with safety measures with additional risk r/t Demetia, CAD, HTN; shuffling gait and blindness to left eye, 8/24/17 fall in room, dycem pad to wheelchair, room change to B28a for safety. Interventions: Rule out medical complication with increased falls, notify md and family of falls or injuries PRN, periodic medication review, ensure safe environment, free of clutter, adequate lighting, clean spills promptly, transfer with assist of extensive one person, educate for safe transfers with use of call light, low bed, toilet before and after meals as needed, helmet to be used for safety, fall assessment on admission quarterly and with changes or falls, ensure appropriate footwear when oob, call bell in reach, provide adequate lighting, assistive device wheelchair within reach, pt eval.tx as indicated. V. On 09/14/17 at 3:12 pm, during interview with the ADON, she stated that R #82 is extensive assist with one person physical assist for transfers. The ADON stated that R #82 does not use the call light and he is not able to be educated on safety measures, due to his Dementia. The ADON stated that one of his interventions is to have a fall mat at his bed side when he is in bed. The ADON confirmed that neuro checks were initiated for fall on 09/08/17 but were not complete and there were none for 08/24/17. The ADON also confirmed that fall risk assessments were not completed after his falls. W. On 09/14/17 at 10:20 am, during interview with the DON, he stated that they have a high acuity in the facility. The DON confirmed residents are falling because they are not being toileted as they should be and that residents get tired of waiting to be put to bed and that it happens at shift change and during meals. X. On 09/15/17 at 11:45 am, during interview with the DON, he stated that R #82 was moved closer to the nurses station because his wife was getting physically aggressive with him. The DON confirmed staff was not following the plan of care for R #82. Y. Record review of the Incident & Accident Process Policy dated 10/15, indicated The facility Administrator will ensure incidents are reported to the appropriate Stage agency in compliance with the State reporting criteria. Incident and accidents, including incidents of unknown origin are investigated by the IDT and reported according to regulatory guidelines. Assessments and investigations are done in a systemic manner: identify hazards and risks; evaluating and analysing hazards and risks implementing interventions to reduce hazards and risks; and monitoring for effectiveness and modifying interventions when necessary. The IDT will review risks, appropriate interventions and trends at least weekly for those residents with falls and other accident related injuries, and the care plan is to be updated as interventions are implemented. Z. Record review of the Fall Assessment/Intervention Process (not dated), revealed All residents on any admission, re-admission, and at least quarterly will be assessed for fall risk and appropriate interventions inititated immediately to reduce the risk of injuries with falls. Process: at the time of a fall the nurse will first evaluate and care for the resident then: Initiate Neurological Evaluation Flow Record for falls with head injury and unwitnessed falls, Daily QA (Quality Assessment) Meeting: The QA committee (IDT) will review and discuss any fall in the morning meeting for input of the IDT team, weekly: the incident log is used for traking, trending and discussion in the weekly falls meeting, the resident's fall injury plan of care will be updated as appropriate, and Fall/incident investigation tool must accompany any fall. The IDT/designee will review and ensure implementation of any recommendations.

§483.25 Quality of care. Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: This REQUIREMENT is Not Met as evidenced by: Based on record review and interview, the facility failed to provide the necessary care and services for residents to attain their highest practicable physical well being, for 4 (R #s 7, 38, 59 and 153) of 4 (R #s 7, 38, 59, and 153) residents reviewed for unnecessary medications, delayed response to symptoms of a urinary tract infection [MEDICAL CONDITION], and pain management. These deficient practices resulted in residents not receiving their scheduled antipsychotic medication [MEDICATION NAME] and [MEDICAL CONDITION] antibiotic medication, hospitalization from an untreated UTI, and causing residents to experience unrelieved pain, which has the potential to result in residents not achieving their highest level of well-being and quality of life. The findings are: Findings related to R #38: A. Record review of the Physician order [REDACTED]. B. Record review of R #38's Medication Administration Record (MAR) for July 2017, revealed there were 5 (five) consecutive days of missed doses of [MEDICATION NAME] from 07/03/17 to 07/07/17. Review of the Nurse's Medication Notes on the back of the MAR, indicated [MEDICATION NAME] was not administered because the medication was not available. C. On 09/13/17 at 3:24 pm, during interview with the Director of Nursing (DON), he stated that R #38 is on a low dose of [MEDICATION NAME]. The DON confirmed R #38 was not administered 4 doses of [MEDICATION NAME], on 07/04/17, 07/05/17, 07/06/17, and 07/07/17. The DON stated that R #38 received medication on 07/03/17 (the MAR shows 07/03/17 dose is circled, indicating resident didn't receive the medication with a note by the nurse stating medication was not available). The DON stated that the reason was because the facility only had 25 mg tablets available and because it's already a small pill they had to wait for pharmacy to deliver pre cut tablets to the facility. The DON also stated that they didn't have a pill cutter available to cut such a small pill in half. D. Record review of the Medication Administration Policy dated 12/12, revealed Medications are administered in accordance with written orders of the prescriber. If breaking tablets is necessary to administer the proper dose the following guidelines are followed: the administration of partial tablets is clearly identified or highlighted on the residents' MAR and a tablet splitter may be used. Findings for R #7 E. Record review of the nursing progress notes dated 06/13/17, indicated that R (resident) #7 had complaints of lower abdomen pain. The CNA (certified nursing assistant) indicated that R #7 had foul smelling urine and that R #7 stated that, I had blood in my urine this afternoon and also stated, you guys already got my urine and i (sic) never got the results back, so i don't know what hap5`pened (sic). Dr. was notified and new orders to: obtain clean catch urine and send to (Name of Hospital) Lab for UA and C&S (urinalysis, culture and sensitivity); start Bactrim (antibiotic) 1 tablet by mouth every 12 hours x10 days; and obtain UA before starting Bactrim. F. Record review of the Laboratory Monitoring Sheet dated 06/13/17 indicated that a lab was ordered for a clean catch urine and a UA C&S, obtain now. This order was DC (discontinued) on 06/15/17. Both RN (registered nurse) #2 and RN #3 confirmed that this order was DC/d before the UA and C&S were done. There was no documentation that indicated that UA was ever attempted for R #7 before it was discontinued by the physician. G. Record review of the nurse's note dated 06/22/17 indicated that the physician ordered a U/A and if unable to void in hat (used for the collection of urine), do a straight catheter and send to lab. H. Record review of the nurses's note dated 06/22/17, revealed that a straight catheter for urine was unsuccessful, resident cooperated. I. Record review of the nurses note dated 06/22/17 revealed? resident refused dinner stated he needed to use the toilet. Resident had watery stools x1. J. Record review of the nurse's note dated 06/23/17, indicated that day shift was advised that resident had loose stools and very little UO (urine output). The nurse's note also indicated that? R #7 was straight cathed in AM on 06/22/17 but no urine was obtained. CNA (certified nursing assistant) changed brief after midnight, it was slightly wet. K. Record review of the nurse's note dated 06/23/17, indicated that R #7 had 10/10 pain and a Tylenol was given. Resident had no urine output. Visible abdominal distention with pain upon palpation. Resident drinking fluids, not eating and refusing meds. Altered mental status, loose stools x 4 on 06/22/17. Attempted to collect urine via straight catheter with no urine output. Dr. notified. Orders to send resident to (Local Hospital) emergency room (ER) for evaluation of no urine output with distention. L. Record review of the nurse's note dated 06/23/17 indicated resident transported to (Local Hospital) ER via facility van accompanied by staff. M. Record review of the nursing progress note dated 06/25/17, indicated that staff spoke with (Local Hospital) nurse. Rsd (resident) being treated for [REDACTED]. Urine is purulent (containing pus), currently receiving ABX (antibiotic) therapy. Discharge not anticipated for at least several days. N. On 09/14/17 at 2:01 pm, during an interview with DON (Director of Nursing), he stated that if you can't do a clean catch for urine which is the least invasive, then if the physician had ordered it, you would do a straight catheter to obtain urine. If you did a straight catheter and did not get any urine then this would indicate that there is something wrong and it would be an emergency. The resident would need to go the hospital. O. On 09/15/17 at 8:34 am, during an interview with Regional Quality Manager, she stated that after looking at the notes, yes there was a lag in the treatment. From the time they attempted to obtain urine through straight catheter, and did not get any urine at that time, to the time that R #7 was sent out the next day, there was a lag in treatment. She also stated that she did not see any documentation of attempts to try to get urine when the physician order [REDACTED]. The order was DC'd without getting urine on 06/15/17. Findings related to R #59: P. Record review of R #59's physician order [REDACTED]. Q. Record review of R #59's physician order [REDACTED]. R. Record review of R #59's Medication Administration Record for June 2017 and July 2017 revealed R #59 missed 5 doses of rifapentine on the following days: 06/11/17, 06/18/17, 06/25/17, 07/15/17 and 07/22/17. S. Record review of R #59's Medication Administration Record for June 2017 revealed R #59 missed 1 dose of [MEDICATION NAME] on 06/14/17. T. On 09/13/17 at 2:38 pm, during an interview with the DON, he stated that he spoke with his Certified Medication Aides (CMAs) today about the missed doses of rifapentine and [MEDICATION NAME] for R #59 and stated that the CMAs were not able to locate the medication in the medication cart resulting in all the missed doses. The DON stated he checked the pharmacy invoices to see when they received the medications and verified that the medication was available and stocked in the carts at the time of all missed doses. Findings related to R #153: U. Record review of R #153's medical record revealed the following: 1. Record review of R #153's medical record, revealed the following: Record review of the Admission Notes dated 08/30/17, indicated the following Diagnoses: [REDACTED]. Resident receives [MEDICAL TREATMENT] treatments three (3) times a week: Tuesday, Thursday and Saturday at 3:45 am. 2. Record review of the admission orders [REDACTED]. Noted a side note that indicates, [MEDICATION NAME] script needs to be changed to - [MEDICATION NAME] 2 mg - take 1/2 tablet (1 mg) before daily dressing change. 3. Record review of the Medication Administration Record (MAR) for September 2017, revealed the following medications that were transcribed: [MEDICATION NAME] 10 mg/[MEDICATION NAME] (APAP) 325 mg 1 tablet q 4 hour pain, [MEDICATION NAME] ([MEDICATION NAME]) 1 mg po 30 min prior to drsng (dressing) change prn and [MEDICATION NAME] -[MEDICATION NAME] 5/325 mg give 1 tab po q 6 hours prn pain. [MEDICATION NAME] q 72 hours and the [MEDICATION NAME] 10 mg/[MEDICATION NAME] 325 mg 1 tablet po with [MEDICAL TREATMENT] (three times per week) were not transcribed on the MAR, therefore R #153 did not receive either the [MEDICATION NAME] q 3 days nor the [MEDICATION NAME]/[MEDICATION NAME] three times a week - prior to going to [MEDICAL TREATMENT]. 4. Record review of the physician orders [REDACTED]. V. On 09/15/17 at 11:30 am, during interview, R #153 stated that he was not receiving his pain medications. He said that he had a patch (the [MEDICATION NAME]) on his left arm that had been there since his hospitalization from the local hospital (he was discharged on [DATE]). He stated that the nursing home staff removed the patch the other day on September 9, 2017 (10 days after he was discharged from the hospital). He said there was an order for [REDACTED]. W. On 09/15/17 at 2:30 pm, during interview, Registered Nurse (RN) #1 confirmed that the [MEDICATION NAME] and the [MEDICATION NAME]/[MEDICATION NAME] were not transcribed onto R #153's MAR and that would indicate that R #153 never received his pain medications at the facility. X. Record review of the PRN Flowsheet for [MEDICATION NAME] and Other Medications dated for the month of September 2017, indicates R #153's pain level on a scale between 1 to 10, and 10 being severe pain, R #153's pain was indicated between 7 to 9 on the scale. Y. Record review of the 24 Chart Check, located on the front of the medical chart, indicated there were 6 days (09/01/17, 09/02/17, 09/03/17, 09/06/17, 09/10/17 and 09/11/17) when a nurse did not initial the 24 hour chart check, indicating he/she had reviewed the orders. Z. On 09/15/17 at 3:15 pm, during interview, the Regional Quality Manager (RQM)) confirmed that the 24 hour chart check indicated that the nurse that signs or initials the document, indicates that the physician orders [REDACTED]. The RQM was asked if there was a corresponding policy and procedure for transcribing physician orders, she stated there was not.

Based on observation, record review and interview, the facility failed to care for residents in a manner that maintains or enhances each residents' dignity for 4 (R #10, 27, 36 and 80) of 4 (R #10, 27, 36 and 80) residents reviewed during random observation by: 1. Not providing incontinence care for R #27 for 7 hours after she urinated on herself. 2. Not covering a Foley catheter bag (flexible tube passed through the urethra and into the bladder to drain urine) while R #36 is on the unit. 3. Not providing dining assistance in the dining room for R #10 and 80. This deficient practice could likely result in the reasonable person to experience feelings of embarrassment, humiliation, shame and depression. The findings are: Findings for R #27 A. On 08/24/16 at 10:08 am, during observation, R #59's Family Member walked down the hall and stated She's (R #27) peeing on the floor. R #27 was seated in her wheelchair in front of the nurse's station. She is wearing khaki pants, a flowered shirt and tennis shoes and a stream of liquid was observed dripping from the rear of her wheelchair onto the floor. B. On 08/24/16 at 10:10 am during observation, the Administrator walked down the hall, observed the puddle of liquid on the floor and stated We got a spill. He moved R #27's wheelchair away from the puddle and requested help. Laundry Services (LS #1) was seen removing a mop from the soiled linen room, mopping up the urine and placing the mop back in the soiled linen room. LS #1 was then waving a wet floor sign over the recently mopped area to dry it. The Administrator and LS #1 did not make any attempts to identify the source of the puddle. C. On 08/24/16 at 10:17 am, during interview with R #59's Family Member, he stated My mother-in-law has been here for 2 years and I know when that happens to her I would want her to be changed right away. I don't think they took that lady to change her yet. D. On 08/24/16 at 12:15 pm during observation, R #27 is still wearing the same khaki pants while she was self-propelling her wheelchair down the hallway. Dampness on her pants cannot be observed from her seated position in the wheelchair. E. On 08/24/16 at 12:53 pm, during observation, R #27 is seated in dining room at her assigned table and is still wearing the same khaki pants. R #27 smells of urine. F. On 08/24/16 at 12:58 pm, during interview with LS #1, she stated I just work laundry, but I help out when I can. They said it was urine. So I just got a mop to clean it up as quickly as I could. When asked if she knew what the spill was, she said Urine. It was yellow. G. On 08/24/16 at 3:17 pm, during interview with Registered Nurse (RN) #2, she stated, I heard someone say this morning that the lady (R #27) was peeing on the floor as I was walking down Hall D; I didn't see who it was he (R #59's Family Member) was talking about. If someone peed on the floor we would have housekeeping clean it up and then the CNA would change the resident. She further stated They (staff) change them (residents) and toilet them before breakfast, after breakfast, before and after lunch and dinner and then again before bed. If they have an accident they would change them right away. H. On 08/24/16 at 3:31 pm, during observation, R #27 is self-propelling down the hall still wearing the same khaki pants. I. On 08/24/16 at 4:22 pm during observation, R #27 is self-propelling in the hallway still wearing the same khaki pants. J. On 08/24/16 at 4:24:35 pm, during interview with Certified Nurse Aide (CNA) #6, she stated, We check and change them (the residents) every hour. When asked about R #27 she stated, She toilets on her own. She never has accidents. I asked her is she needed to use the restroom and she said no. She does wear briefs in case she has an accident, if she did (have an accident) the CNA would change her right away. She has not had any accidents today, I would know, I'm the CNA on this hall (R #27's hall) today. She's wearing briefs today, but I haven't helped her to the bathroom today. When asked about the level of assistance R #27 needs with toileting she stated, She can do it herself. K. On 08/24/16 at 4:34 pm, during observation, Housekeeping Services (HS) #2 pushed R #27 in her wheelchair to her room because she (R #27) stated she needed to use the bathroom. R #27 was still wearing the same khaki pants. L. On 08/24/16 at 4:34 pm, during interview with HS #2, she stated I will get her (R #27) to her room then find someone to help her to the toilet. M. On 08/24/16 at 4:39 pm, during observation, R # 27 came out of her room wearing black pants after being taken to her room to use the bathroom. N. On 08/24/16 at 4:48 pm, during observation, CNA #6 exited R # 27's room with the khaki pants R #27 had been wearing since this morning in a plastic bag and deposited them in the soiled linen room. O. On 08/24/16 4:51 pm, during interview with CNA #6, she stated, I had to change (name of R #27) she was wet. She was trying to make it to the restroom but she said someone told her they were closed, and she wet her pants so I changed them. I think she does have memory issues, but I'm not sure. We check them every couple hours; I came on at 6 this morning, I didn't take her to the bathroom at all today. Her pants weren't really wet just damp. When asked how she would know which residents need assistance with toileting she stated the previous shift will tell me who needs to be taken to the restroom and who doesn't, I just look at them and know if they need help going to the bathroom or not. When asked if there was any documentation which would provide information about what care the residents need she stated Yeah in the charts, but I haven't looked at them. P. Record review of care plan dated 09/16/10 for R #27 revealed that R #27 has impaired cognition related to dementia and Alzheimer's, R #27 is an extensive assist with toileting requiring a one person physical assist, and R #27 is at risk for impaired skin integrity as evidenced by incontinence of bowel and bladder and fragile skin. Q. Record review of Minimum Data Set ((MDS) dated [DATE] for R #27 revealed resident is an extensive assist with toileting (resident involved in activity, staff provide weight-bearing support) with one person physical assist. Findings for R #36 R. Record review of the Physician order [REDACTED].#36 indicated to please supply patient with leg bag for his foley catheter drainage while out of bed. S. Record review of alteration in elimination care plan dated 03/07/16 for R #36 stated dignity cover for Foley drainage bag. T. On 08/23/16 at 7:54 am, during observation in dining room [ROOM NUMBER], R #36's foley catheter drainage bag was visible and uncovered and the tube was lying on the floor during breakfast service. U. On 08/23/16 at 8:36 am, during observation, R #36 foley catheter bag was visible and uncovered and the tube was under his foot as he was trying to ambulate out of dining room [ROOM NUMBER]. V. On 08/23/16 at 5:46 pm, during observation in dining room [ROOM NUMBER], R #36's foley catheter drainage bag was visible and uncovered and the tube was lying on the floor during dinner service. Findings for R #80 W. Record Review of Nutrition care plan for R #80 dated 06/28/16 revealed setup, cue, assist as needed with meal consumption. X. On 08/23/16 at 8:14 am during observation in dining room [ROOM NUMBER], R #80 was sitting in her wheelchair with a tray table in front of her. R #80 pushed her tray under the main table spilling her drink, eggs and toast on herself, the tray table and the floor. Y. On 08/23/16 at 8:27 am, R #80 was observed to be picking the food up off the floor. CNA #5 walked by R #80 without seeing that she was struggling to pick the food up off the floor. At 08/23/16 at 8:30 am, CNA #5 walked by again without offering assistance. At 08/23/16 at 8:32 am, Regional Quality Manager walked by and did not alert staff as to the mess on the floor. At 08/23/16 at 8:34 am, CNA #5 walked by again without offering assistance. Findings for R #10 Z. On 08/22/16 at 6:14 pm and throughout the dinner meal service, R #10 was observed seated in a reclining wheelchair angled away from the dining table. The back of the seat was declined at 20 degrees. R #10 was trying to feed herself, dropping food off the fork and eventually switching to grabbing food with her hands. The dishes on the table were an arm's length away from the resident. Staff were observed in the dining room throughout the meal service and no staff attempted to assist R #10.

This is a repeat deficiency from the annual survey completed on 06/13/14. During resident room observations, the facility failed to ensure that the hot water in resident bathrooms were kept at a safe temperature of less than 120 degrees Fahrenheit. This deficient practice resulted in an Immediate Jeopardy (IJ) at a scope and severity L, being identified at the facility on 08/03/15 at 5:26 pm. The facility Administrator, Director of Nursing (DON), and Social Services Director were notified at this time. On 08/03/15 at 7:41 pm, the Administrator delivered a plan of removal, at this time the Administrator was informed the plan of removal would not be accepted. On 08/05/15 at 8:48 am, the Administrator delivered a second plan of removal, which was accepted. Based on the plan of removal, interventions included: 1. (Name of plumbing and heating company) were called immediately and told facility to drain the water heater tank. Plumbing company are in route to the facility. 2. The Maintenance Director brought down the over-all temperature to 110 degrees prior to draining the tank. 3. The tank was drained immediately. 4. Nurse Management assigned to halls to assure compliance. 5. Maintenance Director and Facility Management personnel to monitor temperatures in 4 rooms on each hall every 30 minutes until temperatures are in regulatory compliance. 6. All temperature probes calibrated and 4 members of the Management personnel were given a temperature log. Staff was in-serviced on how to obtain a proper water temperature, 7. Temperatures will be checked on a daily basis during department head rounds to ensure temperatures are within regulatory guidelines. Information will be added to the daily department head rounds sheet. Sheet will be turned into the Administrator for review. Any temperature that triggers over 110 degrees will be addressed immediately by the Maintenance Director. Temperatures will be tested daily for 2 weeks. If stable, then temperatures will be obtained on a weekly basis per regulatory guidelines. Temperatures will be addressed with monthly QA (Quality Assurance) and plan adjusted accordingly. 8. (Name of plumbing and heating company) will evaluate system and work with facility staff to develop a plan to ensure water heating system is functioning properly. 9. Hand sanitizer will be utilized for hand hygiene. Soap and cool water may be used to wash hands as long as friction is applied for approx. 15 seconds. Personal hygiene wipes will be used for general hygiene purposes. If water systems are down an emergency supply is on hand and secondary resources are available. Based on the plan of removal the IJ was lifted on 08/05/15 at 8:48 am. This resulted in the scope and severity being reduced from a scope and severity of L to level 2, scope and severity F. Based on observation, interview and record review, the facility failed to ensure hot water temperatures were maintained and kept at a safe temperature of less than 120 degrees Fahrenheit (F) to prevent injuries. This deficient practice has the potential to affect all 94 residents identified on the Resident Census List provided by the Administrator on 08/03/15 who receive showers and/or use the bathroom facilities. If hot water temperatures are not maintained residents with dementia and/or numbness of the extremities are likely to experience thermal burns while using restroom sinks or bathing facilities. The findings are: A. On 08/03/15 at 3:24 pm, during observation in R #57's room the hot water in the bathroom sink was 127 degrees Fahrenheit. B. On 08/03/15 during observation on Hall B the following was observed: 1. Room 24 at 3:37 pm, the hot water in the bathroom sink was 125.1 degrees F. 2. Room 77 at 3:40 pm, the hot water in the bathroom sink was 125.3 degrees F. 3. Room 77 at 3:55 pm, the hot water in the bathroom sink was 121 degrees F. 4. Room 25 at 4:25 pm, the hot water in the bathroom sink was 122 degrees F.G. C. On 08/03/15 during observation on Hall C the following was observed: 1. Room 47 at 4:02 pm the hot water in the bathroom sink was 129.4 degrees F. Room 47 is located at the end of Hall C. 2. Room 48 at 4:03 pm, the hot water in the bathroom sink was 117.2 degrees F. Room 48 is located at the end of Hall C. D. Record review of the facility Maintenance Logbook documentation indicated that from February 2015 through May 2015 water temperatures in resident rooms and throughout the facility ranged anywhere from 120 degrees F to 137 degrees F. E. Record review of facility maintenance Logbook Documentation revealed 2. Ensure patient room water temperatures are between 105 degrees and 115 degrees Fahrenheit (or as specified by state requirements). New Mexico-100 degrees to 110 degrees. F. On 08/03/15 at 4:08 pm, during observation of the maintenance closet, one of the hot water heater's had the temperature control set at 128 degrees F. The pipe thermometer just above the hot water heater was reading 128 degrees F. The second hot water heater's temperature control was set at 140 degrees F. The thermometer just above that was reading 140 degrees F. G. On 08/03/15 at 3:59 pm, during interview the Maintenance Supervisor stated, I monitor the hot water temps (temperatures) in the facility. I remember getting temperatures above 120 on several units. The Maintenance Supervisor confirmed that he had made the Administrator aware of the hot water temperatures. The Maintenance Supervisor stated I called a contractor because they installed the new water heaters in February, because the old boiler went bad. Heaters were installed for the kitchen, laundry and one for the hallways (where resident rooms are located). Somewhere along the line the heater for the kitchen is getting mixed up with the hallways, so the kitchen complains the water is too cold. A lot of my plumbing pipes are old and need to be replaced. I started emailing the corporate person (name of plant consultant) and I was told This is too much money and I was told I would have to pay for the repairs out of my own pocket. I called contractors and got a couple of estimates and he (name of plant consultant) told me it was too much money and to get someone who would bid below $1,000. My assistant was cranking up the temp for washing and sanitizing in the kitchen. The water temps are checked every week. The Maintenance Supervisor confirmed the hot water gauges were set at 128 degrees for the halls and 140 degrees for the kitchen. H. On 08/03/15 at 4:57 pm, during interview Certified Nursing Assistant (CNA) #1, stated CNA #1 stated, When I give showers, I have to take my gloves off because the water gets too hot. I have to keep checking and adjusting the temperature. I. On 08/04/15 at 1:25 pm, during interview the Maintenance Supervisor stated, I have my plumber here now and he found the pipes are criss crossing all over. There must be 14 valves up there but it looks like instead of doing the job right, they just cut the pipe and by-passed it with another pipe. It's hard to tell which pipe goes where. J. On 08/04/15 at 4:11 pm, during interview the Maintenance Supervisor stated that he had been talking with the Plant Consultant regarding issues with the hot water since May of last year (2014). The Maintenance Supervisor then stated, the old Administrator knew about this issue (referring to the old pipes) and she said Just go on and do it. It was when I started working with the Plant Consultant that I hit a brick wall. I had sent him (referring to the Plant Consultant) estimates that I had gotten and he rejected all of them.

This is a repeat deficiency from the annual re-certification survey completed on 06/13/14. Based on record review and interview the facility failed to report incidents of injury of unknown origin for 1 (R #75) of 2 (R#s 29 and #75) residents reviewed for reporting incidents to the State Agency (SA). If thorough investigations are not performed when residents experience incidents that are reportable to the SA, (e.g. injuries of unknown source, abuse or neglect), the SA is unable to ensure that residents safety is upheld during and after the investigative process. The findings are: A. Record review of the Incident log dated 05/01/15 thru 07/31/15 indicated an incident on 07/17/15 where R #75 fell and sustained a laceration and was sent the the emergency room for an evaluation. B. Record review of Departmental Notes dated 07/17/15 indicated that R # 75 fell on his left side on his elbow. He had a large laceration that measured 2 cm (centimeter) by 1 cm. C. Record review of the State reportable tracking log for July 2015 had no incidents reported to the SA. D. On 08/07/15 at 8:43 am, during interview with Administrator, he stated that unknown falls and anything that doesn't have a witness should be reported. He stated that if the incidents from 06/07/15 and 07/17/15 had head injury or a laceration and were unwitnessed, then yes they should have been reported. He also stated that the one incident with the laceration should have been reported to the SA.

Based on record review and interview, the facility failed to follow and implement the comprehensive care plan for 1 (R #1) of 1 (R #1) resident who was experiencing pain, facial grimacing, moaning, and who also sustained shoulder dislocation. The facility further failed to ensure that a pain assessment and pain medication was administered as was indicated on the care plan. By not implementing the care plan, this deficient practice has the potential to impact residents who experience pain and are at risk for pain. The findings are: A. Review of the Medical Record for Resident #1 revealed the following: 1. Face Sheet no dated indicated [DIAGNOSES REDACTED]. 2. admission orders [REDACTED]. 3. Physician Recapitulation Orders dated July 2014 and August 2014 also indicated orders for [MEDICATION NAME] 650 mg q 4 hours prn for pain. 4. Departmental Notes dated 08/09/14 indicated, "At 4:00 pm, Certified Nursing Assistant (CNA) notified nurse that rsd (resident) complained of pain to the right arm upon movement ...Rsd did grimace of pain when the CNA ask (sic) in Navajo language, "'Grandma where is the arm pain you were complaining about?"' Rsd replied it hurts but did not state location. Departmental notes dated 08/10/14 at (5:08 pm) indicated CNA transferred resident to chair and noticed resident grimacing and unable to move right arm as usual. Grimacing and moaning during PROM (passive range of motion). Resident states it hurts, inspected shoulder and noticeable difference to right shoulder in comparison to left, and right appears to be larger than left shoulder. 5. Further review of the Departmental Notes revealed that no documentation of pain medication was administered to Resident #1 on 08/09/14 when complaining of pain, or that the physician or family of Resident #1 had been notified of the residents pain on 08/09/14. 6. A PRN (as needed) Medication Administration Record [REDACTED]. 7. Care plan (no date) indicated Resident #1 had a dislocated shoulder to the right side. Interventions are to notify the MD (doctor), family and responsible party of changes ...Care Plan further indicated (Name of Resident #1) has a self-care deficit as evidenced by extensive level of assistance with bed mobility, transfers and additional risks for decline related to dementia. It further indicated Resident #1 is at risk for alteration in comfort related to dislocated right shoulder. Interventions are a pain assessment, identify location and rate of pain prior to and after any interventions, medications as ordered, attempt and document effectiveness of non-pharmacological interventions. 8. Review of a Pain Assessment flow sheet (no date) indicated no pain assessment was completed with Resident #1 complained of pain on August 9, 2014, or on August 10, 2014. B. On 10/07/14 at 10:04 am, during interview the Director of Nursing (DON) stated, "Through best practice with nursing, "It would have been the expectation to follow that care plan for administering the pain meds as ordered, and doing a pain assessment and you are correct that it was not being followed."

Based on observation record review and interviews, the facility failed to properly assess, call the physician and or family, and administer pain medications for 1 (R#1) of 1 (R#1) sampled residents. This failure likely resulted in the resident having pain by facial grimacing, and moaning of the right arm. This incident resulted in a shoulder dislocation. The findings are: A. Review of the Medical Record for Resident #1 revealed the following: 1. Face Sheet no dated indicated [DIAGNOSES REDACTED]. 2. admission orders [REDACTED]. 3. Physician Recapitulation Orders dated July 2014 and August 2014 also indicated orders for [MEDICATION NAME] 650 mg q4 hours prn for pain. 4. Departmental Notes dated 08/09/14 indicated, "At 4:00 pm, Certified Nursing Assistant (CNA) notified nurse that rsd (resident) complained of pain to the right arm upon movement ...Rsd did grimace of pain when the CNA ask (sic) in Navajo language,"' Grandma where is the arm pain you were complaining about?"' Rsd replied it hurts but did not state location. Departmental notes dated 08/10/14 at (5:08 pm) indicated CNA transferred resident to chair and noticed resident grimacing and unable to move right arm as usual. Grimacing and moaning during PROM (passive range of motion). Resident states it hurts, inspected shoulder and noticeable difference to right shoulder in comparison to left, and right appears to be larger than left shoulder. 5. Further review of the Departmental Notes revealed that no documentation of pain medication was administered to Resident #1 on 08/09/14 when complaining of pain, or that the physician or family of Resident #1 had been notified of the residents pain on 08/09/14. 6. A PRN (as needed) Medication Administration Record [REDACTED]. 7. Care plan (no date) indicated Resident #1 had a dislocated shoulder to the right side. Interventions are to notify the MD, family and responsible party of changes ...Care Plan further indicated (Name of Resident #1) has a self-care deficit as evidenced by extensive level of assistance with bed mobility, transfers and additional risks for decline related to dementia. It further indicated Resident #1 is at risk for alteration in comfort related to dislocated right shoulder. Interventions are a pain assessment, identify location and rate of pain prior to and after any interventions, medications as ordered, attempt and document effectiveness of non-pharmacological interventions. 8. Review of a Pain Assessment flow sheet (no dated) indicated no pain assessment was completed with Resident #1 complained of pain on August 9, 2014, or on August 10, 2014. 9. A physician telephone order dated 08/10/14 indicated to send Resident #1 to the ER (emergency room ) for eval (evaluation) of right shoulder due to increased pain and decreased ROM (range of motion). (This was one day after Resident #1 began complaining of pain on 08/09/14. 10. Situation, Background, Assessment, Request (SBAR) document dated 08/10/14 (no time) indicated Resident #1 was unable to do ROM (range of motion) to the right shoulder and pain had increased by movement ...Pain level/location was grimacing and moaning to right shoulder. " 11. An emergency room Progress Note dated 08/11/14 indicated that Resident #1 was brought to the emergency room (on 08/10/14) with a chief complaint of decreased right shoulder range of motion ...Resident #1 was found to have a shoulder dislocation. 12. An Intensive care unit progress note dated 08/11/14 indicated that Resident #1 arrived to the emergency room (on 08/10/14) with a [DIAGNOSES REDACTED]. Further review of the Progress note indicated that Resident #1 experienced [MEDICAL CONDITION] (a rapid heartbeat) in the emergency room post (after) the shoulder reduction. 13. Radiology Report dated 08/10/14 indicated, "At the right shoulder, anterior (near the front)-inferior (lower) dislocation (an injury to a joint) of the glenohumeral joint (the shoulder joint)." B. Review of the facility's Pain Assessment and Management Policy and Procedure revised October 2010 indicated, "Conduct a ...pain assessment ...whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain ...Assess the resident 's pain and consequences of pain at least each shift for acute pain or significant changes in levels of pain..." C. On 10/06/14 at 11:20 am, during interview Licensed Practical Nurse (LPN) #1 stated, that she was working on 08/09/14 (the date of the incident) on the A/D hall day shift and (name of CNA #1) had approached her (LPN #1) saying that (name of Resident #1) was complaining of pain. LPN #1 further stated, "I asked where she (Resident #1) was complaining of pain and she said in Navajo, 'My arm is hurting' but she (the resident) did not specify the location of the pain. This was around 5pm. So, I did a PROM (passive range of motion) to the right arm and after I put her arm on the pillow, she (Resident #1) was complaining of pain. It was my first day working with her on the floor. After that, I got pulled over to another hall to help another resident on another hall. I told (name of CNA #1) if there is more increased pain when doing transfers, please let me know." When LPN #1 was asked if she notified anyone, LPN #1 stated, "I don't remember if I did notify anybody. I don't believe so." When LPN #1 was asked if she notified the physician, LPN #1 stated, "I would notify the Dr. if there were a change and she (referring to Resident #1) were not able to do her Activities of Daily Living (ADLs), and the POA would be notified. The Dr. should have been called because the resident complained of increased pain to the arm." LPN #1 stated, "I have no reason why the Dr. was not notified and he should have been." CNA #1 was also assisting other residents with trays and it was at the shift change, so everything compiled all at once. When LPN #1 was asked if any pain medication was administered to Resident #1 when she was complaining of pain, she stated, "No, it was my error. I was pulled on another hall. I'm the only one that can dispense medication for pain and I knew she was having pain by the facial grimaces she made. If a resident is in pain I would have checked her MARS to see if she had any scheduled pain meds and I would have checked the PRN med to see if she had any type of pain med that was given by the previous shift." When LPN #1 was asked if this occurred, she stated, "No. I did not give her (Resident #1) any pain medication. I just reported it to the next nurse that Resident #1 was complaining of pain to the right shoulder and I was unable to give her any pain meds at that time." D. On 10/06/14 at 11:45 am, during interview Certified Medication Aide (CMA) #1 stated, that on Sunday August 9th, 2014, it was around 4:30 pm when CNA #1 asked me to help transfer (name of Resident #1) from her bed to the chair. When we did that, she (Resident #1) was grimacing like she was in pain. We asked her (the resident) what was wrong, she didn't say much, but we noticed her right arm was hanging and clinging to her body. We asked her to lift her arm and she could barely flex her elbow. I felt her shoulder and it was kind of swollen." It was when we put her into her geri chair that we noticed the facial grimacing. We asked her what was wrong, but she didn't say anything. We asked her if her arm was hurting and she (the resident) said 'Yes.'" E. On 10/06/14 at 12:22 pm, during interview, LPN #2 stated that on 08/10/14 she recalled a CNA (don 't remember who) told her that Resident #1 'Didn't look right.' She stated, "From what I recall, when I did my assessment, she (name of Resident #1) did grimace like she was in pain when I completed PROM on her." F. On 10/06/14 at 2:55 pm, CNA #2 stated, "It was on the 10th (referring to August 10) closer to dinner time and you could see that she (Resident #1) was in pain. She was saying 'Ohh and Owe. We (other staff) asked her if she was in pain and she was saying yes." G. On 10/06/14 at 3:45 pm, during interview, CNA #1 stated, "Before dinner on 08/09/14, I was getting her (Resident #1) up and I noticed she wasn't moving her arm. It was just limp. I asked her in Navajo if she was ok and she was mumbling. When I was getting her up from her bed that is when she was saying 'Awe ya'. She was also saying 'Ouch.' Me and the med tech transferred her to her chair and she was moaning more and saying 'Ouch. I could tell something was wrong because she was moaning, and when we moved her arm at the shoulder area, she was saying 'Ouch'" H. On 10/06/14 at 4:55 pm, during interview regarding if Resident #1 received any pain medication on 08/09/14, the Assistant Director of Nursing (ADON) stated, "I don't see anything in the medical record as far as medication being administered for her (Resident #1) for the 9th of August 2014. For the 10 (2014), I don't see anything in the notes either that she (the resident) was given anything for the pain. I don't see anything in the notes as far as if any pain medication was given or administered. I don't see anything documented as being given. I mean I don't have any idea of what was given, or if anything was given to her. I would have thought they (staff) would have given her (the resident) some pain medication despite the fact. It would have been an expectation to treat someone's pain and it would have been my expectation." I. On 10/07/14 at 10:04 am, during interview the Director of Nursing (DON) stated that the nurses are responsible for giving prn meds and a pain assessment is expected to be done. Through my investigation, I did find issues with not giving the medication when she (Resident #1) had pain, or doing the pain assessment. Through best practice with nursing, if there is pain, it should be handled with either non pharmacological intervention and the staff have to do an assessment to see what type of intervention they will do." J. On 10/07/14 at 4:55 pm, during interview the Administrator stated, "We blew it regarding her (Resident #1) pain and regardless, the nurse should not have left and she should have addressed the residents pain and it wasn't. It should have been taken care of. "

Based on record review and interview, the facility failed to utilize trained staff and provide appropriate procedures to prevent a pressure ulcers in one (#129) out of six (#s8, 44, 110, 111, 126 and 129) residents reviewed for pressure ulcers. This deficient practice negatively impacted the resident through impaired skin integrity, which likely caused her pain and increased risk of infection. The findings are: A. A review of [DIAGNOSES REDACTED].#129's closed medical record did not find any [DIAGNOSES REDACTED]. B. A review of the history and physical document for Resident #129, dated 02/17/14 showed that the resident presented [MEDICAL CONDITION](stroke), right-sided weakness, and [MEDICAL CONDITION] (inability to speak). The skin section of the document notes "No rashes or abrasions noted." C. A review of Resident #129's medical orders dated 02/24/14 noted "Stage II sacral decub (pressure ulcer). 1.1 x 0.8 cm (centimeter), peri (perineal) area, a bit excoriated, had 2x watery diarrhea stools, skin (illeg) clean with wound cleaner, applied duoderm." Signed by RN #2 and an LPN (signature illegible). Unsigned by physician. D. A review of Resident # 129's treatment records for February 2014 and March 2014 shows the prescribed treatment as completed on 02/26/14. No other record of treatment was found. E. A review of Resident #129's care plan found that the skin integrity form was placed into the chart, but without any patient-specific information having been completed. The form therefore read: 1. "Problem: Impaired Skin Integrity AEB (as evidenced by): (blank) with additional risks R/T (blank). Risk for impaired skin integrity R/T (blank). " 2. "Goal & Target Date: Skin will remain intact. Area to (blank) will decrease in size by (blank) cm (centimeters) weekly x30 days. Free from additional skin breakdown/ irritation x90 days. Area to (blank) will be free from infection x 90 days." 3. Approaches included: "Weekly skin checks. Skin assessment quarterly and PRN (as needed). Nurse will document daily on any aspects of wound healing including but not limited to positioning, nutrition and hydration, pain, dressing integrity and labwork. Weekly wound monitoring. Pain meds prior to treatment." F. A review of the Wound Assessment Reports dated 02/24/14 for Resident #129 found that one assessment of the wound had been made. It notes: "Wound Location: Sacrum. Wound Type: Pressure Ulcer. Assessment Occasion: New Wound. Stage 2, sanguineous scant drainage, length 1.1cm, width .8cm, depth (blank), 100% [MEDICATION NAME] tissue, well-defined border, indurated. Physician notified. Responsible party notified." Date wound resolved is noted as 03/05/14. All remaining Wound Assessment Reports for this resident referred to her gastrostomy surgical wound. G. A review of Interdisciplinary Team notes for Resident #129 found the following entries: 1. A nurse's note dated 02/19/14 at 11:56 pm includes the following notations: "Resident is a new admit with a [DIAGNOSES REDACTED]. Skin was intact....Right sided weakness... No complaints of pain or discomfort noted...." 2. A dietary note dated 02/21/14 notes "... Resident has no skin issues to report at this time..." 3. A nurse's note dated 02/26/14 at 4:22 am noting: "New wound care orders: Stage II sacral decub, 1.1x0.8cm clean with wound cleaser apply duoderm (dressing)." 4. A dietary note dated 02/27/2014 notes: "5 days review. Resident continues on an NPO (nothing by mouth) diet and is receiving tube feeding. Current weight is 132.8 lbs and has a weight loss of 2.6 lbs since admission of 135.4 lbs. Resident receives [MEDICATION NAME] bolus (tube feeding). Resident now has a stage II sacral decub and treatment order is in place. Continue to monitor weight." 5. A nurse's note written 03/01/2014 at 2:25pm included the notation: "... Barrier ointment to buttocks. No open area." H. Facility Policy & Procedure related to Skin System document reviewed. Policy includes the statements: "With regard to federal regulations for LTC and F314: 1. Residents who enter the facility without a pressure sore will not develop a pressure sore unless the individual's clinical condition demonstrates that it was unavoidable. 2. A resident having a pressure sore receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing." Listed procedures include: "A Braden risk assessment will be completed on admission, weekly for four weeks and then on a quarterly basis." "The skin committee.... will meet at least weekly to discuss changes, complex wounds, or problems related to the skin, for each resident currently being treated for [REDACTED]. "The skin management nurse will then assume oversight of the care and use documentation along with reporting to keep the CN and UM apprised of the condition." "A weekly skin assessment will be completed by a licensed nurse and kept as part of the medical record. Skin conditions will be updated weekly." "The Unavoidable Pressure Sore form will be used to determine when and if the pressure sore was indeed unavoidable as required in the Federal Regulations." I. A review of the Skin Inspection Reports for Resident #129 found that it is solely a listing of assessments, with determinations of "intact" or "not intact" and indicated the following: 1. On 02/19/14 "intact" 2. On 03/22/14 "intact." 3. On 02/26/14 "not intact - existing." 4. On 03/04/14 "not intact - existing." 5. On 03/11/14 No assessment was shown . 6. On 03/18/14 "not intact - existing." 7. On 03/25/14 "not intact - existing." J. On 06/12/14 at 2:25 pm, during an interview with RN #3, a wound care nurse, stated she was responsible for some ot the documentation of Resident # 129's skin, but had no recall of this resident or her wounds. She also stated that wound care nurses document on skin issues daily. She was shown Resident # 129's closed paper chart, and she also accessed the resident's computer record. She was unable to locate any documentation of pressure ulcer assessment and treatment other than the initial appraisal on 02/24/14 and documentation of a dressing change on 02/26/14.

Based on observation, record review and interviews, the facility failed to ensure one (#1) of one (#1) residents who was identified as being at risk for falls, received adequate supervision and assistance to prevent an accident in which the resident was being transferred from the bed to a wheelchair with only a one person transfer instead of the required two person transfer. The facility also failed to properly assess the resident's injuries when he was complaining of pain two days later, had discomfort to the right lower extremity, and swelling was noted from the knee down. This deficient practice likely caused the resident to sustain a right prox (proximal) (near the center of the body) Fib (fibula) (calf bone) and Distal (away from the center of the body) Tib (tibia) (also known as the shinbone) Fx (fracture). The findings are: A. Review of a Department of Health Incident Report dated 06/03/14, indicated on 06/02/14 when Resident #1 was working with Physical Therapy, the Physical Therapist informed the nurse that resident (referring to Resident #1) had some redness to the RLE (right lower extremity)...Resident had some redness, warm to touch, edema (swelling) and pain upon movement...Resident was diagnosed with [REDACTED]. The incident report further indicated that the resident (Resident #1) did have an incident that occurred on 05/29/14 where he (Resident #1) was lowered to the floor, after a failed transfer from bed to wheelchair. B. Review of the Facility Investigation Summary (no date) indicated, "On 05/29/14 resident (referring to Resident #1) was lowered to the ground by Certified Nursing Assistant (CNA) due to "losing control of resident" during transfer."' C. On 06/11/14 at 12:55 pm, observation of Resident #1 revealed the resident to be seated in a wheelchair. Resident #1 was also observed to have the right lower leg wrapped in a white cast from the knee down to the foot. At this time, the resident was not able to communicate or make his needs known. D. On 06/11/14 at 1:30 pm, observation of Resident #1 revealed a staff member wheeling the resident down the hall in his wheelchair. The resident was not able to self propel himself in the wheelchair. E. Review of the medical record for Resident #1 revealed the following: 1. Face Sheet (no date) indicated [DIAGNOSES REDACTED]. 2. Quarterly Minimum Data Set ((MDS) dated [DATE], indicated Resident #1 requires extensive assistance from staff for Activities of Daily Living (ADLs) as well as requiring two person physical assistance for transferring. The MDS further indicated that Resident #1 was not steady with balance when moving from surface to surface and also had an impairment on one side of the body on both the upper and lower extremities. 3. Care Plan (no date) indicated that Resident #1 is at risk for injury r/t (related to) falls AEB (as evidenced by) decrease mobility and seizures, CVA (Cerebrovascular accident-also known as a stroke) with right hemiparesis and Dementia. 4. Departmental Notes dated 05/29/14 indicated, "CNA was transferring pt. (patient) from his bed to his w/c (wheelchair) and the w/c moved back...Patient was lowered to the floor...Patient was visibly shaken by the incident and began to cry...CNA was instructed to call for help when transferring residents when she needs help, and to take her time to transfer residents for both their and her safety." 5. Departmental Notes dated 05/31/14 indicated, "Resident c/o (complained of) pain and discomfort to RLE. Swelling noted to area from knee down to feet." The Departmental Notes indicated that only Tylenol was administered. (There was no documentation in the Medication Administration Record (MAR) indicating that Tylenol was administered, and no documentation on the Pain Assessment indicating the resident having pain). 6. Departmental Notes dated 06/03/14 (six days after the incident on 05/29/14) indicated, "Therapist (referring to the Physical Therapist) reported that resident (Resident #1) had some redness to right LE (lower extremity) on assessment. Resident (referring to Resident #1) had some redness to RLE, warm to touch, edema and pain when assessed." 7. Review of the Emergency Department Record dated 06/03/14 (six days after the incident occurred) indicated, "Patient with R (right) prox (proximal) (near the center of the body) Fib (fibula) (calf bone) and Distal (away from the center of the body) Tib (tibia) (also known as the shinbone) Fx (fracture). F. On 06/11/14 at 2:15 pm, during interview the Director of Nursing (DON) stated, that "When this incident occurred (referring to the incident of being lowered to the floor by CNA on 05/29/14), she (the CNA) was the only CNA working with him (Resident #1) at the time. He (referring to Resident #1) was emotionally upset when the incident occurred. Then on June 3rd, the PT (physical therapist) noted redness, swelling, and was warm to the touch. When the X-rays came back, he (Resident #1) had a lower extremity fracture." G. On 06/11/14 at 3:20 pm, during interview, the DON stated, "I do see where the Quarterly MDS indicated that he (Resident #1) was a two person transfer. The CNA (who was involved in the incident on 05/29/14) was brand new and she really didn't understand how to use the (accu) nurse headset (a computerized device that staff CNA's use to determine a residents ADLs). She was unfamiliar with using it. The nurses notes (dated 05/29/14) indicated that the wheelchair moved back, but the incident report indicated she (the CNA) lost control of the resident. She (the CNA) had gone through all the proper training and she (the CNA) would have known that (at the time this incident occurred on 05/29/14) he (Resident #1) was supposed to be a two person transfer instead of a one person transfer." H. On 06/11/14 at 4:25 pm, during interview the Physical Therapist stated, "As I was starting to work with him (Resident #1) on June 3rd, (six days after the incident that occurred on 05/29/2014) he (Resident #1) was having a lot of pain on the right lower side and it was really red, swollen and warm to the touch. By the look of his facial expressions, I could tell he (Resident #1) was hurting. He could not tell me what happened. Based on my evaluation, he was a two person transfer and he needed a lot of help with transfers. He was not able to bear any weight on that leg." I. On 06/11/14 at 4:45 pm, during interview Licensed Practical Nurse (LPN) #4 stated, "I was working the floor that day (referring to 06/03/2014) and the first thing I noticed was his right leg was swollen and was very red to the touch. He (Resident #1) was grimacing. He was supposed to be a two person transfer due to his weight. He is very heavy and needed a lot of help."

Based on record review and interviews, the facility failed to ensure the physician was immediately notified of an incident that occurred in which 1 (R #1) of 1 (R #1) resident fell , was having pain, and sustained a re-dislocation of the left hip. By not notifying the physician immediately of the fall, the physician wasn't able to give orders to send the her out to the emergency room . This deficient practice likely caused the resident to remain in pain until the following day and could have caused further injury. The findings are: A. Record review for resident R #1 revealed the following information: 1. Transfer orders from the discharging hospital dated 07/11/13 indicated, R #1 had [DIAGNOSES REDACTED]. The transfer orders also indicated that the resident had a history of [REDACTED]. 2. Departmental Nursing Notes indicated the following: a. On 07/12/13, "Resident requesting pain medications for (left) hip pain, pain medications not available at this time." b. On 07/16/13, "8:40 pm, resident observed on floor next to her bed...there was a 2 cm (centimeter) x 1 cm abrasion (a scraping away of a portion of skin) noted on her lower back near her coccyx area...resident did complain of slight pain to her left hip...(name of Physician #1) was notified by message and fax...No contact was made by telephone with (name of Physician #1)." c. On 07/17/13, (late entry note at 12:27 pm)..."Resident requested for Tylenol related to (r/t) generalized pain." d. On 07/17/13, (late entry note at 2:10 am)..."Resident requested for Tylenol due to (d/t) feeling sore and having tenderness to left hip." e. On 07/18/13, (late entry note at 6:35 am)..."Resident laying in bed awake. Alert and oriented. Reports...that she would be asking for more pain medication soon..." 3. Care Plan dated 07/15/13 indicated, "Risk for Injury r/t falls as evidenced by unobserved fall on 07/15/13...Notify MD (medical doctor) of falls or injuries..." 4. Therapy Screen (no date) indicated, "Pt. (patient) states she fell out of w/c (wheelchair)...Pt. complained of (c/o) Left (L) hip pain on 07/17/13 early AM. Occupational Therapist (OT) reported c/o of pain to registered nurse (RN)...Pt. was admitted to hospital on [DATE] secondary to re-dislocation of left hip after fall incident." B. Interviews for resident R #1 revealed the following information: 1. On 08/06/13 at 2:30 pm, Certified Nursing Assistant (CNA) #1 stated that after she fell , "She (the resident) said she wanted to go to the bathroom...she looked like she was in pain. It was by the expression on her face, and the way she was moving. By her facial expressions, it looked like she was in a lot of pain...She started saying 'Ouch' like she was in pain. She was moaning. She was asking for pain medication. The moaning she was having seemed to increase. She started to say she was hurting more. This was around 9-10 pm. I did tell the nurse (who was identified as RN #1) that she was wanting more pain medication and was complaining of pain on the side of her hip." 2. On 08/06/13 at 3:50 pm, CNA #2 stated, that another resident was flagging her down the hall saying R #1 was on the floor..."After we picked her (referring to R #1) up off the floor, and took her to the bathroom, she was complaining of pain and was crying...she was having more pain and was saying the pain was on her hip." 3. On 08/06/13 at 6:00 pm, RN #1 stated, "Two CNAs (identified as CNA #1 and CNA #2) came up to me, saying she (referring to R #1) was on the floor...I saw her in a seated position at the foot of her bed and half of her legs were under the bed... she said she wanted to get back in bed...she asked for Tylenol...She was a new resident to me... I never got a hold of the Doctor...I sent a fax over to let them know someone had fallen. I got no response...To me, there was no indication to send her out to the ER." 4. On 08/07/13 at 9:55 am, RN #2 stated, "Apparently the night before on (07/16/13), she (referring to R #1) had fallen and she was having a lot of pain...When the family got there the next morning, the family wanted to take her to the ER to be checked out for the hip pain...When I got to work on the morning of 07/17/13, it was the therapist and the day CNA (referring to CNA #3) that reported to me that the resident was in significant pain...The reports I got from the day CNA and the therapist were that the resident was in pain...She was not able to tell me her level of pain but to me is was at 8/10. I was going by the facial expressions she was showing...I don't remember getting in report from the night nurse that the Doctor was called during the night." 5. On 08/07/13 at 10:50 am, (name of Physician #2) stated, "I was on call the morning of 07/17/13...the family was very concerned when they brought her in to us...There was a big concern I was having and that was that she was apparently found down on the floor the night before...I was told she fell on her rear end...they (the nursing facility staff) picked her up and put her into her chair...The primary Doctor was not notified here at the hospital when this happened...That did not happen...They at (name of the facility) told me they left a message, but did not specifically talk with a Doctor...They just left a message...But even so, that may not get to anybody for a couple of days and I really don't know if a message was left or not. I emphasized to the facility, that we would expect them and actually prefer for them to talk to someone instead of leaving a message...She (referring to R #1) had a previous left [MEDICAL CONDITION] prior to going to the facility, then now a re-dislocation and we were not called when this happened. She was not brought to the ER that night when this happened. Per the patient the very next morning (on 07/17/13) when I saw her, she was in a lot of pain. So, no they did not call us, and I felt that they did not treat her pain adequately and it was the family that had to request her to get pain medications. The patient was in pain when she got here to us. On 07/16/13, there was no indication that the Doctor was notified. I definitely would expect to be notified of anything such as this. With this facility, we were not notified. For a patient with a history of falls, that would be my expectation just as a standard of care to be notified." 6. On 08/07/13 at 11:15 am, the Director of Nursing (DON) stated, "According to the nurses notes, a voice message was left for the Doctor then a fax was also sent to him. It would be the actual nurse of the resident to call the provider on call." The DON indicated that after checking to see if there was a fax or a confirmation verifying it was submitted to the Doctor, on the night of 07/16/13, she could not find any documentation that the physician had been notified. 7. On 08/07/13 at 12:55 pm, Family Member #1 of R #1 stated, "On the morning of 07/17/13, I picked her up around 8:15 am, and she was in pain. I could feel her hip swollen...I had to ask the nurse for the pain medication...She couldn't sit up straight and she was leaning to the right to stay off her left hip...When we got to the ER, x-rays showed her hip was dislocated again...The night nurse did not tell me anything about the Doctor being notified when this happened." 8. On 08/07/13 at 12:00 pm, when Physician #1 was asked if he was notified of the fall R #1 had on the evening of 07/16/13, he stated, "I can't remember...I don't recall seeing a fax regarding her having a fall...On that day, I don't specifically recall being notified." 9. On 08/07/13 at 2:30 pm, RN #1 stated, "That night (07/16/13) I don't recall getting a confirmation of the fax I submitted to the Doctor." C. The Facilities "Change in Resident's Condition or Status" Policy and Procedure revised April 2011, indicated, "The Nurse...will notify the resident's Attending Physician or on-call physician when there has been ...an accident or incident involving the resident...a significant change in the resident's physical/mental condition."

Based on record review and interviews, the facility failed to maintain 1 (R #1) of 1 (R #1) residents highest practicable, physical and mental well being by not managing pain when R #1 fell and sustained a re-dislocation of the left hip. This deficient practice likely caused the resident to remain in pain with no relief. The findings are: A. Record review for resident R #1 revealed the following information: 1. Transfer orders from the discharging hospital dated 07/11/13 indicated, R #1 had [DIAGNOSES REDACTED]. The Transfer orders also indicated pain medication [MEDICATION NAME] 5 mg (milligrams) 1-2 tab (tablets) po (by mouth) q (every) 4 hours prn (as needed) for pain." 2. Physicians Prescription Order dated 07/12/13 indicated that [MEDICATION NAME] 5 mg po q 6 hours for pain was ordered and available for use. 3. Occupational Therapy (OT) evaluation and Plan of Treatment dated 07/15/13 indicated, "Patient Verbalized pain level." 4. The Controlled Drug Record indicated that [MEDICATION NAME] 5 mg tablet was not signed out as being administered to the resident when she was in pain on 07/15/13. 5. Departmental Nursing Notes indicated the following: a. On 07/16/13, "8:40 pm, resident observed on floor next to her bed...there was a 2 cm (centimeter) x1cm abrasion (a scraping away of a portion of skin) noted on her lower back near her coccyx area...resident did complain of slight pain to her left hip." There was no documentation indicating that the [MEDICATION NAME] 5 mg was administered to the resident for the pain to her left hip. b. On 07/17/13, (late entry note 12:27 pm)..."Resident requested for Tylenol related to (r/t) generalized pain." c. On 07/17/13, (late entry note 12:40 pm)..."She wanted Tylenol...She was advised Tylenol was given to her already approximately 10 minutes prior to the incident...Was told she would get more pain medication as needed through the night." There was no documentation indicating that the [MEDICATION NAME] 5 mg was administered to the resident for the pain to her left hip. d. On 07/17/13, (late entry note 2:10 am) ..."Resident requested for Tylenol due to (d/t) feeling sore and having tenderness to left hip." e. On 07/18/13, (late entry note at 6:35 am)..."Resident laying in bed awake. Alert and oriented. Reports...that she would be asking for more pain medication soon..." 6. Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The incident occurred at 8:40 pm on 07/16/13 and the MAR indicated [REDACTED]. The only documentation of the [MEDICATION NAME] 5 mg being administered to the resident for her pain was on the morning of 07/17/13. 7. Occupational Therapy Treatment Encounter Note dated 07/17/13 indicated, "Pt. (patient) worked on upper extremities only due to significant complaints of (c/o) pain in Left (L) hip; Pt. reported falling after trying to stand up...Pt. reported being unable to sleep and in pain all night...Pt's left leg was noted for [MEDICAL CONDITION] (swelling)--not seen previously...Pt's. left hip appeared swollen and pt. was almost unable to bear weight on lower left extremity (LLE)." 8. Therapy Screen (no date) indicated, "Pt. (patient) states she fell out of w/c (wheelchair)...Pt. complained of Left hip pain on 07/17/13 early AM. OT reported c/o of pain to registered nurse (RN)...Pt. was admitted to hospital on [DATE] secondary to re-dislocation of left hip after fall incident." 9. Admission Minimum Data Set ((MDS) dated [DATE] indicated that the resident had a fall history. It further indicated that she could indicate if she was in pain and the frequency of pain...and that she could state that pain made it hard for her to sleep and it limited her daily activities. 10. Pain Assessment/Flow Sheet (no date) indicated no documentation of the pain, intensity, action taken, or rating of the pain the resident was experiencing. 11. Admitting hospital History and Physical dated 07/18/13 indicated, "According to her (the resident), she was leaning over to put her shoes on and she slipped off the bed, and then after that, she had left hip pain. The next day (referring to 07/17/13) she was having pain in the left hip and difficulty walking and bearing weight...She was found to be having a left hip dislocation." B. Interviews for resident R #1 revealed the following information: 1. On 08/06/13 at 2:30 pm, Certified Nursing Assistant (CNA) #1 stated, that after she fell , "She (the resident) said she wanted to go to the bathroom...she looked like she was in pain. It was by the expression on her face, and the way she was moving. By her facial expressions, it looked like she was in a lot of pain...She started saying 'Ouch' like she was in pain. She was moaning. She was asking for pain medication. The moaning she was having seemed to increase. She started to say she was hurting more. This was around 9-10 pm. I did tell the nurse (who was identified as RN #1) that she was wanting more pain medication and was complaining of pain on the side of her hip." 2. On 08/06/13 at 3:50 pm, CNA #2 stated, "After we picked her (referring to R #1) up off the floor, and took her to the bathroom, she was complaining of pain and was crying...she was having more pain and was saying the pain was on her hip." 3. On 08/06/13 at 4:15 pm, the OT stated, "On the morning of 07/17/13, I saw her (referring to R #1) and she seemed like she was in pain...I got her set up at the Omni cycle (a type of exercise equipment) arm bike and she was saying her hip was hurting...I checked her left leg and it was swollen at the ankle...I had not seen this before on her...she was saying 'My hip is hurting'...I told the family member (identified as family member #1) that she is really hurting and we should send her to the emergency room ...We got her out to her car, and as the resident went to transfer, she was now having extreme pain...It was her family that said, 'Oh her hip doesn't look right'...I could tell both by her verbal and facial expression, that it was extremely painful for her...I asked the Director of Nursing (DON) what happened and why hasn't she been sent to the emergency room (ER)...I could see between breakfast and when the family got here, her pain greatly increased." 4. On 08/06/13 at 6:00 pm, (RN) #1 stated, "Two CNAs (identified as CNA #1 and CNA #2) came up to me, saying she (referring to R #1) was on the floor...I saw her in a seated position at the foot of her bed and half of her legs were under the bed... she said she wanted to get back in bed...she asked for Tylenol...To me, there was no indication to send her out to the ER." 5. On 08/07/13 at 8:45 am, the Physical Therapist Director stated, "That morning on 07/17/13, I did see her (referring to R #1) with her family and she was complaining of pain." 6. On 08/07/13 at 9:55 am, RN #2 stated, "Apparently, the night before on (07/16/13), she (referring to R #1) had fallen and she was having a lot of pain...When the family got there the next morning, the family wanted to take her to the ER to be checked out for the hip pain...When I got to work on the morning of 07/17/13, it was the therapist and the day CNA (referring to CNA #3) that reported to me that the resident was in significant pain...The reports I got from the day CNA and the therapist were that the resident was in pain...She was not able to tell me her level of pain but to me is was at 8/10. I was going by the facial expressions she was showing." 7. On 08/07/13 at 10:00 am, CNA #3 stated, "When I came in to work on 07/17/13, (name of R #1) was in pain and said 'I fell yesterday evening...'I could see by the look on her face that she was hurting...She said she was hurting on her hip." 8. On 08/07/13 at 10:50 am, Physician #2 stated, "The family was very concerned when they brought her in to us...There was a big concern I was having and that was that she apparently was found down on the floor the night before (referring to 07/16/13)...I was told she fell on her rear end...they (the nursing facility staff) picked her up and put her into her chair...She (referring to R #1) had a previous left [MEDICAL CONDITION] prior to going to the facility, then now a re-dislocation...Per the patient, the very next morning (on 07/17/13) when I saw her, she was in a lot of pain...The nurse only had given her Tylenol that night. But from knowing her from her past history when she had her fracture and the dislocation, she was receiving [MEDICATION NAME] from her previous surgeries but she was only getting regular Tylenol at the nursing facility, which was not sufficient. So, I felt that they did not treat her pain adequately and it was the family that had to request her to get pain medications. The patient was in pain when she got here to us." 9. On 08/07/13 at 12:55 pm, Family Member #1 of R #1 stated, "On the morning of 07/17/13, I picked her up around 8:15 am, and she was in pain...I could feel her hip swollen...I had to ask the nurse for the pain medication...She couldn't sit up straight and she was leaning to the right to stay off her left hip...When we got to the ER, x-rays showed her hip was dislocated again." 10. On 08/08/13 at 7:55 am, the Director of Nursing (DON) stated, "I would have expected the pain assessment to be filled out whenever someone is having pain regardless if someone is alert, oriented, or confused. As a Nurse, I would be assessing the pain when each neurocheck is done. That would be the standard of practice. Especially someone with a status [REDACTED]. I would have expected to see a pain assessment completed after this incident occurred, but that definitely did not occur." C. The facilities Pain Management Policy and Procedure revised October 2010 indicated..."Staff will assess pain using a...standardized pain assessment instrument appropriate to the resident's cognitive level...Administer pain medications as ordered...document the results of the pain assessment in the resident's medical record."

Based on observation, record review and interviews, the facility failed to ensure 1 (R #1) of 1 newly admitted post-op (after surgery) right hip open reduction internal fixation (ORIF) residents was being transferred appropriately to prevent accidents. This failed practice resulted in R #1 presenting to the emergency room with a complaint of 10/10 pain (on a pain scale of 1 to 10 with 10 being the highest level of pain) and sustaining a spiral fracture (a bone fracture caused by a twisting force), non-displaced (where the bone cracks with the broken pieces still in alignment) identified to the distal (farthest from the center) mid diaphysis (the shaft or middle part of a long bone) of the fibula (small long bone of the lower leg). The findings are: A. A Department of Health Incident Report dated 10/31/12, indicated: "Resident was awakened by CNA (Certified Nursing Assistant) to get up for the day...It was a day she had dialysis...Resident was assisted to the left side edge of bed...Resident informed CNAs of what precautions they need to take when transferring her...When CNAs transferred resident, her right leg twisted. Resident stated she complained in Navajo it hurt...At 10:30 am at Dialysis, she complained of pain and informed the nurse what happened...Sent resident to ER (emergency room )...At 1:30 pm emergency room contacted facility to inform them of a distal fibula fracture." B. A facility Incident Report dated 10/31/12, indicated: "At 1330 (1:30 pm) Fx. (fracture) of right distal fibula. The facility received notification from the dialysis clinic (where the resident was transported to on the morning of 10/31/12) which indicated, "Social worker from dialysis called and stated that resident was crying in pain due to the fact that she was transferred incorrectly this morning. She was dragged across the bed even though she told the staff how to do it. She was then put in the van and started to hurt." 1. An attached written statement from Certified Nursing Assistant (CNA) #1. dated 10/31/12 indicated, "On Oct. 31...around 7:15 am, my co-worker asked me to help transfer the resident (referring to R #1) into the wheelchair....We got a draw sheet and transferred her into the chair. She (referring to resident #1) said be careful with my right leg...every morning she tells us to be careful with her legs." 2. An attached written statement from CNA #2, dated 10/31/12, indicated, "On 10/31/12, I went to (name of resident #1's) room this morning to get her up. We did a two person transfer with a draw sheet and sat her in her wheelchair. At that time she told us to be careful with her leg." 3. An attached Staff interview with Resident document dated 10/31/12, indicated, "Resident stated this morning (10/31/12) she was assisted by one CNA with morning grooming and ADLs (Activities of Daily Living). Then, another CNA came in to help with the transfer. One CNA instructed resident to use her good leg to help with standing. Resident informed CNA that she does not have a good leg...Resident stated...when they turned to transfer her into the wheelchair her leg twisted outward. Resident states she stated in Navajo "It Hurts! It Hurts!"...CNAs did not ask if resident was in pain or if she was ok. At 10:30 am, the resident started to feel the pain and told the nurse...She stated she expressed to the girls to be careful with her legs and they should've listened and understood her." C. Record review, and interviews for R #1 revealed the following: 1. Transfer/Rehab/Nursing Home admission orders [REDACTED]. Additional [DIAGNOSES REDACTED]. 2. Physical Therapy Evaluation dated 10/06/12, indicated, "Difficulty in walking, muscle weakness, joint disorder, and Osteoporosis. LE (lower extremity) ROM (range of motion) is impaired limited secondary to pain and weakness. Pain with movement-Intensity is 4/10; Frequency/Duration=intermittent: location: Right hip...Patient verbalized pain level...Oriented to person, place, and time...Transfers with the use of Maximum Assistance...Pt. (patient) presents with progressed weakness and decreased ability to perform bed mobility and transfer, her ADLs (activities of daily living) limited by pain." 3. History and Physical dated 10/12/12, indicated the resident had a recent right hip open reduction internal fixation surgery. 4. Nursing Admission assessment dated [DATE], indicated, "Transfer ability: Total assistance. Weight bearing-none. Communication-clear speech. Oriented to person, place, and time." 5. Physical Therapy Evaluation dated 10/19/12, indicated "Pt. (patient) referred to PT (physical therapy) due to exacerbation (worsening of signs and symptoms) of decrease in strength, decrease in functional ability, decrease in transfers, reduced ability to safely ambulate...Transfers with the use of Maximum Assistance...Pain and weakness on both lower extremities secondary to history of hip and knee fractures and requires maximum assistance in all functional mobility." 6. Admission Minimum Data Set ((MDS) dated [DATE], indicated the resident has no short or long term memory problems, and is independent for cognitive skills for daily decision making. Functional Status for transferring requires extensive assistance. 7. Nursing Notes dated 10/31/12, indicated, assisted with ADLs. Right leg brace intact. The nursing notes did not indicate how the resident was transferred out of bed in the morning however, the CNA notes dated 10/31/12, indicated, "Resident refused her shower due to pain in legs." 8. emergency room record dated 10/31/12, indicated, "Chief complaint: Right ankle pain with injuries. Pain 10/10. Resident...complaining of pain to right ankle this morning because her legs were dangling in the w/c. Pt. states her right ankle was twisted while changing her clothes today this morning in (name of nursing home). Diagnosis: [REDACTED]. Severity of pain: Severe. Twisted lower leg in transfer at nursing home. Associated symptoms: Swelling, snapping, pain on movement. Pain with dangling off bed." 9. X-ray report dated 10/31/12, indicated, "Clinical Indication: Ankle pain. Trauma. There is a spiral fracture, non-displaced identified to the distal mid diaphysis of the fibula." 10. On 01/22/13 at 11:30 am, during interview, when R #1 was asked what happened to her legs, she stated, "When they (referring to the staff) were getting me up out of bed (referring to the morning of 10/31/12), I was trying to tell them to be very careful with my leg and they just got me up really fast and twisted my leg. They were in a big hurry that morning to get me up. They were really rough with me and it hurt." 11. On 01/22/13 at 3:15 pm, the Director of Nursing (DON) stated, "On 10/31/12, she (R #1) was at dialysis and from what I was told, she was transferred incorrectly here at (name of nursing facility) and she was sent to the emergency room . We were made aware that she had a fracture of the right distal fibula. The hospital had called us. On 10/31/12, she was awakened by the CNA who assisted her with her grooming. Then that CNA went and got another CNA to help transfer her. They used a draw sheet to sit her in her w/c. The social worker at dialysis informed us that due to the pain being so unbearable for the resident, she was sent to the ER where she was diagnosed with [REDACTED]. All I see in the therapy notes is that she was a maximum assist." 12. On 01/22/13 at 5:00 pm, a Physical Therapist #1 stated, "On 10/31/12, the CNA's were transferring her (R #1) with only two people. She was supposed to be at least a three person transfer, and there was only two CNA's who transferred her from the bed to the wheelchair. She ended up twisting her ankle and complaining of severe pain. She had a spiral fracture occur on that ankle. Before that day (referring to 10/31/12) she was still a maximum assistance for all transfers. I recall the doctor ordered that under no circumstances, she can't stand or bear any weight. When the resident came into the facility originally, she had a fracture on the right hip where she just had surgery on and she couldn't support her weight. She was a heavy person and needed three people to transfer her to be safe. On her initial evaluation done on 10/06/12 she was a maximum assist for bed mobility meaning you would need to help the patient roll from side to side. For transferring, she could only tolerate less than 30 seconds for standing because the left leg was too weak too support. Before the fracture (on 10/31/12), I would expect three people to be used to get her up from the bed to her wheelchair to make sure its safe. If there was three people, that would have prevented all of this happening." 13. On 01/23/13 at 8:35 am, during interview, Licensed Practical Nurse (LPN) #1 stated, "What I do remember is that she had a special brace on her leg and she told me in Navajo that the CNA's got her up that morning (on 10/31/12) and were trying to rush and hurry to get her up in the wheelchair as soon as possible and she twisted her ankle. She didn't know it at the time. So we went ahead and sent her to dialysis. All she told me was that they were in a hurry that morning and it was uncomfortable for her. So we sent her to dialysis and at dialysis she had increased pain." 14. On 01/23/13, at 9:19 am, during interview, Licensed Independent Social Worker #1 at the dialysis clinic stated, "When she (R #1) came in to dialysis on the morning of 10/31/12, she was complaining of having pain. I remember she was grimacing and you could tell she was in a tremendous amount of pain. She told me she wanted me to know that she was transferred incorrectly at the nursing home that morning by the CNA's. She said they ignored her when she was trying to tell them to be careful with her leg, and they dragged her foot from the bed to the wheelchair which caused her discomfort. When I saw her, I asked her how much pain she was in on a scale of 1-10 and she told me 10." 15. On 01/23/13 at 9:33 am, during interview, CNA #2 stated, "I was new at that time and from what I recall that morning on 10/31/12, I dressed her (R #1) and then I had to leave the room to go ask for another CNA (who was identified as CNA #1) for help. We used a draw sheet to transfer her. I was told to use two people to transfer her." 16. On 01/23/13 at 11:20 am, during interview, Registered Nurse (RN) #1 stated, "Everyone knew she needed at least a minimum of 3-4 people to get her out of bed. She couldn't bear any weight on her legs and the staff knew that." 17. On 01/25/13 at 10:00 am, during interview, a family member of R #1 stated, "From day one, there have been concerns. She (referring to R #1) had a hip replacement before going to the facility. That was a seven hour surgery. Per the doctors orders, she was supposed to be a 3-4 person transfer. At (name of the nursing facility) they were only doing a 1-2 person transfer with her. She was, and still is, very afraid to be transferred. She started to complain to me that the CNA's were rushing her to get her up. I saw for myself first hand how they were trying to transfer her. I saw the CNA's were not transferring her right. They were transferring her with only a little bed sheet and she is a very heavy lady. Especially with her hip replacement that she just had, she was very fragile, and they were only using a little bed sheet to move her. She needed at least 3-4 people to lift her. It came down to where they were using only two people. The Doctor that did her hip surgery told us her bones are so brittle and she cannot bear any weight on that right side because of her hip surgery."

Based on record review and interview, the facility failed to immediately report, investigate and submit a follow-up investigation in the required time for one (#137) of one (#137) residents who sustained an injury of unknown origin, possibly a fall, resulting in a fracture. The findings are: A. During observation, record review and interview for Resident #137 the following was revealed. 1. On 09/26/11 at 9:30 am, the resident was observed in his wheelchair located in physical therapy. His right arm was in a sling. Further observation revealed that his arm was discolored, blue/purplish from his shoulder area to his elbow. 2. Review of the Nursing Admission assessment dated [DATE] does not indicate any pain, injury or bruising to the resident's right arm or shoulder. 3. Review of Nursing Notes on 09/14/11 indicated resident had a [DIAGNOSES REDACTED]. Nursing notes did not reveal any additional documentation prior to the incident on 09/16/11. At which time the resident's condition was brought to the attention of the Assistant Director of Nursing (ADON) by the Physical Therapy Director (PTD). 4. On 09/27/11 at 3:20 pm, during an interview with the PTD, he stated that on 09/16/11 the resident came to physical therapy that morning and had limited range of motion and complained of pain. Upon examination of the resident's right arm and shoulder he saw it was swollen and tender to touch. Through a Navajo speaking interpreter, the resident explained to him that he had fallen. The PTD further stated he then advised the ADON of his findings and the incident. Telling her that the resident should go to the hospital for evaluation. 5. On 09/27/11 at 5:20 pm, during an interview with the ADON, she stated that on 09/16/11 she was at the nurses station when physical therapy asked her to assess the resident due to the complaint of pain in his arm. She looked at his shoulder and compared it to the other, and saw that it was swollen. Removing his shirt, she noticed facial grimacing. At that point she informed the charge nurse, Licensed Practical Nurse (LPN) #3 to contact the doctor. The charge nurse tried to call the physician three times without success. The ADON stated that she intervened and got in touch with the on-call physician. She was given an order to send the resident to the hospital for evaluation. She then called the daughter. Through a Navajo speaking translator she asked the resident what happened. The resident stated that he had fallen last night. Investigation revealed the fall had been the night prior. 6. On 09/27/11 at 3:00 pm, the Director of Nursing (DON) stated that her internal investigation had revealed that the resident was found on the floor 09/15/11 at approximately 4:00 am. She further stated that the investigation is ongoing. 7. On 09/27/11 at 5:45 pm, during an interview with the facility's administrator, he stated that a report was completed with each incident. Staff were inserviced/trained on when and how to report. An incident should be reported to the State Agency (SA) such as an injury or bruise of unknown origin within 24 hours and followed up in 5 days. He doesn't recall details of the resident and incident referred to above. a. The administrator presented an incident report that, according to the cover sheet, was faxed to the State Agency on 09/20/11 at 10:00 am. The report indicated that the incident occurred on 09/15/11 at 4:00 am. 8. The Identification of Abuse (RM-024) Policy & Procedure, effective 05/2004, indicated: a. Policy: "All staff are to report any signs and symptoms of abuse, neglect, and or theft to their supervisor the DON, or Administrator immediately...Staff are obligated by law to report allegations of resident abuse, neglect, or theft to the Department of Health." b. Procedure: "The following are some examples that abuse or neglect actually occurred, as well as, signs and symptoms...bruises, fractures...of questionable origin..."

Based on observation, record review and interview, the facility failed to accurately assess pressure ulcers for two (#108 and 131) of two (#108 and 131) residents. Resident #108 was admitted with "an open sore" that was not routinely being assessed and treatment orders were not obtained for 16 days following admission. Resident #131 had no pressure ulcer upon admission and developed one that proceeded to worsen. The findings are: A. During record review and interview for Resident #108, the following was revealed: 1. The Face Sheet revealed an admitting [DIAGNOSES REDACTED]. 2. Nursing Admission Assessment, dated 04/18/11, indicated, "Dry open area to left buttocks" There were no measurements or stage assessment of the pressure ulcer. 3. The Facility computer generated admission orders [REDACTED]. There was no documentation indicating a pressure ulcer to the left buttock. 4. Norton Plus Pressure Ulcer Scale, dated 04/18/11, indicated the resident was at Moderate risk for developing pressure ulcers. 5. Nursing Notes revealed the following: a. 04/18/11, open area to left buttocks, CIA (communication Interdisciplinary Action) form to wound nurse to treat and obtain tx (treatment). b. 04/20/11, wound care nurse, CIA for request need for dressing change and no orders for care. c. 04/23/11, no orders for dressing change. Wound to left buttocks with eschar tissue (black), with white edges and red tissue surrounding, tender to touch. Reported to DON (Director of Nursing)...will remind day nurse to obtain treatment orders. d. 04/26/11, CNA (certified nursing assistant) reports resident c/o (complain of) left buttock painful...noted skin breakdown left buttock coccyx (gluteal fold) and right buttock. 6. Weekly Skin Assessments revealed on 04/18/11 open area left buttocks-dry and red wound bed. On 04/22/11 open area to left buttocks with black eschar tissue, white edge and red tissue surrounding, tender to touch. On 06/03/11 one area on left buttocks. 7. Physician Telephone orders revealed no treatment order for the open wound was received until 05/03/11. 8. Treatment Record revealed the treatment was not started on the resident's open wound until 05/03/11 (this was 16 days after the resident was admitted with an open wound). At which time the pressure ulcer was identified as measuring 2.4 cm x 3 cm (centimeters) with 70% yellow slough. 9. Comprehensive Care Plan, dated 04/08/11, indicated the resident was admitted with a decubitus ulcer to the left buttocks measuring 2.7 x 1.2 cm. 10. On 09/22/11 at 1:55 pm, during an interview with Registered Nurse (RN)/Wound Nurse #4 she stated, "They are supposed to give me a CIA form to do an assessment. I don't know what to tell you. I don't know what happened. All I can think of is they didn't tell me. If they don't tell me, then I don't know to go look at him. I was on vacation. I'm thinking when I came back no-one told me about it. I don't remember getting a CIA report form. When someone is admitted , the wound nurse does the assessment and whatever we find we are supposed to call the doctor. You need a doctor's order to put any type of dressing on. They are playing doctor and can't be doing that." She then stated, "I really don't recall how I was informed of the wound on 05/03/11. I see I was the one to call the Doctor to get an order to treat it. Before you do any type of treatment or dressing on a patient you always need to get a doctor's order. That is our standard of practice. From looking at my wound report, it stated he was admitted with a Stage II to the left buttock. Treatment was dated 05/02/11 for [MEDICATION NAME]." She then stated, "We knew he came in with it." She then stated, "I'm thinking maybe we didn't do anything until we got the order." 11. On 09/22/11 at 2:50 pm, during an interview, with the ADON (Assistant Director of Nursing) she stated "I would have been pretty persistent to get ahold of the primary or on call doctor. It would be my expectation of the nurses to call the doctor immediately to get an order upon admission if a patient were admitted to our facility without an order for [REDACTED]. 12. On 09/26/11 at 4:55 pm, during an interview with the DON, she stated, "They were using a standing order. We would have had a standing order." After reviewing the complete chart, the DON then stated, "I went through the chart and couldn't find anything." B. During observation, record review and interview for Resident #131 the following was revealed: 1. On 09/21/11 at 2:15 pm, RN #4 was observed performing wound care. The resident's left heel presented as a pressure ulcer covered by eschar therefore unstageable. 2. Progress Notes, dated 09/09/11, indicated: "Plan of Care" a. Left heel pressure ulcer -stage 2 b. [MEDICATION NAME] cap(sule) oral 500 mg (milligrams) 1 cap(sule) QID (four times daily) #28 c. [MEDICATION NAME] (dressing) applied, advised to change daily. Objective - A physical exam of this patient revealed the following findings : SKIN(2): Left heel with stage 2 pressure ulcer, about 1 inch size round and 1 mm (millimeter) depth covered with dry skin. Minimal discharge on socks with bloody tinged. Left foot mild swelling. [MEDICATION NAME] applied to the wound, change daily. 3. Consult Progress Notes, dated 09/09/11, indicated: Patient has left heel ulcer red/draining need evaluation and treatment ASAP (as soon as possible). Arrangements were made to have patient seen today at clinic. 4. Nursing Admission Assessment, dated 08/22/11, indicated no pressure ulcer. Nothing identified on heels. 5. Nursing Notes, dated 08/22/11 through 09/03/11, have no documentation to indicate pressure ulcer on left heel. On 09/09/11 Nursing notes indicated that a pressure ulcer on the resident's left heel was identified at an outside provider appointment. 6. Monthly Summary, dated September 2011, does not indicate the resident having a pressure ulcer. 7. Nutrition Progress Notes, dated 08/30/11 and 09/07/11, indicated "no new wound to report." 8. Admission Minimum Data Set (MDS), dated [DATE] and the 14 day MDS of 09/01/11 identify the resident at risk for developing pressure ulcers and having no unhealed pressure ulcers. 9. Weekly Skin Assessment, dated 08/27/11, did not have documentation to identify the resident's left heel pressure ulcer. 10. On 09/23/11 at 2:50 pm, during an interview the DON, she stated that she has worked to keep the wound nurse consistent and was planning to have her trained for wound care. She verified the discrepancies in the record regarding the residents pressure ulcer identification and assessment.

Based on observation, record review and interview, the facility failed to accurately assess pressure ulcers for two (#108 and 131) of two (#108 and 131) sampled residents. Resident #108 was admitted with "an open sore" that was not routinely being assessed and treatment orders were not obtained for 16 days following admission. Resident #131 had no pressure ulcer upon admission and developed one that proceeded to worsen. The findings are: A. During record review and interview for Resident #108, the following was revealed: 1. The Face Sheet revealed an admitting [DIAGNOSES REDACTED]. 2. Nursing Admission Assessment, dated 04/18/11, indicated , "Dry open area to left buttocks" There were no measurements or stage assessment of the pressure ulcer. 3. The Facility computer generated admission orders [REDACTED]. There was no documentation indicating a pressure ulcer to the left buttock. 4. Norton Plus Pressure Ulcer Scale, dated 04/18/11, indicated the resident was at moderate risk for developing pressure ulcers. 5. Nursing Notes revealed the following: a. 04/18/11, open area to left buttocks, CIA (communication Interdisciplinary Action) form to wound nurse to treat and obtain tx (treatment). b. 04/20/11, wound care nurse, CIA for request need for dressing change and no orders for care. c. 04/23/11, no orders for dressing change. Wound to left buttocks with eschar tissue (black), with white edges and red tissue surrounding, tender to touch. Reported to DON (Director of Nursing)...will remind day nurse to obtain treatment orders. d. 04/26/11, CNA (certified nursing assistant) reports resident c/o (complain of) left buttock painful...noted skin breakdown left buttock coccyx (gluteal fold) and right buttock. 6. Weekly Skin Assessments revealed the following : a. On 04/18/11 open area left buttocks-dry and red wound bed. b. On 04/22/11 open area to left buttocks with black eschar tissue, white edge and red tissue surrounding, tender to touch. c. On 06/03/11 open area on left buttocks. 7. Physician Telephone orders revealed no treatment order for the open wound was received until 05/03/11. 8. Treatment Record revealed treatment was not started on the resident's open wound until 05/03/11 (this was 16 days after the resident was admitted with an open wound). At which time the pressure ulcer was identified as measuring 2.4 cm x 3 cm (centimeters) with 70% yellow slough. 9. Comprehensive Care Plan, dated 04/08/11, indicated the resident was admitted with a decubitus ulcer to the left buttocks measuring 2.7 x 1.2 cm. 10. On 09/22/11 at 1:55 pm, during an interview with Registered Nurse (RN)/Wound Nurse #4 she stated, "They are supposed to give me a CIA form to do an assessment. I don't know what to tell you. I don't know what happened. All I can think of is they didn't tell me. If they don't tell me, then I don't know to go look at him. I was on vacation. I'm thinking when I came back no-one told me about it. I don't remember getting a CIA report form. When someone is admitted , the wound nurse does the assessment and whatever we find we are supposed to call the doctor. You need a doctor order to put any type of dressing on. They are playing doctor and can't be doing that." She then stated, "I really don't recall how I was informed of the wound on 05/03/11. I see I was the one to call the Doctor to get an order to treat it. Before you do any type of treatment or dressing on a patient you always need to get a doctor order. That is our standard of practice. From looking at my wound report, it stated he was admitted with a Stage II to the left buttock. Treatment was dated 05/02/11 for [MEDICATION NAME]." She then stated, "We knew he came in with it." She then stated, "I'm thinking maybe we didn't do anything until we got the order." 11. On 09/22/11 at 2:50 pm, during an interview, with the ADON (Assistant Director of Nursing) she stated "I would have been pretty persistent to get ahold of the primary or on call doctor . It would be my expectation of the nurses to call the doctor immediately to get an order upon admission if a patient were admitted to our facility without an order for [REDACTED]. 12. On 09/26/11 at 4:55 pm during an interview the DON stated, "They were using a standing order. We would have had a standing order." After reviewing the complete chart, the DON then stated, "I went through the chart and couldn't find anything." B. During observation, record review and interview for Resident #131 the following was revealed: 1. On 09/21/11 at 2:15 pm, RN #4 was observed performing wound care. The resident's left heel presented as a pressure ulcer covered by eschar therefore unstageable. 2. Progress Notes dated 09/09/11, indicated: "Plan of Care" a. Left heel pressure ulcer -stage 2 b. [MEDICATION NAME] cap(sule) oral 500 mg (milligrams) 1 cap(sule) QID (four times daily) #28 c. [MEDICATION NAME] (dressing) applied, advised to change daily. Objective - A physical exam of this patient revealed the following findings : SKIN(2): Left heel with stage 2 pressure ulcer, about 1 inch size round and 1 mm (millimeter) depth covered with dry skin. Minimal discharge on socks with bloody tinged. Left foot mild swelling. [MEDICATION NAME] applied to the wound, change daily. 3. Consult Progress Notes, dated 09/09/11, indicated: Patient has left heel ulcer red/draining need evaluation and treatment ASAP (as soon as possible). Arrangements were made to have patient seen today at clinic. 4. Nursing Admission Assessment, dated 08/22/11, indicated no pressure ulcer. Nothing identified on heels. 5. Nursing Notes, dated 08/22/11 through 09/03/11, have no documentation to indicate pressure ulcer on left heel. On 09/09/11 Nursing notes indicated that a pressure ulcer on the resident's left heel was identified at an outside provider appointment. 6. Monthly Summary, dated September 2011, does not indicate the resident having a pressure ulcer. 7. Nutrition Progress Notes, dated 08/30/11 and 09/07/11 indicated "no new wound to report." 8. Admission Minimum Data Set (MDS), dated [DATE] and the 14 day MDS of 09/01/11 identify the resident at risk for developing pressure ulcers and having no unhealed pressure ulcers. 9. Weekly Skin Assessment, dated 08/27/11, did not have documentation to identify the resident's left heel pressure ulcer. 10. On 09/21/11 at 4:50 pm during an interview the DON stated that she would expect that upon admission the nurse would do a head-to-toe inspection of the resident. CNA's have an opportunity to observe residents each time they change or care for the resident. They should notify the nurse of any redness or wound found upon inspection. The nurses do weekly assessments that identify any pressure ulcers or skin condition. She further stated that she has worked to keep the wound nurse consistent. The wound nurse has never attended wound classes/training. and the facility was planning to have her trained for wound care. She verified the discrepancies in the record regarding the resident's pressure ulcer. She stated that she saw the wound prior to the clinic appointment, at which time she described it as eschar and boggy therefore unstageable. She presented a Comprehensive Plan of Care dated 09/23/11. It indicated the Resident has a pressure sore as evidenced by 09/15/11 stage 4 eschar recent location left heel. Noted 09/01/11 as a stage 2 pressure ulcer. C. Review of the facilities Wound Management Program, policy and procedure, dated 01/2005, indicated the following: 1. PROCEDURE - "physician's orders [REDACTED]." 2. "The facility will assess residents weekly for current skin conditions." a. "The skin assessment will be documented on the Weekly Skin Assessment:" 3. The Weekly Skin Assessment should also be completed whenever a new skin condition is noted.

Based on record review and interview, the facility failed to ensure that one (#139) of 33 sampled residents were free of a significant medication error. Resident #139 was administered Potassium Chloride ER 20 meq (milliequivalent) tablets 4 tablets by mouth daily (for a total of 28 days) without a physician's order. This deficient practice likely caused harm Resident #139. The findings are: A. During record review and interview for Resident #139 the following was revealed: 1. Face sheet, dated [DATE], revealed an admitting [DIAGNOSES REDACTED]. 2. admission orders [REDACTED]. 3. A Physician Clinical note, dated [DATE], indicated, "Low K+ (potassium) diet." 4. A Physician Consultant Progress Note, dated [DATE], indicated "Will need to restrict...K+ intake..." 5. Physician's Telephone Orders, dated [DATE], indicated, "Restrict daily dietary potassium to 80 milliequivalents /24 hours." 6. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"potassium 80 meq po (by mouth)/24 hours to be administered at 08:00 am." Further review of the MAR indicated [REDACTED]. (There was not a physician's order for the potassium medication to ever be given). 7. Physician Recapitulation Orders, dated [DATE]-[DATE] indicated "potassium CL (Chloride) ER 20 meq tablet. Take 4 tablets by mouth daily (80 meq) at 08:00 am. Further review of the orders revealed a hand written and signed note from the residents primary care physician which stated, "Not ordered." 8. The MAR, dated [DATE]-[DATE], revealed "potassium CL ER 20 meq tablet. Take 4 tablets by mouth daily at 8:00 am" was initialed as being administered to the resident from [DATE]-[DATE] (a total of 10 days). 9. Nursing Notes revealed the following: a. [DATE]- c/o (complaining of) not feeling well. Has cough and congestion. b. [DATE]- occasional dry non productive cough...c/o aching/painful legs and armpits. c. [DATE]- resident has been spitting up mucus (green) recently... d. [DATE]- resident still feeling sick, weak and with flu symptoms (nasal congestion, runny nose, body aches...poor appetite). e. [DATE]- c/o sore throat and earache to right ear, cough non productive. f. [DATE]- resident stated he had difficulty breathing...oxygen saturation 87% and pulse of 123..."Code Blue"...resident is not breathing and is pulseless...Instructed CNA's (certified nursing assistant) to start CPR (Cardio [MEDICAL CONDITION] Resuscitation), and chest compressions...Resident unresponsive, no cyanosis noted...continued CPR for 13 minutes...resident was in code status upon arrival to emergency room and expired...resident did not come out of code..." 10. On [DATE] at 11:45 am, during interview with the Administrator and the Director of Nursing (DON), both had indicated there would not be a incident report regarding this significant medication error that occurred because it was put into the share computer drive during this time. 11. On [DATE] at 2:22 pm, during interview, the DON stated that from reviewing the resident's record, "I see the admission orders [REDACTED]. I'm seeing what your seeing. I do see that they misread the physician order and it was a transcription error." The DON further stated, "I read the telephone order dated [DATE] to restrict the daily dietary, potassium to 80 milliequivalent's in 24 hours." She further stated, "Some things you may see if a patient was receiving too much potassium would be cardiac [MEDICAL CONDITION] because a high or low level of potassium deals with the heart and rhythms. There should have been further monitoring going on here. There should have been an incident report filled out." 12. On [DATE] at 4:45 pm during interview with the resident's Internal Medicine primary care physician, he stated, "The patient had seen a Nephrologist in May who wrote a physician order to only limit the potassium dietary intake. But the order was misinterpreted at the nursing home in order to actually "administer" the medication potassium." The physician stated, "The bottom line is that my concerns were, could it have been a contributing factor in his death." The physician then stated, "I think the nephrologist was referring only to dietary when talking about the potassium." 13. On [DATE] at 1:55 pm during interview with the resident's Nephrologist Physician, he stated "He (referring to the resident) was never ordered to have Potassium. What I specifically ordered was to have the diet restricted in Potassium. That is all. That is a standard thing. I'm not sure why or how it was interpreted as it was at the nursing home. The order was only to restrict the potassium dietary intake. What I found out later was that they started giving him the potassium as a supplement. It certainly could have contributed to his death. What I would worry about is him getting too much potassium in his system that is why you would want to restrict the potassium intake. You want to restrict the potassium to at least ,[DATE] meq a day. That is why I requested that in my order." The physician then stated, "I just want to emphasize he was never ordered to get any supplements in potassium chloride. I don't even know where that order came from. In a nut shell, it could have contributed to his demise. You would expect to see muscle weakness, [MEDICAL CONDITION], and terminal cardiac arrhythmia." B. Review of the facility Policy and Procedure on Medication Error and Adverse Drug Reaction Reporting, dated ,[DATE], indicated the following: 1. Policy: Medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician...in a timely manner. 2. Guidelines: Medication Error shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, resident... 3. Adverse consequences is an unpleasant symptom or event that is due to or associated with a medication, such as impairment or decline in a resident's mental or physical condition 4. Medication errors and adverse drug reactions are considered significant if they are life threatening and result in death. 5. Procedure: In the event of a significant medication error, immediate action is taken...The prescriber is notified promptly of any significant error...The resident is monitored closely for 24 to 72 hours...the incident is described on the shift change report...