Every finding on record at Skies Healthcare & Rehabilitation Center

Based on record review and interviews, the facility failed to notify the facility provider (Physician's Assistant) and the Director of Nursing (DON) for 1 (R #1) of 1 (R #1) resident with an abnormal urinary analysis (UA; a laboratory test on urine to detect infection) and dark colored urine. If the facility does not notify providers and clinical leadership of abnormal health related findings, residents are at increased risk for deterioration in condition, delayed medical intervention, hospitalization, or additional complications. The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: Sequelae of cerebral infarction (the long-term effects and complications that arise following a stroke, which can significantly impact a person's physical, cognitive, and emotional well-being). Chronic kidney disease. B. Record review of R #1's physician orders, dated 06/17/26, revealed an order for facility staff to complete a urinary analysis with a culture and sensitivity (C and S; a test used to detect urinary tract infections and determine effective antibiotics) test one time due to R #1 experiencing confusion. C. Record review of R #1's nursing progress notes, dated 06/17/26 through 06/18/26, revealed the following: Dated 06/17/26 at 12:15 am, R #1 experienced a change in condition (CIC; any noticeable deviation from a resident's established baseline that could indicate a decline in health, the onset of illness, or a need for adjusted care) related to an altered mental status (any change in a resident's baseline level of awareness, cognition, attention, or behavior that differs from their usual functioning).Dated 06/17/26 at 11:39 am, R #1 experienced an altered mental status that included tiredness, weakness, confusion, and drowsiness. The provider recommended laboratory work (lab work; the collection and analysis of biological samples such as blood, urine, saliva, or tissue in a laboratory setting to assess a person's health status, diagnose conditions, monitor treatments, and detect potential health risks) and UA. Dated 06/18/26 at 1:00 am, a provider encounter note stated R #1 had been feeling off for the past several days. An ammonia level (the amount of ammonia present in the blood, a waste product of protein metabolism that must be processed by the liver to prevent toxicity), UA, and Complete Blood Count (CBC; a blood test measuring levels of red blood cells, white blood cells, hemoglobin, hematocrit, and platelets to assess overall health and detect conditions such as anemia, infection, and blood cancers) were completed on 06/17/26. R #1's ammonia level was normal, with the UA and CBC results pending. D. Record review of R #1's lab results report, dated 06/21/26, revealed R #1's urine was collected on 06/17/26, but it required recollection, and a new physician's order would be needed if UA results were required. R #1's lab report stated Test Not Performed, indicating the UA test could not be completed because the urine sample was not suitable for analysis, and only a urine culture and sensitivity test was completed. E. Record review of R #1's automated UA lab results, dated 06/24/26, revealed R #1's urine was collected on 06/22/26 with the following results: R #1's urine color was amber (abnormal, darker color) with cloudy (non transparent) clarity.R #1's protein was two plus, which can indicate a moderate amount of protein in the urine and suggest possible kidney stress or early kidney issues.R #1's nitrite was positive, which can indicate the presence of bacteria in the urinary tract, suggesting a possible urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra).R #1's bacteria count was many, which can indicate contamination or an active UTI.R #1's UA was flagged, indicating abnormal results. A culture and sensitivity test was not completed with this UA. F. Record review of R #1's electronic health record (EHR), dated 06/24/26 through 06/30/26, revealed documentation was not available indicating facility nursing staff notified a provider after receiving R #1's abnormal UA lab results that were reported to the facility on [DATE]. G. Record review of R #1's nursing progress notes, dated 07/01/26 through 07/02/26, revealed the following: Dated 07/01/26 and signed at 10:42 am, a provider encounter note stated R #1 was found unresponsive by facility staff with oxygen saturations (amount of oxygen in the blood) at 70 percent (normal oxygen saturations are 95 to 100 percent). R #1 was provided oxygen. R #1's recent UA (dated 06/24/26) was abnormal, and the culture and sensitivity test was not completed. During a previous unresponsive episode, R #1 was given one dose of Keflex (an antibiotic) for a suspected UTI. The provider initiated treatment for a suspected UTI and started Keflex for seven days.Dated 07/01/26 at 12:02 pm, R #1 experienced a change in mental status, was very lethargic (sluggish), and not eating. The provider was notified and started R #1 on Keflex. R #1 became unresponsive.Dated 07/02/26 at 5:06 pm, R #1's daughter was made aware of R #1's positive UA. Dated 07/02/26 at 9:00 pm, R #1's daughter requested R #1 be sent to the hospital. R #1 was alert but confused. H. On 07/07/26 at 5:05 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated she collected R #1's UA on 06/22/26 and then worked on a different unit. LPN #1 stated she did not know if she was supposed to notify the provider once R #1's UA lab results were reported to the facility on [DATE], but someone should have. I. On 07/07/26 at 5:28 pm, during an interview, Registered Nurse (RN) #1 stated she helped collect the urine for R #1's UA on 06/22/26 and R #1's urine looked terrible. RN #1 stated R #1's urine on 06/22/26 was dark and maroon (brownish/crimson) colored. RN #1 stated she did not notify the provider of R #1's dark colored urine, or when R #1's UA lab results were reported to the facility on [DATE]. RN #1 stated she thought the provider would be reviewing the UA lab results rather than the nursing staff. J. On 07/08/26 at 1:27 pm, during an interview, RN #2 stated R #1's UA that was collected on 06/22/26 was dark with a strong odor and showed signs of a possible UTI. RN #2 stated when the provider orders a UA with a culture and sensitivity test, she assumes the provider will monitor the resident's EHR for the lab results rather than facility nursing staff. RN #2 stated she would call the provider if they did not review a resident's UA lab result after several days, but she was not in the facility when R #1's UA lab results were reported to the facility on [DATE]. K. On 07/08/26 at 2:16 pm, during an interview, LPN #2 stated if a resident's UA lab results are abnormal, the lab will call the facility, or the provider will already know. LPN #2 stated facility nurses do not notify the provider of abnormal UA lab results. L. On 07/08/26 at 2:32 pm, during an interview, the Physician's Assistant (PA) #1 stated facility nursing staff should notify a provider if a resident has abnormal UA lab results. PA #1 stated she did not know if the facility had a notification process for abnormal UA lab results, but this was her expectation. PA #1 stated she was not notified by facility nursing staff of R #1's abnormal UA lab results reported to the facility on [DATE], or R #1's dark colored urine when nursing staff collected a sample on 06/22/26 and stated she should have been. M. On 07/08/26 at 4:07 pm, during an interview, UM #1 stated R #1's urine was dark in color on 06/17/26 when she assisted with the collection, but she did not know if this was reported to the provider. UM #1 stated nursing staff did not document R #1's abnormal UA lab results that were reported to the facility on [DATE] or whether an attempt was made to notify the provider. UM #1 stated the lab will usually call the facility if a resident's lab results indicate a serious problem, but she expects nursing staff to notify a provider of the lab results right away. N. On 07/08/26 at 5:04 pm, during an interview, the DON stated she was unaware of R #1's dark colored urine on 06/17/26 and 06/22/26, but she would expect facility nursing staff to notify a provider and her of those findings. The DON stated she would expect a provider to be notified of resident's abnormal UA lab results right away and without a multiple day delay.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident, when:Facility staff did not complete a urinary analysis (UA; a laboratory test on urine to detect infection) or a culture and sensitivity (C and S; a test used to detect urinary tract infections and determine effective antibiotics) test as intended and per professional standards.Facility staff did not review and implement the appropriate plan of care for R #1's abnormal UA test results for approximately seven days.If ordered laboratory tests are not completed as intended and staff delay implementing an appropriate plan of care for abnormal health related findings, residents may receive substandard care and treatment, placing them at risk for preventable harm The findings are: A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with the following diagnoses: Sequelae of cerebral infarction (the long-term effects and complications that arise following a stroke, which can significantly impact a person's physical, cognitive, and emotional well-being). Chronic kidney disease. B. Record review of R #1's physician orders, dated 06/17/26, revealed an order for facility staff to complete a urinary analysis with a culture and sensitivity test one time due to R #1 experiencing confusion. C. Record review of R #1's nursing progress notes, dated 06/17/26 through 06/18/26, revealed the following: Dated 06/17/26 at 12:15 am, R #1 experienced a change in condition (CIC; any noticeable deviation from a resident's established baseline that could indicate a decline in health, the onset of illness, or a need for adjusted care) related to an altered mental status (any change in a resident's baseline level of awareness, cognition, attention, or behavior that differs from their usual functioning).Dated 06/17/26 at 11:39 am, R #1 experienced an altered mental status that included tiredness, weakness, confusion, and drowsiness. The provider recommended laboratory work (lab work; the collection and analysis of biological samples such as blood, urine, saliva, or tissue in a laboratory setting to assess a person's health status, diagnose conditions, monitor treatments, and detect potential health risks) and UA. Dated 06/18/26 at 1:00 am, a provider encounter note stated R #1 had been feeling off for the past several days. An ammonia level (the amount of ammonia present in the blood, a waste product of protein metabolism that must be processed by the liver to prevent toxicity), UA, and Complete Blood Count (CBC; a blood test measuring levels of red blood cells, white blood cells, hemoglobin, hematocrit, and platelets to assess overall health and detect conditions such as anemia, infection, and blood cancers) were completed on 06/17/26. R #1's ammonia level was normal, with the UA and CBC results pending. D. Record review of R #1's lab results report, dated 06/21/26, revealed R #1's urine was collected on 06/17/26, but it required recollection, and a new physician's order would be needed if UA results were required. R #1's lab report stated Test Not Performed, indicating the UA test could not be completed because the urine sample was not suitable for analysis, and only a urine culture and sensitivity test was completed. E. Record review of R #1's automated UA lab results, dated 06/24/26, revealed R #1's urine was collected on 06/22/26 with the following results: R #1's urine color was amber (abnormal, darker color) with cloudy (non transparent) clarity.R #1's protein was two plus, which can indicate a moderate amount of protein in the urine and suggest possible kidney stress or early kidney issues.R #1's nitrite was positive, which can indicate the presence of bacteria in the urinary tract, suggesting a possible urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra).R #1's bacteria count was many, which can indicate contamination or an active UTI.R #1's UA was flagged, indicating abnormal results. A culture and sensitivity test was not completed with this UA. F. Record review of R #1's electronic health record (EHR), dated 06/24/26 through 06/30/26, revealed documentation was not available indicating facility staff were aware of R #1's UA results dated 06/24/26, or a culture and sensitivity test was completed for R #1's UA dated 06/24/26. G. Record review of R #1's nursing progress notes, dated 07/01/26 through 07/02/26, revealed the following: Dated 07/01/26 and signed at 10:42 am, a provider encounter note stated R #1 was found unresponsive by facility staff with oxygen saturations (amount of oxygen in the blood) at 70 percent (normal oxygen saturations are 95 to 100 percent). R #1 was provided oxygen. R #1's recent UA (dated 06/24/26) was abnormal, and the culture and sensitivity test was not completed. During a previous unresponsive episode, R #1 was given one dose of Keflex (an antibiotic) for a suspected UTI. The provider initiated treatment for a suspected UTI and started Keflex for seven days.Dated 07/01/26 at 12:02 pm, R #1 experienced a change in mental status, was very lethargic (sluggish), and not eating. The provider was notified and started R #1 on Keflex. R #1 became unresponsive.Dated 07/02/26 at 5:06 pm, R #1's daughter was made aware of R #1's positive UA. Dated 07/02/26 at 9:00 pm, R #1's daughter requested R #1 be sent to the hospital. R #1 was alert but confused. H. On 07/07/26 at 2:20 pm, during an interview, R #1's daughter stated R #1's UTI was left untreated for so long her urine was black. She stated R #1 was not provided antibiotics by the facility for an extended period because the facility told her they were waiting for a culture and sensitivity test to be completed, but this did not occur. R #1's daughter stated R #1 became unresponsive, so she requested R #1 be sent to the hospital. I. On 07/07/26 at 5:04 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated she collected R #1's UA on 06/22/26 and then worked on a different unit. LPN #1 stated she did not know why a facility nurse did not address R #1's UA results from 06/24/26 until 07/01/26, but someone should have. J. On 07/07/26 at 5:25 pm, during an interview, Registered Nurse (RN) #1 stated she helped collect the urine for R #1's UA on 06/22/26 and R #1's urine looked terrible. RN #1 stated R #1's urine on 06/22/26 was dark and maroon (brownish/crimson) colored. RN #1 stated she did not know why a facility nurse did not address R #1's UA results from 06/24/26 until 07/01/26, but someone should have. RN #1 stated on 07/01/26, R #1 became unresponsive but was breathing. RN #1 stated R #1 became more like herself during the afternoon on 07/01/26, but the family wanted R #1 sent to the hospital. K. On 07/08/26 at 1:22 pm, during an interview, RN #2 stated she collected R #1's urine for the UA on 06/17/26, and R #1's urine was dark in color during that collection. RN #2 stated she completed R #1's culture and sensitivity test but failed to obtain a completed UA on 06/17/26. She stated she notified Unit Manager (UM) #1 after failing to obtain the UA on 06/17/26. RN #2 stated R #1's UA collected on 06/22/26 was also dark with a strong odor and showed signs of a possible UTI. RN #2 stated she noticed R #1 was confused. L. On 07/08/26 at 2:27 pm, during an interview, the Physician's Assistant (PA) #1 stated R #1's UA collected on 06/17/26 was not collected properly and this was why the lab result indicated the test was not performed. PA #1 stated R #1 did not have a fever, but she was confused. PA #1 stated R #1's UA results that were reported to the facility on [DATE] were not followed up on for approximately seven days. PA #1 stated she reviews resident lab results three times a week, and she initially documented R #1's UA results dated 06/24/26 as reviewed, but she did not take action to initiate treatment. PA #1 stated there should not have been a seven day delay in reviewing R #1's UA results reported to the facility on [DATE]. She stated a culture and sensitivity test should have been completed with the UA dated 06/24/26, and a UA should have been completed on 06/17/26 as ordered rather than only a culture and sensitivity test. M. On 07/08/26 at 4:02 pm, during an interview, UM #1 stated she assisted with R #1's urine collection on 06/17/26, and the UA was not completed, only the culture and sensitivity test. UM #1 stated R #1's urine was dark in color on 06/17/26 when she assisted with the collection. UM #1 stated she was not sure what happened with R #1's UA results that were reported to the facility on [DATE], because she went on vacation on 06/25/26 until 07/06/26. UM #1 stated it is her expectation the facility nurses are aware of resident's UA results and review them as soon as they are reported to the facility by the laboratory. UM #1 stated there should not have been a seven day delay in reviewing R #1's UA results that were reported to the facility on [DATE]. N. On 07/08/26 at 4:55 pm, during an interview, the Director of Nursing (DON) stated there should not have been a seven day delay in reviewing R #1's UA lab results that were reported to the facility on [DATE]. The DON stated the delay did not meet her expectations, and R #1's UA lab results dated 06/24/26 were also missed by clinical staff during morning meetings.

Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #1, #2 and #3) resident, when:The facility failed to ensure R #1 continued to receive sliding scale insulin immediately after he returned from a hospitalization.If the facility fails to obtain and verify appropriate medication orders for a resident with a history of consistently receiving sliding scale insulin, then residents are likely to experience poorly controlled blood glucose (sugar) levels, worsening symptoms, disease progression, and avoidable complications. The findings are:A. Record review of R #1's face sheet revealed R #1 was admitted to the facility on [DATE] with type 2 diabetes mellitus (DM2; a disease in which the body cannot make or properly use insulin) with diabetic neuropathy (a type of nerve damage that occurs as a complication with diabetes) and was discharged on 12/31/25. B. Record review of R #1's nursing progress notes, dated 10/27/25, revealed R #1 was sent to the hospital for respiratory distress. C. Record review of R #1's hospital physician orders, dated 10/27/25, revealed R #1 received insulin Lispro-U 100 (HumaLog; a rapid-acting insulin used to control blood sugar) while in the hospital. D. Record review of R #1's physician orders, dated 07/17/25 through 11/25/25 revealed the following:Dated 07/17/25, Insulin Lispro (1 unit dial) subcutaneous (under the skin) solution pen-injector 100 unit/mL (milliliter). Inject as per sliding scale subcutaneously before meals and at bedtime for Diabetes Mellitus 2 (if the blood sugar (glucose) level is 201 to 250 administer 4 units; if the blood sugar level is 251 to 300 administer 6 units; if the blood sugar level is 301 to 350 administer 8 units; if the blood sugar level is 351 to 400 administer 10 units; if the blood sugar is 401 to 450 administer 12 units). This medication was discontinued on 10/13/25.Dated 10/14/25, Insulin Lispro (1 unit dial) subcutaneous (under the skin) solution pen-injector 100 unit/mL (milliliter). Inject as per sliding scale subcutaneously before meals and at bedtime for Diabetes Mellitus 2 (if the blood sugar level is 201 to 250 administer 4 units; if the blood sugar level is 251 to 300 administer 6 units; if the blood sugar level is 301 to 350 administer 8 units; if the blood sugar level is 351 to 400 administer 10 units; if the blood sugar is 401 to 450 administer 12 units). This medication was discontinued on 10/25/25. Dated 11/10/25, blood Sugar Checks before meals and at bedtime for diabetes mellitus management. Dated 11/25/25, Empagliflozin (an antidiabetic medication used to improve glucose control) oral tablet, 10 milligrams (mg). Give 1 tablet by mouth in the morning for low blood sugar. This medication was discontinued on 12/22/25.R #1's insulin was not continued by the facility staff when he returned to the facility on [DATE] at 11:11 pm. E. Record review of R #1's Quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 11/29/25, revealed R #1 has an active diagnosis of diabetes mellitus. F. Record review of R #1's physician orders, dated 12/19/26 through 01/09/26, revealed the following: Dated 12/19/25, HumaLog Injection Solution (Insulin Lispro) 100 Unit/mL. Inject subcutaneously per sliding scale before meals and at bedtime for Diabetes Mellitus 2 (if the blood sugar level is 201 to 250 administer 4 units; if the blood sugar level is 251 to 300 administer 6 units; if the blood sugar level is 301 to 350 administer 8 units; if the blood sugar level is 351 to 400 administer 10 units). This medication was discontinued on 12/22/25.Dated 12/22/25, HumaLog KwikPen (insulin) subcutaneous solution pen-injector 100 unit/mL. Inject subcutaneously as per sliding scale before meals and at bedtime for Diabetes Mellitus 2 (if the blood sugar level is 201 to 250 administer 4 units; if the blood sugar level is 251 to 300 administer 6 units; if the blood sugar level is 301 to 350 administer 8 units; if the blood sugar level is 351 to 400 administer 10 units; if the blood sugar is 401 to 450 administer 12 units). This medication was discontinued on 01/09/26.Dated 12/23/25, Empagliflozin oral tablet, 25 mg. Give 25 mg by mouth one time a day for diabetes. G. Record review of R #1's Medication Administration Record (MAR), dated 11/04/25 through 12/19/25, revealed R #1 did not receive any sliding scale insulin for seventy-five (75) documented blood glucose readings over 200, thirty-six (36) blood glucose readings over 300, and two (2) blood glucose readings over 400. H. Record review of R #1's care plan, dated 12/07/25, revealed R #1 was diagnosed with insulin-dependent diabetes. I. Record review of R #1's electronic health record (EHR), dated 06/15/26, revealed the facility nursing staff did not contact the hospital or the facility provider when R #1 returned to the facility on [DATE] without physician orders for insulin use, even though R #1 had been administered insulin before discharge to the hospital on [DATE]. J. On 06/15/26 at 3:00 PM, during an interview, the Director of Nursing (DON) stated when a resident is newly admitted or re admitted , the floor nurse is responsible for obtaining the hospital discharge orders, reviewing them, and clarifying or clearing them with the facility on call provider. She stated physician orders are reconciled during the facility's daily clinical meeting as a secondary check, and the pharmacy completes a medication review for all new admissions within 24 hours. The DON stated facility nurses are expected to call and verify orders if any questions arise or if a critical medication, such as sliding scale insulin, is omitted (left out or excluded) when a resident previously received it. The DON stated R #1 should have continued to receive insulin in the facility prior to 12/19/25, but he did not. K. On 06/22/26 at 11:07 am, during an interview, the Medical Director (MD) stated she expects a physician to be notified immediately whenever a resident's blood glucose level exceeds 400 to ensure diabetes is properly controlled. The MD stated R #1 fell through the cracks upon re admission, and R #1 should have been receiving regular blood sugar checks and insulin when he returned to the facility on [DATE], but he did not.

Based on observation, record review, and interviews, the facility failed to ensure the environment was free of accident hazards for 1 (R #4) of 2 (R #'s 3 and 4) resident, when the facility staff failed to:Use two staff members to safely transfer R #4 with a Hoyer lift (equipment used to move residents who have limited mobility) as required. This deficient practice is likely to result in residents getting injured in avoidable accidents and putting residents at risk of serious injury and harm.The findings are: A. Record review of the facility's Safe Resident Handling/Transfer Equipment, reviewed on 06/16/26, revealed the following:Safe resident handling involves the use of assistive devices to ensure that patients can be transferred safely and that care providers avoid performing high risk patient handling tasks. Patients will be assessed upon admission and on an ongoing basis to determine the patient's ability to transfer and reposition and the need for safe resident handling equipment.Staff will complete training and demonstrate competency in the use of safe resident handling equipment.Manufacturers' instructions will be used for all safe resident handling equipment.Two trained persons are required to operate a total lift (support patients who cannot stand or bear weight independently) or sit to stand lift (assist patients who can bear some weight and participate in standing), regardless if manufacturer instructions state only one person is needed. No on under the age of eighteen may operate a mechanical lift.The purpose is to optimize staff safety and the safety, comfort, and function of patients during transfers, ambulation, and/or repositioning. B. Record review of R #4's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/10/26, revealed R #4 was admitted into the facility on [DATE] and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for transfers. C. Record review of R #4's care plan, dated 05/21/26, revealed R #4 required transfer assistance with a mechanical lift, provided by two Certified Nursing Assistants (CNAs), with nurse monitoring. D. On 06/16/26 at 11:35 am, during an observation, the Activities Assistant (AA) was observed placing a Hoyer lift sling under R #4 before the transfer. The AA then closed R #4's door and transferred R #4 without additional staff assistance. E. On 06/16/26 at 11:43 am, during an interview, the AA stated she used the Hoyer lift to transfer and reposition R #4. She stated she knew it was wrong to use the Hoyer lift alone and acknowledged it was unsafe to transfer a resident using the Hoyer lift without another staff member's assistance. F. On 06/16/26 at 2:55 pm, during an interview, the Director of Nursing (DON) stated her expectation is for staff to follow safety guidelines when transferring a resident who requires a Hoyer lift. The DON stated a Hoyer lift requires two staff members to provide the safest mechanical transfer for a resident and to maintain staff safety. She stated the facility staff should never transfer a resident alone while using a Hoyer lift.

Based on interview and record review, the facility failed to ensure 2 (NAIT #1 and NAIT #2) of 5 (NAITs #1, #2, #3, #4, and #5) Nurse Aides in Training completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 109 residents residing at the facility by allowing untrained staff to provide direct care to residents.The findings are:NAIT #1A. Record review of NAIT #1's personnel record reviewed the following:1. NAIT #1's hire date was 10/09/24.2. NAIT #1 is scheduled to complete her certified nursing aide test on 01/31/26 for certification.B. Record review of NAIT #1's timesheet revealed NAIT #1 worked a total of 151 shifts between 01/01/25 and 12/31/25.C. On 01/08/26 at 1:13 pm, during an interview with the Administrator (ADM), she confirmed NAIT #1 has not yet received her certification and continued to work shifts during that time. She stated her expectation is for all nurse aids to become certified within four months. NAIT #2D. Record review of NAIT #2's personnel record reviewed the following:1. NAIT #2's hire date was 06/29/25.2. NAIT #2's is scheduled to complete her CNA test on 01/31/26 for certification.E. Record review of NAIT #2's timesheet revealed NAIT #2 worked a total of 57 shifts between 08/01/25 and 12/31/25.F. On 01/08/26 at 1:13 pm, during an interview with the ADM, she confirmed NAIT #2 has not yet received her certification and continued to work shifts during that time. She stated her expectation is for all nurse aids to become certified within four months.

Based on observations, and interviews, the facility failed to properly store medications and medical supplies located in the facility medication carts and medication storage room when the staff failed to ensure:-Medication carts are free of any lose pills.-Medication carts are not left unlocked and unattended. -Expired medication and supplies are properly discarded.-Medications of discharged residents are taken out of the medication cart.-Medication fridge temperature is being monitored routinely.These deficient practices have the potential to affect all 109 residents as identified by the census provided by the Administrator on [DATE]. If the facility does not ensure safe storage practices, then residents are at risk for adverse effects due to improper storage and not receiving the full benefits of medications. The findings are:A. On [DATE] at 8:20 am, observation of the 200-hall medication cart, revealed the following: a yellow capsule stamped with PRA 1, a white square tablet stamped with CC, a white round tablet stamped with G10, and a pink round tablet stamped with H1 were found in the second drawer.B. On [DATE] at 8:22 am, during an interview with Certified Medication Aide (CMA) #1, she confirmed those medications found in the second drawer should be disposed of according to facility policy. CMA #1 stated that medication carts should be free of any lose pills as part of the facility infection control.C. On [DATE] at 6:12 pm, during an observation of the 200-hall medication cart, a white round pill stamped with GC216 was found on top of sharps container.D. On [DATE] at 6:14 pm, during an interview with Licensed Practical Nurse (LPN) #4, she confirmed that a white round pill stamped with GC216 was found on top of the sharp's container. LPN #4 stated, per facility policy, medications are disposed by placing them inside a drug buster (a drug disposal system designed to safely and effectively dispose of non-hazardous medications).E. On [DATE] at 8:39 am, during an observation of hall 100, a treatment cart (containing medical supplies and insulin pens) parked outside room [ROOM NUMBER] was left unlocked and unattended.F. On [DATE] at 8:41 am, during an interview with CMA #2, she confirmed the medication cart was left unlocked and unattended. CMA #2 stated that medication carts are to be locked when not in use and it did not happen.G. On [DATE] at 8:44 am, during an observation of the 200 halls, a medication cart was left unlocked and unattended outside room [ROOM NUMBER].H. On [DATE] at 8:46 am, during an interview with Registered Nurse (RN) #1, she confirmed that the cart was left unlocked and unattended. I. On [DATE] at 11:05 am, during an observation of the 100-hall treatment cart revealed the following:1. A ceftriaxone (an antibiotic) 1 gram vial for R #122 was found (R #122 left the facility last month).2. An aquacell dressing (a brand of wound care dressing) with an expiration date of [DATE] was found.3. An unwrapped syringe found in the first drawer.J. Record review of R #122's face sheet revealed a discharge date of [DATE].K. On [DATE] at 11:07 am, during an interview with LPN #5, he confirmed the following:1. R #122 was discharged last month. The antibiotic should have been returned pharmacy or disposed according to facility policy, and it did not happen.2. The aquacell dressing is expired. All expired medication supplies should have been removed, and it did not happen.3. The syringe is unwrapped and appears unused. Unused medical supplies such as a syringe should discarded as soon as they are opened to prevent potential contamination and it did not happen.L. On [DATE] at 11:11am, during an observation of the locked medication room, revealed the following:1. The medication fridge door is open with and internal temperature reading of 52.4 degrees Celsius.2. A culture swab kit (a diagnostic tool used to collect sample and send it to the laboratory) with an expiration date of [DATE].3. A 22-gauge (needle size) syringe with an expiration date of [DATE] was found.M. On [DATE] at 11:14 am, during an interview with LPN #5, he confirmed the following:1. The medication fridge was left open with an internal temperature reading of 52.4 degrees Celsius.2. The culture swab and syringe are expired.

Based on observation, record review and interview, the facility failed to ensure the nutritional needs and preferences were met for all 109 residents list on the resident census list provided on 01/04/26 by the facility Administrator by not following the menu. This deficient practice could prevent residents from eating well, not meeting their nutritional needs and lead to weight loss. The findings are: A. On 01/04/26 at 11:40 am during an observation of lunch in the main dining room, ice cream was served for dessert.B. Record review of the menu for lunch dated 01/04/26 revealed, pizza, broccoli, strawberry streusel.C. On 01/04/26 12:16 pm during an interview with the Dietary Manager, she stated she had an employee call in for a shift and she had to cover the shift. She also stated it was late when she got to facility and she did not have time to make the strawberry streusel.

Based on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to:1. Properly label drink items while on carts in 400 hallway, 2. Properly store milk on ice on cart in 400 hallway,3. Properly label and store foods in the kitchen.These deficient practices are likely to affect all 109 residents listed on the resident census list provided by the Administrator on 1/04/26 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and stored properly. The findings are: A. On 01/04/26 at 11:40 am, observation of the Dietary Department, revealed the following: 1. Half of a five-pound boneless ham was in the walk-in-refrigerator and was not dated.2. One five-pound bag of diced potatoes was open to air and not sealed properly in the walk-in refrigerator.3. One ten-pound box of frozen beef patties was open to air and not sealed properly in the freezer.4. One 5-pound bag of grapes was open to air not sealed properly and was not dated.5. One zip lock bag with what appeared to be 6 halves of ham & cheese sandwiches in the refrigerator and were not dated.B. On 01/04/26 at 11:43 am during an interview with Dietary Manager, he confirmed all items above and stated he expected all items to be sealed properly and dated.C. On 01/05/26 at 8:32 am, an observation of the kitchen cart in hallway 400 revealed what appeared to be coffee, milk, and juice and did not have a label indicating the contents or date it was prepared.D. On 01/05/26 at 8:34 am, during an interview with Registered Nurse (RN) #2, she confirmed the milk, coffee and juice on the 400-hallway cart were not labeled and dated. She stated all beverages should be properly labeled.E. On 01/07/26 at 8:20 am, an observation of the kitchen cart in hallway 400 revealed what appeared to be milk not sitting on ice.F. On 01/07/26 at 8:34 am, during an interview with Certified Nursing Assistant (CNA) #1, she confirmed the milk on the cart down the 400 hallway was not sitting on ice. She confirmed all drinks should be placed on ice to stay cold.

Based on observation, record review and interview, the facility's Administrator (ADM), Infection Prevention Coordinator (IPC) and Interim Director of Nursing (IDON) failed to administer the facility when they knew/should have known and prevented the following deficient practices which occurred in the facility: 1. Not ensuring staff were trained and/or competent before providing care to residents,2. Not ensuring appropriate infection control practices for residents with contact precautions,3. Failure to know specific orders are required for oxygen use. These deficient practices are likely to affect all 102 residents residing in the facility according to the daily census provided by the Admissions Coordinator (AC) on 12/07/25 and could lead to residents not maintaining their highest practicable physical, mental, and social well-being. The findings are: Staffing A. Record review of the Requested Documents form (form surveyors submit to a facility to request certain documents) dated 01/08/26 revealed the Administrator (ADM) wrote the following:1. Nurse Aide in Training (NAIT) #1 was certified as a Certified Nurse Aide (CNA) on 10/09/24.2. NAIT #2 was certified as a Certified Nurse Aide (CNA) on 06/09/25.3. NAIT #3 was certified as a Certified Nurse Aide (CNA) on 04/23/25.B. On 01/08/26 at 1:13 pm during an interview with the ADM, she stated that she was unaware that surveyors needed to see the staff's actual certification status and would gather them to submit to the survey team.C. Record review of NAIT #1's personnel file revealed a start date of 10/09/24, no evidence of NAIT #1 becoming as a certified nurse aide was located in the file.D. Record review of NAIT #2's personnel file revealed a start date of 06/09/25, no evidence of NAIT #2 becoming a certified nurse aide was located in the file.E. Record review of NAIT #3's personnel file revealed the following:1. A start date of 04/23/25.2. No evidence of NAIT #3 becoming a certified nurse aide was located in the file.3. The Non-certified Nursing Aide Job Description was signed and dated by NAIT #3 on 04/16/25. No job description for transportation staff was located in the file.F. On 01/08/26 at 1:47 pm during an interview with the ADM, she confirmed that NAIT #1 and NAIT #2 are scheduled to complete the testing and become certified on 01/31/26. The ADM stated that NAIT #1 and NAIT #2 have continued to work in a nurse aide capacity even though they are not certified. The ADM confirmed that NAIT #3 is not a certified nurse aide and stated that NAIT #3 is not being utilized in a nurse aide role because she is being used as a transport staff. Infection Control PracticesG. Record review of the facility's Infection control policies and procedures for Transmission Based Precautions dated 05/01/25 indicated to refer to Centers for Disease Control and Prevention (CDC).H. Record review of CDC guidelines from CDC website Enhanced Barrier Precautions (EBP) in Nursing Homes. Centers for Disease Control. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html Implementation of Contact precaution or Enhanced Barrier Precautions, the CDC recommends: That clear signs be displayed outside the door of the room where precautions are required. The sign should indicate the type of precaution and PPE to be used during high-contact resident care activities.I. On 01/04/26 at 11:43 am, during a random observation of the 100-hall, revealed R #21 had a sign for Modified Protection Environment at the doorway and 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) hanging from the door. The Modified Protection Environment sign listed the following precautions:1. No live plants2. No dried or fresh flowers3. No Animal Visits4. Avoid visitation from ill persons/caregivers5. Strict hand hygiene must be preformed.The Modified Protection Environment sign did not indicate the type of precautions and PPE to be used during care.J. On 01/05/26 at 8:11 am, during an interview with the infection prevention coordinator, she confirmed. The sign posted at the doorway of R #21's room for Modified Protection Environment did not indicate the type of precautions and PPE to be used during care. R #21 should have an additional sign for contact plus droplet precautions but was not visibly posted. The IPC explained that the resident has additional environment precautions due to being on chemo (medication to treat cancer).K. On 01/05/26 at 8:13 am during an observation of the 100-hall, R #21 had a contact plus droplet precaution sign posted at the doorway of R#21's room with the following precautions:1. Staff must clean hands before enter and leaving room,2. Staff must wear gown and gloves,3. Staff must wear procedure mask and eye protectionL. On 01/07/26 at 8:17am, during a random observation of the therapy room revealed R #21 was in the therapy room. The speech language pathologist (SLP) #1 was assisting R #21 with hygiene and drink, therefore R #21 was not wearing a mask. There were three other staff in the therapy room. No staff were wearing gowns or face shields. There were three other residents in the therapy room not wearing any type of PPE.M. On 01/07/26 at 8:32am during an interview with the IPC, she stated that R #21 is only required to wear a mask as tolerated. The IPC stated that it would be her recommendation to have R #21 perform therapy in his room however his family has asked that he have therapy outside of his room. The IPC also stated that R #21 is not at risk because the increase precaution would depend on his blood cell count to determine the need for reverse isolation (a medical practice designed to protect patients with weakened immune systems from infections by minimizing their exposure to pathogens in the environment). The IPC then stated that although R #21 is on contact plus droplet precautions the purpose of the precaution was because R #21's family requested the precautions. She also state that the facility cannot force residents to stay in their rooms or require residents to wear a mask if they choose not to. The IPC confirmed that R #21 is non ambulatory and requires assistance with all ADL's. She also confirmed R #21 has limited communication requiring yes and no responses.N. On 01/07/26 at 8:51 am during an interview with R #21's representative, she stated R #21 is on neutropenic precautions (infection-prevention measures for individuals with a low white blood cell count) per his oncologist (a doctor who specializes in diagnosing and treating cancer). She stated the facility should have received an order from the facility he was at prior to admission. She confirmed R #21 is currently receiving chemo every other week and the family has requested that R #21 receive therapy in his room due to the current COVID exposure in the facility. She stated the family would prefer that staff wear full PPE when caring for R #21 however was told by the facility that the only need for R #21 to have contact precautions is due to R #21 wound care.O. Record review of the facility's Modified Protection Environment policy revealed the facility will obtain orders for the following:1. Whether the resident should take a bath or shower.2. The amount of time a resident can be outside of their room.3. Requirements for the resident to wear a surgical mask.4. Any other modification or changes needed for the resident.P. On 01/08/26 at 10:22 am, during an interview with the IPC she confirmed that her expectation is that facility polices be followed for all residents. She confirmed the facility is currently on COVID precautions. She confirmed R #21 did not have orders for the following:1. Whether R #21 should take a bath or shower.2. The amount of time a R #21 can be outside of his room.3. Requirements for R #21 to wear a surgical mask.4. The need for Contact plus droplet precautions.The IPC stated the facility does not have neutropenic precautions however the Modified Environment is an alternative for residents who would require neutropenic precautions. She stated the facility provider would give recommendations and orders for residents who need additional precautions based off a resident's increased risk of infection from decreased blood cells from lab work. The IPC stated that risk of infections for residents receiving chemo is not part of her infection program and she could not confirm if R #21 has had a low reading in his blood work. She confirmed the provider was not consulted regarding R #21 and need for additional precautions. Failure to know specific orders are required for oxygen use:Q. Record review of R #20's current medical orders revealed an order dated 03/21/23 for R #20 to use oxygen at one to six liters per minute via (by way of) nasal cannula continuously.R. Record review of R #35's current medical orders revealed an order dated 03/29/25 for R #35 to utilize three to four liters of oxygen per minute via nasal cannula.S. Record review of R #41's physician record revealed there were no orders for use of oxygen or oxygen device care.T. On 01/04/26 at 11:58 am, an observation and interview of R #71 in his room revealed the following:1. A continuous positive airway pressure (CPAP) machine connected to a medical stand located next to R#71's bed.2. R #71 stated that he was sent to the facility with the CPAP and that he uses the CPAP every night.U. Record review of R #71's discharge documentation from a hospital dated 02/03/25 revealed the following:1. R #71's primary diagnosis was acute and chronic respiratory failure with hypoxia (insufficient oxygen in the blood over a long period of time). 2. The use of a CPAP was ordered.V. Record review of R #109's current medical orders revealed the following:1. An order dated 12/31/25, for R #109 to wear oxygen at one to five liters via nasal cannula continuously.2. An order dated 12/31/25, for R #109 to have oxygen on at one to five liters via nasal cannula as needed.W. On 01/08/26 at 11:45 am an interview with the Interim Director of Nursing (IDON) revealed the following:1. The IDON confirmed that the order for R #20's and R #35's oxygen use do not specify the amount of oxygen (liters and flow rate) required.2. The IDON confirmed R #41 does utilize oxygen, should have an order for the use of oxygen and does not.3. The IDON confirmed R #71 does utilize a CPAP, should have an order for the use of the CPAP and does not.4. The IDON confirmed that the order for R #109's oxygen use does not specify the amount of oxygen needed and whether he needs continuous or PRN oxygen.5. The IDON stated that orders do not have to specify the amount of oxygen a person needs because it is up to the nurse and the nurse's judgement to keep a resident's oxygen saturation level above 90.

Based on observation, record review, and interview, the facility failed to implement and follow an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by 1. Not ensuring transmission-based precautions (actions implemented based upon the means of transmission to prevent or control infection) signs are posted outside of rooms with 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).2. Not ensuring staff follow the appropriate precautions posted.These failed practices have the potential to affect all 109 residents living in the facility as identified by the census provided by the Administrator 01/04/26. These deficiencies place residents at risk of contracting infections, hospitalization, and death. The findings are:Transmission Based Precautions:A. Record review of the facility's Infection control policies and procedures for Transmission Based Precautions dated 05/01/25 indicated to refer to Centers for Disease Control and Prevention (CDC).B. Record review of CDC guidelines from CDC website Enhanced Barrier Precautions (EBP) in Nursing Homes. Centers for Disease Control. https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html Implementation of Contact precaution or Enhanced Barrier Precautions, the CDC recommends:1. That clear signs be displayed outside the door of the room where precautions are required. The sign should indicate the type of precaution and PPE to be used during high-contact resident care activities.2. PPE available immediately outside of the resident room.3. Ensure access to alcohol-based hand rub in every resident room4. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room.C. On 01/04/26 at 11:43 am, during a random observation of the 100-hall, revealed the following:1. room [ROOM NUMBER] had a sign for Modified Protection Environment at the doorway and PPE hanging from the door. The Modified Protection Environment sign did not indicate the type of precautions and PPE to be used during care.2. rooms [ROOM NUMBERS] had signs for Special Contact and Droplet Precautions posted at the doorways and PPE hanging from the doors.3. Rooms 104, 106, 110 and 114 had Enhanced Barrier Precautions posted at the doorways and PPE hanging from the doors.D. On 01/04/26 at 12:05 pm, an observation of room [ROOM NUMBER] revealed the resident had an indwelling catheter (a thin, flexible tube inserted into the body used to drain urine from the bladder). E. On 01/04/26 at 1:27 pm during an interview with Certified Nurse Aide (CNA) #5, she confirmed the resident in room [ROOM NUMBER] had an indwelling catheter and did not have a sign for transmission-based precautions or PPE available. F. On 01/05/26 at 8:09 am during an observation of the 100 hall, revealed the infection control coordinator removing a contact plus droplet precaution sign from the PPE caddy (a device hanging on the door of the residents' room to hold PPE for easy accessibility). G. On 01/05/26 at 8:11 am, during an interview with the infection prevention coordinator, she confirmed the following:1. Residents with an indwelling catheter should be on Enhanced Barrier Precautions and have PPE available.2.The sign posted at room [ROOM NUMBER] Modified Protection Environment sign did not indicate the type of precautions and PPE to be used during care. room [ROOM NUMBER] should have an additional sign for contact plus droplet precautions but was not visibly posted. Following PrecautionsH. On 01/04/26 at 12:11 pm during a random observation of the 100 hall, CNA #3 entered room [ROOM NUMBER] without PPE.I. On 01/04/26 at 12:13 pm during an interview with CNA #3, he confirmed room [ROOM NUMBER] is on special contact and droplet precautions. CNA #3 confirmed he should be wearing a gown, N95 respirator (personal protective device that forms a tight seal around the nose and mouth, filtering at least 95% of airborne particles), eye protection or face shield when entering the room and he did not.J. On 01/05/26 at 8:53 am, during a random observation of the 100-hall revealed the following:1 The Occupational Therapist (OT) #1 exited room [ROOM NUMBER] with complete PPE to include gown and mask. 2. OT #1 walked down the hall and then returned to enter room [ROOM NUMBER] still wearing the PPE. K. On 01/05/26 at 8:56 am, during an interview with OT #1, he confirmed that he should not have exited the room before donning (removing) his PPE and should put new PPE on each time he enters the room.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 2 (R #11 and R #63) of 3 (R #11, R #63, R #109) residents reviewed for unnecessary medications, when staff failed to ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice could likely lead to adverse drug effects and poor patient outcomes.The findings are: R#11 A. Record review of R #11's admission Record revealed R #11 was admitted to the facility on [DATE] with the following diagnoses:1. End stage renal disease (final stage of chronic kidney disease, where the kidneys can no longer function adequately, requiring dialysis or a kidney transplant for survival),2. Dependence on renal dialysis (medical procedure used to remove waste products and excess fluid from the blood when the kidneys are no longer able to perform this function effectively),3. Paranoid schizophrenia (a false belief or judgement about external reality, held despite incontrovertible evidence to the contrary, as a symptom of serious mental illness),4. Bipolar disorder (mental health condition characterized by extreme mood swings, including emotional highs and lows, which can significantly impact daily life),5. Presbyopia (gradual loss of your eyes' ability to focus on nearby objects),6. Post-traumatic stress disorder (mental health condition that's caused by an extremely stressful or terrifying event or either being part of it or witnessing it).B. Record review of R #11's physician orders revealed an order for Citalopram Hydrobromide (anti-depressant medication) oral tablet 10 milligrams (MG). Give 10 MG by mouth at bedtime for depression. Start date 09/25/25.C. On 01/08/26 at 11:47 am, during an interview with the Interim Director of Nursing (IDON) she confirmed the following:1. The indicated use of Citalopram Hydrobromide is depression,2. R #11 does not have a diagnosis for depression,3. Medications should be documented to treat specific conditions as diagnosed and these were not. R #63D. Record review of R #63's admission record revealed R #63 was admitted to the facility on [DATE] with the following diagnoses:1. Lymphedema (chronic swelling),2. Chronic pain,3. Bi-polar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),4. Adjustment disorder (a strong emotional or behavioral reaction to a specific, identifiable stressor),5. Hypothyroidism (the thyroid is not making enough thyroid hormone). E. Record review of R #63's physician orders revealed the following:1. An order for Fluoxetine Hydrochloride (HCl) (Anti-depressant medication) oral tablet 20 milligrams (MG). Give 20 MG by mouth one time a day for depression. Start date 01/07/26. 2. An order for Venlafaxine HCl (Anti-depressant medication) oral tablet 75 MG. Give 75 MG by mouth one time a day for depression. Start date 01/06/26.3. An order for Trazodone HCl (Anti-depressant medication) oral tablet 150 MG. Give 2 tablets by mouth at bedtime for insomnia. Start Date 12/24/25. F. On 01/08/26 at 11:47 am, during an interview with the IDON, she confirmed the following:1. R #63's indicated use for Fluoxetine and Venlafaxine is depression.2. R #63's indicated use for Trazadone is insomnia.3. R #63 does not have diagnosis for depression or insomnia.4. Medications should be documented to treat specific conditions as diagnosed and these were not.

Based on record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 4 (R #13, R #63, R #71 and R #94) of 5 (R #13, R #63, R #71, R #94 and R #109) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are:R #13 A. Record review of R #13's admission Record revealed she was originally admitted to the facility on [DATE]. B. Record review of R #13's physician's order dated 12/22/25 revealed R #13 was scheduled to see an audiologist (a healthcare professional who specializes in hearing and balance disorders) for unspecified hearing loss. C. Record review of R #13's care plan dated 11/28/25 revealed R #13 has impaired communication as evidenced by impaired hearing. D. Record review of R #13's MDS assessment dated [DATE] section B, revealed R #13 has adequate hearing and requires no hearing aids. E. On 01/08/26 at 10:46 am, during an interview with the MDS coordinator, she confirmed R #13 is hard of hearing and the MDS assessment 12/06/25 was documented incorrectly. R #63 F. Record review of R #63's admission record revealed R #63 was admitted to the facility on [DATE]. G. Record review of R #63's physician record revealed an order for Pregabalin (anti-convulsant medication) oral capsule 50 milligrams (MG). Give 50 MG by mouth two times a day for chronic pain syndrome. Start Date 12/19/25. H. Record review of R #63's MDS assessment dated [DATE] Section N revealed, R #63 does not take anticonvulsants. I. On 01/08/26 at 10:46 am, during an interview with the MDS coordinator, she confirmed R #63 does take an anticonvulsant medication. The medication should be included in the MDS assessment and was not. R #71 J. Record review of R #71's admission Record revealed R #71 was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease with (acute) exacerbation (symptoms including shortness of breath, quantity and color of phlegm that typically lasts for several days), 2. Vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain), 3. Dysphagia, oropharyngeal phase (a disorder or impairment in initiating a swallow), 4. Crohn's disease (type of inflammatory bowel disease that causes swelling and irritation of the tissues, called inflammation, in the digestive tract. This can lead to belly pain, severe diarrhea, fatigue, weight loss and malnutrition), 5. Insomnia (sleep disorder that can make it hard to fall asleep or stay asleep). K. Record review of R #71's MDS assessment dated [DATE] section O revealed R #71 does not use a Continuous Positive Airway Pressure (CPAP) machine (a medical device that delivers pressurized air through a mask to keep your airway open during sleep). L. Record review of R #71's hospital after-visit summary dated 02/23/25 revealed R #71 was discharged from hospital with a CPAP machine. M. On 01/04/26 at 11:58 am, an observation and interview with R #71 in his room revealed a CPAP machine next to R #71's bed. R#71 stated he does use his CPAP machine every night and has since his admission to facility. N. On 01/08/26 at 11:45 am, during an interview with the Interim Director of Nursing (IDON), she confirmed the CPAP machine was not included in R #71's MDS assessment and stated it should be included in the MDS assessment. R #94 O. Record review of R #94's admission Record revealed she was originally admitted to the facility on [DATE]. P. Record review of R #13's care plan dated 11/14/25 revealed R #94 has impaired communication as evidenced by difficulty making self-understood (expressive) due to garbled speech and Cerebral Palsy (a neurological condition that can present as issues with muscle tone, posture and/or a movement disorder). Q. Record review of R #13's MDS assessment dated [DATE] section B, revealed R #94 has clear speech. R. On 01/08/26 at 10:451 am, during an interview with the MDS coordinator, she confirmed R #94 has speech impairment and the MDS assessment dated [DATE]was documented incorrectly.

Based on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 3 (R #21, R #63 and R #71) of 4 (R #12, R #21, R #63, and R #71) residents reviewed for care plans when staff failed to: 1. Develop a care plan to include interventions for R #21's diagnosis of Multidrug-Resistant Organism (MDRO; a germ that is resistant to many antibiotics),2. Develop a care plan to include interventions for R #21's need for Modified Protective Environment Precautions, (a facility policy with special instructions to protect residents in their environment).3. Develop a care plan for R #63's use of bed rails.4. Develop a care plan for R #71's use of Continuous Positive Airway Pressure Machine (CPAP; a medical device that delivers pressurized air through a mask to keep your airway open during sleep). This deficient practice could likely result in proper care not being provided to residents.The findings are: R #21 A. Record review of R #21's admission record revealed R #21 was admitted into the facility on [DATE] with the following diagnoses: 1. Pancytopenia (serious blood condition where there's a lower-than-normal count of all three blood cell types: red blood cells, white blood cells, and platelets, leading to fatigue, infection risk, and bleeding), 2. Small B-cell lymphoma (slow-growing cancers in fully grown white blood cells that form the backbone of the immune system), 3. Nontraumatic intracerebral hemorrhage (ICH; bleeding directly into the brain tissue), 4. Cognitive communication deficit (difficulty speaking, listening, reading, or writing due to underlying thinking problems like poor memory, attention, problem-solving, or social understanding), 5. Anemia (a condition where the blood lacks enough healthy red blood cells, reducing oxygen delivery to the body, causing fatigue, weakness, paleness, and shortness of breath, often due to iron/vitamin deficiencies, blood loss, chronic diseases, or inherited disorders like sickle cell anemia). B. Record review of R #21's hospital discharge orders dated 12/17/25 revealed a diagnosis of Multidrug-Resistant Organism (MDRO; a germ that is resistant to many antibiotics). C. Record review of R #21's Electronic Health Record revealed an alert for infection prevention and control with an onset date of 12/17/25 for the following diagnoses: wound and Escherichia coli (E-Coli; a bacteria that lives in the intestines) MDRO. D. Record review of R #21's care plan dated 12/18/25 revealed the following: 1. No interventions for MDRO were included in his care plan. 2. No intervention for the use of Modified Protective Environment Precautions were included in his care plan. E. On 01/04/26 at 11:43 am, during a random observation of the 100-hall revealed R #21 had a sign next to his door for Modified Protective Environment Precautions. F. On 01/07/26 at 8:32am during an interview with the Infection Prevention Coordinator (IPC), she confirmed R #21 has a diagnosis of MDRO. She stated R #21 is on Modified Protective Environment Precautions as an alternative for neutropenic precautions (a set of infection control measures for people with a low neutrophil count, which increases their susceptibility to infection). G. On 01/08/26 at 11:50 am, during an interview with the Interim Director of Nursing (IDON), she confirmed R #21 does not have interventions for MDRO and the need for Modified Environment Precautions in his care plan and should. R #63 H. Record review of R #63's admission record revealed R #63 was admitted on [DATE] with the following diagnoses: 1. Lymphedema (chronic swelling), 2. Chronic pain, 3. Bi-polar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 4. Adjustment disorder (a strong emotional or behavioral reaction to a specific, identifiable stressor), 5. Hypothyroidism (the thyroid is not making enough thyroid hormone). I. Record review of R #63's physician orders revealed an order please place assist/side rails x (times) 2. Start date 12/19/25. J. Record review of R #63's care plan dated 12/20/25 revealed there was no intervention for the use of side rails. K. On 01/04/26 at 1:26 pm during a random observation of R #63's room revealed quarter size bed rails on the upper right and left sides of bed. L. On 01/04/26 at 1:27 pm during an interview with R #63 she confirmed she uses the side rails for mobility and repositioning herself. M. On 01/08/26 at 11:50 am, during an interview with the IDON, she confirmed R #63's care plan should include the use of side rails and does not. R #71 N. Record review of R #71's admission Record revealed R #71 was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease with (acute) exacerbation (symptoms including shortness of breath, quantity and color of phlegm that typically lasts for several days), 2. Vascular dementia (changes in thinking and memory that occur when there isn't enough blood flow to part of the brain), 3. Dysphagia, oropharyngeal phase (a disorder or impairment in initiating a swallow), 4. Crohn's disease (type of inflammatory bowel disease (IBD) that causes swelling and irritation of the tissues, called inflammation, in the digestive tract. This can lead to belly pain, severe diarrhea, fatigue, weight loss and malnutrition), 5. Insomnia (sleep disorder that can make it hard to fall asleep or stay asleep). O. On 01/04/26 at 11:58 am during an observation and interview with R #71in his room, revealed a CPAP machine next to R #71's bed. R #71 he stated he does use his CPAP machine every night since admission to facility. P. Record review of R #71's care plan dated 03/29/25 revealed no interventions for the use of Continuous Positive Airway Pressure (CPAP) machine (a medical device that delivers pressurized air through a mask to keep your airway open during sleep). Q. On 01/08/26 at 11:51 am during an interview with IDON, she confirmed the facility failed to develop and implement a care plan that includes R #71's use of CPAP machine. The IDON stated that she expects residents to have a care plan that includes all required interventions including the use of CPAP machines.

Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 5 (R #20, R #35, R #41, R #71, and R #109) of 6 (R #20, R #35, R #41, R #63, R #71, and R #109) residents reviewed for respiratory care when the facility failed to:1. Ensure medical orders include the amount of oxygen (a specific flow rate; measurement of the volume of liquid or gas moving per unit of time) for R #20 and R #35.2. Ensure a medical order was in place for R #41's supplemental oxygen (extra oxygen required to support the body's vital functions) use. 3. Ensure medical orders, care plan and MDS (Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) were in place and accurate for R #71's use of a continuous positive airway pressure (CPAP; a breathing therapy device used to deliver a steady stream of oxygen through a mask) machine.4. Ensure medical orders indicated when to administer R #109 oxygen and the prescribed flow rate needed.These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions. The findings are: R #20 A. Record review of R #20's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Spastic quadriplegic (paralysis of all four limbs) cerebral palsy (a disorder of movement, muscle tone, and posture), 2. Chronic respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide) with hypoxia (low levels of oxygen in body tissues), 3. Dependence on supplemental oxygen, 4. Epilepsy (a seizure disorder). B. On 01/04/26 at 1:48 pm during an observation of R #20 in her room, she was observed lying in her bed wearing a nasal cannula (a medical device used to deliver supplemental oxygen through their nostrils) that was connected to an oxygen concentrator (a medical device that concentrates oxygen and delivers it to someone that needs supplemental oxygen) that was located next to her bed. C. Record review of R #20's current medical orders revealed an order dated 03/21/23 for R #20 to use oxygen at one to six liters per minute via (by way of) nasal cannula continuously. D. Record review of R #20's care plan revised on 06/14/25 revealed R #20 is to have oxygen as ordered. E. On 01/08/26 at 11:45 am, during an interview with the Interim Director of Nursing (IDON), she confirmed that R #20's order for oxygen use does not specify the exact amount of oxygen (liter and flow rate) that R #20 needs. R #35 F. Record review of R #35's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), 2. Iron deficiency anemia (Anemia is a condition in which the blood doesn't have enough healthy red blood cells. Red blood cells carry oxygen to the body's tissues), 3. Chest pain, 4. Muscle weakness, 5. Peripheral vascular disease (slow and progressive disorder of the blood vessels. Narrowing, blockage, or spasms in a blood vessel). G. On 01/04/26 at 11:50 am, an observation of R #35 in his room revealed R #35 wearing a nasal cannula that was attached to the oxygen concentrator that was located next to his bed. H. Record review of R #35's current medical orders revealed an order dated 03/29/25 for R #35 to utilize three to four liters of oxygen per minute via nasal cannula. I. On 01/08/26 at 11:47 am during an interview with the director of Nursing (IDON). She confirmed the order for R #35 does not specify the exact amount of oxygen (liters and flow rate) that R #35 should be on. R #41 J. Record review of R #41's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Pneumonia (infection that inflames the air sacs in one or both lungs), 2. Chronic obstructive pulmonary disease (ongoing lung condition caused by damage to the lungs), 3. Pulmonary hypertension due to lung diseases and hypoxia (chronic lung conditions and low oxygen levels), 4. Chronic kidney disease, stage 2 (mild kidney damage). 5. Iron deficiency anemia (Anemia is a condition in which the blood doesn't have enough healthy red blood cells. Red blood cells carry oxygen to the body's tissues). K. On 01/05/26 at 12:50 pm, an observation of R #41 in her room revealed R #41 wearing a nasal cannula that was connected to an oxygen concentrator that was located next to the bed. L. Record review of R #41's physician record revealed there were no orders for use of oxygen or oxygen device care. M. Record review of R #41's Care plan dated 3/25/25 revealed the following: 1. R #41 is at risk for respiratory complications related to COPD. 2. O2 as ordered. N. On 01/08/26 at 11:47 am during an interview with the Director of Nursing (DON), she confirmed R #41 did not have an order for use of oxygen and should have. R #71 O. Record review of R #71's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease) with exacerbation, 2. Vascular dementia (a type of dementia that results from conditions that damage blood vessels and block blood flow to the brain), 3. Acute and chronic respiratory failure with hypoxia (long-term respiratory failure that could occur suddenly leading to low oxygen levels in the body's tissue), 4. Obstructive sleep apnea (sleep disorder that occurs when a person's breathing is interrupted during sleep), 5. Pneumonia (infection and inflammation of the lung). P. On 01/04/26 at 11:58 am, an observation and interview of R #71 in his room revealed the following: 1. A continuous positive airway pressure (CPAP; a therapy device that delivers a steady stream of sir through a mask) machine connected to a medical stand located next to R #71 bed. 2. R #71 stated the was sent to the facility with the CPAP and that he uses the CPAP every night. Q. Record review of R #71's discharge documentation from a hospital dated 02/03/25 revealed the following: 1. R #71's primary diagnosis was acute and chronic respiratory failure with hypoxia. 2. The use of a CPAP was ordered. R. Record review of R #71's MDS (Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 12/02/25 revealed R #71 does not utilize a non-invasive ventilator (CPAP) machine. S. Record review of R #71's care plan dated 03/29/2025 revealed the care plan does not include the use of a CPAP machine. T. Record review of R #71'a physician orders revealed no current order for the use of the CPAP machine. U. On 01/08/26 at 11:50 am during an interview with the Director of Nursing (DON), she confirmed the following: 1. R #71 does utilize a CPAP machine. 2. R #71 should have an order in place for the use of the CPAP machine. 3. The use of the CPAP should be included in his care plan. 4. The use of the CPAP should be indicated in his MDS assessment. 5. The DON stated that the order, the MDS assessment, and the care plan should be accurate according to the resident's needs and confirmed R #71's is not. R #109 V. Record review of R #109's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), 2. Mild intermittent asthma (a condition that causes airways to swell making it hard to breathe), 3. Permanent atrial fibrillation (an irregular heart rhythm), 4. Obstructive sleep apnea (a disorder where muscles in the throat relax, making breathing difficult or stops breathing), 5. Presence of cardiac pacemaker (a device surgically implanted in the body to deliver electrical pulses to the heart to help the heartbeat in a regular rhythm). W. On 01/05/26 at 10:10 am during an observation of R #109 in her room, she was wearing a nasal canula that was connected to a portable oxygen concentrator that was attached to the back of her wheelchair. X. Record review of R #109's current medical orders revealed the following: 1. An order dated 12/31/25, to wear oxygen at one to five liters via nasal cannula continuously. 2. An order dated 12/31/25, to have oxygen on at one to five liters via nasal cannula as needed. Y. On 01/08/26 at 11:51 am, during an interview with the IDON, she confirmed the order for R #109's does not specify the amount of oxygen R #109 needed and whether he needed continuous or PRN (as needed) oxygen.

Based on observation, record review, and interview, the facility failed to obtain appropriate physician orders and complete assessments prior to installation of bed rails for 1 (R #118) of 2 (R #63 and R #118) residents reviewed for bed rails. This deficient practice could result in the physician and the resident not knowing the needs, risks and benefit of bed rails. The findings are: A. Record review of R #118's admission record revealed R #118 was admitted into the facility on [DATE]. B. Record review of R #118's physician orders revealed there is no order for use of bed rails.C. Record review of R #118's bed rail assessment dated [DATE] revealed R #118 does not need use of bed rails. D. Record review of R #118's baseline care plan dated 01/03/26 revealed there were no interventions for use of bed rails or mobility enablers. E. On 01/04/26 at 1:11 pm during a random observation of R #118's room revealed quarter size bed rails on the upper right and left sides of bed. F. On 01/04/26 at 1:12 pm during an interview with R #118, he confirmed he uses the side rails for mobility and repositioning himself. G. On 01/08/26 at 11:50 am, during an interview with the Interim Director of Nursing (IDON), she confirmed the following:1. R #63 physician orders does not include the size of bed rails and indication of use (reason for use) and should.2. R #118 does not have physician orders for use of bed rails and should prior to installation.3. R #118 assessment does not include the need for bed rails and should be prior to installation.

Based on observations, record reviews and interviews, the facility failed to ensure a medication error rate of less than 5% as ordered to 3 (R #s 5, 20, and 100) of 6 (R #s 1, 5, 20, 33, 86, and 100) residents reviewed. During the survey period, the survey team observed 27 opportunities for error and identified 3 errors, resulting in a medication error rate of 11.11%. Failure to administer medications as ordered could result in residents not receiving the full benefit of the medication regime. The findings are:R #5A. Record review of R #5's physician's order dated 10/15/25 revealed an order of wound care to the sacrum (area of the body at the base of the spine), cleanse with wound cleanser, pat dry, apply zinc (topical medication used to treat and prevent skin irritation), an apply optifoam (a specialty dressing for wound healing).B. On 01/08/26 at 9:16 am, observation of a scheduled wound care to R #5, LPN (licensed practical nurse) #1 used normal saline instead of wound cleanser.C. On 01/08/26 at 9:35 am, during an interview with LPN #1, he stated that he could not find any wound cleanser and decided to use normal saline instead. LPN #1 confirmed that he did not follow the order.R #20D. Record review of R #20's physician's order dated 08/05/25 revealed an order of Reglan (prescription medication used primarily to treat gastroparesis [slow stomach emptying]) tablet 5 mg (milligrams), give 1 tablet via PEG-tube (percutaneous endoscopic gastrostomy tube, is a flexible feeding tube inserted through the abdominal well directly into the stomach) four times a day for gastric motility (refers to the coordinated contraction and relaxations of the stomach muscles).E. On 01/04/26 at 11:20 am, during observation of medication administration, the State Agency (SA) observed three medication cups (each with prescribed medications in them, each with resident room numbers written on them) pre-poured by The Certified Medication Aide (CMA) #1. One of the medication cups has a green oblong pill stamped with Reglan 5 was accidentally touched by the SA. The CMA #1 witnessed the SA touch the medication. CMA #1 continued to crush the medication and administered the contaminated pill to R #20 via PEG-tube.R #100F. Record review of R #100's physician's order dated 11/04/25 revealed an order of rybelsus (prescription medication used to treat type 2 diabetes [DM2; a disease in which the body cannot make or properly use insulin]) tablet 7 mg given by mouth one time a day, take 30 mins before food/drink.G. On 01/06/26 at 8:41 am, during medication administration, LPN #2 was observed to administer the medication while R #100 is finishing his breakfast. H. On 01/06/26 at 8:43 am, during an interview with LPN #2, she stated that she did know it should be given 30 minutes before any food or drink.

Based on observation, interview and record review, the facility failed to ensure a resident received dental services for 2 (R #34 and R #56) of 3 (R #3, R #34, and R #56) residents reviewed for dental care. This deficient practice could likely result in residents experiencing tooth decay, tooth pain, and difficulty chewing. The findings are: R #34A. Record review of R #34's admission Record revealed R #34 was admitted to the facility on [DATE] with the following diagnoses:1. Personal history of transient ischemic attack (TIA; when blood flow to part of the brain stops for a brief period),2. Congestive heart failure (CHF; impaired heart function),3. Diabetes mellitus (a condition that results from insufficient production of insulin, causing high blood sugar),4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),5. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).B. On 01/04/26 at 2:16 pm, an observation and interview with R #34 in her room revealed the following:1. R #34 stated that she had not been to a dentist since her admission at the facility.2. R #34 has several missing teeth throughout her mouth.3. R #34 said she has told several staff members that the broken tooth bothers her but still hasn't had a dental appointment.C. Record review of R #34's care plan initiated on 08/29/22 revealed R #34 exhibits or is at risk for oral health or dental care problems as evidenced by multiple missing teeth.D. Record review of R #34's electronic health record (EHR) revealed a dental appointment dated 08/16/23, no further documentation of dental evaluations.E. On 01/08/26 at 9:53 am during an interview with the Scheduler (SCH) she confirmed R #34 has not had a dental appointment since being admitted to the facility. The Scheduler confirmed that due to R #34's dental issues, she should have been evaluated by a dentist.R #56F. Record review of R #56's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses:1. Type 2 Diabetes Mellitus (DM2; (a condition that results from insufficient production of insulin, causing high blood sugar),2. Acute congestive heart failure (CHF; impaired heart function),3. Non-ST-elevation myocardial infarction (NSTEMI; a type of heart attack)G. On 01/04/26 at 1:25 pm, an interview and observation with R #56 in her room revealed the following:1. R #56 stated that she needs to go to the dentist.2. R #56 has a missing tooth in the front of her mouth.H. Record review of R #56's EHR revealed no documentation of R #56 being evaluated by a dentist since her admission.I. On 01/08/26 at 9:53 am, during an interview with the Scheduler (SCH), she confirmed R #34 and R #56 have not been seen by a dentist since being admitted to the facility. The SCH stated that she expects all residents to have an annual appointment with a dentist. The SCH stated that she tries to keep up with all residents to ensure they are seen by a dentist annually and must've missed scheduling for R #34 and R #56.

Based on observation, and interviews, the facility failed to protect residents' personal health information (PHI) by leaving a document containing multiple residents' information (such as names, diagnoses, treatment plans, or room numbers) in a hallway. This deficient practice has the potential to affect residents residing on the 300 and 200 hall and can lead to unauthorized access to sensitive information, putting residents' privacy at risk.The findings are:A. On 01/05/26 at 2:11 pm, during an observation of the medication cart outside room [ROOM NUMBER], a white piece of paper with residents full name, room number and code status was left unattended and exposed to public view.B. On 01/05/26 at 2:15 pm, during an interview with Licensed Practical Nurse (LPN) #3, she confirmed that the white paper contained resident's identifier and should be kept hidden from public view and it did not happen.C. On 01/07/26 at 8:46 am, during an observation of the medication cart outside room [ROOM NUMBER], the computer containing resident's electronic medical record was left unlocked and exposed to public view unattended.D. On 01/07/26 at 9:02 am, during an interview with Registered Nurse (RN) #1, she confirmed that the electronic health record was left exposed to public view unattended.

Based on observation and interview, the facility failed to ensure call lights in the residents' rooms were within reach of the residents while in the room for 2 (R #22 and R #56) of 4 (R #2, R #8, R #22, and R #56) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance. The findings are:R #22 A. On 01/05/25 at 10:34 am during an observation of R #22's room revealed R #22 was asleep in her recliner. The call light lay on top of the bed where she could not reach it.B. On 01/05/25 at 10:36 am during an interview with Hospice Nurse (HN) #1, she confirmed the call light was not within R #22's reach and the call light should have been. R #56C. On 01/05/25 at 8:58 am during an observation of R #56's room, revealed R #56 was asleep in his recliner. The call light lay on top of the bed where he could not reach it.D. On 01/05/25 at 9:05 am during an interview with Certified Nurse Assistant (CNA) #2, she confirmed the call light was not within R #56's reach and the call light should have been.

Based on observation and interview, the facility failed to promote care with dignity and respect for 1(R #22) of 9(R #1, R #6, R #11, R #22, R #28, R #35, R #41, R #64 and R #71) residents reviewed for dignity and respect by not knocking on R#22's door before entering room. This deficient practice is likely to impact residents' dignity and respect for their personal space.The findings are: A. On 01/04/26 at 8:40 am, during a random observation of the 400-hall, Registered Nurse (RN) #5 walked straight into R #22's room without knocking or announcing himself to R #22. B. On 01/04/26 at 8:42 am, during an interview with RN #5, he confirmed that he should have knocked and announced himself prior to entering R #22's room.

Based on record review and interview, the facility failed to ensure for 1 (R #1) of 3 (R #1, 2 and 3) residents reviewed for bowel monitoring and interventions when the facility failed to monitor R #1 for constipation (problem with passing stool). This deficient practice likely resulted in R #1 having ongoing constipation, fecal impaction (hardened stool stuck in rectum or lower colon due to chronic constipation) and abdominal pain. The findings are: A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses including: - Wedge compression fracture (broken bone) of unspecified thoracic vertebra (upper back bone) with routine healing, - Severe protein-calorie malnutrition (low calorie/food intake), - Gastro-esophageal reflux disease (stomach acids repeatedly flow back into the esophagus-a tube which connects the mouth to the stomach), - Muscle weakness. B. Record review of R #1's quarterly Minimum Data Set (MDS; a comprehensive assessment of a resident's overall abilities, strengths and weakness), dated 01/04/24, revealed the following: - The resident required supervision and touching assistance from staff for toileting. - The resident was always continent (used the toilet without an incident of soiling herself) of bowel and bladder. C. Record review of R #1's care plan revealed the following: - Dated 10/23/23, R #1 was at risk for dehydration as evidenced by poor intake. - Dated 03/28/23, R #1 was at risk for gastrointestinal (stomach, small and large bowel systems) symptoms or complications related to constipation. - The plan directed staff to assess for and report signs and symptoms of nausea or vomiting, abdominal distension, decrease in bowel movements, decrease in bowel sounds, and abdominal pain. D. Record review of R #1's daily tasks [a list of activities performed by assigned Certified Nurses Aide (CNA)], dated February 2024 and 03/01/24 to 03/04/24, revealed the CNA monitored R #1's daily bowel regimen and documented the following: - The CNA did not document any bowel movements for the resident from 02/01/24 to 02/13/24. - The CNA did not document any bowel movements for the resident from 02/17/24 to 02/19/24. - The CNA did not document any bowel movements for the resident from 02/25/24 to 02/27/24. - The CNA did not document any bowel movements for the resident on 03/01/24 and 03/02/24. - Of the 7 days out of 32 days in which a bowel movement was recorded, it was recorded as size small. E. Record review of facility Physician's Reference Orders (a physician order to be started if a resident shows signs of constipation), updated December 2022, revealed a directive for constipation: If the resident did not have a bowel movement for two days then use polyethylene glycol (a laxative medication that induces bowel movement). One tablespoon in 4 ounces of fluid every four hours as needed. F. Record review of R #1's physician orders, dated February 2024 and March 2024, revealed the records did not contain an order for any medication to treat constipation. G. Record review of R #1's Medication Administration Record (MAR; a written documentation of staff's administration of all prescribed medications to the resident), dated February 2024 and March 1st to 4th, 2024, revealed the record did not contain documentation staff administered a laxative to the resident. H. Record review of R #1's medical records, dated February 2024 and March 1st to 4th, 2024, revealed the record did not contain the following: - Documentation the CNAs reported to the nurse that the resident did not have a bowel movement for two or more days, multiple times. - Documentation the staff contacted the doctor regarding the resident did not have a bowel movements for two or more days, multiple times, and did not have a prescription for a laxative. I. Record review of R #1's Daily Care Notes revealed staff documented the following: - On 03/04/24 at 12:31 am, at approximately 9:00 pm a CNA reported aggressive behavior from R #1's roommate. Director of Nursing was notified. Police called but a report was not made. Resident changed to a new room. - On 03/04/24 at 4:43 am, a telehealth visit with R #1. The provider indicated R #1 was seen due to stomach pain and vaginal bleeding. Nurse reported seeing some bright red blood when R #1 was in the bathroom. R #1 was ambulatory and not in acute distress, but she reported stomach pain. R #1 to follow up with her primary care team within the next few hours for a better exam. - On 03/04/24 at 5:48 am, the nurse stated R #1 had vaginal bleeding twice in the morning and complained of abdominal cramps. Staff notified the on-call medical doctor at 5:34 am. There were not any new orders. Follow-up with facility MD. - On 03/04/24 at 10:42 am, a note from nurse stating staff called the resident's family member to notify her of R #1's transfer to hospital. J. Record review of R #1's hospital medical records revealed the following: - On 03/04/24 at 10:43 am, the resident was admitted to the emergency room (ER). - Upon admission the ER doctor performed a rectal exam and found a maroon stool in the rectal vault (the area just beyond the rectal sphincter where stool is formed and stored until being passed.) - On 03/05/24 at 1:28 pm, the resident was examined by use of flexible sigmoidoscopy (an examination of the rectum and end of the large intestine conducted by using a long flexible tube with camera that is passed into a patient's rectum and beyond.) - The result of the examination revealed a large fecal burden (large amount of feces) with solid, semi-solid, dense liquid stool, and a large volume of maroon blood and clots. - The test provided evidence of chronic constipation and fecal impaction (a solid densely packed quantity of feces that is very difficult to move into and past the rectum.) - On 03/05/24 at 8:34 am, the resident was examined by use of a computed tomography (CT) scan (an x-ray that uses computer enhanced imaging to view and diagnose the body's internal functioning). - The result of the examination revealed a 1 to 1.5 centimeter area of suspected arterial (a blood vessel that supplies blood to an area of the body) bleeding at the distal rectum (the far end of the rectum). - R#1 received multiple blood transfusions during the course of her stay without successfully stabilizing her condition. - A death summary, dated 03/07/24 at 5:59 am, stated the resident's cause of death was acute myocardial infarction (heart attack) in the setting of gastrointestinal hemorrhaging (upper and lower abdominal bleeding) K. On 04/18/24 at 12:00 pm during interview with CNA #1, she stated she was a CNA with the facility, and she was a Navajo (a regional American Indian [NAME]) speaker. She stated R #1 was primarily a Navajo speaker, and she was often assigned to R #1 since she was able to communicate with R #1. CNA #1 stated R #1 complained of abdominal pain on 03/03/24 at about 8:30 pm. She stated the abdominal pain was significant, and R#1 cried while talking about the pain. CNA #1 stated she reported this to R #1's nurse. CNA #1 stated R #1 continued to complain and cry during the night. She stated R #1's roommate became upset with R#1. The CNA stated the roommate went to R #1's bed and kicked the end of the bed. CNA #1 stated she reported the incident to the nurse managing R #1's care and began making arrangements for R #1 to move to another room within the facility. CNA #1 stated she frequently checked on R #1 during this time as the resident complained of continued pain in her abdomen. L. On 04/18/24 at 3:30 pm during interview with Licensed Practical Nurse (LPN) #1, she stated she received R #1 from another unit in the facility early in the morning on 03/04/24. She stated she assisted R #1 to the bathroom twice, and both times she noted a small amount of bright red blood in toilet. LPN #1 stated she called the on-call provider and did a televisit (an internet phone call with televised viewing). The televisit provider did not see or talk with R #1, because the resident was in bed. The provider suggested to wait and have the facility provider see R #1 in person later in the morning. M. On 04/18/24 at 2:13 pm during interview with the Director of Nursing (DON), she stated that on the morning of 03/04/24, there was an incident in which R #1's roommate became upset, because R #1 would not stop crying. She stated staff discovered R #1 was having abdominal pain, R#1 was evaluated and then was sent to the hospital. The DON stated the CNAs should monitor residents daily. She stated best practice would be for CNAs to ask all residents daily if they had a bowel movement, report to the nurse, and record in the residents' daily tasks. The DON could not confirm that this had been done for R#1 prior to her transfer to hospital. The DON confirmed the facility had a set of Reference Orders ordered by the Medical Director which included an order for a resident who was constipated. The DON stated this order should begin when a resident is three days without a bowel movement. N. On 04/18/24 at 4:40 pm during interview with the activity aide (AA), she stated she knew R #1 and could communicate with the resident. She stated she spoke enough Navajo language to be able to communicate with R #1. She stated she was often asked to assist with communicating with R #1, and she met with R #1 almost daily. She stated she never asked R #1 if she was constipated, and R#1 did not say if she was constipated or had regular bowel movements. O. On 04/18/24 at 12:40 pm during interview with CNA #2, she stated it was hard to monitor residents who were independent in their toileting activities. She stated she did not always ask residents about their daily toileting activities. CNA #2 also stated she was unable to check with R #1 about her status, because she (CNA #2) could not speak Navajo to communicate with R#1. CNA #2 stated at times she would ask another Navajo speaking staff member to assist her but not always. P. On 04/19/24 at 10:20 am during interview with CNA #3, he stated he asked residents if they were comfortable. He stated the computer monitored the residents' daily bowel movements after the CNAs recorded them. He stated that if a resident went three or more days without a bowel movement then the computer triggered an alert for the nurse to review. Based upon observation, interview, and record review, Immediate Jeopardy was identified on 04/19/24 at 12:40 pm. The facility Administrator was notified in person and by e-mail at this time. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 04/19/24 at 4:17 pm and implementation was verified onsite. The scope and severity was reduced from Level 4, J to Level 2, D The plan of removal included: 1. Identification/Correction: All residents have the potential to be affected by this alleged deficient practice. The following identification/corrections will be completed by 04/19/24: - Licensed nurses will complete assessments on current residents residing in center to determine if any residents were constipated or without bowel movement for greater than three days. - For those who could not answer and had no current documentation, an abdominal assessment will be completed. - Any resident that is independent with toileting will be identified and care plan/kardex will be updated to indicate needed monitoring. - CNAs will document their findings in POC which will be monitored daily by the nurse manager. - Identified issues will be reported to the provider for further direction; medical orders and change in condition process will be implemented. - If a resident is identified as needing immediate medical assistance, 911 will be called and the patient will be transferred to an ER for evaluation. 2. Systemic Measures: The Director of Nursing re-educated current licensed staff regarding policy for resident change in condition. The education includes: - Documentation of ADLs by end of shift, including bowel movements. - CNAs should be alerting nurses if a resident has not had a bowel movement within the past three days, and with consistency concerns like very hard, compacted bowel movement,and loose. - The nurse should use medications/interventions per reference orders provided by the Medical Director for bowel management. If this intervention does not work, the CIC process needs to be followed and provider/family needs to be notified. - Then a bowel management plan needs to be implemented. - The Director of Nursing/designee will begin education 04/19/24. - As of 04/19/24, 100% of currently scheduled staff have been educated on this information. - Any staff member that is not on the current schedule as of 04/19/24, is on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. New hires and agency staff will be educated during orientation. - Agency staff are currently and will continue to be educated by the facility human resources and mentor as part of the orientation process, prior to their first shift. Nurse management/designee will monitor CNA documentation on all shifts via dashboard to ensure documentation is being completed timely. Nurse management will review the dashboard daily in clinical meeting for bowel alerts and follow-up will occur with nurses and CNAs to ensure processes are followed. The Director of Nursing/designee will review resident progress notes, orders, and nursing dashboard during morning clinical meeting to determine if residents noted change in condition identified, and process followed, including monitoring and interpretive services are being used. 3. Quality Assurance and Monitoring: The Director of Nursing/designee will audit CNA documentation daily in clinical meetings five days per week for one month, then weekly times two months. Five random independent residents will be interviewed weekly to ensure that bowel movements are accurately documented for independent residents, times one month. Then three random residents for two months. Administrator and/or designee will bring results of audits to QAPI committee for further recommendations based on tracking and trending presented monthly for the next three months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator. 41988

Based on record review and interview, the facility failed to provide the necessary assessment and adequate pain medication to effectively manage pain for 1 (R #1) of 1 (R #1) resident reviewed for pain management. This deficient practice likely resulted in this resident experiencing severe pain. The findings are: A. Record review of the face sheet indicated that R #1 was admitted on [DATE]. R #1 was admitted with the following diagnoses Zoster (or shingles a viral infection caused by varicella-zoster characterized by painful rash with blisters), Hypertension (high blood pressure), Diabetes II (means that your body doesn't use insulin properly), Hyperlipidemia (abnormally high levels of fats (lipids) in the blood, which include cholesterol and triglycerides), End Stage Renal Disease (kidneys reach advanced state of loss of function) on Dialysis (a blood purifying treatment given when kidney function is not optimum), Depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), Lack of Mobility (not being able to get around as well) and Muscle Weakness. B. Record review of the progress notes dated 03/08/23 at 15:46 (3:46 pm), nursing observations, evaluation, and recommendations for resident fall: resident was found sitting on the floor, he was assisted to get up to the bed. He complained of left hip pain, no injury was observed after the fall. Referred to the provider on call and ordered a routine x-ray. Neurochecks (assess an individual's neurological functions, motor and sensory response, and level of consciousness) initiated will continue to monitor. There was no documentation that pain medication was provided at this time. C. Record review of the assessments in the medical record did not reveal that a pain assessment was completed after R #1 fell on [DATE]. D. Record review of the x-ray taken on 03/08/23 did not reveal any fractures to the pelvis (lower part of the trunk between the abdomen and the thighs). E. Record review of the progress notes dated 03/09/23 at 9:42 am, Interdisciplinary Team (IDT) Note: review of fall 3/8/2023. Resident found sitting on floor next to bed. Resident assessed; complaints on left hip pain, no injuries observed. Neurochecks initiated. Family and provider aware . There was no documentation that pain medication was provided following the fall. F. Record review of the Medication Administration Record (MAR) for March 2023 indicated for pain monitoring Ask resident if they are having pain. Document pain level and new onset Y/N in supplementary documentation and document location of pain in emar PN (progress note) every day and night shift if new onset complete EInteract Change in Condition and Pain Evaluation, if not new initiate non-pharmalogical interventions and document interventions and effectiveness. From March 1st through March 9th [2023] pain level is noted to be 0 indicating R #1 had no pain. H. Record review of the Communication Form (eInteract) indicated that on 03/08/23 after R #1's fall in the pain evaluation section indicated yes resident has pain. That the pain is new and is located at left trochanter (hip) and for question 'does resident show non-verbal signs of pain?' it is marked as yes sad/frightened/frown. No pain scale was indicated and no evidence that pain medication was provided. F. Record review of the MAR for March 2023 indicated that the only medication that resident had ordered by the physician for pain, scheduled or as needed, was Duloxetine two times per day for nerve pain. (Duloxetine is used to treat depression and anxiety. In addition, Duloxetine is used to help relieve nerve pain (peripheral neuropathy) in people with diabetes). No additional pain medication was documented as being administered on the MAR. G. Record review of the Nursing Progress Notes dated 03/09/23 at 11:00 am, indicated that resident had an appointment with Dialysis at 11 am on 03/09/23. He was given his medications before he left including Tylenol because he complained of pain due to his fall the day before. Dialysis nurse called this writer and stated that (name of resident) told them that he had a fall and she was calling to confirm if it's true, what happened because his pain is 10/10 and what was the intervention done. Dialysis called back and informed the facility that they sent him out to (name of hospital) due to his severe pain. Informed Director of Nursing or Center Nurse Executive (DON/CNE) about what happened. H. On 06/06/23 at 3:32 pm, during an interview with dialysis nurse, she remembers the patient resided at SNF/NF (Skilled Nursing Facility/Nursing Facility) and arrived to his dialysis chair time in severe pain and a complaint that he fell . The patient stated he had fallen and was in severe pain. They were not able to transfer him because of the pain. The Nephrology (doctor that specializes in diseases and conditions that affect the kidneys) physician told the nurse to send him out. The patient was sent out and admitted to hospital. R #1 was x-rayed after the fall and it revealed he had multiple fractures of pubic bone. I. On 06/07/23 at 1:46 pm, during an interview with Unit Clerk (UC), she stated that she translates a lot for residents who speak Spanish. She would translate for him and she also checked in on him regularly to make sure he was doing ok. She stated that he (R #1) was having a lot of pain the morning of 03/09/23 (his fall occurred on 03/08/23). She stated that he told her that his pain was a 10 out of 10. She stated that she told the nurse (RN #5) and she thinks the nurse gave him something for his pain. She also remembered a phone call from the Dialysis Clinic asking about the fall and the pain that he was having, and what interventions were in place for him. J. On 06/07/23 at 2:20 pm, during an interview with the CNE, she stated that she did not see an order for any pain medication. She stated that there are standing or reference orders (physician orders that are available for nursing staff to use if needed) that they can use. She stated that she was told that the nurse gave a Tylenol out of the reference orders but it wasn't documented that it was given on the MAR and it should have been. H. On 06/07/23 at 3:15 pm Registered Nurse (RN) #5 stated that she went to R #1 the morning of 03/09/23 before diaylsis, and he was grimacing and told her that his pain level was 10 out 10. She stated that she gave him the Tylenol out of the reference orders that are there for them to use. She stated that there wasn't time to consider giving something else for pain because he was headed out to Dialysis. I. On 06/07/23 at 3:45 pm, during an interview with the CNE, she stated that an automatic pain assessment/evaluation should have been completed when a resident expresses any pain. If they do one and then there is an increase in pain they can always do another one [assessment]. J. Record review of the Hospital Admission: On 03/09/23 at 1303 (1:03 pm). General complaint indicated that resident was seen at Hemodialysis (HD) and examined and stated he was unable to move his RLE (right lower extremity) and is having pain. X-ray completed at 1354 (1:54 pm). Findings of the x-ray indicated that bony structures are osteopenic (low bone mass or low bone density). There are fractures of the left superior and interior pubic rami (a group of bones in their lower pelvis). Oxycodone was given for pain. K. Record review of the Hospital Physical Therapy (PT) progress note on 03/10/23 indicated the following: . (pelvic fx, WBAT (weight bearing as tolerated) lower left extremity (LLE)) pt return from Hemodialysis (HD) and Physical Therapy (PT) eval attempted, pt c/o (complain of) severe L hip pain and states he cannot move at all, pt (patient) was given immediate release pain pill and after some encouragement pt agreed to try and sit on EOB (edge of bed) however upon initiating mobility pt could not tolerate movement of LLE, pt visibly distressed with movement and stated I cant stand it, and mobility attempts discontinued. Therapy will attempt to see pt tomorrow.

Based on record review and interview, the facility failed to notify the physician and family for 1 (R #17) of 1 (R #17) resident reviewed for falls. This deficient practice likely resulted in a delay in identification of a hip fracture and unnecessary pain. The findings are: A. Record review of the face sheet revealed R #17 was admitted to the facility from a local hospital on 03/03/22 with a primary diagnosis of left femur [long bone in upper leg extending from the hip to the knee] fracture and a secondary diagnosis of dementia [a group of symptoms that affects memory, thinking and interferes with daily life] without behavioral disturbance [a pattern of disruptive behaviors]. B. On 11/01/22 at 2:40 pm, during an interview with R #17's husband and Power of Attorney for Health Care [legal document that empowers a specific individual to make decisions on your behalf concerning your medical condition, treatment, and care] (HCPA) decisions, he revealed, on Tuesday [09/27/22] [first name of hospice nurse for R #17] called and said his wife had a fractured ]broken] left hip the upper part of the upper bone of the thigh that extends from hip to knee] and pelvis [a break of the bony structure of the pelvis (to include sacrum, hip bones and tailbone]. I go to the nurses station and said, 'Did my wife fall?' It was one of the traveling nurses [he addressed] and after she looked in the computer [looking for information about R #17 falling], she said, no. The nurse next to her [at the nursing desk], [first name of Registered Nurse (RN) #10], then told him his wife had fallen out of bed on Friday [09/23/22] and she [RN #10] didn't write it up [did not write an incident report - a document that describes an incident that occurred in which a resident might be harmed and where you document calling the provider and the family to notify of the incident]. C. On 11/01/22 at 4:30 pm, during an interview with R #17's hospice nurse, she revealed, she saw R #17 on 09/26/22, that she [R #17] had a dramatic change in status, tremendous pain and could not bear weight on her left leg. She asked for X-rays [to be obtained] and when the results were given to her [on 09/27/22] she called the nurse at the facility [RN #10] and was told [by RN #10] that R #17 had been found on the floor by her bed around dinner time [4:30 pm] on Friday evening [09/23/22] they [facility staff] found her on the floor by her bed, they thought she had just tried to get into her wheelchair (w/c) by herself to go to dinner, she assessed her and thought she was fine [was not injured] so they put her in to her w/c and gave her dinner. D. On 11/03/22 at 11:20 am, during an interview with Registered Nurse (RN) #10 [nurse who was caring for R #17 when she fell on [DATE]] she revealed, I just got too busy and let it slip my mind [to report the incident]. No, I didn't call the husband or the doctor that day. [She confirmed the husband and medical provider were not informed of R #17's fall on 09/23/22 until 09/27/22]. E. On 11/03/22 at 1:35 pm, during an interview with the Nurse Practioner caring for R #17 at the facility she revealed that the residents fall on 09/23/22 had resulted in an acute [new] hip and a pelvic fracture. She had been informed about the hip fracture after the resident had X-rays done on 09/27/22 and she had read the report from the radiologist for the first time today [11/03/22] and it was then she realized the resident also had a pelvic fracture.

Based on record review and interview the facility failed to provide quality care for 1 (R #17) of 1 (R #17) resident reviewed by delaying in identifying a hip fracture [the upper part of the upper bone of the thigh that extends from hip to knee] and pelvis [a break of the bony structure of the pelvis {to include sacrum, hip bones and tailbone}] for 3 days following an unwitnessed fall and then not communicating with staff about the new fracture for consideration when transferring/repositioning the resident which likely resulted in unnecessary pain and further limiting R #17s range of motion. The findings are: Findings R #17 A. Record review of the face sheet revealed R #17 was admitted to the facility from a local hospital on 03/03/22 with a primary diagnosis of left femur [long bone in upper leg that extends from the hip to the knee] fracture and a secondary diagnosis of dementia [a group of symptoms that affects memory, thinking and interferes with daily life] without behavioral disturbance [a pattern of disruptive behaviors]. B. Record review of census revealed R #17 was admitted to hospice [end of life care] services on 04/20/22 C. On 11/01/22 at 2:40 pm, during an interview with R #17's husband and Power of Attorney for Health Care [legal document that empowers a specific individual to make decisions on your behalf concerning your medical condition, treatment, and care] (HCPA) decisions, he revealed, on Saturday [09/24/22] he came to visit R #17 as he does each day. A hospice guy [Home Health Aide [HHA]] comes by and gives her a shower Saturday and touched her side [left] and it hurt. Then [on] Monday here comes the hospice guy [HHA] again to give her a shower and he [the hospice HHA] text me and says she is in a lot of pain and he called [first name of the hospice nurse who cares for R #17] and she [the hospice nurse] ordered an X-ray [test that produces images of the structures inside your body, particularly your bones] [On] Tuesday [09/27/22] [first name of hospice nurse for R #17] called and said she [R #17] had a fractured left hip and pelvis. He [R #17's husband] revealed he used to get her up in her wheelchair [prior to the fall on 09/23/22] when he came to see her, almost daily, she enjoyed being taken around the facility and talking to other residents, now she mostly just yells whenever you disturb [turn her in bed, bathe] her. He stated, She will never get out of bed again. D. On 11/01/22 at 3:30 pm during an interview with the Certified Nursing Aide (CNA) #11 caring for R #17 she revealed, she cares for R #17 often and turns her in bed every two hours when she it there. She stated, she is turned just side to side like everyone. CNA #11 revealed, there have been no new instruction for how to turn R #17 since the new hip and pelvic fractures were diagnosed on [DATE]. E. On 11/01/22 at 4:30 pm, during an interview with R #17's hospice nurse, she revealed, she saw R #17 on 09/26/22, that she [R #17] had a dramatic change in status, tremendous pain and could not bear weight on her left leg as she had previously been able to do. She [the hospice RN] asked for X-rays [to be obtained] and when the results were given to her [on 09/27/22] they revealed R #17 had a left hip fracture and a pelvic fracture. She called the nurse at the facility [RN #10] and was told [by RN #10] that R #17 had been found on the floor by her bed around dinner time [4:30 pm] on Friday evening [09/23/22] they [facility staff] found her on the floor by her bed, they thought she had just tried to get into her wheelchair (w/c) by herself to go to dinner, she assessed her and thought she was fine [was not injured] so they put her in to her w/c and gave her dinner. The hosice RN revealed for R #17's comfort they would keep her in bed as moving her contributed to her pain. She confirmed she had not updated a plan of care to help alleviate R #17's pain related to fractures [with interventions such as specific ways to turn resident, ice or heat packs] but had spoken with R #17's husband to educate him about the need for more pain control with medication. F. On 11/03/22 at 10:30 am, during an interview with the Medical Director, she revealed that because R #17 is a hospice patient, the focus is on her comfort only. She reported that she would think that she [R #17] might not be comfortable lying on the left side. G. On 11/03/22 at 1:20 pm, during an interview with the Hospice Home Health Aide (HHA) he revealed that he was never given any instructions on how to move R #17 after her fall, but from his past work experience with trauma patients he knew how to handle turns so that the resident remains comfortable and the fracture does not become displaced [change the alignment of the fractured bone]. H. On 11/03/22 at 1:35 pm, during an interview with the Nurse Practitioner (NP) caring for R #17 she revealed On Saturday [09/24/22] they [staff at the facility] had told me she [R #17] was agitated (feeling or appearing troubled or nervous) the night before and they [the facility staff caring for R #17] were wondering if she needed more of, I think Ativan [medication for anxiety] and I think morphine [medication for pain] [the NP was not aware of the fractures at that time]. She confirmed that, after becoming aware of the hip fracture on she believes Tuesday [09/27/22] when called about R #17's X-ray report and notified of the hip fracture she had not written any new orders in terms of how to position the resident or other interventions [examples, ice or heat] to promote comfort. She revealed she had just learned of the pelvic fracture when she reviewed the X-ray report on this day [11/03/22]. I. On 11/03/22 at 2:12 pm, during an interview with CNA #15 she revealed, I was there [working on 09/23/22] but I was in the dining room [when R #17 fell ]. They had her [R #17] on the wheelchair when I went back [to the unit] after [the meal] she [R #17] was complaining about pain and she was saying she hurt. CNA #15 confirmed that R #17 was not able to identify the location of the pain. J. On 11/03/22 at 11:20 am, during an interview with Registered Nurse (RN) #10 [nurse who was caring for R #17 when she fell on [DATE]] she revealed, I was working by myself [no other nurse or Certified Medication Aide (CMA) to assist her with medication passes] on the floor that day and I never had to work that floor alone before. I want to say that first, because that had a lot to do with it [not following up with an incident report and calling the physician and the POA after R #17's fall]. I was just passing medications, and it took forever because they [the residents] had all these needs whenever I went into the room. I don't remember if it was 4:00 or 4:30 [pm] when they [the Certified Nursing Assistants (CNA's)] called me to [first name of R #17] room and she was on the floor, the aides [CNA's] said they found her there. She was on the bare floor. She had those soft socks on, no not with the little pads [tread stop/anti slip pads to help prevent falls]. The wheelchair was there [by her bed where she fell ] she might have been trying to move into it or from it. When I did my assessment, any place you touched her she was yelling and moving you couldn't touch anything, but she didn't say she hurt. I moved her arms and legs and there was no difference in her yelling. We got her up in the chair [w/c] and she settled [became more calm] I asked the CNA's [who had workedd with R #17 more often than the nurse had] and they said it was kind of normal behavior for her [R #17] she yelled and did not answer questions [as part of her usual behaviors]. I just got too busy and let it slip my mind [to report the incident]. No, I didn't call the husband or the doctor that day. I did the CIC [Change in Condition/Incident report] when I came back the following Tuesday [09/27/22] and that is when I notified the Nurse Practitioner and the husband. K. On 11/04/22 at 9:51 am, during an interview with RN (Registered Nurse) #12, the nurse who cared for R #17 on the weekend after fall [09/24/22 and 09/25/22] she reported I didn't really know her [R #17] [and didn't know she had new fractures] well, she was combative [ready or eager to fight] with the CNA's that Saturday morning and we couldn't get her changed for quite a while. At the time her husband came in around 8:00 [am], she was just confused and she was kicking and thrashing (moving in a violent way) about. She had difficulty moving out of the bed and yelled more when we did try to get her up.

Based on interview and record review the facility failed to notify the on-call provider of multiple medication errors and keep the on-call provider notified of changes that were occurring with the resident and didn't allow the on-call provider to make informed decisions about the residents care and treatment for 1 (R #210) of 1 (R #210) resident reviewed. This deficient practice likely contributed to the residents death. The findings are: Resident #210 A. Record review of the facility five day follow up report dated 01/10/22 indicated that that R #210 was an [AGE] year-old female with a history of [CONDITION(S)] (CHF) with Ejection Fraction of 25% (ejection fraction is the amount of blood -- given as a percentage -- pumped out of a ventricle during each heartbeat, this evaluates how well the heart is pumping), diagnosed in December of 2021, history of chest pain, chronic pain, pleural effusion (an excessive collection of fluid in the pleural cavity, the fluid-filled space that surrounds the lungs), [CONDITION(S)] (A-fib is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart.), severe pulmonary disease (any condition that affects the blood vessels along the route between the heart and lungs), Hyper tension ([CONDITION(S)] is high pressure in the arteries (vessels that carry blood from the heart to the rest of the body), GERD (gastroesophageal reflux disease is a digestive disorder that affects the lower [CONDITION(S)] sphincter (LES), the ring of muscle between the esophagus and stomach), among other comorbidities. Resident had an open reduction and internal fixation of a [CONDITION(S)] in October 2021. The patient recently had significant fluid removed via a thoracocentesis ( procedure to remove fluid or air from around the lungs) on 12/15/21. B. Record review of a five day follow-up dated 01/10/22 from a faciltiy reported incident (FRI) indicated that the evening of 12/27/21 a medication error occured where R #210 was administered the wrong medication. The medication administered to R #210 was as follows: [MEDICATION(S)] (for pain), 10 mg (milligrams), [MEDICATION(S)] (for pain), 50 mg, [MEDICATION(S)] (anxiety), 25 mg, Famotidine (antacid) 20 mg, Senna (for constipation) 8.6 mg, and Guaifenesin (mucinex), 600 mg. C. Record review of a progress notes dated 12/27/21 at 20:45 (8:45 pm), Wrong medication administered to PT (patient), DON (Director of Nursing aka Center Nurse Executive), Family notified. Will continue to monitor. There was no evidence that the Physician was notified of the medication error. D. Record review of the nursing progress notes dated 12/27/21 at 21:07 (9:07 pm) pt agitated and yelling out at this time. o2 (oxygen) sats (saturation) 57% on 5LPM (liters per minute) with a HR (heart rate) of 135, BP (blood pressure) 90/46. 911 EMERGENCY CALLED. E. Record review of the nursing progress notes dated 12/27/21 at 21:24 (9:24 pm) EMTs arrived on scene. EMTs stated that pt (patient) was stable and that 02 was empty and that the O2 tank was not hooked up properly EMTs took over pt care at this time along with other night nurse. EMTs stated to family that pt was stable and that maybe the nurses should collect a UA (urinalysis) because pt had a fever at this time as well and that we should check for a [CONDITION(S)] (Urinary Tract Infection). Writer notified EMTs of current critical potassium lab of 2.9 (low patassium can result in fatigue, muscle cramps and abnormal heart rhythms); pt had reported episodes of CP (chest pain) previous shift. EMTs continued to speak with family and stated that family should keep pt here at facility because we could treat a [CONDITION(S)] and low potassium here at the facility and that she would just be waiting in the waiting room all night anyway. Family chose to keep pt in facility against writers' (LPN #9) suggestion to be transferred to hospital. F. Multiple outreach efforst were made to R #210's family throughout the survey however never recevied a call back. G. Record review of the nursing progress notes dated 12/28/21 at 00:58 (12:58 am) pt found not breathing at this time. pt is a DNR (Do Not Resuscitate) as stated by husband. DON (CNE Center Nursing Executive) contacted. OMI (Office of the Medical Investigator) also contacted. H. Record review of medical chart vital signs for R #210 indicated that no vitals were documented in the resident chart after 8:31 am on 12/27/21. I. On 03/25/22 at 10:27 am, during an interview with the Center Executive Director (CED), he stated that during his investigation it was revealed that there were two contract nurses. LPN #9 asked that LPN #10 assist her with passing medication to a resident who was agitated. He went on to say that LPN #10 at some point became confused and passed the medications to resident (R #210) instead of R #183 . Both residents had family in their rooms and both residents were agitated. After LPN #10 came out of R #210's room she realizes that she gave the medication to the wrong resident. LPN #10 reported to LPN #9 right away and the physician on-call was called. The physician ordered [MEDICATION(S)]. At that time after the phone call to the on-call, R #210's vitals were checked. Vitals were noted as low, and they provided oxygen to R #210 and called 911. The on-call was called again and dc/d (discontinued) the [MEDICATION(S)] and ordered R #210 be sent out to the hospital. The EMT's arrived at the facility and facility staff informed them of the situation. The EMT's noted at that time that R #210's vitals were stable and recommended that R #210 stay at the facility since she was stable and would only be uncomfortable while she waited to be seen. Family was present in the room at the time with the EMT's and decided that if she was stable to not have her transported to the hospital. The CNE stated that staff were monitoring her and doing frequent vital checks even though the vitals were not written down and in R #210's medical record. Around two hours later she (R #210) was found unresponsive. Since she was DNR they facility staff did not try to resuscitate her. Family was called and notified. When asked if the physician should have been notified about the decision not send her out to the hospital, he stated that he didn't think that would have been necessary. It was the family's decision to not send her out. He confirmed that the monitoring of R #210's vitals should have been documented and they were not. J. Record review of R #210's medical record did not reveal that [MEDICATION(S)] had ever been ordered or administerd to R #210 on 12/27/21. K. On 03/29/22 at 7:39 am, during an interview with RN (Registered Nurse) #1, she stated that she was called the night of the medication incident. She wasn't the CNE at that time. When she was called that night, she was told that there was a med error. She told the nurse that she needed to call the CNE. When asked who had signed out the medications that were given that night, she stated that LPN #9 signed them out. When asked if she had any information on whether the medications had been poured ahead of time, she stated it is not common to pop the medications and not give them right away, this is not how you pass meds. RN #1 also stated that Yes they should have called the physician back to let them know of the situation and get orders of what to do next. They never gave the [MEDICATION(S)], and she stated that from her understanding the family and the nurses wanted to send R #210 to the hospital but the EMT's changed the family's mind. Physician should have been called. L. On 03/30/22 at 9:46 am, during an interview with LPN #10 she stated that the night of 12/27/21 she was working the night shift. LPN #9 asked her to help passing medications on her hall. She agreed to help LPN #9. She stated that she got the medication out of the medication cart and went to R #210's room. She stated that at some point she had gotten confused about which resident she was passing the medications to because as soon as she had given the medications to R #210, she realized that it was the wrong resident. She told LPN #9 right away and the on-call provider was called. Shortly after that R #210's vitals were low, and the paramedics were called out. When they (EMT's) arrived, they were informed of the medication errors. The EMT's kept stating that the oxygen was hooked up wrong and that the reading they had before they were called probably wasn't right. They kept stating that she stable and didn't need to go the hospital. The family was present in the room at this time and the family told facility staff that if she was stable, they didn't want her to be uncomfortable in the ER waiting and the decision was made to keep her at the facility. She stated that she was not aware of the on-call provider being called again to ask for further direction and to inform of the decision that had been made to not send R #210 to the hospital. M. Multiple outreach attmept were made to talk with LPN #9 who no longer worked at the faiclity, however never received a call back. N. On 03/30/22 at 11:40 am, during an interview with Medical Director (MD), she stated that she looked through the logs that are kept of every call that comes through. She stated that on the evening of 12/27/21 someone from the facility called the on-call provider Nurse Practionier (NP #2) at 9:18 pm and the call was about abnormal vitals. The MD stated that she called NP #2 on 03/30/22 and asked about the call, and she was told by NP #2 that she didn't remember any conversation about multiple medication errors and ordering [MEDICATION(S)]. She stated that in their record of phone calls this was the only call from the facility they received on 12/27/21. She stated that there was not a call made about R #210 on 12/26/22 or 12/28/22. She stated that everything is documented, and she believes these records are accurate. The MD also stated that Hydrazine, [MEDICATION(S)], and [MEDICATION(S)] should not be administered all at the same time and that this was also an issue. When asked what she would have done in this situation if she had been called, she stated that she would have ordered [MEDICATION(S)] to be given and send out to the hospital. Even with [MEDICATION(S)] it's not always a guarantee that it will work the way it should, and the resident would have need to be closely monitored. O. On 03/30/22 at during an interview with NP #2, she stated that she was the on-call provider the night of 12/27/21. The NP could not recall any details about what happened on the evening of 12/28/22. She did not have any notes about a medication error, just that R #210 had abnormal vitals. When informed of what happened, she stated that she would have expected [MEDICATION(S)] to have been given and that if there was an order to send the resident out to the hospital that she would have expected it to be followed. P. On 03/30/22 at 6:39 pm, during an interview with Certified Nursing Assistant (CNA) #8 she stated that she was working the night of 12/27/21. She stated that R #210 was agitated the night and that family (granddaughter) was with her in her room. The nurse that night on the hall was LPN #9. CNA #8 stated that she took her vitals and proceeded to go out on the floor to do check and changes. She stated that LPN #9 was doing a bed change with a resident and had asked R #10 to come down and help her with medications. She remembers LPN #10 asking her to keep an eye on her (R #210) this was after the medication error. R #210's vitals were really low after the medication was given. One of the nurses set her up with O2 (oxygen) and her levels went back up. EMT's arrived and they weren't very professional. She was in an out of the room because she had a lot of residents on the hall and was caring for them too. She remembers that the granddaughter wanted to send her out to the ER, but the paramedics stated she was stable. She was writing the vitals on a piece of paper, but she doesn't know where it went. CNA #8 stated that she went back in to check on R #210 and she wasn't breathing and had passed. She called LPN #9 to the room and the EMT's were called back. She stated that R #210 was pulling out her oxygen and she would have to put it back in. She stated that she checked on her often. She stated that she remembers R #210 being lethargic and agitated at the same time. When asked if she was given any specific instruction on how to monitor R #210 after the medication error, the CNA #8 stated no. This failure resulted in an Immediate Jeopardy (IJ) being called on 03/31/22 at 4:30 pm with a scope and severity at level J. Identification/Correction of the IJ All residents have the potential to be affected by inconsistently completing assessments, monitoring, and notifying the physician when change of condition occurs. Licensed nurses assessed current residents residing in center on 03/31/22 to determine presence of a medical change in condition. Identified issues were reported to MD (Medical Director) for further direction and medical orders. Registered nurse reviewed current residents progress notes on 03/31/22 to determine presence of a medical change in condition with steps taken to provide care related to identified medical need. Identified changes of medical condition not reported to MD will be reported and medical orders followed. The Center Nurse Executive re-educated current licensed staff regarding policy for resident change in condition. The Education includes: -Documentation must occur for all change in condition. -The eInteract change in condition assessment needs to be completed filled out with all the details of what happened. -The provider, nurse manager and family must be notified immediately. If the family is present, we still must notify the provider of all changes, including if family is present, we still have to notify the provider of all changes, including if the POA (Power of Attorney) would like nothing to be done about the situation. The provider will decide what needs to happen. -Any and all vital signs need to be reviewed and documented immediately. -Orders need to be put into the system, even if it was after you have taken care of the resident because it was an emergency. -CNA's need to document the vitals that they take and nurses need to ensure they have completed it. -Monitoring needs to continue to happen and documented if the resident is still in the building until we know they have stabilized. -If the condition changes again, or the plan for the resident changes in anyway, the provider and family need to be notified again. Documentation needs to reflect the change, and those notifications occurred again. The removal of the IJ occurred on 04/01/22 at 2:30 pm which was verified on site.

Based on record review, interview, and observation the facility failed to ensure that residents were free from significant medication errors for 2 (R #45 and #210) of 13 (R #6, #9, #14, #16, #22, #36, #45, #95, #164, #166, #173, #205, and #210) residents reviewed for medications. This deficient practice likely resulted in R #210 recieveing medications that were not prescribed to her likely contributing to her death and R #45 not receiving the IV (intravenous) antibiotic as prescribed likely worsening an infection. The findings are: Findings for R #45: A. Record review of R #45's Face Sheet indicated that he was admitted on [DATE] with a below the knee amputation. B. Record review of the trasnfering hospital records revealed that R #45 was admitted to the hospital on 12/31/21 and In the General Admission Inpatient note written by (name of physician) indicated the following: .(R #45) was recently discharged to a rehab facility on 1/27 after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient (R #45) was initially treated with [MEDICATION(S)] and then switched to [MEDICATION(S)] 2 g (grams) every 8 hours with plan for end of therapy on 2/16 . Patient was sent to the emergency department (ED) after being seen in the (infectious disease) ID clinic. CT (cat scan) lower extremity obtained reported concerns of abscess as well as [CONDITION(S)] (infection in the bone) at the stump site. R #45 was discharged with orders for an Antibiotic Regimen: [MEDICATION(S)] 2g (grams) q8h (every 8 hours) Start Date of Antibiotics: 01/20/22 and Projected End Date of Antibiotics: 02/16/22. C. Record review of the R #45's MAR (Medication Administration Record) for February 2022, indicated that following: [MEDICATION(S)] Sodium Chloride Solution Use 100 ml IV (intravenously) one time a day for IV ATB (antibiotic) therapy until 02/16/22. Infuse 30 minutes. This order was discontinued on 02/04/22. D. Record review of the facility physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Infuse 30 minutes. This new order reflected the order from the hospital. E. Record review of the medical chart indicated that R #45 had an appointment at the Outpatient [MEDICATION(S)] Antibiotic Therapy ([NAME]) clinic on 02/17/22. R #45 did go to this appointment. He was admitted to the hospital from that appointment with concerns of purulent discharge (a thick, milky white discharge indicating an unhealthy wound or infection) from his stump. Patient was sent to the ED (Emergency Department)and a CT lower extremity obtained reported concerns of abscess (a swollen area within body tissue, containing an accumulation of puss) as well as [CONDITION(S)] at the stump site. F. Record review of the hospital medical records dated 02/23/22: R #45 was admitted with concerns of BKA stump abscess concerning for [CONDITION(S)]. He was sent to a SNF(Skilled Nursing Facility) to receive IV [MEDICATION(S)] to complete infection treatment, but was readmitted since [MEDICATION(S)] was underdosed at the skilled nursing facility and pt had breakthrough infection. G. On 03/23/22 at 12:43 pm, during an interview, R #45 stated that he had a below the knee amputation (BKA) of his right leg and that while he was here in the facility it became infected and he had to be readmitted to the hospital. H. On 04/05/22 approximately 3:30 pm, during an interview, the Unit Manager confirmed that R #45's IV medication that he was receiving when he arrived was not the right dose and the facility was only giving it once per day. Findings for R #210: I. Record review of the facility five day follow up report dated 01/10/22 indicated that R #210 was an [AGE] year-old female with a history of [CONDITION(S)] (CHF) with Ejection Fraction of 25% (ejection fraction is the amount of blood -- given as a percentage -- pumped out of a ventricle during each heartbeat, this evaluates how well the heart is pumping), diagnosed in December of 2021, history of chest pain, chronic pain, pleural effusion (an excessive collection of fluid in the pleural cavity, the fluid-filled space that surrounds the lungs), [CONDITION(S)] (A-fib is an irregular and often very rapid heart rhythm (arrhythmia) that can lead to blood clots in the heart.), severe pulmonary disease (any condition that affects the blood vessels along the route between the heart and lungs), Hyper tension ([CONDITION(S)] is high pressure in the arteries (vessels that carry blood from the heart to the rest of the body), GERD (gastroesophageal reflux disease is a digestive disorder that affects the lower [CONDITION(S)] sphincter (LES), the ring of muscle between the esophagus and stomach), among other comorbidities. Resident had an open reduction and internal fixation of a [CONDITION(S)] in October 2021. The patient recently had significant fluid removed via a thoracocentesis ( procedure to remove fluid or air from around the lungs) on 12/15/21. J. Record review of a progress notes dated 12/27/21 at 20:45 (8:45 PM), Wrong medication administered to PT (patient), DON (Director of Nursing aka Center Nurse Executive CNE), Family notified. Will continue to monitor. There was no evidence that the Physician was contacted regarding the medication error. K. Record review of the medications that were administered to R #210 included: [MEDICATION(S)] (used to treat moderate to severe pain) 10 mg (milligram), [MEDICATION(S)] (used to treat moderate to severe pain) 50 mg and [MEDICATION(S)] (used to treat anxiety, nausea and vomiting, skin rash, allergies, and itching of the skin) 25 mg Famotidine (used to treat stomach ulcers, conditions with too much stomach acid) 20 mg, Senna (a stool softener) 8.6 mg, and Guaifenesin (cough and cold medication) 600 mg. L. Record review of the nursing progress notes dated 12/27/21 at 21:07 (9:07 PM), pt agitated and yelling out at this time. O2 (oxygen) sats (saturation) 57% on 5LPM (liters per minute) with a HR (heart rate) of 135, BP (blood pressure) 90/46. 911 EMERGENCY CALLED. M. Record review of the nursing progress notes dated 12/27/21 at 21:24 (9:24 pm), EMTs (Emergency Medical Transport) arrived on scene. EMTs stated that pt was stable and that O2 was empty and that the O2 tank was not hooked up properly. EMTs stated that writer (LPN #9) was incompetent in regard to equipment and that since the pt had nail polish on her fingernails, that this was not an accurate reading. EMTs took over pt care at this time along with other night nurse. EMTs stated to family that pt was stable and that maybe the nurses should collect a UA (urinalysis) because pt had a fever at this time as well and that we should check for a [CONDITION(S)] (Urinary Tract Infection). Writer notified EMTs of current critical potassium lab of 2.9 (low patassium can result in fatigue, muscle cramps and abnormal heart rhythms); pt had reported episodes of CP (chest pain) previous shift. EMTs continued to speak with family and stated that family should keep pt here at facility because we could treat a [CONDITION(S)] and low potassium (is an essential mineral and electrolyte that plays a critical role in many functions of the body) here at the facility and that she would just be waiting in the waiting room all night anyway. Family chose to keep pt in facility against writers' suggestion to be transferred to hospital. There was no mention that the Physician was called following the visit by EMTs. N. Multiple attempts were made to contact R #210's family throughout the survey however never received a return call. O. Record review of the nursing progress notes dated 12/28/21 at 00:58 (12:58 am), pt found not breathing at this time. Pt is a DNR (Do Not Resuscitate) as stated by husband. DON contacted. OMI (Office of the Medical Investigator) also contacted. P. On 03/29/22 at 7:39 am during an interview, RN (Registered Nurse) #1 stated that she was called the night of the medication incident. She wasn't the CNE at that time. When she was called that night, she was told that there was a med error. She told the nurse that she needed to call the CNE. When asked who had signed out the medications that were given that night, she stated that LPN #9 signed them out. When asked if she had any information on whether the medications had been poured ahead of time, she stated it is not common to pop the medications and not give them right away, this is not how you pass meds. Q. On 03/29/22 at 1:11 pm, during an interview, Center Executive Director (CED), when asked if the medications that were given the evening on 12/27/21 had been pre-poured before there given he stated he didn't know. When he interviewed LPN #9, he did not ask that question. He stated that the 6 R's of medication administration: (Right drug, Right amount given, Right route, Right patient, Right time and Right record) were not followed. The CED stated that he was more focused on what happened after the medication error occurred. R. On 03/30/22 at 9:46 am, during an interview, LPN #10 stated that the night of 12/27/21, she was working the night shift. LPN #9 asked her to help pass medications on her hall. She agreed to help LPN #9. She stated that she got the medication out of the medication cart and went to R #210's room. She stated that at some point she had gotten confused about which resident she was passing the medications to because as soon as she had given the medications to R #210, she realized that it was the wrong resident. She told LPN #9 right away and the on-call provider was called. Shortly after that R #210's vitals were low, and the paramedics were called out. When they (EMT's) arrived, they were informed of the medication errors. The EMT's kept stating that the oxygen was hooked up wrong and that the reading they had before they were called probably wasn't right. They kept stating that she stable and didn't need to go the hospital. The family was present in the room at this time and the family told facility staff that if she was stable, they didn't want her to be uncomfortable in the ER waiting and the decision was made to keep her at the facility. She stated that she was not aware of the on-call provider being called again to ask for further direction and to inform of the decision that had been made to not send R #210 to the hospital. S. Multiple calls were made to LPN #9 who no longer worked at the facility, however never received a return call. T. On 03/30/22 at 11:40 am during an interview with Medical Director (MD), she stated that Hydrazine, [MEDICATION(S)], and [MEDICATION(S)] should not be administered all at the same time and that this was an issue. When asked what she would have done in this situation if she had been called, she stated that she would have ordered [MEDICATION(S)] to be given and sent out to the hospital. Even with [MEDICATION(S)] it's not always a guarantee that it will work the way it should, and the resident would have needed to be closely monitored. U. On 03/30/22 at 6:39 pm, during an interview with Certified Nursing Assistant (CNA) #8, she stated that she was working the night of 12/27/21. She stated that R #210 was agitated the night and that family (granddaughter) was with her in her room. The nurse that night on the hall was LPN #9. CNA #8 stated that she took her vitals and proceeded to go out on the floor to do check and changes. She stated that LPN #9 was doing a bed change with a resident and had asked LPN #10 to come down and help her with medications. She remembers LPN #10 asking her to keep an eye on her (R#210) this was after the medication error. R #210's vitals were really low after the medication was given. One of the nurses set her up with O2 and her levels went back up and the EMT's arrived. They weren't very professional. She was in an out of the room because she had a lot of residents on the hall and was caring for them too. She remembers that the granddaughter wanted to send her out to the ER, but the paramedics stated she was stable. She was writing the vitals on a piece of paper, but she doesn't know where it went to. CNA #8 stated that she went back in to check on R #210 and she wasn't breathing and had passed. She called LPN #9 to the room and the EMT's were called back. She stated that R #210 was pulling out her oxygen and she would have to put it back in. She stated that she checked on her often. She stated that she remembers R #210 being lethargic and agitated at the same time. When asked if she was given any specific instruction on how to monitor R #210 after the medication error, CNA #8 stated no. V. On 03/31/22 at 2:28 pm, during an interview, RN #9, stated that the process of administering medications is that you look up the resident, pull their medications and pop into a cup and go and given them right away. She stated that yes interruptions do happen when passing medications and you stop what you are doing, lock them in the drawer until you can get back to them. She stated that she has pre-poured medications before, but not for more than two residents at a time. She stated that nurses do it to save time because of being short staffed. She stated that you have to work with another person who you trust. One person pops the medications and the other takes the medications to the resident. X. On 03/31/22 at 3:09 pm, during an interview, LPN #13, stated that he was not working the day of the 12/27/21, but he spoke with LPN #10 on the 27th because she [LPN #10] had called him. She told him that LPN #9 was behind with medications, so she helped pass medications on that hall. They decided that LPN #9 was going to pop the medication and LPN #10 as going to pass the medications. LPN #10 told him that she had messed up and gave the wrong resident (R #210) medications that were prescribed to another resident. LPN #13 stated that the practice of pre-pouring meds is 100% frowned upon. Y. On 04/04/22 at 4:29 pm, during an interview, RN #14, it was stated that the nurses at the facility have been pre-pouring medications.She stated that there had been times when she had pre poured up to 6 residents medications at a time. It was stated that management knew that the staff were pre-pouring medications. This failure resulted in an Immediate Jeopardy (IJ) being called on 03/31/22 at 4:30 pm, with a scope and severity at level J. IJ Plan of Removal: All residents have the potential to be affected by medication errors. All medication carts were observed for loose and pre-poured pills on 03/31/22. The facility medication passes will be observed twice daily and monitored for following medication administration process twice daily and monitored for following medication administration process beginning on 04/01/22. This will include monitoring for nurses/CMA's [Certified Medication Aides] giving medications to other staff to administer to resident and pre-pouring of medications. The Center Nurse Executive re-educated current licensed staff starting on 03/31/22 including the following: -Medication pass should never include pre-pouring medications, or handing it to another person to take to the resident. This is dangerous and can cause serious medication errors. -Medication process is exactly as the competency states. You pass your own medications, one person at a time while following the 6 rights of medication pass (right person, right time, right medication, right route, right dose and right to refuse). -If the resident refuses their meds, you document it as such and discard the medications, do not leave in the cart. -No pills should be loose in your cart, including in medication cups. The removal of the IJ occurred on 04/01/22 at 2:30 pm. Verification of the POR and it's implementation was confirmed onsite.

Based on record review and interview, the facility failed to ensure that a resident received care needed to prevent the development and worsening of a pressure ulcer for 1 (R #15) of 5 (R #15-19) residents reviewed for pressure ulcers. This deficient practice likely resulted in R #15 developing a unstageable pressure wound (full thickness skin and tissue loss in which extent of tissue damage within the ulcer cannot be confirmed) before any treatment orders were implemented. The finding are: A. Record review of the History and Physical (Hand P) for R #15 dated 07/09/21 revealed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . She was admitted to skilled nursing at [Name of Nursing Home] for PT/OT/ST. B. Record review of R#15 Discharge summary dated 07/04/21 from [Local Hospital], identified no skin breakdown. C. Record review of R#15 Weekly Bath and Skin report revealed the following: 1. 7/6/21: normal (no abnormal skin changes); not signed by charge nurse 2. 7/8/21: normal (no abnormal skin changes); not signed by charge nurse 3. 7/10/21: normal (no abnormal skin changes); not signed by charge nurse 4. 7/13/21: normal (no abnormal skin changes); redness/rash and bruising; bilateral ankles and right calf; signed by charge nurse. 5. 7/15/21: normal (no abnormal skin changes); not signed by charge nurse 6. 7/15/21: normal (no abnormal skin changes); not signed by charge nurse 7. 7/17/21: normal (no abnormal skin changes); not signed by charge nurse 8. 7/20/21: normal (no abnormal skin changes); not signed by charge nurse. Completed by CNA (Certified Nurse Aide) #3 9. 7/22/21: normal (no abnormal skin changes); not signed by charge nurse. Completed by CNA (Certified Nurse Aide) #3 10. 7/24/21: completed by CNA, resident refused; not signed by charge nurse 11. 7/27/21: normal (no abnormal skin changes); signed by charge nurse. Completed by CNA (Certified Nurse Aide) #3 12. 7/29/21: redness/rash to buttocks; not signed by charge nurse. Completed by CNA (Certified Nurse Aide) #3 13. 7/31/21: open areas to buttocks; not signed by charge nurse (documented that nurse was notified on report). Completed by CNA (Certified Nurse Aide) #3 14. 8/3/21: open area identified on buttocks; not signed by charge nurse. Completed by CNA (Certified Nurse Aide) #3 D. Record review of TAR (Treatment Administration Records) dated JULY 2021 revealed No treatments for wounds. E. Record review of R#15's TAR dated AUGUST 2021 revealed: 1. 8/1/21 20:00 with note to document on the 24 hours shift report if resident refuses and orders for offloading/turning orders every 2 hours; 2. 8/2/21 for Offloading/turning orders 3. 8/3/21 Daily wound care orders to sacrum ordered but not done; 4. 8/3/21 PRN (as needed) order for Santyl ointment ( to sacrum; 5. 8/4/21 0600 Santyl Ointment to sacrum every day shift started at 6am on 8/4 x1treatment completed; Wound care orders to sacrum daily ordered at 0600 8/4/21 but not done. F. Record review of R#15 Care Plan identified that R#15 was at risk for skin breakdown related to limited mobility dated 7/6/21: Observe for signs/symptoms of skin breakdown and evaluate for any localized skin problems. 1. Revision of Care Plan dated 8/1/21 indicated wounds worsening related to resident refusal to turn and get out of bed; 2. Revision of Care Plan dated 8/2/21 added Offloading/turning orders 3. Revision of Care Plan dated 8/4/21 for sacrum wound orders and wound treatment. G. Record review of R#15 Skin Check dated 8/1/21 identified a scab to inner left ankle; flaking of feet/toes; right leg ortho boot; discoloration to buttocks; rash under pannus on left side H. Record review of R#15 Skin Integrity dated 8/1/21, completed by the Wound Care Nurse/Registered Nurse (RN) #1, identified unstageable necrotic tissue to the sacrum; 15x15cm; light serous drainage; inflamed/indurated; no odor noted; note from nurse that resident vehemently refused offloading to either side of buttocks. I. Record review of R#15 Nursing Progress Note revealed the following: 1. 8/2/21: identifies skin being reviewed with no findings; note incomplete 2. 8/3/21: identified no wounds J. On 08/19/21 at 12:27 pm during interview with Certified Occupational Therapist Assistant (COTA) #1,regarding R #15, she stated She was pretty much bed bound. She was non-weight bearing at the time. She had to do a lot of bed mobility. Would need 2 people to move her. I don't believe we ever stood her. I did a lot of bed dressing, bed baths, arm exercises. She eventually had to be a hoyer lift [for transfers]. COTA #1 confirmed that R #15 stopped making progress and therapy was discontinued on 7/20/21.COTA #1 denied R #15 ever refusing to do treatment. K. On 08/23/21 at 10:00 am during interview with the Wound Care Nurse/ RN #1 she confirmed that in July 2021 she quit for a couple weeks and when she returned [08/01/21], she saw R #15's wounds first. RN #2 stated that the wound was 15 by 15 (centimeters) eschar (black tissue). RN #2 confirmed that she entered wound orders that day. L. On 8/23/21 at 11:02 am and 3:11 pm during interview with the Director of Nursing (DON) she reported that R #15s wound started as a skin tear and the Aides were providing barrier cream during brief changes. DON stated that towards the end of July, It went from bad to worse over night. DON confirmed that upon reviewing the records for R #15, she noted that there was inaccurate documentation identifying that R #15 had no wounds. DON confirmed that the CNAs complete the shower sheets and wounds should be identified on those sheets and CNAs are expected to notify the Nurse of any changes. If there are errors on the shower sheets, per the DON, the Nurses are expected to correct those errors and sign the sheets. DON confirmed that while the Wound Care Nurse was gone in July, I was trying to do everything all at once. DON confirmed that before she [DON] left on vacation on [07/29/21], the CNA notified her of the skin tear and I requested to put barrier cream. DON confirmed that R #15 was total dependence for toileting. DON confirmed that she should have been made aware when the wound got worse. DON confirmed that there is no documentation identifying the wound getting worse from a skin tear to becoming unstageable. regarding R #15, the DON stated I can tell you that she never got out of bed. And the most she would be allowed to be turned is changing and when sheets were changed. Yes she was a risk for pressure sores. M. On 08/23/21 at 3:25 pm during interview with CNA #7, she confirmed that she worked a lot with R #15. Regarding her wound, she stated It started a little skin tear. I let the nurse know and the DON. I was instructed to do the barrier cream and turn and reposition. [Name of R #15] didn't care to be repositioned, she would call to have her have the pillows removed. It started as skin tear. I noticed that as days went on it was getting worse. I reported to [Name of DON] and nurse that she didn't want to be requisitioned. It was hard to keep her on the side. That's when it progressed more and more. She was using a brief. I went in every 2 hours to change her even if she wasn't wet.

Based on interview and record review the facility failed to provide quality care for 1 (R #10) of 3 (R #s 10, 11 and 12) residents looked at for pressure sores, change in condition, physician orders and appointments. These deficient practices caused R #10's medical condition to continue to worsen without staff identifying signs that the resident was having a change in condition that eventually ended with R #10 being admitted to the hospital. The findings are: [NAME] Record review of R #10's face sheet indicated that R #10 was admitted on [DATE] with the following Diagnoses: [REDACTED]. which the heart doesn't pump blood as well as it should), pancreatitis (inflammation of the pancreas (organ behind the lower stomach)), stage 4 severe kidney disease, and an unstageable pressure ulcer (Ulcers covered with slough or eschar (dead tissue) are by definition unstageable) to her right heel. B. Record review of the nursing progress note indicated that on 08/25/19, R #10 was sent out to the emergency room for a heart rate at 52 (normal heart rate ranges from 60 to 100 beats per minute), [MEDICAL CONDITION] (a heart rate that's too slow), and worsening [MEDICAL CONDITION] (Puffiness caused by excess fluid trapped in the body's tissues)/fluid overload. C. Record review of R #10's Inpatient Provider Progress note (hospital note) dated 08/25/19, indicated that the resident presented at the hospital with the following: 1. Juncitonal [MEDICAL CONDITION] emergent [MEDICAL TREATMENT] was started 2. AKI on CKD (Acute Kidney Injury occurs as an abrupt loss of kidney function over hours to weeks and is usually reversible, [MEDICAL CONDITION] arises as a result of progressive loss of kidney function over a period of months or years which leads to irreversible damage) suspect secondary to Urinary -Tract Infection [MEDICAL CONDITION]. 3. Potentially osteo[DIAGNOSES REDACTED] (an infection in a bone). 4. Altered mentation 5. Urinary tract infection frank pyuria (pyuria is the condition of urine containing white blood cells or pus) with white blood count of 80 (high WBC indicates infection) 6. Right foot pressure ulcer concerning for osteo[DIAGNOSES REDACTED]. 7. Heart rate in the 30s and a BUN of 188 (around 7 to 20 mg/dL (2.5 to 7.1 mmol/L) is considered normal) 8. R #10 was admitted to the ICU (Intensive Care Unit) where she received emergent [MEDICAL TREATMENT], IV (Intravenous) antibiotics for UTI [MEDICAL CONDITION] (A life-threatening complication of an infection), and osteo[DIAGNOSES REDACTED] (Inflammation of bone caused by infection) and had right heel pressure wound debridement. Pressure Sore Findings: D. Record review of R #10's nursing progress notes from admission 05/22/19 until 08/12/19 indicated that the wound was being measured, treated and monitored. The wound was mostly eschar (is a slough or piece of dead tissue) and slough (a mass of dead tissue) in with a small amount of serosanguinos (both blood and the liquid part of blood) drainage. There was an odor to the wound as documented in the progress notes. It was also documented in the progress note dated 07/16/19 that there was .no redness, no warmth, no fever, no purulent (consisting of, containing, or discharging pus) drainage . On a progress note dated 07/23/19 the following was indicated: . Observed UN (unstageable) pressure injury to R (right) medial heel. Area measures 3 (cm) X 3.5 cm (centimeters) with mostly a mixture of slough and eschar. There is an increased amount of granulation to the wound bed. Moderate amount of serosanguinous drainage noted. There is a foul odor from drainage due to necrotic (dead) tissue coming off the area. No other s/s (signs and symptoms) of infection. E. Record review of R #10's SIRS (skin integrity report) indicated that on 08/06/19 the wound was 3.5 x 4.0 (cm) with slight serosanguineous drainage noted, surrounding tissue was healthy with no odor. On 08/12/19 the wound measured 3.5 x 3.0 (cm) with purulent drainage and had odor. On 08/19/19 the wound was still at 3.5 x 3.0 (cm) and was marked as having purulent drainage with odor. F. Record review of R #10's progress notes, physician notes, history and physicals and physician orders did not reveal that a physician was notified of the change in condition (purulent drainage) to R #10's right heel wound. G. On 10/16/19 at 7:53 AM, during an interview with the Unit Manager/Wound Care Nurse, she stated that R #10 came in with her unstageable pressure ulcer to her right heel. She stated that the cap to the right heel was all eschar and that you don't have any idea what is under the eschar, or how deep the wound might be. She stated that because of the odor she had spoken to the Nurse Practionier (NP) about it. Because of the eschar the NP didn't want to have a culture done on it, so the NP wanted staff to pay attention to other signs and symptoms that the wound could be getting infected. The Wound Care Nurse/Unit Manager stated that at this time she was doing wound care and the wound was slowly getting better. She confirmed that if R #10 was having purulent drainage as noted on the SIRS 08/12/19 and 08/19/19, that was a sign that her wound was likely infected and that identifying this sign was missed by staff. She stated that she put the nurses in charge of doing the wound care while she was gone, and they would be following all physician's orders for resident wounds. H. On 10/16/19 at 10:30 AM, during an interview with RN (Registered Nurse) #1, she stated that eschar was starting to come off day by day so she felt like it was getting better. She stated that when the wound nurse went on leave for 6 weeks, she did wound care according to the physician orders; it was hard. She stated that the wound did have an odor and it could have been a sign of infection. Lab Work Findings: I. Record review of R #10's physician orders 07/24/19 indicated that an order to check BMP (basic metabolic panel) on 08/05/19 was not done. There were no labs for 08/05/19 in the medical chart and nothing was provided by the end of survey. [NAME] Record review of R #10's physician orders dated 08/16/19 indicated that an order to check BMP, one time only for monitoring x1 day, was not done. There was no labs dated after 08/16/19 in the medical chart and no labs were provided by the end of survey. K. On 10/16/19 at 11:35 AM, during an interview with the Director of Nursing (DON), she stated that all labs that residents have done are automatically uploaded into the system. So if there is a lab that is not in R #10's chart it wasn't done. The DON stated that the previous DON had left a total mess of paper documents and no indication of what had been scanned into the residents file and what had not been scanned in yet. The DON also stated that the Unit Manager in charge of the hall that this resident was on at that time quit and walked out the day she was hired to be the DON in the facility. L. On 10/16/19 at 7:53 AM, during an interview with the Unit Manager/Wound Nurse, she stated that doing lab work, monitoring the resident for s/s (signs/symptoms) of infection and through vitals was how the NP would be monitoring for a change of condition. M. Record review of the vitals indicated that they were normal to resident until the day she went to the hospital on [DATE]. Appointment Findings: N. Record review of the complaint indicated the following: The question was asked to the nurse what the provider was doing in regards to the kidney problems. She (nurse) stated that this was the first time taking care of sister (R#10) and didn't know of any issues. We (my brother and I) asked if a doctor referral could be made to a renal medicine specialist she said she would pass this along to the provider. We gave her name and phone number of the specialist . O. On 10/16/19 at 9:10 AM, during an interview with the Unit Manager (UM), she stated that when she got back from leave, the family had told her that they had requested a renal consult but did not get one. The UM stated that they did get a referral for a renal consult with a provider R #10 had seen previously, however due to missed appointments this provider would not see R #10 and she would need to be seen as a new patient at the clinic. A physician order was put in on 10/07/19. P. On 10/16/19 at 9:10 AM, during an interview the UM also stated that when you look at R #10's labs (last documented lab work completed on 07/22/19) you can see that there was something going on with her kidneys. She stated that it was hard to tell how bad the [MEDICAL CONDITION] was because she was a larger lady, but the NP would prescribe more [MEDICATION NAME] and that would help with the [MEDICAL CONDITION]. Q. On 10/16/19 at 10:30 AM, during an interview RN #1, stated that the swelling in R #10's legs was the reason that the sister asked about getting a renal consult. She stated that she does remember the family asking about a renal consult before she went to the hospital on [DATE]. R. Record review of R #10's nursing progress notes for the month of (MONTH) (2019), physician orders and physician progress notes [REDACTED]. R #10 went to the hospital on [DATE]. S. Record review of R #10's hospital discharge packet 09/12/19 indicated that two appointments were set up for R #10. One at the family practice clinic on 09/17/19 and the other at the orthopedic clinic on 09/27/19. T. On 10/15/19 at 3:35 PM, during an interview with admissions/scheduling, she stated that there is no documentation or indication that R #10 went to her orthopedic appointment that was scheduled on 09/27/19 (Orthopedics had done the wound debridement while R #10 was in the hospital). She stated that before she took over this job (scheduling) it was the Unit Clerk's responsibility to set up appointments for the residents. She stated that previously, transport was responsible to bring back any orders and give these to the Unit Clerk and nursing and they would set up appointments. She stated that she does the scheduling and transport now and feels that she has a good system in place. U. On 10/16/19 at 9:10 AM, during an interview the UM stated that they used to have a Unit Clerk and she would do all new admits. She would set up appointments and transportation to and from appointments. She stated that she does see that one of these appointments was made and the other, for her orthopedic appointment was not scheduled. The UM did not have an answer as to why this was not scheduled.

Based on record review and interview, the facility failed to ensure that residents were free from neglect, for 3 (R #s 1, 2 & 3) of 4 (R #s 1, 2, 3 & 4) residents reviewed during a complaint investigation. Neglect was manifested by: 1. failing to identify that R#1 had developed several pressure related injuries prior to her discharge to the hospital and failed to identify and treat those same injuries upon her return to the facility. 2. failure to act when R #2 began showing signs of a urinary tract infection, and a failure to consistently assess the resident for signs of physical and mental decline after the infection was diagnosed . 3. failing to obtain orders for treatment to a PICC line (peripherally inserted central catheter), an indwelling foley catheter (tubing placed to drain urine from the bladder), and infections, not administering medications per orders, not monitoring resident's skin, and not having an admission skin assessment for R #3. These deficient practices likely contributed to significant physical and mental impairments of the residents named in the complaint. The findings are: Findings related to R #2: A. Record review of a complaint intake found that R #2's family member (FM #1) contacted the state central complaint intake to report that the resident had been neglected while at the facility. According to the complaint intake, delays in responding to FM #1's reports that the resident had likely acquired a urinary tract infection [MEDICAL CONDITION], and that her condition was worsening, resulted in two urgent hospital emergency department (ED) visits. The second visit resulted in a 5-day intensive care unit (ICU) admission, with [DIAGNOSES REDACTED]. B. On 11/21/17 at 10:56 am, during interview with FM #1, she stated that she had reported R #2's pain when urinating and foul-smelling urine to facility staff daily for about a week prior to the first hospital transfer on 10/06/17, but had been told that R #2 could not be treated for [REDACTED]. FM #1 eventually insisted on R #2's transfer to a hospital ED on 10/06/17. Upon R #2's return to the facility on [DATE], FM #1 stated that she continued to alert staff that R #2 was declining, but that facility staff kept passing the buck. On 10/15/17, while sitting in her wheelchair with FM #1 nearby, R #2 became entirely unresponsive. Emergency Medical Services (EMS) was called, and R #2 was transferred to a hospital ED. She spent 5 days in the ICU, with [DIAGNOSES REDACTED]. FM #1 indicated that she found placement for R #2 at another nursing facility at this point, as she felt that care at this facility was inadequate. C. Record review of R #2's hospital medical record for her 10/06/17 ED visit found: 1. A History of Present Illness section, dated 10/06/17, stating (R #2) is a 88 (year old) female presenting to the ED via EMS for a UTI. Per (FM #1), she is a resident of (facility) and has been complaining of increased painful urination for the past week. (FM #1) also notes increased confusion and fatigue. Patient recently had a catheter (a tube for the drainage of urine from the bladder) placed and taken out with visualized puss (sic). (Facility) staff note vaginal discharge and odor. She has slept all day and has not yet eaten . 2. Assessment & Plan section, dated 10/06/17, included statements indicating .(R #2) has been complaining of dysuria (painful urination) over last week. Her urine has been increasingly malodorous (smelling very unpleasant). (FM #1) felt that the facility was not acting fast enough, so she brought (her) to ED to expedite treatment . D. Record review of R #2's hospital medical record for her 10/15/17 ED visit and ICU admission found: 1. a History of Present Illness section, dated 10/15/17, stating (R #2) is a 88 (year old female) who presents via EMS (following) suddenly being unresponsive at her care facility. EMS state that (she) was unresponsive when they got there but did have a pulse (total unconscious time = (approximately) 10 minutes). En route, she became (alert and oriented) but displayed some (abnormal heart beats), nonsustained. Reportedly, (patient) had low BP (blood pressure) (Normal 80/120) when EMS arrived . BP = 70/palpable (a very low blood pressure reading) . 2. An ED course note, dated 10/15/17, indicating During ED course, (patient) had large melena, guiaiac pos stool (a bloody bowel movement). She is anemic as well, which is (an) acute change compared to recent labs last week . (Patient) became hypotensive (exhibited low blood pressure), so will transfuse 1 unit pRBC (packed red blood cells) .MICU (medical intensive care unit) to admit. 3. A Critical Care/Pulmonary (lung disease) Consultation/Admission section, dated 10/15/17, stating . The last few days she has continued to declined (sic) with poor appetite, malaise, and today became unresponsive . She was found to be hypotensive and bradycardic (with a slowed heartbeat) per (FM #1) and EMS was activated. 4. A Discharge Summary note, dated 10/21/17, indicating Active problems: Shock. Acute lower gastrointestinal hemorrhage, acute-on-chronic renal impairment (kidney dysfunction), urinary tract infection, [MEDICAL CONDITION] (a heart rhythm irregularity), other shock, acute [MEDICAL CONDITION] (kidney infection) . E. Record review of R #2's facility medical record found that her [DIAGNOSES REDACTED]. F. Record review of R #2's physician's orders [REDACTED].> 1. An order dated 08/31/17 stating O2 sats (oxygen saturation)(assessment of blood oxygenation)/pulse, every shift. 2. An order dated 08/31/17 stating Pulse ox (used to measure the oxygen level in your blood and your heart rate) every shift to keep oxygen sats greater than or equal to (target O2 sat not filled in.) 3. An order dated 10/07/17 stating [MEDICATION NAME] (Keflex, an antibiotic medication) 500 mg (milligrams). Give 1 tablet by mouth every 12 hours. The order was marked as discontinued on 10/11/17. 4. An order dated 10/10/17 stating [MEDICATION NAME] (an antibiotic medication) capsule 100 mg. Give 1 capsule by mouth two times a day for UTI for 10 days. G. Record review of laboratory results for R #2 found that a urine specimen was collected on 10/03/17, and that results on 10/07/17 indicated the presence of e. Coli (Escherichia coli a type of bacteria, indicating infection). H. Record review of a Nurse Practitioner's note dated 10/09/17 found that it suggested that the responsibility for monitoring R #2's progress on the initial antibiotic was on FM #1, rather than on nursing staff. It stated . instructed (FM #1) to watch (R #2) and if she is not getting better to let me know and we can place her on another more sensitive antibiotic. I. Record review of a Nurse Practitioner's note dated 10/10/17 found statements indicating (FM #1) approached me at the nurses' station stating that she does not believe that (R #2's) UTI is getting better . started (R #2) on [MEDICATION NAME]. (FM #1) states that (R #2) is not eating well and she is pushing (R #2) to drink more fluids . The treatment section of the note stated . nursing staff to monitor VS (vital signs) for increasing fever, monitor for s/s (signs and symptoms) returning infection. Report (malodorous) diarrhea, rashes, itching, discharge or oral thrush (white patches) that might need treatment. J. Record review of R #2's Interdisciplinary Team (IDT) progress notes for October 2017 found no notes that indicated that R #2 was being monitored by nursing staff for signs of infection, low blood pressure or confusion or for her response to antibiotics. The 5 nurses' notes written during her 15 days at the facility in October 2017 were: A. On 10/01/17, R #2 was noted to have nearly fallen, but had been caught by staff and had suffered no injury. B. On 10/06/17, a notation was made that the resident had had an unplanned transfer to a hospital ED. C. On 10/07/17, a skin check was performed and no skin issues were identified. D. On 10/10/17, a note stated First dose of antibiotics given for UTI at 9:59 am. Family present in room and explained to nursing that (R #2) was not acting normally, stating she was aggressive and confused. E. On 10/15/17, a note indicated that the resident had become unresponsive and had been transferred to a hospital ED. K. Record review of R #2's vital sign recordings during the 15 days of her stay at the facility in October 2017 found: 1. that her blood pressure and body temperature were not assessed on 11 of the 15 days. No blood pressure and body temperature data was found for 10/01/17, 10/02/17, 10/03/17, 10/04/17, 10/06/17, 10/07/17, 10/09/17, 10/11/17, 10/13/17, 10/14/17 or 10/15/17. 2. that her oxygen saturation was not recorded as having been measured as expected on 24 of 40 shifts, based on the physician's orders [REDACTED]. No O2 sats were recorded on 10/08/17, 10/09/17, 10/13/17 or 10/15/17. O2 sat was recorded once each day on 10/10/17 and 10/11/17. L. On 11/21/17 at 11:18 am, during interview with the Physician's Assistant, she confirmed that she had not prescribed a treatment for [REDACTED]. She indicated that, after R #2's first ED visit, she received the laboratory results and switched R #2 from the hospital-prescribed Keflex to [MEDICATION NAME], as it would better target the infectious organism. M. On 11/21/17 at 1:55 pm, during interview with the Center Nurse Executive (Director of Nursing), she stated that early recognition of infection has been an area where they (facility staff) know they need to improve. She indicated that there are new forms for staff to complete, to assist in earlier recognition. She confirmed that there was nothing in the documentation to indicate that R #2 had been closely monitored by nursing staff after her first ED visit. She stated that she was not surprised that there was no documentation to indicate that nurses were monitoring R #2's progress in early October 2017. N. On 11/21/17 at 4:00 pm, during interview with the facility Administrator, she stated Things were pretty chaotic when I started (here) in early August (2017). And then my DON (Director of Nursing) resigned. She indicated that many staff members had been terminated since that time, and that she believes that care has improved since R #2's illness the previous month. O. On 11/22/17 at 11:01 am, during interview with the Physician's Assistant, she stated that they (the facility) have issues with staffing. They use a lot of agency staff. A lot of things get missed. I've picked up on a lot of things that have been missed. But I don't want to get anyone in trouble. She indicated that, for a resident with a UTI, nursing staff should be closely monitoring the resident. She stated that this monitoring should include frequent assessments of urine odor and clarity, fevers, blood pressure, changes in heart rate, mental status changes; any indication that the resident is becoming septic (developing a systemic infection). Findings for R #1: P. Record review of the facility's E-Interact form (form used to communicate resident information to the hospital) dated 10/03/17 at 12:17 am indicated the resident did not have any pressure ulcers or any skin impairment upon her discharge to the hospital. Q. Record review of hospital records dated 10/03/17 completed by the physical therapy department revealed the following skin impairments: 1. A deep tissue injury, non-blanching (the skin color does not return to normal after pressure is removed) redness to coccyx (tailbone) are with a length of 3.5 cm (centimeters) and width of 4.4cm. 2. A deep tissue injury, non-blanchable redness to left heel with a length of 3.5cm and a width of 3cm. 3. A deep tissue injury to the right groin. 4. A deep tissue injury to the thigh with a length of 0.2cm and a width of 5cm. 5. A deep tissue injury to the buttocks with a length of 2cm and a with of 1.3cm. R. Record review of R #1's medical record revealed her hospital stay was from 10/03/17 until her discharge back to the facility on [DATE]. S. Record review of hospital records revealed a note completed by a hospital physician dated 10/08/17: Multiple decubitus ulcers (pressure ulcers) of the sacrum (lower back) and other areas, unstageable, all present on admission: Continue wound care management. T. Record review of R #1's admitting nursing assessment dated [DATE] indicated that the question about Skin impairment(s) including Foot Problems, Surgical Wounds [MEDICAL CONDITION] answered as Present. The next section on the assessment which states If present, indicate location, type and description. Initial screen only, all skin issues must be further assessed and measured by initiating corresponding skin assessment was left blank. U. On 11/21/17 at 11:30 am, during an interview with the Director of Nursing (DON), she stated she identified several issues at the beginning of October 2017 regarding inaccurate skin assessments and skin checks not being done on a weekly basis. The DON stated that she cannot speak personally as to when R #1's pressure ulcers or deep tissue injuries first developed but stated that they were first brought to her attention on 10/13/17. She verified that prior to 10/13/17 there was no documentation of any pressure related injuries. When asked about the several deep tissue injuries to her coccyx, heel, groin, thigh and buttocks discovered at the hospital upon admission, the DON stated that she cannot speak to those injuries and cannot say whether they were present prior to her hospitalization . The DON verified that the most recent weekly skin check prior to R #1's hospitalization was on 09/23/17 which did not reveal any skin impairments however the DON could not verify the accuracy of that skin check. The DON also stated that the nurse who is discharging the resident to the hospital should complete a skin assessment at the time of discharge and document any skin problems on the E-Interact form. The DON verified R #1's E-Interact form dated 10/03/17 did not indicate any skin problems but she could not verify the accuracy of it. The DON stated that after the resident was readmitted to the facility on [DATE], the unit manager should have reviewed the hospital records, done an assessment of the skin, documented any skin problems, and started wound treatment at that time. The DON acknowledged a lack of documentation and inconsistent documentation regarding R #1's skin assessments after her return from the hospital. V. Record review of R #1's Skin Check assessment dated [DATE] revealed a bruise on left lower leg. The skin check did not address any pressure ulcers or deep tissue injuries. W. Record review of a Skin Integrity report dated 10/13/17 revealed a pressure injury (no stage noted) to the inner bone of the base of left big toe. X. Record review of a Skin Integrity report dated 10/13/17 revealed an unstageable pressure injury to the inner left heel. Y. Record review of R #1's Skin Check assessment dated [DATE] stated R #1 did not have any injuries or wounds Z. On 11/21/17 at 1:54pm, during an interview with DON, she verified that Skin Check assessment performed on 10/14/17 was inaccurate as the resident had pressure related injuries to her heel, toe and coccyx at that time. The DON could not verify the accuracy of Skin Check assessment dated [DATE]. The DON verified that no treatment was given for wounds prior to hospitalization on [DATE] or after her return from the hospital up until 10/12/17 when there is an order for [REDACTED]. AA. Record review of R #1's Treatment Administration Record for October 2017 revealed no treatment orders for pressure related wounds prior to 10/12/17. Findings for R #3: BB. Record review of the Complaint Intake 11/06/17, stated Residents husband reported that he was concerned that the last two days he has come to visit the resident and she has been in BM (bowel movement) for an unknown amount of time which resulted in skin excoriation. Resident's husband and the resident are afraid to go back to (facility) for fear of further neglect. CC. Record review of the Hospital Incident Report regarding resident's condition dated 10/09/17, revealed Below is a description from the Nursing staff re; the patient's condition upon admission to (hospital) from (facility). Upon arrival of patient, four eye assessment (this is where 2 nurses (or other staff members) go in together once a patient is admitted to the unit and do a thorough skin assessment together) completed with ED (emergency department) RN (registered nurse) redness, excoriation, sloughing, and foul smell found to groin area. Pt (patient) states area is tender to the touch. When asked to move her legs, pt winced. Redness, excoriation, sloughing, and tenderness found from groin to mid thigh. Upon further inspection, slight redness found to both sides of pt's abdomen from hip to mid abdomen. After turning pt to side, more severe redness found to inner and outer buttocks down to the mid thigh area. Skin is tomato red, shiny, bleeding, sloughing, tender to touch. Pt withdraws upon touching the bleeding areas. Pt states it burns. Areas of slough are found on the outer edges of the redness where a multitude of pin sized pustules can be seen. Pustules are not removable. Healing cat scratch to right shin had [MEDICATION NAME] (dressing) and sponge dressing. Dressing clean but not dated. Dressing removed. Scratch healing-has an intact scab with no redness. Sharpie mark on skin from previous visit for [MEDICAL CONDITION] (bacterial infection of the skin) still visible to right lower ankle. Pt has dry skin build up to her face, build up of secretions to both eyes, and flaking dry skin to her lips. Pt's foley (catheter used to drain urine) is draining cloudy yellow urine and pt complains of pain with foley movement. Foley near groin area has dry urine build up. Appears to have lacked peri care. Pt's triple lumen (a thing lowered into a catheter with three separate passages) PICC (peripherally inserted central catheter), with three line is clogged in the purple and yellow lumens. Purple lumen tube is filled with blood. Neither can flush. Third lumen (white) is flushable with much resistance. Dressing is intact but soiled underneath with dry sanguineous (bloody) fluid visible. Dressing resembles those of (name of hospital). No date is visible. Upon questioning the pt, RN uncovers pt has not had a shower in two weeks and she does not recall the PICC line dressing being changed. DD. Record review of R #3's Admission Record (not dated) revealed, she was admitted to the facility on [DATE] and discharged on [DATE] to hospital. R #3 had the following medical diagnoses, muscle weakness, difficulty in walking, lack of coordination, [MEDICAL CONDITIONS] of right lower limb, [MEDICAL CONDITIONS] (a potentially life-threatening complication of an infection) unspecified organism, [MEDICAL CONDITION], unspecified combined systolic (The blood pressure when the heart is contracting) and diastolic (blood pressure when your heart muscle is between beats) heart failure, [DIAGNOSES REDACTED] (deficiency of potassium in the bloodstream), essential hypertension, cutaneous abscess (a localized collection of pus in the skin). EE. Record review of the Admission Nursing assessment dated [DATE], revealed the reason for R #3's admission is exacerbation of chronic illness rehabilitation. Infections requiring interim care planning: [MEDICAL CONDITIONS]. medications: [REDACTED]. R #3 is alert and oriented to person, place, time. Judgement is intact. Toileting for bowel: bathroom, commode, bedpan. Indwelling catheter. Mobility is very limited. Impairment to right lower extremity. PICC, verified on 09/28/17. A Braden score (for predicting pressure sore risk) of 15.0 (12-16 moderate risk). Skin impairments present, but does not include location, type and description. FF. Record review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed R #3 has moisture associated skin damage (e.g., incontinence-associated [MEDICAL CONDITION], perspiration, drainage) and IV (intravenous) medications. GG. Record review of R #3's Medical Record, did not reveal that a Skin Assessment was completed upon admission. HH. Record review of the Skin Check dated 10/03/17, revealed new skin injury/wound identified. New skin injury type: Abrasion, multiple abrasions on buttocks. Rash, Rash on buttocks, inner thighs and creases in groin, under abd (abdominal) pannus (layer of fatty tissue). Moisture associated skin damage. Pressure, right heel, multiple bilateral buttocks stage 1 abrasions, bilateral (both) inner thighs stage 1 abrasions. II. Record review of R #3's Activities of Daily Living (ADL) record dated 09/28/17 to 10/06/17, did not show documentation that R #3 received a shower or bed bath during her 9 day stay at the facility. JJ. Record review of R #3's Interim Care Plan, revealed R #3's had the following focus areas initiated; on 10/04/17, Resident has actual skin breakdown related to. On 10/05/17, resident is at nutritional risk: related to poor intake. At the time of R #3's admission to the facility on [DATE], she did not have an interim care plan focusing on preventing skin breakdown, wound treatment, medications, PICC line, foley catheter, or infections. KK. Record review of the Admission History and Physical dated 09/29/17, indicated R #3 had no obvious rash or [MEDICAL CONDITION] and PICC to right upper arm: triple lumen CVC (Central Venous Catheter) without redness or drainage. The treatment plan for the following [DIAGNOSES REDACTED].> 1. [MEDICAL CONDITION] of right lower limb: continue [MEDICATION NAME]-sulbactam (an antibiotic), intravenously, every 6 hours. 2. [MEDICATION NAME] (an inflammation of the digestive tract) due to [MEDICAL CONDITION]: continue [MEDICATION NAME] (an antibiotic)every 6 hours and [MEDICATION NAME] ([MEDICATION NAME] that helps restore your natural flora) capsule 2 times a day. 3. Heart failure: continue [MEDICATION NAME] (treats high blood pressure) 2 times a day, [MEDICATION NAME] (a diuretic) once a day, and [MEDICATION NAME] (a diuretic) once a day. 4. Chronic [MEDICAL CONDITION]: continue [MEDICATION NAME] (treats high blood pressure) every 6 hours, Apixaban (an anticoagulant) 2 times a day. 5. Essential (primary) hypertension: continue [MEDICATION NAME] (antihypertensive) once a day. 6. Asthma: continue [MEDICATION NAME] (asthma and allergy drug) every night, start [MEDICATION NAME] aerosol (used to prevent and treat difficulty breathing) as needed every 4 hours, and [MEDICATION NAME] Neb (help ease breathing) every 4 hours as needed. 7. [MEDICAL CONDITION]: continue [MEDICATION NAME] (cholesterol medication) once a day. 8. Dysthymic disorder (Persistent [MEDICAL CONDITION]): continue [MEDICATION NAME] (an antidepressant) once a day. LL. Record review of the Physician order [REDACTED].#3 had treatment orders for the PICC and foley catheter. Documentation revealed the following medications: [REDACTED] a. Medications started on 09/27/17: 1. [MEDICATION NAME] Nebulization Solution (help ease breathing) 3 ml (milliliters) every 4 hours for shortness of breath. 2. Apixaban tablet (an anticoagulant) 2.5 MG (milligram) two times a day for anticoagulation (blood thinning medication). 3. [MEDICATION NAME] Suppository (laxative) 10 mg 1 suppository rectally every 48 hours for spastic bowel hold for loose stools. 4. [MEDICATION NAME] (treats high blood pressure) tablet 30 mg every 6 hours [MEDICAL CONDITION](hypertension) 5. [MEDICATION NAME] tablet (treats high blood pressure) 100 mg two times a day [MEDICAL CONDITION] 6. Unaysn Solution Reconstituted (an antibiotic) 3 MG intravenously every 6 hours for infection. 7. [MEDICATION NAME] solution (an antibiotic) 125 mg four times a day for [MEDICAL CONDITION] ([MEDICAL CONDITION] colities is a bacterium that causes diarrhea). b. Medications started on 09/28/17: 8. [MEDICATION NAME]-Sulbactam Sodium solution Reconstituted (an antibiotic) 3 gram intravenously for 6 hours [MEDICAL CONDITION]. 9. [MEDICATION NAME] Solution ([MEDICAL CONDITION] medication) 1 drop in both eyes one time a day. 10. [MEDICATION NAME] Tablet (an antidepressant) 20 mg once a day for depression. 11. [MEDICATION NAME] tablet (antihypertensive) 80 mg once a day for HTN. 12. [MEDICATION NAME] Tablet (an antacid) once a day [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease). 13. [MEDICATION NAME] tablet (a diuretic) 20 mg once a day. 14. [MEDICATION NAME] tablet (a diuretic) 100 mg once a day 15. [MEDICATION NAME] tablet (cholesterol medication) 10 mg once a day. MM. Record review of R #3's Medication Administration Record [REDACTED] 1. [MEDICATION NAME] Nebulization had 9 potential missed doses because the medication was first administered 09/29/17 at 7:00 am. Missed doses occured on 09/27/17 at 7:00 pm and 11:00 pm. Missed doses occured on 09/28/17 at 3:00 am, 7:00 am, 11:00 am, 3:00 pm, 7:00 pm and 11:00 pm. Missed dose occured on 09/29/17 at 3:00 am. 2. Apixaban had 3 potential doses missed because the medication was first administered on 09/29/17 at 7:00 am; . Missed doses occured on 09/27/17 at 7:00 pm. Missed doses occured on 09/28/17 at 7:00 am and 7:00 pm. 3. [MEDICATION NAME] Solution had 1 potential dose missed because the medication was first administrated 09/29/17 at 7:00 am. Missed dose occured on 09/28/17 at 7:00 am. 4. [MEDICATION NAME] had 1 potential dose missed because the medication was first administrated 09/29/17 at 7:00 am; Missed doses occured on 09/28/17 at 7:00 am. 5. [MEDICATION NAME] had 6 potential doses missed because the medication was first administrated 09/29/17 at 7:00 am. Missed doses occured on 09/27/17 at 7:00 pm. Missed doses occured on 09/28/17 at 1:00 am, 7:00 am, 1:00 pm and 7:00 pm. Missed doses occured on 09/29/17 at 1:00 am. 6. [MEDICATION NAME] had 1 potential dose missed because the medication was first administrated 09/29/17 at 7:00 am. Missed dose occured on on 09/28/17 at 7:00 am 7. [MEDICATION NAME] Suppository, had 2 potential doses missed because no medication was administered. Missed doses occured on 09/27/17 and 09/29/17. 8. [MEDICATION NAME] had 1 potential dose missed because the medication was first administrated on 09/29/17 at 7:00 am. Missed dose occured on 09/28/17. 9. [MEDICATION NAME] had 1 potential dose missed because the medication was first administrated on 09/29/17 at 7:00 am. Missed dose occured on 09/28/17. 10. [MEDICATION NAME] had 2 potential doses missed because the medication was first administrated on 09/29/17 at 7:00 am. Missed dose occured on 9/27/17 at 7:00 pm. Missed doses occured on 09/28/17 at 7:00 am and 7:00 pm. 11. [MEDICATION NAME] had 1 potential dose missed because the medication was first administrated on 09/29/17 at 7:00 am. Missed dose occured on 09/28/17 at 7:00 am. 12. Unaysn Solution, had 1 potential dose missed because no medication was administered. Missed dose occured on 09/27/17 at 7:00 pm. 13. [MEDICATION NAME] solution had 6 potential doses missed because the medication was first administrated on 09/29/17 at 7:00 am. Missed dose occured on 09/27/17 at 9:00 pm. Missed doses occured on 09/28/17 at 7:00 am, 11:00 am, 5:00 pm and 9:00 pm. Missed doses occured on 09/29/17 at 5:00 pm and 9:00 pm. 14. [MEDICATION NAME] had 1 potential dose missed because the medication was first administrated on 09/29/17 at 7:00 am. Missed dose occured on 09/28/17 at 7:00 am. NN. Record review of R #3's Treatment Administration Record (TAR) dated September 2017 revealed, [MEDICATION NAME]-Sulbactam Sodium solution had 6 potential dose missed because the medication was first administrated on 09/29/17 at 2:00 pm. Missed doses occured on 09/28/17 at 2:00 am, 8:00 am, 2:00 pm and 8:00 pm. Missed doses occured on 09/29/17 at 2:00 am and 8:00 am. Further review, indicated two other treatments: Pain monitoring and Vital signs. R #3 had no documentation showing the dressings to the PICC and wound to right lower extremity were changed, flushing of the PICC lines, or foley care. OO. Record review of R #3's TAR dated October 2017, revealed [MEDICATION NAME]-Sulbactam Sodium solution [MEDICAL CONDITION] until 10/01/17, order to D/C (discontinue) foley catheter after 2 hr (hours) bladder training. Re-cath if no urine output after 4 hrs one time only for no longer needed for 1 day, 10/02/17, order for No creams applied to groin and leave groin/peri area open to air as much as possible; every shift skin irritation, 10/04/17, pain monitor, and vital signs. On 10/3/17, states NN (no/see nurse notes) for the discontinuation of the foley catheter, indicated R #3's foley was not discontinued. Further review, shows R #3 was complaining of pain, with levels as high as 6 (scale from 0-10). PP. Record review of the Nursing Progress Notes dated 09/27/17 to 10/09/17, revealed the following: 1. On 09/28/17 at 12:28 pm [MEDICATION NAME], No medication available at this time. [MEDICATION NAME], No medication available at this time. At 1:57 am, [MEDICATION NAME]-sulbactam sodium solution, Medication unavailable. At 4:47 pm, [MEDICATION NAME] nebulization, PTs (patients) medication has not been delivered. At 6:18 pm, PT don't (sic) have any of her medication it hasn't been delivered by the Rx (pharmacy) I will administer medication as soon as its delivered. 2. On 09/29/17 at 4:32 pm, [MEDICATION NAME]-Sulbactam, Unavailable. Scheduled for delivery. 3. On 10/01/17 at 6:26 pm, Apixaban Reordered medication and will administer medication as soon as it is delivered. 4. On 10/02/17, Client husband complained of his wife being in a lot of pain due to excoriation of her buttocks and groin due to catheter leaking. Spoke to (name of PA) re (regarding) situation she advised to bladder train and d/c cath (catheter) and monitor for urine output, to re-cath if no urine output after 4 hrs. (PA) ordered for zinc oxide during brief changes. 5. On 10/03/17, at 2:52 am Foley in place. Pt has redness around peri area that was reported during shift change and also this nurse observed it. PICC line in place. At 10:18 am, D/C foley catheter after 2 hr (hours) bladder training. Re-cath if no urine output after 4 hrs one time only for no longer needed for 1 day (copied from the MAR). Chronic foley, needed to conduct bladder retraining before D/C. At 9:57 pm, A skin check was performed. The following New skin injury/wound(s) were identified: Abrasion(s): Description: multiple abrasions on buttocks Rash(s): Description: rash on buttocks, inner thighs & creases in groin, under abd pannus (a dense layer of fatty tissue growth, consisting of subcutaneous fat in the lower abdominal area), MASD-Moisture Associated Skin Damage(s): Location(s): multiple skin abrasions on buttocks Pressure Area(s): Location(s): right heel, multiple bilateral buttocks stage 1 abrasions, bilateral inner thighs stage 1 abrasions. The following skin injury/wound(s) were previously identified and were evaluated as follows: Rash(s): Description: peri area redness MASD-Moisture Associated Skin Damage(s): Location(s): peri area redness. 6. On 10/05/17, Spoke with (PA) in regards to client status. Husband has been very concerned about his wife's condition. The excoriation to her perineum has improved based on my assessment but the one on her buttock has spread to the right butt cheek. (PA) ordered for the client t (TRUNCATED)

Based on observation, interview, and record review, the facility failed to ensure that the residents environment remained free of accident hazards by: 1. Failing to ensure hot water temperatures did not exceed 110 degrees Fahrenheit (F) for 13 (R #'s 1, 5, 8, 51, 72, 91, 97, 107, 126, 146, 222, 247, and 248) of 26 (R #'s 1, 5, 8, 13, 22, 28, 33, 51, 53, 71, 72, 87, 91, 96, 97, 107, 109, 122, 126, 138, 140, 146, 147, 222, 247, and 248) residents on the 200 unit (7 NMAC 9.2.71.L.1.b). 2. Failing to safely transfer 1 (R #143) of 5 (R #'s 15, 56, 76, 143, and 146) residents reviewed for accidents, by not utilizing the appropriate mechanical device to transfer R #143, resulting in him falling to the ground and sustaining a significant injury. If hot water temperatures are not maintained at a safe level, residents are likely to experience thermal burns while using restroom sinks and if residents are not transferred appropriately, this deficient practice is likely to result in avoidable accidents with potentially serious injury. The findings are: Findings regarding hot water temperatures: A. On 08/08/16, observation of resident bathrooms on the 200 unit revealed the following: 1. At 10:41 am, the hot water in the bathroom in room 201 was noted to be at 128.5 degrees F. 2. At 10:42 am, the hot water in the bathroom shared by rooms 205 and 207 was noted to be at 127.2 degrees F. 3. At 11:17 am, the hot water in the bathroom shared by rooms 210 and 212 was noted to be at 127.9 degrees F. 4. At 1:18 pm, the hot water in the bathroom shared by rooms 204 and 206 was noted to be at 122.9 degrees F. 5. At 1:28 pm, the hot water in the bathroom in room 201 was noted to be at 126 degrees F. 6. At 1:29 pm, the hot water in the bathroom shared by rooms 205-207 was noted to be at 122 degrees F. 7. At 1:30 pm, the hot water in the bathroom in room 202 was noted to be at 126.6 degrees F. 8. At 1:33 pm, the hot water in the bathroom in room 203 was noted to be at 125 degrees F. B. On 08/08/16 at 1:30 pm, during interview, R #91 stated that sometimes the water in his bathroom gets hot. R #91 also stated, When it does (get hot), it gets hot. C. On 08/10/16 at 1:52 pm, during interview (after hot water temperatures were identified) the Maintenance Director stated, I fixed the problem. I adjusted the mixing valves and the temperature. The Maintenance Director stated that he monitors the water temperatures weekly, stating that he picks two halls and alternating rooms at random, so he can monitor all four boilers. He stated that the computer program he uses, triggers a task to check the water temperatures weekly, and if they are not done it flags that assignment and generates a notification to the Administrator. The Maintenance Director was asked when was the last time the water temperatures on the 200 unit were checked, he stated, It was about 3 weeks ago. D. Record review of the Maintenance Logbook Documentation provided by the Manager of Clinical Operations (MCO) on 08/11/16, revealed on 08/08/16 the Maintenance Director tested the hot water in four resident bathrooms, one on each unit. In room 102 the hot water was 125.6 degrees F, in room 201 the hot water was 124.4 degrees F, in room 301 the hot water was 125.2 degrees F, and in room 402 the hot water was 125.7 degrees F. The comments indicate, Found water temps high on 08/08/16. Adjusted mixing valves and monitored temps to correct temperatures. E. Record review of a List of Residents on the 200-unit provided by the MCO on 08/11/16, revealed the residents that are cognitively impaired and could get to a sink in their wheelchairs are: R #s 8, 247, 126, 22, 122, 146, and 96. Residents that are able to walk independently on the 200-unit are: R #s 91, 97, 248, 13, 109, 71, 147, and 220. F. Record review of (Name of Maintenance Company) Instructions not dated, indicated the procedures to test water temperatures are: 1. Let the water run for a least three minutes before taking your reading, 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, 3. Check resident rooms at the end of each wing on a rotating basis or per facility policy, and 4. Record results in the water temperature log .note any discrepancies .adjust water heater settings as required and retest if necessary. Findings related to R #143: G. Record review of Admission Record dated 11/03/14, revealed R #143 is a bilateral (both sides) amputee. H. Record review of Minimum Data Set ((MDS) dated [DATE], indicated R #143 is extensive assist (resident involved in activity, staff provide weight-bearing support) with two plus persons physical assist for transfers. R #143 has impairment on both sides of lower extremities. I. Record review of the Risk Management System Summary Report dated 07/30/16, revealed Resident slid out of sara (sit to stand lift-assist in raising weight-bearing patients to a standing position) lift when being lifted from wc (wheelchair), can (sic) stated that resident blacked out for a second and resident let go of the handle on the sara lift and resident slipped to the floor. Wheelchair was not behind resident to catch him when he slipped. At this time there appears to be no injuries. Nero (neurological) checks started. J. Record review of Radiology Results Report dated 08/08/16, revealed Left clavicle (collarbone) fracture is present with 1 cm (centimeter) displacement. K. Record review of the Care Plan, dated 08/06/16, revealed (R #143) is at risk for falls: impaired mobility. Interventions: assess for changes in medical status, pain status, mental status and report to MD (medical doctor) as indicated, assist (R #143) getting in and out of bed with extensive 2 person assistance, provide verbal cues for safety and sequencing when needed, place call light within reach at all times, remind to use call light when attempting to ambulate or transfer. L. On 08/08/16 at 11:10 am, during interview, R #248 stated that she recalled R #143 telling her that he had fallen recently because staff used the wrong lift when transfering him. M. On 08/09/16 at 10:10 am, during interview, with R #143, he stated that he was having pain in his left shoulder from falling on it. R #143 was unable to provide any additional information. N. On 08/10/16 at 10:10 am, during interview, Licensed Practical Nurse (LPN) #5 stated that R #143 has a fracture to his clavicle. LPN #5 also stated that R #143 was transferred using a hoyer lift because he is a bilateral amputee and requires the assistance of two people when transferring. When asked about R #143's fall, she stated, I think he slipped off something and fractured his clavicle. I think he slipped off the lift. O. On 08/10/16 at 10:29 am, during interview, the Director of Nursing (DON) stated, Basically what happened was he (R #143) was in our sit to stand lift, he (R #143) stated that he let go. We did have an agency CNA (certified nursing assistant) with him and I don't remember if there was two of them or just one. So, he did complain of pain, we did an x-ray and it was negative. He continued to have pain, but he wasn't in constant pain, so we did another x-ray and it was positive (for a fracture to his left clavicle). At the time of the fall he was alert and he said he blacked out. The DON confirmed that the agency CNA was using the sit-to-stand lift to transfer R #143. When asked if that was appropriate, she stated, According to our policy no. It can be appropriate if he has his prostheses (artificial limb) on, but he hasn't used it. He doesn't have his lower extremities. The DON confirmed R #143 did not have his prostheses on at the time. Regarding the number of CNAs required to help transfer using a lift, the DON stated, Two. Always two staff helping. The DON was not able to confirm if one CNA was transferring R #143 or two CNAs. The DON further stated, We did investigate, but we didn't do a full investigation. In our meeting we did talk and say he is not appropriate for that lift (sit to stand) and switched him to a hoyer lift. I'm not sure what lift they were using before. The DON stated that R #143 did not hit his head when he fell . P. On 08/10/16 at 10:52 am, during interview, the Administrator stated, There were a couple of breakdowns. When transferring, it should have been two people, not one. It was an agency CNA, they did a single (person) transfer, they should of had two people. From what I understand they were using the wrong lift. There were a couple of procedural breakdowns that happened. The procedure says we're supposed to use two people (for sara lift) and I believe that, that lift is supposed to take weight off, not use it for transfers. It's a weight bearing lift. He did not hit his head. He kept complaining of pain and so we did more extensive x-rays and found an injury. Q. On 08/10/16 at 11:15 am, during interview, LPN #1 stated that they do not train agency staff before they come into the building. Regarding R #143's fall, she stated, They (agency staff) were using the sit to stand lift, he (R #143) has no legs so he can't bear weight, so he fell through. I'm pretty sure it was just the one (CNA transferring). He cannot bear weight and they should of had two people with him. She was asked if agency staff shadow facility staff, she stated, Not usually, unless they feel uncomfortable. We don't have the staff to sit and orient them either. R. On 08/10/16 at 11:25 am, during interview the DON confirmed R #143 did not hit his head when he fell from the sit to stand lift. S. On 08/10/16 at 12:49 pm, during interview, the DON confirmed that there were two agency CNAs working on R #143's hall. The DON also confirmed that the CNA that worked with R #143 had previously worked with him on 07/24/16, 06/03/16, 06/08/16, 06/14/16, and 06/25/16 and by that time the CNA should be familiar with R #143's needs. T. On 08/10/16 at 1:01 pm, during interview, CNA #7, stated that she was working on R #143's hall with the agency CNAs on the day of R #143's accident. CNA #7 stated that she was at lunch and the agency CNA was by herself. She said that the agency CNA was getting R #143 up to put him in the chair. The agency CNA shouldn't have used the sit to stand lift, only when R #143 has his prosthetic leg on. CNA #7 further stated that R #143 was sick at the time and he couldn't hold on to the lift. U. On 08/11/16 at 7:05 am, during interview, the DON confirmed that the Neurological checks that were done for R #143 on 07/30/16 were incomplete. V. Record review of the facilities policy titled Safe Resident Handling/Transfer Equipment dated 11/30/15, revealed: 1. Patients will be assessed to determine the correct equipment to use, 2. Staff will be trained in the use of each type of equipment, 3. The Total Lift is used for those patients who are dependent non-weight bearing or have inconsistent weight bearing .the full body sling is only used when .lower extremity amputation, 4. The Sit to Stand Lift will be used for those patients who meet the following criteria: have some weight bearing ability .use of the sit to stand lift requires two staff members.

Based on record review and interview, the facility failed to implement the care plan for 1 (R #143) of 1 (R #143) residents reviewed for accidents, by not ensuring two Certified Nursing Assistants (CNAs) transferred R #143 from his wheelchair to his bed. This deficient practice likely resulted in R #143 falling to the floor from a sit to stand lift (assist in raising weight-bearing patients to a standing position) and sustaining an avoidable injury. The findings are: A. Record review of the Admission Record dated 11/03/14, revealed R #143 is a bilateral (both sides) [MEDICAL CONDITION]. B. Record review of Minimum Data Set ((MDS) dated [DATE], indicated R #143 is extensive assist (resident involved in activity, staff provide weight-bearing support) with two plus persons physical assist for transfers. R #143 has impairment on both sides of lower extremities. C. Record review of the Care Plan updated on 08/06/16, revealed (R #143) is at risk for falls: impaired mobility. Interventions: Assist (R #143) getting in and out of bed with extensive 2 person assistance. D. On 08/10/16 at 10:52 am, during interview, the Administrator stated, When transferring, it should have been two people, not one. It was an agency CNA, they did a single (person) transfer, they should of had two people.