Every finding on record at Socorro Wellness & Rehabilitation

Based on record review, and interviews, the facility failed to maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision. This has the potential to affect all 54 residents in the facility (residents were identified by the resident matrix provided by the DON on 07/09/26). If the facility does not maintain grievance evidence, then residents' concerns could go without resolution leaving residents feeling frustration and helpless. The findings are: A. Record review of the facility's Grievances/Complaints Policy dated August 2020 revealed the following:1. The disposition of all written grievances and/or complaints is recorded on the Resident Grievance/Complaint Log.2. The Administrator or designee is responsible for recording and maintaining a log.3. The log will be maintained for a period of no less than three (3) years from the issuance of the grievance decision.4. The Resident Grievance/Complaint log is reviewed by the Quality Assurance and Assessment Committee at least quarterly. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. B. On 07/10/26 at 12:53 PM, during an interview the Social Services Worker (SSW) stated the following:1. She did not have the grievances from April 2026-July 2026 because the Administrator took over grievances. He was inputting into the electronic medical record. She did not keep copies.4. She did not have any grievances prior to May of 2025 from when she started working at the facility. 5. She did not have any grievances for the year 2024. C. On 07/10/26 at 10:10 AM, during an interview the DON stated the following:1. The grievance official is the Administrator and coordinates with the SSW. 2. The DON's expectation for grievances is that the facility keeps three (3) years of grievances on file.

Based on observation, record review, and interview, the facility failed to maintain sufficient nursing staffing to ensure the highest practicable physical, mental, and psychosocial well-being of each resident. This failure has the potential to affect all 54 residents (residents were identified by the resident census list provided by the DON on 07/09/26). This deficient practice could likely result in residents not receiving the care and service needed while in the facility. The findings are: A. Record review of the Call Light-Use of Policy revised date January 2026 revealed the following:1. Ensures that all residents have consistent access to a working call light. 2. Residents must be instructed on the proper use of the call light system to promote safety, timely assistance, and improve their quality of care. 3. Staff should respond promptly and courteously to all call lights, ensuring resident needs are met without delay. B. Record review of R #24 admission record no date revealed the following:R #24 was admitted to the facility on [DATE].R #24 had the following diagnosis:Muscle wasting and atrophy (the partial or complete wasting away, shrinking, or progressive decline of a body part, tissue, or organ).Hemiplegia (paralysis that affects only one side of the body,) and hemiparesis (weakness or partial paralysis affecting only one side of the body) following a cerebral infarction (blood flow to an area of the brain is blocked, depriving tissue oxygen and causing cells to die) affecting left nondominated side. Respiratory failure. C. On 07/10/26 at 8:28 AM, during an observation and interview with R #24 revealed the following:1. R #24 was in his room lying in bed watching television. 2. R #24 stated he has had an ongoing issue with the direct staff answering the call lights. 3. The CNA's go into his room and ask R #24, What do you need, and turn the call light off. The CNA's tell R #24 I'll get someone to help you. 4. R #24 stated he waits for another 5 to10 minutes and turns call light on again. 5. When the CNA's go to R #24's room again, R #24 tells the staff, Don't turn the call light off; if you are not going to help me. 5. R #24 stated he knows he is not the only resident at the facility but It doesn't mean that you forget the person who had the light on 30 minutes before. D. Record review of R #25 admission record no date revealed the following:R #25 was admitted to the facility on [DATE].R #25 had the following diagnosis:Chronic respiratory failure with hypoxia (a specific region of your body, lacks the adequate oxygen supply required to function normally).Diabetes mellitus.Atherosclerotic heart disease (the narrowing of the heart's arteries due to a buildup of fatty plaque). E. On 07/09/26 at 1:00 PM, during an observation and interview with R #25, revealed the following:1. R #25 was sitting in her wheelchair in the doorway of her room looking out to the hallway. 2. R #25 has been at the facility for six (6) months.3. R #25 stated the facility could use more help. 4. On bad days her call light is not answered for up to 30 minutes. 5. Sometimes the CNA's come to my room to turn off call light and then R #25 won't see them for a while.6. R #25 stated Sometimes she has incontinence because of the wait times, but this is how it goes. It's first come, first serve. F. Record review of R #26 admission record no date revealed the following:R #26 was admitted to the facility on [DATE].R #26 had the following diagnosis:Nondisplaced intertrochanteric fracture of right femur (a break in the upper portion of the femur (thigh bone) that occurs in the bony region between the greater and lesser trochanters).Muscle wasting and atrophy.Atherosclerotic heart disease. G. On 07/09/26 at 1:38 PM during an observation and interview with R #26, revealed the following: 1. R #26 was wheeling himself in his wheelchair in the hallway.2. R #26 stated at night his call light is answered in 20 minutes, and sometimes up to 40 minutes.3. R #26 stated the staff come in and turn off the call light and leave without helping. They say they will be back, but don't come back. R #26 has to turn on his call light again. This happens a lot. H. Record review of R #28 admission record no date revealed the following:R #28 was admitted to the facility on [DATE].R #28 had the following diagnosis:Hemiplegia and hemiparesis following a cerebral infarction affecting left nondominated side.Diabetes mellitus. Muscle wasting and atrophy. I. On 07/09/26 at 1:25 PM, during an observation of R #28's hallway revealed R #28's call light was on, and the staff turned off the call light at 1:27 PM. J. On 07/09/26 at 1:33 PM, during an observation and interview with R #28, revealed the following:R #28's call light was on.She was in her wheelchair waiting to be changed and put into bed. R #28 stated she had already been waiting for 25 minutes. Sometimes she waits for an hour and a half.R #28 has called her family member three times previously to have the family member call the facility to help her go to bed. R #28 stated on nights there was one CNA working alone. One (1) CNA for each hall. This was in the end of June during the night and weekends.R #28 stated, The staff are always short. Management does not do anything about it. K. On 07/09/26 at 1:46 PM, during an observation of R #28's room and interview with LPN #24 revealed following:1. R #28's call light was on.2. LPN #24 went into R #26 room and came out. 3. LPN #24 stated R #28's light is on because she needs to be changed. The CNAs are doing changes and she's waiting to be changed. L. On 07/09/26 at 1:54 pm, during an observation of R #28's room revealed the following:R #26's call light was still on.The CNA went into R #28's room closed the door and turned off the call light. M. On 07/10/26 at 10:10 AM, during an interview the DON stated the following:1. The DON's expectation is that when the residents turn on the call light, the CNA's and nurses should respond promptly within 10-15 minutes max.2. The staff need to leave call light on until the resident receives their service. 3. The staff have radios they can talk on to get someone to help.4. Sometimes they are providing care on a higher acuity resident and take a bit longer. 5. The DON expects the nurses to help. They can check on residents, answer call lights, and assist residents.

Based on observation and interview, the facility failed to properly store medications, which could affect all 59 residents in the facility (Residents were identified by the resident matrix provided by the ADON on 12/09/25), when they failed to: 1. Ensure medications were not expired in the medication room. 2. Ensure medications were not expired in the electronic medication management dispensing machine. This deficient practice could likely result in residents obtaining medications that are no longer effective, resulting in adverse side effects. The findings are: A. On 12/11/25 at 11:32 AM, during an observation of the medication room, revealed the following: 1. Medication Storage Cabinets a. One (1) bottle of Daily Multivitamin tablets with an expiration date of 08/2025. b. One (1) bottle of Daily Multivitamin tablets with an expiration date of 11/2025. c. One (1) bottle of Ibuprofen (pain reliever) 200 mg tablets with an expiration date of 09/2025. 2. Electronic medication dispensing machine a. One (1) tablet of amlodipine (medication used to treat high blood pressure) 5 mg with an expiration date of 12/02/25. b. Two (2) tablets of sertraline (antidepressant medication) 25 mg with an expiration date of 11/27/25. B. On 12/11/25 at 11:40 AM, during an interview, the ADON confirmed the following: 1. There were two (2) bottles of Daily Multivitamin tablets that were expired in the medication storage cabinets. 2. There was one (1) bottle of Ibuprofen tablets that was expired in the medication storage cabinets. 3. There was one (1) tablet of amlodipine 5 mg that was expired in the electronic medication dispensing machine. 4. There were two (2) tablets of sertraline 25 mg that were expired in the electronic medication dispensing machine. 5. Staff were expected to remove expired medications from the medication cabinets and the electronic dispensing machine.

Based on record review and interview, the facility failed to submit direct care staffing information to the federal agency overseeing certification for long term care facilities for Quarter #4 (July 1, 2024-September 30, 2024). This has the potential to affect all 59 residents in the facility, (residents were identified by the Resident Matrix provided by the ADON on (12/08/25). This deficient practice could likely result in inaccurate direct care staffing information for residents/facility. The findings are:A. Record review of Payroll Base Journal (PBJ) Staffing Data Report (report from the database of the federal agency overseeing certification for long term care facilities) dated Quarter #4 (July 1, 2024-September 30, 2024), revealed no licensed nursing coverage for 24 hours/day for the following dates: 1. 07/14/24, 2. 08/4/24, 3. 08/11/24, 4. 08/18/24, 5. 08/25/24, 6. 09/1/24, 7. 09/8/24, 8. 09/13/24, 9. 09/14/24, 10. 09/15/24, 11. 09/21/24, 12. 09/22/24, 13. 09/28/24. B. On 12/12/2025 at12:47 PM, during an interview with Regional Director, he stated that this company took over on 11/01/25 and was unable to obtain clock ins and outs for nursing staff from previous ownership for Quarter #4 for the following dates (July 1, 2024-September 30, 2024): 1. 07/14/24, 2. 08/4/24, 3. 08/11/24, 4. 08/18/24, 5. 08/25/24, 6. 09/1/24, 7. 09/8/24, 8. 09/13/24, 9. 09/14/24, 10. 09/15/24, 11. 09/21/24, 12. 09/22/24, 13. 09/28/24.

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 there was adequate monitoring for any adverse consequences resulting from the medication for 1 (R #8) of 5 (R #3, R #8, R #25, R #36, and R #70) residents reviewed for unnecessary medications, when staff failed to: 1. Ensure psychotropic medications were prescribed to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior). 2. Perform an AIMS (Abnormal Involuntary Movement Scale test used in medicine to assess side effects of antipsychotic medication) assessment to monitor antipsychotic (a class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders) medication. These deficient practices could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of R #8's admission documents, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8 had the following diagnoses: a. Senile degeneration of brain (an outdated term for age-related cognitive decline, now called dementia, a progressive loss of brain function due to damaged brain cells, most commonly from Alzheimer's, vascular issues, or Lewy body disease, causing memory loss, confusion, and impaired thinking, rather than being a normal part of aging itself). b. Major Depressive Disorder (MDD, a serious mood disorder causing persistent sadness, loss of interest, and impaired daily functioning). c. Personal history of other mental and behavioral disorders (a medical classification, often using the ICD-10 code Z86.59, that indicates a patient has a history of past mental health issues). d. Anxiety (excessive worry, restlessness, rapid heart rate, trouble concentrating, and sleep issues). e. Dementia f. Restlessness and agitation (states of inner tension and inability to stay still). B. Record review of R #8's physician orders, multiple dates, revealed the following: 1. An order dated 09/08/25 and discontinued on 09/15/25, for quetiapine fumarate (an atypical antipsychotic medication used to treat schizophrenia and bipolar disorder) 50 mg two times a day for agitation. 2. An order dated 10/20/25, for quetiapine fumarate 50 mg twice a day for agitation and anxiety. C. Record review of R #8's MAR, dated September 2025, revealed R #8 received quetiapine fumarate as ordered from 09/08/25 to 09/15/25. D. Record review of R #8's MAR, dated October 2025, revealed R #8 received quetiapine fumarate as ordered from 10/22/25 to 10/31/25. E. Record review of R #8's MAR, dated November 2025, revealed R #8 received quetiapine fumarate as ordered the entire month. F. Record review of R #8's MAR, dated December 2025, revealed R #8 received quetiapine fumarate as ordered from 12/01/25 to 12/12/25. G. Record review of R #8's entire medical record, no date, revealed the following: 1. No order for AIMS assessment, and 2. No AIMS assessment had been documented. H. On 12/12/25 at 2:35 PM, during an interview, the Regional Clinical Nurse (RCN) confirmed the following: 1. R #8 had an order for quetiapine fumarate for agitation and anxiety. 2. R #8 did not have an appropriate diagnosis for the use of antipsychotic medication. 3. Staff were expected to ensure residents were not administered antipsychotic medication unless they had a specific psychiatric diagnosis. 4. Staff did not complete an AIMS assessment on R #8. 5. Staff were expected to complete an AIMS assessment prior to starting an antipsychotic medication and at least every three (3) months after.

Based on record review and interview, the facility failed to provide the required discharge or transfer information to the resident and the resident's representatives in writing for 3 (R #2, R #5, and R #66) of 3 (R #2, R #5, and R #66) residents sampled for hospitalizations, when staff failed to: 1. Notify the residents and resident representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand for R # 2 and R #5. 2. Ensure residents or their representative received a written notice of the bed hold policy which indicated the duration the bed would be held for R #66. These deficient practices could likely result in the resident and/or their representative not knowing the reason for a transfer or discharge, the location of the transfer or discharge, their rights to advocate and make informed decisions regarding the resident's healthcare, the services that the resident received while at the facility, the resident's current health status, or the resident's current medications leading to adverse outcomes for the resident. The findings are: R #2 A. Record review of R #2's admission documents, no date, revealed R #2 was admitted to the facility on [DATE]. B. Record review of R #2's progress note, dated 08/18/25, revealed R #2 was sent to the hospital due to weakness. C. Record review of R #2's entire medical record, no date, revealed staff did not document a notice of transfer for R #2's transfer to the hospital on [DATE]. D. On 12/12/25 at 9:24 AM, during an interview, the Regional Clinical Nurse (RNC) confirmed the following: 1. Staff did not complete a transfer notice and should have for R #2's transfer to the hospital on [DATE]. 2. Staff were expected to complete a written transfer notice when a resident was transferred to the hospital and give a written copy of the transfer notice to the resident or their representative. R #5 E. Record review of R #5's admission documents, no date, revealed R #5 was admitted to the facility on [DATE]. F. Record review of R #5's progress note, dated 06/09/25, revealed R #5 was sent to the hospital due to hypotension (low blood pressure, where blood pressure readings are below the normal range). G. Record review of R #5's entire medical record, no date, revealed staff did not document a transfer notice for R #5's transfer to the hospital on [DATE]. H. On 12/15/25 at 9:36 AM, during an interview, the RNC confirmed that there was not a transfer notice documented in R #5's medical record. The RNC stated that when a resident is transferred a notice should be provided to the resident or their representative. R #66 I. Record review of R #66's face sheet revealed the following admission date of 07/10/25. J. Record review of R #66's progress note dated 09/04/25 revealed resident was admitted to the hospital and had a Computed Tomography (CT scan that uses X-rays and computer to create detailed cross-sectional images of inside the body) done revealing Pyogenic Arthritis of the right hip (known as septic arthritis, a serious condition characterized by inflammation of the hip joint due to bacterial infection). K. Record review of progress notes dated 09/04/25 and 09/05/25 revealed on 09/05/25 at 11:14 PM Resident had not returned from dialysis. Finally called the hospital to look for resident. Resident was admitted to the emergency room (ER) at 5:05 pm via ambulance from the Dialysis Center. CT revealed Pyogenic Arthritis of the R (right) hip. Resident will be transferred out to (name of hospital). Nurse from the emergency room will call back with final report. L. On 12/11/25 at 5:01 PM, during an interview, the Social Service Worker (SSW) stated R #66 was sent to the hospital from dialysis, and the facility was not told by dialysis center that they sent resident out. SSW called dialysis center and was told R #66 was sent to hospital. SSW stated that R #66's family came into the facility when R #66 was in the hospital and stated they wanted R #66 to transfer to (name of nursing home) because that facility was a better fit for R #66. SSW stated that R #66's family picked up his personal belongings and left the facility. SSW stated she does not remember alerting the ombudsman when R #66 transferred to another nursing home. SSW stated she is the admission Coordinator, but nursing does the admission documentation for bed holds and transfer and nursing communicates to the physician to obtain orders. M. On 12/12/25 at 11:43 AM, during an interview with the Regional Clinical Nurse, she stated R #66 was transferred to the hospital from dialysis, and there was no bed hold notice in R #66 record. The Regional Clinical Nurse confirmed that her expectation is that staff complete the NM bed hold notice.

Based on record review and interview, the facility failed to develop an accurate, person-centered comprehensive care plan for 4 (R #2, R #25, R #69, and R #70) of 5 (R #2, R #7, R #25, R #69, and R #70) residents reviewed for comprehensive care plans (plan that has measurable goals and timeframes to meet a resident's medical, nursing, mental health and psychosocial needs). This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: R #2 A. Record review of R #2's admission documents, no date, revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 had the following diagnoses: a. Infection and inflammatory reaction due to indwelling ureteral stent (infection or swelling due to a thin, flexible tube placed in the ureter (the tube from kidney to bladder) to keep it open, allowing urine to flow past blockages like kidney stones or after surgery, often causing symptoms like frequent urination, burning, urgency, or blood in urine). b. Calculus of kidney (a hard deposit of minerals and salts (like calcium, oxalate, uric acid) that forms in the kidneys when urine becomes too concentrated). c. Calculus of ureter (a kidney stone that has moved into the ureter, the tube connecting the kidney to the bladder, causing severe, colicky pain (renal colic) in the flank, abdomen, and groin, often with nausea, vomiting, and blood in the urine). d. Obstructive and reflux uropathy (blocks urine flow, causing backup (hydronephrosis) and potential kidney damage, while vesicoureteral reflux (VUR) (a type of obstructive uropathy) is urine flowing backward from bladder to kidneys, often due to faulty valves). B. Record review of R #2's physician order, dated 08/23/25, revealed the following: 1. An order to change foley catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) every 30 days. 2. An order for foley catheter care (strict hygiene, cleaning the insertion site daily with soap and water, keeping the drainage bag below bladder level, ensuring tubing is free of kinks, and staying hydrated to prevent urinary tract infections (UTIs) and blockages, always washing hands before and after handling to reduce germ spread) every shift. 3. An order to change foley catheter as needed for leakage or drainage. 4. An order to irrigate (the process of injecting a sterile solution (like saline) into the catheter tube to clear blockages from mucus, blood clots, or debris, ensuring it stays open and drains properly, preventing complications) catheter as needed. C. Record review of R #2's care plan, dated 08/18/25, revealed the care plan did not include interventions for: 1. Staff to provide catheter care for R #2's foley catheter every shift. 2. Staff to change R #2's foley catheter every 30 days. 3. Staff to change R #2's foley catheter as needed. 4. Staff to irrigate R #2's foley catheter as needed. D. On 12/12/25 at 9:35 AM, during an interview, the MDS coordinator confirmed R #2's care plan did not include interventions for caring for R #2's foley catheter and should have. E. On 12/12/25 at 11:22 AM, during an interview, the Regional Clinical Nurse (RNC) confirmed staff should document all interventions for caring for a resident's catheter in the care plan. R #25 F. Record review of R #25's admission Record (no date) revealed the following: 1. R #25 was admitted to the facility on [DATE]. 2. R #25 had a diagnosis of chronic pain syndrome (pain that persists beyond the normal healing time, typically lasting 3 to 6 months or longer and often includes additional symptoms such as depression and anxiety which can interfere with daily life). G. Record review of R #25's physician's orders revealed an order dated 09/09/25, for Suboxone sublingual film (combination opioid medication that is designed to dissolve under the tongue and is used by some healthcare providers to manage chronic pain) 4-1 mg give 1 film sublingually (under the tongue) three times a day related to chronic pain syndrome. H. Record review of R #25's care plan, dated 09/09/25, revealed staff did not document in the care plan that R #25 was taking the opioid medication Suboxone. I. On 12/12/25 11:50 AM, during an interview, the RCN confirmed the following: 1. R #25's care plan did not include a plan for the medication Suboxone. 2. Her expectation is that the care plan would have a specific plan in place for this type of medication. R #69 J. Record review of R #69's admission documents, no date, revealed the following: 1. R #69 was admitted to the facility on [DATE]. 2. R #69 had the following diagnoses: a. Chronic Obstructive Pulmonary Disease (COPD) a progressive lung disease making breathing difficult). b. Chronic respiratory failure with hypoxia (a long-term condition where the lungs can't supply enough oxygen to the blood). c. Solitary pulmonary nodule (a small, round spot in the lung). d. Dependence on supplemental oxygen (body needs extra oxygen to keep organs healthy due to low blood oxygen (hypoxemia), often from lung diseases like COPD). K. Record review of R #69's physician order, dated 11/13/25, revealed the following: 1. An order for Albuterol-Budesonide Inhalation Aerosol (is a dual-action prescription medication used as a rescue inhaler for adults with asthma) give two (2) puffs every four (4) hours as needed for shortness of breath (SOB). 2. An order for oxygen via nasal cannula at a rate of six (6) to eight (8) liters per minute (LPM, oxygen flow rate) for COPD. 3. An order to raise the head of the bed or provide a pillow while resident was in bed for shortness of breath due to COPD. 4. An order to change oxygen tubing and oxygen concentrator filter every week. L. On 12/11/25 at 10:26 AM, during an interview with LPN #17, she stated the following: 1. R #69 used a special high flow nasal cannula. 2. R #69's nasal cannula had two ports that connected to two oxygen concentrators. 3. R #69 required two oxygen concentrators to deliver his oxygen through the special high flow nasal cannula. M. Record review of R #69's care plan, dated 11/17/25, revealed the following: 1. Staff did not document in the care plan that R #69 required a special high flow nasal cannula to deliver his oxygen. 2. Staff did not document in the care plan that R #69 required the use of two oxygen concentrators. 3. Staff did not document in the care plan that R #69's nasal cannula or oxygen concentrator filter needed to be replaced every week. 4. Staff did not document in the care plan that R #69 needed the head of the bed elevated or pillows behind his back when in bed. 5. Staff did not document in the care plan that R #69 had an order for Albuterol-Budesonide when he had shortness of breath. N. On 12/11/25 11:51 AM, during an interview, the ADON confirmed the following: 1. R #69's care plan did not include his orders for Albuterol-Budesonide. 2. R #69's care plan did not include orders to elevate R #69's head of bed or give a pillow when in bed. 3. R #69's care plan did not include that he required a special high flow nasal cannula. 4. R #69's care plan did not include that his nasal cannula and oxygen concentrator filter needed to be replaced weekly. 5. Staff were expected to document all interventions that were in place to help a resident's respiratory status on the care plan. R #70 O. Record review of R #70's electronic medical record (EMR) revealed the following: 1. R #70 was readmitted to the facility on [DATE]. 2. R #70 had a diagnosis of pulmonary embolism (blockage in one of the pulmonary arteries in the lungs, usually caused by blood clots that travel from the legs or other parts of the body). P. Record review of R #70's physician's order revealed an order dated 11/11/25, for Apixaban tablet (anticoagulant medication used to prevent and treat blood clots, commonly prescribed to treat conditions such as pulmonary embolism) give 5 mg two times a day for blood thinner. Q. Record review of R #70's care plan, dated 09/09/25, revealed staff did not document in the care plan that R #25 was taking Apixaban for history of pulmonary embolism and the risks associated with this medication. R. On 12/12/25 at 11:52 AM, during an interview, the RCN confirmed the following: 1. R #25's care plan did not include a plan for the medication Apixaban. 2. Her expectation is that the care plan would have a specific plan in place for this type of medication and include the risks associated with this medication.

Based on record review observation, and interview, the facility failed to ensure care plan revisions occurred for 6 (R #7 R #8, R #17, R #25, R #36, and R #60) of 8 (R #5, R #6, R #7, R #8, R #17, R #25, R #36, and R #60) residents reviewed for care plan accuracy when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #7 A. Record review of R #7's admission record, no date, revealed the following: 1. R #7 was admitted to the facility on [DATE]. 2. R #7 had the following diagnoses: a. Chronic respiratory failure with hypoxia (lungs consistently can't get enough oxygen into the blood). b. Simple chronic bronchitis (a condition causing a persistent, mucus-producing cough for months, often linked to smoking or irritant exposure). B. Record review of R #7's physician's orders, multiple dates, revealed the following: 1. An order dated 08/21/24, for oxygen via nasal cannula (a simple, common medical device with two soft prongs that fit into the nostrils, delivering supplemental oxygen or increased airflow from a supply source (like an oxygen concentrator) through a tube) at one (1) to two (2) liters per minute (LPM, flow rate of oxygen). 2. An order dated 10/17/25 to change oxygen tubing and water on oxygen concentrator (a medical device that provides concentrated oxygen to people with breathing problems by taking in ambient air, removing nitrogen and impurities, and delivering purified, oxygen-enriched air through a nasal cannula or mask) and portable oxygen tank every week. C. Record review of R #7's care plan, dated 08/27/25, revealed staff did not include interventions in place for R #7's order for oxygen or for changing R #7's nasal cannula weekly. D. On 12/12/25 at 3:20 PM, during an interview, the RNC confirmed the following: 1. R #7's care plan did not include resident's order for oxygen or to change his nasal cannula weekly. 2. Staff were expected to document oxygen orders in resident care plans. 3. Staff were expected to document orders for changing resident nasal cannula in the care plan. R #8 E. Record review of R #8's admission documents, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8 had the following diagnoses: a. Senile degeneration of brain (an outdated term for age-related cognitive decline, now called dementia, a progressive loss of brain function due to damaged brain cells, most commonly from Alzheimer's, vascular issues, or Lewy body disease, causing memory loss, confusion, and impaired thinking, rather than being a normal part of aging itself). b. Major Depressive Disorder (MDD, a serious mood disorder causing persistent sadness, loss of interest, and impaired daily functioning). c. Personal history of other mental and behavioral disorders (a medical classification, that indicates a patient has a history of past mental health issues). d. Anxiety (excessive worry, restlessness, rapid heart rate, trouble concentrating, and sleep issues). e. Dementia f. Restlessness and agitation (states of inner tension and inability to stay still). F. Record review of R #8's physician orders, multiple dates, revealed the following; 1. An order dated 10/20/25, for quetiapine fumarate (an atypical antipsychotic medication used to treat schizophrenia and bipolar disorder) 50 mg two times a day for agitation and anxiety. 2. An order dated 08/15/25, for Lasix (a prescription loop diuretic primarily used to treat fluid retention (edema) 10 mg once a day for edema (swelling from excess fluid trapped in body tissues). G. Record review of R #8's care plan, dated 09/17/25, revealed the following: 1. Staff did not document that R #8 was taking an antipsychotic medication or any interventions in place for monitoring. 2. Staff did not document that R #8 was taking a diuretic medication or any interventions in place for monitoring. H. On 12/12/25 at 2:35 PM, during an interview, the Regional Clinical Nurse (RCN) confirmed the following: 1. Staff did not revise R #8's care plan to include that she was taking the antipsychotic medication quetiapine fumarate or any interventions in place to monitor R #8 for side effects of antipsychotic medication. 2. Staff did not revise R #8's care plan to include that she was taking the diuretic medication Lasix or any interventions in place to monitor R #8 for side effects of diuretic medication. 3. Staff were expected to revise resident care plans when they start taking antipsychotic or diuretic medications. R #17 I. Record review of R #17's admission record, no date, revealed R #7 was admitted to the facility on [DATE] with the following diagnoses: 1. Lack of coordination. 2. Unspecified abnormalities of gait and mobility. 3. Muscle weakness. J. Record review of R #17's physician order, dated 07/10/25, revealed an order for anti rollback device on R #17's wheelchair. K. Record review of R #17's care plan revealed the following: 1. On 09/22/25, R #17 would be evaluated for an anti-roll back lock for his wheelchair. The care plan does not document that R #17 had been evaluated and that the wheelchair lock had been installed on his wheelchair. The care plan does not document the interventions for the roll back lock. 2. On 02/25/25, R #17 had a painful tooth infection and R #17 would see a dentist. L. On 12/11/25 at 10:53 AM, during an interview with CNA #8, she stated R #17 did have an infection but that he had been to the dentist and that the infection was resolved. CNA #8 stated that the resident has a history of falls and that the rollback device was to assist the resident with transfers so that his wheelchair would lock and not roll away. M. On 12/11/25 at 11:24 AM, during an interview, the Social Services Coordinator stated that the resident went to the dentist on 03/25/25. N. On 12/11/25 at 12:19 PM, during an interview, the MDS Coordinator confirmed that R #17 does not currently have a tooth infection. The MDS Coordinator stated that the care plan should have been updated when infection resolved. O. On 12/11/25 at 1:23 PM, during an interview, the DON stated that resident care plans should be updated with the most current interventions (action, treatment, or procedure used to diagnose, prevent, manage, improve a health condition, or support overall well-being). The DON stated that if a diagnosis was resolved, the care plan should be updated. R #25 P. On 12/10/25 at 10:04 AM, during an observation and interview, the following was revealed: R #25 stated he doesn't like the pureed diet (smooth, moist, pudding-like foods that require no chewing, ideal for those with swallowing or chewing difficulties from surgery, illness, or conditions like dementia) and wants to see if it can be changed. R #25 stated he likes to snack on other foods such as cottage cheese, crackers and snack cakes. Two chocolate snack cakes were on R #25's bedside table. Q. Record review of R #25's admission Record (no date) revealed the following: 1. R #25 was admitted to the facility on [DATE]. 2. R #25 had a diagnosis of dysphagia (difficulty swallowing). R. Record review of R #25's physician's order revealed an order dated 10/06/25, for large portions diet puree texture (smooth and creamy substance made from blending food to a liquid consistency), thin consistency (liquid consistency that is not sticky and is easy to swallow). S. On 12/12/25 9:45 AM, during an interview with the dietitian, the following was revealed. 1. R #25's like to pick and choose what he eats, he only likes meat and desserts. 2. She confirmed that chocolate snack cakes are not the consistency of the diet that is ordered for R #25. T. Record review of R #25's care plan, revision (update) date 09/18/25, revealed staff did not document in the care plan that R #25 is noncompliant with his ordered diet. U. On 12/12/25 11:55 AM, during an interview, the RCN confirmed the following: 1. R #25's care plan did not include a revision to include that R #25 is not compliant with his ordered diet. 2. Her expectation is that the care plan would have a specific plan in place for his noncompliance and actions staff can't take to assist him. R #36 V. Record review of R #36's admission documents, no date, revealed the following: 1. R #36 was admitted to the facility on [DATE]. 2. R #36 had the following diagnoses: a. Psychotic disorder with delusions due to known physiological condition (involves firmly holding false beliefs (delusions) for at least a month, without prominent psychotic symptoms like hallucinations or disorganized speech). b. Major depressive disorder (MDD, a serious mood disorder causing persistent sadness, loss of interest, and impaired functioning, marked by symptoms like sleep/appetite changes, fatigue, guilt, poor concentration, and suicidal thoughts). c. Anxiety disorder (serious mental illnesses marked by excessive, persistent fear and worry that disrupt daily life). W. Record review of R #36's physician's orders, multiple dates, revealed the following: 1. An order dated 11/05/25, for quetiapine fumarate 25 mg three times a day for psychosis (a state where a person loses touch with reality, experiencing symptoms like hallucinations (seeing/hearing things not there) or delusions (fixed false beliefs), alongside disorganized thinking, speech, and behavior, often with paranoia or confusion, and can stem from mental illnesses). 2. An order dated 11/22/25, for sertraline 50 mg once a day for depression. X. Record review of R #36's care plan, revised 09/22/25, revealed staff did not document R # 36's orders and antipsychotic and antidepressant medications, or any interventions in place to monitor these medications. Y. On 12/12/2025 at 2:32 PM, during an interview, the RCN confirmed the following: 1. Staff did not revise R #36's care plan to include that she was taking the antipsychotic medication quetiapine fumarate or any interventions in place to monitor R #36 for side effects of antipsychotic medication. 2. Staff did not revise R #36's care plan to include that she was taking the antidepressant medication sertraline or any interventions in place to monitor R #36 for side effects of antidepressant medication. 3. Staff were expected to revise resident care plans when they start taking antipsychotic or antidepressant medications.

Based on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #6) of 2 (R #5 and R #6) residents when staff failed to: 1. Identify open wounds on R #6's lower legs. 2. Follow up on the burning sensation when R #6 urinated. These deficient practices could likely lead to residents needs not being met and/or a worsening of their condition. The findings are:A. On 12/10/25 at 10:10 AM, during an interview, R #6 stated he was in a lot of pain. He stated that it burned really bad when he urinated and that it was almost unbearable. R #6 also stated that his legs hurt really bad. R #6 further stated he had told staff but that nothing had been done about it. R #6 stated that he has told several staff that he was hurting for months. R #6 stated that he had been in pain for about 3 months. B. On 12/10/25 at 1:54 PM, during an observation of R #6's legs, revealed resident's lower legs were discolored and there were open wounds and scabbing on both legs. C. Record review of R #6's skin assessments revealed the following: 1. 11/08/25 did not document any skin impairments. 2. 11/16/25 no assessment was done. 3. 11/23/25 did not document wounds on R #6's lower legs. 4. 11/30/25 did not document wounds on R #6's lower legs. 5. 12/07/25 did not document any skin impairments. D. On 12/12/25 at 9:38 AM, during an interview and observation, the DON observed and confirmed that R #6 had open wounds on both of his lower legs and that she had not been made aware of the wounds. E. On 12/12/25 at 9:43 AM, during an interview, CNA #11 stated that she did know that R #6 had wounds on his lower legs. F. On 12/12/25 at 9:46 AM, during an interview, LPN #8 stated that she knew R #6 had wounds on his lower legs. LPN #8 stated that she had let the DON know that R #6 had wounds but doesn't remember when. LPN #8 confirmed that there is no documentation of the wounds on R #6's legs or that the provider and the DON were notified. G. On 12/12/25 at 10:15 AM, during an interview, ADON confirmed that she did R #6's skin assessment on 12/07/25. The ADON stated that when she does the skin assessments she is with the residents. The ADON confirmed that she did not document any wounds on R #6's lower legs on 12/07/25. The ADON stated she doesn't remember seeing any wounds on R #6's legs. The ADON stated that she is not aware of any wounds that R #6 has on his legs. H. On 12/12/25 at 10:16 AM, during an observation of R #6's legs, the ADON confirmed that R #6 does have wounds on both legs. I. On 12/12/25 at 11:05 AM, during an interview, LPN #9 stated that she usually does R #6's skin assessments. LPN #9 stated that she was aware of a wound on R #6's hand, but that she had not seen any wounds on the resident's legs. J. Record review of R #6's medical record, no date, revealed that there was no documentation that R #6 was having pain while he urinated. There was no documentation that the provider was notified of R #6's pain during urination. K. On 12/12/25 at 11:09 AM, during an interview, LPN #9 stated that R #6 had told her that it was burning down there. LPN #9 stated that she asked R #6 to clarify where it was hurting and that R #6 stated he couldn't feel it. LPN #9 stated she was confused and could not figure out what R #6 was saying or where it hurt. LPN #9 stated that she isn't sure if she notified the provider. LPN #9 stated did not document that R #6 was complaining of pain. L. On 12/12/25 at 1:06 PM, during an interview, R #6 stated to the surveyor and ADON that he was in a lot of pain. R #6 stated that his legs were hurting and that it burned when he urinated. M. On 12/12/25 at 3:25 PM, during an interview, the Regional Clinical Nurse (RCN) stated that the sores on R #6's legs should have been identified and that the provider should have been made aware of the sores. The RCN stated that if R #6 was complaining of pain while urination, that the provider should have been notified and that a urinalysis should have been done.

Based on observation, interview, and record review, the facility failed to follow professional standards of practice for oxygen therapy for 3 (R #7, R #69, and R #76) of 3 (R #7, R #69, and R #76) residents reviewed for respiratory care, when staff failed to: 1. Ensure residents wore their oxygen continuously for R #7 and R #76. 2. Ensure oxygen concentration was administered per physician's order for R #69. 3. Document respiratory assessments (a systematic evaluation of breathing, using inspection, palpation, percussion, and auscultation to check vital signs, observe breathing patterns, feel the chest, tap for sounds, and listen with a stethoscope for lung sounds and chest movement) for R #69. If the facility is not assessing respiratory status and following orders for oxygen use then the resident may be low on oxygen, which could potentially cause health concerns such as shortness of breath, confusion, rapid heart rate, fatigue, and blue skin (cyanosis). The findings are:R #7 A. Record review of R #7's admission documents, no date, revealed the following: 1. R #7 was admitted to the facility on [DATE]. 2. R #7 had the following diagnoses: a. Chronic respiratory failure with hypoxia (lungs consistently can't get enough oxygen into the blood). b. Simple chronic bronchitis (a condition causing a persistent, mucus-producing cough for months, often linked to smoking or irritant exposure). B. Record review of R #7's physician's orders, multiple dates, revealed an order dated 08/21/24, for oxygen via nasal cannula (a simple, common medical device with two soft prongs that fit into the nostrils, delivering supplemental oxygen or increased airflow from a supply source (like an oxygen concentrator) through a tube) at one (1) to two (2) liters per minute (LPM, flow rate of oxygen). C. On 12/10/25 at 10:23 AM, during an interview and observation of R #7 in his room, the following was revealed: 1. R #7 was sitting in his wheelchair next to his bed. 2. R #7 was observed not wearing a nasal cannula and his oxygen concentrator (a medical device that provides concentrated oxygen to people with breathing problems by taking in ambient air, removing nitrogen and impurities, and delivering purified, oxygen-enriched air through a nasal cannula or mask) was turned off. 3. R #7 stated he only wears his oxygen at night and if he needs it during the day. D. On 12/11/25 at 2:08 PM, during an observation of R #7 in the dining area, he was observed not wearing a nasal cannula and he did not have a portable oxygen concentrator with him. E. On 12/11/25 at 2:47 PM, during an interview with LPN #16, she stated R #7 only wears his oxygen at night and if his oxygen gets below 90% during the day. F. On 12/11/25 at 2:54 PM, during an interview, the ADON confirmed the following: 1. R #7 uses oxygen at night and as needed during the day. 2. R #7's physicians order was for R #7 to wear his oxygen continuously at one (1) to two (2) LPM. 3. Staff were expected to ensure residents wear oxygen as ordered and notify the provider if there is a change in the residents' condition that indicates the order may need to be changed. R #69 G. Record review of R #69's admission documents, no date, revealed the following: 1. R #69 was admitted to the facility on [DATE]. 2. R #69 had the following diagnoses: a. Chronic Obstructive Pulmonary Disease (COPD) a progressive lung disease making breathing difficult). b. Chronic respiratory failure with hypoxia. c. Solitary pulmonary nodule (a small, round spot in the lung). d. Dependence on supplemental oxygen (body needs extra oxygen to keep organs healthy due to low blood oxygen (hypoxemia), often from lung diseases like COPD). H. Record review of R #69's hospice admission orders, dated 11/12/25, revealed an order for oxygen via nasal cannula at eight (8) to ten (10) LPM. I. Record review of R #69's physician's order, dated 11/13/25, revealed the following: 1. An order for Albuterol-Budesonide Inhalation Aerosol (is a dual-action prescription medication used as a rescue inhaler for adults with asthma) give two (2) puffs every four (4) hours as needed for shortness of breath (SOB). 2. An order for oxygen via nasal cannula at a rate of six (6) to eight (8) LPM for COPD (did not match order from hospice for eight (8) to ten (10) LPM). 3. An order to raise the head of the bed or provide a pillow while resident was in bed for shortness of breath due to COPD. 4. An order to change oxygen tubing and oxygen concentrator filter every week. J. Record review of R #69's progress notes, multiple dates, revealed the following: 1. On 11/20/25, staff documented that R #69 had his oxygen concentrator at 10 LPM and staff educated him that oxygen concentrator should be at eight (8) to ten (10) LPM, but resident refused. Staff did not document that a provider was notified. Staff did not document an assessment of R #69's respiratory status. 2. On 11/26/25, staff documented that R #69's oxygen concentrator was decreased to 15 LPM (outside the ordered range of 6-8 LPM, staff did not document how high the oxygen concentrator was at before it was decreased). Staff documented that resident was calmer than before and didn't have sputum production (the body's way of creating mucus in the lower airways (bronchi/bronchioles) to trap particles, which is then coughed up) or nasal drainage (excess mucus from the nose, often caused by colds, flu, allergies, or irritants). Staff documented that they notified hospice staff and that the hospice nurse would come to see R #69. Staff did not document an assessment of R #69's respiratory status other than oxygen saturation (the percentage of oxygen carried in red blood cells, normally 95-100% in healthy people). 3. On 11/28/25, staff documented that R #69 had an episode of shortness of breath and his oxygen saturation dropped to 42%. Staff gave ordered albuterol and medications to decrease R #69's anxiety and his oxygen increased to 93% on 14 LPM of oxygen (outside the ordered range of 6-8 LPM). Staff did not document an assessment of R #69's respiratory status. Staff did not document that a provider was notified regarding R #69's episode of shortness of breath or that he was using 14 LPM of oxygen. K. On 12/11/25 at 9:02 AM, during an interview, LPN #16 stated the following: 1. When there is a concern with a resident who was on hospice, they call the hospice number and speak with the nurse. The nurse will notify the hospice provider and call them back with any changes in orders. 2. She notified the hospice nurse any time R #69 had respiratory issues. 3. R #69 had an order for oxygen at a rate of 6-8 LPM. 4. R #69 would turn up his own oxygen, and they would educate him that he needed to keep it at the ordered rate. 5. She was not aware that hospice had ordered for R #69's oxygen to be at a rate of 8-10 LPM. 6. R #69 usually had his oxygen at 10 LPM. 7. She assessed R #69's lung sounds but never documented a respiratory assessment for R #69. L. On 12/11/25 at 11:51 AM, during an interview, the ADON confirmed the following: 1. Staff were expected to assess resident respiratory status at least every shift and document it in the medical record. 2. R #69's order in his medical record was for 6-8 LPM and the admitting orders from hospice was for 8-10 LPM. 3. Staff were expected to ensure the orders in the medical record matched the admitting orders that were received from hospice. 4. If a resident was needing a higher oxygen concentration, staff were expected to notify the provider and enter orders according to the providers response. R #76 M. Record review of R #76's admission documents, no date, revealed the following: 1. R #76 was admitted to the facility on [DATE]. 2. R #76 had a diagnosis of chronic respiratory failure (a long-term condition where the lungs can't effectively get enough oxygen into the blood or remove enough carbon dioxide, leading to gradual symptoms like shortness of breath, fatigue, confusion, and a bluish tint to skin or nails). N. Record review of R #76's admission orders, dated 12/05/25, for continuous oxygen starting at two (2) LPM and increase to keep oxygen greater than 90%. O. Record review of R #76's physician's order, dated 12/05/25, revealed an order to increase oxygen requirement by two (2) LPM to keep oxygen saturations greater than 90% (did not match admission order to start at two (2) LPM). P. On 12/10/25 at 9:05 AM, during an observation of R #76 in her room, revealed the following: 1. R #76 was lying in her bed. 2. R #76 was wearing a nasal cannula. 3. R #76's oxygen concentrator was set at three (3) LPM. Q. On 12/11/25 at 1:49 PM, during an interview and observation of R #76 in her room, revealed the following: 1. R #76 was lying in her bed. 2. R #76's nasal cannula was laying on her oxygen concentrator. 3. R #76's oxygen concentrator was off. 4. R #76 stated that staff had put her to bed after lunch and forgot to put her oxygen on her. R. On 12/11/25 at 1:51 PM, during an interview, LPN #16 stated the following: 1. R #76 should always wear her nasal cannula. 2. R #76's oxygen concentrator was usually set at 3 LPM. 3. R #76's had a physician's order for oxygen to start at two (2) LPM and increase oxygen till R #76's oxygen saturation was above 90%. 4. She confirmed that R #76 was not wearing her nasal cannula and should have been. S. On 12/12/25 at 3:14 PM, during an interview, the Regional Clinical Nurse (RCN) confirmed the following: 1. R #76's order was entered incorrectly and stated to increase oxygen requirement by two (2) LPM until oxygen saturation was above 90%. 2. R #76's physician's order should have said that R #76's oxygen concentrator should start at two (2) LPM and increase to keep oxygen saturation above 90%. 3. Residents should wear their oxygen as ordered unless they refuse. 4. If a resident refuses to wear oxygen, staff should notify the physician and document the physician's response.

Based on record review, observation, and interview the facility failed to ensure residents obtained dental services for 4 (R #6, R #7, R #36, and R #60) of 8 (R #4, R #5, R #6, R #7, R #10, R #17, R #36, and R #60) residents sampled for dental services, when staff failed to: 1. Schedule a follow up visit for R #6. 2. Schedule routine annual dental services for R #7 and R #60. 3. Schedule dental services for R #7's broken tooth. 4. Schedule dental services after R #36 lost her dentures. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications. R #6 A. Record review of R #6's admission record, no date, revealed R #6 was admitted to the facility on [DATE]. B. On 12/10/25 at 10:05 AM, during an interview, R #6 stated that he has problems with his teeth. R #6 stated he was supposed to go the dentist, but that staff has not made an appointment for him. C. On 12/12/25 at 10:27 AM, during an interview with the Social Services Coordinator (SSC), she stated that R #6 had a dentist appointment on 07/25/25. SSC stated that there was a follow up appointment scheduled for 07/28/25, but the R #6 refused to go. The SSC stated that a follow up appointment has not been rescheduled for R #6. R #7 D. Record review of R #7's admission documents, no date, revealed R #7 was admitted to the facility on [DATE]. E. On 12/10/25 at 10:14 AM, during an interview and observation of R #7 in his room, revealed the following: 1. R #7 stated his bottom right front tooth broke a couple of months ago. 2. R #7 told one of the staff about his broken tooth and they said they would send him to the dentist. 3. R #7 had a broken tooth on the bottom front right side of his mouth. 4. R #7 said he did not remember the last time that he had seen the dentist. F. On 12/12/25 at 10:52 AM, during an interview, LPN # 16 stated the following: 1. She was not aware that R #7 had a broken tooth. 2. Staff are supposed to notify the social services coordinator for any dental needs so she can make the resident an appointment. G. On 12/12/25 at 11:08 AM, during an interview, the Social Services Coordinator (SSC) confirmed the following: 1. She was not aware that R #7 had a broken tooth. 2. R #7 did not have an appointment scheduled to see the dentist for his broken tooth. 3. Staff were expected to notify her if anyone had emergent dental needs so she could schedule a dental appointment. 4. She did not know the last time R #7 had seen a dentist. 5. She was not aware that residents were supposed to be scheduled at least annually for routine dental appointments. R #36 H. Record review of R #36's admission documents, no date, revealed R #36 was admitted to the facility on [DATE]. I. On 12/10/25 at 9:59 AM, during an interview, R #36's family member (FM) stated the following: 1. R #36 had top dentures when she was admitted to the facility. 2. R #36 had lost her bottom dentures prior to being admitted to the facility. 3. R #36 had not been seen by the dentist since she was admitted to the facility. J. On 12/12/25 at 9:43 AM, during an observation and interview of R #36, revealed the following: 1. R #36 stated she did not have any teeth or dentures. 2. R #36 stated she had dentures, but she was not sure what happened to them. 3. R #36 did not have any of her own teeth and she was not wearing dentures. K. On 12/12/25 at 11:01 AM, during an interview, the SSC stated the following: 1. She was not aware that R #36 was missing her dentures. 2. She had not made an appointment for R #36 to see the dentist for dentures. L. On 12/12/25 at 11:15 AM, during an interview, the Regional Clinical Nurse confirmed the following: 1. Staff are expected to notify the SSC when a resident has any dental needs so she can schedule an appointment for the resident. 2. The SSC is expected to offer to schedule routine dental appointments annually for the residents. R #60 M. Record review of R #60's admission record, no date, revealed R #60 was admitted to the facility on [DATE]. N. On 12/10/25 at 11:56 AM, during an interview, R #60's Power of Attorney (POA a person that has the legal authority to act on the behalf of another person) stated R #60 had not been to the dentist. R #60's POA did not know how long it had been but stated she thought it had been years. O. Record review of R #60's medical record, no date, revealed no documentation of R #60 going to the dentist for routine dental care. P. On 12/12/25 at 10:35 AM, during an interview, the SSC confirmed that she had not scheduled R #60 for a routine dental appointment.

Based on record review, and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #7, R #69, and R #76) of 3 (R #7, R #69, and R 76) residents reviewed for respiratory treatment when staff failed to: 1. Document oxygen concentrator (a medical device that provides concentrated oxygen to people with breathing problems by taking in ambient air, removing nitrogen and impurities, and delivering purified, oxygen-enriched air through a nasal cannula or mask) rates for residents requiring oxygen for R #7, R #69, and R #76. 2. Ensure resident's orders entered in the computer matched the admitting orders for R #69 and R #76. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information. The findings are: R #7 A. Record review of R #7's admission documents, no date, revealed the following: 1. R #7 was admitted to the facility on [DATE]. 2. R #7 had the following diagnoses: a. Chronic respiratory failure with hypoxia (lungs consistently can't get enough oxygen into the blood). b. Simple chronic bronchitis (a condition causing a persistent, mucus-producing cough for months, often linked to smoking or irritant exposure). B. Record review of R #7's physician's orders, multiple dates, revealed an order dated 08/21/24, for oxygen via nasal cannula (a simple, common medical device with two soft prongs that fit into the nostrils, delivering supplemental oxygen or increased airflow from a supply source (like an oxygen concentrator) through a tube) at one (1) to two (2) liters per minute (LPM, flow rate of oxygen). C. Record review of R #7's oxygen saturation documentation, dated 12/02/25 to 12/11/25, revealed the following: 1. On 12/02/25 at 9:11 PM, staff documented R #7's oxygen saturation (amount of oxygen carried by red blood cells) was 91%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 2. On 12/03/25 at 7:23 PM, staff documented R #7's oxygen saturation was 93%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 3. On 12/04/25 at 8:28 AM, staff documented R #7's oxygen saturation was 94%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 4. On 12/04/25 at 7:33 PM, staff documented R #7's oxygen saturation was 93%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 5. On 12/05/25 at 7:41 PM, staff documented R #7's oxygen saturation was 93%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 6. On 12/06/25 at 8:27 AM, staff documented R #7's oxygen saturation was 94%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 7. On 12/06/25 at 8:11 PM, staff documented R #7's oxygen saturation was 94%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 8. On 12/07/25 at 10:57 PM, staff documented R #7's oxygen saturation was 95%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 9. On 12/08/25 at 8:58 AM, staff documented R #7's oxygen saturation was 94%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 10. On 12/09/25 at 1:06 AM, staff documented R #7's oxygen saturation was 93%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 11. On 12/09/25 at 11:47 PM, staff documented R #7's oxygen saturation was 94%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 12. On 12/10/25 at 8:44 AM, staff documented R #7's oxygen saturation was 93%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 13. On 12/10/25 at 9:03 PM, staff documented R #7's oxygen saturation was 95%, and R #7 was using a nasal cannula. Staff did not document the oxygen concentrator rate. R #69 D. Record review of R #69's admission documents, no date, revealed the following: 1. R #69 was admitted to the facility on [DATE]. 2. R #69 had the following diagnoses: a. Chronic Obstructive Pulmonary Disease (COPD) a progressive lung disease making breathing difficult). b. Chronic respiratory failure with hypoxia (a long-term condition where the lungs can't supply enough oxygen to the blood). c. Solitary pulmonary nodule (a small, round spot in the lung). d. Dependence on supplemental oxygen (body needs extra oxygen to keep organs healthy due to low blood oxygen (hypoxemia), often from lung diseases like COPD). E. Record review of R #69's hospice admission orders, dated 11/12/25, revealed an order for oxygen via nasal cannula at eight (8) to ten (10) LPM. F. Record review of R #69's physician order, dated 11/13/25, revealed an order for oxygen via nasal cannula at a rate of six (6) to eight (8) LPM for COPD (did not match hospice admission orders). G. Record review of R #7's oxygen saturation documentation, dated 11/17/25 to 11/30/25, revealed the following: 1. On 11/24/25 at 12:34 PM, staff documented R #69's oxygen saturation was 90%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 2. On 11/24/25 at 10:31 PM, staff documented R #69's oxygen saturation was 90%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 3. On 11/25/25 at 8:27 AM, staff documented R #69's oxygen saturation was 90%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 4. On 11/26/25 at 12:44 AM, staff documented R #69's oxygen saturation was 93%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 5. On 11/26/25 at 7:49 AM, staff documented R #69's oxygen saturation was 79%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 6. On 11/26/25 at 12:36 PM, staff documented R #69's oxygen saturation was 80%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 7. On 11/27/25 at 7:37 AM, staff documented R #69's oxygen saturation was 89%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 8. On 11/27/25 at 9:10 AM, staff documented R #69's oxygen saturation was 95%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 9. On 11/24725 at 11:41 PM, staff documented R #69's oxygen saturation was 97%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 10. On 11/28/25 at 8:45 AM, staff documented R #69's oxygen saturation was 93%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 11. On 11/28/25 at 9:08 PM, staff documented R #69's oxygen saturation was 91%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 12. On 11/29/25 at 12:35 AM, staff documented R #69's oxygen saturation was 93%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 13. On 11/29/25 at 7:47 AM, staff documented R #69's oxygen saturation was 92%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 14. On 11/29/25 at 8:50, staff documented R #69's oxygen saturation was 93%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 15. On 11/30/25 at 8:51 AM, staff documented R #69's oxygen saturation was 85%, and R #69 was using a nasal cannula. Staff did not document the oxygen concentrator rate. R #76 H. Record review of R #76's admission documents, no date, revealed the following: 1. R #76 was admitted to the facility on [DATE]. 2. R #76 had a diagnosis of chronic respiratory failure. I. Record review of R #76's admission orders, dated 12/05/25, for continuous oxygen starting at two (2) LPM and increase to keep oxygen greater than 90%. J. Record review of R #76's physician's order, dated 12/05/25, revealed an order to increase oxygen requirement by two (2) LPM to keep oxygen saturations greater than 90% (did not match admission order to start at two (2) LPM). K. Record review of R #76's oxygen saturation documentation, dated 12/05/25 to 12/11/25, revealed the following: 1. On 12/06/25 at 8:51 AM, staff documented R #76's oxygen saturation was 94%, and R #76 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 2. On 12/08/25 at 9:65 AM, staff documented R #76's oxygen saturation was 90%, and R #76 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 3. On 12/09/25 at 9:05 AM, staff documented R #76's oxygen saturation was 91%, and R #76 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 4. On 12/10/25 at 8:49 AM, staff documented R #76's oxygen saturation was 90%, and R #76 was using a nasal cannula. Staff did not document the oxygen concentrator rate. 5. On 12/11/25 at 8:43 AM, staff documented R #76's oxygen saturation was 96%, and R #76 was using a nasal cannula. Staff did not document the oxygen concentrator rate. L. On 12/11/2025 at 2:54 PM, during an interview, the ADON confirmed the following: 1. R #69's hospice admission orders and the orders entered in R #69's medical record did not match. 2. R #76's admission orders and the orders entered in R #76's medical record didn't match. 3. Staff were expected to ensure orders were entered into the medical record correctly and if they had questions, they should contact the provider to verify. 4. Staff did not document oxygen concentrator rates for R #7, R #69, and R #76 when they documented oxygen saturations. 5. Staff were expected to document oxygen concentrator rates when they documented oxygen saturations in the medical record.

Based on record review and interview, the facility failed to report allegations of misappropriation of resident funds (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's money without the resident's consent) to the State Agency within 24 hours of allegation for 1 (R #36) of 2 (R #2 and R #36) residents reviewed for misappropriation of funds, when staff failed to report allegations of missing money. If the facility fails to report allegations of misappropriation of resident funds to the state agency within 24 hours of the allegation, then corrective action may not be taken, and residents may suffer increased anxiety and fear that their money is not being protected. The findings are: A. Record review of R #36's admission documents, no date, revealed R #36 was admitted to the facility on [DATE]. B. On 12/10/25 at 9:47 AM, during an interview, R #36's family member (FM) stated the following: 1. He gave Human Resources (HR) money to put in an account for R #36 shortly after she arrived (he did not know the date). 2. The previous facility that R #36 was at sent a check to the facility that was supposed to be placed in R #36's account. 3. He notified the MDS coordinator two or three months ago (2-3 months before surveyor interview) that the business office manager (BOM, acting as a central point for internal/external communication and problem-solving to support business goals and a productive environment) told him that there was no record of R #36 having a facility account or any money. C. Record review of the facility's Grievance Report, dated 10/23/25, revealed the following: 1. On 10/23/25, R #36's FM reported to the MDS coordinator that he had given the facility $140 to put in an account for R #36. 2. The money disappeared. D. Record review of the state agency (SA) incident reporting system, no date, revealed the SA did not receive an incident report regarding the allegation of misappropriation of resident funds for R #36. E. On 12/12/25 at 1:03 PM, during an interview, the Regional Director (RD) confirmed the following: 1. The facility did not report the allegation of misappropriation of resident funds to the SA. 2. The facility administrator was expected to report allegations of misappropriation of resident property or funds to the SA within 24 hours of the allegation.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation of resident funds (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's money without the resident's consent) 1 (R #36) of 2 (R #2 and R #36) residents reviewed for misappropriation of resident funds when staff failed to have evidence of a thorough investigation of misappropriation of resident funds. If the facility does not adequately investigate allegations of misappropriation of resident funds, then corrective action is not implemented to protect other residents from misappropriation of resident funds, then residents may suffer increased anxiety and fear that their money is not being protected. The findings are: A. Record review of R #36's admission documents, no date, revealed R #36 was admitted to the facility on [DATE]. B. On 12/10/25 at 9:47 AM, during an interview, R #36's family member (FM) stated the following: 1. He gave Human Resources (HR) money to put in an account for R #36 shortly after she arrived (he did not know the date). 2. The previous facility that R #36 was at sent a check to the facility that was supposed to be placed in R #36's account. 3. He notified the MDS coordinator two or three months ago (2-3 months before surveyor interview) that the business office manager (BOM, acting as a central point for internal/external communication and problem-solving to support business goals and a productive environment) told him that there was no record of R #36 having a facility account or any money. C. Record review of the facility's Grievance Report, dated 10/23/25, revealed the following: 1. On 10/23/25, R #36's FM reported to the MDS coordinator that he had given the facility $140 to put in an account for R #36. 2. The money disappeared. D. On 12/12/25 at 1:03 PM, during an interview, the Regional Director (RD) confirmed the following: 1. The facility did not have evidence that a thorough investigation was conducted for the allegation of misappropriation of R #36' funds. 2. The facility administrator was expected to conduct a thorough investigation for all allegations of misappropriation of resident property or funds.

Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set Assessment (MDS; federally mandated assessment instrument completed by facility staff) was accurate for 1 (R #36) of 8 (R #4, R #5, R #6, R #7, R #10, R #17, R #36, and R #60) residents reviewed for dental care. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs. The findings are: A. Record review of R #36's admission documents, no date, revealed R #36 was admitted to the facility on [DATE]. B. On 12/10/25 at 9:59 AM, during an interview, R #36's family member (FM) stated that R #36 had top dentures when she came to the facility and was missing her bottom dentures prior to admission. C. On 12/12/25 at 9:43 AM, during an observation and interview of R #36, the following was revealed: 1. R #36 stated she did not have any teeth or dentures. 2. R #36 stated she had dentures, but she was not sure what happened to them. 3. R #36 was observed to not have any of her own teeth and she was not wearing dentures. D. On 12/12/25 at 9:44 AM, during an interview, CNA #16 stated that R #36 did not have any dentures. E. Record review of R #36's admission MDS, dated [DATE], revealed staff did not document that R #36 was edentulous (lacking teeth). F. On 12/12/25 at 9:47 AM, during an interview, the MDS Coordinator confirmed the following: 1. R #36 did not have her own teeth or dentures since admission. 2. Staff did not document on R #36's admission MDS that she was edentulous. 3. R #36's admission MDS was inaccurate, and staff should have documented that R #36 was edentulous.

Based on observation, record review, and interviews, the facility failed to meet professional standards of practice (established guidelines and expectations that ensure the delivery of high-quality care to residents) for 2 (R #5 and R #17) of 7 (R #5, R #6, R #7, R #17, R #36, R #69 and R #76) residents reviewed for neglect when staff failed to follow physician orders. If the facility is not providing care per physician's orders, and providing care that meets professional standards of practice, then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the care ordered by the physician. The findings are: R #5 A. Record review of R #5's admission record, no date, revealed the following: 1. R #5 was admitted to the facility on [DATE]. 2. R #5's diagnoses include the following: a. Diastolic (congestive) heart failure (heart's main pumping chamber (left ventricle) becomes stiff and can't relax properly to fill with enough blood between beats). b. Chronic atrial fibrillation, unspecified (long-term, irregular heart rhythm where the upper chambers quiver chaotically). c. Unspecified atrial fibrillation (the heart's upper chambers (atria) beat irregularly and often too fast due to chaotic electrical signals). d. Presence of a cardiac pacemaker (a small, battery-powered device implanted under the skin that regulates your heartbeat). e. Cardiomyopathy (chronic disease of the heart muscle). B. Record review of R #5's physician orders revealed an order dated 10/04/24 and discontinued 06/08/25 for amiodarone (a potent antiarrhythmic medication used to treat and prevent serious, life-threatening heart rhythm disorders) 200 mg one time a day, hold for blood pressure less than SBP (the top number in a blood pressure reading, representing the pressure in your arteries when your heart contracts (beats) and pushes blood out) 100, DBP (the pressure in your arteries when your heart rests and refills with blood between beats, representing the bottom, lower number in a blood pressure reading) less than 50 and pulse (a rhythmical throbbing of the arteries as blood is propelled through them) less than 60. C. Record review of R #5's MAR medication administration record (MAR; a form used to document medication administration), dated June 2025, revealed R #5's prescription amiodarone was documented as given every am from the 1st to the 8th. R #5's blood pressure was not documented. D. Record review of R #5's blood pressure summary for June 2025 revealed from the 1st until the 8th, R #5's blood pressure was only documented 4 times out of the 8 times the medication was given before the prescription was discontinued. E. Record review of R #5's MAR dated May 2025, revealed R #5's prescription amiodarone was documented as given every am. R #5's blood pressure was not documented. F. Record review of R #5's blood pressure summary for May 2025 revealed that out of the 31 days in May, R #5's blood pressure was only documented 4 times. G. Record review of R #5's MAR dated April 2025, revealed R #5's prescription amiodarone was documented as given every am. R #5's blood pressure was not documented. H. Record review of R #5's blood pressure summary for April 2025 revealed that out of the 30 days in April, R #5's blood pressure was only documented 5 times. I. On 12/11/25 at 6:28 PM, during an interview, the DON stated R #5's blood pressure should be checked every time staff administer amiodarone. J. On 12/12/25 at 8:59 AM, during an interview, the Regional Clinical Nurse (RCN) confirmed that staff were not documenting that they checked R #5's blood pressure before giving her amiodarone as per the order dated 10/24/25 to 06/08/25. The RCN stated that the expectation is that R #5's blood pressure should be taken and documented before her amiodarone is given. R #17 K. Record review of R #17's admission record, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17's diagnosis of a contracture, left hand (tissues (skin, fascia, tendons) tighten, pulling one or more fingers into a bent position, often towards the palm, making them hard to straighten). L. Record review of R #17's physicians order, dated 10/08/25, revealed splint ordered patient to wear left modified palm guard daily or as tolerated. M. On 12/11/25 at 9:19 AM, during an observation of the secured unit, revealed R #17 was not wearing a splint. N. On 12/11/25 at 9:22 AM, during an interview, CNA #9 stated she did not know that R #17 was supposed to wear a splint on his left hand. O. On 12/11/25 at 9:23 AM, during an interview, CNA #10 stated that she was told about the splint yesterday. She stated that she remembered seeing the resident wear a splint a while back, but that she had not seen the splint, or the resident wear the splint for a long time. CNA #10 stated that the splint used to be in the resident's drawer in his room but that she didn't know where it was anymore. P. On 12/11/25 at 9:31 AM, during an interview, the DON stated that she did not know anything about the order for R #17's splint. The DON stated that the order was discontinued yesterday (12/10/25). The DON stated that R #17 was not compliant with wearing the brace, so they discontinued the order. Q. Record review of R #17's care plan, dated 10/27/25, revealed no documentation that R #17 was not compliant with wearing the splint. R. On 12/11/25 at 9:46 AM, during an interview with the Director of Rehabilitation (DOR), she stated that the splint was ordered by an occupational therapist (OT). The DOR confirmed that the order was for R #17 to wear the splint daily or as tolerated. The DOR stated that the order was discontinued without consultation with the OT. The DOR stated that they should have been consulted with before the order was discontinued. S. On 12/11/25 at 10:25 AM, during an interview, the RCN confirmed that the order for R #17's splint was discontinued on 12/10/25. The RCN stated that hospice discontinued the order. The RCN stated that the occupational therapist should have been consulted prior to discontinuing the order.

Based on record review, observation, and interview, the facility failed to ensure appropriate treatment for urinary conditions (conditions affect the kidneys, bladder, and tubes connecting them, ranging from common issues like Urinary Tract Infections (UTIs), incontinence, and kidney stones to more complex problems like overactive bladder, interstitial cystitis, and prostate issues (in men) for 1 (R #2) of 4 (R #2, R #5, R #6, and R #76) resident's reviewed for urinary conditions, when staff failed to provide services for Foley Catheter tubing (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for R #2.This deficient practice could result in residents being susceptible to worsening of infection or becoming septic (potentially life-threatening when the body responds to infection by damaging its own tissues) The findings are: A. Record review of R #2's admission documents, no date, revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 had the following diagnoses: a. Infection and inflammatory reaction due to indwelling ureteral stent (infection or swelling due to a thin, flexible tube placed in the ureter (the tube from kidney to bladder) to keep it open, allowing urine to flow past blockages like kidney stones or after surgery, often causing symptoms like frequent urination, burning, urgency, or blood in urine). b. Calculus of kidney (a hard deposit of minerals and salts (like calcium, oxalate, uric acid) that forms in the kidneys when urine becomes too concentrated). c. Calculus of ureter (a kidney stone that has moved into the ureter, the tube connecting the kidney to the bladder, causing severe, colicky pain (renal colic) in the flank, abdomen, and groin, often with nausea, vomiting, and blood in the urine). d. Obstructive and reflux uropathy (blocks urine flow, causing backup (hydronephrosis) and potential kidney damage, while vesicoureteral reflux (VUR: a type of obstructive uropathy) is urine flowing backward from bladder to kidneys, often due to faulty valves). B. Record review of R #2's physician order, dated 08/23/25, revealed the following: 1. An order completed on 09/09/25 (order was incorrectly entered and automatically discontinued on 09/09/25), to change foley catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) every 30 days. 2. An order for foley catheter care (strict hygiene, cleaning the insertion site daily with soap and water, keeping the drainage bag below bladder level, ensuring tubing is free of kinks, and staying hydrated to prevent urinary tract infections (UTIs) and blockages, always washing hands before and after handling to reduce germ spread) every shift. 3. An order to change foley catheter as needed for leakage or drainage. 4. An order to irrigate (the process of injecting a sterile solution (like saline) into the catheter tube to clear blockages from mucus, blood clots, or debris, ensuring it stays open and drains properly, preventing complications) catheter as needed. C. Record review of R #2's MAR, dated September 2025, revealed on 09/08/25, staff documented that R #2 refused for his catheter to be changed. D. Record review of R #2's MAR, dated October 2025, revealed on 10/22/25, staff documented that they changed his foley catheter. E. Record review of R #2's MAR, dated November 2025, revealed staff did not document changing R #2's foley catheter. F. Record review of R #2's MAR, dated December 2025, revealed staff did not document changing R #2's foley catheter. G. On 12/12/25 at 9:05 AM, during an interview with LPN #16, she stated the following: 1. Typically, resident's foley catheters should be changed out every 30 days. 2. R #2's order for foley catheter change every 30 days was incorrectly entered and incorrectly discontinued on 09/09/25. 3. R #2's foley catheter was only changed once since 08/23/25. H. On 12/12/25 9:10 AM, during an interview, the ADON confirmed the following: 1. Foley catheters should be changed every 30 days unless there is an order for something different. 2. R #2's order for foley catheter change every 30 days was incorrectly entered so it discontinued on 09/09/25. 3. R #2's foley catheter was only changed once on 10/22/25. 4. Staff were expected to ensure resident's foley catheters were changed as ordered.

Based on record review and interview, the facility failed to ensure hospice services met professional standards for 2 (R #8 and R 69) of 2 (R #8 and R #69) residents reviewed for hospice services when staff failed to: 1. Ensure resident medical records had relevant communication indicating the delivery of hospice services (services provided for a person experiencing an advanced, life-limiting illness) for R #8 and R #69. 2. Ensure there was a coordinated plan of care in R #8's medical record delineating services that hospice was responsible for and services the facility was responsible for. These deficient practices could likely lead to residents not receiving the services needed due to lack of collaboration and communication between the facility and hospice provider. The findings are: R #8 A. Record review of R #8's admission documents, no date, revealed the following: 1. R #8 was admitted to the facility on [DATE]. 2. R #8 had a diagnosis of senile degeneration of brain (an outdated term for age-related cognitive decline, now called dementia, a progressive loss of brain function due to damaged brain cells, most commonly from Alzheimer's, vascular issues, or Lewy body disease, causing memory loss, confusion, and impaired thinking, rather than being a normal part of aging itself). B. Record review of R #8's physician's order, dated 09/08/25, revealed an order for R #8 to be admitted to hospice services. C. Record review of R #8's entire medical record, no date, revealed the following: 1. R #8's medical record did not have any documentation from the hospice staff regarding services that were provided to R #8. 2. R #8's medical record did not have a coordinated plan of care delineating services that hospice was responsible for and services the facility was responsible for. D. Record review of the hospice binder (binder in the nurses' station for hospice documentation), no date, revealed the following: 1. There was no documentation in the binder for R #8's hospice services provided. 2. There was no documentation of a coordinated care plan delineating services that hospice was responsible for and services the facility was responsible for. E. On 12/11/25 at 4:05 PM, during an interview, LPN #16 stated the following: 1. R #8's hospice provider did not provide the facility with documentation regarding the services they provide. 2. She had not seen a coordinated care plan delineating services that hospice was responsible for and services the facility was responsible for R #8. 3. She was unsure which days hospice staff were expected to see R #8. 4. She was unsure what services hospice staff were supposed to provide for R #8, and which services were supposed to be provided by facility staff. F. On 12/11/25 at 4:38 PM, during an interview, the ADON confirmed the following: 1. Documentation from hospice providers should be available to staff in the hospice binder. 2. There was no documentation in the hospice binder or in R #8's medical record regarding services that were provided by R #8's hospice provider. 3. There was no coordinated care plan in the hospice binder or in R #8's medical record delineating services that hospice was responsible for and services the facility was responsible for. 4. R #8's hospice provider does not provide the facility with documentation regarding the services that they provide to residents receiving hospice services. R #69 G. Record review of R #69's admission documents, no date, revealed the following: 1. R #69 was admitted to the facility on [DATE]. 2. R #69 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), a progressive lung disease making breathing difficult). H. Record review of R #69's orders, dated 11/13/25, revealed an order to admit R #69 for hospice services. I. Record review of R #69's entire medical record, no date, revealed R #8's medical record did not have documentation from the hospice staff regarding services that were provided to R #69. J. On 12/11/25 at 11:51 AM, during an interview, the ADON confirmed the following: 1. R #69's hospice provider does not provide documentation regarding care that was provided by hospice staff. 2. If the hospice staff do not talk to the facility staff, they will not know what services were provided for the residents. 3. Staff do not have any documentation to look at to determine what services the hospice staff provided. 4. Hospice staff are expected to give documentation to the facility regarding the services that were provided to residents. 5. The medical records clerk is expected to scan any documentation into resident medical records that hospice staff provide. 6. R #69's medical record did not contain any documentation regarding services provided by the hospice staff. K. On 12/11/25 at 3:29 PM, during an interview, the medical records clerk confirmed the following: 1. The hospice provider did not provide any documentation regarding care provided to R #8 and R #69. 2. R #8 and R #69's hospice provider did not provide documentation to the facility. 3. Hospice providers were expected to provide visit notes after each visit so she could scan them in the resident medical record, and a copy should be kept in the hospice binder at the nurse's station. L. On 12/11/25 at 4:40 PM, during an interview, the Regional Clinical Nurse (RCN) confirmed the following: 1. Each hospice resident should have a coordinated care plan delineating services that hospice was responsible for and services the facility was responsible for. 2. Staff should know where to locate the coordinated care plan. 3. Hospice staff are expected to provide the facility with documentation every time they visit a resident.

Based on observation, record review, and interview, the facility failed to ensure that the bed rail and bed were compatible for 1 (R #17) of 1 (R #17) resident reviewed for accidents. This deficient practice could likely result in serious injury if residents fall while attempting to transfer while using the bed rail. The findings are:A. On 12/10/25 at 1:37 PM, during an observation of R #17 in his bed, revealed that R #17's bed rail was loose. The bed rail moved side to side parallel to the length of the bed approximately 1 to 2 inches. The bed rail appeared to be an aftermarket attachment to the side of the bed. When R #17 reached for the bed rail to assist with getting up from lying down, the bed rail gave. B. Record review of R #17's medical record, no date, revealed that there was no documentation that the bed rail has been inspected for proper installation. C. On 12/10/25 at 4:26 PM, during an interview, the ADON confirmed that the bed rail was not sturdy. The ADON stated she did not know if the bed rail had been inspected for proper installation.

Based on record review and interview, the facility failed to protect 25 out of 25 residents on the secure unit and North Hall (residents were identified by the resident census report, dated 10/18/24, provided by the Administrator on 12/13/24) sampled for abuse and neglect, when a staff member: 1. Abandoned residents by frequently leaving the building to go to his car multiple times throughout the shift. 2. Wore air pods (wireless headphones for listening to music and answering phone calls) in both ears, which prevented him from hearing what was occurring on the unit. 3. fell asleep on the unit couch during the dinner meal. 4. Used loud, foul, abusive language. These deficient practices could result in residents' needs not being met, staff not being unaware of urgent resident needs, and residents feeling unsafe in their home. The findings are. A. Record review of the Incident Report, dated 10/25/24, revealed the following: 1. An abuse and neglect type of incident occurred on 10/19/24 at 6:00 PM. 2. CNA #1 was asleep on the job. 3. CNA #1 smelled of alcohol. 4. CNA #1 became belligerent, cussed at staff, and threatened to kill staff. 5. CNA #1 got into an RN's space and threatened to hit her. 6. The Incident Report was submitted to the State Agency on 10/25/24 at 4:59 PM. B. Record review of the Follow Up Report, dated 10/28/24, revealed the following: 1. Residents in the common area witnessed the yelling and cussing between CNA #1 and other staff. 2. The residents in the North Hall heard the yelling and cussing between CNA #1 and other staff. C. On 12/11/24 at 12:40 PM, during an interview, RN #1 stated the following: 1. She was told to communicate any concerns she may have during her shift to the Scheduler, and the scheduler would notify the DON since the DON was out of town. 2. CNA #1 was scheduled to work on 10/18/24 in the secure unit 3. On 10/18/24 (inconsistent with date on incident report) CNA #1 came in late for his first shift as a traveling CNA. 4. CNA #1 did not help CNA #2 get residents up, change the residents' briefs, or provide showers for the residents in the secure unit. 5. CNA #1 wore his air pods throughout the shift. 6. CNA #1 frequently went to his car throughout his shift. 7. She notified the Scheduler multiple times about her concerns with CNA #1 not assisting CNA #2 with resident care, wearing his air pods, and going to his care frequently. 8. On 10/18/24 at 5:30 PM, all the residents were in the dining room, and CNA #1 was asleep on the couch. 9. On 10/18/24 at 5:30 PM, she woke CNA #1 up and told him that he needed to gather his belongings and leave the facility. 10. CNA #1 smelled like alcohol when she woke him up. 11. CNA #1 yelled profanities and threatened her. 12. CNA #1 continued to yell at her as he was escorted out of the building through the secure unit then down the North Hall. 13. She was nervous CNA #1 would hurt her or the residents. 14. CNA #1 lunged at her. 15. She felt nervous and threatened by CNA #1's behavior. 16. Police found alcohol bottles in CNA #1's car. 17. The Scheduler notified the DON about what occurred. D. On 12/11/24 at 1:58 PM, during an interview, the Scheduler stated the following: 1. She stated the DON was out of town on the weekend of 10/18/24, and staff were expected to communicate concerns to her (Scheduler). She stated she would handle what she could and notify the DON, if necessary. 2. She was responsible for CNA scheduling. 3. She worked on 10/18/24 when CNA #1 worked. 4. CNA #1 worked for an outside agency. 5. CNA #1's first time working at the facility was on 10/18/24. 6. CNA #1 was an hour late for his shift. 7. She observed CNA #1 going out to his car multiple times throughout the shift. 8. RN #1 told her CNA #1 kept going out to his car, was on his phone, and sat around. 9. She told CNA #1 he could not keep going out to his car during his shift or be on his phone. 10. On 10/18/24 at 5:30 PM, CMA #1 sent her a picture of CNA #1 sleeping on the couch in the secure unit. 11. She told staff to send CNA #1 home. 12. CNA #1 became belligerent (hostile and aggressive) with staff when they woke him up. 13. Staff called the police due to CNA #1's behavior. 14. She went back to the facility on [DATE] when staff notified her that they called the police. 15. She notified the DON and the Administrator about the situation when she went back to the facility. E. On 12/11/24 at 3:18 PM, during an interview, CNA #3 stated the following: 1. On 10/28/24, he heard CNA #1 yelling and cussing while staff passed out dinner trays in the North Hall. 2. He saw CNA #1 get close to RN #1, and he looked like he was going to hit her. 3. RN #1 and another male staff member tried to get CNA #1 out of the building. 4. CNA #1 became aggressive toward the other male staff member. 5. He diffused the situation and walked CNA #1 out of the building. 6. CNA #1 went to the front of the building, but the door was locked. 7. Staff refused to let CNA #1 back in the building. 8. The police found alcohol in CNA #1's vehicle. F. On 12/11/24 at 3:29 PM, during an interview, CMA #1 stated the following: 1. On 10/18/24, CNA #2 told her that CNA #1 was not providing resident care. 2. She assisted CNA #2 with passing out lunch trays and other resident care, because CNA #1 was not helping. 3. She notified the Scheduler that CNA #1 took a lot of breaks. 4. The Scheduler said for staff to get through that shift, and they would not allow CNA #1 to come back to the facility. 5. On 10/28/24 at 5:30 PM, the residents ate dinner in the common area of the secure unit, and CNA #1 was asleep on the couch. 6. She sent a picture of CNA #1 sleeping on the couch to the Scheduler. 7. The Scheduler said for CNA #1 to leave the facility. 8. RN #1 woke CNA #1 up and told him to leave. 9. CNA #1 yelled and cussed at RN #1 through the unit and down the hall outside the unit. 10. She did not leave the unit but could hear CNA #1 yelling while staff escorted him through the building. G. Record review of the photo taken by CMA #1, no date, revealed the following: 1. CNA #1 sat on the couch with his head tilted to the side and his eyes closed. 2. CNA #1 had an air pod in his left ear. 3. CNA #1 had his cell phone in his hand. H. On 12/11/24 at 3:55 PM, during an interview, CNA #2 stated the following: 1. She was scheduled to work in the secure unit on 10/18/24. 2. She worked with CNA #1 during her shift on 10/18/24. 3. It was CNA #1's first shift at the facility. 4. CNA #1 frequently left the building. 5. CNA #1 had his air pods in both ears throughout the shift. 6. CNA #1 was on his phone a lot throughout the shift. 7. She had to complete all resident care herself. 8. CNA #1 took more than an hour lunch (lunch breaks are supposed to be 30 minutes.) 9. After lunch, CNA #1 appeared intoxicated. 10. She asked CNA #1 for assistance with resident care, but he told her he was busy on a phone call. 11. She told CNA #1 multiple times that he was going to get in trouble for being on his phone and going outside frequently, and CNA #1 responded that he did not care. 12. At dinner time at 5:00 PM, all the residents were in the common area getting ready to eat dinner and CNA #1 was asleep on the couch. 13. RN #1 woke CNA #1 up. 14. CNA #1 appeared to be under the influence of something when he woke up. 15. CNA #1 became aggressive toward RN #1 and tried to hit RN #1. 16. CNA #1 out of the secure unit while RN #1 walked and yelled at RN #1. I. On 12/12/24 at 9:18 AM, during an interview, Nurse Aide (NA) #1 stated the following: 1. On 10/18/24, all the residents in the secure unit were in the common area for dinner. 2. CNA #1 was asleep on the couch. 3. CNA #1 became aggressive after RN #1 woke him up. 4. CNA #1 continued to yell at RN #1 through the secure unit and down the North hall. 5. CNA #1 tried to hit RN #1. 6. A kitchen worker stepped in to prevent CNA #1 from hitting RN #1. 7. The residents in the secure unit and North Hall were able to hear the yelling that took place between CNA #1 and RN #1. 8. She took multiple videos of the incident between CNA #1 and RN #1, because she was afraid for RN #1 and the residents. 9. She stated the police told the staff they found a bottle of alcohol in CNA #1's vehicle. J. Record review of the video footage in the secure unit, no date, revealed the following: 1. RN #1 followed CNA #1 down the North Hall. 2. RN #1 told CNA #1 to leave because he fell asleep while he was responsible for the care of 11 residents. 3. CNA #1 loudly told RN #1 profanities. 4. CNA #1 turned around, approached the nurse, started yelling at the nurse, and made fists with both of his hands. 5. A male staff member approached CNA #1, and CNA #1 started yelling at the male staff member in Spanish. CNA #1 then told the staff members profanities in English. 6. RN #1 and the male staff member continued to follow CNA #1 down the hall. 7. CNA #1 got in the male staff members face and yelled to stop following him. 8. RN #1 told CNA #1 they would follow him until he was out of the building. 9. CNA #1 pulled up the sleeves of his shirt and made fists while he approached the male staff member and RN #1. 10. CNA #1 loudly said profanities at RN #1 and the male staff member. 11. CNA #3 stepped in and escorted CNA #1 out of the building. K. Record review of the police report, dated 10/19/24, revealed the following: 1. The police were called to the facility on [DATE] due to a male (CNA #1). 2. Police noticed an open alcohol container in CNA #1's vehicle and removed it. 3. On 10/19/24, police made contact with CNA #1 and he stated he was intoxicated while being at work. L. On 12/12/24 at 11:28 AM, during an interview, the DON stated the following: 1. The incident with CNA #1 and RN #1 occurred on 10/18/24, not 10/19/24 as indicated on the incident report submitted to the State Agency. 2. Staff should have notified her when CNA #1 left the building frequently, did not help with resident care, and when he fell asleep. 3. She was not notified about the events that occurred on 10/18/24 until the Scheduler notified her after the police were called. 4. She was unsure what time staff notified her on 10/28/24.

During an annual survey the following deficient practice was found to be Immediate Jeopardy: 1) R #3 had received an extra dose of [MEDICATION NAME] (anticoagulant medication) after already receiving a first dose that day from (MONTH) 22, (YEAR) -November 27, (YEAR); then again on (MONTH) 29, (YEAR). 2) IDON confirmed that the nurse taking new order on (MONTH) 21, (YEAR) did not discontinue old order. 3) No education or in-servicing had been given to nursing staff giving anticoagulation medication regarding discontinuation of medication upon receiving new orders from physicians. 4) Upon receiving R #3's INR (a measure of coagulation monitored for resident on anticoagulation medication) of 5.37 (normal therapeutic range for an INR is 2.00 -3.00; meaning blood is thinned more than normal to prevent clotting of the blood. This is higher and therefore, thinner than therapeutic range) on (MONTH) 28, (YEAR), the Physician's Assistant was notified and did not reduce the dosage of R #3's [MEDICATION NAME]. 5) No assessment of the resident was performed on R #3 for any side effects of an INR of 5.37. This resulted in an Immediate Jeopardy that was called on 12/05/18 at 2:30 pm. A Plan of Removal was submitted on 12/06/18 at 10:40 am and approved. Plan of Removal stated: Effective Immediately: All licensed nurses will be required to be trained and execute the following (Name of facility) Policy's in their daily practice: * Medication Administration, including scheduling and Medication aides * PCC-[MEDICATION NAME]([MEDICATION NAME]) order with separate INR order (job aid for order entry) * [MEDICATION NAME]-[MEDICATION NAME] and PT/INR Lab Order Tracking tool (6/15/17) * Laboratory Process (10/31/18) 1. All licensed nurses will be educated of the (Name of facility) Policies and procedures listed above by the Interim DNS before being allowed to work on the floor. DNS/Designee will audit Order Listing report daily for new [MEDICATION NAME] orders. The order listing report will also be used to audit changes to existing orders, INRs and compare to [MEDICATION NAME]-[MEDICATION NAME] and PT/INR Order Tracking Tool. 2. On 12/5/18 at 14:30 the facility received notification of an Immediate Jeopardy (IJ) 1445 - RN MDS coordinator reviewed all potentially effected residents by comparing orders and INR results. 1500 - Staff nurses assessed the four residents with current [MEDICATION NAME] orders for abnormal bleeding, changes in level of cognition or consciousness and unusual bruising, a progress note was generated. 1515 - Orders were received from Medical Director/Designee to obtain INRs on all residents currently having [MEDICATION NAME] orders. 1600- New orders received for one resident to change [MEDICATION NAME] order. The remaining three resident's orders reflected no change. Redraws ordered on all four residents. On-The-Spot training was given to both nurses as they entered the orders from Medical director/Designee. These nurses also attended the Nurse Education (see below). 1900- Nurse Education, as listed above, was provided to licensed nursing staff. Eight nurses were in attendance. The remaining nurses will be required to receive the same education prior to their working their next shift, upon hire and will include agency staff. Plan of Correction Submitted for approval 12/6/2018. Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted on 12/06/18 at 11:10 am. This resulted in the scope and severity reduced from a K to an E. Based on interview and record review, the facility failed to meet professional standards for quality by not following physician orders [REDACTED].#3) of 4 (R #1, R #2, R #3, R #4) residents sampled for medication errors, when they gave R #3 an additional dose (2 doses total each day) above the scheduled dose of [MEDICATION NAME] on the following days: 11/22/18-11/27/18, and 11/29/18. This deficient practice resulted in R #3's INR being 5.37 (High above normal therapeutic range) that could likely result in R #3 not being able to clot blood if he were to receive a laceration and bleed out. The findings are: A. Record review of the incident report dated 11/30/18 revealed, MDS nurse discovered that there were two orders for [MEDICATION NAME] being given at 1700 and 2000 and both were signed off in eMAR. No adverse outcome. Order on 11/28 supersedes former order. Nurse (LPN #1) taking order on 11/28 failed to d/c (discontinued) former order . Former order of [MEDICATION NAME] was not d/c'd with new order. This writer d/c'd old order. Resident had INR draw on 12/2 and new orders until next INR on 12/6/18. B. Record review of R #3's MAR for (MONTH) (YEAR) revealed: 1. [MEDICATION NAME] Tablet ([MEDICATION NAME] Sodium) Give 7 mg by mouth in the evening related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (An irregular, often rapid heart rate that commonly causes poor blood flow.) (I48.2) Pt INR in am -Start Date- 11/19/2018 1700 -D/C Date- 11/30/2018 0921. It was documented as given on 11/20/18, 11/22/18-11/27/18, and 11/29/18. 2. [MEDICATION NAME] Tablet 4 MG ([MEDICATION NAME] Sodium) Give 2 tablet by mouth at bedtime related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) -Start Date- 11/21/2018 2000 -D/C Date- 11/28/2018 1600. It was documented as given on 11/21/18-11/27/18. 3. [MEDICATION NAME] Tablet 4 MG ([MEDICATION NAME] Sodium) Give 1 tablet by mouth at bedtime related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) until 12/02/2018 23:59 Date of the next Draw (PT/INR) to be Sunday 12/2/2018 -Start Date- 11/28/2018 2000 -D/C Date- 11/30/2018 0923. It was documented as given on 11/29/18. C. Record review of R #3's Physicians Orders revealed: 1. [MEDICATION NAME] Tablet ([MEDICATION NAME] Sodium) Give 7 mg by mouth in the evening related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) Pt INR in am -Start Date- 11/19/2018 1700 -D/C Date- 11/30/2018 0921. 2. [MEDICATION NAME] Tablet 4 MG ([MEDICATION NAME] Sodium) Give 2 tablet by mouth at bedtime related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) -Start Date- 11/21/2018 2000 -D/C Date- 11/28/2018 1600. 3. [MEDICATION NAME] Tablet 4 MG ([MEDICATION NAME] Sodium) Give 1 tablet by mouth at bedtime related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) until 12/02/2018 23:59 Date of the next Draw to be Sunday 12/2/2018 -Start Date- 11/28/2018 2000 -D/C Date- 11/30/2018 0923. D. Record review of R #3's PT/INR Lab Report dated 11/28/18 revealed INR 5.37. Recommended Therapeutic Range for monitoring oral anticoagulation therapy: Standard intensity anticoagulation (e.g. [MEDICAL CONDITION] .) 2.00 -3.00 INR. High intensity anticoagulation .3.01-4.00 INR E. On 12/04/18 at 1:11 pm, during an interview, the MDS Coordinator stated, I looked at his (R #3's) MARs (Medication Administration Record) and stumbled across it (the medication error) doing MDS. F. On 12/05/18 at 10:42 am, during an interview, the IDON stated that the nursing department had received education on receiving [MEDICATION NAME] orders on 11/28/18. The IDON confirmed that LPN #1 was present for that education. G. Record review of the Sign in sheet for Education on 11/28/18 revealed LPN #1's name and signature. H. On 12/05/18 at 11:10 am, during an interview, the IDON stated The [MEDICATION NAME] was duplicate order, (Name of MDSC) found it and reported it to me. We got it (the duplicate order of [MEDICATION NAME]) d/cd and informed the doctor. It was found on the 30th (November (YEAR)) and new pt/INR was done on the 2nd (December (YEAR)). The IDON also stated, I have yet to talk to the nurse who failed to d/c the order, or others who administered the medication ([MEDICATION NAME]). The IDON confirmed that [MEDICATION NAME] was a high risk medication, and an INR of 5.37 was high. The DON also stated that the PA was notified (of R #3's INR of 5.37) and did not lower that dose on the (MONTH) 28, (YEAR). I. On 12/05/18 at 12:40 pm, during an interview, LPN #1 confirmed that she had taken the in-service on 11/28/18 regarding [MEDICATION NAME] orders. LPN #1 stated I told the other nurse do not give it ([MEDICATION NAME]) because it has been d/cd. My computer had gone down. It was my responsibility, but the other nurse was running late. I could not continue (to d/c the previous [MEDICATION NAME] order). I made it known to my oncoming person. K. On 12/05/18 at 2:30 pm, during an interview the IDON confirmed that no assessment was performed on R #3 for side effects (profuse bruising,or bleeding on R #3's body) of receiving double doses the high risk anticoagulation medication resulting in an INR of 5.37. L. Review of Audrey Berman PhD, RN, Geralyn Frandsen EdD, RN, Shirlee J. Snyder EdD, RN. (YEAR). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice - 10th Ed. Upper Saddle River, NJ. Pearson Education, Inc. ISBN 10: 0-13- 6-7, ISBN 13: 978-0-13- 6-2. eISBN-10: 0-13- 4-5, eISBN-13: 978-0-13- 4-6. STAT!Ref Online Electronic Medical Library. http://online.statref.com/Document.aspx?docAddress=G4VciehnhuDTXOk5ttJ-uQ!!. 12/13/2018 4:31:15 PM CST (UTC -06:00). Revealed: Ten Rights of Medication Administration: RIGHT MEDICATION· The medication given was the medication ordered. RIGHT DOSE· The dose ordered is appropriate for the client. RIGHT TIME· Give the medication at the right frequency and at the time ordered according to agency policy. RIGHT ROUTE (by mouth, on the skin, by injection, etc)· Give the medication by the ordered route. RIGHT CLIENT· Medication is given to the intended client. RIGHT CLIENT EDUCATION· Explain information about the medication to the client (e.g., why receiving, what to expect, any precautions). RIGHT D[NAME]UMENTATION· Document medication administration after giving it, not before.· If time of administration differs from prescribed time, note the time on the MAR and explain the reason and follow-through activities (e.g., pharmacy states medication will be available in 2 hours) in nursing notes. RIGHT TO REFUSE· Adult clients have the right to refuse any medication. RIGHT ASSESSMENT· Some medications require specific assessments prior to administration (e.g., apical pulse, blood pressure, lab results). RIGHT EVALUATION· Conduct appropriate follow-up (e.g., was the desired effect achieved or not? Did the client experience any side effects or adverse reactions?).

During an annual survey the following deficient practice was found to be Immediate Jeopardy: 1) R #3 had received an extra dose of [MEDICATION NAME] (anticoagulant medication) after already receiving a first dose that day from (MONTH) 22, (YEAR) -November 27, (YEAR) then again on (MONTH) 29, (YEAR). 2) IDON confirmed that the nurse taking new order on (MONTH) 21, (YEAR) did not discontinue old order. 3) No education or in-servicing had given to nursing staff giving anticoagulation medication regarding discontinuation of medication upon receiving new orders from physicians. 4) Upon receiving R #3's INR (a measure of coagulation monitored for resident on anticoagulation medication) of 5.37 (normal theraputic range for an INR is 2.00 -3.00; meaning blood is thinned more than normal to prevent clotting of the blood. This is higher and therefore, thinner than theraputic range) on (MONTH) 28, (YEAR). The Physician's Assistant was notified and did not reduce the dosage of R #3's [MEDICATION NAME]. 5) No assessment of the resident was performed on R #3 for side effects of an INR of 5.37. This resulted in an Immediate Jeopardy that was called on 12/05/18 at 2:30 pm. A Plan of Removal was submitted on 12/06/18 at 10:40 am and approved. Plan of Removal stated: Effective Immediately: All licensed nurses will be required to be trained and execute the following (Name of facility) Policy's in their daily practice: * Medication Administration, including scheduling and Medication aides * PCC-[MEDICATION NAME]([MEDICATION NAME]) order with separate INR order (job aide for order entry) * [MEDICATION NAME]-[MEDICATION NAME] and PT/INR Lab Order Tracking tool (6/15/17) * Laboratory Process (10/31/18) 1. All licensed nurses will be educated of the (Name of facility) Policies and procedures listed above by the Interim DNS before being allowed to work on the floor. DNS/Designee will audit Order Listing report daily for new [MEDICATION NAME] orders. The order listing report will also be used to audit changes to existing orders, INRs and compare to [MEDICATION NAME]-[MEDICATION NAME] and PT/INR Order Tracking Tool. 2. On 12/5/18 at 14:30 the facility received notification of an Immediate Jeopardy (IJ) 1445 - RN MDS coordinator reviewed all potentially effected residents by comparing orders and INR results. 1500 - Staff nurses assessed the four residents with current [MEDICATION NAME] orders for abnormal bleeding, changes in level of cognition or consciousness and unusual bruising, a progress note was generated. 1515 - Orders were received from Medical Director/Designee to obtain INRs on all residents currently having [MEDICATION NAME] orders. 1600- New orders received for one resident to change [MEDICATION NAME] order. The remaining three resident's orders reflected no change. Redraws ordered on all four residents. On-The-Spot training was given to both nurses as they entered the orders from Medical director/Designee. These nurses also attended the Nurse Education (see below). 1900- Nurse Education, as listed above, was provided to licensed nursing staff. Eight nurses were in attendance. The remaining nurses will be required to receive the same education prior to their working their next shift, upon hire and will include agency staff. Plan of Correction Submitted for approval 12/6/2018. Upon implementation of the Plan of Removal by surveyor verification, the Immediate Jeopardy was lifted on 12/06/18 at 11:10 am. This resulted in the scope and severity reduced from a K to an E. Based on interview and record review, the facility failed to assess residents after significant medication errors for 1 (R #3) of 4 (R #1, R #2, R #3, R #4) residents sampled for medication errors, when they gave R #3 an additional dose (2 doses total each day) above the scheduled dose of [MEDICATION NAME] on the following days: 11/22/18-11/27/18, and 11/29/18. This deficient practice resulted in R #3's INR being 5.37 (High above normal therapeutic range) that could likely result in R #3 not being able to clot blood if he were to receive a laceration and bleed out. The findings are: A. Record review of the incident report dated 11/30/18 revealed, MDS nurse discovered that there were two orders for [MEDICATION NAME] being given at 1700 and 2000 and both were signed off in eMAR. No adverse outcome. Order on 11/28 supersedes former order. Nurse (LPN #1) taking order on 11/28 failed to d/c (discontinued) former order . Former order of [MEDICATION NAME] was not d/c'dwith new order. This writer d/c'd old order. Resident had INR draw on 12/2 and new orders until next INR on 12/6/18. B. Record review of R #3's MAR for (MONTH) (YEAR) revealed 1. [MEDICATION NAME] Tablet ([MEDICATION NAME] Sodium) Give 7 mg by mouth in the evening related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) Pt INR in am -Start Date- 11/19/2018 1700 -D/C Date- 11/30/2018 0921. It was documented as given on 11/20/18, 11/22/18-11/27/18, 11/29/18 2. [MEDICATION NAME] Tablet 4 MG ([MEDICATION NAME] Sodium) Give 2 tablet by mouth at bedtime related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) -Start Date- 11/21/2018 2000 -D/C Date- 11/28/2018 1600. It was documented as given on 11/21/18-11/27/18. 3. [MEDICATION NAME] Tablet 4 MG ([MEDICATION NAME] Sodium) Give 1 tablet by mouth at bedtime related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) until 12/02/2018 23:59 Date of the next Draw to be Sunday 12/2/2018 -Start Date- 11/28/2018 2000 -D/C Date- 11/30/2018 0923. It was documented as given on 11/29/18. C. Record review of R #3's Physicians Orders revealed: 1. [MEDICATION NAME] Tablet ([MEDICATION NAME] Sodium) Give 7 mg by mouth in the evening related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) Pt INR in am -Start Date- 11/19/2018 1700 -D/C Date- 11/30/2018 0921. 2. [MEDICATION NAME] Tablet 4 MG ([MEDICATION NAME] Sodium) Give 2 tablet by mouth at bedtime related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) -Start Date- 11/21/2018 2000 -D/C Date- 11/28/2018 1600. 3. [MEDICATION NAME] Tablet 4 MG ([MEDICATION NAME] Sodium) Give 1 tablet by mouth at bedtime related to CHRONIC [MEDICAL CONDITION] FIBRILLATION (I48.2) until 12/02/2018 23:59 Date of the next Draw to be Sunday 12/2/2018 -Start Date- 11/28/2018 2000 -D/C Date- 11/30/2018 0923. D. Record review of R #3's PT/INR Lab Report dated 11/28/18 revealed INR 5.37. Recommended Therapeutic Range for monitoring oral anticoagulation therapy: Standard intensity anticoagulation (e.g. [MEDICAL CONDITION] .) 2.00 -3.00 INR. High intensity anticoagulation .3.01-4.00 INR. E. On 12/04/18 at 1:11 pm, during an interview, the MDS Coordinator stated, I looked at his (R #3's) MARs (Medication Administration Record) and stumbled across it (the medication error) doing MDS. F. On 12/05/18 at 10:42 am, during an interview, the IDON stated that the nursing department had received education on receiving [MEDICATION NAME] orders on 11/28/18. The IDON confirmed that LPN #1 was present for that education. G. Record review of the Sign in sheet for Education on 11/28/18 revealed LPN #1's name and signature. H. On 12/05/18 at 11:10 am, during an interview, the IDON stated The [MEDICATION NAME] was duplicate order, (Name of MDSC) found it and reported it to me. We got it (the duplicate order of [MEDICATION NAME]) d/cd and informed the doctor. It was found on the 30th (November (YEAR)) and new PT/INR (lab work) was done on the 2nd (December (YEAR)). The IDON also stated, I have yet to talk to the nurse who failed to d/c the order, or others who administered the medication ([MEDICATION NAME]). The IDON confirmed that [MEDICATION NAME] was a high risk medication, and an INR of 5.37 was high. The DON also stated that the PA was notified (of R #3's INR of 5.37) and did not lower that dose on the (MONTH) 28, (YEAR). I. On 12/05/18 at 12:40 pm, during an interview LPN #1 confirmed that she had taken the in service on 11/28/18 regarding [MEDICATION NAME] orders. LPN #1 stated I told the other nurse do not give it ([MEDICATION NAME]) because it has been d/cd. My computer had gone down. It was my responsibility, but the other nurse was running late. I could not continue (to d/c the previous [MEDICATION NAME] order). I made it known to my oncoming person. K. On 12/05/18 at 2:30 pm, during an interview the IDON confirmed that no assessment was performed on R #3 for side effects (profuse bruising,or bleeding on R #3's body) of recieving double doses the high risk anticoagulation medication resulting in an INR of 5.37.

Based on record review, observation, and interview, the facility failed to keep residents free from accidents for 1 (R #1) of 4 (R #1, R #2, R #3, & R #4) residents sampled for accidents, when they failed to remove the remote from R #1's bed (R #1 has advanced dementia and is a fall risk requiring his bed to be in the lowest position) allowing R #1 to raise the bed to the highest position, and fell out of bed. This deficient practice resulted in R #1 having some lacerations to his head, bruising, and a fractured clavicle. The finding are: A. Record review of R #1's Medical Chart revealed [DIAGNOSES REDACTED]. B. Record review of the Care Plan dated 04/02/17 revealed, Resident is at risk for falls R/T (related to) impaired mobility, hemiparesis, and dementia with poor safety awareness . ENVIRONMENTAL: low bed; scoop mattress; fall mat at bedside; do not put bedside table near bed due to risk of injury with fall. Keep bed controls out of resident's reach . C. Record review of the progress note dated 03/16/17 revealed, Note Text: Staff heard bed alarm sounding at 0215 (2:15 am). found pt on the floor, head just off the fall mat, bed control by his hand, bed elevated to maximum height. Pt (patient) has 7 cm hematoma to L (left) forehead, with x2 (times 2) lacerations, one 2 cm, one 1.5 cm to L forehead with minimal bleeding. Neuro's checked, normal for pt's baseline. Pt is alert per usual. Unable to determine deformity of lower extremities due to contractures of legs, pt has minimal pain upon palpation of lower extremities. Upper L arm has normal ROM (range of motion) and strength, pt is moving it well. RUE (right upper extremity) appears normal, contracted at baseline. Pupils PERRLA (pupils equal, round, react to light, accommodation). (Name of Doctor) called, will not send to ER unless pt's neuro status declines. Telfa and kling dressing applied to forehead. Pt returned to bed via total lift, tolerated well without yelling, grimacing, or guarding. D. Record review of the Facility investigation dated 03/16/17 revealed, (Name of R #1) appears to have been playing with the bed control and elevated the bed and rolled out. The document was signed by Interim DON (IDON) and the Minimum Data Set Coordinator. E. Record review of Radiology Consultation Report, completed date of 03/17/17, revealed R #1 had a left clavicle fracture. F. On 05/08/17 at 4:41 pm, during an observation of R #1's room revealed R #1 to have an adjustable bed. Attached to the footboard of the bed was the controls to adjust the bed, to allow staff to adjust the bed. The remote had been removed. G. On 05/09/17 at 9:37 am, during an interview CNA #1 stated that during the night of R #1's fall RN #1, CNA #2 and herself were working that night. CNA #2 had gone on break. CNA #1 stated that she heard R #1 yelling in his room. CNA #1 found R #1 on the floor yelling. The remote to R #1's was next him on the floor. When asked about R #1's bed, CNA #1 stated that it was raised in the highest position. CNA #1 confirmed that R #1's bed was not supposed to be raised because he was a fall risk. It looked like he rolled out bed, because he can roll side-to-side. H. On 05/09/17 at 10:53 am, during an interview, CNA #2 stated that at the time of R #1's fall she was on break. CNA #2 did confirm that R #1's was in the lowest position before she went on break. I. On 05/09/17 at 11:16 am, during an interview and observation of R #1's room, the Maintenance Director (MD) confirmed that maintenance removed R #1's remote to adjust his bed after the fall. MD pointed out that R #1's bed had a cord that attached to the bottom of the bed that can be removed. The MD also pointed out that there were manual controls on the footboard of the bed that staff can operate. The remote is not essential to adjust the bed. J. On 05/09/17 at 11:35 am, during an interview, the IDON stated that the facility determined that R #1 had been playing with the remote to his bed and raised it to the highest position, and R #1 did fall out of bed in the highest position.

On 07/18/16 at 3:17 pm, R #46 was observed smoking with oxygen on and his nasal canula on. Lead CNA (LCNA #1) confirmed that R #46 was smoking with his oxygen tank and his nasal canula were on. RN #1 confirmed that R #46 should take off his nasal canula and turn off the oxygen tank while smoking. Staff who take residents to smoke do not stay outside to supervise residents. The Tobacco Use Assessment the facility was using for R #46 was from a previous admission. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 07/18/16 at 4:28 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: Effective immediately: All residents who smoke will have to be supervised by a staff member. no exceptions. 1. All current and new staff will be educated of the new smoking procedure by the Administrator, Department Head, or Charge Nurse before allowed to work on the floor, and all residents will be informed orally or in writing in a language they can understand of the the new smoking procedure. DNS will audit all Admissions to ensure the Tobacco Use Assessment is completed if applicable. His will begin immediately. 2. Staff will obtain the cigarettes and lighter from Charge Nurse and escort residents outside to smoking area; if residents require oxygen, the residents will be escorted to central supply room where staff will remove all oxygen tubing from wheelchair/walker, place tubing in plastic bag to keep clean and turn off oxygen tanks. Staff will then place the tanks on the floor inside of the supply room leaving an oxygen sign outside of the door before exiting the building with the resident. Staff will light the cigarette for each resident and remain in possession of the lighter. Staff will remain outside to supervise smoking activity. When residents are finished smoking, staff will escort residents back into the building. If residents requires oxygen staff will escort residents back to the supply room, place oxygen tubing back on, turn on oxygen tanks, and place tanks back on wheel chair/walker. The smoking times will remain as follows: 9am hour 11am hour 1pm hour 3pm hour 6pm hour Based on the Plan of Removal and observation, the IJ was lifted on 07/19/16 at 5:37 pm. This resulted in the scope and severity being reduced from a Level 4, Scope K to Level 2, Scope E. Based on observation, interview and record review, the facility failed to accurately assess 1 (R #46) of 3 (R, #42, R #46, and R #50) residents observed for smoking, when they used the Tobacco Use Assessment from a previous admission and failed to reassess R #46 upon readmission. This deficient practice could likely cause the facility to have inaccurate information in order to determine the safety of residents who smoke, that could lead to unsafe smoking situations. The findings are: A. Record review of R #46's Physicians Orders dated 02/10/16 revealed oxygen via nasal canula 1-4 liters per minute as needed . for [MEDICAL CONDITIONS]. B. Record review of R #46's Care Plan dated 02/22/16 revealed The resident uses tobacco products . Remove resident's oxygen prior to smoking. C. On 07/18/16 at 3:17 pm, observation of the smoking area revealed Lead CNA (LCNA #1) brought R #50 out to the smoking area. LCNA #1 lit R #50's cigarette and went back inside. R #46, R #42, and R #42's family member was outside smoking already. As soon as LCNA #1 went back inside R #46 reached over to the oxygen tank on the back of his wheelchair turned it on and put on his nasal canula. R #46 continued to smoke. Surveyor went to find LCNA #1. LCNA #1 was asked if R #46 was allowed to have his oxygen on while smoking. LCNA #1 stated, No. LCNA #1 then went outside to the smoking area and confirmed that R #46 was smoking with his oxygen tank and his nasal canula on. D. On 07/18/16 at 3:53 pm, during an interview RN #1 confirmed that R #46 should take off his nasal canula and turn of the oxygen tank. E. On 07/18/16 at 3:58 pm, during an interview LCNA #1 stated the staff all take turns taking residents outside to smoke. Staff take off his nasal canula and turn off oxygen tanks, but do not stay out there. F. Record review of the Tobacco Use assessment dated [DATE] was from a previous admission. G. On 07/18/16 at 4:07 pm, during an interview, the DNS confirmed the smoking assessment was from his previous admission. H. Record review of the Policy & Procedure Smoke-Free Locations, revised date March 2016, revealed Smoking by residents/clients when using oxygen is in use is prohibited . Upon admission, all resident/clients who smoke or use tobacco products will be assessed using the Tobacco Use Assessment.

On 07/18/16 at 3:17 pm, R #46 was observed smoking with oxygen on and his nasal canula on. Lead CNA (LCNA #1) confirmed that R #46 was smoking with his oxygen tank and his nasal canula were on. RN #1 confirmed that R #46 should take off his nasal canula and turn of the oxygen tank while smoking. Staff who take residents to smoke do not stay outside to supervise residents. The Tobacco Use Assessment the facility was using for R #46 was from a previous admission. This deficient practice resulted in an Immediate Jeopardy (IJ) being identified at the facility on 07/18/16 at 4:28 pm. The facility took corrective action by providing an acceptable Plan of Removal. Based on the plan, interventions included: Effective immediately: All residents who smoke will have to be supervised by a staff member. no exceptions. 1. All current and new staff will be educated of the new smoking procedure by the Administrator, Department Head, or Charge Nurse before allowed to work on the floor, and all residents will informed orally or in writing in a language they can understand of the the new smoking procedure. DNS will audit all Admissions to ensure the Tobacco Use Assessment is completed if applicable. His will begin immediately. 2. Staff will obtain the cigarettes and lighter from Charge Nurse and escort residents outside to smoking area; if residents require oxygen, the residents will be escorted to central supply room where staff will remove all oxygen tubing from wheelchair/walker, place tubing in plastic bag to keep clean and turn off oxygen tanks. Staff will then place the tanks on the floor inside of the supply room leaving an oxygen sign outside of the door before exiting the building with the resident. Staff will light the cigarette for each resident and remain in possession of the lighter. Staff will remain outside to supervise smoking activity. When residents are finished smoking, staff will escort residents back into the building. If residents requires oxygen staff will escort residents back to the supply room, place oxygen tubing back on, turn on oxygen tanks, and place tanks back on wheel chair/walker. The smoking times will remain as follows: 9am hour 11am hour 1pm hour 3pm hour 6pm hour Based on the Plan of Removal and observation, the IJ was lifted on 07/19/16 at 5:37 pm. This resulted in the scope and severity being reduced from a Level 4, Scope K to Level 2, Scope E. Based observation, interview, and record review, the facility failed to: 1) supervise residents exhibiting unsafe practices while smoking for 1 (R #46) of 3 (R, #42, R #46, and R #50) residents observed for smoking, when they failed supervise R #46 who was wearing his nasal canula from his oxygen tank while smoking, 2) keep residents free from accident for 2 (R #49, and R #60) of 2 (R #49, and R #60) randomly observed residents, when RN #1 failed to lock her medication cart while leaving it unattended. These deficient practices could likely cause sever burns or death from the oxygen catching fire and possibly exploding harming anyone in the vicinity; Also, residents could have adverse side-effects from receiving medication they received from an unlocked medication cart, causing injury or death. The findings are: Smoking with Oxygen on A. Record review of R #46's physician's orders [REDACTED]. for COPD (chronic obstructive pulmonary disease). B. Record review of R #46's care plan dated 02/22/16 revealed, The resident uses tobacco products . Remove resident's oxygen prior to smoking. C. On 07/18/16 at 3:17 pm, observation of the smoking area revealed Lead CNA (LCNA #1) brought R #50 out to the smoking area. LCNA #1 lit R #50's cigarette and went back inside. R #46, R #42, and R #42's family member were outside smoking already. As soon as LCNA #1 went back inside, R #46 reached over to the oxygen tank on the back of his wheelchair, turned it on, and put on his nasal canula. R #46 continued to smoke. Surveyor went to find LCNA #1. LCNA #1 was asked if R #46 was allowed to have his oxygen on while smoking. LCNA #1 stated, No. LCNA #1 went outside to the smoking area and confirmed that R #46 was smoking with his oxygen tank and his nasal canula were on. D. On 07/18/16 at 3:53 pm, during an interview, RN #1 confirmed that R #46 should take off his nasal canula and turn of the oxygen tank. E. On 07/18/16 at 3:58 pm, during an interview, LCNA #1 stated the staff all take turns taking residents outside to smoke. Staff take off his nasal canula and turn off oxygen tanks, but do not stay out there. F. On 07/18/16 at 4:01 pm, during an interview, the Director of Maintenance stated that he does take resident outside to smoke but he does not stay outside with them. When asked, he stated that he does not know the resident's care plan. G. On 07/18/16 at 4:03 pm, during an interview, the Director of Central Supply stated that she also takes residents outside but does not stay outside with them. When asked, she stated that he does not know the resident's care plan. H. Record review of the Tobacco Use assessment dated [DATE] was from a previous admission. I. On 07/18/16 at 4:07 pm, during an interview, the DON confirmed the smoking assessment was from his previous admission. J. Record review of the Policy & Procedure Smoke-Free Locations, revised date March 2016, revealed Smoking by residents/clients when using oxygen is in use is prohibited . Upon admission, all resident/clients who smoke or use tobacco products will be assessed using the Tobacco Use Assessment. Medication Carts K. On 07/18/16 at 12:05 pm, observation of the secured unit revealed RN #1 was across the room at the sink washing her hands with her back to the medication cart. The medication cart was in the middle of the large room in front of the hallway leading to the main building. The medication cart was unlocked. R #49 was walking by the medication cart. L. On 07/18/16 at 12:07 pm, during an interview RN #1 confirmed the medication cart was unlocked. I should have locked it, I was not counting on stepping away. M. On 07/20/16 at 8:46 am, observation of the secured unit revealed RN #1 was assisting a resident with her back to the medication cart that was on the other side of the row of recliners in the TV area. The medication cart was unlocked. R #49 and R #50 were near the medication cart. N. On 07/20/16 at 8:50 am, during an interview RN #1 confirmed that the medication cart was unlocked. RN #1 said that it was an emergency. O. On 07/21/16 at 8:44 am, during observation of medication administration, LPN #1 walked away from medication that was sitting the hallway and into the nurses station. The cart was unlocked and unattended. P. On 07/21/16 at 8:46 am, during an interview with LPN #1, she stated, I forgot to lock my medication cart. I should lock it when I leave the cart. Q. On 07/22/16 at 8:34 am, during an interview, the DNS confirmed that medication carts should be locked when nursing staff step away. R. Record review of the Procedure Acquisition, Receiving, Dispensing and Storage of Medications, revised date December 2015, revealed Medication will be stored in a locked medication cart, drawer or cupboard .

Based on record review and interview, the facility failed to update the care plans of 2 (#22, 70) of 33 sampled residents evaluated for care planning (#5, 6, 8, 9, 10, 16, 22, 23, 27, 28, 29, 31, 32, 33, 35, 36, 39, 41, 42, 43, 44, 45, 48, 49, 50, 51, 53, 57, 59, 63, 66, 68 and 70). Resident #70 was developmentally disabled and admitted to the facility at the same time as her mother, resident #22, who had been her caregiver prior to admission. Review of resident #22 and resident #70's medical records revealed abusive behavior between the two residents. Review of the care plans of the two residents revealed no plan instructing staff on how to address the behaviors between the two residents. Failure to care plan interventions to address behaviors between the two residents likely caused emotional distress to both residents and had the potential to result in continuing abusive behavior. The findings are: A. Review of the record for resident #22 revealed a Face Sheet dated 08/17/12 documenting admission on the same date. B. Review of resident #22's Cumulative [DIAGNOSES REDACTED]. C. Review of the record for resident #22 revealed an Interdisciplinary Progress Note dated 08/22/12 at 7:00 pm documenting, "has been abused by daughter (resident #70), daughter hit her on the arm yesterday +(and) called her a 'dog' + '[***] '. Tonight she would not let CNA (Certified Nursing Assistant) put a night gown on her. ..." D. Review of the record for resident #22 further revealed an Interdisciplinary Progress Note dated 09/12/12 at 1:40 pm documenting, "(name of resident #22)'s daughter (roommate) (sic) stated that (name of resident #22) pinched her L (left) breast. (name of resident #22) + daughter are both upset + crying. They both fight frequently." E. Review of the record for resident #70 revealed a Face Sheet dated 08/17/12 documenting admission on the same date. F. Review of resident #70's Cumulative [DIAGNOSES REDACTED]. G. Review of the record for resident #70 revealed a History and Physical dated 08/24/12 documenting, "43 Y/O (year old) (symbol for female) c (with) mental [MEDICAL CONDITION] + (and) [MEDICAL CONDITION]. Pt. (patient) admitted along c her mother who has been her caregiver for life. Since admit it has been observed that she is verbally abusive to her mother. Her mom states that she has always been this way + very impulsive + hyperactive. ..." H. Review of the care plans of resident #22 and resident #70 revealed no care plan for behavior. I. On 09/13/12 at 5:25 pm, during an interview, the Minimum Data Set (MDS) Coordinator was asked about the 08/22/12 altercation between the two residents. She stated, "I had been told that she (resident #70) was calling her mom (resident #22) names. We discussed in the care conference with her brother, (name of resident #22)'s son, that we were concerned about the behavior because what was reported to me was that they were interfering in each others care and that we should consider moving them into different rooms, and he didn't want to do that yet." When asked about the absence of a care plan addressing the problem, she stated, "There is no behavior care plan because usually the Social Services Director does that and I have not created one yet." When asked if resident #70 should have a care plan for behavior, she stated, "She should have one. It's that I don't have a Social Services Director and I just didn't do it. I should have done it. It wasn't specifically designated, but I am in charge of the care plan and oversee them." Based on record review and interview, the facility failed to update care plans for 3 (#'s 36, 48, and 51) of 33 sampled residents evaluated for care planning (#5, 6, 8, 9, 10, 16, 22, 23, 27, 28, 29, 31, 32, 33, 35, 36, 39, 41, 42, 43, 44, 45, 48, 49, 50, 51, 53, 57, 59, 63, 66, 68 and 70). Resident #36 had a fall with an injury that resulted in stitches on the left side of her forehead above her left eye. The resident was observed to pick at the stitches. The fall nor the behavior was care planned for the resident. Resident #48 had several falls that were not updated in the care plan. Resident #51 had a scab at the end of her nose that was diagnosed as squamous [MEDICAL CONDITION] and it was not care planned. This failed practice had the potential for residents to have issues that could put them at risk for not having care needs met. The findings are: Resident #36 A. On 09/11/12 at 4:00 pm, during an observation of the special care unit (SCU), resident #36 was sitting at the table. She was noted to have several stitches on the left side of her forehead, above the left eye. B. Record review of resident #36's Face Sheet dated 08/16/12 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]., dementia with psychotic features. C. Review of the Interdisciplinary Progress Notes revealed that on "09/08/12 at 2215 (10:15 pm) Called to SCU (Special Care Unit) by staff- Resident found on floor in her BR (bedroom) (# given) lying on her Left side (sic). Blood obvious on floor under her head. When turned nurse noted 2 1/2 cm (centimeter) lacerasion (sic) just above L (left) eyebrow...Staff reported that prior to incident resident was in bed. Bed alarm did not go off. She went into bathroom alone- staff were in hallway near room & (and) heard 'Bump' when she fell ." Physicians orders dated 09/08/12 were written to transfer resident to the emergency room for evaluation. Further review of the Interdisciplinary Progress Notes revealed on "09/09/12 at 0145 (1:45 am) resident returned to facility via ambulance- ...6 sutures at L (left) eyebrow. Order to remove in 6 days & to apply ice to region intermittently... resident assisted to bed (Bed alarm checked & is functioning.) (sic)" D. Review of the Comprehensive Care Plan dated 08/30/12 revealed that the resident is at risk for falls, further review under the section for plans of approach, there is no alarm included and the care plan has not been updated to reflect the fall in which the resident received an injury that had to have stitches. E. On 09/13/12 at 4:30 pm, during an interview, the MDS Coordinator stated that it is expected that nurses will add to the care plan when an incident occurs, but incident reports and and interventions should be added by MDS. She stated, "I have let that go and have not added to the care plans when I should have. I should have care planned for the stitches too, she will pick at them." F. On 09/14/12 at 8:40 am, during an observation, the resident was observed to be sleeping in the recliner in the common area. When she woke up she acted as though she was washing her face and when she came to the stitches she began to pick at them. G. On 09/14/12 at 10:30 am, during an interview, Certified Nursing Assistant (CNA) #1 was asked if she knew what she needed to do to take care of the wound and stitches that the resident had. She stated that the nurses take care of the treatments, "We just need to keep her from picking at them (the stitches)." Resident #48 A. On 09/11/12 at 12:00 pm, during an observation, resident #48 was observed to be assisted by a staff member, walking to the table for lunch. She had a very unsteady gait. B. Review of resident #48's Face Sheet dated 08/16/12 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. C. Review of the Incident Details forms revealed the resident had a fall on the following dates: 1. On 09/04/12 at 7:40 pm- "the resident was found sitting on the floor near the recliner she had been sitting on. A guest visiting another resident alerted the CNA's." 2. On 08/04/12 at 11:45 am- "The resident was arranging flowers at the sink. She was witnessed to have grabbed the sink and go to a sitting position with "butt" approx (approximately) 6 " (inches) off the floor then let go, She hit "butt" on the floor and fell back. She hit head on floor (not real hard) (sic). 'I got dizzy.'" 3. On 05/18/12 at 5:30 am- "resident was up and ambulating unassisted next to CNA. CNA turned to strip her bed and resident fell into CNA." 4. On 05/08/12 at 2:20 pm- "found the resident on the floor, face down near bed." 5. On 01/25/12 at 8:40 am- "the resident was playing noodle ball, lost her balance and fell backward. She sustained a small bump on back of head." 6. On 12/03/11 at 7:15 am- "the resident was found on the floor in her room." D. Review of the annual MDS dated [DATE], revealed Section J. Falls: J1800. Had the resident had any falls since admission or prior assessment: Yes. J1900. If there had been falls how many were there with: a. no injury=1, b. injury =1 and c. major injury=0. Review of the quarterly MDS date 08/03/12 indicated that the resident had falls with no injury. E. Review of the Comprehensive Care Plan dated 08/08/12 revealed that the fall of 09/04/12 was not recorded. F. On 09/13/12 at 4:20 pm, during an interview, the MDS Coordinator stated that she has been bad about updating. She stated that she may not have been at that care plan meeting in August. "No one would have added to the care plan but me." She stated that there was nothing in the notes about the incident after the stand up meeting. "During the stand up we go over all incident reports and I was at the meeting on the 5th (09/05/12), but I was not aware of the fall on the 4th (09/04/12)." Resident #51 A. On 09/11/12 at 12:00 pm, during an observation, resident #51 was at the table feeding herself and talking. She had a scab on the tip of her nose. B. Review of resident #51's Face Sheet dated 08/16/12 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. C. Review of Initial Interdisciplinary Data Collection Tool dated 08/16/12 under Skin, revealed a skin tear on the right wrist area, a history of pressure ulcers and dry flaky skin. Interdisciplinary Assessments and Summery reviews dated 08/23/12 revealed..."(name of guardian) spoke to (name of physician) about spot on nose (possible [DIAGNOSES REDACTED]) et (and) suggest a cream or other treatment..." Physician's Telephone Orders dated on 08/30/12 read, "Imiquimod 5% cream- apply sparingly to [MEDICAL CONDITION] nose 3x/wk ( 3 times a week) at bed time- Dx (Diagnoses) [DIAGNOSES REDACTED] CA (Cancer) on M, W, F (Monday, Wednesday, and Friday) for max 16 wks (weeks)." Review Progress Note dated 08/30/12 revealed, "[MEDICAL CONDITION] to nose- Basel cell CA. Trial of imiquimod topical discussed with POA (Power of Attorney)- No derm (dermatology) referral wanted, due to hardship of travel. Topical (applied to skin) empiric (A practitioner whose skill or art is based on what has been learned through experience) TX (treatment) at request of POA." Review of the care plan revealed that there was no care plan for the treatment to the nose or the Basal [MEDICAL CONDITION]. D. On 09/13/12 at 4:10 pm, during an interview, the MDS Coordinator was referred to the physician orders [REDACTED]. She said, "a lot of times the wound care nurse will tell me. I do depend on staff to tell me changes to make to the care plan, the wound care nurse would tell me if something was needed." She stated, "I usually do a generic care plan when there are skin issues like resident #51(called by name) has. It has been there a long time. I've seen it and have talked to the POA before, because she is a nurse here. She (POA) indicated that this was a long standing problem. It probably should be care planed." E. Review of the Policy for Care Plan "issued November 2002 and revised on 4/04; 1/09" Last paragraph reads...This plan of care will be modified to reflect the care currently required/provided for the resident."

Based on record review and interview, the facility failed to address the behavioral needs of 2 (#22, 70) of 33 sampled residents evaluated for care planning (#5, 6, 8, 9, 10, 16, 22, 23, 27, 28, 29, 31, 32, 33, 35, 36, 39, 41, 42, 43, 44, 45, 48, 49, 50, 51, 53, 57, 59, 63, 66, 68 and 70). Resident #70 was developmentally disabled and admitted to the facility at the same time as her mother, resident #22, who had been her caregiver prior to admission. Review of resident #22 and resident #70's medical records revealed abusive behavior between the two residents. Review of the residents' records revealed no plan or guidance to staff on how to address the behaviors between the two residents. Failure to address behaviors between the two residents likely caused emotional distress to both residents and had the potential to result in continuing abusive behavior. The findings are: A. Review of the record for resident #22 revealed a Face Sheet dated 08/17/12 documenting admission on the same date. B. Review of resident #22's Cumulative [DIAGNOSES REDACTED]. C. Review of the record for resident #22 revealed an Interdisciplinary Progress Note dated 08/22/12 at 7:00 pm documenting, "has been abused by daughter (resident #70), daughter hit her on the arm yesterday +(and) called her a 'dog' + '[***] '. Tonight she would not let CNA (Certified Nursing Assistant) put a night gown on her. ..." D. Review of the record for resident #22 further revealed an Interdisciplinary Progress Note dated 09/12/12 at 1:40 pm documenting, "(name of resident #22)'s daughter (roommate) (sic) stated that (name of resident #22) pinched her L (left) breast. (name of resident #22) + daughter are both upset + crying. They both fight frequently." E. Review of the record for resident #70 revealed a Face Sheet dated 08/17/12 documenting admission on the same date. F. Review of resident #70's Cumulative [DIAGNOSES REDACTED]. G. Review of the record for resident #70 revealed a History and Physical dated 08/24/12 documenting, "43 Y/O (year old) (symbol for female) c (with) mental [MEDICAL CONDITION] + (and) [MEDICAL CONDITION]. Pt. (patient) admitted along c her mother who has been her caregiver for life. Since admit it has been observed that she is verbally abusive to her mother. Her mom states that she has always been this way + very impulsive + hyperactive. ..." H. Review of the care plans of resident #22 and resident #70 revealed no interventions addressing behavioral needs. I. On 09/13/12 at 5:25 pm, during an interview, the Minimum Data Set (MDS) Coordinator was asked about the 08/22/12 altercation between the two residents. She stated, "I had been told that she (resident #70) was calling her mom (resident #22) names. We discussed in the care conference with her brother, (name of resident #22)'s son, that we were concerned about the behavior because what was reported to me was that they were interfering in each others care and that we should consider moving them into different rooms, and he didn't want to do that yet." When asked about the absence of a care plan addressing the problem, she stated, "There is no behavior care plan because usually the Social Services Director does that and I have not created one yet." When asked if resident #70 should have a care plan for behavior, she stated, "She should have one. It's that I don't have a Social Services Director and I just didn't do it. I should have done it. It wasn't specifically designated, but I am in charge of the care plan and oversee them." Based on record review and interview, the facility failed to revise interventions to prevent self-injurious behavior for 1 (#36) of 3 sampled residents evaluated for skin conditions (#10, 36, and 51). Resident #36 had a fall with an injury that resulted in stitches on the left side of her forehead above her left eye. The resident was observed to pick at the stitches. Review of the resident's record revealed no planned interventions to prevent picking. This failed practice had the potential to result in delayed healing or re-injury of the wound site. The findings are: Resident #36 A. On 09/11/12 at 4:00 pm, during an observation of the special care unit (SCU), resident #36 was sitting at the table. She was noted to have several stitches on the left side of her forehead, above the left eye. B. Record review of resident #36's Face Sheet dated 08/16/12 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]., dementia with psychotic features. C. Review of the Interdisciplinary Progress Notes revealed that on "09/08/12 at 2215 (10:15 pm) Called to SCU (Special Care Unit) by staff- Resident found on floor in her BR (bedroom) (# given) lying on her Left side (sic). Blood obvious on floor under her head. When turned nurse noted 2 1/2 cm (centimeter) lacerasion (sic) just above L (left) eyebrow...Staff reported that prior to incident resident was in bed. Bed alarm did not go off. She went into bathroom alone- staff were in hallway near room & (and) heard 'Bump' when she fell ." Physicians orders dated 09/08/12 were written to transfer resident to the emergency room for evaluation. Further review of the Interdisciplinary Progress Notes revealed on "09/09/12 at 0145 (1:45 am) resident returned to facility via ambulance- ...6 sutures at L (left) eyebrow. Order to remove in 6 days & to apply ice to region intermittently... resident assisted to bed (Bed alarm checked & is functioning.) (sic)" D. On 09/13/12 at 4:30 pm, during an interview, the MDS Coordinator stated that it is expected that nurses will add to the care plan when an incident occurs, but incident reports and and interventions should be added by MDS. She stated, "I have let that go and have not added to the care plans when I should have. I should have care planned for the stitches too, she will pick at them." E. On 09/14/12 at 8:40 am, during an observation, the resident was observed to be sleeping in the recliner in the common area. When she woke up she acted as though she was washing her face and when she came to the stitches she began to pick at them. F. On 09/14/12 at 10:30 am, during an interview, Certified Nursing Assistant (CNA) #1 was asked if she knew what she needed to do to take care of the wound and stitches that the resident had. She stated that the nurses take care of the treatments, "We just need to keep her from picking at them (the stitches)." G. Review of the Comprehensive Care Plan dated 08/30/12 revealed that the care plan had not been updated to reflect the presence of stitches or interventions to protect the stitches from being picked at by the resident.