Every finding on record at Spanish Hills Wellness Suites

Based on observation, interview, and document review, the facility failed to ensure the facility failed to ensure the hand sink in the kitchen food preparation area dispensed hot water; kitchen equipment was free of greasy buildup and food debris; floors were maintained free of heavy food debris and spillage; the ventilation hood filter was free of visible dust and grease buildup; and food items were properly stored in the freezer.The deficient practices had the potential to compromise food safety, increase the risk of foodborne illness, and create conditions conducive to pest infestation and physical hazards, placing residents, staff, and visitors at risk.Findings include:On 02/24/2026 at approximately 8:30 AM, during the initial kitchen tour following concerns were observed:-In the food preparation area, a designated handwashing sink did not dispense hot water due to a malfunctioning hot water handle, preventing appropriate handwashing and sanitation practices. -Heavy grease build-up and food debris were present on the sides of the fryer. -The ventilation hood filter located on the cook line was visibly dusty and greasy.-Heavy food debris and dried food spillage were observed on floors beneath multiple pieces of kitchen equipment, including the stove, fryer, oven, toaster, cook line table, tray line steam table, dishwasher, walk in refrigerator, and dry storage shelving. -The oven contained visible residue from old, burned food and grease. -The dishwasher machine exhaust was visibly soiled with grease and dust. -The toaster was heavily soiled with food debris. -Multiple frozen food items, including milkshakes, luncheon loaf, cheese omelets (15 lbs.), buttermilk pancakes (12 lbs.), and pork sausage (six 10 lb boxes), were stored in the walk in refrigerator instead of the freezer, contrary to manufacturer instructions requiring frozen storage.On 02/24/2026 at 8:45 AM, a cook reported the kitchen and equipment were required to be cleaned weekly and acknowledged the unsanitary conditions observed. The cook confirmed the food items requiring frozen storage should have been stored in the freezer rather than the walk in refrigerator.On 02/25/2026 at 10:00 AM, the Dietary Manager explained the kitchen should have been cleaned daily to maintain a safe food service environment. The Manager acknowledged that items requiring frozen storage should have been stored as per the manufacturer's recommendation.The facility's policy titled Sanitation and Food Safety in Food and Nutrition Services dated 10/15/2025, documented the Dietary Manager had the responsibility for the food safety and sanitation of the kitchen and should provided a cleaning schedule for each area and piece of equipment.The facility's policy titled Cleaning the Toaster, indicated the toaster was maintained in a clean and sanitary condition by emptying the crumb tray, washing, rinsing, and sanitizing the crumb tray in the 3-compartment sink daily.The facility policy titled Cleaning Ovens, dated 10/15/2025, indicated the oven was cleaned for spills as they occur, baked-on food debris as needed, and the interior cleaned with fresh water daily. The policy provided directions for a weekly oven cleaning, including removing and cleaning the racks, loosening baked-on grease or carbonized food with a brush or scraper, removing loosened soil, rinsing with water, and allowing them to dry.

Based on observations, interviews, and document review, the facility failed to follow effective sanitation practices in the kitchen area and did not implement the pest control service's recommendations to prevent the proliferation of insects in the kitchen area. This deficient practice had contributed to the ongoing pest activity, increasing the risk of food contamination and compromising the safety and sanitation of the food service environment.Findings include:On 02/24/2026 at approximately 8:30 AM, during the initial kitchen tour following concerns were observed:Heavy food debris and dried food spillage were observed on floors beneath multiple pieces of kitchen equipment, including the stove, fryer, oven, toaster, cook line table, tray line steam table, dishwasher, walk in refrigerator, and dry storage shelving.The oven contained visible residue from old, burned food and grease.The toaster was heavily soiled with food debris.During the kitchen inspection, three live cockroaches were observed in food service areas: one on the floor in the dishwashing area, one in the floor drainage under a sink at the cook line, and one at the door of the walk in refrigerator. Pest control reports dated 01/15/2026, 01/22/2026, 01/30/2026, 02/12/2026, and 02/19/2026, revealed cockroach activity had been consistent on each service visit, and a recommendation to clean regularly was provided.On 02/24/2026, the maintenance Director explained the pest control contractor provided services every other week and as needed. The Maintenance Director confirmed pest control interventions could be ineffective if the kitchen staff did not maintain proper cleaning in the area.The facility policy titled Pest Control dated 10/15/2026, documented the proper sanitation would be maintained, and clutter would be reduced to prevent food and harborage for pests.

Based on observation, medical record review, interview, and document review, the facility failed to ensure a care plan was developed for the care of extensive skin dryness in the lower extremities for 1 of 42 sampled residents (Resident 119). This deficient practice had the potential to worsen skin dryness and compromise skin integrity.Findings include:Resident 119 (R119) was admitted on [DATE] with diagnoses including bilateral lower extremity pain, onychomycosis, cellulitis of the right big toe, and morbid obesity.On 02/24/2026 at 11:00 AM, an observation revealed extensive flaky skin dryness with visible scaling of R119's bilateral lower extremities.A physician order dated 01/12/2020, documented instructions to apply antifungal cream to the bilateral lower extremities daily and as needed for dryness.The medical record lacked documented evidence a care plan was developed and implemented to address the resident's dry skin condition.On 02/27/2026 at 10:30 AM, the Director of Nursing (DON) confirmed the antifungal medication could have been administered at any time between 6:00 AM and 6:00 PM, as ordered by the physician. The DON indicated a corresponding care plan should have been developed to ensure the care of R119's skin condition.The facility's policy titled Person-Centered Care Plan dated 06/09/2023, documented a person-centered care plan was created to guide staff in the provision of treatment, care and services necessary for residents to obtain and maintain the highest physical, mental and psychosocial well-being.

Based on observation, interview, record review and document review, the facility failed to ensure dietary orders were followed for a resident receiving a chopped diet for 1 of 42 sampled residents (Resident 16). The deficient practice created potential for choking, aspiration and/or compromised nutritional status of the resident.Findings include:Resident 16 (R16) was admitted on [DATE] with diagnoses including spinal stenosis, anorexia, morbid obesity, history of stroke, dysphagia, and altered mental status.A physician diet order dated 01/23/2026 documented no added salt, consistency chopped.On 02/25/2026 at 12:50 PM, R16 was lying in bed with head of bed elevated eating lunch. R16's meal ticket documented no added salt-chopped and included the following items: -Three chicken tenders with one portion of dipping sauce-One half cup mashed potatoes with 2 ounces of gravy-One half cup chopped steamed cabbage-One serving of chopped lemon meringue pieR16's meal tray consisted of a chicken patty on bun cut into four quarters, French fries, green beans, chocolate cream pie. R16 explained the chicken patty on bun had been cut into four quarters by a Certified Nursing Assistant (CNA).R16's meal tray did not reflect the items listed on the meal ticket.When comparing the meal ticket to the food on the tray, R16 explained did not have any of those foods on the tray. R16 began eating the chicken sandwich and started coughing. R16 explained items on meal tray were usually chopped in smaller pieces.On 02/25/2026 at 1:30 PM, CNA3 confirmed R16's food items on the plate did not match the meal ticket.On 02/25/2026 at 1:35 PM, a Licensed Practical Nurse (LPN), explained food was chopped in the kitchen for chopped diet orders prior to being delivered to the residents. The LPN stated if food items on the meal tray do not match the meal ticket, the CNA was to notify the kitchen prior to serving the meal.On 02/25/2026 at 3:36 PM, CNA4 explained when passing meal trays, the process was to ensure the meal tickets matched food on tray and came from the kitchen as ordered. If the meal tray and ticket did not match, the meal was brought to the kitchen and switched for the proper meal. CNA4 delivered R16s meal tray and did not pay attention to the diet order. CNA4 acknowledged the tray was incorrect and the food was not chopped. CNA4 explained residents consuming incorrect textured foods were at risk for choking.R16's nutritional care plan approach edited 01/23/2026 documented interventions to include diet as ordered by physician: No Added Salt, Chopped.On 02/26/2026 at 1:30 PM, a Speech Therapist explained R16 was followed by speech services and required a chopped diet to prevent them from taking too big of bites of food, due to impulsivity and to prevent choking. On 02/27/2026 at 1:41 PM, the Director of Nursing (DON), explained staff were expected to ensure residents were provided with the appropriate diet consistency when distributing meal trays. The DON explained the process started in the kitchen, where staff were responsible for checking and preparing the meal tray to the appropriate order. When staff set up the meal tray, they were expected to review the meal ticket. If there was a discrepancy, staff brought the tray back to the kitchen or to the attention of kitchen staff to get the appropriate meal. The DON confirmed a chicken sandwich cut in four quarters did not constitute a chopped diet order. The DON explained the tray should have been the correct consistency before leaving the kitchen and the CNA should have alerted the kitchen when the tray was discovered to not be accurate. The facility policy titled Therapeutic diets revised on 10/15/2025, documented to prepare and serve all therapeutic and mechanically altered diets as planned, and to check all trays for accuracy before they were served to the patient/resident.

Based on interview, record review and document review, the facility failed to ensure a copy of the discharge notice was sent to the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 42 sampled residents (Resident 150). This failure had the potential to lead to resident rights not being advocated for improper discharges.Findings include:Resident 150 (R150) was admitted on [DATE] with diagnoses including unspecified diastolic congestive heart failure, chest pain, and atrial fibrillation. R150 was discharged on 01/08/2026.R150's medical record lacked documented evidence of notification to the State LTC Ombudsman.On 02/26/2026 at 2:37 PM, the Director of Case Management explained the process for reporting to the LTC Ombudsman was to generate a list of discharged residents at the end of each month and send it by facsimile to the LTC Ombudsman. The Director of Case Management reviewed R150's medical record and confirmed the LTC Ombudsman was notified regarding the discharge. The Director of Case Management stated there was no proof, tracking or documentation kept to confirming the LTC Ombudsman was notified of any resident discharges.On 02/27/2026 at 1:54 PM, the Director of Nursing (DON) stated the expectation for reporting resident discharges to the LTC Ombudsman was the responsibility of case management. The DON explained at the end of each month, case management sent a list of discharges to the LTC Ombudsman for notification. The DON was unaware of how case management tracked the LTC Ombudsman notifications.The facility policy titled Discharge notification, revised on 05/09/2025, documented the Social Services Staff/or designee was charged with ensuring that systems were in place to provide written notification of transfer or discharge to the LTC Ombudsman. The notifications were documented in the resident's medical record.

Based on observation, interview, and document review, the facility failed to maintain proper waste management practices by allowing 3 of 3 outdoor waste dumpsters to remain uncovered. This deficient practice had the potential to attract pests and create unsanitary conditions in the waste handling area.Findings include:On 02/24/2026 at 8:40 AM, three outdoor garbage dumpsters were observed uncovered and overfilled, creating conditions that could attract pests and result in unsanitary waste handling practices.On 02/24/2026 at 9:30 AM, the Maintenance Director confirmed the observation and stated the garbage service company picked up waste weekly. The Maintenance Director acknowledged the dumpsters should have been kept covered at all times to prevent pest activity and odors.The facility's policy titled Waste Disposal, dated 10/16/2025, documented that waste would be disposed of in a manner that prevents transmission of disease, nuisances, or breeding areas for insects and feeding areas for animals such as rodents. The policy further indicated staff should ensure waste containers and dumpsters remain covered.

Based on observation, medical record review, interview, and document review, the facility failed to ensure 1) prescribed splints were applied as ordered for 1 of 42 residents (Resident 17), and 2) a staff member did not document an antifungal ointment as administered when it was not available in the medication cart and not applied to the resident for 1 of 42 sampled residents (Resident 119). This deficient practice had the potential to result in worsening contractures due to the lack of consistent joint positioning, and to result in untreated skin dryness, worsening skin breakdown, and missed medication doses.Findings include:Resident 17 (R17) was admitted on [DATE] with diagnoses including cerebrovascular accident with left side weakness, atrial fibrillation, and hypertension.A physician order dated 12/02/2025 documented the use of splints as follows: a waffle boot to the left lower extremity and a carrot orthosis to the left hand for 6 hours or as tolerated.A physical therapy evaluation dated 07/23/2025 documented R17 could safely wear an orthotic on the left foot for up to 4 hours.On 02/24/2026 at 9:40 AM, R17 was observed in bed with a contracture of the right hand and paralysis of the left side of the body. The waffle boot and carrot orthosis were not observed to be applied as ordered.On 02/25/2026 at 9:00 AM, R17 was observed in bed. The prescribed splints were not observed to be applied.On 02/25/2026 at 10:00 AM, review of the Medication Administration Record (MAR) revealed a nurse had signed at 9:00 AM, indicating the splints had been applied.On 02/25/2026 at 11:30 AM, R17 was observed in bed. The prescribed splints were not observed to be appliedOn 02/25/2026 at 11:40 AM, a Registered Nurse (RN) assigned to care for R17 confirmed the resident was not wearing the prescribed splints. The RN acknowledged the MAR had been signed to indicate the splints were applied but the application had not yet occurred because they had been busy. The RN checked R17's room and was unable to locate the splints.A care plan dated 12/30/2025, documented R17 required a waffle boot on the left lower extremity and a carrot orthosis on the left hand to prevent further contracture. The care plan indicated R17 refused the splints, and approaches included encouraging residents to comply with wearing or placing splints as ordered.2) Resident R119 was admitted on [DATE] with diagnoses including bilateral lower extremity pain, onychomycosis, cellulitis of the right big toe, and morbid obesity.On 02/24/2026 at 11:00 AM, an observation revealed extensive flaky skin dryness with visible scaling of R119's bilateral lower extremities.A physician order dated 01/12/2020 documented instructions to apply antifungal cream to the bilateral lower extremities daily and as needed for dryness.The medical record lacked documented evidence a care plan was developed and implemented to address the resident's dry skin condition.On 02/27/2026 at 9:00 AM, the treatment administration record (TAR) revealed the antifungal medication was signed as administered in the spot corresponding to that day.On 02/27/2026 at 10:15 AM, a Registered Nurse (RN) assigned to care for R119 stated the resident received antifungal ointment daily for skin dryness to the bilateral lower extremities. Upon request to review the medication, the RN confirmed the antifungal ointment was not available in the medication cart and a new container had to be retrieved from the supply room. The RN acknowledged the medication had not been applied but had been documented as administered on the MAR. The RN verbalized medication should not have been charted as given if it was not available.On 02/27/2026 at 10:30 AM, the Director of Nursing (DON) confirmed the antifungal medication could have been administered at any time between 6:00 AM and 6:00 PM, as ordered by the physician. The DON acknowledged the antifungal medication should not have been documented as administered when it was not available, as this created the potential for a missed dose. The DON indicated the resident's skin condition should have been accurately documented on the weekly skin assessments, and a corresponding care plan should have been developed.The facility's policy titled Medication Management Program last revised on 01/15/2025, documented the authorized staff member should return to the medication cart immediately after the administration of the medication to document the administration by signing with initials on the MAR. The policy indicated that if the medication was not given, a rationale should be documented.

Based on observation, interview and document review, the facility failed to ensure expired food items were discarded from two resident refrigerators. The deficient practice had the potential for expired foods to be consumed, which could lead to foodborne illness. Findings include:On 02/24/2026 at 11:26 AM, the refrigerator in resident room [ROOM NUMBER] contained:- one unopened container of yogurt, expired 12/18/2025- two unopened bottles of Starbucks Vanilla Frappuccino, expired 12/15/2025- two slices of blueberry pie, each in a clamshell container not datedOn 02/24/2026 at 11:36 AM, a Certified Nursing Assistant (CNA1), confirmed the findings in the refrigerator in resident room [ROOM NUMBER]. CNA1 explained CNA staff were responsible for cleaning the refrigerators and removing expired food items as part of daily duties when cleaning resident rooms. CNA1 stated expired items should have been discarded to prevent residents from consuming and getting sick.On 02/24/2026 at 11:56 AM, a Registered Nurse (RN), stated the resident refrigerators were checked daily and nurses and CNAs were responsible to monitor them and expired items discarded. The RN explained expired items would need to be removed to prevent residents from consuming and possibly developing stomach issues such as pain or diarrhea. On 02/24/2026 at 12:06 PM, the refrigerator in resident room [ROOM NUMBER] contained a ham and cheese sandwich, wrapped in cellophane, with a handwritten date on it. The date was written in black ink, 02/2026 was legible, however, the numerical day of the month was smeared and could not be determined. A resident who occupied room [ROOM NUMBER], stated the ham and cheese sandwich had, been in there a while.On 02/24/2026 at 12:16 PM, CNA2, confirmed the ham and cheese sandwich in the refrigerator for room [ROOM NUMBER], and declared the date on the cellophane wrapper was 02/01/2026. CNA2 placed ham and cheese sandwich back into the refrigerator and stated, in case the resident wants to eat it later.On 02/24/2026 at 12:19 PM, a Registered Nurse (RN), confirmed the ham and cheese sandwich in the refrigerator for room [ROOM NUMBER] and stated the writing for the date was unclear. The RN indicated would discard the item and stated food items should be in refrigerator less than 3 days.On 02/27/2026 at 1:46 PM, the Director of Nursing (DON) explained the resident refrigerators should not contain expired food items. The expectation was the night shift staff checked the refrigerators weekly and removed and discarded expired items right away. The DON indicated regardless of food items being opened, if date was expired, it should have been disposed of. The DON explained residents who consumed expired food were at risk for illness or infection. The facility policy titled Food from outside sources, safe handling of, revised on 06/20/2023, documented foods were labeled to identify the resident's name, container contents, and the date it was prepared. Items were stored for three days. Expired and unlabeled items would be discarded.

Based on interview, record review and document review, the facility failed to ensure a report submitted to the state agency (SA) regarding an allegation of sexual abuse was thoroughly completed for 1 of 6 sampled residents (Resident 2). The deficient practice had the potential to compromise the safety of residents. Findings include: Resident 2 (R2) R2 was admitted on [DATE] with diagnoses including closed fracture of the right femur, schizoaffective disorder, major depressive disorder, and an anxiety disorder. An initial report of the Facility Reported Incident (FRI) submitted to the SA on 01/22/2025, revealed R2 alleged being touched inappropriately by a staff member described as a white male wearing a ponytail. A final report of the FRI submitted to the SA on 01/28/2025, revealed the facility was not able to substantiate R2's allegation of sexual abuse due to the description of the alleged male R2 provided did not match any of the staff members in the facility. On 03/06/2025 at 1:50 PM, a Restorative Nurse Assistant (RNA) with a beard and a ponytail indicated was familiar with R2. The RNA conveyed having provided restorative services to R2 alongside another staff member, but the RNA had not been alone with the resident at any given time. The RNA reported being suspended for one day due to an incident involving R2, but the reason for the suspension was not made clear to the RNA. On 03/06/2025 at 2:00 PM, the Director of Nursing (DON) confirmed the RNA's suspension on 01/22/2025 was related to R2's sexual abuse investigation. The DON acknowledged the RNA was suspended because the RNA was the only male staff member who wore a ponytail. The facility report (initial and final) lacked documentation of the RNA's suspension due to the staff member fitting the description provided by R2. On 03/06/2025 at 3:09 PM, the DON reviewed the facility report and conveyed the report contained inaccurate information regarding there not being any staff members who fit the description of the alleged staff member. The DON indicated the suspension of the RNA was part of the facility's abuse protocol and investigation and should have been included in the final report. The DON explained the former abuse coordinator completed the report which was submitted to the SA. The DON could not speak to why the RNA's suspension was excluded from the facility report. On 03/06/2025 at 3:15 PM, the Abuse Coordinator indicated being employed on 02/06/2025 and could not speak to R2's incident which occurred in January 2025. The policy titled Abuse, Neglect, Exploitation, or Mistreatment revised on 11/1/2027 documented the facility would conduct an internal investigation of the allegation and report the results of the investigation to enforcement agencies which includes the State Agency. Investigations were to be prompt, comprehensive, responsive to the situation and contain founded conclusions.

Based on observation, interview, and document review, the facility failed to ensure dented cans and expired food products were discarded, and the kitchen floor and essential cooking equipment were cleaned and maintained in sanitary conditions. The deficient practice had the potential to expose residents to foodborne illnesses. Findings include: On [DATE] at 8:00 AM, an inspection was conducted in the kitchen with the Kitchen Manager. The following concerns were identified: - The fryer exhibited the oil visibly aged and contaminated. Food debris was prevalent, further contributing to the unsanitary condition. The fryer's surfaces were coated with a layer of grease and food debris. - The floor under the stove and oven was found to be greasy, dusty, and littered with food debris. - The lateral surfaces of the stove were greasy. - The toaster was greasy, with its exterior covered in grease and visibly soiled with food debris. - A mixer was visibly soiled with food remains. - A breadcrumbs container with expiration date [DATE]. - Three cartoons of thickened apple juice 1.36 litters expired on [DATE]. - Two containers of sour cream 5 pounds (LB) expired on [DATE]. - A container of peanut butter expired on [DATE]. - A container of gravy not dated found over the food preparation table. - A plastic receptacle containing hot dogs was found in the walk-in refrigerator with expiration date [DATE]. - Two dented cans of cheese sauce and a can of sliced pickled beets 6 LB each, found in the dry storage. - The potable water dispenser showed with white build up calcium matter around the nozzle. The water supply pipe was covered in formations of blue and white matter. - The ice maker machine had white build up calcium matter in the ice bin baffle. - The exhaust vent of the dishwasher was heavily soiled, with a significant accumulation of dust on its surface. On [DATE] in the morning, the kitchen manager acknowledged all the findings represented unsanitary conditions and should have been corrected timely. The facility policy titled Food Safety in Receiving and Storage dated [DATE], documented food products expiration dates and use-by dates should be checked to ensure dates were within acceptable parameters. The facility policy titled Manual Cleaning and Sanitizing Stationary Equipment and Work Surfaces dated [DATE], indicated stationary equipment and work surfaces would be cleaned and sanitized before use, between use, and any time contamination occurred or was suspected.

Based on observation, record review, document review, and interview, the facility failed to assess a resident's nutritional status during a period of substantial weight loss for 1 of 24 residents (Resident 87). The deficient practice had the potential to place the resident at risk of malnutrition and dehydration, compromising the residents' health and increasing susceptibility to further medical complications. Findings include: Resident 87 (R87) R87 was admitted on [DATE], with diagnosis including encephalopathy, nausea with vomiting, and drug induced subacute dyskinesia. A Malnutrition Screening Tool dated 09/09/2024, documented R87 was eating poorly due to decreased appetite. R87 scored positive for nutritional risk. R87's Vitals Report dated 09/07/2024, documented an initial resident weight of 150 pounds (lbs.) upon admission. The Vitals Report documented resident weight of 120.1 lbs. on 10/09/2024. R87 sustained weight loss of 29.99 lbs. or 19.93% of R87's total body weight between 09/07/2024 and 10/09/2024. A Nutritional Assessment at Admissions dated 09/11/2024, under the Estimated Nutritional Needs section, calories per day, protein grams per day, and fluid milliliters per day were observed blank. The Evaluation of Nutritional Needs section of the form was blank and lacked information for nutritional diagnosis, interventions, goals, monitoring, and evaluation. A Nutritional Review dated 12/10/2024, documented resident weight of 117.2 lbs. and significant weight loss had occurred. The medical record lacked documented evidence a nutritional assessment or review was performed from 09/11/2024 until 12/10/2024. On 01/08/2025 at 1:31 PM, the Director of Nursing (DON) acknowledged R87's medical record lacked documented evidence of nutritional assessments during the time R87 sustained significant weight loss. The DON reported the Registered Dietitian (RD) was on medical leave. The DON explained the lack of nutritional assessments and interventions could have been detrimental to resident care and may have contributed to exacerbation of wounds and comorbidities. On 01/10/2025 at 11:00 AM, the Administrator acknowledged the facility had identified concerns with weight loss not addressed timely. The Administrator explained excessive weight loss needed to be addressed including dietary needs, food preferences, percentage of intake, supplements, and include close collaboration with the physician. A facility policy titled Nutritional Assessment/Evaluation revised 06/20/2023, documented a comprehensive nutritional assessment was to be completed upon the resident's admission, annually, and whenever a significant change in status occurred. The assessment/evaluation was to include an assessment of the overall nutritional status of the resident.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician's order had been obtained for the presence of the nephrostomy tube, the insertion site had been monitored, and dressing changes had been scheduled for 1 of 24 sampled residents (Resident 98). This deficient practice increased the risk of infection, complications from improper management, and a lack of continuity in care. Findings include: Resident 98 (R98) R98 was admitted on [DATE], and readmitted on [DATE], with diagnoses including palliative care, dysuria (painful or difficult urination) and malignant neoplasm of the prostate. On 01/07/2025 at 12:48 PM, R98 voiced a complaint to a Registered Nurse (RN) about a peeling dressing. The RN checked the resident's back and confirmed placement of a capped nephrostomy tube, with the nephrostomy dressing soiled, peeled off, and appearing old and undated. R98 indicated a shower had caused the dressing to become wet, but it had not been changed. The RN acknowledged R98 had been receiving hospice services but was unsure if the hospice nurse had been responsible for changing the dressing. R98's medical records lacked documented evidence a physician's order had been obtained for the presence of the nephrostomy tube, the insertion site had been monitored, and dressing changes had been scheduled. The RN confirmed no order for R98's nephrostomy and no care or monitoring orders had been in place. On 01/08/2025 at 12:16 PM, RN Charge Nurse indicated the nephrostomy tube required an order, the insertion site should have been monitored for signs and symptoms of infection, and the dressing change should have been scheduled. On 01/09/2025 at 1:39 PM, the Director of Nursing (DON) indicated R98 was on hospice services and had been visited by hospice staff. The DON confirmed the absence of a physician's order for the presence of the nephrostomy tube, monitoring, and care orders. The DON indicated despite R98 being on hospice, orders should have been documented in the resident's electronic records to ensure continuity of care and shared responsibility between hospice and facility staff. The DON indicated monitoring of the insertion site for signs and symptoms of infection should have been conducted, with the tube discontinued if no longer needed. The DON confirmed R98's nephrostomy tube had not been monitored for signs and symptoms of infection, and the dressing had been changed inconsistently. A facility policy titled Physician Orders, revised 05/05/2023, documented a qualified licensed nurse was required to obtain and transcribe orders following facility practice guidelines. Upon a resident's admission, the physician's orders, including routine care orders, were obtained. The orders were communicated in writing, either through paper medical records or electronically in facilities using electronic medical records.

Based on observation, record review, and interviews, the facility failed to place hand splint for contracture management for 1 of 24 sampled residents (Resident 44). The deficient practice placed the resident at risk to develop contractures, decrease hand functionality, and cause pain and discomfort. Findings include: Resident 44 (R44) R44 was admitted on [DATE], with diagnoses including cerebrovascular accident (CVA) with weakness right side of the body. On 01/07/2025 in the morning, R44 was lying on the bed clutching the right hand with the left hand. The resident indicated they could not move the right hand, and a splint was previously used but was not sure why the splint was no longer applied. A care plan developed on 04/20/2023 and updated on 12/18/2024, documented R44 should have received restorative nursing program (RNP) (a set of nursing interventions that help residents maintain or improve their ability to function independently) for right resting hand splint due to the increased risk to acquire a contracture. The care plan indicated R44 should have been wearing a resting hand splint in the right hand up to eight hours a day to prevent contracture. The minimum date set (MDS) quarterly assessment dated [DATE] and the last annual MDS assessment dated [DATE], revealed the restorative program was not performed including splint or brace assistance. Physician order dated 05/13/2024 documented right-hand splint and left ankle foot orthosis to be worn daily up to 8 hours a day as tolerated. The order was discontinued on 10/21/2024 because R44 was discharged (transfer to hospital). The medical record lacked documented evidence a new physician order for splinting was obtained when R44 was readmitted to the facility. The physical therapy discharge summary dated 04/16/2024, revealed R44 was discharged for skilled therapy services since had attained the highest practical level of function for their condition, and recommended a referral to the clinical team for restorative program review. On 01/09/2025 at 3:45 PM, a Licensed Practical Nurse (LPN) reviewed R44's physician orders and confirmed there was no orders for splinting. The LPN indicated R44 went to the hospital back in October 2024 and it is possible the order was not carried on. The LPN confirmed a care plan was developed for the hand splint and acknowledged a physician order should have been obtained to ensure the implementation of the care plan. On 01/10/2025 at 8:15 AM, the Director of Nursing (DON) explained R44 had been transferred several times to a hospital and the order for splint was not carried on. The DON indicated R44 was in the process to be re-evaluated for physical therapy (PT) but could not explain why the resident was not assessed upon re-admission. On 01/10/2025 at 9:30 AM, the PT Director explained R44's last PT assessment was performed March 2024 and discharged from the skilled program on 04/15/2024 since the resident attained the maximal potential for their condition. The PT Director indicated R44 was referred to restorative program for home exercise. The PT Director indicated R44 was not re-assessed after being discharged and readmitted because there were no significant changes. The PT Director explained a person having a stroke that affect a side of the body could benefit from the use of splint and orthosis for limb positioning, joint alignment, and to prevent contractures. On 01/10/2025 at 10:45 AM, a restorative aid explained R44 was receiving restorative services for transfers but not for splinting since there was no physician order for splints. The facility policy titled Joint Mobility/Range of Motion Program and Splinting dated 10/25/2024, documented residents would be assessed for joint mobility upon admission, re-admission, quarterly, annually, and with significant changes through the comprehensive nursing assessment. The policy indicated a restorative program would be implemented through the care plan to increase, maintain, or prevent deterioration of joint mobility and to maximize physical function when referral to therapy was not indicated or upon discharge from skilled therapy, and orthotics, assistive or prosthetic devices would be provided if indicated.

Based on observation, interview, record review, and document review, the facility failed to ensure an expired medication was not administered to 1 of 7 unsampled residents (Unsampled Resident 02). The deficient practice had a potential for a non-viable medication to be administered to the resident. Findings include: Unsampled Resident 02 (UR2) UR2 was admitted to the facility on [DATE] with diagnoses of other sequelae of cerebral infarction, anxiety disorder (unspecified), chronic kidney disease stage 3 (unspecified), and dementia with mood disturbance (unspecified). On [DATE] at 09:45 AM, a punch card of Hydralazine HCL 10 milligram (mg) tablets for UR2 was observed expired on [DATE], in the 400-hall medication cart. On [DATE] at 09:46 AM, a Licensed Practical Nurse, confirmed the Hydralazine HCL 10mg tablets were expired and should have been discarded for resident safety. On [DATE] at 09:47 AM, the Assistant Director of Nursing, also verified the Hydralazine HCL 10mg tablets were expired and should have been discarded for resident safety. On [DATE] at 09:48 AM, the Licensed Practical Nurse stated the expired Hydralazine HCL 10mg tablets were documented to have been administered to UR2 on [DATE] at 9:01pm for elevated Blood Pressure (BP) of ,d+[DATE] mmHg by the Registered Nurse working that night. UR2's vitals were taken on [DATE] at 11:45pm indicating the resident's blood pressure was ,d+[DATE] mmHg per the facilities vitals report. A physician order for UR2 on [DATE] was for one Hydralazine HCL 10mg tablet to be administered orally every 4 hours, as needed (PRN), for systolic blood pressure greater than 160. A care plan for UR2's blood pressure medication related to hypertension was created on [DATE] for medication administration, monitoring blood pressure, and observing for signs and symptoms of elevated blood pressure. A facility policy titled Medication Management Program: Administering the Medication Pass revised [DATE], documented prior to administering the medications, the nurse is responsible for checking for expiration dates and removing any expired products.

Based on observation, interview, record review, and document review, the facility failed to provide an ongoing program of activities designed to meet the interests of the residents for 2 of 24 sampled residents (Residents 26 and 117) and 7 unsampled residents. The deficient practice had the potential risk to cause psychosocial distress to the residents. Findings include: Resident #26 (R26) R26 was admitted to the facility on [DATE], with diagnoses including erythematous condition (unspecified), anxiety disorder (unspecified), and secondary hyperparathyroidism of renal origin. On 01/07/2025 in the morning, R26 explained had been at the facility for about 6 years and liked to come to activities and do single solitary activities like reading newspapers and magazines. R26 explained R26 would like to see more trips out of the facility to events and shopping places. R26 had an Activity Evaluation dated 04/09/2024 which documented the resident had identified needs where programming should be focused on community outings, large groups, independent activities, and outdoor activities. Resident #117 (R117) R117 was admitted to the facility on [DATE], with diagnoses including acute embolism and thrombosis of right femoral vein, pain (unspecified), and edema (unspecified). On 01/07/2025 in the morning, R117 explained had been at the facility for about 2 months. R117 stated participated in the activities which were of interest as long as was not in pain. R117 explained if was able to change one thing about the facility to make it better would change the transportation to get the residents out to shop again. R117 stated the facility used to take the residents out to places but hadn't in a while. R117's medical record lacked documented evidence of an Activity Evaluation to document the resident's identified needs as to where programming should be focused. Activity calendars lacked documentation of any outdoor activities or outings for December or January. Previous months activity calendars were unable to be found. On 01/08/2025 at 01:55 PM, the Administrator verbalized the facility had two buses/vans and two drivers. The Administrator also explained the facility utilized outside transportation company contractors for transports which conflict with their own facility transports or when they have a bus/van down for mechanical reasons. The administrator went on to explain only two buses/vans have been down due to mechanical issues for about a week or less in the last four months. On 01/10/2025 at 12:38 PM, the Activity Director explained the activity department sometimes gets ideas for activities from Resident Council. Sometimes the activity department also gets ideas from upcoming holidays or special events. The Activity Director explained the outings are not put on the schedule due to them having to schedule the buses/vans with their in-house transportation. When they do schedule an outing, the activity department will put up signs to notify the residents of the upcoming outing. The Activity Director stated the facility tries to make a shopping trip for the residents once a month. The Activity Director also explained was off in mid-August and came back to work in November Unsampled Residents (Residents 72, 76, 51, 66, 09, 58, 02) Resident Council Minutes dated 12/18/2024, docoumented residents had asked for an outing to a specific shopping center be added to the January Activity Calendar schedule. The Activity Director agreed to add it to the January Activity Calendar schedule. During a Resident Council meeting on 01/09/2025 in the afternoon, the Unsampled Residents acknowledged there had not been a trip to a specific shopping center since August 2024. The facility policy and procedure titled, Activity/Recreation Programming, last revised 11/04/2024, documented the facility will implement an ongoing resident centered activities program that incorporates the resident's needs, interests, hobbies, and cultural preferences which are integral to maintaining and/or improving physical, intellectual, psychosocial, emotional, spiritual wellbeing and independence as well as to create opportunities for each resident to have a meaningful life by supporting the domains of wellness (security, autonomy, growth, connectedness, identity, joy, and meaning).

Based on observation, record review, interviews and document review, the facility failed to: 1) implement a care plan for restorative hand splinting services to prevent contractures for 1 of 24 sampled residents (Resident 44), and 2) develop care plans for side rails, weight loss and pressure ulcer for 3 of 24 sampled residents (Residents 62, 87, and 129). The deficient practice placed the residents at risk for worsening health conditions related to contractures, injuries, malnutrition and pressure ulcers. Findings include: The facility policy titled Care Plan Process, Person-Centered Care dated 05/30/2023, documented the facility would develop and implement baseline and comprehensive care plan for each resident that include instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. 1) Implementation of a Care Plan: Resident 44 (R44) R44 was admitted on [DATE], with diagnoses including cerebrovascular accident (CVA) with weakness right side of the body. On 01/07/2025 in the morning, R44 was lying on the bed clutching the right hand with the left hand. The resident indicated could not move the right hand, and a splint was previously used but was not sure why the splint was no longer applied. A care plan developed on 04/20/2023 and updated on 12/18/2024, documented R44 should have received restorative nursing program (RNP) (a set of nursing interventions that help residents maintain or improve their ability to function independently) for right resting hand splint due to the increased risk to acquire a contracture. The care plan indicated R44 should have been wearing a resting hand splint in the right hand up to eight hours a day to prevent contracture. The minimum date set (MDS) quarterly assessment dated [DATE] and the last annual MDS assessment dated [DATE], revealed the restorative program was not performed including splint or brace assistance. Physician order dated 05/13/2024 documented right-hand splint and left ankle foot orthosis to be worn daily up to 8 hours a day as tolerated. The order was discontinued on 10/21/2024 because R44 was discharged (transfer to hospital). The medical record lacked documented evidence a new physician order for splinting was obtained when R44 was readmitted to the facility. On 01/09/2025 at 3:45 PM, a Licensed Practical Nurse (LPN) reviewed R44's physician orders and confirmed there was no orders for splinting. The LPN indicated R44 went to the hospital back in October 2024 and it is possible the order was not carried on. The LPN confirmed a care plan was developed for the hand splint and acknowledged a physician order should have been obtained to ensure the implementation of the care plan. On 01/10/2025 at 8:15 AM, the Director of Nursing (DON) explained R44 had been transferred several times to a hospital and the order for splint was not carried on. The DON indicated R44 was in the process to be re-evaluated for physical therapy (PT) but could not explain why the resident was not assessed upon re-admission. On 01/10/2025 at 9:30 AM, the PT Director explained R44's last PT assessment was performed March 2024 and discharged from the skilled program on 04/15/2024 since the resident attained the maximal potential for their condition. The PT Director indicated R44 was referred to restorative program for home exercise. The PT Director indicated R44 was not re-assessed after being discharged and readmitted because there were no significant changes. The PT Director explained a person having a stroke that affect a side of the body could benefit from the use of splint and orthosis for limb positioning, joint alignment, and to prevent contractures. On 01/10/2025 at 10:45 AM, a restorative aid explained R44 was receiving restorative services for transfers but not for splinting since there was no physician order for splints. 41903 2) Development of a Care Plan: Resident 62 (R62) R62 was admitted on [DATE], with diagnosis including Parkinson's disease without dyskinesia, chest pain, and syncope and collapse. On 01/07/2025 at 3:27 PM, R62 was observed sitting in a wheelchair at the bedside. Bed side rails were observed up on bilateral sides of the bed. R62 reported side rails were put up to facilitate movement. On 01/10/2025 at 8:37 AM, a Nurse confirmed side rails were up and in use for R62 to hold on to, for bed mobility. A Side Rail Review and Consent dated 12/06/2024, documented the use of side rails was considered for syncope, status post fall, hypertension, and hypothyroidism to aid with repositioning, bed mobility and transfers. The medical record lacked documented evidence a comprehensive care plan was developed for the use of side rails. On 01/10/2025 at 9:53 AM, the Director of Nursing (DON) acknowledged a comprehensive care plan was not developed for R62's side rails use. The DON confirmed a comprehensive care plan should have been developed when the side rails consent was completed. Resident 87 (R87) R87 was admitted on [DATE], with diagnosis including encephalopathy, nausea with vomiting, and drug induced subacute dyskinesia. A Malnutrition Screening Tool dated 09/09/2024, documented R87 was eating poorly due to decreased appetite. R87 scored positive for nutritional risk. R87's Vitals Report dated 09/07/2024, documented an initial resident weight of 150 pounds (lbs.) upon admission. The Vitals Report documented resident weight of 120.1 lbs. on 10/09/2024. R87 sustained weight loss of 29.99 lbs. or 19.93% of R87's total body weight between 09/07/2024 and 10/09/2024. A Nutritional Assessment at Admissions dated 09/11/2024, under the Estimated Nutritional Needs section, calories per day, protein grams per day, and fluid milliliters per day was observed blank. The Evaluation of Nutritional Needs section of the form was observed blank and lacked information for nutritional diagnosis, interventions, goals, monitoring and evaluation. A Nutritional Review dated 12/10/2024, documented resident weight of 117.2 lbs. and significant weight loss had occurred. A Care Plan edited 12/12/2024, documented R87 was at nutrition and/or dehydration risk related to dysphagia, anxiety, and recent weight loss. The Care Plan documented the problem start date as 11/13/2024. The medical record lacked documented evidence a comprehensive care plan was developed for R87 to address the significant weight loss sustained between 09/07/2024 and 10/09/2024, until 11/13/2024. On 01/08/2025 at 1:31 PM, the Director of Nursing (DON) confirmed a comprehensive care plan for nutrition and weight loss had not been developed for R87 during the period of substantial weight loss. The DON explained the lack of a care plan, goals, and interventions could have been detrimental to resident care and may have contributed to exacerbation of wounds and comorbidities. Resident 129 (R129) R129 was admitted on [DATE], with diagnosis including spinal stenosis site unspecified, cellulitis, and polyneuropathy. On 01/07/2025 at 10:07 AM, R129 reported had a wound on right heel that was not present during admission to the facility. A Progress Note dated 12/21/2024, documented R129 had a bedside wound consult for the heels. R129's right heel had an open area 1.6 centimeters (cm) x 1.2 cm, depth 0.2 cm from trauma. R129 stated possibly hit foot while at therapy. A Physician Order dated 12/21/2024, documented weekly wound treatment: Cleanse right heel trauma with normal saline/wound cleanser, apply Silvasorb (a gel used to treat wounds), three times weekly for 30 days. A Wound Care Progress Note dated 01/06/2025, documented R129 was seen for follow up of the right heel wound. Notification received of right heel wound culture done showed positive for Methicillin Resistant Staphylococcus Aureus (MRSA). The medical record lacked documented evidence a comprehensive care plan was developed for R129's right heel wound. On 12/09/2025 at 8:53 AM, the Director of Nursing (DON), acknowledged the medical record lacked a comprehensive care plan for R129's heel wound. The DON reported a comprehensive plan should have been developed including goals and interventions.

Based on observation, interview, record review, and document review, the facility failed to ensure a baseline care plan was formulated to manage the resident's care with a nephrostomy tube for 1 of 24 sampled residents (Resident 98). This deficient practice could have led to an increased risk of complications related to improper management and a lack of continuity in care. Findings include: Resident 98 (R98) R98 was admitted on [DATE] and readmitted on [DATE] with diagnoses including palliative care, dysuria (painful or difficult urination), and malignant neoplasm of the prostate. On 01/07/2025 at 12:48 PM, R98 verbalized a complaint to a Registered Nurse (RN) about a peeling dressing. An RN checked the resident's back and confirmed the nephrostomy dressing had peeled off, appeared old and undated, and was soiled. R98 indicated a shower had caused the dressing to become wet, but it had not been changed. Complaints of itchiness on the surrounding skin were noted. The RN acknowledged R98 was receiving hospice services but was unsure if the hospice nurse was responsible for changing the dressing. R98's medical records lacked documented evidence a baseline care plan was formulated for the management of R98's nephrostomy. The RN confirmed no care plan was in place. On 01/08/2025 at 12:16 PM, the Charge Nurse indicated the nephrostomy tube required a baseline care plan with management instructions on proper care for the nephrostomy. On 01/09/2025 at 1:39 PM, the Director of Nursing (DON) confirmed the absence of a baseline care plan. The DON indicated licensed nurses were responsible for formulating the care plan, which should have been followed through by nursing leadership. The DON indicated a baseline care plan should have been developed to monitor the insertion site for signs of infection and address dressing changes. The DON indicated there should have been a baseline care plan following R98's admission. A facility policy titled Care Plan Process, Person-Centered Care, dated 05/05/2023, documented the facility's commitment to developing and implementing a baseline and comprehensive care plan for each resident, including instructions to provide effective, person-centered care meeting professional standards of quality care. The baseline person-centered care plan was to be developed and implemented within 48 hours of the resident's admission.

Based on observation, interview, record review, and document review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 24 sampled residents (Resident 69). The deficient practice had the potential to deprive the residents of concern and other residents of necessary behavioral health services. Findings include: Resident 69 (R69) R69 was readmitted on [DATE], with diagnoses including schizoaffective disorder, anxiety disorder, depression, and post-traumatic stress disorder. On 01/07/2025 in the afternoon, R69 stated was on the Resident Council and had been at the facility for about three years. The resident related had been in a bad accident, had post-traumatic stress disorder (PTSD) from it, and also has bipolar illness. A PASARR level one document dated 08/06/2021, revealed R69 did not have dementia, mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility placement. A review of the resident's medical notes revealed R69's schizoaffective disorder was diagnosed on [DATE], the post-traumatic stress disorder was diagnosed on [DATE], the anxiety disorder was diagnosed on [DATE], and the resident's depression was diagnosed on [DATE]. On 01/09/2025 in the morning, the Social Services Director (SSD) explained the SSD was responsible for referring residents who met criteria for PASARR two by completing the online PASARR request. When asked if a residents' diagnoses of schizoaffective disorder and post-traumatic stress disorder would be representative of a mental illness, intellectual disability, or a related condition which the Medicaid Service Manual documents a PASARR II must be completed for, SSD agreed these diagnoses would be an indication. The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities or related condition, a PASARR Level II screening must be completed to evaluate the individual and determine if nursing facility services and/or specialized services are needed and can be provided in the nursing facility. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASARR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority. The medical record lacked documented evidence a referral for a PASARR level two screening was completed.

Based on observation, interview and document review, the facility failed to provide a clean and sanitary homelike environment by ensuring proper floor cleaning procedures were performed in 16 of 90 residents' rooms (rooms 406 to 422). The deficient practice had the potential to increase infection risk and denied the residents the right to a safe and clean homelike environment. Findings include: 1) Residents' room cleanness: On 01/07/2025 at 9:30 AM, Resident #28 (R28) verbalized concerns related to the cleanness of the resident's room. R28 indicated the room had been cleaned on a daily basis but dust and debris remained on the edges between the wall and the floor at the baseboard. On 01/07/2025 at 10:00 AM, a housekeeping staff confirmed room [ROOM NUMBER] had been cleaned. The housekeeping staff acknowledged the edges between the wall and the floor at the baseboard were not cleaned. On 01/07/2025 at 10:12 AM, the housekeeping supervisor confirmed the observation and verbalized all the surfaces of the room should have been cleaned. On 01/07/2025 during the inspection of rooms 406 to 422, it was corroborated dust and debris remained at the edges between the wall and the floor after the rooms were cleaned. The housekeeping supervisor confirmed the observations. The facility policy titled General Cleaning dated March 2006, documented the routine cleaning and disinfection procedures would be performed in a way to provide a clean, safe decontaminated environment for the residents. The policy indicated staff should check areas above eye levels and dust as needed and move furniture weekly to clean underneath and behind.

Based on observation, document review, record review, and interview, the facility failed to provide a working over the bed light for 1 of 24 residents (Resident 125). The failed practice had the potential to deprive the resident of using a urinal bottle independently overnight. Findings include: Resident 125 (R125) R125 was admitted on [DATE], with diagnosis including hemiplegia affecting left nondominant side, hereditary and idiopathic neuropathy, and cerebrovascular disease. On 01/07/2025 at 10:07 AM, R125 was observed in bed with a urinal bottle hung on the bedside nightstand. R125 reported had moved into the room two weeks prior and was not provided a remote control for the over the bed light. R125 was informed the remote control was sent out for repair. R125 explained was able to use the urinal bottle independently, however, had not been able to use the urinal bottle at night due to not being able to see in the dark. R125 explained needed the light on to position the urinal bottle correctly. R125 stated wanted to continue to use the urinal bottle independently, but instead had to call staff for help at night. The Resident Census dated 12/27/2024, documented a room change to room [ROOM NUMBER] Bed B. On 01/08/2025 at 12:42 PM, a Nurse reported was not aware R125 did not have a remote control to turn on the light above the bed and was unable to use the urinal bottle at night. On 01/08/2025 at 1:21 PM, the Maintenance Director, confirmed the remote control for the over the bed light had been sent for repair. The Maintenance Director stated did not have an expected date for completion of the repair. The Maintenance Director acknowledged a remote control could have been removed from an empty room or the resident moved to another room, to prevent disruption of care to the resident. On 01/09/2025 at 11:16 AM, the Assistant Director of Nursing (ADON), acknowledged R125 should have been provided a light to be able to continue to use the urinal bottle at night independently while repairs were done, both to preserve R125's independence, and continue to encourage self-care. A policy titled Resident Room Environmental revised 11/01/2017, documented promoting and preserving resident independence and self-sufficiency should be considered when arranging the resident living space.

Based on observation, interview, record review and document review, the facility failed to prevent a cognitively impaired resident from drowning in an unsecured tub in the spa room and to ensure the spa room was not accessible to the residents for 1 of 6 sampled residents (Resident #1). Findings include: Resident #1 Resident #1 was admitted on [DATE], with [DIAGNOSES REDACTED]. On [DATE] in the morning, an initial tour of the facility was conducted. The spa room was located on the right side of the corridor coming from the 300-hall going toward the television area and activity room. There were two other doors on the right prior to the spa room. The first door opened to a clean linen supply closet which was locked and accessed by staff using a code. The second door opened to an Oxygen supply room which was locked and accessed by staff using a code. The third door which did not have a lock prior to [DATE], opened to the spa room. The spa room had a floor weighing scale to the left, a sink and a toilet. There was a stand-alone whirlpool tub located in the middle area of the spa room which was approximately five feet long by three feet wide and three and a half feet tall. The tub had a door on one side which could be opened to step inside the tub and sit on the built-in seat. The spa room was not always in direct sight of the staff. The nursing station was at the far end of the 300-hall. An Initial Elopement Risk Assessment Form dated [DATE], documented the resident was at risk for elopement and wandering due to [DIAGNOSES REDACTED]. There was no documented evidence a baseline care plan was initiated to address elopement/wandering concerns for the resident. There was no documented evidence in the medical record interventions were in place to prevent the resident from eloping and wandering within the facility. On [DATE] at 1:24 PM, the Certified Nurse Aide (CNA) #1 revealed care was provided to Resident #1 for several days and indicated the resident was very confused and wandered throughout the facility using the wheelchair. The CNA recalled one time while working in the 200-hall, found the resident wandering there and had to bring the resident back to the charge nurse assigned to the resident in the 300-hall. The CNA indicated the resident was a frequent wanderer inside the facility. There was no documented evidence in the medical record of the incident. There was no documented evidence in the medical record the patient was reassessed for elopement risk after the incident. On [DATE] in the afternoon, the Clinical Services Director indicated they were not aware the resident was seen by staff wandering within the facility. The CNA should have informed the nurse of the incident and the nurse should have documented the incident in the medical record. The resident should have been reassessed for increased concerns of elopement and the care plan should have been revised to address the increased need for monitoring the resident. On [DATE] in the morning, the Clinical Services Director indicated Resident #1 was last seen around 8:00 AM on [DATE]. The charge nurse had prepared the resident's medications for the morning but decided to put the medications aside when the CNA informed the nurse the resident had gone to the dining room and was trying to get coffee. A nurse progress note dated [DATE], revealed the resident was found face down in the water inside a whirlpool tub in the spa room. The resident was unresponsive and was pulled out of the tub by the staff and resuscitation efforts were initiated until emergency medical personnel arrived at the scene. The resident was taken to the emergency room where the resident expired. On [DATE] at 10:56 AM, CNA #1 revealed on the morning of the incident, the door to the spa room was open and when the CNA entered the room, found the resident's upper body floating in the water. The jets on the tub were still working and the water level was almost to the top of the tub. On [DATE] at 11:00 AM, the CNA #1 indicated the door in the spa room was always left open. The only floor scale in the facility was inside the spa room and the CNAs brought the residents there to be weighed so the spa room was always left open. There was also a toilet and a sink where the CNAs could wash their hands. The CNA revealed of being informed the whirlpool tub was not functional and indicated it was never used for the residents. On [DATE] at 11:10 AM, the Clinical Services Director confirmed the spa room did not have a lock prior to and during the incident. The lock was installed the week of [DATE], after the incident occurred. The director acknowledged the spa room should have been always locked to prevent residents from wandering inside. The director indicated the facility did not have a policy on the purpose/use of the spa room and the whirlpool tub. On [DATE] in the afternoon, the CNA #2 indicated the facility did not use a wanderguard system for their residents who were at risk for elopement/wandering. The CNA confirmed and provided the names of other confused residents who frequently entered the open spa room to use the toilet and had to redirect them. The CNA indicated management was made aware of the safety concern for the open spa room a while ago because residents were frequently seen wandering inside. On [DATE] at 1:12 PM, the Licensed Practical Nurse (LPN) #1 indicated the door in the spa room did not have a lock and was always left open. The CNAs weighed the residents there all the time. The LPN acknowledged the resident was a high fall risk and should have been monitored. The door in the spa room should have been locked and should not have been left open. On [DATE] at 1:36 PM, the LPN #2 acknowledged it was a risk to always have the door in the spa room open. The area where the spa room was not always visible to the staff and the staff were not able to monitor the residents every time they tried to go inside the spa room. On [DATE] at 1:40 PM, the LPN #3 acknowledged it was a risk to leave the door in the spa room open all the time. The LPN confirmed one of her residents always would walk inside the spa room to use the floor scale because the resident knew it was there. On [DATE] at 1:44 PM, the CNA #3 indicated residents who were frequent wanderers should have been monitored by the staff every 15 minutes and leaving the door in the spa room open was not safe. The CNA acknowledged Resident #1 was a frequent wanderer inside the facility. On [DATE] at 1:52 PM, the Physical Therapy Assistant (PTA) indicated Resident #1 required moderate to maximum assistance to perform transfers. The resident was able to perform wheelchair mobility independently inside the facility but was still considered unsafe because the resident always forgot to lock the wheelchair brakes prior to transfers. The PTA had instructed the nursing staff to always monitor the resident for safety reasons when the resident was using the wheelchair. The PTA recalled the nursing staff informed him the resident was able to ambulate without any assistive device on some occasions when the resident wanted to wander. The resident refused to ambulate with the therapist during therapy sessions. On [DATE] at 2:05 PM, the LPN #4 acknowledged the spa room should have been closed. The LPN recalled taking care of another resident a while ago who had dementia who also entered and wandered into the spa room. On [DATE] at 2:10 PM, the Director of Plant Operation indicated the staff was never told the whirlpool tub was not working. The director revealed he was never told by management to shut off the water valve for the whirlpool tub even if it was not being utilized by the residents. On [DATE] at 3:59 PM, the Clinical Services Director explained if a resident was assessed to have an elopement/wandering risk, a care plan should have been initiated immediately at the time to include interventions to prevent the resident from eloping within or outside the facility. Even if there was no incident of elopement or wandering, the residents who were assessed to be at risk should have had a care plan initiated. Upon admission if a resident was assessed not to have elopement risk but during the resident's stay in the facility a change in the resident's condition made the resident more inclined to wander or elope such as an improvement in functional status or decline in cognitive abilities, then the resident should be reassessed for elopement risk concerns. On [DATE] in the afternoon, the Clinical Services Director confirmed the door to the spa room should have had a lock. The door should not have been left open and the room should not have been accessible to the residents in the facility. The director acknowledged the facility's failure to perform reassessments when the resident was observed several times wandering within the facility. The director acknowledged the facility failed to initiate a care plan to address the resident's wandering episodes and implement interventions to monitor and prevent the resident from wandering. A review of facility policy titled Elopement Risk Evaluation, revised [DATE], the purpose of the policy as stated is the facility will evaluate all patients/residents for elopement potential. The procedures state all patients/residents are evaluated on admission by a licensed nurse for elopement risk utilizing a Risk of Elopement Review form. All patients/residents are re-evaluated for elopement potential by a Licensed Nurse/Social Service or designee periodically throughout a patient's/resident's stay and with a significant change. Interventions will be added to the patient's/resident's Care Plan after analyzing the information obtained. The Licensed Nurse or Social Service designee completes and elopement risk review and presents the information to the Interdisciplinary Team for further interventions. The completed review is maintained in the clinical record. The physician is notified of the patient's/resident's risk for elopement and the interventions that are recommended/implemented for prevention of elopement and patient/resident safety. The Care Plan is immediately updated with the initiation of the interventions and changes in interventions, as needed by the MDS Nurse/Designee. The Licensed Nurse documents in the Nurses' Notes and Behavior Monitoring Flow Record any exit seeking behavior on an ongoing basis and interventions are adjusted as needed. The information gathered from the QA&A Audit Tool will be reviewed by the internal facility Performance Improvement Committee for interventions if needed. An interim Plan of Care must be started on admission if a patient/resident is admitted as an elopement risk. Complaint #NV 134