Every finding on record at Spanish Trails Wellness & Rehabilitation

Based on record review and interview, the facility failed to complete a Significant Change (a major decline or improvement in a resident's physical or mental condition that is not self limiting, affects more than one area of health status, and requires review and potential care plan revision) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) for 1 (R #3) of 1 (R #3) resident, when: R #3 began receiving hospice services while in the facility as ordered by a physician.This deficient practice could likely result in the residents not receiving the appropriate care and services they need. The findings are:A. Record review of R #3's face sheet revealed an admission date of 04/06/26 and a discharge date of 05/24/26, with the following diagnoses:Cerebral infarction (an area of dead tissue in the brain resulting from a blockage or narrowing in the arteries supplying blood and oxygen to the brain).Intracranial hemorrhage (bleeding from a broken blood vessel within the brain).Nonpyogenic thrombosis of intracranial venous system (blood clots form in the brain's veins or venous sinuses without infection, potentially leading to increased intracranial pressure and neurological complications).Cortical blindness right side of brain (total or partial loss of vision). B. Record review of R #3's physician orders, dated 04/10/26, revealed an active order for hospice services. C. Record review of R #3's MDS assessments located in the electronic health record (EHR), revealed the following: Dated 04/09/26, R #3's admission and 5-day MDS assessment revealed staff documented the resident was not receiving hospice services. Dated 06/04/26, R #3's discharge MDS assessment revealed staff documented the resident was not receiving hospice services. Dated 04/09/26 through 06/04/26, a significant change MDS was not completed or available to indicate that R #3 was receiving hospice services. D. On 06/10/26 at 11:28 am, during an interview, the MDS Coordinator stated a resident who begins receiving hospice services should be reflected on a significant change MDS assessment. The MDS Coordinator stated a significant change MDS assessment should have been completed for R #3 because the resident was receiving hospice services while in the facility, but it was not.

Based on record review and interview, the facility failed to meet professional standards for 2 (R #1, and R #5) of 2 (R #1, and R #5) resident reviewed medication errors when staff failed to:1. Ensure that an order was obtained before administering routine blood sugars checks for R #5.2. Ensure medications were available for administration for R #1 and R #5.3. Ensure Medication Administration Record is updated/corrected when medications are not administered for R #5.If the facility fails to administer medications as prescribed by the physician, then residents are not likely to receive the therapeutic value of medications prescribed, and if lab results are not relayed to the physician, then the physician is unable to properly monitor and assess the physical condition of the resident. The findings are:R #5: A. Record review of R #5's Physicians orders dated 12/16/25 revealed, Jardiance (medication used to control blood sugar levels) oral tablet 10 mg (milligram) by mouth one time daily. B. Record review of R #5's Medication Administration Record (MAR) dated 01/29/26 through 02/06//26 revealed: Jardiance was not available but indicated it had been administered on 01/30/26, 01/31/26, and 02/04/26 through 02/06/26. C. On 02/06/26 at 10:31 AM during an interview with Certified Medication Aide CMA) #1 she stated, R #5 did not get his Jardiance (medication used to control blood sugar levels). CMA #1 further stated that the last time R #5 received his Jardiance was on 01/28/26 and was not available after that date. CMA #1 stated that she had marked in the MAR on 01/30/26, 01/31/26 and 02/06/26 as medication been administered by her to R #5 and she did not administer the medication because it was not available. CMA #1 confirmed that the medication had not been available since January 29, 2026, and it had not been administered from 01/30/25 through 02/06/26. D. On 02/06/26 at 10:44 AM during an interview with Registered Nurse (RN) #1, she stated that R #5's Jardiance had not been available since Friday (01/30/25) and R #5 had not been getting his medication since that date. E. On 02/06/26 at 11:21 AM during an interview with Licensed Practical Nurse (LPN) #1, she stated that the medication Jardiance was not available for administration and it had been marked in the MAR that it had been administered by mistake by CMA #1 and was unaware of how to fix the issue. LPN #1 further stated that she had been checking R #5's blood sugars to ensure that his sugar levels were withing range. LPN #1 further stated that she did not have a Physicians order to have blood sugars checked and she should have obtained an order. LPN #1 further stated that she is not documenting R #5's sugar levels in the residents' chart because there is not a physicians order to check blood sugar levels and she was using those levels for her information to ensure that R #5's sugar levels are within range (between 70-130 mg Milligrams). R #1: F. Record review of R #1's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses (including but not limited to): 1. Hemiplegia (one-sided paralysis or weakness of the face, arm and leg) and hemiparesis (one-sided muscle weakness) following cerebral infarction (is a type of stroke caused by a blood clot that blocks a brain artery) affecting left dominant side. 2. Muscle weakness (generalized) 3. Need for assistance with personal care. 4. Chronic migraine without aura (the most common type of migraine). G Record review of R #1's physician orders revealed the following: 1. 12/26/25: Warfarin Sodium (blood thinning medication) oral tablet 1 milligrams (mg), give one tablet for one time a day for cerebral infarction affecting left dominant side. Discontinued 01/13/26. 2. 01/13/26: Warfarin Sodium oral tablet 1 mg, give one tablet every Monday, Wednesday, Friday, Saturday, and Sunday for cerebral infarction affecting left dominant side. Discontinued 01/15/26. 3. 01/13/26: Warfarin Sodium oral tablet 1 mg, give two tablets every Tuesday, and Thursday for cerebral infarction affecting left dominant side. Discontinued 01/15/26. 4. 01/15/26: Warfarin Sodium oral tablet 1 mg, give 3 mg every Monday, Wednesday, Friday, Saturday, and Sunday for cerebral infarction affecting left dominant side. Discontinued 01/18/26. 5. 01/18/26: Warfarin Sodium oral tablet 1 mg, give 4 mg every Monday, Wednesday, Friday, Saturday, and Sunday for cerebral infarction affecting left dominant side. Discontinued 01/23/26. 6. 01/23/26: Warfarin Sodium oral tablet 1 mg, give 5 mg every evening for cerebral infarction affecting left dominant side until 01/26/26. Discontinued 01/26/26. 7. 01/29/26: Warfarin Sodium oral tablet 1 mg, give 6 mg one time a day for cerebral infarction affecting left dominant side. H. Record review of R #1's Medication Administration Record (MAR) for January 2026 revealed R #1 missed warfarin doses on (01/18/26, 01/19/26, and 01/21/26). I. On 02/06/26 at 11:01 am, during an interview with the Director of Nursing (DON), she confirmed R #1's warfarin 01/18/26, 01/19/26, and 01/21/26 were missed. The DON also confirmed that warfarin is a one of the high-risk medications and should be given as ordered. The DON stated that she was not aware that R #1 missed any dose of warfarin. The DON also stated that she expects the nurses to notify her and the pharmacy if the medication were not available.

Based on record review, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #2) of 3 (R #1, R #2, and R #3) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met.The findings are:A. Record review of R #2's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses (including but not limited to): 1. Age-related osteoporosis (bones to become weak and brittle) without current pathological fracture. 2. Epileptic spasms (is a brief, involuntary muscle contraction that typically lasts 1-3 seconds), not intractable, without status epilepticus (is a medical emergency characterized by prolonged seizure activity, typically defined as a seizure lasting more than 5 minutes or multiple seizures occurring without recovery in between.). 3. Gastro-esophageal reflux disease (GERD - is a chronic condition where stomach acid flows back into the esophagus, leading to symptoms such as heartburn, regurgitation, and irritation of the esophageal lining) without esophagitis (inflammation and irritation of the esophagus). 4. Hemiplegia (one-sided paralysis or weakness of the face, arm and leg) and hemiparesis (one-sided muscle weakness) following cerebral infarction (is a type of stroke caused by a blood clot that blocks a brain artery) affecting left dominant side. 5. Insomnia (common sleep disorder characterized by difficulty falling asleep), unspecified. 6. Major depressive disorder (major depression - is a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), recurrent, moderate. 7. Need for assistance with personal care.B. Record review of R #2's MDS revealed the following: 1. 09/16/25 section C: R #2's BIMS was 15. 2. 12/17/25 section C: R #2 was not assessed for BIMS (Brief interview for mental status - test used in long-term care settings to check how well your brain is working). C. On 02/06/26 at 10:55 am, during an interview with the MDS coordinator, she confirmed R #2's MDS assessment dated [DATE] showed the resident was not assessed for BIMS. She also confirmed that this is not an accurate assessment. The MDS coordinator stated that MDS assessment are done in person and it did not happen for this assessment. She also stated that this particular assessment was done by remotely.

Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are:A. Record review of R #1's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses (including but not limited to): 1. Hemiplegia (one-sided paralysis or weakness of the face, arm and leg) and hemiparesis (one-sided muscle weakness) following cerebral infarction (is a type of stroke caused by a blood clot that blocks a brain artery) affecting left dominant side. 2. Muscle weakness (generalized) 3. Need for assistance with personal care. 4. Chronic migraine without aura (the most common type of migraine).B. Record review of R #1's physician orders revealed the following: 1. 12/23/25: Aspirin (low-dose aspirin commonly used to help prevent heart attacks and stroke) Oral Tablet 81 milligrams (mg) once a day for clot (thick mass of coagulated liquid, especially blood, or of material stuck together) prevention. 2. 12/26/25: Warfarin Sodium oral tablet 1 mg for cerebral infarction affecting left dominant side.C. Record review of R #1's baseline care plan dated 12/26/25 and revealed the following: 1. R #1 has an advance directive as evidenced by full code. 2. R #1 is at risk for falls related to psychotropic medication use, poor balance and weakness. 3. R #1 has potential for pain. 4. Use of anticoagulant (blood thinning medication) was not addressed in the baseline care plan. D. On 02/06/26 at 10:14 am, during an interview with the Director of Nursing (DON), she confirmed R #1's baseline care plan, dated 12/23/25, did not address the use of anticoagulant and should have been completed within 48 hours and it did not happen.

Based on interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 (R #2) of 1 (R #2) resident reviewed for care plans. This deficient practice is likely to result in staff being unaware of the current and actual needs of the residents. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are:A. Record review of R #2's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses (including but not limited to): 1. Age-related osteoporosis (bones to become weak and brittle) without current pathological fracture. 2. Epileptic spasms (is a brief, involuntary muscle contraction that typically lasts 1-3 seconds), not intractable, without status epilepticus (is a medical emergency characterized by prolonged seizure activity, typically defined as a seizure lasting more than 5 minutes or multiple seizures occurring without recovery in between.). 3. Gastro-esophageal reflux disease (GERD - is a chronic condition where stomach acid flows back into the esophagus, leading to symptoms such as heartburn, regurgitation, and irritation of the esophageal lining) without esophagitis (inflammation and irritation of the esophagus). 4. Hemiplegia (one-sided paralysis or weakness of the face, arm and leg) and hemiparesis (one-sided muscle weakness) following cerebral infarction (is a type of stroke caused by a blood clot that blocks a brain artery) affecting left dominant side. 5. Insomnia (common sleep disorder characterized by difficulty falling asleep), unspecified. 6. Major depressive disorder (major depression - is a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and various emotional and physical problems), recurrent, moderate. 7. Need for assistance with personal care.B. Record review of R #2's care plan dated 01/21/26 revealed the following: 1. R #2 is at risk for elopement (leaving a safe supervised area or caregiver without permission) related to elopement evaluation risk score. 2. R #2 has diagnosis of dementia (a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities) placing her at risk for altered nutritional status. 3. R #2 has history of stroke that has affected R #2's behavior, has tendency to make demands and inappropriate comments to staff. 4. Other conditions such as epileptic spasms, GERD, cerebral infarction, insomnia, major depression and activities of daily living (ADL) were not addressed.C. On 02/06/26 at 10:32 am, during an interview with the Director of Nursing (DON), she confirmed R #2's care plan, dated 01/21/26, did not address the other conditions that is pertinent to the resident's care. The DON also confirmed that this is not a person-centered care plan. The DON stated that care plans should reflect the resident as a whole and it did not happen.

Based on interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (R #4) of 1 (R #4) resident reviewed for accidents and supervision when: The facility failed to ensure that a resident that need supervision/assistance was accompanied to a doctor's appointment and not left unattended for an extended period of time. This deficient practice is likely to make residents feel helpless and ignored, and possible experiencing avoidable accidents and/or injuries. A. On 02/06/26 at 1:20 PM during an interview with R #4's brother he stated. I got a phone call from the doctor's office asking who was supposed to pick my brother up, and they were concerned about his safety. He (R #4) had a stroke (medical emergency that occurs when blood flow to part of the brain is blocked or sudden bleeding in the brain) this was a follow-up appointment. I called the facility to ask why he was left alone. No one responded.B. On 02/06/26 at 1:24 PM during an interview with R #4's sister she stated. He had a scheduled appointment, and because of his cognitive ability he could not be left alone. The facility made it clear to me that he (R#4) would not be left alone. He (R #4) ended up at [name of local hospital -name of Doctor office] sitting in a wheelchair with a paper and I don't think he was taken in to see the doctor because he was alone and is unable to cognitively care for himself. The driver later told me 'I guess we should have had someone sitting with him'. [Name of doctor] called and informed me that he had been abandoned.C. Record review of care plan dated 09/27/25 revealed [Name of R #4] has history of falling r/t (related to) CVA (when blood flow to a part of the brain is interrupted, poor safety awareness, and wanting to independently move for himself, does not use call light or place brakes in his wheelchair. Interventions: More visual frequent visual rounding on resident offering frequent help as needed. Observe frequently and place in supervised area when out of bed D. On 02/06/26 at 2:30 PM during an interview with central supply/transport driver, (CS) she stated that she was not aware that this resident (R #4) needed someone to go with him. The process was that the Director of Nursing would mark on the appointment sheet if the resident required and escort and that is how we knew if we needed to take an escort. CS stated she coordinates the transports and should be made aware by nursing staff if an escort is needed. I was told by the driver that transported R #4 that if he came without an escort, they would not see him. We were trained by the facility Transport Director. You do not stay at the appointment. Your job is to drive them to the appointment and no patient care.E. On 02/06/26 at 11:21 PM during an interview with Licensed Practical Nurse (LPN) #1, she stated that not every person that goes out to an appointment goes with an escort. LPN #1 further stated that the person that schedules the appointments would know if an escort is needed. She is not aware of R #5 being left alone at his appointment.

Based on interview, and record review, the facility failed to ensure that residents are free of a significant medication error for 1 (R #1) of 1 (R #1) resident reviewed. The facility failed to administer a prescribed anticoagulant, Warfarin, (medication used to control blood sugar levels) for three consecutive doses. This failure occurred despite the resident's high-risk clinical status for stroke and systemic embolism.The findings are:A. Record review of R #1's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses (including but not limited to): 1. Hemiplegia (one-sided paralysis or weakness of the face, arm and leg) and hemiparesis (one-sided muscle weakness) following cerebral infarction (is a type of stroke caused by a blood clot that blocks a brain artery) affecting left dominant side. 2. Muscle weakness (generalized). 3. Need for assistance with personal care. 4. Chronic migraine without aura (the most common type of migraine).B. Record review of R #1's physician orders revealed the following: 1. 12/26/25: Warfarin Sodium (blood thinning medication) oral tablet 1 milligrams (mg), give one tablet for one time a day for cerebral infarction affecting left dominant side. Discontinued 01/13/26. 2. 01/13/26: Warfarin Sodium oral tablet 1 mg, give one tablet every Monday, Wednesday, Friday, Saturday, and Sunday for cerebral infarction affecting left dominant side. Discontinued 01/15/26. 3. 01/13/26: Warfarin Sodium oral tablet 1 mg, give two tablets every Tuesday, and Thursday for cerebral infarction affecting left dominant side. Discontinued 01/15/26. 4. 01/15/26: Warfarin Sodium oral tablet 1 mg, give 3 mg every Monday, Wednesday, Friday, Saturday, and Sunday for cerebral infarction affecting left dominant side. Discontinued 01/18/26. 5. 01/18/26: Warfarin Sodium oral tablet 1 mg, give 4 mg every Monday, Wednesday, Friday, Saturday, and Sunday for cerebral infarction affecting left dominant side. Discontinued 01/23/26. 6. 01/23/26: Warfarin Sodium oral tablet 1 mg, give 5 mg every evening for cerebral infarction affecting left dominant side until 01/26/26. Discontinued 01/26/26. 7. 01/29/26: Warfarin Sodium oral tablet 1 mg, give 6 mg one time a day for cerebral infarction affecting left dominant side.C. Record review of R #1's Medication Administration Record (MAR) for January 2026 revealed R #1 missed warfarin doses (01/18/26, 01/19/26, and 01/21/26).D. On 02/06/26 at 11:01 am, during an interview with the Director of Nursing (DON), she confirmed R #1's warfarin 01/18/26, 01/19/26, and 01/21/26 were missed. The DON also confirmed that warfarin is a one of the high risk medications and should be given as ordered. The DON stated that she was not aware that R #1 missed any dose of warfarin. The DON also stated that she expects the nurses to notify her and the pharmacy if the medication were not available.

Based on interviews and record reviews, the facility failed to ensure 1 (R #1) of 1 (R #1) resident reviewed received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being by not ensuring that staff received the appropriate training to mitigate resident aggressive behaviors. This deficient practice likely resulted in R #1 attacking an Certified Nurse Assistant (CNA), resulting in R #1 falling. The findings are:A. Record review of R #1's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses (including but not limited to): 1. Fournier gangrene (an infection), 2. Unsteadiness on feet, 3. Cognitive communication deficit (affects the ability to communicate effectively due to impairments in cognitive processes), 4. Depression (feeling of sadness and loss of interest), 5. Cerebral infarction (stroke or CVA [cerebrovascular accident], blood flow to a part of the brain is obstructed). B. Record review of R #1's care plan dated 11/24/25 revealed the following: 1. Problem start date (11/23/25) Witnessed fall caused while resident was being aggressive trying to kick and hit the aide resulting in this fall. Approach: SSD (Social Services director) will start looking a place to discharge the resident too due to physically combative with by kicking hitting and punching staff. Problem start date 10/02/25 (name of R #1 requires splint to right hand pinky finger due to fracture.2. Problem: start date 09/16/25(Name of R #1) has been physically abusive towards other residents. Goal: Resident will not harm self or others secondary to physically abusive behavior.Approach: Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Obtain a Psych consult/psychosocial therapy. Provide 1:1 oversight with resident as needed. No other interventions identified. 3. Problem: start date 06/26/25 (Name of R #1) has a history of anxiety and depression.Approach: Convey an attitude of acceptance toward the resident. Encourage resident to verbalize feelings and fears. Clarify misconceptions. Establishing a trusting relationship with the resident. Report emergence of signs of isolation. No other interventions identified. C. Record review of current active (12/29/25) physicians orders revealed the following:Buspirone HCI oral tablet 10 MG (milligrams) one tablet daily for depression.Sertraline HCI oral tablet 50 MG give 1 tablet daily for depression.Trazodone HCI 50 MG give 0.5 table daily for insomnia.D. On 12/23/25 at 11:36 am, during an interview with R #1, he recalled being upset on the night of 11/22/25, when the wound dressing on his legs got wet after the shower, immediately R #1 asked Licensed Practical Nurse (LPN) #1 to complete the dressing change to both legs. After just wrapping the left leg, LPN #1 left and brought staff with her and R #1 felt threatened with the presence of staff not assigned to him that night. R #1 stated CNA #1 came in and told (CNA #2) that he would provide the care needed to R #1. R #1 asked CNA #1 to leave. CNA #1 did not leave the room when asked to leave by R #1. R #1 felt that CNA #1 was provoking him when he did not leave and walked around the bed to start to provide care. R #1 felt as if CNA #1 was intimidating him due to the aggressive behavior he showed to LPN #1. R #1 stood on his feet and attack CNA #1. R #1 felt he was acting in self-defense when CNA #1 did not leave his room and when he proceeded to walk around his bed. R #1 stated he got into a wrestling match with CNA #1 and remembered falling to the floor and the only way to defend himself was by kicking CNA #1. R #1 also stated that more staff came in once he was on the floor and CNA #1 left and the rest of the staff helped him back to bed. R #1 was unable to recall if CNA #1 had caused the injury R #1 further stated it was late at night and he was so angry he went to bed and the next morning when he woke up, he felt pain on his pinky finger. E. On 12/26/25 at 10:40 am, during an interview with CNA #1, he stated the night of 11/22/25, CNA #2 (who had been asked by LPN #1) came to ask him to help her with R #1's care (getting his pants up as requested by LPN #1). CNA #1 stated R #1 is known for his aggressive behavior. CNA #1 entered R #1's room and asked CNA #2 to stay at the door while he provided care. CNA #1 asked R #1 what was going and R #1 started yelling at him to leave. CNA #1 replied we are just here trying to help you. CNA #1 stated he went around the bed to have a better view of his ostomy bag (a collection pouch to catch urine or stool), and immediately R #1 jumped him and cornered him. R #1 started swinging at him and R #1 immediately fell to the floor and continued kicking CNA #1. CNA #1 stated that as soon as he was able to move away from R #1 (CNA #2, LPN #1 and another staff [does not recall the name of the staff]) started coming in and CNA #1 proceeded to leave the room. CNA #1 further stated that R #1 had a prior incident with another resident and he was the CNA that intervened in the incident, after that incident R #1 had a negative attitude toward him.G. On 12/26/25 at 12:14 pm, during an interview with LPN #1, she recalled the night of 11/22/25, R #1 had a nasty attitude. LPN #1 went in the room after R #1 had a late shower to provide dressing change to his legs. LPN #1 stated she made the decision to remove herself from the situation (as she felt threatened by R #1's increase aggressive behavior) after providing wound care (does not remember the exact treatment provided) and asked CNA #2 to help R #1 pull his pants up. CNA #2 grabbed CNA #1 and entered the room. LPN #1 stated that a few minutes later, she heard CNA #2 yelling the resident is fighting [name of CNA.] LPN #1 quickly ran back to the room with the other night staff (do not recall which staff came in with her) and saw CNA #1 standing by bed A (bed A is empty, and R #1 is assigned to bed). LPN #1 further stated she did not see the actual altercation and saw R #1 on the floor. LPN #1 went straight to R #1 and asked him to try to calm down so they can assist him back to bed.H. On 12/26/25 at 2:06 pm, during an interview with the Administrator, she stated they took CNA #1 off the schedule immediately pending investigation. The administrator also stated that she was unable to get a hold of CNA #1 and subsequently terminated him when she substantiated her investigation. On 11/24/25 she concluded that CNA #1 had all the opportunity to remove himself from the situation and that did not happen. Immediately after the incident the administrator conducted abuse re-training and de-escalation training for the staff. On 11/28/25 they conducted safe interviews with all the residents, especially the residents CNA #1 was assigned and did not find any similar situations. Administrator further stated that all staff when hired is giving an abuse/neglect training but not de-escalation or any other training for staff related to managing difficult or aggressive behaviors. De-escalation training was conducted with staff after 11/23/25. I. On 12/29/25 at 8:03 am, during an interview with CNA #2, she stated LPN #1 asked her to help R #1 pull his pants up. CNA #2 stated she is not assigned to R #1 and is aware of R #1's behavior, so she asked CNA #1 for help. CNA #2 stated that as soon as R #1 saw CNA #1, he started yelling profanity to CNA #1. CNA # 2 stated that the next thing she saw was R #1 on his feet attacking CNA #1. CNA #2 quickly asked for help and LPN #1 and another nurse showed up. CNA #2 also stated that R #1 is nice to everyone except CNA #1 because of a prior incident (incident when CNA #1 intervened between R #1 and another resident).

Based on record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #2) of 2 (R #'s 1 and 2) residents when the staff failed to:Follow physician orders for weekly skin assessments. Obtain a physician's order and complete a swallow study (a test that evaluates how well your throat and esophagus function while swallowing) without delay after recommendations by the Speech Language Pathologist (SLP). These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider.The findings are:A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] with the following diagnoses: Metabolic Encephalopathy (a change in brain function caused by systemic metabolic disturbances, such as electrolyte imbalances, liver failure, or infections).Dysphagia (Difficulty swallowing).Moderate Malnutrition.Weakness.Dementia. Weekly Skin Assessments: B. Record review of R #2's physician orders dated 09/05/25 revealed R #2 is to have weekly skin assessments completed on Sunday by a facility licensed nurse. C. Record review of R #2's skin assessments dated 09/05/25 through 11/11/25 revealed the following: 09/05/25: No skin alterations noted.09/19/25: Skin assessment was not completed and left blank.10/06/25: Stage 2 pressure ulcer (characterized by a shallow, open wound that has broken through the top layer of skin but not the fatty tissue beneath) with a length of 2 centimeters (cm), width of 2 cm, and a depth of 0.5 cm was present on coccyx (lower back).10/13/25: Stage 2 pressure ulcer present to coccyx and redness to groin area.10/19/25: Stage 2 pressure ulcer present to coccyx and redness to groin area.10/27/25: Stage 2 pressure ulcer to buttocks.11/10/25: Redness in groin area.Skin assessments were not completed for each week as ordered. D. On 11/13/25 at 10:51 am during an interview with Registered Nurse (RN) #1, she stated skin assessments are supposed to be completed for residents weekly as ordered by a physician. E. On 11/13/25 at 1:40 pm during an interview with the Interim Director of Nursing (IDON), she confirmed R #2 was not receiving weekly skin assessments as ordered and should have. The IDON stated R #2 not receiving weekly skin assessments as ordered did not meet her expectations. Swallow Study: F. Record review of R #2's Speech Therapy Notes revealed the following: 10/02/25: R #2 was seen by SLP for skilled swallow evaluation and R #2's swallow initiation was severely impaired.10/08/25: SLP has recommended R #2 complete a swallow study and informed R #2's family of recommendation.10/09/25: SLP continues to recommend swallow study for R #2.10/10/25: SLP continues to recommend swallow study for R #2.G. Record review of R #2's physician orders dated 10/20/25 revealed speech therapy swallow study for evaluation and treat for aspiration risks (as the potential for foreign materials, such as liquids, solids, or secretions, to be inhaled into the lungs, leading to serious respiratory complications) and concerns. Study was completed on 10/23/25. H. Record review of R #2's Speech Therapy progress notes dated 11/03/25 indicated the swallow study was completed on 10/23/25 with the study results verbally delivered to R #2's family by the Speech Therapist on 11/03/25. I. On 11/12/25 at 2:07 pm during an interview with R #2's son, he stated R #2 needed a swallow study completed and it took a long time for R #2 to get that done. R #2's son stated he wanted his mom to be able to eat pureed food. J. On 11/13/25 at 1:25 pm during an interview with the SLP, she stated she requested R #2 have a swallow evaluation completed for several weeks, but it was not done until 10/23/25. The SLP stated that better communication between the facility nursing staff and therapy would have been beneficial so R #2's swallow study could have been completed sooner than it was. K. On 11/13/25 at 1:42 pm during an interview with IDON, she confirmed R #2's swallow study orders should have been placed sooner than 10/20/25 due to the SLP requesting a swallow study being completed several weeks earlier.

Based on record review and interview, the facility failed to provide daily care needs including brief changes for 2 (R #'s 1 and 2) of 3 (R #'s 1, 2, and 3) residents reviewed for care needs.Failure to provide for residents' daily care needs can result in residents feeling dirty, unclean and ashamed.The findings are: R #1: A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses including: Parkinsonism (a chronic, progressive disease of the nervous system). Acute Respiratory Failure (failure of the lungs to inflate and deflate properly) with hypoxia (low blood oxygen level). R #1 was discharged from the facility on 09/22/25 to return home. B. Record review of R #1's 5-day Minimum Data Set Assessment (a collection of assessments that determines a person's abilities and needs) dated 08/25/25 revealed the following: Brief Interview for Mental Status (a test that measures a person's memory and mental abilities) resulted in a score of 15 out of 15 indicated clear memory and mental abilities. Functional Abilities rated R #1 was in need of some assistance with self-care and mobility, that she used a wheelchair to move about, that she was dependent on staff to assist with toileting (moving to and from the toilet) and dressing. R #1 was noted to be incontinent (unable to control) of bowel and bladder. C. Record review of R #1's initial care plan dated 08/25/25 revealed a plan to encourage the use of her call light, monitor for pain and provide medication as needed. R #1 is incontinent of bowel and bladder. D. Record review of R #1's daily Point of Care (a portion of each resident's Electronic Medical Record that documents CNA's interaction and care provided) revealed there was no documentation by CNA #1 or any other CNA from the evening of 08/29/25 until the morning of 08/30/25 (indicating staff did not assist R #1 with toilet or brief changing needs throughout the entire pm shift). E. On 11/13/25 at 1:42 pm during an interview with the Interim Director of Nursing (IDON), she confirmed R #1's brief should have been changed throughout the pm (night) shift. R #2: F. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE]. G. Record review of R #2's care plan dated 09/13/25 revealed R #2 had current moisture-associated skin damage (MASD) to her right buttock. Staff interventions included frequent brief checks and changes during (2 hour) rounds. H. Record review of R #2's Point of Care (POC) History (ADL tracking tool) dated 09/05/25 through 11/11/25 revealed the following: 09/05/25 through 09/30/25: R #2's brief was changed due to urine only one or two times per 24 hours for 21 days during that timeframe. 10/01/25 through 10/31/25: R #2's brief was changed due to urine only one or two times per 24 hours for 26 days during that timeframe. 11/01/25 though 11/11/25: R #2's brief was changed due to urine only one or two times per 24 hours for 10 days during that timeframe. I. Record review of R #2's skin assessments dated 09/05/25 through 11/11/25 revealed the following: 09/05/25: No skin alterations noted. 09/19/25: Skin assessment was not completed and left blank. 10/06/25: Stage 2 pressure ulcer (characterized by a shallow, open wound that has broken through the top layer of skin but not the fatty tissue beneath) with a length of 2 centimeters (cm), width of 2 cm, and a depth of 0.5 cm was present on coccyx (lower back). 10/13/25: Stage 2 pressure ulcer present to coccyx and redness to groin area. 10/19/25: Stage 2 pressure ulcer present to coccyx and redness to groin area. 10/27/25: Stage 2 pressure ulcer to buttocks. 11/10/25: Redness in groin area. J. On 11/12/25 at 2:01 pm during an interview with R #2's son, he stated there have been multiple times where R #2's brief was not changed for over 12 hours in a day. R #2's son also stated that he has complained to the facility nursing staff about R #2 not being changed often, and facility CNAs (Certified Nursing Assistants) have told him that they don't always change R #2 throughout the day. R #2's son confirmed R #2 has experienced skin breakdown due to the lack of brief changes by the facility staff. K. On 11/12/25 at 4:05 pm during an interview with CNA #2, she stated R #2's brief should be checked every 1.5 to 2 hours because R #2 will have frequent diarrhea. CNA #2 stated she will always check R #2 frequently when she works, but she is aware of other CNAs not changing R #2 as often as they should be. CNA #2 confirmed all brief changes are documented in the POC history in the electronic health record. L. On 11/12/25 at 4:10 pm during an interview with Registered Nurse (RN) #3, she confirmed CNAs should be checking R #2's brief at least every two hours and she should be changed more than one to two times in 24 hours. M. On 11/13/25 at 10:44 am during an interview with RN #1, she stated R #2 has frequent urination and diarrhea and should be checked and/or changed often during a shift. RN #1 also stated she is aware that R #2's brief is not checked or changed as frequently as it should be because R #2 began to develop redness in her groin area which is indicative of being in a soiled brief for extended periods of time. N. On 11/13/25 at 1:39 pm during an interview with the Interim Director of Nursing (IDON), she stated usually MASD (Moisture-Associated Skin Damage) in the groin area is caused by incontinence and she would expect R #2's brief to be checked/changed every two hours and as needed. The IDON confirmed R #2 should have been changed more than one to two times per 24 hours, and that did not happen.

Based on record review and interviews, the facility failed to protect 1 (R #1) of 1 (R #1) resident reviewed from neglect. The facility failed to ensure that a resident was provided care and assistance by staff during the night of 08/29/25.Failure to prevent neglect of residents can result in residents' frustration and fear of being left alone and not assisted with care needs.The findings are:A. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses including:Parkinsonism (a chronic, progressive disease of the nervous system).Acute Respiratory Failure (failure of the lungs to inflate and deflate properly) with hypoxia (low blood oxygen level).R #1 was discharged from the facility on 09/22/25 to return home.B. Record review of R #1's 5-day Minimum Data Set assessment (a collection of assessments that determines a person's abilities and needs dated 08/25/25 revealed the following:Brief Interview for Mental Status (a test that measures a person's memory and mental abilities) resulted in a score of 15 out of 15 indicated clear memory and mental abilities.Functional Abilities rated R #1 was in need of some assistance with self-care and mobility, that she used a wheelchair to move about, she was dependent on staff to assist with toileting (moving to and from the toilet) and dressing.R #1 was noted to be incontinent (unable to control) of bowel and bladder.C. Record review of R #1's initial care plan dated 08/25/25 revealed a plan to encourage the use of her call light, monitor for pain and provide medication as needed. R #1 is incontinent of bowel and bladder.D. Record review of R #1's daily Point of Care (a portion of each resident's Electronic Medical Record that documents Certified Nurse's Aides (CNA) interaction and care provided) revealed there was no documentation by CNA #1 or any other CNA from the evening of 08/29/25 until the morning of 08/30/25 (indicating staff did not assist R #1 with toilet or brief changing needs throughout the entire pm shift). E. Record review of the facility's incident report dated 09/05/25 revealed an investigation that CNA #1 failed to provide care to R #1 from the evening of 08/29/25 until the morning of 08/30/25. The investigation stated that CNA #1 had left R #1 in a urine-soaked brief through the night, failed to respond to R #1's call light to provide assistance and neglected her throughout the shift. The report stated the neglect of CNA #1 towards R #1 was substantiated. F. On 11/13/25 at 2:36 pm during interview with the facility administrator, she stated she had been notified of an incident of possible neglect on 08/30/25 during the early morning hours. Administrator further stated she was informed by telephone of CNA #1 neglecting care for R #1 for the entire night from 08/29/25 at about 7:00 pm until 08/30/25 at 6:00 am. Administrator stated she interviewed staff and determined the allegation of neglect was true.

Based on record review and interview, the facility failed to thoroughly document the investigation of neglect of for 1 (R #1) of (R #1) resident reviewed for abuse or neglect. The facility was notified of an instance of neglect and investigated the allegation of neglect but failed to document the completed investigation.Failure to document reported investigations could result in confusion and misunderstanding of investigation results.The findings are:A. Record review of R #1 face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:Heart Failure (Failure of the heart to properly move blood through the body).Parkinson's Disease (a chronic medical condition that affects motor and non-motor systems of the body).Respiratory Failure (difficulty breathing).R #1's face sheet also revealed she was discharged from the facility on 09/22/25.B. Record review of New Mexico Health Care Authority Complaint and Incident records revealed incident #2604414 dated 08/30/25 stated R #1 was neglected by a Certified Nurse's Aide (CNA) #1 on 08/30/25. C. Record review of the facility's follow-up report for incident #2604414 dated 09/05/25 revealed that CNA #1 was reported to have provided no care to R #1 on the night of 08/29/25 to 08/30/25. The report stated R #1 was left in her room for most of the 12 hours from 08/29/25 at 6:00 pm until 08/30/25 6:00 am. The administrator began an immediate investigation on the morning of 08/30/25 by calling the facility and interviewing staff by phone. She provided her report of the incident which included only the follow up report. Administrator did not provide documentation of any interviews, of any training and of any follow-up documentation.D. On 11/13/25 at 2:45 pm during an interview, the Administrator stated she was notified early morning on 08/30/25 of an incident involving R #1 and CNA #1. Administrator stated she began an immediate investigation by telephone. Administrator stated she called and spoke with the weekend nurse supervisor and with CNA #1. Administrator determined the incident report was accurate and constituted neglect. Administrator substantiated the complaint and directed all staff to be retrained on abuse and neglect. Administrator stated she did not have any written documentation to support her investigation report or follow up training.

Based on record review and interview, the facility failed to develop a comprehensive care plan for 1 (R #1) of 3 (R #1, #2, and #3) residents. Failure to develop a comprehensive care plan could result in residents not receiving optimal care that meets their daily needs and preferences.The findings are: A. Record review of R #1 face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses:Heart Failure (Failure of the heart to properly move blood through the body).Parkinson's Disease (a chronic medical condition that affects motor and non-motor systems of the body).Respiratory Failure (difficulty breathing).R #1's face sheet also revealed she was discharged from the facility on 09/22/25.B. Record review of R #1's Minimum Data Set (MDS-a collection of assessments that describes a person's abilities and needs) 5-day admission dated 08/25/25 revealed that the MDS assessment was completed and signed by the MDS Registered Nurse on 09/04/25. C. Record review of R #1's Electronic Medical Record (EMR) between the dates of 08/22/25 to 09/22/25 failed to find a comprehensive care plan.D. Record review of R #1's care plan dated 11/12/25 revealed an initial care plan was completed on 08/22/25 with additions dated 08/25/25. E. On 11/13/25 at 1:48 pm, during an interview, the interim Director of Nursing (iDON) stated she reviewed R #1's care plan as well as R #1's EMR. iDON was unable to locate a complete comprehensive care plan. iDON confirmed that an initial care plan had been completed but the comprehensive care plan had not been completed. iDON confirmed that the facility should have completed the comprehensive care plan for R #1.

Based on observation, record review and interview, the facility failed to follow physician orders for 1 (R #1) of 1 (R #1) resident. This deficient practice is likely to result in residents receiving care that is not medically appropriate. The findings areA. Record review of R #1's face sheet dated 07/10/25 revealed he was admitted to the facility on [DATE] with the following diagnoses:-Gastro Esophageal Reflux Disease (GERD) (a digestive disease in which acid is often regurgitated during/after eating).-Cognitive (mental) Communication Deficit.-Type 2 Diabetes Mellitus (chronic disease affecting blood sugar levels).-Generalized Anxiety (nervousness) Disorder.B. Record review of R #1's physician orders revealed an order dated 01/29/25 to give all medications that are appropriate with food or snack. Ordered by (Name of Medical Doctor).C. On 07/10/25 at 9:20 am during observation and interview with R #1, he was seen in his room, in his bed. He stated he had already received and eaten his meal. He stated he was still waiting for his morning medications to be administered. He stated he preferred to receive his morning medications with his meal as he felt this was less irritating to his stomach. D. On 07/10/25 at 1:20 pm during interview with Licensed Practical Nurse (LPN) #1, she stated this was a nursing order and not a doctor's order and that it should have been discontinued after R #1's return from the hospital. LPN #1 stated that R #1 had stated in the past that he wanted his medications with meals. She stated R #1 had been sent to the hospital a week before (on 07/02/25). LPN #1 stated she discussed medications with R #1 when he returned from the hospital. She stated that after this discussion, she should have discontinued this order as he no longer needed his medications with meals. E. On 07/10/25 at 1:40 pm during interview with R #1 in his room with a Hospice Clergy present, R #1 stated he still preferred to receive his medications, especially his morning medication, to be administered with his meal.

Based on record review and interview, the facility failed to accurately document the changing conditions of 1 (R #3) of 3 (R #2, 3, 4) residents. The facility documented conflicting resident daily assessments for R #3's conditions. This deficient practice is likely to result in resident care and care plans being confusing and inadequate. The findings are: A. Record review of R #3's face sheet dated 07/10/25 revealed she was admitted to the facility on [DATE] and discharged from the facility on 05/09/25 to return home with home health services. B. Record review of R #3's Admitting History and Physical dated 03/29/25 revealed she was admitted to the facility with the following diagnosis:-Left Intertrochanteric Femur Fracture (Broken Hip)C. Record review of R #3 Minimum Data Set (a set of assessments that describes a person's needs and abilities: MDS) dated [DATE] revealed the following:-MDS Section C (section that assesses cognitive patterns) Brief Interview for Mental Status (BIMS) (a simple test that assesses a person's mental ability) revealed a score of 10 out of 15 indicating moderate impairment of R #3's memory and cognition.-MDS section G (a set of assessments that describe a person's functional abilities) revealed that upon admission R #3 required stand by assistance with meals and oral hygiene. R #3 required full assistance with toileting and bathing. -MDS Section H (a set of assessments that describe a person's ability to control bowel and bladder) revealed that R #3 was occasionally incontinent of bladder and frequently incontinent of bowel.D. Record review of R #3's care plan dated 03/28/25 stated a problem category of cognitive loss/dementia (a chronic progressive disease that causes decline in memory and mental abilities). E. Record review of R #3's daily nursing notes dated 03/28/25 through 05/09/25, revealed the following: 1. Record review of R#3's daily nursing notes dated 03/28/25 at 11:06 pm revealed R #3 refused all medications. The notes state she reported taking only 3 medications at home. She refused to take the prescribed antibiotic. R #3 was educated as to the need for these medications, why these medications are used and risks of non-compliance. 2. Record review of R#3's daily nursing notes dated 03/29/25 at 5:49 pm revealed R #3 refused continence care (care of the body following an incidence of bowel or bladder release). R #3 was educated on the need for regular continence care to prevent skin breakdown. R #3 stated she didn't need a lecture. R #3 requested a change of room due to bed placement. 3. Record review of R#3's daily nursing notes dated 03/29/25 at 2:05 pm revealed R #3 refused medication.4. Record review of R#3's daily nursing notes dated 03/29/25 at 6:56 pm revealed R #3 refused Tuberculosis (a chronic infectious disease of the lungs) testing stating I don't need it. I don't want it. 5. Record review of R#3's daily nursing notes dated 03/29/25 at 11:55 pm revealed R #3 insisted that she doesn't want to be bothered during the night and that she doesn't want to be checked for incontinence (inability to control bowel and/or bladder) needs. R #3 stated she was tired of being bothered. 6. Record review of R#3's daily nursing notes dated 03/31/25 at 3:11 pm revealed R #3 refused all meds. R #3 refused continence care (a check by staff to determine if resident has had an episode of incontinence). R #3 was educated on the need for regular incontinence care, R #3 responded that she already knew this.7. Record review of R#3's daily nursing notes dated 04/01/25 at 12:19 pm revealed R #3 met with Assistant Director of Nursing (ADON) to discuss her ongoing refusal of medication and care needs. R #3 stated she will not follow current recommendations as she knows better than those of us here who are not educated enough to manage her care. Nurse Practitioner (NP) #1 was notified and informed of R #3's refusals. A referral was ordered to counseling services.8. Record review of R#3's daily nursing notes dated 04/04/25 at 6:39 pm revealed R #3 refused to have her surgical dressing changed told staff it looked good to her. The nurse again explained the importance of daily care needs and concern for R #3's continued refusal of antibiotics. R #3 told the nurse to leave now and close the door.9. Record review of R#3's daily nursing notes dated 04/04/25 at 9:30 pm revealed R #3 refused care and insisted she be left alone until the morning. The nurse explained the need for regular incontinence checks and regular incontinence care. R #3 informed the nurse she would think about it.10. Record review of R#3's daily nursing notes dated 04/08/25 at 12:59 pm revealed R #3 refused to be weighed.11. Record review of R#3's daily nursing notes dated 04/09/25 at 12:46 pm revealed R #3 refused medications. R #3 was educated about their medications and the need to take prescribed dosages. NP #1 was notified of the refusal.12. Record review of R#3's daily nursing notes dated 04/19/25 at 6:55 pm revealed R #3 refused three times-wound care and shower/bed bath stating she did not want to be disturbed.13. Record review of R#3's daily nursing notes dated 04/22/25 at 11:03 am revealed R #3 was provided information for home health care in planning for a safe discharge. R #3 stated she wanted to be discharged .14. Record review of R#3's daily nursing notes dated 04/26/25 at 3:04 pm revealed R #3 requested to be left alone, refused bath, wound care and skin check. 15. Record review of R#3's daily nursing notes dated 05/01/25 at 12:22 pm revealed Administrator (ADM) and Social Services Director (SSD) met with R #3 and discussed discharge plans. ADM and SSD informed R #3 that they felt her discharge home alone would be unsafe due to her need for cognitive (mentation/thinking) is impaired and she would require 24 hour/7 day a week support. ADM and SSD explained to R #3 that if she could not provide constant in-home support then she might need to consider long term care. R #3 is said to be completely against this idea of admitting to long term care. ADM and SSD explained they had contacted family for R #3 and they also suggested a guardian (a person who is appointed to be responsible for decision making for another person) be appointed for R #3. ADM and SSD explained the option of leaving against medical advice. R #3 ordered ADM and SSD to leave the room. 16. Record review of R#3's daily nursing notes dated 05/03/25 at 2:03 pm revealed R #3 twice refused to have surgical dressing changed, to allow a skin check to be done or to take a bath/shower. 17. Record review of R#3's daily nursing notes dated 05/06/25 at 3:22 pm revealed SSD met with R #3 to discuss discharge home. R #3 stated she had neighbors who would transport her home when discharged . R #3 stated she could provide all other needed care herself through outside services and with home health care assistance.18. Record review of R#3's daily nursing notes dated 05/06/25 at 3:26 pm revealed R #3 left a message for SSD that her neighbors would not be able to come pick her up from the facility when discharged .19. Record review of R#3's daily nursing notes dated 05/01/25 at 12:22 pm revealed Administrator (ADM) and Social Services Director (SSD) met with R #3 and discussed discharge plans. ADM and SSD informed R #3 that they felt her discharge home alone would be unsafe due to her need for cognitive (mentation/thinking) is impaired and she would require 24 hour/7 day a week support. ADM and SSD explained to R #3 that if she could not provide constant in-home support then she might need to consider long term care. R #3 is said to be completely against this idea of admitting to long term care. ADM and SSD explained they had contacted family for R #3, and they also suggested a guardian (a person who is appointed to be responsible for decision making for another person) be appointed for R #3. ADM and SSD explained the option of leaving against medical advice. R #3 ordered ADM and SSD to leave the room. 20. Record review of R#3's daily nursing notes dated 05/03/25 at 2:03 pm revealed R #3 twice refused to have surgical dressing changed, to allow a skin check to be done or to take a bath/shower. 21. Record review of R#3's daily nursing notes dated 05/06/25 at 3:22 pm revealed SSD met with R #3 to discuss discharge home. R #3 stated she had neighbors who would transport her home when discharged . R #3 stated she could provide all other needed care herself through outside services and with home health care assistance.22. Record review of R#3's daily nursing notes dated 05/06/25 at 3:26 pm revealed R #3 left a message for SSD that her neighbors would not be able to come pick her up from the facility when discharged .23. Record review of R#3's daily nursing notes dated 05/09/25 at 9:00 am revealed R #3 was noted to be ready for discharge, medications and discharge instructions were provided. R #3 was observed as she stood, transferred to a wheelchair, and put her shoes on independently. R #3 was advised that she was leaving against medical advice. R #3 refused to sign a facility provided document of her choosing to leave against medical advice. R #3 was wheeled to the front door of the facility where she was to meet her arranged transport at 10:00 am.24. Record review of R#3's daily nursing notes dated 05/09/25 at 11:52 am revealed R #3 failed to exit the building and met with transport service at the designated time. R #3 made alternate arrangements for transport and left the building at 12:13 pm.F. Record review of R#3's Provider Progress Notes dated 03/31/25, 04/03/25, 04/07/25, 04/10/25, 04/14/25, 04/17/25, 04/21/25, 04/24/25, 04/28/25, 04/30/25, 05/05/25 and 05/07/25 revealed R #3 had voiced multiple complaints about multiple issues. Review of Provider Progress Notes revealed multiple notes that R #3 had refused medications. Review of Provider Progress Notes also revealed notes that R #3 was continuing to plan for a safe discharge with the assistance of Social Services. Review of all Provider Progress Notes failed to find any notation that R #3 was planning to discharge against medical advice as indicated by nursing notes. Review of all Provider Progress Notes do not indicate that the provider had met with or discussed with R #3 any of her plans to discharge against medical advice. G. On 07/10/25 at 3:45 pm during an interview with the facility Director of Nursing (DON), Assistant Director of Nursing (ADON) and SSD they stated R #3 had voiced multiple concerns regarding her medications. They stated R #3 had frequently refused routine care and ADL (Activities of Daily Living) (daily care needs that all persons require to maintain health and wellbeing) assistance. They stated on 05/01/25 there were discussions about R #3 going home. They stated R #3 was advised that she was not competent to be living at home alone. They stated R #3 rejected this advice. They stated that this was discussed with R #3's medical team including her nurse practitioner and her medical doctor (MD). ADON stated she and MD had met with R #3 and discussed their concerns for discharge home alone and R #3 continued to refuse to accept advice for any other care except to be discharged home. SSD stated she had assisted R #3 to be referred to home health care before her discharge. SSD stated this had been discussed with nurse practitioner and the nurse practitioner had signed an order for home health care. DON reviewed R #3's medical record and confirmed that the medical provider's progress notes contained no documentation of R #3's demand to be discharged or notation of her decision to be discharged against medical advice. DON confirmed that this should have been included in the medical provider's documentation.

Repeat Deficiency from 03/10/25 Based on record review and interview, the facility failed to notify the resident's provider or Emergency Contact (EC) of the resident's change in condition for 1 (R #30) of 2 (R #15 and #30) residents reviewed for changes of condition (new or worsening symptoms). If the facility is not notifying the provider and EC when the resident experiences a change of condition, then both would be unable to make decisions related to treatment and advocate for the resident's care. The findings are: A. Record review of R #30's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: -Acute Respiratory (breathing) Failure with Hypoxia (low blood oxygen). -Heart Failure. -Unspecified Kidney Disease. -Malignant (cancer) Neoplasm (tumor) of upper third of Esophagus (throat). The face sheet further revealed the name and phone number of an EC for R #30. B. Record review of R #30's daily care notes revealed the following: -02/06/25 R #30 was sent to the hospital by R #30's dialysis (process of mechanically exchanging toxic elements from the blood) provider due to being short of breath. The note did not contain any indication that the provider or EC was contacted and told of the transfer. -02/25/25 R #30 was sent to the hospital by R #30's dialysis provider due to a lab hemoglobin (red blood cell that transport oxygen through out the body) value that was low. The note did not contain any indication that the provider or EC was contacted of the transfer. -03/01/25 R #30 was sent to the hospital by R #30's dialysis provider due to a lab hemoglobin value that was low. The note did not contain any indication that the provider or EC was contacted of the transfer. -04/13/25 R #30's left arm was moderately swollen. The provider was notified and ordered R #30 be transferred to hospital for evaluation. Transport was arranged. The note did not contain any indication that the EC was contacted and told of the transfer. C. On 04/22/25 at 3:30 pm during interview with Registered Nurse #1, he stated that R #30 was being transferred to the hospital to have a blood transfusion. RN #1 stated that he had called the provider with lab results earlier and was directed to transfer R #30 to the hospital. RN #1 stated he should be calling the EC to inform him of the transfer and that contacting the EC was required with each transfer to the hospital. There is no indication that EC had been contacted on 02/06/25, 02/25/25, 03/01/25 and on 04/13/25. RN #1 confirmed EC had not been contacted according to daily care notes.

Past non-compliance Based on interview and record review, the facility failed to prevent misappropriation of resident money when debit card was used by unauthorized parties for 1 (R #47) of 2 (R #47, and 156) residents reviewed for exploitation (the fact of making use of a situation to gain unfair advantage for oneself). This deficient practice is likely to cause residents to feel unsafe, experience anger and frustration along with dealing with debit card theft, and fraud. The findings are: A. Record review of the facility's investigative narrative report dated [DATE] revealed that R #156 had been admitted to the hospital on [DATE] and $1300.00 was withdrawn from her account on [DATE]. R #156 expired in the hospital on [DATE]. The facility was unable to substantiate abuse or neglect or misappropriation. The facility is unable to determine who, make purchases or withdrew money from her account. All pertinent information has been turned over to law enforcement for further investigation. Staff have been in-serviced on abuse and neglect and misappropriation, along with Professional Boundaries. These in-services will continue to be on-going. Both [name of staff #1 and #2) have been terminated from facility for failure to report the lost or stolen card and other conflicts of interest. B. Record review of the facility's grievance summaries reported by R #47 on [DATE] revealed I want to talk to her about the mother and daughter, the family who used to work here. The daughter and mother were Certified Nurse Aides (CNA)'s and the mother has my debit card. C. Record review of the facility's Initial Incident Report dated [DATE] at 5:31 pm revealed, Resident reported that a CNA who used to work here in 2023 took his debit card without his permission. D. On [DATE] at 10:30 am during an interview with R #47, he stated, that his debit card had been stolen and he knew who it was and he had been asking to speak to one of the employees certified Medication Aide (CMA) #1 that still worked at the facility because she was related to the CNA that had stolen his debit card. R #47 stated he had never been asked if he had ever had any missing personal items before by any of the facility staff. R #47 further stated that he had been asking other staff if they knew how to get hold of CMA #1, CNA #1 and CNA #2 and they were not able to get him any information. He became aware of the missing money when he was told by the facility that his application for assistance had been denied some time in November of 2024 due to having a bank account. R #47 at that time([DATE]) investigation was started and R #47 was taken to the bank and discovered that he was missing approximately $23,000.00. E. On [DATE] at 2:33 pm during an interview with facility Administrator (ADM), she stated that she had terminated [name of CMA #1] related to the case of the missing debit card with R #47. Administrator stated that during an interview with CMA #1, she stated that R #47 had asked her to ask her mom (staff #1) to return his debit card. The facility felt that CMA #1 should have reported the missing debit card when R #47 had asked her to ask her mom (staff #1) for the debit card back in November of 2024. ADM stated that the facility was reimbursing R #47 and had interviewed other residents in the facility to ensure that this incident was not occurring to any others in the building. Facility informed law enforcement on [DATE], in-services were conducted on [DATE] with all staff. F. On [DATE] at 12:32 pm during an interview with former Administrator (FA), she stated that concerns had been brought to her by R #156's son after his mother R #156 had passed away. Facility was informed that that several hundred dollars had gone missing from R #156's account. A police report was filed and in-services were done with the staff on [DATE]. FA did not recall interviewing any residents to ensure that they had not had any issues with missing money or issues with any of the staff asking for money or had access to personal bank accounts. FA further stated that she was unable to substantiate the allegation of abuse, neglect or misappropriation. The facility was unable to determine who made purchases and withdrew the money from R #156's account and all information had been given to law enforcement on [DATE]. Both staff #1 and #2 had been terminated for false reporting and conflict of interest on [DATE]. G. On [DATE] at 4:54 pm during an interview with Social Services Director (SSD), she stated that a facility staff came to her and told her R #47 wanted to speak to her immediately on [DATE]. R #47 presented her with a bank letter and she in turn brought it to the business office. R #47 further informed her that his bank card had been stolen by a family that used to care for him at the facility (staff #1, #2 and CMA #1), he then stated that he had asked CMA #1 to ask her mother (staff #1) to return his bank card. SSD stated at that point they started an investigation and took R #47 to the bank, law enforcement was called and other residents were interviewed to confirm that this had not occurred to any other residents. CMA #1 was terminated [DATE] for not reporting that R #47 had been asking her to have her mother return his bank card. H. On [DATE] at 1:47 pm during a follow-up interview with R #47, he stated that he thought Staff #1, Staff #2 and CMA #1 were his friends and he did not believe that they would take anything from him. R #47 stated he gave them is food card so that they could purchase food items for him at the grocery store and he gave them his food card PIN number (personal identification number) which was also the PIN for his debit card. R #47 did not give them his debit card as far as he can remember it was in his wallet, they took it without his permission. There was a large amount of money missing from his account. R #47 was taken to the bank to get his bank statements and he confirmed there were large amounts of withdrawals that he had not consented to on his bank statements. The facility transported him to the bank to retrieve the bank statements. R #47 felt that he had been betrayed and has lost trust of other people and he is afraid to allow other facility staff to have access/knowledge of his financial business. I. On [DATE] at 3:33 pm during an interview with the Assistant Business Office Manager (ABOM), she stated that she had submitted a re-certification application for R #47 in [DATE] was submitted without bank statements, and she received a denial letter approximately thirty days later. ABOM went to talk with R #47 about his denial letter and was informed by R #47 that he was not receiving his bank statements and was not able to provide bank statements to have his application re-submitted. ABOM stated that facility did not follow up at the time because they did not have a Business office Manager (BOM) at the time of the denial to assist R #47 in getting bank statements or re-submitting his application for approval. Bank statements would have confirmed that R #47 had large withdrawals from his account at the time of submission of his application.

Based on record review and interview, the facility failed to ensure staff revised the care plan for 6 (R #'s 1, 54, 55, 70, 73, and 79) of 6 (R #'s 1, 54, 55, 70, 73, and 79) residents reviewed when staff failed to: 1. Conduct a quarterly care plan meeting as required for R #'s 1, 54, 55, 70, and 73 in accordance with their admitted and Minimum Data Set (MDS) assessments. 2. Update R #79's plan of care to include resident and resident's family assistance with colostomy (surgery to create an opening for the colon (large intestine) through the abdomen). These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: Care Plan Meetings: R #1: A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE]. B. Record review of R #1's MDS resident assessment page located in R #1's Electronic Health Record (EHR) revealed R #1's last two quarterly MDS assessments occurred on 09/09/24 (quarterly review) and 12/05/24 (quarterly review). C. Record review of R #1's care conference report reviewed on 04/24/25 revealed R #1 had a care plan meeting on 09/19/24 and then one was not conducted until 01/28/25. R #54: D. Record review of R #54's face sheet revealed R #54 was admitted into the facility on [DATE]. E. Record review of R #54's MDS resident assessment page located in R #54's EHR revealed R #54's last two quarterly MDS assessments occurred on 10/27/24 (quarterly review) and 01/27/25 (annual review). F. Record review of R #54's care conference report reviewed on 04/24/25 revealed R #54 had a care plan meeting on 11/12/24 and then one was not conducted until 04/17/25. R #55: G. Record review of R #55's face sheet revealed R #55 was admitted into the facility on [DATE]. H. Record review of R #55's MDS resident assessment page located in R #55's EHR revealed R #55's last two quarterly MDS assessments occurred on 12/05/24 (quarterly review) and 03/07/25 (annual review). I. Record review of R #54's care conference report reviewed on 04/24/25 revealed R #54 had a care plan meeting on 12/17/24 and then one was not conducted until 04/24/25. R #70: J. Record review of R #70's face sheet revealed R #70 was admitted into the facility on [DATE]. K. Record review of R #70's MDS resident assessment page located in R #70's EHR revealed R #70's last two quarterly MDS assessments occurred on 11/21/24 (quarterly review) and 02/18/25 (annual review). L. Record review of R #70's care conference report reviewed on 04/24/25 revealed R #70 had a care plan meeting on 11/14/24 and then one was not conducted until 03/11/25. R #73: M. Record review of R #73's face sheet revealed R #73 was admitted into the facility on [DATE]. N. Record review of R #73's MDS resident assessment page located in R #73's EHR revealed R #73's last two quarterly MDS assessments occurred on 11/15/24 (quarterly review) and 02/15/25 (annual review). O. Record review of R #73's care conference report reviewed on 04/24/25 revealed R #73 had a care plan meeting on 08/15/24 and then one was not conducted until 01/28/25. P. On 04/24/25 at 5:28 pm during an interview with the Director of Nursing (DON), she stated all care plan meetings should be conducted every 90 days (quarterly). The DON confirmed R #'s 1, 54, 55, 70, and 73 care plan meetings were not completed quarterly, and should have been. Updated Care Plan: R #79: Q. Record review of R #79's face sheet revealed R #79 was admitted into the facility on [DATE]. R. Record review of R #79's physician orders dated 04/03/25 revealed the facility nursing staff were to change R #79's colostomy wafer and pouch weekly and as needed. S. Record review of R #79's care plan dated 04/11/25 revealed R #79 has a colostomy, but R #79 and/or R #79's family providing colostomy care was not care planned. T. On 04/22/25 at 4:28 pm during an interview with R #79's father, he stated that his wife (R #79's mother) or him will change R #79's colostomy bag most of the time. R #79's father also stated that the facility nurses will help, but the nurses are aware of them providing colostomy care for R #79. U. On 04/25/25 at 4:21 pm during an interview with the Assistant Director of Nursing (ADON) #1, she stated that sometimes R #79 and R #79's parents will provide colostomy for him. The ADON #1 also stated the facility nurses will complete colostomy care for R #79 when his parents are not around. The ADON #1 confirmed R #79 and R #79's parents providing colostomy care for R #79 should be care planned, and it was not.

Based on observation and interview, the facility failed to store and serve food under sanitary conditions when staff failed to ensure: 1. Food items were labeled and dated in the kitchen refrigerator and freezer. 2. Food was stored appropriately and not left open to air in the kitchen freezer. 3. Food items were not expired in the kitchen and dry storage. These deficient practices are likely to affect all 117 residents listed on the resident census list provided by the Administrator on [DATE] and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On [DATE] at 11:43 am, observation of the kitchen revealed the following: 1. Three large cheese pizzas were not labeled or dated and stored in the kitchen freezer. 2. One large cardboard box of green beans were left open to air and stored in the kitchen freezer. 3. Thirteen 24 count plastic containers of chocolate chip cookies was not labeled or dated and stored in the kitchen dry storage. 4. One 5 pound (lb) and 5 ounce (oz) package of La Banderita yellow corn tortillas had an expiration date of [DATE], and an opened dated of [DATE], was stored in the kitchen dry storage. 5. Two 12 count packages of Natures Own hamburger buns had an expiration date of [DATE], and was stored in the kitchen dry storage. 6. One 12 count package of Natures Own hotdog buns had an expiration date of [DATE], and was stored in the kitchen dry storage. B. On [DATE] at 12:10 pm during an interview with the Dietary Manager (DM), she confirmed all findings listed above and stated that all food items should be labeled, dated, stored appropriately, and not expired.

Based on interview and record review, the facility failed to promote care with dignity and respect for 1 (R #1) of 1 (R #1) resident reviewed for residents' rights by walking into the room to speak to a staff member who's performing personal care on a resident. This deficient practice is likely to result in residents feeling as if they were unimportant and not having privacy. The findings are: A. On 04/22/25 at 12:30 PM during an interview with R #1, she stated that she felt a nurse did not treat her with respect when she went into the bathroom without announcing herself when she was showering. The nurse needed to talk to the Certified Nurse Aide (CNA) who was assisting me with my shower. R #1 further stated, Just because she's a nurse doesn't mean it's okay to just go into someone's bathroom to talk to another staff. I felt like she didn't respect my privacy. B. Record review of R #1's face sheet revealed she was admitted to the facility on [DATE]. C. Record review of R #1's Minimum Data Set (MDS; a standardized, comprehensive assessment of an adult's functional, medical, psychosocial, and cognitive status), dated 03/07/25, revealed the following: - Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15. - Functional Abilities-Shower/bathe self: 02. Substantial/maximal assistance. D. On 04/25/25, at 9:39 AM, during an interview with the Assistant Director of Nursing (ADON #2), she stated that R #1 has never mentioned anything about a nurse making her feel uncomfortable or disrespected. She added that if R #1 did feel uncomfortable or disrespected in any way, it would be a concern that she would look into. The expectation for staff entering a room where a resident is receiving personal care is that they knock and announce themselves before entering. E. On 04/25/25, at 10:22 AM, during an interview with CNA #1, she stated that R #1 only allows certain staff members to assist her with showers/care. She will openly say, 'It's not that I don't like you, but I don't like the way you do things, and I'll wait for my care to be done by staff I prefer.' CNA #1 further stated, R #1 likes things done in a specific way, and if you follow her preferences without taking offense, you'll get along with her and gain her trust. R #1 is very vocal and straightforward about expressing her opinions. F. On 04/25/25, at 2:22 PM, during an interview with the Director of Nursing (DON), she stated that the expectation for entering a resident's room, bathroom, or shower room is that staff should knock, wait to be allowed in, acknowledge the residents, and inform them they need to speak briefly with the other staff members. She added that R #1 has not brought up this incident to her. She also mentioned that she would be conducting training to remind staff about the protocol for entering rooms when personal care is being provided. G. On 04/25/25, at 2:45 PM, during an interview with R #1's roommate, she confirmed that the incident with the nurse walking in unannounced while R #1 was showering did occur. She further stated that R #1 was upset and felt like her privacy was violated.

Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury; skin damage which results from unrelieved pressure on the body) for 1 (R #128) of 1 (R #128) residents reviewed when staff failed to: 1. Timely identify the community acquired wound, monitor for changes in the wound, and notify the physician the wound was worsening for R #128. 2. Updating wound care treatment orders in relation to R #128's pressure ulcer becoming worse. This deficient practice likely resulted in R #128's pressure ulcer worsening and developing poor health outcomes. This deficient practice is also likely to lead to residents developing pressure ulcers and wounds worsening. The findings are: A. Record review of R #128's face sheet revealed R #128 was admitted into the facility on [DATE]. B. Record review of R #128's admission observation, dated [DATE], revealed staff did not identify pressure ulcers present upon admission. C. Record review of R #128's weekly skin check revealed staff documented the following: - Dated [DATE], open areas to bilateral heels and buttock. Wound care as directed. Staff did not stage or measure R #128's wounds on the weekly skin check. - Dated [DATE], open areas to bilateral heels and buttock. Wound care as directed. Staff did not stage or measure R #128's wounds on the weekly skin check. - Dated [DATE], R #128 had a pressure ulcer on her sacrum and both heels with daily wound care. Staff did not stage or measure R #128's wounds on the weekly skin check. - Dated [DATE], R #128 had a pressure ulcer on her sacrum and both heels with daily wound care. Staff did not stage or measure R #128's wounds on the weekly skin check. - Dated [DATE], R #128 had a pressure ulcer on her coccyx with a healing wound on her left foot. Staff did not stage or measure R #128's wounds on the weekly skin check. - Dated [DATE], R #128 had alterations in skin, but staff did not document anything else. - Dated [DATE], R #128 had a pressure ulcer located on her sacrum that measured 0.5 centimeters (cm) length by 0.5 cm width and 3.6 cm depth. - Dated [DATE], R #128 had a pressure ulcer on her sacrum and left heel. Staff did not stage or measure R #128's wounds on the weekly skin check. D. Record review of R #128's history and physical (provider assessment), dated [DATE], revealed R #128 had a community acquired pressure ulcer in the sacrum, gluteus, and heels. Staff did not document treatments and measurements. E. Record review of R #128's weekly skin evaluation, dated [DATE], (first weekly skin assessment with pressure ulcer measurements completed by nursing staff) revealed R #128's pressure ulcer was located on her sacrum (a triangular bone in the lower back) and measured 1.5 centimeters (cm) length, 1 cm width, and 0.5 cm depth. Wound was identified as Stage 2 (partial thickness skin loss). F. Record review of R #128's Medication Administration Record (MAR) revealed the following wound care treatments being completed for R #128: - On [DATE] through [DATE]: Wound care to sacrum - Clean with wound cleanser, pat dry. Paint with SkinKote (protective prep pad that helps safeguard the skin against irritation) and cover with dry dressing daily. - On [DATE] through [DATE]: Weekly Wound Treatment: Sacrum - Clean with skin integrity, pat dry, apply Therahoney (substance used to treat wounds) to wound bed. Change Monday, Thursday, and as needed if wet/soiled/dislodged. - On [DATE] through [DATE]: Weekly Wound Treatment: Sacrum- Clean with skin integrity, pat dry, apply Therahoney to wound bed, skin prep to peri wound, loosely pack with Maxorb Ag (antimicrobial wound dressing) ribbon, cover with silicone dressing. May change as needed if soiled or dislodged. - On [DATE] through [DATE]: 15 grams (g) liquid protein for pressure ulcer of sacral region. G. Record review of R #128's care plan dated [DATE] revealed the following: - Problem: Resident is at risk for further avoidable/unavoidable skin injuries related to age and aging, dementia, depression, actual pressure injuries present on admission - Approach: Report any signs of skin breakdown (sore, tender, red, or broken areas). H. Record review of R #128's wound management detail report revealed the following: - On [DATE]: wound location- Sacrum, length was 0.5 cm, width is 0.5 cm, depth was 3 cm, and stage 4 (the most serious deep wound that may impact muscle, tendons, ligaments, and bone). - On [DATE]: wound location- Sacrum, length is 0.5 cm, width is 0.5 cm, depth cannot be measured, and stage 4. - On [DATE]: wound location- Sacrum, length was 2.5 cm, width was 2.5 cm, depth was 1 cm, and stage 4. - On [DATE]: wound location- Sacrum, length was 3 cm, width was 3 cm, depth was 2 cm, stage 4, and declining (becoming worse than before). Did not identify signs or symptoms of infection. Comments included the wound was worsening and present upon admission with the provider notified on [DATE] that the wound became a stage 4. I. Record review of R #128's nursing progress notes revealed the following: - Dated [DATE] through [DATE], the record did not contain any indication of R #128's pressure ulcer worsening. - Dated [DATE], the ADON #1 and the PA discussed R #128's sacrum pressure ulcer due to R #128's skin appeared to be swollen around the pressure ulcer. J. Record review of R #128's MAR, dated [DATE], revealed staff completed the following wound care treatments: - Dated [DATE] through [DATE]: Weekly Wound Treatment: Sacrum- Clean with skin integrity, pat dry, apply Thera honey to wound bed, skin prep to peri wound, loosely pack with Maxorb Ag (antimicrobial wound dressing) ribbon, cover with silicone dressing. May change as needed if soiled or dislodged. - Dated [DATE] through [DATE]: 15 G liquid protein for pressure ulcer of sacral region. - No additional orders/wound care treatments were ordered or completed. K. Record review of R #128's PA progress note revealed the following: - Dated [DATE], the record did not contain any indication of R #128's pressure ulcer worsening. - Dated [DATE], the record did not contain any indication of R #128's pressure ulcer worsening. - Dated [DATE], the PA was at R #128's bedside to observe R #128's pressure ulcer, and the PA gave orders to send R #128 to the emergency room (ER) for an x-ray due to sacrum pressure ulcer concerns and to rule out osteomyelitis (infection of the bone). L. Record review of R #128's medical record revealed staff provided wound care daily. M. Record review of R #128's Nurse Practitioner (NP) progress note, dated [DATE], revealed the record did not contain any indication of R #128's pressure ulcer worsening. N. Record review of R #128's hospital documents, dated [DATE], revealed R #128 was diagnosed with sacrococcygeal decubitus ulcer (pressure ulcer located on sacrum) and osteomyelitis. The emergency room (ER) physicians also determined R #128's pressure ulcer was incurable, and R #128 was placed on hospice care. O. On [DATE] at 5:39 pm during an interview with R #128's daughter, she stated R #128's became worse while in the facility which required R #128 to be sent to the hospital in May (2024). R #128's daughter also stated the hospital physician's informed her that R #128's infection was too severe and insisted R #128 be placed on hospice until she died . P. On [DATE] at 1:03 pm during an interview with Licensed Practical Nurse (LPN) #1, she stated nurses were to notify the Assistant Director of Nursing (ADON) #1 or the Physician Assistant (PA) #1 immediately if resident wounds become worse. LPN #1 also stated the facility completed wound care for R #128, but it quickly became infected. LPN #1 did not know exact date when R #128's wound became infected. LPN #1 stated R #128 preferred to stay in bed and did not want to be repositioned or move from the bed to wheelchair. Q. On [DATE] at 2:31 pm during an interview with PA #1, she stated R #128's wound began to have discharge, so she ordered an x-ray. She stated the x-ray was unable to rule out osteomyelitis. PA #1 also stated R #128's wound worsened, but staff did not make her aware that R #128's worsened until the day she saw R #128 on [DATE]. PA #1 stated she did not see R #128's pressure ulcer until [DATE]. PA #1 stated she should have been notified as soon as R #128's wound was determined to be declining, because she only saw residents once a month or with any new issues. R. On [DATE] at 5:43 pm during an interview with the Director of Nursing (DON), she stated PA #1 should have been notified when R #128's pressure ulcer started to worsen (get bigger in size). S. On [DATE] at 4:28 pm during an interview with ADON #1, she stated she wanted to change R #128's wound care treatment, because the wound began to decline. She stated to do that, they needed to send R #128 to the ER to rule out osteomyelitis. ADON #1 stated R #128 was seen by a provider multiple times, but ADON #1 could not recall informing PA #1 of R #128's pressure ulcer declining. ADON #1 stated she could not provide documentation to show staff informed PA #1 of R #128's pressure ulcer decline prior to [DATE]. T. On [DATE] at 3:47 pm during an interview with PA #1, she stated she was aware R #128 did not move her body often. She stated R #128 would not help her move, because R #128 was very weak when she visited the resident. PA #1 stated she was aware of R #128's wound, but she would not have observed the wound unless the nursing staff informed her of a change. PA #1 confirmed R #128's wound was unstageable and then became a stage 4. She stated R #128's documentation that listed R #128's pressure ulcer as a Stage 2 pressure ulcer was incorrect. PA #1 also stated staff eventually told her that R #128's pressure ulcer was worsening. The PA stated she did not know when staff told her, and she did not document that information in R #128's electronic health record.

Based on record review and interview, the facility failed to provide treatment and care in accordance with professional standards for 1 (R #1) of 1 (R #1) resident reviewed by 1. Not assessing and monitoring R #1 for injury after (2) falls likely resulting in a delay in treatment for (4) days. 2. Not notifying the Physician of change in condition (increase in pain) or providing effective pain management following (2) falls resulting in an open fracture (fractured bone is external environment) of R #1's lower right leg. These deficient practices likely resulted in R #1 experiencing significant pain and delayed treatment. The findings are: A. Record review of R #1's Face Sheet revealed R #1 was admitted into the facility on [DATE] with diagnosis of Paraplegia unspecified (paralysis of legs and lower body). List of diagnosis is not all inclusive. B. Record review of R #1's Nursing Progress Notes date 04/13/23 at 4:14 pm revealed, At 3:57 pm, EMS [Emergency Medical Services] via stretcher take resident back to [Name of Local Hospital] for altered mental status, EMS did state, that pt [patient] does not make sense while communicating with res [resident (R #1)] for extended period of time 25 minutes. Res. [R #1] first found on floor beside bed, transportation stated, res. [R #1] flopped himself out of W/C [wheelchair] onto floor and now bleeding, upon assessment, writer sees resident moving in center of bed and blood is seen on floor, writer is asking resident [R #1] where is he bleeding from, resident more concerned about his trash can being close to bed. Writer asks resident to turn over, writer sees two open areas that are bleeding under bilateral buttocks, behind thighs, areas, cleansed and dressings applied. Res. [R #1] states did not hit his head. Vitals Taken, within normal limits. Resident not making sense to writer nor staff, incident noted. 30 minutes from this fall, writer is then called to res. [R #1] room due to pt. [patient] on the floor under roommates bed, moving around throughout floor in room, writer ask, what are you doing, res. [R #1] states, trying to get help, writer informed, you always call us on the call light and we use the hoyer [lift], why are you falling onto the floor, resident did not answer, he asking for help to get onto the bed. Any questions that staff ask, resident [R #1] ignores and wants his personal items next to him. Vitals taken, blood pressure elevated, all other WNL [Within Normal Limits]. Writer called on call [Name of Provider], received order to send res. [R #1] out to ER [emergency room ] for further evaluation. Progress note did not identify that R #1 was assessed for injury to R #1's lower extremities. C. Record review of the Physician Progress Note dated 04/13/23 revealed Nursing staff called to report the patient [R #1] has returned from the hospital today and he continues to be confused and at this time nursing staff is requesting that the be patient be transferred to the emergency department for further evaluation and management. Progress Note did not identify concern or request for evaluation related to R #1's recent falls. D. Record review of R #1's Census Page revealed R #1 returned from the hospital to the facility on [DATE] at 2:20 pm. E. Record review of Physician progress note dated 04/14/23 revealed Patient returned from the hospital on 4/13 [23] but was found on the floor twice yelling for help. He was helped back to bed and nursing staff overnight reported seemed altered so oncall was notified and recommended he go back to the ER. He stated he was trying to walk yesterday night. He thought he could walk. Paperwork from his return to ER was reviewed and labs show no abnormalities, CXR (chest X-ray), CT (computed tomography; scan X-ray inside body) was all negative but UA (urinary analysis) was positive. F. Record review of R #1's medical record did not identify any progress notes or assessment of R #1 on 04/15/23. G. Record review of R #1's Weekly Skin Check dated 04/16/23 at 3:26 am revealed no documentation of injury or concerns related to R #1's right foot/lower leg. H. Record review of R #1's Nursing Progress Notes dated 04/16/23 at 11:15 am revealed, WOUND ON RIGHT FOOT is whipping [weeping]. Wound care done. Skin assessment done. [Name of Assistant Director of Nursing (ADON) #1] notified. see dr (doctor) communication. I. Record review of R #1's physician orders dated 04/13/23 revealed 1. acetaminophen (pain medication) [OTC] [Over the Counter] tablet; 325 mg [milligram]; Amount to Administer: 2 tabs; oral. 2. oxycodone - Schedule II tablet; 15 mg; Amount to Administer: 1 tab; oral. J. Record review of R #1's Medication Administration Record (MAR) dated 04/13/23-04/17/23 revealed the following: 1. R #1 was administered Acetaminophen 5 times on 04/16/23 with 3 out of the 5 administrations resulting in Somewhat Effective pain reduction. R #1 received Acetaminophen dose on 04/17/23. 2. R #1 received Oxycodone (medication used to treat pain) 2 times on 04/14/23, 1 time on 04/15/23, 3 times on 04/16/23 with 1 dose being Somewhat Effective, and 1 time on 04/17/23 that was Somewhat Effective. Pain scale was marked as 0 for both days. K. Record review of R #1's Change in Condition Skin Check dated 04/17/23 at 5:25 am revealed, Bruise and swelling right lower leg and foot. L. Record review of R #1's Physician Progress Note dated 04/17/23 at an unknown time revealed, Chief Complaint/Nature of Presenting Problem: He [R #1] is seen today in his room by the request of nursing who is concerned because his right foot has been inverted (facing in) swollen and bluish in color since a fall approximately 48 hours ago. He [R #1] reports he is having severe pain in the affected foot and I will increase his pain medication to Q 2 [every 2] instead of Q 6 [every 6] hours prn [as needed]. No x-rays have yet been ordered and I will order a right foot and right knee 2 views each. M. Record review of R #1's Nursing Progress Notes dated 04/17/23 at 9:05 am revealed, X-ray 2 view right foot and knee. Pain medication increased to Q4 [every 4] hours X [times] 48 hours for right foot and ankle pain. Right foot is swollen and black/purple in color. Foot is pointed outward. Received order [from provider] for PXR [x-ray]. Ordered STAT (immediately). N. Record review of R #1's Nursing Progress Notes dated 04/17/23 at 1:21 pm revealed, Sending to [Name of local Hospital] for fractured right ankle, non-emergent per [Name of Provider]. O. Record review of R #1's Hospital Documentation dated 04/17/23 revealed, Hospital Course By Problem: Open Fracture of the right distal tibia (lower leg) and fibula (bone in leg). Due to mechanical fall, reportedly 4 days PTA [Prior To Arrival]. P. Record review of R #1's Hospital Surgery Documentation dated 04/18/23 at 12:26 am revealed, PROCEDURE: 1. Application of external fixator (device use to stabilize bones), right lower extremity. 2. Closed reduction of distal tibia and fibula fracture, right side 3. Wound debridement (the removal of damaged tissue) down to the level of bone, right distal fibula. 4. Application of wound VAC (device used to heal wounds), right lower extremity. Q. On 05/08/23 at 4:42 pm during an interview with R #1, he stated, I broke my foot in 3 places. I tried to stand up [on 04/13/23 and fell ]. I broke my leg and ankle. They [doctors at the hospital] said I lost 3 inches of bone. I was in pain for 4 days and I told my nurse [on 04/15/23, 04/16/23, and 04/17/23]. She [nurse on 04/15/23 and 04/16/23] didn't do a good job [managing R #1's pain] and I was in pain. My regular nurse [Registered Nurse (RN) #1] came back and sent me [to the ER] right away. The surgeon said he thought he might have to amputate [cut off (a limb) by surgical operation] it [R #1's right leg]. My pain was worse than 10 [0 meaning no pain, 10 meaning most pain, during 04/15/23-04/17/23]. As soon as she [RN #1] saw me [on 04/17/23], she [RN #1] called 911 right away. R. On 05/09/23 at 1:52 pm during an interview with RN #1, she stated, I was off on Sunday [04/16/23]. I'm off Thursday-Sunday. His [R #1's] foot was purple, swollen, and facing in. I read some other people's [nursing staff] notes where they [nurses] saw a change [in R #1's foot on 04/15/23 and 04/16/23]. I was told that it [R #1 fell and injured his foot] was on Thursday [04/13/23], and it [bruising and swelling of R #1's foot] would have happened a couple of days ago. We got the x-rays, and I told the ADON [Assistant Director of Nursing], I notified the family, and the x-rays came back. He [R #1] complained of pain [on 04/17/23]. RN #1 confirmed an x-ray should have been ordered sooner than it was for R #1. S. On 05/09/23 at 3:56 pm during an interview with RN #2, she stated, I'm not aware if he [R #1] fell [to injure his foot]. I believe I sent a picture [of R #1's deformed foot on 04/16/23 to [Name of ADON #1]. Usually, I will send pictures if it's bad. Sunday (04/16/22), we don't have any doctor's and I'm not sure why [R #1 wasn't sent to the hospital until 04/17/23]. RN #2 confirmed she did not request an x-ray order for R #1 but she did send a picture of R #1's photo to ADON #1 on 04/16/23. T. On 05/09/23 at 4:12 pm during an interview with RN #3, she stated, Yeah, it [contacting the provider for R #1's increase in pain due to a fall on 04/13/23] should have been done by the previous nurse [RN #2] because it [R #1's increase in pain and change of right foot's appearance] happened during her [RN #2's] shift [on 04/15/23 and 04/16/23]. I don't know why she [previous nurse] didn't do it. RN #3 confirmed that she remembers R #1 being in significant pain when she worked with him on 04/15/23 and 04/16/23. U. On 05/09/23 at 5:13 pm during an interview with ADON #1, she stated, He [R #1] fell on the 13th [04/13/23] and he [R #1] went back to the ER [on 04/13/23] when he was admitted [to the facility on [DATE]] because his mentation was not clear [R #1 was not alert and was confused]. We did an x-ray in house [on 04/17/23] and sent him [R #1] to the ER. We would want the provider to be called if we can't manage it [pain] and be effective. We called the provider on [04/17/23] to get a physician order [for an x-ray order and to be sent to the ER]. ADON #1 confirmed she was not sent a photo of R #1's foot by RN #2. ADON confirmed that she wasn't aware that R #1 wasn't assessed for injury as a result of the falls at theER on [DATE]. V. On 05/10/23 at 11:32 am during an interview with Medical Doctor (MD) #1, she stated, I don't see any note [by a provider that was contacted by the facility] until my note [on 04/17/23]. No one eyeballed [looked at resident's injury] him [R #1] by our staff since the 5th [04/05/23]. There's no note [by a clinical provider] that he [R #1] fell [on 04/13/23]. It [facility contacting a provider for x-ray and transfer to the ER] should not wait[ed] until Monday [04/17/23]. MD #1 confirmed that she was not notified that R #1 was also experiencing an increase in pain. W. On 05/10/23 at 12:04 pm during an interview with the Director of Nursing (DON), she stated, A provider should have been notified [of R #1's foot change and increase in pain], if he's [R #1] saying he's in pain. DON confirmed a clinical provider should have been contacted sooner for R #1's foot injury and was not. X. On 05/10/23 at 12:20 pm during an interview with Emergency Medical Technician (EMT) #1, He [R #1] was telling me [04/17/23] that he was in pain and that staff was told for several days that he was in pain and staff was putting it off. The nurse that day [RN #1] upped his pain medications that day and that only started on the 17th [04/17/23]. He [R #1] was sleeping and his leg was obviously deformed. The bruising had spread all the way to back of his calf. She [RN #1] wasn't sure when the injury happened and I guess he [R #1] had reported a fall 4 days prior [on 04/13/23] and he [R #1] was complaining of pain 4 days prior. Y. On 05/10/23 at 12:59 pm during an interview with the Director of Nursing (DON), she stated, The nurse gave him [R #1] Oxycodone, Trazodone [anti-depressant medication], and Baclofen [medication for muscle spasms on 04/15/23 and 04/16/23]. She [RN #3] thinks it's [R #1's pain medication being marked as somewhat effective, while not giving R #1 additional pain medication]. She gave him Tylenol (Acetaminophen) at 4:09 am that morning [04/16/23]. DON confirmed R #1 was requesting additional pain medication on 04/15/23 and 04/16/23.

Past Non-compliance Based on record review and interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1(R #7) of 3 (R#'s 7, 8, and 9) residents reviewed by: 1. Not administering oxygen as ordered 2. Not providing medications to treat a resident's anxiety 3. Not conducting an assessment of R #7 upon admission to facility and when notified that resident was in distress. These deficient practices are likely to result in residents experiencing worsened conditions and/or death. The findings are: A. Record review of Nursing progress notes dated [DATE] at 12:54 am [time nurses note was written] revealed resident was admitted to facility [approximately 7:00 pm]. B. Record review of R #7's face sheet revealed resident was admitted to facility on [DATE] with the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Acute [CONDITION(S)] with [CONDITION(S)] Primary/Admission Pulmonary 2. Type 2 diabetes mellitus (a condition that affects the way the body process blood sugar) 3. [CONDITION(S)], (abnormally high concentration of fats in the blood) 4. Personal history of COVID-19 (an acute respiratory illness) 5. Elevated white blood cell count, 6. Retention of urine, 7. Pneumonia due to [CONDITION(S)]-associated (an acute respiratory illness) coronavirus (an acute respiratory illness) 8. Pain, 9. Generalized anxiety disorder 10. Acute pharyngitis, unspecified (inflammation of the tonsils and/or pharynx) 11. Essential (primary) hypertension (a condition in which the force of the blood against the artery walls is to high) 12. Constipation (a condition in which there is difficulty in emptying the bowels) 13. [CONDITION(S)] disease of prostate, 14. Weakness C. Record review of Physicians Orders dated [DATE] revealed: 1. [MEDICATION(S)] 1 mg (milligram) tab (tablet) Three times a day PRN (as needed) (medication used to treat anxiety) 2. [MEDICATION(S)] 5 mg three times a day (medication used to treat anxiety) 3. Cepacol Sore Throat-cough Lozenge ,d+[DATE].5 mg PRN every two hours 4. [MEDICATION(S)] u-100 insule pen 100 unit/ml 5. [MEDICATION(S)] 40 mg (medication used to prevent blood clots) 6. [MEDICATION(S)] 17 g (grams) (used to treat constipation) 7. Pepcid 20 mg 1 tab twice a day (used to treat excess stomach acid) 8. Simethlcone 80 mg (medication used to reduce bloating caused by excessive gas) 9. Tamsulosin 0.4 mg w cap (medication used to symptoms of an enlarged prostate gland) 10. [MEDICATION(S)] XL 50 mg (medication used to treat high blood pressure) 11. O2 (oxygen) at 5 LNC (liters nasal canula-plastic tube used to deliver oxygen from concentrator to patient) 12. CCHO (diabetic diet-Constant controlled carbohydrate diet) D. Record review of Nurses progress notes dated [DATE] at 11:46 am [late entry] revealed Resident came by transportation. Weighed resident he weighed 180.4 (pounds). Resident moved from w/c (wheelchair) to bed by staff. Resident is weak and is very anxious. E. Record review of Nursing progress notes [recorded as late entry on [DATE] at 11:50 am for [DATE]] Residents wife (R #7) came out of room and stated she was going home . Nurse let her know she was putting his meds (medications) and orders in computer. RX (prescription) for [MEDICATION(S)] (anxiety medication) was faxed to pharmacy. F. On [DATE] at 10:21 am during an interview with FM (Family Member) #1 (R #7's wife), she stated that her husband (R #7) had been transported to [Name of LTC facility] on [DATE] at about 7:00 pm. When he arrived at facility he was weighed by a CNA (Certified Nurse Aide) and [name of RN (Registered Nurse) #2] and then transferred with a gait belt to the bed. He was connected to the oxygen in the room and he was to be on 5L (Liters) of oxygen. Wife stated that she did not witness that the oxygen was set at 5L. She then stated that at about 7:20 pm, her husband was experiencing a full blown panic attack and the call light was activated and no one came to the room. She was unable to leave the room because her husband was having real bad anxiety, so she went to the door and looked up and down the hallway looking for help. Call light was still activated and she went to her husband's bedside and asked him to meditate and after some time was able to get him calm. At that point, she was able to walk over to the nurses station to ask for her husband's medication, where she encountered RN #2 asleep. RN #2 told her that her husband had a lengthy medical record and would be checking on him when she had time and she also stated that his medications had not arrived and she would be ordering them from the pharmacy. She stated I let her know that my husband had an anxiety attack and needed his medication as soon as possible because he was having a lot of anxiety. G. Record review of the medical record did not identify that R #7 had been administered any medications during his stay. H. Record review of Nurses progress noted dated [DATE] at 12:55 pm (late entry) revealed: CMA (Certified Medication Aide) started vitals on patient and noted SpO2 (oxygen level) of ,d+[DATE]% (percent, BP (blood pressure) ,d+[DATE], MAP 55 (calculation used to check whether there's enough blood flow to supply blood to all major organs), P (pulse) 114, T (temperature) 96.9, patient had nasal canula initu (sic) going at 2 L (liters) per minute, patient was pulled up in bed and elevated to high fowlers (seated upright) position and was switched to facemask, 911 was called at patients bedside, Spo2 increased to 85% then patient became unresponsive, pulse was checked no pulse, placed in supine (lying down face up) position, CPR (Cardiopulmonary Resuscitation -emergency procedure used in an effort to manually preserve intact brain function) was started call was ended with 911 (number used to contact emergency services), chest compressions were started without ambu bag (self inflating bag used to assist with breathing), head tilt chin lift until crash cart was brought to bed side. Completed 5 cycles of CPR were completed patient was reassessed eyes fixed and dilated (eye muscles relaxed and no visible signs of life), no caroid (two main arteries that carry blood to the head and neck) pulse palpated, no spontaneous breath sounds, CPR continued [Name of ambulance company] arrived at 7:26 am and took over CPR after completed several round of CPR patient was pronounced dead at 8:01 am. Wife was contacted and informed of his status via telephone and arrived at 7:55 am just before his death pronouncement. I. Record review of Vital sign sheet dated [DATE] to [DATE] revealed: 1. [DATE] at 11:51 pm BP ,d+[DATE], Respiration 22 per minute, Pulse 73 per minute, Temperature 98.4 Fahrenheit, O2 Saturation 93%. Oxygen Use at 5 liters 2. [DATE] at 6:55 am BP ,d+[DATE], at 9:33 am Temperature 96.9 , Pulse 114 per minute, at 9:38 am O2 saturations 61%. Oxygen use at 2 liters. 3. No other vital signs were recorded for R #7. J. On [DATE] at 10:21 am during an interview, FM #1 stated at about 7:23 am on [DATE], FM #1 received a call from RN #1 letting her know that he had gone to check on her husband and he did not have any O2 on and he was working on him [staff were providing life saving measures-CPR- Cardiopulmonary resuscitation emergency procedure used to manually preserve brain function] at that time. FM #1 arrived at facility before 8:00 am and was told visiting hours were not until 8:00 am and was told she could not enter the facility. She was met by Social Services Assistant at the facility entrance door and was told she need to call a mortuary to come pick up the body. The body was removed from the facility about 8:00 pm. K. Record review of Record of Death and Mortician's Receipt dated [DATE] revealed R #7 expired at 8:01 am on [DATE]. L. On [DATE] at 11:56 am during an interview with RN #1, he stated. At about 6:55 am the CNA (CNA #1) came to me and told me the patients O2 is at 64%, I ran down the hallway to assess him. I did not like his breathing pattern. I called 911 while I was on the phone with 911 we put a mask (oxygen mask) on him to get more O2 and put him on a high fowler position, he became unresponsive. I turned the O2 up to 5L it was set at 2L. I did 3 rounds of CPR by the time we got the crash cart in we started using the ambu bag when the ambulance arrive we had done 6 rounds of CPR and they switched to automatic compression device with no positive results. His wife was called and she arrived when they were calling the time of death. [Name of RN #2] was the night nurse and was assigned to this hallway. I was called and I jumped into emergency mode. I did not administer any medications nor do I know if his medications had arrived. I do know that his O2 was set at about 2L. I moved it to 5 L when I saw he was having breathing issues. M. On [DATE] at 2:23 pm during an interview with CNA #1, she stated. I was doing rounds about 7:00 am and I noticed he was having a had time breathing. I checked his O2 and it was real low I told [name of RN #1] to look at the patient and he went to get a mask (oxygen). His [R #7's] O2 was in the 60% we got it up to the 70's. [Name of RN #1] went to call 911 at that point his eyes were fixated I ran to get [name of RN #1] and we started compressions, the paramedics arrived and they did compressions. The wife arrived, it was all very fast. I know I was asked to bring in another concentrator because the one in the room was not filling up the bag and when I brought in the other concentrator the bag filled up immediately. I documented on my notes that when I checked the O2 it was at 2L. I do not know how many liters residents are to be at. I just document what they are at when I am doing my rounds. The nurses are the ones that set the liters according to the orders that is above my scope of practice. N. On [DATE] at 5:39 pm during an interview with the Administrator, she stated. I did an investigation and from my understanding, he (R #7) was admitted about 7:00 pm on [DATE] and expired on [DATE]. [Name of RN #2] was the night nurse the day R #7 was admitted . The nurse told me that the medications did not arrive with the resident and she was waiting for after hours (medications that are ordered from local pharmacy). RN #2 did not use the omicell (system that's helps acquire, dispense and provides medications on an as needed basis for emergency purposes). I would have expected her to use the omnicell to get the medications needed. We took the resident because his oxygen was stable and was at ,d+[DATE] liters. I wish the nurse would have assessed his anxiety because that is an indication of distress and does not help the fact that the nurse did not give the anxiety medication. We do not take titrate orders (oxygen adjusted based on residents needs) the nurses have to clarify a set amount of O2, he (R #7) came in with continuous O2 ordered with no liters indicated . RN #2 changed the orders herself to 5L. We spoke with the Physician and she stated she did not approve the 5L of O2. RN #2 wrote the order for 5L of O2 without consent from the Physician or without consulting any one else. When we admitted him (R#7) he was to be on 4L from my understanding, therapy later discovered in the notes from the hospital indicating that he (R #7) was on ,d+[DATE]L of O2 at the hospital prior to discharge. After he arrived he was stable aside from the anxiety that started and the wife requested medication for his anxiety. Nurse did not administer the anxiety medication because it had not arrived from the local pharmacy. Again I would have expected her to access it from the omnicell. Resident should not have gone without his medication when we have the omnicell. The above identified non-compliance resulted in a Past Non-compliance Immediate Jeopardy (IJ) at a scope and severity of J (a pattern of jeopardy to resident health and safety). A Plan of Removal was not required because the facility demonstrated current compliance relating to this deficiency by: 1. Identifying all current residents that have a history of respiratory distress/illnesses and require oxygen (O2). 2. Identifying all current residents that have scheduled and PRN (as needed) antianxiety medications ordered, while also providing the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. O2 monitoring checklist- Resident on how many liters, Oxygen by Physician Order, Pulse Oxygen Saturation level (percent), Pulse Rate, Level of Activity (lying, sitting, standing), and Does resident have any issue regarding Oxygen? 4. PRN antianxiety monitoring checklist- Is resident on PRN anxiety, Is PRN anitanxiety meds [medications] have been administered per physician order, Does resident complain about his PRN Antianxiety meds? 5. In-Service Summary and Attendance dated [DATE] which covered Medication Management Program 6. Medication Pass Review/ Checklist- Which included Infection Control, Med Cart/ Safety, Procedures, Documentation, and Enteral Procedures that was completed. 7. Staff Education/ Orientation Policies and Procedures- Nursing Medication Administration Observation Checklist. 8. QAPI (Quality Assurance and Performance Improvement) Planning and Execution Checklist. Surveyors conducted observations, record review, and interviews with selected residents and staff to confirm current facility compliance.

Based on record review and interview, the facility failed to meet professional standards of care for 1 (R #5) of 3 (R #5, 7, and 10) residents reviewed by not providing physical therapy services as ordered by a physician. This deficient practice likely resulted in R #5 to have a decrease in mobility and pain, preventing her from ambulating on her own and going to activities, likely resulting in psychosocial harm and despair. The findings are: A. Record review of R #5's face sheet revealed R #5 was admitted into the facility on [DATE]. B. Record review of R #5's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review of R #5's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .) Debility(physical weakness) 2/2 chronic comorbidities (more than one disease or condition present in the same person at the same time), PT [Physical Therapy]/ OT [Occupational Therapy] eval [evaluation]. D. Record review of R #5's Physical Therapy Evaluation and Plan of Treatment dated 11/09/21 revealed, Clinical Impressions: Pt [patient] is cooperative and motivated to participate in therapy but her functional mobility is currently limited by overall weakness and c/o [complains of] BLE [bilateral lower extremity] pain and tingling sensation; Reason for Skilled Services: Patient requires skilled PT [Physical Therapy] services to increase LE [Lower Extremity] ROM [Range of Motion] and strength, increase functional activity tolerance, increase independence with gait, promote safety awareness and enhance rehab potential in order to enhance patient's quality of life by improving ability to perform functional mobility with reduced risk of falls and return to prior level of functional abilities; and Risk Factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is at risk for: falls, further decline in function, immobility, increased agitation, increased dependency upon caregivers and increased pain. E. Record review of R #5's Electronic Health Record (EHR) Resident Documents page revealed R #5 was seen for Occupational Therapy on 10/01/21 and 10/11/21. R #5's first Physical Therapy appointment was on 11/09/21. F. Record review of R #5's Therapy Progress Note dated 11/15/21 revealed, History of Present Illness: She [R #5] was transferred to LTC [Longterm Care] and is frustrated that her PT [Physical Therapy] stopped. G. Record review of R #5's progress notes dated 11/22/21 revealed, Rsd [resident] was crying and feeling depressed about not getting regular physical therapy sessions she came to the facility for. Rsd (resident) stated that 'she was walking when she first got here about 3 months ago and now, she cant carry her own weight on her feet anymore, which makes her so sad'. Writer encouraged her to not be too hard herself and that the day shift nurse will be informed to follow up on the request for a PT schedule. Rsd received her PRN [as needed] pain meds [medications] to manage her pains. H. On 12/15/21 at 11:40 am during an interview with R #5, R #5 became emotionally distressed and stated, I didn't get therapy for a long time like I was supposed to. I couldn't get out of bed and I love going to the activity room to watch football. I told them I needed therapy. I'm still not getting it [therapy] like I should be. I thought I should be getting it [therapy] 3 times a week. She [Physical Therapist] just comes whenever and doesn't check on me. I. On 12/15/21 at 3:51 pm during an interview with Physical Therapist (PT) #1, she stated, She's [R #5] three times a week for physical therapy. She [R #5] was evaluated on 11/09/21. We get orders from the doctor to evaluate her [R #5]. She [R #5] was requesting therapy at that point, and it was patient driven. We got the referral and order from her [R #5's] doctor. She [R #5] was noted to have a decline in her functional mobility. She [R #5] had pain in her low back and legs, difficulty with mobility. Prior to that, I believe she [R #5] was walking herself to get to activities. She [R #5] said for about a week or, so she was unable to walk and was having pain. I know I was asked to screen her a week prior [to 11/09/21 PT evaluation] by our former Director of Rehab (DOR) and after that I was asked for an evaluation. She [R #5] had Occupational Therapy in October [2021], but it looks like it was just evaluation and one treatment. I'm not sure why it [R #5 PT evaluation and treatment] wasn't done sooner. PT #1 confirmed R #5 did not receive Physical Therapy in a timely manner from the 08/20/21 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] J. On 12/15/21 at 4:42 pm during an interview with the DOR, she stated, We submitted a request [for R #5 to receive therapy services sooner], and [Name of Business Office Manager] said we needed to wait for an approval which was going through [Name of previous Administrator]. DOR confirmed R #5's Physical Therapy should have been started sooner and it was not.

Based on interviews and record reviews, the facility failed to ensure 1 (R #1 ) of 8 (R #1, 2, 3, 4, 5, 6, 7, and 8) residents reviewed for abuse and neglect, received quality care. This deficient practice likely caused harm to a resident due to a change in condition going unidentified and addressed by staff; not providing timely assessments that were consistent, ongoing, and documented. The findings are: [NAME] On 12/19/19 at 8:30 am during an interview with R #1, he stated that he was sick for two or three days before he went to the hospital back in (MONTH) (2019). R #1 stated that Licensed Professional Nurse (LPN) #1 didn't want to send him to the hospital. R#1's friend came in on Monday, and she called 911. R #1 stated that he was so sick. R #1 also stated that he was in the hospital for about one week. R #1 stated that LPN #1 was not the only staff member that knew he was sick. R #1 became sick on Friday (09/20/19) before he went to the hospital on Monday (September 23 rd). He also stated that when he was sick he hadn't been eating much or going down to the dining room for meals. B. Record review of the nursing progress notes dated 09/22/19, indicated that at 9:57 AM, Resident c/o (complaint of) feeling sick and general malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify) T: (temperature) 99.1, R: (respirations) 20, B/P: (blood pressure); 101/68, O2: (oxygen); 94% On-call provider notified and received order to provide comfort care, Tylenol (relieves and comforts aches and pains) and [MEDICATION NAME] nasal spray (treats nasal congestion, sneezing, runny nose, and itchy or watery eyes caused by seasonal or year-round allergies [REDACTED]. Resident seemed satisfied with this and condition will be monitored for further changes. C. Record review of the nursing progress notes dated 09/23/19, indicated that at 4:02 AM RSD (resident) in bed resting quietly thru out the shift in NAD ( no acute distress) . RSD (resident) spiking a fever Tylenol 325 mg given with positive result. VS (vital signs) stable. RSD being monitoring closely during shift. Call light in reach. will cont. to monitor. D. Record review of the nursing progress notes dated 09/23/19, indicated that at 12:00 PM Resident sent out to hospital this shift for evaluation and treatment of [REDACTED]. E. Record review of the History and Physical dated 09/23/19 indicated that nursing is concerned that pt (patient) has confined himself to bed after c/o of malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify) x2 (days). He is ambulatory over the weekend and took his meals in the dining room. Today he is SOB (short of breath) with O2 sat in the 70's on 2L (liters) O2. His cough productive of thick green sputum, his fever 101, SOB with O2 sat 70's/ Symptoms are c/w (consistent with) pneumonia in pt with underlying [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS]. F. Record review of the hospital documentation indicated on 09/23/19 resident arrived to the hospital at 12:43 PM, presented with 4 days of Myalgias (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify) and fatigue. When (EMT's) arrived resident presented as hypoxic ([MEDICAL CONDITION] is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) and febrile (having or showing the symptoms of a fever) he was placed on a non re-breather (assist in the delivery of higher concentrations of oxygen). Resident was admitted with O2 at 68%. Resident was informed that he likely had dual shock of cardiac (widespread infection causing organ failure) and an element of mild septic shock (dangerously low blood pressure) with mostly cardiogenic shock (an acute physiological condition caused by the inability of the heart to pump sufficient blood for the needs of the body) Patient was not sent with medical reconciliation. (process of comparing a patient's medication orders to all of the medications that the patient has been taking). Multiple attempts were made to call the facility. [NAME] Record review of the hospital documentation Assessment and Plan indicated that R #1 was being treated for [REDACTED].(action taken to prevent disease). H. On 12/18/19 at 2:01 pm, during interview with the Complainant she stated that on that day the 23rd (09/23/19) mid-morning, she had been waiting at the nurses station and no one would acknowledge her. So she decided to go to R #1's room. She stated that R #1 told her that he wasn't feeling well and he looked like he was on his death bed. His roommate told her that R #1 had been very sick. At that time she stated that she told R #1 that she would be back and went to the nurses station and asked for the physician to see R #1. She stated that she asked a case worker to come and take a look at R #1 and caseworker told her that she couldn't because she was too busy. The complainant stated that she was so upset because he (R #1) could hardly breathe, he was lying in bed, gasping. She stated that LPN #1 came in and asked what's wrong (name of resident #1). She stated that she told him can't you see, this man is sick. She stated that then he told me that I shouldn't have called 911 because police and ambulances were going to come and that didn't look good. She stated that she told LPN #1 to leave the room. The physician came in and examined R #1 and she overheard her say that doesn't look good. The complainant also stated that they wanted to put him on life support when he got to the hospital, but R #1 didn't want that. I. On 12/19/19 at 10:05 am, during an interview with the Director of Nursing (DON), when asked what monitoring a resident entails, the DON stated that it depends on the physician's orders [REDACTED]. If there was a lung issue occurring with a resident than you would assess the lungs, or for gastrointestinal issues you would check on those areas. The DON agreed that all of this should be documented in the chart. [NAME] On 12/19/19 at 1:07 pm, during an interview with Licensed Professional Nurse (LPN) #1, he stated that from what he can remember R #1 had been sick a couple of days before they started monitoring him. LPN #1 stated that nothing serious had been going on with R #1. He stated that on that Monday (September 23rd) someone related to him, came in and called 911. LPN #1 stated that she (family friend) was the one that called 911. LPN #1 stated that the friend came to the nurse's station and told him that R #1 needed to be looked at by a nurse or provider. He went to the room and that is when she told him that she called 911. LPN #1 stated that he did go and find the physician and asked for the physician to look at R #1. The physician took his (R #1) vitals and noted a productive cough and a fever. The physician agreed that R #1 needed to be sent out to the hospital. LPN #1 also stated that monitoring a resident means frequent checks, frequent vital sign check, checking on them for any changes in condition. If there was an acute change in condition than the resident would need to be sent to the hospital. When asked about how R #1 looked to him, he stated R #1 seemed about the same that day as he had for the past couple of days. LPN #1 stated that he typically works Sunday and Monday (09/22/19 and 09/23/19). K. On 12/19/19 at 12:06 pm, during an interview with the Administrator, she remembers that this lady came in to visit with R #1 and was raising heck about him being sick. She wanted him sent out to the hospital. She really doesn't remember that much about the situation because she never became directly involved. She stated that the friend of R #1 never came to her or filed a grievance. L. On 12/20/19 at 8:57 am during an interview with the physician, she stated that this is a resident who will refuse medication at times, not wear his oxygen and has a lot of respiratory issues. The physician stated that R #1 is usually very chatty. She stated that when she examined him on the 23rd (09/23/19), he was not chatty, he was in bed, which was not normal, and it was obvious that he was uncomfortable. There was a significant change in condition for him from how he normally was to how he was that day. The physician stated that she would defer to what the facility standard would be for monitoring a resident. She stated that there is a difference between skilled nursing, long term care nursing and hospitals, so she would leave that to the facility. She stated that all vitals and monitoring would be expected to be documented. M. Record review of the Treatment Administration History dated 09/01/19 to 09/22/19 revealed oxygen saturation (measures percentage of hemoglobin binding sites in the bloodstream occupied by oxygen- value below 90% indicates oxygen deficiency) between 89% and 97%. No other record of vitals taken available.

Based on interviews and record reviews, the facility failed to ensure that staff members possessed the competencies and skill sets necessary to identify, provide timely nursing care and related services to meet the resident needs for 1 (R #1 ) of 8 (R #1, 2, 3, 4, 5, 6, 7, and 8) residents looked at for abuse and neglect. This deficient practice likely resulted in a resident's change in condition to go unidentified by not providing timely assessments, consistent, ongoing, and documented monitoring. The findings are: [NAME] On 12/19/19 at 8:30 am during an interview with R #1, he stated that he was sick for two or three days before he went to the hospital back in (MONTH) (2019). R #1 stated that Licensed Professional Nurse (LPN) #1 didn't want to send him to the hospital. R#1's friend came in on Monday, and she called 911. R #1 stated that he was so sick. R #1 also stated that he was in the hospital for about one week. R #1 stated that LPN #1 was not the only staff member that knew he was sick. R #1 became sick on Friday (09/20/19) before he went to the hospital on Monday (September 23rd). He also stated that when he was sick he hadn't been eating much or going down to the dining room for meals. B. Record review of the nursing progress notes dated 09/22/19, indicated that at 9:57 AM, Resident c/o feeling sick and general malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify) T: (temperature) 99.1, R: (respirations) 20, B/P: (blood pressure); 101/68, O2: (oxygen); 94% On-call provider notified and received order to provide comfort care, Tylenol (relievse and comforts aches and pains) and [MEDICATION NAME] nasal spray (treats nasal congestion, sneezing, runny nose, and itchy or watery eyes caused by seasonal or year-round allergies [REDACTED]. Resident seemed satisfied with this and condition will be monitored for further changes. C. Record review of the nursing progress notes dated 09/23/19, indicated that at 4:02 AM RSD (resident) in bed resting quietly thru out the shift in NAD ( no acute distress) . RSD (resident) spiking a fever Tylenol 325 mg given with positive result. VS (vital signs) stable. RSD being monitoring closely during shift. Call light in reach. will cont. to monitor. D. Record review of the nursing progress notes dated 09/23/19, indicated that at 12:00 PM Resident sent out to hospital this shift for evaluation and treatment of [REDACTED]. E. Record review of the History and Physical dated 09/23/19 indicated that nursing is concerned that pt (patient) has confined himself to bed after c/o (complaints) of malaise (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify) x2 (days). He is ambulatory over the weekend and took his meals in the dining room. Today he is SOB (short of breath) with O2 sat in the 70's on 2L (liters) O2. His cough productive of thick green sputum, his fever 101, SOB with O2 sat 70's/ Symptoms are c/w (consistent with) pneumonia in pt with underlying [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS]. F. Record review of the hospital documentation indicated on 09/23/19 resident arrived to the hospital at 12:43 PM, presented with 4 days of Myalgias (a general feeling of discomfort, illness, or uneasiness whose exact cause is difficult to identify) and fatigue. When (EMT's) arrived resident presented as hypoxic ([MEDICAL CONDITION] is a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) and febrile (having or showing the symptoms of a fever) he was placed on a non re-breather (assist in the delivery of higher concentrations of oxygen). Resident was admitted with O2 at 68%. Resident was informed that he likely had dual shock of cardiac(widespread infection causing organ failure) and an element of mild septic shock (dangerously low blood pressure) with mostly cardiogenic shock (an acute physiological condition caused by the inability of the heart to pump sufficient blood for the needs of the body) Patient was not sent with medical reconciliation. (process of comparing a patient's medication orders to all of the medications that the patient has been taking). Multiple attempts were made to call the facility. [NAME] Record review of the hospital documentation Assessment and Plan indicated that R #1 was being treated for [REDACTED].(action taken to prevent disease). H. On 12/18/19 at 2:01 pm, during interview with the Complainant she stated that on that day the 23rd (09/23/19) mid-morning, she had been waiting at the nurses station and no one would acknowledge her. So she decided to go to R #1's room. She stated that R #1 told her that he wasn't feeling well and he looked like he was on his death bed. His roommate told her that R #1 had been very sick. At that time she stated that she told R #1 that she would be back and went to the nurses station and asked for the physician to see R #1. She stated that she asked a case worker to come and take a look at R #1 and caseworker told her that she couldn't because she was too busy. The complainant stated that she was so upset because he (R #1) could hardly breathe, he was lying in bed, gasping. She stated that LPN #1 came in and asked what's wrong (name of resident #1). She stated that she told him can't you see, this man is sick. She stated that then he told me that I shouldn't have called 911 because police and ambulances were going to come and that didn't look good. She stated that she told LPN #1 to leave the room. The physician came in and examined R #1 and she overheard her say that doesn't look good. The complainant also stated that they wanted to put him on life support when he got to the hospital, but R #1 didn't want that. I. On 12/19/19 at 10:05 am, during an interview with the Director of Nursing (DON), when asked what monitoring a resident entails, the DON stated that it depends on the physician's orders [REDACTED]. If there was a lung issue occurring with a resident than you would assess the lungs, or for gastrointestinal issues you would check on those areas. The DON agreed that all of this should be documented in the chart. [NAME]On 12/19/19 at 1:07 pm, during an interview with Licensed Professional Nurse (LPN) #1, he stated that from what he can remember R #1 had been sick a couple of days before they started monitoring him. LPN #1 stated that nothing serious had been going on with R #1. He stated that on that Monday (September 23rd) someone related to him, came in and called 911. LPN #1 stated that she (family friend) was the one that called 911. LPN #1 stated that the friend came to the nurse's station and told him that R #1 needed to be looked at by a nurse or provider. He went to the room and that is when she told him that she called 911. LPN #1 stated that he did go and find the physician and asked for the physician to look at R #1. The physician took his (R #1) vitals and noted a productive cough and a fever. The physician agreed that R #1 needed to be sent out to the hospital. LPN #1 also stated that monitoring a resident means frequent checks, frequent vital sign check, checking on them for any changes in condition. If there was an acute change in condition than the resident would need to be sent to the hospital. When asked about how R #1 looked to him, he stated R #1 seemed about the same that day as he had for the past couple of days. LPN #1 stated that he typically works Sunday and Monday. K. On 12/19/19 at 12:06 pm, during an interview with the Administrator, she remembers that this lady came in to visit with R #1 and was raising heck about him being sick. She wanted him sent out to the hospital. She really doesn't remember that much about the situation because she never became directly involved. She stated that the friend of R #1 never came to her or filed a grievance. L. On 12/20/19 at 8:57 am during an interview with the physician, she stated that this is a resident who will refuse medication at times, not wear his oxygen and has a lot of respiratory issues. The physician stated that R #1 is usually very chatty. She stated that when she examined him on the 23rd (09/23/19), he was not chatty, he was in bed, which was not normal, and it was obvious that he was uncomfortable. There was a significant change in condition for him from how he normally was to how he was that day. The physician stated that she would defer to what the facility standard would be for monitoring a resident. She stated that there is a difference between skilled nursing, long term care nursing and hospitals, so she would leave that to the facility. She stated that all vitals and monitoring would be expected to be documented. M. Record review of the Treatment Administration History dated 09/01/19 to 09/22/19 revealed oxygen saturation (measures percentage of hemoglobin binding sites in the bloodstream occupied by oxygen- value below 90% indicates oxygen deficiency) between 89% and 97%. No other record of vitals taken available.

Based on observation, record review and interview, the facility failed to ensure that residents were free of neglect/abuse for 2 (R #s 32 and 231) of 4 residents (R #s 32, 86, 132 and 231) reviewed for neglect/abuse as a result of: 1. A Certified Nursing Assistant (CNA) allowing a vulnerable resident to fall from bed during her care due to not following appropriate procedures. 2. A nurse failing to notify a provider of a decrease in residents level of consciousness (L[NAME]) (the level of awareness of one's surroundings) and administering narcotic medication to a resident with a decreased level of consciousness. 3. R #32's continuous abused by her roommate despite the facility being informed of the problem occurring. These deficient practices likely resulted in R #32, suffering continuous abuse from her roommate and for R #231 her unsuccessful resuscitation and death. The findings are: Findings for R #231: [NAME] Record review of R #231's face sheet revealed the resident was admitted on [DATE]. Her [DIAGNOSES REDACTED]. B. Record review of R #231's Minimum Data Set (MDS), dated [DATE] revealed, the resident had no speech, needed extensive assistance (resident involved in activity, staff provide weight bearing support) for bed mobility and transfers with 2 person assist and extensive assist with one person assist for dressing and personal hygiene. She also required a tube feed for nutrition. C. Record review of R #231's nursing progress notes dated [DATE] revealed the following from Licensed Practical Nurse (LPN) #3: 1. 8:00 am CNA (Certified Nursing Assistant) called nurse to resident's room stat (immediately) .entered the room to find resident on floor on back with Certified Nursing Assistant (CNA) .CNA reported resident fell off of bed during a bed bath. Nurse (writer) placed pillow under patients head and began to assess for injury. Patient made eye contact with nurse and was blinking L (left) eye per usual in response to questions .neuro (neurological) checks (neurological checks at this facility included, eye opening, orientation, pain (using the GCS), also arm and leg movement, pupil response to light gag reflex and temperature, blood pressure , pulse and breathing) initiated .no injury noted at that time .MD (Medical Doctor) on call - (name of doctor) notified of fall and ordered to continue monitoring patient for s/sx (signs/symptoms) of injury or Mental Status Change .Nurse reported incident to Manager on Duty (MOD) (Social Services Director (SSD)) .Nurse called Patient's Mother .Mother was not reached at that time and there was no opportunity to leave voice message. 3. 9:00 am, no injury or mental status change noted at this time. 4. 11:30 am, Contact made with patient's mother .information given re: fall (first name of residents mother) .requested that prn (as needed) pain medicine pain med (medication)be given asap (as soon as possible) because of the possibility of R (right) Shoulder pain d/t (due to) chronic pain from prior injury to the area. PRN opioid (Tylenol #3) pain med given at this time without consulting the physician. 5. 12:00 pm, Family & nurse entered res (resident) room to find res pale, blue lips & fingernails (a sign of low oxygen in the blood). Difficulty detecting VS (vital signs, most often respirations, blood pressure and heart rate) pulse weak, resp (respirations, breaths) and irregular. 911 called. CPR (cardio [MEDICAL CONDITION] resuscitation) started and continued until EMTs (Emergency Medical Technicians) arrived and took over situation. D. Record review of a witness statement from the Social Services Director dated [DATE] revealed, Nurse (first name of LPN #3) also stated that CNA (first name of CNA #4) had rolled (name of R #231) away from her while bathing her and she fell from the bed. CNA was bathing resident alone. E. Record review of R #231's Neurological Evaluation Flow Sheet, (assess for changes in the residents brain and nervous systems) dated [DATE], included a Glasgow Coma Scale (GCS) (assessment of reduced levels of consciousness (L[NAME]) the GCS provides a score in the range ,[DATE]; patients with scores of ,[DATE] are usually said to be in a coma) dated [DATE] completed by LPN #3 revealed: 1. At 8:00 am, the GCS score was documented as, 15 (Resident opens eyes spontaneously). 2. At 8:45 am, the GCS was documented as, 7 (resident opens eyes to speech). 3. At 9:15 am, 9:45 am, 10:15 am, 10:45 am, the GCS was documented as, 5. (Resident does not open eyes even to pain). F. Record review of nursing progress notes revealed, [DATE] at 11:30 am, PRN (as needed) narcotic pain medication given at this time. There is no pain assessment documented prior to administration of the narcotic. G. Record review of provider orders revealed, on [DATE], Tylenol-[MEDICATION NAME] # 3, a narcotic pain medication mixed with a non-narcotic pain medication, .for pain level 4 + (four plus level of pain., indicates, distressing, strong pain.) H. Record review of witness statement of the SSD revealed that she, 8:,[DATE]:00 am: SSD checked on resident, resident's eyes were open and blinking but she was otherwise unresponsive to SSD's inquiry 11 am: SSD checked on resident, she was still unresponsive to SSDs inquiry, her eyes were open and blinking. I. On [DATE] at 10:33 am, during an interview, the Ombudsman revealed, She (R #231) understood what you said to her, she would blink her eyes, yes and no. [NAME] On [DATE] at 4:10 pm, during an interview the SSD revealed, she did not know the resident and did not know what was normal/not normal behavior for her. She did not know if the residents eye blinks were meaningful or not. She also confirmed that the provider was not notified of the residents decreased L[NAME]. K. Record review of a witness statement (not dated) by LPN #3 regarding events [DATE] the day of R # 231's death revealed: 1. 8 A (8:00 am) CNA called me (nurse 400 (unit)) to come to patient's room STAT (immediately) .patient lying on floor on her back .patient responded to speech with eye contact , eyes following, . 2. 10:45 A, Neuro (symbol for checks) continue. (symbol for no) abnormal findings BP (blood pressure) lower than earlier findings today but WNL (within normal limits). 3. 11 (the minutes indicated are not clear) Phone conversation (symbol for with) nurse and patients mother (first name of R #231's mother) urged staff to administer PRN pain med .PRN pain med- narcotic - given. 4. 11:45 A Staff and family entered patient room to assess. Patient appeared blue and pulse was irregular at 10/min (10 beats per minute) .called 911 requesting ambulance for patient who had become unresponsive. L. Record review of R #231's nursing progress note written by RN (Registered Nurse) #3, dated [DATE] at 6:33 am, revealed, On [DATE] at 1200 (12 noon) this writer was called to LTC (Long Term Care) . EMS (Emergency Medical Service/EMT) was already on the scene performing CPR .Patient was on the floor unresponsive with a reading (on the heart monitor) of asystole (no heart beat) .Patient was pronounced (pronounced dead) by this writer at 1302 (1:02 pm). M. Record review of employee interviews regarding residents death revealed (First name of LPN #3) was interviewed a second time in person on [DATE] by (names past administrator, current administrator and Director of Nursing (DON)). (First name of LPN #3) was asked to go through what happened with (name of R #231) on Saturday (resident died on Saturday [DATE]). She (LPN #3) stated she would have done differently she reported she would have called the provider when she noticed changes in the neuro checks and that she could not believe she missed a head injury. She reports her (R #231) respirations changed and she was not making sounds like staff reported she normally did. She noticed (these symptoms) around 9:,[DATE]:00 (am). N. Record review of the autopsy report dated [DATE] revealed This is a 53 yo (year old) woman with a history of motorcycle accident in 1989, choroid [MEDICATION NAME] (cells that produce cerebrospinal fluid in the brain) surgery in the 1990s and [MEDICAL CONDITION] (damage to brain from interruption of blood supply, ie stroke) in 2013 subsequent to an episode of pneumonia. She had a large left sided subdural hematoma (pool of blood between brain and covering) due to a fall out of bed in 2013 that was surgically evacuated. She has been at a skilled nursing facilities with G tube (Gastrostomy: tube inserted through the belly that brings nutrition directly to the stomach) placement and she had a history of [REDACTED]. She has documented cognitive communication deficit. She was seen to have fallen from her bed approximately 4 hours prior to death. The report also revealed that that upon examination there was an acute compression [MEDICAL CONDITION] vertebra (lower spine) and a [MEDICAL CONDITION] side of the sacrum (end of spine that intercepts with hip). A Review of the POS [REDACTED]. In summary the death was a result of injuries sustained from a fall from bed in a vulnerable patient the cause of death is certified to be due to a fat embolism due to [MEDICATION NAME] trauma. O. On [DATE] at 8:50 am the Director of Nursing (DON) confirmed that LPN #3 and CNA #4 had completed competency evaluations at the facility and that if the competency check sheets were initialed they had been assessed as competent for that skill. P. Record review of skills check off sheet for CNA #4 dated [DATE] she had been checked (deemed competent/ Director of Nursing (DON)) by the nurse educator on a partial bed bath. Q. Record review of, Annual Skills Competency Check, dated [DATE] for LPN #3 revealed she was checked off (deemed competent/DON) on neurological checks and on pain management. R. On [DATE] at 11:15 am, during an interview with LPN #4 she stated that if a resident was nonverbal and had fallen, she would check the resident's vital signs, call the provider, family and send the resident to the hospital. She also stated that she was aware of the Glasgow Coma Scale and how to use it and would check the resident's pupils. S. On [DATE] at 11:20 am, during an interview with Registered Nurse (RN) #2 she stated that she was an agency nurse and had received training from the facility on neurological checks and use of the Glasgow Coma Scale. T. On [DATE] at 11:45 am, during an interview with RN #3 when asked what she would do for a resident after a fall, she stated that she would do neurological checks, get vital signs, call the doctor, report and follow the orders. She also stated that the Glasgow Coma Scale is part of the neurological check sheet. U. On [DATE] at 12:15 pm, during an interview with the Administrator she stated that they did training with staff after the incident with R #231. They did an inservice with the nurses on the incident ([DATE]) and emergency response that included neurological checks and Glasgow Coma Scale on [DATE]. They also did a training and competency check with the CNAs in (MONTH) 2019. V. Review of the nurse and CNA inservices indicated that the training's on neurological checks and use of the GCS had occurred between [DATE] and [DATE]. Based on record review and interview, non-compliance at Immediate Jeopardy occurred on [DATE] for R #231. The immediate Jeopardy was removed when R #231 died and no other resident were identified to be at risk. The scope and severity is reduced to level 3, H. Findings for R #32: W. On [DATE] at 10:39 am, during an interview, R #32 stated My roommate tells me all the time that she is going to steal everything I have and she steals from me all the time. She stated The other day she stole my walker and left it all the way down the long hall. She told me, if I wanted it back, I had to go get it and if I wanted to keep it, I should take care of it. She also stated She has also stolen my teeth (dentures), food, bathing stuff, blankets and clothes and she comes over to my side to get my things or look in my closet whenever she wants to, whether I am here or not. She also stated, (First name of R #31) told me that she tried on my teeth (dentures) and that she would have kept them, if they had fit her. During observation, it was noted that R #32 had used a white rope to tie down some personal items (blankets, a wheelchair, etc.) and she stated that she had to keep the pile of personal items between the window and her bed so that R #31 could not get to them very easily. The resident's son/power of attorney (POA) was present and stated, It's a shame that my mom has to live her life like this. They stated that since she moved in with R #31 about a month ago, R #31 has been harassing her and they have reported this to (first name of DON) every time something happens (2 or 3 times a week) and the DON told them on [DATE] that R #31 has dementia and there is nothing they can do about it. They also reported these issues to (first name of the Social Services Assistant (SSA)) at least once a week and she told them last week that she would come by sometime soon to discuss the roommate issues, but she hasn't yet. The resident's son/POA visits daily (usually in the morning). X. Record review of R #32's resident census history, revealed R #32 had been living with R #31 since [DATE]. Y. Record review of R #32's progress notes dated [DATE] to [DATE], revealed no documentation regarding a roommate issue. There were no related grievances filed or listed in the Compliant/Grievance Logs for (MONTH) & (MONTH) 2019. The facility's S[NAME]IAL SERVICES POLICIES AND PR[NAME]EDURES: COMPLAINTS/GRIEVANCES PR[NAME]ESS revised [DATE] states: 1. POLICY: The facility's Leadership will support the patient's/resident's right to voice complaints/grievances to the facility or other agencies or entity that hears grievances regarding concerns they have about services and treatment received including but not limited to the following: a. Treatment b. Care c. Failure to follow advanced directives d. Failure to providing information related to returning to the community e. Management of funds f. Lost articles g. Behavior of other patients/residents and staff h. Violations of resident rights i. Environmental issues (lighting, heat, etc.) 2. PR[NAME]EDURE: The facility's Leadership will accept grievances/complaints from the patient/resident, family member or visitor according to Facility Procedures and state specific rules and regulations. Grievances/Complaints are accepted by the following, but not limited to: a. Administrator b. Department manager or his/her designee c. Supervisor d. Unit manager Z. On [DATE] at 11:27 am, during an interview, the DON reported he had discussed roommate issues with R #32 and her son/POA a couple of times, but there was no plan to move either resident at this time. A[NAME] On [DATE] at 10:10 am, during an interview, R #58 stated that R #31 told her that she stole R #32's dentures and that she was going to keep them, but they didn't fit her. BB. On [DATE] at 2:35 pm, during an interview, the Administrator reported there was an issue between roommates R #31 and R#32, in which R #32 became frustrated with R #31 so they decided to move R #32 to another room on [DATE]. The Administrator was not aware of the issues until the SSA informed her on [DATE].

This is a repeat deficiency from a survey dated [DATE]. Based on interviews and record reviews, the facility failed to ensure that staff members possessed the competencies and skill sets necessary to provide nursing and related services for 1 (R #231) of 1 (R #231) resident reviewed for unexpected death by: 1. A Certified Nursing Assistant (CNA) allowed a vulnerable resident to fall from bed during her care due to not following appropriate procedures. 2. Nursing staff failed to notify the resident's provider when the Glasgow Coma Scale (GCS) (assessment of reduced levels of consciousness (L[NAME]) (decreased, from persons normal, response to surroundings), the first assessment that usually will change when there's neurological/[MEDICAL CONDITION]) results indicated new onset non-responsiveness. 3. Nursing staff administering opioid pain medication that has a side effect of causing sleepiness when the residents was being documented as having a decreased L[NAME] after a fall. These deficient practices likely resulted in the residents death: The findings are: [NAME] Record review of face sheet revealed the resident was admitted on [DATE]. Her [DIAGNOSES REDACTED]. B. Record review of R #231's Minimum Data Set (MDS), dated [DATE] revealed, the resident had no speech, needed extensive assistance (resident involved in activity, staff provide weight bearing support) for bed mobility and transfers with 2 person assist and extensive assist with one person assist for dressing and personal hygiene. She also required a tube feed for nutrition. C. Record review of R #231's nursing progress notes dated [DATE] revealed the following from Licensed Practical Nurse (LPN) #3: 1. 8:00 am CNA (Certified Nursing Assistant) called nurse to resident's room stat (immediately) .entered the room to find resident on floor on back with Certified Nursing Assistant (CNA) .CNA reported resident fell off of bed during a bed bath. Nurse (writer) placed pillow under patients head and began to assess for injury. Patient made eye contact with nurse and was blinking L (left) eye per usual in response to questions .neuro (neurological) checks (neurological checks at this facility included, eye opening, orientation, pain (using the GCS), also arm and leg movement, pupil response to light gag reflex and temperature, blood pressure , pulse and breathing) initiated .no injury noted at that time .MD (Medical Doctor) on call - (name of doctor) notified of fall and ordered to continue monitoring patient for s/sx (signs/symptoms) of injury or Mental Status Change .Nurse reported incident to Manager on Duty (MOD) (Social Services Director (SSD)) .Nurse called Patient's Mother .Mother was not reached at that time and there was no opportunity to leave voice message. 3. 9:00 am, no injury or mental status change noted at this time. 4. 11:30 am, Contact made with patient's mother .information given re: fall (first name of residents mother) .requested that prn (as needed) pain medicine pain med (medication)be given asap (as soon as possible) because of the possibility of R (right) Shoulder pain d/t (due to) chronic pain from prior injury to the area. PRN opioid (Tylenol #3) pain med given at this time without consulting the physician. 5. 12:00 pm, Family & nurse entered res (resident) room to find res pale, blue lips & fingernails (a sign of low oxygen in the blood). Difficulty detecting VS (vital signs, most often respirations, blood pressure and heart rate) pulse weak, resp (respirations, breaths) and irregular. 911 called. CPR (cardio [MEDICAL CONDITION] resuscitation) started and continued until EMTs (Emergency Medical Technicians) arrived and took over situation. D. Record review of a witness statement from the Social Services Director dated [DATE] revealed, Nurse (first name of LPN #3) also stated that CNA (first name of CNA #4) had rolled (name of R #231) away from her while bathing her and she fell from the bed. CNA was bathing resident alone. E. Record review of the, Neurological Evaluation Flow Sheet, dated [DATE] (a form that is meant to assess for changes in the residents brain and nervous systems) included a GCS score (score range is ,[DATE]; patients with scores of ,[DATE] are usually said to be in a coma). 1. At 8:00 am, the GCS score was documented as, 15 (Resident opens eyes spontaneously). 2. At 8:45 am, the GCS was documented as, 7 (resident opens eyes to speech). 3. At 9:15 am, 9:45 am, 10:15 am, 10:45 am, the GCS was documented as, 5 (Resident does not open eyes even to pain). F. Record review of LPN #3 witness statement (not dated) indicated she had a phone conversation with the resident's mother and the mother wanted her to give the resident her pain medication (Tylenol #3, an opioid) which she did. At the time the medication is documented as given the GCS is indicating the resident is likely comatose (a state of deep unconsciousness). G. Record review of provider orders revealed, on [DATE], Tylenol-[MEDICATION NAME] # 3, a narcotic pain medication mixed with a non-narcotic pain medication, .for pain level 4 + (four plus level of pain., indicates, distressing, strong pain.) H. Record review of nursing progress notes revealed, [DATE] at 11:30 am, PRN (as needed) opioid pain medication given at this time. There is no pain assessment documented prior to administration of the opioid (Tylenol #3). I. Record review of nursing progress notes on [DATE], revealed the provider was not notified when the residents neurological status decreased and that the resident subsequently expired at 1:02 pm on [DATE]. The provider had not been notified of the residents decreased L[NAME]. [NAME] Record review of the autopsy report dated [DATE] revealed This is a 53 yo (year old) woman with a history of motorcycle accident in 1989, choroid [MEDICATION NAME] (cells that produce cerebrospinal fluid in the brain) surgery in the 1990s and [MEDICAL CONDITION] (damage to brain from interruption of blood supply, ie stroke) in 2013 subsequent to an episode of pneumonia. She had a large left sided subdural hematoma (pool of blood between brain and covering) due to a fall out of bed in 2013 that was surgically evacuated. She has been at a skilled nursing facilities with G tube (Gastrostomy: tube inserted through the belly that brings nutrition directly to the stomach) placement and she had a history of [REDACTED]. She has documented cognitive communication deficit. She was seen to have fallen from her bed approximately 4 hours prior to death. The report also revealed that that upon examination there was an acute compression [MEDICAL CONDITION] vertebra (lower spine) and a [MEDICAL CONDITION] side of the sacrum (end of spine that intercepts with hip). A Review of the POS [REDACTED]. In summary the death was a result of injuries sustained from a fall from bed in a vulnerable patient the cause of death is certified to be due to a fat embolism due to [MEDICATION NAME] trauma. K. On [DATE] at 8:50 am the Director of Nursing (DON) confirmed that LPN #3 and CNA #4 had completed competency evaluations at the facility and that if the competency check sheets were initialed they had been assessed as competent for that skill. L. Record review of skills check off sheet for CNA #4 dated [DATE] she had been checked for skills including partial bed bath and checked off (deemed competent) by the nurse educator. M. Record review of, Annual Skills Competency Check, dated [DATE] for LPN #3 revealed she was checked off (deemed competent) on neurological checks and on pain management by a nurse educator. N. On [DATE] at 11:15 am, during an interview with LPN #4 she stated that if a resident was nonverbal and had fallen and hit their head, she would check the resident's vital signs, call the provider, family and send the resident to the hospital. She also stated that she was aware of the Glasgow Coma Scale and how to use it and would check the resident's pupils. O. On [DATE] at 11:20 am, during an interview with Registered Nurse (RN) #2 she stated that she was an agency nurse and had received training from the facility on neurological checks and use of the Glasgow Coma Scale. P. On [DATE] at 11:45 am, during an interview with RN #3 when asked what she would do for a resident after a fall with head injury, she stated that she would do neurological checks, get vital signs, call the doctor, report and follow the orders. She also stated that the Glasgow Coma Scale is part of the neurological check sheet. Q. On [DATE] at 12:15 pm, during an interview with the Administrator she stated that they did training with staff after the incident with R #231. They did an inservice with the nurses on the incident ([DATE]) and emergency response that included neurological checks and Glasgow Coma Scale on [DATE]. They also did a training and competency check with the CNAs in (MONTH) 2019. R. Review of the nurse and CNA inservices indicated that the training's on neurological checks and use of the GCS had occurred between [DATE] and [DATE]. Based on record review and interview, non-compliance at Immediate Jeopardy occurred on [DATE] for R #231. The immediate Jeopardy was removed when R #231 died and no other resident were identified to be at risk. The scope and severity is reduced to level 3, H.

Based on record review, interview and observation, the facility failed to make prompt efforts to resolve a resident grievance for 1 of 1 (R #s 32) residents reviewed. This deficient practice is likely to result in continued resident to resident abuse and the residents' rights not being honored. The findings are: Findings for R #32: [NAME] On 08/07/19 at 10:39 am, during an interview, R #32 stated My roommate tells me all the time that she is going to steal everything I have and she steals from me all the time. She stated The other day she stole my walker and left it all the way down the long hall. She told me, if I wanted it back, I had to go get it and if I wanted to keep it, I should take care of it. She also stated She has also stolen my teeth (dentures), food, bathing stuff, blankets and clothes and she comes over to my side to get my things or look in my closet whenever she wants to, whether I am here or not. She also stated, (First name of R #31) told me that she tried on my teeth (dentures) and that she would have kept them, if they had fit her. During observation, it was noted that R #32 had used a white rope to tie down some personal items (blankets, a wheelchair, etc.) and she stated that she had to keep the pile of personal items between the window and her bed so that R #31 could not get to them very easily. The resident's son/power of attorney (POA) was present and stated, It's a shame that my mom has to live her life like this. They stated that since she moved in with R #31 about a month ago, R #31 has been harassing her and they have reported this to (first name of DON) every time something happens (2 or 3 times a week) and the DON told them on 08/06/19 that R #31 has dementia and there is nothing they can do about it. They also reported these issues to (first name of the Social Services Assistant (SSA)) at least once a week and she told them last week that she would come by sometime soon to discuss the roommate issues, but she hasn't yet. The resident's son/POA visits daily (usually in the morning). B. Record review of R #32's resident census history, revealed R #32 had been living with R #31 since 07/11/19. C. Record review of R #32's progress notes dated 07/07/19 to 08/06/19, revealed no documentation regarding a roommate issue. There were no related grievances filed or listed in the Compliant/Grievance Logs for (MONTH) & (MONTH) 2019. The facility's S[NAME]IAL SERVICES POLICIES AND PR[NAME]EDURES: COMPLAINTS/GRIEVANCES PR[NAME]ESS states: 1. POLICY: The facility's Leadership will support the patient's/resident's right to voice complaints/grievances to the facility or other agencies or entity that hears grievances regarding concerns they have about services and treatment received including but not limited to the following: a. Treatment b. Care c. Failure to follow advanced directives d. Failure to providing information related to returning to the community e. Management of funds f. Lost articles g. Behavior of other patients/residents and staff h. Violations of resident rights i. Environmental issues (lighting, heat, etc.) 2. PR[NAME]EDURE: The facility's Leadership will accept grievances/complaints from the patient/resident, family member or visitor according to Facility Procedures and state specific rules and regulations. Grievances/Complaints are accepted by the following, but not limited to: a. Administrator b. Department manager or his/her designee c. Supervisor d. Unit manager D. On 08/07/19 at 11:27 am, during an interview, the DON reported he had discussed roommate issues with R #32 and her son/POA a couple of times, but there was no plan to move either resident at this time. E. On 08/08/19 at 10:10 am, during an interview, R #58 stated that R #31 told her that she stole R #32's dentures and that she was going to keep them, but they didn't fit her. F. On 08/15/19 at 2:35 pm, during an interview, the Administrator reported there was an issue between roommates R #31 and R#32, in which R #32 became frustrated with R #31 so they decided to move R #32 to another room on 08/08/19. The Administrator was not aware of the issues until the SSA informed her on 08/08/19.