Every finding on record at White Sands Healthcare

Based on record review, observation, and interviews, the facility failed to obtain consent from a resident representatives prior to giving a significant haircut to a resident living on the memory care unit for 1 (R #2) of 4 (R #1, R #2, R #3 and R #4) residents reviewed. This deficient practice could likely result in residents feeling a loss of humanity and dignity. The findings are: A. Record review of the facility's admission Agreement, dated 12/2023, revealed the facility may share medical information with family to identify a surrogate decision maker when an individual was incapacitated and unable to give or receive information. B. Record review of R #2's admission Record revealed R #2 was admitted into the facility on [DATE] with the following diagnoses: 1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), with severe behavioral disturbances,2. History of traumatic brain injury (TBI; head or neck injury). C. Record review of R #2's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment, dated 04/13/26, revealed R #2's Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) was 00, severe impairment. D. Record review of R #2's skilled evaluation, dated 04/09/26, revealed the resident had impaired decision-making ability. E. On 06/24/26 at 1:32 pm, during an observation and interview, R #2 had short hair, and the length was to her ears. R #2 was unable to say if she liked the length of her hair. F. On 06/23/26 at 2:44 pm, during an interview, R #2's husband stated he was upset when the facility cut R #2's hair without consulting him first. He stated his wife always had long hair that reached her mid back. He stated the facility cut her hair very short, above her ears. G. On 06/24/26 at 1:37 pm, during an interview, the Memory Care Activities Director (AMC) stated the facility should notify the family or representative of a resident in the memory care unit prior to scheduling haircuts. She stated R #2's husband was the decision maker for the resident. She stated they called R #2's husband before they cut the resident's hair, but he did not answer. The AMC stated they went ahead and cut R #2's hair. The AMC stated R #2 consistently had hair in her face and would not allow staff to brush or style her hair out of her face. The AMC stated she was concerned for R #2 safety. H. On 06/24/26 at 1:57 pm, during an interview, the Administrator (ADM) stated it was her expectation for staff to notify resident representatives prior to cutting a resident's hair in memory care. She stated it was also her expectation for staff to document the consent in the resident's progress notes. She staff should also document any safety concerns regarding a resident in the resident's record. She stated staff should have notified R #2's representative prior to cutting R #2's hair.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 3 (R #2, R #6, and R #9) of 5 (R #2, R #5, R #6, R #9, and R #31) residents reviewed for unnecessary medications, when staff failed to:1. Ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record for R #2.2. Ensure as needed psychotropic medications are limited to only 14 days or indicate the duration of the as needed (PRN) order for R #9.These deficient practices could likely lead to adverse drug effects and poor patient outcomes. The findings are:R #2 A. Record review of R #2's admission Record revealed R #2 was admitted to the facility on [DATE] with the following diagnoses: 1. Unspecified mood disorder (mental health condition that is characterized by a persistent feeling of sadness, hopelessness, and loss of interest or pleasure in activities that were once enjoyable), 2. Generalized anxiety disorder (an overall feeling of fear or apprehension), 3. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 4. Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety), 5. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), B. Record review of R #2's physician's order dated 07/28/24 for divalproex sodium, five-hundred milligrams (mg) to be given by mouth two times a day for mood stabilizer. C. Record review of R #2's physician's order dated 05/02/25 for quetiapine fumarate, one-hundred mg to be given by mouth two times a day for mood disorder. D. On 03/12/26 at 10:30 am, during an interview with the Director of Nursing (DON), she confirmed the following: 1. R #2's indicated use of divalproex sodium is mood stabilizer, 2. R #2 does not have a diagnosis for mood stabilizer, 3. R #2's indicated use of quetiapine fumarate is mood disorder, 4. R #2 does not have a diagnosis for mood disorder, nor does mood stabilizer qualify as a specific condition for prescribing quetiapine fumarate. 5. Medications should be documented to treat specific conditions as diagnosed and these were not. R #6 E. Record review of R #6's admission Record revealed R #6 was admitted to the facility on [DATE] with the following diagnoses: 1. Peripheral vascular disease (PVD; poor circulation), 2. Extramedullary plasmacytoma not having achieved remission (a rare type of plasma (liquid part of the blood) cell neoplasm (cancer) that occurs outside the bone marrow (a soft fatty substance in the cavities of bones, in which blood cells are produced). F. Record review of R #6's physician's order dated 12/11/25 for aspirin oral chewable tablet, eighty-one mg to be given by mouth once a day for prophylactic measures. G. Record review of R #6's physician's order dated 12/12/25 for Bactrim DS (an anti-infective) oral tablet 800-160 mg (Sulfamethoxazole-Trimethoprim) to be given once a day for chemotherapy. H. On 03/12/26 at 10:30 am, during an interview with the DON, she confirmed the following: 1. R #6's indicated use of aspirin is prophylactic measures, 2. R #6 does not have a diagnosis for prophylactic measures, nor does prophylactic measure stand as a diagnosis, 3. R #6's indicated us of Bactrim DS is chemotherapy, 4. R #6 does not have a diagnosis for chemotherapy. 5. Medications should be documented to treat specific conditions as diagnosed and these were not. R #9 I. Record review of R #9's admission Record revealed R #9 was admitted to the facility with the following diagnoses: 1. Dementia, 2. Anxiety (feelings of fear or apprehension), 3. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 4. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 5. Seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). J. Record review of R #9's physician record revealed: 1. An order dated 12/01/25 for Lorazepam oral tablet 0.5 mg to be given by mouth every four hours as needed for anxiety. 2. An order dated 12/19/25 for Temazepam oral capsule fifteen mg to be given by mouth as needed for insomnia (a common sleep disorder) at bedtime. K. On 03/12/26 at 10:27 am, the DON confirmed the PRN psychotropic medications Lorazepam and Temazepam for R #9 did not have a stop date and did not have a rational to extend the use of the medications.

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 2 (R #9 and R #31) of 4 (R #5, R #9, R #11, and R #31) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are: R #9A. Record review of R #31's physician's orders revealed an order dated 08/13/25 for Aspirin enteric coating (EC; Specialized barrier to oral medications to prevent dissolution in the acidic stomach) oral tablet eighty-one milligrams (mg) to be given by mouth in the morning for analgesic (pain medication).B. Record review of R #31's quarterly MDS assessment dated [DATE] revealed R #9 does not receive scheduled pain medications.C. On 3/12/25 at 10:03 am, during an interview with MDS Coordinator (MDS), she confirmed R #9 's quarterly MDS is inaccurate because she does take Aspirin for pain regularly.R #31D. Record review of R #31's physician order dated 09/22/23 for Depakote (anti-convulsant medication) tablet 250 milligrams mg to be given by mouth three times a day for major depressive disorder.E. Record review of R #31's quarterly MDS assessment dated [DATE] revealed R #31 does not take anticonvulsant medication. F. On 3/12/25 at 10:03 am, during an interview with MDS, she confirmed that Depakote is an anticonvulsant and the quarterly MDS for R #31 is inaccurate.

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) for 2 (R #114 and R #115) of 4 (R #5, R #9, R #114 and R #115) 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: R #114 A. Record review of R #114 admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar), 2. Hyperlipidemia (a condition in which there are high levels of fat particles in the blood; high cholesterol), 3. Obstructive sleep apnea (OSA; a common sleep disorder), B. Record review of R #114's electronic health record revealed no baseline care plan. C. On 03/12/26 at 10:27 am, during an interview with the Director of Nursing (DON), she confirmed there was not a baseline care plan to include minimum healthcare information necessary to properly care for R #114 and this does not meet her expectations. R #115 D. Record review of R #115's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Thrombosis of atrium (a condition where blood clots form in the atria of the heart), and ventricle as current complications following an acute myocardial infarction (heart attack), 2. Enterocolitis due to clostridium difficile (C. Diff.; a bacterium that causes inflammation of the colon and is primarily associated with antibiotic use), 3. Type 2 diabetes mellitus, 4. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), 5. Anxiety (feelings of fear or apprehension), 6. Epilepsy (a seizure disorder), 7. Retention of urine. E. Record review of R #115's baseline care plan dated 03/09/26 revealed only the date was completed, no other information is included. F. On 03/12/26 at 10:00 am, during an interview with the DON, she confirmed that R #115's baseline care plan does not meet her expectations because it should have been completed accurately and within 48 hours and it was not.

Based on observation and interview, the facility failed to ensure food was served under sanitary conditions when staff failed to follow safe food handling practices when they:1. Touched the rims of cups while serving residents' drinks.2. Failed to sanitize their hands after touching dirty (items that may be soiled or contaminated) and serving residents' meals. These deficient practices are likely to affect all 111 residents listed on the resident census list provided by the Administrator on 03/08/26 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and stored properly.The findings are:A. On 03/08/26 at 12:16 pm, an observation of the lunch dining services revealed the following:1. Licensed Vocational Nurse (LVN) #3 assisted R #82 into the dining area by holding her hand and walking with her. LVN #3 then served R #92 her lunch meal without washing or sanitizing her hands. 2. LVN #3 served R #47's meal and touched the cup by the top of the rim when placing it on the table.3. LVN #3 served R #36's meal and touched the cup by the top of the rim when placing it on the table.4. Certified Nurse Aide (CNA #1) assisted R #95 with putting on a clothing protector and then served R #155. Business Office Manager (BOM) served R #89's meal and touched the cup by the top of the rim when placing it on the table.6. BOM served R #107's meal and touched the cup by the top of the rim when placing it on the table.7. Hospitality Aide (HA) #1 touched R #2's shoulder and then served R #20 his lunch meal without washing or sainting his hands.B. On 03/08/26 at 12:47 pm during an interview with the Licensed Vocational Nurse (LVN) #1, he confirmed that staff should be sanitizing or washing their hands after touching dirty surfaces and handling food items and trays. LVN #1 stated that staff should never touch dishes by the rim when serving.

Based on record review and interview, the facility failed to ensure the PASARR (Preadmission Screening and Resident Review) Level I Identification Screen was accurate for 2 (R #68 and R #98) of 5 (R #1, R #2, R #10, R #68, and R #98) residents reviewed for PASARR screening. If the facility does not ensure PASARR screenings are completed accurately, then residents with serious mental illness may not receive required evaluations or specialized services, placing them at risk for unmet mental health needs and a decline in psychosocial well-being. The findings are:R #68 A. Record review of R #68's admission Record revealed R #68 was admitted to the facility on [DATE] with the following diagnoses: 1. Metabolic encephalopathy (is a change in how your brain works due to an underlying condition), 2. Generalized anxiety disorder (GAD; is a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things), 3. Hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and Hemiparesis (one-sided muscle weakness) following 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) affecting right dominant side, 4. Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease). B. Record review of R #68's PASARR form dated 08/23/25 revealed R #68 does not have a suspected mental illness diagnosis. C. On 03/12/26 at 10:48 am, during an interview with the Director of Nursing (DON), she confirmed that the diagnosis of GAD should have been indicated on the PASARR form for R #68 and it was not. R #98 D. Record review of R #98's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's disease (a progressive mental deterioration), 2. Encounter for therapeutic drug level monitoring, 3. Delusional disorders (a serious mental health condition characterized by persistent, false beliefs that are not based on reality), 4. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment) with agitation and anxiety (feelings of fear or apprehension), 5. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), 6. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) with psychotic features (symptoms of psychosis such as delusions or hallucinations), 7. Anxiety disorder, 8. Obsessive compulsive disorder (a disorder that features unwanted thoughts and fears as obsessions), 9. Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety), 10. Panic disorder (an anxiety disorder characterized by frequent and unexpected panic attacks). E. Record review of R #98's hospital discharge paperwork dated 01/03/26 revealed R #98 was admitted to this behavioral health hospital on [DATE] and received in-patient care until her discharge on [DATE]. F. Record review of R #98's PASARR form dated 12/18/25 revealed R #98 does not have a diagnosis or suspected mental illness. G. On 03/12/25 at 10:00 am, during an interview with the DON, she confirmed that R #98's PASARR form does not meet her expectations because it is not correct.

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 2 (R #8 and R #59) of 8 (R #1, R #2, R #4, R #6, R #7, R #8, R #10, and R #59) residents reviewed when staff failed to: -Revise R #8's care plan using his name, not another resident's name.-Revise R #59's care plan to indicate a fall mat was in use.These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated accurately. The findings are:R #8 A. Record review of R #8's care plan, dated 02/17/26 revealed the following: 1. Focus areas for enhanced barrier precautions revealed Nursing to educate [Name of other resident] and/or family members on the evidence-based practice justification for utilizing enhanced barrier precautions when providing direct care. 2. Focus area for vision revealed the use of another resident's name in the interventions. B. On 03/12/26 at 10:30 am, during an interview with the Director of Nursing (DON) she confirmed other residents' names were used in R #8's care plan. R #59 C. Record Review of R #59's admission Record revealed she was admitted to the facility on [DATE] with the following diagnoses: Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), Age-related nuclear cataract (is the clouding and hardening of the central part of the eye's lens) right and left eye, Generalized anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities), Insomnia (common sleep disorder that can make it hard to fall asleep or stay asleep). D. On 03/08/26 at 1:24 pm, during a random observation of R #59, R #59 was up walking around her room, and a fall mat was noted to be lying on the floor by R #59's bed. E. Record review of R #59's care plan dated 12/02/25 revealed no indications that R #59 uses a fall mat. F. On 03/12/26 at 10:50 am, during an interview with DON, she stated anytime a resident uses a fall mat, it must be included in the care plan. The DON confirmed R #59's care plan does not include the use of a fall mat.

Based on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #9) of 5 (R #2, R #4, R #8, R #9, and R #31) residents reviewed for respiratory care when the facility failed to ensure medical orders indicated when to administer R #9's oxygen. These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions. The findings are:A. Record review of R #9's admission Record revealed R #9 was admitted to the facility on [DATE] with the following diagnoses:1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),2. Anxiety (feelings of fear or apprehension),3. Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs),4. Major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life),5. Seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures),6. Chronic obstructive pulmonary disease (COPD; lung disease).B. Record review of R #9's physician order dated 02/24/26 for oxygen 1-3 liters per minute (LPM) per nasal cannula (flexible tube with two prongs inserted into the nostrils to deliver supplemental oxygen) via oxygen concentrator (a medical device that concentrates oxygen and delivers it to someone that needs supplemental oxygen) and/or oxygen tank (aluminum or steel containers storing compressed oxygen for medical respiratory support).C. On 03/10/26 at 8:32 am during a random observation of the activity room, R #9 was observed wearing a nasal canula connected to a portable oxygen concentrator.D. On 03/12/26 at 10:27 am, during an interview with the Director of Nursing (DON), she confirmed R #9's order for oxygen use does not specify the frequency (as needed or continuous) that R #9 needs and it should.

Based on observation, record review, and interview, the facility failed to obtain appropriate physician orders prior to installation of bed rails for 1 (R #5) of 3 (R #5, R #11, and R #31) residents reviewed for bedrails. This deficient practice could result in the physician, staff, and residents not knowing the needs, risks and benefits of bed rails. The findings are:A. Record review of R #5's admission Record revealed R #5 was admitted to the facility on [DATE].B. Record review of R #5's physician orders revealed no order for the use of bedrails.C. On 03/09/26 at 2:12 pm, a random interview and observation of R #5's room revealed quarter size bedrail on the upper left side of the bed. R #5, he confirmed he uses the side rail for mobility and repositioning himself. D. On 03/12/26 at 10:27 am, during an interview with the Director of Nursing (DON), she confirmed the R #5 does not have physician orders for use of bedrails and should prior to installation of the bedrail.

Based on observation and interview, the facility failed to post nurse staffing data daily at the beginning of the shift that included the following:- Facility name.-The current date.-The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift.1. Registered nurse,2. Licensed practical nurse,3. Certified nurse aides,4. Resident census.The deficient practice has the potential to affect all 111 residents as identified by the census provided by the Administrator (ADM) on 03/08/26 and could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 03/09/26 at 10:01 am a random observation of the facility revealed the facility's staff data posting was dated 03/08/26.B. On 03/09/26 at 10:07 am, during an interview with the Registered Nurse (RN) #1, she confirmed the staff data posting was dated 03/08/26 and had not been updated. She confirmed it should be updated daily but was not.

Based on observation, interview, and record review, the facility failed to ensure all medications were not expired in the medication storage room. This deficient practice has the potential to affect any resident requiring emergency opioid overdose reversal by providing a medication with potentially reduced efficacy. The findings include:A. On [DATE] at 11:17 am, during an observation of the medication storage room, a vial of Naloxone 0.4 mg/ml, one milliliter (ml) as needed (PRN) injection was located in the medication refrigerator. The manufacturer's expiration date printed on the vial was 12/2025.B. On [DATE] at 11:30 am, during an interview with the Director of Nursing (DON), she confirmed the Naloxone vial was expired and stated it should have been removed from the refrigerator and placed in the designated pharmacy return or destruction area.C. A review of the facility's Medication Storage and Expiration pharmacy policy and procedure manual revised in 09/2010, revealed staff are required to audit medication storage areas on a regular basis and remove any medications that have reached their expiration date.

Based on observation, record review, and interview, the facility failed to maintain proper infection prevention measures for 2 (R #5 and R #115) of 4 (R #4, R #5, R #10, and R #115) residents reviewed by not:1. Ensuring Personal Protective Equipment (PPE) was properly used,2. Ensuring Enhanced Barrier Protection (EBP) signage is visibly posted and PPE is available near resident's room when precautions are in place.These deficiencies place residents at risk of contracting infections, hospitalization, and death. The findings are: A. On 03/09/26 at 11: 42 am, during a random observation of the 300 hall, Certified Nurse Aide (CNA) #2 was observed exiting room [ROOM NUMBER] wearing a gown and gloves. B. On 03/09/26 at 11:43 am during an interview with CNA #2, she confirmed she should not have exited the room wearing her PPE and is required to take off her PPE prior to exiting the room but did not. C. On 03/09/26 at 1:37 pm during an interview with the Infection Prevention Coordinator (IPC). She stated that her expectation is for staff to don (put on) PPE prior to entering and doff (take off) prior to exiting the room. Staff should put on new PPE anytime they are re-entering the room to provide care. D. On 03/08/26 at 9:37 am, a random observation of the facility revealed no signage or PPE available near R #115's door/room. E. Record review of R #115's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Enterocolitis due to clostridium difficile (C. Diff.; a bacterium that causes inflammation of the colon and is primarily associated with antibiotic use), 2. Retention of urine. F. On 03/08/26 at 10:22 am, during an observation and interview with R #115, a plastic tube connected to a bag collecting urine was observed on the side of R #115's leg. R #115 confirmed that he was admitted to the facility with the diagnosis of C. Diff. and with the use of a foley catheter (a thin, sterile tube inserted into the bladder to drain urine). G. On 03/09/26 at 11:02 am, during an interview with Licensed Vocational Nurse (LVN) #2, he confirmed that EBP should be in place due to R #115's current use of a catheter and diagnosis of clostridium difficile.

Based on record review and interview, the facility failed to keep a resident free from abuse for 1(R #4) of 8(R #1-8) residents reviewed for abuse when Nurse Aide in Training (NAIT) #2 was verbally and physically abusive to R #4 when providing care. This deficient practice likely resulted (based upon the reasonable person standard) in R #4 experiencing emotional distress and trauma. The findings are:A. Record review of R #4's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment),2. Anxiety (feelings of fear or apprehension) disorder,3. Legal blindness (inability to see),4. Cerebrovascular disease (refers to a group of disorders affecting blood flow to the brain, leading to conditions such as stroke, aneurysms, and vascular malformations).B. Record review of R #4's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 08/22/25, revealed a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 1 (severe impairment).C. Record review of R #4's care plan dated 07/31/25 revealed the following:1. R #4 is dependent on staff for meeting his emotional, intellectual, physical, and social needs.2. R #4 has a self-care deficit related to activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating).D. Record review of the facility's Reportable Incident form dated 09/05/25 revealed NAIT #2 was popping (to strike or knock sharply) R #4 on the mouth, told R #4 to hush and covered R #4's mouth with her hand.E. Record review of R #4's progress note dated 08/29/25 revealed the following:1. CNA #1 reported to LPN #1 on 08/22/25 that NAIT #2 slapped R #4 and covered his mouth.2. CNA #1 provided an audio recording of the incident.F. Record review of CNA #1's written witness statement dated 08/28/25 revealed NAIT #2 became agitated with R #4 and slapped R #4 on the mouth and told him to hush. NAIT #2 aggressively placed R #4 into the sit and stand machine (an adaptive device used to aid a person from a sitting to standing position) and when R #4 continued to speak, NAIT #2 put her hand over R #4's mouth. After putting R #4 to bed, NAIT #2 threw R #4's feet up and told him to go to sleep. R #4 then stated that he needed to urinate, and NAIT #2 told him to urinate in his brief.G. On 10/21/25 multiple attempts were made to reach CNA #1 via phone calls (8:50 am, 8:51 am, and 12:44 pm) and a text message (at 12:46 pm). There was no reply or returned call from CNA #1.H. Record review of NAIT #2's written witness statement dated 08/29/25 revealed the following:1. NAIT #2 admitted to telling R #4 to hush while preparing to use the sit and stand machine.2. NAIT #2 denied ever hitting R #4 and admitted to playfully tapping him while he was talking.I. Record review of Licensed Practical Nurse (LPN) 1's written witness statement dated 09/08/25 revealed on 08/29/25, CNA #1 witnessed and reported to her that NAIT #2 slapped R #4, covered R #4's mouth, and was yelling at R #4 to shut up. CNA #1 provided an audio recording of this incident.J. Record review of the audio recording dated 08/22/25, provided by Administrator on 10/14/25 revealed CNA #1 recorded NAIT #2 verbally abusing R #4 by:1. Yelling at R #4 to hush and shut up,2. Mocking R #4 by repeating the same words he was saying,3. Saying .I want to thump the shit of him sometimes,4. Threatening R #4 by telling him that they are going to drop him because he doesn't know how to be quiet,5. Yelling instructions such as let go and hold on to R #4,6. Telling R #4 to urinate in his brief after R #4 said he needed to urinate.K. Record review of the NAIT #2's timecard revealed NAIT #2 worked at the facility 08/24/25, 08/27/25, and 08/28/25.L. On 10/14/25 at 3:25 pm, during an interview with R #4, he stated he was unable to recall the incident.M. Record Review of R #4's Trauma Informed assessment dated [DATE] indicated that R #4 had past childhood trauma in elementary school. R #4 indicated he still feels scared, helpless and horrified regarding this past trauma and experiences nightmares. R #4 also indicated he will go out of his way to forget past trauma. N. Record Review of R #4's Safe Survey (tool used to help identify residents' concerns with staff) dated 08/29/25 revealed R #4 is afraid of a staff member at the facility but unsure of their name.O. On 10/14/25 at 4:31 pm, during an interview with the Director of Nursing (DON), she stated once the facility was made aware of an allegation of abuse on 08/29/25 an investigation was initiated, and NAIT #2 was immediately placed on suspension. The DON confirmed that following the substantiation of the facility's investigation of abuse and NAIT#2's employment was terminated on 09/10/25. Based on interview and record review, Immediate Jeopardy (IJ) was identified, and the Administrator and Director of Nursing were notified in person on 11/17/25 at 6:15 pm.The facility took corrective action by providing an acceptable Plan of Removal (POR) on 11/18/25 at 1:55 pm which verified implementation of the plan of removal as of 09/03/25. Immediate Jeopardy was removed on 09/03/25, which constituted Past Non-Compliance IJ. Plan of removal:R #4 was immediately assessed by using a Trauma Informed Assessment. No immediate concerns noted. Completed 08/29/25.Tele-visit with Psych provider, agreed with Trauma Informed Assessment for R #4, no immediate trauma and will continue psych caseload. Completed 08/29/25.Safe survey for all facility residents were immediately initiated with no immediate concerns verbalized. Residents verbalized desire to continue living in facility and feel safe. Completed 09/03/25 and then again on 11/18/25.Referral for additional spiritual services for support within the community for R #4 via hospice team. Completed 08/29/25.R #4's Care Plan updated for trauma-informed care.Record review of R #4 records on 10/14/25 verified the above records.All staff were re-educated on 08/29/25 and 08/30/25.1. Abuse and neglect definition, signs and symptoms of abuse and reporting and when to report.2. Zero-tolerance expectation.3. Resident rights.4. Mandatory reporting within 2 hours.Record review of Training sign-in sheets on 10/14/25 verified staff training was conducted for all facility staff on 08/29/25 and then again on 09/30/25.Interviews with NAIT #1, CNA #1-3 on 10/14/25 verified that they received the above training.

Based on record review and interview, the facility failed to report an allegation of abuse for 1(R #4) of 8(R #1-8) residents reviewed for abuse, when staff waited 7 days to report witnessed staff to resident abuse. If the staff fail to report allegations of abuse to the facility administration, then corrective measured may not be acted on and the facility would be unable to assure residents are free from abuse. The findings are:Cross reference findings for F600A. Record review of R #4's complaint report dated 08/29/25 revealed on 08/22/25 an alleged incident of abuse had occurred as follows:- Certified Nurse Aide (CNA) #1 had witnessed NAIT (Nurse Aide in Training) #2 cover R #4's mouth with hand, tap his mouth with her hand, and told R #4 to shut up.-The incident was reported to the management team on 08/29/25. NAIT #2 continued to work until management was notified of incident. NAIT #2 remained in the unit and the residents in the unit were at risk for further abuse by the accused NAIT #2.B. Record review of facility timesheets identified that NAIT #1 worked at the facility on 08/22/25, 08/24/25, 08/27/25 and 08/28/25.C. On 10/14/25 at 2:40 pm during interview with Registered Nurse RN) #1 confirmed that CNA #1 told her about the incident on 08/22/25 and CNA #1 reported to RN #1 that she [CNA #1] didn't know what to do about it [reason for not reporting sooner.] RN #1 immediately reported what CNA #1 told her to the Unit Manager/LPN #2 on 08/29/25. D. On 10/14/25 at 2:42 PM during interview with the Director of Nursing (DON), she confirmed the facility failed to report the allegation of abuse within the required two-hour timeframe because she did not become aware of the allegation until 08/29/25. DON confirmed that the initial report was submitted to the State Agency on 08/29/25, seven days after the incident. Based on interview and record review, Immediate Jeopardy (IJ) was identified, and the Administrator and Director of Nursing were notified in person on 11/17/25 at 6:15 pm.The facility took corrective action by providing an acceptable Plan of Removal (POR) on 11/18/25 at 1:55 pm which verified implementation of the plan of removal as of 09/03/25. Immediate Jeopardy was removed on 09/03/25, which constituted Past Non-Compliance IJ. Plan of removal:R #4 was immediately assessed by using a Trauma Informed Assessment. No immediate concerns noted. Completed 08/29/25.Tele-visit with Psych provider, agreed with Trauma Informed Assessment for R #4, no immediate trauma and will continue psych caseload. Completed 08/29/25.Safe survey for all facility residents were immediately initiated with no immediate concerns verbalized. Residents verbalized desire to continue living in facility and feel safe. Completed 09/03/25 and then again on 11/18/25.Referral for additional spiritual services for support within the community for R #4 via hospice team. Completed 08/29/25.R #4's Care Plan updated for trauma-informed care.Record review of R #4 records on 10/14/25 verified the above records.All staff were re-educated on 08/29/25 and 08/30/25.1. Abuse and neglect definition, signs and symptoms of abuse and reporting and when to report.2. Zero-tolerance expectation.3. Resident rights.4. Mandatory reporting within 2 hours.Record review of Training sign-in sheets on 10/14/25 verified staff training was conducted for all facility staff on 08/29/25 and then again on 09/30/25.Interviews with NAIT #1, CNA #1-3 on 10/14/25 verified that they received the above training.

Based on interview and record review, the facility failed to ensure a Nurse Aide in Training (NAIT) completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 108 residents residing at the facility by allowing untrained staff to provide direct care to residents. The findings are:A. Record review of NAIT #1's personnel record reviewed the following:1. NAIT #2's hire date was 11/15/24.2. NAIT #2 became a Nurse Aid in training on 02/16/25.3. NAIT #2's date of Certified Nurse Aide certification was 8/26/25.B. Record review of NAIT #2's timesheet revealed NAIT #2 worked a total of 99 shifts between 02/16/25 and 08/26/25.C. On 10/14/25 at 5:29 pm, during an interview with the Human Resources Director (HRD), she confirmed NAIT #2 received her certification late and continued to work shifts during that time. She stated her expectation is for all nurse aids to become certified within four months.

Based on record review and interview, the facility failed to prevent an accident for 1 (R #1) of 1 (R #1) resident reviewed for falls, when the facility failed to ensure staff used a mechanical lift as required.This deficient practice resulted in R #1 falling and sustaining a Subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) was identified on (Computed Tomography; a medical imaging procedure that uses x-rays to create detailed cross-sectional images of the body) CT that required treatment at a hospital for higher level of care.A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] and currently has the following diagnoses:1. Type 2 Diabetes.2. Alzheimer's (brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks).3. Anxiety (feeling of unease, worry, or nervousness).4. Repeated Falls.5. Hypertension (A condition in which the force of the blood against the arty walls is too high).6. Epilepsy7. Muscle Weakness8. Parkinson's Disease B. Record review of R #1's nursing progress notes revealed the following:- On 06/19/25, staff documented the resident sent to the Emergency Department (ED) to evaluate and treat, status post fall.C. Record review of witness statements revealed the following:-On 07/01/25, Hospitality Aide (HA) stated she was in R #1's room when the fall occurred because she was doing 1:1 monitoring (a person that maintains constant visual observation of a resident to ensure resident safety). She stated that R #1 was placed in a mechanical lift sling by CNA #1 without assistance from other staff. She stated once CNA #1 had R #1 in the mechanical lift sling, she raised R #1 in the air when she heard a snap and R #1 fell out of the sling. R #1 fell to the floor, hitting his legs on the corner of the mechanical lift and his head on the base of the mechanical lift.-On 07/01/25, Certified Nursing Aide (CNA) #1 stated she getting R #1 up for the day using the mechanical lift, she stated when she got R #1 in the sling and had him up in the air with the mechanical lift, she heard a pop and R #1 dropped to the floor. CAN #1 stated he fell before I could do anything. She stated that R #1 fell on his buttocks and his legs hit the legs of the lift and his head hit the base of the lift.-On 07/01/25, Licensed Practical Nurse (LPN) #1 stated he was the charge nurse assigned to R #1 at the time of R 1#'s fall on 06/19/2025. He stated that he was notified that R #1 had fallen from the lift. When he arrived to R #1's room he observed R #1 sitting on the floor with CNA #1 attending to him. He stated that R #1 was awake, alert and oriented to self and was his normal baseline at time of assessment.C. Record review of R #1's Investigation Report (5 day report), dated 06/30/25, revealed that R #1 fell from a [NAME] lift during a bed-to-chair transfer, landing on his back hitting his head. R #1 was sent to the emergency room for evaluation and treatment. Subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) was identified on (Computed Tomography; a medical imaging procedure that uses x-rays to create detailed cross-sectional images of the body) CT and R #1 was referred to Covenant Hospital in Lubbock for further neurological treatment. R #1 had repeat CT on 06/21/25 indicating resolution of the subarachnoid hemorrhage and subsequently readmitted back to nursing home facility.D. Record review of R #1's care plan, initiated on 06/02/25 and revised on 07/01/25, revealed the following: - Focus: R #1 has an ADL self-care performance deficit related to Dementia, Parkinson's disease and visual disturbances secondary to presbyopia, nuclear sclerosis bilaterally, refraction disorder and cataracts.- Interventions: R #1 requires total assistance by staff to move betweensurfaces and as necessary and requires total assistance by staff with sittingto stand transfers, chair to bed transfers, toilet transfers and shower transfers. R #1 requires transfers with Hoyer lift with 2 people and was initiated on 10/20/20 and revised on 07/01/25. E. Record review of R #1's Minimum Data Set (MDS) Section GG (Functional Abilities and Goals), dated 06/27/25, revealed the following:-R #1 requires maximal assistance to roll between his left and right side. -R #1 requires maximal assistance when moving from sitting on the side of the bed to lying flat on the bed. - R #1 is completely dependent when moving from lying flat on the bed to sitting on the side of the bed. - R #1 is completely dependent when transferring from chair to bed or bed to chair.F. On 07/16/25 at 10:40 am during an interview with Assistant Director of Nursing (ADON) stated during the investigation it was revealed that CNA #1 initiated the transfer alone without assistance. She stated the Hospitality Aide (HA) was in the room at the time of the fall but was only there performing one to one monitoring of the resident. The ADON stated CNA per competency training dated 02/19/25, her expectation was for CNA #1 to get help prior to attempting a hoyer lift. The ADON also states their policy states there has to be two certified

Based on record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 (R #1) of 1 (R #1) resident reviewed for medication administration when staff failed to administer medication per physician's orders. This deficient practice could likely lead to the residents having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication. The findings are: A. Record review of R #1's Physician's orders revealed the following: 1. Metoprolol succinate (beta-blocker used to treat chest pain (angina), heart failure, and high blood pressure) ER (extended release), extended release 24-hour, started on 11/24/23. Give 50 MG (milligram; dose of medication) by mouth one time a day for hypertension (high blood pressure). Hold if SBP (Systolic blood pressure; the top number in a blood pressure reading) is less than 120, DBP (Diastolic blood pressure; the bottom number in a blood pressure reading) is less than 80, HR (Heart rate; number of times the heart beats in a min) is less than 60. 2. Losartan Potassium (used to relax blood vessels to increase the supply of the blood and oxygen to the heart.) 100 MG, started on 11/25/23. Give 1 tablet by mouth one time a day for hypertension. Hold if SBP is less than 120. B. Record review of R #1's Medication Administration Record (MAR) for May 2025, revealed staff administered the following medications: 1. Metoprolol succinate ER, 50 MG, on 05/02/25, 05/04/25, 05/07/25, 05/11/25, 05/12/25, 05/13/25, 05/16/25, 05/17/25, 05/18/25, 05/20/25, and 05/22/25 for SBP less than 120, DBP less than 80. 2. Losartan Potassium 100 MG, on 05/07/25, 05/11/25, and 05/13/25 for SBP less than 120. C. Record review of R #1's blood pressures were documented as follows: 1. 05/02/25-132/75 2. 05/04/25-134/75 3. 05/07/25-114/78 4. 05/11/25-118/80 5. 05/12/25-132/74 6. 05/13/25-115/72 7. 05/16/25-122/78 8. 05/17/25-125/77 9. 05/18/25-131/74 10. 05/20/25-128/72 11. 05/22/25-120/74 D. On 05/23/25 at 10:35 am during an interview with the Director of Nursing (DON), she stated the following: 1. R #1 received her Metoprolol Succinate and Losartan Potassium medications outside the prescribed parameters. 2. Medication was administered outside the prescribed parameters causing a significant medication error. 3. She stated her expectations are for the nurses to follow the orders as written, hold the medication and call the doctor to verify instructions.

Based on observation and interview, the facility failed to ensure all treatment carts were locked while unattended. This deficient practice had the potential to affect all 27 people residing in rooms on the 200 hall by allowing unauthorized people access to their medical supplies and personal health information. The findings are: A. On 05/22/25 at 10:15 am, a random observation of the facility revealed the treatment cart located in the 200 hall was unlocked, and the facility employees were not in the area. B. On 05/22/25 at 10:15 am, during an interview with Registered Nurse (RN) #1, she confirmed the treatment cart was unlocked and she locked the cart. RN #1 stated the treatment cart should be locked and secured while not in use. C. On 05/23/25 at 10:25 am, during an interview with the Director of Nursing (DON), she confirmed that all treatment carts should be locked while not in use.

Based on observation and interview, the facility failed to safeguard resident's personal health information by leaving a list of residents with their associated wound care orders in plain view. This deficient practice had the potential to affect all 27 people residing in the rooms on the 200 hall by allowing unauthorized people access to their personal health information. The findings are: A. On 05/22/25 at 10:15 am, a random observation of the facility revealed a paper document with names of the residents and their wound care orders sitting face up on top of the treatment cart. B. On 05/23/25 at 10:25 am, during an interview with the Director of Nursing (DON), she confirmed that all personal health information should be safeguarded and should never be left in view of people that are not authorized to see it.

Based on interview, record review, and observation the facility failed to ensure residents received information on how to contact the State Survey Agency to file a complaint. This deficient practice could likely affect all 110 residents residing in the facility as identified on the census provided by the Administrator (ADM) on 01/05/25. The findings are: A. On 01/05/25 at 12:15 pm during a random observation of the facility, signs or posters regarding filing a complaint with the state survey agency were not visible throughout the facility. B. On 01/07/25 at 10:58 am during an interview with the Resident Council (RC; R #9, R #28, R #29, R #36, R #46, R #73, R #77, R #86, and R #97), they stated they were unaware they could contact the State Survey Agency to file a complaint. C. On 01/08/25 at 12:39 pm during an interview and random observation of the facility with the Administrator, one sign regarding contacting the State Survey Agency to file a complaint hung on the front entrance door and faced outside the building. Further observation revealed there were not any signs or posters visible to residents from inside the facility. The bottom of the sign was approximately four feet from the ground and printed on a piece of paper measuring 8.5 inches wide by 11 inches long. The sign included information to call the New Mexico Department of Health intake hotline to file a complaint. Further observation revealed there were not any signs or posters visible to residents from inside the facility. The ADM confirmed there are not any other signs with information on how to contact the State Agency that were accessible to the residents inside the facility.

The following deficiency was cited during a recertification survey that was initiated on 10/16/17. An immediate jeopardy was identified on 10/24/17 at 11:25 am, and a Plan of Removal was accepted on 10/24/17 at 5:17 pm. Based on observation and interview, the facility failed to prevent an infestation of the kitchen with insects specifically cockroaches. This deficient practice has the potential to cause foodborne illness for the 97 (excluding one resident that is receiving a tube feeding) Residents who eat meals served from the kitchen. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J identified on 10/24/17 at 11:25 am. The facility administrator was notified at this time. The facility provided an acceptable Plan of Removal on 10/24/17 at 5:10 pm. Based on the Plan of Removal, the interventions included: 1. (Name of Pest Control Company) will be in the building on 10/24/17 to treat the Dining Area and Kitchen for pests, particularly cockroaches. The Pest Control Company will be in the facility for 7 days, starting 10/24/17 and thereafter weekly to treat the Dining Area and Kitchen for pests. 2. The Dietary Manager or designee will perform deep cleaning in the whole kitchen area. All items in the kitchen including all preparation and cooking areas will be cleaned and sanitized daily prior to meal preparation and service until there is no evidence of cockroaches. This will be documented on an audit tool and kept in a binder. 3. (Name of Contract Company) has started repairing the dishwashing area, patching and repairing holes in walls, replacing broken tiles in the entire kitchen. 4. As of 10/24/17 dinner will be served from the employee lounge on disposable products. On 10/25/17 all meals will be provided by local restaurants and served on disposable products. Any increased sightings of cockroaches, meals will not be served from the kitchen and will be catered through local restaurants. 5. Administrator or designee will re-educate all staff regarding Policy and Procedure on Pest Control to include notification of the administrator of any sightings of pests particularly cockroaches in the facility. The Administrator or designee will immediately notify the Pest Control Company of identified issue(s). 6. Administrator or designee will perform daily rounds at random times to include night time hours during the week in the Dining Area and Kitchen to start on October 25, 2017. Any identified issue(s) will be reported immediately to the Administrator. These rounds will be documented in an audit tool and kept in a binder. The facility Administrator will monitor plan and make changes until issues are resolved. Based on the Plan of Removal, the Immediate Jeopardy was lifted on 10/24/17 at 5:10 pm. This resulted in the scope and severity being reduced from a scope and severity of J to a scope and severity of G. Based on observation and interview the facility failed to: 1. Prevent insects from being present in the Dining Area and Kitchen where food is stored, prepared, and served. 2. Failed to maintain the kitchen in a manner that was safe and sanitary by not repairing known areas where insects could live and breed. This deficient practice has the potential to cause foodborne illness for the 97 Residents who eat meals served from the kitchen. The findings are: A. On 10/18/17 at 9:19 am during an interview, R #54 stated, I've seen cockroaches particularly around the laundry area. I let them know about it. They are around the kitchen, too. B. On 10/18/17 at 11:43 am during an interview, R #134 stated, There have been cockroaches in my room, down the hall, and in the kitchen. C. On 10/19/17 at 1:57 pm during an observation and interview in the dietary manager's office (located within the kitchen), it was pointed out to the Registered Dietician (RD) that a cockroach was crawling up the wall. RD stated, We need to get rid of that then got a napkin and smashed the cockroach on the wall. D. On 10/19/17 at 3:48 pm during an observation and interview, a cockroach was crawling on the floor in the dishwashing room in the kitchen. Maintenance Director (MD) was asked if the building had been treated for [REDACTED]. They have spread into the resident rooms . E. On 10/20/17 at 8:53 am during an observation of the kitchen, 4 cockroaches crawled out of a floor drain underneath the meat steamer. F. On 10/23/17 at 3:30 pm, during an observation of the Kitchen and the Service Hall outside the Kitchen revealed: 1) The floor and walls were dirty with a brown substance on them. 2) The double doors in the Service Hall opened to the outdoors where the trash dumpster's were located. The dumpster's lids were not closed. 3) Underneath the rack that held the clean cups were 8 chipped floor tiles and when the rack was moved, a live cockroach ran out from underneath the rack. Underneath the rack were 3 large cockroach traps. 4) The Service Hall floor had 3 areas, approximately one foot by 10 inches, of a spilled dried brown substance. G. On 10/24/17 at 11:25 am, the following was observed in the Kitchen area: 1) Approximately 4 feet of the ceiling molding just off the Service Hall was loose. 2) In the dry storage room where food is kept there was a dead cockroach. 3) Along one wall in the Kitchen an 8 foot long area of baseboard was missing. 4) The fire compression wall had 5 feet long area of unsealed tile chipped and missing. 5) Underneath the preparation table, by the large mixer, there was a live cockroach that ran under loose, unsealed tiles. 6) There was an old unused stove vent hanging over a preparation table that was rusted and open to the outside of the building. 7) In the room where the dish machine is located large portions of the backsplash were open and pulling away from the wall. 8) Approximately a 10 by 4 foot area of tile underneath the dish machine was not sealed and live cockroaches were seen. 9) There were numerous holes in the walls and missing tile behind the stove area. 10) Behind the coffee and drink preparation table there was a hole in the wall approximately 18 inches by 2 1/2 feet that extended into the wall where the water pipes were located. 11) In the Dietary Manager's office that opened into the Kitchen there was a hole in the wall approximately 14 inches by 18 inches that was opened all the way into the wall with the water pipes exposed. 13) In the serving area dead cockroaches were seen in the overhead lights. 14) In the dry food storage area single packages of condiments, individual peanut butter, and individual sugar and salt packets were being stored in card board boxes. H. On 10/23/17 at 3:30 pm, during an interview, the Dietary Manager (DM) stated that he/she started on 09/18/17 and noticed a bug problem. It was in bad shape when I got here. I have been asking to get it all fixed but nothing has been done. The (Name of pest control company) was called in to assess and have been coming back every week, but we are still seeing cockroaches. The DM stated that the purse and phone on the service cart next to the mixer should not be there, but they don't want to put their purse on the floor because they are afraid of what might get in it. I. On 10/23/17 at 4:39 pm, during an interview, the pest control company representative, the representative stated I have been going weekly. I need to fog and flush. I am going to do the ceiling with some dust. There is a lot of areas that need to be sealed because roaches can go in there and breath. I was aware of the issue since last month. They didn't know when they could do the over night service. Some guy told me to wait until the end of the month, so it could get scheduled. The whole kitchen needs to be remodeled in order to get rid of the cockroaches. It only takes two cockroaches. J. Record review of the facility's policy titled Pest Control dated 09/2015, revealed, III. Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly to the contractor. K. Record review of the facility's pest control policy statement, undated revealed, Policy Statement - It is the center policy that there is a program established for the control of insects and rodents for the dining services department. Action steps - 1. The Food Services Director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed. 2. As appropriate supplies will be removed from card board boxes. 3. National Sanitation Foundation (NSF) containers will be used for food storage. L. On 10/23/17 at 3:50 pm, during an interview, the Administrator and Director of Nursing, conceded that the facility had a bug problem.

The following deficiency was cited as a result of a Complaint survey initiated on 04/18/17. An Immediate Jeopardy was identified on 04/19/17 and a plan of removal was accepted on 04/19/17. Based on record review, observation and interview, the facility failed to provide the necessary supervision and intervention to prevent injury for two ( R #'s 4 and 7) of seven ( R #1, 2, 3, 4, 5, 6, and 7) residents reviewed for accidents/incidents. This failure likely resulted in 1) R #4, who has a known history of inserting foreign objects into her vagina, inserting a pencil into her vagina, and 2) R #7 wheeling himself two blocks from the facility, over uneven terrain, to a local Emergency Department (ED) to seek treatment for [REDACTED]. This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J, identified at the facility on 04/19/17 at 11:45 am. The facility administrator was notified at this time. The facility provided an acceptable Plan of Removal on 04/19/17 at 4:00 pm. Based on the plan of removal, the interventions included: 1. One to one supervision by facility staff for R #4, 2. Referral to Physical Therapy, Occupational therapy and Speech therapy for R #4, 3. Re-assessment by psychotherapist and development of treatment plan for R #4, 4. Medical Director was notified of IJ concerning R #4 and R #7, 5. Re-education on facility Resident Elopement Policy and Procedure, 6. Re-education on facility policy and procedure on Resident Change in Condition, 7. Elopement risk and risk for self-injurious behavior updated on each resident and care plans updated as needed, Based on the Plan of Removal and observation, the Immediate Jeopardy was lifted on 04/19/17 at 4:00 pm. This resulted in the scope and severity being reduced from a scope and severity of J to a G. Based on record review, observation, and interview the facility failed to 1) supervise R #4, a resident with a known history of inserting foreign objects into her vagina, 2) be aware of R #7 leaving the facility, wheeling himself two blocks over uneven terrain to seek Emergency Department (ED) treatment for [REDACTED].#6, who had repeatedly voiced his desire to leave the facility. R #6 was found 1/10th of a mile from the facility by local law enforcement, 4) use a mechanical lift to transfer R #1, which was required, resulting in a fall and a fractured femur 5) supervise and revise the care plan for R #3 after multiple falls, which included injuries to the face, for five ( R #'s 1, 3,4,6, and 7) of seven (R #'s 1, 2, 3, 4, 5, 6, and 7) residents reviewed for supervision to attempt and prevent accidents. The findings : Resident #4 A. Review of facility admission records indicated R #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. B. Review of R #4's care plan initiated 08/22/16 revised 03/23/17 indicated, Resident is placing spoons in her vagina causing bleeding. The goal indicated is that R #4 will be free from injury or bleeding related to placing objects in her vagina. Interventions include: staff to keep all objects that can be placed in vagina out of resident's room; sex toy provided to resident to use to masturbate instead of foreign objects. C. Review of licensed nurse progress notes for R #4 indicated the following: 1. 03/23/17 12:50 am-Reported by Certified Nursing Assistant (CNA) that resident had a plastic cup in her vagina, I went to check on her, by the time I got there, she had the cup out, will continue to monitor for any complications related to incident. Resident was told not to put anything else but her toy in there. 2. 04/12/17 5:49 pm-resident has placed a pencil, eraser end up in vagina. Unable to observe for tears due to thick white discharge. Resident sent to (name of local emergency department) for further evaluation. D. On 04/18/17 at 3:35 pm, during an interview, Licensed Practical Nurse (LPN) #1 stated she was the nurse on 04/12/17. LPN #1 stated the resident's daughter had been visiting and told LPN #1 that she could not find the television remote or any of R #4's sex toys. I ask an aide to check her (R #4). When I got to the resident's room, (name of CNA) was pulling out a pencil from the resident's vagina. I told the aide to stop, but the resident was insistent on getting up out of bed. The resident was at a 45 degree angle, so we finished pulling the pencil out and threw it away. It was a regular pencil, probably about 6 inches long. LPN #1 stated she does not know what the process is for ensuring that R #4 does not have foreign objects and in her room or how the facility ensures R #4 has sex toys for masturbation. E. On 04/19/17 at 10:30 am, during an interview, LPN #2 was ask to come to R #4's room and assist with locating any available sex toys for R #4. LPN #1 stated she could not find any, and did not know where the resident might have placed them. LPN #2 stated she had found more pencils in the resident's bedside dresser the past Friday and Saturday. LPN #2 was asked if she had reported finding more pencils in R #4's bedroom so recently after the 04/12/17 incident, she stated, no. F. On 04/19/17 at 10:50 am, during an interview, the Administrator and Director of Nursing (DON) reviewed R #4's plan of care. The administrator stated he was unaware of R #4 inserting a plastic cup into her vagina on 03/23/17. The DON stated R #4's care plan had not been updated after the 04/12/17 incident of R #4 inserting a pencil into her vagina. Neither the Administrator or DON were aware that staff continued to find pencils in R #4's room after the 04/12/17 incident. Resident #7 G. Record Review of R #7's admission record indicated the resident was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. H. Record review nursing progress notes for R #7 dated 03/13/17 at 5:50 pm indicated: Resident eloped. Review of a facility communication form dated 03/13/17 at 5:50 pm indicated: resident family member called facility concerned after seeing resident in (name of acute care hospital) parking lot. I. Record review of the ED physician documentation dated 03/13/17 at 5:51 pm, indicated: patient presents to ED with complaints of abdominal pain, patient did come in by wheelchair from 2 blocks away without knowledge of nursing facility staff. J. Observation of the possible route (s) R #7 would have taken from the facility to the acute care hospital ED on 4/18/17 at 4:30 pm revealed series of parking lots, small roads, concrete and asphalt tops, parking lot for the facility, a neighboring office complex, the air ambulance launch pad, and parking lot for the acute care hospital. K. On 04/19/17 at 10:50 am during an interview with the Administrator and Director of Nursing, they stated the incident of R #7's elopement was not investigated because R #7 did not return to the facility after 03/13/17. Findings for R#1 L. Record review of facility facesheet dated 12/08/16 revealed R #1 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. M. Record review of ADL (activities of daily living) Care Plan for R #1 dated 12/12/16 revealed, Focus: R #1 has an ADL self-care performance deficit related to (r/t) CVA (stroke) - [DIAGNOSES REDACTED]. Goals: R #1 will demonstrate the appropriate use of wheel chair to increase ability in moving about in the facility through the review date. Interventions: dated 01/13/17 . Transfer: The resident requires Mechanical Lift (Hoyer) with 2 staff assistance for transfers. N. Record review of SBAR (Situation, Background, Assessment, Request) dated 02/24/17 revealed, (name of Certified Nursing Aid (CNA) #1) and (name of CNA #2) were transferring resident into shower chair when CNA's had to guard resident to the floor. Resident was then lifted off the floor with a Hoyer lift x 2 into shower chair. CNA's took resident into the shower room and showered him. After dressing resident, he then complained of pain to his right leg. After I assessed the resident I noted swelling to right leg and resident complained of pain @ 8 (AM). (name of Director of Nursing (DON)) assessed the resident. Sent to ER (emergency room ) for evaluation. O. Record review of Nursing Admission (MDS) data set [DATE] revealed, Admission details: Fracture right femur .Immobilizer on right leg. P. On 05/04/17 at 10:00 am, during an interview Registered Nurse (RN) #2 stated that, when (name of resident) fell he was assessed by the DON and sent to the hospital for evaluation. I got a report from the hospital that he had a fractured femur. When asked if (name of resident) transfer was done by (mechanical) lift the RN stated that the CNA's said they did not use the lift but were doing a 2-person transfer. Q. On 05/04/17 at 10:30 am, during an interview, the DON stated that during the follow up investigation the CNA's involved stated they had not used the lift but a 2-person transfer and they assisted him to the floor because he was so weak he couldn't help them. When asked if (name of resident) had been care planned for transfers by (mechanical) lift prior to this incident the DON stated, Yes. Findings for R #3 R. Record review of the facility Admission Record for R #3 dated 08/11/16 indicated [DIAGNOSES REDACTED]. S. Record review of facility incident/accident reports dated 03/11/17-04/24/17 for R #3 indicated the following: 1. 03/11/17-11:45 am-resident was attempting to ambulate to the restroom, he had tied his wheelchair to the bed and while attempting to climb over it he fell to the floor. 2. 03/12/17 11:30 pm-resident was reaching for his wheelchair when he fell from the bed to the floor landing on his bottom. Resident received an abrasion on his left forearm. 3. 03/15/17-7:15 am-resident fell after tripping on his his walker which he ties to his bed. 4. 04/20/17 at 7:30 pm-resident found sitting on the floor by his bed. 5. 04/21/17 at 5:30 pm-fall with injury-resident found on floor getting himself back up. states he tripped over his feet, nose bleeding at this time. There is also an abrasion to the right knee cap. 6. 04/25/17-3:30 am resident found sitting on the floor by his bed. T. Record of the facility Fall Management policy with a revision date of 08/2012 indicated: fall event, the IDT (interdisciplinary team) modifies and implements a care plan and treatment approach to minimize repeat falls. The care plan committee members will review weekly all residents with falls for documentation, compliance, and interventions. U. Record review of R #3's care plan dated 08/12/16 indicated no new interventions for the six falls R #3 sustained. V. On 05/05/17 at 11:18 am during an interview, the Resident Care Management Director stated there was no documentation written into the care plan to indicate new interventions to attempt to reduce the falls for R #3. Resident #6 W. Record review of facility Admission Record for R #6 dated 02/27/17 revealed [DIAGNOSES REDACTED]. X. Record review of nursing note dated 02/28/17 at 9:14 am revealed, Note Text: In with pt (patient) this morning to try to get an assessment done on the pt he is a bit agitated and wants to get the hell out of here. He said that he is wanting to go back to his home that's way the heck up north. Tried to discuss his situation and that his family is trying to get him a place to stay up there. He did say that he is leaving today . Z. On 05/04/17 at 2:15 pm, during an interview, the Director of Care Transitions (DCT) stated R #6 was admitted to the facility based on adjustments to medications that were made at (name of behavioral health unit). The DCT stated, They (name of behavioral health unit) couldn't find a local facility to accept the resident. The DCT stated, apparently the (Name of transportation agency) picked the resident up and told him it would be a short ride down the street, and then he ended up here (5-6 hour drive). The resident was not happy. AA. On 05/04/17 at 2:35 pm, during an interview, the Social Services Director (SSD)was asked why R #6 was transferred to and admitted so far from his home. SSD stated, I talked to him when he got here while I was doing the assessment .I contacted (Name of facility) and (Name of health facility) and both denied him because of his behaviors; he had been at both places and they didn't want him back .said he needed a locked unit .R #6 started getting upset. I put him on community reintegration, but the sister said she didn't think she could handle him . BB. Record review of facility Incident/Accident Report dated 04/06/17, 11:00 am revealed, Incident/injury . 1. Elopement. findings: took out the front door. List [DIAGNOSES REDACTED]. CC. Record review of facility Progress Notes dated 04/06/17 revealed, Resident found walking outside towards highway. Stated that he was going to hitch hike back to (Name of city) or walk there himself. He was not easily redirected back to the building. Stated if wander guard is going to be put on that he would remove it. DD. On 05/03/17 at 4:00 pm during an interview, DON was asked if R #6 wears a wander guard. DON stated, I wasn't going to put a wander guard on him because he said he would cut it off. I won't use a wander guard to restrain a resident. EE. On 5/4/17 at 3:25 pm, during an interview, Staff member #1 stated a police officer with the local police department was the one who saw R #6 on 04/06/17 up the road by the blue sign (sign for long term care facility). That sign is observed to be approximately 1/10th of a mile east of the facility. FF. On 05/04/17 at 5:34 pm, during an interview, Law Enforcement Officer (LEO)#1 was asked what happened on 04/06/17 with R #6. The LEO stated, I was in my patrol car and the gentlemen, it was weird to me, I go out there all the time when I am off and on duty. I knew he was a resident, he was on a walker and he had almost made it to the intersection of (name of road that runs north and south) and the road the facility is on. I went to the facility and told Business Office Manager there is a man down at the blue sign. He is wearing a flannel and a beanie and he is headed to the highway. She said that's (name of R #6). She went and told the administrator and the DON. The DON told the Social Service Assistant (SSA) to get in the van and they flew (ran) out the door. They got in the van and drove down there (by the blue sign) to get him. When I was leaving the facility, SSA was out of the van trying to talk to him (R #6). GG. On 05/05/17 at 8:33 am, during an interview, Social Services Assistant (SSA), was asked what happened on 04/06/17 with R #6. The SSA replied, Me and and the DON drove down to the sign and brought him back. We went down and asked him to come back with us, he told us he would walk to (Name of city). I did drive the van then and DON was with me. R #6 got in the van with us; it took a lot to get him to get in the van.

Based on record review and interview, the facility failed to update the care plan to incorporate changes needed for one (R #3) of seven ( R #'s 1, 2, 3, 4, 5, 6, and 7) residents reviewed for revision to care plans. This failure caused R #3 to continue to fall, experience facial injury, with the potential for more serious injury. The findings are: A. Record review of the facility Admission Record for R #3 dated 08/11/16 indicated [DIAGNOSES REDACTED]. B. Record review of facility incident/accident reports dated 03/11/17-04/24/17 for R #3 indicated the following: 1. 03/11/17-11:45 am-resident was attempting to ambulate to the restroom, he had tied his wheelchair to the bed and while attempting to climb over it he feel to the floor. 2. 03/12/17 11:30 pm-resudent was reaching for his wheelchair when he fell from the bed to the floor landing on his bottom. Resident received an abrasion on his left forearm. 3. 03/15/17-7:15 am-resident fell after tripping on his his walker which he ties to his bed. 4. 04/20/17 at 7:30 pm-resident found sitting on the floor by his bed. 5. 04/21/17 at 5:30 pm-fall with injury-resident found on floor getting himself back up. States he tripped over his feet, nose bleeding at this time. There is also an abrasion to the right knee cap. 6. 04/25/17-3:30 am resident found sitting on the floor by his bed. C. Record of the facility Fall Management policy with a revision date of 08/2012 indicated: fall event, the IDT (interdisciplinary team) modifies and implements a care plan and treatment approach to minimize repeat falls. The care plan committee members will review weekly all residents with falls for documentation, compliance, and interventions. D. Record review of R #3's care plan dated 08/12/16 indicated no new interventions were added to try and prevent further falls after any of the six falls R #3 sustained. E. On 05/05/17 at 11:18 during an interview, the Resident Care Management Director stated there was no documentation written into the care plan to indicate new interventions to attempt to reduce the falls for R #3.

Based on record review and interview the facility failed to follow the care plan for: 1) use of a Hoyer (mechanical) lift for transfers for R #1 and 2), keep all objects out of R #4's room that she could use to insert into her vagina for two (R #'s 1 and 4) of seven (R #'s 1, 2, 3, 4, 5, 6, and 7) residents reviewed for implementation of care plans. This failure caused R #1 to suffer a fracture to the right femur (bone in the thigh) and R #4 inserting a plastic cup and pencil into her vagina. The findings are: A. Record review of facility face sheet dated 12/08/16 revealed R #1 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of ADL (activities of daily living) Care Plan for R #1 dated 12/12/16 revealed, Focus: R #1 has an ADL self-care performance deficit related to (r/t)[MEDICAL CONDITION](stroke) - [MEDICAL CONDITION]. Goals: R #1 will demonstrate the appropriate use of wheel chair to increase ability in moving about in the facility through the review date. Interventions: dated 01/13/17 . Transfer: The resident requires Mechanical Lift (Hoyer) with 2 staff assistance for transfers. C. Record review of SBAR (Situation, Background, Assessment, Request) dated 02/24/17 revealed, (name of Certified Nurses Aide (CNA) #1) and (name of CNA #2) were transferring resident into shower chair when CNA's had to guard (sic. guided) resident to the floor. Resident was then lifted off the floor with a Hoyer lift x 2 (2 person assist) into shower chair. CNA's took resident into the shower room and showered him. After dressing resident, he then complained of pain to his right leg. After I assessed the resident I noted swelling to right leg and resident complained of pain @ 8 (AM). (name of Director of Nursing (DON)) assessed the resident. Sent to ER (emergency room ) for evaluation. D. Record review of Nursing Admission (MDS) data set [DATE] for R #1 revealed, Admission details: Fracture right femur .Immobilizer on right leg. E. On 05/04/17 at 10:00 am, during an interview Registered Nurse (RN) # 2 stated that, when (name of resident) fell he was assessed by the DON and sent to the hospital for evaluation. I got a report from the hospital that he had a fractured femur. When asked if (name of resident) transfer was done by (mechanical) lift, the RN #2 stated that the CNA's said they did not use the lift but were doing a 2-person transfer. F. On 05/04/17 at 10:30 am, during an interview, the DON stated that during the follow up investigation the CNA's involved stated they had not used the lift but a 2-person transfer and they assisted him to the floor because he was so weak he couldn't help them. When asked if (name of resident) had been care planned for transfers by (mechanical) lift prior to this incident the DON stated, Yes. G. Record review of facility admission records indicated R #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. H. Record review of R #4's care plan initiated 08/22/16 and revised 03/23/17 indicated, Resident is placing spoons in her vagina causing bleeding. The goal indicated is that R #4 will be free from injury or bleeding related to placing objects in her vagina. Interventions include: staff to keep all objects that can be placed in vagina out of resident's room; sex toy provided to resident to use to masturbate instead of foreign objects. I. Review of licensed nurse progress notes for R #4 indicated the following: 1. 03/23/17 12:50 am-Reported by Certified Nursing Assistant (CNA) that resident had a plastic cup in her vagina, I went to check on her, by the time I got there, she had the cup out, will continue to monitor for any complications related to incident. Resident was told not to put anything else but her toy in there. 2. 04/12/17 5:49 pm-resident has placed a pencil, eraser end up in vagina. Unable to observe for tears due to thick white discharge. Resident sent to (name of local emergency department) for further evaluation. J. On 04/18/17 at 3:35 pm during an interview, Licensed Practical Nurse (LPN) #1 stated she was the nurse on 04/12/17. LPN #1 stated the resident's daughter had been visiting and told LPN #1 that she could not find the television remote or any of R #4's sex toys. I ask an aide to check her (R #4). When I got to the resident's room, (name of CNA) was pulling out a pencil from the resident's vagina. I told the aide to stop, but the resident was insistent on getting up out of bed. The resident was at a 45 degree angle, so we finished pulling the pencil out and threw it away. It was a regular pencil, probably about 6 inches long. LPN #1 stated she does not know what the process is for ensuring that R #4 does not have foreign objects and in her room or how the facility ensures R #4 has sex toys for masturbation. K. On 04/19/17 at 10:30 am during an interview, LPN #2 was ask to come to R #4's room and assist with locating any available sex toys for R #4. LPN #1 stated she could not find any, and did not know where the resident might have placed them. LPN #2 stated she had found more pencils in the resident's bedside dresser the past Friday and Saturday. LPN #2 was asked if she had reported finding more pencils in R #4's bedroom so recently after the 04/12/17 incident, she stated, no.

The following deficiency was a result of a QIS Recertification/Extended/Complaint survey that was initiated on 10/11/16. An immediate jeopardy was identified on 10/14/16, and a plan of removal was accepted on 10/14/16. Based on record review and interview the facility failed to ensure a resident received supervision and immediate physician assessment after a vaginal injury for 1 (R #131) of 4 (R # 44, 69, 114, and 131) residents reviewed for incidents/accidents. This failed practice likely resulted in R #131 becoming injured by a metal spoon inserted in her vagina. The resident was bleeding from this injury and was not sent to be evaluated by a physician. The findings are: This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J, being identified at the facility on 10/14/16 at 3:30 pm. The facility Administrator was notified at this time. The facility provided an acceptable written Plan of Removal on 10/14/16 at 8:18 pm. Based on the Plan of Removal, interventions included: 1) R #131 was sent to (name of local hospital) for evaluation by order of primary physician. 2) R #131 was offered a safe alternative such as a sexual toy and was educated by the Director of Nursing or designee on how to safely operate device. 3) Director of Nursing of designee will re-educate all staff regarding Policy and Procedure on Abuse and Neglect Prohibition. 4) Interim Administrator or designee will review and assess other residents that might be at risk of harming themselves during times of sexual preferences. Based on the Plan of Removal on 10/14/16, the IJ was lifted on 10/14/16 at 8:18 pm. This resulted in the scope and severity being reduced from a scope and severity of J to a scope and severity of G. A. On 10/13/16 at 7:10 pm, in a telephone interview, R #131's Family Member (FM) #2 stated that on 08/20/16 during a visit he/she assisted R #131 to the bathroom. When R #131's depends were pulled down he/she discovered that R #131 was bleeding onto the depends. At that time FM #2 went to the nurses station to get assistance. FM #2 stated that LPN #4 found a metal spoon protruding from R #131's vagina. LPN removed the spoon and the depends and threw them both in the trash. FM #2 stated I felt that it should have been shown to other staff and not just thrown in the trash. FM #2 stated that to their knowledge the staff did not come back to check on R #131. B. Record review of the facility SBAR (Situation Background Assessment Recommendation) completed by Licensed Practical Nurse (LPN) #4 dated 08/20/16 revealed: Went to resident's room to find out where the bleeding was coming from, went to wipe and found a metal spoon in her vagina. C. On 10/11/16 at 4:10 pm, in a telephone interview, Licensed Practical Nurse (LPN) #4 stated, I was working mornings that day. (Name of R# 131 family member) came to the nursing station. He/she told me that the resident was bleeding and asked if I would come and check. During assessment I found blood in her depends and went to clean/wipe the area and found a metal spoon in her vagina. LPN #4 stated that he/she removed the spoon. D. On 10/11/16 at 3:58 pm, during an interview Certified Nurse Assistant, (CNA) #6 stated that at one time he/she found a television remote inside R #131's vagina, and recently found a hairbrush. I'm sure I told someone, but everyone knew the resident was masturbating with these personal items. E. On 10/11/16 at 4:00 pm, during an interview, CNA #7 stated that R #131 regularly inserts bottles of deodorant, toothbrushes, and other objects in her vagina. I have asked the resident why she is continuously doing this and she told me that she needs to be satisfied and can do it herself. CNA #7 stated that the CNAs try to watch R #131 closely because she tries to take silverware from the dining room and needs to be monitored. We report this to the nurse and the nurse would be the one to document. F. On 10/11/16 at 4:20 pm, in an interview, the Director of Nursing stated that since there was no injury to R #131 it was not a reportable incident. The DON stated that he/she feels it is more of a behavior of a resident pleasing themselves, and there wasn't that much blood. G. On 10/13/16 at 11:30 am, during an interview, the DON stated that he/she didn't send R #131 for a physical examination and assessment because he/she did not believe that it was serious enough. H. Record review of R #131's medical records indicated no documentation of nursing notes or physician's orders [REDACTED].

The following deficiency was a result of a QIS Recertification/Extended/Complaint survey that was initiated on 10/11/16. An immediate jeopardy was identified on 10/14/16, and a plan of removal was accepted on 10/14/16. Based on record review and interview the facility failed to ensure incidents of neglect did not occur towards 1 (R #131) of 4 (R # 44, 69, 114, and 131) residents reviewed for incidents/accidents. This failed practice likely resulted in R #131 having a serious injury after a metal spoon was discovered in R #131's vagina. The resident was bleeding from this injury and was not sent to be evaluated by a physician. The findings are: This deficient practice resulted in an Immediate Jeopardy at a scope and severity of J, being identified at the facility on 10/14/16 at 3:30 pm. The facility Administrator was notified at this time. The facility provided an acceptable written Plan of Removal on 10/14/16 at 8:18 pm. Based on the Plan of Removal, interventions included: 1) R #131 was sent to (name of local hospital) for evaluation by order of primary physician. 2) R #131 was offered a safe alternative such as a sexual toy and was educated by the Director of Nursing or designee on how to safely operate device. 3) Director of Nursing of designee will re-educate all staff regarding Policy and Procedure on Abuse and Neglect Prohibition. 4) Interim Administrator or designee will review and assess other residents that might be at risk of harming themselves during times of sexual preferences. Based on the Plan of Removal on 10/14/16, the IJ was lifted on 10/14/16 at 8:18 pm. This resulted in the scope and severity being reduced from a scope and severity of J to a scope and severity of G. Based on record review and interview the facility failed to develop a comprehensive care plan to include measurable goals and interventions for 2 (R#34, R #131) of 2 (R #34, R #131) residents reviewed for developing a care plan for: 1) Elopement and wandering into unsafe places and 2) Weight loss, 3) Behaviors. This deficient practice is likely to result in staff being unaware of the residents care issues and fail to provide appropriate interventions to meet the residents highest practicable physical, mental, and psychosocial well-being. The findings are: Resident # 131 A. Record review of the facility facesheet dated 10/12/16 revealed Resident # 131 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. B. Record review of the Incident/Accident Report dated 8/20/16 revealed: Resident had blood coming from vagina, found a metal spoon in vagina. C. Record review of the SBAR (Situation Background Assessment Recommendation) dated 08/20/16 revealed: Went to room to find were the bleeding was coming from, went to wipe and found metal spoon in the vagina. D. On 10/11/16 at 4:00 pm, during an interview Certified Nursing Assistant (CNA) # 6 stated that the resident had a habit of putting different objects in her vagina. I don't remember the dates, but we found a hairbrush one time as well as a television remote. We often find her with her pants down trying to place objects in the vagina, it is a daily occurrence. E. On 10/11/16 at 4:05 pm, during an interview, CNA #7 stated that the resident is continuously placing items in her vagina. (Name of resident) has used a bottle of deodorant and a toothbrush. We try to watch the resident closely because there have been several attempts to take silverware from the dining room. CNA #7 stated, These incidents happen daily, The CNAs report to the nurse, the nurse would be the one to document. F. On 10/11/16 at 4:10 pm, during an interview, the Director of Nursing (DON) stated that there was not a care plan for the resident putting objects in her vagina. I didn't know masturbation was a behavior. Resident #34 G. Record review of the facility facesheet dated 06/08/16 revealed Resident # 34 was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. H. Record review of Elopement Risk for Resident #34 dated 06/08/16 revealed, a risk score of 16. At risk for elopement is a score of 12 or higher. Record review of physician's orders [REDACTED]. Record review of Progress Notes for Resident #34 dated 09/16/16, 09/17/16 and 09/18/16 revealed, Pt (patient) has removed Wanderguard. I. On 11/08/16 at 11:20 am, during an interview with the 100 Hall Charge Nurse the Charge Nurse stated, She does exhibit exit seeking behaviors this is the reason for the Wanderguard. J. On 11/08/16 at 12:45 pm, during an interview with the Minimum Data Set Coordinator, (MDSC) the MDSC stated, There is no care plan for elopement and the Wanderguard. K. Record review of physician's orders [REDACTED]. L. Record review of Weights for Resident #34 revealed: .09/09/16: 110, 10/06/16: 105, 11/01/16: 104. M. Record review of Nutrition Data Collection for Resident #34 dated 06/10/16 revealed, .Weight: 118 . Comprehension: disoriented/confused .Eating Ability: Supervision .Average meal intake percentage/day: 50% .Summary: Could benefit from current dietary orders .Continue to monitor. Refer to RD for admission assessment. Continue plan of care. N. Record review of Nutrition RD (Registered Dietitian) Assessment for Resident #34 dated 06/22/16 revealed, . At risk evidenced by poor po (by mouth) intake related to (r/t) leaving >25% of food q (every) meal .Nutrition Interventions: .current dietary order Reg/Reg (regular/regular) also receives Med Plus 2.0 (a nutritional supplement) TID (three times a day) . current po intake is fair . could benefit from weight maintenance . eats meals in the dining w/supervision . could benefit from current dietary order with high kcal (calorie)supplement to encourage weight maintenance, continue to monitor and f/u (follow-up) prn (as necessary). Nutrition Goals: Weight maintenance. O. Record review of Dietary Progress Note for Resident #34 dated 07/20/16 revealed, RD f/u Wt Variance: Current Wt: 108# (7/14/16), Wt: 118 (6/8/16) .current dietary order Reg/Reg also receives Med Plus 120 ml TID and current po intake is fair, . has experienced a -8.5% wt change in the past 30 days which is a significant and undesirable wt loss, resident po intake is better when eats in the activity room, could benefit from current dietary order with high kcal supplement, continue to monitor and f/u prn. P. On 11/08/16 at 12:00 pm, an observation was conducted during the noon meal. During the meal R #34 was observed to want to get up from the meal and leave the dining area. Q. On 11/08/16 at 9:30 am, during an interview with the Dietary Manager (DM), the DM stated, (Name of Resident #34) is suppose to be assisted with eating. I have not been notified of any weight loss. When asked about the residents dietary care plan, the DM stated, I don't do the care plans the RD does. He is here at least once a week. If there is a dietary issue the nurses fill out a communication form, send it to me, and I give it to the RD when he is here. R. On 11/06/16 at 3:10 pm, during a telephone interview, when asked if there were any Dietary Progress notes done after 07/20/16, the RD stated, No there are not, at least not in my computer. When asked if the RD was aware of R #34's weight loss in September, October and November of 2016, the RD stated, I was unaware of the weight loss for those months. If there is a pattern of weight loss we place a resident on weekly weights and R #34 was not on weekly weights. When asked if the RD is responsible for doing the nutritional care plan, the RD stated, Yes, and I guess I missed doing one on the resident.