The Nm Behavioral Health Institute At Las Vegas

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide documentation confirming 2 (NA #1 and NA #3) of 5 (NA #1, NA #3, NA #4, and NA #5) Nurse Aides had 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 102 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents. The findings are: NA #1:A. Record review of NA #1's personnel record revealed the following:1. NA #1's is a current employee with a hire date of [DATE]. NA #1's date of Certified Nurse Aide Training was completed on [DATE].3. NA #1 is not certified and has not taken her certification test as of [DATE].NA #3:B. Record review of NA #3's personnel record revealed the following:1. NA #3's is a current employee with an original hire date of [DATE], rehire on [DATE]. 2. NA #3's date of original Certified Nurse Aide Training was completed on [DATE].3. NA #3's certification had expired on [DATE].4. NA #3 had not registered to attend a NATCEP or CEP training as of [DATE].C. On [DATE] at 9:58 am, during an interview with the Director of Nursing (DON), she confirmed NA #1 received her certified nurse aide training late and continued to work shifts during that time. The DON also confirmed that NA #3 has been working shifts at this facility even though NA #3's certification has been expired since 2017. The DON stated her expectation is for all nurse aides to attend the certified nurse aide training and become certified within four months of hire date.

Based on record review and staff interview, the facility failed to ensure the annual performance review for the certified nursing assistants (CNAs) was completed for 1 (CNA #2) of 5 (CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5) CNAs reviewed. This could lead to residents not receiving the care and services as described on the care plan. The findings are:A. Record review of the facility's Personnel Records revealed CNA #2's hire date of 05/18/13. The most recent annual performance evaluation for CNA #2 was dated 10/29/24. B. On 12/12/25 at 11:43 am during an interview, the Director of Nursing (DON) could not confirm if CNA #2 had an annual performance evaluation completed since 10/29/24 and stated, [Name of city where this facility's Human Resources office is located] keeps up with the evaluations, they are sent to me when it is time for the employees to sign the yearly evaluation. She stated that she does expect the evaluations to be completed every 12 months.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify a resident's representative of a transfer or discharge and the reasons for the move in writing prior to the transfer or discharge for 1 (R #104) of 3 (R #29, R #104, and R #106) residents reviewed for transfers and discharges. This deficient practice could lead to residents' representatives being unaware of the residents' health status. The findings are:A. Record review of R #104's admission Minimum Data Set Assessment (MDS; a federally mandated assessment instrument completed by facility staff) dated 09/04/25, revealed the following: 1. R #104 was admitted to the facility on [DATE] with the following diagnoses:- Epilepsy (a seizure disorder),- Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), - Human Immunodeficiency Virus (HIV; a virus that attacks the body's immune system),- Personal history of traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head).2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15, cognitively intact. B. Record review of R #104's progress notes dated 09/23/25 revealed the following:1. The facility's social worker attempted to contact R #104's guardian via phone to inform them of R #104's discharge from the facility and was unsuccessful, this documentation was completed at 11:25 am. 2. R #104 was discharged from the facility at 12:00 pm and sent to a local psychiatric hospital. C. On 12/12/25 at 9:36 am, during an interview with the Director of Nursing (DON), she confirmed that R #104's guardian was not notified prior to the discharge taking place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 #19 and R #32) of 4 (R #8, R #15, R #19, and R #32) residents reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are:R #19
A. Record review of R #19's admission Record revealed she was originally admitted to the facility on [DATE] with the following diagnoses:
1. Alzheimer's disease (a progressive mental deterioration), unspecified,
2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),
3. Essential (primary) hypertension (HTN; high blood pressure).
B. Record review of R #19's progress notes revealed the following:
1. On 09/05/25 at 7:45 am, facility staff found R #19 asleep in a chair in the activity room. When staff woke R #19 up and assisted her to get in her wheelchair, she complained of pain in her left hip. R #19 was assessed by Registered Nurse (RN) #1 where swelling to the left hip and outward rotation (movement of a limb away from the midline of the body) of the left foot as well as R #19's inability to bear weight (not able to support or hold weight) was discovered. R #19 was sent to the hospital for further evaluation.
2. On 09/05/25 at 12:33 pm, the facility was notified that R #19 had a comminuted fracture (type of bone fracture where the bone is broken into three or more separate pieces) of her left femur (the thigh bone).
C. Record review of R #19's Discharge MDS dated [DATE] revealed R #19 was discharged from the facility and her return is anticipated.
D. Record review of R #19's readmission admission MDS dated [DATE], section J1700 revealed the following:
1. R #19 did not have any falls in the last two to six months prior to admission or reentry as indicated by a zero (the answer for no) being placed in the Enter Code column, meaning the facility staff that answered the questions in this section indicated that R #19 had not fallen.
2. R #19 did not have any fractures related to a fall in the six months prior to admission or reentry.
E. On 12/11/25 at 11:43 am, during an interview with the Director of Nursing (DON), she confirmed that R #19's MDS should indicate that she suffered a fracture related to a fall and it does not. The DON stated she expects all MDS assessments to be accurate and confirmed this one is not accurate.
R #32
F. Record review of R #32's face sheet revealed he was admitted to the facility on [DATE].
G. Record review of R #32's health record revealed R #32 had an appointment for hearing aid fitting dated 06/29/23.
H. Record review of R #32's care plan dated 11/29/25 revealed no care plan for hearing aid use.
I. Record review of R #32's annual MDS assessment dated [DATE] revealed the following:
-Section B0200: Moderate difficulty (hearing), speaker has to increase volume and speak distinctly.
-Section B0300: No hearing aid or other hearing appliance used.
J. On 12/08/25 at 10:11 am during an observation and interview with R #32 in his room, a pair of hearing aids were on top of his bedside table. R #32 stated that he does not wear his hearing aids because they do not fit him. R #32 stated he told multiple staff (he does not recall the names) that his hearing aids do not fit him and requested if he can get a new one and never receive any response or actions from the facility. R #32 stated that he needs his hearing aids to enjoy some activities provided in the facility.
K. On 12/11/25 at 3:48 am, during an interview, the Social Services Supervisor (SSS) stated I do not recall if R #32 needs hearing aids, but I know he is hard of hearing. The nursing staff has to let me know if any residents in the facility need services like hearing aids, otherwise I won't know.
L. On 12/12/25 at 8:10 am, during an interview with MDS (Minimum Data Set) Coordinator, she stated that she is not aware that R #32 has hearing aids. MDS coordinator confirmed that it should have been in the MDS assessments and did not happen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to create an accurate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 2 (R #1 and R #19) of 3 (R #1, R #19, and R #29) 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 #1
A. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses:
1. Chronic viral hepatitis C (inflammation of the liver),
2. Chronic obstructive pulmonary disease (COPD; lung disease),
3. Dependence on supplemental oxygen,
4. Personal history of traumatic brain injury (TBI; injury to the brain caused by an outside force, usually a violent blow to the head),
5. Blindness (loss of eyesight), one eye, low vision in the other eye,
6. 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 #1's electronic health record revealed R #1's baseline care plan is dated 04/29/25 and revealed the following
1. R #1 has impaired gas exchange related to hypoxia; requiring the use of oxygen as needed.
2. R #1 has a potential for behavioral expressions related to impaired cognitive function secondary to Dementia.
3. R #1 has a risk for falls related to unsteady gate.
4. R #1 has self-care deficits Actual/Potential related to mobility/Blind.
5. Dietary was not addressed on this baseline care plan.
C. On 12/12/25 at 9:58 am, during an interview with the Director of Nursing (DON), she confirmed R #1's baseline care plan was dated 04/29/25 and should have been completed within 48 hours. The DON also confirmed that the baseline care plan omitted required information, such as dietary requirements.
R #19
D. Record review of R #19's admission Record revealed she was readmitted to the facility on [DATE] with the following diagnoses:
1. Alzheimer's disease (a progressive mental deterioration), unspecified,
2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),
E. Essential (primary) hypertension (HTN; high blood pressure).
F. Record review of R #19's progress notes dated 10/21/25 revealed R #19 was readmitted to the facility on [DATE] with a surgical incision (a deliberate cut made through the skin and underlying tissues during surgery) noted on her left hip that measured two centimeters in length.
G. Record review of R #19's EHR revealed no evidence of a baseline care plan.
H. Record review of R #19's comprehensive care plan revealed it was initiated on 10/30/25.
I. On 12/12/25 at 9:11 am, during an interview with the DON, she confirmed the facility failed to create and implement a baseline care plan for R #19 when she was readmitted to the facility. The DON stated that she expects a baseline care plan to be created within 48 hours of a resident being admitted to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 (R #32) of 1 (R #32) resident reviewed who was identified as having a hearing impairment and utilizing a hearing aid. This deficient practice could likely result in staff being unaware of the current and actual needs of the residents. The findings are: A. Record review of R #32's face sheet revealed he was admitted to the facility on [DATE].B. Record review of R #32's health record revealed R #32 had an appointment for hearing aid fitting dated 06/29/23.C. Record review of R #32's care plan dated 11/29/25 revealed the care plan did not contain any information on R #32's hearing aid use.D. Record review of R #32's annual MDS (minimum data set) assessment dated [DATE] revealed the following:-Section B0200: Moderate difficulty (hearing), speaker has to increase volume and speak distinctly.-Section B0300: No hearing aid or other hearing appliance used.E. On 12/08/25 at 10:11 am during an observation and interview with R #32 in his room, a pair hearing aids were observed to be on top of his bedside table. R #32 stated that he does not wear his hearing aids because they do not fit him. R #32 stated he told multiple staff (he does not recall the names) that his hearing aids do not fit him and requested if he can get a new one and never receive any response or actions from the facility. R #32 stated that he needs his hearing aids to enjoy some activities provided in the facility. F. On 12/11/25 at 3:48 am, during an interview with Social Services Supervisor (SSS), she stated I do not recall if R #32 needs hearing aids, but I know he has hard of hearing. The nursing staff has to let me know if any residents in the facility is needing services like hearing aids, otherwise I won't know.G. On 12/12/25 at 8:10 am, during an interview with MDS Coordinator, she stated she is not aware that R #32 has hearing aids. MDS coordinator confirmed that it should have been in the MDS assessments and did not happen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure staff revised the care plan for 1 (R #29) of 3 (R #1, R #29, and R #32) residents reviewed when staff failed to update a care plan after a resident was diagnosed with dementia. This deficient practice could result in residents' care and needs not being addressed. The findings are:A. Record review of R #29's admission Record revealed she was admitted to the facility on [DATE].B. Record review of R #29's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/09/25, revealed the following:1. R #29's most recent admission or reentry to this facility was on 05/13/22.2. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) was not conducted because the resident is rarely or never understood.3. R #29's active diagnoses include a diagnosis of Non-Alzheimer's Dementia (a variety of dementia types that are not caused by Alzheimer's disease which is a type mental deterioration). C. Record review of R #29's care plan, last updated on 08/14/25 revealed the care plan did not contain any goals or interventions in place for R #29 dementia or the care and support she needs.D. On 12/11/25 at 11:43 am, during an interview with the Director of Nursing (DON), she confirmed that R #29's care plan does not meet her expectations because it does not include her having dementia or the care and support she needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 1 (R #11) of 1 (R #11) resident when the staff failed to follow physician order for derma saver palm pillow (a pillow to keep fingernails from digging into palms) to R #11's right hand. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are: A. Record review of R #11's face sheet revealed he was admitted to the facility on [DATE] with multiple diagnoses including, but not limited to:-Cerebrovascular accident (or CVA, is a medical term that refers to types of strokes), TIA (A transient ischemic attack is a short period of symptoms similar to those of a stroke), or stroke (can occur when blood flow to the brain is blocked or there is sudden bleeding in the brain).-Quadriplegia (a symptom of paralysis that affects all a person's limbs and body from the neck down).B. Record review of the care plan dated 10/22/25 revealed impaired physical mobility related to right hand contracture (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing deformity).C. Record review of R #11's current medical orders revealed an order dated 12/04/25 for R #11 to wear a derma saver palm pillow (a skin protection and pressure reducing product) on the right hand anytime R #11 is awake.D. On 12/10/25 at 2:27 pm during an observation of R #11's room, revealed R #11 was awake in his room, and not using the derma saver palm pillow because it was observed to be on the bedside table.E. On 12/10/25 at 2:27 pm, during an interview, Licensed Practical Nurse (LPN) #2 confirmed that R #11 is awake in his room and is not wearing the derma saver palm pillow. LPN #2 confirmed the derma saver palm pillow was located on the bedside table. F. On 12/11/25 at 2:40 pm during observation of R #11 room, revealed R #11 awake in his room and the derma saver palm pillow on the bedside table.G. On 12/11/25 at 2:40 pm, during an interview, the Patient Care Associate (PCA) #1, confirmed R #11's derma saver palm pillow is on the bedside table. PCA #1 stated that R #11 should have the derma saver pillow on his right hand when awake and did not happen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for 1 (R #32) of 1 (R #32) resident reviewed. This deficient practice had the potential to result in unmet hearing needs, miscommunication, and decreased participation in daily activities. The findings are: A. Record review of R #32's face sheet revealed he was admitted to the facility on [DATE].B. Record review of R #32's health record revealed R #32 had an appointment for hearing aid fitting dated 06/29/23.C. On 12/08/25 at 10:11 am during an observation and interview with R #32 in his room, a pair hearing aids were on top of his bedside table. R #32 stated that he does not wear his hearing aids because they do not fit him. R #32 stated he told multiple staff (he does not recall the names) that his hearing aids do not fit him and requested if he can get a new one and never receive any response or actions from the facility. R #32 stated that he needs his hearing aids to enjoy some activities provided in the facility. D. On 12/10/25 at 1:36 pm, during an interview, Patient Care Associate (PCA) #2, confirmed R #32's hearing aids are on top of his bedside table. PCA #2 confirmed that R #32 has hard of hearing and would benefit from a proper fitting hearing aid.E. On 12/11/25 at 3:48 pm, during an interview, Social Services Supervisor (SSS) stated I do not recall if R #32 needs hearing aids, but I know he has hard of hearing. The nursing staff has to let me know if any residents in the facility is needing services like hearing aids, otherwise I won't know.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure resident records were accurate for 1 (R #15) of 3 (R #12, R #15, and R #77) residents reviewed for catheter care (proper cleaning and maintenance of a catheter). This deficient practice could likely cause staff confusion and residents to get care and services that are not needed. The findings are: A. Record review of R #15's admission Record revealed he was admitted to the facility on [DATE] with the following diagnoses:1. Unspecified bilateral hearing loss (reduction of hearing ability in both ears),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),3. Post-traumatic stress disorder (PTSD; a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety),4. Calculus in bladder (bladder stones; hard mineral deposits that form in the bladder),5. Benign prostatic hyperplasia with lower urinary tract symptoms (a condition in older men where the prostate gland enlarges leading to urinary issues),6. Personal history of urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra).B. Record review of R #15's current physician orders revealed an order dated 04/28/25 to change R #15's catheter monthly and prn (as needed). C. Record review of R #15's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment dated [DATE] revealed R #15 does not utilize a catheter of any kind.D. On 12/08/25 at 12:00 pm, during an observation and interview with R #15, revealed R #15 did not have a catheter and stated that he hasn't had one of those in a long time.E. Record review of R #15's progress notes revealed a health status note dated 07/25/25 where R #15's physician wanted the catheter removed and physically removed the catheter.F. On 12/11/25 at 9:37 am, during an interview with the Director of Nursing (DON), she confirmed that R #15's order was never discontinued and should have been.

Based on observation, and interviews, the facility failed to properly store medications in the facility by making sure:-Medications in bubble wraps are not compromised (not opened or punctured and secured in the original packaging from the pharmacy). -All medical supplies are not expired.These deficient practices are likely to result in expired medications and medical supplies being used in resident care resulting in residents being at risk of possible infections and not receiving the full benefits of medication.The findings are:A. On 12/10/25 at 9:07 am during an observation of the medication cart, in the locked unit, revealed the following:-A medication bubble card labeled with the name of R #70 and containing Clonazepam (a prescribed medication used to manage anxiety) 1 mg (milligrams). The bubble pack labeled number 1 had a small green pill in the bubble. The bubble had been opened.- A 25g (gauge refers to the size of the hole in a needle) needle with an expiration date of 09/10/25.B. On 12/10/25 at 9:07 am, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that the bubble card is compromised. LPN #1 also confirmed that the needle is expired.C. On 12/11/25 at 1:36 pm, during an interview with Director of Nursing (DON), she confirmed that the compromised medication inside the bubble card and the expired needle should have been discarded properly and did not happen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide food that accommodates resident allergies, intolerances, and preferences for 1 (R #8) of 1 (R #8) resident observed for food preferences. This deficient practice is likely to result in food intolerance and/or an allergic reaction to the food being served to the residents. The findings are:A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE].B. Record review of R #8's meal card (card that identifies what to serve or not serve each resident) revealed R #8 is not to have chocolate and is allergic to peas. C. On 12/09/25 at 11:31 am, during an observation of dining, R #8 was served his lunch meal, on his plate was pasta that contained peas. Also noted on his tray was a bowl of chocolate pudding. R #8 stated to staff that he could not eat that because he is allergic to peas and chocolate.D. On 12/09/25 at 11:33 am during an interview with Certified Nurse Aide (CNA #1), she stated R #8's meal ticket stated R#8 has an allergy to peas and cannot have chocolate. She confirmed that these two foods were served to R #8 and should not have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility's Administrator (ADM) and Director of Nursing (DON) failed to administer the facility when they knew/should have known and prevented the following deficient practices which occurred in the facility: 1. Not ensuring staff were trained and/or competent before providing care to residents. 2. Allowing untrained and uncertified nurse aides to train other nurse aides. These deficient practices are likely to affect all 102 residents residing in the facility according to the daily census provided by the Admissions Coordinator (AC) on [DATE] and could lead to residents not maintaining their highest practicable physical, mental, and social well-being. The findings are: A. Record review of the facility's progress notes for R #12 revealed on [DATE] R #12 had fallen out of mechanical lift sling while being transferred by Nurse Aide (NA) #1 and NA #2. R #12 landed on the floor and was lying on his back, left leg was under bed, right leg propped on bed, and laceration (a wound produced by tearing) to back of head was noted. Physician notified at 7:43 pm, instructed to send the resident out to hospital via ambulance. R #12 was transported to hospital via ambulance at 8:15 pm. B. On [DATE] at 3:53 pm, during an interview with Director of Nursing (DON), she confirmed R #12 fell during a mechanical lift transfer. The DON confirmed that Nurse Aide (NA) #1 was training NA #2 and were the staff with R #12 during that transfer. The DON stated that NA #1 is not a certified nurse aide but is trained to operate a mechanical lift; and NA #2 is also not a certified nurse aide and has not completed training to become a certified nurse aide. C. On [DATE] at 11:37 am, during an interview with the administrator, he stated that one of two mechanical lift operators must be a certified nurse aide. The administrator confirmed that during the transfer of R #12, both NA's #1 and #2 are not certified and they must not operate the mechanical lift together.D. Record review of the facility's personnel records revealed the following:1. NA #1's is a current employee with a hire date of [DATE]. NA #1's date of Certified Nurse Aide Training was completed on [DATE].3. NA #1 is not certified and has not taken her certification test as of [DATE].4. NA #3's is a current employee with a hire date was [DATE].5. NA #3's date of original Certified Nurse Aide Training was completed on [DATE].6. NA #3's certification expired on [DATE].7. NA #3 had not registered to attend a NATCEP or CEP training as of [DATE].E. On [DATE] at 9:58 am, during an interview with the Director of Nursing (DON), she confirmed NA #1 received her certified nurse aide training late and continued to work shifts during that time. The DON also confirmed that NA #3 has been working shifts at this facility even though NA #3's certification has been expired since 2017. The DON stated her expectation is for all nurse aides to attend the certified nurse aide training and become certified within four months of hire date.F. On [DATE] at 11:18 am during an interview with the DON, she stated that she assigns nurse aides and certified nurse aides to the unit they are to work in, but it is the floor nurses that make the assignments of which staff work together and with which residents. The DON stated that she does not notify the floor nurses of which staff are trained and certified and which staff are not. The DON stated that she feels that allowing uncertified nurse aides to train untrained nurse aides is acceptable. G. On [DATE] at 11:37 am during an interview with the ADM, he stated that untrained and uncertified nurse aides should only work with and receive training from certified nurse aides. The ADM was unable to answer how the facility ensures that residents receive care and support from trained, competent, and certified nurse aides, instead he stated, I know it needs to be corrected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to meet professional standards of care for 3 (R #8, #42, and #52) of 3 (R #'s #8, #42, and #52) residents reviewed by not providing restorative nursing services (a type of rehabilitation that helps residents regain or maintain their independence and physical abilities) as ordered by a physician. This deficient practice is likely to result in the resident experiencing psychosocial harm (harm to someone's mental health) and despair. The findings are:
R #8:
A. Record review of R #8's face sheet revealed R #8 was admitted into the facility on [DATE].
B. Record review of R #8's physician order/referral dated 07/10/24 revealed R #8 was to receive restorative nursing services weekly that focused on Upper extremity [arms] exercises that focus on range of motion (ROM).
C. Record review of the facility restorative nursing program schedule dated 08/01/24 through 08/23/24 revealed R #8 was offered/provided six (6) restorative nursing sessions out eight (8) opportunities.
D. On 08/19/24 at 4:21 pm during an interview with R #8, she stated that she was not offered restorative nursing services as often as she would like.
E. On 08/23/24 at 12:14 pm during an interview with the Physical Therapy Assistant (PTA) #1, she stated that they try to offer R #8 restorative nursing services at least two times a week, but that doesn't always happen because PTA #1 and the other restorative staff are needed on the units instead. PTA #1 confirmed R #8 should be seen by restorative nursing services at least two times a week and that does not consistently happen.
R #42:
F. Record review of R #42's face sheet revealed R #42 was admitted into the facility on [DATE].
G. Record review of R #42's physician order/referral dated 08/01/24 revealed R #42 was to receive restorative nursing services weekly that focused on ambulation (the ability to walk or move about without assistance) and ROM.
H. Record review of the facility restorative nursing program schedule dated 08/01/24 through 08/23/24 revealed R #42 was offered/provided one restorative nursing sessions out eight (8) opportunities.
I. On 08/23/24 at 2:42 pm during an interview with PTA #1, she stated that they are supposed to help ambulate R #42, but they cannot because they do not have the staff available to do that while also taking residents to appointments and working on the units. PTA #1 confirmed R #8 had only been offered one restorative nursing service session since 08/01/24, and he should have been offered more.
R #52:
J. Record review of R #52's face sheet revealed R #52 was admitted into the facility on [DATE].
K. Record review of R #52's physician order/referral dated 02/27/24 revealed R #52 was to receive restorative nursing services weekly that focused on ROM.
L. Record review of the facility restorative nursing program schedule dated 07/01/24 through 07/19/24 revealed R #52 was offered/provided one restorative nursing sessions out six (6) opportunities.
M. Record review of the facility restorative nursing program schedule dated 08/01/24 through 08/23/24 revealed R #52 was offered/provided two (2) restorative nursing sessions out eight (8) opportunities.
N. On 08/23/24 at 2:49 pm during an interview with PTA #1, she confirmed R #52 was not offered consistent restorative nursing sessions due to staffing issues and R #52 should be offered more restorative nursing sessions.
O. On 08/23/24 at 3:04 pm during an interview with the Director of Nursing (DON), she stated she was not aware of restorative nursing staff not completing their treatments with the residents. DON confirmed residents that are receiving restorative nursing services should be offered/provided those multiple times per week as expected.

Based on record review and interview, the facility failed to prevent abuse for 1 (R #79) of 1 (R #79) resident reviewed when the facility staff failed to recognize the difference between horseplay and unwanted touching and harassment between a staff and resident. This deficient practice likely resulted in R #79 increase of isolation and fear of further abuse. The findings are:
A. On 08/19/24 at 2:47 pm, during an interview with R #79, she stated. One of the activities persons kicked me in the ass (buttocks). They (staff) thought she was messing around. I did not think she was messing around, she kicked me. That's not funny. They sent her home for a couple of days. I felt bad because she [Activities Assistant (AA) #1] might have a ton of bills to pay or whatever. This happened on August first. I told (name of Registered Nurse #1). After that I kind of just stayed in my room because I didn't want to see her [AA #1] or do activities when she is there. She might do it again. I don't want to cause trouble and they will make me leave here (facility). R #79 further stated that she has participated less in the activity program and feels that AA #1 is upset with her and does not talk to her anymore.
B. Record review of camera footage dated 08/01/24 revealed the following:
- At 11:36:04 am, R #79 walked down the hallway, headed to the dining room.
- At 11:36:09 am, R #79 turned to her right side, Agency Tech (T) #1 talked to R #79. Licensed Practical Nurse (LPN) #1 was at the medication cart, AA #1 stood next to the medication cart and Tech (T) #1 sat on a short bench in the hallway where R #79 walked.
- At 11:36:12 am, R #79 stopped in the hallway in front of LPN #1, T #1 AT #1 and AA #1 when AA #1 approached R #79 and kicked R #79 in the backside.
-At 11:36:14 am, R #79 turned around and looked at AA #1 and R #79 rubbed her left buttock with her left hand.
- At 11:36:18 am, AA #1 kicked towards R #79 a second time, R #79 reached down to try and catch AA #1's leg.
-At 11:36:20 am, R #79 pointed to AA #1 as AA #1 approached R #79 and hugged her. R #79 held her left arm between herself and AA #1. AA #1 continued to hug her and R #79 pats her on the back with her right arm and appeared to push AA #1 away. AA #1 and R #79 proceed to walk down the hallway towards the dining room.
-At 11:36:31 am, AA #1 patted R #79 on the left buttock, R #79 steps back and grabbed AA #1 by the arm, picked up her right foot and kicked towards AA #1 on her right leg. AA #1 kicked towards R #79. R #79 moved back against the wall and proceeds to put her walker between herself and AA #1. AA #1 shook R #79's walker while R #79 was holding onto the walker. LPN #1, T #1 and AT #1 all appeared to watch the incident down the hallway.
-At 11:37:18 am, R #79 put her walker in the entryway of the dining room, AA #1 took the walker, shuffled a short distance with the walker and then returned the walker and proceeded to walk down the hallway away from the dining room. R #79 remained in the dining room.
C. On 08/21/24 at 4:19 pm, during an interview with AA #1, she stated, she was familiar with R #79, and they liked to joke and horseplay. Regarding the incident on 08/01/24, she stated that R #79 was on her way to the dining room and she was playing around with R #79 and did not believe that she had kicked R #79. AA #1 stated she was just playing around with R #79 and did not feel that she had hurt her in any way. Since the incident she has been told that she is not to interact with R #79 alone and if she needs to go to R #79's room she is to take another staff with her and she is not to approach her other then to invite her to an activity. AA #1 also stated that Registered Nurse (RN) #1 was told by R #79 about the incident. AA #1 was heading out for the day and did not return for several days. An investigation was conducted and then she was told she could return to work.
D. On 08/22/24 at 10:19 am during an interview with AT #1, she stated that she was present during the incident between AA #1 and R #79. She did witness AA #1 tap the side of R #79's thigh. R #79 stated to AA #1 that she was too old to box. AT #1 also stated that they (AA#1) do horseplay. She further stated, I do not believe staff should kick residents in anyway. I did see the whole thing along with [Name of LPN #1] and [Name of T #1]. I did think it was wrong for her to play around like that. I think she [AA #1] took things a little too far. I know now [Name of R #79] stays in her room more. I did notice a change in [name of R #79] when she hears [name of AA #1]'s voice, and she will go into her room and does not come out. AT #1 stated that R #79 will go to activities when AA #1 is not here. AT #1 stated that she did not say anything [report the incident] because the nurse was there and she [nurse] had not done anything about it.
E. On 08/22/24 at 10:59 am, during an interview with RN #1, she stated, the incident had been reported to her by R #79 on 08/03/24 and she thought it could be considered mistreatment/abuse and she reported it to the Standards and Compliance department at the facility, to Adult Protective Services, and the Health Care Authority on 08/03/24. RN #1 further stated, she had to prioritize R #79's safety by removing the staff from the facility. RN #1 also stated she had interviewed AA #1 and she told her that they [AA #1 and R #79] were playing. R #79 revealed to RN #1 that AA #1 had kicked her on the buttocks. RN #1 stated there is a boundary and it is not a good idea to play with a resident in that manner. RN #1 had noticed that she (R #79) is a little more paranoid and she will make comments about it (kicking incident between R #79 and AA #1). RN #1 stated. I do not think it is acceptable behavior to kick a resident. If I saw something like that happen, I would intervene and I would let the staff know it is not appropriate. Residents are to be treated with respect and dignity.
F. On 08/22/24 at 11:29 am, during an interview with T #1, she stated that during the time of the incident on 08/01/24, she was waiting for lunch to start, and R #79 was headed to lunch. AA #1 was teasing R #79 and then AA #1 kicked R #79 on the buttocks. There were other staff there that saw AA #1 kick R #79 and they [staff witnesses] all thought they were just playing, no one intervened. I do not think that kicking a resident is ok. It was not a hard kick. I think it is inappropriate, but not abusive. T #1 further stated that she has noticed changes in R #79 and she is more anxious, and she is quieter since the incident. T #1 further stated that she did not report it because she thought they were just playing around.
G. On 08/22/24 at 11:45 am, during an interview with the Director of Nursing (DON), she stated she was aware of the incident between AA #1, and R #79 and her understanding was that the investigation confirmed that they were horseplaying however kicking a resident is not acceptable. DON was not part of the investigation. DON further stated that after reviewing the video footage she would consider the actions of AA #1 to be abuse. DON felt that these actions should have been reported as abuse.
H. On 08/22/24 at 12:02 pm, during an interview with Activity Director (AD). He stated, he was aware of the incident between AA #1 and R #79. He had spoken with AA #1 and it was determined that it was horseplay. AA #1 was trained on boundaries following the incident. He stated that a kick is overboard and could border on abuse and a playful kick is excessive and should not happen. AD stated he did not review the video but standards and compliance had determined it was horseplay.
I. On 08/22/24 at 3:31 pm, during an interview with Interim Administrator, he stated, that after viewing the video footage he did believe that it was abuse and the investigation was inappropriate and that kicking a resident is never acceptable. Administrator stated he was not involved in the investigation because standards and compliance are the ones that do the investigations. He was aware of the incident but was dependent on the outcome from standards and compliance.
J. On 08/23/24 at 9:35 am, during an interview with Licensed Practical Nurse (LPN) #1, she stated, she was passing medications at the time of the incident. R #79 was on her way to the dining room and the staff were joking around with R #79. LPN #1 does not recall seeing AA #1 kick R #79. She stated that kicking a resident is not acceptable and if she would have seen it [AA #1 kick R #79], she would have intervened.

Based on record review and interview, the staff failed to immediately report a witnessed incident of abuse to a supervisor and the facility failed to report an incident of abuse to the state survey agency within 2 hours for 1 (R #79) of 1 (R# 79) resident reviewed for incidents/accidents. If the facility fails to report incidents of abuse to the State Agency, then the implementation of measures to prevent further abuse is delayed. The findings are:
A. On 08/19/24 at 2:47 pm, during an interview with R #79, she stated. One of the activities persons kicked me in the ass (buttocks). They (staff) thought she was messing around. I did not think she was messing around, she kicked me. That's not funny. They sent her home for a couple of days. This happened on August first. I told (name of Registered Nurse #1). After that I kind of just stayed in my room because I didn't want to see her [AA #1] or do activities when she is there. She might do it again. I don't want to cause trouble and they will make me leave here (facility). R #79 further stated that she has participated less in the activity program and feels that AA #1 is upset with her and does not talk to her anymore.
B. Record review of camera footage dated 08/01/24 revealed the following:
- At 11:36:04 am, R #79 walked down the hallway, headed to the dining room.
- At 11:36:09 am, R #79 turned to her right side, Agency Tech (T) #1 talked to R #79. Licensed Practical Nurse (LPN) #1 was at the medication cart, AA #1 stood next to the medication cart and Tech (T) #1 sat on a short bench in the hallway where R #79 walked.
- At 11:36:12 am, R #79 stopped in the hallway in front of LPN #1, T #1 AT #1 and AA #1 when AA #1 approached R #79 and kicked R #79 in the backside.
-At 11:36:14 am, R #79 turned around and looked at AA #1 and R #79 rubbed her left buttock with her left hand.
- At 11:36:18 am, AA #1 kicked towards R #79 a second time, R #79 reached down to try and catch AA #1's leg.
-At 11:36:20 am, R #79 pointed to AA #1 as AA #1 approached R #79 and hugged her. R #79 held her left arm between herself and AA #1. AA #1 continued to hug her and R #79 pats her on the back with her right arm and appeared to push AA #1 away. AA #1 and R #79 proceed to walk down the hallway towards the dining room.
-At 11:36:31 am, AA #1 patted R #79 on the left buttock, R #79 steps back and grabbed AA #1 by the arm, picked up her right foot and kicked towards AA #1 on her right leg. AA #1 kicked towards R #79. R #79 moved back against the wall and proceeds to put her walker between herself and AA #1. AA #1 shook R #79's walker while R #79 was holding onto the walker. LPN #1, T #1 and AT #1 all appeared to watch the incident down the hallway.
-At 11:37:18 am, R #79 put her walker in the entryway of the dining room, AA #1 took the walker, shuffled a short distance with the walker and then returned the walker and proceeded to walk down the hallway away from the dining room. R #79 remained in the dining room.
C. On 08/22/24 at 10:19 am during an interview with AT #1, she stated that she was present during the incident between AA #1 and R #79. She did witness AA #1 tap the side of R #79's thigh. R #79 stated to AA #1 that she was too old to box. AT #1 also stated that they (AA#1) do horseplay. She further stated, I do not believe staff should kick residents in anyway. I did see the whole thing along with [Name of LPN #1] and [Name of T #1]. I did think it was wrong for her to play around like that. I think she [AA #1] took things a little too far. I know now [Name of R #79] stays in her room more. I did notice a change in [name of R #79] when she hears [name of AA #1]'s voice, and she will go into her room and does not come out. AT #1 stated that R #79 will go to activities when AA #1 is not here. AT #1 stated that she did not say anything [report the incident] because the nurse was there and she [nurse] had not done anything about it. AT #1 confirmed that she never checked on the resident after the incident.
D. On 08/22/24 at 10:59 am, during an interview with RN #1, she stated, the incident had been reported to her by R #79 on 08/03/24 and she thought it could be considered mistreatment/abuse and she reported it to the Standards and Compliance department at the facility, to Adult Protective Services, and the Health Care Authority on 08/03/24. RN #1 further stated, she had to prioritize R #79's safety by removing the staff from the facility. RN #1 also stated she had interviewed AA #1 and AA #1; they both told her that they were playing. R #79 revealed to RN #1 that AA #1 had kicked her on the buttocks. RN #1 stated there is a boundary and it is not a good idea to play with a resident in that manner. RN #1 had noticed that she (R #79) is a little more paranoid and she will make comments about it (kicking incident between R #79 and AA #1). RN #1 stated. I do not think it is acceptable behavior to kick a resident. If I saw something like that happen, I would intervene and I would let the staff know it is not appropriate. Residents are to be treated with respect and dignity.
E. On 08/22/24 at 11:29 am, during an interview with T #1, she stated that during the time of the incident on 08/01/24, she was waiting for lunch to start, and R #79 was headed to lunch. AA #1 was teasing R #79 and then AA #1 kicked R #79 on the buttocks. There were other staff there that saw AA #1 kick R #79 and they [staff witnesses] all thought they were just playing, no one intervened. I do not think that kicking a resident is ok. It was not a hard kick. I think it is inappropriate, but not abusive. T #1 further stated that she has noticed changes in R #79 and she is more anxious, and she is quieter since the incident. T #1 further stated that she did not report it because she thought they were just playing around. T #1 confirmed that she never checked on the resident to confirm how she felt about the interaction.
F. On 08/23/24 at 9:35 am, during an interview with Licensed Practical Nurse (LPN) #1, she stated, she was passing medications at the time of the incident [on 08/01/24]. R #79 was on her way to the dining room and the staff were joking around with R #79. LPN #1 does not recall seeing AA #1 kick R #79. She stated that kicking a resident is not acceptable and if she would have seen it [AA #1 kick R #79], she would have intervened.
G. Record review of the facility self report revealed that the incident between AA #1 and R #79 was reported to the State Agency on 08/03/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury; skin damage which results from unrelieved pressure on the body) for 1 (R #16) of 1 (R #16) residents reviewed when staff failed to update wound care treatment orders according to R #16's care plan and in relation to R #16's pressure ulcer becoming worse.
This deficient practice is also likely to lead to residents developing more/other pressure ulcers and wounds worsening. The findings are:
A. Record review of R #16's face sheet revealed R #16 was admitted into the facility on [DATE].
B. Record review of R #16's care plan dated 07/09/24 revealed, Focus: Impaired skin integrity related to Stage II [2] pressure injury (level of skin damage which results from unrelieved pressure on the body) to coccyx (tailbone).
Interventions: If pressure injury is not improving within 2 weeks of using current treatment, reassess and notify medical provider for a change of treatment.
C. Record review of R #16's coccyx pressure ulcer assessment dated [DATE] through 08/23/24 revealed the following:
1. 07/05/24: Length: 3 cm (centimeters), Width: 1 cm.
2. 07/08/24: Length: 3 cm, Width: 1 cm.
3. 07/10/24: Length: 3 cm, Width: 1 cm.
4. 07/12/24: Length: 3 cm, Width: 1 cm.
5. 07/15/24: Length: 3 cm, Width: 1 cm.
6. 07/17/24: Length: 3 cm, Width: 1 cm.
7. 07/19/24: Length: 3 cm, Width: 1 cm.
8. 07/22/24: Length: 3 cm, Width: 1 cm.
9. 07/24/24: Length: 3 cm, Width: 1 cm.
10. 07/26/24: Length: 3 cm, Width: 1 cm.
11. 07/29/24: Length: 3 cm, Width: 1 cm. Wounds showing no signs of improvement.
12. 07/31/24: Length: 4 cm, Width: 1 cm.
13. 08/02/24: Length: 4 cm, Width: 1 cm.
14. 08/05/24: Length: 4 cm, Width: 1 cm.
15. 08/07/24: Length: 4 cm, Width: 1 cm.
16. 08/09/24: Length: 4 cm, Width: 1 cm.
17. 08/12/24: Length: 4 cm, Width: 1 cm.
18. 08/14/24: Length: 4 cm, Width: 1 cm.
19. 08/16/24: Length: 4 cm, Width: 1 cm.
20. 08/19/24: Length: 4 cm, Width: 1 cm.
21. 08/21/24: Length: 2.5 cm, Width: 0.5 cm.
D. Record review of R #16's Medication Administration Record (MAR) dated 07/01/24 through 07/31/24 revealed the following medications/treatments used for R #16's coccyx pressure ulcer:
1. Apply skin protectant, cover with 2x2 (2 by 2) gauze and transparent tape twice a day and as needed- completed twice a day, every day from 07/01/24 through 07/10/24.
2. Apply skin protectant, cover with 2x2 gauze and transparent tape daily- completed once a day, every day from 07/11/24 through 07/31/24.
E. On 08/23/24 at 10:44 am, during an interview with Licensed Practical Nurse (LPN) #2, she stated R #16's coccyx pressure ulcer was a stage 2 and was not getting better until recently. LPN #2 confirmed R #16's pressure ulcer treatment and care had not changed since R #16 developed on 06/28/24 the pressure ulcer (Apply skin protectant, cove with 2x2 gauze and transparent tape daily) .
F. On 08/23/24 at 1:03 pm during an interview with the Director of Nursing (DON), she stated she would expect R #16's pressure ulcer treatment to change according to her care plan which stated if R #16's pressure ulcer did not improve within two weeks treatment would change. DON confirmed R #16's pressure ulcer treatments changed, but not within the two week timeframe as expected. Treatment was changed from BID (twice a day) to daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure that 1 (R #16) of 1 (R #16) residents reviewed was free from accidents and hazards. Facility was using a call light attached to R #16's clothing to alert staff when resident attempts to transfer on her own. Call light would detach from the wall and ring and staff would be alerted that resident was attempting to transfer self. This deficient practice is likely to put residents at risk of unsafe situations. The findings are:
A. Record review of R #16's face sheet revealed R #16 was admitted into the facility on [DATE].
B. Record review of R #16's nursing progress notes dated 06/09/24 through 06/10/24 revealed the following:
1. 06/09/24: R #16 was found on the floor next to her bed by staff. R #16 was attempting to use the restroom on her own prior to fall and told staff her left hip hurt badly. R #16 was transported to the emergency room (ER).
2. 06/10/24: R #16 was diagnosed with two fractures in the ER and returned to the facility.
C. On 08/20/24 at 10:13 am during an observation of R #16's room, R #16 sat in a wheelchair with the room call light attached to her left shoulder shirt.
D. Record review of R #16's care plan dated 07/09/24 revealed R #16 was at risk for falls. R #16's care plan interventions stated, I am able to use the call bell. It will be kept within my reach. Staff will educate me on using the call bell with transfers.
E. On 08/23/24 at 9:42 am during an interview with Certified Nursing Assistant (CNA) #6, she stated R #16 has become less independent and is prone to falls. CNA #6 also stated the staff attaches R #16's call light onto her clothing because when R #16 attempts to self transfer, the call light will disconnect from the wall (since it's attached to her body), which will alert staff.
F. On 08/23/24 at 10:47 am during an interview with Licensed Practical Nurse (LPN) #2, she stated R #16 sustained a left hip fracture after her most recent fall on 06/09/24. LPN #2 also stated the nursing staff will attach R #16's call light to her clothing, so staff will be alerted if R #16 attempts to self transfer.
G. On 08/23/24 at 11:04 am during an observation of R #16's room, R #16 laid in bed with the call light attached to right shoulder.
H. On 08/23/24 at 12:59 pm during an interview with the Director of Nursing (DON), she stated the expectation is staff can clip R #16's call light to blanket or something like that, but not to R #16's clothing. DON confirmed the way the staff is currently using the call light for R #16 is considered a form of a restraint and should not be happening.

Based on observation, interviews, and record review, the facility failed to have recipes for all menu items and to ensure staff followed nutritionally calculated recipes for pureed diets. This failure had the potential for food not to meet the nutritional requirements of all residents who ate pureed foods. The findings are:
A. On 08/20/24 at 8:55 am, during an interview, the Supervisor stated the menu for the resident's lunch was pork enchiladas, mixed vegetables, beans, and fruit. She stated the alternative was egg salad sandwich, and residents with a pureed diet were having pureed carrots instead of pureed mixed vegetables.
B. Observation on 08/20/24 at 8:56 am revealed the Supervisor prepared pureed enchiladas for the residents' lunch service. She placed six corn tortillas (six inch), six servings of enchilada mixture, and scooped an unmeasured amount of thickening powder into a food processor. The Supervisor pureed the mixture to a pudding consistency.
C. On 08/20/24 at 8:58 am during an interview, the Supervisor stated the scoop for the thickening powder was equal to one cup. She stated she put ½ cup (c) of thickening powder into the enchilada puree.
D. Record review of the facility's recipes revealed a recipe for green chicken or pork enchiladas for regular diets. Further review revealed the records did not contain a recipe for green chicken or pork enchiladas for pureed diets.
E. Observation on 08/20/24 at 9:00 am, revealed pureed carrots in bowls in the warmer for the residents' lunch service. Taste test of the pureed carrots revealed the mixture tasted flavorless.
F. On 08/20/24 at 9:02 am during an interview, the Supervisor stated the puree carrots was made of carrots and thickening powder.
G. Record review of the facility's recipes revealed a recipe for pureed carrots with the following instructions:
- Recipe for 240 servings.
- Ingredients: fresh steamed carrots, thickener, hot water, vegetable base, salted and melted butter.
- Process carrots to a fine consistency.
- Add thickener, vegetable base mixed with hot water, and butter.
- Process until smooth.
H. Observation on 08/20/24 at 9:22 am revealed the [NAME] prepared pureed carrot cake for the residents' meal. She placed 12 slices of carrot cake, 12 cups of water, and two cups of a thickening powder into a food processor. She pureed the mixture to a smooth consistency. Taste test showed the mixture tasted watery. The [NAME] placed the mixture into styrofoam bowls and topped with an icing mixture.
I. On 08/20/24 at 9:32 am, the [NAME] stated she had recipes in her phone and in a binder. She stated she made the pureed carrot cake in the past, so she did not refer to the recipe.
J. Record review of the facility's recipes revealed the facility did not have a recipe for pureed carrot cake.
K. Observation on 08/20/24 at 9:45 am revealed the Supervisor prepared pureed beans for the residents' lunch service. She placed 24 ounces (oz) of beans and broth mixture and scooped an unmeasured amount of thickening powder into a food processor. She pureed the mixture to a smooth consistency. The Supervisor added an unmeasured amount of tap water to the mixture and continued to puree to a smooth consistency.
L. On 08/20/24 at 9:50 am during an interview, the Supervisor stated she added ¾ c of thickening powder to the beans and ½ c of water. The Supervisor stated she knew how to prepare the pureed food because she worked at the facility for a long time. She stated, she measured all the ingredients, and there was a sheet posted in the kitchen regarding the consistency of each diet type. The Supervisor stated there were recipes for the menu items, and there was a recipe for everything.
M. Record review of the facility's recipes revealed a recipe for pureed beans with the following instructions:
- Recipe for 240 servings.
- Ingredients: pinto beans cooked with onions, chopped garlic cloves, bay leaf, salt, oregano.
- Place the cooked beans in food processor and process fine and until the texture is very smooth.
- Scrape down the sides of the bowl and repeat the process.
N. On 08/20/24 at 10:25 during an interview, the Director of Food Services stated, she was responsible for the residents' meals, the menus, and the recipes. She stated the Dieticians created the menus and approved the recipes based on an analysis of the residents' needs. The Director stated the residents asked for more authentic New Mexican food, and the menu did not have those items. She stated she created the recipe for the green chicken or pork enchiladas to meet the residents' requests.
O. On 08/20/24 at 10:50 am during an interview with the Director of General Services, the Director of Food Services, and the Dieticians, and the Supervisor, Dietician 1 and Dietician 2 stated they were responsible to develop and analyze the menus. They stated, they made the menus from scratch in order to take into account what the residents wanted to eat. They stated they also approved the recipes, but there was not a recipe for all food items. The Dieticians stated staff cooked the way they were used to, because the most important part of the recipe was the meat. They stated the meat was pre-portioned, so all cooks used the same amount of meat in their recipe. The Dieticians stated cooks should use the recipe closest to what they were preparing, even if it was not for the exact food item on the menu. The Dieticians reviewed the green chicken or pork enchilada recipe. They stated they had not seen and did not approve the enchilada recipe. The Dietician stated it was expected all food items on the menu had a recipe for staff to follow and that they review and approve all recipes served to the residents. They stated this was important for consistency across all cooks and preparation, for nutritional values, and for flavor. The Dieticians stated there was not a recipe for the carrot cake puree, but it was expected staff would use milk instead of water. They stated the milk had more nutritional value and flavor. The Dieticians stated it was expected staff would use thickening powder sparingly, because it did not have any nutritional value. They stated staff should not use thickening powder by the cup. They stated the Supervisor did not need to add thickening powder to the beans. The Dieticians stated they performed competency audits of the dietary staff, but the audits did not include an observation of the preparation of pureed foods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to provide food that accommodated resident preferences for 2 (R #9 and R #69) of 2 (R #9 and R #69) residents reviewed for food preferences. This deficient practice is likely to result in weight loss due to the residents not eating or an allergic reaction to the food being served to the residents. The findings are:
A. Record review of R #69's face sheet revealed, R #69 was admitted into the facility on [DATE].
B. Record review of R #69's care plan dated 7/10/2024, revealed the following:
-Focus: Diet is Therapeutic Diet.(diet modified to fit the nutrition need of a resident)
-Interventions: Provide diet as ordered and honor all food preferences.
C. Record review of facility incident report form dated 03/20/24, R #69 requested a chicken sandwich (choice #2 ) for dinner. R #69 did not receive chicken sandwich as ordered because the dietary had only sent three chicken sandwiches for the unit.
D. Record review of facility incident report form dated 03/20/24, revealed there were only three chicken sandwiches sent to the unit for 14 residents as an alternate meal and regular menu items were sent for all residents.
E. Record review of R #9's facesheet revealed R #9 was admitted to the facility on [DATE].
F. Record review of R #9's nutritional assessment review dated 06/30/2024 revealed Regular LCS (Low Concentrated Sweets), bland diet, no Chile, Glucerna (nutritional supplement) with lunch and milk with all meals. HS (evening) snack. Honor all food preferences.
G. Record review of facility incident report form dated 03/20/24 stated there were only three chicken sandwiches sent to the unit for 14 residents as an alternate meal and R #9 was not able to get one.
H. On 08/22/2024, during an interview with Dietary Manager, she stated only a set amount of alternate food is sent to the units. If a resident request an alternate food, and there were not enough food then the can call and request a alternate meal. The resident will have to wait until service of meals are done and then they would accommodate the residnets' alternative request which could take a considerable amount of time to wait.

Based on observation, interviews, and record review, the facility failed to maintain the kitchen in a sanitary manner when staff failed to:
- Perform hand hygiene and to change gloves as often as necessary to avoid cross contamination,
- Store open food protected and with labels and dates to prevent cross contamination and outdated usage,
- Utilize hair restraints and beard guards in a manner which restrained all hair while in the kitchen,
- Use the sanitizing solution according to manufacturer's instructions,
- Protect clean disposable wares (includes dishware, drinkware, and flatware such as spoons, forks, and knives) to prevent contamination,
These failures had the potential to result in cross contamination and foodborne which could affect all residents who ate food from the kitchens. The findings are:
Handwashing and Glove Use
A. Record review of the facility's Sanitation and Infection Control, Hand Hygiene policy, dated January 2014, revealed staff directed to wash hands with soap and water at the following times:
- Before handling food or clean utensils, dishes, equipment,
- Before putting on gloves,
- After touching hair, skin, beard, or clothing,
- After handling soiled silverware,
- After handling garbage,
- After removing gloves,
- After any other activity that may contaminate the hands.
B. Observation on 08/20/24 at 12:15 pm, of the kitchen located on Unit #1 revealed Server 1 wore gloves and entered the kitchen. The Server touched the door, the trash can, and dirty dishes. The Server took clean dishes out of the dishwasher and put them away. The Server did not remove his gloves and did not perform hand hygiene when he moved from dirty tasks (touching dirty dishes, cleaning the kitchen, taking out trash, and similar) to clean task (touching clean dishes, preparing food, and similar). At 12:26 pm, Server 1 touched dietary cards and dirty dishes. He took the dirty dishes to the three-compartment sink (a sink with three sections to wash, rinse, and sanitize) and touched the hose with dish detergent to fill a tub of dishes with soapy water. He took the tubs to the dirty side of the dishwashing area, removed a clean pitcher from the dishwasher, and placed it on the storage shelf. Server 1 did not remove his gloves and did not perform hand hygiene when moving from dirty dishes to clean dishes. The Server placed the same gloved hand on a trash can, with part of his fingers inside the can, to move it across the floor. He removed the trash bag of waste from the can, and he placed a new trash bag in the can. The Server removed clean dishes from the dishwasher and put them away. The Server did not remove his gloves and did not perform hand washing after touching the trash can.
C. On 08/21/24 at 8:40 am, during an interview, the Supervisor stated the facility had a policy for glove use and handwashing, and staff have been trained on the policy. She stated staff should hand wash before putting on gloves and after removing the gloves. She stated staff should also hand wash every time they entered the kitchen, when they moved from a dirty task to a clean task, and after they used the restroom, took a break, or touched their face or body. She stated staff should change their gloves when soiled, between processes, and after touching something that was not food related. The Supervisor stated staff should not treat their gloved hands like their bare hands.
D. Observation on 08/21/24 at 11:25 am of the kitchen located on Unit #2 revealed Server 2 wore gloves and prepared for the resident's lunch service. The Server threw a piece of paper into the trash can and touched the lid. The Server continued to touch the steam table, the door to the dining room, a piece of paper, the refrigerator door handle, serving containers of butter and supplement drinks, and drink pitchers. The Server did not change her gloves or wash her hands after touching the trash can and before touching the steam table and food related items. At 11:34 am, the Server removed her gloves and performed hand washing. Server 1 pressed the buttons to open the partition between the kitchen and the dining room. She put on new gloves. The Server touched the resident food trays, dietary cards, the thermometer, food containers. The Server touched the resident plates, serving utensils, refrigerator doors, and bread slices with her gloved hands. She pulled up the sleeve on her right arm using her gloved left hand. The Server touched resident bowls with her gloved thumb on the food surface area. The Server did not wash her hands after touching the divider buttons and before putting on gloves. The Server did not change her gloves and perform hand washing after she touched the refrigerator doors and her sleeve and before she touched food and food related items.
E. On 08/21/24 at 12:15 pm, during an interview, the Director of General Services stated the Supervisors were responsible to ensure the kitchen was maintained in a clean, orderly, and sanitary manner. She stated it was expected staff would perform handwashing when they moved from a dirty task to a clean task. She stated staff should wear gloves when handling ready to eat food, like bread. She stated staff should wash their hands before they put on and after they removed their gloves. The Director stated staff should not treat their gloved hands like their bare hands.
Unprotected, Unlabeled, and Undated Open Food Items
F. Record review of the facility's Production, Purchasing, Storage: Food and Supply Storage Procedures policy, dated January 2014, revealed staff directed to cover, label, and date unused portions and open packages.
G. Observation on 08/19/24 at 12:20 pm, of the dry storage area, revealed two, 25 pound (lb) bags of pinto beans open to air.
H. Observation on 08/20/24 at 8:52 am, of the walk-in refrigerator Morning Box, revealed the following:
- One package of sliced ham open to air,
- One, 16 ounces (oz) container of beef base opened and undated,
- One, 16 oz container of vegetable base opened and undated.
I. On 08/20/24 at 8:53 am, during an interview, the Director of General Services stated opened food should be labeled, dated, and sealed. She said it was expected staff would have wrapped the opened ham slices with saran wrap to protect it from the air. She stated she and the Supervisors walked through the walk-ins every day and looked for items that were not in compliance. The Director of General Services stated she was not aware the unlabeled, undated, and unprotected food items were in the walk-in.
J. Observation on 08/20/24 at 8:28 pm of the dry storage area, revealed one 5 lb bag of powdered cocoa loosely rolled, opened, and exposed to air.
K. On 08/20/24 at 8:30 am, during an interview, the Stocker stated, she was responsible to ensure the dry storage area was maintained in an orderly and sanitary manner. She stated she checked the dry pantry every day to ensure items were stored correctly, labeled, dated, and protected. The Stocker stated staff used the cocoa for breakfast. She stated they forgot to secure the cocoa bag with the plastic tabs when they rolled the top closed. The Stocker stated staff should have ensured the bag remained rolled closed to prevent exposure to air.
L. On 08/21/24 at 8:40 am, during an interview, the Supervisor stated the facility had a policy on food storage, and staff have been trained on the policy. She stated it was expected for staff to label and date open food with the date the food was opened. She stated food should be securely protected from air to prevent cross contamination.
Hairnets and [NAME] Guards
M. On 08/20/24 at 10:50 am during an interview with the Director of General Services, the Director of Food Services, and the Dieticians, Dietician 1 and Dietician 2 stated they were responsible to perform audits of kitchen staff, and they performed the audits twice a week. The Dieticians stated they completed a form for each audit and gave the form to the Director of General Services to address any issues with the dietary staff.
N. Observation on 08/21/24 at 11:07 am revealed Server 1 in the kitchen Unit #1 took the food temperatures in preparation for the resident's lunch service. The Server wore a beard guard, but the beard guard did not cover the Server's mustache. The Server's mustache measured approximately 1/4 inch () to 1 in length.
O. Observation on 08/21/24 at 11:25 am revealed Server 2 in the kitchen Unit #2 prepared food items for the resident's lunch service. The Server wore a hairnet, but the hairnet did not cover all the Server's hair. The Server's hair hung loosely around her face and measured approximately 2 1/2 in length. Further observation revealed two Dieticians stood in the kitchen and observed Server 2, but the Dieticians did not coach the Server to cover all her hair with the hairnet while working with the residents' food.
P. On 08/21/24 at 12:15 pm, during an interview, the Director of General Services stated the Supervisors were responsible to ensure the kitchen was maintained in a clean, orderly, and sanitary manner. She stated the facility had a policy on hair nets, and staff are trained on the policy. She stated all staff must wear hairnets at all times when they enter the kitchen, and they are to wear beard guards, as needed, at all times in the kitchen. She stated they must wear hairnets and beard guards regardless of the length of their hair. The Director stated the hairnets and beard guards should cover all the hair.
Dishes Not Sanitized According to Manufacturer's Instructions
Q. Review of the facility's Sanitation and Infection Control, Sanitizing Food Contact Surfaces policy, dated January 2014, revealed staff directed to immerse items in the sanitizing solution for a minimum of 60 seconds when washing dishes in the pot sink (three-compartment sink).
R. Review of the manufacturer's instructions for the sanitizing solution used by the facility in the three-compartment sink revealed the product could be used to clean and sanitize hard, non-porous surfaces of equipment. To sanitize, allow surfaces to remain wet for at least 60 seconds.
S. Observation on 08/21/24 at 8:05 am revealed the Dishwasher washed pots and pans in the three-compartment sink. The Dishwasher washed a pan in the soapy water, placed the pan in the clean rinse water, dipped the pan in the sanitizing solution, and placed the pan on the rack to air dry. The Dishwasher washed a plastic container in the soapy water, rinsed it in the clean water, dipped it the sanitizing solution, and placed it on the rack to air dry. The Dishwasher did not submerge the pan or the plastic container in the sanitizing solution for one minute, per the manufacturer's instructions. At 8:15 am, the Supervisor watched the Dishwasher dip the pots and pans into the sanitizing solution instead of submerging the items for one minute. The Supervisor coached the Dishwasher and told her to submerge the items in the sanitizing solution for one minute. At 8:22 am, the Dishwasher washed a baking sheet in the soapy water, rinsed it in the clean water, dipped it into the sanitizing solution, and placed it on the rack to air dry. The Dishwasher did not submerge the baking sheet in the sanitizing solution for one minute, per the manufacturer's instructions.
T. On 08/21/24 at 8:25 am during an interview, the Dishwasher stated items should be submerged into the sanitizing solution and not just dipped. The Dishwasher stated she was not exactly sure how long the items should be in the sanitizing solution, but she thought it should be around one minute.
U. On 08/21/24 at 8:40 am, during an interview, the Supervisor stated staff should completely submerge the dishes in the sanitizing solution for one minute when they washed dishes in the three-compartment sink. The Supervisor stated she observed the Dishwasher failed to sanitize the dishes correctly, so she told the Dishwasher to leave the items in the sink for one minute. The Supervisor stated it was expected the Dishwasher would have followed the directions for sanitizing the equipment. She stated dipping the dishes into the sanitizing solution was not sufficient.
V. On 08/21/24 at 12:15 pm, during an interview, the Director of General Services stated the Supervisors were responsible to ensure the kitchen was maintained in a clean, orderly, and sanitary manner. She stated staff should ensure dishes are completely submerged in the sanitizer solution for one minute to ensure the items were properly sanitized.
Protection of Disposable Ware
W. Observation on 08/20/24 at 8:31 am of the dry storage area revealed the following:
- One box of plastic spoons opened and unprotected.
- One box of plastic forks opened and unprotected.
- One box of plastic knives opened and unprotected.
- One box of disposable aluminum serving pans opened with food surface exposed and unprotected.
X. Record review of the facility's Production, Purchasing, Storage: Food and Supply Storage Procedures policy, dated January 2014, revealed staff directed as follows:
- Store all single-service items with food contact surfaces facing down.
- After single-serve items, such as disposable plates or containers, have been opened, they must be stored inverted on clean surfaces to prevent contamination.
- The policy did not address the storage of plastic wares, such as forks, spoons, and knives.
Y. On 08/20/24 at 8:33 am, the Stocker stated she was responsible to ensure items in the dry storage area were stored in a sanitary manner. She stated staff got plastic ware for the residents' breakfast service. She stated it was expected the staff would cover the plastic ware after they got what they needed. The Stocker stated the disposable aluminum pans should also be protected. She stated when the items are unprotected and open to air then they are at risk of contamination by dust, flies, or other contaminants.
Z. On 08/21/24 at 8:40 am, during an interview, the Supervisor stated the facility had a policy on ware storage, and the staff have been trained on the policy. She stated it was expected wares were stored in their original packaging. She stated staff should take what they needed out of the box and use the plastic to recover the items. The Supervisor stated disposable wares should not be exposed to air to prevent cross contamination.
AA. On 08/21/24 at 12:15 pm, during an interview, the Director of General Services stated the Supervisors were responsible to ensure the kitchen was maintained in a clean, orderly, and sanitary manner. She stated it was expected disposable wares were covered and not exposed to the air and potential contaminates. She stated staff should take what they needed and cover the items. She stated the Stocker checked the storage areas daily to ensure all items were covered, but other staff were also responsible to ensure the items were covered after they got what they needed.

Based on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of no less than 12 hours per year for 2 (CNAs #1 and #2) of 5 (CNAs #1, #2, #3, #4, and #5) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents. The findings are:
CNA #1:
A. Record review of the facility staffing list revealed CNA #1 was hired on 04/30/22.
B. Record review of CNA #1's annual required in-service training revealed CNA #1 had only completed 8 out of 12 hours of required training by hire date.
C. Record review of the facility staffing schedule dated 06/23/24 through 08/23/24 revealed CNA #1 worked 124 total shift hours during that timeframe.
CNA #2:
D. Record review of the facility staffing list revealed CNA #2 was hired on 06/17/17.
E. Record review of CNA #2's annual required in-service training revealed CNA #2 had only completed 10 out of 12 hours of required training by hire date.
F. Record review of the facility staffing schedule dated 06/23/24 through 08/23/24 revealed CNA #2 worked 317 total shift hours during that timeframe.
G. On 08/22/24 at 4:08 pm during an interview with the Director of Nursing (DON), she confirmed CNAs #1 and #2 did not have at least 12 hours of completed in-service training's and should have. DON stated CNAs should not be working with residents without the completed required training's.

Based on observation, record review, and interview, the facility failed to ensure that 1 (R #21) out of 1 (R #21) resident was safely transferred from bed to wheelchair using two staff members. This deficient practice has the potential to cause an accident when two staff members aren't used to transfer a resident who requires a mechanical lift (a lift that helps residents move from bed to wheelchair etc .).
The findings are:
Resident #21:
A. On 07/18/23 around 10:00 am, an observation of an unidentified Certified Nursing Assistant (CNA) was answering R #21's call light. Unidentified CNA came out of R #21's room a few minutes later and walked down the hall. A few minutes later unidentified CNA came back to the room with a Sara lift (a mechanical lift used to assist residents with transferring when they can't lift their full body weight). She went back into R #21's room with the Sara lift and approximately 10 to 15 minutes later, unidentified CNA came back out of R #21's room with a bag of trash and the Sara lift.
B. On 07/18/23 around 10:30 am, during observation and interview with R #21, she was observed sitting in her wheelchair watching TV. When asked if she was helped by the CNA to transfer to her wheelchair, she stated yes.
C. On 07/19/23 at 2:22 pm, during an interview with Licensed Professional Nurse (LPN) #1 she stated that it is ok to use the Sara lift alone, without another staff person if the physician or a staff member in physical therapy writes an order that it is ok. If the order is not written that way, then two staff members should be used to transfer a resident from bed to wheelchair (or visa versa). If it states in the care plan that it (transfers) requires two staff members, then two staff members should be used.
D. Record review of R #21's care plan last revised on 06/21/23 indicated that Maxi lift (a floor lift designed to enable a single caregiver to manage demanding everyday resident transfers and repositioning tasks) was crossed out, and Sara lift was written in. The care plan reflected that R #21 required total assistance of two staff and the Sara lift for safe transfers.
E. On 07/20/23 at 2:38 pm, during an interview with Director of Nursing (DON), she stated that it depends on what physical therapy indicates is safe as far as transfers go. If it states in the care plan that it should be two people (doing the transfer), then it should be two people.

Based on interview, observation, and record review, the facility failed to provide proper infection control practices by not performing hand hygiene between resident care for 4 (R #12, R #22 R #47, and R #76) out of 4 (R #12, R #22, R #47, and R #76) residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between residents and/or staff.
The findings are:
A. On 07/19/23 at 8:20 am, during an observation of the medication pass for R #12, Registered Nurse (RN) #5 failed to perform hand hygiene prior to passing R #12's medication, and after passing R #12's medication no hand hygiene was performed before RN #5 went on to the R #22.
B. On 07/19/23 at 8:24 am, during an observation of the medication pass for R #22, RN #5 put on gloves prior to passing medication, however, no hand hygiene was done before she put on gloves, or after taking them off.
C. On 07/19/23 at 11:03 am, during an observation of the medication pass for R #76, RN #6 failed to complete hand hygiene prior to passing R #76's medication, and after passing R #76's medication. No hand hygiene was done prior to her moving from R #76 to R #47.
D. On 07/19/23 at 11:08 am, during an observation of the medication pass for R #47, RN #6 failed to complete hand hygiene prior to passing medication for R #47.
E. On 07/20/23 at 2:35 pm, during an interview with the Director of Nursing (DON), she explained her expectation for hand hygiene would occur between resident care, before and after changing gloves, passing trays, between medication passes, before and after each resident, and any care the resident might have.
F. Record review of the facility's policy titled, Control of Infection, revised date of 10/14/22, stated Hand Hygiene
Clean hands are the single most important factor in preventing the spread of pathogens (bacteria or virus that can cause disease) and antibiotic resistance (occurs when germs like bacteria develop the ability to defeat the drugs designed to kill them) in healthcare settings.
1.
Hand Hygiene shall be performed:
b.
Immediately before touching a patient
e. Washing hands (or hand sanitizer use) must be done promptly and thoroughly between patient/resident/client contacts, including medication administration and after contact with blood or bodily fluids, secretions, excretions and contaminated equipment or articles whether or not gloves have been worn.

Based on observation, record review, and interview, the facility failed to ensure that residents are free of any significant medication errors for 1 (R #22) of 1 (R #22) resident reviewed for medication administration, when they failed to administer medication without regard to manufacturer's instructions for administration. Residents may likely not experience the maximum benefit intended and fail to achieve their highest level of well-being. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects, or not receiving the desired therapeutic effect of the medication due to it not being administered as prescribed.
The findings are:
A. On 07/19/23 at 8:23 am, during an observation of medication administration to R #22 by Registered Nurse (RN) #5, the medication prescribed, Fenofibrate Nano crystallized (a medication prescribed to lower cholesterol levels in the blood) 1 tablet was opened and then crushed by RN #5 and added to applesauce before being given to R #22.
B. Record review of the U.S. Food and Drug Administration website recommendations for use of Fenofibrate Nano crystallized, accessed on 07/24/23 at 11:15 am, at https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/021350s013lbl.pdf, states: Administration instructions inform patients to take Fenofibrate Nano crystallized tablets whole and to not crush the tablets. According to the FDA, crushing non crushable medications can cause serious side effects, may prevent medication from working properly, and could alter how your body processes and responds to the drug.
C. Record review of facility policy titled, Medication Management dated 09/22/2020 stated, Prior to crushing medications, nurses must verify with the pharmacy that the medication and patient will not be adversely affected by this practice.
D. On 07/19/23 at 8:15 am, during interview with RN #5, she stated the pharmacy provides the facility with a medication do not crush list and that none of the medications she crushed were on that list. RN #5 provided this surveyor with the list, Fenofibrate Nano crystallized was not on the list provided.
E. Record review showed that the facility's do not crush list was provided by the Director of Pharmacy (DOP). The facility uses the Institute for Safe Medication Practices (ISMP) do not crush list, dated 11/01/2018.
F. On 07/20/23 at 4:00 pm, during interview with the DOP revealed that the do not crush list provided to the facility was from 2018 and is in the process of being updated. The Pharmacists' Letter list (peer reviewed website that pharmacists use to guide medication administration) does show Fenofibrate Nano crystallized cannot be crushed, and must be swallowed whole.
G. Record review of the Pharmacist Letter website located at and accessed 07/25/2023, https://pharmacist.therapeuticresearch.com/Content/Segments/PRL/2014/Aug/Meds-That-Should-Not-Be-Crushed-7309, dated 02/2023, does show that Fenofibrate Nano crystallized as being non-crushable.

Based on observation, record review, and interview, the facility failed to maintain oxygen equipment according to professional standards for 2 (R #8 and R #17) of 3 (R #8, R #17, and R #53) residents reviewed for respiratory care by not ensuring the posting of caution and safety signs indicating the use of oxygen in the resident's room and
This deficient practice could likely result in: Staff not recognizing that oxygen is being used in a residents room, this could result in a dangerous (able or likely to cause harm or injury), firehazard (material, substance, or action that increases the likelihood of an accidental fire occurring).
A. Record review of the facility policy, Medical Oxygen Handling and Storage, last revised 07/13/20, revealed, Procedures. IV. All rooms with oxygen tanks/concentrators will be labeled with O2 (oxygen) precautions. Signs may be obtained from the safety department. Protocol. 3. Appropriate signage must be placed on the door of the patient's using oxygen.
Resident #8:
B. Record review of physician's orders for R #8 revealed the following orders related to oxygen use: Physician order, dated 06/20/23, Oxygen at 2 liters per minute at night continuously for lifetime. At night for COPD (Chronic Obstructive Pulmonary Disease - a chronic inflammatory lung disease that causes obstructed airflow from the lungs).
C. On 07/17/23 at 2:29 pm, during an observation, there was no Oxygen in use signage posted on the door of R #8's room.
Resident #17:
D. Record review of the physician's orders for R #17 revealed the following orders related to oxygen use: Physician order, dated 05/18/23, Oxygen via nasal prongs (nasal cannula is a device used to deliver oxygen through the nose) 2 liters per minute to achieve 90% oxygen saturation (measures the level of oxygen in your bloodstream). Change O2 tubing and humid filter (Humidifiers are devices that release water vapor or steam. They boost the amount of moisture in the air, also called humidity) every 7 days and PRN (as needed).
E. On 07/18/23 at 9:40 am, during an observation, there was no Oxygen in use signage posted on the door of R #17's room.
F. On 07/20/23 at 2:35 pm, during an interview with the Director of Nursing (DON), when asked if rooms should have signage that shows oxygen is in use in a resident's room, she stated, Yes, they should have them.