Gallup Nursing & Rehabilitation Llc

Based on a record review and interviews, the facility failed to ensure medical records were complete for 1 (R #51) of 1 (R #51) resident reviewed when staff failed to: Document accurately and completely when R #51 was not administered medication per physician's orders. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents. The findings are: A. Record review of R #51's physician's orders dated 11/20/25 revealed, R #51's carvedilol (medication used to treat chronic heart failure, left ventricular dysfunction following heart attack, and high blood pressure) administration for hypertension (HTN; high blood pressure) to be held for systolic blood pressure (the pressure in the arteries when the heart beats, represented as the first (top) number in a blood pressure reading) of less than 110 mmHg or a heart rate less than 60 beats per minute. B. Record review of R #51's Medication Administration Record (MAR) dated 01/01/26 to 01/21/26 revealed the administration for carvedilol on 01/01/26 was documented as not administered, to see progress note. C. Record review of R #51's MAR dated 01/01/26 (for blood pressure and heart rate) revealed R #51 had a systolic blood pressure of 118 mmHg and heart rate of 70 beats per minute, which was within stated parameters of order for administration. D. Record review of R #51's progress notes dated 01/01/26 to 01/02/26 revealed no progress note documented withholding administration of carvedilol for R #51. E. Record review of R #51's MAR dated 01/01/26 to 01/21/26, revealed R #51's evening systolic blood pressure on 01/01/26 was 118 mmHg and a heart rate of 70 beats per minute, same as the morning measurements. The evening dose of carvedilol is documented as administered to R #51. F. Record review of R #51's MAR dated 01/01/26 to 01/21/26 revealed the evening dose of carvedilol on 01/16/25 was not administered to R #51, and it was documented as see nurses note. G. Record review of R #51's MAR vital signs (body temperature, pulse rate, respiration rate [rate of breathing], oxygen saturation [amount of oxygen in the blood], and blood pressure) dated 01/16/26, revealed R #51's systolic blood pressure was 156 mmHg and a heart rate of 60 beats per minute. H. Record review R #51's nursing notes dated 01/16/26 to 01/17/26 revealed a nursing note was not entered regarding withholding administration of carvedilol for R #51 with R #51's vital signs being within parameters to administer the medication. I. On 01/22/26 at 9:45 AM, during an interview with Director of Nursing (DON), she stated it is her expectation if a nurse is entering a medication as held and to see nurse's note or progress note, then a nurse's note or progress note should be documented stating the reasoning for holding medication. The DON confirmed R #51's medical record, regarding medication administration, was not accurate and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 1 (R #34) of 1 (R #34) resident reviewed for infection control when: The facility did not ensure R #34's urinary catheter (a thin, sterile tube inserted into the bladder to drain urine) drainage bag had a privacy bag (bag that covers urination drainage bag) present. The facility did not ensure R #34's urinary catheter tubing (is the flexible tube that carries urine from the catheter (inside the bladder) to the drainage bag outside the body) remained off the floor to prevent contamination. These deficient practices are likely to result in repeated and ongoing exposure of residents to increased risk of infection, cross-contamination, and injury. The findings are: A. Record review of the facility's Catheter Care Procedure (steps to maintain the catheter and drainage system), last revised June 2020, revealed the accepted procedure was to secure catheter tubing to keep the drainage bag below the level of the patient's bladder and off the floor. Policy revealed privacy bags will be placed over drainage bags when resident it out of bed. B. Record review of R #34's Face Sheet, revealed R #34 was originally admitted to the facility on [DATE] with diagnoses of Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), and Bladder neck obstruction (bladder neck becomes narrowed or blocked, leading to difficulty urinating). C. Record review of R #34's minimum data set (MDS, which was part of the federally mandated process for clinical assessment of all residents in nursing homes) completed on 10/20/25, indicated R #34 had a brief interview for mental status (BIMS; screening for cognitive impairment) score of 6 (00-07 is severe impairment). D. Record review of R #34's physician orders dated 08/15/25 revealed R#34 required an Indwelling Foley catheter (soft tube placed into the bladder that stays in place to continuously drain urine into a collection bag) PRN (as needed) for chronic urinary retention (bladder does not empty completely). E. On 01/20/26 at 12:04 pm, during a dining room lunch observation, R #34's catheter bag did not have a privacy bag present while R #34 was sitting in his wheelchair. F. On 01/20/26 at 12:56 pm, during an interview with Certified Nursing Aid (CNA) #5, she stated all residents should have a privacy bag covering their urinary drainage bags. G. On 01/22/26 at 1:00 pm, during an observation of the common tv area, R #34 sat in his wheelchair with his catheter tubing touching the ground. H. On 01/22/26 at 1:25 pm, during an interview with CNA #6, she stated the last CNA forgot to attach R #34's urinary catheter bag to his chair. She stated the catheter tube for R #34 should not be dragged onto the floor, as it could cause infection. CNA #6 also stated R #34's catheter tube could become caught and pulled out of the resident, causing discomfort. I. On 01/23/26 at 10:33 pm, during an interview with Director of Nursing (DON), she stated urinary catheter tubing should not be dragged on the floor. The DON stated if the catheter tube is touching the ground, it could cause an infection. The DON also stated the urinary catheter tube could get caught on something and pull the tube out of the resident. She confirmed there should always be a privacy bag on all the residents' catheter bags when they are out of their room. J. On 01/23/26 at 10:58 am, during an interview with the Administrator (ADM), she stated resident's catheter tubing should not be dragged across the ground, as it could get snagged and pull on the resident's appendage. The ADM also stated it is her expectation urinary catheter tubing for residents would be properly secured under the residents' chair. She confirmed residents should always have a private bag to cover the resident's catheter bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #67) of 1 (R #67) resident reviewed for baseline care plans. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are: A. Record review of the facility's Care Plans- Baseline policy dated December 2016 revealed, to ensure resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission. B. Record review of R #67's face sheet revealed R #67 was admitted into the facility on [DATE]. C. Record review of R #67's baseline care plan revealed R #67's care plan was initiated on 01/12/26 (initiated and completed after 48 hours of admission). D. On 01/23/26 at 9:31 am, during an interview with Director of Nursing (DON), she stated it is her expectation R #67's baseline care plan should have been completed on 01/11/26. E. On 01/23/26 at 10:58 am, during an interview with the Administration (ADM), she stated it is her expectation resident's baseline care plans be completed within 48 hours.

Based on record reviews and interviews, the facility failed to follow physician orders for 2 (R #50 and R #51) of 2 (R #50 and R #51) residents reviewed when: Facility staff failed to administer or withhold blood pressure medications as directed by blood pressure parameters (boundary or limit defining scope of particular activity or process) per R #50 and R #51's physician's order. If the facility does not follow physician orders for the management of a resident's blood pressure, then it is likely to result in the resident not maintaining optimal health outcomes as established by the medical provider. The findings are: R #50: A. Record review of R #50's physician's order dated 07/16/25 revealed, R #50's lisinopril (medication used to treat high blood pressure) medication was ordered to be held for systolic blood pressure (the pressure in the arteries when the heart beats, represented as the first (top) number in a blood pressure reading) less than 110 millimeters of mercury (mmHg). B. Record review of R #50's Medication Administration Record (MAR) dated 01/01/26 to 01/21/26, revealed R #50's lisinopril was administered on 01/05/26 with a systolic blood pressure of 105 mmHg. R #51: C. Record review of R #51's physician's orders dated 11/20/25 revealed, R #51's carvedilol (medication used to treat chronic heart failure, left ventricular dysfunction following heart attack, and high blood pressure) administration for hypertension (HTN; high blood pressure) to be held for systolic blood pressure of less than 110 mmHg or a heart rate less than 60 beats per minute. D. Record review of R #51's MAR dated 01/01/26 to 01/21/26, revealed the administration for carvedilol on 01/01/26 was documented as not administered, to see progress note. E. Record review of R #51's MAR dated 01/01/26 (for blood pressure and heart rate) revealed R #51 had a systolic blood pressure of 118 mmHg and heart rate of 70 beats per minute, which was within stated parameters of order for administration. F. Record review of R #51's progress notes dated 01/01/26 to 01/02/26 revealed the progress note did not document withholding administration of carvedilol for R #51. G. Record review of R #51's MAR dated 01/01/26 to 01/21/26, revealed R #51's evening systolic blood pressure on 01/01/26 was 118 mmHg and a heart rate of 70 beats per minute, same as the morning measurements. The evening dose of carvedilol is documented as administered to R #51. H. Record review of R #51's MAR dated 01/01/26 to 01/21/26, regarding administration of evening dose of carvedilol on 01/16/26, revealed R #51 was not administered the medication, and it was documented to see nurse's note. I. Record review of R #51's MAR vital signs (body temperature, pulse rate, respiration rate [rate of breathing], oxygen saturation [amount of oxygen in the blood], and blood pressure) dated 01/16/26, revealed R #51's systolic blood pressure was 156 mmHg and a heart rate of 60 beats per minute. J. Record review R #51's nursing notes dated 01/16/26 to 01/17/26 revealed a nursing note was not entered regarding withholding administration of carvedilol for R #51 with vital signs within parameters to administer medication. K. On 01/22/26 at 9:25 AM, during an interview with Director of Nursing (DON), she stated it is her expectation for resident's vital signs to be monitored and documented in the electronic MAR, and for medications to be administered or held according to parameters within the provider's order. The DON reviewed the MARs for R #50 and R #51, and stated her expectation is to hold lisinopril for R #50 on 01/05/26 as order states to hold for systolic blood pressure less than 110 mmHg, and R #50's systolic blood pressure was 105 mmHg. The DON stated the carvedilol for R #51 should have been administered on 01/16/26 as the systolic blood pressure and heart rate were within parameters written by provider to administer medication. The DON stated it is her expectation that nursing staff follow physician orders.

Based on observation and interview, the facility failed to maintain a safe environment and protect the residents from the potential for accidents and hazards by: Failing to ensure adhesive tape (is a strip of material with a sticky surface on one side that is used to hold, fasten, or secure items in place) applied to resident room floors remained secured and flat to the surface in Room (RM) #41, Failing to ensure a water hose connected to the ice machine remained secured within its protective case, allowing water to drip onto the floor in a hall that is accessible to all residents. This deficient practice is likely to affect all 57 residents listed on the facility census by creating a tripping and slipping hazards, which can put the residents at risk for falls and potential injury. The findings are: A. On 01/21/26 at 10:31 a.m., during an observation of RM #41, multiple strips of adhesive tape were applied directly on the bedroom floor near the bedside area. Several strips of tape appeared worn, partially detached, and curling upward at the edges. Dark adhesive residue remained on the floor where tape had deteriorated (worn out, damaged, or in worse condition than before, often from age, use, or lack of maintenance) or been removed, creating uneven and sticky surface areas which were a potential hazard for the room occupants. B. On 01/21/26 at 11:00 a.m., during an observation of the hallway leading to the dining room, a hose was connected to a wall-mounted water source next to the ice machine and it was actively dripping water onto the floor, creating a small puddle. The hose was intended to be secured within a clear plastic protective case; however, the clear plastic case did not securely hold the hose in place. C. On 01/23/26 at 10:30 a.m., during an interview with the Maintenance Supervisor (MS), he stated it was his expectation that tape applied to floors should be flat to the ground to prevent a tripping hazard. He further stated the water hose nozzle should be secured inside the clear plastic case to prevent dripping water onto the floor, which could cause a resident to fall. D. On 01/23/26 at 10:31 a.m., during an interview with the Administrator (ADM), she stated the hose should be always secured to prevent water from dripping onto the floor, as this could cause a fall. She also stated tape placed on the floor should remain flat with the surface to prevent residents from tripping or falling.

Based on observation and interview, the facility failed to ensure residents had a safe and functional environment for 7 (Rooms: RM's #15, 31, 33, 34, 36, 37, 43, 44 ) of 13 (RM's #15, 16, 17, 21, 25, 31, 33, 34, 36, 37, 43, 44, 45 and 49) rooms observed when the facility failed to: Repair walls with intact, smooth, and cleanable surfaces (scuff marks, chipped paint, uneven paint, visible putty).Repair windowsills and surrounding tiles.Repair fixtures and building components (heating vent and electrical outlet). These deficient practices are likely to expose residents to an unsafe and uncomfortable environment. The findings are: A. On 01/21/26 at 3:12 pm during an observation of RM #15, the windowsill closest to Bed B was unpainted and separating from the wall with a gap approximately 0.5 inches.
B. On 01/23/26 at 9:50 am, during an observation of RM # 31, the bathroom walls had scuff marks and chipped paint.
C. On 01/23/26 at 9:51am, during an observation of RM #33, the windowsill closest to Bed B had a loose tile.
D. On 01/23/26 at 9:53 am, during an observation of RM #34, the windowsill closest to Bed B had a loose tile.
E. On 01/23/26 at 9:55 am, during an observation of RM #36, observation revealed the residents heating vent had three horizontal broken slats (vent was damaged and could not properly control the flow of warm air). Further observation revealed the bathroom had scuff marks and chipped paint on the walls.
F. On 01/23/26 at 9:57 am, during an observation of RM #37, observation revealed scuff marks on bathroom walls.
G. On 01/21/26 at 10:13 am and 11:46 am, during an observation of RM #44, observation revealed the following:
The interior bathroom door had visible wood putty (soft material used to fill holes, cracks, or gaps in wood to make the surface smooth before painting or finishing) that was not painted.
The bathroom door and multiple walls had uneven paint coverage.
Scuffed walls were present behind Bed-B.
The windowsill beside of Bed-B was separating from the wall with an approximate one-inch gap. The electrical outlet housing (protective cover or casing that surrounds an electrical outlet and holds it securely in place) behind Bed A was separated from the wall.
H. On 01/21/26 at 10:13 am and 11:46 am, during an observation of RM #43, the windowsill near Bed-B was separating from the wall.
I. On 01/23/26 at 9:21 am, during an interview with the Maintenance Supervisor (MS), he stated all the scuff marks should be painted evenly. The MS also stated all the windowsills should be in good repair and not separating from the wall, as it could cause a draft or a resident could hurt themself. He stated it is his expectation the resident's rooms would all be in good repair, so they feel like they are at home.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #1) of 3 (R #'s 1, 2 and 3) residents when they failed to properly assess a resident following an unwitnessed fall that resulted in injury. If the facility fails to properly assess residents who have an unwitnessed fall with an injury, then the residents may experience unidentified life-threatening conditions such as a brain bleed. This deficient practice likely contributed to the hospitalization and passing of R #1. The findings are:
A. Record review of Face Sheet for R #1 revealed an admission date of 7/13/24 and a discharge date of 09/21/24 and included the following diagnoses:
- Lack of Coordination
- Muscle Wasting and Atrophy (wasting away)
- Depression (mood disorder that causes a persistent feeling of sadness and loss of interest)
- Generalized Muscle Weakness (muscle weakness that affects the whole body)
- Dysphagia (difficulty swallowing)
- Difficulty in Walking
- Parkinson's Disease (a brain disorder that affects movement such as shaking, stiffness, and difficulty with balance and coordination)
- Hypertension (high blood pressure)
B. Record review of R #1's nursing progress note, dated 07/14/24, revealed he was admitted to the facility for skilled nursing services related to frequent falls.
C. Record review of R #1's care plan initiated on 07/15/24 revealed resident was at risk for falls related to history of multiple falls, poor safety awareness, poor vision, Parkinson's, hypotentsion, new environment, deficit to his left side, decline in condition and needs assistance with ADLs (activities of daily living).
D. Record review of R #1's nursing progress note, also dated 07/14/24, revealed that R #1 was found laying on the floor between the two beds.
E. Record review of R #1's nursing progress note, dated 07/15/24, revealed that R #1 is a very high fall risk, having had one fall. Daughter stated he has very poor safety awareness and had multiple falls in the community with injury. Staff to continue to monitor.
F. Record review of R #1's nursing progress note, dated 09/03/24, revealed that R #1 has poor safety awareness due to dementia and will attempt self-transfer/ambulation without assistance. Therapy informed of fall and care plan updated. Progress note did not provide any information on a recent fall.
G. Record review of R #1's nursing progress note, dated 09/10/24, revealed that R #1 is impulsive and requires assistance with Activities of Daily Living (ADLs). Resident is not safely able to transfer or ambulate independently. Therapy notified of fall and care plan updated. Progress note did not provide any information on a recent fall.
H. Record review of R #1's nursing progress note, dated 09/13/24 at 3:50 am, revealed that R #1 was found on the floor in his room laying on his stomach at the foot of the bed about one foot from the floor safety mat. Upon assessment resident noted to have a cut about 4 centimeters (cm - unit of measure) long over his right eye and that neuro checks (an evaluation used to assess the mental status of individuals with head injuries) were initiated.
I. Record review of R #1's nursing progress note, dated 09/14/24, revealed the following vital signs were taken on 09/13/24:
Blood pressure (BP) - 93/52
Temperature - 98.0
Pulse - 70, regular
Respirations - 18
Oxygen (O2) - 97 percent (%) on room air (not using supplemental oxygen)
J. Record review of R #1's nursing progress note, dated 09/15/24, revealed the following vital signs were taken on 09/14/24:
Blood pressure (BP) - 104/44
Temperature - 97.9
Pulse - 64, regular
Respirations - 24
Oxygen (O2) - 95%
K. Record review of R #1's nursing progress note, also dated 09/15/24, revealed that R #1 had a change in condition of altered mental status and included the following vital signs:
Blood pressure (BP) - 124/61
Temperature - 97.5
Pulse - 73, regular
Respirations - 20
Oxygen (O2) - 93%
This nursing note also revealed that R #1 was alert and oriented x1 (times one), began mumbling words, slowly responding to his name. Send to emergency room (ER) for CT scan (computed topography - medical imaging technique used to obtain detailed internal images of the body).
L. Record review of R #1's Neuro Evaluations revealed that no neuro evaluations were completed or documented following R #1's unwitnessed fall on 09/13/24.
M. Record review of R #1's Fall Risk Evaluations revealed no fall risk evaluation was completed following R #1's unwitnessed fall on 09/13/24.
N. Record review of facility reportable incidents revealed no documentation of R #1's unwitnessed fall with injury on 09/13/24.
O. Record review of facility Response to Falls policy revealed:
Post-Fall Assessment and Monitoring -
a. Following each resident fall, the Licensed Nurse will complete an incident report and perform a post-fall assessment and investigation.
b. The Licensed Nurse will also complete the Neurological Flow Sheet for any un-witnessed fall, or witnessed fall with known head injury for 72 hours following the fall.
c. Nursing staff, with the attending physician's guidance, will follow up on any fall associated with an injury until the resident is stable, and delayed complications like that of a late fracture or a subdural hematoma (bleeding of or near the brain) have been ruled out or resolved. i.) Delayed complications such as late fractures and major bruising may occur hours or several days after a fall. ii.) Signs of subdural hematoma or other intracranial bleeding (bleeding in the brain) can occur up to several weeks after a fall.
P. Record review of R #1's hospital documentation dated 09/15/24, revealed that patient presented with altered mental status; his baseline is awake and alert x 3 (times three), however here he is awake and alert x 0; per nursing, this patient had a couple of falls over the last few days with 1 possibly as recently as last night; he is not moving his left lower extremity; he has bruising around the right orbital rim and around the right eye; the degree at onset was severe, the degree at present is severe. Patient was intubated (the process of inserting a tube into the mouth or nose and then into the airway). Patient has periorbital ecchymosis (dark purple or blue bruises under the eyes); was found to have a large left temporal lobe bleed (sudden bleeding in the brain); patient is greatly deconditioned (decline in physical fitness due to inactivity) and only exhibits limited movement in each of the limbs. I think that this bleed is probably the result of one of his falls. Patient was accepted by the triage physician at [name of hospital], he is now intubated, sedated (to make calm) on fentanyl (pain medication) and precedex (sedating medication used for patients who are intubated); awaiting transfer, flight team on their way.
Q. Record review of R #1's radiology report dated 09/15/24 for CT scan of head, revealed the following:
1. Temporal parenchymal hemorrhage (bleeding in the brain) - this could represent an evolving hemorrhagic infarction (stroke) or a direct contusion (bruise) to the brain parenchyma (brain tissue).
2. Subdural (area between the brain and the skull) and subarachnoid (area between the brain and the tissue covering the grain) hemorrhage (blood loss).
3. Small intraventricular hemorrhage (type of bleeding that occurs within the ventricles of the brain).
R. Record review of R #1's nursing progress note, dated 09/16/24, revealed that R #1 was admitted to [name of hospital].
S. Record review of R #1's care plan initiated 09/19/24 revealed At risk for abnormal bleeding or hemorrhage due to antiplatelet (medications that prevent blood clots from forming) use.
T. On 12/17/24 at 11:01 am during an interview with the Director of Nursing (DON) and the Administrator (ADM), the DON stated that she would expect there to be neuro checks done for 72 hours and that a resident would only be sent out if there was an identified change in condition. DON further stated that R #1 had falls in July and then he was doing good with not having any and then it changed and he started having falls and the falls got closer together. She stated that she would have expected there to be neuro checks and verified that there were none done for R #1 following his unwitnessed fall on 09/13/24. DON stated that rounds are done each shift but that they are not documented.
U. On 12/17/24 at 12:32 pm during an interview, Assistant Director of Nursing (ADON) stated that when she began her day shift on 09/13/24, the night shift nurse relayed the information about R #1 being found laying on the floor and that he had a laceration to the right side of his forehead and that the night nurse had began neurological checks for him, however there were none documented. ADON further stated that she was the only nurse on the floor on 09/15/24 because the other nurse had called out of work and that she remembers that R #1 was taking his medications and was verbally responding to her and was able to stand for her on 09/13/24 and 09/14/24, but that on 09/15/24 she noticed that he was choking on his medications (medications were administered crushed and with thickened liquids) and that he was also having weakness and was not responding to her. The ADON confirmed that the resident was sent out to the hospital.
V. Record review of the complaint intake received by the State Survey Agency on 11/20/24 identified that R #1 passed away in the hospital.
Based upon the evidence, immediate jeopardy was identified. The facility Administrator was notified on 12/17/24 at 2:43 pm.
The facility took corrective action by providing an acceptable Plan of Removal (POR) on 12/18/24 at 12:11 pm. Implementation of the POR was verified onsite on 12/18/24 by conducting record reviews and staff interviews.
Plan of removal:
Resident was discharged to the hospital. Resident had an unwitnessed fall and neurological checks were incomplete.
Residents who reside at the facility that have experienced an unwitnessed fall or a fall in which the resident hit their head have the potential to be affected by this alleged deficient practice.
Review of the last seventy-two hours of fall occurrence were reviewed to validate, if any resident experienced unwitnessed fall and that neuro checks and vital signs were completed as scheduled, any issues identified to be addressed upon discovery. This audit was completed by the Director of Nursing by 12/17/24.
Neurological Checks and Obtaining/Completing Vital Signs re-education for Licensed Nurses were initiated on 12/17/24 by Director of Nursing.
If omissions noted within neurological checks and/or vital signs, Director of Nursing/designee to conduct a neurological assessment of the resident to ensure no neurological changes are noted, any issues identified to be addressed upon discovery.
Director of Nursing and/or designee was re-educated by the Clinical Consultant on 12/17/24 on the following:
- Fall documentation related to neurological checks and vital sign obtaining/completion as scheduled.
Director of Nursing and/or designee will re-educate Licensed Nurses including agency personnel on the following:
- Fall documentation related to neurological checks and vital sign obtaining/completion as scheduled.
The above education will be completed by the Director of Nursing/designee, this education will be initiated on 12/17/24, all other licensed nurses will be educated prior to their next scheduled shift. This information will be presented in new hire orientation.
The above audits to be completed daily for two weeks, then three times a week for two weeks, then twice a week for two weeks, then weekly for four weeks, then bi-monthly for additional two weeks, then randomly thereafter, any concerns identified to be addressed upon discovery.
Facility Administrator will be responsible for the overall implementation and validation of this plan. Facility Medical Director will be informed of this plan and given progress updates. The Medical Director was notified of the Immediate Jeopardy on 12/17/24.

Based on record review and interview, the facility failed to provide facility Initiated Reports (mandatory self-initiated facility report of an incident) to the State Survey Agency (SSA) for 1 (R #1) of 3 (R #'s 1, 2 and 3) residents reviewed for incidents when staff failed to report an unwitnessed fall with an injury for R #1. The findings are:
A. Record review of R #1's nursing progress notes dated 09/13/24 revealed that R #1 was found on the floor in his room laying on his stomach at the foot of the bed about 1 foot from floor safety mat. Upon assessment, resident was noted to have a cut about 4 centimeters long over his right eye. The wound was cleansed with normal saline, antibacterial ointment (topical medication used to prevent infections) was applied, and the wound was covered with a bandage which was used to reinforce and keep the resident from touching it.
B. Record review of R #1's nursing progress note, also dated 09/15/24, revealed that R #1 had a change in condition of altered mental status. This nursing note also revealed that R #1 was alert and oriented x1 (times one), began mumbling words, slowly responding to his name. Send to emergency room (ER) for CT scan (computed topography - medical imaging technique used to obtain detailed internal images of the body).
C. Record review of facility's Incident Report Log, received on 12/16/24 from the Administrator (ADM), revealed that no incident for R #1 having an unwitnessed fall with an injury had been reported.
D. Record review of facility Response to Falls policy revealed:
Post-Fall Assessment and Monitoring -
a. Following each resident fall, the Licensed Nurse will complete an incident report and perform a post-fall assessment and investigation.
b. The Licensed Nurse will also complete the Neurological Flow Sheet for any un-witnessed fall, or witnessed fall with known head injury for 72 hours following the fall.
c. Nursing staff, with the attending physician's guidance, will follow up on any fall associated with an injury until the resident is stable, and delayed complications like that of a late fracture or a subdural hematoma (bleeding of or near the brain) have been ruled out or resolved. i.) Delayed complications such as late fractures and major bruising may occur hours or several days after a fall. ii.) Signs of subdural hematoma or other intracranial bleeding (bleeding in the brain) can occur up to several weeks after a fall.
E. On 12/17/24 at 12:09 am during an interview, the Administrator (ADM) verified that the facility had not filed an incident report for R #1 for the unwitnessed fall with injury that occurred on 09/13/24 and further stated that she [Administrator] is the one responsible for filing the incident reports with the SSA but that she can only report an incident if she is made aware of it. She stated that the unwitnessed fall with injury had not been reported to her and that it should have been reported by the nurse. She stated that the nurse who wrote the progress note regarding the fall was an agency nurse who is no longer employed with the facility.

Based on record review and interview, the facility failed to meet professional standards of practice for 1 (R #208) of 1 (R #208) residents reviewed for medication administration, when staff did not administer R #208's lactulose [a medication used to prevent and treat complications of hepatic encephalopathy (liver disease) by decreasing the amount of ammonia in the blood] as ordered by the medical provider. 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. The findings are:
A. Record review of R #208's Physician orders revealed the following: Lactulose. Give 45 milliliters (ml) by mouth three times a day for enchphalopathy with a start date of 08/30/24.
B. Record review of R #208's Medication Administration Record (MAR), dated September 2024, revealed staff did not administer the lactulose midday dose to the resident due to hold/see nursing notes on 9/3/24.
C. Record review of R #208's nurse progress note, dated 09/03/24, revealed the resident had three loose stools since the morning. Staff did not administer the lactulose.
D. On 10/10/24 at 3:33 PM, during an interview, the DON stated staff should not have held R #208's lactulose due to loose stools. The DON stated R #208's lactulose was ordered to address encephalopathy not constipation, and the medication helped to decrease ammonia levels in the blood. The DON stated loose stools would be indicative of the medication having the desired outcome.

Based on interview and record review, the facility failed to ensure their binding arbitration agreement included a provision for convenient venue (a location in which to carry out arbitration proceedings which should be agreed upon and suitable for both parties) selection. Failure to include this provision in the agreement could likely result in residents who choose to seek arbitration experiencing frustration and difficulty deterring them from exercising their rights. This deficient practice has the potential to affect 56 of the 57 facility residents who signed the binding arbitration agreement. The findings are:
A. Record review of the facility's Voluntary Arbitration Agreement, undated, revealed it did not contain a provision for the selection of a convenient venue should arbitration become necessary.
B. On 10/10/24 at 1:00 pm during an interview with the facility Administrator, she confirmed the binding arbitration agreement did not include a provision for a convenient venue selection and added the provision was stated in the facility's admission Guide.
C. Record review of the facility's admission Guide revealed a provision for convenient venue selection in cases of arbitration. Further review revealed the guide did not include a signed acknowledgement that the resident received it, understood it, and that it was to be included as a part of the Voluntary Arbitration Agreement.

Based on record review and interview, the facility failed to create a Baseline Care Plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #108) of 3 (R #15, #25 and #108) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents' condition due to staff not being aware of the care residents' need and residents not being able to attain or maintain their highest practical level of well-being. The findings are:
A. Record review of the Face Sheet for R #108 revealed an admission date of 9/26/24 and included the following diagnoses:
- Acute respiratory failure with hypoxia (when there is not enough oxygen in your blood/body tissue).
- Type 2 diabetic mellitus with neuropathy (high blood sugar with nerve damage).
- Hyperlipidemia (high blood fat levels).
- Obstructive sleep apnea (repeated breathing interruptions during sleep).
- Hypertension (high blood pressure).
- Atherosclerotic heart disease (build up of fats, cholesterol and other substances in and on the artery walls).
- Congestive heart failure (when your heart can't pump blood well enough to meet the body's needs).
- Pneumonia due to coronavirus disease (infection in the lungs).
- Asthma (condition that affects the lungs and makes breathing difficult).
- Muscle wasting and atrophy (loss of muscle mass and strength).
- Overactive bladder.
- Difficulty in walking.
- Post COVID-19 condition [any medical condition that continues for more than 3 months linked to Covid-19 (contagious respiratory infection)] .
B. Record review of baseline care plan for R #108 revealed it was created on 09/30/24, which was more than 48 hours after the resident's admission.
C. One 10/10/24 02:31 PM during an interview with the Administrator, she stated staff should have created the baseline care plan for R #108 within 48 hours. She verified staff did not complete a baseline care plan for R #108 until three days after the resident was admitted to the facility.

Based on observation, record review, and interview, the facility failed to promote care with dignity and respect for 1 (R #35) of 1 (R #35) residents reviewed for residents' rights when staff closed the resident's room door against his wishes and without communicating why to the resident. This deficient practice is likely to result in residents feeling disrespected and as if they were kept in their room against their will. The findings are:
A. On 10/07/24 at 1:35pm during at interview, R #35 stated the Housekeeping Manager (HM) #1 angrily slammed his door shut last week while he was listening to his music, which made him feel like the staff did not respect or care about his feelings.
B. On 10/07/24 at 2:00pm, during an observation, R #35 listened to music. The volume was loud enough to be heard in the immediate hallway. Other residents in the hallway did not appear to be affected by the music.
C. On 10/10/24 at 12:47pm, during an interview with HM #1, she recalled the incident in which she shut the resident's door and stated R #35's music was playing loudly while the staff had a meeting in the nearby conference room. She stated she was asked by the facility Administrator to close the resident's door. She stated she informed the resident that she would close his door. She stated she did not wait for a response from the resident, because she could tell he was agitated.
D. On 10/10/24 at 1:00pm, during an interview and record review with the Administrator, she stated she was aware of the incident. The Administrator provided a written statement from HM #1, dated 10/04/24, which revealed HM #1 informed R #35's roommate rather than R #35 that she was closing the door.

H. On 06/12/23 at 12:16 pm during a lunch meal observation, Certified Nurse Aide (CNA) #1 was observed to be handling the cups/bowls by the rim of the dish, with her bare hand covering the opening of the dish, as she was serving meals to residents.
I. On 06/12/23 at 1:31 pm during a random lunch meal observation revealed, CNA #3 was observed to be handling the cups of beverages and bowls of soup by the rim of the dish, with her bare hand covering the opening of the dish as she was serving meals to residents.
J. On 06/14/23 at 11:55 am during a random lunch meal observation revealed, CNA #3 was observed to be handling the cups of beverages and bowls of stew, with her bare hand covering the opening of the dish, as she was serving meals to residents.
Based on observation and interview, the facility failed to store and serve food under sanitary conditions by not ensuring:
1. Freezer units' temperatures were taken daily,
2. Proper handling techniques were used when handling cups and glasses when drinks were distributed to residents served in the dining room
3. Hands were not sanitized prior to handling residents' meals after handling resident's adaptive equipment during a meal.
These deficient practices are likely to affect all 57 residents listed on the resident census list provided by the Administrator on 06/16/23; and could likely lead to foodborne illnesses in residents if safe food handling practices are not adhered to.
The findings are:
A. On 06/12/23 at 10:42 am during an observation during the initial tour of the kitchen, the reach-in freezer's (located on the back wall of the kitchen) temperature log was observed to have missing temperatures for the for the evening dates of 6/9/23, 06/10/23, and 6/11/23. The temperature for the day shift of 6/10/23 was also missing. The chest freezer's (deep freezers shaped like a trunk with the door that opens up rather than to the side) temperature log was observed to have missing evening temperatures for 06/06/23, 06/07/23, 06/08/23, 06/09/23, and 6/11/23. The temperature was also missing for the day shift of 06/10/23.
B. On 06/12/23 at 10:51 am, during an interview, with Dietary [NAME] (DC #1) confirmed that the dates were missing from the temperature logs for the dates observed. She stated that she was only responsible for the day temperatures and did not know why the evening temperatures were missing for those dates. She reported that the dietary manager was currently out on leave.
C. On 06/12/23 at 12:17 pm during a dining observation, several facility staff, Licensed Pratical Nurse (LPN) #12, Certified Nursing Assistants (CNA) and unidentified facility staff were observed handling residents' cups and glasses by the rim of the cups as they distributed residents drinks throughout the meal.
D. On 06/16/23 at 9:53 am during an interview, the Director of Nursing stated glasses and cups should be held around the outside of the cup, not on the top when serving residents.
E. On 06/12/23 at 12:30 pm, during an observation of meal services, Medical Record's staff (MR #1) brought an unknown female resident into the dining room. As she was assisting the resident to her seat, MR #1 had to move another unknown female resident so that her legs would go over the legs of the table. MR #1 leaned over, moved the unknown resident's resident feet. Then, without washing or sanitizing her hands, MR #1 handled a meal tray and served it to the unknown resident she had just brought into the dining room.
F. On 06/12/23 at 12:49 pm, during an observation, MR #1, rubbed an unknown male resident on the back, then without washing or sanitizing her hands, went and got another unknown resident some fry bread which was on a plate, and gave it too him.
G. On 06/16/23 at 9:53 am, during an interview with the Center Executive Nurse (CNE), she confirmed that staff should be performing hand hygiene (hand washing) between each resident and after touching a resident.

Based on record reviews, interviews and observations, the facility failed to provide proper infection control practices by:
1. Not performing hand hygiene between residents, and
2. Providing resident care, not removing used gloves before entering the hallway.
These deficient practices could likely affect all 57 residents in the facility on the census provided by the Center Executive Director (CED) on 06/12/23. Failure to practice infection control standards could likely cause the spread of infection and illnesses to residents and staff within the facility.
The findings are:
A. On 06/12/23 at 4:04 pm, during observation, Registered Nurse (RN) #1 walked from R #47's room with her gloves on. RN #1 then went into the treatment cart with the dirty gloves on, going through wound treatment items. RN #1 then walked down the hallway to the nurse's station, still wearing her dirty gloves, discarded her gloves and performed hand hygiene using hand alcohol gel.
B. On 06/12/23 at 4:05 pm, during an interview with R #47's regarding wound care. R #47 stated, Nurses had been changing her dressing when she remembered she needed to get something she had forgotten.
C. On 06/12/23 at 4:05 pm, during an observation of R #47's wound care revealed the wound was open, and the old dressing was sitting on the residents bed.
D. On 06/12/23 at 4:06 pm, during an interview with RN #1, she stated, We should be performing hand hygiene before going into resident's room. After we do any type of care. We should not wear gloves in the hallway.
E. On 06/16/23 at 9:45 am, during an interview with the Center Nurse Executive (CNE) she stated, Hand hygiene should be done before and after resident care, if they are exposed to any splashes (to scatter liquid or to cause liquid to scatter through the air or onto something) from the resident, or before entering and after the resident's room, after they touch anything dirty, they should do hand hygiene.
D. Record review of the facility's policy titled: Infection Control Policy and Procedures regarding Hand Hygiene, Purpose: To improve hand hygiene practices and reduces the transmission of pathogenic microorganisms:
Process:
1.1
Before patient/resident (hereinafter patient) care
1.2
Before an aseptic procedure
1.3
After any contact with blood or other body fluids, even if gloves are
worn
1.4
After patient care
1.5
After contact with the patient's environment

Based on record review and interview, the facility failed to ensure that the resident's responsible party, Power of Attorney (POA) and/or family was notified of a resident's change in condition for 1 (R #49) of 1 (R #49) resident reviewed for weight decline. This deficient practice could likely result in the resident's responsible party, POA, and/or family not participating in important decisions regarding the resident's health and well-being.
The findings are:
A. Record review of R #49's nutrition progress notes dated 05/16/23, indicated the following: Current weight 124.4 lbs (pounds) triggers for 90-day weight loss -7.5% (percent) change comparison weight 2/20/23 150.2 Lbs, -17.2%, -25.8 lbs.
B. Record review of R #49's Change in Conditions reports (CIC) for the dates of 04/07/23 through 05/19/23 revealed that no CIC reports had been completed for R #49's significant weight loss. The change of condition was not reported to POA.
C. On 06/13/23 at 10:15 am, during an interview with the POA/daughter of R #49, she stated that she was not called or informed of R #49's decrease in weight documented on 05/16/23 in R #49's nutrition progress notes. POA/Daughter was never notified of any weight loss.
D. On 06/16/23 at 9:45 am, during an interview with the Center Nursing Executive (CNE), she confirmed that Nursing staff should be notifying residents' responsible party, Power of Attorney (POA), or family members regarding weight loss. The CNE stated that a CIC report should be completed to show that the residents' responsible party, Power of Attorney (POA) and/or family was notified. CNE confirmed that a CIC wasn't in the chart for R #49.
E. Record review of the facility's policy and procedure titled: Weights and Heights, under Significant weight change management:
2.1.1
Significant weight change is defined as:
2.1.1.1 5% in one month
2.1.1.2 10% in six months
2.3
The licensed nurse will notify:
2.3.2 Patient representative of weight changes and Dietitian recommendations.
Notification will be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to implement an ongoing one-to-one, resident-centered activities program for 1 (R #52) of 3 (R #s 14, 20 and 52) residents looked at for activities. This deficient practice does not encourage stimulation for residents who have a physical condition; as it does not allow them to attend the regularly scheduled activities programs. This could potentially cause depression and an overall decline of the resident's well-being.
The findings are:
A. Record review of R #52's Face Sheet revealed that he was admitted to the facility on [DATE] with the following diagnoses: Severe Protein Calorie Malnutrition (refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and is being fed with a feeding tube (medical device to provide nutrition to people who cannot obtain nutrition by mouth) for all nutrition, Cerebral Palsy (a group of disorders that affect movement, muscle tone, balance, and posture and is caused by abnormal brain development or damage to part of the brain that controls muscles), Cachexia (a wasting disorder that causes extreme weight loss and muscle wasting), Dysphagia (a condition with difficulty in swallowing food or liquid and may interfere in a person's ability to eat and drink), Profound Intellectual Disabilities (require round-the-clock support and care. They depend on others for all aspects of day-to-day life and have extremely limited communication ability), Contractures all four limbs (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), Adolescent Idiopathic Scoliosis (a condition in which the spine is curved sideways in one or more areas with no known cause), Adult Failure to Thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). This is not all inclusive list of diagnoses.
B. On 06/12/23 at 2:30 pm, an observation was made of R #52. He was lying in bed with eyes opened. There was no TV or music on for stimulation or background noise.
C. On 06/13/23 at 8:59 am, an observation was made of R #52. He was awake, lying in bed with no music or TV on for stimulation or background noise.
D. On 06/13/23 at 10:22 am, during an interview with Family Member (FM) #10, she stated that R #52 can sit up in a chair and likes to wear a hat. He likes music and that if a TV is on, it needs to be closer to him so he can see it. When asked about phone calls with her son (R #52) or a video visit, FM #10 was told by a staff member (name not recalled) that they are too busy to do that.
E. On 06/14/23 at 8:29 am, during an interview with Activities Director (AD), she stated that it takes time to work with R #52 and he will respond to you with his eyes. AD stated that she does talk to FM #10, who told her [the AD] that she [FM #10] speaks with him in Navajo, so she [the AD] also speaks to R #52 in Navajo. AD will turn on music for him (R #52) and most of the time, she will turn it on a local Navajo station. AD stated that FM #10 has a wheelchair for him, but hasn't brought it in [to the facility] yet. There is also a hat that he likes to wear, but FM #10 hasn't brought it in [to the facility] either. FM #10 told her about a game she plays with R #52, where she has a handkerchief and plays peek a boo with him. The AD stated that she isn't comfortable with that game at this time; so she is waiting for FM #10 to come in so she [the AD] can see how she [FM #10] does it.
F. On 06/16/23 at 11:44 am, during an interview with the AD Assistant and the AD, the AD Assistant stated that R #52 doesn't really know her [the AD Assistant] voice and he won't engage with her. When asked about reading to R #52, the AD stated that they had not tried that yet.
G. Record review of the Recreation Assessment Care Plan initiated on 03/03/23 indicated the following interventions in activities summary: Resident is admitted on [DATE] from hospital. He is alert, resident unable to make needs known, unable to communicate. [R #52's] mother states he enjoys listening to native radio station, if TV is closer, he is able to watch TV, enjoys wearing cap by observing color, plays with handkerchief. Resident will be receiving one to one room visits 3 x (times)/week, working with sensory activities and hand massage. Resident will be encouraged to participate with activities of choice. Will monitor resident to next assessment period.

Based on record review and interview, the facility failed to report an Injury of Unknown Origin to the State Survey Agency, for 1 (R #11) of 3 (R #s 11, 28, and 35) residents reviewed for Injury of Unknown Origin. This deficient practice is likely to result in the State Survey Agency not being aware of facility incidents, and unable to assure residents a safe and hazard free environment.
The findings are:
A. Record review of Face Sheet dated 10/01/15 for R #11 revealed this as an initial admission date and included the following diagnoses: Age-Related Osteoporosis (weakened bones due to the aging process), Weakness, Dementia (a group of symptoms that affect memory and thinking and interfere with daily life), Cognitive Communication Deficit (difficulty with thinking, understanding, and speaking), Personal History of Healed Traumatic Fracture (break in a bone), Pain, and Presence of Left Artificial Hip Joint.
B. Record review of the Minimum Data Set (assessment tool used to assess the health and needs of residents) dated 04/14/23 revealed in Section C - Cognitive (how a person thinks, learns and remembers) Patterns - Brief Interview for Mental Status (an assessment used to determine cognitive ability in the elderly) revealed a score of 9 (scores are as follows: 0-7 = Severe cognitive impact; 8-12 = Moderate impairment; and 13-15 = cognitively intact).
C. Record review of Progress Notes dated 09/24/22 at 00:37 (12:37 am) revealed, CNA (Certified Nurse Aide) alerted this nurse to bruising to Resident's (R#11) left knee and right hip. When asked, Resident reports she fell between the bed and wall in the evening (09/23/22) and they helped. Resident did not specify who or what day; however NOC (night shift) CNA reports Resident did not have bruising during night shift of 09/22/22 . Bruising is purple/blue in color, surrounded by erythema (redness of the skin) .
D. Record review of Facility Incidents Log, as provided by the Administrator (ADM)on 06/14/23, revealed no documentation regarding an injury of unknown origin for R #11 for 09/24/22.
E. On 06/16/23 at 10:13 am during an interview, the ADM and Corporate Administrator (CADM) verified that there was no incident report filed for R #11 for an Injury of Unknown Origin for 09/24/22. CADM stated that if there is an injury of unknown origin, she would expect it to be reported to the State Agency.

Based on record review, interview, and observation, the facility failed to ensure that restorative services (person-centered and designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) were being provided for 1 (R #15) of 1 (R #15) resident reviewed for mobility capabilities (ability to move purposely as you go throughout your day). This deficient practice could likely result in resident joints feeling contracted (when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity) or weakened.
The findings are:
A. Record review of R #15's physician order dated 05/15/22 revealed Resident was to wear a left functional hand splint (a supportive device that helps prevent moving the affected body part while it is healing) in the AM, off at PM as tolerated. Staff to remove splint for hygiene, PROM (passive range of motion) and skin check. Every Shift (6 am to 6 pm). Order stated that the hand splint should be on during the AM shift, and taken off during the PM shift.
B. Record Review of R #15's care plan revised 04/21/23 revealed that R #15 is at risk for contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) and skin integrity (breakdown of skin tissue) due to cerebral vascular accident (CVA) and contracture to left hand.
C. On 06/12/23 at 2:36 pm, during interview, R #15 stated that she was supposed to have a splint on her left hand, and that they (facility staff) never put it on her anymore.
D. On 06/12/23 at 2:36 pm, during an observation, the resident didn't have a splint on the left hand.
E. On 06/14/23 at 9:46 am, during an observation, the resident didn't have a splint on her left hand.
F. On 06/14/23 at 12:05 pm, during an observation, the resident didn't have a splint on her left hand.
G. Record review of the administration record of the ETAR (Electronic Treatment Record) was documented that the splint was on June 1 through June 15, 2023 during the AM shift and off during the PM shift.
H. On 06/16/23 at 9:45 am, during an interview, the Center Executive Nurse (CNE) stated nurses are responsible for placing the splint on the resident. She confirmed that they are to put it in place during the morning, and then remove it during the night.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 1 (R #110) of 1 (R #110) resident reviewed for behavioral health concerns, was receiving necessary behavioral health care to meet the resident's needs. This deficient practice could likely cause the resident to not receive the mental health care and assistance that they may need.
The findings are:
A. Record review of the Face Sheet for R #110 indicated that resident was admitted on [DATE] to the facility and was discharged on 04/07/23. She had a mental health diagnosis of Bi-Polar Disorder (mental health condition that causes extreme mood swings that include emotional highs and lows, and depression).
B. Record review of the admission nursing note dated 02/10/23 at 12:00 pm indicated in the Mental Health/Behavior section: Pt. (patient) has expressed/verbalized sadness or symptoms of depression.
C. Record review of the physician orders dated 02/24/23 indicated that a referral to (name of company that provides comprehensive behavioral care via video, and in-person psychology and psychiatry health services) was ordered.
D. Record review of a nursing note dated 02/26/23 at 14:48 (2:48 pm) indicated in the Mental Health/Behavior section: Pt. has expressed/verbalized sadness or symptoms of depression.
E. On 06/16/23 at 9:15 am, during an interview with Social Services Director (SSD), she confirmed that no appointment was made for mental health services for R #110. The SSD stated that her new assistant put in the order for mental health services on 02/24/23, but forgot to let her [the SSD] know about it, so the appointment was not made.

J. On 06/12/23 at 4:47 pm, a medication cart was observed unlocked and unattended across hall from the therapy room. LPN #2, was observed to exit a resident's room at the end of the hall. The cart was observed to be unlocked for approximately 2 minutes. LPN #2 returned to the cart and was observed and heard to lock (with an audible click) the medication cart by pushing in the lock, which locks the cart.
K. On 06/12/23 at 4:52 pm during an interview, LPN #2 confirmed the medication cart was unlocked and that it should be locked when unattended. She stated she had gone to give a resident medications. When she got back to the cart, she observed that it was unlocked, and locked it.
Based on observations and interviews, the facility failed to:
1. Ensure that opened and accessed (has been opened or accessed) for a flex pen weren't dated as to when they were initially opened/accessed, by nursing staff.
2. Ensure that undated medications (not dated when opened) were not stored with dated medications that are available for use
3. Ensure that expired supplies are not stored with unexpired supplies in the storage rooms
4. To properly store medications in medications carts.
5. Ensure treatment/medication carts were kept locked when not in use.
These deficient practices have the likelihood to result in 57 (fifty-seven) residents that were identified on the census list provided by Center Executive Director (CED) on 06/12/23, to receive medications that had either lost their potency or effectiveness. The findings are:
Regarding Opened and Un-labeled Medications:
A. On 06/12/23 at 10:45 am, during observation of the Hall A Medications Cart, three (3) medications were found to be undated as to when they were opened:
1. Senna Plus (a stool softener/laxative) in a bottle was opened with no open date. Upon inspection the bottle was noted to be about 1/4 full and this was confirmed with CMA (Certified Medication Aide) #1.
2. Omeprazole (used to treat stomach and esophagus problems such as acid reflux and ulcers) 20 mg (milligram) capsules were open and was 1/4 the way full a bottle. This was confirmed with CMA #1 that no open date was found.
3. Mucus Relief Guaifenesin (used to relieve chest congestion) Extended tablets 600 mg. These were house stock (medications used by residents in the facility). There was about 1/2 left in the bottle as confirmed by the CMA #1 and there was no open date located on the bottle.
B. On 06/12/23 at 10:53 am, during observation of the Hall B Medication Cart, two (2) medications that were found to be undated as to when they were opened.
1. Famotidine (used to prevent and treat heartburn and acid indigestion) tablets 10 mg. The bottle was open with no open date. Confirmed this with CMA #1 that the bottle was open and that 18 tablets remained out of 30 tablets.
2. Loperamide Hydrochloride (is used to treat diarrhea) 2 mg tablets were not in the box they originated in. Two (2) tablets were found to be stored in a small plastic bag on the top shelf of the medications cart. No open date was found.
C. On 06/12/23 at 11:03 am, during observation of Hall D Medication Cart revealed one (1) opened medications that had not been dated.
1. Aspercreme lidocaine patches (a cream to relieve minor muscle pain) came in a box of five (5) with four (4) left in the box. The box had no open date listed on the box.
Findings related to Insulin Flex Pens
D. On 06/12/23 at 11:03 am, during observation of the Hall D Cart revealed:
1. One (1) Insulin Glargine (a long-acting type of insulin) flex pen (is prefilled with insulin you don't have to load it) for R #15. This flex pen showed there were 140 units left out of 300 units. There was no open date and no use by date. It was confirmed by Licensed Practicing Nurse (LPN) #2 that there was no open date, and no use by date.
2. One (1) Insulin Glargine flex pen for R #8. The flex pen showed there were 140 units left out of 300 units. There was no open date and no use by date. It was confirmed by LPN #2 that there was no open date and no use by date.
Findings related to Medication Storage Room:
E. On 06/14/23 at 9:04 am, during observation of the medication storage room for the entire facility revealed fourteen (14) clear needleless connectors (devices that allow quick access to the infusion line). Two (2) expired 04/12/23, two (2) expired on 05/01/23, and five (5) expired on 05/18/23, and five (5) expired on 06/02/23. All were found in a drawer mixed in with needleless connectors (devices that allow quick access to the infusion line) that had not expired.
F. On 06/14/23 at 9:07 am, during an interview with Licensed Practical Nurse (LPN) #2, she was unsure of the process on how expired supplies or medications are handled, but said that the Center Nursing Executive (CNE) and the Assistant Director of Nursing (ADON) do come in and pick at things (supplies or medications) checking them for expirations dates. LPN #2 also stated that when she is obtaining a medication or supply, she checks the expirations date to ensure it is not expired.
G. On 06/14/23 at 9:20 am during an interview with the CNE, she was asked what the process was to discard expired supplies from the medication storage room. CNE stated,every month when I am preparing the medication for destruction, I looked at the OTC's (over the counter medications) and the supplies for expirations. What I will do is take the ones that expire first and place it to be used first. If I find they are expired. I will throw them away. When asked how CNE discards expired medications that are over the counter and not prescription, or narcotics they get thrown away. Supplies get thrown away.
Findings related to treatment/medication carts kept locked when not in use:
H. On 06/14/23 at 8:24 am, during observation, the medication cart for Hall D was noted to be unlocked with no staff near or observing it.
I. On 06/4/23 at 8:26 am, during an interview with LPN #2, she stated, I did get nervous. I usually always lock it. This is my first week on the floor.