**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, staff failed to notify the physician and Director of Nursing (DON) of changes in a resident's eye for 1 (R #1) of 1 (R #1) residents. This deficient practice could result in the resident not receiving a medical assessment or treatment, which could result in a worsening of symptoms. The findings are: A. Record review of R #1's face sheet revealed the following: -The resident was admitted to the facility on [DATE]. -The resident had a diagnosis of glaucoma (a group of eye conditions that can cause blindness). -The resident had a diagnosis of dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment). -The resident had a diagnosis of cataract (a cloudy area in the normally clear lens of the eye). B. Record review of R #1's Physician Orders, dated 07/24/24, revealed the following: -Staff to complete resident body check (a visual observation during personal care) each shower day, dated 07/24/24. -Refer to eye care providers as needed, dated 07/24/24. C. Record review of R #1's Care Plan, dated May 2025, revealed the resident had a diagnosis of dementia. D. On 09/10/25 at 8:27 AM, observation revealed R #1 sat in a geriatric chair (a specialized reclining chair with safety straps used to support residents who cannot sit safely in a regular chair) in the common area. Further observation revealed the resident's left eye was red and swollen, with mucus drainage present on the eyelid and cheek. The resident rubbed their left eye. Staff did not provide assistance or perform eye care. E. On 09/10/25 at, 12:10 PM, observation revealed R #1's left eye was closed shut and had dried fluid/mucous around the closed eyelid. F. Record review of R #1's medical records revealed the following: - Staff did not document the resident's eye redness, fluid drainage, or swelling. - Staff did not document they notified the physician of the resident's eye condition. G. On 09/10/25 at 1:25 PM, during an interview, the Registered Nurse (RN) #1 stated R#1's left eye was closed with redness and fluid/mucous on 09/10/25. RN #1 stated she wiped the resident's eye with a warm washcloth but did not document the resident's eye condition in the progress notes, notify the Director of Nursing (DON), or contact the physician. H. On 09/10/25 at, 1:28 PM, during an interview, the DON stated it was her expectation for the RNs to report any resident changes to her and the physician. She stated staff did not report R #1's eye changes to her for further assessment and provider notification. I. On 09/10/25 at 2:30 PM, during an interview, the Administrator stated RN #1 should have reported the change in the resident's eye condition to the DON. She stated it was her expectation for staff to communicate any change in the residents. The Administrator stated if staff did not communicate a resident's eye change, then the resident may have adverse reaction if care was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to:- Ensure a medication cart located on the East Hall was inaccessible to unauthorized individuals for 1 (medication cart #1) of 3 (medication carts #1, #2, and #3) medication carts. - Pick up and dispose of a dropped medication for 1 (R #3) of 1 (R #3) residents. If the facility fails to ensure medication is secured against unauthorized access, then residents are at risk of adverse drug reactions, medication errors, overdose, or death. The findings are: Unattended Medication [NAME]. Record review of the facility's Medication Storage Policy, dated 12/11/24, revealed all medication carts must remain locked and secured when not in use. B. On 09/10/25 at 8:24 a.m., during an interview, Registered Nurse (RN) #1 stated the medication cart must remain locked. She stated leaving the cart unlocked could allow a resident to access medications not prescribed to them, which could lead to overdose. C. On 09/10/25 at 8:51 AM and 11:30 AM, observation revealed the East Hall medication cart was unlocked and unattended by staff. Further observation revealed the medication cart contained antidepressants, controlled substances, resident routine daily medications, and insulin injectable pens. D. On 09/10/25 at 2:15 PM, during an interview, the Director of Nursing (DON) stated it was her expectation for all medication carts to remain locked and secured. The DON stated it was the floor nurse's responsibility to ensure medication carts remained locked. Dropped [NAME]. On 09/10/25 at 12:15 p.m., observation revealed a half, yellow pill located on the floor under the East Hall medication cart. Further observation revealed a resident ambulated near the medication cart. F. On 09/10/25 at 1:14 p.m., during an interview, RN #1 stated she dropped the half yellow pill at 9:00 a.m. She stated she did not pick it up, because she was busy. She stated staff were expected to document a dropped medication on the resident's Medication Administration Record (MAR) and in the resident's progress notes. She stated she did not document the dropped medication. RN #1 identified the dropped pill as R #3's sertraline (Zoloft, an antidepressant medication). G. On 09/10/25 at 2:15 PM, during an interview, the Director of Nursing (DON) stated staff must pick up and dispose of dropped medication immediately in a Sharps container and document the incident on the resident's MAR as not administered. The DON stated it was the floor nurse's responsibility to ensure dropped medications were immediately addressed. She stated there was always a chance a resident could pick up the medication and ingest it. The DON stated the dropped medication belonged to R #3.

Based on record review and interviews, the facility failed to ensure R #56 was free from chemical restraints when staff administered a psychotropic medication (group of drugs that affect behavior, mood, thoughts, or perception) for the purpose of keeping the resident in bed, rather than for the treatment of a documented medical condition. If staff fail to administer psychotropic medication for the treatment of a documented medical condition, then it may be considered a restraint and place the resident at a higher risk of adverse side effects. The findings are: A. Record review of R #56's face sheet revealed an admission date of 12/16/20 and included the following diagnosis: - Schizophrenia (a disorder that affects an individual's ability to think, feel, and behave clearly),- Neurosyphilis (an infection of the nervous system, specifically of the brain and spinal cord).B. Record review of R #56's Physicians Orders, dated 04/02/25, revealed an order for lorazepam (anti-anxiety medication) 1 milligram (mg) tablets. Give one tablet every three to four hours as needed for anxiety, for 15 days.C. Record review of R #56's Nurse progress notes, dated 04/03/25, revealed staff administered lorazepam 1mg to R #56, to help keep him in bed.D. Record review of R #56's Medication Administration Record (MAR), dated 04/01/25 through 04/30/25, revealed staff administered lorazepam 1 mg on 04/03/25 and documented the reason as, because the resident tried to get out of bed.E. On 07/03/25 at 11:08 am during an interview, Registered Nurse (RN) #1 stated R #56 tried to get out of bed on 04/03/25, because he was anxious. RN #1 stated the resident fell previously, and staff were afraid he would fall again. RN #1 stated she documented she administered lorazepam to keep R #56 from getting out of bed. RN #1 stated she probably should not have documented using the words to keep him in bed because it sounded like she used the medication as a restraint. F. On 07/03/25 at 11:17 am during an interview, the Director of Nursing (DON) stated the documentation in the nurses note stated, I also gave him some Ativan to help keep him in bed. The DON stated R #56 was non-verbal, and he only spoke one or two words. The DON stated R #56 appeared anxious, agitated, fearful, and was at the end of life. The DON stated the documentation in R #56's MAR, dated 04/03/25, stated staff administered lorazepam to R #56 to keep the resident from getting out of bed. The DON stated it was not the facility's practice to administer medications to control behavior, and it was her expectation for nurses to document appropriate reasons for administering medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff monitored and maintained oxygen therapy equipment for 1 (R #10) of 1 (R #10) residents reviewed for oxygen use. If the facility fails to ensure residents using supplemental oxygen have functioning equipment, then residents may experience dangerously low oxygen saturation levels (amount of oxygen in the blood), respiratory distress, and hospitalization.The findings are: A. Record review of R #10's face sheet dated, 02/06/2025, revealed the resident was admitted to the to the facility on [DATE] with the following diagnoses:-Alzheimer's disease (progressive neurodegenerative brain disorder),-Respiratory failure,-Chronic obstructive pulmonary disease (COPD; lung disease). B. Record review of R #10's physician orders, dated 07/24/24, revealed an order for oxygen at 2 to 4 liters per minute (lpm) via nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs) continuously to keep saturation above 90 percent (%) every shift. C. Record review of R #10's Quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment, dated 04/20/2025, revealed the following:- Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 6, severe cognitive impairment.- R #10 experienced shortness of breath with exertion (walking, bathing, transferring), shortness of breath when sitting at rest, and shortness of breath when lying flat. D. On 07/03/25 at 2:16 PM, during an observation, R #10 lay in his bed with his oxygen nasal cannula in place. The resident was connected to a portable oxygen tank (a lightweight mobile device intended for ambulation or transport). R #10's oxygen concentrator (device that concentrates the oxygen from a gas supply) was located next to his bed and was off. E. On 07/03/25 at 2:23 PM, during an observation and interview, Certified Nursing Assistant (CNA) #1 entered R #10's room and checked the resident's portable oxygen tank. She stated R #10's portable oxygen tank was empty. CNA #1 measured R #10's oxygen saturation level at 78% (Normal oxygen saturation levels range between 95% and 100%.) F. On 07/03/25 at 2:30 PM, during an observation, RN #1 entered R #10 ‘s room and measured R #10's oxygen saturation level at 85%. The resident was connected to the oxygen concentrator via nasal cannula. G. On 07/03/25 at 2:30 PM, during an interview, RN #1 stated it was the CNA's responsibility to ensure residents' portable oxygen tanks were full. She stated R #10 frequently went in and out of his room throughout the day and sometimes forgets to reconnect himself to the concentrator. She stated staff have found his portable oxygen tank empty on previous occasions. H. On 07/03/2025 at 3:06 PM, during an interview, RN #3 stated R #10 went to his room to lie down after lunch. RN #3 stated portable oxygen tanks have a limited supply of oxygen, and oxygen concentrators provide a continuous flow of oxygen. I. On 07/03/25 at 3:19 PM, during an interview, CNA #2 stated the CNAs fill the portable oxygen tanks at the end of each shift for the oncoming shift. She stated the CNAs should check the resident's oxygen equipment to ensure the correct oxygen flow, confirm the tubing was not twisted, and check the humidifier bottle. CNA #2 stated staff should switch the residents from the portable oxygen tank to the concentrator when the residents were in their rooms. She stated cognitive residents connect themselves to the concentrator, but R #10 had dementia, remained in his room, and had inconsistent cognitive clarity. She stated staff should complete rounds after lunch, to include the residents' oxygen level.

Based on interviews and record review, the facility failed to ensure Level I PASRR (Screening for Mental Illness and Intellectual Disability) Level I screenings were reviewed for accuracy and properly completed for two of two residents reviewed for PASRR (R #22, and R #25). If the facility fails to review Level I PASRR screenings for accuracy and ensure that they are properly completed, then residents with serious mental illness or intellectual disability may be admitted without appropriate screening or specialized service determination, resulting in inappropriate placement and potential harm.(The findings are)R #22A. Record review of R #22's PASRR Level 1 screening, dated 06/15/23, revealed the resident did not have a diagnosis of or a suspicion of a serious mental illness. B. Record review of R #22's face sheet revealed an admission date of 06/15/23 with the following diagnoses:(List not all inclusive)-Bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs).C. Record review of R #22's physician orders revealed the following:-Oxcarbazepine 150mg., one tablet daily for diagnosis of Bipolar.-Lurasidone HCL 40 mg., one tablet daily for diagnosis of Bipolar. R #25D. Record review of R #25's PASRR Level 1 Screening, dated 01/29/24, revealed the resident did not have a diagnosis of or a suspicion of a serious mental illnessE. Record review of R #25's face sheet revealed an admission date of 01/30/24 with the following diagnoses:(List not all inclusive)-Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).F. Record review of R #25's physician orders revealed the following:-Duloxetine HCL 60 mg., one tablet daily for depression.G. On 07/03/25 at 1:27 PM, during an interview, the Social Services Director (SSD) stated it was expected for the sending facility to send the Level 1 PASRR with the other transfer documents. The SSD stated she reviews the resident's medical history before completing a new resident's Level 1 PASRR. The SSD stated if a resident has a qualifying mental health or developmental diagnosis, she submits the Level 1 PASRR recommendation to the determining agency. She stated she informs the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) to review any PASRR's requiring attention. The SSD stated it was her expectation for all PASRR's to be screened properly prior to the admission of the resident. She stated Level I PASRR screenings must be current and accurately reflect any qualifying diagnoses. She stated R #18's PASRR was incorrect because staffed checked the resident did and did not have a diagnosis or suspected mental illness. She stated R #22's and 25's PASRR was incorrect because both residents have a diagnosis or a mental illness, identified in Section C.

Based on observation and interview, the facility failed to:- Ensure expired kitchen items were disposed of and not accessible in the refrigerator.- Use appropriate techniques to thaw frozen shrimp.- Store food off the floor.These deficient practices could potentially cause a foodborne illness for all residents in the facility. The findings are:Expired Food A. On 07/01/25 at 9:30 am, during an initial kitchen tour, observation revealed containers of cottage cheese with expiration dates of 06/22/25 and 06/26/25.B. On 07/01/25 at 9:30 am, during an interview, the Dietary Manager (DM) stated staff should have thrown away the expired cottage cheese. He stated expired food should not be in the refrigerator. The DM stated staff should check the refrigerator daily for expired food. Thawing Food C. On 07/01/25 at 1:45 pm, observation revealed four, 2 pound bags of shrimp sat in a 10 inch (in) by 10 in. by 17 in container in the sink. The bags of shrimp floated in water in the container, and a narrow stream of water trickled into the container. Further observation revealed the four bags of shrimp were not fully submerged in the water, and the stream of water did not agitate the water in the container. D. On 07/01/25 at 1:47 pm during an interview, the DM stated the shrimp was for dinner on 07/01/25. He stated there were three ways to thaw food: in the microwave, under running water, and in the refrigerator. He stated the shrimp should be submerged in the water in the container, and the running water should be strong enough to agitate the water in the container. Food Storage E. On 07/01/25 at 1:50 pm, observation revealed a box of Uncrustable (name brand) sandwiches and a box of uncooked bacon sat on the floor of the walk-in refrigerator. F. On 07/01/25 at 1:50 pm, during an interview, the DM stated food should be stored on the shelves and not directly on the floor. The DM stated he did not know why the food was on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident's physician when a resident did not eat for an extended period of time and loss significant weight for 1 (R #1) of 1 (R #1) resident. If the facility is not notifying the physician then residents are likely to experience adverse effects, worsening of their condition, and potential complications from not receiving the proper care. The findings are: A. Record review of R #1's face sheet, dated 11/19/24, revealed R #1 was admitted to the facility 06/14/19. B. Record review of R #1's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 07/01/24, revealed R #1 had a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of seven (7), severely impaired. C. Record review of R #1's physician orders, dated September 2024, revealed the following: a. Diagnoses included: - Alzheimer's disease (a disease which causes irreversible changes in memory, thinking, and behavior), - Type 2 diabetes mellitus (DM2, a condition which results from insufficient production of insulin, causing high blood sugar), - Unspecified dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), - Encephalopathy (a degenerative brain disease that alters brain function or structure.) b. Diet: Regular. D. Record Review of R #1's meal intake revealed the following: a. On 09/01/24, R #1 refused breakfast and dinner. b. On 09/04/24, R #1 refused breakfast. c. On 09/05/24, R #1 refused breakfast, lunch, and dinner. d. On 09/06/24, R #1 refused breakfast and lunch. e. On 09/07/24, R #1 refused breakfast, lunch, and dinner. f. On 09/08/24, R #1 refused breakfast, lunch, and dinner. g. On 09/09/24, R #1 refused breakfast and lunch. h. On 09/10/24, R #1 refused breakfast and lunch. i. On 09/11/24, R #1 refused breakfast and lunch. j. On 09/12/24, R #1 refused breakfast and lunch. k. On 09/13/24, R #1 refused breakfast and lunch. l. On 09/14/24, R #1 refused lunch and dinner. m. On 09/15/24, R #1 refused breakfast and dinner. n. On 09/16/24, R #1 refused breakfast, lunch, and dinner. o. On 09/17/24, R #1 refused breakfast, lunch, and dinner. p. On 09/17/24, R #1 refused lunch and dinner. E. Record Review of R #1's of monthly weights revealed the following: a. In March 2024, the resident weighed 207.4 pounds (lbs.) b. In June 2024, the resident weighed 199.4 lbs. c. In August 2024, the resident weighed 200.6 lbs. d. In September 2024, the residents weighed 186.4 lbs. e. The resident experienced a 7.8 percent (%) weight loss in one month (August to September 2024) and a 10.13% weight loss in six months (March to September 2024.) F. Record review of R #1's New Mexico Medical Orders for Scope of Treatment (MOST; a legal document which outlines the care the resident wants when they become incapacitated and unable to speak for themselves) form, dated 01/17/24 and signed by the PA and the resident, revealed the resident was full code but did not want artificial nutrition. G. Record review of R #1's Physician's Progress Notes revealed the following: a. Date of service was 09/11/24. Signed by the Physician's Assistant (PA) on 09/16/24. admission date 06/14/19, with a readmission from the hospital on [DATE]. The resident recently had pneumonia, poor intake, and concentrated urine. Staff reported possible small coffee ground emesis (vomit) with some hypoxemia (low levels of oxygen in the blood). The resident was provided one liter normal saline (NS) secondary to poor intake. Resident continued to be resistant to her oral medications and care. Review of body systems (ROS) showed decline. Resident allowed staff to feed her highly sweetened foods and fluids. The resident's weight was documented as 186 lbs with a note to re-weigh the resident. The resident was irritable, oriented to person and situation, had limited short-term recall and poor judgment. The record did not address the resident's weight loss over the one month and six month period. b. Date of service was 09/18/24. Signed by the PA on 09/26/24. Discharge Summary. The resident became hypoxic (low levels of oxygen in the blood) with some apnea (temporary cessation of breathing.) Since returning from the hospital, the resident would only drink concentrated sweets such as malts, no pureed food. The resident had been resistant to all care. No labored breathing at visit with use then reporting changes of apnea. discharged to the hospital, stabilized by Emergency Medical Technicians (EMT.) H. Record review of R #1's nurses notes revealed the following: a. Dated 09/16/24, resident was alert and verbal, usually answered with one or two words. R #1 required assistance with all meals. b. Dated 09/18/24, resident had apnea attacks. R #1 was unresponsive to verbal stimuli with rapid shallow breathing. c. Dated 09/18/24, staff notified the Assistant Director of Nursing (ADON) of the resident's condition. R #1 was sent to the hospital. d. The record did not contain documentation to show staff notified the resident's physician (the Medical Director) regarding the resident's refusal to eat, significant weight loss, and discharge to the hospital. I. On 02/14/25 at 11:00 am, during an interview with Hospital Caseworker (HC), she stated the resident was dehydrated and appeared malnourished when she was admitted to the hospital on [DATE]. The HC stated the resident was admitted to the hospital on [DATE] and passed away 30 days later while at the hospital. J. On 02/14/25 at 11:42 am, during an interview, the ADON stated R #1 would eat only when she wanted to eat. The ADON stated R #1 often cursed, hit, and spat at the staff when they assisted the resident with eating. The ADON stated they could not force residents to eat, but they could encourage them. The ADON stated R #1 refused to get a gastrostomy tube (G-tube; a tube surgically inserted through the abdomen into the stomach and used to provide fluids, nourishment, and medications). The ADON stated they did not send the resident to the hospital for failure to eat. She stated she did not believe the hospital would intervene, because hospitals and nursing homes often have differing perspectives on care. K. On 2/27/25 at 11:55 am, during an interview, the Medical Director (MD) stated he worked at the facility since June or July of 2024. He stated he did not have the opportunity to see all the residents, but his PA saw the residents on a regular basis. The MD stated the PA saw R #1 in September 2024, but she did not notify him of the resident's failure to eat or significant weight loss. The MD stated staff did not notify him that R #1 was not eating and lost significant weight. He stated it was expected for staff and the PA to notify him immediately if a resident did not eat or if a resident lost significant weight. He stated the facility failed to keep him informed of residents' conditions on previous occasions and he brought this to their attention. The MD stated he would have referred to the resident's advanced directives (MOST) to take into consideration the resident's wishes, but even if the resident did not want artificial nutrition, he could have made changes to the resident's orders and adjustments to the resident's diet if he had known. The MD stated if the resident received shakes or super foods (fortified foods) then that information should be reflected in the resident's orders and documented in the resident's medical record. L. On 02/27/25 at 12:22 PM, during an interview with the Physician Assistant, she stated she was not aware the resident refused to eat for two weeks. She stated she was aware the resident lost weight. The PA stated she did not notify the MD regarding the resident's weight loss, because she felt the resident's weight loss was warranted due to the resident's obesity. The PA stated she deferred to the facility's Registered Dietician (RD) since the RD had its own standards. She stated if she had been concerned about the resident's weight loss, then she would have prescribed liquid protein for the resident to consume. The PA stated she did not see the resident before R #1 left the facility, and she did not feel the need to contact the MD for any changes in the resident's care.

Based on observation and interview, the facility failed to discard food after it reached its shelf life or after it expired. This failure was likely to affect all 52 residents listed on the census provided by the Administrator on 03/11/24. This deficient practice could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being discarded timely. The findings are: A. On 03/11/24 at 10:22 am, observation of the walk-in fridge revealed the following: 1. Cabbage, use by date 03/10/24, 2. Cilantro, use by date 02/19/24, 3. Parsley, use by date 03/09/24. B. On 03/11/24 at 10:22 am, during an interview, the Dietary Manager confirmed the cabbage, cilantro, and parsley should be discarded on or by the use by date.