Other·March 16, 2026

State Citation (A) was written. 42 CFR  483.10(g)(14)(i)(B) Notification of Changes (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with her or her authority, the resident representative(s) when this is - (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications) 42 CFR  483.20(g) Accuracy of Assessments The assessment must accurately reflect the residents' status. 42 CFR  483.21 (b)(3)(i) Meet Professional Standards of Quality The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. 42 CFR  483.35(a)(3) Nursing Service The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment (a)Sufficient Staff (3) The facility must ensure that licensed nurses have the specific competencies, and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care 22 CCR 72311(a)(3)(B) Nursing Services-General (a) Nursing Service shall include, but not be limited to the following (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 22 CCR 72523 (a)(c)(2)(D) Patient Care Policies and Procedures. (a) Written patient care policies and procedures shall be established and implemented to ensure that patient-related goals and facility objectives are achieved. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (2) Nursing services policies and procedures which include: (D) Notification of the licensed healthcare practitioner acting within the scope of his or her professional licensure regarding sudden or marked adverse change in a patient's condition. On December 17th, 2025, at 9:30 a.m., an unannounced visit was conducted at the facility to investigate complaint number 2682602 regarding the quality of care provided for a resident during a change of condition assessment conducted by the registered nurse prior to Resident 1 being transferred to a general acute care facility and passing away. The facility failed to ensure: 1.) Services provided and arranged by the facility met professional standards for quality of care of Resident 1 when Registered Nurse (RN) 1 failed to communicate the complete findings to Resident 1's physician for the assessment conducted on 4/8/25 at 12:16 p.m. 2.) Registered nurses had the appropriate competencies, and skill sets necessary to care for Resident 1's change of condition needs when Registered Nurse (RN) 1 did not complete a full neurological assessment of Resident 1 and did not follow facility protocols to notify the primary physician of all changes. These failures resulted in further decline of Resident 1's clinical status until the evening of 4/8/25 when Registered Nurse (RN) 2 notified the physician at 7:34 pm (5 hours and 18 minutes after RN 1 first called the physician) of Resident 1's decline, and an emergency transport was ordered to transfer Resident 1 to the nearest general acute care hospital (GACH A) emergency department where Resident 1 was diagnosed with intracranial hemorrhage (bleeding in the brain, a type of stroke), coma, and required immediate intubation (someone who has a breathing tube placed through their mouth or nose into their windpipe to keep the airway open, support breathing) for life support. Resident 1 was then transferred to GACH B for a higher level of care to support the care of the evolving brain bleed, Resident 1 subsequently passed away on 4/16/25 at 4:29 a.m. During a review of Resident 1's "Admission Record" (document containing resident demographic information and medical diagnoses) dated 12/17/25 for Resident 1's admission to the facility on 3/28/25 for physical and occupation rehabilitation due to recent motor vehicle accident. Resident 1's diagnosis included but was not limited to idiopathic peripheral autonomic neuropathy (nerve damage affecting automatic body functions such as heart rate and digestion), diabetes mellitus II (a chronic metabolic disease where the body either does not produce enough insulin or does not use insulin effectively) constipation (a condition in which there is difficulty in emptying the bowels and possibly causing hard stools), hypertension (high blood pressure), and muscle weakness (a general lack of strength), multiple fractures of ribs, left side, fracture of right lower leg, neuromuscular dysfunction of bladder (nerve damage disrupts normal bladder control, causing issues with storing or emptying urine), hypothyroidism (does not produce enough essential hormones, causing your body's functions to slow down), atrial fibrillation (an irregular and often very rapid heart rhythm) and muscle spasms (a sudden, involuntary, and often painful contraction of one or more muscles). During a review of Resident 1's "Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment)," dated 3/31/2025, the "MDS," indicated, Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 0-15 ) score of 13 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 1 was cognitively intact. During a review of Resident 1's "Admission/Re-admission Summary Note" dated 3/28/25 at 4:40 p.m., the "Admission/Re-admission Summary Note" indicated, "...Resident was admitted from [GACH A] due to frontal car collision... resident is alert and oriented [person, place, time], able to make her needs known..." During a review of Resident 1's "Nurses Notes" dated 3/28/25 at 3:52 p.m., the "Nurses Notes" indicated, Resident 1 was fully awake, alert and oriented and responsive without a neurological deficit. The nurses noted indicated that the resident was receiving pain management with oxycodone (pain reliever used to treat moderate to severe pain) HCL oral tablet 5 (milligrams-mg units of measurement and it was well controlled. During a review of Resident 1's "Weekly Summary Notes (WSN)," dated 4/3/25 at 6:18 p.m., the WSN indicated, Resident 1 was alert and oriented to person, place, time and situation and only required limited assistance by staff with basic activities of daily living. During a review of Resident 1's "Physicians Progress Note," dated 4/7/25 at 1:35 p.m., the "Physicians Progress Note" indicated, "...Chief complaint: Mobility and [Activities of Daily Living] dysfunction secondary to right ankle fracture...now with improving endurance and safety...no falls, vital signs stable, no new issues reported. Participating well in therapy... During a review of Resident 1's "Physical Therapy Treatment Encounter Notes (PTTEN)," dated 4/7/25, the "Physical Therapy Treatment Encounter Notes," indicated date of service 4/7/25... Resident 1 required moderate cueing for body mechanics and education on importance otherwise engaged. Resident 1 fatigues easily and requires prolonged rest between sets and interventions as session progresses. PTTEN indicated Resident 1was agreeable to therapy. PTTEN indicated Resident 1 instructed to stand and to transfer from bed to wheelchair minimum assistance required minimum cueing for hand/foot sequencing. PTTEN indicated Resident 1 instructed in and completed multiple stand pivot transfer with minimum assistance using parallel bars in order to facilitate safe transfers. During a review of Resident 1's "Physical Therapy Treatment Encounter Notes (PTTEN)," dated 4/8/25, the "Physical Therapy Treatment Encounter Notes," indicated on 4/8/25, Resident 1 was encountered semi-fowlers (the individual lies on their back on a bed with the head of the bed elevated at 30-45 degrees), daughter at bedside. PTTEN indicated "[Resident 1] and daughter stating that they don't feel (Resident 1) can do therapy today as she's having a lot of bowel movements as she was given a suppository ..." During an interview on 12/17/25 at 8:45 a.m., with Resident 1's daughter (RD), RD stated she came to visit her mother on the morning of 4/8/25 approximately a little after 10 a.m. and her mother was not her normal self. RD stated her mother was usually excited to see her and have a conversation with me as well as being eager for her therapy sessions as she was working to get back home as soon as possible, but on 4/8/25, her mother did not want to talk at all and was telling her she had an excruciating headache. RD stated her mother refused therapy that morning and refused to eat due to her headache. RD stated her mother fell asleep during the morning of her visit. RD stated Registered Nurse (RN) 1 came into her mother's room around lunch time to give her mother her medication. RD stated RN 1 had difficulty waking her mother up to administer her medication. RN 1 tried to get her mother to drink soda from a straw, but her mother was not able to drink. RD stated once RN 1 realized her mother was not swallowing the pill, RN 1 stuck her hand in her mother's mouth to find the pill, but she could not find it. RD verbalized her concerns to RN 1. RD stated her mother went back to sleep and she called the facility administrator to voice her concerns about her mother's change in condition and interaction with RN 1. During an interview on 12/17/25 at 10:50 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he does not recall working with Resident 1. LVN 1 stated it was communicated to him by other nursing staff that Resident 1 was sent out for further evaluation to the local hospital and did not return to the facility. LVN 1 stated that when there is a change of conditions for a resident, the nursing staff is expected to document in the Situation, Background, Assessment and Recommendation (SBAR), change in condition (CIC) and progress nursing (PN) notes, the assessment conducted, communication provided to the responsible party, the primary physician and recommendations made. LVN 1 stated a change of condition can include any of following: change in baseline that could include mental status, physical status, behavioral status; meal consumption and medication administration. LVN 1 stated licensed nurses are trained to document the change of condition accurately and notify the appropriate personnel as indicated in our nursing job descriptions. LVN 1 stated by notifying and providing a complete clinical description of the resident the physician will provide a plan of care specific for that resident. LVN 1 stated an inaccurate resident clinical assessment that is communicated to a physician would be unsafe and potentially harm the resident. During an interview on 12/18/25 at 8:15 a.m., with the certified nursing assistant (CNA) 1, CNA 1 stated a resident change of condition could include going from high energy to low energy, refusing meals, refusing care or having behaviors and it should all be reported to the charge nurse immediately. CNA 1 stated Resident 1 was usually wide awake, up in her wheelchair and able to communicate to staff about any issues, concerns, wants, needs and pain. I do not recall this resident being sleepy or groggy while caring for her, she was very alert and able to use the call light for assistance. During a concurrent interview and record review on 12/18/25 at 9 a.m., with the Assistant Director of Nurses (ADON) 1, the facility's document titled "PN" for Resident 1, dated 4/8/25 at 12:16 p.m. was reviewed. The "PN" indicated, "...[ADON] was notified by charge nurse to accompany to residents' room to take a look at Resident [1]... Resident [1] had eyes closed and was responsive. Resident [1] was asked by [RN 1] to squeeze [RN 1's] hands 4 times. Resident responded with 4 squeezes. Resident nodded her head with yes and no questions answered appropriately...". ADON 1 stated RN 1 asked her to "help" check on Resident 1 with her since Resident 1's daughter was concerned because her mother was so "sleepy". ADON 1 stated "I only made visual observations as [RN 1] assessed [Resident 1] ...I never checked on [Resident 1] physically myself." ADON 1 stated the daughter was concerned about her mother's well-being since it was a change from her norm. ADON 1 stated she is a licensed vocational nurse and her scope of practice only allows her to collect data and not assess, so she observed RN 1 assessment of Resident 1 while present in the room only. During a concurrent interview and record review on 12/18/25 at 9:10 a.m., with the ADON 1, the facility's document titled "PN" for Resident 1, dated 4/8/25 at 3:50 p.m. written by RN 1 was reviewed. The "PN" indicated, "...Writer tried waking up [Resident 1] and she was able to nod her head yes and no and open her mouth.... She took her medicine and sucked on it.... Writer wore a glove felt in her mouth until resident swallowed her medication..." ADON 1 stated it is not usual practice to place a gloved hand in a resident's mouth unless you are doing a mouth sweep for someone who is unconscious or choking. During a concurrent interview and record review on 12/18/25 at 9:15 a.m., with the ADON 1, the facility's document titled "Situation, Background, Assessment and Recommendation (SBAR)" for Resident 1, dated 4/8/25 at 3:20 p.m. written by RN 1 was reviewed. ADON 1 stated RN 1 called the physician one time on 4/8/25 at 3:20 p.m. ADON 1 stated documentation on the SBAR did not have the full documented assessment for Resident 1. The SBAR did not indicate Resident 1 had difficulty swallowing requiring a mouth sweep with a gloved hand by RN 1, changes in resident verbal baseline responses and meal refusals. ADON 1 stated the full assessment was not communicated to the primary physician for clinical recommendations appropriate for Resident 1. ADON 1 stated by not providing an accurate description of Resident 1's current condition, the physician only made recommendations based on the information provided by RN 1. During a review of the facility's document titled "Documentation Survey Report (an internal document indicating consumed meal percentages)", for Resident 1, printed on 12/18/25, the "Documentation Survey Report" indicated, "Resident Refused" her breakfast, lunch and dinner meals for 4/8/25. The "Documentation Survey Report" indicated, on 4/6/25, Resident 1 ate 26-50 % of their meal for breakfast, 76-100% for lunch and 51-75% for dinner and on 4/7/25, Resident 1 ate 26%-50% for breakfast and lunch and 51-75% for dinner. During an interview on 12/18/25 at 9:30 a.m., with the Medical Director (MD) for the facility, the MD stated it is the expectation for licensed nurses to provide physicians with a full and accurate description of a resident's assessment and their current condition. The MD stated based on Resident 1's SBAR records written by RN 1 on 4/8/25 at 3:20 p.m., the only communication to the primary physician did not include the full and accurate assessment of Resident 1's change of condition. The MD stated it is important and expected for all aspects of the assessment including changes in vital signs, verbal responses, difficulty with arousal, changes in appetite, and medication refusals to be communicated to all primary physicians. The MD stated physicians are dependent on information provided by the nursing staff in order to make the necessary recommendations and decisions for a plan of care, evaluation and treatment. During a concurrent interview and record review on 12/18/25 at 10 a.m., with RN 1, the facility's docum