Every finding on record at Accura HealthCare of Pierce

Licensure Reference Number 175 NAC 12-006.09(A) Based on record review and interview, the facility failed to ensure Resident 7's Pre-admission Screening and Resident Review (PASRR-screening used to determine if a person had or was suspected of having Mental Illness (MI), Intellectual Disability (ID), or a Related Condition (RC)) was completed accurately. The sample size was 2 and the facility census was 36. Findings are:Review of Resident 7's Minimum Data Set (MDS-federally mandated comprehensive assessment used in the development of resident care plans) dated 3/17/26 revealed the following;-admitted on [DATE],-was not considered by the state PASRR to have MI, ID, or RC, and-had diagnoses of major depressive disorder and schizophrenia (a range of problems affecting thinking, behavior, and emotions). Review of Resident 7's Diagnosis Report dated 7/26/22 revealed the following diagnoses; Adjustment Disorder with mixed anxiety and depression (the development of emotion and or behavior symptoms related to a stressor but out of proportion to the stressor) and Schizoaffective Disorder, bipolar type (a chronic mental health condition characterized by symptoms of schizophrenia, such as delusions and hallucinations and symptoms of mood disorders such as mania or depression).Review of Resident 7's PASRR completed by the hospital on [DATE] revealed the resident had no suspected or known mental health diagnosis, intellectual disability or related condition.Review of Resident 7's current Care Plan with a revision date of 4/17/25 revealed the resident had diagnosis of Schizophrenia with physically aggressive behaviors and the resident took psychotropic (drugs that affect a person's mental state) medications.During an interview on 4/20/26 at 9:59 AM, the Director of Nursing ( DON) confirmed the resident's admission PASRR was completed by the hospital and the assessment did not identify the resident's diagnosis of Schizophrenia and Major depressive disorder. The PASRR had been completed incorrectly and did not accurately reflect the residents' MI diagnoses. In addition, due to the incorrect level 1 PASRR screen a level 2 PASRR was not completed.

Licensure Reference Number: 175 NAC 12-006.09(H)Based on record review and interview; the facility failed to provide monitoring and treatment related to changes in bowel elimination for Resident 13. The sample size was 4 and the facility census was 36.Findings are: Review of a Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) for Resident 13 dated 4/13/26 revealed the resident was cognitively intact with diagnoses of stroke, high blood pressure, peripheral vascular disease, diabetes, hemiplegia (paralysis of one side of the body), anxiety and depression. The resident was always involuntary of bowel and required substantial to maximal assistance with toileting.Review of Resident 13's current Care Plan with revision date of 5/12/2025 revealed the resident was at risk for constipation due to decreased mobility, poor oral intakes, and refusal at times to take medications to promote bowel movements. Interventions included the following:-monitor medications for potential side effects of constipation and keep the resident Primary Care Practitioner (PCP) informed.-monitor for changes in mental status, confusion, sleepiness, inability to maintain posture, slow pulse, abdominal distension, vomiting, bowel sounds and abdominal tenderness, rigidity or guarding as potential complications of constipation.-monitor and document bowel movement patterns each day.-administer medications as ordered. Review of the facility form titled Bowel Movement Needs List (updated 5/10/2023) revealed staff were to identify all residents who had not had a bowel movement in the last 2, 3, 4 or 5 days. Interventions were to be implemented with assessments and results documented. Further review revealed the following interventions if the resident did not have a bowel movement:-on day 2 the staff were to offer the resident prune juice.-on day 3 the staff were to offer the resident Milk of Magnesia.-on day 4 the staff were to administer a Bisacodyl suppository.-on day 5 with no bowel movements the staff were to administer a Fleets enema. Staff were to monitor/document results with interventions and were to assess bowel sounds every shift. Review of the resident's documented bowel eliminations from 3/1/26 to 3/31/26 revealed the resident had no documented bowel movement from 3/7/26 to 3/12/26 (5 days). Review of the resident's Medication Administration Record (MAR) for 3/2026 revealed Resident 13 had the following orders:-Miralax one scoop daily which the resident was to receive daily.-Bisacodyl Delayed Release tablets 5 milligrams (mg) to be given every 24 hours as needed for constipation. The resident was not offered and/or administered the Bisacodyl throughout the month. -Dulcolax suppository 10 mg to give one every 24 hours as needed for constipation which was not offered and/or administered throughout the month. -Milk of Magnesia 30 milliliters (ml) to be given every 24 hours as needed for constipation which was not offered and/or administered throughout the month. Review of the resident's medical record revealed the resident did not have a bowel movement from 3/7/26 to 3/12/26; the resident was not offered prune juice on 3/9 when the resident went 2 days with no bowel movement, was not offered Milk of Magnesia on 3/10 after the resident went 3 days with no bowel movement and was not offered a Bisacodyl suppository on 3/11 after the resident had gone 4 days without a bowel movement. In addition, there was no evidence that the staff completed an assessment of bowel sounds. Review of the resident's documented bowel eliminations from 4/1/26 to 4/30/26 revealed the resident had no documented bowel movement from 4/1/26 to 4/4/26 (4 days), 4/4/26 to 4/10/26 (6 days) and from 4/10/26 to 4/14/26 (4 days). Review of the residents' MAR for 4/2026 revealed the resident was given the as needed Bisacodyl 5 mg on 4/9/26 and the staff documented the results as ineffective, the as needed Milk of Magnesia 30 ml on 4/7/26 and on 4/9/26 and both times administration was charted as ineffective. Review of the resident's medical record revealed the following regarding Resident 13:-went 4 days with no documented bowel movement from 4/1/26 to 4/4/26. No documentation that the resident: was offered prune juice on 4/2 when the resident went 2 days without a bowel movement, was offered the Milk of Magnesia on 4/3 after the resident went 3 days without a bowel movement. In addition, there was no evidence that the staff completed an assessment of bowel sounds during this time.-went 6 days with no documented bowel movement from 4/4/26 through 4/09/26. No documentation that the resident: was offered prune juice on 4/6 when the resident went 2 days without a bowel movement, was given Milk of Magnesia 30 ml on 4/7 (day 3) but staff documented this was ineffective and was then given a Bisacodyl tablet and Milk of Magnesia on 4/9/26 (day 5) which were both documented as ineffective. There was no evidence that the facility assessed the resident's bowel sounds or notified the resident's PCP the resident had been without a bowel movement for 6 days. -went 4 days without a bowel movement from 4/11/26 through 4/13/26. The resident was not offered prune juice on 4/12 (day 2), and/or was not offered Milk of Magnesia on 4/13/26, 3 days with no bowel movement. In addition, there was no evidence that the staff completed an assessment of bowel sounds. During an interview on 4/20/26 at 1:00 PM, the Director of Nursing (DON) confirmed the resident did have ongoing episodes of constipation but would frequently refuse when the staff offered as needed medications for constipation. However, the refusal of the offered as needed medications were not always documented. In addition, the staff should have documented assessment of the resident when the resident went 4-6 days with no bowel movement to ensure no potential complications. During an interview on 4/21/26 at 1:44 PM, Licensed Practical Nurse (LPN)-E reported the direct care staff were to document the residents' bowel movements each shift and then a list was made each day of the residents who had not had bowel movements for 2, 3, 4 and 5 days. LPN-E confirmed the staff were to follow the interventions listed on the Bowel Movement Needs List to prevent complications related to ongoing constipation.

Licensure Reference Number 175 NAC 12-006.04(H)(ii)(1) Based on record review and interview; the facility failed to employ a qualified Dietary Manager (DM). This had the potential to affect food service provided to all residents who were served food from the kitchen. The facility census was 33. Findings are: A. Review of the facility Job Description: Director of Dining Services with a revised date of 07/18/2024 revealed the necessary qualification of a Director of Dining Services was to meet State requirements for Dietary Manager. B. A review of an undated staff list revealed DM-N was listed as the Dining Services Manager. During an interview on 2/6/25 at 1:30 PM, the facility Administrator (ADM) verified that the current DM did not have the required training to meet the qualifications for the DM position. ADM also confirmed that the Registered Dietician was not full time at the facility.

Based on record review and interview; the facility failed to identify and monitor specific target behaviors, to have documented non-pharmacological interventions to address potential behaviors and to attempt a Gradual Dose Reduction (GDR) and/or have a documented contraindication for the GDR related to use of a psychotropic (a drug or substance that affects how the brain works) medication for 1 (Resident 26) of 5 sampled residents. The facility census was 33. Findings are: A. Review of the facility policy Behavior Management: Psychotropic Medication Management dated 5/2014 revealed residents receiving psychotropic medications to treat behavioral symptoms are to be evaluated, monitored and managed by an Interdisciplinary Team (IDT). The following was identified: -residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. -psychotropic medication included Antipsychotics, antidepressants, anti-anxiety, and hypnotics. -residents and their families were educated on the benefits and risks of psychotropic medications as well as alternate treatments available. -residents who used psychotropic medications received gradual dose reductions, unless clinically contraindicated, to discontinue those medications. -the Physician in collaboration with the Consultant Pharmacist re-evaluated the use of medication and considered whether the medication could be reduced or discontinued. B. Review of Resident 26's Minimum Data Set (MDS- federally mandated comprehensive assessment used to develop resident Care Plans) dated 12/2/24 revealed the resident had diagnoses of: Parkinson's disease and non-Alzheimer's dementia, had severe cognitive impairment, and took an antipsychotic medication. Review of an Order Summary Report for Resident 26 revealed an order dated 2/12/24 for Seroquel (psychoactive medication used to treat schizophrenia, bipolar disorder, and depression) 25 milligrams (mg) to be given twice a day. Review of a form titled Consultant Pharmacist Recommendation to the Physician dated 8/12/24 revealed a recommendation for a GDR of the resident's Seroquel. The form was returned from the physician on 8/26/24 and the physician ordered continue present medication. Further review of the form revealed no evidence as to why the GDR was clinically contraindicated. Review of the resident's current Care Plan dated 1/2/25 revealed the resident used a psychoactive medication. Interventions included monitoring the effectiveness of the medication and monitoring for adverse side effects, administering the medication as ordered and consulting with the pharmacist and the physician to consider dosage reduction when clinically appropriate. Further review of the resident's care plan revealed no evidence of specific target behaviors and no evidence of non-pharmacological interventions. During an interview on 2/6/25 at 10:29 AM, Nurse Aide (NA)-B indicated the resident did not have behaviors and NA-B was uncertain why the resident was on the antipsychotic medication. Interview on 2/10/25 at 9:18 AM with the Registered Nurse Clinical Consultant and the Director of Nursing revealed the following: -the resident had no target behaviors identified for use of the Seroquel. -the resident's care plan did not list non-pharmacological interventions for use of the Seroquel. -8/26/24 the resident's physician refused a GDR and failed to indicate clinical rationale as to why the GDR could not be attempted.

Based on record review and interview; the facility failed to develop and implement individualized interventions to prevent or to minimize the effects of potential trauma triggers for 1 (Resident 23) of 21 residents sampled. The facility census was 33. Findings are: Review of Resident 23's Minimum Data Set (MDS, a federally mandated assessment tools used for care planning) dated [DATE] revealed the resident was admitted [DATE] with diagnoses of: anxiety, depression and post-traumatic stress disorder (PTSD- mental health condition that is caused by an extremely stressful or terrifying event) and the resident was assessed as being cognitively intact. Review of a Trauma Informed Care assessment dated [DATE] at 11:58 AM revealed the resident identified a personal preference for the staff not to approach the resident from behind without warning. In addition, the resident did not like loud slamming noises or doors slamming. When the resident was asked about potential events in the resident's life that might have caused the resident trauma; the resident identified being a survivor of abuse, a history of homelessness and imprisonment, and the traumatic loss of a loved one. The resident also identified drinking self to near death on 5 different occasions. The resident did not like bright flashing lights or violent men's voices. Further review of the assessment revealed no evidence the facility staff developed individualized interventions to alleviate or to lessen the resident's PTSD triggers. Review of Resident 23's current Care Plan dated [DATE] revealed the resident had a diagnosis of PTSD. Further review of Resident 23's care plan revealed there were no indications of what Resident 3's triggers were for the PTSD and what interventions staff were to use to mitigate the triggers. During an interview on [DATE] at 1:35 PM with Resident 23 revealed potential triggers for PTSD but indicated the facility had not addressed triggers with the resident and no interventions were in place to prevent potential triggers. During an interview with the Social Service Director (SSD), the Administrator and the Director of Nursing (DON) on [DATE] at 10:08 AM, the following was confirmed: -the facility did not have a policy related to trauma-informed care. -no interventions were developed and/or implemented to minimize or mitigate potential trauma triggers for Resident 23.

Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on record review and interview; the facility failed to implement nutritional interventions for the prevention of weight loss for 1 (Resident 21) of 3 sampled residents. The facility census was 33. Findings are: A. Review of the Nutritional Status-Unintended Weight Loss Policy dated 4/2013 revealed the staff were to strive to improve the resident's weight by identifying risk factors associated with weight loss and determining appropriate individualized interventions. Staff were to monitor weight and/or food intake and report to the Registered Dietician (RD) as applicable. Staff then to develop and implement individualized interventions to address unintended weight loss. B. Review of Resident 21's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 11/25/24 revealed the resident was admitted [DATE] with diagnosis of seizure disorder and depression. The resident's cognition was moderately impaired the resident's weight was 223 pounds (lbs.) Review of Weights and Vitals Summary Sheet (document used to record the resident's weights) revealed Resident 21's weight was 232 lbs. on 1/2/25. Review of a Registered Dietician (RD) Progress Note dated 1/27/25 at 3:12 PM revealed the resident's weight was now 212 lbs. (down 20 lbs. or a 9% loss in 3 weeks). The RD interviewed the resident who made a recommendation for the resident to receive Ensure (nutritional drink with added calories and protein) once a day for weight loss. Review of the resident's Medication Administration Record (MAR) dated 1/2025 revealed an order dated 1/28/25 for Ensure supplement once a day for weight loss. Further review of the MAR revealed no indication as to how much supplement the resident was to be given. In addition, on 1/28, 1/29, 1/30 and 1/31 the MAR identified the supplement was not provided for the resident as the supplement was not available. Review of Resident 21's MAR dated 2/2025 revealed on 2/1, 2/2, 2/3, 2/4 and on 2/5 the Ensure nutritional supplement remained unavailable and was not given to the resident. Further review revealed the supplement was discontinued on 2/5/25 and a new order was received for Mighty Shakes 120 cubic centimeters (cc) once a day. During an interview with the RD on 2/6/25 at 3:03 PM, the RD confirmed the resident had a significant weight loss since admission. The RD had made a recommendation on 1/28/25 for the resident to receive Ensure Supplement once a day for weight loss. The RD confirmed the resident's MAR did not identify how much nutritional supplement the resident was to receive. The RD was also aware the supplement was not given from 1/28 to 2/6 (10 days) despite the resident's significant weight loss. The RD was unaware the facility only offered the Mighty Shake nutritional supplement and did not provide Ensure.

Based on record review and interview; the facility failed to complete a new Preadmission Screening and Resident Review (PASRR- federally mandated preadmission screening to determine appropriate placement and services for those residents with Mental Illness/Intellectual Disability or Related Disorders (MI/ID/RD)) for 1 (Resident 29) of 2 sampled residents when the initial PASRR approval time expired. The facility census was 33. Findings are: Review of the facility policy for Pre-admission Screening for MR/MI dated ,d+[DATE] revealed the following: -The facility verified that all residents were screened prior to admission to determine whether they had a Mental Illness (MI) or Mental Retardation/Developmental Disability (MR/DD) diagnosis and if the facility was able to meet the specialized needs of the resident. A Level II screen was done to assist the facility in determining the types of services required to care for the resident. -The Social Services staff worked with the interdisciplinary team to arrange for and provide individualized interventions as part of the resident care plan. Review of Resident 29's PASRR Level II determination notification dated [DATE] revealed the resident was found to have a serious mental illness, the resident did require and was appropriate for nursing facility services, was approved for 180 days (through [DATE]), and did not require specialized services at that time. Review of Resident 29's medical record revealed no evidence the facility had completed an updated screen following the approved 180 days. During an interview on [DATE] at 1:56 PM the Director of Nursing (DON) confirmed Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) assessments were being completed by an outside source and confirmed the facility was unaware Resident 29 had a Level II PASRR completed on [DATE] and unaware the resident was approved for only 180 days at that time, The DON was unsure if any further PASRR had been completed. Further interview on [DATE] at 3:13 PM the DON confirmed the facility had not been able to locate any further evidence a new PASRR assessment was completed for resident 29 after the initial assessment expired.

Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview; the facility failed to accurately code 2 (Resident 22 and 29) of 12 sampled residents' Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) to accurately reflect their Preadmission Screening and Resident Review (PASRR-federally mandated preadmission screening designed to determine appropriate placement and services for residents with mental illness (MI), intellectual disability (ID), or developmental disability (DD) status.). The facility census was 33. Findings are: A. Review of the Resident Assessment Instrument (RAI)-instruction for accurate completion of Resident MDS revealed the following instructions for completing: - All individuals who are admitted to a Medicaid certified nursing facility, regardless of the individual's payment source, must have a Level I PASRR completed to screen for possible mental illness, intellectual disability, developmental disability, or related conditions. - Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State. Steps for Assessment: 1. Complete for Admission assessment, Annual assessments, and Significant Change/Correction Assessments. 2. Review the Level I PASRR form to determine whether a Level II PASRR was required. 3. Review the PASRR report provided by the State if Level II screening was required. Coding Instructions: - Code 0, no: if any of the following apply: - PASRR Level I screening did not result in a referral for Level II screening, or - Level II screening determined that the resident does not have a serious MI and/or ID/DD or related conditions, or - Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition. B. Review of Resident 22's PASRR screening completed on 11/11/21 revealed a PASRR Level II was completed, and the resident was found to have an intellectual disability or related condition. The resident was approved for unlimited days of nursing facility care. Review of Resident 22's MDS dated [DATE] revealed the resident was not referred for a Level II screening or have a serious MI/ID/DD or related condition. Further review indicated the resident had diagnosis of bipolar and schizophrenic disorders. Review of Resident 22's Care Plan with a revision date of 11/21/24 revealed the resident had bipolar disorder, major depressive disorder, and schizoaffective disorder. In addition, the resident had impaired cognitive function and Down Syndrome and had a Level II PASRR. During an interview on 2/6/25 at 7:46 AM, the Director of Nursing (DON) confirmed Resident 22 had an intellectual disability and would require a Level II PASRR screening. During an interview on 2/6/25 at 1:09 PM, the DON confirmed Resident 22's PASRR status was not correctly coded on the MDS dated [DATE]. C. Review of Resident 29's PASRR dated 5/28/24 revealed a PASRR Level II was completed, and the resident was found to have a serious mental illness. The resident was found to be appropriate for nursing facility care with 180 days approved. Review of Resident 29's MDS dated [DATE] revealed the resident was not referred for a Level II screening or have a serious MI/ID/DD or related condition. Further review revealed the resident had an anxiety disorder and depressive disorder. Review of Resident 29's Care Plan with a revision date of 9/19/24 revealed the resident took an antidepressant and psychotropic (mind altering) medications and was a Level II PASRR. During an interview on 2/6/25 at 1:56 PM, the DON confirmed the MDS completed on 6/27/24 indicated the resident did not have a Level II assessment, however the resident did have a Level II Assessment and thus the MDS was incorrectly coded.

Licensure Reference Number 175 NAC 12-006.06(A) Based on record review and interviews; the facility failed to notify residents of the resolution for grievances for 2 (Resident 11 and 16) of 21 sampled residents. The facility census was 33. Findings are: A. Review of the facility Grievance Process with a revision date of January 2023 revealed the procedure of the grievance process was that the Grievance Official would: -be responsible for overseeing the grievance process, -receive and track grievances, -lead investigations, and -issue written grievance decisions to the resident. The written grievance would include: -the date the grievance was received, -a summary statement of the resident's grievance, -the steps taken to investigate the grievance, -a summary of the findings regarding the concern, -any corrective action taken by the facility and -the date that the grievance was resolved. Review of a Grievance Form dated 12/10/24 revealed Resident 11 was missing a pink turtleneck shirt. Further review of the form revealed that no pertinent findings were documented. On 12/11/24 Activity Assistant (AA)-P went through the closets of all the resident's and found nothing. The grievance was signed as resolved on 12/11/24. The form revealed that the resident was notified of the resolution on 12/11/24. Review of a Grievance Form dated 12/10/24 revealed Resident 16 was missing a pink shirt and a pair of red leggings with pink flowers on them. No pertinent findings were documented. AA-P on 12/11/23 went through all the resident's closets and found nothing. The grievance was signed as resolved on 12/11/24. The form revealed the resident was notified of the resolution on 12/11/24. Review of a Grievance Form dated 1/7/25 revealed Resident 16 was missing a t-shirt gown and socks. Further review of the form revealed on 1/13/25 the laundry aide documented the resident had complained of the missing items for the last 3 months. No action was taken, and the grievance was signed as resolved on 1/13/25. The grievance form indicated the resident was notified of the resolution, but no date was documented. Interview with Resident 11 on 2/10/25 at 9:15 AM verified that the resident had not been notified if personal items had been found when a grievance had been completed for missing personal items. Interview with Resident 16 on 2/10/25 at 9:15 AM verified that the resident had not been notified if personal items had been found when a grievance had been completed for missing personal items. Interview with AA-P on 2/10/25 at 10:15 AM verified that all resident closets in the facility had been looked through for the missing items for Residents 11 and 16. Interview with Registered Nurse (RN)-M on 2/10/25 at 10:30 AM verified that the facility does not have a policy for resident missing items. Interview with the Activities Director (AD)-I on 2/10/25 at 10:45 AM verified that when missing personal items were reported a grievance form was filled out and then given to the Department Head pertaining to the grievance. Staff checked the resident's room, other resident's rooms and laundry staff were notified of the missing items. Interview with the Social Services Director (SSD)-L on 2/10/25 at 11:45 AM verified that when a resident had missing personal item a grievance form was filled out and given to the laundry staff. Laundry staff had 5 days to look for the missing item, then the form was returned to the Administrator. SSD-L verified that the residents were not notified if the clothing was found or not unless the resident asked.

Licensure Reference Number 175 NAC 12-006.11E Based on observations, record review and interview, the facility failed to ensure measures were implemented to prevent the potential of food borne illnesses related to food storage and unserviceable cookware items. This had the potential to affect all residents who consumed food from the kitchen. The facility census was 35. Findings are: A. Review of the facility policy Sanitation dated 6/2015 revealed the following related to dry storage goods: 1) products would be labeled with delivery date indicating month, day and year the product was receive and 2) follow the expiration date for all packaged goods and discard three months after opening. B. Review of the facility policy Cleaning and Sanitizing dated 06/2015 revealed pots and pans should be free of pitting, carbon build up, grease and food particles. C. Observations during the follow-up kitchen sanitation tour conducted on 2/21/24 from 11:00 AM to 11:35 AM revealed the following: -The dry goods storage room had a clear plastic container with a lid that was labeled Breadcrumbs and dated 8/17/22. -A large frying pan with black carbon build up on the inside walls of the pan and a square metal serving pan that had 4 blackened areas inside on the bottom of the pan. During an interview with the Dietary Manager on 2/21/24 at 11:30 AM, the Dietary Manager confirmed the following: -The breadcrumbs stored in the dry storage room were not in the original container, had been dated 8/17/2022, there was no expiration date identified and they should have been discarded. -The frying pan and serving pan had been used for meal services, had carbon build on the inside of the cookware and should not have been used.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to accurately code Residents 3, 16, 23, 26, and 30's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) to reflect the resident's current nutritional interventions. The sample size was 15 and the facility census was 34. Findings are: A. Review of Resident 3's MDS dated [DATE] revealed the following: -diagnoses of high blood pressure, cerebral palsy, seizure disorder, anxiety, and depression, -did not receive parenteral (administration in a way not involving the intestines or digestive tract) or Intravenous (IV) feedings, -did not have a feeding tube, -received 25% or less of total calories through parenteral or IV feedings, and -received 500 cubic centimeters (cc) per day or less of fluids through IV or tube feedings. B. Review of Resident 16's MDS dated [DATE] revealed the following: -diagnoses of atrial fibrillation, high blood pressure, reflux disease, diabetes, stroke, depression, and chronic lung disease, -did not receive parenteral or IV feedings, -did not have a feeding tube, -received 25% or less of total calories through parenteral or IV feedings, and -received 500 cubic centimeters (cc) per day or less of fluids through IV or tube feedings. C. Review of Resident 23's MDS dated [DATE] revealed the following: -diagnoses of high blood pressure, arthritis, dementia, malnutrition, anxiety, and chronic lung disease, -was receiving Hospice services, -did not receive parenteral or IV feedings, -did not have a feeding tube, -received 25% or less of total calories through parenteral or IV feedings, and -received 500 cubic centimeters (cc) per day or less of fluids through IV or tube feedings. D. Review of Resident 26's MDS dated [DATE] revealed the following: -diagnoses of anemia, heart failure, high blood pressure, arterial disease, renal (kidney) disease, and diabetes, -did not receive parenteral or IV feedings, -did not have a feeding tube, -received 25% or less of total calories through parenteral or IV feedings, and -received 500 cubic centimeters (cc) per day or less of fluids through IV or tube feedings. E. Review of Resident 30's MDS dated [DATE] revealed the following: -diagnoses of high blood pressure, septicemia (an invasion of the blood stream by an infective organism), hemiplegia (paralysis of one side of the body), malnutrition, depression, and respiratory failure, -was receiving Hospice services, -did not receive parenteral or IV feedings, -did not have a feeding tube, -received 25% or less of total calories through parenteral or IV feedings, and -received 500 cubic centimeters (cc) per day or less of fluids through IV or tube feedings. Interview on 2/22/24 at 11:41 AM with the Director of Nursing (DON) and the Registered Nurse Consultant confirmed the facility did not have any residents receiving tube, parenteral, or IV feedings in November and December of 2023. Further interview confirmed the MDS assessments that were completed 11/21/23 through 12/6/23 were not completed correctly regarding nutrition interventions for resident's 3, 16, 23, 26 and 30. Further interview on 2/26/24 at 8:15 AM confirmed the facility did not have a policy on completing resident assessments and that the facility used the RAI (Resident Assessment Instrument) manual for guidance.

Licensure Reference Number 175 NAC 12-006.09D8 Based on record review and interview, the facility failed to ensure Resident 31's weight loss was reported to and reviewed by a facility dietitian to ensure the resident was receiving the required calories and nutrition. The sample size was 13 and the facility census was 34. Review of the facility policy Weight Changes dated 6/2015 revealed the following; -The nutritional statuses of residents were evaluated routinely, and appropriate nutrition interventions were implemented to prevent weight loss. -Weight changes were evaluated and monitored by the nutritional services staff and appropriate interventions were implemented. -For unplanned weight loss the facility evaluated the resident and calculated the estimated nutritional needs. -The facility documented the interventions and effectiveness in the progress notes, and -monitored the resident with the interdisciplinary team during weekly meetings. Review of Resident 31's Minimum Data Set (MDS-federally required comprehensive assessment used to develop resident care plans) dated 1/25/24 revealed, the following diagnoses of diabetes, and morbid obesity. In addition, the resident had a recorded weight of 258 pounds with unplanned weight loss. Review of the Resident 31's Care Plan dated 11/17/23 revealed, the resident was on a Consistent Carbohydrate Diet, was diabetic and morbidly obese. The resident was monitored for signs and symptoms of malnutrition including a significant weight loss of 5% in a month, and 7.5% in 3 months, and a Registered Dietitian (RD) evaluated and made recommendations as needed. Review of the RD reviews from 11/13/23 through 2/21/24 revealed, no evidence the RD reviewed Resident 31's status after 11/17/23 despite a 16.43% weight loss. Review of Resident 31's Weight Record from 11/13/23 through 2/21/24 revealed the resident's admission weight on 11/13/23 was 280 pounds, on 12/29/23 the resident's weight was 269 (3.93% loss), on 1/26/24 the resident's weight was 249 pounds (a loss of 11.07% since admission), on 2/14/24 the resident's weight was 238 pounds (down 15% since admission), and on 2/21/24 the Resident's weight was 234 (a total weight loss percent of 16.43%). Review of fax communication sent to the Resident's physician on 2/14/23 revealed, the physician was notified of an 18-pound weight. loss and poor appetite. The physician ordered a twice daily supplement of Ensure. Review of the Resident's Treatment Administration Record revealed, the Ensure Supplement was started on 2/15/24 (after a weight loss of 15%) During an interview on 2/20/24 at 1:36 PM Resident 31 reported some weight loss and a loss of appetite. The resident also reported receiving supplements. Resident 31 reported having a personal goal of weight loss and was pleased with the loss. During an interview on 2/21/24 at 2:54 PM the Director of Nursing (DON) confirmed, the facility had no evidence a dietitian had reviewed the resident's nutritional status since 11/17/23 despite a weight loss of 46 pounds or 16.43% since admission, to ensure the resident was receiving needed calories and nutrition. In addition, the DON reported the resident was pleased with the weight loss and the physician was aware. The DON was however, unaware of who was currently the facility RD (Registered Dietitian) and had no knowledge of who was reviewing resident's nutritional status and reviewing weight loss, to provide the physician with nutritional need-based recommendations. During an interview on 2/21/24 at 3:29 PM the facility Administrator confirmed, the facility did not currently have a Registered Dietitian and had not had one for approximately one month.

Licensure Reference Number 175 NAC 12-006.09C Based on record review and interview, the facility failed to ensure individualized Care Plans were developed to address: 1) changes in fluid restriction amounts and current discharge status for Resident 26 and 2) current discharge status and hospice services for Resident 30. The sample size was 2 and the facility census was 35. Findings are: A. Review of the facility policy Care Plan Development dated 8/2015 revealed the following: -An individualized, comprehensive care plan will be developed for each resident in the facility using results from the RAI/MDS assessment [Minimum Data Set - a federally mandated comprehensive assessment tool used to develop resident care plans] and input from the resident/family/legal representative and disciplinary team. -The care plan would be developed within 21 days of admission or 7 days after the completion date of a comprehensive MDS assessment and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. -Includes measurable objectives, interventions, goals and timetables. -The care plan will be reviewed and revised as needed, when a significant change in condition is noted, when outcomes were not achieved or when outcomes are completed, and at least every 92 days. -Any changes must be reported to the MDS coordinator for review. -Documentation must be consistent with the resident's plan of care and revisions will be done on an as needed basis and can be done by any member of the interdisciplinary team. B. Record review of Resident 26's undated current care plan revealed the following: -The resident had the potential for fluid volume overload related to kidney failure with a goal to follow the diet and 1500 milliliter (ml) fluid restriction daily which was revised 5/22/23, -The resident was residing at the facility for Short-term Rehab with a goal to return home when medically stable which was initiated on 4/11/23. During an interview with Resident 26 on 2/20/24 at 8:30 AM, the resident stated [gender] was admitted to the facility in April of 2023 and resided at the facility permanently with no plans to discharge. Record review of Resident 26's Medication Administration Record dated 2/1/24 to 2/29/24 revealed a physician's order dated 9/26/23 for a fluid restriction of 2000ml [240 at meals, 90 with each med pass (4 med passes), 460 every 12 hour shift every shift.] There was no evidence of a current order related to a fluid restriction for 1500 ml. During an interview with the Director of Nurses (DON) on 2/22/24 at 2:45 PM, the DON confirmed Resident 26's Care Plan was not accurate regarding the resident's discharge status that indicated [gender] was there for short-term rehabilitation and the amount of the resident's fluid restriction should have been updated to reflect 2000ml per day on 9/26/23. C. Record review of Resident 30's MDS dated [DATE] (identified as a significant change MDS assessment) revealed the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses of high blood pressure, infection of the blood, stroke, respiratory failure, and depression. The assessment further revealed the resident was also receiving hospice services. Record review of Resident 30's undated Care Plan revealed the following: -The resident was at the facility for short-term rehabilitation with a goal to participate in Physical Therapy/Occupational Therapy services to be able to return home which was initiated on 4/13/23, -The Care Plan did not include any information regarding the resident's hospice services, what services were involved and who was responsible for providing those services. During an interview with the DON on 2/26/24 at 09:15 AM, the DON confirmed Resident 30's Care Plan was not accurate related to the resident's discharge status that indicated [gender] was there for short-term rehabilitation and the resident's hospice services. The DON also confirmed the Care Plan should have been updated to reflect the changes.

Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review and interview, the facility failed to: 1) prevent the potential spread of Covid-19 infection related to two residents (Resident's 26 and 35) who had potential symptoms and were not tested according to current guidelines and 2) track pathogens [an organism causing disease to its host] to identify potential trends related to infection surveillance. The total sample size was 15 and the facility census was 35. Findings are: A. Review of the facility policy Pandemic Covid-19 Plan with a revised date of 4/2023 revealed the following: -The facility would implement interventions to eliminate potential exposures. -All residents would be screened for signs/symptoms of Covid-19 to include, but not limited to; fever, cough, shortness of breath, headache, fatigue, loss of smell or taste and diarrhea. -Place residents with suspected or confirmed Covid-19 in a private room when available with the door closed. -Provide Covid-19 resident testing per Center for Disease Control (CDC)/Center for Medicare & Medicaid Services (CMS) guidelines. Residents that refuse Covid-19 testing will be placed in isolation for 10 days. B. An observation of Resident 26 on 2/20/24 at 11:00 AM revealed the resident was congested and a harsh cough. The resident stated the cough had been a lot worse approximately 4 to 5 days ago, was congested and taking cough medication, and had been going out of the facility to dialysis 3 days a week. The resident also stated [gender] had not been tested for Covid-19. Record review of Resident 26's nursing progress notes revealed the following: -1/10/24 at 6:36 AM, the resident complained of nausea on Sunday, had a cough and was feeling kind of achy and had a low back ache. There was no evidence the resident was tested for Covid-19. -1/25/24 at 9:46 AM, the resident had a cough and was taking an antibiotic for a respiratory infection. There was no evidence the resident was tested for Covid-19. -1/28/24 at 1:03 PM, the resident continued taking an antibiotic for a respiratory infection and reported a productive cough. There was no evidence the resident was tested for Covid-19. -2/2/24 at 11:12 PM, the resident continues to have some chest congestion and cough and was taking an antibiotic for a respiratory infection. There was no evidence the resident was tested for Covid-19. -2/6/24 at 3:57 AM, the resident continues to have some chest congestion and cough. There was no evidence the resident was tested for Covid-19. Record review of Resident 26's Medication Administration Record dated 2/1/24 to 2/29/24, revealed the resident had been given doses of Guaifensesin (cough medication) on 2/17/24, 2/18/24, 2/19/24, and 2/20/24 for a cough. Further review revealed no evidence the resident had been tested for Covid-19. C. Record review of Resident 35's nursing progress notes revealed the following: -1/18/24 at 11:41 AM, the resident had a cough and 'green snot with red streaks'. There was no evidence the resident was tested for Covid-19. -1/18/24 at 12:45 PM, the physician prescribed an antibiotic for a respiratory infection and there no evidence the resident was tested for Covid-19. -1/19/24 at 12:47 PM, the resident's lung sounds were coarse on the right side. There was no evidence the resident was tested for Covid-19. An interview with the Director of Nurses (DON) on 2/22/24 at 8:40 AM confirmed the facility had been following current CDC guidelines regarding Covid-19 and testing of residents. The DON also confirmed facility staff should have tested Resident 26 and Resident 35 for Covid-19 infection upon identification of symptoms and there was no evidence in both resident's medical records they had been tested . 45739 Licensure Reference Number 175 NAC 12-006.17 D. Review of the facility policy Antimicrobial Stewardship Program last revised 9/2019 revealed the facility would: -monitor antibiotic use through available reports such as clinical practice guidelines, antibiograms (a table showing how susceptible a series of organisms are to different antimicrobials [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease]), clinical evaluation, and prescribing documentation, -monitor cultures (the growth of organisms in the laboratory), and if obtained, before treatment begins and if indicated, and -change treatments based on results. Review of the facility form Infection Control Log for November and December in 2023 and January 2024 revealed no documentation that the facility was tracking culture results. Interview on 2/22/24 at 10:50 AM with the DON revealed that the facility had not been tracking the bacteria's that grow from culture reports. Further interview on 2/26/24 at 10:50 AM with the DON and the Registered Nurse Consultant confirmed that pathogens had not been tracked and the facility was not identifying trends of pathogens.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure as needed psychotropic (medications which alter consciousness, mood and thoughts) medications were limited to 14 days or had a defined duration of administration for Resident's 23 and 32. The total sample size was 15 and the facility census was 34. Findings are: A. Review of the facility policy Behavior Management Psychoactive Medication Management dated 5/2014 revealed residents receiving psychoactive medications to treat behavioral symptoms would be evaluated, monitored, and managed by the interdisciplinary team and the interdisciplinary team would seek an appropriate duration for each medication. B. Review of Resident 23's Minimum Data Set (MDS-a federally mandated assessment tool used in care planning) dated 11/28/23 revealed the following: -diagnoses of high blood pressure, arthritis, dementia, malnutrition, anxiety, and chronic lung disease, -the resident had cognitive impairment, -the resident exhibited behaviors of difficulty focusing attention and disorganized thinking, and -the resident was dependent with toilet assistance, transferring, and dressing. Review of Resident 23's Care Plan last revised on 12/14/24 revealed the resident used psychotropic medications related to dementia with behavioral disturbances and anxiety. Review of Resident 23's Medication Administration Records (MAR) for January and February 2024 revealed an order for Ativan (psychotropic medication) 0.5 milligrams (mg) as needed for anxiety ordered 10/4/23 with no stop date or duration. Review of Resident 23's Medical Record revealed no documentation that the Pharmacist had addressed the Ativan order and no documentation that the ordering Physician had been contacted regarding the duration of the Ativan. C. Review of Resident 32's MDS dated [DATE] revealed the following: -diagnoses of arthritis, osteoporosis, dementia, and Parkinson's disease, -the resident had cognitive impairment, - the resident exhibited behaviors of difficulty focusing attention and disorganized thinking, and -the resident required assistance with toileting, transferring, and dressing. Review of Resident 32's Care Plan last revised 2/21/24 revealed the resident had a history of wandering and had impaired cognitive function. Staff were to monitor for side effects of medications. Review of Resident 32's MAR for January and February 2024 revealed the resident had an order for Ativan 0.5mg as needed for anxiety with an order date of 12/26/23 with no stop date or duration date. Review of Resident 32's Medical Record revealed no documentation that the Pharmacist had addressed the Ativan order and no documentation that the ordering Physician had been contacted regarding the duration of the Ativan. Interview on 2/22/24 at 2:44 PM with the Director of Nursing (DON) confirmed the Ativan orders for Residents 23 were given past the 14-day limits with no duration limits documented.

Licensure Reference Number 175 NAC 12-006.05(1) Based on record review and interview, the facility failed to provide 1 (Resident 28) of 3 sampled residents with the cost of continuing to receive skilled Medicare Services, a choice of whether to appeal the facilities Medicare determination to discontinue services, or the reason for the discharge from skilled Medicare services. The facility census was 34. Findings are: Review of Resident 28's Notice of Medicare Non-Coverage revealed, the resident representative was notified on 1/12/24 that skilled Medicare services last day of coverage would be 1/15/24. Further review of the Advanced Beneficiary Notice (ABN- form provided to inform the resident/representative of the reason Medicare would not continue to pay, the cost of continuing to receive skilled services, and an option to appeal the facilities decision about coverage) did not indicate the resident/representative decision to appeal and/or their desired billing options. During an interview on 2/22/24 at 11:30 AM the Business Office Manager (BOM) revealed, the BMO was unsure of what information was to be on the notice of Non-Coverage for Medicare services. The BOM confirmed, the facility was listing a monthly cost for a non-skilled semi-private room on the notice form as the resident planned to continue to reside in the facility. In addition the notice did not reveal the cost of continuing to receive skilled care services or the specific reason why services were being discontinued. The BOM confirmed that Resident 28's responsible party did not have documented evidence of being provided with a choice to continue to receive services or request an appeal. During an interview on 2/22/24 at 11:38 AM the facility Administrator confirmed, the facility did not have evidence they were providing residents or their responsible parties with the daily cost of receiving skilled care once the facility determined services would no longer be covered by Medicare, or documented proof that an appeal option was presented to Resident 28.

Based on observation, record review and interview; the facility failed to ensure the daily posting of nursing hours included the required information. This had the potential to affect all residents. The facility census was 34. Findings are: Observation on 2/20/24 at 10:05 AM revealed, the staff posting was near the nurse's station and was missing the facility name and the census for the day. Observation on 2/21/24 at 7:15 AM revealed, the staff posting was missing the facility name and the census. Observation on 2/22/24 at 9:10 AM revealed, the staff posting was missing the facility name and the census. Review of the daily staff postings for the month of February 2024 revealed, 2/1/24 through 2/22/24 postings were missing the facility name and 2/12/24 through 2/18/24 and 2/20/24 through 2/22/24 were missing the facility census. Interview on 2/26/24 at 10:50 AM with the Director of Nursing (DON) and the Registered Nurse Consultant confirmed, facility did not have a policy for staff posting requirements. Further interview confirmed, the staff postings did not have the required documentation.

Licensure Reference Number 175 NAC 12-006.04A3d Based on record review and interview, the facility failed to complete the required background checks for 1 (Cook-N) of 5 sampled staff. This had the ability to affect all residents. The facility census was 34. Findings are: Review of the facility policy Abuse Prevention Program and Reporting, last reviewed 8/2019 revealed, the facility would screen all potential employees prior to hire for a history of abuse, neglect or mistreatment of resident/patients, exploitation and/or misappropriation of resident property during the hiring process and screening would consist of but not be limited to the following: -inquiries into state licensure, -inquiries into state nurse aide registry/dependent child/adult abuse registry, and -criminal background checks. Review Cook-N's file revealed Cook-N was hired in January 2024 and there was no documentation that a criminal background check or an Adult Protective Services (APS) Central Registry/Nebraska Child Abuse and Neglect (CAN) Central Registry check had been completed. An interview with the Administrator on 2/26/24 at 12:42 PM confirmed, there was no documentation that Cook-N had a criminal background check, or an APS/CAN registry check completed upon hire.

Licensure Reference Number 175 NAC 12-006.17 Based on observation, interview, and record review; the facility failed to perform hand hygiene at appropriate intervals, properly wear and dispose of Personal Protective Equipment (PPE- gowns, gloves, masks, shield used to protect the care giver from potential contamination and to prevent the spread of infection), and maintain a contingency plan for unvaccinated staff to prevent the spread of COVID-19. This had the potential to affect all facility residents. The facility census was 34. Findings are: A. Review of the facility policy COVID-19 Immunizations: Employee, with a revision date of 2/23 revealed the following; -the facility recognized the major impact and mortality of COVID disease on residents/patients of long-term care facilities and the effectiveness of vaccines in preventing illness, hospitalization , and death. The facility, as recommended by the CDC, provided COVID-19 vaccines to facility employees, -to ensure the facility provided employee vaccinations when available for administration, to minimize the risk of COVID-19 viral transmission to and from staff and residents; employees were provided with education related to the benefits, potential risk and side effects of the COVID-19 in a manner that was understood, -all employees were offered the COVID-19 vaccination per the Center for Disease Control (CDC) and the Food and Drug Administration (FDA) and manufacturer guidelines, when available to the facility and/or provided information on where it could be obtained, -no staff member would be required to be vaccinated if they objected, -staff could request a vaccine exemption, and -the facility would maintain exemption records, education records, consents, and vaccine logs, and -unvaccinated staff who declined the COVID-19 vaccine or who did not provide the facility with proof of vaccination would receive additional training related to PPE and COVID-19. B. Review of the facility policy Contact Precautions with a revision date of 3/22 revealed the facility would do the following; -implement standard precautions (set of infection control practices used to prevent transmission of diseases that can be acquired while handling patients) and contact precautions (set of infection control practices intend to prevent the spread of infectious agents including organisms which are spread through indirect or direct contact). -place infected residents in a private room when available, -wear gloves when entering the resident room, -change gloves after contact with infective material, -remove gloves before leaving the room and wash hands immediately with an antimicrobial agent or waterless antiseptic agent, and -ensure hands did not touch potentially contaminated environmental surfaces or items after glove removal. C. Review of the facility policy Pandemic COVID-19 Plan with a revision date of 4/2023 revealed the following; -the purpose of the plan was to provide the appropriate care and services to residents/patients with COVID-19 in the facility, identify residents/patients who needed to be discharged to receive care and services, and to provide a safe work environment for employees during a pandemic, -the Pandemic COVID-19 plan included a comprehensive infection control response which included but was not limited to; -elimination of potential exposures, -engineering controls, -administrative controls, -PPE, -work practice controls, -Resident/Patient care and services, -vaccination, -employee health and education, and -staffing considerations. Further review revealed the facility; -implemented interventions to eliminate potential exposures, -followed standard, droplet, and contact precautions when caring for a resident with COVID-19, -provided education and monitored for implementation of respiratory hygiene, -maintained isolation procedures, -provided PPE to staff and instructed the staff in the use of the PPE, -implemented work practice controls to reduce the risk of transmitting COVID-19, -initiated vaccination plans to provide vaccine as available to residents and staff, -followed employee heath guidelines for health monitoring and return to work guidelines, and -provided education to all staff including contracted services, with a focus on prevention of disease transmission, hand washing, the use of hand sanitizers, and identification and reporting of COVID-19 symptoms, -informed caregivers of revisions in resident plans of care, and -reviewed and revised the pandemic plan based on guidance provided from the Centers for Disease Control and Prevention (CDC) and Occupation Safety and Health Administration (OSHA). D. During an interview on 4/18/23 at 8:54 AM, Nurse Aide (NA)-B revealed not being vaccinated for COVID-19. The NA was not aware of any additional requirements the facility had for unvaccinated staff. E. During an interview on 4/18/23 at 8:57 AM with NA-C, revealed NA-C was not vaccinated for COVID-19. The NA was not aware of any additional requirements the facility had for unvaccinated staff. F. During an observation on 4/18/23 at 8:59 AM, NA-C exited facility room [ROOM NUMBER] in which the resident was in isolation, removed gloves and put on a clean gown and gloves and did not hand sanitize. G. During an observation on 4/18/23 at 9:00 AM, Medication Aide (MA)-D exited facility room [ROOM NUMBER] in which the resident was in isolation, removed a face mask, did not hand sanitize, and placed on a clean mask and then hand sanitized. H. During an observation on 4/18/23 at 9:07 AM, NA-E exited room [ROOM NUMBER] in which a resident was in isolation, wearing gloves, a face shield and a mask. NA-E then placed a food tray on a covered cart, removed gloves, and did not hand sanitize. Nurse Aid-E then walked down the hall toward the nurses station, obtained a can of spray sanitizer, removed and sprayed the face shield, waved the shield in the air to dry, walked to room [ROOM NUMBER] with the food cart, placed on gloves without sanitizing, accepted a food tray from room [ROOM NUMBER] from another staff member, placed the food tray on the cart, then removed gloves and hand sanitized. I. During an observation on 4/18/23 at 9:15 AM, NA-E put on a mask, gown and gloves: no face shield was applied, NA-E then entered room [ROOM NUMBER] and closed the door. At 9:25 AM NA-E exited room [ROOM NUMBER]; gloves and gown were off, NA- E then hand sanitized, removed the used mask and placed it on top of a box of new gloves sitting on a caddy containing clean PPE. NA-E then put on a clean mask, picked up the dirty mask and walked down the hall with it in ungloved hands and placed it in the trash receptacle on the medication cart. Again NA-E did not hand sanitize and walked to a hallway door to the back entrance of the facility and opened the door. NA-E then proceeded to the nurses station and opened that door. At the nurses station the NA-E retrieved a key and opened 2 locked supply room doors, and from the second one retrieved a tube of skin barrier cream. NA then set the cream on the caddy of clean PPE outside of resident room [ROOM NUMBER]. NA-E then put on a clean gown, shield and gloves, did not hand sanitize and re-entered room [ROOM NUMBER] with the skin barrier cream. At 9:27 AM, NA-E exited room [ROOM NUMBER], hand sanitized, removed mask and without hand sanitizing again put on a clean mask. J. During an observation on 4/18/23 at 9:28 AM NA-B exited room [ROOM NUMBER] and placed a sealed bag of linen or trash on the hallway floor next to the resident room, removed a mask, placed the soiled mask on top of the sealed bag, put on a new mask and then hand sanitized. K. During an observation on 4/18/23 at 9:43 AM NA-E exited room [ROOM NUMBER] in which a resident was in isolation, removed a gown, shield, and gloves at the doorway and disposed of the used PPE in the trash just outside the doorway, NA-E removes the used mask and placed it on the clean PPE caddy, hand sanitized, put on new mask, then picked up the used mask and discarded it. NA-E then reached into the clean PPE caddy and retrieved a gown without sanitizing hands after handling the used mask. NA-e then put on the clean gown and gloves, clean shield and entered room [ROOM NUMBER]. L. During an observation on 4/18/23 at 9:50 AM, Registered Nurse (RN)-G was sitting at the nurses station with a mask positioned below the nose. M. During an observation on 4/18/23 at 9:55 AM, Housekeeper-F was wearing a mask above the chin, crooked across the nose, and gaping on both sides of the face below and above the mask. N. During an observation on 4/18/23 at 10:00 AM, laundry staff-H was in the laundry room; no face mask was worn. O. During an interview on 4/18/23 at 10:00 AM with Laundry Staff -H revealed the staff was not aware of the need to wear a mask while in the laundry room. P. During an Observation on 4/18/23 at 10:05 AM, Dietary Cook-J was in the facility kitchen wearing a surgical mask rather than a N95 mask (an OSHA approved mask that filters out at least 95% of airborne particles). Q. During an interview on 4/18/23 at 10:05 AM Dietary Cook-J revealed the staff was not vaccinated for COVID-19. The staff reported not being aware an N95 mask was required during a facility outbreak. Dietary Cook-J did report currently participating in COVID-19 testing twice weekly, due to the facility outbreak. Further interview revealed Dietary Cook -J was not aware of any additional requirements for unvaccinated staff. R. During an interview on 4/18/23 at 12:30 PM with RN-K revealed the following; -the initial COVID-19 positive staff was identified on 4/6/23, and the facility implemented outbreak testing on the same day for all staff and residents; no additional positive COVID-19 tests were identified. -on 4/8/23 one COVID-19 positive resident test was identified, and the facility plan was to continue with outbreak testing and increased resident screening for signs and symptoms of COVID-19. -on 4/10/23 one COVID-19 positive resident was identified through screening and routine testing. The facility contacted the corporate Infection Preventionist and a virtual infection prevention meeting was held. All communal dining and activities were suspended on 4/10/23 and all staff were wearing N95 masks for residents in isolation. -on 4/13/23 the facility continued outbreak testing, and daily or every other day positive residents and staff had been identified, -on 4/13/23 all staff were required to wear N95 masks throughout the facility, -additional interview with RN-K, confirmed RN-K was not aware of any additional requirements for unvaccinated staff, -further interview confirmed that staff were to perform hand hygiene with each glove change, were not to touch clean PPE after touching potentially soiled PPE or surfaces, without first sanitizing, and staff must sanitize anytime potentially contaminated surfaces or PPE were touched, and -as of 4/17/23, 21 facility residents had tested positive for COVID-19. S. Review of the facility Vaccine Matrix completed by the facility on 4/18/23 revealed the facility had 52 staff members, and 34 staff members were vaccinated for COVID 19 and 18 staff members had been granted a vaccine exemption. T. During an interview on 4/19/23 at 8:35 AM the facility Administrator confirmed the facility had no evidence unvaccinated facility staff had completed additional training for PPE and COVID-19 no evidence that unvaccinated contract or agency staff had received any additional training for PPE or COVID-19 in accordance with the facility policy. U. During an interview on 4/19/23 at 10:30 AM, RN-O confirmed the facility had 23 Residents test positive for COVID-19 since 4/8/23.

Licensure Reference Number 175 NAC 12-006.09C1c Based on record review and interview the facility failed to revise the Care Plans for 3 of 3 sampled residents (1,2, and 3) to address the care needs related to positive COVID-19 infections. The facility census was 34. Findings are: A. Review of the facility policy Care Plan Development dated 08/15 revealed the following; -an individualized, comprehensive Care Plan would be developed for each resident in the facility, -the Care Plan would identify resident needs and strengths, build on resident ability, -the Care Plan would be reviewed and revised as needed, and -the Care Plan would serve as an integral part of the care of residents. B. Review of the facility Testing Log for residents from 4/6/23 through 4/17/23 revealed the following; -on 4/8/23 Resident 1 tested positive for COVID-19 -on 4/10/23 Resident 2 tested positive for COVID-19 -on 4/17/23 Resident 3 tested positive for COVID-19 C. Review of Resident 1's Care Plan with a revision date of 4/18/23 revealed the resident was admitted to the facility on [DATE], had schizophrenia, and Parkinson's disease, and had chosen long term placement in the facility. The Care Plan had no information regarding the resident's positive COVID-19 status until 4/18/23 (10 days after the positive COVID-19 test). D. Review of Resident 2's Care Plan with a revision date of 4/18/23 revealed the resident was admitted to the facility on [DATE], had chronic heart disease and was iron deficient. The Care Plan had no information regarding the resident's Positive COVID-19 status until 4/18/23 (8 days after the positive COVID-19 test). E. Review of Resident 3's Care Plan with a revision date of 4/19/23 revealed the resident was admitted to the facility on [DATE], had hypertension (high blood pressure) and a history of stroke. The Care Plan had no information regarding the resident's positive COVID-19 status until 4/19/23 (2 days after the positive COVID-19 test). F. During an interview on 4/19/23 at 10:15 AM the facility Administrator confirmed Resident's 1, 2, and 3's Care Plans did not address the care needs related to positive COVID-19 prior to 4/18/23 when specific COVID-19 Care Plan information was requested by the survey team member.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on observations, record review and interview; the facility failed to assess, develop and implement interventions related to: 1) Resident 42's pain management, skin condition and problems with persistent diarrhea; 2) Resident 18's suicidal comments, pain management and increased body tremors; 3) Resident 50's aggressive behaviors; 4) monitoring and nutritional support for Resident 20 who was receiving [MEDICAL TREATMENT] (A method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood); and 5) changes in condition for Residents 49 and 65. Facility census was 45. Findings are: A. Review of Resident 42's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/27/15 revealed [DIAGNOSES REDACTED]. The 4/27/15 MDS indicated the resident had moderate cognitive impairment, was receiving scheduled pain medications, was unable to answer questions regarding pain and had no skin impairments. Review of the 6/2015 Medication Administration Record (MAR) revealed Physician's Orders dated 1/14/15 for the following pain medications: -[MEDICATION NAME] (Tylenol-medication used to treat pain) 325 milligrams (mg) tablet-give 2 tablets by mouth daily. -[MEDICATION NAME] 325 mg 2 tablets every 4 hours as needed for pain (prn) -[MEDICATION NAME] ([MEDICATION NAME]-medication used to treat pain and inflammation) 15 mg daily for severe pain. Review of Nurse's Notes dated 6/7/15 at 8:00 AM revealed Resident 42 had a .very irritated anal area and the resident stated it hurts! Documentation indicated the area appeared .bumpy and rough. No open areas were noted but the resident's .Brief is stained red. Documentation indicated the physician was notified per facsimile (fax). Review of a fax dated 6/7/15 revealed the physician was notified that Resident 42's .skin inside the anal area appears to have many small open areas, and it appears rough and bumpy. Resident's brief had red stains in it. Resident states that the area hurts. The fax was returned to the facility from the physician on 6/9/15 (2 days later) with orders for application of [MEDICATION NAME] Compound (a topical ointment used to relieve pain) 2 times daily for 2 weeks. Review of the 6/2015 MAR revealed the [MEDICATION NAME] Compound topical ointment was started on 6/10/15. Resident 42 did not receive prn [MEDICATION NAME] although the resident voiced complaints of pain. There was no evidence in the medical record that showed assessments were completed regarding Resident 42's complaints of pain and irritated skin area. Review of a fax to the physician dated 6/10/15 revealed Resident 42 was having loose stools (diarrhea). The physician gave orders for [MEDICATION NAME] AD (medication used to treat and control diarrhea) 1 tablet by mouth every 8 hours as needed for loose stools. Review of the 6/2015 MAR revealed Resident 42 did not receive [MEDICATION NAME] AD on 6/10/15 and 6/11/15. Review of the 6/2015 MAR revealed the resident received [MEDICATION NAME] on 6/12/15 at 8:50 AM due to loose stools. Documentation of results at 10:30 AM indicated the [MEDICATION NAME] helped a little. Further review revealed the resident received [MEDICATION NAME] on 6/13/15 at 8:50 AM for loose stools and results were recorded as helped. On 6/15/15 at 9:26 AM Resident 42 was observed seated in a wheelchair in their room and Resident 42 stated repeatedly, Please help me. Please help me. At 9:51 AM Resident 42 was observed seated in the recliner in room and stated My butt hurts. Nursing Assistant (NA)-F, NA-E and NA-B were observed to provide Resident 42's morning care and toileting assistance on 6/16/15 from 8:06 AM until 8:30 AM. The resident had an incontinent liquid bowel movement. The resident's buttocks area was red and excoriated. Registered Nurse (RN)-P applied [MEDICATION NAME] Compound topical ointment to the resident's buttocks area. Resident 42 made no comments during toileting and treatment procedure. Review of Resident 42's 6/2015 MAR revealed no [MEDICATION NAME] was administered on 6/16/15. There was no evidence in the medical record to show Resident 42's diarrhea and excoriated skin areas on the buttocks were assessed and monitored. On 6/18/15 at 6:35 AM and 7:00 AM, Resident 42 was observed seated in a wheelchair in the sitting area by the nurses station stating Help me. Help me. Why won't anyone help me? At 7:35 AM, the resident was seated in the wheelchair in the dining room and continued to repeat Help me. Help me. Interview with NA-H on 6/18/15 at 8:15 AM revealed NA-H had assisted Resident 42 out of bed that morning. NA-H stated the resident did not have a bowel movement that morning but reported the resident had diarrhea for several weeks and stated, It just runs out like water. NA-H indicated the resident's problems with diarrhea were reported to the charge nurses. NA-H stated the resident's buttocks area was still pretty sore. NA-H and NA-F were observed to provide toileting assistance for Resident 42 on 6/18/15 from 9:24 AM until 9:40 AM. The resident was incontinent a small amount of liquid bowel movement and the resident's buttocks area was red and excoriated. The resident stated Ow Ow while sitting on the toilet. NA-H and NA-F assisted the resident to stand and Licensed Practical Nurse (LPN)-N examined the resident's buttocks area and commented the skin area was open on one side. LPN-N instructed NA-H and NA-F to apply [MEDICATION NAME] (a topical cream which provides a barrier to protect the skin from moisture) to Resident 42's buttocks area. As NA-H and NA-F provided perineal hygiene the resident stated Ouch. LPN-N asked if the resident had pain and the resident stated yes. Interview with LPN-N at 9:40 AM on 6/18/15 revealed LPN-N was aware Resident 42 had been having problems with diarrhea. LPN-N indicated the resident received regularly scheduled pain medications earlier that morning and it was too soon to administer the prn [MEDICATION NAME]. LPN-N was not sure if the resident had a physician's order for treatment of [REDACTED]. Interview with the Director of Nurses (DON) on 6/18/15 at 11:00 AM revealed assessments of Resident 42's continued diarrhea and excoriated skin areas should have been completed when first observed. Review of a Head To Toe Skin Checks form (form used to monitor skin condition) dated 6/18/15 revealed Resident 42 had abrasions to bilateral buttocks. Review of a Weekly Pressure Ulcer Record form dated 6/18/15 revealed Resident 42 had a 1 centimeter (cm) diameter open area to the right buttocks near the crevice. The skin surrounding the area was red and measured approximately 3 cm in diameter. Documentation further indicated there was a 4 cm in diameter red area on the left buttocks near the crevice. Review of Doctor's Progress Notes dated 6/21/15 revealed Resident 42 was seen by the physician to evaluate the resident's persistent diarrhea. The physician also documented the resident's buttocks were .raw, inflamed & (and) surface ulcers & maceration. No pressure ulcers. The physician gave orders for a stool specimen to be sent to the laboratory for testing to rule out a [DIAGNOSES REDACTED]. The physician ordered continued application of barrier cream ([MEDICATION NAME]) to the resident's buttocks areas. B. Review of the facility policy for Suicide Precautions with a revision date of 7/11/14 included the following: A suicide attempt or suicidal thoughts, especially those accompanied by a suicide plan, are common reasons for inpatient hospitalization . When assessment determines that a patient is at risk for suicide, standard interventions include increasing the level of supervision and observation, taking suicide precautions and removing means of suicide . The policy identified basic suicide precautions included keeping the resident room door open unless the resident was accompanied by a staff member, checking the resident's whereabouts and safety every 15 minutes, staying with the resident while taking medications and monitoring to ensure the resident was not concealing medications, checking all articles brought in by visitors and monitoring the resident during shaving. The policy also indicated documentation of safety checks was to be completed. C. Review of Resident 18's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of Nurse's Notes dated 4/20/15 at 2:00 PM revealed Resident 18 stated Someone needs to kill me. Review of Nurses Notes on 4/20/15 from 2:00 PM to 6:00 PM revealed Resident 18 was repeating comments about killing self. Review of Nurses Notes on 4/25/15 at 3:30 PM revealed Resident 18 told staff several times that the resident was going to kill self. Review of Nurses Notes dated 4/26/15 from 6:00 AM to 1:45 PM revealed Resident 18 was repeatedly asking staff to kill (gender) . There was no evidence in the medical record to show Resident 18 was assessed following suicidal comments or that suicide precautions were implemented to assure the resident's safety. The DON verified during interview on 6/18/15 at 7:05 AM that interventions such as every 15 minute checks should have been put in place following Resident 18's suicidal threats. D. Review of Resident 18's admission orders [REDACTED] -[MEDICATION NAME] liquid 650 mg by mouth every 4 hours as needed. -[MEDICATION NAME] 325 mg tablets-give 2 tablets by mouth every 4 hours as needed for pain. -[MEDICATION NAME] (medication used for pain relief) 200 mg-give 2 tablets by mouth for pain every 6 hours as needed. -[MEDICATION NAME] ([MEDICATION NAME]-medication used to control tremors and stiffness of muscles) 1 mg-give 1 tablet by mouth 2 times daily as needed for tremors. Review of Resident 18's Pain Evaluation (an assessment of intensity, frequency and location of pain) dated 5/28/15 revealed the resident denied pain or hurting in the past 5 days. Review of the Care Plan (revision date 6/10/15) revealed Resident 18 had a potential for pain related to [MEDICAL CONDITION] (arthritis) and [MEDICAL CONDITION] (a disease which makes bones weak and more likely to break) with a goal for the resident to verbally express increased satisfaction with pain control. Interventions included the following: -Positioning/support -Exercise program, stretching exercises -Music/television -Relaxation -Administer [MEDICATION NAME] (pain medications) as ordered -Medicate for pain prior to treatments and therapy if indicated On 6/11/15 at 2:18 PM, Resident 18 was observed seated in a wheelchair in the sitting area by the nurses station. The resident made a comment about hurting and not feeling good. Review of Nurse's Notes dated 6/12/15 at 1:00 PM revealed Resident 18 complained of legs and feet hurting. Review of Resident 18's MAR dated 6/12/15 revealed no [MEDICATION NAME] or [MEDICATION NAME] was administered following the resident's complaints of pain at 1:00 PM. Documentation indicated Tylenol was administered at 7:00 PM that day (6 hours later) for complaints of hurting; however there was no evidence to indicate whether or not the Tylenol was effective in relieving the resident's pain. There was no evidence in the medical record to show an assessment was completed regarding the resident's pain. Review of Nurse's Notes dated 6/12/15 at 1:00 PM revealed a fax was sent to the physician regarding Resident 18's right hand tremors and sucking on tongue. There was no evidence in the medical record to show an assessment was completed regarding the resident's tremors or sucking on tongue. Review of the 6/2015 MAR revealed Resident 18 did not receive [MEDICATION NAME] on 6/12/15 for symptoms of tremors. Review of Nurse's Notes dated 6/14/15 from 6:00 AM until 6:00 PM indicated Resident 18 complained of a .bad neck ache and Tylenol was administered. Review of the MAR dated 6/14/15 revealed Resident 18 received Tylenol 650 mg at 5:30 PM that day for complaints of a neck ache. There was no evidence to indicate the pain was assessed and whether or not the Tylenol was effective in relieving the resident's pain. Review of Nurse's Notes dated 6/15/15 from 6:00 PM until 6:00 AM revealed Resident 18 complained of a neck ache but refused to take [MEDICATION NAME] when offered. There was no evidence of an assessment of the resident's pain. There was no evidence [MEDICATION NAME] was offered nor were alternative interventions for the prevention of pain attempted. At 4:05 PM on 6/16/15, Resident 18 was seated in a wheelchair in the sitting area by the nurses station repeating ouch ouch. The resident commented about hurting all over. RN-P was in the area when Resident 18 made the comment and indicated staff would be getting the resident something to help. Review of Resident 18's MAR dated 6/16/15 revealed the resident did not receive [MEDICATION NAME] or [MEDICATION NAME] that day for complaints of pain. At 2:10 PM on 6/17/15, Resident 18 was observed seated in a wheelchair in the activity room during the scheduled music activity. Resident 18 stated ow ow several times during the activity. NA-O told Resident 18 several times you're all right. There was no evidence NA-O reported Resident 18's complaints of pain and review of Resident 18's MAR dated 6/17/15 revealed the resident received no [MEDICATION NAME] or [MEDICATION NAME] for pain that day. On 6/18/15 at 11:35 AM, Resident 18 was observed seated in a wheelchair in the sitting area by the nurses station. Resident 18 stated ouch ouchand My arms are shaking and they hurt. When asked about Resident 18's complaints of pain and shaking during interview with LPN-N at 11:36 AM on 6/18/15, LPN-N indicated the resident complains of pain all the time. LPN-N commented about checking to see what the resident could take for pain. Review of the MAR from 6/1/15 until 6/18/15 revealed Resident 18 had not received pain medications ([MEDICATION NAME] or [MEDICATION NAME]) since administration of Tylenol at 5:30 PM on 6/14/15. Resident 18 had not received [MEDICATION NAME] for complaints of tremors/shaking. Review of the MAR on 6/19/15 revealed documentation that LPN-N administered Tylenol 650 mg at 12:00 noon to Resident 18 on 6/18/15. Documentation indicated the resident obtained no relief from the Tylenol. There was no evidence alternative interventions were provided in an attempt to relieve pain. In addition, the resident received no [MEDICATION NAME] on 6/18/15 after complaints of tremors/shaking. Interview with LPN-J on 6/22/15 at 7:25 AM revealed Resident 18 was seen by the physician on 6/21/15 due to tremors of the arms and hands. LPN-J was unaware Resident 18 had a physician order for [REDACTED]. LPN-J checked the 6/2015 MAR and verified the resident had not received [MEDICATION NAME]. LPN-J indicated a dose of [MEDICATION NAME] would be administered right away for the resident's tremors/shaking. E. Review of Resident 50's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 1/12/15 MDS indicated the resident displayed adverse physical, verbal and other behaviors, along with wandering behaviors at a frequency of 1 to 3 days during the assessment period. Review of Resident 50's current Care Plan (revision date 4/15/15) revealed the resident displayed behaviors which included Cries out, strikes out at staff, curses, exit seeks. Interventions included the following: -Explain all procedures before working with resident -Assist resident to group activities -Provide activity box when in room or becomes restless -Provide one to one interaction with resident if tearful or restless -Assist resident with turning on television as resident likes game shows Review of a facility investigation dated 5/15/15 revealed there was an altercation at approximately 5:00 PM that day between Resident 50 and Resident 37. Documentation indicated Resident 37 on the way to the dining room when Resident 50 lashed out and kicked Resident 37. Interventions for the prevention of future altercations included the following: -Use diversional techniques to keep mind active and involved in positive behavior -Educated staff on preventative measures to keep these 2 residents apart -Educated staff at meal times to assist these 2 residents down the hall at different times -Educated staff to provide afternoon naps to avoid an overload of sensory stimuli that leads to fatigue which leads to aggressive behavior Interview with NA-A on 6/15/15 at 3:37 PM revealed Resident 50 had a history of [REDACTED]. NA-A indicated staff monitored the resident's whereabouts and attempted to keep the resident away from other residents. At 9:00 AM on 6/17/15, Resident 50 was observed seated in a wheelchair and wheeling self out of the dining room and to the entrance of the Wing 1 corridor. Resident 50 remained seated at the entrance of the Wing 1 corridor until 9:15 AM as other residents walked by while returning to their rooms from the breakfast meal. The resident was not redirected from the area. From 9:15 AM until 9:44 AM, Resident 50 wheeled self throughout the corridors of the facility. No diversional activities were offered during this time. Resident 50 was observed seated in a wheelchair by the dining room entrance adjacent to the front entrance of the facility from 1:25 PM until 1:55 PM on 6/17/15. During this time residents walked by Resident 50 while returning to their rooms following the noon meal. NA-O was assisting other residents to pass by Resident 50 as NA-O helped the residents exit by the front entrance to sit on the patio. Resident 50 was not redirected away from the area. At 1:55 PM as NA-O was assisting Resident 37 back into the building through the front entrance, Resident 50 became angry and began swearing and yelling at NA-O. Resident 50 wheeled self rapidly through the corridor and followed NA-O to the entrance of the Wing 1 corridor. Resident 50 reached forward and grabbed the back of Resident 37's wheelchair in an angry manner. The Maintenance Director intervened and separated Resident 50 from Resident 37. Resident 50 proceeded to wheel self throughout Wing 2 and Wing 3 corridors in an agitated manner. No diversional activity or one to one interaction was provided to divert Resident 50's wandering and agitated behavior. At 2:30 PM, Resident 50 was observed seated in a wheelchair in the Activity Room with 13 other residents who were attending a music activity. NA-O was present in the area to monitor resident interactions. Interview with NA-O at 2:35 PM on 6/17/15 revealed Resident 50 was not supposed to sit in high traffic areas and it did not take much to set the resident off. Review of an Incident/Accident Report dated 6/17/15 at 3:30 PM revealed Resident 50 hit Resident 32 over the head with a clothing protector. Resident 50 then slapped Resident 32 on the left shoulder. The incident occurred in the corridor to the dining area. Review of a facility Incident/Accident Interviews form dated 6/21/15 regarding Resident 50 hitting Resident 32 at 3:30 PM on 6/17/15 revealed the incident was witnessed by NA-O. Documentation indicated NA-O was outside with residents doing activities when NA-O heard Resident 50 swearing. NA-O turned around and witnessed Resident 50 slap Resident 32 on the left shoulder. F. Review of the facility policy titled [MEDICAL TREATMENT], Care of Residents, Revised July 2014, revealed the following related to Post [MEDICAL TREATMENT]/Ongoing care: - Review and ensure orders upon admission are received for follow-up [MEDICAL TREATMENT] center appointments, shunt (During [MEDICAL TREATMENT], the blood is accessed through a tube inserted into the vessels of the arm and referred to as an arteriovenous (AV) fistula or shunt.) care, diet and fluid restriction at physician's discretion. - Check vital signs every shift for the 24 hours post-[MEDICAL TREATMENT] or in accordance with physician's orders. - Upon return from [MEDICAL TREATMENT], the nurse will check for thrill (A thrill is checked by lightly placing fingertips over the fistula site and feeling for vibration of blood circulating through the fistula.) and bruit (A bruit is checked by placing a stethoscope over the fistula area and listening for blood flow.) twice during the first 8 hours after the resident returned. - The nurse will assess the condition of the access site for bleeding, redness, tenderness or swelling. If any of these conditions are noted, contact physician and document findings. The policy further revealed the following Nurses' notes - key documentation elements: - Vital signs, - Auscultation and palpation for presence of bruit or thrill, - Temperature and color of fistula site and surrounding skin, - Condition of dressing, and - Signs and symptoms of infection, including redness, swelling, excessive tenderness, and drainage. G. Review of Resident 20's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was receiving [MEDICAL TREATMENT]. Review of Resident 20's Care Plan dated 5/27/15 indicated the resident was receiving [MEDICAL TREATMENT] 3 times weekly on Monday, Wednesday and Friday, and had an AV fistula in the right arm. Nursing interventions included the following: - vital signs every shift for 24 hours post-[MEDICAL TREATMENT] or per physician's orders; - after return from [MEDICAL TREATMENT], check for thrill and bruit 2 times per shift on day the resident returned, then daily; and - monitor fistula site to right arm post-[MEDICAL TREATMENT], and report increased redness or swelling. Further review of the Care Plan revealed dietary interventions related to the resident's [MEDICAL CONDITION] and need for [MEDICAL TREATMENT], including the following: - Boost Glucose Control (a high protein nutritional supplement especially formulated for residents with diabetes) 1 can with [MEDICAL TREATMENT]; - 1500 cc (cubic centimeters) fluid restriction, 8 ounces at meals; and - provide extra protein. Review of current Physician's Orders dated 5/19/15 revealed an order with a Start Date of 12/18/11 for Boost Glucose Control 1 can 3 times daily with [MEDICAL TREATMENT]. Review of Resident 20's MAR dated 8/2014 through 10/2014 revealed no documentation the Boost nutritional supplement was administered to Resident 20 as ordered by the physician. Review of a [MEDICAL TREATMENT] Communication Record (a form completed with each [MEDICAL TREATMENT] treatment and used to communicate information and recommendations between the facility and the [MEDICAL TREATMENT] center) dated 11/21/14 revealed documentation completed by the [MEDICAL TREATMENT] center staff that [MEDICATION NAME] (the main protein found in the blood) low per (by) [MEDICAL TREATMENT] standard. Further documentation indicated Resident 20's [MEDICATION NAME] level had dropped from 3.8 to 3.6, and the [MEDICAL TREATMENT] center goal was 4.0. The [MEDICAL TREATMENT] center staff recommended Boost Glucose Control 1 can daily, 3 times weekly, and requested it be sent with the resident for each [MEDICAL TREATMENT] appointment. Review of MARs dated 11/2014 and 12/2014 revealed no documentation the Boost nutritional supplement was administered to Resident 20 as recommended by the [MEDICAL TREATMENT] center. Review of Dietary Progress Notes by the Registered Dietician (RD) dated 12/18/14 indicated Resident 20 was receiving extra protein with meals and Boost Glucose Control on days of [MEDICAL TREATMENT] treatment, and no new recommendations were made. Review of Resident 20's Nurse's Notes dated 3/2/15 through 6/16/15 revealed the following: - 3/9/15 at 9:00 AM - The resident left the facility for [MEDICAL TREATMENT] treatment. - 3/9/15 at 11:00 AM - The [MEDICAL TREATMENT] center called the facility and reported resident's blood pressure was low, and they provided fluids and didn't take any fluid off. - 3/9/15 at 3:30 PM - The resident returned from [MEDICAL TREATMENT], and there was no documentation to indicate the blood pressure was checked again until 3/13/15 at 7:00 AM (4 days later). - There was no documentation to indicate assessments of vital signs, thrill and bruit, and condition of the fistula site were completed by the facility upon return from [MEDICAL TREATMENT] treatments in accordance with the Care Plan and facility policy. Review of MAR's and Treatment Records dated 3/2015 through 6/2015 revealed no documentation to indicate assessments of vital signs, thrill and bruit, and condition of the fistula site were completed by the facility upon Resident 20's return from [MEDICAL TREATMENT] treatments in accordance with the Care Plan and facility policy. Furthermore, there was no documentation to indicate the Boost nutritional supplement was administered as ordered by the physician and/or recommended by the [MEDICAL TREATMENT] center. Review of a Medical Nutritional Therapy Review dated 5/15/15 indicated Resident 20's [MEDICATION NAME] level was 3.2 on 4/15/15 (0.8 units below the [MEDICAL TREATMENT] center's standard of 4.0). Review of Dietary Progress Notes by the RD dated 5/19/15 indicated the resident's plan of care was reviewed and remains appropriate. The RD did not assess Resident 20's low [MEDICATION NAME] level or need for increased protein. Review of laboratory results dated [DATE] indicated Resident 20's [MEDICATION NAME] level remained low at 3.3. During interview on 6/16/15 at 1:42 PM, Registered Nurse (RN)-D indicated Resident 20 used to have a fluid restriction but was unaware of current dietary interventions and/or restrictions. Interviews on 6/17/15 from 7:04 AM until 7:48 AM revealed the following: - The Dietary Manager (DM) verified Resident 20 was on a protein diet, and the dietary department provided lunch for the resident to take to [MEDICAL TREATMENT] treatments. - The DM was unaware of a fluid restriction or the recommendation for Boost Glucose Control to be provided at [MEDICAL TREATMENT] appointments. - Medication Aide (MA)-I and Licensed Practical Nurse (LPN)-J were unaware of the physician's order and/or [MEDICAL TREATMENT] center recommendation for Boost nutritional supplement and have never seen this done. - LPN-L indicated the Boost nutritional supplement was administered to the resident by the [MEDICAL TREATMENT] center staff, and the resident may be refusing it. - Resident 20 reported getting a nutritional supplement at the [MEDICAL TREATMENT] center quite a while ago, but denied getting it at this time. During interview on 6/17/15 from 9:04 AM until 10:58 AM, RN-G indicated the resident returned RN-G verified there was no physician's order to discontinue the Boost Glucose Control, and there was no documentation to indicate it was ever administered. RN-G also verified if post-[MEDICAL TREATMENT] monitoring of vital signs and assessments of the fistula were done, they would be documented in the Nurses' Notes, MAR or Treatment Record.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b Based on observations, record review and interviews; the facility failed to assess, develop, revise and implement nutritional interventions for the prevention of weight loss for Residents 50, 9, 18 and 35 and for [MEDICAL TREATMENT] management ([MEDICAL TREATMENT] is a method used to treat kidney disease by clearing metabolic waste products, toxins, and excess fluid from the blood. The blood is accessed through a tube inserted into the vessels of the arm and referred to as an arteriovenous (AV) fistula) for Resident 20. Facility census was 45. Findings are: A. Review of Resident 50's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 1/12/15 revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident weighed 109 pounds. Review of the Vital Signs & (and) Weight Flow Sheet (a form used to document weights) revealed Resident 50's weight was 121.3 pounds on 8/7/14 and 111.4 pounds on 11/9/14 (a loss of 9.9 pounds and an 8.1 percent (%) significant weight loss in 3 months). Review of the Review/Plan form dated 11/13/14 revealed the consultant Registered Dietician (RD) assessed Resident 50's weight loss. Documentation indicated the resident's current body weight was 111 pounds which was an 8% significant weight loss over the past 90 days. The RD indicated a plan to continue to fortify (addition of extra calories) food and drinks, provide Med Pass (nutritional supplement drink) 90 cubic centimeters (cc) 3 times per day, and offer a Magic Cup (brand of frozen supplement) daily. Review of Resident 50's Vital Signs & Weight Flow Sheet revealed the following weights: 12/3/14-109.9 pounds 12/16/14-108.2 pounds 1/1/15-107.8 pounds 1/9/15-108.8 pounds 1/17/15-108.5 pounds 1/28/15-110.8 pounds Review of documentation of supplement intakes for 1/2015 revealed Med Plus (Med Pass) 90 cc was to be offered 2 times daily (instead of 3 times daily as indicated by the RD on 11/13/14). Documentation indicated the resident refused the Med Plus on 9 occasions and there was no documentation to indicate the resident received the Med Plus on 6 occasions. In addition, documentation indicated the resident refused the daily Magic Cup on 10 occasions. There was no documentation to indicate the Magic Cup was provided on 11 occasions. Review of a Nutritional Status Review form signed by the RD and dated 1/22/15 revealed No nutrition concerns noted. Review of documentation of supplement intakes for 2/2015 revealed Med Plus 90 cc was offered 2 times daily and the resident refused the Med Plus on 20 occasions. There was no documentation the Med Plus was provided on 16 occasions. Documentation indicated the daily Magic Cup was refused on 6 occasions and there was no evidence the Magic Cup was provided on 17 occasions. Review of Resident 50's Vital Signs & Weight Flow Sheet revealed the following weights: 2/11/15-109.8 pounds 2/25/15-109.6 pounds Review of documentation of supplement intakes for 3/2015 revealed Med Plus 90 cc was offered 2 times daily and the resident refused the Med Plus on 41 occasions. There was no documentation regarding the amount of Med Plus consumed on 4 occasions. Documentation indicated the daily Magic Cup was refused on 19 occasions and there was no evidence the Magic cup was provided on 5 occasions. Review of Resident 50's Vital Signs & Weight Flow Sheet revealed the following weights: 3/7/15-104 pounds 3/11/15-105.4 pounds 3/18/15-107.2 pounds 3/25/15-96.5 pounds 3/26/15-106.2 pounds (reweight) Review of a Nutritional Status Review form signed by the RD dated 3/31/15 revealed the resident's current weight was 106.2 pounds which was a non-significant weight loss. The RD indicated current interventions included fortified foods/drinks, Magic Cup daily and Med Pass 90 cc 3 times daily. The RD recommended offering the resident a Great Shake (nutritional supplement drink) 2 times daily. Review of documentation of supplement intakes for 4/2015 revealed no evidence the Great Shake was provided 2 times daily as recommended by the RD. Documentation indicated Med Plus was offered 2 times daily (not 3 times as indicated by the RD) and the resident refused the Med Plus on 37 occasions. There was no documentation regarding provision of Med Plus on 11 occasions. Documentation indicated the daily Magic Cup was refused on 19 occasions and there was no evidence the Magic cup was provided on 7 occasions. Review of Resident 50's Vital Signs & Weight Flow Sheet revealed the following weights: 4/1/15-100.3 pounds (a significant weight loss of 5.5% since 3/26/15) 4/8/15-100 pounds 4/15/15-101.4 pounds Review of a Nutritional Status Review form signed by the RD dated 4/21/15 revealed .Weight loss continues despite numerous interventions in place. Weight is down severely 8.49% past 30 days. Documentation further indicated the resident showed no desire to eat and refused meals at times. The RD indicated there were No new recommendations at this time. Review of documentation of supplement intakes for 5/2015 revealed a Great Shake was offered 2 times daily and the resident refused on 33 occasions with no documentation on 13 occasions. The Med Plus continued to be offered 2 times daily (instead of 3 times as recommended by the RD) and the resident refused on 30 occasions with no documentation on 14 occasions. The daily Magic Cup was refused on 11 occasions with no documentation on 17 occasions. Review of Resident 50's Vital Signs & Weight Flow Sheet revealed the following weights: 5/6/15-99.2 pounds 5/21/15-99.6 pounds 5/27/15-98.8 pounds Review of a Nutritional Status Review form signed by the RD dated 6/2/15 revealed the resident's current weight was 98.8 pounds. Documentation stated .Is showing severe loss of 9.75% in past 90 days. Consuming 68% average all meals. Nutrition interventions remain . which included Great Shakes, Med Pass and Magic Cups. The RD made no new recommendations although there was evidence the resident was frequently refusing the supplements. Review of a Nutritional Status Review form signed by the RD dated 6/16/15 revealed the resident's current weight was 99 pounds which was a severe loss of 9.67% in 90 days. Documentation indicated the resident was refusing the Great Shakes, Med Pass and Magic Cups and was consuming an average of 49% of all meals. The RD recommended continuing to fortify foods/drinks at meals, adding fortified juice 3 times daily between meals and discontinuing Med Pass, Great Shake and Magic Cup. Interview with Dietary Cook (DC)-M on 6/17/15 at 11:35 AM revealed food was to be fortified during the noon meal by adding extra cheese to the taco casserole. Observation of the noon meal on 6/17/15 revealed Resident 50 was served at 12:10 PM and extra cheese had not been added to the taco casserole. The Dietary Manager (DM) verified during interview on 6/17/15 at 2:05 PM that Resident 50 was on a fortified diet and should have received extra cheese added to the taco casserole. B. Review of Resident 9's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 12/13/14 MDS indicated the resident's weight was 96 pounds and the resident was receiving hospice services. Review of the Medical Nutritional Therapy Review form dated 12/13/14 revealed Resident 9 was on a Regular Mechanical Soft diet with 1 scoop of [MEDICATION NAME] (powdered protein supplement) added to food items with each meal and Great Shakes 2 times daily. Documentation further indicated the resident's ideal body weight was 104 pounds to 131 pounds. Review of a Review/Plan form dated 2/5/15 revealed the RD identified the resident's current weight was 89.8 pounds. The RD further documented the residents average meal intake was 76% with some refusals at times and the resident continued to receive [MEDICATION NAME] 1 scoop 3 times daily with meals, meals were fortified, and a 4 ounce Great Shake was provided 2 times daily. The RD indicated the resident remained on Hospice services and made no new recommendations. Review of documentation of supplement intakes for 3/2015 revealed the resident did not receive the 4 ounce Great Shake 2 times daily. Out of 62 occasions where Great Shakes should have been provided, documentation indicated the resident consumed all of the Great Shake on 27 occasions, half of the Great Shake on 1 occasion and refused the Great Shake on 4 occasions. There was no documentation to indicate the Great Shakes were offered on 30 occasions. Review of documentation of supplement intakes for 4/2015 revealed Resident 9 received and consumed 4 ounce Great Shake 2 times daily except for 3 refusals and 1 occasion where there was no documentation. Review of documentation of supplement intakes for 5/2015 revealed Resident 9 did not receive the 4 ounce Great Shake 2 times daily. Out of 62 occasions where Great Shakes should have been provided, documentation indicated the resident consumed all off the Great Shake on 32 occasions and refused on 1 occasion. There was no documentation to indicate the Great Shakes were offered on 29 occasions. Review of the current Care Plan with a review date of 6/11/15 revealed a goal for Resident 9's weight to be stabilized within a weight range of 90 to 110 pounds or a weight gain of 2 to 3 pounds a month. Interventions included provision of a Regular Mechanical Soft diet with 1 scoop [MEDICATION NAME] 3 times a day with meals, offer enhanced or fortified foods and 4 ounce Great Shake 2 times per day. Review of documentation of supplement intakes for 6/1/15 through 6/16/15 revealed Resident 9 did not receive the 4 ounce Great Shake 2 times daily. Out of 32 opportunities when Great Shakes should have been provided, documentation indicated the resident consumed all of the Great Shake on 14 occasions and refused on 3 occasions. There was no documentation to indicate the Great Shakes were offered on 15 occasions. Review of the Vital Signs &Weight Flow Sheet revealed Resident 9's weight on 6/11/15 was 87.8 pounds. Interview with Nursing Assistant (NA)-E at 1:59 PM on 6/16/15 revealed Resident 9 did not get up for breakfast that morning as the resident was allowed to sleep in if the resident desired. NA-E stated the resident was offered toast and juice upon arising but had refused and the resident did not eat anything until the noon meal. Review of the Meal Detail Report (documentation of meal intake) for 6/1/15 through 6/16/15 revealed out of 16 breakfast meals, the resident refused breakfast on 7 days and there was no documentation regarding consumption of the breakfast meal on 4 occasions. There was no evidence in the medical record to indicate the resident's preference to sleep later in the morning was assessed and interventions developed to assure the resident was encouraged or provided with something to eat upon arising. Observation of the noon meal on 6/17/15 revealed DC-M dished up Resident 9's meal at 11:52 AM. The resident's diet card (a card which identifies the current diet order) indicated Resident 9 was to receive a Regular Mechanical Soft fortified diet with 1 scoop of [MEDICATION NAME] added to each meal. DC-M did not add extra cheese to the taco casserole in accordance with the plan for fortified diets. When the diet order was questioned, DC-M stated Resident 9 should have had extra cheese on food items to fortify the diet. DC-M then added extra cheese to the resident's taco casserole. DC-M did not add 1 scoop of [MEDICATION NAME] to the food. The DM verified during interview on 6/17/15 at 2:05 PM that [MEDICATION NAME] had not been added to Resident 9's food items at the noon meal as there was no [MEDICATION NAME] available in the facility. The DM indicated an order would be placed to obtain a supply of [MEDICATION NAME]. C. Review of Resident 18's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. Review of documentation of supplement intakes for 4/2015 revealed Resident 18 was receiving and consuming a 4 ounce Great Shake supplement 2 times daily. Review of the MDS dated [DATE] revealed the resident was readmitted to the facility following a psychiatric hospitalization . Review of Physician admission orders [REDACTED]. There were no physician orders for resuming the 4 ounce Great Shake supplement 2 times daily. Review of the Vital Signs & Weight Flow Sheet dated 5/21/15 revealed Resident 18's weight was 166.2 pounds (a 17.8 pound weight loss). There was no evidence in the medical record to show Resident 18's weight loss was reassessed upon readmission to the facility. Review of documentation of supplement intakes from 5/20/15 through 5/31/15 revealed the 4 ounce (120 cc) Great Shake was restarted on 5/22/15 although there was no evidence to indicate the physician was notified of the weight loss and there were no orders or recommendations for the Great Shake. Documentation indicated the Great Shake was provided 2 times daily on 5/22/15 through 5/24/15, 1 time daily on 5/25/15 through 5/27/15 and twice on 5/29/15. Documentation indicated the resident consumed 100 cc to 120 cc of the Great Shake when it was offered. Review of Resident 18's current Care Plan (revised on 6/10/15) indicated a goal to stabilize weight within a weight range of 160 pounds to 174 pounds. Interventions included provision of a Reduced Concentrated Sweet Mechanical Soft diet with small portions, offer enhanced or fortified foods and offer snacks 3 times a day and as needed. Review of documentation of supplement intakes from 6/1/15 through 6/16/15 revealed the 4 ounce Great Shake was provided 1 time daily on 9 occasions and 2 times daily on 4 occasions. There were 2 documented refusals. Review of a Nutritional Status Review form dated 6/16/15 revealed the RD reviewed Resident 18's weight loss (27 days after the resident was readmitted to the facility with a significant weight loss). The RD indicated the resident's current weight was 166 pounds which was a .severe loss of 10.81% in 180 days. Consuming 74% average all meals per recorded intake past week. Recommend NSA (no salt added) Great Shake TID (3 times daily). The RD and DM confirmed during interview on 6/16/15 at 3:29 PM that Resident 18's weight loss was not assessed until 6/16/15. The DM indicated there were problems with provision and documentation of resident supplements and snacks. Observation of the noon meal on 6/17/15 revealed DC-M dished up Resident 18's meal at 11:50 AM. The resident's diet card indicated Resident 18 was to receive a Reduced Concentrated Sweet, High Fiber, Mechanical Soft diet with fortified foods. DC-M did not add extra cheese to the taco casserole in accordance with the plan for fortified diets. When the diet order was questioned, DC-M stated Resident 18 should have had extra cheese on food items to fortify the diet. DC-M then added extra cheese to the resident's taco casserole. D. Review of Resident 35's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further revealed the resident was independent with eating and drinking and was on a mechanically altered, therapeutic diet. The assessment identified Resident 35 was not on a prescribed weight loss regimen and the resident's weight was 188 lbs. Review of the MDS dated [DATE] revealed the resident continued with a mechanically altered, therapeutic diet with a weight of 175 pounds (13 pounds or 7% weight loss in 1 month). Review of the Vital Signs & Weight Flow Sheet for Resident 35 revealed the following weights: -2/13/15-197 pounds -3/10/15- 177.8 pounds (19.2 pounds or 9.7% loss in 1 month) -4/6/15- 187.7 pounds -5/4/15-175.2 pounds (12.5 pounds or 6.6% loss in 1 month or 11% loss in 90 days) Review of the Review/Plan form by the RD dated 5/19/15 revealed the following resident showing a severe weight loss of 6.66% in 30 days and 11.43% in 90 days. Recommendation received for Med Pass 60 cc three times a day. Review of Change of Condition facsimile (fax) sent to Resident 35's physician on 5/19/15 revealed notification of weight loss and request for an order to start Med Pass 60 cc three times a day per the RD's recommendation. The fax indicated Resident 35 was already receiving Magic Cup twice a day. Review of Resident 35's medical record revealed the Med Pass 60 cc to be given three times a day was not initiated until 5/28/15 (9 days after the RD's recommendation). Further review revealed no documentation that Resident 35 had ever received the Magic Cup. Review of documentation of supplement intakes from 5/28/15 to 5/31/15 revealed the resident refused the Med Pass 60 cc, 8 out of 11 times it was offered Review of Resident 35's Care Plan with a revision date of 6/3/15 revealed the resident had poor intakes with a recent [DIAGNOSES REDACTED]. The Care Plan indicated the resident disliked the Med Pass. Review of Resident 35's medical record revealed no documentation as to what snacks the resident was offered, when the snacks were provided or if the resident consumed the snacks. Review of documentation of supplement intakes from 6/1/15 to 6/15/15 revealed the resident refused the Med Pass 60 cc, 40 out of the 45 times the supplement was offered. Review of Vital Signs & Weight Flow Sheet revealed Resident 35's weight on 6/9/15 was 166.6 pounds (8.6 pounds or 4.9% loss in 1 month). During an interview on 6/17/15 from 10:00 AM to 10:30 AM, the DM verified Resident 35 had never received the Magic Cup supplement and Resident 35 did not receive the Med Pass 60 cc until 9 days after the RD recommended. In addition the DM verified there was no documentation in Resident 35's medical record to indicate the resident's poor supplement intake had been identified or assessed by the DM or the RD and no other interventions had been implemented to prevent weight loss for Resident 35. E. Review of Resident 20's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The MDS further indicated the resident was receiving [MEDICAL TREATMENT] (a method of treating [MEDICAL CONDITION] by clearing metabolic waste products, toxins, and excess fluids from the blood). Review of Resident 20's current Care Plan dated 5/27/15 indicated the resident was receiving [MEDICAL TREATMENT] 3 times weekly on Monday, Wednesday and Friday. Dietary interventions included the following: - Boost Glucose Control (a high protein nutritional supplement especially formulated for residents with diabetes) 1 can with [MEDICAL TREATMENT]; - 1500 cc (cubic centimeters) fluid restriction, 8 ounces at meals; and - provide extra protein. Review of current Physician's Orders dated 5/19/15 revealed an order with a Start Date of 12/18/11 for Boost Glucose Control 1 can 3 times daily with [MEDICAL TREATMENT]. Review of Medication Administration Records (MAR) dated 8/2014 through 10/2014 revealed no documentation the Boost nutritional supplement was administered to Resident 20 as ordered by the physician. Review of a [MEDICAL TREATMENT] Communication Record (a form completed with each [MEDICAL TREATMENT] treatment and used to communicate information and recommendations between the facility and the [MEDICAL TREATMENT] center) dated 11/21/14 revealed documentation completed by the [MEDICAL TREATMENT] center staff that [MEDICATION NAME] (the main protein found in the blood) low per (by) [MEDICAL TREATMENT] standard. Further documentation indicated Resident 20's [MEDICATION NAME] level had dropped from 3.8 to 3.6, and the [MEDICAL TREATMENT] center goal was 4.0. The [MEDICAL TREATMENT] center staff recommended Boost Glucose Control 1 can daily, 3 times weekly, and requested it be sent with the resident for each [MEDICAL TREATMENT] appointment. Review of MAR's dated 11/2014 and 12/2014 revealed no documentation the Boost nutritional supplement was administered to Resident 20 as recommended by the [MEDICAL TREATMENT] center. Review of Dietary Progress Notes by the Registered Dietician (RD) dated 12/18/14 indicated Resident 20 was receiving extra protein with meals and Boost Glucose Control on days of [MEDICAL TREATMENT] treatment, and no new recommendations were made. Review of MAR's and Treatment Records dated 3/2015 through 6/2015 revealed no documentation to indicate Boost nutritional supplement was administered as ordered by the physician and/or recommended by the [MEDICAL TREATMENT] center. Review of a Medical Nutritional Therapy Review dated 5/15/15 indicated Resident 20's [MEDICATION NAME] level was 3.2 on 4/15/15 (0.8 units below the [MEDICAL TREATMENT] center's standard of 4.0). Review of Dietary Progress Notes by the RD dated 5/19/15 indicated the resident's plan of care was reviewed and remains appropriate. The RD did not assess Resident 20's low [MEDICATION NAME] level or need for increased protein. Review of laboratory results dated [DATE] indicated Resident 20's [MEDICATION NAME] level remained low at 3.3. During interview on 6/16/15 at 1:42 PM, Registered Nurse (RN)-D indicated Resident 20 used to have a fluid restriction but was unaware of current dietary interventions and/or restrictions. Interviews on 6/17/15 from 7:04 AM until 7:48 AM revealed the following: - The Dietary Manager (DM) verified Resident 20 was on a protein diet, and the dietary department provided lunch for the resident to take to [MEDICAL TREATMENT] treatments. - The DM was unaware of a fluid restriction or the recommendation for Boost Glucose Control to be provided at [MEDICAL TREATMENT] appointments. - Medication Aide (MA)-I and Licensed Practical Nurse (LPN)-J were unaware of the physician's order and/or [MEDICAL TREATMENT] center recommendation for Boost nutritional supplement and have never seen this done. - LPN-L indicated the Boost nutritional supplement was administered to the resident by the [MEDICAL TREATMENT] center staff, and the resident may be refusing it. - Resident 20 reported getting a nutritional supplement at the [MEDICAL TREATMENT] center quite a while ago, but denied getting it at this time. During interview on 6/17/15 from 9:04 AM until 10:58 AM, RN-G indicated the resident returned from a hospitalization in 7/2014, and the readmission physician's orders did not include the fluid restriction the resident was on prior to hospitalization . RN-G verified the orders should have been clarified. RN-G further verified there was no physician's order to discontinue the Boost Glucose Control, and there was no documentation to indicate it was ever administered.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7, 12-006.09D7a Based on observations, record review and staff interview; the facility failed to assure a safe environment was provided for residents identified at risk for falls and wandering. The outside exit door of the Activity Room was propped open and staff failed to respond to the door alarm for 3 minutes. Resident 38, who was at risk for wandering and falls, was seated in a wheelchair outside of the building on an unsecured patio and was unattended during this time. In addition, the facility failed to transport Resident 47 to the whirlpool room in a safe manner on 2 occasions. Facility census was 51. Findings are: A. Review of admission orders [REDACTED]. Review of facility policy entitled "Resident Elopement" with a revision date of 8/20/12 identified when an employee heard a door alarm, the employee should immediately go to the site of the alarm. Review of Resident 38's Minimum Data Set (MDS- a federally mandated comprehensive assessment tool used for care planning) dated 5/28/13 revealed [DIAGNOSES REDACTED]. The assessment indicated the resident had short and long term memory loss with severely impaired decision making skills, required limited assist of one with locomotion, used a wheelchair for mobility in the corridor and had behaviors of wandering, rejection of cares and physical behaviors directed at others 1-3 days during the 7 day assessment period. Review of Fall Risk Evaluation for Resident 38 dated 5/28/13 identified a total score of 20. A total score of 10 or above represents a high risk for falls. Review of an Elopement Risk Review for Resident 38 completed 5/28/13 indicated the resident was at risk for elopement. Review of Resident 38's Care Plan (revised 6/6/2013) indicated the resident was at risk for elopement due to mobility status, [DIAGNOSES REDACTED]. Interventions included: -Provide safe location for wandering behaviors as needed. -Check placement and function of wander-guard bracelet every shift. -Increase observation of resident during and after visitors. Care Plan also indicated Resident 38 was at risk for wandering related to [DIAGNOSES REDACTED]. Interventions included: -Evaluate resident for placement of safety/monitoring device (wander-guard bracelet) quarterly. -Observe for increased safety risks, wandering into others rooms, constant wandering without rest, and exit seeking behaviors. In addition, Resident 38 was identified as a potential for injury related to falls due to impaired cognition, Alzheimer's disease, recent falls, history of falls, ambulatory/incontinent, balance problems and poor safety awareness with frequent attempts to self-transfer. The Care Plan identified Resident 38 had 11 falls during the last quarter. Interventions included: -Check on resident frequently. -Pressure alarm (device which consists of a control unit/box and a pressure sensitive pad. An alarm sounds when a resident moves from a certain position) to bed and chair at all times. -TABs alarm (personal alarm with a pull string that attaches magnetically to the alarm with a garment clip to the resident. When the resident attempts to rise out of the chair or bed the pull string magnet is pulled away from the alarm which causes the alarm to sound, alerting the care giver) to chair and bed at all times. -Fall mat to right side of bed closest to the window. -High/low bed to be kept in lowest position whenever resident in bed. -Self releasing safety belt with alarm to wheelchair. -Redirect resident if noted to be wandering down hallway to unoccupied area. -Encourage staff to answer alarms when going off and to toilet resident routinely and as needed. Review of Resident 38's Nurse's Notes revealed the following: -4/26/13 at 6:30 AM ...alarm sounding, staff responds to alarm and finds resident on back beside bed. -4/30/13 at 6:30 PM ...found on left side in activity room on floor. Resident had been up in wheelchair and wandered into an unsupervised area. Resident unaware of safety needs. -5/1/13 at 6 PM, Resident wanders through facility ... -5/4/13 at 5 PM, Resident wandering through the hallway ... -5/7/13 at 8:25 PM, Resident noted wandering about facility ... -5/8/13 at 12:15 AM, Resident found lying on floor beside bed ... -5/8/13 at 5:30 PM, Resident has been up in the wheelchair and self-propels around the facility. -5/9/13 at 5 PM, Resident wanders in wheelchair through facility ... -5/12/13 at 11 AM, Resident has been trying to stand up multiple times this morning... -5/13/13 at 9:20 PM, Resident noted to be wandering the hallways ... -5/17/13 7:00 PM, Resident noted to be walking wheelchair out of the activity room, alarms sounding ... -5/17/13 at 7:45 PM, Resident found by staff sitting on the floor next to bed ... -5/23/13 at 1:15 AM, Staff entered resident's room and found resident on the floor next to the bed ... -5/25/13 at 5:00 PM, Resident wanders through facility halls and other areas ... -5/25/13 from 8:30 PM to 11:30 PM, Resident tries repeatedly to get up out of bed ... -5/26/13 at 5 PM, Resident wandering through the hallways, occasionally sets off alarms when attempting to stand up. -5/27/13 at 10 PM, Resident wanders about facility in wheelchair. -6/3/13 at 4:15 PM, Resident was found on the floor beside bed ... -6/7/13 at 5:30 PM, All alarms sounding, resident found on the floor in Chapel area by the desk ... -6/9/13 from 2 AM to 4 AM, Resident up and restless, makes repeated attempts to self-transfer, resident in wheelchair at Nurse's desk... -6/9/1 from 6 PM to 10 PM, Resident aimlessly wandering through facility with several attempts made to self- transfer ... -6/18/13 at 6 PM, Observed resident lying on the floor on back in Room 46 with wheelchair behind resident ... Intervention initiated to place resident on hourly checks to monitor whereabouts. -6/29/13 at 8:20 PM, Resident found on floor in hallway, tipped over wheelchair and lying on back. Resident to remain on hourly checks ... -6/30/13 at 10:20 AM, Resident up in wheelchair wandering about ... -7/1/13 at 2 AM, Resident's alarms sounding, resident attempting to get up. Resident up in wheelchair wandering the area ... -7/6/13 at 4 PM, Resident continues to wander through the facility ... -7/7/13 at 6 PM, Resident continues to wander through the facility ... -7/25/13 at 7:30 PM, Resident is up in wheelchair and self-propels in the halls ... -7/28/13 at 2:30 AM, Resident awake and restless, trying to get out of bed. Placed up in wheelchair at Nurse's Station ... During an observation on 7/24/13 at 3:15 PM, Resident 38 self-propelled in a wheelchair from the Activity Room down the Wing 1 hallway to the Nurse's Station. Resident observed to have a TABs alarm, sensor alarm, and a self-releasing safety-belt in place. A wander-guard bracelet was noted to the resident's left ankle. During an interview on 7/25/13 from 8:40 AM to 8:45 AM, Registered Nurse (RN)-S verified Resident 38 was self-mobile in wheelchair and frequently wandered around in the facility. In addition, RN-S identified Resident 38 had sustained several falls over the last quarter and remained at high risk for injury related to falls and wandering. During observation of the Activity Room on 7/25/13 at 10:48 AM; the door which led to an outside unsecured concrete patio was propped open with a chair and a continuous alarm was heard sounding. No facility staff was observed in the Activity Room at this time. Further observation revealed Resident 38 was outside of the facility on the patio. Two concrete sidewalks extended off the patio. 1 sidewalk led to a road adjacent to a baseball field approximately 50 feet from the patio and the second sidewalk led to the facility parking lot which was approximately 50 feet from the patio. No facility staff was observed outside with the resident. Resident 38 had removed the self-releasing seat belt and had attempted to stand up from the wheelchair. The TABs alarm remained attached to the back of the resident's shirt but was pulled taunt, and the alarm for the self-releasing seat belt and the sensor pad were both sounding. No facility staff responded to the open door alarm or to the Resident's personal alarms which all continued to sound. At 10:51 AM (3 minutes later), the Activity Director (AD) wheeled Resident 47 out of the facility through the alarming open door and positioned the resident on the patio next to Resident 38. The Activity Director cued Resident 38 to sit down and silenced the resident's alarms, then walked back into the facility leaving both residents unsupervised outside on the patio. The AD retrieved a 2-way radio from a desk in the Activity Room and returned outside and used the radio to request staff assistance to the Activity Room. The Activity Room door remained propped open and door alarm continued to sound, but no further facility staff responded to the alarm. During an observation on 7/25/13 at 10:58 the AD removed the chair from the Activity Room door leading to the unsecured patio and closed the door silencing the door alarm. No additional facility staff responded to the door alarm during the 10 minutes the door was open and alarming. During an interview on 7/25/13 at 11:00 AM, the AD verified Resident 38 was at risk for elopement and falls. In addition, the AD indicated the door had been propped open so residents could be taken outside for an activity. When asked if AD would normally leave the door open with residents outside and unsupervised, the AD indicated it depended on whether or not there was an Activity Assistant scheduled to work. During an interview on 7/25/13 at 11:05 AM, the Administrator verified the AD should not have left the Activity Room door propped open and left Resident 38 outside unattended. In addition, the Administrator indicated all staff should immediately respond to a continuously sounding alarm. During an interview on 7/25/13 at 2:30 PM, the Administrator identified Residents 38, 6, 60, 32, 30, 54, 50, 37, 28, 44 and 15 were at risk for wandering, exit seeking and/or using a wander-guard bracelet. During the environmental tour completed 7/31/13 from 10:32 AM to 11:27 AM, the Maintenance Supervisor verified the distance from where Resident 38 was positioned on the patio was 41 feet from the road and 51 feet from the facility parking lot. ABATEMENT STATEMENT Based on the following, the facility has removed the immediacy of the situation: 1.) Assessments regarding wandering, elopement and risk for falls have been completed on all facility residents. 2.) A list of all residents identified at risk for elopement, wearing a wander-guard bracelet and at risk for falls compiled and posted in manner to alert all staff. 3.) All staff educated on assuring the safety of residents; residents not to be left unattended outside, reviewed list of residents identified at risk for falls, elopement and wearing a wander-guard bracelet, no outside doors to be left propped open and staff to respond in timely manner to door alarms and wander-guard alarms and resident personal alarms. Education also provided to temporary staff employed by nursing pool agencies (pool staff) regarding safety of residents and the system implemented to assure pool staff were alerted to residents identified at risk for falls, elopement and wearing wander-guard bracelets. 4.) Schedule completed to assure adequate coverage for activities using Department Managers whenever an Activity Assistant not available. All Department Managers were educated on need to provide assistance as scheduled with activities. 5.) The Interdisciplinary Team updated the care management assignment cards of all residents to ensure interventions were identified for residents at risk for falls and elopement to ensure resident safety. The immediacy has been removed, however, the deficient practice is not totally corrected. Therefore, the scope and severity has been lowered to D. B. Review of the Owner's Operator and Maintenance Manual for the 1900/1900S Bath Lift (A bath lift is a type of wheeled chair which may be used for transport. The same chair is then used to lower and raise a resident into a whirlpool bathtub) dated 7/13 revealed the following "...During transfer, raise the seat so the resident's feet are suspended from the floor. DO NOT roll caster base over objects such as carpet, raised carpet bindings, door frames, or any uneven surfaces or obstacles that would create an imbalance of the lift and could cause the lift to tip over." C. Review of Resident 47's MDS dated [DATE] revealed [DIAGNOSES REDACTED]. The 7/8/13 MDS indicated the resident required extensive assistance for transfers. On 7/25/13 at 8:30 AM, NA-O (Nursing Assistant) was observed to wheel Resident 47, who was seated in the bath lift chair, down the corridor of Wing 2, over the raised carpet edge strip, across the carpeted area of the sitting area by the nurses' station, and over the raised carpet edge strip at the entrance of Wing 3. The bath lift chair seat was raised to a height of approximately 3.5 feet which caused the resident's feet and legs to dangle in the air. On 7/29/13 at 7:50 AM, NA-L was observed to wheel Resident 47, who was seated in the bath lift chair, down the corridor of Wing 2, over the raised carpet edge strip, across the carpeted area of the sitting area by the nurses' station, and over the raised carpet edge strip at the entrance of Wing 3. The bath lift chair seat was raised to a height of approximately 3.5 feet which caused the resident's feet and legs to dangle in the air. Interview with NA-T on 7/31/13 at 11:40 AM revealed residents were to be raised to a height where feet were "just barely" off of the floor when being transported in the bath lift chair. NA-T verified witnessing Resident 47 being transferred in the bath lift chair with the chair elevated to a level that was "too high". NA-T was not aware the policy indicated the bath lift chair was not to be rolled over raised objects such as carpet or raised carpet bindings.