Every finding on record at Boulder City Hospital SNF

Based on observation, interview and document review the facility failed to ensure a resident was treated with dignity and respect by allowing an inappropriate signage to be posted for 1 of 12 sampled residents (Resident 9). This deficient practice had the potential to compromise the resident's privacy. Findings include:On 05/05/2026 at 12:50 PM, two hand-written notes posted on R9's wall documented NPO nothing by mouth and please be careful when changing (NAME) because the orange cap on his tube feed keeps getting lost and then he gets tube feed all over him. On 05/05/2026 at 1:00 PM, a Registered Nurse (RN), indicated the signage should not be posted on the wall with personal information. The RN indicated it was considered a dignity issue. On 05/05/2026 at 1:14 PM, a Certified Nursing Assistant (CNA), indicated signage of resident's personal information should not be posted on the wall. The CNA confirmed having personal information posted is a breach in the residents' privacy and is a dignity concern. On 05/05/2026 at 1:30 PM, the Director of Nursing (DON) confirmed having a sign posted with resident information is a dignity concern and is against facility policy. The facility policy titled Residents Rights dated 01/20/2026 documented, residents have the right to privacy over their personal and clinical records. Residents privacy would include protected health information, personal care and medical treatments.

Based on observation, interview, record review, and document review, the facility failed to ensure a two-person assist was provided during a resident transfer and the resident's injury was timely reported to the assigned licensed nurse for 1 of 20 sampled residents (Resident 1).The deficient practice had the potential to result in further injury, delayed assessment and treatment, increased risk of infection, and other complications.Findings include:Resident 1 (R1) was admitted on [DATE], with diagnoses including weakness.The Minimum Data Set (MDS) dated [DATE] identified R1 had severe cognitive impairment. R1's interim functional status assessment documented the resident was dependent for chair/bed-to-chair transfer and toilet transfer requiring the assistance of two or more helpers.A Skin Assessment, provided by the facility in photocopy form with a partially cut image resulting an unclear date. The Skin Assessment documented a wound to R1's left arm during the AM shift. The Skin Assessment was signed by a Certified Nursing Assistant (CNA) and a Licensed Nurse.A facility report documented on 04/18/2026 at approximately 6:00 PM, R1 was observed in bed with a skin tear to the left upper forearm covered with dressing. Nursing staff identified there was no prior documentation or physician order for R1's identified injury. The report indicated the Director of Nursing (DON) was notified, and treatment was initiated after obtaining a provider order. The report revealed the facility conducted an investigation including staff interviews, record review, and a review of video surveillance. Investigation findings indicated the injury likely occurred on 04/17/2026 during a transfer from chair to bed performed by a CNA. R1 was unable to recall the cause of the injury and denied pain or that any staff harmed them. R1 indicated they felt safe at the facility and exhibited no psychosocial distress.On 05/05/2026 at 11:20 AM, R1 was verbally alert with confusion. When asked about the injury that occurred last month, the resident responded, I don't know. R1's bilateral arms were covered with protective sleeves; and a white bandage was noted on the left forearm beneath the sleeve.On 05/07/2026 at 1:35 PM, three Certified Nursing Assistants (CNAs) assigned to R1 on 04/17/2026 and 04/18/2026 were interviewed regarding R1's left arm injury. The CNAs acknowledged awareness of the incident. CNA1 and CNA3 indicated R1 was alert with episodes of confusion. CNA1 verbalized R1 was fragile, dependent for care, unable to safely transfer independently, and routinely required a two-person assist and/or Hoyer lift during transfers due to fearfulness, resistance during movement, frailty, and inability to assist with transfers. CNA1 indicated an agency CNA assigned to R1 transferred the resident without assistance despite R1's baseline two-person assist requirement and failed to immediately report the skin tear to nursing staff after the transfer. CNA2 indicated the facility investigation and video surveillance findings identified an agency CNA as the individual involved in the transfer when the injury occurred. CNA2 acknowledged the agency CNA failed to follow transfer assistance requirements, failed to report the injury timely, and provided wound treatment outside the CNA scope of practice. CNA3 verbalized the facility expectations required immediate reporting of any resident injury to the licensed nurse. The CNAs confirmed the agency CNA had frequently worked at the facility prior to the incident but was no longer observed working at the facility following R1's injury.On 05/07/2026 at 1:48 PM, the Social Worker indicated awareness of R1's injury and assisted with the investigation by interviewing residents and staff, ensuring the resident's well-being, and assessing for psychosocial distress following the incident. The Social Worker was not present during the initial investigation because the incident occurred over the weekend. The Social Worker indicated investigation findings revealed an agency CNA caused a skin tear to R1 during a transfer and subsequently failed to immediately report the injury to nursing staff. The Social Worker indicated the agency CNA was no longer permitted to work at the facility following the incident. The Social Worker indicated the failure to report the injury could be considered resident neglect. The Social Worker indicated the late reporting prevented prompt nursing assessment, treatment, physician notification, and implementation of interventions. The Social Worker indicated staff were expected to immediately report resident injuries to the licensed nurse. The Social Worker further indicated R1 did not demonstrate psychosocial distress related to the incident.On 05/05/2026 in the afternoon, the Director of Nursing (DON) indicated R1 was identified with a skin tear to their left arm on 04/18/2026. The DON indicated an agency CNA transferred R1 from chair to bed without assistance. The DON confirmed R1's baseline requirement for a two-person assist with the use of a Hoyer lift due to inability to transfer independently. The DON indicated video surveillance showed sufficient staffing was available, however the agency CNA failed to request assistance. The DON indicated the facility initiated an investigation for the injury of unknown origin, which included staff interviews, resident interviews, laboratory staff interview, staffing review, record review, and video surveillance review. The DON indicated video surveillance showed R1 without visible skin tear prior to entering the room with the agency CNA and later showed the agency CNA retrieving treatment supplies from the treatment cart after completing the transfer.The DON indicated the agency CNA failed to report R1's injury to nursing staff. Nursing staff later identified a dressing in place on R1's left arm; however, there was no corresponding documentation or treatment order in the medical record. The DON explained R1's injury was subsequently assessed, the physician and responsible party were notified, and treatment orders were initiated. The DON indicated the agency CNA provided inconsistent statements during the investigation and could not identify another staff member allegedly present during the transfer. The DON indicated the facility determined the skin tear likely occurred during the transfer from chair to bed performed by the agency CNA on 04/17/2026. The DON further indicated the agency CNA failed to timely report the injury to the Licensed Nurse. The DON indicated the agency CNA was reported to the agency and would no longer be permitted to work at the facility.On 05/07/2026 in the afternoon, the Risk Manager indicated the facility thoroughly investigated R1's injury of unknown origin. The Risk Manager indicated law enforcement was involved, and the agency CNA was reported to the Board. The Risk Manager confirmed the investigation findings and identified the transfer requirement was not followed, as R1 required two-person assistance with transfers. The Risk Manager indicated the agency CNA failed to obtain assistance during the transfer and failed to timely report R1's injury, which was later discovered when a dressing was observed on R1's left forearm during the investigation.A facility policy titled Resident Rights - Abuse, revised 02/11/2011, indicated residents have the right to be free from all forms of abuse, including physical abuse. The policy indicated the facility must implement procedures to protect residents from abuse, neglect, and mistreatment.

Based on observation, interview, record review, and document review, the facility failed to ensure the appropriate isolation precaution signage was used and appropriate personal protective equipment (PPE) worn while obtaining blood from the central intravenous line access for 1 of 20 sampled residents (Resident #37).The deficient practice had the potential to increase the risk of cross-contamination, transmission of infectious organisms, and infection to the resident, staff, and others within the facility. Findings include:Resident 37 (R37) was admitted on 04/30 2026, with diagnoses including urinary tract infection.On 05/05/2026 at 11:01 AM, an implanted port was noted on R37's right upper chest with a transparent dressing dated 05/04/2026. Intravenous (IV) antibiotic medication was infusing at the time of observation. Enhanced Barrier Precautions (EBP) signage was posted at the door, and a personal protective equipment (PPE) bin with supplies was available at the room's entrance.On 05/06/2026 at 2:40 PM, contact precautions signage was posted by R37's room door. The signage indicated to wear a gown and gloves prior to entering the resident's room, PPE supplies were available in the bin except for a mask. A Registered Nurse was observed drawing blood from the IV port on R3's chest without a gown. On 05/06/2026 at 2:50 PM, the same RN explained R37 was on contact isolation precautions due to body fluids infection. The RN explained R37 had not been turned or repositioned; therefore, a gown had not been worn while staff attempted to complete the blood draw procedure. The RN was observed going in and out of the room while continuing the procedure, including repeatedly accessing R37's chest intravenous (IV) port, filling multiple blood collection vials directly from the IV port without wearing a gown, and flushing the IV port at the completion of the procedure.On 05/06/2026 at 2:55 PM, a Charge Nurse (CN) explained when a resident was on contact isolation should wear a gown, gloves and mask were required depending on what kind of precautions. The CN was uncertain why R37 was on isolation and acknowledged there was no order in place. The CN could not differentiate the difference between EBP and contact precautions or transmission-based precautions (TBP).On 05/06/2026 at 3:10 PM, another RN indicated the EBP and TBP precautions are the same with gloves and mask should have been used upon entering the resident's room to prevent contamination.On 05/06/2026 at 3:20 PM, the Director of Nursing indicated R37 should have been on EBP not and not contact precautions. The DON indicated recently the facility provided education to staff regarding the types of precautions. The DON advised the staff to remove the contact precautions signage and change to EBP. The DON indicated a gown should have been worn when caring with R37's IV line.A facility policy titled Guidelines for Isolation Precautions revised 02/23/2024, indicated Enhanced Barrier Precautions (EBP) required staff to wear gown and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms (MDROs). The policy identified device care or use, including central lines, as a high-contact resident care activity requiring gown and gloves. The policy further indicated residents with any skin opening requiring a dressing and/or indwelling medical devices were at increased risk for MDRO transmission and healthcare workers should anticipate wearing gown and gloves during such care activities.

Based on observation, interview, and document review the facility failed to ensure an adequate pull string was attached to the emergency call light located in a resident's bathroom. The deficient practice had the potential to compromise resident safety and well-being in an emergency. Findings include: On 05/22/25 at 03:25 PM, an observation of the emergency call light in room [ROOM NUMBER], did not have a proper pull string (a cord which activated the device which was mounted to the wall). On 05/22/25 at 03:50 PM, the Licensed Practical Nurse (LPN) observed the emergency call light and stated the emergency call light did not have an adequate pull string to call for assistance. The LPN verbalized a resident would not be able to use the call light easily. On 05/22/25 at 03:52 PM, the Director of Nursing verbalized an emergency call light pull string must be long enough for a resident to reach in case of an emergency. On 05/22/25 at 03:53 PM, the Risk Manager stated the emergency call system should have a pull string accessible for residents. On 05/22/25, the facility policy and procedure titled Call Light System, revised 09/23/2014, documented all residents would have a call system accessible.

Based on interview and document review, the facility failed to ensure employees completed mandatory dementia training, for one of 10 sampled employees (Employee 9). The deficient practice had the potential to result in an employee being unprepared to respond appropriately to the altered mentation of residents with dementia. Findings include: On 05/22/2025, at 8:52 AM, 10 employee files were reviewed with the Director of Human Resources. Employee 9 (E9) was hired on 11/15/2024 for the position of Certified Nurse Assistant. On 05/22/2025, in the morning, the Director of Human Resources revealed mandatory dementia training was to be completed within 30 days after hire. The Director of Human Resources reported the purpose of the dementia training was to prepare employees to respond appropriately to residents with altered mentation. The Director of Human Resources verbalized E9's file lacked documented evidence dementia training had been completed. The facility policy and procedure title Mandatory Training (New Hires), dated 08/30/2018, indicated the facility provided all new hires with dementia training, to be completed within 30 days after general orientation.

Based on interview, record review, and document review the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted timely for 5 of 5 residents reviewed for Resident Assessment (Residents 11, 28, 27, 3, and 9). The deficient practice had the potential to impact resident care by also delaying the resident care plan. Findings include: The facility policy titled Assessments Periodic for Minimum Data Set (revised 10/25/2021) documented periodic assessments were conducted by the MDS Coordinator. The results of the assessments were used to create resident care plans and calculate resource utilization grouping categories used by regulators, payers, and surveyors. The facility MDS data from the resident assessment indicated data was more than 120 days for Residents 11, 28, 27, 3, and 9. The State MDS Coordinator documented in June 2023, there was a 20% late submission for residents at the facility. On 06/07/2024 in the afternoon, the Minimum Data Set (MDS) Coordinator indicated working remotely and only coming to the facility when there was a technical issue with connecting from home. The MDS Coordinator verbalized if there was a technical issue which prevented transmitting the resident assessment data, it could be late due to having to make preparations to come to the facility. The MDS Coordinator indicated it was the responsibility of the MDS Coordinator to notify the interdisciplinary team of assessment timeframe and develop a calendar for assessment completion. The MDS Coordinator explained having 14 days to complete transmission of the MDS data once the resident assessment was completed. The MDS Coordinator confirmed all MDS data was sent in batches, indicating there could be some assessments transmitted late based on the specific admitted s. The MDS coordinator verified the process of completing the resident assessment and as there was no direct contact with the resident, notes would be reviewed and if needed the author of assessment notes would be contacted. The MDS coordinator acknowledged the practice could lead to inaccurate or outdated information by the time the resident assessment was completed. The MDS coordinator verbalized there was no designated back up in case the MDS coordinator was not able to work, or access needed information. On 06/07/2024 in the afternoon, the Director of Long Term Care confirmed there was no access to any other staff member including the Director of Long Term Care to transmit MDS data as required. The Director of Long Term Care verbalized having to contact the MDS Coordinator on several occasions to correct data which was inaccurate on the resident assessment. The MDS Coordinator job description documented the MDS Coordinator was responsible to assess and/or coordinate the assessment of all residents and to complete the Resident Assessment Instrument (RAI) and transmit data to the appropriate entities timely.

Based on interview and document review the facility failed to ensure the quarterly payroll based journal (PBJ) data was submitted to Center for Medicare and Medicaid Services (CMS). The deficient practice prevented CMS from analyzing staffing patterns and populate the staffing component of the Nursing Home Compare website. A review of the facility Certification and Survey Provider Enhanced Reporting System (CASPER) report revealed the facility failed to submit staffing data for the first quarter of 2024. On 06/04/24 at 1:28 PM, the Minimum Data Set (MDS) Coordinator indicated being the person responsible for submitting the PBJ data and was aware the PBJ data was not submitted for the first quarter of the 2024 fiscal year. The MDS Coordinator explained being at facility once a week and was not in the facility when it was due. The MDS coordinator verbalized most of work was done remotely however, was unable to access information from remote workstation and was planning on completing the next day however became ill. The MDS coordinator revealed being the only one at the facility with access and ability to complete the report and indicated the Chief Nursing Officer was made aware the PBJ data was not submitted. 06/04/24 01:49 PM, the Director of Long-Term Care (Director) verbalized starting position in March of 2024 which was after the submission was due. The Director was aware the PBJ data was not submitted for the first quarter of 2024 and there was no system in place at the time for back up if the MDS Coordinator was not able to complete. The Director indicated the MDS Coordinator started working remote in December of 2023 and only came to the facility if required because of technical difficulties at remote workstation. The MDS Coordinator was the only staff member with access to reporting system to submit PBJ data.

Based on observation, interview, record review, and document review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 1 of 15 sampled residents (Resident 35). The deficient practice had the potential to deprive the resident of concern and other residents of necessary behavioral health services. Findings include: Resident 35 (R35) R35 was admitted on [DATE], with a diagnosis of schizophrenia. On 06/04/2024 in the morning, R35 was up in a wheelchair and stated had been at the facility for about 3 months. A PASARR level one document dated 01/12/2024, indicated R35 did not have dementia, mental illness (MI), intellectual disability (ID), mental retardation (MR), or any related condition (RC) and was deemed appropriate for nursing facility placement. The admission diagnoses from an acute care facility dated 01/26/2024, documented R35 had no cognitive deficits or diagnoses. The acute care facility physician progress note dated 01/28/2024, documented after talking to R35 and the family of R35, the nurse practitioner added the schizophrenia diagnosis to the admitting diagnoses and referred for a psychiatric (psych) consult and resident was subsequently placed on antipsychotic medication. On 06/06/2024 at 1:34 PM, the Social Worker (SW) confirmed the PASSAR level one was completed prior to the resident being admitted to the acute care facility and receiving the schizophrenia diagnosis. The SW confirmed the purpose of the PASARR was to ensure residents were appropriately placed and the facility could meet the needs of the residents. The SW explained the SW was responsible for completing the online PASARR requests. The SW indicated it was believed the referral for a PASARR level two was not necessary because the resident was not receiving any psych services and was stable on antipsychotic medication. On 05/28/2024, an alert charting nurse progress note documented the patient was masturbating while staff was providing care. The unacceptable behavior was discussed with the resident and the resident agreed and was cooperative. The medical record lacked documented evidence R35 was referred for a PASARR level two. The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities, or related condition, a PASARR Level II screening must be completed to evaluate the individual and determine if nursing facility services and/or specialized services are needed and can be provided in the nursing facility. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASARR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority.

Based on observation, interviews, record review, and document review, the facility failed to follow or clarify physician order regarding a suprapubic catheter size prior to insertion. The deficient practice had the potential to result in discomfort or inadequate drainage of the bladder. Findings include: Resident 31(R31) R31 was admitted on [DATE] with diagnoses including obstructive uropathy and severe neurocognitive deficit. On 06/04/2024 at 9:15 AM, resident was sitting in bed awake and alert. Resident indicated staff recently changed catheter. On observation the resident had suprapubic catheter inserted on right side abdomen. Dressing was soiled with yellow tinged fluid. On 06/07/2024 at 10:00 AM, a Licensed Practical Nurse (LPN) indicated all wound and any care treatments such as catheter care would be documented in the treatment book at the nurse's station. The treatment book would contain the most recent order for resident care. The treatment administration record for R31 indicated an order to change suprapubic catheter with 18 french 30 milliliter(mL) balloon monthly. A physician order in the electronic medical record indicated to change with 18 french 5 mL balloon every two weeks. On 06/07/2024 at 10:15 AM, the charge nurse confirmed suprapubic catheter currently inserted in R31 was a 16 french with 10 mL balloon. On 06/07/24 at 10:20 AM, the charge nurse indicated all catheter supplies were stored in the clean utility for residents which were not on hospice, the charge nurse confirmed resident was not on hospice. The charge nurse indicated the nurse completing the catheter change would use the order from the treatment administration record as the correct order and if the catheter was not available, the nurse would be able to get the correct size from the hospital central supply. If the correct size catheter was not available, the nurse would need to contact the physician to clarify order. The charge nurse indicated the staff should always follow the physician order and complete appropriately or clarify order. The facility policy titled Physician orders Execution (revised 08/24/2009) documented at no time was staff to execute a physician order which was inconsistent with their Practice Act or facility policies and procedures. Staff was not to perform an intervention without the required physician order. The facility policy titled Catheter Care (revised 09/06/2011) documented the facility would provide consistent care of an indwelling catheter to reduce infection, promote adequate drainage and comfort. Change catheters monthly with a physician order.

Based on observation, document review and interview, the facility failed to ensure stored foods were labeled and dated and food items were discarded prior to the expiration date. This deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness. Findings include: On [DATE] at 8:15 AM, an open bag of chicken tenders was stored in the walk-in freezer without a label as to what is in the bag or a date as to when the bag was opened. The Dietary Manager explained the open bagged item should have been dated as to when the bag was opened and labeled before placing the opened bag back in the freezer. The Dietary Manager had the staff label and date the bag during the survey. The Dietary Manager was able to determine when the bag was opened by the menu details. On [DATE] at 8:17 AM, a container of cottage cheese was stored in the walk-in refrigerator with an expiration date of [DATE]. The Dietary Manager explained the item should have been discarded. The Dietary Manager explained the process for checking for expiration dates was for staff to check the dates when a new shipment was received. The Dietary Manager discarded the expired food item during the survey. An undated policy with the subject entitled food storage revealed that all foods and supplies are to be clearly labeled. On [DATE], the Dietary Manager stated did not have any specific policies on labeling and dating foods nor on expired foods.

Based on observation, interview, record review and document review, the facility failed to ensure admission and weekly skin assessments were completed in accordance with the facility's wound care protocol for 3 of 12 sampled residents (Residents #17, #23 and #32). The failure resulted in a delay in treatment interventions which potentially placed the residents at risk for worsened or infected wounds. Findings include: Resident #17 (R17) R17 was admitted on [DATE] and readmitted on [DATE], with diagnoses including multiple sclerosis and chronic debility. On 04/18/2023 at 9:35 AM, R17 laid awake and alert in a bariatric specialty mattress. The resident reported being a longtime resident of the facility but recently returned from the hospital. The resident indicated having a stage three pressure ulcer in the sacral area which was identified and treated by hospital staff. The resident indicated no one in the facility had examined the resident's pressure ulcer since R17's readmission on the evening of 04/17/2023, nor discussed treatment options with the resident. The Hospital Discharge Summary dated 04/13/2023, documented left ischium (a bony prominence below the buttocks area) stage three and sacral diffused moisture-associated skin damage (MASD). Wound instructions included start Triad cream daily, continue aggressive offloading, turn every two hours, low air loss mattress to aid in offloading. The medical record lacked documented evidence an admission skin assessment was completed, and wound care instructions were transcribed and carried out since R17's readmission on 04/17/2023. An Admission note dated 04/17/2023, documented R17 had redness to buttocks. On 04/18/2023 in the afternoon, the Licensed Practical Nurse (LPN) assigned to R17 indicated visualizing R17's buttocks area during morning care and indicated the resident had more than redness to buttocks but rather had an open area described as red and beefy. The LPN indicated following old wound care orders which were in place prior to the resident's transfer to the hospital on 04/07/2023. The LPN acknowledged the LPN did not complete an admission skin assessment because the night shift nurse was expected to have done it. The LPN acknowledged not communicating the resident's pressure ulcer with the charge nurse, the director of nursing (DON) or a physician. On 04/18/2023 in the afternoon, the Director of Nursing (DON) indicated being a treatment nurse for many years and personally monitored residents with existing wounds. The DON indicated R17 did not have a pressure ulcer but rather a MASD in the buttocks area when R17 was sent to the hospital on 04/07/2023. The DON indicated R17's stage three pressure ulcer must have developed in the hospital and the LPN who identified R17's pressure ulcer on 04/18/2023 should have communicated the wound with the charge nurse, the DON, and the physician. The DON indicated it was not acceptable for the LPN to carry out old wound care orders because the orders were appropriate for R17's MASD and may not be appropriate for a stage three wound. The DON indicated an admission skin assessment must be completed within 24 hours of a resident's admission or readmission for timely interventions and to distinguish between hospital-acquired versus facility-acquired wounds. On 04/20/2023 at 8:05 AM, R17 indicated the admission nurse did not perform a head-to-toe skin assessment when the resident was readmitted on the evening of 04/17/2023. The resident recounted the pressure wound was covered with an Opti foam dressing and the nurse did not remove the dressing for visualization. Three Opti foam dressing kits were observed on the resident's bedside table, the resident indicated the resident was discharged with wound supplies in case the facility wanted to use them. On 04/20/2023 at 8:13 AM, the LPN and charge nurse were present when the resident consented to a wound observation. The nurses assisted R17 to the left side to visualize the resident's buttocks area. The charge nurse described the wound by direct observation as stage three to the left buttocks which was bright red and beefy and measured approximately 4.0 centimeters (cm) length (L) x 3.0 cm in width (W) x 0.5 cm in depth (D). The wound was covered with one piece of plain gauze, no drainage was present, and there was diffused MASD in the surrounding areas. The resident verbalized the pain from the wound was eight out of ten (8/10) on the pain scale. On 04/20/2023 at 8:21 AM, the charge nurse indicated when the resident was readmitted , medication orders from the hospital discharge summary were reviewed and discussed with the physician. The charge nurse explained not being informed the resident returned from the hospital with a stage three pressure wound. The charge nurse indicated reviewing R17's discharge medications and entered admission medication orders after discussing with the physician. The charge nurse reviewed the resident's hospital records and acknowledged not reading the document thoroughly and as a result, the charge nurse did not see the presence of a stage three ischium pressure ulcer and wound care instructions. The charge nurse acknowledged an admission skin assessment was not completed nor was the newly identified wound communicated by the LPN which resulted in a delay in wound care consult and appropriate treatment orders for R17's wounds. According to the charge nurse, the delay may potentially result in worsened wound and/or an infection. On 04/20/2023 at 8:29 AM, the Director of Nursing (DON) reviewed the Wound Care policy and confirmed an admission skin assessment was to be completed on all residents within 24 hours. The DON indicated not being familiar with the Wound Care Order sheet which was an assessment tool mentioned in the facility policy but was not being utilized. The DON indicated not being aware photographs were to be taken when a wound was identified on admission and every 72 hours thereafter to track progress in healing or failure to heal. The DON acknowledged an admission skin assessment which should have included photo documentation was not done for R17 when the resident was readmitted on [DATE]. On 04/20/2023 at 8:44 AM, the DON reviewed R17's hospital records and confirmed there was mention of a stage three pressure ulcer to the ischium with wound care instructions to use Triad cream daily. The DON indicated the charge nurse entered medication orders but failed to enter wound care orders. The DON emphasized the LPN who visualized the resident's wound in the morning of 04/18/2023 should have notified the charge nurse, the DON, and the physician to obtain orders for wound care consult and appropriate treatment orders. The Wound Care policy revised 02/06/2013, documented every resident upon initial assessment, was to be observed for the presence of a wound. If a wound was present, the Wound Care Order sheet must be initiated with a telephone order obtained from a physician upon discovery. A photograph of a presenting wound or pressure sore was taken upon admission and placed in the resident's medical record. Subsequent periodic photographs were to be taken every 72 hours showing the change in the wound or pressure sore to track healing or failure to heal. Resident #23 (R23) R23 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, severe morbid obesity, mitral and tricuspid valve insufficiency. On 04/18/2023 in the morning, R23 was seated in a wheelchair inside the resident's room. The resident indicated having multiple open wounds on back of thighs which were not improving and were painful. The resident indicated monitoring own wounds using personal cellphone camera because the facility was not monitoring the wounds. The resident indicated some nurses applied Vitamin A and D ointment on the wounds and some did not treat the wounds at all. The resident indicated had complained about the painful thigh wounds to nursing staff and a physical therapist (PT) came to evaluate the wounds, but nothing was done about it. The medical record lacked documented evidence weekly skin assessments were performed and treatment orders were obtained for the resident's thigh wounds. On 04/19/2023 at 11:07 AM, the charge nurse confirmed there were treatment orders in place for the resident's moisture-associated skin damage (MASD) to buttocks and abdominal fold redness but there were no treatment orders for the resident's back of thigh wounds. The charge nurse explained the facility did not utilize a form or tool specific to weekly skin assessments but rather, nurses documented the residents' skin condition in the nursing weekly summary notes. A four-month look back of the R23's weekly summary notes revealed the resident's skin condition was not included when the nurses performed R23's weekly assessments on 04/17/2023, 04/10/2023, 04/03/2023, 03/20/2023, 03/06/2023, 02/27/2023, 02/20/2023, 02/06/2023 and 01/23/2023. On 04/19/2023 at 11:12 AM, the Director of Nursing (DON) confirmed there were no treatment orders in place for R23's back of thigh wounds and corroborated the charge nurse's explanation skin assessments were included in the nurses' weekly summary notes. The DON indicated it was not acceptable R23's skin condition was not included in the nurses' weekly summaries. According to the DON, newly identified wounds would be communicated to the charge nurse, the DON, the physician, and the Physical Therapist (PT) who performed wound evaluations and was involved in treatment of complicated wounds. On 04/19/2023 at 11:16 AM the PT explained complicated wounds necessitating advanced wound care such as sharps debridement and wound vacuum device were referred to PT when traditional treatment performed by nurses were not improving the resident's wound. If a wound could not be managed in-house, the resident would be referred to a wound clinic or a dermatologist. The PT clarified R23's bilateral posterior thigh wounds which were first identified by the PT on 02/01/2023, were not considered pressure sores because it was not located on a bony prominence but rather caused by friction and sheer from sitting in the wheelchair complicated by the resident's morbid obesity. An Outpatient PT Evaluation dated 02/01/2023, documented resident referred for wound consult to buttocks region. R23 reported painful areas in bilateral posterior thighs. Areas of scattered denuding (removal of surface layers) on bilateral posterior thighs with no dressing present. Recommendation for nursing to continue with current intervention while PT would do product research for better interventions. On 04/19/2023 at 11:33 AM, the PT explained a wound evaluation would include wound measurements, description of wound base, presence of tunneling and undermining, odor, drainage, type, amount and condition and pain. The PT indicated a full wound evaluation was not completed for R23 and findings were not reported to the physician because the PT indicated the wounds were stable and current regimen was working. The medical record lacked documented evidence there was a treatment regimen for the resident's bilateral posterior thigh wounds. On 04/19/2023 at 11:47 AM, R23 consented to a wound observation conducted by the DON and the PT with inspector present. The resident stood from wheelchair and leaned towards the bed exposing backside. The DON counted six open wounds on the resident's left back thigh with the largest one measuring 1.5 cm length (L) x 1.0 cm width (W) x 0.00 cm depth (D). The resident sat back down in wheelchair and showed the DON an open area on the left abdominal area which was caused by the resident's fingernails when the resident tried to lift abdominal fold for the nurse. The PT described the wound as a trauma wound measuring 1.0 cm (L) x 2.0 cm (W) x 0.3 cm (D). The resident then lifted abdominal fold and pointed to two open areas which was causing the resident pain. Using a ruler, the DON described the wounds as open areas of MASD origin measuring 1.5 cm (L) x 2.0 cm (W) x 0.00 (D) for the first wound and 1.0 cm (L) x 0.5 cm (W) x 0.00 (D) for the second wound. On 04/19/2023 at 12:00 PM, the DON explained R23 was admitted on [DATE] with wounds on chest and back of head but there were no wounds on the bilateral posterior thighs, abdominal folds, and abdomen. The DON indicated performing weekly skin assessments were important for timely identification and treatment of new wounds. The DON indicated the PT who identified skin impairments to R23's bilateral posterior thighs on 02/01/2023 should have communicated findings with the charge nurse, the DON, and a physician to ascertain whether a wound consult and treatment orders were necessary. On 04/19/2023 at 12:09 PM, the PT acknowledged not communicating findings from the PT evaluation on 02/01/2023 to nursing staff because no new recommendations were deemed necessary. The PT determined the physician did not need to be notified of the findings because R23's wounds appeared to be stable, and the current regimen was working. The PT indicated not knowing there were no treatment orders in place for R23's bilateral posterior thighs and assumed the ointment used for the resident's buttocks were being applied on R23's thighs as well. On 04/19/2023 at 12:25 PM, the DON verbalized routine skin assessments allowed nurses to track whether a wound was healing or worsening and allowed for re-evaluation of current regimen to assess for effectiveness. The Wound Care policy revised 02/06/2013, documented assessment and documentation of wound status and dressing changes performed at least weekly would include clinical data demonstrating evidence of progress in healing or failure to heal. An order sheet for Wound Care was to be provided to the physician when a wound was identified to obtain comprehensive orders. 40131 Resident 32 (R32) R32 was admitted on [DATE], with diagnoses including dementia and debility. The Brief Interview of Mental Status dated 02/23/2023, documented a score of 6/15, which means R32's cognitive status was severely impaired. On 04/18/2023 at 10:16 AM, R32 was lying in bed in a supine position. An intravenous (IV) antibiotic, Cefepime was hanging and connected to R32. An odor was noted around the resident. The assigned Licensed Practical Nurse (LPN) indicated the antibiotic was for R32's wound infection in the coccyx. The PT Evaluation dated 03/14/2023, documented a stage II pressure wound in the coccyx with a size of 3.2 x 1.2 x 0.3 cm, no tunneling, no undermining, and minimal serosanguinous drainage. The PT Note dated 04/06/2023, documented the wound as a stage IV pressure injury with a size of 2.4 x 1.2 x 2.2 cm. The PT Note dated 04/10/2023, documented the coccyx wound as a stage IV pressure injury with a size of 2.7 x 2.0 x 2.2 centimeters (CM), tunneling of 1.4 cm at 1:00 o'clock, and a moderate odor. The serosanguinous amount was moderate-heavy. On 04/19/2023 at 12:03 PM, the LPN performed wound care on R32's coccyx area. The LPN confirmed the dressing was soiled, undated, and the alginate packed inside the wound had disintegrated. The LPN was uncertain when it was last treated or the dressing changed however, the treatment order was daily. R32's medical record lacked documented evidence a skin assessment or wound measurement was consistently performed. On 04/18/2023 at 11:00 AM, the charge RN confirmed the skin assessment, wound measurement, or photograph were not consistently completed per policy.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician order was obtained for the insertion of a peripherally inserted central catheter (PICC) line, and care orders were transcribed for 1 of 12 sampled residents (Resident 32). The failure to obtain a physician's order before inserting the PICC line and to manage the PICC line insertion site could potentially lead to serious medical complications for the resident which may include infections, bleeding, nerve damage, or life-threatening events. Findings include: R32 was admitted on [DATE], with diagnoses including dementia and debility. The Brief Interview of Mental Status dated 02/23/2023, documented a score of 6/15, which means R32's cognitive status was severely impaired. The Informed Consent for Procedure Administration of Anesthetic and/or the Rendering of Other Medical Services dated 04/07/2023, documented the procedure Peripherally Inserted Central Catheter (PICC) Line was consented to by a family through telephone. The PICC Insertion Record dated 04/08/2023, documented a PICC line was inserted into the RUA PICC line. On 04/18/2023 at 10:16 AM, R32 was lying in bed. An intravenous (IV) antibiotic, Cefepime was hanging and connected to R32 ' s PICC line inserted in the right upper arm (RUA). The PICC line dressing was undated and wrapped with a bandage. The Nurse Progress Note dated 04/18/2023, documented the PICC line was discontinued. On 04/19/2023 at 2:00 PM, the PICC line which had been inserted in R32's RUA was discontinued. A Licensed Practical Nurse (LPN) indicated the reason for discontinuing the PICC line was R32 would be admitted to hospice services. The medical records of R32 did not have any documented evidence a physician's order was in place for the insertion, utilization, care, or management of the PICC line, or for its discontinuation. On 04/20/23 at 10:10 AM, a Registered Nurse (RN) indicated R32's PICC line was inserted on 04/08/2023, and consent was obtained from the family via telephone conversation. The RN indicated R32 was a hard stick and required multiple antibiotic medications for the osteomyelitis and an unstageable wound in the coccyx area. The RN confirmed there were no orders in place for the PICC line insertion and care orders. The RN explained the process was to obtain and transcribe PICC line orders prior to insertion, and a care order set should have been in place. The RN explained the PICC line order set included the changing of the dressing, monitoring the site for signs of infection, and flushing, but these were not done. On 04/20/2023 at 11:15 AM, the Charge Registered Nurse (CRN) confirmed there were no orders for the PICC line insertion/discontinuation or care orders in place. The CRN indicated the process was to get consent from the resident or the family, obtain the orders, and transcribe in the resident's electronic record. On 04/20/2023 at 11:30 AM, the Director of Nursing (DON) confirmed there were no orders in place for the PICC line insertion or discontinuation. The DON indicated the nurses were responsible and expected to obtain PICC line orders and transcribe to the resident's electronic record before insertion. The DON confirmed there were no care orders for PICC line management such as: flushing, site monitoring, and dressing changes. A facility policy titled PICC lines dated 11/06/2020, documented the need to provide a reliable source of venous access for antibiotics. A physician's order would be written and signed by the physician and placed in the medical record. The PICC line should be flushed twice a day. PICC line dressing was to be changed after the first 24 hours, every 7 days, and as needed. A facility policy titled Physician Orders revised on 11/18/2012, documented the facility would provide all medication, treatment, and authorized care by staff for residents based on physician orders. The orders must be transcribed and verified by the nurse before being implemented. Medication orders must be linked to a diagnosis in the progress note or within the order.

Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure the Oxygen (O2) orders were followed and parameters were clarified for 2 out of 12 sampled residents (Residents 32 and 9). The failure to follow O2 orders and clarify parameters could have potentially led to serious health complications, such as hypoxia (O2 deficiency) and hyperoxia (excess O2 supply), organ damage, cognitive impairment, and death. Findings include: A facility policy titled Procedure for Administering Oxygen by Cannula revised 05/21/2023, documented to verify the order. Adjust the flowmeter as ordered. Resident 9 (R9) R9 was admitted on [DATE], with diagnoses including cerebrovascular accident and myocardial infarction. The Brief Interview of Mental Status dated 03/13/2023, documented a score of 15/15, indicating R9's cognitive status was intact. The Minimum Data Set, dated dated dated [DATE], documented R9 was receiving Oxygen therapy. On 04/18/2023 at 09:55 AM, R9 was lying in bed with the head of the bed elevated, receiving O2 at 1 LPM through a nasal cannula. The O2 tubing did not have a date. R9 indicated the O2 order was for 2 LPM continuously, the O2 was helpful, and there were no breathing difficulties. A physician order dated 03/21/2023, documented R9 was prescribed Oxygen therapy at 2 LPM continuously through a nasal cannula. The order specified, the O2 flow rate should be adjusted as tolerated to maintain an O2 saturation level of 92% or greater. The order did not provide any parameters regarding how much titration was required for adjusting the O2 flow rate. On 04/19/2023 at 9:30 AM, the Charge Registered Nurse (CRN) confirmed the O2 flow meter order for R9 was 2 LPM, but the O2 was being administered at only 1 LPM. The CRN indicated the Respiratory Therapist, and the nurses were expected to verify the order to ensure the correct O2 flow rate was being delivered and the titration parameters should have been clarified. On 04/19/2023 at 9:45 AM, the Director of Respiratory Services acknowledged R9's order should have been clarified as administering O2 at 2 LPM continuously through a nasal cannula, and titrating O2 at 1-6 LPM to maintain O2 saturation at 92% or greater. The Director of Respiratory Services conveyed the O2 flow rate orders and parameters should have been followed. On 04/19/2023 at 9:55 AM, the Director of Nursing (DON) confirmed R9's O2 order had not been followed. The DON indicated the staff was expected to verify and follow the orders for the O2 flow rate to ensure the residents received what had been prescribed, and if there was any confusion it should have been clarified. Resident 32 (R32) R32 was admitted on [DATE], with diagnoses including dementia and debility. The Brief Interview of Mental Status dated 02/23/2023, documented a score of 6/15 indicating R32's cognitive status was severely impaired. On 04/18/2023 at 10:18 AM, R32 lay in bed. R32 was receiving 1 LPM of O2 through a nasal cannula connected to the wall's O2 supply, and both the tubing and the humidifier bottle lacked date labels. Noisy respirations could be heard during R32's breathing, and shortness of breath was noted. A physician order dated 04/17/2023, documented 2, nasal cannula, greater than or equal to 90, PRN usage or titrate as tolerated, or off days/on nights, etc., constant indicator. On 04/19/2023 at 9:01 AM, R32 lay in bed, and O2 was being delivered at 1 LPM through a nasal cannula. A Licensed Practical Nurse (LPN) confirmed R32 was receiving O2 at 1 LPM and verified the O2 order. The LPN stated R32's O2 order was a PRN and could be titrated to maintain saturation at more than 90%, but that it was supposed to be at 2 LPM. On 04/19/2023 at 9:30 AM, the Charge Registered Nurse (CRN) confirmed the O2 orders were confusing, as it was unclear whether it was PRN or continuous and there were no titration parameters indicated. The CRN indicated the Respiratory Therapist was responsible for O2 orders. On 04/19/2023 at 9:45 AM, the Director of Respiratory Services acknowledged R32's order was of 2 LPM continuously through nasal cannula and titration parameters should have been clarified. On 04/19/2023 at 9:55 AM, the DON confirmed the prescribed setting for R32's O2 flow meter was 2 LPM continuously, but it had been administered at 1 LPM. The DON indicated the staff was expected to verify the O2 orders to ensure the residents safety. The hospice policy titled Oxygen Safety (undated) stated that Oxygen was considered a drug and that excessive or insufficient amounts could be harmful. It was advised to use Oxygen only as prescribed by the physician.

Based on interview, record review and document review, the facility failed to ensure a pharmacy recommendation which was approved and signed by a physician for a resident's psychiatric evaluation was carried out for 1 of 12 sampled residents (Resident #23). The failure potentially delayed a re-evaluation of the resident's medication regimen which was essential in maintaining the highest practicable mental, physical, and psychosocial well-being of the resident. Findings include: Resident #23 (R23) R23 was admitted on [DATE], with diagnoses including major depressive disorder and anxiety disorder. A Pharmacy note to attending physician or prescriber dated 03/07/2023, documented Resident #23 is receiving multiple psychotropic agents and due for psychiatric follow up. The document contained a physician/prescriber response dated 03/21/2023 which read, Agreed. Psychiatric consult pending. The medical record lacked documented evidence the physician order for psychiatric consult was entered into R23's medical record and staff followed up with the psychiatrist to re-evaluate R23's medication regimen. On 04/20/2023 at 10:05 AM, the charge nurse indicated being familiar with the pharmacist recommendations for R23's psychiatric consult due to being on multiple psychoactive medications. The charge nurse acknowledged not following through on R23's psychiatric consult since the psychiatrist signed the recommendation on 03/21/2023. The charge nurse verbalized agreeing R23 needed to be seen by a psychiatrist due to ensuing behaviors of yelling and cursing at staff. The charge nurse indicated R23 was last seen by the psychiatrist on 11/18/2020 for anxiety management. On 04/20/2023 at 10:12 AM, the Director of Nursing (DON) indicated the psychiatrist was in the facility on 03/21/2023 and personally signed the pharmacy note. The DON reported reaching out to the psychiatrist on 03/22/2023 to schedule R23's evaluation but the psychiatrist did not respond to the DON and there were no further attempts to contact the psychiatrist since 03/22/2023. On 04/20/2023 at 10:30 AM, the DON indicated having issues with the current psychiatric provider who was difficult to reach. The DON indicated the medical director should be notified when facility experienced issues with other providers who could not attend to the resident's needs. The DON acknowledged issues with psychiatry services had not been discussed with the medical director and should have been. On 04/20/2023 at 10:38 AM, the Consultant Pharmacist recalled writing R23's medication regimen review on 03/07/2023 wherein the pharmacist made a recommendation to have the resident seen by a psychiatrist. The Consultant Pharmacist explained residents who were on multiple psychoactive medications benefited from psychiatric oversight especially because the resident was known to continue with behaviors. The Consultant Pharmacist indicated a yearly psychiatric evaluation, at minimum was recommended for residents on multiple psychoactive medications. The Medication Administration policy reviewed 09/10/2021, documented the consultant pharmacist will do a complete review of all residents' records, medications, and orders monthly. The Consultant Pharmacist recommendations are reviewed by the charge nurse and director of nursing (DON). If action is required, the consultant pharmacist generates a note to the attending physician/prescriber. The attending physician/prescriber is asked to agree, disagree, or provide another alternative. Documentation of follow through is noted in the resident's electronic health record.

Based on interview, record review and document review, the facility failed to ensure there was a documented indication for use for psychotropic medications orders for 1 of 12 sampled residents (Resident #23). The failure potentially placed the resident at risk for receiving unnecessary medications. Findings include: Resident #23 (R23) R23 was admitted on [DATE], with diagnoses including major depressive disorder and anxiety disorder. The Psychotropics/Antipsychotics Use policy revised 09/02/2015, documented the resident's entire medication regimen would be managed and monitored to achieve the following goals: to achieve the highest practicable mental, physical, and psychosocial well-being in collaboration with the attending physician and facility staff. Each resident would receive only those medications, in doses and for the duration clinically indicated to treat the resident's assessed conditions. Prior to initiating an antipsychotic medication, the physician would complete the antipsychotic diagnosis form and a medical rationale must accompany the medication order. A physician order dated 03/13/2023, documented to give Buspirone 15 milligrams (mg) by mouth every six hours. The medical record lacked a documented rationale for use of Buspirone (anti-anxiety drug). A physician order dated 09/12/2022, documented to give Trazadone 100 mg by mouth at hour of sleep. The medical record lacked a documented rationale for use for Trazadone (anti-depressant). A physician order dated 12/20/2022, documented to give Xanax 0.25 mg by mouth every 8 hours routinely. The medical record lacked documented rationale for use for Xanax (anti-anxiety). A physician order dated to give Wellbutrin extended released (XL) 50 mg by mouth once daily as evidenced by isolation and feelings of depression. The medical record lacked documented rationale for use of Wellbutrin (anti-depressant). A Skilled Nursing Facility Informed Consent for Psychotherapeutic Medication and Antipsychotic diagnosis form dated 07/27/2022, documented medication orders for the following: -Trazadone 50 mg -Wellbutrin XL 150 mg -Buspirone 20 mg -Xanax 0.25 mg The consent form lacked documented diagnoses or indication for use of the above-mentioned medications. On 04/20/2023 at 2:13 PM, a Licensed Practical Nurse (LPN) reviewed the psychotropic consent form and confirmed the form which was signed by the resident, a nurse, and a physician on 07/27/2022 did not contain any medical diagnoses or indication for use for Trazadone, Wellbutrin, Buspirone and Xanax. On 04/20/2023 at 2:15 PM, the Director of Nursing (DON) reviewed the facility's policy on psychotropic medications and R23's Skilled Nursing Facility Informed Consent for Psychotherapeutic Medication and Antipsychotic diagnosis form signed 07/27/2023 and confirmed the nurse and physician who signed the document did not follow the facility's policy when they failed to document a medical diagnoses or indication for use of R23's Trazadone, Wellbutrin, Buspirone and Xanax. On 04/20/2023 at 2:26 PM, the Medical Director reviewed the facility's policy on physician orders and R23's Skilled Nursing Facility Informed Consent for Psychotherapeutic Medication and Antipsychotic diagnosis form signed 07/27/2023. The Medical Director indicated R23's medication orders for Trazadone, Wellbutrin, Buspirone and Xanax should have included had documented medical diagnoses or indication for use in accordance with the facility policy. The Medical Director indicated having signed the same forms for other residents and made sure an indication for use was present. The facility policy Physician Orders revised 11/18/2012, documented antipsychotic medications were to be prescribed for a specific identified diagnoses which is written as part of the order.

Based on observation, interview and document review, the facility failed to ensure outdoor and indoor visitation was provided for 10 of 34 residents. Findings Include: On 10/12/2021 at 8:00 AM, There were signs on the front door entrance to the hospital indicating No visitors allowed due to COVID-19. The Long-Term Care (LTC) unit was accessed by entering the hospital waiting room area and walking through the building to the LTC unit. The LTC unit was in the back of the building and was a separate area from the hospital. The LTC unit had multiple doors to the outside and had two courtyards. One courtyard had an awning with three tables and multiple chairs. Part of the courtyard had benches located in a sunny area. The other courtyard was not blocked in. There was access to the parking lot, and it was located on the west side of the building. The courtyard was a cemented area with a table. There was a door from the LTC unit to the courtyard. CMS QSO 20-39 Revised 04/27/2021 documents: Facilities should allow indoor visitation at all times and for all residents (regardless of vaccination status), except for a few circumstances when visitation should be limited due to a high risk of COVID-19 transmission (note: compassionate care visits should be permitted at all times). These scenarios include limiting indoor visitation for: - Unvaccinated residents, if the nursing home's COVID-19 county positivity rate is >10% and <70% of residents in the facility are fully vaccinated; - Residents with confirmed COVID-19 infection, whether vaccinated or unvaccinated until they have met the criteria to discontinue Transmission-Based Precautions; or - Residents in quarantine, whether vaccinated or unvaccinated, until they have met criteria for release from quarantine. Required Visitation Facilities shall not restrict visitation without a reasonable clinical or safety cause, consistent with 42 CFR § 483.10(f) (4) (v). A nursing home must facilitate in-person visitation consistent with the applicable CMS regulations, which can be done by applying the guidance stated above. On 10/12/2021 at 9:12 AM, Resident #32 (R32) had family pictures located around the room. R32 indicated having one daughter and 5 grandchildren, but they couldn't visit because visitation was not allowed due to COVID-19. R32 had regular video calls with family. On 10/12/2021 at 9:30 AM, two residents in room [ROOM NUMBER] indicated to being at the facility for a while and verbalized the facility was not allowing visitation by family and friends. The facility was only allowing face time and window visits. Both residents reported wanting to visit family in person. According to the facility the last visitation was on 8/10/2021. On 10/13/2021 at 9:32 AM, Resident #11 (R11) and Resident #19 (R19) were roommates and indicated care provided by the facility was adequate. The residents did not have visitation due to COVID-19 and communicated with family and friends through other means. On 10/13/2021 at 9:45 AM, Resident #23 (R23), verbalized wanting visitation to be allowed at the facility. R23 explained it had been months since holding a grandchild. On 10/13/2021 at 10:38 AM, Resident #22 (R22) had family pictures in the room. R22 indicated being very close to a brother but they had not seen each other for a while due to no visitation at the facility. R22 and the brother talked on the phone often. On 10/13/2021 at 1:00 PM, during the Resident Council meeting, four of the five residents verbalized wanting visitation at the facility to resume. They indicated the facility would not allow visitation due to a resident being positive at some point in the past two months. One resident tearfully explained I want to see my other half, and I feel caged. The resident explained a family member was [AGE] years old and could not do window visits. The windows were closed, and they had to speak through the phone. When there were in person visits, the family had visited often. The resident reported to having a hard time explaining to the family member why they could not visit each other. The resident talks to family 5 to 6 times a day over the phone. On 10/15/2021 at 10:30 AM, the resident from the Resident Council meeting, again reported to being upset and angry that visitation was not allowed with their partner. The resident verbalized the one resident who had tested positive for COVID-19 had been discharged a long time ago and no one currently had COVID-19. The resident requested we do something to have the facility start visitation again. Another resident described the window was closed and they could only hear each other through the phone. The resident verbalized to not liking this form of visitation. The resident explained the facility also prohibited residents from visiting each other in resident rooms. The resident missed seeing friends and being able to sit and talk and watch TV in a more private setting. It wasn't the same when they had to watch a movie with several residents in the activity room. The resident explained when they were in the activity room masks were not required. Another resident explained the open areas outside were utilized to visit with family back in March and during the summer, so they did not understand why they could not have visits now. On 10/13/21 at 1:41 PM, the Activities Director (AD) verbalized visitation was allowed in December 2020, for Hospice residents. Indoor visitation for all other residents resumed on 03/26/2021. The facility started allowing indoor visits in the resident rooms if there was no roommate or in the small activity room. The facility utilized the plastic box provided by the State's Ombudsman's office when providing outdoor visitation on the long-term patio located on the west side of the LTC unit. The AD verbalized on 08/10/2021, the Chief Nursing Officer (CNO) communicated to all staff, visitation of family and friends would stop for the hospital and LTC unit due to the community COVID-19 positivity rate. There were no cases of COVID-19 in the LTC unit at the time the visits were stopped. The AD frequently discussed visitation with the CNO and has been told the CNO was monitoring cases in the community. On 10/13/2021 at 2:46 PM, the Director of Nursing (DON), the Infection Preventionist (IP) and the CNO explained the visitation was now based on transmission rate and no longer county positivity rate since the end of August 2021. The county positivity rate for COVID-19 in August 2021 according to the IP: -08/10/2021 18.4 % (last in-person visit in the LTC unit) Per IP no resident or staff cases -08/17/2021 not recorded, but high Per IP no resident or staff cases -08/24/2021 15% positivity rate Per IP no resident or staff cases -08/31/2021 10.9% positivity rate. Per IP no resident or staff cases The facility switched to transmission-based rates and no longer relied on county positivity rates in September 2021. The following dates were recorded as high transmission rates for COVID-19: 09/ 07/2021, 09/14/2021, 09/21/2021, 09/28/2021, 10/05/2021 and 10/12/2021. There were no resident cases of COVID-19 in September 2021. The CNO read page 3 of the CMS QSO-20-39-NH revised 04/27/2021 re: indoor visitation. The revised CMS memo did not indicate facilities were to use the transmission rate to determine visitation. The IP reported a CNA was positive for COVID-19 during morning check using the Veritor rapid test kit on 10/08/2021 and was sent home. A polymerase chain reaction (PCR) test confirmed the CNA was positive for COVID-19. The CNA had not worked in over a week when tested , and no one was exposed. The DON, the IP and the CNO verbalized currently there were no COVID-19 positive residents in the facility (SNF and Hospital). The last COVID-19 positive resident was discharged last week and was only admitted to the facility for three days. On 10/13/2021 at 2:58 PM, the IP verbalized the vaccination rate was 97%. One resident was in the process of obtaining the second injection for the COVID-19 vaccination. The IP was to provide the list of staff vaccinated but the list was not provided. The IP indicated quite a few staff members had been vaccinated. The CNO explained the LTC unit was a distinct part of the critical access hospital so access to the LTC unit was through the hospital. The hospital itself was on lock down to visitors as well as acute hospitals in the area. There was no other alternative access to the LTC unit except through the hospital. The CNO reported as of 10/13/2021, there were no cases of COVID-19 in the hospital. The CNO verbalized that due to the high rate of COVID-19 transmission rate in the county and the chance a COVID-19 patient could come into the emergency room of the hospital the facility had stopped all visitation for both the hospital and the LTC unit. Outdoor visits were ongoing with the designated area outside the DON's office. It remained hot up until the last couple of weeks and then it was windy, so visits were halted due to the weather. The emergency room waiting area was to the left as you entered the facility. Patients in the waiting area all had surgical masks on. Visitors would walk to the right of the waiting area and be screened by the receptionist who was behind a Plexiglas window. Visitors would have no need to walk through the emergency room waiting area to gain access to the LTC unit. The LTC unit had other doors leading to the outside. On 10/13/2021 at 3:05 PM, the Activities Director verbalized not knowing outdoor visitations were still allowed. The last indoor visit was on 08/10/2021. The Activities Director was the only staff member who coordinated visitations. On 10/13/21 at 3:14 PM, the DON indicated outdoor visits were offered during summer, but it was so hot and windy residents didn't want to continue with outdoor visits. Window visits and virtual visits were being used as an alternative. The CNO verbalized not having received the revised QSO-20-39-NG memo revised on 4/27/2021 from the Centers for Medicare/Medicaid Services (CMS), which documented to allow visitation for LTC residents. The CNO verbalized to not having an updated policy reflecting the new CMS changes for visitation. The current facility policy, Covid-19 Visitation Action Plan, revised 08/11/2021, documented all visitors would need to wear a mask, wash hands, be screened, escorted from the lobby to the appropriate area, only one visitor at a time and to social distance. This policy was previously revised on 03/11/2021, which allowed visitation.

Based on interview and document review, the facility failed to ensure an allegation of staff to resident verbal abuse was reported to management in a timely manner by a staff member for 1 of 14 residents (Resident #10). Findings include: Resident #10 (R10) R10 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On 10/14/2021, a Certified Nursing Assistant (CNA) reported to the Director of Nursing (DON) that R10 had reported being verbally abused on 09/30/2021. R10 reported an unknown staff member came into the resident's room and told the resident would be better off dead. On 10/15/2021 at 10:30 AM, the CNA verbalized R10 had reported to the CNA the allegation of verbal abuse on 09/30/2021 but forgot to inform management. The CNA was aware the abuse should have been reported right away. R10 had reported another staff member had told the resident would be better off dead. The CNA reported to getting busy and forgetting to report the allegation. On 10/15/2021 at 11:00 AM, the DON reported having several in services and meetings about abuse. The CNA was part of these trainings. The facility policy, Reporting Suspected Abuse, dated 05/17/2018, documented a suspected incident of resident abuse and/or neglect must be reported immediately to a Manager/Director, the Risk Manager, and the Chief Nursing Operator.

Based on interview, record review and document review, the facility failed to ensure a medication was administered as ordered for 1 of 14 sampled residents (Resident #31). Findings include: Resident #31 (R31) R31 was admitted on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/2021 at 10:07 AM, the Charge Registered Nurse (RN) indicated medications ordered to be given every eight hours were automatically scheduled for 6:00 AM, 2:00 PM and 10:00 PM, unless the physician specified a different time schedule. The Charge RN indicated R31's [MEDICATION(S)] was scheduled for 6:00 AM, 2:00 PM and 10:00 PM, but nurses were allowed a one-hour window to administer scheduled medications specifically one hour before or one hour after the scheduled time. R31's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/14/2021 at 10:10 AM, the Charge RN indicated the nurse who administered R31's [MEDICATION(S)] on the evening of 10/13/2021 did not document a reason why the medication was administered more than two hours earlier than scheduled. The Charge RN indicated it was possible the resident requested the medication early due to pain issues, but this request would need to be approved by the physician and documented in medical record. The Charge RN indicated the night shift nurse did not follow the facility's medication administration protocol to administer medications as scheduled and failed to document the reason why the medication was given off schedule. On 10/14/21 at 10:49 AM, the Director of Nursing (DON) explained the facility medication administration practice allowed for scheduled medications to be given one hour before or one hour after the scheduled time. If a resident requested the medication earlier than scheduled, the nurse must explain to the resident why the medication could not be given early, should have performed an assessment, and identified alternative interventions to address the resident's needs. The DON indicated a medication could only be given off schedule with physician's approval and this must be documented in the medical record. The DON indicated the night nurse who administered the resident's [MEDICATION(S)] on 10/13/2021 did not follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/15/21 at 8:11 AM, Resident # 31 indicated receiving [MEDICATION(S)] three times a day for nerve pain but never requested the medication because it was scheduled. The resident indicated not asking the nurse for [MEDICATION(S)] on the evening of 10/13/2021 but took the medication when the nurse came to administer it. The facility policy titled Medication Administration revised 06/19/19, documented timed medication will be administered within one hour before or after the time.

Based on observation, interview, record review and document review, the facility failed to ensure care orders were entered and carried out for a [CONDITION(S)] (a medical device which provides a means for the collection of waste from the colon), in accordance with the resident's care plan and facility policy for 1 of 14 sampled residents (Resident #31). Findings include: Resident #31 (R31) R31 was admitted on [DATE] and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/12/2021 at 3:05 PM, R31 was awake and alert, in bed and able to communicate needs. The resident pulled gown up which revealed a [CONDITION(S)] pouch secured around a stoma (an opening in the abdominal wall). The resident indicated the certified nursing assistants (CNAs) emptied the bag when it was filled with stool every couple of days but could not recall when the bag was last replaced. The medical record lacked documented evidence care orders were entered and treatment interventions were carried out for R31's [CONDITION(S)] from 08/27/2021 through 10/15/2021. On 10/15/2021 at 9:14 AM, a Licensed Practical Nurse (LPN) indicated the CNAs were responsible for emptying and replacing R31's [CONDITION(S)] bag as needed. The LPN indicated not being aware how frequently the bag needed to be changed. The LPN explained [CONDITION(S)] care was typically documented in the treatment sheets located in the treatment binder in the nurse's station. The LPN indicated there was no treatment sheet for R31's [CONDITION(S)] care in the treatment binder. On 10/15/2021 at 9:18 AM, a Registered Nurse (RN) indicated the CNAs were responsible for emptying R31's [CONDITION(S)] bag as needed when filled with stool, while any CNA or nurse could replace the [CONDITION(S)] bag as needed when loose or leaking. The RN explained licensed nurses were responsible for assessing the stoma and surrounding skin which could be done without removing the appliance ([CONDITION(S)] bag). The RN could not recall when R31's [CONDITION(S)] bag was last replaced and by whom since there was no treatment sheet in the treatment binder. On 10/15/2021 at 9:35 AM, two CNAs explained the CNAs were responsible for emptying [CONDITION(S)] bags every shift or when heavy with stool. The CNAs explained replacing the bag was not a CNA task, but rather the duty of the nurses. The CNAs verbalized not being aware how often the nurses changed the resident's [CONDITION(S)] bag but were taught to identify and report any abnormalities such as a swollen or pale stoma, dirt in the surrounding skin, and when the bag was loose or leaking. On 10/15/2021 at 9:37 AM, the Minimum Data Set (MDS) Coordinator explained the resident was admitted with a [CONDITION(S)] on 03/19/2018. The MDS Coordinator provided the resident's [CONDITION(S)] care plan which included interventions such as skin assessments, monitoring the stoma, providing ostomy care, replacing the appliance when needed and reporting complications to the physician. The MDS Coordinator indicated the care orders for R31's [CONDITION(S)] were discontinued when the resident was transferred to the hospital on 08/26/2021 and were not reactivated when the resident was readmitted on [DATE]. On 10/15/2021 at 9:44 AM, the Administrative Clerk/CNA explained the charge nurse was responsible for entering orders when a resident returned from the hospital. The Administrative Clerk/CNA reviewed R31's medical record and confirmed care orders were not entered for the resident's [CONDITION(S)] upon returning from the acute setting on 08/27/2021. On 10/15/21 at 9:51 AM, the Director of Nursing (DON) indicated the CNAs were responsible for emptying [CONDITION(S)] bags and licensed nurses were responsible for skin and stoma assessments, changing the appliance when needed and reporting abnormalities to the physician. The DON explained the charge nurse was responsible for entering orders and generating treatment sheets for readmitted residents. The DON confirmed care orders were not entered and treatment sheets were not generated for R31's [CONDITION(S)] following the resident's readmission on 08/27/2021. The DON indicated the charge nurse was off duty and was not available for interview. On 10/15/21 at 9:54 AM, the Medical Records Clerk confirmed there were no care orders entered nor treatment sheets generated for R31's [CONDITION(S)] device since 08/27/2021. The facility policy titled Caring for [CONDITION(S)] reviewed 08/17/2021, revealed [CONDITION(S)] care would be documented along with the resident's response, unusual findings would be reported to the physician.

Based on observation, interview, record review and document review, the facility failed to ensure: 1) residents were assessed and monitored following an incident of inappropriate touching for 2 of 9 sampled residents (Residents #1, #5), 2) an inappropriate touching incident was reported promptly, and 3) effectiveness of the interventions implemented were evaluated. Findings include: 1) Assessment/Monitoring Resident #2 (R2) R2 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/20/2021 at 9:20 AM, R2 was observed ambulating independently from the bed, to the toilet and back to bed. R2 was verbally responsive, alert, and oriented. The Brief Interview for Mental Status dated 04/19/2021, documented 13/15 which indicated R2's cognitive status was intact. Resident #1 (R1) R1 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/20/2021 at 9:21 AM, R1 was observed in the television (TV) room, sitting in the wheelchair. R1 exhibited a pleasant demeanor, awake and alert, unable to determine level of orientation as the resident would not verbally respond to questions but would smile during the interaction. The Nursing Progress Notes dated 05/11/2021, documented R2 was observed pulling up R1's top and inappropriately touching R1's breast. The facility reported incident documented the Resident-to-Resident inappropriate touching behavior occurred on 05/10/2021 at 10:00 PM. The Certified Nursing Assistant #1 (CNA1) reported the observation after viewing the incident from the outside patio through the glass walls of the TV Room. CNA1 returned inside and removed R1 from the TV room. On 05/20/2021 at 9:25 AM, a registered nurse (RN1) indicated R1 was alert but would not verbally respond to questions. RN1 explained R2's inappropriate touching of R1's breast was nonconsensual since R1 has dementia. The RN indicated both residents should have been assessed following the incident and monitored for at least 72 hours despite R1 not showing observable signs of effects of the incident. RN1 confirmed there was no assessment for R1 and there was no documentation R1 was monitored and evaluated. R2 however, was monitored and underwent psychiatric evaluation. On 05/20/2021 in the morning, the RN charge nurse and RN supervisor indicated R1 should have been assessed and monitored to prevent future occurrence of a similar incident. Both indicated there was no assessment and monitoring in place for R1. The RN charge nurse indicated the long term-care (LTC) director was responsible for the investigation and follow-up on all abuse incidents. On 05/20/2021 at 11:55 AM, the LTC director confirmed there was no documented evidence R1 was assessed and monitored following incident of inappropriate touching. The LTC director indicated staff members were expected to document the behavior of the resident in resident's chart. On 05/20/2021 in the afternoon, the nurse practitioner (NP) indicated there should have been an assessment and close monitoring of residents who were involved in the incident of non-consensual sexual contact to prevent the same from happening again. The NP indicated the resident's behavior should be closely monitored for the potential of psychosocial harm. The interventions and monitoring should have been documented to ensure clear communication of the incident to staff and to ensure continuity of care. On 05/20/2021 at 4:00 PM, the chief nursing officer (CNO) indicated both residents should not have been left unmonitored in the TV room. Staff members were expected to have monitored R1 and R2's behavior following the incident, keep both residents separated and documented the interventions in the progress notes or the Treatment Administration Record. 2) Reporting On 05/20/2021 at 2:20 PM, during a telephone interview, certified nursing assistant #2 (CNA 2) revealed around 7:00 PM on 05/10/2021, both residents (R1 and R2) were observed in the TV room, when R2 rubbed R1's hands and legs. CNA2 explained R1 was sitting in the wheelchair and R2 was sitting on the couch facing R1. CNA2 immediately redirected and moved R2 away from the TV room. CNA2 explained the incident was not reported because R2 was redirected. CNA2 indicated later that night around 10:00 PM, R2 inappropriately touched the breast of R1 in the TV room. CNA2 revealed was in the breakroom and witnessed the incident through the glass window of the TV room and responded immediately to separate the residents. CNA2 indicated education was provided to staff members regarding abuse prevention and to keep the residents separated. On 05/20/2021 in the afternoon, a telephone interview with an RN (RN2) revealed was unaware of the initial 7:00 PM incident as described by CNA2, but was informed regarding the second incident at 10:00 PM, when R2 inappropriately touched R1's breast. On 05/20/2021 at 3:00 PM, the LTC director expressed unawareness of the incident that happened at 7:00 PM on 05/10/2021 as reported by CNA2 to the surveyor at the time of investigation. The LTC director indicated CNA2 was expected to report the incident immediately to the nurse or supervisor as the redirection done by CNA2 was not enough to prevent further recurrence. The LTC director explained prompt reporting could have prevented a similar incident from occurring if the residents were appropriately monitored. The LTC director acknowledged the abuse protocols were not followed. The facility policy titled Adult/Elder Abuse Prevention dated 11/25/2020, documented a suspected incident of abuse must be reported immediately to a supervisor. Failure to report such a suspected incident may be viewed as an attempt to conceal the incident and may result in corrective action up to and including termination. 3) Evaluation of interventions implemented: A review of medical records lacked documented evidence interventions were implemented for R1's inappropriate touching incident of 05/10/2021. A previous intervention with a similar incident had occurred on 10/16/2020, with no evaluation or follow-up regarding effectiveness. On 05/20/2021 at 11:55 AM, the LTC director explained the nursing supervisor and the risk manager were responsible for auditing and following up abuse investigations. However, both employees no longer work at the facility. The LTC director acknowledged both reassessment and evaluation were not done. The LTC director indicated assessment should have been completed immediately following an incident and monitoring should have been done every shift for at least 72 hours. The LTC director indicated staff members were expected to document in the progress notes and the interventions must be evaluated. On 05/20/2021 at 4:00 PM, the CNO indicated the incident should have been investigated thoroughly, interventions implemented, and a follow-up completed. The CNO explained the LTC director was responsible for thorough investigation of incidents to ensure appropriate interventions were implemented and future occurrences prevented. The CNO confirmed the facility did not evaluate or document the effectiveness of the intervention. The facility policy titled Adult/Elder Abuse Prevention dated 11/25/2020, revealed each resident had the right to be free from sexual abuse. The facility was to protect residents from real or perceived abuse from anyone, including but not limited to other residents. All allegations, observations or suspected cases of abuse that occurs in the facility would be investigated and would analyze the occurrence to determine any changes to prevent any further occurrence. Upon receipt of the initial report the LTC Department Director and or the Chief Nursing Officer or in their absence the facility designee, would take steps to perform a thorough investigation of any suspected abuse. FRI #NV 893 R5 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A facility reported incident dated 10/23/2020, documented R5 inappropriately touched another resident. A staff member had witnessed the incident and both residents were immediately separated. Both residents were assessed and there was no evidence of any harm noted. On 05/20/2021 at 8:40 AM, Certified Nursing Assistant (CNA) indicated behavior monitoring was documented by keeping track in a behavioral binder. On 05/20/2021 at 8:55 AM, the Charge Nurse revealed behaviors were monitored by documenting behaviors in the paper chart located at the nurse's station. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated 07/27/2020, documented to monitor R5 for behaviors per physician orders. The medical record lacked documented evidence R5 behaviors were being monitored by staff. On 05/20/2021 at 10:01 AM, the Charge Nurse verified R5 behaviors were not being monitored as outlined in the care plan and as ordered by the physician. On 05/20/2021 at 11:23 AM, the Director of Nursing (DON) indicated if there was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON confirmed R5's behaviors were not being monitored as ordered. FRI #NV 359

Based on observation, interview, medical record and document review, the facility failed to ensure one of five residents was monitored closely to prevent elopement (Resident #1). Findings include: Resident #1's medical record revealed the resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident had been transferred from an acute care facility where he was admitted for bizarre behavior. Once stabilized, it was determined he was unable to care for himself, and was not safe to be discharged . The resident was admitted for placement and was assigned a public guardian. The nurse's admission note dated 5/23/15, documented, the resident was awake and oriented to person, disoriented to time, place and situation. The resident history and preference form dated 5/23/15, documented the resident's prior living situation - Law enforcement detention. The nurse's note dated 6/22/15 documented Called (physician name) regarding resident leaving facility, order for resident to be in a more locked unit if continues. Psych (psychiatric) unit if is a harm to self. Readback. The nurse's notes dated 6/22/15, indicated the resident had returned to the facility at 2000 (8:00 PM) and continued to exit seek, but did not elope. The nurse's note dated 6/22/15 at 11:57 documented the physician was notified of resident attempting to leave the facility and had ripped bed sheets under bed. Has not attempted to leave the facility. The public guardian was notified and expressed concerns about the resident needing a more secure location, e.g. a locked unit at (name) skilled nursing facility or a gero-psych unit if the resident was a danger to himself. The resident was seen by the PA (Physician Assistant) on 6/22/15 at 3:25 PM. Per progress notes - Asked to see pt today for possible suicidal ideation. Nursing staff found a torn up sheet under patients bed that looked like a rope. Per PA assessment, resident denies suicidal ideations, appears in good spirits Overall seems appropriate. Nurse's note dated 6/24/15 documented the CNA attempted to apply wanderguard when resident came back from an outing. Resident refused four times. Nurse's note dated 6/24/15 at 9:48 documented - For the last three days resident has left the building. The charge nurse looked at the ankle blue band (Wanderguard) was securely attached but did not have the actual piece that beeps through the censors. The staff tried to put on a new one, but the resident becomes agitated and refuses. Nurse's note dated 7/1/15 at 1:40 AM, documented the resident was walking around unit without the wanderguard. The staff asked where it was and the resident pulled it out of his pocket. The staff explained to resident why it was needed and the resident responded I'm faster than you, how can you help me? On 7/1/15, at 2:00 PM, the nurse's notes documented the resident removed the wanderguard that was placed last night, applied a new one this morning. Now off lying on bedside table. Resident refuses to apply a new one. Informed public guardian, states they are still looking for a locked facility. Documentation provided by the Risk Manager regarding the elopement of the resident indicated: - 6/14/15 - At 10:00 rounds were made by the nurses and by the CNA. (Certified Nursing Assistant). The resident could not be found. The nurses and CNA's looked in all the resident's rooms and bathrooms. The rooms in the hospital were also checked. The house supervisor was notified and a Code Elvis was called while the staff continued to look for the resident. The resident was eventually found by a church. The resident was taken to the ER (emergency room ) and was given IV (Intravenous) fluids . The resident returned to the facility at 14:45 (2:45 PM). - 6/22/15 - CNA could not find resident. Code was set. Police found resident at BMX park. - 6/23/15 - 10 minutes after seeing patient walk by the nurse's station, CNA states resident was missing. Code was set. Metro found resident at baseball field. No injuries. There was no care plan developed to monitor the resident for elopement. There was no documented evidence the resident was reassessed and additional measures implemented after each elopement to prevent the resident from eloping again. An interview with the LTC RN Manager revealed the resident had a Wanderguard on but frequently removed the Wanderguard. The resident had eloped on 6/14/14, in the morning and was later found at a church. The resident was taken to the ER, given IV fluid for dehydration and then readmitted to the SNF. The RN Manager verbalized she was not aware the resident kept removing the Wanderguard and refused to have it in place, and added she should have been notified. The RN verbalized the physician should also be notified of this. The RN stated she did not know if arrangements were being made for the resident to go to a more secure facility. The RN stated there was currently no SW (Social Worker) working at the facility who could make discharge arrangements. The RN indicated at the current time she was responsible to make such arrangements. The RN confirmed there was no care plan initiated for the resident regarding the use of the Wanderguard, since there was no MDS Coordinator at the facility. The MDS would trigger the issues for the care plan. The RN Manager verbalized, currently that was her responsibility as well. On 7/1/15, interviewed the CNA, Unit clerk regarding the process to check the Wanderguards to ensure they were working. The CNA verbalized, she usually checked all the Wanderguards every Friday. However, she does not document anywhere that the Wanderguards were checked. On 7/1/15 at 3:00 PM, asked the CNA Unit Clerk to check several Wanderguards to see if they were functioning. The CNA obtained the monitor used to check the Wanderguards and went to Resident #1's room. The CNA was accompanied by another CNA, who was in training, the LTC RN Manager, and the Inspector. The CNA informed the resident she was going to check the Wanderguard. The CNA checked the resident's ankle, where the Wanderguard was usually placed. The Wanderguard was not on that ankle. The CNA then asked to check the other ankle. The Wanderguard was not on that ankle either. The Wanderguard was laying the Resident's bedside table. The CNA placed the Wanderguard back on the resident's ankle and checked to see if it was working properly, and it was. The RN Manager verbalized she was not aware the resident's Wanderguard was off the resident. On 7/1/15 at 3:15 PM, the resident was interviewed. The resident was alert and appeared oriented to self. He verbalized he knew he was in this facility and did not want to be there. He added, he did leave the facility on several occasions. He feels comfortable in the desert and chooses to be there. Explained to the resident the need to stay in the facility and to notify staff if he were going to leave the unit. Explained the purpose of the Wanderguard which was to ensure his safety. The resident did not want to listen and stated he could care for himself. The facility policy titled Wander Guard - Use of dated 8/11/11, documented: - Policy: - Wander Guard devices will be used for residents in Boulder City Hospital Long Term Care (BCH LYC) unit that are observed or have a history of wandering, elopement to prevent unauthorized exit from the unit and to promote safety and well-being of the resident - Procedure: . - Actions to be taken regarding Assessment and treatment for [REDACTED]. - Licensed staff to assess reason resident is attempting to leave and attempt to meet resident's need, distract, engage or redirect as appropriate . - Residents identified with a potential for elopement risk will have a care plan with interventions created and modified as needed - The restorative aide will check weekly to ensure that the wander guard is functioning . - Staff will check on a daily basis to ensure that the residents under their care have the wander guard inn place . - Review the resident's status quarterly during care conference or more frequently as indicted. CPT # NV 181