Every finding on record at College Park Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure residents were free from medication errors exceeding 5 percent during observed medication administration passes. Three errors were identified out of 25 medication administration opportunities, resulting in a medication error rate of 12 percent. This deficient practice had the potential to result in reduced therapeutic effectiveness, adverse drug reactions, and compromised resident safety.Findings include:1) On 09/18/2025 at 8:15 AM, a medication administration observation was conducted with Registered Nurse (RN1) and Resident 13 (R13). RN1 administered Fluticasone 200 micrograms (mcg), 1 puff via inhalation (a steroid nasal spray used to treat allergy symptoms), to R13. RN1 did not direct R13 to rinse their mouth with water following administration.A Physician Order dated 07/02/2025 specified Fluticasone 200 mcg, 1 puff once daily for chronic obstructive pulmonary disease, with special instructions to rinse the mouth with water after administration and not to swallow.On 09/18/2025 at 11:00 AM, RN1 acknowledged the omission and confirmed that Fluticasone could cause oral fungal infections if the mouth was not rinsed after use.2) On 09/18/2025 at 8:15 AM, a medication administration observation was conducted with Registered Nurse (RN2) and Resident 49 (R49). RN2 administered:- Aspirin 81 milligrams (mg) in chewable form. The Physician Order dated 12/08/2024 specified Aspirin delayed-release/enteric-coated 81 mg once daily for cerebral infarction.- Vitamin D3, 1 tablet, the Physician Order dated 01/08/2025 directed 2 tablets (25 mcg each) once daily for vitamin D deficiency.On 09/18/2025 at 11:10 AM, RN2 acknowledged the discrepancies and stated the physician orders should have been verified prior to administration.The facility's policy titled Medication Management Program, last revised 01/15/2025, directed staff to validate the physician order, match the medication and label with the Medication Administration Record (MAR), and read the medication label before removing it from the drawer, and again before and after administration to ensure the correct administration of medications.

Based on observation, interview, record review and document review, the facility failed to ensure that 1 of 20 sampled residents (Resident 1) had an updated comprehensive person-centered care plan. The deficient practice had the potential to place residents at risk of not receiving the appropriate care. Findings include:Resident 1 (R1) was admitted on [DATE] with a diagnosis of Parkinson's disease with dyskinesia.On 09/17/2025 at 10:00 AM, observed R1 with a mitten on the right hand. A Physician Order dated 07/08/2025, documented R1 to have a right-hand mitten to prevent resident from pulling out tubing's for 14 days. A Physician Order dated 07/23/2025, documented for R1 to have a right-hand mitten to prevent resident from pulling out tubing's for 14 days. A Behavior Note dated 07/10/2025, documented R1 had disconnected self from ventilator four times in 20 minutes and was observed pulling at tracheostomy once and was disconnected. A Progress Note dated 07/22/2025, documented the respiratory therapist (RT) was alerted to R1's room because the ventilator alarm was going off. R1 pulled off the ventilator circuit and removed the pulse oximeter sensor off.A Progress Note dated 08/17/2025, documented the respiratory therapist (RT) noted R1 had pulled the closed suction catheter off and had disconnected self from the ventilator. On 09/17/2025 at 3:42 PM, a Registered Nurse (RN), stated the facility did utilize restraints. The facility used mittens to protect the residents from pulling on their tubes, ventilators, tracheostomy or wires. On 09/17/2025 at 2:50 PM, a Registered Nurse (RN) provided a hard copy of R1's care plan, which showed the care plan was created on 09/17/2025 for the hand mittens.On 09/18/2025 at 8:40 AM, the Assistant Director of Nursing (ADON), stated when a resident had a change in condition or new physician orders were placed the resident's care plan was updated. The ADON verified that R1's care plan was not updated at the time when the mitten order was placed and clarified the care plan was created on 09/17/2025 and should have been updated once the order was placed on 07/08/2025 and on 07/23/2025.

Based on observation, interview, and document review, the facility failed to ensure that raw food, residents and staff food was stored by guidelines and facility policies. This deficient practice had the potential to contaminate and spread bacterial growth. Findings include: On 09/16/2025 at 8:10 AM, prep refrigerator had employee food stored inside, which contained a container of blueberries and a protein drink. On 09/16/2025 at 8:21 AM, walk-in refrigerator had employee food stored inside with contents containing a container of kimchi, an avocado and a cucumber.On 09/16/2025 at 8:22 AM, walk-in refrigerator had a box of raw shrimp, raw chicken and raw turkey stored above of cooked food.On 09/16/2025 at 8:23 AM, the Assistant Kitchen Manager voiced that raw meats should not be placed above any cooked food and employee food was not allowed where resident foods were stored.On 09/16/2025 at 8:30 AM, the Administrator expressed employees were not allowed to store personal food items in the kitchen refrigerators. The Administrator explained that employees were to store personal food items in the employee refrigerator, located in the employee breakroom. The facility policy titled Food Safety in Receiving and Storage, dated 06/20/2023, documented store raw animal foods by placing on shelves in order of cooking temperatures with the food requiring the highest cooking temperature, such as chicken, on the lowest shelf. The facility policy titled Safe Food Handling, dated 06/20/2023 documented all foods and beverages in the facility that belong to employees were stored in employee refrigerators or other designated areas and labeled with the employee's name and the date the item was placed in the facility storage area.

Based on observation, interview, and record review, the facility failed to ensure that mattresses and equipment used in resident rooms were maintained in a clean and sanitary condition for 2 resident rooms observed (rooms [ROOM NUMBERS]). The deficient practice had the potential to contribute to an environment that was not homelike and posed a risk for cross-contamination and infection for residents.Findings include:On 09/17/2025 at 10:00 AM, during an inspection of resident room [ROOM NUMBER], two floor mattresses were observed placed bilaterally on the floor near a resident's bed, close to the door, and a pole used to hang gastrostomy feeding formula was located on the right side of the bed. The mattresses and the pole were visibly soiled with dried feeding formula residue, dust, and other unidentified stains.On 09/17/2025 at 10:40 AM, during an inspection of Resident room [ROOM NUMBER], a floor mattress was observed on the left side of the bed near the window. The mattress was visibly soiled with dust and other unidentified stains.On 09/18/2025 at 8:30 AM, the floor mattresses and the pole remained unchanged in resident room [ROOM NUMBER] and 41. A Registered Nurse (RN) and the Infection Preventionist (IP) were present and confirmed the observations. The IP stated the mattresses, and pole should have been cleaned daily and as needed, especially when formula or other fluids were spilled. The IP acknowledged that failure to maintain cleanliness could lead to cross-contamination and attract pests.On 09/19/2025 at 1:18 AM, the Environmental Services Supervisor explained residents' rooms were cleaned twice daily and as needed. The Supervisor indicated the floor mattresses should have been cleaned as part of the housekeeping task and nurses should have cleaned the pole.The facility policy titled Patient/Resident Room Cleaning/Bathroom Cleaning dated 10/03/2006 documented a routine procedure that would be performed to clean and disinfect resident rooms and their bathroom to provide a clean, safe decontaminated environment for all the residents.

Based on interview, record review, and document review, the facility failed to ensure a copy of the discharge notice was sent to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 23 sampled residents (Resident 11). The deficient practice had the potential for resident rights not being advocated for improper discharges.Findings include:Resident 11was re-admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy, cellulitis of abdominal wall, gastrostomy malfunction, and pain.R11 had a Brief Interview for Mental Status (BIMS) score of 0 indicating severe cognitive impairment. The facility was not able to provide records of the resident's discharge notice having been sent to a representative of the Office of the State Long-Term Care Ombudsman when the resident was sent to the hospital.On 09/19/2025 at 3:32 PM the Social Services Director (SSD) was not aware discharge notices for residents who had been discharged to a hospital had to be submitted to the Ombudsman's office. The SSD thought discharge notices for residents who had been discharged to the community were to be sent to the Ombudsman's office.On 09/19/2025 at 3:36 PM, the Administrator confirmed the SSD should have been sending all discharge notices, regardless of the discharge destination, to the Ombudsman's office. A facility policy titled Discharge Notification, revised on 05/09/2025, indicated the Social Services Staff/ or designee was charged with ensuring systems were in place to provide written notification of transfer or discharge to the resident and, if known, a family member or legal representative prior to the resident's transfer/discharge and the Long-Term Care Ombudsman. The notifications must be documented in the residents' medical record. The transfer/discharge notice must have complied with federal and state regulations.

Based on record review, interview, and document review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for 1 of 20 sampled residents (Resident 4), by inaccurately coding a psychiatric diagnosis. This deficient practice had the potential to have a negative impact on the residents' care planning, and the coordination and delivery of services.Findings include: The Minimum Data Set (MDS) was a standardized assessment tool used to assess the clinical needs and functional capabilities of individuals residing in a skilled nursing facility.Resident 4 (R4) was admitted to the facility on [DATE] with diagnoses including dementia, depression, and schizophrenia.A Psychiatric Consult note dated 02/27/2025 documented a diagnosis of schizoaffective disorder bipolar type.A Nursing Progress Note dated 05/06/2025 indicated R4 was transferred to the hospital for gastrostomy tube (G-tube) re-placement.The MDS Discharge assessment dated [DATE] listed schizophrenia as the only psychiatric diagnosis and non-Alzheimer's dementia as a neurological diagnosis. The assessment did not include bipolar disorder as a diagnosis, despite the earlier psychiatric documentation.The medical record revealed R4 returned to the facility on [DATE]. The hospital Discharge summary dated the same day listed a history of schizophrenia but did not include bipolar disorder.The MDS Quarterly assessment dated [DATE] newly documented diagnosis of bipolar disorder. However, R4's medical record lacked evidence of a psychiatric evaluation or physician documentation supporting the diagnosis.On 09/18/2025 at 2:24 PM, a Social Services Assistant (SSA) stated R4 was admitted to schizoaffective disorder, bipolar type, but had not been diagnosed with bipolar disorder alone. The SSA acknowledged the bipolar diagnosis in 08/06/2025 MDS appeared to be an error.On 09/19/2025 at 10:00 AM, the MDS Coordinator confirmed R4 did not have a current diagnosis of bipolar disorder, and the entry in the 08/06/2025 MDS was likely a data entry error. The facility's policy titled Minimum Data Set (MDS), last revised 09/28/2023, stated the facility was responsible for addressing all resident needs and that staff were accountable for the accuracy of data entered into the MDS.

Based on interview, record review, and document review, the facility failed to ensure a baseline care plan was initiated after a resident was admitted for 1 of 23 sampled residents (Resident 104). The deficient practice had the potential to place residents at risk for inappropriate care, supervision, and other incidents.Findings include:Resident 104 (R104) was re-admitted to the facility on [DATE] with diagnoses including other sequelae of other cerebrovascular disease, metabolic encephalopathy, non-ST elevation myocardial infarction, atherosclerotic heart disease, hemiplegia and hemiparesis.The hospital discharge records documented R104 was to be transferred to a nursing facility with hospice for end-of-life care.A Nursing Progress Notes on 05/13/2025 at 5:28 PM revealed the resident was seen by the hospice nurse who stated the resident was officially under hospice now, and the family were already informed and signed the consents.A hospice company consent was signed by the family representative on 05/14/2025 and the hospice staff on 05/13/2025 with the effective date of 05/13/2025.The facility lacked documentation, a baseline care plan was initiated which included hospice care or services. On 09/19/2025 in the morning, the Medical Records Director was unable to find documentation of a baseline care plan which included hospice care or services.On 09/19/2025 at 1:33 PM, the Assistant Director of Nursing (ADON) stated once the resident was on hospice, the hospice provider would provide the facility with a binder which contained the resident's care plan. The facility would then update their care plans in the residents' medical record so the two care plans would be aligned. A facility's policy titled Care Plan Process, Person-Centered Care, revised on May 5, 2023, documented the facility would develop and implement the baseline person-centered care plan within 48 hours of a resident's admission which would include the minimum healthcare information necessary to properly care for the resident including, but not limited to initial goals based on admission orders, dietary orders, therapy services, social services, and PASARR (Pre-admission Screening and Resident Review) recommendations, if applicable.

Based on observation, staff interview, record review, and document review, the facility failed to ensure heel protective devices were implemented for 1 of 20 sampled residents (Resident 22). This deficient practice had the potential to contribute to the development or worsening of pressure injuries, pain, and impaired skin integrity.Findings include: Resident 22 (R22) was admitted on [DATE] with diagnoses including atrial fibrillation, congestive heart failure, diabetes mellitus, and non-ST elevation myocardial infarction (NSTEMI).A Wound Management Record dated 03/20/2025 documented a left heel pressure ulcer (PU).The Pressure Ulcer Scale for Healing (PUSH) chart dated 03/20/2025 recorded left hell PU length of 0.7 centimeters (cm) and width of 1.0 cmA Braden Scale assessment dated [DATE] identified R22 as being at moderate risk for pressure ulcer development. The care plan dated 07/25/2025 documented interventions for pressure injury prevention, including the use of a low air loss mattress, daily mattress setting checks, repositioning using draw sheets or similar devices, and use of pillows or pads to offload pressure from bony prominences.A Physician Order dated 05/05/2025 directed staff to apply heel protectors, check placement daily, and replace as needed.On 09/16/2025 at 10:45 AM, R22 was observed in bed without heel protectors in place.On 09/17/2025 at 3:50 PM, a Registered Nurse (RN) confirmed R22 was not wearing heel protectors and acknowledged a physician order to protect the heels while the resident was in bed.On 09/17/2025 at 4:00 PM, a Wound Care Physician (WCP) confirmed R22 had a Stage 3 pressure ulcer on the left heel. The physician stated heel protectors were ordered to prevent further deterioration and should be applied whenever the resident was in bed.The facility's policy titled Movement or Management of Tissue Load, last revised 09/07/2017, emphasized the importance of reducing pressure on heels and elbows due to their small surface area, especially for residents at risk for pressure ulcer development.

Based on document review and interview, the facility failed to ensure residents mail were delivered on Saturdays for 1 of 23 sampled residents (Resident 12) and 2 unsampled residents (Residents 54 and 57). The deficient practice had the potential for residents' mail not to be delivered on the weekend. Findings include:1) Resident 12 (R12) was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia, metabolic encephalopathy, and other specified sepsis.R12 had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. 2) Resident 54 (R54) was re-admitted to the facility on [DATE] and was a long-term care resident.3) Resident 57 (R57) was re-admitted to the facility on [DATE] and was a long-term care resident.On 09/18/2025 in the morning, during a resident council meeting, R12 indicated mail was not delivered to residents on Saturdays. If mail were delivered to the facility on Saturday, the residents would have to wait until Monday to get the mail. R54 and R57 indicated residents did not receive mail from the post office on Saturday. R54 indicated orders from Amazon were delivered to resident rooms. On 09/18/2025 at 2:18 PM, the Social Services Director (SSD) explained the mail person delivered the mail to the front desk. The front desk Receptionist would give the mail to the Business Office Manager (BOM) to sort. The BOM sorted the mail between facility mail and resident mail. Then the BOM called the SSD to collect the mail. Once the SSD received the mail, the SSD delivered the mail to the residents. The SSD revealed any mail which came on Saturday would be held until Monday until the process would be restarted.On 09/18/2025 at 3:11 PM, the Administrator stated the receptionist would separate the mail delivered on Saturdays for the facility and residents. After the mail was sorted, the activity staff would be notified to deliver the mail to the residents. On 09/18/2025 at 3:51 PM, the Activity Director (AD) stated activity staff had not delivered resident mail since the AD had been working at the facility. The AD explained the SSD was responsible for delivering resident mail on weekdays and thought the charge nurse had the responsibility on Saturdays.On 09/18/2025 at 4:05 PM, the Charge Nurse affirmed resident mail had not been given to nursing to distribute to the residents on Saturdays.The facility policy titled Communication, Effective - Resident Right For, revised on 06/09/2023, indicated the facility-designated individual delivered mail to the residents on the date it was received.

Based on interview, record review and documentation review, the facility failed to ensure 1 of 4 sampled residents (Resident #1) received a physical therapy evaluation in accordance with a physician's orders. This deficient practice could lead to the resident's continued decline in function and/or mobility. Findings include: Resident #1 (R1) R1 was admitted to the facility on [DATE] with diagnoses of degenerative diseases of nervous system, pain, muscle weakness, lack of coordination, and major depressive disorder. A Physician's Order dated 11/13/2024 documented, PT (Physical Therapy) Evaluation and Treatment. R1's medical record lacked documented evidence a PT evaluation had been completed. On 03/13/2025 at 11:30 AM, the Director of Rehabilitation (DOR) and physical therapist acknowledged R1's medical record lacked documented evidence R1 had been evaluated for physical therapy. The DOR stated was told the resident had refused the evaluation, but there was no documentation of the refusal. The DOR indicated the physical therapist should have attempted the evaluation and documented in the evaluation R1 refused the evaluation, or the physical therapist could have discharged the PT order and let nursing, and the physician know. The DOR explained this physician order for a PT Evaluation was a standing order for all newly admitted residents. Nursing informs therapy the resident was admitted , and therapy conducts the evaluations as ordered. The DOR also indicated the physical therapist had access to the physician's orders. The DOR verified an evaluation had not been completed for R1 in accordance with the physician's order from 11/13/2024. A facility policy entitled Physician Orders- Telephone and Verbal under Rehabilitation Services Policies and Procedures with a complete revision on 03/01/2019, and an email revision on 04/15/2021 documented, a qualified medical personnel will take and implement telephone and verbal orders according to Facility Practice Guidelines. Complaint #NV00072898

Based on interview and document review, the facility failed to maintain a safe and functional environment for 1 of 4 residents sampled (Resident #1). This deficient practice led to unusable devices and could have caused harm to the resident. Findings include: Resident #1 (R1) R1 was admitted to the facility on [DATE] with diagnoses of degenerative diseases of nervous system, pain, vitamin deficiency, muscle weakness, lack of coordination, and major depressive disorder. On 11/13/2024, the Maintenance Request Log documented work orders were put in for room [ROOM NUMBER]A which included: -need an overbed table and a TV that works for the new Admit -need a wall phone -the bed foot board is loose The work order for an overbed table and a TV that works for R1 upon admission, was documented as having been completed by staff on 11/13/2024. The other two work orders were not marked as having been completed. On 11/15/2024, the Maintenance Request Log documented another work order was put in for room [ROOM NUMBER]A for a wall phone. This request was marked completed on 11/15/2024. On 11/16/2024, the Maintenance Request Log documented another work order was put in for room [ROOM NUMBER]A for a loose bed foot board. This request was marked completed on 11/16/2024. On 03/13/2025 at 8:45 AM, the Maintenance Assistant confirmed the work orders for the phone and foot board were not marked as having been completed. The Maintenance Assistant explained had thought the work orders had been completed by the other maintenance worker, but just not marked as having been completed. However, the Maintenance Assistant was not sure why there would have been duplicate work orders put in two and three days later for the same items if they had been fixed previously. The Maintenance Assistant verified there was no documented evidence the work orders for the phone and foot board had been completed the first time they were put in. The facility policy titled Routine Maintenance under Maintenance/Housekeeping Policies and Procedures dated 03/2006, indicated the facility would perform routine maintenance on floors, walls, fixtures, and equipment. Complaint #NV00072898

Based on interview, record review, and document review, the facility failed to ensure medications were administered timely to 1 of 4 sampled residents (Resident #1). The deficient practice had a potential for the intended use of the medication to be insufficient or ineffective with a possible cause of harm to the resident. Findings include: Resident #1 (R1) R1 was admitted to the facility on [DATE] with diagnoses of degenerative diseases of nervous system, pain, vitamin deficiency, and major depressive disorder. A physician order dated 11/18/2024 for Methocarbamol 1000 milligram (mg) tablet was ordered for pain and was to be given at 9:00 AM, 1:00 PM, 5:00 PM, and 9:00 PM. The medication administration record (MAR) revealed the resident missed the 1:00 PM and 5:00 PM doses on 11/18/2024, and the first dose of the medication was administered at 9:00 PM. The MAR documented the medication was not administered because the medication was not available. A physician order dated 11/14/2024 for Thiamine HCl (Vitamin B1) 100 mg tablet was ordered for vitamin deficiency and was to be given at 8:00 AM. The medication administration record (MAR) revealed the resident missed the 8:00 AM dose on 11/18/2024. The MAR documented the medication was not administered because the medication was not available. On 03/13/2025 at 11:20 AM, the Assistant Director of Nursing (ADON), confirmed the Omnicell (an automated medication dispensing system which stores and tracks medications) did contain Methocarbamol 500mg tablets and the tablets were available in the Omnicell at the facility which could have been used for the resident. On 03/13/2025 at 11:45 AM, the Director of Nursing (DON), confirmed it is the policy of the facility to use the Omnicell machine for unavailable medications. The DON stated there is someone in the facility at all times which has access to the Omnicell machine. The DON also verified the Thiamine HCl (Vitamin B1) was a house stocked item and if staff were truly out of the medication, the facility could have sent someone to the pharmacy to get the medication over the counter. A facility policy titled Medication Management Program: Administering the Medication Pass with a complete revision on 05/05/2023 and an email revision on 01/15/2025, documented if a medication was unavailable, contact the pharmacy and document accordingly. Notify the physician for possible alternatives available in e-kits (emergency kits) at time of discovery. Complaint #NV00072898

Based on observation, interview, record review and document review, the facility failed to ensure physician orders were followed for administration of the medication Docusate Sodium (a stool a stool softener), and to notify the physician for a possible alternative when the medication became unavailable for one unsampled resident (Resident 27). Failure to administer medication as prescribed had the potential to effect the therapeutic treatment and bowel regulation for the resident. Findings include: Resident 27 (R27) was admitted on [DATE] with diagnoses including Alzheimer's Disease, unspecified dementia, cognitive communication deficit, dysphagia and constipation. R27 had a gastronomy tube (soft, flexible tube that's surgically inserted into the stomach to provide nutrition, hydration, and medication). On 09/26/2024 8:20 AM, the Licensed Practical Nurse (LPN) prepared and administered the following medications to R27: -Lactulose 10 grams (gm)/15 milliliter (ml) Solution (Sol) - 15 ml. -Levetiracetam Oral 100 milligrams (mg)/1ml Sol - 5 ml. -Enoxaparin Sodium 40 ml/0.4 ml - 1 ml. The LPN indicated Docusate Sodium was not available. On 09/26/2024 at 8:43 AM, the LPN indicated the Docusate was a house supply. The LPN indicated they would talk to the supervisor to order the medication and see if the medication was available. A Physician order dated 06/25/2024 documented to give Docusate Sodium OTC (over-the counter) liquid; 50 mg/5ml; 100 mg = 10 ml via the gastric tube for constipation. The order indicated to hold for loose stools. Review of R27's Medication Administration Record (MAR) for September 2024 documented the Docusate Sodium scheduled administration times as 9:00 AM and 9:00 PM. The MAR revealed the following: 9:00 AM Scheduled Administration Administered on: 09/06/2024, 09/07/2024, 09/08/2024, 09/13/2024, and 09/16/2024. Not administered: Refused on 09/01/2024. Not administered: Due to condition on 09/12/2024 and 09/21/2024. Late Administration: Charted late on 09/03/2024, 09/09/2024, 09/17/2024, 09/19/2024, 09/22/2024, and 09/25/2024. Not administered: Drug/Item unavailable on 09/05/2024, 09/09/2024, 09/10/2024, 09/11/2024 (waiting on pharmacy), 09/14/2024, 09/15/2024, 09/19/2024, 09/20/2024 (waiting on pharmacy), 09/23/2024 (reordered) and 09/26/2024 (charge nurse aware). 9:00 PM Scheduled Administration Administered on: 09/01/2024, 09/02/2024, 09/03/2024, 09/05/2024 - 09/08/2024, 09/12/2024, 09/13/2024, 09/15/2024, and 09/22/2024 - 09/26/2024. Not administered: Refused on 09/17/2024. Late Administration: Charted late on 09/03/2024, 09/09/2024, 09/19/2024, 09/22/2024, 09/25/2024. Not administered: Drug/Item unavailable on 09/04/2024, 09/05/2024, 09/09/2024, 09/10/2024, 09/11/2024, 09/14/2024, 09/16/2024 - 09/21/2024. Review of R27's Physician and Nursing Progress Notes lacked documented evidence the physician had been notified of the unavailability R27's Docusate Sodium. A Physician Order Report for 09/01/2024 - 09/30/2024 documented R27 was not able to understand or exercise their right and responsibilities. On 09/27/2024 at 8:38 AM, the Assistant Director of Nursing (ADON) checked the house stock supply room for the Docusate. The ADON indicated there no Docusate available in the house stock supply room. The ADON verbalized they would check with central supply to see if the medication was available. The ADON explained the expectation was for the nurse to inform the central supply person if the medication was not available in the house stock supply room, and if it was not available in central supply to let the physician know to have an alternative medication prescribed. On 09/27/2024 at 8:42 AM, the ADON reviewed R27's Medication Administration Record and acknowledged the documentation regarding the unavailability of the medication. The ADON was made aware of the documentation of R27's refusal of the medication and the late administration followed by the unavailability of the medication. When inquired about R27's ability to refuse medication, the ADON indicated R27 was nonverbal, and they could tell if R27 was in pain or uncomfortable by facial grimacing or movement, but R27 would not say anything. On 09/27/2024 at 8:45 AM, the ADON checked the C-Hall medication cart for the availability of the Docusate. The ADON indicated the medication was not in the cart. The ADON verbalized if the medication was not available in central supply, they would call pharmacy and get an authorization number for the OTC medication. The pharmacy would supply a certain amount, and the facility would pay for the medication. On 09/27/2024 at 10:10 AM, the ADON explained they had spoken with the nurses who administered the Docusate to R27 when the liquid was unavailable. The ADON indicated the nurse's administered medication in the tablet form. The ADON indicated if the order indicated to give the liquid the nurses should have administered the liquid or called the physician for an alternative. The ADON indicated based on R27's condition rather than documenting refused, the nurses had an option of not administered due to condition if the resident had loose stools. The facility policy titled Medication Management Program, revised May 5, 2023, documented if a medication was unavailable, contact the pharmacy and document accordingly. Notify physician for possible alternatives available in e-kits at time of discovery.

Based on interview, record review and document review, the facility failed to ensure a discharge summary was completed for 1 of 3 sampled close records reviewed (Resident 89). The deficient practice had the potential for the facility failing to provide the necessary information to continuing care providers pertaining to the course of treatment while the resident was still at the facility and the resident's plan of care after discharge. Findings include: Resident 89 (R89) R89 was admitted on [DATE] and discharged on [DATE], with diagnoses including autonomic dysreflexia, hematuria, and paraplegia. A Nurse Practitioner Progress Note dated 04/17/2023, documented resident was stable to be transferred to another healthcare facility today. Discharge summary to follow. R89's medical record lacked documented evidence a discharge summary was completed for the resident. On 07/13/2023 at 1:34 PM, the Medical Records Director confirmed the findings and revealed the physician should have completed R89's discharge summary within 30 days upon discharge. On 07/13/2023 at 1:50 PM, the Director of Nursing (DON) acknowledged R89 had an anticipated discharge, and a discharge summary should have been completed for the resident. The facility's policy titled Physician Documentation dated 03/01/2013, documented a discharge summary would have been completed within 30 days of discharge. The discharge summary would have included the following: - Resident name - Resident number - admitted - discharge date - Name of the attending physician - Admitting diagnosis - Final diagnosis - Treatment modalities - Resident's response to treatment - Discharge disposition - Pertinent social information - Rehabilitation potential - Condition at discharge - Date and signature of the attending physician

Based on observation, interview and record review, the facility failed to ensure the gastrostomy tube (G-tube) feeding and water flush bag were labeled with the name of the resident, room number, infusion rate, and date and time the feeding and water flushes started for 1 of 10 sampled residents (Resident 45). The deficient practice had the potential for the resident receiving expired or incorrect G-tube feeding, and inaccurate rate of feeding and water flushes. Findings include: Resident 45 (R45) R45 was admitted on [DATE], with diagnoses including encounter for attention to gastrostomy, cerebral infarction, and dependence on respirator. On [DATE] at 9:28 AM, the resident was lying in bed. There was a G-tube feeding and a water flush bag connected to the resident's G-tube through a feeding pump (enteral pump). The feeding pump was on. The stickers attached to the G-tube feeding and the water flush bag were not filled-out with the name of the resident, room number, rate of the feeding and flushes, and date and time the feeding and water flushes started. On [DATE] at 9:39 AM, a Registered Nurse (RN) confirmed the findings and acknowledged R45's G-tube feeding, and water flush bag should have been labeled with the name of the resident, room number, infusion rate for both feeding and flushes, and date and time the feeding and flushes started. The RN explained complete labeling of feeding and water flush bag was necessary to make sure the resident was getting the correct feeding, rate, and flushes. On [DATE] at 1:54 PM, the Director of Nursing (DON) explained the nurses were expected to label the G-tube feeding and the water flush bag with the resident's name, room number, name of the feeding formula, rate, date, time started, and nurse's initials. The label should have been completed to make sure the feeding and water flushes were given to the right resident, and the resident was receiving the correct amount of feeding and water flushes as ordered.

Based on interview, record review and document review, the facility failed to ensure weekly skin assessments were performed on a resident who was at risk for skin breakdown for 1 of 23 residents (Resident 90). The deficient practice placed the resident and other residents at risk for a delay in identification of new skin impairments along with appropriate interventions. Findings include: Resident 90 (R90) R90 was admitted on [DATE] and readmitted on [DATE], with diagnoses including Parkinson's disease, tracheostomy, and gastrostomy status. R90's Skin Integrity care plan initiated 04/30/2021, documented R90 was at risk for skin breakdown due to advanced age, poor dietary intake, hemodynamic instability, and bedfast status. Interventions included weekly skin assessments by nursing. An Admission Observation document dated 08/06/2021, revealed R90 was admitted with dry, cool skin with normal color and turgor and a coccyx wound. A wound progress record dated 08/16/2021, documented R90's sacral wound had resolved, and treatment orders were to be discontinued. A physician's order dated 11/22/2021, documented to perform weekly skin checks by licensed nurse. The medical record lacked documented evidence weekly skin assessments were completed for R90 with the exception of three skin assessments recorded on 05/12/2022, 05/17/2022 and 05/19/2022. The look back period for the record review was from 08/06/2021 (readmission) until 08/23/2022 (discharge to hospital). On 07/12/2023 at 1:10 PM the Director of Nursing (DON) explained an admission head-to-toe skin assessment was performed for all residents, after which weekly skin assessments would be completed by floor nurses. Skin assessments were typically done on resident's bath days for visibility. According to the DON, newly identified skin impairments would be reported to the wound team specifically the wound care physician who would evaluate and give treatment orders for the resident's wound. On 07/12/2023 at 1:19 PM, the wound care physician indicated visiting the facility once a week to treat existing wounds and evaluate newly identified skin impairments. The physician indicated being familiar with the facility's policy with regards to performing skin assessments on admission and weekly thereafter. The physician verbalized skin assessments were important because early identification of wounds ensured timely interventions and better outcomes. The physician indicated relying on the nurses to notify the physician of new skin abnormalities otherwise the physician would not be able to intervene. On 07/12/2023 at 3:07 PM, the Medical Records (MR) Director confirmed there were only three recorded skin assessments performed for R90 on 05/12/2022, 05/17/2022 and 05/19/2022 for the period covering 08/06/2021 through 08/23/2022. A nurse's note dated 08/23/2022, revealed R90's genitals were swollen and hard and R90 screamed out of pain when a nurse assessed the site. Resident sent to hospital. The Physician Emergency Department note dated 08/23/2022, indicated R90 presented with a chief complaint of Fournier's gangrene (necrotizing fasciitis or gangrene affecting the perineum) scrotum and penis. A hospital wound consult report dated 08/24/2022, revealed R90 was diagnosed with Fournier gangrene involving entire shaft of penis and scrotum. Examination revealed scrotum is not gangrenous however it was tense consistent with probable purulent collection with large phlegmon (localized area of acute inflammation). Surgery tomorrow. R90 was at risk for losing the entire shaft of penile skin as well as probably most of scrotum. It is unlikely whether the penis can be salvaged depending on intraoperative findings. Prognosis was poor. A hospital Critical Care Progress note dated 08/28/2022, revealed R90 had a total penectomy (removal of penis), scrotectomy (removal of scrotum) and orchiectomy (removal of testicles). The Wound Care policy revised 06/01/2015, documented weekly skin assessments should be performed and documented by a licensed nurse on all residents. Abnormal findings should be reported to the physician. Complaint #NV00068222

Based on observation, interview, record review and document review, the facility failed to ensure a medication was administered per the physician's order for one unsampled resident (Resident 73). Failure to administer medication as prescribed had the potential for adverse medication reaction and might have delayed the therapeutic treatment for the resident. Findings include: On 07/12/2023 at 8:00 AM, during the medication pass observation, a Licensed Practical Nurse (LPN) administered Resident 73's (R73) medications including Vitamin B12 500 micrograms (mcg) one tablet by mouth. The physician's order for R73 dated 05/05/2023, documented Vitamin B12 1,000 mcg one tablet oral. On 07/12/2023 at 9:57 AM, the LPN confirmed Vitamin B12 500 mcg one tablet was given to R73 during the medication pass observation. Upon verifying the physician's order, the LPN acknowledged the physician's order was not followed. On 07/13/2023 at 1:51 PM, the Director or Nursing (DON) explained the nurses were expected to verify the physician's order prior to giving the medication to the resident. The facility's policy titled Physician Orders dated 05/05/2023, documented the facility should have not administered medications or biologicals except upon the order of a physician/prescriber.

Based on observation, interview, record review and document review, the facility failed to notify the representative of a cognitively impaired resident of the resident's urinary tract infection (UTI) for 1 of 23 sampled residents (Resident 68). The deficient practice deprived the resident's representative of the right to be informed of the resident's health status. Findings include: Resident 68 (R68) R68 was admitted on [DATE] and readmitted on [DATE], with diagnoses including encephalopathy, cognitive communication deficit and gastrostomy status. On 07/11/2023 at 9:20 AM, a contact precautions signage was posted outside R68's door and a personal protective equipment (PPE) caddie was observed by the room entrance. A Certified Nursing Assistant (CNA) indicated being unfamiliar with the resident's infection status, but staff were required to don gown, gloves, and mask before entering the resident's room. On 07/11/2023 at 9:25 AM, R68 laid in bed supine, eyes opened with a blank stare. The resident was unable to respond to questions even when asked to communicate by moving head or blinking eyes. The quarterly minimum data set (MDS) dated [DATE], revealed R68 had a brief interview of mental status (BIMS) score of three (severely impaired cognition). R68's face sheet identified a family member as R68's emergency contact. A physician's order dated 07/06/2023, documented to perform urinalysis (UA) with reflux culture. A laboratory report received 07/10/2023, revealed urine culture was positive for extended spectrum beta-lactamase (ESBL - an enzyme found in some strains of bacteria which was resistant to most antibiotics), specifically, Klebsiella pneumoniae and Proteus mirabilis. A nursing note dated 07/10/2023, revealed the nurse practitioner (NP) was notified of R68's urine culture results. The medical record lacked documented evidence R68's family member was notified of the resident's urine culture results. On 07/11/2023 at 1:57 PM, R68's family member indicated the last phone call received from the facility was in May 2023 regarding a consent for placement of an intravenous line. The family member verbalized there had been no communication from the facility since May 2023. On 07/23/2023 at 9:28 AM, the night shift charge Registered Nurse (RN) reviewed R68's laboratory report dated 07/10/2023 and confirmed R68's urine culture results were indicative of an active UTI. The Charge Nurse indicated a UTI was a significant change in condition where R68's family member was required to be notified. The RN indicated charge nurses were responsible for notifying physicians and resident representatives regarding any changes in residents' condition. The RN confirmed not notifying R68's family member and was uncertain whether the day shift charge nurse or the Infection Preventionist (IP) may have notified R68's family member of the resident's UTI. On 07/13/2023 at 9:38 AM, the day shift charge RN reviewed R68's laboratory report dated 07/10/2023 and recalled notifying the NP of R68's positive urine culture on 07/10/2023. The charge nurse indicated R68's family member should have been notified since a UTI was a significant change in condition, but the charge nurse acknowledged not notifying R68's family member of the resident's UTI. On 07/13/2023 at 9:44 AM, the IP confirmed R68's urine culture results dated 07/10/2023 was reflective of active UTI. The IP indicated not notifying R68's family member of the resident's UTI because charge nurses were responsible for notifying resident representatives. The IP indicated being responsible for tracking antibiotic starts related to newly identified infections. On 07/13/2023 at 10:15 AM, the surveyor was present when the charge nurse informed R68's family member by telephone regarding R68's positive culture results. The charge nurse was overheard telling R68's family member the NP had reviewed the urine culture results and was waiting on infectious disease for orders. On 07/13/2023 at 10:20 AM, R68's family member informed the surveyor this was the first time the family member was informed of the resident's UTI which was identified by the facility on 07/10/2023. On 07/13/2023 at 1:40 PM, the Director of Nursing (DON) indicated a UTI was considered a significant change in condition where nurses were required to notify the physician and resident representative as soon as practicable but no more than one hour from identification. The DON verbalized it was not acceptable for R68's family member to not have been notified of the resident's UTI until 07/13/2023 (three days later). The Significant Change policy revised 05/05/2023, documented the physician and resident representative or appropriate family member will be notified when there was a change in the resident's condition. An example of a significant change in condition was a urinary tract infection.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician's order was obtained and care orders were implemented before the administration of Oxygen for 2 of 23 sampled residents (Residents 2 and 240). The deficient practice could lead to the potential risk of administering incorrect or inappropriate oxygen levels to residents, compromising their respiratory health and overall well-being. Findings include: Resident 2 (R2) R2 was admitted on [DATE] and readmitted on [DATE] with diagnoses including acute respiratory failure and anoxic brain damage. On 07/11/2023 at 9:45 AM, R2 was lying in bed, head slightly elevated with eyes open and no verbal response. There was a technician in room preparing to obtain blood samples for diagnostic testing. Oxygen concentrator was on and dispensing oxygen at 2 liters per minute, nasal cannula tubing was connected to concentrator and coiled up next to resident, not currently being administrated. The lab technician verbalized the resident was not currently receiving oxygen. On 07/13/23 at 9:19 AM, R2 was lying in bed with eyes closed, head elevated approximately 30 degrees, oxygen concentrator in room and tubing connected and coiled up and placed inside drawer of bedside nightstand. A certified nursing assistant was in the room and verified oxygen was not being utilized by resident and verbalized R2 was on oxygen as needed. The medical record lacked documented evidence there was a physician order to administer oxygen. On 07/13/23 at 9:24 AM, A Registered Nurse (RN1) indicated when resident was on continuous flow oxygen there would be order to specify how many liters and if there were any parameters such as monitoring the oxygen saturation level and providing oxygen based on whether the level was low or high. The RN explained if a resident was receiving oxygen intermittently based on oxygen saturation, the order should reflect the specific parameters to follow and would need to be clarified if oxygen was being administered differently than ordered parameters. On 07/13/23 at 10:41 AM, A Registered Nurse (RN2) indicated R2 was no longer on oxygen and previously was receiving oxygen as needed due to seizure activity and was discontinued in June. RN2 explained when resident's oxygen was discontinued, the concentrator in room should be have been removed and sent back for cleaning and storage until needed. The medical record revealed physician order for oxygen 3 liters per minute initiated on 04/13/2021 and discontinued on 05/22/2023. On 07/13/23 at 12:49 PM, The Director of Nursing (DON) confirmed there were no physician orders for resident to receive oxygen currently. The DON explained once an order for oxygen was discontinued, the oxygen concentrator would be removed from the room to avoid confusion among staff on determining if resident required oxygen. Once removed, respiratory therapy would disinfect concentrator and place clean bag over unit and send to storage until it was needed. Resident 240 (R240) R240 was admitted on [DATE] with diagnoses including anemia and type 2 diabetes mellitus. A nursing progress note dated 07/07/2023 documented, Patient was admitted with oxygen at 2 liters per minute via nasal cannula. On 07/11/2023 at 1:30 PM, R240 was lying in bed, tube feed being administered, eyes closed. Oxygen concentrator was set to 2 liter per minute and in operation with tubing connected to concentrator, not currently on resident. On 07/13/23 at 10:49 AM, R240 was lying in bed, tube feed being administered, eyes closed. Oxygen concentrator was set to 2 liters per minute and in operation with tubing connected to concentrator, not currently on resident. RN2 confirmed resident not currently wearing nasal cannula. On 07/13/23 at 10:52 AM, RN2 confirmed resident had oxygen order for 2 liters per minute continuous oxygen. The RN explained the CNA may have forgotten to put the oxygen back on resident after cleaning the resident. The RN verbalized when resident was receiving oxygen the order would specify if it should be as needed or continuous. A physician order dated 07/07/2023 documented oxygen via nasal cannula at 2 liters per minute continuous. On 07/13/23 at 12:29 PM, The DON indicated when there was an order for oxygen, it would identify the parameters of order such as continuous or as needed, and liter flow per minute. The DON confirmed the order for R240 was for continuous oxygen and the expectation was the resident would always have nasal cannula in place unless needed to be taken off for safety or personal care. The DON indicated the staff would be responsible for identifying if the resident was observed with oxygen off and if it was occurring frequently then Respiratory Therapy should be contacted for possible new evaluation. The facility policy titled Respiratory Treatment, Care and Services Program (revised 05/05/2023) documented the facility ensured the safe, appropriate, and effective provision of respiratory treatment, care, and services in accordance with professional standards of practice. Oxygen therapy care plan elements include when to initiate or discontinue oxygen therapy, safety precautions, type of oxygen delivery system, equipment settings including flow rate.

Based on observation, interview and document review, the facility failed to ensure an insulin prefilled syringe and a multi-dose vial of medication stored in 1 of 3 medication carts inspected (A-Hall medication cart) were labeled with the open date and expiration date. The deficient practice had the potential for the residents receiving expired medications. Findings include: On 07/12/2023 at 9:20 AM, an inspection of the A-Hall medication cart was conducted with a Licensed Practical Nurse (LPN). A Novolog Flex Pen Prefilled syringe (insulin) and a multi-dose vial of Lidocaine Hydrochloride (HCl) Injection 20 milliliter (ml) vial were found inside the cart. The medications were opened and there were remaining amounts of insulin in the syringe and Lidocaine in the vial. The medications were not labeled with the open date and expiration date. The LPN confirmed the observations and acknowledged the Novolog Flex Pen syringe should have been dated when opened. The medication was good for 28 days from the time it was opened. The LPN indicated the Lidocaine HCl Injection was a multi-dose vial and should have been labeled with the open date and expiration date. The LPN revealed not being aware whether the multi-dose vial was also good for 28 days from the date it was opened. The LPN explained the label with the open date and expiration date should have been indicated to make sure the medications were not expired. The LPN acknowledged there could have been a risk of administering expired medications to residents if the medications were not labeled. The LPN confirmed the medications belonged to two active residents. On 07/13/2023 at 1:57 PM, the Director of Nursing (DON) indicated the nurses were expected to label the insulin pen prefilled syringe and the multi-dose vial of Lidocaine HCl with the open date because the medications would have expired in 28 days after they were opened. The facility's policy titled General Guidelines for Storage of Medication and Biologicals dated 04/01/2022, documented once any multi-dose packaged medication or biological was opened, nursing would have marked the multi-dose products (i.e., inhalers, insulin, ophthalmic and the like) with the date opened and follow manufacturer/supplier guidelines with respect to expiration dates.

Based on observation, interview and record review the facility failed to ensure oxygen and intravenous fluids were administered in accordance with physician's orders [REDACTED].#1). Findings include: Resident #1 Resident #1 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. During the initial tour, on 3/24/15 at 8:10 AM, Resident #1 was in bed with a nasal cannula in nares and connected to an oxygen cylinder tank. The resident's respirations were 32 per minute and the resident was making a grunting sound with respiratory effort. The resident's lips were bluish in color. Resident #1 had a Peripheral IntraVenous (PIV) line attached to the right hand with 0.9% normal saline fluid running at a rate of 10 drops per minute as calculated in the drip chamber. There was 550 cc (cubic centimeters) remaining in the bag. The left hand also had capped PIV line. The saline solution was not labeled or dated and did not have a time written on it. The LPN reported Resident #1 was on continuous oxygen but would have to check the orders to confirm the amount of oxygen. Average normal values for an adult male vital signs are as follows: -respirations 12-16 breaths per minute. -heart rate 60-100 beats per minute. -blood pressure 120 mmhg (millimeters of mercury) systolic and 80 mmhg diastolic. -oxygen saturation 95-100% with a rate below 90% may result in the need for oxygenation. On 3/23/15 a physician's orders [REDACTED]. On 3/24/15 at 8:13 AM, the LPN confirmed the oxygen cylinder tank was empty. The LPN indicated the last time the tank was checked or changed was unknown. The LPN left the room to "get some oxygen". The LPN returned with a concentrator, humidifier, and left the room to check how many liters of oxygen was ordered for Resident #1. The LPN returned at 8:15 AM and verbalized Resident #1 was ordered to have 2-4 liters of oxygen continuous. The LPN changed the cylinder tank and applied the concentrator but did not apply the humidifier bottle. The humidifier was placed in a wheelchair. The LPN checked the oxygen saturation which registered 81%. On 3/24/15 at 8:20 AM, the LPN elevated the head of the resident's bed and increased the oxygen to 4 liters. The oxygen saturation registered 85%. On 3/24/15 at 8:26 AM, the LPN agreed to report this information to a Registered Nurse (RN) and Respiratory Therapist (RT). The LPN verbalized she would go get a breathing treatment. Resident #1's blood pressure was reported by nursing staff as 85 systolic /55 diastolic at approximately 8:30 AM. The Respiratory Therapist (RT) arrived after an alert from nursing. Upon entering the room, RT checked Resident #1's saturation using a fingertip pulse oximeter which registered between 77%-80%. The RT attempted to adjust the machine, educated the resident on pursed lipped breathing, and elevated the resident's legs. The RT verbalized she would get another pulse oximeter machine. On 3/24/15 at approximately 9:00 AM, the RT reported the resident's oxygen saturation rate was 92% on 4 liters of continuous oxygen, the pulse rate was 142 beats per minute, the blood pressure was 95/49. On 3/24/15 at 9:12 AM, the RN verbalized the physician was calling back. The RN confirmed there was no label with the date or time the IV bag of Normal saline was started. The RN verified the bag hung was started at 6:56 PM and verified the fluid remaining in the bag. The RN indicated the rate was 75 cc (cubic centimeters) per hour and it was running at 75 cc per hour because of the dial- a- flow tubing. The RN did not acknowledge the drop factor in the chamber of the PIV line. The RN confirmed the liter of fluid should have been infused into Resident #1 already. The RN then proceeded to apply a label. On 3/24/15 at 9:15 AM, the RN verbalized the physician was made aware of the vital signs documented in the medical record a blood pressure of 90/54, and 87% oxygen saturation rate. The RN informed the physician Resident #1 had received the liter of fluids ordered last night and the physician ordered Resident #1 transferred to the hospital for evaluation. Resident #1 verbalized feeling bad with pain all over at a 10/10 pain scale. The LPN dispensed a Narco (narcotic pain medication) from the medication cart and entered Resident #1's room to administer the dose. The LPN did not re-check the vital signs and did not acknowledge the previously low blood pressures. The LPN was asked immediately prior to administration of the Narco if the blood pressure had been checked and should the narcotic pain medication be given without rechecking the vital signs and with paramedics arrival to the facility. The LPN agreed and did not administer the medication and paramedics entered to take over Resident #1's care. On 3/25/15 in the morning, the Director of Nursing (DON) confirmed the staff did not report the oxygen tank for Resident #1 was empty or the IV had not been running in accordance with physician's orders [REDACTED]. The DON confirmed if a resident did not receive IV fluids as ordered the resident could experience dehydration and low blood pressures. The DON acknowledged it was the facility expectation the nursing staff should identify change of condition , provide nursing intervention, assessment, and communicate accurately to the physician. Perry and Potter - Eighth Edition Chapter 31 Medication Administration documented in part "...when administering medication in large IV infusions, regulate the IV rate according to the health care provider's order. Monitor patients closely for adverse reactions to the medication and fluid volume overload. Also check the site frequently for infiltration and phlebitis..."

Based on observation, interview, record review, and document review, the facility failed to: 1) Accurately assess 1 of 19 sampled residents (Resident #18) for vital signs and pain medication side effects following shortness of breath and decreased oxygen saturation levels; 2) Notify the physician and family member upon a change of condition for 1 of 19 sampled residents (Resident #18); 3) Ensure a resident with a significant change of condition was transferred to an acute care facility timely for 1 of 19 sampled residents (Resident #18); 4) Follow physician's orders [REDACTED].#4, #7, and #15); and 5) Follow the facility's policy and procedure regarding falls for 1 of 19 sampled residents (Resident #15). Findings include: 1) Resident #18 Resident #18 was admitted [DATE] with [DIAGNOSES REDACTED]. The Daily Skilled Nurse's Notes dated 7/13/12 indicated the resident's condition was as follows: Nocturnal Shift: "Observed to be on sob (short of breath), placed 02 (oxygen) @ (at) 2liter via n/c (nasal/cannula) 02 sat (saturation level) 91%, hob (head of bed) elevated to assist in (illegible). 0315 (3:15 AM): (Name of physician) MD informed of pt's (patient's) condition, gave order by phone noted and carried out. Started an SVN (small volume nebulizer) tx (treatment) of Atrovent 1 unit dose q (each) 4 hrs (hours) prn (as needed) sob. 0330 (3:30 AM): O2 sat @ 2 L/M (liters/minute) via N/C = 95%. Continue on monitoring for sob..." Day Shift: "7AM: Received report res (resident) has a temp (temperature) of 101.3. Tylenol 325 mg (milligrams) 2 tabs (tablets) given @ 7AM. Pt is responsive (and) ate breakfast about 10%. @ 9AM - check pt (with) temp of 99.9 tympanic. Pt is still responsive but notice sleepy. On 02 @ 2L/NC (with) 02 sat @ 86%. @ 10AM 02 sat level stays the same and given a PRN Atrovent for sob (and) congestion. @ 11AM 02 sat at 86% (and) (increased) congestion. Notified charge nurse (and) ordered to continue to monitor. Pt hob (up) (and) repositioned. Pt continues to sleep (with) 02 on. @ 1PM notified charge nurse of her condition (and) update for the noticed (increased) congestion, 02 sat level remains 86% (with) 02. Charge nurse says continue to monitor, pt on abt (antibiotic) for PNA (pneumonia). LPN (licensed practical nurse) suggested to get a CXR (chest x-ray) but charge nurse ordered to continue to monitor bec (because) pt is on abt - pna. @ 2:45 PM checked pt (and) found her unresponsive (with) 02 sat at 86%, T 97.7, BP (blood pressure) 121/50, P (pulse) 106. BS (blood sugar) level was 112. Upon observation noted labored breathing. Notified charge nurse of condition, charge nurse called 9-1-1. Notified dtr (daughter) @ 5:15 PM re (regarding) transfer to (name of acute care facility) at 3PM. Based on review of Side One of the 7/13/12 Daily Skilled Nurse's Note for the Day Shift, there was lack of documentation that Resident #18's lung sounds were assessed. Further documentation in the clinical record indicated the following nursing record with a date and time of 7/13/12, 5:00 PM at the bottom of the sheet: "...The most recent vital signs are: blood pressure 121/50, pulse 106, respirations 18, temperature 97.9, pulse ox (oximetry) 86. I am concerned about the O2 sat because level is declining. This started @ (at) 10AM and has stayed the same...Primary [DIAGNOSES REDACTED]. Pertinent meds (medications) or recent med changes 0 (zero). Mental status - lethargic. Respiratory @ 2L. Breath sounds: congested...I think the problem may be chest congestion OR the patient / resident seems to be unstable and may get worse. We need to do something - Notified charge nurse (AM shift) ordered to continue to monitor res (resident) status...1PM: suggested CXR (chest x-ray) to charge nurse. Charge nurse said cont (continue) to monitor. Pt on ABT (antibiotics) - PNA. Final disposition / Plan: @ 2:45 PM checked pt: She is unresponsive. Chk (checked) v/s (vital signs) & O2 sat @ 86.1 on O2/2L NC (nasal cannula). Notified charge nurse. Charge nurse called 9-1-1. Reported to physician (blank)." Resident #18 was transferred to an acute care facility on 7/13/12 at approximately 2:45 PM. The acute care facility's progress note indicated at 4:00 PM the resident, in [MEDICAL CONDITION], presented to the acute care facility with altered mental status and shortness of breath, and responded to [MEDICATION NAME] (a reversing agent for narcotics), which was administered by the paramedics who responded at the facility. The progress note further indicated, "...In ED (emergency department), noted resp (respiratory) distress...intubated for airway protection...on vent (ventilator)...BP = 169/96; HR (heart rate) = 110; RR (respiratory rate) =[MEDICAL CONDITION]" The acute care facility's history and physical examination [REDACTED]. Healthcare-associated pneumonia; 3. Questionable aspiration..." On 7/26/12 at 12:45 PM, the LPN (LPN #4) who had administered medications and provided care to Resident #18 on 7/13/12, indicated her responsibilities included monitoring patients for antibiotics and any status change, and stated, "A change in condition that I would receive report about is vital signs, temperature, increase in blood pressure, and any behaviors. If I am receiving report about shortness of breath, I would make sure the oxygen is on and I would check sats. If the sats are less than 90 I would call the doctor. If a resident is short of breath I would elevate the resident's head, listen to lung sounds, check vital signs (including the heart rate and auscultation of the lungs), and continue to monitor, and document everything. I would assess and notify the charge nurse and she would notify the doctor...When there's a change in condition, we should call the doctor and notify the family." On 7/26/12 in the afternoon, LPN #4 reviewed the Medication Administration Record (MAR) for the month of July 2012, and verified on 7/13/12, a [MEDICATION NAME] Patch, 700 mg, was placed on at 6:00 AM, and Tylenol, 325 mg (2 tablets) was administered at 7:00 AM. LPN #4 verified at 8:00 AM on 7/13/12, 60 mg of [MEDICATION NAME] and 100 mg of [MEDICATION NAME] was administered. LPN #4 verified at 10:00 AM on 7/13/12, an Atrovent Treatment was administered. LPN #4 verified at 11:00 AM on 7/13/12, Tylenol, 325 mg (2 tablets) was administered. (The MAR documented, "Tylenol: Reason: (high) temp 99.9. Result: 3PM Temp (lower) 97.7".) LPN #4 verified at 1:00 PM on 7/13/12, [MEDICATION NAME], 100 mg, was administered. The chart for Resident #18 was reviewed with LPN #4, who verified there was a change in condition at 9:00 AM, and stated, -"I was on orientation with another LPN. I remember this patient. I notified the charge nurse about the 86% oxygen sats at 9:00 AM. The 86% oxygen sats did alarm me. We notified the charge nurse, who said just to continue to monitor. We should have called the doctor. I should have done heart rate (HR), respiratory rate (RR), lung sounds, checked auscultation of the lungs, and mental status at 9:00 AM and written it all in the chart...No, this was not done; I could not have notified the doctor of these vital signs if I did not write them down." LPN #4 indicated there was no pain assessment completed before giving Resident #1 the [MEDICATION NAME] and the [MEDICATION NAME] on 7/13/12 at 8:00 AM, and verbalized, "She was responding when I gave her the pain medication but she was sleepy...No, it's not okay to give someone pain medication when (the patient is) sleepy." LPN #4 further stated, "We didn't take any action until 10:00 AM when we gave her a breathing treatment. We did not call the doctor or notify the family member at 9:00 AM... At 10:00 AM the vital signs should also have warranted a telephone call to the doctor. I would have called a long time before but I was in orientation and I didn't know this patient well. We should have notified the family then. It was my gut feeling but the charge nurse kept giving me the same answer just to continue to monitor. LPN #4 indicated she gave Resident #18 [MEDICATION NAME], 100 mg, at 1:00 PM. LPN #4 verified there was a lack of documententation complete vital signs were taken, and stated, "There's no respiratory rate documented. It was not a full set of vitals. The lung sounds were not documented. I did the lung sounds, and there were crackles." On 7/26/12 in the afternoon, the chart was reviewed with a Charge Nurse (RN (Registered Nurse) #1). RN #1 stated, "At 7:00 AM when the resident had a high temperature the doctor should have been called. Anytime there is a shortness of breath after a treatment when the 02 sats are still down, the doctor should be notified. And then check on the resident every 15 minutes and document everything in the chart." RN #1 stated, "At 9:00 AM the physician and the family should definitely have been notified. There was definitely a change in condition at 11:00 AM and the resident should have been sent out to the hospital." RN #1 further stated, "There was no documentation of the RR and an assessment of the lung sounds. The policy and procedure was not followed." The facility failed to ensure nursing staff followed the policies and procedures regarding assessing pain and transferring a resident to an acute care facility upon identifying a change in condition as follows: "Documentation - Licensed Nursing (NP-D-10, revised 9/2011): "...8. A. Significant Change: A significant change in condition is noted in the nursing progress notes as soon as possible after observation of the patient / resident. Notification of the physician / family member and / or responsible party of such occurrences are also noted in the medical record. B. If the condition of the patient / resident calls for the transfer of the patient / resident to an acute care facility, the date, time of admission, name of the facility, the mode of transportation surrounding the transfer is documented in the final progress note... C. The final nursing progress note describes the condition of the patient / resident at the time of discharge and addresses destination, mode of transportation, those who accompanied the patient and what time the patient / resident left the facility." "Physician Communication / Change in Condition - NP-P-15", revised 9/2011: "Policy: 1. To improve communication between physicians and nursing staff in order to promote optimal patient / resident care. 2. To provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's / resident's condition. Procedures: 1. Complete assessment of the patient / resident which may include but is not limited to: E. Vital signs, TPR (temperature, pulse, respiration), BP (blood pressure), I/O (intake / output), Lung Sounds, N/V (nausea / vomiting) abdominal assessment, last BM (bowel movement), blood glucose... 2. Notify the physician of any change in medical condition. (The physician notification grid may be used as a reference tool regarding acceptable notification timeframes.) The nurse will document all assessments and changes in the patient's / resident's condition in the medical record. 3. If the physician does not respond within an acceptable time frame, the Medical Director and Director of Nursing will be notified... 4. The patient's / resident's family member / legal representative will be notified of any change in condition requiring an emergent transfer to the hospital. 6. All attempts to notify physicians and family members / legal representatives will be thoroughly documented in the patient's / resident's medical record..." The attached Physician Communication Grid indicated the following: "-Condition: Shortness of Breath: Treatment required within 1 hour: Acute onset or with chest pain, change in vs, labored breathing, O2 saturation < (less than) 95; Treatment required within 4 hours: Gradual onset of SOB (shortness of breath), O2 saturation 95%..." The last paragraph of this Physician Communication Grid states, "These guidelines are not intended to substitute for good nursing judgement. If the nurse feels uncomfortable with a situation he / she should not delay contacting the physician or call 911 if it appears to be a life-threatening event. The above applies 24 hours a day 7 days a week!" "Pain Management", revised 11/2011: "Policy: Staff will implement the Facility Pain Management Program, including Evaluation / Re-evaluation for patients / residents experiencing either acute or chronic pain. Procedures: 1. Upon admission, provide the patient's / resident's / family with the handout 'Your Guide to Managing Pain'. 2. Upon admission, re-admission, quarterly, and with a significant change in condition complete Section E of the Nursing Data Collection Tool. A. If pain is 'triggered', initiate a pain management care plan which includes non-pharmacological and pharmacological interventions for the resident's pain relief. B. Interventions should be specific for the resident based on the information collected during the evaluation and interview process. C. Initiate the 'Pain Flow Sheet' for ongoing documentation of PRN (as needed) medication administration and effectiveness. D. Document pain as the fifth vital sign, evaluating or checking with the resident for the presence of pain during the morning, afternoon, evening medication pass and PRN. 3. With new onset of pain, between admission and quarterly evaluations, utilize the Pain Evaluation Tool. Initiate the 'Pain Flow Sheet' as determined by resident need, following documentation parameters set forth above. 4. Obtain information from the evaluation process to determine at what level pain will interfere with the resident's quality of life and prohibit them from carrying out normal life activities. This information should be incorporated into the development of the resident's pain management care plan." 2) Resident #12 Resident #12 was admitted [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Additional physician's orders [REDACTED]. 7/2/12: [MEDICATION NAME] mg po bid (twice daily). 7/7/12: (Increase) [MEDICATION NAME] 2 mg IV (intravenous) q (every) 3 hrs prn. 7/7/12: (Increase) [MEDICATION NAME] 30 mg po (by mouth) q 8 hrs. 7/16/12: (Increase) [MEDICATION NAME] 3 mg IV PRN for pain. The Nursing Notes indicated the following: 7/6/12, 10:30 AM: "Pt (patient) called and complaining of pain and swelling of the left inguinal area. Felt like lump. (Physician) was called and ordered to do X-ray and US (ultrasound) of left inguinal area. Extra dose of [MEDICATION NAME] was also given IV as ordered." 7/16/12, 11:30 AM: "Complained that pain medication [MEDICATION NAME] 2 mg IV q 3 don't work. (Physician) notified (with) order (increase) [MEDICATION NAME] 3 mg IV Q4 hrs." 7/23/12, 4:00 PM: "(Physician) notified of CT hip result (with) order." The Daily Skilled Nurse's Notes indicated the following: 7/7/12, 5:00 AM: "Pt c/o (complained of) excruciating pain on inguinal L (left) side area. Called MD (medical doctor) (with) N.O. (new orders) of [MEDICATION NAME] 2 mg q 3 (hours) to be examined by (physician) in am..." 7/7/12 (no time indicated): "...Pt was seen by (physician) this am. (Increase) [MEDICATION NAME] 30 mg po q 8 (hours)...CT for hip (and) lab orders..." 7/14/12, 1:00 AM: "...Continues on pain management for L inguinal mass (with) moderate pain..." The Ultrasound of the Lower Extremity Soft Tissues dated 7/6/12 indicated: "Findings: There is heterogeneous soft tissue with nodularity. The area in question measures 3 cm (centimeters) in greatest dimension...Impression: Nonspecific heterogeneity and nodularity in the left inguinal region. This could represent enlarged lymph nodes, a primary soft tissue mass, or possibly a hernia which is not peristasis. Abscess is felt to be less likely. Given the somewhat atypical sonographic appearance, correlation to a CT may be helpful." The CT (Computerized Tomography) Scan, which was not completed until 7/19/12, indicated: "Left hip: Impression:..3. Large left inguinal hernia containing omentum and colon." (Note: The date the fax (facsimile) was received indicated at the top of the paper was 7/23/12 at 1:51 PM.) On 7/24/12 in the morning and 7/25/12 in the afternoon, Resident #12 indicated he was in a lot of pain and took a lot of pain medications. He stated his pain had gotten a lot worse since he noticed the lump in his groin. He further indicated he had been waiting to hear about his CAT scan results for weeks. Resident #12 indicated the nurses told him they couldn't show him the results because they had to "call legal and get permission" first. Resident #12 verbalized he was very worried about the results and what would happen next. On 7/25/12 in the afternoon, Resident #12 indicated the physician had examined the lump almost 3 weeks ago, and had ordered an ultrasound. The resident had an x-ray and an ultrasound a few weeks ago, and a CAT scan more than a week ago. Resident #12 verbalized he was in a lot of pain since he noticed the lump in his abdomen and his doctor had to prescribe a lot more pain medicine, that he had kept asking the nurses about the results of the CAT scan, but they wouldn't tell him the results. On 7/25/12 in the afternoon, the Director of Nursing (DON) verified the CT scan was not completed until 7/19/12, and the results were not received by the facility until 7/23/12. The DON verified there was no documented reason for the delay in getting the CT scan, and only stated the radiology department must have been very busy. The facility failed to ensure there was no delay of care in following the physician's orders [REDACTED]. 3) Resident #4 Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 6/28/12, a physician's orders [REDACTED]. On 7/23/12 at 10:00 AM, Resident #4 received his 10:00 AM, snack which consisted of a Bologna sandwich on wheat bread. The resident's tray table contained 3 Bologna sandwiches. One sandwich was dated 7/21/12 and the other 2 sandwiches were dated 7/22/12. Resident #4 stated the sandwiches were snacks the facility provided for the last few days. The resident stated, "I told them I wanted peanut butter and jelly not Bologna. They don't listen." On 7/24/12, in the morning Resident # 4's 10:00 AM, snack consisted of a Bologna sandwich. Resident # 4 stated "see they don't listen." 4) Resident #7 Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The clinical record contained a physician's orders [REDACTED]. The clinical record contained a physician's orders [REDACTED]. The clinical record documented the resident had physician's orders [REDACTED]. The MAR dated May 2012, lacked documentation bowel monitoring had been done on the 6:00 PM to 6:00 AM shift from 5/9/12 through 5/30/12. The MAR dated June 2012, documented Resident # 7 did not have a bowel movement on 6/26/12, 6/27/12, 6/28/12, 6/29/12 and 6/30/12. The MAR dated June 2012, documented Resident # 7 had been given a [MEDICATION NAME] 10 mg suppository and [MEDICATION NAME] 100 mg (stool softener) on 6/29/12. The back of the MAR lacked documentation of the date, time and effectiveness of the [MEDICATION NAME] suppository and [MEDICATION NAME] given on 6/29/12. The MAR lacked documentation any further intervention had been done when the resident did not have a bowel movement on 6/29/12. On 7/23/12 at 3:20 PM, the Director of Education stated if a resident did not have a stool times 3 days then the physician would be called or offered something to soften the stool. The resident's stomach would be assessed for bowel sounds, bloating, if it was soft, firm or tender. The Director of Education stated they should have documented the results of the medication on the back of the MAR and called the physician. The Director of Education verbalized we did not follow the physician's orders [REDACTED]. Documentation provided by the facility entitled, Nursing Physical Assessment of the Older Adult, "A Study Guide" dated revised 10/07, documented medications associated with constipation including, Narcotics, Anti-depressants and Anti-psychotics. The documentation indicated selected disease and conditions know to be associate with constipation including [MEDICAL CONDITIONS], diabetes and depression. 5) Resident #15 A. Resident #15 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. The form entitled, Nursing Data Collection tool dated 5/17/12, documented Resident #15 was continent and her bowel elimination pattern was regular-at least once every 3 days. The Physician's initial admission orders [REDACTED]. The Medication Administration Record (MAR) dated May 2012, documented Resident #15 had received [MEDICATION NAME] 0.5 mg orally on 5/21/12, 5/27/12, 5/28/12 and 5/29/12. The MAR dated May 2012, documented Resident #15 had received [MEDICATION NAME] 150 mg orally. The medication had been started on 5/17/12. The MAR dated May 2012, documented Resident #15 had received [MEDICATION NAME] 1 mg 11 times from May 19 through May 27 2012. The MAR for May 2012, lacked documentation bowel monitoring had been done every shift in accordance with the facility's policy. There was no documentation the resident's bowel movements had been monitored on the 6:00 PM to 6:00 AM shift on 5/17/12, 5/18/12, 5/21/12 and 5/27/12. The MAR for May 2012, documented Resident #15 did not have a bowel movement on 5/21/12, 5/22/12 or 5/23/12. The clinical record lacked documentation Resident #15 had a physician's orders [REDACTED]. The Daily Skilled Nurse's Notes dated 5/22/12 and 5/23/12 lacked documentation Resident #15's bowel sounds had been assessed. On 7/25/12 at 1:55 PM, the Director of Nursing (DON) stated bowel monitoring was to be done every shift. The DON stated it had not been done for Resident #15. The DON stated after 3 days if the resident did not have a bowel movement the resident abdomen should be assessed and the resident given something to help their bowels move. The DON reviewed the clinical record and verbalized no laxative order had been obtained or laxative given when the resident did not have bowel movement for 3 days. The DON was not able to locate documentation Resident #15's abdomen had been assessed for bowel sounds or the physician was notified of no bowel movement times 3 days. The DON reviewed the MAR and stated [MEDICATION NAME] and [MEDICATION NAME] were medications which caused constipation. On 7/26/12 at 11:20 AM, a Charge Nurse stated the facility's policy on bowel monitoring indicated bowel monitoring was done every shift and documented on the MAR. If the areas on the MAR were blank, it meant they did not monitor the bowel movements. The Charge Nurse verbalized if a resident did not have a bowel movement for 3 days the physician should be contacted to get an order to help them have a bowel movement. The resident should be assessed for active bowel sounds, pain and if the abdomen was soft, or distended. The Charge Nurse stated it was dangerous for the resident to go 3-4 days without a bowel movement or intervention. The resident might have an impaction. The Charge Nurse stated the resident should have a bowel movement in 2 days. B. The facility's policy entitled, What You Need to Know, Fall management dated 10/10, documented Fall risk was identified thorough the Nursing Data Collection Tool completed upon admission. If a resident was assessed as being a fall risk, the resident would be considered a fall risk. The policy indicated the Fall Risk Evaluation form was completed immediately when a resident was identified as a fall risk and when a resident had a fall. The documentation listed fall triggers including: Fall in last 30 days, use of anti-depressants, anti-anxiety, anti-hypertensive, [MEDICAL CONDITION] and cardiovascular medications. When a resident was identified as a fall risk, the facility may use visual identifiers to allow all staff to maintain awareness of the risk. Visual identifiers assist the staff to identify those residents at risk for falls. One example of a visual identifier was a "falling star". The Nursing Data Collection Tool dated 5/17/12, documented on the section prior falls, fell in past 30 days. The Nursing Data Collection Tool documented Resident #15 received anti-depressant and pain medications. The clinical record contained a form entitled, Fall Risk Evaluation dated 5/17/12. The documented Fall Risk score for Resident #15 was 10. The form indicated a resident who scored a 10 or higher was a risk for a fall. Consider environmental risk factors in resident interventions. The back of the Fall Risk Assessment form indicated if a resident scored 10 or above, interventions should be initiated. Document interventions below and on the resident's care plan. The area on the back of the fall Risk Assessment form lacked documented interventions for 5/17/12. The interim Care Plan dated 5/17/12, documented Resident #15 was a fall risk. The goal was to minimize falls and to encourage the use of the call light. The care plan lacked documentation a visual identifier such as a "falling star" had been put in place as a fall prevention intervention. The clinical record lacked documentation the physician had been notified of the resident's fall risk score. There was no documentation to indicate the physician had been contacted for any fall prevention interventions such as a low bed or tab alarm. The clinical record documented Resident #15 had physician's orders [REDACTED]. . The MAR dated May 2012, documented Resident #15 had received [MEDICATION NAME] 1 mg ([MEDICAL CONDITION] medication) orally twice a day. The medication had been started on 5/28/12. Nurse's Notes dated 5/28/12 at 6:30 AM, documented resident was laying on the floor in the hallway beside her room. The resident was assessed by staff and assisted into a wheelchair. The Fall Risk Evaluation form dated 5/28/12, documented Resident #15's fall score risk was 20. The back of the Fall Risk Evaluation form lacked documentation interventions had been put into place after the resident's fall on 5/28/12. The clinical record lacked documentation the physician had been notified of the resident's fall risk score. There was no documentation to indicate the physician had been contacted for any fall prevention interventions such as a low bed or tab alarm. The clinical record lacked documentation Resident #15's fall care plan had been updated after the fall on 5/28/12. Nurse's Notes dated 5/29/12 at 8:00 AM, documented Resident #15 was found on the floor lying on her left side. A full body assessment completed and the resident was transferred back to bed with a 4 person assist. The clinical record contained a physician's orders [REDACTED]. The clinical record lacked documentation a Fall Risk Evaluation had been completed after the residents fall on 5/29/12. The back of the Fall Risk Evaluation form dated 5/29/12, documented low bed and tab alarm. On 7/25/12 at 12:55 PM, a Registered Nurse (RN) stated a resident with a history of a fall in the last 30 days should be on the Falling Star program. A yellow arm band was placed on the resident and a star was posted on or by the door to the resident's room. The RN stated a physician's orders [REDACTED]. The RN verbalized if a resident scored greater than 10 on the Fall Risk assessment, had a fall in the last 30 days,was on anti-depressants and pain medications a tab alarm should be in place. On 7/25/12 at 2:15 PM, the DON stated the clinical record lacked clear documentation "our policy for falls was followed." Complaint #NV 497

Based on record review and interview, the facility failed to ensure a safe discharge for 2 of 15 residents (Resident #14, Resident #15). Findings include: Resident #14 Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Social Service Progress Notes dated [DATE], indicated the resident was alert and oriented, and able to make his own decisions. The original discharge plans revealed the resident was to be discharged home to a motel where the resident had lived for many years. If the resident's condition declined and he was unable to care for himself, the social worker (SW) indicated arrangements would be made for Home Health Care or Hospice. The Social Service Progress Notes dated [DATE] documented the resident's friend (Name) requested the resident be discharged to the (Name) Assisted Living Facility (ALF). The resident's friend was not the legal Power of Attorney. A Skilled Nurse's Note dated [DATE] documented the d/c (discharge) team met with the resident on that day and resident discussed his wishes to go to an assisted living facility, where his friend was located, and to be followed with a hospice agency of his choice. During the timeframe from [DATE], until the day of discharge, the daily skilled nurse's notes documented a decline in the resident's physical functioning. The documentation indicated the resident required extensive assistance of one person for bed mobility, transfer, locomotion, eating and toilet assistance on [DATE]. The night shift nurse's notes dated [DATE] indicated Resident #14 had periods of confusion and according to the CNA (Certified Nursing Assistant), the resident was declining in his mobility and strength. The notes indicated it was very difficult for Resident #14 to transfer to the commode. The day shift nurse's notes dated [DATE], documented the resident had decreasing mobility and sustained a fall with a minor injury to his left eyebrow. The nurse's notes dated [DATE], documented a continued decline and Resident #14 became totally dependent on staff for transfers, and was no longer ambulating. A representative from the ALF completed an initial assessment on [DATE]. The assessment form did not include Resident #14's status regarding ambulation and the need for assistive devices, such as a wheelchair. The form did not document the resident's level of care status required at the ALF, and did not have the resident's signature. The referral forms were completed by the MD on [DATE] and did not incude the level of care status of the resident. The forms were sent to the assisted living facility, who accepted the patient. The physician's orders [REDACTED]. Documentation on the Social Service Progress Notes dated [DATE], revealed the ALF came to pick up the resident and transfer him on [DATE], at 4:30 PM. The representative who had done the original assessment verbalized Resident #14's condition had "decompensated" from the time of the original assessment, two weeks prior. The representative indicated, the facility would still accept the resident. The SW Notes documented the representative from the ALF arrived with a driver and indicated they had no wheelchair to transport the resident. The ALF attempted to load Resident #14 into the van on a bench seat. The resident was unable to assist with the transfer. The SN facility stopped the transfer because they felt it was not a safe discharge. The SNF then proceeded to transfer the resident to the ALF in their own van using a Geri-Chair for transportation of the resident. The administrator (Adm) was interviewed on [DATE] at 2:00 PM. The Adm indicated the resident had expressed interest in going to the same ALF where his friend had been located. The Adm also indicated the resident's friend verbalized adamantly that he would sign the resident out AMA (Against Medical Advice) if the facility did not transfer the resident to the ALF. The administrator verbalized the ALF representative (rep) who initially assessed the resident indicated she was a nurse. When the representative and van driver came to pick up Resident #14 on [DATE], the representative again indicated she was a nurse. The administrator believed the ALF was capable of handling the resident since the ALF rep acknowledged the resident's decline in physical status, yet agreed to accept the resident. In addition, the administrator was aware the resident was to be accepted by a hospice. When the ALF came to transport Resident #14 to the ALF on [DATE], the Adm indicated she was contacted by staff regarding their concern over the transportation. The Adm indicated it was very hot outside, the ALF had not brought a wheelchair, and were unable to get Resident #14 in the ALF's van. The Adm stopped the transfer because she felt it was not safe. The Adm then provided transportation to the ALF. On [DATE] at 1:00 PM, the discharge planner (DP) was interviewed. The DP indicated he was familiar with the resident and assisted with the referral and transfer. He indicated he relied on the "nurse" who did the evaluation for the ALF to determine if the resident's level of care could be provided at the ALF. The DP also added he believed the transfer was appropriate since Resident #11 would be accepted by a Hospice. There was no documentation regarding the resident's knowledge and agreement to be transferred to this ALF. There was no documention the SN facility reassessed Resident #14s medical condition, following the resident's decline, prior to discharge to ensure the resident was appropriate to be cared for at the ALF. There was no documentation Resident #14 was reassessed following the difficult attempt at transfer, to ensure the transfer to the ALF was still appropriate. Review of the Hospice initial intake at the ALF, revealed Resident #14's respiratory rate was 48 at the time of admission to the ALF. Resident #14 expired on [DATE] at 1:40 am. Complaint #NV 075 Resident #15 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The history and physical examination PLAN: We will continue all her current medications....The patient is to continue with physical therapy and occupational therapy. The patient is going to need social worker at some point because her daughter is unable to take care for her at home and needs public guardian." The physician's orders [REDACTED].(patient's) choice. D/C (with) meds (medications)..." The Discharge Evaluation and Plan dated [DATE] indicated Resident #15's discharge was uncertain due to "...EPS (Elder Protective Services) case/reverse mortgage...Special Care Needs: Financial Assistance, Housing Assistance. Discharge Plan of Care: Resident needs d/c planning to return to community private home vs (versus) assisted living. Goal: Resident will be able to return to community. Approach: Work with EPS worker and res (resident) to determine d/c safety..." The Discharge Instructions for Care dated [DATE] indicated the following medications: [REDACTED] (75 mg po qd, Quantity of 2), [MEDICATION NAME] 150 mg po qd, Quantity of 5), [MEDICATION NAME] (50 mg po 2x (times) a day, Quantity of 15), [MEDICATION NAME] (20 mg po at bedtime, Quantity of 4), [MEDICATION NAME] (,[DATE] mg ,[DATE] tabs po q 6 hours, prn (as needed for) pain, Quantity blank), [MEDICATION NAME] (30 mg 1 cap po q hs (bedtime) prn, Quantity blank), [MEDICATION NAME] (20 mg po qd, Quantity of 7), and [MEDICATION NAME] (100 mg po bid (twice daily) prn constipation). The Policy and Procedure regarding Discharge Planning and Notification (original ,[DATE], revised ,[DATE]) indicated: "Social Services staff, as members of the interdisciplinary Team, will participate in the development of a discharge plan for patients/residents with a potential for discharge to a private residence, another nursing home, or to another type of residential facility. This policy applies to both voluntary and involuntary transfers/discharges. All patients/residents will be discharged /transferred from the Facility by order of his/her attending physician, in a safe, secure and correct manner." On [DATE] at 12:15 PM, the Administrator and the Director of Nursing (DON) verified the previous Director of Social Services had left the position approximately 3 weeks ago without giving notice to the facility. They further verified Employee #15 was the designated case manager in charge of discharging Resident #15 on [DATE]. On [DATE] in the afternoon, Employee #15 indicated he discharged Resident #15 to her private home on [DATE], but did not send the resident's medications or the prescriptions. Employee #15 indicated he was not sure whether Resident #15 had the funds available to buy food and to pay the utility bills upon discharge. Complaint #NV

Based on record review and interview, the facility failed to ensure proper assessment, monitoring and treatment to prevent the development or decline of pressure sores for 2 of 14 residents (Residents #3, #11). Findings include: Resident #3 Resident #3 was originally admitted to the facility on [DATE], and last readmitted on [DATE], with [DIAGNOSES REDACTED]. Resident #3's wound treatment and progress note dated 6/19/11, documented the resident had a Stage II pressure ulcer on the coccyx. Wound care orders included cleanse the area with NSS (Normal Saline Solution), pat dry, apply [MEDICATION NAME] every 3 days and prn (as necessary) for 30 days and then to reevaluate. The resident's wound care record for June, 2011, documented the treatment was done every three days as ordered. The wound care progress note dated July 2011, documented Resident #3 continued to receive the wound care every 3 days until July 31, 2011. Resident #3's wound care progress notes dated August, 2011, documented the wound care order had been changed on July 18, 2011. The new order was to Cleanse the pressure ulcer on the coccyx area with NSS, pat dry, apply Santyl ointment, cover with DSD (Dry Sterile Dressing) daily for 30 days. Resident #3's wound care progress note indicated the resident had been receiving this treatment since August 1, 2011. There was no physician order included in Resident #3's record for the change in wound care orders for 7/18/11. The facility did not supply the order prior to the surveyor's exit on 9/1/11. On 9/8/11, the facility provided additional information which included a physician's order dated 9/6/11, as a late entry for 7/18/11. The order indicated "Cleanse P.U. (Pressure Ulcer) coccyx area with NSS, pat dry, apply santyl, cover with DSD daily x 30 days." The facility failed to follow the daily wound care orders from 7/19/11 through 7/31/11. The nurse's notes dated 8/18/11 documented "Wound at sacral coccyx area with Santyl Treatment from Stage II became a Stage III...Ordered low air mattress for pt...Informed CNA on duty to frequently turn pt side to side...Informed med (medication) nurse to monitor CNA for pt's care/diaper change with episode of BM..." On 8/31/11 at 9:00 AM observed wound care on Resident #3. The resident was alert and oriented and totally dependent on staff for turning and positioning. The resident had been lying on her back. During the wound care, the resident grimaced and complained of pain. The sacral wound was large, open, and deep with tunneling. Following the wound care, Resident #3 was asked if she was turned and positioned frequently, at least every two hours. The resident responded "No." On 9/1/11 at 10:00 AM, observed Resident #3 in her bed on her back. Resident #3's care plan indicated the resident was to be turned and positioned every two hours. There was no documention in the resident's chart regarding turning and positioning. On 9/1/11 at 1:00 PM, the Director of Education (DOE) was asked about the facility's policy regarding turning and positioning. The DOE indicated the facility does not have a written policy. The staff were given the turning times and positions on the back of their ID badges. This documentation specified the time of day and the position the resident should be turned to, such as 1:00 PM, right side, 3:00 PM, back. The DOE indicated staff do not document the turning of residents. It was assumed the turning and positioning schedule was performed on all residents who were in bed. Resident #3's care plan for pressure ulcers dated 6/19/11 included an approach for a pressure relieving device for bed and wheelchair. There was no documented evidence the resident had a pressure relieving device on her bed until 8/18/11, when the low air loss mattress was ordered. This was applied when the pressure ulcer had developed into a Stage III Ulcer. On 9/1/11 at 10:00 am, the wound care nurse revealed the air loss mattresses were not ordered for residents until the pressure ulcer had developed into a Stage III. Resident # 11 Resident #11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An initial skin assessment done on admission revealed the resident had pressure ulcers on the bilateral heels, a skin tear on his left hand and a post operative surgical wound in the occipital region. There was no documentation the resident had a pressure ulcer on his sacral/coccyx area. The physician's orders upon admission included orders for wound care for existing wounds and to reevaluate in 1 month, and a weekly skin check on shower days every Wednesday. Resident #11's care plan identified the problem of current skin concerns including the pressure ulcers of the heels. The approaches included assist with turning and positioning every 2 hours and prn (when necessary), provide pressure relieving device for bed and wheel chair, use padding between pressure areas and positioning devices for proper body alignment. There was no documented evidence the resident had heel protectors or padding on the bed for pressure relief. Review of the medical record revealed there was no documented evidence of a weekly skin check, either on shower days or at other times. The wound care nurse documented the condition of the current wounds, and changes, but they do not check the resident's entire body. The shower logs were checked for the May 19, 2011 through July 2011 to determine if the weekly skin checks were done by the CNA. During this timeframe, the resident had only 3 skin condition reports: 1) 5/20/11 - No shower given as resident stated he took a bath earlier and did not want to be bothered, No skin assessment documented. 2) 5/28/11 - Resident refused shower - skin integrity marked as "clear", although the resident had pressure ulcers on heels and other "skin tears" 3) 6/11/11 - Shower/skin check completed with open area noted on Left foream, no other skin conditions noted. The resident's care plan dated 6/14/11 indicated the resident developed a blister on the sacral area. Treatment included cleanse with NSS, pat dry, apply Opsite. Change prn and monitor daily. There was no documentation the sacral area was monitored and no documentation by the wound care nurse until 6/23/11. On 6/23/11, the wound care nurse documented on a nurse's note which indicated the sacral pressure ulcer had developed originally as an unopen blister, and now had opened; size 3.0 x 2.0 cm with wound base yellow and sloughing. MD notified. Low air loss mattress and boots ordered. Wound care was initiated daily. The daily nurse's notes indicated the resident's skin was clear, without problems until 6/29/11. On 8/31/11 at 1PM, an interview with the wound care nurse revealed the wond care team performs an evaluation only when notified by the staff licensed nurse or CNA that a resident had a skin ulcer or problem. Then the wound nurse would perform an initial assessment of the wound and begin treatment. The wound care nurse performed weekly skin assessments of the wounds they have been treating. When a resident, such as this, had ulcers and abrasions on his heels and arms, the wound care nurse would assess those areas. The wound care nurse would not assess the sacral/coccyx area since there had been no identification of problems in that area by staff. In summary, the facility failed to monitor the resident's skin condition at least weekly and failed to provide measures such as the low air mattress to prevent the development of a pressure ulcer. Complaint #NV 930

Based on observation, interview, record review and document review, the facility failed to ensure care and services were provided to 1 of 20 sampled residents to maintain an acceptable weight (Resident #16). Findings include: Resident #16 Resident #16 was admitted on [DATE], with [DIAGNOSES REDACTED]. Documentation on the Minimum Data Set assessment with a reference date of 6/7/11, indicated Resident #16 required assistance with eating. The resident had no natural teeth or dentures. On 6/2/11, the registered dietitian (RD) assessed Resident #16 at nutritional risk due to cognitive impairment, decreased awareness of needs, mechanically altered diet and oral dysphagia. A review of the RD's nutritional assessment for Resident #16 dated 6/2/11, revealed the section for evaluation of nutritional needs including caloric needs, protein needs and fluid needs were blank. On 7/8/11 at 11:15 AM, the RD was shown Resident #16's nutritional assessment. The RD stated, "I just forgot to fill it out, but I know what (Resident #16) needs. I know (Resident #16) is losing weight because (the resident) is not eating enough." On 6/2/11, the RD developed a care plan in regards to Resident #16's nutritional risk. The care plan was a pre-printed plan. The approaches checked include : "Diet per MD (physician) order; monitor and record meal percentages; monitor weight & document; speech therapy eval (evaluation) PRN (as needed); food preferences PRN; nutrition consult PRN and per schedule; offer alternate entree for items refused or taken poorly; and, provide supplement as ordered. Documentation in Resident #16's record indicated the following recorded weights: -6/04/11-147 pounds; -6/11/11-144 pounds; -6/18/11-139 pounds; -6/28/11-132 pounds; and, -7/02/11-129 pounds. The resident lost 18 pounds in approximately one month, from 6/4/11 to 7/2/11, for a severe weight loss of 12.2%. Interventions documented in Resident #16's record were as follows: -5/31/11 ST (Speech Therapy) consult. The ST recommended a pureed mechanical soft diet which the physician ordered on [DATE]. -6/1/11 Ensure Plus one can three times a day (a nutritional supplement) was ordered by the physician. -6/20/11 after a documented 9 pound weight loss, the RD requested a medication to stimulate the resident's appetite, which was ordered by the physician on 6/23/11. -6/23/11 The physician changed the resident's diet to a mechanical soft. -6/30/11 The physician ordered a second medication to stimulate the resident's appetite. There was no documentation in Resident #16's record the dietitian, diet technician or dietary manager questioned and recorded the resident's food and fluid likes and dislikes. Documentation in the record indicated Resident #16 often refused to drink the nutritional supplement. There was no documentation in the record the facility staff investigated the reasons for the refusals. There was no documentation the facility staff considered another means of supplementing Resident #16's nutritional intake. On 7/7/11 during observation of the lunch meal, Resident #16 was noted to have a chef salad for the entree. A staff member attempted to feed the resident the chef salad. The resident had difficulty chewing and swallowing one bite of salad and refused further attempts by staff to feed the resident the salad. On 7/8/11 at 7:50 AM, Resident #16 was in the dining room. On the resident's breakfast tray was a large slice of watermelon. A staff member attempted to feed the resident a bite of watermelon. The resident had difficulty chewing and swallowing the melon and refused further attempts by staff to feed the resident the watermelon. Documentation provided by the facility indicated raw vegetables were not allowed on a mechanical soft diet. The documentation also stated only soft fruits were permissible. On 7/8/11 at 11:15 AM, the registered dietitian (RD) indicated the employee did not make the menus as this was done by a "corporate dietitian." The RD stated, "Whatever is on the menu for a mechanically soft diet is what the kitchen will serve the resident." At the same time, a Speech Therapist (ST) who provided services to Resident #16 to improve swallowing abilities was asked if a chef salad and watermelon were appropriate food choices for the resident. The ST indicated the observed foods served Resident #16 were not appropriate for the resident's lack of teeth and difficulties swallowing. Also during the breakfast meal, on 7/8/11 at 7:50 AM, Resident #16 was noted to be slumped down in the chair. A staff member sat next to the resident assisting the resident to eat. On 7/8/11 at 7:53 AM, a speech therapist (ST) entered the dining room, approached Resident #16 and spoke with the resident. The ST observed the staff member attempt to feed the resident in the slumped position. The ST did not offer to assist the staff member to reposition Resident #16 in an appropriate dining position. On 7/8/11 at 11:15 AM, the ST indicated Resident #16 had not been in the proper dining position during the breakfast meal. The ST stated, "I have encouraged staff to sit (Resident #16) upright for meals." On 7/8/11, the print out of the resident's food intake for 6/1/11-7/7/11 was requested, as this information was not filed in the resident's record. A review of the report indicated from 6/1/11 through 7/7/11, Resident #16 consumed 1-25% or less at 27 of 106 meals documented. There was no documentation in Resident #16's record an alternate entree was offered as per the care plan. The facility's policy titled "Weighing the Patient/Resident" dated 7/2009, indicated a newly admitted resident was to be weighed daily for three days, weekly for three weeks then monthly or per physician's orders [REDACTED]. Resident #16 was weighed on admission, nine days later, once a week for two weeks, then ten days later, and the last weight recorded was on 7/2/11 which was four days from the previous weight. The facility's policy titled "Preventing/Controlling Undesirable Weight Loss" dated 10/2009, read "...The Registered Dietitian/Designee will review the patient/resident's nutritional status to prevent and control undesirable weight loss." The policy continued, "Procedures:...2. Visit the patient/resident during a meal to observe intake and dining needs/concerns. Monitor closes for any feeding problems...4. Review the Medical Record or Activity of Daily Living (ADL) sheets to determine the percent meal intakes for patients/residents with weight issues. 4. Consider a 3-day calorie count (as applicable)...6. Keep food preferences updated so that patients/residents do not continually receive foods they will not or cannot eat...8. Address significant weight loss or gain immediately in the dietary progress notes and by developing and/or updating the plan of care...11. The following interventions can be used to increase calories: - A. Add half & Half, margarine, and brown sugar to hot cereals. - B. Use whole milk for patient's/resident's beverage and in cooking. - C. Add one tablespoon of corn syrup to a cup of fruit juice. - D. Puddings, custards, and soups can be made with Half and Half and non-fat dry milk. - E. Add margarine, gravies, mayonnaise, salad dressings, and sauces to potatoes, pasta, meat, breads, vegetables, etc. - F. Serve cottage cheese, yogurt, ice cream, or sandwiches as snacks. - G. Add sour cream to meats, potatoes, and/or vegetables. - H. Add cream cheese to fruits, breads, or crackers. - I. Add whipped topping to cocoa, baked goods, gelatin, pudding, fruit, pancakes and waffles." There was no documentation in Resident #16's record any of the interventions were used to increase the number of calories the resident consumed. There was no documentation in the resident's record a calorie count was obtained to ascertain the resident's current intake to develop a comprehensive, multi-disciplinary approach to the resident's continued weight loss.

Based on observation, interview, record review and document review, the facility failed to have a process in place to assess the medical justification of continued urinary catheter use for residents who were admitted to the facility with an urinary catheter for 2 of 20 sampled residents admitted to the facility with urinary catheters (Resident #16 and #8). Findings include: The facility's policy titled, "Catheter/Urinary Catheter, Use of" dated 7/2009, indicated urinary catheters were only to be used for documented [MEDICAL CONDITION], renal dysfunctions, contamination of a stage III or IV pressure ulcers where urine would impede healing or terminal illness. The policy stated the facility would evaluate the resident's need for continued catheter use within 14 days of admission and ongoing. Resident #16 Resident #16 was admitted on [DATE], with [DIAGNOSES REDACTED]. Documentation in the record indicated the resident was admitted to the facility with a urinary catheter in place. Resident #16's record lacked documented evidence the facility had assessed the medical necessity of continued use of the urinary catheter. There was no documentation of an assessment which included consideration of the risks & benefits of an indwelling catheter and the potential for removal of the catheter There was no documentation the facility considered possible complications resulting from the continued use of an indwelling catheter, such as symptoms of pain, discomfort, bleeding and urinary tract infection. Documentation in Resident #16's record indicated the resident was admitted to the facility with a urinary tract infection requiring antibiotic use. There was no documentation the facility considered the continued use of the urinary catheter as a factor of the urinary tract infection. On 6/21/11, the physician ordered, "[MEDICATION NAME] (an antibiotic) 250 mg (milligrams) p.o. (by mouth) bid (twice) daily x 14 days UTI (Urinary Tract Infection)." On 6/23/11, the medication was changed to [MEDICATION NAME], another antibiotic. There was no documentation the facility considered the continued use of the urinary catheter as a factor of the urinary tract infection. On 7/1/11, the physician ordered Bactrim (an antibiotic) for urinary tract infection. There was no documentation the facility considered the continued use of the urinary catheter as a factor of the urinary tract infection. On 7/8/11, a review of Resident #16's Medication Profile indicated the resident's urinary catheter had been discontinued. A review of the resident's record indicated the record lacked documented evidence the facility performed an assessment for the continued use of the catheter, a physician's orders [REDACTED]. On 7/8/11 at 8:15 AM, a staff nurse reviewed Resident #16's record and acknowledged the lack of documented information. The facility failed to assess Resident #16 for continued Foley catheter use as per its policy. The resident developed two urinary tract infections while the catheter was in place. When questioned about the catheter, the facility discontinued the catheter without an assessment or a documented physician's orders [REDACTED]. Resident #8 Resident #8 was admitted on [DATE], with [DIAGNOSES REDACTED]. Documentation in the record indicated the resident was admitted to the facility with a urinary catheter in place. On 7/6/11 in the afternoon, Resident #8 indicated the catheter was placed initially at the acute care hospital, but has been changed since then. Resident #8's record lacked documented evidence the facility had assessed the medical necessity of continued use of the urinary catheter. There was no documentation of an assessment which included consideration of the risks & benefits of an indwelling catheter and the potential for removal of the catheter There was no documentation the facility considered possible complications resulting from the continued use of an indwelling catheter, such as symptoms of pain, discomfort, bleeding and urinary tract infection. On 7/6/11 at 1:20 PM, Employee #13, the Registered Nurse (RN) responsible for Resident #8's care that day, indicated the employee did not know the medical justification for Resident #8's continued urinary catheter use.

Based on interview and record review, the facility did not provide necessary services to ensure 1 of 3 sampled residents attained the highest well-being in accordance with the plan of care (Resident #2). 1. On 10/13/10, Employee #2 provided the policy and procedure titled, "Suicidal Precaution Management" (NP-S-7), Original: 07/2009. The document stated in part: "Procedures: Immediate interventions: A patient/resident, who is voicing suicidal thoughts or attempts suicide, is a danger to self or others. The following steps are taken: A. Physician, Psychiatrist/ Counselor/ Psychologist and family are notified immediately. If the patient/ resident doesn't have a psychiatrist then a referral is made at this time... E. Staff visually observes patient/ resident every fifteen (15) minutes while on suicide precaution...N. Nurses document every shift...". 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was discharged on [DATE]. On 07/10/10, Resident #2's physician wrote an order for [REDACTED]. Resident #2's care plan, dated 07/23/10, identified the need, "Resident is currently taking [MEDICAL CONDITION] medications as evidenced by depression". One approach to reach the stated goal is "Psych consult as needed" (Psychiatric consult). The discipline identified as responsible is "NSG" (Nursing). On 08/17/10, Employee #1 documented that a Certified Nurses Aide (CNA) told her that Resident #2 "told his wife to bring a razer (sic) and pills to this facility so he could kill himself". She also documented that she asked Resident #2 about the report and he denied suicidal thoughts and asking his wife to bring the objects. She documented that he said he was "OK today he miss being home with his wife". On 10/13/10 at 2:02 PM, Employee #4, the CNA that reported Resident #2's request to his wife, was interviewed. Employee #4 stated that he was working when the receptionist paged him overhead to take a telephone call. He stated that a woman identified herself as Resident #2's wife and stated that she had spoken to Resident #2 and he had asked her for a razor and pills. He stated that he immediately told the resident's nurse and Employee #1. During the 10/13/10 interview with Employee #1, she stated that she did not think Resident #2 was contemplating suicide because "he didn't have a plan". She also stated that she spoke with the resident's nurse after the incident. She document that Resident #2's wife stated "maybe (Resident #2) was trying to make me feel sorry for him". On 08/17/10, Resident #2's nurse documented "wife calls 3X (three times) verbalizing that resident called her to bring him blade and that he plans to commit suicide and that he had attempted 9X (nine times). Resident was ask (sic) if he plans on committing suicide and resident verbilizes i do not plan on doing it and i did not talk to her... staff and aides were alerted". On 08/18/10, Resident #2's nurse documented "(no) agitation, (no) pain, needs attended. Monitor for suicidal behavior". No other documentation regarding monitoring for suicidal behaviors was located. On 09/24/10, Resident #2's nurse documented that a CNA reported the resident had blood on his arm. The nurse found Resident #2 with a blade in his hand and cuts on his arms. The nurse documented the resident told her "he has a lot of problem and he wanna die". Resident #2 was transferred to the hospital. There was no documented evidence the facility ensured Resident #2 was evaluated by a psychiatrist or the resident was monitored for suicidal behavior according to the facility's policy.

Based on interview and clinical record review, and document review, the facility failed to ensure social services follow up on indicated psychiatric services. As a result, one resident was not evaluated by a mental health care provider. He subsequently attempted suicide. 1 of 3 sampled residents (Resident #2). Findings Include: 1. On 10/13/10, Employee #2, the Director of Nursing, provided the policy and procedure titled, "Suicidal Precaution Management" (NP-S-7), Original: 07/2009. The document stated in part: "Procedures: Immediate interventions: A patient/resident, who is voicing suicidal thoughts or attempts suicide, is a danger to self or others. The following steps are taken: A. Physician, Psychiatrist/ Counselor/ Psychologist and family are notified immediately. If the patient/ resident doesn't have a psychiatrist then a referral is made at this time... E. Staff visually observes patient/ resident every fifteen (15) minutes while on suicide precaution...N. Nurses document every shift...". 2. Prior to his admission, Resident #2 was screened on 07/09/10. This evaluation identified services that are required to meet resident's medical needs using a Pre-Admission Screening/Resident Review-II (PASRR II). This document is required by the Federal Omnibus Budget Reconciliation Act. The rules pertaining to the PASRR process are found in the Code of Federal Regulations Part 483, Subpart C, Volume 57, No. 230. This screening found that Resident #2 met the "Nursing Facility level of services and may be admitted it the facility is able to provide or arrange for the Specialized Services...". Among the needed specialized services were "Psychiatrist Follow-up Services". Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was discharged on [DATE] to an acute care facility after a suicide attempt. On 10/13/10, Resident #2's clinical record was reviewed. Resident #2's Social Service Progress Notes indicated that a new admission assessment by Employee #1, a facility social worker, was documented on 07/12/10. Employee #1 documented that Resident #2 was transferred from an acute facility with an injury as a result of possible spousal abuse. On 07/17/10, Employee #1 charted that she met with a representative from the Elder Abuse Unit. This representative provided an application for Clark County Public Assistance for long term placement. On 07/18/10, Employee #1 completed a 14-day assessment. On 07/29/10, Employee #1, a social worker, documented that Resident #2 "was referred to have a psycholgist (sic) to assist him to deal with his problems". Employee #1 was interviewed on 10/13/10 at 12:25 PM. She stated that when she made this referral, she did so by entering Resident #2's name in the "Psychiatrist Log", and that was the method that she use to ask for a psychiatric evaluation. Employee #1 stated that the facility has had a series of different psychiatrists beginning around June, 2010. She guessed that there were approximately four different psychiatrists beginning around the time Resident #2 was in the facility. Employee #1 stated the facility "kept having problems with having psychiatrists come". She stated that once Resident #2's name was entered in the log, she could not be sure exactly when or if he would be seen by the psyciatrist. She stated that she remembered making a phone call and finding out that he had not been seen, but she could not remember when she made the call. Documentation regarding the phone call during which she was told he had not been evaluated, could not be located. She also stated that she eventually asked the psychologist team at the facility to talk to Resident #2, but before he was seen, he attempted suicide and was placed on a "Legal 2000" and discharged to an acute care facility. On 08/03/10, Employee #1, the social worker, stated that Resident #2 stated that he had spoken to his wife and wanted to go home. She documented that she responded that the facility "is required to keep him in a safe environment" and encouraged him to keep participating in activities at the facility. She also documented that she contacted his worker at the Elder Abuse Unit and she had stated "a discharge plan home is not a plan, due to spousal abuse". During the 10/13/10, 12:25 PM interview, Employee #1 stated that Resident #2 often voiced a desire to see his wife and go home. On 08/17/10, Employee #1, the social worker, documented that a Certified Nurses Aide (CNA) told her that Resident #2 "told his wife to bring a razer (sic) and pills to this facility so he could kill himself". She also documented that she asked Resident #2 about the report and he denied suicidal thoughts and asking his wife to bring the objects. She documented that he said he was "OK today he miss being home with his wife". On 10/13/10 at 2:02 PM, Employee #4, the CNA that reported Resident #2's request to his wife, was interviewed. Employee #4 stated that he was working when the receptionist paged him overhead to take a telephone call. He stated that a woman identified herself as Resident #2's wife and stated that she had spoken to Resident #2 and he had asked her for a razor and pills. He stated that he immediately told the resident's nurse and the social worker, Employee #1. During the 10/13/10 interview with Employee #1, she stated that she did not think Resident #2 was contemplating suicide because "he didn't have a plan". She also stated that she spoke with the resident's nurse after the incident. She documented that Resident #2's wife stated "maybe (Resident #2) was trying to make me feel sorry for him". On 09/24/10, Resident #2's nurse documented that a CNA reported the resident had blood on his arm. The nurse found Resident #2 with a blade in his hand and cuts on his arms. The nurse documented the resident told her "he has a lot of problem and he wanna (sic) die". Resident #2 was transferred to the hospital. On 09/24/10, Employee #1 documented "nursing staff told this worker (Resident #2) need to be Legal 2000 to the emergency due to self mutilation... he was transferred (to an acute facility)".