Every finding on record at Coronado Ridge Skilled Nursing & Rehabilitation Ce

Based on observation, interview, record review and document review the facility failed to ensure medication was secured for 1 of 37 sampled residents (Resident 44). The deficient practice had the potential risk of unauthorized access to medication, or misuse of medication within the facility. Findings include:Resident 44 (R44) was admitted on [DATE] with diagnoses including metabolic encephalopathy, acute respiratory failure with hypoxia, chronic obstructed pulmonary disease and pruritus.On 07/22/2026 at 9:39 AM, a white medication jar labeled Triamcinolone cream was located on R44's nightstand. R44 explained had been using the medication for psoriasis, and the staff did not apply the cream.On 07/22/2026 at 9:47 AM, a Registered Nurse (RN) confirmed finding and explained the Triamcinolone cream was a medication and should not be at the bedside. The RN explained R44 would need to have a physician order for the use of the medication and would also need to verify if the medication could be kept at bedside.R44's medical record lacked a physician order for Triamcinolone cream and a self-administration of medication assessment.On 07/23/2026 at 8:44 AM, the Director of Nursing (DON) explained resident medications should not be kept bedside. The DON confirmed R44 did not have a physician order for the Triamcinolone cream, and it should not have been at R44's bedside. The DON explained mediations required an order for use and would not be left at bedside unless the physician ordered the medication to be at bedside and a self-administration assessment had been conducted to ensure the resident was safe to self-administer.The facility policy titled Medication Labeling and Storage, revised 02/2023, documented the facility stored all medication and biologicals in locked compartments under proper temperature, humidity and light controls. The nursing staff was responsible for maintaining medication storage.

Based on observation, interview, record review, and document review, the facility failed to ensure staff put on required personal protective equipment (PPE) and performed hand hygiene before entering a resident room under Contact Precautions for 1 of 37 sampled residents (Resident 60). The deficient practice had the potential to increase the risk of transmission of infectious organisms to residents, staff, and visitors.Findings include:Resident (R60) was admitted on [DATE] with diagnoses including spinal stenosis of the cervical region, metabolic encephalopathy, enterocolitis due to Clostridioides difficile (C. difficile - a bacterium that can cause infection in the colon, leading to diarrhea and inflammation of the large intestine), and acute kidney failure.A physician order dated 07/01/2026 documented that R60 was to be maintained on contact precautions every shift due to the diagnosis of C. difficile infection.On 07/23/2026 at 12:35 PM, the Certified Nursing Assistant (CNA) was observed entering and exiting R60's room, where the resident was on contact precautions due to a diagnosis of C. difficile. The CNA was observed transporting the resident's meal tray into the room. The CNA did not perform hand hygiene or put on the required PPE including the appropriate gown and gloves, as required for contact precautions before entering the room.Following the observation, the CNA acknowledged should have followed contact precaution protocols, including hand hygiene and wearing the required PPE when entering the resident's room.On 07/23/2026 at 1:05 PM, a Registered Nurse (RN) indicated staff were required to wear the appropriate PPE whenever providing care or entering the room of a resident who was on contact precautions.The RN confirmed the Certified Nursing Assistant (CNA) should have worn both a gown and gloves when entering R60 because the resident was on contact precautions due to a diagnosis requiring additional infection control measures. The verbalize entering the resident's room without the required PPE was not acceptable.The RN emphasized proper hand hygiene, including the use of hand sanitizer or washing hands with soap and water when appropriate, was required before and after contact with residents and their environment. The RN indicated adherence to PPE requirements and hand hygiene practices was essential to prevent the transmission and spread of infections, including C. difficile, within the facility.On 07/23/2026 at 1:17 PM CNA indicated all staff entering R60's room were required to wear appropriate PPE due to the resident being on contact precautions.The CNA explained staff were required to perform hand hygiene by either washing hands with soap and water or using hand sanitizer when entering and exiting the resident's room. The CNA indicated following these infection prevention measures was necessary to help prevent the spread of infection and maintain a safe environment for residents and staff.On 07/23/2026 at 2:52 PM, the Infection Preventionist (IP), explained when a resident's room displayed signage indicating contact precautions, all staff were required to put on the appropriate PPE including gowns and gloves, before entering the resident's room.The IP indicated staff were required to perform hand hygiene both before entering and after exiting the resident's room. The IP explained used PPE was required to be removed and discarded in the designated red biohazard bag after leaving the room to prevent potential contamination and the spread of infection.The IP acknowledged if staff entered or exited a resident's room without wearing the required PPE or failed to perform hand hygiene properly, there was an increased risk of transmitting infectious organisms to other residents, staff, and the environment. The IP emphasized adherence to contact precaution procedures, including appropriate PPE use and hand hygiene practices, was necessary to reduce the risk of infection transmission within the facility.On 07/23/2026 at 3:30 PM, the Director of Nursing (DON) explained the Contact Precautions signs posted outside the resident's room indicated staff were required to put on the appropriate PPE before entering the room.The DON confirmed staff were expected to perform hand hygiene and apply the required PPE, including gowns and gloves, before entering the resident's room. The DON verbalized adherence to PPE requirements and proper infection prevention practices was necessary to reduce the risk of infection transmission and prevent the spread of infectious organisms within the facility.The facility policy titled Isolation- Categories of Transmission-Based Precautions, revised September 2022, documented when a resident was placed on transmission-based precautions, appropriated notification was placed on the room entrance door and on the front of the chart so that personnel and visitors were aware of the need for and the type of precaution. The signage informed the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room.

Based on observation, interview, record review and document review, the facility failed to ensure a resident who was assessed to require one-on-one (1:1) assistance with feeding was not left to eat by themselves for 1 of 37 sampled residents (Resident 10). The deficient practice placed the resident at risk for aspiration and potentially contributed to recent weight loss.Findings include: Resident 10 (R10) was admitted on [DATE] and readmitted on [DATE], with diagnoses including Parkinson's disease with dyskinesia and dysphagia.The quarterly minimum data set 06/05/2026 revealed R10 had moderately intact cognition and was dependent on staff with eating. A speech therapy (ST) treatment encounter note dated 04/01/2026, revealed R10 was receiving enteral nutrition through feeding tube and would be on therapeutic trial of pureed diet with nectar-thickened liquids following modified barium swallow (MBS) test. Upright for all meals, 1:1 assistance, encourage dining room.A physician order dated 04/01/2026, documented an order for 1:1 assistance, upright for all meals, encourage dining room.A nutritional assessment dated [DATE], revealed R10 weighed 143.0 pounds on 05/05/2026 and 133.8 pounds on 06/02/2026 which was a nine percent (9 %) weight loss over 30 days, considered significant. The recommendation was to continue the diet order per physician and for ST to initiate Glucerna oral nutrition shakes.On 07/23/2026 at 7:55 AM, R10 laid in bed with head of bed elevated approximately 30 to 40 degrees and was eating breakfast independently. There was food around R10's mouth and there were no staff members in the room. The certified nursing assistant (CNA) assigned to R10 entered the room and confirmed R10 was almost done with breakfast and was eating by themself because R10 could eat independently.On 07/23/2026 at 10:29 AM, the Director of Rehabilitation (DOR) explained R10 used to be a long-term care resident at the facility and was NPO (nothing by mouth) receiving enteral nutrition. R10 moved to the sister facility, was hospitalized and returned to this facility on 03/08/2026 as an NPO enteral feed resident. According to the DOR, R10 received multiple visits from the ST, and an MBS test was completed on 03/31/2026 which resulted in a diet upgrade of consistent carbohydrate diet pureed nectar-thickened consistency on 04/01/2026. The ST transcribed the orders into the electronic health record (EHR) with instructions to provide 1:1 assistance with meals and ensure upright position. The DOR clarified ST recommendations to provide 1:1 feeding assistance in upright position were geared towards safety and aspiration precautions rather than weight loss or gain as this would be the RD's role.On 07/23/2026 at 10:53 AM, the Registered Dietician (RD) indicated R10's diet order to provide 1:1 feeding assistance with meals in upright position was still an active order. The RD confirmed R10 had significant weight loss from 05/05/2026 to 06/30/2026, specifically a 9 % weight loss over a 30-day period. The RD indicated expecting CNAs to provide R10 with assistance from meal service to completion and to report fluctuations in intake to the nurses or RD.On 07/23/2026 at 11:02 AM, the RD did a 14-day lookback on R10's meal consumptions and indicated intakes fluctuated from 50% to 100% with multiple refusals. The RD indicated not having staff present at this morning meals was not in accordance with care plan and physician orders. The RD defined 1:1 assistance meant a CNA, nurse or a therapist would be seated with the resident from meal service to completion. According to the RD, this was the expectation until therapy re-evaluates and changes. On 07/23/2026 at 11:09 AM, the CNA assigned to R10 indicated not being aware there was an order to provide 1:1 feeding assistance because the resident seemed to have been doing well eating by themselves. The CNA defined 1:1 feeding assistance to mean a staff member would be with the resident from meal service to completion. The CNA confirmed R10's head of bed was not upright and there was not staff providing assistance during breakfast due to the meal ticket not reflecting instruction to provide 1:1 assistance. On 07/23/2026 at 11:19 AM, the Licensed Practical Nurse (LPN) indicated not being aware R10 had orders for 1:1 feeding assistance in upright position. The LPN reviewed meal consumptions and indicated expecting CNAs to report meal refusals and fluctuating consumptions to the nurse to allow for education and communication with inter-disciplinary team (IDT). The LPN indicated failure to provide feeding assistance was also missed opportunity to intervene early. On 07/24/2026 at10:32 AM the Director of Nursing (DON) indicated if there was an order for 1:1 feeding assistance, assistance should be provided where staff would need to be with the resident during the meal.The facility's Assistance with Meals policy revised March 2022, documented staff would serve residents who required assistance with eating.

Based on interview, record review, and document review, the facility failed to verify a resident's prescribed enteral nutritional orders and ensure the necessary enteral formula was available prior to accepting the resident for admission, and after admission failed to implement an enteral nutritional regimen for 1 of 37 sampled residents (Resident 128). The deficient practice had the potential to result in delayed implementation of the resident's prescribed enteral nutrition regimen, inadequate nutritional and hydration support, compromised nutritional status, and avoidable decline.Additional deficient practice was identified in connection with this F693 citation. Refer to:Refer to Tag F628 (Discharge Process): the facility failed to ensure a resident's transfer was coordinated by failing to contact, make prior arrangements for the transfer, confirm the receiving facility agreed to accept the resident, communicate the resident's enteral nutrition needs, document the discharge process in the medical record, and provide a telephone report to the receiving facility prior to transfer.Refer to Tag F600 (Free from Abuse/Neglect): the facility failed to establish and implement an enteral nutrition regimen for a resident after accepting the resident for admission, resulting in the resident receiving no documented enteral nutrition and only 240 milliliters (ml) of documented water flushes during their stay.Findings include:Resident 128 (R128) was admitted [DATE], discharged [DATE], with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction, gastrostomy status, and aphasia following cerebral infarction.A Care Plan dated [DATE], documented R128 had a swallowing problem was admitted with an abdominal gastrostomy tube (G-tube) related to impaired oral intake and received enteral feedings related to dysphagia.A Medication Reconciliation Summary dated [DATE] received from the sending facility documented the following orders:Jevity (non-plant based, non-vegan enteral formula) 1.5 calories, take one can via feeding tube six times a day for enteral feeds, order status expired.Complet(R) Standard (plant-based, vegan enteral formula) 1.4 calories, take one container by mouth six times a day via peg tube, order status discontinued.Complet(R) Standard (plant-based, vegan enteral formula) 1.4 calories, take one container via peg tube six times a day, order status on hold.R128's medical record lacked documented evidence the facility contacted the sending facility to clarify the enteral feed orders, nutritional needs and preferences, and the need for a vegan enteral formula was addressed during the admission process.An admission assessment dated [DATE] lacked documented evidence of information regarding vegan or plant-based feeding formula preferences.A facility census list documented R128 was admitted to the facility [DATE] at 8:10 PM and discharged [DATE] at 9:00 PM.R128's medical record at the facility lacked documented evidence of a physician order for an enteral feeding formula following admission, an enteral nutrition regimen was implemented during R128's admission at the facility from [DATE] through [DATE], and the facility offered R128 alternative enteral feeding formulas or intravenous (IV) fluids. On [DATE] at 10:35 AM, the Registered Dietitian (RD), reported beginning employment at the facility on [DATE] and was not employed at the time of R128's admission. The RD recalled previously caring for R128 at another facility. The RD indicated R128 was vegan and wanted a specific vegan or plant-based tube feeding formula. The RD explained the facility was supposed to admit residents whose specific care needs they could accommodate. The need for a vegan or plant-based formula should have been identified prior to admission or during the admission process. The RD confirmed R128's medical record lacked documented evidence of a physician order for an enteral feeding formula.On [DATE] at 11:46 AM, the Case Manager explained the type of enteral feeding the resident required was not available at the facility. The Case Manager reported prior to admissions the facility should have identified R128 and required a special formula. The Case Manager found out the following day after the admission, a vegan or plant based enteral feeding formula was not available for R128. The Case Manager explained the nursing department was responsible for entering admission orders, should have identified the special feeding formula was not available and should have notified Central Supply to place an order.On [DATE] at 2:20 PM, the Director of Nursing (DON), explained the admissions nurse was responsible for reviewing the feeding order to ensure the facility had the formula available. The DON acknowledged discharge documents from the sending facility included three different and not active enteral feeding orders. The DON explained staff may not have recognized the concern with the feeding orders because they routinely substituted enteral formulas available at the facility and may not have recognized one of prescribed formulas was plant-based and unavailable. The DON acknowledged the admissions nurse should have reviewed the orders and identified there was not an active order for an enteral feeding formula. The expectation was R128 should have been offered feeding formula options and IV fluids for hydration.On [DATE] at 9:17 AM, the Central Supply staff member reported being the only Central Supply staff member for 6.5 years and the only staff member to order enteral formula. The staff member explained the facility did not keep vegan or plant-based formulas in stock because they were not used frequently and would be ordered when needed. The staff member explained Central supply worked closely with the Admissions Office to ensure the supplies needed for residents upon admission.The Central Supply staff member reported the Admissions Office was supposed to check what incoming residents' feeding formula needs were and had a list of what formulas the facility had available to ensure the facility had the correct enteral feeding formula the resident needed. The staff member explained ordering a new type of formula would have taken Central Supply approximately two days to receive the product. The staff member reported did not recall if was asked to order a vegan formula for a resident in March/[DATE].On [DATE] at 9:42 AM, a Licensed Practical Nurse (LPN), explained during the admissions process they would have reviewed the orders on the discharge summary, contacted the physician, and gone over the medication orders from the sending facility. The LPN reviewed R128's discharge orders from the sending facility and identified three conflicting and confusing nonactive enteral feeding orders, which would have needed clarification from the sending facility prior to admission to determine the resident's correct enteral feeding order before initiating care. The LPN explained all actions taken were supposed to be documented in the medical record.On [DATE] at 10:01 AM, a Registered Nurse (RN), explained being R128's nurse for day shift on [DATE]. The RN learned R128 wanted only a specific strawberry flavored, vegan, enteral formula brand and sent a message to the Dietitian. The RN acknowledged the medical record lacked a physician order for an enteral feeding formula. The RN acknowledged the actions taken by the RN regarding R128's enteral nutrition were not documented in the medical record by the RN and should have been documented.On [DATE] at 10:22 PM, the Administrator, acknowledged the admissions team should have identified R128's feeding formula needs prior to admission, and options offered to R128 should have been documented.A facility policy titled admission Criteria revised 2019, documented the facility admitted on ly residents whose medical and nursing care needs could be met. The objectives of the admission criteria policy included to admit residents who can be cared for adequately by the facility including enteral nutrition needs.A facility policy titled Medication Orders revised [DATE], documented when recording orders for enteral tube feedings, specify the specific type of feeding, amount, frequency of feeding and rationale.A facility policy titled Enteral Tube Feeding via Continuous Pump revised [DATE], documented the purpose of this procedure was to provide a guideline for the use of a pump for enteral feedings. Preparation included to verify that there was a physician's order for this procedure. Review the residents' care plan and provide for any special needs of the resident.Complaint #2972095

Based on interviews, observation, record review, and document review, the facility failed to ensure assistance with Activities of Daily Living (ADLs), including personal hygiene was provided for 1 of 37 sampled residents (Resident 115). This deficient practice had the potential to compromise the resident's skin integrity, oral hygiene, overall health status, comfort, and dignity.Findings include:Resident 115 (R115) was admitted to the facility on [DATE] with diagnoses of encounter for other orthopedic aftercare, fracture of the unspecified part of the neck of the unspecified femur, subsequent encounter for closed fracture with routine healing, and pain due to internal orthopedic prosthetic devices, implants, and grafts.On 7/22/2026 at 8:39 AM, R115 indicated they came to the facility on [DATE]. R115 stated, Nobody has washed my face, brushed my teeth, or showered me.The Activities of Daily Living (ADL) care plan for R115, dated 07/16/2026 documented R115 required one-to two-person assistance to initiate and complete most ADL task, including toileting, transfers, hygiene/grooming, bathing, showering, and eating. The care plan documented R115 would maintain or improve the current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use, and personal hygiene.On 07/23/2026 at 9:04 AM, the Certified Nursing Assistant (CNA) indicated residents routinely received daily personal hygiene care, including brushing their teeth, combing their hair, and washing their faces each morning. The CNA further mentioned residents were scheduled to receive either a bed bath or a shower twice weekly and could receive an additional bed bath or shower upon request or as needed. The CNA acknowledged R115 had not received any personal hygiene care in the morning.On 07/23/2026 at 9:35 AM, the Registered Nurse (RN) indicated upon admission, each resident was placed on a bathing or shower schedule that included two showers per week. The RN explained that if a resident was unable to receive a shower as scheduled, CNAs were expected to provide a bed bath instead.The RN verbalized Certified Nursing Assistants (CNAs) were responsible for providing residents with daily personal hygiene care. For residents who were unable to independently complete all hygiene tasks, CNAs were expected to provide the necessary assistance, including assisting the resident to the bathroom, setting up a toothbrush with toothpaste, and providing a washcloth so the residents could wash their face independently, as appropriate to the resident's abilities. The RN confirmed daily personal hygiene care was expected to be provided to all residents in accordance with their assessed needs and plan of care.On 07/23/2026 at 10:11 AM, the Assistant Director of Nursing (ADON) acknowledged R115 had reported not receiving personal hygiene care since admission to the facility. Specifically, R115 reported, No staff has helped me brush my teeth, brush my hair, wash my face, or provided me with a shower or bed bath since I came here.The ADON indicated residents were placed on a shower schedule upon admission and were routinely scheduled to receive showers twice weekly or more frequently upon request. The ADON daily personal hygiene care was expected to be provided to all residents every day. For residents who required assistance, staff was expected to provide hands-on assistance or set up the necessary supplies and equipment to enable the resident to complete personal hygiene tasks or receive a shower, consistent with the resident's assessed needs and plan of care.The ADON indicated the shower schedule and documentation of personal hygiene services should be reviewed to verify the care provided. However, during the survey, the ADON was unable to provide documentation identifying R115's scheduled shower days or documentation demonstrating personal hygiene care, including showers, bed baths, oral hygiene, grooming, or other daily hygiene assistance, had been provided since the resident's admission.On 07/24/2026 at 9:00 AM, the Director of Therapy indicated R115's functional abilities and need for assistance with Activities of Daily Living (ADLs). The Director of Therapy stated R115 required maximum assistance and was unable to independently complete ADLs. The Director of Therapy further reported R115 was dependent on staff for dressing, toileting, and showering and R115 required setup assistance for oral hygiene, including brushing teeth, as well as combing hair and washing hands and face.The facility policy titled Activities of Daily Living (ADL), Supporting, revised March 2018, documented residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview, record review, and document review, the facility failed to ensure a resident's transfer was coordinated by failing to contact, make prior arrangements for the transfer, confirm the receiving facility agreed to accept the resident, communicate the resident's enteral nutrition needs, document the discharge process in the medical record, and provide a telephone report to the receiving facility prior to transfer for 1 of 37 sampled residents (Resident 128). The deficient practice had the potential to result in the resident transferring to a facility unprepared to receive the resident, meet the resident's care needs, and result in additional delays in receiving enteral nutrition.Additional deficient practice was identified in connection with this F628 citation:Refer to Tag F600 (Free from Abuse/Neglect): The facility failed to establish and implement an enteral nutrition regimen for a resident after accepting them for admission, resulting in the resident receiving no documented enteral nutrition and only 240 milliliters (ml) of water flushes during their stay. This total lack of therapeutic nutrition and systemic care neglect directly escalated the urgency of the poorly coordinated transfer cited under F628.Refer to Tag F693 (Enteral Nutrition): The facility failed to verify the resident's prescribed enteral nutritional orders and ensure the necessary enteral formula was available prior to admission. This failure necessitated the emergency transfer, which was then executed without proper communication or facility-to-facility coordination.Findings include:Resident 128 (R128) was admitted [DATE] and discharged [DATE], with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction, gastrostomy status, and aphasia following cerebral infarction.A Care Plan dated 04/01/2026, documented R128 had a swallowing problem, was admitted with an abdominal gastrostomy tube (G-tube) related to impaired oral intake, and received enteral feedings related to dysphagia.A physician order dated 04/01/2026, documented an order to send R128 to the receiving facility for MIC-KEY (a brand of gastrostomy tube) dietary needs.R128's medical record lacked documented evidence of the following:-The receiving facility was contacted regarding R128's discharge and transfer.- The receiving facility agreed to accept R128 or was aware R128 would be transferred.- The receiving facility was informed of R128's enteral nutritional needs. - A telephone report was given to the receiving facility prior to R128's transfer. On 07/23/2026 at 11:46 AM, the Case Manager acknowledged the receiving facility should have been called regarding R128's transfer and the facility should have received approval from the receiving provider prior to discharged . The Case Manager confirmed R128's medical record lacked documented evidence the receiving facility was contacted. The Case Manager explained they were the only staff member at the facility who contacted the receiving facility via email. The Case Manager acknowledged the medical record lacked documented evidence of the Case Manager's contact with the receiving facility and acknowledged the communication with the receiving facility should have been entered in R128's medical record and reported the emails had been purged from the facility's email account and could not be recovered.On 07/23/2026 at 2:20 PM, the Director of Nursing (DON), acknowledged R128's medical record lacked documented evidence the receiving facility was contacted regarding R128's transfer. The DON reported communication with the receiving facility may have been via email and explained facility emails were purged approximately every couple of months. The DON reported they did not know why it took so long to transfer resident out when the concern with the enteral feeding formula was identified. The DON indicated options may have been discussed or offered but acknowledged R128's medical record lacked documented evidence of any care, discussions or actions.On 07/24/2026 at 9:50 AM, the Director of Nursing (DON), acknowledged R128's medical record lacked documented evidence of the process, including communication with the receiving facility, notification the resident was sent to the receiving facility and details of the transportation used to transfer the resident. On 07/24/2026 at 10:01 AM, a Registered Nurse (RN), acknowledged they did not document the RN's actions in R128's medical record including the process of R128's discharge. The RN explained they were not involved in R128's discharge and did not perform a telephone report to the receiving facility because the RN assumed R128 was expected at the receiving facility.On 07/24/2026 at 10:22 AM, the Administrator acknowledged R128's discharge process and communication with the receiving facility should have been documented in R128's medical record. The Administrator was unable to provide any documented evidence the receiving facility was informed of the resident's transfer. The facility was unable to provide documented evidence of emails sent to the receiving facility regarding R128's transfer.A facility policy titled Discharging the Resident revised December 2016, documented preparation for resident discharge included if the resident was being discharged to a hospital or another facility, the facility was to ensure a transfer summary was completed and telephone report was called to the receiving facility. Documentation including the date and time of the discharge, all assessment data obtained during the procedure, and how the resident tolerated the procedure.A facility policy titled Transfer or Discharge, Facility-Initiated, dated October 2022, documented information conveyed to the receiving provider included the basis for the transfer or discharge. If the resident was being transferred or discharged because their needs cannot be met at the facility documentation should have included the basis for the transfer or discharge, the specific resident needs that cannot be met, the facility's attempt to meet those needs and the receiving facility's services that were available to meet those needs and special instructions or precautions for the care of the resident.Complaint #2972095

Based on interview, record review, and document review, the facility failed to establish and implement an enteral nutrition regimen for a resident after accepting the resident for admission, resulting in the resident receiving no enteral nutrition and only 240 milliliters (ml) of water flushes during the resident's stay at the facility for 1 of 37 sampled residents (Resident 128). The deficient practice had the potential to result in inadequate nutrition, dehydration, and avoidable decline in the resident's condition.Additional deficient practice was identified in connection with this F600 citation:Refer to F628 (Transfer and Discharge Process): the facility failed to ensure a resident's transfer was coordinated by failing to contact, make prior arrangements for the transfer, confirm the receiving facility agreed to accept the resident, communicate the resident's enteral nutrition needs, document the discharge process in the medical record, and provide a telephone report to the receiving facility prior to transfer. This breakdown in transfer safety metrics left the resident vulnerable without continuous clinical oversight, compounding the care and nutrition neglect cited under F600.Refer to F693 (Enteral Nutrition): the facility failed to verify the resident's prescribed enteral nutritional orders and ensure the necessary enteral formula was available prior to accepting the resident for admission, and after admission failed to implement an enteral nutritional regimen. This pre-admission and post-admission clinical failure directly caused the wholesale lack of therapeutic nutrition and systemic hydration neglect identified under this F600 citation.Findings include:Resident 128 (R128) was admitted [DATE] and discharged [DATE], with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction, gastrostomy status, and aphasia following cerebral infarction.A Care Plan dated 04/01/2026, documented R128 had a swallowing problem, was admitted with an abdominal gastrostomy tube (G-tube) related to impaired oral intake, received enteral feedings related to dysphagia and was at risk of dehydration.R128's medical record lacked documented evidence of the following:- A physician order for an enteral feeding formula following admission.- An enteral nutrition regimen was implemented during R128's admission at the facility from 03/31/2026 through 04/01/2026. - The facility offered alternative enteral feeding formulas or intravenous (IV) fluids.- Enteral nutrition was provided during R128's stay at the facility. A Medication Administration Record (MAR) for April 2026, documented a bolus of flush gastrostomy (G) tube with water for a total volume of 240 milliliter (ml) every 4 hours, start date 04/01/2026. The MAR documented R128 received one 240 ml water flush on 04/01/2026. R128's medical record lacked documented evidence of any additional water flushes during R128's stay at the facility.On 07/23/2026 at 10:35 AM, the Registered Dietitian (RD), reported beginning employment at the facility on 06/01/2026 and was not employed at the time of R128's admission. The RD recalled previously caring for R128 at another facility and indicated R128 was vegan and wanted a specific vegan or plant-based tube feeding formula. The RD explained the facility was supposed to admit residents whose specific care needs could be accommodated. The RD indicated the need for a vegan or plant-based formula should have been identified prior to admission or during the admission process and confirmed R128's medical record lacked documented evidence of a physician order for an enteral feeding formula.On 07/23/2026 at 11:46 AM, the Case Manager explained the type of enteral feeding the resident required was not available at the facility. The Case Manager reported prior to admission, the facility should have identified R128 required a special formula. The Case Manager discovered the day after the admission, a vegan or plant based enteral feeding formula was not available. The Case Manager explained the nursing department was responsible for entering admission orders, should have identified the special feeding formula was not available and should have notified Central Supply to place an order.On 07/23/2026 at 2:20 PM, the Director of Nursing (DON), acknowledged the admissions nurse should have reviewed the orders and identified there was no active order for an enteral feeding formula. The DON explained R128's medical record lacked documented evidence an alternate formula or IV fluids were offered or administered to the resident during the time between admission and discharge. The DON explained the expectation was R128 should have been offered feeding formula options and IV fluids for hydration. The DON acknowledged R128's medical record lacked documented evidence R128 received enteral nutrition during the approximately 24-hour stay at the facility and did not know why it took so long to transfer R128 out of the facility after the concern with the formula was identified. The DON indicated options may have been discussed or offered, acknowledged R128's medical record lacked documented evidence of such discussions or offers.On 07/24/2026 at 9:17 AM, the Central Supply staff member reported being the only Central Supply staff member for 6.5 years and the only staff member to order enteral formula. The staff member reported vegan or plant-based enteral formulas were not kept in stock at the facility, required an order, could not recall being asked to order a vegan formula for a resident in March or April 2026.On 07/24/2026 at 9:42 AM, a Licensed Practical Nurse (LPN), explained a resident should not have remained without prescribed enteral nutrition or adequate fluids. The LPN indicated they would have immediately notified a supervisor, sought to obtain the appropriate enteral formula or arrange transfer if necessary. The LPN explained all actions taken were supposed to be documented in the medical record. The LPN acknowledged a resident remaining without enteral nutrition and receiving only minimal fluids for approximately 24 hours could have been detrimental to the resident's health. The LPN acknowledged the situation may have constituted neglect because the resident's nutritional and hydration needs were not met, and care should have been provided to the resident.On 07/24/2026 at 9:50 AM, the Director of Nursing (DON), confirmed the only fluids documented in R128's medical record as administered was a 240 milliliter (ml) water flush on 04/01/2026. The DON acknowledged R128's medical record lacked documented evidence of additional fluids provided including intravenous (IV) fluids. The DON reported a staff member purchased enteral formula for R128 at a local grocery store and some of the formula was administered. The DON acknowledged R128's medical record lacked documented evidence an enteral feeding formula was purchased at a local grocery store or was administered to R128. A written statement, undated, from the Assistant Director of Nursing (ADON), documented it was brought to the attention of the ADON, R128 was refusing enteral feeding formulas available at the facility due to R128's vegan dietary preferences. The ADON indicated purchasing the vegan formula preferred by R128 at a local grocery store. The ADON provided the formula to R128's floor nurse for use as appropriate. The ADON could not recall whether the formula was administered following delivery.On 07/24/2026 at 10:01 AM, a Registered Nurse (RN), explained being R128's nurse for day shift on 04/01/2026. The RN explained learned R128 wanted only a specific strawberry flavored, vegan enteral formula brand and sent a message to the Dietitian. The RN reported the facility purchased four bottles of the enteral formula preferred by R128 at a local grocery store and the RN administered two bottles of the enteral formula. The RN explained the Dietitian at the time, R128 required 12 bottles of the enteral formula per day, and the facility could not supply that amount of formula to cover the two days of feedings necessary until the facility received the enteral feeding formula order. The RN was unable to explain why only two bottles of enteral formula were administered or how the determination was made to administer R128 only two bottles of formula. The RN acknowledged R128's medical record lacked a physician order for enteral feeding formula. The RN acknowledged failing to document their actions in R128's medical record, including the alleged administration of two bottles of enteral formula, and offers of alternate enteral formulas. The RN reported providing the remaining two bottles of enteral formula to R128 to take to the receiving facility at discharge. On 07/24/2026 at 10:22 AM, the Administrator acknowledged options offered to R128 should have been documented in R128's medical record.A facility policy titled Abuse and Neglect, Clinical Protocol revised March 2018, documented neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility management and staff would institute measures to address the needs of residents and minimize the possibility of abuse and neglect.Complaint #2972095

Based on interview, record review and document review, the facility failed to provide documented evidence of the actions taken and follow-up made after the facility was notified of a reported positive case of Legionella (a bacteria which caused Legionnaires' disease by spreading through contaminated water mist, not water itself, which people inhale) for a resident who was discharged from the facility on 08/02/2025 and tested Legionella Polymerase Chain Reaction positive (PCR test was a laboratory technique used to detect and amplify specific genetic sequences, such as those from viruses or bacteria) at a hospital on [DATE] for 1 of 9 sampled residents (Resident 1). The deficient practice had the potential to prevent early detection and possible transmission of infection among the residents.Findings include:Resident 1 (R1) was admitted on [DATE] and discharged on 08/02/2025, with diagnoses including cerebral edema, urinary tract infection, Escherichia Coli (E. Coli), and dependence on supplemental Oxygen. The Hospital Transfer form dated 08/02/2025, documented R1 was sent to a hospital on [DATE] at 5:40 PM. The reason for transfer was altered mental status. The Nurse's Notes dated 08/02/2025, documented the physician ordered to send R1 to the hospital. The American Medical Response (AMR) ambulance came and picked up R1 at 5:40 PM. The hospital's Emergency Department (ED) Physician Notes dated 08/02/2025, documented the provider contact time was 08/02/2025 at 5:52 PM. The chief complaints were altered mental status and shortness of breath. R1's hospital test results documented the following:Legionella species by qualitative PCR: DetectedDate/Time: 08/04/2025 at 10:55 AM Pacific Daylight Time (PDT)Legionella Source: NasopharyngealLegionella pneumophila by PCR: DetectedLegionella species by qualitative PCR: DetectedSource Type: Nasopharyngeal swabSource: Collected on 08/04/2025 at 10:55 AM PDTInterpretive Information: Legionella species by qualitative PCR(Legionella species was the broad [NAME] of bacteria, while Legionella pneumophila was a specific species within that [NAME] and the most common cause of Legionnaires' disease.) On 09/03/2025 at 11:53 AM, the Infection Preventionist (IP) Nurse revealed the duties and responsibilities of an IP Nurse included surveillance, prevention, and reporting of infections and overseeing the infection prevention program of the facility. The IP Nurse explained a community-acquired infection referred to an infection which was present on admission and the symptoms were manifested within 48 hours upon a resident's admission. The IP Nurse indicated a healthcare-associated infection (HAI) referred to an infection acquired at the facility and the symptoms developed after 48 hours from admission. On 09/03/2025 at 12:24 PM, the IP Nurse confirmed receiving a phone call from the hospital on [DATE] in the morning about R1 being tested positive for Legionella. The IP Nurse revealed not asking questions about the resident. After the phone call, the IP Nurse spoke to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) and relayed the information about the resident who was tested positive for Legionella at the hospital. The IP Nurse asked the DON and ADON on when was the last time the water system was tested for Legionella. The IP Nurse revealed being directed to the Maintenance Director. The IP Nurse indicated calling the Maintenance Director who told the IP Nurse the water system was tested in February 2025 for Legionella and the results were negative. The IP Nurse had another conversation with the Maintenance Director and the IP Nurse was told the facility would no longer test for Legionella because of the negative results in February 2025. The IP Nurse revealed after the phone call from the hospital, the IP Nurse reviewed R1's medical record including the chest X-ray results on 07/11/2025 which showed no infiltrates. The IP Nurse indicated R1 had no symptoms of pneumonia and the hospital transfer on 08/02/2025 was not related to pneumonia. The IP Nurse acknowledged they should have asked the hospital more questions about R1 such as the date when the resident was tested positive for Legionella and if the resident was symptomatic. The IP Nurse explained the conversation or the phone call with the hospital should have been documented. The IP Nurse confirmed not documenting the information received from the hospital about R1 being tested positive for Legionella. The IP Nurse indicated the details of the information that R1 was tested positive for Legionella could have been presented and discussed with the DON and ADON for further actions such as initiating an investigation, testing the water system for Legionella and resident tracking/tracing. The IP Nurse acknowledged by knowing the date the resident was tested positive for Legionella, the facility could have determined if the Legionella was acquired at the facility or not. The IP Nurse explained the water system should have been tested for Legionella, tracing or surveillance should have been done. The IP Nurse revealed Legionella was a reportable disease and should have been reported immediately by phone to the Health District if identified. The IP Nurse explained not remembering the name of the hospital IP who called on 08/06/2025. The IP Nurse revealed the caller introduced self as the hospital IP. On 09/03/2025 at 1:19 PM, the ADON confirmed being told by the IP Nurse about R1 testing positive for Legionella but not sure of the exact date when the notification occurred. The ADON indicated the conversation with the IP Nurse about R1 occurred sometime in August 2025 and prior to 08/28/2025 when the Health District notified the facility about what happened to R1. On 09/03/2025 at 2:15 PM, the Clinical Resource indicated the IP Nurse should have asked questions from the hospital IP like the date when the resident was tested positive for Legionella and the date when the resident was discharged from the facility. The Clinical Resource acknowledged the IP Nurse should have documented in the progress notes the conversation with the hospital IP and the actions taken in response to the information provided by the hospital. The Clinical Resource explained the IP Nurse should have reported the information to the Interdisciplinary Team (IDT) and the Administrator, and called the Southern Nevada Health District for guidance. The Clinical Resource revealed these actions and interventions were part of the surveillance for infections and the facility should have followed the water management plan. On 09/03/2025 at 2:44 PM, the IP Nurse explained the surveillance for infections included verifying who were the former occupants of the rooms where R1 stayed and reviewing medical records to determine if the residents manifested symptoms of respiratory infection or pneumonia. The IP Nurse confirmed these actions were not implemented after receiving the call from the hospital IP on 08/06/2025. On 09/03/2025 at 3:11 PM, the Maintenance Director confirmed being told by the IP Nurse about receiving a call from the hospital that somebody was tested positive for Legionella. The Maintenance Director revealed the IP Nurse did not mention the name of the resident. The Maintenance Director explained it was not important to know the name of the resident and the IP Nurse could not reveal the name of the resident to the Maintenance Director because of HIPAA (Health Insurance Portability and Accountability Act). The Maintenance Director indicated informing the Administrator on 08/11/2025 about the positive Legionella case reported by the hospital to the IP Nurse. The Maintenance Director confirmed the Administrator said no when asked if the facility would test the water system for Legionella. The Maintenance Director revealed not being aware of the period or timeframe when the resident stayed at the facility because the Maintenance Director did not know who the resident was. On 09/03/2025 at 4:05 PM, the Administrator indicated not being aware of the 08/06/2025 phone call from the hospital about a resident previously admitted at the facility and tested positive for Legionella at the hospital. The hospital Infection Preventionist Summary documented R1's Legionella reported, also notified (name of the facility) 08/08/2025 at 8:56 AM, and name of the IP Nurse. The facility's policy titled Surveillance for Infections dated September 2017, documented the Infection Preventionist would conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The purpose of the surveillance of infections was to identify both individual cases and trends of epidemiologically significant organisms and Healthcare-Associated Infections, to guide appropriate interventions and to prevent future infections.Complaint 2603300

Based on observation, interview, document review and record review the facility failed to ensure a resident who required oxygen therapy was not connected to an empty oxygen tank and to obtain a physician's order for oxygen for 1 of 24 sampled residents (Resident 157). This deficient practice had the potential to lead to serious complications, including hypoxia, respiratory failure, and damage to vital organs. Findings include: Resident 157 (R157) was admitted on [DATE] with a diagnosis of chronic respiratory failure with hypoxia, acute kidney failure, unspecified, chronic obstructive pulmonary disease, unspecified and pneumonia, unspecified organism.On 08/12/2025 at 10:35 AM, R157 was connected to a nasal canula, and an oxygen tank attached to the wheelchair, and the tank was empty and off.On 08/12/2025 at 10:45 AM, a Registered Nurse (RN) indicated the resident was on two liters of oxygen continuously due to a diagnosis of chronic respiratory failure and chronic obstructive pulmonary disease. The RN verified the oxygen tank was empty and turned off.On 08/13/2025 at 1:17 PM, a Certified Nursing Assistant (CNA) voiced R157 had been on two liters of oxygen since being admitted on to the unit.R157's care plan dated 08/08/2025 documented oxygen therapy pertaining to chronic obstructive pulmonary disease and chronic respiratory failure. The interventions were to administer oxygen and breathing treatments as ordered by the physician.On 08/13/2025 at 4:07 PM, a Registered Nurse (RN) verified R157 did not have an active order for oxygen. The RN indicated an order for oxygen was required. The facility Oxygen Administration policy revised on 10/2022, documented to verify there was a physician's order, to review the physician order and facility protocol for oxygen administration and review the residents care plan to assess for any special needs.

Based on record review, document review, and interview, the facility failed to ensure a Physician Order for Life-Sustaining Treatment (POLST) form was witnessed and signed by two staff members, to validate a verbal consent for a do not resuscitate (DNR) status received from a resident's family member for 1 of 24 sampled residents (Resident 7). The deficient practice had the potential to result in a resident not receiving care consistent with their resuscitation preferences.Findings include: Resident 7 (R7) was admitted [DATE], readmitted [DATE], with diagnosis including unspecified mononeuropathy, chronic respiratory failure with hypoxia, and type 2 diabetes mellitus with diabetic neuropathy.A Care Plan dated 06/06/2025, documented R7 had a POLST-DNR and the code status would be reviewed on a quarterly basis and as needed. R7's electronic medical record documented a code status of do not resuscitate. A POLST form dated 06/02/2025, documented do not resuscitate (allow natural death). The words verbal consent were handwritten on both page 1 and 2 of the form. Section E, Validating Signatures (Required), provided options to be circled which included patient and agent signature, to identify who signed the form. None of the options were selected. On the signature line there were two words crossed out and one ineligible writing. The space provided for printed name and date were left blank.On 08/13/2025 at 11:47 AM, the Director of Nursing (DON), explained a verbal DNR consent on a POLST form required two nurses to witness and sign the form. The DON confirmed on R7's POLST form the signature line contained two writings that were crossed out and the remaining writing was not legible. The DON confirmed no indicators were circled to identify who signed the form. The DON was unable to determine if two nurses had signed R7's POLST. The DON confirmed R7's POLST form did not include the two signatures required for verbal consent and therefore it was not acceptable for a verbal DNR status determination. The DON explained that the consequences of incorrect code status could have resulted in life sustaining treatment not provided to a resident in error.On 08/15/2025 at 12:47 PM, a Licensed Practical Nurse reported a verbal consent for a do not resuscitate status on a POLST form required two staff members to witness and sign the form. The LPN explained best practice included following up with a signature at a later date when resident's representative became available.The facility Do Not Resuscitate Order policy revised March 2021, documented do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. The interdisciplinary care planning team would review advanced directives with the resident during quarterly care planning sessions to determine if the resident wished to make changes in such directives.

Based on observation, interview, record review and document review, the facility failed to ensure 1) a physician order was obtained for moderate to severe pain medication, 2) the resident's pain was routinely monitored and 3) pharmacological and non-pharmacological pain interventions were offered and/or provided for a resident who was assessed to be at risk for pain for 1 of 24 sampled residents (Resident 154). The deficient practice had the potential to negatively impact residents' overall wellbeing.Findings include: Resident 154 (R154) was admitted on [DATE], with diagnoses including fracture of lower end of left radius (one of two bones in the forearm), left ulna styloid process (a small bony projection located at the end of the ulna bone in the forearm), left orbital floor (a thin bone which forms the floor of the eye socket), unspecified phalanx (bones in fingers or toes) of left middle finger and maxillary fracture (upper jaw bone).1) On 08/12/2025 at 11:17 AM, R154 laid in bed with left arm wrapped in bandage and supported by a sling while the right arm had a black splint (immobilizing device). R154 had facial bruising more pronounced on the left side particularly around left eye. R154 reported falling in the front yard and sustaining several fractures. R154 reported current pain level was 8 out of 10 (severe) and indicated not knowing what pain medication was ordered.On 08/12/2025 at 11:20 AM, R154's family member indicated wanting to speak with a physician to request stronger pain medications since R154 was receiving Percocet at the hospital, which was effective in managing the resident's pain, but the medication was not ordered at the facility.An admission assessment dated [DATE], revealed R154 was admitted to the facility at 6:20 PM and was assessed to have current or recent pain and was at risk for pain related to generalized body pain for bilateral wrist fractures. Pain care plan interventions included administering pain medications as ordered, monitoring for pain every shift with a goal of resident verbalizing improvement in pain level within one hour of pain management interventions.2) On 08/12/2025 at 2:24 PM, R154 laid in bed and appeared to be in discomfort as evidenced by facial grimace and a report of pain 10/10. R154 reported the wound nurse just unwrapped the resident's bandages which caused the resident severe pain. The resident's family member indicated the wound nurse did not ask the resident about pain during wound care.On 08/12/2025 at 2:36 PM, Licensed Practical Nurse (LPN) 1 was informed of R154's complaint of severe pain.A Physician Order dated 08/11/2025, documented to monitor pain every shift using pain scale: 0/10 (no pain), 1/10 to 2/10 (least pain), 3/10 to 4/10 (mild pain), 5/10 to 6/10 (moderate pain) and 7/10 to 8/10 (severe pain) and 9/10 to 10/10 (very severe/worst/ horrible pain).The medical record lacked documented evidence LPN1 conducted a pain evaluation on R154 on 08/12/2025 (day shift).A Physician Order dated 08/11/2025, documented to give Acetaminophen 325 milligrams (mg), two tablets by mouth every six hours as needed for pain level 1 to 3/10.The medical record lacked documented evidence pain medication to manage mild, moderate, severe to very severe pain was obtained by the admitting nurse upon R154's admission.3) A Physician Order dated 08/11/2025, documented to attempt non-pharmacological approaches to pain such as redirecting, repositioning, offer snacks, adjust room temperatures, offer fluids, offer distraction or activities.The medical record lacked documented evidence non-pharmacological interventions were offered or provided for R154's pain on 08/12/2025. On 08/13/2025 at 7:30 AM, R154 appeared weak and drowsy in bed. R154 reported barely getting any sleep due to being in pain all night. R154's current pain level was 8/10 (severe) pain. The facility Pain Assessment and Management policy revised October 2022, documented residents with acute or significant worsening of chronic pain should be assessed every 30 to 60 minutes after onset and reassessed as indicated until relief was obtained.A Physician Order dated 08/11/2025 (4:27 PM), documented to give Tramadol hydrochloride tablet 50 mg. Give one tablet by mouth every eight hours as needed for moderate to severe pain 4/10 to 10/10 in pain scale.The medical record lacked documented evidence that R154's acute and significant pain related to multiple fracture injuries was monitored in accordance with facility policy.The medical record lacked documented evidence Tramadol (opioid used for moderate to severe pain) had been administered to R154 since the order was obtained from the physician on 08/12/2025 at 4:27 PM related to R154's complaints of severe pain. On 08/13/2025 at 7:28 AM, LPN3 recounted R154 complaints of pain with a level 4/10 yesterday afternoon and LPN3 administered Acetaminophen (ordered for pain level 1/10 to 3/10) at 3:28 PM because there was no pain medication ordered for pain level greater than 3/10. LPN3 reviewed R154's medical record which revealed an order for Tramadol on 08/12/2025 at 4:27 PM but LPN3 indicated the medication had not been administered. On 08/13/2025 at 7:55 AM, LPN2 indicated pain management should be a high priority for R154 given the resident's injuries on admission. LPN2 explained nurses were not allowed to retrieve pain medications from the medication-dispensing system until pharmacy received a copy of the order. LPN2 indicated notifying the physician group regarding R154's complaints of severe pain at 3:00 PM, the Nurse Practitioner (NP) expressed reservations regarding Percocet due to side effects and the resident's age and medical condition and discussed opting for Tramadol with R154's family member. The NP sent the order for Tramadol to pharmacy at 4:21 PM.On 08/13/2025 at 8:58 AM, the NP indicated R154 was receiving strong pain medications intravenously and orally while at the hospital, but opioids were not part of the discharge medication list. Upon being informed by facility staff of R154's pain, the NP decided to order Tramadol versus Percocet because it was associated with less side effects given the resident's advanced age and condition.On 08/13/2025 at 9:05 AM, the NP indicated pain management should be prioritized for residents such as R154, and facility staff should have communicated R154's report of moderate to severe pain with the providers sooner to prevent worsening pain. The NP indicated pain medications should have been obtained to cover the entire pain scale 1/10 to 10/10 for the medication to be made immediately available when moderate to severe pain was reported by R154 with no delay in intervention.On 08/13/2025 at 9:35 AM, a Consultant Pharmacist confirmed controlled medications may not be retrieved from the medication-dispensing system until pharmacy had received the physician order or script. The Pharmacist reviewed R154's medical record and indicated R154 received two tablets of Percocet at the hospital on [DATE] at 2:00PM.On 08/14/2025 at 8:27 AM, the Director of Nursing (DON) indicated R154 was admitted to the facility on the evening of 08/11/2025. The DON confirmed the resident was admitted with multiple injuries related to a fall and was at risk for acute and worsening pain and medication orders were limited to Tylenol for pain level 1 to 3/10. The DON indicated expecting the admission nurse to obtain pain medications to cover moderate to severe pain (level 4-10) and confirmed this was not done by the admission nurse.On 08/14/2025 at 8:37 AM, the DON confirmed the LPN3 administered Tylenol to R154 on 08/12/2025 at 3:28 PM for pain level 4/10 as there was no pain medication ordered for pain level greater than 3/10. On 08/14/2025 at 8:40 AM, the DON verified R154 was not provided pharmacological and non-pharmacological pain interventions from admission on the evening of 08/11/2025 until 08/12/2025 at 3:28 PM.On 08/14/2025 at 8:48 AM, the Clinical Resource Nurse expected the night nurse to conduct more frequent checks for the resident due to the resident's clinical condition which placed the resident at risk for acute and worsening pain. The Clinical Resource Nurse was aware the facility policy required more frequent checks on residents with acute or worsening pain.On 08/14/2025 at 9:01 AM, the Clinical Resource Nurse verbalized the pain assessment and management policy was not followed with regards to lack of pain assessment on 08/12/2025 (day shift) and the admitting nurse failing to obtain pain medication orders to manage moderate to severe pain.The facility Pain Assessment and Management revised October 2022 revealed the purpose of the procedure was to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs that address the underlying causes of pain. Pain management was defined as the process of alleviating the resident's pain based on clinical condition. Pain management was multi-disciplinary which includes assessing for potential pain, recognizing presence of pain, monitoring effectiveness of interventions.

Based on observation, interview, record review and document review, the facility failed to ensure a baseline care plan was initiated and completed for a resident who was admitted with a peripheral intravenous (IV) access for 1 of 24 sampled residents (Resident 3). The deficient practice had the potential to place residents at risk for not receiving IV access care.Findings include: R3 was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD).On 08/12/2025 at 11:23 AM, R3 had a purple-colored single lumen peripheral IV catheter in the right inner forearm. The admission assessment dated [DATE], revealed R3 was admitted on the evening of 08/10/2025 with an IV line with site location and purpose unspecified.The medical record lacked documented evidence that a baseline care plan was initiated and completed for R3's peripheral IV line.On 08/13/2025 at 1:51 PM, the Director of Nursing (DON) indicated the admission nurse must document the presence of an IV access for residents admitted with one. The DON reviewed R3's admission assessment which confirmed R3 was admitted with an IV line, but the site location and purpose was not documented. The DON indicated that the resident's peripheral line was considered an immediate care need and should be included in the baseline care plan. The DON confirmed R3's peripheral IV was not included in the resident's baseline care plan and should have been.The facility Baseline Care Plan policy revised December 2016, documented a baseline care plan to meet the resident's immediate care needs must be developed within 48 hours of admission.

Based on observation, interview, record review and document review, the facility failed to ensure 1) a clarification order was obtained for a resident's peripheral intravenous (IV) line for a newly admitted resident with no IV medication orders for 1 of 24 sampled residents (Resident 3); 2) a physician's order was followed regarding rotating sites for a peripheral IV line for 1 of 24 sampled residents (Resident 155) and 3) the facility policy was followed regarding removal of peripheral IV lines for 2 of 24 sampled residents (Residents 3 and 155). The deficient practice had the potential to place the residents at risk for phlebitis (site infection).Findings include: 1) Resident 3 (R3) was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD).On 08/12/2025 at 11:23 AM, R3 had a purple-colored single lumen peripheral IV catheter in the right inner forearm. The admission assessment dated [DATE], revealed R3 was admitted on the evening of 08/10/2025 with an IV line with site location and purpose unspecified.Review of R3's admission orders revealed R3 did not have IV medication orders. On 08/12/2025 at 11:45 AM, the Wound Care Registered Nurse (RN) confirmed R3 had a peripheral IV line in right inner forearm which was dangling due to dressing being loose. R3 explained the line was inserted at the hospital for IV antibiotic therapy but antibiotics were changed to oral route prior to hospital discharge on [DATE]. R3 indicated the IV line had not been used since admission to the facility on [DATE].On 08/12/2025 at 11:47 AM, an RN described R3's IV site as undated with gauze pad underneath a transparent dressing which was coming loose. The RN indicated the admission nurse should have contacted the physician for clarification orders on whether the line should be removed since there were no IV medication orders. The RN indicated a compromised IV dressing placed R3 at risk for phlebitis or infection. On 08/13/2025 at 2:57 PM, the Director of Nursing (DON) indicated if a resident was admitted with a peripheral line with an undated dressing with gauze covering the insertion site, the admission nurse was expected to seek clarification with the physician on whether to maintain or remove the line. The DON indicated if the line were to be maintained, the dressing must be replaced with a transparent dressing and maintenance protocol must be followed with site monitoring and flushing every shift, or the physician may opt to have the line removed. The DON confirmed there was no physician clarification regarding R3's peripheral line upon admission on [DATE].On 08/13/2025 at 3:00 PM, the DON reviewed R3's medical record and confirmed site monitoring and flushing were missed on 08/11/2025 and R3s peripheral line should have followed maintenance protocol until the line was removed on 08/13/2025.The facility admission Assessment and Follow Up: Role of the Nurse policy revised September 2012, documented the admission nurse would gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission for the purpose of managing the resident and initiating the care plan. The nurse would notify the attending physician of the resident's immediate needs.2) Resident 155 (R155) was admitted on [DATE], with diagnoses including right femur fracture and anemia.On 08/12/2025 at 11:41 AM, R155 had peripheral IV access on the left hand with dressing dated 08/07/2025. R155 explained the IV was placed at the facility and was being used for medication administration.On 08/12/2025 at 11:57 AM, Licensed Practical Nurse (LPN) 1 indicated being assigned to R155 and explained using the resident's peripheral IV to administer IV Venofer (Iron Sucrose). LPN1 indicated peripheral IV lines were meant for short term use and LPN1 was familiar with physician's orders to rotate R155's IV site every three days. LPN1 confirmed physician's orders were not followed when the resident's IV line was not removed and placed at a different location on 08/10/2025. A Physician Order dated 08/07/2025, documented to insert peripheral IV Site Location: right hand for IV Venofer. A Physician Order dated 08/07/2025, change peripheral IV every three days and as needed for infiltration.The medical record lacked documented evidence that the physician order to rotate R155's peripheral site was followed.On 08/13/2025 at 3:36 PM, the Clinical Resource Nurse confirmed peripheral lines were meant for short term use and the facility protocol was to rotate sites every three days unless the physician ordered the line to stay in place. The Clinical Resource Nurse confirmed the physician orders were not followed when R155's peripheral line was not rotated on 08/10/2025 (Day three).3) R3 was admitted on [DATE] and readmitted on [DATE], with diagnoses including end stage renal disease (ESRD).The admission assessment dated [DATE], revealed R3 was admitted on the evening of 08/10/2025 with an IV line with site location and purpose unspecified.A Physician Order dated 08/13/2025, documented to discontinue IV line.On 08/13/2025 at 3:18 PM, the Infection Preventionist (IP) indicated removing R3's right forearm peripheral line around noon today and described the line as loose and not flushing well. The IP removed the IV line and acknowledged not notifying the physician regarding the removal and the IP did not document the procedure in R3's medical record.R155 was admitted on [DATE], with diagnoses including right femur fracture and anemia.On 08/12/2025 at 11:41 AM, R155 had peripheral IV access on left hand with dressing dated 08/07/2025. R155 explained the IV was placed at the facility and was being used for medication administration.A Physician Order dated 08/13/2025, documented to discontinue IV line.On 08/13/2025 at 3:42 PM, LPN2 reported R155's peripheral IV was removed by the floor nurse after lunch today. The medical record lacked documented evidence for nursing staff who removed the peripheral IV lines of R3 and R155 followed documentation requirements per facility policy.The facility Peripheral IV Catheter Removal policy revised March 2022, revealed the following information should be documented in the resident's medical record: 1) date and time of the procedure including resident's tolerance, 2) location where catheter was removed from, 3) reason for removal (end of treatment, rotating sites, complications, etc.), and 4) any communication with physician or oncoming shift.

Based on interview, record review, and document review, the facility failed to ensure the resident's pain medication was administered as ordered and appropriately managed for 1 of 5 sampled residents (Resident 1), and the pain was timely assessed for 1 of 5 sampled residents (Resident 3). This deficient practice had the potential to result in unmanaged pain, delayed relief, and decreased quality of life for the affected residents. Findings include: A facility policy titled Pain-Clinical Protocol revised October 2022, documented the nursing staff would assess each individual for pain upon admission to the facility, whenever there was a significant change of condition, and when there was an onset of new pain or worsening of existing pain. Resident 1 (R1) R1 was admitted on [DATE], readmitted on [DATE], and discharged on [DATE], with diagnoses including fracture of the first lumbar vertebra, long-term use of opiates, and complex regional pain syndrome. A care plan initiated on 11/13/2024 documented R1 was at risk for pain related to generalized body pain, impaired mobility, history of falls, and self-care deficit. The goal was for R1 to voice or demonstrate a level of comfort within 30 minutes to 1 hour after interventions were rendered. Pain was to be managed through the review date. The Admission Minimum Data Set, dated dated dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15/15, indicating intact cognitive status. The pain assessment indicated over the 5-day assessment period, R1's pain almost constantly affected the ability to sleep at night and interfered with therapy activities. The Physician Progress Notes dated 12/13/2024, documented on 12/04/2024, R1 had difficulty tolerating physical therapy due to pain. On 12/06/2024, pain continued to be reported as a barrier by both the resident and therapy staff. The physician reviewed medications and discussed the ongoing pain issue. As a result, the Hydromorphone (Dilaudid) dosage was increased from 4 milligram (mg) to 6 mg every 4 hours, with instructions to monitor R1 closely. A Physician Order dated 11/30/2024, documented Hydromorphone 4 mg every 4 hours as needed. A subsequent Physician Order dated 12/06/2024, documented an increase in the Hydromorphone dosage to 6 mg every 4 hours as needed. The Medication Administration Record (MAR), documented continued administration of Hydromorphone 4 mg from 12/06/2024 until R1's discharged on [DATE], despite the new order for 6 mg. A review of R1's medical records from 12/06/2024 to 12/17/2024, revealed a lack of documented evidence the increased Hydromorphone 6 mg dosage was administered as ordered to manage R1's pain. On 04/16/2025 at 11:56 AM, the Nurse Supervisor confirmed the new order for Hydromorphone 6 mg was received and confirmed on 12/06/2024 but was not administered as prescribed. The Nurse Supervisor explained the previous order for 4 mg had not been discontinued, but the dosage increase was communicated to the assigned nurse. The Nurse Supervisor verbalized a pain assessment should have been performed due to the increased dose but was not completed. On 04/16/2025 at 12:15 PM, a Registered Nurse (RN) assigned to the resident was uncertain why the Hydromorphone 6 mg was not administered as ordered. The RN conveyed the duplicate pain medication orders with the same frequency should have been clarified and documented, but there was no documentation it was done. The Occupational Therapy Treatment Encounter dated 12/09/2024, documented the Occupational Therapist (OT) arrived in R1's room and instructed R1 to begin getting out of bed. R1 stated a pain pill was needed. The OT reminded R1 the pain medication had been administered, and another dose could not be given until 4 hours had passed. R1 continued to argue with the OT and R1 was observed in severe pain. On 04/16/2025 at 2:39 PM, the OT confirmed R1 had complained of an increased level of pain and on occasions, R1 had declined therapy because the pain medication was either not administered or was ineffective. The OT acknowledged the pain had been an ongoing issue for R1. On 04/16/2024 at 2:33 PM, the Physical Therapist (PT) verified R1's previous treatment and explained R1 required standby assistance for bed mobility and minimal assistance for transfers and ambulated 10 feet with a walker using minimal assistance. The PT indicated R1's pain was reported at a pain level increased to 10 out of 10 on 12/06/2024. The PT explained the pain medication was vital for a resident receiving therapy to promote participation in therapy sessions. The PT indicated R1 was discharged from therapy services after leaving against medical advice. On 04/16/2024 in the afternoon, the Director of Nursing (DON) indicated the physician should have discontinued the previous order once the dosage was increased. The DON indicated the facility staff should adhere to the physician's prescribed orders to effectively manage the resident's pain. 41903 Resident 3 (R3) R3 was admitted [DATE] and discharged [DATE] with diagnosis including displaced intertrochanteric fracture of right femur, difficulty in walking, and need for assistance with personal care. A Weekly Skin Evaluation dated 02/12/2025, documented the following were identified during an admit wound care evaluation: Right lateral knee surgical incision, right medial knee surgical incision, right knee front surgical incision, right lower thigh surgical incision, right upper thigh surgical incision, and bilateral heels type protective. A Care Plan dated 02/13/2025, documented the resident had chronic pain. A Vitals and Pain Only Evaluation dated 02/11/2025 at 21:38, documented R3's vital signs were obtained on 02/11/2025 at 9:28 PM. The pain assessment section of the evaluation form documented a pain assessment was performed on 02/12/2025 at 7:22 AM. The Vitals and Pain Only Evaluation form lacked documented evidence a pain assessment was performed for R3 upon admission on 02/11/2025 and a pain assessment was not completed until 02/12/2025 at 7:22 AM. On 04/16/2025 at 2:25 PM, the Director of Nursing (DON) confirmed R3's Vitals and Pain Only Evaluation performed upon admission 02/11/2025 at 9:38 PM lacked documented evidence R3 was assessed for pain upon admission. The DON acknowledged the first documented pain assessment for R3 was completed on 02/12/2025 at 7:22 AM. The DON confirmed there was no documented evidence the resident was assessed for pain at admission. The DON confirmed R3 should have been assessed for pain upon admission. On 04/16/2025 at 3:35 PM, a Registered Nurse (RN), explained a pain assessment should have been done as part of the initial assessment upon admission. The RN reported if the pain assessment was not done, pain would not have been identified, orders for pain medication would not have been requested timely and the resident could have remained in pain for an extended period of time unnecessarily. A facility policy titled Pain Management, revised October 2022, documented the nursing staff would assess each individual for pain upon admission to the facility.

Based on interview, record review and document review, the facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for 1 of 4 sampled residents (Resident 1). The deficient practice potentially deprived the resident and/or resident representative of the right to be informed of the medications' risks, benefits and potential side effects. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including puncture wound of right lower leg and fracture of upper and lower end of right fibula (a lower leg bone) and Alzheimer's disease. R1's medical record contained a legal document which revealed R1 had appointed a family member to be R1's legal representative or power of attorney (POA). A physician's order dated 09/02/2024, documented to give Buspirone (anti-anxiety) hydrochloride five milligrams (mg) by mouth two times a day for anxiety as evidenced by verbalization of feeling anxious and being uncooperative. The medical record lacked documented evidence an informed consent was obtained for R1's Buspirone prior to first administration on 09/03/2024. A physician's order dated 09/04/2024, documented to give Mirtazapine (anti-depressant) 7.5 mg by mouth one tablet at bedtime for anxiety as evidenced by being verbally abusive. The medical record lacked documented evidence an informed consent was obtained for R1's Mirtazapine prior to first administration on 09/05/2024. A physician's order dated 09/06/2024, documented to give Depakote (mood-stabilizer) 125 mg delayed release by mouth two times a day for agitation and aggressive behavior. The medical record lacked documented evidence an informed consent was obtained for R1's Depakote prior to first administration on 09/07/2024. On 01/02/2025 at 9:53 AM, the Director of Staff Development (DSD) explained informed consent forms were completed every time psychotropic medications (drugs which affect the brain and nervous system to treat mental illnesses and conditions which impact mind, emotions and behaviors) were ordered for a resident. According to the DSD, nurses were trained to explain the medication's purpose, risks, benefits and potential side effects to the resident and/or representative prior to administering the first dose. After discussion, the nurse would they themselves sign the document and obtain a signature from the resident or representative. On 01/02/2025 at 11:17 AM, a Registered Nurse (RN) who was familiar with R1 recalled the resident had been on a few psychotropic medications while at the facility. The RN explained informed consent forms were completed and signed by the nurse and residents and/or representative, but the RN could not recall if the RN was assigned to R1 when the medications were ordered by the physician. The RN explained two nurses would obtain a verbal consent from the representative by phone and the two nurses would sign the informed consent form if the resident's representative was not available. On 01/02/2025 at 12:27 PM, the Assistant Director of Nursing (ADON) indicated nurses were trained to complete informed consent forms for each psychotropic medication order. The informed consent form included information such as name of the medication, dose and frequency, indication for use, drug classification, target behaviors, risk and benefits and potential side effects. According to the ADON the completion of the form signified the resident and/or representative received education regarding the medication to include possible side effects and still consented to receive the medication. The ADON corroborated the DSD and RN's explanation on the facility's process where the nurses completing the form would obtain a signature from the alert resident, appointed representative or telephonically with two nurse's signatures. On 01/02/2025 at 12:38 PM, the DON reviewed R1's medical record and confirmed there were no consent forms completed for the resident's psychotropic medications. The DON indicated expecting nurses to complete a consent form every time a psychotropic medication was prescribed by a physician to treat psychiatric disorders. The DON confirmed the facility did not follow its antipsychotic use policy. On 01/02/2025 at 1:15 PM, the Consultant Pharmacist indicated medications such as Buspirone, Mirtazapine and Depakote all required informed consents primarily because it was a regulatory requirement to inform the resident and/or representative of risks and potential side effects with psychotropic medications prior to first administration. The pharmacist explained while Depakote was an anti-epileptic drug it was commonly used for bipolar disorder and dementia residents with behaviors as a mood stabilizer since the drug was known to decrease impulsivity. The Use of Antipsychotic Medications policy revised July 2022, documented residents would only receive antipsychotic medications when necessary to treat specific conditions for which they were indicated. Residents and/or their representatives would be informed of the recommendation, risks, benefits, purpose and potential adverse consequences of antipsychotic medication use. The Psychotropic Drug Informed Consent form included the following information: psychotropic drug order, medical diagnosis, drug classification (e.g. anti-anxiety, mood stabilizer, hypnotic, anti-psychotic), risk versus benefits, drug purpose, possible side effects, date of informed consent, date and signature of licensed nurse and resident or resident representative.

Based on interviews, record review, and document review, the facility failed to ensure a care plan was initiated after a resident alleged physical abuse from a staff member for 1 of 4 sampled residents (Resident 3). The deficient practice placed the resident at risk for inappropriate care, supervision, and incidents. Findings include: Resident 3 (R3) R3 was originally admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage, encephalopathy, old myocardial infarction, essential hypertension, and dysphagia. Facility documentation revealed the resident had reported to direct care nursing staff, a certified nursing assistant (CNA) described as a female, was rough when handling the resident during peri care and resident was hit on the forearm/hand. The resident reported this to the direct care staff at approximately 8:55am who then reported it immediately to the administrator. On 01/02/2025 at 2:26pm, R3 stated one of the staff had hit R3 on the hand for no reason. R3 stated the staff member just came into the room and hit R3. R3 had told the other CNAs and caregivers this staff person hit R3. R3 remembered the incident but was unable to expand upon the details of the incident at this time of this interview. Facility documentation revealed, the facility noted the family of R3 indicated R3 had a history of false allegations against care staff at other facilities. The facility also documented would revise the care plans to include their Cares in Pairs program (two staff members during resident care) in relation to this resident's accusation of abuse. The facility lacked documented evidence the Cares in Pairs program was care planned as of the incident date of 10/21/2024 up to the survey date of 01/02/2025 at 8:00am. There were no psychosocial/behavioral care plans regarding the resident's potential/tendencies to make false allegations toward staff/others with goals and interventions to safeguard the resident from repeated behavior. On 01/02/2025 a Licensed Practical Nurse (LPN) was asked if the LPN was aware this resident was supposed to be Cares in Pairs, the LPN stated was not aware R3 was Cares in Pairs. On 01/02/2025, a CNA exiting R3's room stated R3 does not require two people to assist with care as the resident was easy to complete tasks with just one person. The only time R3 needed two people was when they needed to transfer the resident. Because R3 is total assist with transfers, two people are required for the safety of both the resident and the staff during the transfer. When asked if the CNA was aware this resident was supposed to be Cares in Pairs, the CNA stated was not aware R3 was Cares in Pairs. On 01/02/2025 at 3:53 pm, the DON stated R3 was a Cares in Pairs resident which means two caregivers were required for the resident's care. The DON acknowledged there was no care plan related to this incident and agreed it would have been beneficial to have this allegation incident care planned to say what interventions the staff were doing, and should be doing, to not have this incident happen again. The facility's policy titled Care Plans, Comprehensive Person-Centered, documents a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs will be developed and implemented for each resident no more than 21 days after admission. The care plan interventions are to be derived after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on observation, interview, record review and document review, the facility failed to develop a baseline care plan for a soft collar device, an ACE wrap dressing (an elastic compression bandage typically wrapped around a sprain or strain) and CAM (controlled ankle movement) boot device for 2 of 22 sampled residents (Residents 244 and 250). The deficient practice placed the residents at risk for discomfort, skin integrity issues to affected areas and complications to surgical sites. Findings include: Resident 244 (R244) R244 was admitted on [DATE], with diagnoses including cervical disc disorder with myelopathy and status post cervical spine (C3 to C5 - neck region) decompression with anterior and posterior fusion. On 08/06/2024 at 8:42 AM, R244 laid awake in bed with a family member at bedside. A white foam collar with areas of discoloration was observed around the resident's neck. R244 indicated undergoing neck surgery more than a month ago and was admitted to this facility with the soft collar device. R244 indicated no staff had removed the collar to clean or assess R244's skin underneath since the resident's admission. R244 reported getting a shower three days ago where staff cleaned the resident while avoiding the neck area. R244 indicated not being certain how the neck collar was supposed to be managed, cleaned, replaced, or removed since the resident had yet to see the surgeon. A history and physical hospital report dated 07/18/2024, revealed R244 underwent a cervical procedure on 06/11/2024 and was being discharged to a skilled nursing facility with a soft collar. An Admission note dated 07/24/2024, revealed R244 was admitted with a soft collar which had to be on 24 hours a day seven days a week (24/7) with steri-strips present on front and back of neck. The medical record lacked documented evidence R244's baseline care plan included care and management interventions for the resident's soft collar device. 08/08/24 11:25 AM, the Licensed Practical Nurse (LPN) reviewed R244 's medical record and confirmed care and management of R244's soft collar device was not included in the resident's baseline care plan but there should have been. Interventions for use of the soft collar device should have included timely referral to surgeon, wearing schedule and duration, skin assessments, hygiene of the resident's affected site and the collar itself, and therapy and nursing duties. Resident 250 (R250) Resident # 250 was admitted on [DATE], with diagnoses including fracture of right tibia and encounter for change or removal of surgical dressing. On 08/06/2024 at 9:58 AM, R250 was alert and awake watching television. R250 indicated falling at home which resulted in a right leg fracture necessitating surgery. R250 pulled blanket up which revealed a black boot device on right leg with ACE wrap bandage underneath. R250 indicated a nurse removed the boot device a week ago and looked at the site but according to R250 the boot device had not been removed for about a week, no one checked on the surgical site routinely and no one had communicated plans for the surgical wound which included a post-operative appointment with the surgeon. A hospital discharge summary dated 07/08/2024, documented R250 fell at home and sustained a right tibia fracture and posterior malleolus fracture. Discharge to skilled nursing facility (SNF), follow up with specialists in one to two weeks. Integumentary wound information included right lower surgical leg incision CAM (controlled ankle motion) boot and ACE wrap. An admission/readmission note dated 07/17/2024, documented R250 had surgical incisions to the right thigh, right lateral shin, right medial shin, right medial ankle, and right ankle. A Consultation date dated 07/22/2024, documented R250 was at the facility following fall at home with right tibial shaft fracture and posterior malleolus fracture. R250 underwent open reduction and internal fixation (ORIF) surgery on 06/29/2024. Noted sutures on right leg, and CAM boot to right ankle. Physician documented sutures may be removed by the wound nurse and R250 would need to follow up with orthopedic surgeon. The medical record lacked documented evidence a care plan was developed for R250's ACE wrap dressing and CAM boot device. On 08/08/24 at11:08 AM, the Licensed Practical Nurse (LPN) explained baseline care plans were initiated on admission by the admitting nurse and completed by any nurse within 48 hours of admission. The baseline care plan should include immediate needs such as fall risk assessments, skin integrity and/or impairments, code status, allergies, transmission-based precautions, devices such as intravenous lines, Foley catheters, and breathing treatments. The LPN indicated the purpose of the baseline care plan was to ensure immediate needs were met and appropriate care could be given timely. On 08/08/24 at 11:17 AM, the resident's care plan was reviewed, and the LPN confirmed the baseline care plan did not include management of R250's ACE wrap and CAM boot device. According to the LPN, interventions should have been in place on how to manage the ACE wrap and boot device which would include a wearing schedule and duration, skin assessments, follow up with orthopedic surgeon and assessment for complications such as deep vein thrombosis. On 08/08/2024 in the afternoon, the Director of Nursing (DON) indicated interventions for R244's soft collar and R250's ACE wrap and boot device should have been included in the residents' baseline care plan. The Baseline care plan policy revised March 2022, documented the baseline plan of care was developed within 48 hours of admission to meet the resident's immediate health and safety needs. The baseline care plan included instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.

Based on observation, interview, record review and document review, the facility failed to ensure documentation of application of an ordered Thrombo-Embolus deterrent (TED) stocking (stockings that help prevent blood clots and swelling in the legs) was completed for 1 of 22 sampled residents (Resident 3). The failure had the potential to adequately assess the resident's efficacy of treatment, determine resident's need for further intervention, and compliance with the physician's order. Findings include: Resident 3 (R3) R3 was admitted on [DATE], with diagnoses including heart failure and essential hypertension. On 08/06/2024 at 12:44 PM, R3 was observed sitting up in the wheelchair next to the foot of the bed. Noted R3 had edema (swelling) at both legs, skin was reddish and shiny. R3's lower pants elastic bands were making indentation markings onto the skin. R3 was observed with no TED stockings in place. R3's comprehensive care plan had a focus problem identified for: - Activities of daily living (ADL) self-care needs created 07/13/2023, documented as an intervention was TED hose on in the am and off at bedtime. - Dependent edema to bilateral lower extremities (1+ non-pitting) CHF and recurrent pneumonia created 07/13/2023, documented as an intervention included bilateral TED hose/Compression Stockings knee high. Apply in the AM and remove at bedtime. R3's physician orders dated 09/11/2024, documented apply bilateral knee-high TED hose/compression stockings in the AM, and remove at bedtime related to, dependent edema to bilateral lower edema. The physician's order was transcribed into the medication administration record (MAR) for nursing to sign off once the application and donning off the therapeutic device was completed. R3's MAR for the application of the stocking revealed the following dates were not completed or signed off: August 1 to 6 and August 8 to 9, 2024. R3's MAR and progress notes lacked documented evidence as to why the application of the stockings were not signed off. On 08/08/2024 in the morning, one Registered Nurse and one Licensed Practical Nurse confirmed TED stocking application orders were entered into the MAR to ensure the application were completed by nursing. The nurses indicated orders for application had to be signed off to signify the task was completed. 08/09/2024 at 10:37 AM, the Assistant Director of Nursing (ADON) reviewed the medical record and confirmed the MAR was not signed off for the application of the TED stockings on the specified dates. The ADON during the review of the medical record, was not able to show additional evidence the morning shift nurses had justification on the unsigned orders. The ADON indicated the expectation was for nursing to sign off the task once completed for it was a physician's order and part of R3's plan of care. At 1:45 PM, the ADON indicated the facility had no specific policy for TED stockings and was able to provide a policy for heart failure management. The facility policies titled: Heart Failure - Clinical Protocol revised November 2018, documented the physician will review and make recommendations for relevant aspects of the nursing care plan. The physician will prescribe treatments for residents with heart failure that are consistent with relevant guidelines and protocols. Care Plans, Comprehensive Person-Centered revised March 2022, documented the comprehensive, person-centered care plan describes the services that are to be furnished to attain the resident's highest practicable physical, mental and psychosocial well-being.

Based on observation, interview, record review, and document review, the facility failed to ensure care and management orders were obtained, transcribed, and carried out for a soft collar device, an ACE wrap (an elastic compression bandage typically wrapped around a sprain or strain) and a boot device for 2 of 22 sampled residents (Residents 244 and 250) and a post-operative appointment was scheduled timely for 1 of 22 sampled residents (Resident 250). The deficient practice placed the residents at a potential risk for discomfort, skin integrity issues to the affected areas and complications to surgical sites. Findings include: Resident 244 (R244) R244 was admitted on [DATE], with diagnoses including cervical disc disorder with myelopathy and status post cervical spine (C3 to C5 - neck region) decompression with anterior and posterior fusion. On 08/06/2024 at 8:42 AM, R244 laid awake in bed with a family member at bedside. A white foam collar with areas of discoloration was observed around the resident's neck. R244 indicated undergoing neck surgery more than a month ago and was admitted to this facility with the soft collar device. R244 indicated no staff had removed the collar to clean or assess R244's skin underneath since the resident's admission. R244 reported getting a shower three days ago where staff cleaned the resident while avoiding the neck area. R244 indicated not being certain how the neck collar was supposed to be managed, cleaned, replaced, or removed since the resident had yet to see the surgeon. A History and Physical report dated 07/18/2024, revealed R244 underwent a cervical procedure on 06/11/2024 and was being discharged to a skilled nursing facility (SNF) with a soft collar device. An Admission note dated 07/24/2024, revealed R244 was admitted with a soft collar which had to be on 24 hours a day seven days a week (24/7) with steri-strips present on front and back of neck. The medical record lacked documented evidence the physician's order to wear R244's soft collar 24/7 was transcribed and clarification orders regarding duration of wear and management of the device related to hygiene and skin assessments were obtained. On 08/07/2024 at 9:57 AM, the Licensed Practical Nurse (LPN) who admitted R244 recounted speaking with the hospital nurse regarding keeping R244's soft collar on 24/7 but the LPN could not recall any other recommendations regarding R244's soft collar device such as duration of the 24/7 wearing schedule and instructions on how to manage the device until R44's post-operative appointment with R244's surgeon. The LPN reviewed R244's medical record and confirmed there were no orders entered for care and management of the resident's soft collar. On 08/07/2024 at 10:11 AM, the LPN acknowledged aside from failing to transcribe orders to keep R244's soft collar on at all times, the LPN indicated clarification orders should have been obtained regarding maintaining hygiene underneath the collar device to prevent infection of surgical sites, skin assessments to prevent skin impairments as well as assessing patient comfort. On 08/07/2024 at 10:05 AM, the Treatment Registered Nurse (RN) indicated admission orders which included medications, treatment services and management of devices should be entered immediately on admission and finalized within 24 hours from admission after a head-to-toe assessment had been completed. On 08/07/2024 at 11:00 AM, R244 laid in bed wearing a soft cervical collar. The treatment RN positioned R244 upright and removed the neck collar. The treatment nurse described the white collar as soiled, had outlines of sweat stains with areas of discoloration, the neck area had a moderate amount of hair, old steri-strips, purple lines which appeared to be old surgical markings and old scabs. R244 verbalized not having seen the surgeon since the surgery on 06/11/2024 and reiterated no staff had removed the collar to clean the skin underneath or to check for skin impairments. On 08/07/2024 at 1:58 PM, the treatment nurse indicated the admitting nurse should have entered care orders which included skin checks and clarification of the wearing schedule. The treatment nurse acknowledged care orders were not entered and transcribed and as a result there was a delay in appropriate monitoring and care which could have led to potential skin impairments. On 08/07/2024 at 3:26 PM, the Director of Nursing (DON) indicated the admitting nurse was expected to transcribe the 24/7 wear order of R244's soft collar device, obtain care orders which would have included skin checks, wearing schedule and duration. The DON indicated when the facility admitted a resident post-surgery, the surgeon's orders were to be followed until the post-operative appointment unless one of the attending physicians modified or made changes to the order. The Admission Criteria policy revised March 2019, documented prior to admission, the resident's attending physician provided the facility with information needed for the immediate care of the resident, including orders covering at least: routine care orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed inter-disciplinary care plan. Resident 250 (R250) Resident # 250 was admitted on [DATE], with diagnoses including fracture of right tibia and encounter for change or removal of surgical dressing. On 08/06/2024 at 9:58 AM, R250 was alert and awake watching television. R250 indicated falling at home which resulted in a right leg fracture necessitating surgery. R250 pulled blanket up which revealed a black boot device on right leg with ACE wrap bandage underneath. R250 indicated a nurse removed the boot device a week ago and looked at the site but according to R250 the boot device had not been removed since. According to R250, no one assessed the affected leg routinely and no one had communicated plans for the ACE wrap, boot device and post-operative appointment with the surgeon. A hospital discharge summary dated 07/08/2024, documented R250 fell at home and sustained a right tibia fracture and posterior malleolus fracture. Discharge to skilled nursing facility (SNF), follow up with specialists in one to two weeks. Integumentary wound information included right lower surgical leg incision CAM (controlled ankle motion) boot and ACE wrap. A Consultation note dated 07/22/2024, documented R250 was at the facility following fall at home with right tibial shaft fracture and posterior malleolus fracture. R250 underwent open reduction and internal fixation (ORIF) surgery on 06/29/2024. After medical stabilization, R250 went to a rehabilitation facility. Due to non-weight bearing status, the R250 was currently at this SNF to continue with rehabilitation. Noted sutures on right leg, and CAM boot to right ankle. Physician documented sutures may be removed by the wound nurse and R250 would need to follow up with orthopedic surgeon. A rehabilitation note dated 08/01/2024, documented follow up with orthopedic surgeon. The medical record lacked documented evidence R250 had been scheduled for an orthopedic follow-up appointment since the surgery on 06/29/2024 and clarification orders were obtained regarding the wearing schedule of R250's ACE wrap and boot device as well skin checks to affected leg. On 08/07/2024 at 10:34 AM, the treatment Registered Nurse (RN) explained the wound team signed off on R250's surgical wound after steri-strips were ordered to be removed for part of the surgical incision on 07/22/2024 and remaining steri-strips were removed on 07/23/2024. The treatment nurse indicated weekly skin checks still needed to be performed by the floor nurses. On 08/07/2024 at 10:21 AM, the LPN who was steadily assigned to R250 indicated not being aware R250 had not been scheduled for a follow up appointment with the orthopedic surgeon. The LPN reviewed R250's medical record and indicated a skin assessment was performed to R250's affected leg on 07/18/2024 and 07/25/2024 but the scheduled skin check for 08/01/2024 was missed. The LPN indicated not being familiar with the wearing schedule of R250's ACE wrap and boot device and confirmed there were currently no care and management orders in place for R250's ACE wrap and CAM boot. On 08/07/2024 at 10:24 AM, the treatment nurse indicated skin assessments were performed on admission and on a weekly basis. A wearing schedule for the ACE wrap and boot device should have been obtained or clarified at least. While the resident was no longer on the wound team's case load, floor nurses were expected to notify wound team of the following information: surgeon's consult report and use or presence of an ACE wrap and/or boot device to maintain skin integrity by entering care orders for the affected extremity. On 08/07/2024 at 1:07 PM, LPN Case Manager #1 confirmed R250 had not been scheduled to see the orthopedic surgeon because the facility did not know who the resident's surgeon was and received no information from the previous rehabilitation facility regarding which hospital the surgery had been performed. On 08/07/24 at 1:23 PM, LPN Case Manager #2 reviewed R250 's medical record and confirmed there was nothing to indicate R250 had been seen by the orthopedic surgeon since the surgery on 06/29/2024. LPN Case Manager #2 verbalized it was important for the resident to be seen by the surgeon post-operative to obtain care orders, clearance for upgrade weight-bearing status, diagnostic orders to make sure affected site was healing properly, identification of complications like infections and other treatment services such as wound care. The surgeon's input also helped determine discharge planning. On 08/07/2024 at 1:30 PM, LPN Case Manager #1 and #2 acknowledged there had been a significant delay from R250's surgery on 06/29/2024 because typically, most post-operative appointments occurred within two to three weeks of surgery. On 08/07/24 at 2:11 PM, the treatment nurse indicated being able to speak with the surgeon's office after determining the surgeon's name while reviewing R250's medical record. The treatment RN indicated the surgeon wanted R250 to wear the ACE wrap and boot device at all times for two weeks following the surgery on 06/29/2024. The surgeon's office indicated the previous facility communicated it was R250's preference to wear the ACE wrap and boot device at all times. According to the treatment nurse, the surgeon's office confirmed R250 had not been seen by the orthopedic surgeon since the surgery. The treatment nurse confirmed there was a delay with R250's post-operative appointment with the surgeon, failure to obtain care orders to R250's affected leg after the wound team had removed the steri-strips on 07/22/2024, and weekly skin checks were missed on 08/01/2024. On 08/07/2024 at 2:24 PM, the treatment RN and treatment LPN removed the boot device and ACE wrap from R250's right leg which revealed indentation marks. The treatment RN described R250's leg as being excessively dry with indentation markings. The treatment LPN applied Vitamin A and D cream on the affected leg and R250 reacted by stating, that feels so good! R250 stated being more comfortable when the ACE wrap and boot device were off, and the resident denied wanting to keep boot on nor even being asked regarding the devices. R250 indicated no staff member had discussed, explained, or communicated the care plan for the resident's affected leg which included a wearing schedule for the ACE wrap and boot device and appointment with the surgeon. The treatment RN acknowledged the resident expressed increased comfort after the ACE wrap and boot were removed. On 08/07/2024 at 3:41 PM, the Director of Nursing (DON) acknowledged there was a significant delay with the resident's post-operative appointment and a missed weekly skin check on 08/01/2024. The DON expected the nurses to be more proactive with regards to scheduling follow up appointments with surgeons and expected nurses to discuss and communicate care with patients and physicians. The Resident Mobility and Range of Motion (ROM) policy revised July 2017, documented residents with limited range of motion would receive treatment and services to increase and/or prevent further decrease in ROM. Residents with limited mobility would receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. As part of the comprehensive assessment, the nurse will identify conditions that place the residents at risk for pain, skin integrity issues, muscle wasting and atrophy and other complications. The care plan would include interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and ROM. The care plan would include type, frequency, and duration of interventions, as well as measurable goals and objectives.

Based on interview, record review and document review, the facility failed to ensure psychoactive medication side effects monitoring was documented for 1 of 22 sampled residents (Resident 3). The failure to document side effects of psychoactive drugs had a potential to facilitate dose adjustments if needed and the efficacy of the medication for the resident. Findings include: Resident 3 (R3) R3 was admitted on [DATE], with diagnoses of anxiety disorder and schizophrenia. R3 physicians' orders documented the following orders: - 07/12/2019, Monitor for Adverse Side Effects (S/E): Anticholinergic (dry mouth, urinary retention, blurred vision); orthostatic hypotension (arrhythmias); sedation, confusion, hallucinations, and agitation- every shift. - 08/02/2019, Antidepressant Drug S/E Monitor: Dry mouth, blurred vision, tachycardia, urinary retention, constipation, confusion, delirium, hallucinations, flushing, increased blood pressure, postural hypotension, sedation, fatigue, dizziness, ataxia, insomnia, headache, dry eyes, increased or decreased appetite, weight loss or gain, nausea, diarrhea, anxiety, nervousness, seizures, sexual dysfunction, mania, possible liver enzyme or blood abnormalities, possible falls, suicidal ideation, serotonin syndrome, every shift for Medication: Trazodone - 08/02/2019, Antidepressant Monitor of Depression as evidence by (AEB): crying/tearfulness. Drug: Venlafaxine. Every Shift - 08/02/2019, Anti-Psych Drug Side Effect Monitor: Dry Mouth, Blurred Vision, Tachycardia, Urinary Retention, Constipation, Confusion, Delirium, Hallucinations, Flushing, Increased Blood Pressure, Sedation, Loss of Appetite, Photosensitivity, Possible Blood Abnormalities, Fainting, Falls, Cardiac Arrhythmias, Orthostatic Hypotension, Increased In Cholesterol & Triglycerides, Unstable or Poorly Controlled Blood Sugar, Weight Gain, Akathisia, Parkinsonism, Dystonia, Tardive Dyskinesia. Every shift for Medication: Risperdal. - 11/27/2019, Anti-Anxiety Drug S/E Monitor:0-NONE, 1-Sedation, 2-Drowsiness, 3-Lethargy, 4-Confusion, 5-Memory Impairment, 6-Apathy, 7-Fatigue, 8-Dizziness, 9-Depression,10-Nausea and/or Vomiting, 11-Change in Appetite, 12-Headaches, 13-Blurred Vision, 14-Impaired Coordination, 15-Possible Falls, 16-Subdued Behavior, 17-Withdrawal Compared to Baseline, or 18- Limitation in Functional Capacity. every shift; describe observations in progress note. - 06/18/2021, Anti-Psychotic Monitor of episodes of Schizophrenia, Unspecified AEB: Delusional - cannot tell what is real from what is imagined. Unshakable beliefs in something untrue. Drug: Seroquel. every Shift, - 02/16/2023, Anti- Anxiety Monitor of episodes of Anxiety AEB: compulsion behaviors (medication administration demands, requests to go out and smoke, plastic cups placement & designated beverages, brief and bra application, etc.) Drug: Vistaril/Hydroxyzine Pamoate Capsule; every shift - 05/09/2023, Anti-Psychotic Monitor of episodes of delusional behavior AEB: Irrational thoughts. Drug: SEROQUEL. Every shift. - 05/09/2023, Anti-Psych Drug Side Effect Monitor: 0-NONE, 1-Dry Mouth 2-Blurred Vision 3-Tachycardia 4-Urinary Retention 5-Constipation 6-Confusion 7-Delirium 8-Hallucinations 9-Flushing 10-Increased Blood Pressure 11-Sedation 12-Loss of Appetite 13-Photosensitivity 14-Possible Blood Abnormalities 15-Fainting 16-Falls 17-Cardiac Arrhythmias 18-Orthostatic Hypotension. every shift 19-Increased Cholesterol/Triglycerides 20-Poorly Controlled Blood Sugar 21-Weight Gain 22-Akathisia 23-Parkinsonism 24-Dystonia 25-Tardive Dyskinesia 26-EPS (shuffling/gait/rigid muscles/shaking) 27-NMS (rigid muscle/fever/labile BP/tremor), Notify MD. All the listed medications were transcribed onto the medication administration record (MAR) to be signed off by nursing once the observation of the side effects of the psychoactive medications were completed every shift. R3's MAR for the monitoring of the side effects for the listed psychoactive medications revealed the following dates were not completed or signed off: August 1 to 6 and August 8 to 9, 2024. R3's MAR and progress notes lacked documented evidence of any monitoring and as to why the monitoring was not signed off. R3's comprehensive care plan had a focus problem identified for: - The resident has a behavior problem of yelling/screaming, and hoarding things in room. Diagnosis: Schizophrenia. One of the intervention listed: Administer medications as ordered. Monitor/document for side effects and effectiveness. - At risk of becoming physically aggressive towards others related to biting at staff. One of the intervention listed: The resident will be/remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction or cognitive/behavioral impairment through review date. Administer psychotropic medications as ordered by physician. Monitor for side effects and effectiveness every shift. - The resident has medical diagnosis - Depression. One of the intervention listed: The resident will be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Administer antidepressant medications as ordered by physician. Monitor/document side effects and effectiveness every shift. - Resident has medical diagnosis Anxiety AEB: compulsion behaviors (medication administration demands, requests to go out and smoke, plastic cups placement & designated beverages, brief and bra application, etc.). One of the intervention listed: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Administer anti-anxiety medications as ordered by physician. Monitor side effects and effectiveness every shift. R3's comprehensive care plan documented the resident should have been monitored for the current psychotropic medication regimen. 08/09/2024 at 10:37 AM, the assistant director of nursing (ADON) reviewed the medical record and confirmed the MAR was not signed off for the monitoring of the side effects of the psychotropic medications on the specified dates. The ADON during the review of the medical record, was not able to provide additional evidence the morning shift nurses had justification on the unsigned monitoring orders. The ADON indicated the expectation was for nursing to sign off the task once completed for it was a physician's order and part of R3's plan of care. On 08/09/2024 at 2:45 PM, a registered nurse explained behavior monitoring for psychotropic medication side effects was entered in the MAR. Next to the ordered medication would have an option to click Monitor and any observed side effect will be entered there. The facility policy titled Psychotropic Medication Use revised July 2022, documented residents receiving psychotropic medications are monitored for adverse consequences.