Every finding on record at Gardnerville Health & Rehabilitation Center

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with a history of falls and deemed a high fall risk per assessments completed by the Physical Therapist (PT) received interventions during activities of daily living (ADL) care to mitigate the resident's risk of fall resulting in the resident sustaining a fall with injury for 1 of 5 residents reviewed for facility reported incidents (FRI) (Resident #2). This deficient practice resulted in the resident sustaining a fracture to resident's left lower extremity with the potential to result in the resident experiencing increased levels of pain and difficulty with ADLs causing the resident to experience a decrease in quality of life. Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including encephalopathy, unspecified, obesity, unspecified, and restlessness and agitation. A FRI, dated 07/19/2026, documented Resident #2 was being assisted with a shower by a Nurse Assistant in Training (NAT). The NAT left the resident alone in the shower room to retrieve more towels and the resident was found on the floor of the shower room upon the NAT's return. The resident was assessed by nursing staff and complained of pain. The resident was sent out of the facility to the Emergency Department (ED) for evaluation and was diagnosed with a left tibial plateau fracture. A Morse Fall Scale, dated 05/28/2026, documented the resident was a low fall risk. A Physical Therapy Treatment Encounter Note, dated 05/29/2026, documented the resident was a high fall risk due to cognition, balance and safety awareness deficits, and a primary medical history of atrial fibrillation on Eliquis (a blood thinning medication), morbid obesity, diabetes mellitus type 2, cognitive decline, chronic venous stasis, and restless sleep. A Progress Note, dated 07/07/2026, documented the resident had fallen during the previous evening and had been found lying on the bathroom floor. The resident had landed on the resident's left side and was having pain in the resident's left ribs, hips, and down the resident's spine. The resident was transferred to the hospital for evaluation. An Interdisciplinary Team (IDT) Fall Review, dated 07/06/2026, documented Resident #2 had fallen in the resident's room. The contributing factors were determined to be the resident was ambulating/transferring without assistance, was confused, and had a gait imbalance. The root cause of the fall was documented as the resident had poor safety awareness, could be impulsive, and did not ask for help with transferring. The review documented no new interventions were required as a result of the fall. A Physical Therapy Treatment Encounter Note, dated 07/07/2026, documented the resident had a fall in the bathroom on 07/06/2026, and needed assistance with all transfers. PT recommended no self-transferring. The resident remained a high fall risk. A Progress Note, dated 07/14/2026, documented the resident was found sitting on the floor of the resident's bathroom with the resident's legs out in front of the resident and the resident's wheelchair directly behind the resident. The resident stated the resident had forgotten to ask for help. An IDT Fall Review, dated 07/14/2026, documented Resident #2 had fallen in the resident's room. The contributing factor was determined to be the resident had been ambulating/transferring without assistance. The root cause of the fall was documented as poor safety awareness by the resident and a tendency to self-transfer without assistance. Interventions in place included not leaving the resident alone in the room. The review documented no new interventions were required as a result of the fall. A Progress Note, dated 07/19/2026, documented the resident had been found on the shower room floor. The NAT had stated the NAT had left the resident alone for approximately three minutes to grab towels and when the NAT returned the resident was on the floor. The resident reported the resident had pain in the resident's left knee and left hip, abrasions were noted to the resident right knee, and the resident had a skin tear to the resident's left second toe. The resident was sent to the ED for evaluation. An ED Provider Note, dated 07/19/2026, documented the resident had presented to the ED after a ground level fall in the shower and complaints of pain in the resident's left knee. The resident had a tibial plateau fracture. The resident was not walking independently and was made aware the injury would set the resident's progress back, but the resident and the resident's family were concerned about the effects a surgery would have on the resident's dementia. A knee immobilizer was placed on the resident, and the resident was discharged back to the facility with the splint in place. An IDT Fall Review, dated 07/19/2026, documented the resident fall in the shower room. The contributing factors were determined to be ambulating/transferring without assistance and being confused. The root cause of the fall was documented as the resident had been left alone in the shower room and attempted to stand from the shower chair unassisted. The resident had frequent falls due to confusion and decreased mobility. A new intervention to prevent future falls was required and was documented as the resident was not to be left alone behind closed doors. An ADL self-care performance deficit care plan, initiated 06/09/2026, had a documented intervention of assistance by one staff with bathing. The intervention was initiated on 08/01/2026, 13 days after the resident's fall with injury. On 08/05/2026 at 1:40 PM, the interim Director of Nursing (DON) confirmed a Morse fall scale was not completed after each of the resident's falls to reassess the resident's fall risk. The DON confirmed the Morse fall scale should have been completed after each fall and updated to indicate the resident was a high fall risk. The DON explained the ADL care plan would be the instructions the NAT would see on the Kardex. The DON confirmed the intervention of assistance by one staff with bathing was not included in the resident's care plan until 08/01/2026. On 08/05/2026 at 2:05 PM, the NAT verbalized the NAT recalled the incident on 07/19/2026. The NAT explained the NAT reviewed the Kardex prior to assisting residents with ADLs, including a shower, to determine the residents' needs. The NAT verbalized the NAT did not recall the Kardex documenting the resident always required the assistance of one person when showering. The facility job description titled Nursing Assistant/NAT, revised 03/2025, documented the NAT would care for residents in the facility consistent with the plan of care. The facility policy titled Fall Management and Neurological Check, updated 01/2025, documented care plans would be updated to reflect individualized interventions to reduce or prevent falls. A resident's care plan would be reviewed after a fall to determine effectiveness of current interventions. FRI 3105971

Based on interview, clinical record review, and document review, the facility failed to ensure a resident exhibiting behavior symptoms were monitored for behaviors, triggering factors, and effective interventions for 1 of 5 residents reviewed for Facility Reported Incidents (FRI) (Resident #4). This deficient practice had the potential to result in a resident suffering unnecessary mental anguish and psychosocial harm from lack of behavior management or the resident causing physical or psychosocial harm to other residents in the facility due to the resident's unmanaged behaviors. Findings include: Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including vascular dementia, unspecified severity, with other behavioral disturbance and urinary tract infection, site not specified. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including restlessness and agitation, anxiety disorder, unspecified, and cognitive communication deficit. A FRI, dated 07/05/2026, documented Resident #4 had threatened to snap Resident #5's DVDs and neck if Resident #5 put the same DVD on again. A FRI, dated 07/14/2026, documented Resident #4 became angry at Resident #5 when Resident #5 rolled up in the resident's wheelchair to watch television. Resident #4 yelled a derogatory name at Resident #5 and told Resident #5 to leave. Resident #4 then kicked Resident #5's wheelchair. The Care Plan for Resident #4 documented the following:Impaired psychosocial well-being as evidenced by behaviors requiring intervention and psychotropic drug utilization, initiated on 06/24/2026, and revised on 08/01/2026. Behaviors directed toward others included accusing/allegations, agitation, anger, cursing, grabbing, hitting, kicking, physical aggression, pushing, screaming, being sexually inappropriate, spitting, and threatening others.Triggers included pain or discomfort, changes in routines, overstimulation, trauma, loss of independence, approach of staff or others, feeling unsafe, altered sleep patterns, difficulty communicating, loneliness, confusion, boredom, and receiving care.Interventions included redirection, removing from the situation, meaningful activity, reapproach, one to one, offering food or drink, toileting, assessing and addressing pain or discomfort, reassurance, reduce stimuli, listen to concerns, and encouraging the resident to express feelings. The Progress Notes for Resident #4 lacked documentation of the resident's behaviors directed toward Resident #5. The Tasks for Resident #4 did not include a task for monitoring behavior. On 08/05/2026 at 1:55 PM, the interim Director of Nursing (DON) confirmed there was no documentation of Resident #4's behaviors during the incidents from the FRIs in the resident's clinical record. The DON verbalized the behaviors would be documented by the CNA under the Tasks. The DON confirmed the Tasks for Resident #4 did not include a task for behavior monitoring and there was no behavior monitoring documented by the nursing staff. The DON explained documenting a resident's behaviors would provide a picture of what needed to be care planned for the resident and what interventions would help manage the resident's behaviors. The facility policy titled Behavior Management, updated 01/2019, documented resident's exhibiting behavior symptoms would be evaluated, and appropriate interventions would be implemented. If a resident exhibits a new behavior symptom, staff implemented the Behavior Monitor Flowsheet. The Behavior Monitor Flowsheet (number of behaviors, trigger, intervention, and outcome) would be completed as the indicated behavior was exhibited. FRI 3069456 and 3093441

Based on clinical record review, interview, and document review, the facility failed to ensure 5 of 5 residents reviewed for immunizations (Resident #15, #5, #59, #46, and #1) were eligible to receive pneumococcal vaccines by failing to assess immunization status, determine if additional vaccine doses were indicated based on current Center for Disease Control and Prevention (CDC) recommendations and identifying contraindications or precautions prior to making a vaccine determination. This deficient practice resulted in Substandard Quality of Care and had the potential for residents to receive unnecessary vaccines and for eligible residents to not be offered recommended immunizations, placing the residents at increased risk for developing vaccine-preventable illnesses, including pneumococcal disease.Findings include:Resident #15Resident #15 was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia, type II diabetes mellitus without complications, chronic kidney disease stage 3B, and acute diastolic (congestive) heart failure. A diagnosis of pneumonia, unspecified organism, was added on 06/23/2026.A document titled Standing Vaccine Consent and Administration Form signed by the resident on 06/08/2026 did not document screening for eligibility.Resident #15's Nevada Immunization Record ([NAME]) documented the resident was administered one dose of Pneumococcal Conjugate Vaccine (PCV) 20 on 06/07/2024, prior to being admitted to the facility. The CDC application (app), titled PneumoRecs VaxAdvisor, indicated when Resident #15 was administered a dose of PCV-20 on 06/07/2026, the resident's pneumococcal vaccines were up to date, and the resident did not require additional pneumococcal vaccines.Resident #15's electronic health record (EHR) included a facility Immunization Report. The facility Immunization report did not include the following documentation:-Documentation Resident #15 had been screened for eligibility to receive a pneumococcal vaccine including if the resident was up to date with pneumococcal vaccines or was eligible to receive a pneumococcal vaccine per CDC recommendations.-Documentation regarding a pneumonia vaccine, including Resident #15 was administered one dose of PCV-20 on 06/07/2024, prior to being admitted to the facility or at any other time.-Documentation Resident #15 was up to date with pneumococcal vaccines and an additional dose was not necessary.On 06/25/2026 at 12:11 PM, the Infection Preventionist (IP) verbalized the expectation was information regarding a resident's influenza and pneumococcal vaccination status was to be documented in the resident's EHR under the immunization tab. The IP explained the IP did not have a tool available to screen residents for eligibility to receive an influenza or pneumococcal vaccine and documented by exception only. The IP confirmed the IP did not screen residents for eligibility to receive the vaccines, including allergies and contraindications. On 06/25/2026 at 12:16 PM, the IP explained when a new resident was admitted to the facility the expectation was the admitting nurse would ask the resident if the resident would like to receive a pneumococcal and/or influenza vaccine. The IP followed up with the resident and asked if the resident wanted to receive the vaccines and entered the resident's response into the resident's facility immunization record. Resident #5Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including encephalopathy, unspecified, type 2 diabetes mellitus with other specified complications, chronic obstructive pulmonary disease, unspecified, other pulmonary embolism without acute core pulmonale, and fragile X chromosome. A document titled Standing Vaccine Consent and Administration Form signed by Resident #5's representative on 02/24/2025, did not document screening for eligibility to receive vaccines, including influenza and pneumococcal vaccines.Resident #5's [NAME] documented the resident last received an influenza vaccine on 10/22/2024 and was administered one dose of PCV-13 on 11/19/2017, and one dose of Pneumococcal Polysaccharide Vaccine (PPSV -23) on 10/05/2018.The CDC application (app), titled PneumoRecs VaxAdvisor, indicated Resident #5 was eligible to receive one dose of either PCV-20 or PCV-21, based on the resident's age, and the length of time following the last pneumococcal vaccine received.Resident #5's EHR included an Immunization Report, and the report documented the status for influenza and pneumococcal vaccine as refused but did not include the date the vaccines were refused. The facility did not provide documentation of screening for eligibility to receive a pneumococcal or influenza vaccine.On 06/25/2026 at 12:23 PM, the IP confirmed resident #5's EHR did not include documentation the resident was screened for eligibility to receive an influenza or pneumococcal vaccine. Resident #59Resident #59 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including paraplegia, unspecified, pressure ulcer right buttock, stage 4, chronic vascular disorders of the intestine, resistance to multiple antimicrobial drugs, unspecified severe protein calorie malnutrition, and methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere.A facility document titled Residential Multi-Vaccine Consent Form revised 10/13/2023, completed on 06/02/2025 did not document screening for eligibility to receive vaccines, including influenza and pneumococcal vaccines.Resident #59's EHR included an Immunization Report, and the report documented influenza and pneumococcal vaccines were refused but did not include the date of refusal and did not document if any vaccines were previously administered. The facility did not provide documentation of screening for eligibility to receive a pneumococcal or influenza vaccine.On 06/25/2026 at 12:24 PM, the IP confirmed Resident #59 was not screened for eligibility to receive influenza or pneumococcal vaccines. Resident #46Resident #46 was admitted to the facility on [DATE], with diagnoses including sick sinus syndrome, moderate protein-calorie malnutrition, and cognitive communication deficit.A facility document titled Residential Multi-Vaccine Consent Form revised 10/13/2023, completed on 02/26/2025 did not document screening for eligibility to receive vaccines, including influenza and pneumococcal vaccines.Resident #46's [NAME] documented the resident last received an influenza vaccine on 08/22/2023 and received one dose of PCV-13 on 09/14/2021, and one dose of PCV-20 on 12/28/2022.The CDC application (app), titled PneumoRecs VaxAdvisor, indicated Resident #46's pneumococcal vaccine was up to date when the resident was administered PCV-20 on 12/28/2022, and vaccination with additional pneumococcal vaccine was not necessary. Resident #46's facility Immunization Report documented the following-An influenza vaccine was administered at the facility on 10/22/2025, but lacked documentation an influenza vaccine was administered when the resident admitted to the facility during the 2024/2025 influenza season. -A dose PCV-13 was refused, and the entry was not dated. -The resident was not eligible to receive a dose of PCV-20, the date and/or the reason the resident was not eligible to receive a pneumococcal vaccine was not documented. -On 05/22/2025, the facility administered one dose of PCV-20 to Resident #46 when the CDC recommendation indicated an additional dose of a pneumococcal vaccine was not necessary. On 06/25/2026 at 12:34 PM, the IP confirmed Resident #46's EHR lacked documented evidence the resident was screened for eligibility to receive an influenza or pneumococcal vaccine upon admit or annually thereafter. Resident #1Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including pulmonary hypertension, unspecified, moderate protein-calorie malnutrition, chronic viral hepatitis C, and adult failure to thrive.Resident #1's [NAME] documented the resident was administered one dose of PCV-15 on 03/05/2024. An influenza vaccine was not documented.Resident #1's facility Immunization Report documented an influenza vaccine, and PPSV23 pneumococcal vaccine were refused but did not document a date the vaccines were refused and did not document if any vaccines were previously administered. The facility did not provide documentation of screening for eligibility to receive a pneumococcal or influenza vaccine.The CDC application (app), titled PneumoRecs VaxAdvisor, indicated Resident #1 was eligible to receive one dose of PPSV23, one dose of PCV-20, or one dose of PCV-21.On 06/25/2026 at 12:35 PM, the IP confirmed Resident #1 was not screened for eligibility to receive an influenza and/or pneumococcal vaccine.On 06/29/2026 at 12:15 PM, a Licensed Practical Nurse (LPN) 1 verbalized when a resident was admitted to the facility the LPN obtained a generalized consent to treat and asked the resident if the resident did or did not want to receive an influenza or pneumococcal vaccine. The information was given to the IP, and no further action was taken by the admitting nurse. On 06/29/2026 at 12:18 PM, LPN2 explained when admitting a new resident to the facility, LPN2 asked the resident if they did nor did not want to receive influenza and/or pneumococcal vaccines. The LPN2confirmed the admitting nurse did not screen the residents for eligibility to receive the vaccines including allergies or previously administered vaccines. The LPN2 confirmed the admitting nurse was not responsible for determining what specific vaccines a resident was eligible to receive and explained screening for eligibility was completed by the IP.On 06/29/2026 at 12:46 PM, Resident #59 verbalized when the resident was admitted to the facility a nurse asked if the resident would like to receive influenza and/or pneumococcal vaccines and asked if the resident was allergic to anything. Resident #59 confirmed the resident was not asked any questions specific to vaccines and verbalized the resident was not provided with educational materials related to the vaccines.The facility policy titled Influenza and Pneumococcal Vaccine Administration Program: Medical Director Authorization updated 06/09/2026, documented Influenza vaccination was offered to facility residents annually. Prior to vaccine administration contraindications for the vaccine were reviewed and documented. Licensed nursing staff reviewed and evaluated the current CDC influenza vaccine information statement with the resident and/or the resident representative and did not administer the vaccines if there was a potential contraindication. Pneumococcal vaccines were offered to facility residents upon admission and when annual vaccinations were due per CDC guidelines. Licensed nursing staff reviewed and evaluated potential contraindications with the resident and/or the resident representative using the current version of the CDC pneumococcal vaccine information statement. The EHR was maintained with documentation of residents who received vaccination as well as those who declined or did not get vaccinated.The facility policy titled Pneumococcal Vaccination of Residents updated 06/19/2025, documented the facility offered pneumococcal vaccination to residents in accordance with CDC recommendations and federal requirements. Each resident's pneumococcal immunization status was determined upon admission or soon afterwards and was documented in the resident's EHR medical record. The facility offered pneumococcal vaccination according to the CDC's recommendations for vaccinating persons at high risk for serious complications from pneumococcal pneumonia. High risk individuals included those over [AGE] years of age and individuals with risk factors such as alcoholism, chronic lung disease, cigarette smoking, homelessness, and injection drug use.The policy further documented the facility followed CDC guide for pneumococcal vaccine timing for adults and utilized available CDC electronic application platforms to determine appropriate vaccination and cadence. The EHR was updated and documented when pneumococcal vaccination information/education provided and if a vaccine was administered or declined. Vaccination refusal and reasons why such as contraindications or the resident did not want the vaccine was documented in the EHR immunization record. A CDC document titled Vaccine Administration: Before Giving Vaccine dated 07/10/2025, documented vaccine Administration started with a series of actions which occurred before a vaccine was given. These actions included viewing vaccination history, assessing for recommended vaccines, and screening for contraindications and precautions.The guidance recommended reviewing the residents' vaccination history and using the current Advisory Committee on Immunization Practices (ACIP) immunization schedule to review which recommended vaccines were needed based on the resident's age and vaccination history, including a review for any missed doses and determining if additional vaccines were indicated based on the patient's health status, occupation, or other risk factors.The guidance further recommended screening for contraindications and precautions. Screening helped to prevent adverse reactions such as anaphylaxis. Prior to administering a vaccine, residents were to be screened for contraindications and precautions. CDC recommended using a standardized screening tool to promote correct and consistent screening practices.

Based on observation, interview and document review, the facility failed to ensure 1) medications were accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication and 2) 2 of 2 medication storage carts were kept clean and organized when medications which were contaminated and/or in a container without a secure closure were not immediately removed from stock and disposed of. This deficient practice had the potential to result in unauthorized access to medication, misuse of medication within the facility and contaminated medication to be administered to residents.Findings include:Unauthorized access to medicationsOn 06/24/2026 at 2:02 PM, a Certified Nursing Assistant (CNA) entered a code on the keypad to the central supply room door and entered the room.On 06/24/2026 at 2:05 PM, the CNA verbalized the central supply room was used to store briefs, personal care supplies and medical stuff including bandages, catheters, and alcohol. The CNA confirmed medications were stored in the room and verbalized CNAs and nurses could access the room.On 06/24/2026 at 2:10 PM, two large metal cabinets were observed in the central supply room. Both cabinets had two doors. The cabinet doors were unlocked and left partially open, with various medications stored inside. The Minimum Data Set 3.0 (MDS) Coordinator verbalized nurses, CNAs, the Administrator and maintenance employees had access to the central supply room. The MDS Coordinator confirmed the cabinets contained medications and were left unlocked. The MDS Coordinator verbalized the cabinets were usually left unlocked because of the lock on the supply room door.On 06/25/2026 at 11:30 AM, the MDS Coordinator denied CNAs and maintenance employees were authorized to administer medication and should have access to medication.The facility policy titled Storage of Medication, dated 09/2018, documented the medication supply was to be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Medication rooms, cabinets and medication supplies were to remain locked when not in use or attended by persons with authorized access.Medication storageOn 06/24/2026 at 2:26 PM, during an inspection of the 100-hall medication cart, a white, oblong-shaped medication tablet was observed at the bottom of a drawer in the cart. The tablet was loose and not packaged.On 06/24/2026 at 2:35 PM, the MDS Coordinator confirmed the tablet was loose at the bottom of the drawer, donned a glove and removed the tablet from the drawer.On 06/24/2026 at 2:57 PM, during an inspection of the 500-hall medication cart, the following were observed in various drawers in the cart and confirmed by the MDS Coordinator:-A small, round white medication tablet lying at the bottom of a drawer.-A small, round yellow medication tablet lying at the bottom of a drawer.-A lidocaine patch lying on a purple, plastic tray at the bottom of a drawer. The patch was open and lacked a package.-A lidocaine patch in a drawer. The package was open and the patch was exposed.On 06/24/2026 at 3:12 PM, the MDS Coordinator verbalized opened items in the medication cart could be an infection control issue as patches were going directly on residents' skin. Loose tablets without packaging were a safety issue since the tablets were no longer labeled and staff would not know what the medications were. Additionally, the tablets were an infection control concern and could be contaminated or tampered with.The facility policy titled Storage of Medication, dated 09/2018, documented medication storage should be kept clean, well lit, organized and free of clutter. Outdated, contaminated, discontinued or deteriorated medications and those in containers which were cracked, soiled, or without secure closures were to be immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order existed.

Based on interview and record review, the facility failed to provide sufficient nursing staff to meet the needs of residents as identified in the facility assessment for 6 of 25 reviewed days. This deficient practice had the potential to result in staffing levels below the facility established Per Patient Day (PPD) requirements and had the potential to negatively affect resident care, safety, and timely delivery of services. Findings include:The Facility Assessment revised 08/26/2025, documented the following required daily staffing levels: Certified Nursing Assistant (CNA): 105.04 hours per day, equal to 8.75 CNAs per day. Review of June 2026 staffing schedules revealed the following: 06/01/2026, the June 2026 actual staffing schedule documented seven CNAs worked. 06/06/2026, the June 2026 actual staffing schedule documented seven CNAs worked. 06/08/2026, the June 2026 actual staffing schedule documented six CNAs worked. 06/13/2026, the June 2026 actual staffing schedule documented five CNAs worked. 06/14/2026, the June 2026 actual staffing schedule documented seven CNAs worked. 06/20/2026, the June 2026 actual staffing schedule documented seven CNAs worked. On 06/25/2026 at 11:14 AM, the Scheduler/CNA verbalized staffing needs were determined by the Per Patient Day (PPD) requirements based on the census to ensure adequate staffing. The Scheduler/CNA stated the facility's average census was 55 residents, with an average of five to six CNAs during AM shifts and three to four CNAs during PM shifts. The Scheduler/CNA explained sufficient staffing was necessary to meet resident needs, showers, care tasks, and safety.The Scheduler/CNA confirmed 06/01/2026, 06/06/2026, 06/08/2026, 06/13/2026, 06/14/2026 and 06/20/2026 the CNAs worked did not meet the minimum CNA PPD requirement set by the facility. The Facility Assessment revised 08/26/2025, documented the facility would make a good effort to evaluate the overall number of facility staff needed to ensure enough qualified staff were available to meet each resident's needs.

Based on interview, observation, and record review, the facility failed to ensure a resident remained free from verbal abuse when a Certified Nursing Assistant (CNA) used an elevated tone, and re entered the resident's room after being removed for 1 of 52 residents (Resident #23). This deficient practice had the potential to put residents at risk for emotional harm. Findings include:Resident #23 Resident #23 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including need for assistance with personal care, atrial fibrillation, anxiety disorder and cognitive communication deficit. On 06/22/2026 at 4:03 PM, survey staff heard Resident #23 verbalize, I am going to report this. The resident sounded distressed and upset. CNA1 verbalized they were explaining a matter with Resident #23. A new CNA entered the room and informed CNA1 that they had the situation handled. On 06/24/2026 at 2:52 PM, CNA2 verbalized on 06/22/2026 the resident wanted the food cut up. When CNA2 entered the room, CNA1 appeared stressed and exited the room. CNA1 returned and leaned on the resident's table, stating, I told you CNA2 was going to come in, and was again instructed by CNA2 to leave the room. CNA2 did not feel the tone was appropriate and notified the Scheduler/CNA who notified the Administrator. On 06/25/2026 at 10:41 AM, Resident #23 verbalized not recalling exactly what CNA1 said during the encounter. The resident verbalized CNA1 yelled and behaved in an intimidating manner. The resident confirmed CNA1 returned and stated, I hope you don't make me leave. The resident reported not feeling good when the CNA1 yelled and became upset. The resident reported CNA1 had not returned since the incident occurred. The resident reported not being fearful of remaining in the facility and reported no previous similar incidents. On 06/25/2026 at 11:08 AM, the Scheduler/CNA, verbalized abuse could include physical, verbal, failure to change a resident timely, withholding services, and not providing proper care such as bathing or turning. The Scheduler/CNA was not present for the incident on 06/22/2026; however, it was reported to the Scheduler/ CNA Resident #23 pressed the call light and CNA1 answered. The resident informed CNA1 that assistance was needed with changing and CNA1 stated they would return shortly. Resident #23 then yelled at CNA1 stating CNA1 always turned off the call light and never returned. CNA1 responded to the resident in an elevated tone, which the Scheduler/CNA described as inappropriate. CNA2 provided the required care to Resident #23 and removed CNA1 from the situation. The incident was reported to the Administrator to initiate a Facility Reported Incident investigation. CNA1 was suspended pending further review. The Abuse Coordinator and Social Worker followed up with Resident #23 to ensure the resident felt safe and was free from emotional distress. The facility's investigation conducted from 06/22/2026 - 06/26/2026, documented Assessments were conducted on the hall to ensure no additional concerns were present with other residents. All residents verbalized feeling safe in the facility. The facility policy titled Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property and Exploitation, updated 03/2025, documented verbal abuse may be a type of mental abuse. Verbal abuse includes the use of oral, written or gestured communication or sounds to residents within hearing distance regardless of age, ability to comprehend or disability. Examples of mental and verbal abuse include yelling or hovering over a resident with the intent to intimidate.

Based on observation, interview, record review and document review, the facility failed to make prompt efforts to resolve grievances when a grievance form was not given to facility leadership timely for 1 of 14 sampled residents (Resident #40). This deficient practice had the potential to result in residents having unresolved complaints/grievances. Findings include:Resident #40Resident #40 was admitted to the facility on [DATE], with a diagnosis of emphysema, unspecified.On 06/22/2026 at 12:31 PM, Resident #40 was seated at a table in the dining room on the 500 unit. Resident #40 informed a Certified Nursing Assistant (CNA), the resident was unable to locate the resident's lower denture. The resident verbalized the resident was not sure if the dentures were left in the resident's pocket when the clothing went to laundry or if the denture was left on a meal tray. The CNA verbalized the CNA would let someone know.On 06/22/2026 at 1:53 PM, Resident #40 verbalized Resident #40 recently received new dentures, and the lower denture was lost. The resident denied having any difficulty chewing or swallowing.On 06/25/2026 at 9:49 AM, the Administrator verbalized the Administrator handled all grievances and explained when a grievance was received, the Administrator typically discussed the concern at the facility's standup meeting the following day. The Administrator confirmed the Administrator was familiar with Resident #40's missing dentures and verbalized the Administrator did not have a grievance related to the dentures as the Administrator thought the dentures had been located.On 06/25/2026 at 11:00 AM, the Administrator provided a copy of a Grievance Form. The Grievance form was dated 06/22/2026 and documented Resident #40's bottom dentures were missing. The resident had the dentures in the resident's pocket because they bothered the resident. The CNA searched all pockets, bathroom, etc. and did not find the dentures.On 06/25/2026 at 11:05 AM, the Administrator explained Resident #40 informed the Activities Director (AD) the resident's dentures were missing on 06/22/2026. The AD filled out a grievance form and slipped the grievance form under the Director of Nursing (DON)'s office door however; the DON had not been present in the building all week. The Administrator verbalized staff were expected to ensure the Administrator and/or the DON were notified of all grievances right away. The Administrator confirmed by placing the grievance form under the DON's office door when the DON was not working for several days and failure to notify the Administrator of the grievance resulted in a delayed response to the grievance. The Administrator verbalized dentures were important for residents and missing dentures could cause discomfort or a resident may not be able to eat.The facility policy titled Grievance Procedure, updated 11/2016, documented staff were trained at orientation and periodically on the facility's grievance procedure, including: the need to take grievances seriously, what to do with grievances, when to put a grievance in writing, and when to report to the supervisor and to the state according to mandated reporting requirements. Grievances were resolved immediately, when possible, by the individual receiving the grievance. When immediate resolution was not possible, the grievance was routed to the grievance official and/or social services/designee within 24 hours. The individual receiving the grievance filled out a grievance form and Social Services/designee logged the grievance on the grievance log. The Executive Director reviewed the grievance log at the daily standup meeting for needed resolution and/or follow up.

Based on record review and interview, the facility failed to develop an initial care plan for a peripherally inserted central catheter (PICC) line for 1 of 14 sampled residents (Resident #59). This failure created the potential for unmet care needs related to management of the PICC line. Findings include:Resident #59 Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including urinary tract infections, resistance to multiple antimicrobial drugs, and paraplegia. Resident #59 care plan initiated on 11/17/2025 and revised on 06/11/2026 lacked documented evidence a care plan was developed for Resident #59's PICC line. On 06/29/2026 at 10:40 AM, the Minimum Data Set (MDS) Coordinator verbalized a care plan would be required for a PICC line and confirmed an initial care plan was not created for Resident #59. The Resident Assessment Instrument (RAI) 3.0 manual, Chapter 2, the Care Area Assessment (CAA) Process and Care Plan Completion dated 10/2025, documented the residents' plan of care would be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. The resident's care plan would be revised based on changing goals, preferences, and needs of the resident and in response to current interventions.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure care plans were developed related to 1) the monitoring and supervision of high-risk medications including narcotics and diuretics, 2) the care of indwelling devices, and 3) pain management for 3 of 14 sampled residents (Resident #38, #5, and #18). This deficient practice had the potential to result in residents not receiving the necessary care and services to ensure medications were monitored for the appropriate side effects including increased risk for falls, severe hypotension, constipation, bowel impaction, and complications related to other potential side effects of narcotic and diuretic medications, increased risk for catheter-associated urinary tract infections (CAUTIs), and unrelieved pain. Findings include: Resident #38 Resident #38 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, urinary tract infection, site not specified, and pressure ulcer of the sacral region, stage III. A Physician Order dated 02/20/2026, documented spironolactone 25 milligram (mg) oral tablet, give one tablet by mouth one time a day for diuretic, hold for a systolic blood pressure less than 90, monitor for signs and symptoms of dehydration. A Physician Order dated 05/20/2026 documented methadone hydrochloride (HCl), give 2.5 mg by mouth three times a day for chronic pain, for 30 days. A Physician Order dated 06/03/2026 documented Dilaudid (hydromorphone) 2 milligram (mg) oral tablets, give 0.5 tablets by mouth every six hours as needed for pain. Resident #38's Comprehensive Care Plan did not include a care plan related to the use and monitoring of methadone, dilaudid and spironolactone. On 06/29/2026 at 12:58 PM, the Minimum Data Set (MDS) Coordinator confirmed Resident #38's Comprehensive Care Plan did not include a care plan related to the use of methadone, dilaudid, or spironolactone. The MDS Coordinator verbalized it was important to have the medications care planned to inform staff the resident needed to be monitored for concerns related to side effects of the medications. Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Osteomyelitis of vertebra, sacral and sacrococcygeal region, diabetes mellitus 2 with neuropathy, and stage 4 pressure ulcer to sacrum. On 06/22/2026 at 9:15 AM, Resident #5 had a Foley catheter in place. The drainage bag was secured to the bed frame, and clear yellow urine was in the bag. The resident representative verbalized the resident had a Foley catheter in place. A Minimum Data Set (MDS) admission assessment, completed 03/20/2025, documented Resident #5 had an indwelling catheter. A Physicians Order dated 03/11/2025, documented Foley catheter 16Fr with 30cc balloon, clean Foley site every day and evening shift for skin impairment management. On 06/24/2026 at 3:23 PM, during a review of Resident #5's care plan, the care plan included a focus area of enhanced barrier precautions related to the catheter. The care plan for Resident #5 lacked a plan for addressing Resident #5's Foley catheter care interventions and goals. A Progress Note dated 03/16/2025, documented Resident #5's catheter was leaking, sterile gloves donned, saline water 5 milliliters (ml) inserted, 18 ml withdrawn, urine return still noted, filled foley balloon per order with 30 ml of saline. On 06/25/2026 at 2:44 PM, the Registered Nurse (RN) verbalized a care plan for a resident with a Foley catheter should include monitoring for signs and symptoms of infection, cleaning of the insertion site, assuring privacy cover was in place over the drainage bag, keeping the drainage bag below the level of the bladder, and changing of the catheter. On 06/25/2026 at 3:34 PM, the acting Director of Nursing (DON) verbalized a care plan for a resident with a Foley catheter should include interventions and goals related to signs and symptoms of infection, cleaning of the insertion site, assuring privacy cover was in place over the drainage bag, keeping the drainage bag below the level of the bladder, and changing of the catheter. The acting DON confirmed a focus area related to the care of the resident's catheter was not on Resident #5's care plan. The Centers for Medicare and Medicaid Services, Long-Term Care Facility Resident Assessment Instrument 3.0 RAI User's Manual, version 1.1.9.1, documented the facility was to develop a care plan for each resident which included measurable objectives and timeframes, and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan was to be revised on an ongoing basis to reflect changes in the resident and care the resident was receiving. Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, unspecified and major depressive disorder, recurrent, moderate. On 06/22/2026 at 11:09 AM, Resident #18 verbalized pain management was a big issue for the resident. The resident had pain in the resident's back, left leg, and shoulder. For pain control, the resident took oxycodone 30 milligrams every three hours. The pain medication kept the pain at a tolerable level. A Minimum Data Set 3.0 (MDS) assessment dated [DATE], section J, documented Resident #18 had pain almost constantly. The pain, rated at its worst, was a 10 on a 0-10 scale. Resident #18's Care Plan documented the resident had pain which interfered with sleep, rehabilitation activities, and day to day activities. Goals included the resident would voice a level of comfort of (SPECIFY residents states range of comfort) out of (SPECIFY) through the review date. Interventions included the following: -The resident's pain is aggravated by: (SPECIFY) -The resident's pain is alleviated/relieved by: (SPECIFY) -Monitor/record pain characteristics (SPECIFY FREQ) and PRN: quality, severity, anatomical location, onset, duration, aggravating factors, relieving factors. -The resident is able to: (SPECIFY: call for assistant when in pain, reposition self, ask for medication, tell you how much pain is experienced, tell you what increase or alleviates pain). On 06/25/2026 at 3:54 PM, the MDS Coordinator verbalized the care plan for residents with pain should include interventions such as assessing objective and subjective manifestations of pain, administering pain medication as prescribed, monitoring for side-effects, and offering non-pharmaceutical pain management interventions. On 06/25/2026 at 4:45 PM, the MDS Coordinator reviewed Resident #18's Care Plan and confirmed the Care Plan related to pain was not resident-specific due to several areas reflecting SPECIFY and not being filled with in the resident's level of comfort, aggravating factors, alleviating factors and frequency of pain monitoring. On 06/25/2026 at 5:02 PM, the MDS Coordinator denied the facility had a policy related to care planning and explained the facility followed the Resident Assessment Instrument 3.0 (RAI) manual. The Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.20.1, updated 10/2025, documented the MDS was to be analyzed and combined with other relevant information to develop and individualized care plan. The care plan was to be revised on an ongoing basis to reflect changes in the resident and the care the resident was receiving.

Based on observation, interview, clinical record review and document review, the facility failed to ensure staff received training and were deemed competent by the facility to provide care to Peripherally Inserted Central Catheters (PICCs) prior to being assigned to care for 1 of 14 sampled residents (Resident #59). This deficient practice had the potential to result in insertion site and blood stream infections for residents due to lack of knowledge of correct technique for dressing changes and signs and symptoms of potential complications. Findings include:Resident #59 Resident #59 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses including resistance to multiple antimicrobial drugs, urinary tract infection and neuromuscular dysfunction of bladder. On 06/22/2026 at 2:20 PM, Resident #59 verbalized having been in the facility since 2025 and recently transferred to the hospital for a severe urinary tract infection with blood in the urine. Resident #59 reported having an indwelling catheter. Observation revealed a PICC line dressing dated 06/14/2026. Resident #59 was receiving IV antibiotics through the PICC line. A Physician's Order dated 06/11/2026, documented PICC site maintenance with transparent and gauze dressing changes 24 hours post insertion, then every seven days and as needed. The order directed staff to measure upper arm circumference 10 centimeters (cm) above external catheter length. If gauze was present, dressings were to be changed every 48 hours until 06/24/2026. Resident #59's June 2026 Intravenous (IV) Treatment Administration Record (TAR) documented the same PICC site maintenance and measurement requirements. The TAR documented dressing care was completed by Licensed Practical Nurse (LPN)1 on 06/16/2026 and 06/23/2026. The IV TAR also documented PICC flush orders using 5 milliliters (ml) normal saline before and after infusion, twice daily, until 06/24/2026. The TAR documented the central line flush orders were administered by the following staff members on the following dates:-LPN1 on 06/15/2026, 06/16/2026, 06/22/2026 and 06/23/2026.-LPN2 on 06/12/2026, 06/13/2026, 06/18/2026, 06/19/2026 and 06/20/2026-LPN3 on 06/14/2026.-LPN4 on 06/20/2026. On 06/24/2026 at 5:12 PM, the Minimum Data Set (MDS) Coordinator explained dressings for PICC lines were to be changed every seven days or if soiled or dislodged. PICC line flushing was to occur daily during every shift. The importance of dressing changes was for infection prevention, keeping line patent and usable. The MDS Coordinator verbalized, not knowing when the dressing was last changed. The Regional Director of Clinical Operations (RDCO) reported the TAR documented a dressing change on 06/23/2026. The RDCO stated Resident #59 completed IV antibiotics on 06/22/2026 and flushing had been occurring twice daily. The RDCO reported PICC orders were discontinued on 06/23/2026 and no flush was completed on 06/23/2026. A new flush order would have been required for continued PICC maintenance. On 06/24/2026 at 5:21 PM, the MDS Coordinator confirmed Resident #59's bandage remained dated 06/14/2026 and should have been changed by 06/21/2026. The MDS Coordinator verbalized it was not appropriate for the TAR to document completed dressing changes when the date on the dressing did not correspond. On 06/25/2026 at 3:52 PM, the MDS Coordinator verbalized an LPN must be IV certified to perform PICC line flushes. On 06/29/2026 at 10:55 AM, the MDS Coordinator explained the Director of Nursing was responsible for ensuring staff had appropriate certifications and competencies prior to being assigned PICC care. The MDS Coordinator confirmed LPN1 lacked documented IV certification and was documenting dressing changes as completed even though the dressing appeared unchanged. The facility document titled Infusion Therapy Procedures - Dressing Change for Vascular Access Devices, dated 08/2016, documented initial dressings must be changed PRN if saturated, and 24-48 hours post insertion for midlines, PICCs, or other central venous access devices if gauze or drainage was present. Transparent dressings with Biopatch may remain for seven days unless compromised. The facility's LPN job description documented essential functions includes dresses wounds and administer specified medication intravenously and notes time and about on resident charts (as allowed by state law). Nevada Administrative Code (NAC) 632.242, documented an LPN may perform specialized skills within their scope only if they maintain original documentation of training and annual verification of continued competency. The Lippincott Manual of Nursing Practice (12th ed., 2025) documented the importance of routine and as needed IV dressing changes, including changing transparent dressings every seven days and replacing any dressing that becomes damp, loose, or soiled. The CDC document titled Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-Related Infections, dated 02/28/2024, documented the following:-Recommendations for catheter education, training, and staffing: Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters.-Recommendations for catheter site dressing regimens: Replace catheter site dressing if the dressing becomes damp, loosened or visibly soiled. Replace dressing used on short-term central venous catheters (CVCs) at least every seven days for transparent dressings. Replace dressings every two days for gauze dressings. Cross reference tag F694.

Based on observation, interview, and record review, the facility failed to ensure a resident received timely bathing, hygiene, and personal care services consistent with the resident's needs and preferences for 1 of 14 sampled residents (Resident #44). This deficient practice had the potential to result in residents not receiving routine bathing services, caused extended periods without showers, and failed to maintain dignity, comfort, and basic hygiene. Findings include:Resident #44 Resident #44 was admitted on [DATE], with diagnoses including need for assistance with personal care, psychosis, and major depressive disorder. On 06/22/2026 at 11:22 AM, Resident #44 verbalized not receiving scheduled showers on Sundays and Wednesdays. The resident stated scheduled showers don't happen, reported going 23 days without a shower, and stated the last shower received was on 06/21/2026. The resident described feeling dirty and crappy due to not receiving routine bathing. Resident #44's Documentation Survey Report V2 for May 2026 lacked documentation of a shower provided or declined from 05/03/2026 to 05/13/2026 (13 days) and from 05/17/2026 to 05/27/2026 (nine days). Resident #44's Care Plan dated 07/07/2025, documented Resident #44 activities of daily living self-care performance deficit and needed assistance with personal care. Resident #44 prefers showering two days per week, requiring one staff assistance. On 06/24/2026 at 2:40 PM, a Certified Nursing Assistant (CNA) explained residents were scheduled for showers two times per week. The CNA stated staff were responsible for offering a shower or an alternative if the residents declined. Staff were expected to transport the resident to the shower room and return the resident afterward. The CNA was unsure which days Resident #44 received showers. A shower aide was scheduled for 06/24/2026, but the CNA was unsure if a shower occurred. The CNA stated staff were expected to complete skin and hygiene sheets and verbalized it would not be appropriate for a resident to go more than two weeks without being offered a shower. On 06/24/2026 at 2:45 PM, a Registered Nurse (RN) explained CNAs had a daily list of assigned showers. If a resident needed assistance or refused, staff were expected to educate the resident and attempt transport to the shower room. The RN stated shower sheets were provided to nurses after bathing to identify new skin issues and staff were required to sign and chart shower documentation in the resident's Electronic Health Record (EHR). On 06/24/2026 at 4:18 PM, the Infection Preventionist (IP) stated if a shower was not documented, it did not occur. The IP verbalized Resident #44 required a one person assist in the shower and a two person transfer from bed to chair and was dependent on staff for bathing. The IP confirmed the lack of shower documentation for Resident #44 and stated it was important for the residents to receive showers for skin condition, overall health, and infection prevention.The Administrator and IP reported there was no facility specific shower policy and staff followed CMS guidance. Cross reference tag F842.

Based on observation, interview, clinical record review and document review, the facility failed to ensure Peripherally Inserted Central Catheter (PICC) line dressing changes were performed according to physician orders for 1 of 14 sampled residents (Resident #59). This deficient practice had the potential to result in insertion site and bloodstream infections for residents. Findings include:Resident #59 Resident #59 was admitted to the facility on [DATE] and readmitted [DATE], with diagnoses including resistance to multiple antimicrobial drugs, urinary tract infection and neuromuscular dysfunction of bladder. On 06/22/2026 at 2:20 PM, Resident #59 verbalized having been in the facility since 2025 and recently transferred to the hospital for a severe urinary tract infection with blood in the urine. Resident #59 reported having an indwelling catheter. Observation revealed a PICC line dressing dated 06/14/2026. Resident #59 was receiving IV antibiotics through the PICC line. A Physician's Order dated 06/11/2026, documented PICC site maintenance with transparent and gauze dressing changes 24 hours post insertion, then every seven days and as needed. The order directed staff to measure upper arm circumference 10 centimeters above external catheter length. If gauze was present, dressings were to be changed every 48 hours until 06/24/2026. Resident #59's June 2026 Intravenous (IV) Treatment Administration Record (TAR) documented the same PICC site maintenance and measurement requirements. The TAR documented dressing care was completed by LPN1 on 06/16/2026 and 06/23/2026. On 06/24/2026 at 5:12 PM, the Minimum Data Set (MDS) Coordinator explained dressings for PICC lines were to be changed every seven days or if soiled or dislodged. The importance of dressing changes was for infection prevention, keeping line patent and usable. The MDS Coordinator verbalized, not knowing when the dressing was last changed. The Regional Director of Clinical Operations (RDCO) reported the TAR documented a dressing change on 06/23/2026. On 06/24/2026 at 5:21 PM, the MDS Coordinator confirmed Resident #59's bandage remained dated 06/14/2026 and should have been changed by 06/21/2026. The MDS Coordinator verbalized it was not appropriate for the TAR to document completed dressing changes when the date on the dressing did not correspond. On 06/29/2026 at 10:55 AM, the MDS Coordinator explained the Director of Nursing was responsible for ensuring staff had appropriate certifications and competencies prior to being assigned PICC care. The MDS Coordinator confirmed LPN1 lacked documented IV certification and was documenting dressing changes as completed even though the dressing appeared unchanged. The facility document titled Infusion Therapy Procedures - Dressing Change for Vascular Access Devices, dated 08/2016, documented initial dressings must be changed PRN if saturated, and 24-48 hours post insertion for midlines, PICCs, or other central venous access devices if gauze or drainage was present. Transparent dressings with Biopatch may remain for seven days unless compromised. The Lippincott Manual of Nursing Practice (12th ed., 2025) documented the importance of routine and as needed IV dressing changes, including changing transparent dressings every seven days and replacing any dressing that becomes damp, loose, or soiled. The CDC document titled Summary of Recommendations: Guidelines for the Prevention of Intravascular Catheter-Related Infections, dated 02/28/2024, documented the following:-Recommendations for catheter education, training, and staffing: Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters.-Recommendations for catheter site dressing regimens: Replace catheter site dressing if the dressing becomes damp, loosened or visibly soiled. Replace dressing used on short-term central venous catheters (CVCs) at least every seven days for transparent dressings. Replace dressings every two days for gauze dressings. Cross reference tags F658.

Based on observation, interview, clinical record review and document review, the facility failed to ensure the administration of a controlled medication was documented in the controlled drug record for 1 unsampled resident (Resident #31). This deficient practice had the potential to result in inaccurate record keeping of the administration of controlled substances, misappropriation of a resident's medications and a resident's symptoms not being managed effectively.Findings include:Resident #31Resident #31 was admitted to the facility on [DATE], with a diagnosis of quadriplegia, C1-C4 incomplete.A medication order and the May 2026 Medication Administration Record (MAR) for Resident #31 documented oxycodone hydrochloride (HCl) oral tablet 10 milligrams (mg). Give 10 mg by mouth every six hours as needed for pain management.On 06/24/2026 at 2:35 PM, during a review of the controlled drug logbook in the 100-hall medication storage cart, page 11 of the logbook documented Resident #31 had one tablet remaining of Oxycodone immediate release (IR) 10 mg. There were no corresponding bubble packs of Oxycodone matching page 11 of the logbook inside the narcotics drawer of the medication cart. The Minimum Data Set 3.0 (MDS) Coordinator verbalized all controlled substances were to be documented in the logbook and the number of the page in the logbook was written on the medication package. The MDS Coordinator searched the medication cart and confirmed the remaining tablet of Oxycodone 10 mg, as documented in the logbook, was not present in the cart.On 06/24/2026 at approximately 2:40 PM, the MDS Coordinator verbalized the MDS Coordinator reviewed Resident #31's May 2026 MAR and explained a dose of Oxycodone was administered in the morning on 05/06/2026 was not accounted for in the logbook as required. The MDS Coordinator verbalized the Director of Nursing (DON) was responsible for reviewing the narcotic logbook to ensure documentation was accurate and complete.The facility policy titled Controlled Medication Storage, dated 11/2017, documented medications included in the Drug Enforcement Administration (DEA) classification as controlled substances were subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations. The DON and the consultant pharmacist monitored for compliance with federal and state laws and regulations in the handling of controlled medications. A controlled medication accountability record was prepared when receiving inventory of schedule II medication and included the following information: name of the resident, prescription number, date received, name, strength and dosage form of the medication, quantity received and name of the person receiving the medication. Current controlled medication accountability records were kept in the MAR or narcotic book. When completed, accountability records were to be submitted to the DON and maintained on file at the nursing care center.A Department of Justice/Drug Enforcement Administration Drug Fact Sheet, dated December 2024, documented oxycodone products were schedule II narcotics under the controlled substances act.

Based on observation, interview, clinical record review and document review, the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 29 opportunities observed and two errors. The medication error rate was 6.9%. This deficient practice had the potential to result in residents receiving medications in a manner inconsistent with physician orders and professional standards, placing them at risk for ineffective treatment, adverse drug reactions, and compromised health outcomes.Findings include:Resident #4Resident #4 was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.The June 2026 Medication Administration Record (MAR) for Resident #4 documented the following:-sennosides oral capsule 8.6 milligrams (mg). Give 8.6 mg by mouth one time a day for constipation - hold for loose stools give two tabs.-Zofran oral tablet 4 mg (ondansetron hydrochloride). Give 4 mg by mouth every four hours as needed for nausea.On 06/24/2026 at 9:02 AM, a Registered Nurse (RN) began preparing medication for Resident #4. The RN verbalized the scheduled medications included sennoside 8.6 mg and the medication was not available in the medication cart. The prepared medications included one scopolamine patch.On 06/24/2026 at 9:21 AM, the RN administered the prepared oral medications to Resident #4. Resident #4 declined to have the scopolamine patch administered and verbalized the resident would rather take Zofran. Resident #4's Zofran was not present in the medication cart. The RN informed Resident #4 the RN would attempt to locate additional supply of Zofran and bring it to the resident.On 06/24/2026 at 9:27 AM, the RN entered the medication storage room and attempted to access the Pyxis (an automated medication dispensing cabinet). The Pyxis was not currently functioning, and the RN was not able to access any medications inside the machine. The RN informed the Minimum Data Set 3.0 (MDS) Coordinator of the inability to access the medication. The MDS Coordinator verbalized the MDS Coordinator would attempt to restart the machine and bring the medication to the RN once the machine was working.On 06/24/2026 at 9:39 AM, after locating additional stock of sennoside 8.6 mg tablets, the RN placed one tablet in a medication cup, entered the dining room and administered the tablet to Resident #4. The RN explained to Resident #4 the Zofran was not currently available and the RN was attempting to get the medication for the resident.On 06/25/2026 at 9:10 AM, the June 2026 MAR for Resident #4 lacked documented evidence ondansetron was administered to the resident on 06/24/2026.On 06/25/2026 at 9:21 AM, the RN confirmed one tablet of sennoside 8.6 mg was administered to Resident #4 during the morning medication pass the previous day. The RN reviewed Resident #4's MAR and confirmed the instructions for the medication documented to give two tabs. The RN verbalized the RN administered the medication based on the mg listed in the instructions and had not noticed the instructions to administer two tabs. The RN verbalized the RN should have caught the discrepancy and contacted the physician to clarify the order prior to administration of the medication.The RN verbalized a dose of Zofran was administered by the RN to Resident #4 in the morning on 06/24/2026, after the Pyxis machine was restarted. The RN recalled administering the medication at approximately 10:30 AM. The RN reviewed Resident #4's MAR and confirmed the administration was not documented.On 06/25/2026 at 9:42 AM, the MDS Coordinator and the Regional Nurse Consultant (RNC) verbalized medication administration errors included not following doctor's orders, giving medications outside of the one-hour administration window, not following pharmacy recommendations and giving an incorrect dose. Documentation of medication administration was to be completed immediately after giving the medication.The RNC explained the expectation of nursing staff when a medication order was not clear or had conflicting information was to call the provider. The RNC and MDS Coordinator confirmed administering a medication without a clear order and/or prior to contacting the physician to clarify conflicting information in an order would be considered a medication administration error.The facility policy titled Medication Administration General Guidelines, dated 09/2018, documented medications were administered in accordance with written orders of the prescriber. If necessary, the nurse contacted the prescriber for clarification. Staff were to verify the medication was correct three times before administering the medication: when pulling the medication package from the med cart, when the dose was prepared, and before the dose was administered. The individual who administered the medication dose recorded the administration on the resident's MAR immediately following the medication being given. In no case was the individual who administered the medications to report off-duty without first recording the administration of any medications. When As Needed (PRN) medications were administered, documentation provided included date and time of administration and the signature or initials of the person recording the administration.

Based on observation, interview, and record review, the facility failed to maintain accurate and complete clinical records for 1 of 14 sampled residents (Resident #44) when the facility did not ensure bathing documentation, refusal documentation was accurately recorded and to ensure residents with indwelling urinary catheters received care and services necessary to prevent Urinary Tract Infections (UTIs) including care planning and catheter care/cleaning for 3 of 14 sampled residents (Residents #59, #5, and #18). This deficient practice had the potential to result in incomplete medical records resulting in an inaccurate representation of the residents' care needs, services provided and risks for complications related to catheter use including obstruction, UTI, and sepsis. Findings include: Resident #44 Resident #44 was admitted on [DATE], with diagnoses including need for assistance with personal care, psychosis, and major depressive disorder. On 06/22/2026 at 11:22 AM, Resident #44 verbalized not receiving scheduled showers on Sundays and Wednesdays. The resident stated scheduled showers don't happen, reported going 23 days without a shower, and stated the last shower received was on 06/21/2026. The resident described feeling dirty and crappy due to lack of bathing. Resident #44's Documentation Survey Report V2 for May 2026 lacked documentation of a shower provided or declined for the following periods: 05/03/2026 to 05/13/2026 (13 days) 05/17/2026 to 05/27/2026 (nine days) Resident #44's Care Plan dated 07/07/2025 documented the resident had an activity of daily living self care performance deficit and required assistance with personal care. The care plan documented Resident #44 preferred showering two days per week and required one staff assistance. On 06/24/2026 at 2:40 PM, a Certified Nursing Assistant (CNA) explained residents were scheduled for showers two times per week. The CNA stated staff were responsible for offering a shower or offering an alternative if the residents declined. Staff were expected to transport the resident to the shower room and return the resident afterward. The CNA was unsure which days Resident #44 received showers. A shower aide was scheduled on 06/24/2026, but the CNA was unsure if a shower occurred. The CNA stated staff were expected to complete skin and hygiene sheets and verbalized it would not be appropriate for a resident to go more than two weeks without being offered a shower. On 06/24/2026 at 2:45 PM, a Registered Nurse (RN) stated CNAs had a daily list of assigned showers. If a resident needed assistance or refused, staff were expected to educate the resident and attempt transport to the shower room. The RN stated shower sheets were provided to nurses after bathing to identify any new skin issues and staff were required to sign and chart showers in the resident's Electronic Health Record (EHR). On 06/24/2026 at 4:18 PM, the Infection Preventionist (IP) stated if a shower was not documented, it did not occur. The IP verbalized Resident #44 required a one person assist in the shower and a two person transfer from bed to chair, and the resident was dependent on staff for bathing. The IP confirmed lack of shower documentation for Resident #44 and stated it was important for the residents to receive showers for skin condition, overall health, and infection prevention. The Administrator and IP verbalized CNA documentation was incorrect. The CNAs documented resident refusals and could not be verified if Resident #44 had refused showers. The Administrator and IP stated blank entries indicated care was not provided and progress notes would need to be reviewed for accuracy. The Administrator and IP reported there was no facility specific shower policy and staff followed CMS guidance. Cross reference tags F684. Resident #59 Resident #59 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including resistance to multiple antimicrobial drugs, urinary tract infection, and neuromuscular dysfunction of the bladder. On 06/22/2026 at 2:20 PM, Resident #59 verbalized having been in the facility since 2025, reported being hospitalized for three to four days for a severe UTI with blood in the urine, and reported having an indwelling catheter with recurring UTIs. An Order Summary Report for Resident #59 documented the following physician's orders dated 06/11/2026: -Foley Catheter size 16 (French) Balloon: 5CC change as needed (PRN) damage, occlusion, or obtaining UA. As needed for change PRN damage, occlusion, or obtaining UA. -Ertapenem Sodium Solution Reconstituted 1 gram, 1 gram intravenously every 24 hours for ESBL E Coli for 12 Days infuse 1,000 milligram (mg) into a venous catheter every 24 hours for 12 days. Resident #59's Care Plan dated 03/11/2026 documented the resident had an indwelling catheter related to neurogenic bladder and required catheter care every shift. Resident #59's Task Record lacked a scheduled task for catheter care. Resident #59's clinical record lacked documented evidence of catheter care having been provided to the resident. On 06/25/2026 at 11:28 AM, the Minimum Data Set (MDS) Coordinator reported CNAs were responsible for catheter care and cleaning, and nurses were responsible for catheter changes. The MDS Coordinator explained catheter care was required every shift and CNAs documented catheter care in the resident's Electronic Medical Record (EHR) under tasks. The MDS Coordinator verbalized there was no facility policy related to catheter care and reported she was still attempting to locate documentation of catheter care for Resident #59. On 06/25/2026 at 3:44 PM, the MDS Coordinator verbalized catheter care documentation was important for monitoring outcomes and risks. The MDS Coordinator stated Resident #59 had a UTI possibly related to poor technique or lack of catheter care. The MDS Coordinator was unable to produce documentation verifying catheter care was completed for Resident #59. Missing or incomplete documentation failed to verify catheter care required by the resident's care plan was provided. Resident #5 Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal regionnta, diabetes mellitus 2 with neuropathy, and stage 4 pressure ulcer to sacrum. On 06/22/2026 at 9:15 AM, Resident #5 had a Foley catheter in place. The drainage bag was secured to the bed frame, and clear yellow urine was in the bag. The resident representative verbalized the resident had a Foley catheter in place and had recently recovered from a UTI. An MDS admission assessment, completed 03/20/2025, documented Resident #5 had an indwelling catheter. A Physicians Order dated 03/11/2025, documented Foley catheter 16Fr with 30cc balloon, clean Foley site every day and evening shift for skin impairment management. Resident #5's Task Record lacked a scheduled task for catheter care. Resident #5's clinical record lacked documented evidence of catheter care having been provided to the resident. On 06/24/2026 at 3:23 PM, during a review of Resident #5's care plan, the care plan Included a focus area of enhanced barrier precautions related to the catheter. The care plan for Resident #5 lacked a plan for addressing Resident #5's Foley catheter care interventions and goals. A Physicians Order dated 03/11/2026, documented Cefdinir Oral Capsule 300 milligrams give one capsule by mouth two times a day for UTI for seven days. On 06/25/2026 at 3:20 PM, the MDS Coordinator verbalized nurses and CNAs were responsible for catheter care. The MDS Coordinator explained CNAs were responsible for catheter and peri care, and nurses were responsible for changing catheters. On 06/25/2026 at 3:44 PM, the MDS Coordinator verbalized it was important for staff to document catheter care because it showed the facility was working to prevent infections. Urinary catheters were a high-risk area for infection and failure to provide catheter care placed residents at increased risk for UTI. The MDS Coordinator confirmed catheter care documentation could not be located for Resident #5. The MDS Coordinator confirmed if documentation of catheter care isn't completed, there is no guarantee catheter care was done. Resident #18 Resident #18 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis, unspecified and major depressive disorder, recurrent, moderate. On 06/22/2026 at 12:04 PM, Resident #18 was lying in the resident's bed. A urinary catheter drainage bag was secured to the resident's bed frame and contained a large amount of yellow urine. The resident verbalized the catheter was recently changed by facility staff and the resident currently had a Urinary Tract Infection (UTI). An Order Summary Report for Resident #18 documented the following physician's orders: -Foley catheter size 16 (French), balloon: ten cubic centimeters (cc). Change As Needed (PRN) damage, occlusion, or obtaining urinalysis (UA). The order date was 06/04/2026. -Levaquin tablet 500 milligrams (mg). Give 500 mg by mouth one time a day for proteus mirabilis UTI for five days. The order date was 06/22/2026. Resident #18's Care Plan documented the following: -Resident #18 had a potential for infection related to indwelling catheter. Interventions included providing catheter care every shift. The date initiated was 06/04/2026. -Actual infection UTI indwelling catheter. Resident demonstrated the following signs and symptoms: new/worse urgency, frequency, suprapubic pain, and costovertebral angle tenderness. Interventions included: administer antibiotic as ordered, assist with catheter care every shift, and encourage/assist with appropriate peri-care technique. The date initiated was 06/23/2026. On 06/25/2026 at 10:41 AM, a CNA verbalized CNAs were responsible for providing catheter care for residents. If a resident had a catheter the CNA would perform catheter care at least once per day with a washcloth, soap and water. The care was documented under the tasks sections of the Electronic Medical Record (EMR). Resident #18's Task Record lacked a scheduled task for catheter care. Resident #18's clinical record lacked documented evidence of catheter care having been provided to the resident. On 06/25/2026 at 11:28 AM, the MDS Coordinator verbalized CNAs were responsible for providing urinary catheter care/cleaning and nurses were responsible to change catheters when necessary. Catheter care was required to be provided every shift, and CNAs would document the care in the tasks section of the EMR. The MDS Coordinator denied the facility had a policy related to catheter care and verbalized the MDS Coordinator would attempt to find any documented evidence catheter care had been provided to Resident #18. On 06/25/2026 at 2:59 PM, the MDS Coordinator verbalized the MDS Coordinator was not able to provide any evidence catheter care had been provided to Resident #18. On 06/25/2026 at 3:44 PM, the MDS Coordinator verbalized it was important for staff to document catheter care because it showed the facility was working to prevent infections. Urinary catheters were a high-risk area for infection and failure to provide catheter care placed residents at increased risk for UTI. The Healthcare Infection Control Practices Advisory Committee's Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, updated 06/06/2019, and accessed on the Centers for Disease Control and Prevention (CDC's) website on 07/06/2026, documented proper technique for urinary catheter maintenance included but was not limited to: using standard precautions including use of gloves and gown as appropriate during any manipulation of the catheter or collection system and routine hygiene (cleansing of the meatal surface during daily bathing or showering).

Based on interview and document review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure residents were screened for eligibility to receive an influenza and/or pneumococcal vaccine upon admit and annually thereafter. This deficient practice resulted in a substandard quality of care related to the facility's immunization program. Findings include:On 06/29/2026 at 3:03 PM, the Administrator confirmed the QAPI committee had not identified a concern related to screening residents for eligibility to receive influenza and/or pneumococcal vaccines at admit and annually thereafter. The Administrator explained the Administrator was not sure how the QAPI committee could have identified the concern and verbalized identifying the concern could have led to a change in the immunization process by adding a document with targeted questions. The facility policy titled QAPI Plan updated and approved 02/06/2026, documented QAPI was a dynamic process used to facilitate the identification of areas for improvement and to drive quality of care and services. The QAPI committee was tasked with identifying areas requiring performance improvement, collecting data, developing and implementing corrective action, and creating monitors to determine and validate changes were effective and sustained. Cross reference with tag F883

Based on interview, personnel record review, and document review, the facility failed to ensure initial and annual communication training was completed timely per facility policy for 8 of 20 sampled employees (Employee #4, #10, #11, #12, #13, #15, #16 and #17). This deficient practice had the potential to prevent residents with communication needs from attaining or maintaining their highest practicable physical, mental and psychosocial well-being. Findings include:Employee #4 Employee #4 was hired as the Registered Dietician on 12/08/2025. Employee #4's personnel record documented Communication Training completed on 05/13/2025; however, lacked annual training completed for 2026. Employee #10 Employee #10 was hired as a CNA hired on 01/16/2026. Employee #10's personnel record lacked documented evidence of Communication Training completed upon hire. Employee #11 Employee #11 was hired as a Speech Pathologist on 02/03/2026. Employee #11's personnel record lacked documented evidence of Communication Training completed upon hire. Employee #12 Employee #12 was hired as the Infection Preventionist on 03/11/2026. Employee #12's personnel record lacked documented evidence of Communication Training completed upon hire. Employee #13 Employee #13 was hired as a Registered Nurse on 01/13/2026. Employee #13's personnel record lacked documented evidence of Communication Training completed upon hire. Employee #15 Employee #15 was hired as a Licensed Practical Nurse hired on 01/26/2026. Employee #15's personnel record lacked documented evidence of Communication Training completed upon hire. Employee #16 Employee #16 was hired as a Certified Nursing Assistant (CNA) hired on 04/23/2026. Employee #16's personnel record lacked documented evidence of Communication Training completed upon hire. Employee #17 Employee #17 was hired as a CNA hired on 11/28/2025. Employee #17's personnel record lacked documented evidence of Communication Training completed upon hire. On 06/29/2026 at 8:43 AM, the Business Office Manager (BOM) explained there was orientation training upon hire and annual training thereafter. The agency staff do not go directly through the facility for orientation training. The BOM confirmed Employee #4, #10, #11, #12, #13, #15, #16 and #17 personnel record lacked documented evidence of Communication training completed upon hire and annually. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, documented education provided for new employees and contract staff provided as part of orientation and scheduled annually, includes Communication Training.

Based on interview, personnel record review, and document review, the facility failed to ensure initial Quality Assurance and Performance Improvement (QAPI) training was completed timely per facility policy for 5 of 20 sampled employees (Employee #9, #10, #15, #16 and #17). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations. Findings include:Employee #9 Employee #9 was hired as a Certified Nursing Assistant (CNA) hired on 08/05/2020. Employee #9's personnel record documented QAPI training completed on 09/16/2024, however, lacked documented evidence of annual QAPI training completed in 2025. Employee #10 Employee #10 was hired as a CNA hired on 01/16/2026. Employee #10's personnel record lacked documented evidence of QAPI training completed upon hire. Employee #15 Employee #15 was hired as a Licensed Practical Nurse hired on 01/26/2026. Employee #15's personnel record lacked documented evidence of QAPI training completed upon hire. Employee #16 Employee #16 was hired as a CNA hired on 04/23/2026. Employee #16's personnel record lacked documented evidence of QAPI training completed upon hire. Employee #17 Employee #17 was hired as a Certified Nursing Assistant hired on 11/28/2025. Employee #17's personnel record lacked documented evidence of QAPI training completed upon hire. On 06/29/2026 at 8:43 AM, the Business Office Manager (BOM) explained there was orientation training upon hire and annual training thereafter. The agency staff do not go directly through the facility for orientation training. The BOM confirmed Employee #9, #10, #15, #16 and #17's personnel record lacked documented evidence of QAPI training completed upon hire and annually. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, documented education provided for new employees and contract staff provided as part of orientation and scheduled annually, includes Quality Assurance Program.

Based on interview, personnel record review, and document review, the facility failed to ensure initial and annual infection control training was completed timely per facility policy for 3 of 20 sampled employees (Employee #9, #15 and #16). This deficient practice had the potential to put residents at risk of contracting avoidable infections and diseases. Findings include:Employee #9 Employee #9 was hired as a Certified Nursing Assistant (CNA) hired on 08/05/2020. Employee #9's personnel record documented Infection Control training completed on 09/23/2024, however, lacked documented evidence of annual QAPI training completed in 2025. Employee #15 Employee #15 was hired as a Licensed Practical Nurse hired on 01/26/2026. Employee #15's personnel record lacked documented evidence of Infection Control training completed upon hire. Employee #16 Employee #16 was hired as a CNA hired on 04/23/2026. Employee #16's personnel record lacked documented evidence of Infection Control training completed upon hire. On 06/29/2026 at 8:43 AM, the Business Office Manager (BOM) explained there was orientation training upon hire and annual training thereafter. The agency staff do not go directly through the facility for orientation training. The BOM confirmed Employee #9, #15 and #16's personnel record lacked documented evidence of Infection Control training completed upon hire and annually. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, documented education provided for new employees and contract staff provided as part of orientation and scheduled annually, includes Infection Control Training.

Based on interview, personnel record review, and document review, the facility failed to ensure initial and annual compliance and ethics training was completed timely per facility policy for 3 of 20 sampled employees (Employee #2, #9 and #16). This deficient practice had the potential to put residents at risk of receiving care from employees unaware of facility regulations. Findings include:Employee #2 Employee #2 was hired as the Director of Nursing on 07/29/2024. Employee #2's personnel record documented compliance and ethics training completed on 04/01/2025; however, lacked annual training completed for 2026. Employee #9 Employee #9 was hired as a Certified Nursing Assistant hired on 08/05/2020. Employee #9's personnel record documented compliance and ethics training completed on 05/02/2025; however, lacked annual training completed for 2026. Employee #16 Employee #16 was hired as a Certified Nursing Assistant hired on 04/23/2026. Employee #16's personnel record lacked documented evidence of initial compliance and ethics training. On 06/29/2026 at 8:43 AM, the Business Office Manager (BOM) explained there was orientation training upon hire and annual training thereafter. The agency staff do not go directly through the facility for orientation training. The BOM confirmed Employee #2, #9 and #16's personnel record lacked documented evidence of Compliance and Ethics training completed upon hire and annually. The facility policy titled, Nursing Personnel Education and Training, published 11/2016, documented education provided for new employees and contract staff provided as part of orientation and scheduled annually, includes Compliance and Ethics Training.

Based on observation, interview, clinical record review, and document review the facility failed to ensure 1 of 13 sampled residents (Resident #27) received appropriate care to prevent a urinary tract infection (UTI) when facility policy and Centers for Disease Control and Prevention (CDC) recommendations related to Transmission-Based Precautions (TBP) were not followed and the resident remained in a shared room with another resident known to have an active infection with a Multidrug-Resistant Organism (MDRO). This deficient practice resulted in potentially avoidable isolation of the resident, UTI with an MDRO, and treatment with Intravenous (IV) antibiotics (ABX). Findings include: Resident #32 Resident #32 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypoxia and chronic kidney disease, stage four (severe). On 04/28/2025 at 7:31 AM, a sign was attached to the door frame of Resident #32 and Resident #27's room. The sign indicated the room had contact precautions in place, requiring a gown and gloves be donned prior to entering the room. A Personal Protective Equipment (PPE) cart was in the hall outside the room. The cart contained gowns, gloves, surgical masks and N95 masks. On 04/28/2025 at 7:47 AM, a Licensed Practical Nurse (LPN) assigned to care for Resident #32 and Resident #27 verbalized the contact precautions were in place due to Extended-Spectrum Beta-Lactamase (ESBL) in the resident's urine. The LPN confirmed two residents were staying in the room and verbalized both residents were on contact precautions. The following were included in Resident #32's clinical record: A Results Report for a urinalysis, complete with reflex to culture. The collection date was 02/12/2025, and the reported date was 02/17/2025. The report documented a urine culture result of greater than 100,000 CFU/ ml of E. coli. The therapy comments section of the report documented the organism was confirmed as an ESBL producer. Orders-Administration Notes dated 02/20/2025 and 02/21/2025, documented Ertapenem Sodium solution reconstituted, one gram IV every 24 hours for UTI for ten days. Awaiting peripherally inserted central catheter line placement. A Daily Skilled Note dated 02/28/2025, documented Resident #32 had a right arm midline. Resident on regimen of Ertapenem x 4 days to be completed 03/01/2025, no adverse reaction noted. On 04/29/2025 at 3:22 PM, the Infection Preventionist (IP) verbalized an MDRO was a multidrug-resistant organism. Residents were at high risk for contracting an MDRO if an ABX was inappropriately prescribed, when a catheter was inserted when not necessary or without using sterile technique, and when there was a lack of appropriate PPE. TBP included contact, droplet, and airborne precautions. The IP explained the intent of TBP was to protect the resident and keep residents from transmitting organisms to other residents. On 04/29/2025 at 3:33 PM, during an interview with the Director of Nursing (DON) and the IP, the DON and IP explained residents requiring TBP included residents infected with MDROs. Nursing was allowed to implement TBP, following the facility's policy for infection control and per CDC guidelines. If a resident was on contact precautions, the resident may be allowed to have a roommate if the roommate had the same organism. The IP and DON confirmed TBP were in place for Resident #27 on 04/28/2025. The DON confirmed Resident #27 had a roommate, Resident #32, and verbalized the residents had shared a room for a long time. On 04/30/2025 at 2:27 PM, during an interview with the DON, the IP, and the Regional Director of Clinical Operations (RDCO), the DON explained the indication for placing Resident #27 on TBP was ESBL E. coli in the resident's urine. The DON confirmed Resident #32 had been infected with the same organism. The IP verbalized Resident #32 was positive for ESBL E. coli per the results of a urine culture collected on 02/12/2025. Resident #32 was sent to the hospital not long after the collection of the urine specimen, returned to the facility on [DATE], and was placed on contact precautions. The DON denied Resident #32 was placed in a private room upon return to the facility and explained the resident was placed in a shared room with Resident #27. The DON and IP reviewed Resident #32's urine culture result report dated 02/17/2025. The DON confirmed the therapy comments section at the bottom of the report documented the organism was confirmed as an ESBL producer. The IP acknowledged the report indicated the organism was resistant to multiple drugs. The IP confirmed Resident #32 should have been placed in a private room upon return to the facility on [DATE]. Resident #27 Resident #27 was admitted to the facility on [DATE], with diagnoses including spastic hemiplegia affecting right dominant side, bipolar II disorder, major depressive disorder, recurrent, unspecified, anxiety disorder, unspecified, and post-traumatic stress disorder, chronic. On 04/28/2025 at 2:53 PM, Resident #27 verbalized the resident was on isolation precautions related to a UTI. The resident was taking ABX to treat the UTI and complained of nausea and vomiting since starting the ABX. Resident #27 became tearful during interview and verbalized the resident had been in isolation for approximately one month. The resident explained the resident had really bad anxiety and the isolation made the anxiety worse. On 04/28/2025 at approximately 3:30 PM, a Certified Nursing Assistant (CNA) was preparing to enter Resident #27's room. The CNA affirmed the CNA was assigned to provide care to both Resident #27 and Resident #32 during the shift. The following were included in Resident #27's clinical record: A Progress Note dated 03/19/2025 documented Resident #27 complained of dysuria and frequency. Nurse spoke to the physician and obtained an order for a urinalysis (UA). A Lab Results Report, with a collection date of 03/19/2025 and a reported date of 03/24/2025, documented a urine culture result of greater than 100,000 Colony Forming Units (CFU)/ milliliter (ml) of ESBL producing Escherichia coli (E. coli). The organism showed resistance to the following: Ampicillin, Ampicillin/Sulbactam, Cefazolin, Cefepime, Ceftazidime, Ceftriaxone, Cefuroxime, Ciprofloxacin, Gentamicin, Levofloxacin, Nitrofurantoin, Tobramycin, and Trimethoprim/Sulfamethoxazole. An Orders-Administration Note dated 03/24/2025, documented Ceftolozane-Tazobactam IV solution reconstituted 1.5 (1-0.5) grams (GM). Use 1.5 GM IV every eight hours for E. coli/ ESBL UTI. A Nursing Progress Note dated 03/25/2025, documented new order obtained for Meropenem 500 milligrams (mg) IV every eight hours for UTI. New order for Normal Saline (NS) one liter for rehydration. 22 gauge to left wrist started, no complaints of pain, no signs or symptoms of infiltration. NS infusing, will continue to monitor. An Orders-Administration Note dated 04/04/2025, documented resident to be in isolation due to ESBL in urine. Meals to be given on disposable trays. All care provided by staff to be done in room. Resident to be in private room with no roommate. Every day and night shift for isolation precautions. A Physician's Order dated 04/14/2025, documented Linezolid oral tablet 600 mg, give one tablet by mouth two times a day for UTI for 14 days. A Physician's Order dated 04/17/2025, documented contact precautions for enterococcus faecalis in urine. Every day and night shift until 05/01/2025. End contact isolation 72 hours after ABX regimen is complete. A Daily Census Report dated 02/24/2025, documented there were 18 empty beds in the facility. The facility's Monthly Line Listing of infections for February 2025, documented Resident #32 had a UTI. The date of infection was listed as 02/13/2025. The pathogen/organism was E. coli ESBL, the infection was healthcare associated, and contact precautions were initiated. Resident #32's clinical record documented on 02/13/2025, the resident was sharing a room with Resident #27. The facility's Monthly Line Listing of infections for March 2025, documented Resident #27 had a UTI. The date of infection was listed as 03/25/2025. The pathogen/organism was E. coli, the infection was healthcare associated, and contact precautions were initiated. The facility's CNA and nurse schedule for March 2025 documented one nurse worked in the facility during the night shift on 03/01/2025 through 03/05/2025. On 04/29/2025 at 4:32 PM, the DON explained an adequate number of staff to care for residents in the facility varied by acuity. At a minimum, the facility would staff one nurse and three CNAs at night. The DON confirmed the facility had shifts when only one nurse was in the facility to provide nursing care to all residents. On 04/30/2025 at 2:27 PM, the IP explained the first time the facility was aware of and had documentation of Resident #27 testing positive for ESBL E. coli was 03/25/2025, after sharing a room with Resident #32. The facility policy titled Transmission Based Precautions, published 01/2025, documented it was the policy of the facility to implement Transmission-Based Precautions (TBP) for residents known to be, or suspected of being, infected with infectious agents. The four types of TBP included contact, droplet, airborne, and enhanced barrier precautions. The need to implement TBP was determined by the IP, DON, and/or consultation with the local health department. Precautions were based on CDC guidelines. Contact, or touch, was the most common and most significant mode of transmission of infectious agents. Contact transmission could occur by directly touching the resident, through contact with the resident's environment, or by using contaminated gloves or equipment. Options for residents on contact precautions could include a private room, cohorting with another infected or colonized resident or sharing a room with a resident with limited risk factors. The CDC document titled 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, updated 09/2024, documented MDROs were generally defined as microorganisms which were resistant to one or more classes of antimicrobial agents. MDROs of concern included those producing ESBL. Documented outbreaks in long-term care facilities were caused by various viruses and bacteria and could lead to substantial morbidity and mortality and increased medical costs. Prompt detection and implementation of effective control measures were required. Placement of a resident in a single room was preferred when there was concern about transmission of an infectious agent, including residents on contact and droplet precautions. Recommendations for residents infected or colonized with an MDRO judged as clinically important by the infection control program included contact in addition to standard precautions. Cross reference tag F880.

Based on observation, interview, and document review, the facility failed to ensure 1) staff received the training necessary to correctly identify the location of an exit door alarm and ensure all residents were accounted for, 2) 2 of 5 residents identified as at risk for elopement did not elope from the facility (Residents #1 and #2), 3) 1 of 8 sampled residents was provided the services necessary to prevent a fall (Resident #2). Findings include: Exit door alarms On 01/26/22 at 1:50 PM, a Licensed Practical Nurse (LPN) communicated an alarm would sound off when any of the facility's exit doors were opened. Staff responded to the alarm panel located at the facility's nurse's station when an alarm was heard. Staff checked the panel to determine where in the facility the sounding alarm was located to ensure a resident had not eloped. Residents identified as elopement risk wore wander-guards on their wrist or ankles. On 01/26/22 at 2:42 PM, the Executive Director explained each hallway (Hall 100, Hall 200, and Hall 500) exit doors had alarms and the alarms were activated when the doors were opened without using a code. The facility's front door and courtyard door did not have alarms installed. On 01/26/22 at 3:04 PM, the Executive Director communicated all exit door alarms were checked by the Director of Maintenance (DOM) weekly to ensure the alarms properly functioned. On 01/26/22 at 3:06 PM, the Executive Director confirmed elopement/exit door alarm drills were not conducted by the facility. On 01/26/22 at 3:38 PM, the DOM verbalized all exit door alarms were checked daily to ensure proper functioning. On 01/27/22 at 10:41 AM, the Activities Director explained residents at risk for elopement wore wander guards. Wander guards set off an alarm when residents approached or attempted to open an exit door. Staff responded to the nurse's station and checked the alarm panel to determine which door the alarm was at and responded to the door indicated on the alarm panel. On 01/27/22 at 12:37 PM, an elopement/door alarm drill was conducted with the DOM. The DOM pushed open the 100 Hall exit door. A stopwatch was activated to time the facility's response to the alarm. On 01/27/22 at 12:39 PM, after 2.08 minutes the alarm stopped and no one responded to the door to investigate. The alarm was deactivated by an unknown source. On 01/27/22 at 12:41 PM, the stopwatch was stopped at 4.07 minutes. The 100 Hall door was not visible from the hall or nurse's station and no one came to physically check the 100 Hall door/alarm. The Minimum Data Set (MDS) Coordinator, a Licensed Practical Nurse (LPN), two Certified Nursing Assistants (CNA), and a Nursing Assistant Trainee (NAT) were observed at the nurse's station. On 01/27/22 at 12:45 PM, an NAT explained the alarm panel indicated the alarm at 12:37 PM was located in the 500 Hall and the location of the alarm was communicated to staff working in the 500 Hall. The NAT confirmed the NAT did not check the 100 Hall exit door. On 01/27/22 at 12:46 PM, CNA1 communicated the CNA was at the front of the building when the alarm went off and did not respond to the alarm. On 01/27/22 at 12:49 PM, an LPN explained the alarm panel indicated the alarm st 12:37 PM was in the 500 Hall. The LPN communicated the LPN did not check the exit door in the 100 or 200 Halls and was not sure who turned off the alarm in the 500 Hall. The LPN confirmed when the alarm was cleared by staff in the 500 Hall, no further action was taken. On 01/27/22 at 12:56 PM, CNA2 communicated CNA2 was working at the nurse's station desk when the alarm was heard. CNA2 explained CNA1 and the NAT responded to the alarm panel and verbalized the alarm was in the 500 Hall. CNA2 confirmed CNA2 did not check any of the exit doors due to the alarm was in the 500 Hall and other staff were aware and had addressed the issue. On 01/27/22 at 1:00 PM, the DOM re-tested the system by activating the 100 Hall exit door alarm. The alarm was deactivated by unknown source before the DOM was able to read the alarm panel. On 01/27/22 at 1:02 PM, the DOM conducted a re-test of the 100 Hall exit alarm. The alarm was deactivated by an unknown source after approximately 10 seconds. The top line of text on the alarm panel read as follows and was confirmed by the DOM: -05 Hall -The numeral 1 was noted in bottom left corner of the panel. On 01/27/22 at 1:05 PM, the 500 Hall CNA (CNA3) verbalized the CNA heard the alarm go off three times. The first time the alarm went off, CNA3 checked with other staff members to determine which exit door was alarming. CNA3 explained staff at the nurse's station communicated to CNA3 the alarm was located at the 500 Hall exit door. CNA3 communicated the CNA deactivated the alarm each time the alarm was sounded. CNA3 explained the alarm was deactivated because the CNA knew the alarm was not triggered by a resident in the 500 Hall. CNA3 confirmed the CNA did not check with other staff to determine where the alarm panel indicated the second and third alarms were located and did not ensure all residents were accounted for prior to shutting off the alarm. On 01/27/22 at 1:11 PM, the 500 Hall exit door alarm was activated. The alarm panel read as follows and was confirmed by the DOM: -Alarm 04 500 hall On 01/27/22 at 1:14 PM, the 200 Hall exit door alarm was activated. The alarm panel read as follows and was confirmed by the DOM: -Alarm 03 200 hall. On 01/27/22 at 1:20 PM, the DOM verbalized staff did not respond as expected to the exit door alarms. The DOM needed to provide training related to reading the alarm panel to all facility staff. The DOM confirmed staff did not correctly identify the location of the alarm, did not respond to the alarms correctly, and training was needed. The DOM confirmed each time the 100 Hall alarm was activated, staff deactivated the 100 Hall alarm without investigating the area and ensuring residents were all safe from elopement. On 01/27/22 at 6:28 PM, the Executive Director confirmed door alarms were only tested to ensure the alarms worked and staff responded. The Executive Director confirmed staff did not receive training related to reading the alarm panel and did not receive training related to responding to exit door alarms. On 01/27/22 at 6:32 PM, the Executive Director explained conducting elopement drills would provide the facility with information related to staff response to alarms including where staff responded to first and how staff identified where alarms were located. The Executive Director confirmed if elopement drills had been conducted, the facility would have identified staff were reading the alarm panel first and responding to the wrong door when the 200 Hall exit alarm was activated. On 01/27/22 at 6:35 PM, the Executive Director acknowledged and confirmed when alarms were not correctly identified and investigated by facility staff, residents were at risk of eloping and the potential for serious injury or death was present. Elopement Resident #1 Resident #1 was admitted to the facility on [DATE], with diagnoses including unspecified dementia without behavioral disturbance, major depressive disorder, recurrent, mild, and personal history of [CONDITION(S)] (TIA), and cerebral infarction without residual effects. An alert charting progress noted dated 11/16/21, documented Resident #1 eloped from the facility on 11/16/21, by exiting through the 200 Hall exit door. Resident #1 was found in the facility's parking lot. On 01/26/22 at 2:49 PM, the Executive Director explained Resident #1 eloped via the facility's 200-hall exit door and was found in the parking lot between the facility and the facility next door. The resident was wearing a wander guard and had previously been assessed as an elopement risk. Resident #1 eloped from the facility via the 200 Hall exit door. The 200 Hall exit door was an alarmed door and was not equipped to detect a wander guard. The Executive Director confirmed Resident #1 eloped from the facility. Elopement with fall Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including vascular dementia with behavioral disturbance, major depressive disorder, recurrent, mild, and other specified anxiety disorders. Facility Reported Incident (FRI) #NV 310 dated 11/28/21, documented on 11/24/21, Resident #2 eloped from the facility by exiting through the facility's 500 Hall door and was found in the facility's south parking lot. Resident #2 was found down on the resident's hands and knees. Resident #2 had injuries on the forehead, face, and nose. Resident #2 was transported to the hospital emergency room for evaluation. An Elopement/Exit Seeking Evaluation form dated 11/06/21, documented Resident #2 had a history of exit seeking, was at significant risk of getting into an unsafe situation, stayed near an exit door, wandered aimlessly, exhibited signs of sundown syndrome, had impaired judgement and/or safety awareness, and was at risk for elopement. A Morse Fall Scale form dated 08/23/21, documented Resident #2 had fall risk score of 65, indicating the resident was at high risk of falling. A Morse Fall Scale form dated 09/17/21, documented Resident #2 had fall risk score of 40, indicating the resident was at moderate risk of falling. An alert charting elopement note dated 11/24/21, documented Resident #2 was a high fall risk and frequently attempted to leave the building. The resident was located outside of the building. An nursing progress note dated 11/24/21, documented Resident #2 had a ground level fall with multiple abrasions and complained of discomfort to both knees. Resident #2's fall risk care plan dated 10/17/20, documented the resident needed a safe environment with even floors. Resident #2's fall care plan documented Resident #2 had a fall on 11/24/21, and the interventions from the fall risk care plan dated 10/17/20 were to be continued. On 01/26/22 at 1:50 PM, an LPN communicated resident elopement risk were identified during the admissions process by assessing the resident's history, and completing an elopement risk assessment. The LPN communicated the LPN was not present when Residents #1 and #2 eloped from the facility. The LPN recalled providing care to Resident #2 following Resident #2's elopement and fall and verbalized the resident had a few abrasions and a cut on the forehead. On 01/26/22 at 2:46 PM, the Executive Director confirmed on 11/24/21, Resident #2 eloped from the facility, fell in the parking lot, and had injuries to the face and head. Resident #2 was previously identified as an elopement risk on 10/17/20. On 01/26/22 at 2:48 PM, the Executive Director confirmed Resident #2's care planned interventions were not effective in preventing the resident from eloping. 01/26/22 at 2:52 PM, the Executive Director communicated the facility was responsible for ensuring resident safety and when residents eloped from the facility, the resident was at risk for adverse outcomes including injury and death. On 01/26/22 at 2:57 PM, the Divisional Director of Clinical Operations explained and confirmed Resident #2 had an uneven gait and fell because the resident was on uneven ground. The facility policy titled, Missing Resident/Elopement Procedures, dated 09/2016, documented the facility used a systematic procedure to locate residents believed to have eloped. Elopement was defined as a resident leaving a safe area without staff knowledge or presence. The policy lacked documented evidence of a plan related to exit door alarm procedures. The facility policy titled, Elopement/Wandering, dated 03/2018, documented elopement drills were completed annually and as needed to validate staff competence and monitoring system integrity. The Maintenance Department or designee tested the monitoring system at alarmed exits daily. The policy lacked documented evidence of a plan to respond to exit door alarms. The facility policy titled, Fall Evaluation (Morse Scale) and Management, dated 03/2018, documented when a residents Morse fall scale was greater than 45, the resident was considered a high potential for falls. Care plan interventions for fall management were implemented. The policy lacked documented guidance related to fall prevention. FRI #NV 310 FRI #NV 268

Based on interview, record review and document review, the facility failed to document the administration of PRN (as needed) medications to include time and effectiveness, monitor the parameters of a medication, and prevent early administration of medications for 5 of 7 sampled residents (Resident #1, #2, #5, #6, and #3). An Immediate Jeopardy was identified on 04/20/17 at 3:18 PM, due to a lack of documentation for the administration of PRN medications to include narcotics, the early administration of scheduled and PRN medications, and the monitoring of the effectiveness for PRN medications of residents. The Administrator was notified. The Immediate Jeopardy was abated at 6:12 PM on 04/20/17. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's admitting physician's orders [REDACTED]. Resident #1's physician orders, dated 01/25/17, documented the following narcotic medications: -[MEDICATION NAME] mg (milligrams) tablet by mouth two times a day for chronic pain -[MEDICATION NAME] 10/325 tablet by mouth every six hours as needed for breakthrough pain -[MEDICATION NAME] 100 mg capsule by mouth two times a day for chronic pain Resident #1's telephone order, dated 01/26/17, documented [MEDICATION NAME] 0.25 mg by mouth, every eight hours, as needed for anxiety. Resident #1's Medication Administration Record (MAR) revealed the following for [MEDICATION NAME]: The resident missed an administration on 01/26/17 at 9:00 PM, indicated by the nurse's initials circled. The reverse side of the MAR lacked documented evidence of a reason for the missed administration. The MAR lacked nurse's initials for the 01/27/17 at 9:00 PM and 01/28/17 at 9:00 AM administration of [MEDICATION NAME]. Resident #1's Controlled Drug Record, with time of administration, nurse's initials, and physical count of medication, revealed the following for [MEDICATION NAME]: The resident received an administration of [MEDICATION NAME] on 01/26/17 at 9:00 PM. The resident received two administrations of [MEDICATION NAME] on 01/27/17 at 9:00 PM. The resident received one administration of [MEDICATION NAME] on 01/28/17 at 9:00 AM. Resident #1's MAR and Controlled Drug Record indicated the resident received [MEDICATION NAME] on 01/29/17 at 9:00 AM. Resident #1's MAR revealed the resident received [MEDICATION NAME] one time on 01/29/17. The MAR lacked documented evidence of a time of the PRN (as needed) administration, a reason for administration, and the result. Resident #1's Controlled Drug Record indicated the resident received [MEDICATION NAME] on 01/26/17 at 9:00 PM and on 01/29/17 at 12:00 PM. Resident #1's MAR revealed the resident received [MEDICATION NAME] on the following dates and times: 01/25/17 (no time), 01/26/17 (no time), 01/27/17 at 5:30 PM, 01/29/17 at 7:00 AM, and 01/30/17 (no time). Resident #1 was discharged on [DATE]. Resident #1's Controlled Drug Record indicated the resident was administered [MEDICATION NAME] nine times in January 2017, to include the following: -an administration on 01/25/17 at 8:00 PM and 01/26/17 at 12:30 AM; a four and a half hour window of time on a PRN medication ordered for every six hours. - an administration on 01/29/17 at 7:00 AM and 12:00 PM; a five hour window of time on a PRN medication ordered for every six hours. - no administration documented on 01/30/17. Resident #1's MAR indicated the following for [MEDICATION NAME] Extended Release (ms Contin): - the record lacked nurse's initials for the scheduled administration on 01/28/17 at 9:00 AM -the resident was administered the medication on 01/28/17 at 9:00 PM, as ordered -a nurse initialed the resident was administered the medication on 01/29/17 at 9:00 AM. Resident #1's Controlled Drug Record indicated the following for [MEDICATION NAME] Extended Release: -the record lacked documented evidence the scheduled dose was administered on 01/28/17 at 9:00 AM as evidence by the running tally count of medication remaining -the medication was administered on 01/28/17 at 9:00 PM, as ordered -the documented administration on 01/29/17 at 7:00 AM was ten hours after the previous dose and two hours prior to the next scheduled dose. Resident #1's MAR documented the resident received the PRN [MEDICATION NAME] on 01/29/17 at 7:00 AM without documented evidence of a reason or an effect on the reverse side of the MAR. Resident #1's Daily Skilled Nurse's Notes documented on 01/24/17, the day of the resident's admission, the following vitals: -Oxygen Saturation 85% -Pulse 100 -Respiratory 20 -Blood Pressure 167/86 Resident #1's Daily Skilled Nurse's Notes documented on 01/25/17 severe pain with no respiratory concerns. Resident #1's Daily Skilled Nurse's Notes documented on 01/26/17 moderate pain, no respiratory concerns with lung sounds diminished bilaterally, and Oxygen saturation at 90%. Resident #1's Daily Skilled Nurse's Notes documented on 01/27/17 the resident's pain was 3/10, no respiratory concerns with lung sounds diminished, Oxygen saturation at 95%, sleeping too much, and no side effects. Resident #1's Daily Skilled Nurse's Notes documented on 01/28/17 the resident was sleeping too much, no adverse effects from medication, a slight wheezing with no respiratory concerns, and Oxygen saturation 95%. Resident #1's Daily Skilled Nurse's Notes documented on 01/29/17 the resident had increased pain at lunch and had verbalized the pain was severe. The note lacked documented evidence the resident had been in pain prior to lunch. The nurse documented no cough or congestion was noted. The AM nurse documented the following vitals: -Oxygen saturation 93% -Respiratory 18 -Pulse 80 -Blood Pressure 126/52 The nursing note documented at 3:30 PM the resident was resting in bed with no signs of distress or shortness of breath. The nursing note indicated at 4:45 PM the staff attempted to wake the resident but the resident was not responding. The nurse documented the following vitals: -Respiratory 15 -Pulse 101 -Blood Pressure 123/71 -Oxygen saturation 77%-88% The nursing note revealed the following chronological actions were taken: - A nasal cannula was placed on Resident #1 with a flow of 5 liters. The resident's Oxygen saturation was up to 88%-89%. -The nurse administered a breathing treatment and placed a mask on the resident with a flow of 5 liters. The resident's Oxygen saturation was up to 90%. -The resident's respirations continued to decline to 13 per minute. The resident exhibited very little to no response with painful stimuli. -The nurse received an order to transfer the resident to the emergency room for evaluation and treatment. -The paramedics arrived by 5:00 PM. -The resident's respirations had dropped to 8 per minute. -The Emergency Medical Technicians (EMT) administered [MEDICATION NAME]. Resident #1's Nurse's Notes, dated 01/30/17, documented a late entry from the AM shift of 01/29/17. The Licensed Practical Nurse (LPN) documented the following occurred in chronological order: -At 7:00 AM the resident was complaining of severe pain with crying and grimacing. PRN and scheduled medications were given. -The resident had wet cough and lungs with bronchi. The resident was lethargic and complained of pain. -The resident was layed down after breakfast and slept between meals. Vitals were stable. -The resident was assisted to lunch and asked for more pain medication and verbalized the pain was severe. -Pain medications were given and layed down in bed. -The resident slept comfortably for the rest of the shift. -Shortness of breath was doccumented on exertion and with anxiety related to pain. On 04/18/17 at 3:00 PM, the Director of Nursing Services (DNS) confirmed Resident #1 was given the [MEDICATION NAME] Extended Release too early on 01/29/17 at 7:00 AM. The DNS explained it was scheduled for 9:00 AM and the earliest the LPN was allowed to have administered the medication was 8:00 AM. The DNS explained Resident #1 did not receive the [MEDICATION NAME], ordered for every six hours as needed, too early when the LPN administered the medication on 01/29/17 at 7:00 AM and 12:00 PM because state regulations allowed a nurse to administer a PRN medication up to one hour early. The DNS verbalized a PRN medication order for administration was allowed to be administered one hour less than the physician's orders [REDACTED]. On 04/19/17 at 10:11 AM, an LPN#1 verbalized she thought it was acceptable to refer to the Controlled Drug Record first to determine the last time a resident received a PRN narcotic however she would also look at the MAR to verify the order. The LPN explained the nurses were required to document the date and time of the medication administration on the front page of the MAR and the reason and effectiveness on the reverse side of MAR for PRN medications. The LPN verbalized the documentation of medication administration on each resident's MAR did not always happen and she did not always do it herself. The LPN#1 explained a PRN medication ordered for every six hours was appropriate to administer at five hours. The LPN#1 verbalized a resident administered [MEDICATION NAME] Extended Release and [MEDICATION NAME] at 7:00 AM, [MEDICATION NAME] at 9:00 AM, and [MEDICATION NAME] and [MEDICATION NAME] at 12:00 PM could experience side effects to include drowsiness, nausea, vomiting, overdose, lethargy, drop in blood Pressure, decreased Oxygen saturation and change in vital signs. On 04/19/17 at 1:47 PM, during a telephone interview with a Pharmacist #1, the facility's pharmacy's Clinical Manager and Supervisor of the facility's Consultant Pharmacist #2, the following information was verbalized regarding Resident #1's medication administration on 01/29/17: - A PRN medication order would be required to be followed with a wait time between administrations at a minimum of hours as documented on the physician's medication order. The nurse was not allowed to administer a PRN medication one hour less frequency from documented order. -The facility was out of compliance with the administration for Resident #1's [MEDICATION NAME] Extended Release on 1/29/17 at 7:00 AM as it was scheduled for 9:00 AM and for the administration of [MEDICATION NAME] at 12:00 PM as it was scheduled for every six hours when the nurse administered it after five hours. -The recommendation for the administration of the [MEDICATION NAME] and [MEDICATION NAME] at 12:00 PM was to administer only one and check the resident an hour later. The combination of the two medications could cause increased drowsiness. Also, the nurse would be unable to assess which medication was being effective. Ultimately, the administration of [MEDICATION NAME] and [MEDICATION NAME] at the same time was a clinical judgement call. The Pharmacist #1 verbalized the following regarding the documentation of medication administration: -Medications administered to residents were documented on the MAR and Controlled Drug Record (if necessary). -A PRN medication was required to have a time of administration documented on the narcotic Controlled Drug Record and MAR. -A PRN medication was required to have documented on the MAR reverse side of page the drug name, dose, time, and reason at the time of administration. -The pharmacist process was to review the effectiveness of PRN medications based on the documentation on the reverse side of the MAR. -The pharmacist process was to review a percentage sample of resident MARS each month. -The review would take into consideration the routine use of PRN medications to include pain medications. Routine use of pain medications could result in a referral to the physician for pain management. -A facility without documented evidence of administration of PRN medications on the MAR would result in a pharmacist not seeing the true administration of a medication resulting in an increased opportunity for adverse affects of medications not given as prescribed by the physician. -The pharmacist process did not include a review of the Controlled Drug Record monthly. The record was reviewed by the pharmacist quarterly to verify accurate medication administration. -Inconsistencies observed in the documentation and administration of medications would have been documented by the pharmacist on the Quarterly Improvement: Consultant Pharmacist Report. The report was emailed to the Administrator and Director of Nursing. The pharmacist process was to implement a plan to assist the facility in correcting identified issues if the facility was unable to show improvement after two months. Review of the Quarterly Improvement: Consultant Pharmacist Report revealed the Pharmacist #2 identified and recommended the following Suggestions for Improvement: -In 10/2016 the suggestion was There are holes in medication administration and behavior monitoring, please address with staff. -From 12/2016 to 04/2017, five reports documented the suggestion Significant number of holes on medication administration and behavior monitoring, please address with staff. The Quarterly Improvement: Consultant Pharmacist Report revealed the Pharmacist #2 identified in 10/2016, 11/2016, 12/2016, 01/2017, 02/2017, 03/2017, and 04/2017 no irregularities observed for the following areas: -Controlled substance documentation was accurate and complete. -Medications to be administered with parameters were given according to the order. -Documentation was complete including PRN medication documentation and sites of administration. On 04/20/17 at 8:45 AM, an LPN#2 confirmed she remembered administering [MEDICATION NAME] and [MEDICATION NAME] to Resident #1 on the morning of 01/29/17 but had no recollection of administering [MEDICATION NAME]. The LPN explained she must have because she signed for the administration. The LPN#2 verbalized the morning of 01/29/17 Resident #1 was tense and the LPN administered something for muscles. The resident was crying out in pain and the LPN explained the [MEDICATION NAME] Extended Release would not help the resident at the time, therefore, the LPN explained she administered the [MEDICATION NAME]. The LPN verbalized she had not followed regulation when she administered the [MEDICATION NAME] two hours prior to the scheduled time of 9:00 AM. The LPN#2 explained the 12:00 PM administration of [MEDICATION NAME] was in a one hour time frame of the ordered every six hours and therefore, the LPN was able to administer the medication and had the resident lay down in bed. The LPN#2 verbalized she attempted to space out Resident #1's medications the best she could throughout her shift with the following schedule: -7:00 AM [MEDICATION NAME] Extended Release, [MEDICATION NAME], and [MEDICATION NAME] -9:00 AM [MEDICATION NAME] -12:00 PM [MEDICATION NAME] and [MEDICATION NAME] The LPN#2 confirmed she documented the resident was experiencing lethargy and sleeping during the AM shift but had not considered the behaviors unusual. The LPN#2 confirmed she had not documented the effectiveness of the PRN medications for Resident #1 and should have on the reverse side of the MAR. The LPN#2 explained Resident #1 was complaining of severe pain on 01/29/17. The LPN verbalized the 7:00 AM medications were not effective. The LPN confirmed she should have contacted the Nurse Practitioner but did not report the severe pain and lack of effectiveness of the medications that had been administered. On 04/20/17 at 9:30 AM, the DNS explained with the critical thinking of a nurse, the nurse would not want to administer [MEDICATION NAME] Extended Release, [MEDICATION NAME] and [MEDICATION NAME] at the same time. The DNS verbalized the physician medication orders for Resident #1 did not indicate the medications could not be administered at the same time, therefore, the LPN who administered the three medications on 01/29/17 at 7:00 AM was not technically wrong. Resident #1's acute hospital summary on the date of discharge, 01/24/17, documented she is not coughing anymore. Chest X-ray shows stable lower lungs pneumonia. Clinically she has no symptoms of the pneumonia .She has chronic hip pain severe back pain .She may need to see pain management if she continues to have uncontrolled pain. On 04/20/17 at 9:30 AM, the DNS explained Resident #1 had been in chronic pain since admission. The DNS verbalized the Nurse Practitioner could have made a referral to a pain specialist but had not because the resident was so new. The DNS confirmed Resident #1's clinical record lacked documented evidence a physician or nurse practitioner had examined the resident during the admission period. The DNS reviewed Resident #1's nursing progress note dated 1/30/17 and verbalized she would have addressed the resident's lethargy and reviewed the medications. The DNS explained the pneumonia could have made the resident sleepy. The facility submitted a self-report to the state on 01/30/17 and documented the same findings, respiratory distress due to pneumonia. The DNS confirmed the facility did not consult their Pharmacist #2 regarding Resident #1's respiratory distress on 01/29/17. The DNS confirmed the facility's final decision after investigating the incident with Resident #1 on 01/29/17 was the resident had respiratory distress due to pneumonia. However, on 01/24/17 the acute hospital clinical record documented no symptoms of pneumonia. The clinical record at the long term care facility lacked documented evidence of a decline due to pneumonia from date of admission to 01/29/17. LPN progress note dated 01/29/17 read no cough/congestion noted. The next day, 01/30/17, after the resident was transferred to the hospital due to non-responsiveness, a late entry note documented by an LPN dated 01/30/17 changed the resident condition to evidence of a wet cough and lungs with bronchi. The DNS stated during the interview that she had not assessed the resident, and was not in the facility at the time of the transfer. The DNS reviewed the Daily Skilled Nurse's Notes for Resident #1 and explained the resident was sleeping a lot due to the pneumonia. The DNS verbalized Resident #1 slept often from her date of admission, therefore it became a normal behavior. The DNS explained the pain medications also made the resident tired. The DNS verbalized the end-of-month medication reconciliation had not been assigned to a staff member. The DNS explained it had been her position to educate the nurse's to include documentation and administration of medications. The DNS verbalized the facility was aware that a couple of nurses were not documenting in accordance with the facility policy. The DNS explained it was the facility policy to require medication administrations be documented in the MAR, however the nurses always looked at the Controlled Drug Record to review the last time a resident received a medication. The DNS verbalized the state surveyors needed to review the Controlled Drug Record for administrations of narcotics because the MAR often lacked the documentation of administration for the facility's residents. The DNS verbalized the facilty advised the Pharmacist #2 to always review the Controlled Drug Record in place of the MAR for the administration of narcotics. The DNS confirmed Resident #1's medical record lacked documented evidence of a signed informed consent for the administration of [MEDICATION NAME]. The DNS verbalized the informed consent was required prior to the administration and Resident #1 had been administered [MEDICATION NAME] at the facility. On 04/20/17 at 11:34 AM, the DNS reviewed the Controlled Drug Record for [MEDICATION NAME] and could not explain why Resident #1 was documented as having received two administrations of [MEDICATION NAME] on 01/27/17 at 9:00 PM. The DNS confirmed the physical running count of the medication was accurate and the document and clinical record lacked documented evidence the medication had been wasted. The DNS confirmed the resident could have received a double administration of [MEDICATION NAME] according to the facility documentation. On 04/20/17 at 11:50 AM, the Administrator verbalized he only reviewed the Pharmacy Quality Improvement Report if the DNS notified him of issues. The Administrator admitted he had not noticed the Suggestions for Improvement from the Pharmacist #2 were identical for the past five consecutive months. On 04/20/17 at 11:53 AM, during a telephone interview, the Pharmacist #1 verbalized Resident #1's medication administration on 01/29/17 at 7:00 AM to include [MEDICATION NAME] Extended Release, [MEDICATION NAME] and [MEDICATION NAME] (muscle relaxer) all have drowsiness side effects and result in increase risk of side effects when administered together. The [MEDICATION NAME] administered at 9:00 AM and the [MEDICATION NAME] at 12:00 PM also have a drowsiness side effect. The Pharmacist #1 explained if a facility had referred a pharmacist to refer to the Controlled Drug Record to review medication administration in place of the MAR then the Quality Improvement report from the pharmacist should have identified the issue of incomplete documentation. The Quality Improvement reports from 01/2017 to 04/2017, failed to indicate Pharmacist #2 had identified the use of the Controlled Drug Record in place of the MAR as a concern for the administration of narcotic drugs in the facility. The Pharmacist #1 explained Suggestions for Improvement were expected to be discussed by the Pharmacist #2 to the Administrative team at the facility. The Pharmacist #2 would offer a plan to assist the facility with improvement. After two consecutive months without improvement from the nursing staff, the Pharmacist #2 process would be to escalate the concerns to the Administrator and/or the facility's corporate office. On 04/20/17 at 12:05 PM, the Administrator confirmed the Pharmacist #2 had not brought the Suggestions for Improvement to his attention on the occasions he had conversation with her. The Administrator verbalized he had not heard of or seen any plans for improvement or direction from the Pharmacist #2 or the corporation. On 04/20/17 at 12:18 PM, an LPN#3 confirmed she was Resident#1's nurse for her shift on 01/29/17. The LPN explained she did walking rounds at approximately 3:30 PM and observed Resident #1 resting in bed. The LPN#3 explained at about 4:30 PM a Certified Nursing Aide (CNA) attempted to get Resident #1 up for dinner and reported to LPN#3 the resident was lethargic and opening eyes a little but not waking up. The LPN took the resident's vitals and the Oxygen saturation was in the low 80s. The LPN put on a nasal canula with Oxygen and got an order from the Nurse Practitioner for a nebulizer treatment. The treatment brought the Oxygen up but not stable. The LPN explained the resident was opening her eyes but not responding. The LPN explained she received an order to transfer the resident to the hospital. Two sets of paramedics responded to the call. The second paramedic reviewed Resident #1's MAR and asked the LPN#3 if she had administered [MEDICATION NAME] to the resident. The LPN verbalized she had not considered administering [MEDICATION NAME]. The paramedics administered [MEDICATION NAME] at the facility. The LPN confirmed she had not observed Resident #1 awake during her shift. On 04/20/17 at 12:32 PM, the Administrator confirmed the Quality Assurance committee had not addressed concerns from the Pharmacist #2. On 04/20/17 at 1:25 PM, the DNS reviewed Resident #1's Controlled Drug Record for [MEDICATION NAME] and confirmed the administration on 01/25/17 at 8:00 PM followed by an administration four and a half hours later on 01/26/17 at 12:30 AM was too early according to the order for the resident to receive the [MEDICATION NAME] every six hours as needed. The DNS was unable to explain why the resident missed the scheduled administration of [MEDICATION NAME] Extended Release on 01/28/17 at 9:00 AM. On 04/25/17 at 4:40 PM, the Administrator verbalized the Pharmacist #2 had not met the requirements of a pharmacist or the pharmacist contract with the facility. Resident #1's History of Present Illness (HPI), dated 01/29/17, from the acute hospital documented when the paramedic arrived at the facility the resident was breathing at six breaths per minute. The resident received two administrations of [MEDICATION NAME] 0.5 mg IV with improvement in respiratory status and the resident's altered mental status. The physician of the acute hospital documented Resident #1's symptoms were consistent with an opiate overdose .It would seem that the patient has been receiving excessive amounts of sedating medications at her skilled nursing facility prompting her visit today .The patient's altered mental status/respiratory distress was felt to be imminently life and/or organ threatening. The Final Impression revealed Resident #1 had a polysubstance overdose, accidental or unintentional, initial encounter. Resident #5 Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5's physician's orders [REDACTED]. Resident #5's MAR, dated 01/2017, indicated the resident received [MEDICATION NAME] five times for the entire month. The reverse side of the MAR lacked documented evidence for the reason, pain level, or effectiveness of the medication. Resident #5's Controlled Drug Record for [MEDICATION NAME] revealed the resident was administered the medication 16 times in the month of January, 2017. Resident #5's physician's orders [REDACTED]. Resident #5's MAR indicated the resident received PRN [MEDICATION NAME]-[MEDICATION NAME] 0.5 mg-3 mg (2.5 mg base)/3 milliliter nebulization soln (1 vial) without a time of administration, reason, or effectiveness as follows: -01/2017 administered 2 times -02/2017 administered 5 times Resident #5's physician's orders [REDACTED]. Resident #5's MAR revealed the blood sugar was not monitored to indicate if the Humalog was necessary and lacked nurse's initials for administration and monitoring on the following dates and times: 02/08/17 at 11:30 AM, 02/10/17 11:30 AM, 02/20/17 11:30 AM, 03/02/17 4:30 PM, and 03/13/17 at 11:30 AM. Resident #5's physician's orders [REDACTED]. Resident #5's MAR for January 2017 revealed the [MEDICATION NAME] was administered 19 times at 9:00 PM without blood pressure or pulse monitoring. The MAR indicated the medication was not given on 01/30/17 and 01/31/17 due to a lack of nurse's initials for administration or lack of documentation for a reason it was missed. Resident #5's MAR for February 2017 revealed the [MEDICATION NAME] was administered 3 times at 9:00 PM without blood pressure or pulse monitoring. The MAR indicated the medication was not given on 02/05/17 at 9:00 AM and 02/24/17 at 9:00 AM due to a lack of nurse's initials for administration or lack of documentation for a reason it was missed. Resident #5's MAR for March 2017 revealed the [MEDICATION NAME] was administered 3 times at 9:00 PM without blood pressure or pulse monitoring. On 04/19/17 at 10:11 AM, a LPN reviewed Resident #5's administration of [MEDICATION NAME]. The LPN verbalized there was no way to know if the medication was administered within the set parameters if the monitoring was not done and documented on the MAR. The LPN explained the blood pressure and pulse was needed information because the result of administering [MEDICATION NAME] without monitoring could result in the resident dropping in blood pressure, becoming lethargic or dizzy. The LPN confirmed the CNAs only record the resident's vitals in the morning and the licensed nurse would have to take the vitals for the 9:00 PM medication administration. The LPN verbalized if a resident missed a necessary Humalog administration, they could become hyperglycemic or hypoglycemic. The symptoms could include shaking, diaphoretic and unconsciousness. The LPN confirmed the facility could not provide evidence medications were administered if a MAR lacked nurse's initials for administration. The LPN explained if the resident had missed the administration, the nurse was to initial and circle the nurse initials to indicate the medication was not administered. The LPN verbalized nurses were required to review the MAR and treatment records prior to leaving the facility for completed documentation, to include the reverse page of the MAR for PRN medication administration. On 04/19/17 at 1:47 PM, during a telephone interview, the Pharmacist #1 explained a nurse administering [MEDICATION NAME] without the monitoring of blood pressure and pulse was not administering medication per physician's orders [REDACTED]. On 04/20/17, in the morning, the DNS confirmed Resident #5's administration for [MEDICATION NAME] at 9:00 PM revealed a problem with documenting and monitoring of blood pressure and pulse. The DNS confirmed pain monitoring had not been completed on the MAR for the specific administration of PRN [MEDICATION NAME]. On 04/26/17 at 10:56 AM, a Licensed Nurse confirmed pain assessments should be documented on the MAR. The Licensed Nurse verbalized the monitoring of pain was important because pain could effect the resident's appetite and cause them not to eat, increased blood pressure, increased heart rate and not wanting to participate in therapy. The Licensed Nurse verbalized a scheduled and PRN medication could be administered thirty minutes prior to documented time frame on the physician's orders [REDACTED]. Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's physician's orders [REDACTED]. Resident #2's Controlled Drug Record for [MEDICATION NAME] revealed the facility administered the medication 38 times between 04/08/17 and 04/20/17. Resident #2's MAR for 04/2017 indicated the resident received [MEDICATION NAME] four times. Resident #2's physician's orders [REDACTED]. Resident #2's Controlled Drug Record for [MEDICATION NAME] revealed the facility administered the medication 9 times between 04/07/17 and 04/12/17. Resident #2's Controlled Drug Record revealed on 04/11/17 the resident was administered [MEDICATION NAME] at 2:00 PM and four hours later at 6:00 PM. On 04/12/17 [MEDICATION NAME] was administered at 11:00 AM and five hours and fifteen minutes later at 4:15 PM. The PRN medication order reflected the resident could receive the medication every six hours. Resident #2's MAR for 04/2017 indicated the resident received [MEDICATION NAME] three times between 04/07/17 and 04/12/17. One administration documented the pain assessment and none of the administrations documented the effect. Resident #2's physician's orders [REDACTED]. Resident #2's Controlled Drug Record for [MEDICATION NAME] revealed the facility administered the medication 14 times between 04/13/17 and 04/20/17. Resident #2's MAR for 04/2017 indicated the resident received [MEDICATION NAME] five times from 04/13/17 to 04/20/17. One of the administrations documented the time and none of

Based on record review, policy review, interview, and review of facility staffing, the facility failed to ensure quality care of residents. The facility failed: 1) to identify and provide prompt treatment of [REDACTED].#2, #8); 2) to ensure resident received tube feeding as ordered resulting in resident being hungry (Resident # 2); 3) to answer call light for resident with shortness of breath (Resident #13); 5) to ensure a resident was bathed (Resident #13); 4) to remove a resident from a bed pan for an extended period of time resulting in a pressure sore (Resident #6) and 5) to provide oral care (Resident #20). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3 was oriented to person, place and time. Record review revealed the resident lived in an assisted living facility prior to hospitalization and nursing facility placement. Record review of Resident #3's hospital stay revealed she presented to the emergency room of a hospital on [DATE]. The resident's Emergency Physician Record dated 12/25/12, documented the resident's coccyx area was reddened. The resident's History and Physical dated 12/25/12, revealed the resident's coccyx was reddened and recommended turning her every two hours. The resident's hospital flow sheet dated 12/25/12, revealed the resident's skin was reddened but blanchable in most areas. The resident's Discharge Evaluation and Plan from the hospital did not reveal the presence of a pressure ulcer. The resident was discharged from the hospital on [DATE] to the skilled nursing facility. Review of the facility admission record entitled "Resident-Data Collection, dated 12/28/12, revealed Resident #3 had "one pressure sore stage I (1/4") very fragile skin". Review of the resident's nurses notes dated 12/28/12, revealed "skin on sacrum thin, red/purple and stage 1". Admission physician orders dated 12/28/12 revealed "sacrum (wound care checks skin care)" but no clear treatment, other than use of a pressure pad and weekly skin checks, were written for a pressure ulcer. No further evidence of assessment, monitoring or treatment of [REDACTED]. On 3/13/13, the facility wound care nurse, Employee #3, was interviewed. The wound nurse was asked to provide evidence Resident #3 received treatment for [REDACTED].#3's record. The wound care nurse was unable to find evidence of pressure ulcer re-assessment, treatment or monitoring on 12/29/12, 12/30/12, 12/31/12 or 1/1/13. The wound care nurse reported she was keeping some residents wound documentation in her office. Review of the facility form entitled "Weekly Skin Report- Pressure Ulcers" dated 1/2/13, revealed Resident #3 had an unstageable coccyx wound measuring 2.5 cm in length, 2.7 cm width and 0 cm in depth. The wound was noted to have scant serous drainage, the wound bed was pink/beefy red and no slough was noted. A second wound evaluation was done on 1/9/13, and indicated the wound was 2.7 centimeters (cm) in length and 2.7 cm in width. No depth was recorded. The wound bed remained pink/beefy red and 85% slough was noted. Record review revealed there were no physician orders for treatment of [REDACTED]. On 1/9/13, a nurses note written by Registered Nurse, Employee #8, who did the admitting evaluation of Resident #3's coccyx area, revealed the resident had a new open wound on the coccyx. The nurses note indicated the resident's wound was cleansed, treated with Hydrogel and an Island dressing was placed. On 1/10/13, a nurse practitioner wrote an order for [REDACTED]. On 1/14/13, an order was written for a Waffle mattress for the resident's decubitus ulcer, however, no order was written at that time for cleansing, use of Hydrogel or application of the Island dressing. Review of Resident #3's treatment administration record (TAR) for January 2013, revealed an undated "order" (not supported by a physician or mid level practitioner's order) for wound care to the coccyx. The TAR revealed the resident's ulcer was to be cleansed with wound cleanser, followed by an application of Hydrogel then covered with an Island Dressing daily and as necessary until healed. The TAR revealed the resident received wound care on 1/13/13, twice on 1/14/13, 1/19/13, twice on 1/20/13 and once on 1/21/13. Additional treatments were noted on the Weekly Skin Report- Pressure Ulcers dated 1/2/13 and 1/9/13. No evidence was found to indicate the resident received daily wound care to her coccyx on 1/1/13, 1/3/13, 1/4/13, 1/5/13, 1/6/13, 1/7/13, 1/8/13, 1/10/13, 1/11/13, 1/12/13, 1/15/13, 1/16/13, 1/17/13, and 1/18/13. Review of Resident #3's TAR for January 2013 revealed a skin assessment was to be done from head to toe on a weekly basis. The TAR indicated skin assessments were not done on 1/1/13, 1/4/13, 1/8/13 and 1/15/13. On 1/22/13, the nurse practitioner at the facility wrote an order for [REDACTED]. Change QD (daily) and PRN (as necessary) times 14 days then re-eval." Record review revealed Resident #3 was not seen at a hospital wound clinic until 1/23/13. On 3/13/13, the wound care nurse was again interviewed. The nurse acknowledged Resident #3 did not receive wound care as needed until 1/19/13 and that the resident should have had a dressing change to the coccyx wound on a daily basis. The nurse acknowledged there was no physician order for [REDACTED]. On 3/13/13, Registered Nurse, Employee #8, reported she was doing resident admission assessments, including pressure ulcer assessments, over the past eight months she worked at the facility. The nurse confirmed she completed Resident #3's Resident -Data Collection on 12/28/12. The nurse reported she was not sure she staged the ulcer correctly and might have made a mistake. The nurse confirmed she wrote a note on 1/9/13 indicating the wound was new. Resident #3 was interviewed on 3/13/13 and reported she was upset the facility delayed the care of her pressure ulcer once they found it. The resident stated she could not return to her assisted living facility because her pressure ulcer did not improve fast enough. In a conversation with the wound care nurse, Employee #3, she reported the assisted living facility would only take residents with Stage II ulcers or less and the resident was denied re-admission the the assisted living due to her Stage III pressure ulcer. Review of Resident #3's admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had a Stage I pressure ulcer. The MDS revealed the resident did not have a Stage II, Stage III, Stage IV or an unstageable ulcer. The MDS indicated the resident did not receive pressure ulcer care, medications or dressings to the ulcer. Review of the facility policy and procedure entitled "Skin Integrity" effective 2/2000, revealed the nurse was to complete a weekly visual skin inspection and a progress note which was to be written in the medical record. Review of the policy entitled "Wound /Skin Evaluation and Documentation: dated 2/2000 and last revised April 2005, revealed 'The nurse completes the Wound/Skin Evaluation and Documentation form for skin ulcers/ bruises/ skin tears/wounds when identified and weekly until resolved." The policy also indicated an order for [REDACTED]. Resident #2 Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of a self reported incident dated 9/14/12 revealed that in September of 2012 a staff nurse failed to administer a tube feeding to Resident #2 on two separate days. The tube feedings were the sole source of nutrition for Resident #2, and were ordered for six [MEDICATION NAME] feedings per day. Resident #2 was below his ideal body weight and the dietary goal was to increase his weight. According to the incident report, Resident #2 complained of being hungry. Investigation of the incidents indicated they were substantiated. Resident #2 did not receive [MEDICATION NAME] feedings on the day shift of September 5, 2012 and September 7, 2012. A review of Resident #2's record of re-admission to the facility on [DATE] revealed an order for [REDACTED]. An interview with the wound care nurse on 3/12/13 revealed she had not assessed Resident #2 for wound care since his re-admission. There was no documented evidence in the record that wound care was initiated until 3/12/13 after assessment by the wound care nurse. Resident #8 Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's record revealed a weight loss of 21 pounds from admission to 2/16/13. There were no pressure sores evident on Resident #8 on admission. According to the dietary assessment Resident #8's nutritional intake was poor from the date of admission. Resident #8 developed a pressure sore on the coccyx and the heel after admission to the facility. There was no evidence of aggressive interventions to prevent the weight loss or the development of the pressure ulcers until 2/24/13. Resident #13 Resident #13, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was post-operative, on 1/15/13 she had surgery at an acute care hospital. The surgery was a right ileofemoral and popliteal thrombectomy via groin incision and right leg angiogram. The resident was alert and oriented. Discharge instructions from the acute care hospital included instructions to report "difficulty breathing even when at rest" to a physician's office immediately. Resident #13 reported to a representative from the State Elder Protective Services (EPS) that on 1/29/13, she was experiencing shortness of breath. The resident alleged she rang her call bell for three hours but no one came. After three hours, the resident called home and spoke with her son's fiancee. The fiancee called the facility administration asking they go in and check on the resident. On 3/15/13 at 2:00 PM, the fiancee indicated in interview that she immediately went to the facility to check on the resident herself and found her in bed having some difficulty breathing. The resident said staff had repositioned her and she felt better so the fiancee left reassured. The nurse on duty during this episode of shortness of breath (Employee #9), stated she arrived on duty on 1/29/13 at 6:00 AM. She went into Resident #13's room around 6:30 AM and saw the resident with her phone in her hand. The resident told her she had just called home for help because no one came when she called for three hours on her call bell. Employee #9 repositioned the resident and left the room. Employee #9 said she then returned around 9:00 AM, administered medications and changed the resident's dressing at her surgical site. When asked in interview on 3/14/13 at 8:40 AM if the resident was short of breath, Employee #9 stated "she always was". On 1/30/13 around 6:35 AM, Employee #9 saw Resident #13's blood pressure was low "in the 80's" and called the Nurse Practitioner (NP) on call. The NP told her he would be coming to the facility shortly and would check on the resident at that time. The Director of Nurses (DON) called the NP again and got verbal orders to send the resident out to the hospital. Employee #9 indicated she did not write any nurses notes on 1/29/13 or 1/30/13 or write out the transfer orders. Record review confirmed this. The DON wrote nurses notes on 1/30/13 but did not document any times so the time line of events was unclear. It was not possible to determine when the resident started having difficulties and when she was transferred out. Interviews with the DON, Assistant Director of Nurses, Employee #9, Employee #10 (a certified nursing assistant) and the resident's fiance failed to clarify discrepancies in the time line. Resident #13 was transferred to the local acute care hospital sometime on the morning of 1/30/13. She was diagnosed with [REDACTED]. Bathing Resident #13 was alert and oriented. She indicated in interview with a representative from the State Elder Protective Services and also to her family that she was not given a bath or showered during her entire stay at the facility (1/24/13 - 1/30/13). There was no documented evidence of baths having been given. A CNA who cared for the resident (Employee #10) indicated in interview on 3/12/13 at 2:00 PM, she did not bathe the resident because she believed therapists were bathing her. Resident #6 Resident #6 was admitted to the facility on [DATE] with a recent re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's medical record revealed on 11/26/12, the afternoon nurse documented the following, "Resident found on bed pan (fracture pan) from day shift. CNAs (certified nursing assistants) very upset as no CNA had reported she was on a fracture pan and did not call to inform. Yes, residents are to be checked q 2 (every two) hours but only two CNAs showed for work. One did not show up. Two pressure sores were noted, one was opened about 3/4 inch diameter, the other, just red. Resident placed in side lying position and turned q 2 hours." On 3/13/13, the registered nurse, (RN- Employee #8), who documented the event regarding Resident #6 on 11/26/12 was interviewed. The RN reported she was at her medication cart, at approximately 5:30 PM, when she heard Resident #6 call out for help. The RN reported the CNAs went into the room at that time and assisted the resident to sit up in bed for dinner. The RN then reported at approximately 7:30 PM, the CNAs came to her, very upset they had found the resident on the bed pan. The RN reported the change of shift was 2:00 PM. The resident had been on the bed pan for at least 5 1/2 hours. Review of Resident #6's minimum data set (MDS) revealed the resident required extensive assistance with most of her activities of daily living. The resident could feed herself. The resident was alert and extremely hard of hearing, but was able to make her needs known. On 12/7/12, the State ombudsman interviewed Resident #6. The resident reported to the ombudsman she had a "big sore on her butt". The resident was unable to tell the ombudsman how the sore got there, but stated, "they forgot, but they take good care of me." On 3/12/13, wound care on Resident #6 was observed. The resident continued to receive treatment for [REDACTED]. The facility staffing for 11/26/12 was reviewed. The census on 11/26/12 was 43 residents. On the day shift there was one RN, one LPN (licensed practical nurse), three CNAs, and one restorative CNA. For evenings there were two RNs, and three CNAs. On 3/13/13, the Director of Nurses (DON) and regional clinical consultant were interviewed regarding the incident of Resident #6 being left on the bedpan. The DON and regional clinical consultant confirmed the incident never should have happened. The DON explained the staffing ratio is supposed to be 10 residents to one CNA. The DON reported the investigation of the incident indicated there were two CNAs on the evening shift, and one hospitality aide. The DON reported the hospitality aide could answer call lights but was not able to assist the resident with personal care. The staffing for the evening shift on 11/26/12 was reviewed with the DON and regional clinical consultant. There was no explanation on why rounds were not made every two hours as required on Resident #6. Resident #20 Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility self -reported incident revealed family members complained Resident #20 had not received oral care, she had on a dirty shirt, hair was not combed, her bra was on backwards, brief was twisted to the side, and hearing aids were in the wrong ears. The facility investigation revealed the CNAs administering the AM care had found the dirty shirt hanging up in the closet. The CNAs reported there were no clean bras, so the bra was taken out of the dirty laundry, had front closures, but they put it on backwards by mistake. The CNAs reported they were not aware the hearing aids were in the wrong ears. One of the CNAs reported she had forgotten to do the oral care. The facility substantiated the neglect. The CNA resigned. The facility had no evidence the CNA was reported to the licensing board. The facility did not list corrective action or additional education for the facility CNAs. Review of the facility policy, Abuse, Neglect and Misappropriation of Resident Property Prohibition Policy 1.01, published November 2012, revealed the following, "Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The Nursing Center (Center) implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members and others who may have unsupervised access to residents. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. 42 CFR(Code of Federal Regulations) 483.13(b) and (c) in the State Operations Manual also include the definition of abuse, the willful deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." On 3/13/13, the DON was interviewed regarding the facility staffing. The DON explained there was usually one CNA to 10 residents. The DON reported they did not have a system to increase staffing based on acuity of the residents, for example if there were multiple isolation rooms, requiring more staff time to gown up prior to entering the rooms. The DON reported the hospitality aides counted as a CNA on the staffing hours, but the hospitality aides were not able to assist with any personal care of the residents. Review of the hospitality aide memo revealed it was instituted on Monday, September 24, 2012. The description was, "The hospitality aide is again being utilized in our facility. They are not intended to take the "place" of a C.N.A., but they are going to be used in conjunction with the C.N.A. to be able to meet our residents needs." "Here is a list of duties that a hospitality aide CAN DO...: Push a wheel chair to and from the dining room. Push a wheelchair out to the smoking area. (But the cannot supervise the smoke break). Answer a call light. Fill water pitchers, or get them ice. Pass linens and towels. Stock rooms with personal hygiene products. Sit and read to a resident, or play games. 1 on 1 for a very confused resident. Make beds. May pass trays ONLY AFTER CORRECT DIET AND RESIDENT have been VERIFIED by nursing. Here is a list of things the hospitality aide CANNOT DO...: Any direct patient care- And this means... Cannot turn residents in bed. Cannot help to transfer a resident from bed to chair, or toilet. Cannot take the resident to the bathroom, or change their. Cannot empty urinals or commodes. (Because these need to be measured and recorded). Cannot FEED residents. Cannot take care of hygiene needs (bathe, shower or brush teeth). Cannot help to dress them. Cannot chart on residents. (needs to be completed by the C.N.A.) If you have any questions, please ask (staff member names). And please help them to feel welcome in our facility. You still have your jobs to do- this will help us with the "little things" that mean so much to our residents!" On 3/13/13, the DON confirmed there had been no change in the staffing levels after the incident occurred with Resident #6 being left on the bed pan for an extended period of time. The DON reported there was a now a policy that management staff should be called in on shifts with multiple staff call offs.

Based on record review, policy and procedure review and staff interview, failed to assess, treat and/or prevent pressure ulcers for 4 of 21 residents (Resident #3, #2, #8, #6). Findings include: Resident #3 Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #3 was oriented to person, place and time. Record review revealed the resident lived in an assisted living facility prior to hospitalization and nursing facility placement. Record review of Resident #3's hospital stay revealed she presented to the emergency room of a hospital on [DATE]. The resident's Emergency Physician Record dated 12/25/12, documented the resident's coccyx area was reddened. The resident's History and Physical dated 12/25/12, revealed the resident's coccyx was reddened and recommended turning her every two hours. The resident's hospital flow sheet dated 12/25/12, revealed the resident's skin was reddened but blanchable in most areas. The resident's Discharge Evaluation and Plan from the hospital did not reveal the presence of a pressure ulcer. The resident was discharged from the hospital on [DATE] to the skilled nursing facility. Review of the facility admission record entitled "Resident-Data Collection, dated 12/28/12, revealed Resident #3 had "one pressure sore stage I (1/4") very fragile skin". Review of the resident's nurses notes dated 12/28/12, revealed "skin on sacrum thin, red/purple and stage 1". Admission physician orders dated 12/28/12 revealed "sacrum (wound care checks skin care)" but no clear treatment, other than use of a pressure pad and weekly skin checks, were written for a pressure ulcer. No further evidence of assessment, monitoring or treatment of [REDACTED]. On 3/13/13, the facility wound care nurse, Employee #3, was interviewed. The wound nurse was asked to provide evidence Resident #3 received treatment for [REDACTED].#3's record. The wound care nurse was unable to find evidence of pressure ulcer re-assessment, treatment or monitoring on 12/29/12, 12/30/12, 12/31/12 or 1/1/13. The wound care nurse reported she was keeping some residents wound documentation in her office. Review of the facility form entitled "Weekly Skin Report- Pressure Ulcers" dated 1/2/13, revealed Resident #3 had an unstageable coccyx wound measuring 2.5 cm in length, 2.7 cm width and 0 cm in depth. The wound was noted to have scant serous drainage, the wound bed was pink/beefy red and no slough was noted. A second wound evaluation was done on 1/9/13, and indicated the wound was 2.7 centimeters (cm) in length and 2.7 cm in width. No depth was recorded. The wound bed remained pink/beefy red and 85% slough was noted. Record review revealed there were no physician orders for treatment of [REDACTED]. On 1/9/13, a nurses note written by Registered Nurse, Employee #8, who did the admitting evaluation of Resident #3's coccyx area, revealed the resident had a new open wound on the coccyx. The nurses note indicated the resident's wound was cleansed, treated with Hydrogel and an Island dressing was placed. On 1/10/13, a nurse practitioner wrote an order for [REDACTED]. On 1/14/13, an order was written for a Waffle mattress for the resident's decubitus ulcer, however, no order was written at that time for cleansing, use of Hydrogel or application of the Island dressing. Review of Resident #3's treatment administration record (TAR) for January 2013, revealed an undated "order" (not supported by a physician or mid level practitioner's order) for wound care to the coccyx. The TAR revealed the resident's pressure ulcer was to be cleansed with wound cleanser, followed by an application of Hydrogel then covered with an Island dressing daily and as necessary until healed. The TAR revealed the resident received wound care on 1/13/13, twice on 1/14/13, 1/19/13, twice on 1/20/13 and once on 1/21/13. Additional treatments were noted on the Weekly Skin Report- Pressure Ulcers dated 1/2/13 and 1/9/13. No evidence was found to indicate the resident received daily wound care to her coccyx on 1/1/13, 1/3/13, 1/4/13,1/5/13, 1/6/13, 1/7/13, 1/8/13, 1/10/13, 1/11/13, 1/12/13, 1/15/13, 1/16/13, 1/17/13, and 1/18/13. Review of Resident #3's TAR for January 2013 revealed a skin assessment was to be done from head to toe on a weekly basis. The TAR indicated skin assessments were not done on 1/1/13, 1/4/13, 1/8/13 and 1/15/13. On 1/22/13, the nurse practitioner at the facility wrote an order for [REDACTED]. Change QD (daily) and PRN (as necessary) times 14 days then re-eval." Record review revealed Resident #3 was not seen at a hospital wound clinic until 1/23/13. On 3/13/13, the wound care nurse was again interviewed. The nurse acknowledged Resident #3 did not receive wound care as needed until 1/19/13 and that the resident should have had a dressing change to the coccyx wound on a daily basis. The nurse acknowledged there was no physician order for [REDACTED]. On Registered Nurse, Employee #8, reported she was doing resident admission assessments, including pressure ulcer assessments, over the past eight months she worked at the facility. The nurse confirmed she completed Resident #3's Resident -Data Collection on 12/28/12. The nurse reported she was not sure she staged the ulcer correctly and might have made a mistake. The nurse confirmed she wrote a note on 1/9/13 indicating the wound was new. Resident #3 was interviewed on 3/13/13 and reported she was upset the facility delayed the care of her pressure ulcer once they found it. The resident stated she could not return to her assisted living facility because her pressure ulcer did not improve fast enough. In a conversation with the wound care nurse, Employee #3, she reported the assisted living facility would only take residents with Stage II ulcers or less and the resident was denied re-admission to the assisted living due to her Stage III pressure ulcer. Review of Resident #3's admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #3 had a Stage I pressure ulcer. The MDS revealed the resident did not have a Stage II, Stage III, Stage IV or an unstageable ulcer. The MDS indicated the resident did not receive pressure ulcer care, medications or dressings to the ulcer. Review of the facility policy and procedure entitled "Skin Integrity" effective 2/2000, revealed the nurse was to complete a weekly visual skin inspection and a progress note which was to be written in the medical record. Review of the policy entitled "Wound /Skin Evaluation and Documentation: dated 2/2000 and last revised April 2005, revealed 'The nurse completes the Wound/Skin Evaluation and Documentation form for skin ulcers/ bruises/ skin tears/wounds when identified and weekly until resolved." The policy also indicated an order for [REDACTED]. Resident #2 Resident #2 was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. A review Resident #2's record of re-admission to the facility on [DATE] revealed an order for [REDACTED]. An interview with the wound care nurse on 3/12/13 revealed she had not assessed Resident #2 for wound care since his re-admission. There was no documented evidence in the record that wound care was initiated until 3/12/13 after assessment by the wound care nurse. Resident #8 Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #8's record revealed a weight loss of 21 pounds from admission to 2/16/13. There were no pressure sores evident on Resident #8 on admission. According to the dietary assessment Resident #8's nutritional intake was poor from the date of admission. Resident #8 developed a pressure sore on the coccyx and the heel after admission to the facility. There was no evidence of aggressive interventions to prevent the weight loss or the development of the pressure ulcers until 2/24/13. Resident #6 Resident #6 was admitted to the facility on [DATE] with a recent re-admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Resident #6's medical record revealed on 11/26/12, the afternoon nurse documented the following, "Resident found on bed pan (fracture pan) from day shift. CNAs (certified nursing assistants) very upset as no CNA had reported she was on a fracture pan and did not call to inform. Yes, residents are to be checked q 2 (every two) hours but only two CNAs showed for work. One did not show up. Two pressure sores were noted, one was opened about 3/4 inch diameter, the other, just red. Resident placed in side lying position and turned q 2 hours." On 3/13/13, the registered nurse, (RN- Employee #8), who documented the event regarding Resident #6 on 11/26/12 was interviewed. The RN reported she was at her medication cart, at approximately 5:30 PM, when she heard Resident #6 call out for help. The RN reported the CNAs went into the room at that time and assisted the resident to sit up in bed for dinner. The RN then reported at approximately 7:30 PM, the CNAs came to her, very upset they had found the resident on the bed pan. The RN reported the change of shift was 2:00 PM. The resident had been on the bed pan for a minimum of 5 1/2 hours, if she was placed on the bedpan at 2:00 PM. Review of Resident #6's minimum data set (MDS) revealed the resident required extensive assistance with most of her activities of daily living. The resident could feed herself. Interview with the resident revealed she was alert and extremely hard of hearing, but was able to make her needs known. On 12/7/12, the State Ombudsman interviewed Resident #6. The resident reported to the ombudsman she had a "big sore on her butt". The resident was unable to tell the ombudsman how the sore got there, but stated, "they forgot, but they take good care of me." On 3/12/13, wound care on Resident #6 was observed. The resident continued to receive treatment for [REDACTED]. Cross reference F 224