Every finding on record at Green Valley Health and Wellness Suites

Based on observation, interview, and document review, the facility failed to ensure dishware was sanitized by facility policy in the three-compartment sink of the main kitchen. This deficient practice had the potential to cause spreading foodborne illnesses exposing all residents who received meals from the kitchen.Findings Include:On 01/27/2026 at 7:48 AM, the quaternary ammonium sanitizer solution in the three-compartment sink measured approximately 50-100 parts per million (ppm), indicating the sanitizer solution in the three-compartment sink was low.On 01/28/2026 at 7:30 AM, the Food Service Manager indicated the quaternary ammonium sanitizer solution should be maintained between 200-400 ppm as per most health and food safety standards and manufacturer guidelines. The Food Service Manager stated the proper cleaning process included washing, rinsing, and sanitizing all utensils and equipment. The Food Service Manager stated the three-compartment sink must be tested daily.The facility's policy of titled Manual Cleaning and Sanitizing with a Three-Compartment sink, dated 10/15/2025, documented immersion for at least one minute in a clean solution of 150-200 ppm of quaternary ammonium 75 Fahrenheit or hotter.

Based on interview, record review and document review the facility failed to ensure informed consent was obtained prior to administration of psychotropic medications for 1 of 48 sampled residents (Resident 14). The deficient practice had the potential for the residents to not be informed of risk, benefits, and potential side effects of the medication.Findings include: Resident 14 (R14) was admitted on [DATE] with diagnoses including metabolic encephalopathy, depression, and unspecified mood disorder.A Physician Order dated 01/12/2026 documented Duloxetine (an antidepressant medication) capsule, delayed release, 30 milligrams (mg) twice a day.R14's medical record lacked documented evidence informed consent was obtained prior to the first administration of duloxetine on 01/12/2026.On 01/28/2026 at 4:40PM, the Director of Nursing (DON) confirmed R14's medical record lacked consent for Duloxetine.On 01/29/2026 at 10:34 AM, a Licensed Practical Nurse (LPN) explained a consent for psychotropic medication was required prior to the administration of the medication.On 01/30/2026 in the afternoon, the Director of Nursing explained the expectation was for staff to obtain a consent for psychotropic medication prior to administration. The facility policy titled Medication Management, Psychotropic Drugs-Use of, revised 04/17/2025 documented a consent form would be completed for each psychotropic medication prescribed.

Based on observation, interview, record review, and document review, the facility failed to ensure a comprehensive person-centered care plan for activities was created for 1 of 48 sample residents (Resident 1). The deficient practice had the potential for residents not to receive care and services in accordance with assessed needs. Findings include:Resident 1 (R1) was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, pleural effusion, and hypothyroidism. R1 was on contact isolation.On 01/27/2025 in the morning, R1 enjoyed working on puzzles. R1 had not attended activities and was unaware of what activities the facility offeredR1's medical record lacked a care plan for activities which outlined specific interventions with measurable goals to promote R1's quality of life.On 01/30/2026 at 9:30 AM, an Activity Aide completed an activity assessment for R1 upon admission. The Activity Aide was unaware of the staff member responsible for completing the activity care plan.On 01/30/2026 at 9:35AM, the Minimum Data Set (MDS) Director confirmed R1 lacked an activity care plan and explained the activity care plan should have been completed within 14 days of admission and was unaware of the staff member responsible for completing the activity care plan.The facility policy titled Care Plan Process, Person-Centered Care, revised 05/05/2023, documented person-centered care plan includes trying to understand what each resident was communicating and identifying what was important to each resident regarding daily routines and preferred activities.

Based on observation, interview, record review and document review, the facility failed to obtain a physician order for the use of a knee brace for 1 of 48 sampled residents (Resident 14). The deficient practice had the potential to result in discomfort, impaired circulation or skin breakdown.Findings include:Resident 14 (R14) was admitted on [DATE] with diagnoses including metabolic encephalopathy, depression, displaced transverse fracture of left patella, and unspecified mood disorder.On 01/27/2026 in the morning, R14 had knee brace lying on top of the dresser located at the foot of R14's bed.A Physician Order dated 11/24/2025 documented Restorative Nursing Services: passive range of motion to left lower affected side, non-weight bearing left lower side, active range of motion to upper extremities and to unaffected lower right side, at least 6 days per week.On 01/30/2025 at 9:18 AM, the Restorative Nurse Assistant (RNA) explained R14's knee brace originally came from physical therapy, and the brace was applied by RNA services. The RNA explained R14 frequently refused the use of the brace due to pain and would yell for the brace to be removed.R14's medical record lacked a physician order, RNA notes, and care plan for the knee brace.On 01/30/2026 in the morning, the Medical Records Director confirmed R14's medical record lacked documentation of RNA services provided, a physician order for the knee brace.On 01/30/2026 at 9:22AM, the Unit Manager confirmed R14 required a physician order for knee brace.The facility policy titled Physician Orders, revised 05/05/2023, documented the facility has physician orders for the resident's immediate care to include but not limited to routine care orders to maintain or improve the resident's functional abilities.The facility policy titled Restorative Nursing, revised 10/25/2024, documented restorative program approaches and interventions are included in the plan of care. The interventions and results are documented.

Based on observation, interview, record review, and document review the facility failed to ensure it was free of a medication error rate of less than five percent (%) for 2 of 48 sampled residents (Resident 74 and Resident 86). The deficient practice posed a potential risk of injury or harm to the residents.Findings include:On 01/29/2026 in the morning, a Medication Administration Pass observation was performed with 28 opportunities observed with two errors. The medication error rate was 7.14%.1) Resident 74 (R74) was admitted on [DATE] with diagnoses including displaced fracture of lateral condyle of left femur, unspecified protein calorie malnutrition, and atrial fibrillation.On 01/29/2026 at 7:50AM, during the Medication Administration Pass observation the Licensed Practical Nurse (LPN) prepared and administered R74's scheduled morning medications.A Physician Order dated 01/07/2026 documented Azelastine spray 137 micrograms (mcg), two nasal sprays once a day at 8:00AM.R74's Azelastine spray was not administered per physician order.On 01/29/2026 at 9:53 AM, the LPN confirmed the physician order for Azelastine spray and explained the medication had been overlooked and should have been administered as ordered.2) Resident 86 (R86) was admitted on [DATE] with diagnoses including sarcopenia, pressure ulcer of right buttock stage three, and generalized muscle weakness.On 01/29/2026 at 8:57AM, during the Medication Administration Pass observation the LPN prepared and administered R86's scheduled morning medications.A Physician Order dated 01/01/2026 documented Lovenox 40 milligrams (mg) subcutaneously (SQ) once a day at 8:00AM.R86's Lovenox was not administered per physician order.On 01/29/2026 at 9:53AM, the LPN confirmed the physician order for Lovenox and explained the medication had been omitted and should have been administered as ordered.The facility policy titled Medication Management Program, revised 01/15/2025, documented the authorized staff member administers medications according to accepted standards of practice and incompliance with regulatory requirements.

Based on observation, interview, record review and document review the facility failed to 1) ensure medications were secured for 1 of 48 sampled residents (Resident 67) and 2) expired multi-dose vial of medication was disposed. The deficient practice had the potential risk of unauthorized access to medication, or misuse of medication within the facility and potential for the facility staff to administer expired medications.Findings include:1) Resident 67 (R67) was admitted on [DATE] with diagnoses including recurrent dislocation of right hip, acute osteomyelitis of right femur, and fibromyalgia.On 01/27/2026 at 7:52 AM, R67 had one 10-ounce (oz) spray bottle of 91 percent (%) Isopropyl alcohol, a spray bottle of Hydrogen Peroxide, and one 10 oz bottle of Mylanta on the overbed table.On 01/30/2026 at 7:48 AM, R67 had one 10oz spray bottle of 91% Isopropyl Alcohol, a 10oz bottle of Mylanta, and one tube of Neosporin on top of the overbed table. R67 explained being able to use the Isopropyl Alcohol and Neosporin for skin scrapes and the Mylanta only if needed for heartburn.R67's medical record lacked a medication self-administration assessment and physician's order for 91% Isopropyl Alcohol, Mylanta and Neosporin. On 01/30/2026 at 7:50AM, the Director of Nursing (DON) confirmed findings and explained Certified Nurse Assistants (CNAs) and nurses should remove medications from the resident's bedside when observed. The DON explained the process for a resident to keep medications at bedside was to conduct a medication self-administration assessment and obtain a physician order for the medications to remain at bedside.2) On 01/30/2026 at 8:20 AM, during a tour of the second-floor medication storage room with the Unit Manager, an open one milliliter (ml) multi-dose vial of Tuberculin Diluted Aplisol dated 11/27/22025 was in the medication refrigerator. The Unit Manager explained the medication should have been discarded within 30 days of opening.The facility policy titled Medication Storage, General Guidelines for Storage of Medication and Biologicals, revised 04/17/2024, documented outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock and disposed of according to procedures for medication destruction.

Based on interview and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee included the Medical Director. The deficient practice had the potential to delay quality improvement actions leading to problems going unaddressed, delayed correction actions or risks not being mitigated.Findings include:The Quality Assessment and Assurance Meeting Minutes documented the Medical Directed did not attend on 01/16/2025, 03/27/2025, 04/25/2025, 05/22/2025, 06/24/2025, 08/28/2025, 10/16/2025 and 01/15/2026.On 01/30/2026 at 11:30 AM, the Administrator confirmed the Medical Director had not been attending the QAPI meetings. The Administrator explained the Medical Director had scheduling conflicts and did not attend the meetings at least quarterly.The facility's policy titled Leadership Framework revised 12/03/2019 documented the facility (QAA) committee team will meet at least monthly to meet the demands of identified facility needs and will be composed of at a minimum, the Administrator, Director of Nursing, Medical Director or Designee, Infection Control Officer, and individual in leadership role.

Based on interview, record review, and document review, the facility failed to ensure a resident was not involuntarily discharged without a valid reason, when a resident returned to the facility after a therapeutic leave and was not allowed to reenter the facility, for one of two sampled residents (Resident 2). The deficient practice had the potential to cause residents to experience adverse effect such as mental distress and unmet medical needs. Findings include:The facility policy titled Against Medical Advice (AMA) -Day Outing/Therapeutic Leaves of Absence indicated a resident may leave for a day outing or therapeutic leave of absence (LOA) with family and friends at any time during their stay with written permission from their physician. If the physician denied permission, then the patient may elect the right to sign out against medical advice. The facility policy titled Discharge /Transfer, dated 10/23/2019, indicated for involuntary discharge, the facility would develop a safe discharge plan, including but not limited to securing an alternate location, and have the discharge plan approved by the resident or guardian, obtain a physician order for discharge, complete and provide a written notice of transfer/discharge to the resident and the Office of the State Long-Term Care Ombudsman. Resident 2 (R2) was admitted on [DATE] with diagnoses including congestive heart disease and muscle weakness. The resident was discharged on 07/02/2025. The type of discharge was listed as against medical advice (AMA). R2's admission Minimum Data Set (MDS), dated [DATE], indicated R2 had good memory function and no behaviors. The MDS indicated the resident was able to transfer and ambulate independently. A Physician Order dated 06/20/2025 indicated the resident may go on pass on their own risk for up to four hours at a time. The order indicated the resident should inform staff with as much advance notice as reasonably possible. A Discharge Summary Note, dated 07/02/2025, entered as a late entry on 07/12/2025, indicated the resident was discharged AMA. The Discharge Summary indicated R2 left on pass. The Discharge Summary indicated R2 was discharged AMA due to facility policy for noncompliance to 4-hour pass rule.A Voluntary Discharge Notification Against Medical Advice and Release of Liability Form, dated 07/02/2025, indicated the form lacked a diagnosis. The form indicated R2 was in violation of a four-hour pass per provider order and facility policy. The form indicated Pt didn't sign. A Nursing Progress Note dated 07/02/2025, and documented at 9:30 PM, indicated the AMA form was not signed by R2. The note indicated the resident violated a four-hour pass order from the provider and had violated facility policy. The note indicated R2 had left with the person that drives him when he goes out on pass with belongings in hand.A Nursing Noted dated 07/02/2025, and documented at 8:34 PM, indicated the Assistant Director of Nursing (ADON) had called the writer and asked if R2 was in the building back from the four-hour pass. The note indicated R2 had not returned to the facility. The ADON instructed the writer not to let the patient back into the building except to give the resident their belongings and if resident refused to leave and became a problem to call the police. The note indicated R2 returned at 9:15 PM. The note indicated R2 was given belongings and informed the resident could not stay at the facility any longer because the resident had abused the four-hour pass. The note indicated R2 was unhappy and stated it was not right that the facility was kicking the resident out. The note indicated R2 called someone and asked to be picked back up because of being told that the resident could not stay at the facility anymore. The note indicated the person arrived and R2 left with this person at 9:30 PM.On 09/18/2025 at 9:52 AM, the Assistant Director on Nursing (ADON), verbalized R2 had been discharged from the facility on 07/02/2025. The ADON reported the facility had experienced an ongoing problem with R2 going out on a four-hour pass and not returning on time. The ADON reported R2 would leave the facility without telling anyone. The ADON verbalized on 07/02/20254, R2 went out for pass in the morning, and was supposed to return around noon. The ADON reported R2 returned to the facility about 9:30 PM. The ADON reported when finding out the resident had not returned timely, the ADON instructed staff to pack the resident's belongings and put them in the lobby, and not to let the resident come back into the facility. The ADON instructed staff that when R2 arrived, they were to hand the resident the belongings and not to allow the resident to come into the building. The ADON indicated staff informed the resident because the ADON verbalized the facility policy and procedure directed if a resident was not back from a four-hour pass within four hours, it was to be considered an AMA discharge. The ADON revealed a resident wanting to leave against medical advice would be asked to sign a form before leaving the facility. The ADON revealed R2 did not sign the AMA form. On 09/18/2025, at 10:32 AM, the Case Manager, revealed on admission R2 was going to be long term. The Case Manager verbalized R2 was a long-term resident. The Case Manager reported R2's four-hour leave pass was enough time to do what the resident wanted to do. The Case Manager indicated the four-hour pass time limit was so that missed doses of medication were not an issue. The Case Manager indicated an involuntary discharge could be due to non-compliance. The Case Manager indicated for an involuntary discharge a written notification would be provided 30 days in advance, if the resident was determined to be not appropriate for the facility. On 09/19/2025, in the afternoon, the Director of Nursing (DON) stated for an involuntary discharge for a situation where the resident was non-compliant, the facility would give a thirty-day notice of intent to discharge, and this would also be given to the Long-Term Ombudsman. The DON verbalized these notifications were not provided to R2. The DON stated R2 had been warned verbally not to come back late from therapeutic leave pass and continued to be non-compliant. The DON verbalized R2 was not discharged AMA as described as the resident did not want to leave the facility. The DON verbalized the resident had been given many opportunities to correct the non-complaint behavior but did not do so. The DON verbalized the facility was frustrated with the resident's continued non-compliance and therefore determined R2 should not be allowed to return to the facility. The DON verbalized under normal circumstances R2 would have been furnished with a 30-day notice of intent to perform an involuntary discharge. The DON indicated R2 had been manipulative and had not been answering their cell phone while out on pass, and this had led to the facility not letting the resident come back to the facility. The DON verbalized the resident had not wanted to leave the facility. The DON verbalized the resident had been argumentative, aggressive, and cursing in the lobby area. The DON verbalized at that point we did not consider him a patient anymore. The DON verbalized, not considering the discharge unsafe as the resident had no problem staying out of the facility for many hours and did not need the services of the facility. On 09/18/2025 at 11:05 AM. the Licensed Practical Nurse (LPN) reported when discharging a resident against medical advice, staff must educate the resident on the dangers of leaving the facility and explain the risk versus benefits. The LPN verbalize R2 knew the rules about going out on pass. The LPN verbalized explaining the need to come back to the facility within four hours to R2 multiple times, and R2 stated understanding. The LPN verbalized despite this the resident stayed out late on pass multiple times.On 09/18/2025, in the afternoon, the Administrator (ADM) stated the facility did not have a written policy to discharge a resident AMA if they exceeded the time limit of out on pass. Facility staff who had stated this had been mistaken. The ADM did not know why staff thought the facility had this policy. The ADM verbalized R2 should have been furnished with a 30-day notice of intent to discharge, and the Ombudsman should have been notified as well. The ADM verbalized the facility had multiple opportunities to address R2's non-compliance with coming back timing from out on pass. The ADM verbalized the facility had become frustrated and did not allow the resident to return. Complaint 2572306

Based on observation, interview, and document review, the facility failed to ensure infection control practices were maintained for 2 of 3 unsampled residents (Resident 6 and Resident 7). The deficient practice had the potential to increase risk of cross-contamination, spread infectious diseases, and compromise health and safety for residents. Findings include: Resident 6 (R6) On 04/17/2025 at 8:28 AM a Certified Nurse Assistant 1 (CNA) was inside R6's room with gloves on picking food off R6's chest and placing it onto a meal tray. The CNA 1 picked up the meal tray and exited R6's room. R6 had a sign posted to the left of the door which documented the following: -Contact Precautions providers and staff must: put on gloves and gown before room entry and discard gloves and gown before room exit. The CNA 1 acknowledged the posted sign and explained not having had education on infection control and was just entering the room quickly to pick up the meal tray. The CNA 1 explained being unsure of what infection R6 had and explained a gown should have also been worn as indicated on the sign. On 04/17/2025 at 09:00AM, a Licensed Practical Nurse (LPN) and a Certified Nurse Assistant 2 (CNA 2) were observed entering R6's room with no gloves or gown. A Registered Nurse confirmed the observation explaining the staff should have donned a gown and gloves prior to entering the room. On 04/17/2025 at 1:25 PM a housekeeper was in R6's room mopping with no gown. The housekeeper explained having received training on infection control and was instructed to follow the signs posted but was just mopping the room and did not think a gown was required. The housekeeper read the signage posted on the entry of R6's room and confirmed a gown should have been worn. Gloves and gowns were available and hanging on the outside of R6's room door. Resident 7 (R7) On 04/17/2025 at 7:35 AM, a Registered Nurse (RN) explained residents with Enhanced Barrier Precautions (EBP) signs required staff to put on personal protective equipment prior to entering the resident room. On 04/17/2025 at 8:35 AM, R7's room door was closed. R7's room had a sign posted to the left of the door which documented the following: Enhanced Barrier Precautions providers and staff must wear gloves and gown for the following high-contact resident care activities: -Dressing -Bathing/Showering -Transferring -Changing linens -Providing hygiene -Changing briefs or assisting with toileting -Device care or use: central line, urinary catheter, feeding tube, tracheostomy -Wound care: any skin opening requiring a dressing Upon knocking on the door, a Certified Nurse Assistant 3 (CNA 3) opened the door. standing at the door threshold with gloves and explained providing care. Another Certified Nurse Assistant 4 (CNA 4) was in the middle of R7's room without gloves or gown standing beside R7 who was seated in a shower chair. CNA 3 explained being a new employee and having received infection control training. CNA 3 acknowledged the sign posted at the entry of R7's room and explained having had a gown on but had removed it in the room. CNA 4 explained having had a gown and gloves on and had removed them in the room after preparing R7 for transport to the shower room. CNA 4 stated being unsure about being able to wear a gown and gloves in the hallway to transport R7. A Registered Nurse present outside of R7's room explained staff would need to have a gown and gloves on to assist R7 to the shower and while performing tasks such as transfers, bathing, and transport. Gloves and gowns were available and hanging on the outside of R7's room door. On 04/17/2025 at 2:00 PM, the Infection Prevention Nurse (IP) explained staff were educated upon hire in orientation and throughout the year regarding infection control and prevention. The expectation was for staff to adhere to signage posted outside the resident room as it was specific to the resident's individual needs. Staff were to avoid the use of personal protective equipment (PPE) such as gloves and gowns in the hallways and PPE was to be removed at the threshold of the resident room prior to staff exiting. The IP explained residents on Enhanced Barrier Precautions required PPE to be utilized during high touch patient care activities. The IP explained picking food off a resident would be a high touch activity requiring PPE. The IP confirmed a housekeeper entering a contact isolation room would need to utilize PPE as listed on the signage. The IP explained the expectation was for staff to follow the signs posted as it would cause a risk for spreading infections by not using the appropriate PPE. The facility policy titled Infection Prevention and Control, revised 05/15/2023, documented the facility would post clear signage on the door or wall outside of the room indicating the type of precautions and required PPE. The facility would perform periodic monitoring and assessment of EBP procedures to determine additional training and education.

Based on observation, interview and document review, the facility failed to ensure that medications were secured for 1 of 3 unsampled residents (Resident 5). The deficient practice had the potential risk of unauthorized access to medication, or misuse of medication within the facility. Findings include: Resident 5 (R5) R5 was admitted on [DATE] with diagnoses including cellulitis of right lower limb, type 2 diabetes mellitus with hyperglycemia, and difficulty in walking. A physician order dated 11/02/2024 documented Latanoprost drops 0.005% administer one drop to both eyes at bedtime. On 04/17/2025 at 7:57 AM, R5 had a prescription bottle on the bedside table labeled Latanoprost 0.005% with directions to apply one drop to both eyes at bedtime. R5 explained the nurse had left the medication on the bedside table the previous night. On 04/17/2025 at 8:05 AM, a Licensed Practical Nurse (LPN) confirmed the medication was present at R5's bedside and removed the medication from the resident's room explaining the medication should be stored in the medication cart due to the medication having specific administration times and it was also a safety issue to ensure others do not obtain the medication. On 04/17/2025 at 4:21PM the Director of Nursing explained medication was not to be left at the bedside and would need to be secured in the medication cart. The DON explained if the medication was not secured staff would not be able to ensure the medication was administered as per the physician orders. The facility policy title Medication Storage, revision date 04/17/2024, documented in accordance with State and Federal Laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity.

Based on interview and document review, the facility failed to ensure resident grievances were investigated and a determination, and/or resolution, was provided to the residents. This deficient practice had the potential to result in a resident having unresolved complaints/grievances. Findings include: On 04/17/2025 in the afternoon, the Social Worker (SW) verbalized the Activity Director takes the issues presented in the Resident Counsel Meeting Minutes and turns them into Grievances by inputting them into the Grievance program on the computer. Since there were a lot of new staff, not everyone had access to go into the computer to input the investigation and resolutions of the grievances. The SW also stated there was no documentation of investigations and/or resolutions for the grievances which needed to be inputted into the Grievance computer program. The Resident Council Meeting Minutes dated 02/19/2025, documented unresolved old issues of night shift not doing rounds every two hours and staff being aggressively rude to residents on night shift. New issues included: agency nurse not giving medication on time to room [ROOM NUMBER]B on dayshift, call lights not answered for at least two hours, and ice water not being passed on both shifts. The January and February Grievance Logs documented the following were unresolved: On 01/15/2025 Multiple residents mentioned CNA was mean with attitude and takes naps in dayroom on the couch while delegating duties to other staff. This CNA also does not like to give showers. This CNA also only changed residents one time through the night when supposed to check residents every two hours. On 02/19/2025 Ice not being passed on both shifts On 02/19/2025 Call lights not answered for at least two hours by staff On 02/20/2025 Resident stated when agency nurse was here, they were always late with their anxiety medication on the day shift. The Resident Council Meeting Minutes dated 03/19/2025, documented unresolved old issues of call lights not answered and ice water was not passed every shift. New issues included: Rooms 236A, 207B, 231B, and 237A were soaked with urine; staff stole perfume and body wash and the call lights took too long to be answered; night shift did not change residents every two hours, staff only changed resident once and then had to wait to the next shift to be changed; staff were sleeping on night shift; some CNAs and Nurses could be rude on night shift; residents asked for snacks and hot tea and were told the facility was out; room [ROOM NUMBER]A saw staff take snacks from their room. The March Grievance Log documented the following were unresolved: On 03/19/2025 Were soaked up their backs with urine from not being changed for room [ROOM NUMBER]A On 03/19/2025 Were soaked up their backs with urine from not being changed for room [ROOM NUMBER]B On 03/19/2025 Were soaked up their backs with urine from not being changed for room [ROOM NUMBER]B On 03/19/2025 Were soaked up their backs with urine from not being changed for room [ROOM NUMBER]A On 03/19/2025 Staff stole resident perfume and body wash and sodas from room [ROOM NUMBER]A On 03/19/2025 Call Bells took too long to answer On 03/19/2025 Staff slept on night shift in the cubby hole On 03/19/2025 The resident in room [ROOM NUMBER]A saw staff take snacks from their drawer On 03/19/2025 Night shift did not change resident every two hours and changed them at 7:30pm and would not get changed again until 5:30am. On 04/17/2025 in the afternoon, the Director of Nursing (DON) verified there was no documentation of investigations and/or resolutions for the grievances which needed to be inputted into the Grievance computer program. The DON was able to provide All Staff Meeting Agendas for February and March where resident rounding, respectfulness, tardiness, and call lights were talked about. The DON was not able to provide sign in sheets for those attending the All-Staff Meetings. The facility was unable to provide the documented evidence for grievance investigations/resolutions which included: 1. The steps taken to investigate the grievance 2. A summary of the pertinent findings or conclusions regarding the resident's concerns(s) 3. A statement as to whether the grievance was confirmed or not confirmed 4. Any corrective action taken or to be taken by the facility as a result of the grievance and the date the written decision was issued The facility policy titled, Complaints/Grievances Process, revised 10/23/2019, documented after receiving a grievance/complaint, the facility's Leadership will seek a problem resolution and will keep the patient/resident informed of the progress towards resolution.

Based on interview, record review, and document review, the facility failed to ensure a resident who had functional impairments was appropriately discharged for 1 of 4 sampled residents (Resident 4). This failure could potentially lead to medical complications or adverse events which could result in hospitalization, prolonged illness, or even death. Findings include: Resident 4 (R4) R4 was admitted to the facility on [DATE] and discharged home on [DATE], with diagnoses including fracture of shaft of humerus of right arm, chronic obstructive pulmonary disease, cerebral infarction, and chronic atrial fibrillation. A Notice of Medicare Non-Coverage (NOMNOC) document was issued to R4 on 12/09/2024. Neither the family of R4 or R4 themselves, had filed an appeal at this time. On 04/17/2025 at 08:15 AM, a Case Manager (CM) stated responsible for the resident discharges. The CM revealed had gone to R4 on 12/9/2024 to explain the NOMNOC to R4 and to get R4 to sign the document. R4 declined the appeal process as R4 was fine with going home. The discharge plan was always for R4 to go home. The plan included R4 discharging home with support from a friend, home health, and the Aging and Disability Service Department (ADSD) Worker. A family member had concerns with the discharge plan of R4 returning home alone but understood R4 wanted to go home and not to a group home and could not afford assisted living or long-term care. The ADSD Worker said would assist in making the appointments for R4 and would set up the home services for R4. It was also discussed with the ADSD worker R4 did not need any medical equipment as R4 had a wheelchair, front wheeled walker, and commode at home already. The CM affirmed the nurse gave R4 the medication punch cards and went over when and how to take those medications. The nurse had R4 sign for the medication punch cards. The CM explained had went over the discharge instructions with R4 and R4 had signed the form indicating staff had gone over the instructions, and everything was placed in a green folder for R4 to take home. A Care Conference Note on 12/04/2024 documented R4 desired to discharge back home to the address on file where R4 lives alone. However, R4 had support from the best friend. Home Health and State of NV Aging and Disability Health Care Worker will provide resources and assistance for R4 upon discharge. A Modified Data Set (MDS) assessment which was completed on 12/13/2025, documented R4 had no communication deficits, no memory issues, was alert and oriented, had no problems with decision making, and had no mood or behavioral issues. A Brief Interview for Mental Status (BIMS) assessment was completed, and R4 scored 15/15 indicating intact cognition. On 04/22/2025 in the morning, a Aging and Disability Services Division (ADSD) worker stated ADSD workers are not case managers and do not set up home health services. The ADSD worker revealed it was never told to the facility case manager the ADSD worker would set up Home Health Services or any physician appointments. The ADSD worker stated had received the referral for this resident and then went to meet the resident at this facility. The ADSD worker stated had never met each other before meeting at this facility. The ADSD worker affirmed the family member was upset in the way the relative was sent home. The ADSD worker revealed R4 was unable to provide the ADSD worker with any discharge summary, discharge instructions or medications in order to review the medication instructions. The ADSD worker also revealed R4 was sitting on the couch upon entering R4's house and R4 was physically unable to move from the couch. An Occupational Therapy Evaluation dated 11/27/2024 noted R4 required moderate assistance to complete bathing, toileting, and lower body dressing. Occupational Therapy Treatment Encounter Notes documented R4 remained needing moderate assistance to complete bathing, toileting, and lower body dressing on 12/09/2024 and 12/10/2024. The Occupational Therapy discharge evaluation dated 12/12/2024 noted R4 now only required contact guard assistance to complete bathing, toileting, and lower body dressing. This Occupational Therapy discharge evaluation recommended only an assistive device for safe functional mobility was needed. On 05/07/2025 at 09:20 AM, a Certified Occupational Therapist Assistant (COTA) stated R4 was non weight bearing on the right upper extremity and was wearing a sling at all times. R4's weight bearing had not changed during the entire stay. The last notes placed R4 at moderate assistance needed for bathing, toileting, and lower body dressing due to this non weight bearing restriction. On 05/07/2025 at 10:20 AM, the Director of Rehabilitation (DOR) stated R4 was using a front wheeled walker with one arm, the left upper extremity, and was doing fine with it as R4 was contact guard assist and sometimes supervision using the assistive device this way. When R4 was told were going home alone and told to show the therapist what the resident could do, this was how the therapist got the last documented assistance R4 required. R4's issues were only endurance and stamina. R4 was sent home from Occupational Therapy as a set up/contact guard assist level with recommendations for an assistive device for mobility safety. The DOR revealed no home health was recommended by Occupational Therapy, Physical Therapy would have recommended Home Health for the resident and Occupational Therapy should have recommended Home Health for the resident due to the resident's functional levels needing hands on assist for bathing, toileting, and lower body dressing. The facility lacked any documented evidence the CM had set up Home Services like Home Health for nursing or therapy services on the discharge of R4 from the facility despite a physician order dated 12/10/2024 for the resident to be discharged home with home health services to include skilled nursing, Physical Therapy, and Occupational Therapy. On 05/07/2025 at 12:57 PM, the Administrator confirmed the clinical team coordinates with the provider, social services, and the case managers to make sure the facility discharges are safe and appropriate in coordination with the resident and/or the resident's representative. If a third party stated would assist with the discharge/discharge plan, it would be expected social services/case management would follow up to make sure the items and services were set up for the resident prior to discharging from the facility. The facility policy titled Discharge Planning revised 06/09/2023, documented all residents would be discharged from the facility by order of the attending physician in a safe, secure, and correct manor. The Social Services Staff would provide and coordinate for the resident referrals for home health, durable medical equipment, and other community resources and document these efforts in the medical record. Complaint #NV00073436

Based on interview, record review and document review, the facility failed to ensure a discharge summary was completed for 1 of 4 sampled residents (Resident 2). The deficient practice had the potential for the facility failing to provide the necessary information to continuing care providers pertaining to the course of treatment while the resident was at the facility and the resident's plan of care after discharge. Findings include: Resident 2 (R2) R2 was admitted on [DATE] and discharged on 03/31/2025 with diagnoses including Friedreich ataxia, unspecified symptoms and signs involving cognitive functions and awareness, and functional quadriplegia. A progress noted dated 03/31/2025 documented 911 was called to the building to transfer resident, asking if R2 had a place to go when discharged and R2 stated did not want to return to this facility. The ambulance attendants were given R2's face sheet and list of medications. R2 was transferred to hospital. R2's medical record lacked documented evidence a discharge summary was completed for the resident. On 04/17/2025 at 4:00 PM, the Medical Records staff confirmed there was no discharge summary for R2. On 04/17/2025 at 4:15 PM, the Director of Nursing (DON) explained a discharge summary was a recapitulation of the residents stay. The Director of Nursing confirmed R2 should have had a discharge summary completed. The facility policy titled Discharge Summary, complete revision date 06/09/2023, documented the discharge summary was completed when the resident was permanently discharged for any reason and return to the facility was not anticipated.

Based on record review and interview, the facility failed to ensure medication was administered per physician order for 1 of 4 sampled residents (Resident 2). The deficient practice had the potential for the resident not achieving the therapeutic effect (specific and desired effect) of the medication. Findings include: Resident 2 (R2) R2 was admitted on [DATE] and discharged on [DATE] with diagnoses including Friedreich ataxia, unspecified symptoms and signs involving cognitive functions and awareness, and functional quadriplegia. A physician order dated 03/25/2025 documented Clonazepam 0.5 milligrams (mg) one tablet oral twice a day at 8:00AM and 8:00 PM. The Medication Administration Record for 03/25/2025 at 9:21PM documented Clonazepam 0.5 mg one tablet oral twice a day at 8:00 AM and 8:00PM not administered: drug/item unavailable Comment: New admit. Awaiting delivery from pharmacy. Will give upon arrival per hospice. On 04/17/2025 at 11:26 AM, a Pharmacist confirmed the pharmacy received the Clonazepam order on 3/25/2025 at 8:14PM. The medication order was filled and delivered to the facility on [DATE] at 9:44PM. On 04/17/2025 at 1:40PM, a Licensed Practical Nurse (LPN) explained the facility had an Omnicell (an automated medication dispensing system) stocked with medications for staff to access if medications were needed. The LPN explained to access the Omnicell staff would call the pharmacy to verify the medication order and get a code, two nurses would then enter the information and code into the Omnicell to obtain the medication. At 1:50 PM, the LPN showed the location of the Omnicell and reviewed the Omnicell inventory list located in a white binder on the side of the Omnicell machine. The LPN confirmed the inventory list documented Clonazepam 0.5mg was available with a supply stock of six tablets in the Omnicell. On 04/17/2025 at 4:20 PM the Director of Nursing (DON) explained medication administration was to be recorded and would be indicated on the Medication administration record (MAR). The DON explained the medication for R2 could have been obtained from the Omnicell or administered after pharmacy delivered the medication. The DON explained staff would need to contact the physician to clarify administration due to the delivery of the medication occurring more than an hour after the scheduled administration time. The DON confirmed the medication had not been administered.

Based on observation, interview, record review, and document review, the facility failed to ensure a peripherally inserted central catheter (PICC) line dressing care was changed for 1 of 3 sampled residents (Resident 1), and a physician order for flushing protocol was obtained, transcribed, and implemented for 1 of 3 sampled residents (Resident 2). The deficient practice had a potential for a resident to develop an infection from poor maintenance of an intravenous site and a potential for catheter occlusion. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including diabetes mellitus and chronic hepatitis. The Admission Minimum Data Set for Brief Interview for the Mental Status dated 01/17/2025, documented a score of 15/15, which indicated R1's cognitive status was intact. On 02/04/2025 at 11:21 AM, R1 was seated in a wheelchair with a PICC line in the right upper arm. The dressing was undated, peeling, and soiled with dried, reddish-brown blood-like residues. R1's medical records lacked documented evidence a physician order for the maintenance of the dressing changes was obtained, transcribed, and implemented. On 02/04/2025 at 11:21 AM, a Registered Nurse (RN) confirmed the observation and explained a dressing change was attempted, but a PICC line dressing kit was unavailable. The RN explained the dressing should have been changed weekly, and failure to do so increased the risk of infection. The RN verified and confirmed there was no order for a dressing change or documentation of the actual insertion date existed. The RN indicated R1 was admitted on [DATE] with a PICC line, which was later dislodged on 01/16/2024, and replaced as ordered. On 02/04/2025 in the afternoon, R1 verbalized the previous PICC line was in the left upper arm, was dislodged, and a new PICC line on the RUA had been inserted for more than a week, flushed only twice, and the dressing had not been changed since it was inserted. R1 expressed a desire for a dressing change as it was soiled and peeling off. On 02/04/2024 at 3:25 PM, the interim Director of Nursing (DON) indicated the PICC line dressing change protocol required changes every 7 days from the date it was last changed. The DON explained the PICC line dressing should have been dated to determine the next scheduled change. The DON verified and confirmed there was no physician's order in place for the PICC line weekly dressing change for R1. The DON acknowledged without the order, the licensed nurses would not have been prompted to complete or implement the task. Resident 2 (R2) R2 was admitted on [DATE], and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), dementia, protein-calorie malnutrition, and failure to thrive. The Admission Minimum Data Set, dated dated dated [DATE], documented the brief interview of the mental status score of 00/15, which indicated R2's cognitive status was severely impaired. The PICC Procedural Note dated 12/03/2024, documented the PICC line was inserted in R2's right upper arm for the total parenteral nutrition (TPN) and antibiotics. A physician Order dated 12/03/2024, documented the Clinimix TPN was to be infused through the PICC line only, with a bag and line change every 24 hours. R2's medical records lacked documented evidence a physician order for the PICC line saline flushing protocol was obtained, transcribed, and consistently implemented. A Nursing Progress Note dated 12/18/2024, documented a new order for PICC line replacement for Clinimix TPN administration due to the current PICC line of R2 was not patent or flushing. On 02/04/2025 at 11:35 AM, a Licensed Practical Nurse (LPN1) indicated the saline flushing protocol should have been in place to ensure patency. The LPN explained failure to flush the PICC line could result in clogging, and the dressing should have been changed at least weekly or as needed if wet or soiled. The LPN indicated Licensed Nurses assigned to the resident were responsible for intravenous protocol, including monitoring, flushing, and dressing changes. The LPN confirmed no order for saline flushing protocol was in place when R2's PICC line was inserted on 12/03/2024. The LPN acknowledged in the absence of the order, the licensed nurses would not have been prompted to complete the PICC line flushing. On 02/04/2025 at 11:54 AM, a Licensed Practical Nurse (LPN2) indicated the PICC line required an order for flushing protocol, weekly dressing changes, and monitoring for the signs and symptoms of infection at least every shift. The LPN indicated the PICC line should have been flushed promptly before and after administration to maintain patency and prevent clogging, and the dressing should have been changed weekly or as needed. On 02/04/2025 at 3:25 PM, the interim Director of Nursing (DON) verified R2's PICC line had been inserted on 12/03/2024 to administer TPN. The DON confirmed flushing orders were not obtained when the PICC line was initially inserted on 12/03/2024. The DON explained the previous PICC line was not flushing, leading to the insertion of a new line on 12/18/2024, along with maintenance orders. The DON indicated the Licensed nurses were expected to obtain and implement the flushing protocol to maintain patency. The DON acknowledged while PICC line care and maintenance were included in the order set, was unsure why the flushing protocol was not transcribed and implemented. A facility policy titled PICC Line revised 05/05/2023, documented Licensed Nurses may perform the following procedures with the PICC. 1. Assessing/Dressing Care of a PICC line. Procedure Reference: Lippincott Nursing Procedure 9th. Edition. Label the dressing with the date you performed the procedure or the date the dressing is next due to be changed as directed by your facility. A facility policy titled Physician Orders revised 05/05/2023, documented a qualified licensed nurse was responsible for obtaining and transcribing orders in accordance with facility practice guidelines. In facilities with electronic medical records, Medication Administration Records or Treatment Records were generated electronically. Complaint #NV00073041

Based on record review, interview, and document review, the facility failed to implement a person-centered care plan for the utilization and maintenance protocol of a peripherally inserted central catheter (PICC) line for 1 of 3 sampled residents (Resident 2). This deficient practice posed a potential risk of improper care, including inadequate dressing changes and improper flushing, which could lead to complications such as infection, catheter occlusion, thrombus formation, or other adverse health outcomes. Findings include: Resident 2 (R2) R2 was admitted on [DATE], and readmitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), dementia, protein-calorie malnutrition, and failure to thrive. The PICC Procedural Note dated 12/03/2024, documented the PICC line was inserted in R2's right upper arm for total parenteral nutrition (TPN) and antibiotics administration. A physician's order dated 12/03/2024, documented the Clinimix TPN was to be infused through the PICC line only, with a bag and line change every 24 hours. R2's medical records lacked documented evidence a person-centered care plan was formulated for the utilization and maintenance of the PICC line. On 02/04/2024 at 3:25 PM, the interim Director of Nursing (DON) verified R2's PICC line had been inserted on 12/03/2024, for TPN administration. The DON confirmed no care plan had been formulated when the PICC line was inserted. The DON indicated the Minimum Data Set (MDS) department was responsible for formulating the care plan if the PICC line was inserted after the resident's admission, while the licensed nurses were responsible if a resident was admitted with a PICC line. On 02/04/2025 at 4:03 PM, the Director of MDS confirmed no care plan had been put in place. The Director was unaware the PICC line had been inserted, and it had not been mentioned during the morning meeting. The Director indicated the expectation was for the licensed nurses to initiate the custom care plan, which would prompt the MDS department. The Director indicated there had been a lack of communication, as the MDS department did not perform routine visual assessments, and the PICC line insertion for R2 had not been identified. A facility policy titled Care Plan Process, Person-Centered Care, dated 05/05/2023, documented the facility would develop and implement a baseline and comprehensive care plan for each resident, including instructions needed to provide effective, person-centered care meeting professional standards of quality care. The facility would coordinate the development of the person-centered care plan within the required timeframes. Complaint #NV00073041

Based on observation, interview, record review and document review, the facility failed to ensure an initial Preadmission Screening and Resident Review (PASRR) was completed prior to a resident's admission for 1 of 18 sampled residents (Resident 2). The deficient practice had a potential for a newly admitted resident not to receive the necessary screening for the appropriateness to be admitted to a skilled nursing facility. Findings include: Resident 2 (R2) was admitted on [DATE], with diagnoses including depression and anxiety disorder. On 12/17/2024 at 10:46 AM, R2 was observed lying in low bed and remained quiet when being interviewed. There was a one to one (1:1) staff at the bedside and stated the resident could get very anxious when being left alone. The 1:1 staff member indicated the resident does not have any history of falls but wonders around the hallways and gets very anxious. Review of R2's progress notes from admission to current revealed the resident at most times would require 1:1 monitoring due to the severity of the anxiety behavior. R2's Psychiatry Progress Notes dated 05/09/2024 and 06/11/2024, documented under Assessment: 1. Generalized anxiety disorder 2. Unspecified depressive disorder 3. Neurocognitive disorder secondary to dementia Review of R2's hospital records prior to admission to the facility revealed: - Psychiatric Progress Notes dated 05/02/2024, documented diagnoses of anxiety disorder, depression, panic disorder and insomnia. - Cardiology Progress Notes dated 05/08/2024, documented under history of present illness: the patient uses 3 liters of oxygen per nasal cannula at home. At this time, the patient was placed on high flow Oxygen and was treated with breathing treatments. Subsequently, the patient was weaned off and place back on 3 liters nasal cannula; however, due to panic attacks the patient was placed back on high flow. The patient was assigned to 1:1 care and medication for anti-anxiety. - Pulmonary Progress Notes dated 05/08/2024, documented under history of present illness: the patient was originally able to wean down to 3 liters nasal cannula, however, began to have panic attacks which required to be placed back on high flow due to desaturation (low blood Oxygen). Due to patient's psychiatric history and requiring psychiatric medications, psychiatry was consulted due to ongoing panic attacks. - Discharge Summary from the hospital dated 05/09/2024, revealed the resident had psychiatric behaviors during the stay at the facility requiring psychiatric medication management and 1:1 monitoring. Discharge diagnoses included depression and anxiety. R2's medical record lacked documented evidence of an admission PASRR. A Level of Care (LOC - assessment of an individual's needs to determine the appropriate level of care within a nursing facility) was present and was dated 07/08/2022. On 12/19/2024 at 12:43 PM, the Director of Admissions acknowledged the lack of a PASRR assessment in R2's medical record. The Director indicated any PASRR older than 2013 was unable to be retrieved due to a system upgrade. The Director performed a PASRR look up for the R2 and revealed the last completed assessment was 2008. The Director confirmed a LOC assessment does not screen for any mental illness (MI) or intellectual disability (ID). On 12/19/2024 at 1:43 PM, the Director of Social Services confirmed the resident should have had a PASRR level 1 screening which evaluated any related diagnosis from the previous hospitalization . The Director acknowledged the resident had behavioral issues during the stay at the hospital and a newer PASRR could have identified any newer MI diagnosis and could have changed the determination or recommendations. The Director indicated based on the demonstration of behaviors and psychiatric evaluation R2's status could have triggered the facility to revisit the resident's current needs or LOC or even a PASRR level 2. The facility policy titled PASRR Documentation Policy revised 06/09/2023, documented all applicants to a Medicaid-certified nursing facility are evaluated for mental illness or intellectual disability, prior to admission. The individual seeking admission receives a PASRR level 1 screen for ID and MI before or upon admission.

Based on observation, interview, record review, and document review, the facility failed to ensure incontinent care was provided to a dependent resident who was soiled, wet, and had requested assistance for 1 of 30 sampled residents (Resident 229). This deficient practice had the potential to result in skin breakdown, infections, discomfort, and a diminished quality of life. Findings include: Resident 229 (R229) was admitted on [DATE], with diagnoses including overactive bladder, cramp and spasm, and pain. On 12/17/2024 at 9:33 AM, R229 was verbally alert and oriented but totally dependent on assistance for care due to a spinal injury. A suprapubic catheter was observed in place, draining yellow urine, with the urinary catheter bag lowered and placed in a basin. R229 verbalized although had the catheter, had intermittently been able to urinate through the urethra. R229 reported an incident had occurred on December 12, 2024, having urinated in bed twice due to a bladder spasm and pressed the call light for help, but no assistance arrived for several hours, and staff were observed walking past the room and ignoring repeated pleas for help. R229 called the facility operator at approximately 11:00 PM to report being wet since 8:00 PM and was promised a staff member would respond, but no one came. When staff arrived, the staff claimed to have previously entered the room but chose not to wake the resident. R229's frustration led to a verbal dispute, and the staff member left without offering help, telling the resident to go ahead, call 911. R229 called 911, and Metro police arrived on the scene, and an investigation was conducted. R229's medical record lacked documented evidence the incontinent care was provided on 12/12/2024 and 12/13/2024. On 12/18/2024 at 2:00 PM, the interim Director of Nursing (DON) indicated being aware of R229's multiple concerns, which had been investigated by the Administrator. The DON explained the process was to answer the call light within 5-10 minutes to check the status of the resident. The DON confirmed staff were expected to provide the care requested by the resident. The DON confirmed the lack of documented evidence showing incontinent care had been provided on 12/12/2024 and 12/13/2024, following R229's admission. The DON indicated staff were expected to provide incontinent care when requested and not ignore the request. On 12/20/2024 at 11:20 AM, a Licensed Practical Nurse (LPN) indicated being assigned to R229 during admission on December 12, 2024. The LPN reported R229 arrived at approximately 4:30 PM from out of state. The LPN explained initial care preparation included room setup and addressing unique needs like a breathing machine, sling, and specific medications. The LPN indicated R229 was upset as the initial care fell short of expectations. The LPN was aware R229 was left wet and soiled for long periods as reported, leading to a call to 911. The LPN indicated the Certified Nursing Assistant (CNA) was expected to clean R229 and to document in the point of care after providing care and emphasized if it was not documented, it was considered not done. On 12/20/24 at 12:03 PM, a day shift CNA who was assigned to R229 on the day of admission indicated R229 was admitted approximately after 4 PM, in time for meal service and end-of-shift rounds. The CNA explained the resident was dissatisfied due to initial miscommunication about equipment and preferences which led to confusion. The dissatisfaction led to the resident being resistant when obtaining vital signs and weights. The CNA indicated miscommunication contributed to the resident's dissatisfaction. Bowel and bladder care was not provided during the CNA's shift and left for completion at the end of shift at 7:30 PM. The CNA confirmed incontinent care was not provided during the day shift and expected the night CNA would provide the care. The CNA indicated the following day R229 complained was left wet and soiled and had an altercation with the night shift agency CNA. On 12/20/2024 at 12:34 PM, the Administrator confirmed R229's concerns were investigated and addressed. The Administrator indicated delays in response to call lights exacerbating the resident's perception of being ignored. The Administrator was unaware R229 had called 911 after reporting unmet care needs. The Administrator indicated the delays in providing care, especially incontinent care, were unacceptable. The Administrator indicated no intentional neglect was observed, but communication and prioritization were inadequate. On 12/20/2024 at 2:38 PM, the Minimum Data Set (MDS) Director confirmed the Point of Care Activities of Daily Living (ADL) report dated 12/12/2024 and 12/13/2024, which lacked documented evidence incontinent care was provided. A facility policy titled Activities of Daily Living, Optimal Function revised 05/2023, documented tasks related to personal care, including dressing, grooming, oral hygiene, transfer, bed mobility, and communication systems. The facility staff develop and implement interventions in accordance with the resident's assessed needs, goals for care, preferences, and recognized standard of practice that address the identified limitations in ability to perform ADLs. Complaint NV00072983

Based on observation, interview, record review, and document review, the facility failed to ensure: nutritional assessments were completed and interventions were implemented when a significant weight change occurred for 1 of 18 sampled residents (Resident 14), and residents' weights were obtained as scheduled for 3 of 18 sampled residents (Residents 14, 16 and 39). The deficient practices could have had the potential to delay interventions, increase the risk of health complications, and negatively impact residents' overall health and well-being. Findings include: 1) Resident 14 (R14) was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia, dysphagia (difficulty swallowing) and anxiety disorder. The Observation Details List dated 05/09/2024, documented R14 was at risk for malnutrition. R14's Weight Summary documented the following: - 12/05/2024: 131 pounds (lbs.), Routine body mass index (BMI): 26.46 (Height: 4'7) - 11/01/2024: 132 lbs., Routine BMI: 26.66 - 10/08/2024: 130.6 lbs., Routine BMI: 26.38 - 09/01/2024: 130 lbs., Routine BMI: 26.25 - 08/01/2024: 129.3 lbs., Routine BMI: 26.11) - July 2024: (No weights obtained/documented) - 06/30/2024: 139 lbs., Routine BMI: 28.07 - 06/13/2024: 143 lbs., Admission BMI: 28.88 - 05/21/2024: 142 lbs., Routine BMI: 28.68 - 05/07/2024: 160 lbs., Admission BMI: 32.31 R14's medical records lacked documented evidence a nutritional assessment was completed in August when a weight change was identified, and no interventions were implemented. On 12/18/2024, at 10:02 AM, the Director of Dietary Services (DDS) explained R14 was admitted at 160 lbs. and experienced significant weight loss within a month. The DSS confirmed R14 was on a regular diet with double portions, with a goal to prevent further weight loss. The DSS indicated R14's BMI remained stable. The DDS indicated R14 ate well, followed a no-added-salt diet, but frequently refused breakfast. The DDS explained factors influencing weight changes included hydration levels, errors in weight records, and health conditions such as heart disease or fluid shift. The DDS indicated further nutritional assessments were necessary to establish health trends following significant weight changes. On 12/18/2024 at 11:21 AM, the Registered Dietitian (RD) indicated R14's weight loss in August was desirable and R14's BMI was stable. The RD explained R14 was hospitalized on [DATE] and readmitted on [DATE]. The RD explained a nutritional assessment was warranted when there were significant weight changes and should have been monitored to enable interventions to be implemented. The RD indicated the Director of Nursing (DON) was responsible for weight monitoring. On 12/20/2024 at 12:30 AM, the interim DON explained weight records were documented in the electronic health record, and monthly weights should have been monitored. The DON indicated a nutritional assessment was warranted when significant weight changes occurred. The DON confirmed there was no nutritional assessment completed when R14 experienced a significant weight loss in August. R14's medical records lacked documented evidence the resident was weighed in July, and the resident was reweighed after weight loss was identified in August. On 12/19/2024, at 8:51 AM, R14 was observed at the bedside, appearing agitated and confused. A breakfast tray was set up at the bedside, containing scrambled eggs, bacon, pancakes, oatmeal, and a juice cup with a straw. R14 refused the meal. A Certified Nursing Assistant reported offering an alternative meal, which was also refused. A Care Plan dated 05/07/2024, documented R14 was at risk for malnutrition and dehydration related to COVID-19, dementia and gastroesophageal reflux disease (GERD). The interventions included to monitor the resident's weight. The goal was to maintain nutritional status as evidenced by no significant weight change. On 12/18/2024, at 10:02 AM, the Director of Dietary Services (DDS) explained the weight monitoring protocol involved obtaining weights upon admission and monthly thereafter unless concerns arose, and re-weighs were performed when weight changes were identified. The DSS indicated R14 was admitted at 160 lbs. and experienced significant weight loss within a month. No weights were documented for July, despite discharge and readmission in June. The DSS confirmed R14 was on a regular diet with double portions, consuming 75-100% of meals to prevent further weight loss. The DSS indicated R14's BMI remained stable. The DDS indicated a Registered Dietitian (RD) reviewed nutritional needs and monitored weight changes. On 12/18/2024 at 11:21 AM, the RD confirmed weights were not retaken after weight changes were identified, and a monthly weight was missed in July. The RD indicated the weights should have been obtained upon the resident's admission or readmission and monthly thereafter and retaken when there were weight changes and should have been monitored to enable interventions to be implemented to prevent further weight loss. The RD indicated the Director of Nursing (DON) was responsible for weight monitoring. On 12/20/2024 at 12:30 AM, the interim DON indicated weight measurements were taken upon admission, readmission, daily for the first three days thereafter, and then monthly. The resident's weights were taken by the CNA and recorded by the DON on the electronic health record, and monthly weights should have been monitored. The DON confirmed the weight was missed in July, and R14's weight was not retaken when weight loss was identified. The DON indicated the weights should have been obtained and documented. 2.) Resident 16 (R16) was admitted on [DATE], with diagnoses including dysphagia, anemia and vitamin deficiency. R16's Weight Summary documented no weights were recorded for July and November 2024. On 12/18/2024 11:11 AM, the RD confirmed there had been no documentation indicating R16's weights were obtained in July and November. The RD explained it was the DON's responsibility to ensure weights were obtained as scheduled and documented in the resident's electronic record. On 12/20/2024 at 2:33 PM, the DON confirmed there was no documented evidence R16's weight was obtained in July and November. The DON stated R16's weight should have been obtained and documented electronically as scheduled or as directed per policy. 37718 Resident 39 (R39) was admitted on [DATE] with diagnoses including stroke, trouble swallowing, diabetes, and malnutrition. A Physician Order dated 06/25/2024 indicated Monthly Weights, Once A Day on the 1st of the Month. R39's record indicated the following weights: 06/27/2024 367 lbs. 09/01/2024 410.5 lbs. 10/08/2024 411.2 lbs. 12/04/2024 159.4 lbs. 12/11/2024 151.8 lbs. There was no weight documented for the month of November A Registered Dietician note dated 12/09/2024 indicated Requested reweigh from nursing. On 12/18/2024 at 11:12 AM, the Registered Dietician (RD) verbalized R39 had been grossly overweight on admission. The RD verbalized since the resident was on hospice, the diet was centered on the resident's desires and tastes, and extra sweets could be given without restriction. The RD verbalized on 12/04/2024 there was a major weight change as evidenced by a recorded weight of 151.8 lbs. which was a 63.19% weight loss. The RD verbalized the large amount of the loss warranted immediate re-weighing to check the accuracy of the weight. The RD verbalized this had not done immediately. The RD reported requesting nursing to re-weight R39, which was done on 12/11/2024 and confirmed the weight loss. On 12/18/2024 at 11:57 AM, the interim Director of Nurses (DON) reviewed R39's weight record and verbalized R39's weight was not taken for the month of November but should have been. The policy and procedure titled Weighing the Resident revised on 05/05/2023 indicated resident weights would be recorded at least monthly. The policy and procedure indicated if the month-to-month weight shows more than a five percent gain or loss, the resident was reweighed in the presence of licensed personnel.

Based on observation, interview, record review and document review, the facility failed to ensure a peripherally inserted central catheter (PICC) line dressing care and maintenance was completed for 1 of 18 sampled residents (Resident 35). The deficient practice had a potential for a resident to develop an infection from poor maintenance of an intravenous site. Findings include: Resident 35 (R35) was admitted on [DATE] and a recent re-admission on 12/13/2024, with diagnoses including hemiplegia and cellulitis of the abdominal wall. On 12/17/1024 at 11:04 AM, R35 was observed with a right upper arm PICC line, the dressing on the PICC line was dated 11/21/2024. R35's family member indicated the resident had no intravenous antibiotics or fluids given for more than a month. On 12/17/24 at 2:24 PM, a Registered Nurse (RN) indicated a PICC line dressing should be changed every week by nursing. The RN confirmed the date on R35's PICC line and acknowledged the dressing should have been changed. The RN indicated all care, and maintenance should be documented under the medication and administration record (MAR). R35's physicians order dated 09/07/2024, documented under Other Tests: PICC line placement, Frequency: Once - One Time. The physician's order lacked documented evidence of any orders for the care and maintenance of the PICC line. On 12/19/2024 at 1:43 PM, the Interim Director of Nursing (DON) verbalized the facility expectation was to change a PICC line dressing every week. PICC line dressing was placed as a physician's order as part of the care and maintenance of the line together with saline flushes. The orders were then signed off on the MAR when completed. The Interim DON confirmed the missing orders from R35's medical record and verbalized the orders could have been missed the due to the resident's recent re-admission on 12/12/13/2024. The facility policy tiled PICC Line revised 05/05/2023, documented Licensed Nurses may perform the following procedures with the PICC. 1. Assessing/Dressing Care of a PICC line. Procedure Reference: Lippincott Nursing Procedure 9th. Edition. Label the dressing with the date you performed the procedure or the date the dressing is next due to be changed as directed by your facility.