Every finding on record at Henderson Health and Rehabilitation

Based on observation, interview, record review, and document review, the facility failed to ensure the resident's wheelchair was properly secured in the transportation van, and the required pre-trip inspection was completed prior to transport for 1 of 10 sampled residents (Resident 1). The deficient practice resulted in an actual resident fall, had the potential to cause serious injury during transportation, and placed residents at risk for avoidable accidents and fall-related injuries. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including end stage renal disease, muscle weakness and dependence on renal dialysis.The Minimum Data Set, dated [DATE], documented a score of 13/15, which indicated R1's cognitive status was intact.The facility report dated 06/03/2026, documented the facility driver acknowledged failing to complete the required pre-trip safety checklist and using a cell phone while driving contrary to facility policy. The investigation determined that R1's wheelchair had not been properly secured to the front wheelchair anchors and combined with the driver's distraction and abrupt braking, resulted in the wheelchair tipping and the resident slipping from the wheelchair.The facility camera review revealed on 05/29/2026, the Driver failed to properly secure R1's front wheelchair securement hooks before transport. As a result, when the Driver braked abruptly, the wheelchair tipped backwards, causing R1 to fall.On 07/23/2026 at 10:15 AM, the loading process of another resident into the facility transportation van was observed. The Senior Driver demonstrated the required transportation procedure by securing the two rear wheelchair securement locks, applying the resident's lap belt and shoulder harness, and securing the two front wheelchair securement locks. The Senior Driver verified the wheelchair was properly secured by ensuring it did not move before transport. The Senior Driver also demonstrated completion of the required pre-trip checklist before transport and the post-trip checklist after transport. The Senior Driver indicated that the involved Driver failed to follow the required transportation pre-trip process, which resulted in R1's fall. The Senior Driver explained R1's wheelchair tipped backward because the two front wheelchair securement hooks had not been properly secured before transport. A Counseling/Disciplinary Notice documented disciplinary action against the involved Driver dated 06/01/2026, documented the involved Driver failed to complete pre & post checklist on transport, on cellular phone during transport 05/29/2026, during R1's transfer. The involved Driver was suspended pending investigation.On 07/23/2026, at 1:05 PM, the Transportation Supervisor (TS) indicated receiving a telephone report from the driver on 05/29/2026, regarding R1's fall during transportation back to the facility. The TS confirmed the driver reported failing to secure the front wheelchair anchors before transport and acknowledged the transportation pre-trip checklist had not been completed. The TS explained the pre-trip inspection included both the vehicle safety inspection and wheelchair securement verification to ensure all four wheelchair anchor points, the lap belt, and shoulder harness were properly secured before transport. The TS indicated failure to complete the pre-trip inspection created a risk that the wheelchair was not properly secured. The TS further explained drivers were expected to refrain from using cell phones while operating the vehicle. The TS confirmed the driver had completed the required transportation training before the incident but failed to follow the facility's transportation protocols and was terminated following the incident.On 07/23/2026, at 2:20 PM, the Director of Nursing (DON) indicated the driver initially reported the front wheelchair securement had been completed; however, after reviewing the transportation camera footage, the driver acknowledged the front wheelchair lock had not been secured. The DON confirmed the transportation pre-trip checklists for the day of the incident had not been completed and explained all drivers were required to complete and submit the transportation checklists at the beginning and end of each shift. The DON confirmed the driver was terminated following the incident. The DON indicated R2 was immediately assessed, neurological evaluations were completed, emergency medical services were activated, and R2 was transferred to the hospital for further evaluation. The DON indicated the attending physician requested a CT scan, which was reported as negative and no fracture. On 07/23/2026, at 2:45 PM, R1 was interviewed in R1's room with the assistance of a Certified Nursing Assistant (CNA) serving as a Spanish interpreter. R1 was Spanish-speaking, alert, oriented, verbally responsive, and exhibited no signs of acute distress. R1 recalled the 05/29/2026 transportation incident while returning from dialysis. R1 indicated the wheelchair moved backward during a sudden stop, tipped backward, and caused R1 to strike the back of the head and injure an arm. R1 indicated not observing whether the wheelchair had been properly secured because R1 had been seated during transport. R1 indicated the facility responded promptly following the incident, R1 was monitored, and was transported to the hospital for evaluation. R1 denied fractures and denied any current pain, injury, or lasting effects. On 07/23/2026 in the afternoon, the Director of Transportation (DOT) indicated being aware the transportation incident had occurred before the DOT's employment. The DOT indicated the required pre-trip and post-trip transportation checklists should have been completed for each transport. The DOT indicated the four wheelchair securement locks, lap belt, and shoulder harness should have been properly secured before transport to ensure the resident's safety. The DOT indicated all drivers were expected to follow the facility's transportation protocols and indicated the Director would ensure the required pre-trip and post-trip transportation checklists were completed for each driver.A facility policy titled Fall Management revised January 2022, required the facility to implement appropriate interventions, including adequate supervision and assistive devices, to assist each resident in attaining and maintaining the highest practicable level of function and to minimize the risk of falls and fall-related injuries.

Based on observation, interview, record review, and document review, the facility failed to ensure the medication was administered as ordered for 2 of 10 (Residents 2 and 3). The deficient practice had the potential to result in ineffective treatment, exacerbation of existing medical conditions, recurrence or progression of symptoms, avoidable discomfort or distress and compromised resident safety. Findings include:Based on observation, interview, record review, and document review, the facility failed to ensure the medication was administered as ordered for 2 of 10 (Residents 2 and 3). The deficient practice had the potential to result in ineffective treatment, exacerbation of existing medical conditions, recurrence or progression of symptoms, avoidable discomfort or distress and compromised resident safety. Findings include: Resident 3 (R3) was admitted on [DATE], with diagnoses including bipolar disorder, anxiety disorder and epilepsy.The Hospital Discharge summary dated [DATE], documented R3's discharge medications including Clonazepam 0.5 mg by mouth twice a day.A Physician Order dated 07/21/2026, documented Clonazepam oral tablet 0.5 milligrams (mg) to give 1 tablet by mouth twice a day for anxiety disorder.On 07/23/2026 at 8:15 AM, during observation of the medication administration pass, a Registered Nurse (RN) prepared and administered R3's medications, except Clonazepam. The RN indicated the Clonazepam was unavailable and would contact the pharmacy.The Medication Administration Record (MAR) dated 07/22/2026 and 07/23/2026, documented R3's Clonazepam was not administered as ordered on three occasions.On 07/23/2026, at 8:40 AM, a Registered Nurse (RN) confirmed Clonazepam, ordered on 07/21/2026, was not administered as prescribed, resulting in the resident missing three scheduled doses. The RN explained nursing staff were responsible for completing medication reconciliation upon admission, ensuring all required prescriptions were obtained, promptly notifying and following up with the physician and pharmacy when prescribed medications were unavailable, ensuring medications were obtained and available for timely administration, and documenting all communications, prescriptions obtained, and interventions in the resident's progress notes.On 07/23/2026, at 8:45 AM, R3 was in bed, alert, oriented and verbally responsive having been admitted to the facility approximately two to three days earlier and that the medications were still being transitioned. R3 indicated not receiving prescribed medications that had been routinely taken prior to admission and expected the medications to be administered timely. On 07/23/2026, at 5:14 PM, the Pharmacist confirmed no prescription had been received for R3's Clonazepam, as to why the medication had not been dispensed or delivered. The Pharmacist explained that controlled substances and psychotropic medications required an electronic prescription before the pharmacy could dispense the medication. The Pharmacist indicated the pharmacy's scheduled deliveries to the facility occurred at 5:00 AM, 1:00 PM, and 12:00 AM. The Pharmacist indicated once the required electronic prescription was received, the medication would be delivered on the next scheduled delivery.Resident 2 (R2) was admitted on [DATE], with diagnoses including encephalopathy and rhabdomyolysis.The Hospital Discharge summary dated [DATE], documented R2's discharge medications including Temazepam 30 milligram (mg) 1 capsule by mouth at bedtime.A Physician Order Dated 04/02/2026, documented Temazepam 30 mg 1 capsule by mouth at 8:00 PM for insomnia.A Care Plan dated 04/03/2026 documented R2 was receiving hypnotic therapy related to a history of insomnia prior to admission to the facility.The Medication Administration Record (MAR), dated 04/03/2026 and 04/04/2026, documented a code of 7, indicating the medication was not administered and to refer to the nurse's notes.The Nursing Progress Notes dated 04/03/2026, documented Not in patient's stock. Follow up pharmacy or Primary Care Physician.The Nursing Progress Notes dated 04/04/2026, documented Per pharmacy, no prescription was received. Will follow up with the attending physician.R2's medical record lacked documented evidence that the facility successfully contacted the sending hospital or the attending physician to obtain the required prescription following R2's admission.On 07/23/2026 at 9:10 AM, the Charge Nurse (CN) verified R2 was admitted on [DATE], and confirmed Temazepam for insomnia was ordered on 04/02/2026, but was not administered on 04/03/2026 and 04/04/2026, as documented. The CN explained the admission process required nursing staff to transcribe physician orders based on the hospital discharge medications. The CN indicated controlled substances and psychotropic medications required a physician's prescription to be sent to the pharmacy for dispensing. Nursing staff were expected to obtain the medication from Pyxis (facility medication dispenser) to prevent a delay in administration, if authorized. The CN explained the assigned nurse was responsible for ensuring the medication was available for administration within the scheduled medication administration window of one hour before to one hour after the scheduled administration time. On 07/23/2026 at 12:12 PM, the attending physician indicated hospital physicians were responsible for providing prescriptions for controlled substances, including R2's Temazepam, upon discharge to the facility. The physician acknowledged hospitals did not consistently provide discharge prescriptions for controlled substances, which could contribute to delays in initiating the medication. The physician explained that if the hospital failed to provide the prescription, the facility was expected to notify the provider so a prescription could be issued. The physician indicated there was no recollection of being notified that R2's Temazepam was unavailable or that doses had been missed. The physician indicated during daily evaluations at the facility that the physician did not receive a report that R2 was not receiving Temazepam or that there was difficulty obtaining the medication. The physician indicated the expectation was for nursing staff to promptly notify the provider whenever a psychotropic medication was unavailable so appropriate intervention could occur.On 07/23/2026 at 2:20 PM, the Director of Nursing (DON) indicated nursing staff were expected to ensure medications ordered upon admission were available for administration. The DON explained that if a resident arrived without the required prescription from the discharging hospital, nursing staff were expected to attempt to obtain an electronic prescription from the hospital. If a prescription was unavailable, nursing staff were expected to promptly notify the attending physician or provider to obtain an emergency prescription. The DON indicated nursing staff were expected to document physician notification and any interventions taken when prescribed medication was unavailable. The DON indicated that if a medication was not administered because it was unavailable, nursing staff were expected to accurately document the omission, the reason the medication was not administered, and the physician notification in the progress note. On 07/23/2026, at 5:14 PM, the Pharmacist indicated Temazepam was a psychotropic medication that required an electronic prescription before it could be dispensed. The Pharmacist confirmed no prescription had been received for R2's Temazepam. The Pharmacist explained that the facility was aware the pharmacy could not dispense medications requiring a prescription until the required prescription had been obtained and received by the pharmacy before the medication could be delivered.A facility policy titled, Medication Administration, (undated), directed staff to administer medications accurately, safely, and timely in accordance with the attending physician's written orders and to document physician communications in the resident's medical record, as appropriate.Complaint 2979289

Based on interviews, record review and document review, the facility failed to ensure residents were free from sexual abuse for one of ten sampled residents (Resident 4). The deficient practice placed other residents at risk of being sexually abused.Findings include:Based on interview, record review and document review, the facility failed to ensure residents were free from sexual abuse for one of ten sampled residents (Resident 4). The deficient practice placed other residents at risk of being sexually abused. Findings include: On 07/20/2026 at 4:27 PM, A facility report incident documented R5 grabbed or pinched R4's breast. The incident was captured on facility video, witnessed by other residents, and reported to staff. The video showed R4 quickly jerking away as R5 extended an arm and appeared to make contact. Witnesses stated R4 screamed when R5 grabbed the breast. Staff overheard that two weeks earlier R5 had made inappropriate comments to R4. Resident 5 (R5) was readmitted to the facility on [DATE] with diagnoses including encephalopathy, type 2 diabetes mellitus, schizoaffective disorder, and dysphagia. The resident was discharged on 07/22/2026 after being found unresponsive and expired. A quarterly minimum data set (MDS) assessment dated [DATE] documented a BIMS score of 05/15 with behavioral symptoms directed towards others. Physician order dated 05/29/2026 documented R5 may be seen and treated by a psychiatrist and by a mental health worker. A change in condition note dated 07/20/2026 documented the resident inappropriately touched a female resident's breast. The evaluation recommended continued monitoring and transferring the resident to a different building. The family/resident representative was notified on 07/20/2026. A physician progress note dated 07/20/2026 documented psychiatric follow up. A physician order dated 07/21/2026 documented monitoring for increased sexual behaviors towards peers and staff every shift for 3 days. Care plans and monitoring physical and verbal and verbal behaviors, impaired cognition, thought process, and inappropriate physical contact. Interventions included immediate redirection, relocating the resident Building A, psychosocial monitoring, and psychiatric consult as indicated. Resident 4 (R4) was readmitted to the facility on [DATE] with diagnoses including cerebral palsy, impulse disorder, hypotension and unspecified intellectual disabilities. A physician order dated 11/19/2025 (resume all previous orders) included behavior monitoring related to generalized anxiety and impulse disorders. A minimum data set (MDS) assessment dated [DATE] documented the resident was moderately impaired cognitive skills with verbal behavioral symptoms and wandering present. A physician order dated 06/27/2026 documented patient on 1:1every shift for inappropriate behaviors. A physician order dated 07/06/2026 documented to consult with psychotherapist for Cognitive Behavioral Therapy (CBT) related to violent behaviors when not getting their way. A physician order dated 07/08/2026 documented to discontinue 1:1 and downgrade to line of site observations every 15 minutes x 24 every shift for Impulsive/ Physically aggressive. Care plans and monitoring in place included for communication, behaviors, wandering, yelling/screaming, combative, impulse control, physical abuse, and antipsychotic/antianxiety medications. A review of progress notes documented behavior monitoring including episodes of yelling, screaming, grabbing other residents' food, lowering self to the floor and putting hands into brief/private part area. The notes also documented monitoring of right breast for redness or bruising every shift. A change in condition note dated 07/20/2026 documented the provider was notified, an assessment was completed, and no new changes were observed. The physician progress note indicated the resident was nonverbal with functional debility and had no new skin issues. The provider recommended discharge to a structured, restricted environment with 1:1 supervision due to altered mental status and elopement risk. Case management was initiated for discharge planning to an appropriate facility. A separate change in condition note dated 07/20/2026 documented that the family/resident representative was notified that the resident had been inappropriately touched on the breast by a male resident; no redness or bruising was observed. Weekly skin checks dated 07/20/2026 documented no new skin issues found on evaluation. The facility policy titled Abuse: Prevention of and Prohibition Against, dated 10/2022, documented residents have the right to be free from sexual abuse. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. On 07/23/2026 at 1:30 PM, a Registered Nurse (RN), indicated abuse training occurred at onboarding and was discussed at staff meetings. The RN explained the abuse coordinator was notified when allegations of abuse occurred, and vulnerable residents were kept safe depending on the resident and the scenario. The RN explained the resident of concern (R4) was redirected to do activities often or would be taken to another building to divert from a situation. On 07/23/2026 at 1:36 PM, a Licensed Practical Nurse (LPN) reported abuse training occurred annually. The LPN recalled working the day of the incident and hearing that R5 grabbed R4's right breast in the hallway. The LPN indicated the incident was reported, an assessment completed, monitoring initiated, notifications made, and R5 was relocated. The LPN verbalized staff ensured R4 remained in view and conducted skin checks each shift, and 1:1 supervision was used when needed. On 07/23/2026 at 1:36 AM, a Licensed Practical Nurse (LPN) reported abuse training occurred annually. The LPN explained abuse was reported to the administrator, the resident was assessed, and the physician and family were notified. The LPN recalled working the day of the incident and hearing that R5 grabbed R4's right breast in the hallway. The LPN was unsure who witnessed the incident but stated the event was reported, an assessment was completed, monitoring was initiated, notifications were made, and R5 was moved to another building. The LPN explained following the incident, staff ensured R4 remained in view and conducted skin checks each shift. The LPN indicated all staff were responsible for protecting residents, often redirecting R4 or bringing them to safe areas away from other residents. The LPN indicated R4 could not be isolated but 1:1 supervision was provided when needed for safety. On 07/23/2026 at 1:55 PM, R4 was observed calm sitting in their wheelchair, eating popcorn. R4 was nonverbal and communicated using touch and expression. A skin check was completed by nursing staff; revealed no redness and no pain to right breast area. On 07/23/2026 at 2:05 PM, the administrator indicated suspected abuse was immediately reported. The administrator indicated staff were not expected to determine whether abuse occurred but to discuss with nursing and social services for follow up. Abuse training occurred upon hire and annually and covered all forms of abuse. The administrator recalled the incident and indicated other residents reported the incident to activity staff that a male resident (R5) attempted to grab the breast of a female resident (R4). The administrator explained that an investigation ensued, confirmed contact occurred between the residents, and verified the abuse occurred. The administrator explained staff were expected to be situationally aware to protect vulnerable residents, and the interdisciplinary team was used to address safety concerns. The administrator explained that R4 could not be secluded and benefited from being around other residents. The administrator acknowledged staff recognized which residents R4 was safe to be around, and a camera was intentionally placed outside R4's room for monitoring. The administrator confirmed that two abuse incidents involving R4 occurred within a three month period. The administrator explained the expectation was for residents to be free from abuse, or that abuse did not occur at the facility. On 07/23/2026 at 2:54 PM, the Social Worker (SW), explained when abuse or neglect was reported, the abuse coordinator was notified, and a decision made to investigate and/or to report. The SW indicated R4 was under guardianship and would be considered a vulnerable adult. The SW indicated priorities to keep R4 safe included individual monitoring, one-to-one (1:1), addressing concerns with the guardian and appropriate placement. On 07/23/2026 at 3:08 PM, the Assistant Director of Nursing (ADON), explained staff was aware that R4 required frequent redirection and was often taken to their room, the unit or activities to keep busy. Nursing staff used line-of -sight, or 1:1 supervision for safety when behaviors occurred. The ADON explained R4 liked to touch others, and staff were aware to keep R4 separate when concerns arose. Alert charting was entered in the electronic medical record (EMR) for nurses to be aware of the R4's needs and was moved to Building B or other areas when issues could occur. The ADON explained following an abuse incident in July 2026, 1:1 supervision was ordered from 06/27/2026 to 07/08/2026. The ADON 1:1 supervision meant staff (usually a Certified Nursing Assistant (CNA) remained with the resident to redirect, de-escalate and provide care with changing, dressing and related tasks. On 07/23/2026 at 4:11 PM, the Director of Activities indicated they did not see incident, two residents reported it. The Director of Activities interviewed witnesses, who explained R4 was walking in the hallway and R5 grabbed R4's breast. The Director of Activities reported two weeks prior, activity staff overheard R5 inappropriately whisper to R4 in Spanish something like Do you want me to lick you, or do you want to lick me? The verbal message was reported to the administrator and on call nurse. The Director of Activities indicated following the incident, the residents were told to separate, R5 was told not to speak inappropriately to R4. The Director of Activities staff were advised to keep the residents separated. On 07/23/2026 at 4:42, the administrator indicated being aware of the verbal interaction between R5 and R4 but did not consider it reportable. The administrator verbalized depending on the severity, verbal interactions could be considered abuse. The administrator explained the language barrier complicated the incident being reportable and revealed R5 only spoke Spanish and the staff translator only spoke English. The administrator indicated the staff member could not repeat what was said in English equivalent to the Spanish translation and therefore the translation was questionable and left doubt on the reporting of what was said. The IDT team agreed with the findings that it was not a reportable incident. The administrator acknowledged R5 grabbed R4s breast 2 weeks later. The facility policy titled Abuse: Prevention of and Prohibition Against, dated 10/2022, documented residents have the right to be free from sexual abuse. Sexual abuse was defined as non-consensual sexual contact of any type with a resident. FRI #3105888

Based on observation, interview, record review, and document review, the facility failed to ensure 1) residents' medications were administered and accurately documented for 2 of 8 sampled residents (Residents 1 and 2) and 2) medication errors were reported and follow-up was completed when medication errors were identified for 1 of 8 sampled residents (Resident 1). The deficient practice had the potential to result in unmanaged pain, delayed treatment, compromised continuity of care, an increased risk for complications, decline in functional status, hospitalization, and decreased quality of life.Findings include:1) Resident 1 (R1) was admitted on [DATE], with diagnoses including chronic pain syndrome, diabetic polyneuropathy, pressure ulcers to the sacral region and unstageable right heel.A Physician Order dated 01/23/2026, documented Oxycodone Hydrochloride oral tablet 20 milligram to give one tablet by mouth every 6 hours as needed (PRN) for pain.The Social Services Summary dated 01/24/2026, documented R1 was alert and oriented. A Brief Interview for Mental Status score of 15/15 indicated intact cognition, evidenced by accurate recall and orientation.A Care Plan dated 01/24/2026, documented R1 had acute/chronic pain with an intervention to administer pain medication as ordered and to monitor.The Physician Progress Note dated 01/24/2026, documented a plan for ongoing medical management, including pain management with medications referenced in the nursing Medication Administration Record (MAR).The MAR dated 01/25/2026, documented Oxycodone was administered at 5:39 AM.The Controlled Drug Record dated 01/25/2026, did not reflect that Oxycodone was removed from the controlled substance supply. The Nursing Progress Note dated 01/25/2026, documented a family member expressed concern R1's pain medication was not administered at 5:30 AM. The MAR indicated the medication was signed or documented as given; however, review of the narcotic book and count indicated the medication was not administered at that time.The Nursing Progress Note dated 01/25/2026, documented the nurse administered the pain medication at approximately 10:30 AM due to the electronic MAR timing. Family members expressed dissatisfaction with the nurse and the charge nurse regarding the delay and discrepancy.The Nursing Progress Note dated 01/25/2026, documented family requested a formal apology from the nurse and administration, and the concern was communicated to social services.On 04/06/2026 in the afternoon, the Social Worker indicated there had been complaints related to food; however, the Social Worker was unaware of any medication error involving R1.On 04/06/2026 at 2:10 PM, during a telephone interview a Licensed Practical Nurse (LPN) assigned to R1 on the night shift from 01/24/2026-01/25/2026 was unable to recall R1 or any medication error involving R1. The LPN described the process for PRN Oxycodone administration as assessing the resident's pain, documenting the need for medication, administering the medication, and then documenting administration in the Medication Administration Record (MAR). The LPN acknowledged medication should not have been documented as administered prior to actual administration. The LPN confirmed that documenting a medication as administered when it was not given, while the medication remained in the controlled substance supply constituted a medication error. The LPN indicated medication errors should have been reported to the supervisor for investigation. On 04/06/2026 at 3:25 PM, the Assistant Director of Nursing (ADON1) verified and confirmed that Oxycodone was documented as administered in the MAR; however, there was no corresponding documentation in the narcotic record, and the medication remained in the controlled substance supply. ADON1 confirmed if the medication remained in supply, it had not been removed and was not administered.ADON1 described that licensed nurses were expected to remove Oxycodone from the controlled substance supply, document the removal in the narcotic record, administer the medication to the resident, confirm ingestion, and then document administration in the MAR. ADON1 confirmed that documenting a medication as administered when it was not given was a medication error and was not consistent with nursing practice. ADON1 confirmed the documentation in the MAR should occur after the medication was administered and ingested.ADON1 explained when a discrepancy was identified, the entry should have been corrected in accordance with facility policy and reported for investigation. ADON1 confirmed the discrepancy constituted a medication error and required review of the MAR, narcotic record, and staff actions. ADON1 was not aware of the incident at the time it occurred. ADON1 indicated the incident was not reported by the licensed nurse involved and did not appear on the 24-hour report, as the required documentation trigger was not completed. ADON1 confirmed the incident required investigation and follow-up including interviewing staff, notifying the physician; however, no evidence of investigation or follow-up was implemented.On 04/08/2026 at 1:24 PM, during a telephone interview the Nurse Practitioner (NP) indicated primary responsibility, included pain management. The NP confirmed licensed nurses were expected to administer Oxycodone and other pain medications in accordance with prescribed orders. The NP indicated failure to administer pain medication as ordered, while documenting it as given, would result in unmanaged pain. The NP indicated the facility was expected to report when a medication error occurred.A facility policy titled Medication Error (undated), indicated medication errors were to be documented and reported in accordance with state and federal requirements. The policy defined a medication error as any preventable event that may cause or lead to inappropriate medication use, inaccurate administration, or harm while the medication was under the control of a healthcare professional or resident. The policy indicated medication errors may result from failures in professional practice, procedures including administration, omissions, or inaccurate documentation. Medication errors were to be reported timely to the Director of Nursing or the supervising nurse. The DON or designee was responsible for timely notification of the resident's physician and authorized representative and for initiating an investigation within 24 hours of identification, with documentation entered into the facility's risk management system and reviewed for trends and opportunities for improvement.2) Resident 2 (R2) was admitted on [DATE], with diagnoses including hypertension, pulmonary embolism and pneumonia.On 04/08/2026 at 9:41 AM, during a medication pass observation a Licensed Practical Nursing 2 (LPN2) prepared R2's medications, signed off the MAR and saved indicating the medications were successfully administered, and then proceeded to R2's bedside to administer the medications.On 04/08/2026 at 9:50 AM, LPN 2 described the medication administration process. LPN2 indicated the residents' medications were prepared by reviewing the MAR and pulling the medications. Documentation in the MAR was initiated during preparation by checking off medications to indicate they were pulled and ready for administration. Medications were then administered to the residents, and the MAR was saved after successful administration. LPN2 confirmed R2's MAR was signed off and saved, indicating the medications were administered when they were not. LPN2 identified familiarity with R2 as the reason for the action. LPN2 acknowledged this practice was not consistent with facility policy or accepted professional nursing standards and confirmed the appropriate process required administering the medication first and documenting after administration to ensure accuracy, as residents may refuse or not ingest medications.On 04/07/2026 at 9:55 AM, ADON2 indicated the standard nursing practice for medication administration was to verify the medication against the MAR, prepare the medication, administer it to the residents, and document administration after the medication was given. ADON2 confirmed documentation should not occur prior to administration to ensure accuracy, particularly in cases of refusal or incomplete ingestion. ADON2 confirmed documentation prior to administration was not consistent with standard nursing practice, as the outcome of administration must be known before recording in the MAR.On 04/07/2026 at 10:30 AM, the ADON1 described expectations for medication administration. ADON1 indicated staff were expected to verify the resident and medication using the five rights, prepare medications, perform required assessments, administer medications, and document administration after the medication was successfully administered. ADON2 confirmed that documentation prior to administration was not consistent with standard nursing practice, as residents may refuse or not ingest medications, resulting in inaccurate documentation and increasing the risk for medication errors.On 04/08/2026 in the afternoon, the attending physician acknowledged that licensed nurses were expected to exercise clinical judgment in administering medications as ordered and to document administration appropriately in the resident's record.A facility policy titled Administration of Medications (undated), indicated medications were to be administered as prescribed by the resident's provider and in accordance with the resident's plan of care. The policy indicated the nurse administering the medication was to document administration after the medication was given. The policy further indicated when PRN medications were administered, the nurse was to document the date and time of administration and subsequently document the resident's response to the medication, as appropriate.

Based on interview, record review, and document review, the governing body of the facility failed to oversee services performed by a contracted vendor, including ensuring the accuracy of documentation of resident behaviors and for 6 of 28 residents (Residents 4, 9, 11, 15, 18, and 19). This deficient practice had the potential to lead to inappropriate tiering and state payments for residents in a Medicaid Behaviorally Complex Care Program.Findings include:F0837: Governing BodyBased on interview, record review, and document review, the governing body of the facility failed to oversee services performed by a contracted vendor, including ensuring the accuracy of documentation of resident behaviors and for 6 of 28 residents (Residents 4, 9, 11, 15, 18, and 19). This deficient practice had the potential to lead to inappropriate tiering and state payments for residents in a Medicaid Behaviorally Complex Care Program.Findings:The investigation included a review of a document titled Behavior Frequency Documentation Data Sheet, consisting of four pages for tracking resident behaviors:Page 1 consisted of columns for date, tracked behaviors, Other, and staff initials, with a grid for days 1-31 and instructions to check applicable behaviors daily. Pages 2-3 consisted of sections listing behaviors and a table with columns for the date, time, behaviors, intervention, and signature.Resident #4 (R4) was re-admitted to the facility on [DATE], with diagnoses including peripheral vascular disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and personal history of transient ischemic attack.R4's Behavior Frequency Documentation Data Sheets for September 2025 revealed staff checked off behaviors which occurred on each day and initialed. Review of the document revealed initials were recorded by two different staff members. Fourteen of these entries, marked as AB, were associated with a staff member whose identity could not be verified. Interventions documented for R4 included a token economy system, loss of privileges, group contingency systems, seating arrangement changes, and frequent movement breaks. All interventions were noted as effective; however, these interventions were unapproved for this resident.Resident #9 (R9) was re-admitted to the facility on [DATE], with diagnoses including unspecified dementia, cognitive communication deficit, atherosclerosis of aorta, and anxiety disorder.R9's Behavior Frequency Documentation Data Sheets for September 2025, revealed staff checked off behaviors which occurred on each day and initialed. Review of the document revealed initials were recorded by two different staff members. Nine of these entries were associated with the staff member whose identity could not be verified.Interventions documented for R9 included those noted as effective such as scheduled movement breaks, clear consequences and a quiet corner or calming space; and those noted as successful such as student-teacher conferences, school-wide PBIS (positive behavior interventions and supports), behavior tracking apps, classroom jobs and those noted as somewhat effective such as whole-class reward systems. All of these interventions were unapproved for this resident.Resident #11 (R11) was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease, cerebral infarction, metabolic encephalopathy, and bipolar disorder.R11's Behavior Frequency Documentation Data Sheets for August 2025 revealed staff checked off behaviors which occurred each day and initialed. Review of the document revealed initials were recorded by two different staff members. Fifteen entries, marked as AB, were associated with a staff member whose identity could not be verified.Resident #15 (R15) was admitted to the facility on [DATE], with diagnoses including unspecified atrial fibrillation, aneurysm of carotid artery, atherosclerotic heart disease, and unspecified schizophrenia.R15's Behavior Frequency Documentation Data Sheets for August 2025, revealed staff checked off behaviors which occurred each day and initialed. The record contained 15 unidentified initials. Review of the document revealed initials were recorded by two different staff members. Fifteen entries, marked as AB, were associated with a staff member whose identity could not be verified.Resident #18 (R18) was re-admitted to the facility on [DATE], with diagnoses including gastrostomy malfunction, type 2 diabetes mellitus, unspecified hypotension, and unspecified dementia.R18's Behavior Frequency Documentation Data Sheets for September 2025 revealed staff checked off behaviors which occurred each day and initialed. The record contained 10 unidentified initials. Review of the document revealed initials were recorded by two different staff members. Ten of these entries, marked as AB, were associated with the staff member whose identity could not be verified.Resident #19 (R19) was admitted to the facility on [DATE], with diagnoses including other schizophrenia, morbid obesity, drug induced akathisia, and unspecified abnormal involuntary movements.R19's Behavior Frequency Documentation Data Sheets for September 2025 revealed staff checked off behaviors which occurred each day and initialed. The record contained 14 unidentified initials. Review of the document revealed initials were recorded by two different staff members. Fourteen of these entries, marked as AB, were associated with the staff member whose identity could not be verified.Interventions documented for R19 included those noted as effective such as time-outs, loss of privileges and proximity control; and those noted as successful such as a calm down corner, and teacher praise; those noted as failed such as expulsion and corporal punishment; and those noted as ineffective such as detention and corporal punishment again. All of these interventions were unapproved for this resident.On 12/03/2025, during a telephone interview, the Chief Clinical Officer with the contracted agency indicated not noticing any abnormalities with R4, R9, R11, R15, R18, or R19's documentation and had approved it to be sent to the Medicaid Behaviorally Complex Care Program in an application for consideration.On 12/04/2025 a Care Coordination Director (CCD) with the contracted agency, explained the behaviors the care coordination staff documented came from nursing documentation, care plans, meetings, and personal observations. The interventions the care coordination staff documented should have come from the resident care plans. The information gathered was used to fill out the BCCP resident application on behalf of the facility. The CCD was not aware if anyone at the facility reviewed the applications before their company submitted the applications to the Medicaid Behaviorally Complex Care Program responsible for approval. On 12/04/2025, the Director of Nursing explained none of the facility staff documented on the Behavior Frequency Documentation Data Sheets as the facility staff did not have access to these sheets. The DON verified the interventions documented on the sheets did not come from the care plans for R4, R9, or R19, and verified the facility had not been using any of the listed interventions for behaviors.On 12/04/2025, the Director of Nursing explained none of the facility staff documented on the Behavior Frequency Documentation Data Sheets as the facility staff did not have access to these sheets. The DON verified the interventions documented on the sheets did not come from the care plans for R4, R9, or R19 as the facility had not been using any of the listed interventions for behaviors.On 12/04/2025, during email correspondence, the Chief Clinical Officer with the contracted agency communicated there was an ongoing investigation regarding the use of the initials AB in the resident documents because those initials did not correspond with any current contracted staff.On 12/04/2025, in the afternoon during a telephone interview, a Behavior Coordinator with the contracted agency admitted to using initials other than their own on the Behavior Frequency Documentation Data Sheets. The Behavior Coordinator used a template already containing initials similar to a supervisor, so they left them in place.The Behavior Coordinator reported using an internet-based artificial intelligence (AI) application to generate the interventions and determine whether the interventions were effective. The Behavior Coordinator was unsure of the meaning of certain interventions, such as seclusion, detention, suspension, expulsion, or corporal punishment, but noted that these terms sounded bad.The Behavior Coordinator further disclosed being new to the position at the time and had only received one day of training and a few weeks of shadowing other coordinators. They had not been trained on processes to ensure documentation accuracy. The Behavior Coordinator stated the supervisor had instructed them over a month prior to stop using the term corporal punishment. The Behavior Coordinator explained that during a group meeting held a week earlier, the provider directed staff to discontinue using the templates altogether.The Behavior Coordinator indicated once staff completed the sheets, the sheets were placed in a completed folder for the Lead Behavior Coordinator to review and forward to the office.On 12/31/2025 in the morning, during a telephone interview, a Lead Behavior Coordinator, with the contracted agency explained that prior to October, each coordinator submitted their data sheets directly to the office staff, who gathered the sheets and submitted them with the application packet to the physician for final review and submission to the State.After October, a new process was implemented: each coordinator placed the completed data sheets in a designated folder. The Lead Behavior Coordinator reviewed the sheets for accuracy and then moved them to a Management Review folder. Once management reviewed the sheets, they were forwarded to the office staff, who compiled them with the application packet for physician review and submission to the State.The Lead Behavior Coordinator admitted instructing the Behavior Coordinator to stop using spanking and corporal punishment as interventions after noticing those terms on the sheets and explained where to find the correct information. The Lead Behavior Coordinator acknowledged being aware that the Behavior Coordinator was using other initials to sign off on paperwork but had not reported it. The Lead Behavior Coordinator stated they were not aware the Behavior Coordinator was using AI to generate interventions.The Lead Behavior Coordinator also reported a supervisor held a meeting one week prior to the state survey, instructing staff to discontinue using templates and showed them where to locate the required information.The facility's Governing Body Policy and Procedure, revised 04/2025, documented the Governing Body provided support and direction to the facility and appointed an administrator who was responsible for the management and operation of the facility.The facility provided a copy of the Independent Services Agreement, effective July 1, 2022; amended 6/4/2024, which outlined the service provider's responsibility to maintain complete service records, including legible and accurate progress notes and observations, and to promptly incorporate these records into the facility's clinical and business records. The agreement stated that any work product created in the course of providing services became the exclusive property of the facility. The facility retained responsibility for ensuring that all services met professional standards and principles within the facility.Complaint 2651442

Based on observation, interview, record review, and document review, the facility failed to ensure Enhanced Barrier Precaution (EBP) signage was posted and staff wore appropriate personal protective equipment (PPE) when providing direct care to residents with indwelling medical devices for 4 of 35 sampled residents (Residents 132, 196, 89 and 194). These deficient practices had the potential to place residents, staff, and visitors at risk for cross-contamination and transmission of multidrug-resistant organisms (MDROs), compromising the infection prevention and control program.Findings include:1) Resident 132 (R132) R132 was admitted on [DATE], with diagnoses including dysphagia (difficulty swallowing), gastrostomy, and colostomy. A review of medical records revealed R132 had a percutaneous endoscopic gastrostomy tube (PEG), colostomy and a wound on the left great toe. On 07/29/2025 in the morning, there was no enhanced barrier precaution signage posted by the door, and no PPE was available at the door entrance. On 07/30/2025 in the morning, the staff members were in and out of room [ROOM NUMBER] and providing direct care with R132. On 07/31/2025 at 8:00 AM, a Licensed Practical Nurse (LPN) was not aware of residents with indwelling devices such as gastrostomy tubes, intravenous lines, and urinary catheters required Enhanced Barrier Precautions (EBP), and PPE should have been worn during the provision of direct care. The LPN was unable to explain the difference between transmission-based precautions and enhanced barrier precautions. On 07/31/2025 at 10:10 AM, the Infection Preventionist (IP) indicated the facility was in the final phase of implementing Enhanced Barrier Precautions (EBP) in alignment with Centers for Disease Control (CDC) guidelines. The IP confirmed the facility was not in compliance with EBP requirements at the time of the survey but emphasized that a structured rollout plan was underway. The IP stated residents with a history of multidrug-resistant organisms (MDROs), indwelling devices (such as G-tubes), or chronic wounds were identified for EBP. The IP indicated the primary risk of not wearing appropriate PPE was potential exposure to organisms with the possibility of transmission from one resident to another. 2) Resident 89 (89) was originally admitted on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus, and dysphagia. On 07/29/2025 at 11:38 AM, R89 was noted to have a feeding tube in place. There were no signs on the resident's door indicating Enhanced Barrier Precautions. Staff were observed providing care without putting on gowns. On 07/31/2025 at 10:42 AM, a Licensed Practical Nurse (LPN) acknowledged the need for PPE, and wearing gown, the LPN added had brought this issue to the infection control manager's attention and was told not to worry about it yet and the LPN indicated had not received an in-service training on wearing a gown. On 07/31/2025 at 2:41 PM, a Registered Nurse (RN), was unaware wearing a gown was required when providing care for residents with a feeding tube. There was no signage to indicate the resident was on enhanced barrier precautions and the RN had not received formal training. On 07/31/2025 at 2:43 PM, a Licensed Practical Nurse was unaware wearing a gown was required when providing care for residents with a feeding tube. The LPN was notified on 07/31/2025 to start wearing a gown when performing tube feeding care. On 08/01/2025 at 8:51 AM, a Licensed Practical Nurse wore gloves for when providing tube feeding care but not a gown, as staff were not trained to do so unless the resident had a known infection. 3) Resident 194 (R194) was admitted on [DATE], readmitted [DATE], with diagnosis including anoxic brain damage, dysphagia (difficulty swallowing), and encounter for attention to gastrostomy (a surgical procedure to create an opening in the stomach for feeding). On 07/29/2025 in the morning, R194's feeding pump was next to the bed. There was no signage indicating enhanced barrier precautions or information regarding what personnel protective equipment (PPE) was required for staff to wear while provided care to R194's gastrostomy tube (G-tube). The medical record lacked documented evidence of a physician order for enhanced barrier precautions related to R194's G-tube. On 07/30/2025 at 4:40 PM, a Licensed Practical Nurse (LPN), confirmed R194 received feeding enterally via G-tube. The LPN confirmed there were no enhanced precautions signage posted on R194's door. The LPN reported enhanced precautions were not required for a resident that had tube feeding. The LPN wore gloves, and no gown was needed while providing care to R194's G-tube. The LPN explained enhanced precautions which would include additional PPE required would be for a resident receiving wound care. On 07/31/2025 at 10:22 AM, the Infection Preventionist (IP), explained gowns and gloves were both required while providing care to residents with a G-tube. The IP explained training had not been provided to nurses regarding implementation of the facility's standard and transmission-based precautions program. The IP acknowledged the facility had not yet posted enhanced barrier precaution (EBP) signage for all residents identified as requiring such precautions. On 07/31/2025 at 3:03 PM, the Assistant Director of Nursing (ADON), explained that a resident requiring EBP related to tube feeding should have had a physician order for EBP. The ADON explained the expectation was nurses wear a gown and gloves when providing G-tube care. The ADON reported nurses may not have known what PPE was required to be used during G-tube care, due to training not completed for nurses. 4) Resident 196 (R196) was admitted on [DATE], with diagnoses including aphasia and attention to gastrostomy (G-tube) tube. On 07/30/2025 at 1:26 PM, a License Practical Nurse caring for R196 confirmed the facility had not informed nursing staff a G-tube would require enhanced barrier precaution, wherein a staff had to utilize personal protective equipment (PPE) when caring for residents with an indwelling medical device. The nurse confirmed being aware of guidelines for years now and when asked about it at the facility, the response would be it would be coming soon. On 07/30/2025 at 1:26 PM, a Certified Nursing Assistant (CNA) verbalized not putting on PPE when proving incontinent care to residents with indwelling medical device because the facility had not imposed the practice. On 07/31/2025 at 10:45 PM, the Infection Preventionist (IP) confirmed the facility was aware of the Center for Disease Control guidelines (CDC) for EBP and the facility followed CDC guidelines when implementing infection control practices. The IP indicated the facility was slowly integrating the EBP guidelines for indwelling medical devices and currently had only implemented EBP for wounds and multi drug resistant organisms (MDRO) colonized residents. The IP stated the facility was in the process of incorporating the integration as part of the quality assurance process. The IP was not able to explain the delay in implementing the policy approved in April 2025. The facility policy titled Infection Prevention and Control Program (IPCP) Standard and Transmission – Based Precautions revised on 04/2025 documented Enhanced Barrier Precautions (EBP): All residents with any of the following. Wounds and /or indwelling medical devices (e.g. central line, feeding tube, tracheostomy or ventilator) regardless of MDRO colonization status. During high contact resident activities: Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of: central line, feeding tube, tracheotomy/ventilator, wound care – any skin opening requiring a dressing. Required PPE: Gloves and gowns prior to high contact care activity. Change PPE before caring for another resident. Face protection may also be needed if performing activity with risk of splash or spray.

Based on observation, interview, and document review the facility failed to ensure foods were stored properly and ice machines were cleaned in 1 of 2 ice makers in the facility. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness. Findings include: On 07/29/2025 in the morning, there was an open bottle, without a lid, containing apple cider vinegar in the dry food storage area with a use-by date of October 19, 2024.There was an open bottle of lemon juice in the reach in cooler with a use-by date of July 20, 2025.On 07/29/2025 at 8:34 AM, the Dietary Director explained the apple cider vinegar should not have been stored without a lid and both the lemon juice and the apple cider vinegar should have been discarded on or before the use-by date.On 07/31/2025 in the morning, there was an ice machine in the B building back auxiliary hall closet with a white and brownish film on the bottom of the inner ice shield, and the plastic ice scoop was resting on the top of the ice machine.On 07/31/2025 at 10:26 AM, the Dietary Director explained the ice machines were cleaned periodically and had been recently cleaned. The Dietary Director stated the ice scoop should be in a holder on the side of the machine.A document titled Food and Nutrition Services, revised February 2017 revealed all storage, preparation, distribution, and service of food and beverage was conducted under sanitary conditions in accordance with state regulations and federal law.A document titled Food Storage and Retention Guide referenced the facility used the Food and Drug Administration (FDA) 2017 Food Code.The FDA 2017 Food Code documented a use-by date was the last date recommended for the use of the product. Stored food or beverage which has been packaged by a food processing establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date. Any food or beverage must be discarded if it exceeded a manufacturer's use-by date.

Based on observation, interview, record review, and document review, the facility failed to ensure the ordered pain-scale parameters were followed for 1 of 35 sampled residents (Resident 8). This deficient practice had the potential to result in unmanaged pain, delayed or inappropriate analgesic administration, functional decline, and diminished quality of life. Findings include: Resident 8 (R8) was admitted on [DATE], with diagnoses including quadriplegia (complete paralysis of all four limbs), a non-pressure chronic ulcer of the buttock, and muscle spasms. On 07/29/2025 at 2:05 PM, R8 indicated having frequent pain with a pain scale of 7-10. R8 indicated the pain medication was administered as needed.A Physician Order dated 12/20/2022, documented Oxycodone Hydrochloride tablets, 10 milligrams (mg), by mouth every 4 hours as needed for severe pain level 7-10.The Medication Administration Record showed Oxycodone was administered when pain levels were below the ordered pain level of 7-10 on the following dates:-July 1, 2025: Pain level 5; medication administered twice/day.-July 7, 2025: Pain level 5; medication administered twice/day.-July 8, 2025: Pain level 5; medication administered once/day.-July 14, 2025: Pain level 6; medication administered once/day.-July 15, 2025: Pain level 6; medication administered once/day-July 21, 2025: Pain level 5; medication administered once/day.-July 30, 2025: Pain level 6; medication administered twice/day.On 08/01/2025 at 12:02 PM, the Assistant Director of Nursing (ADON) indicated nursing staff were expected to follow physician orders as written, particularly for as needed pain medication. ADON explained when an order specified administration for pain levels 7 to 10, medication was not to be given if the reported pain level was below 7. The ADON indicated the nurse was to notify the provider to clarify or adjust the order or request an alternative pain management intervention.On 08/01/2025 at 12:02 PM, the Director of Nursing (DON) confirmed nursing staff were expected to follow the pain level or parameters as prescribed.A facility titled Medication Administration (undated), documented resident medications were administered in accordance with written orders of the physician.A facility policy titled Pain Management, revised August 2012, documented the goal of the pain management program was to ensure pain was identified and treated effectively and consistently.

Based on observation, interview, record review, and document review, the facility failed to ensure Oxygen (O2) was administered as ordered and failed to clean the Oxygen concentrator for 2 of 35 sampled residents (Resident 123 and 166). The deficient practice had the potential to result in resident hypoxemia or Oxygen toxicity due to incorrect flow rates, equipment malfunction, and transmission of respiratory pathogens from contaminated equipment, thus compromising respiratory status and overall safety.Findings include:1) Resident 123 (R123) was admitted on [DATE], with diagnoses including edema and atherosclerotic heart disease.A Physician Order dated 11/04/2022, documented to administer O2 inhalation at 2-3 liters per minute (LPM) though nasal cannula as needed for O2 saturation below 90 percent (%) to maintain O2 saturation above 90%.The medical record lacked documented evidence that R123's Oxygen administration and saturation was being monitored to ensure the flow rate was appropriate to keep the resident's oxygenation saturation above 90. On 07/29/2025 at 10:50 AM, R123 was in bed confused, with O2 flowing at 5.0 liters per minute (LPM) through nasal cannula. No signs and symptoms of respiratory distress.On 08/30/2025 at 8:05 AM, R123 was in bed with O continuously flowing at 5 LPM through nasal cannula.On 08/31/2025 at 2:04 PM, R123 was in bed with O2 continuously flowing at 5LPM via nasal cannula. A Licensed Practical Nurse (LPN) confirmed R123's O2 was flowing at 5 LPM continuously when the order was for 2-3 liters. The LPN indicated the Licensed Nurses were responsible for ensuring Oxygen orders were being followed as prescribed to prevent toxicity.On 08/31/2025 at 2:00 PM, the Assistant Director of Nursing (ADON) confirmed R123's O2 was administered at 5 LPM when the order was 2-3 LPM through nasal cannula. The ADON indicated that the Licensed Nurses were expected to check and monitor the residents' O2 as prescribed. 2) Resident 166 (166) was admitted on [DATE] and readmitted on [DATE], with diagnoses including asthma, and hypotension.A Physician Order dated 03/14/2025, documented O2 at 2 LPM through nasal cannula as needed.A Care Plan dated 03/14/2025, documented R166 had O2 therapy at 2LPM through nasal cannula. The interventions included to administer and monitor O2 as ordered.On 07/29/2025 at 10:50 AM, R123's Oxygen was observed flowing at 3.5 LPM through nasal cannula. The cannula was not positioned in R123's nostrils. The O2 concentrator filter was covered with dust. No signs or symptoms of respiratory distress were observed.On 07/30/2025 in the morning, R123's O2 flowing at 3.5 ml via nasal cannula. The O2 concentrator filter was covered with dust.On 07/31/2025 at 1:50 PM, R123's O2 flowing at 3.5 ml through nasal cannula. The Oxygen concentrator filter was covered with dust. A Licensed Practical Nurse (LPN) confirmed the O2 was flowing continuously at 3.5 LPM when the order was 2 LPM through nasal cannula as needed. The LPN was uncertain who was responsible for cleaning the filter because there was no order in place. The LPN confirmed R166's O2 liter flow and saturation should have been monitored but there was no monitoring order in place.On 07/31/2025 at 2:00 PM, the Discharge Planner confirmed O2 saturation was not monitored, and the liter flow was not administered as ordered. The physician orders should have been clarified to include the indication for use, delivery method (PRN or continuous), specific liter flow, and oxygen saturation parameters. The Discharge Planner acknowledged failure to include this information resulted in a lack of monitoring and incomplete implementation of the O2 orders per protocol.A facility policy titled Oxygen Administration (undated), documented to obtain physician orders for O2 administration including the O2 saturation. Monitor the resident's response to O2 therapy.

Based on observation, interview, and record review, the facility failed to ensure the tube-feeding (TF) formula bag and tubing was labeled for 3 of 35 sampled residents (Residents 118, 251, and 222). The deficient practices could have the potential for formula contamination, inaccurate nutrient intake, infection, dehydration, and nutritional compromise.Findings include:1) Resident 118 (R118) was admitted on [DATE], and readmitted on [DATE], with diagnoses including epilepsy and anoxic brain damage. On 07/29/2025 at 10:36 AM, R118's TF bag was unlabeled except for the date 07/28/2025. On 07/31/2025 at 1:38 PM, R118's TF bag was labelled with R118's name, date, and time but no TF rate and nurse initials. On 07/31/2025 at 2:25 PM, a Licensed Practical Nurse (LPN) indicated the TF bag should have been completely labeled with formula, TF rate, resident's name, room number, nurse initials, date, and time. On 07/31/2025 at 2:26 PM, the Assistant Director of Nursing (ADON) indicated the TF should have been completely labeled. 2) Resident 251 (R251) was re-admitted on [DATE], with diagnoses including cognitive communication deficit, metabolic encephalopathy, dementia, altered mental status, unspecified intellectual disabilities, and generalized anxiety disorder. On 07/29/2025 in the morning, R251 had a feeding tube pump in the room. The tube feeding line was not dated and the date on the tube feeding solution was 07/27/2025. 3) Resident 222 (R222) R222 was re-admitted on [DATE], with diagnoses including seizures, anxiety disorder, depression, and lack of expected normal physiological development in childhood. On 07/29/2025 in the morning, R222 was attached to an active feeding tube line which was not dated. On 07/29/2025 in the morning, the unit Nurse verified the 7/27/2025 date on the feeding tube solution and the undated tubing in the room of R251 and the undated tubing in the room of R222. On 07/31/2025 at 08:28 AM, the LPN described the dating process when it was time to change the residents feeding. The date and time had to be checked for the entire system as it needed to be replaced every 24 hours. This included noting the date and time on the formula and on the tubing lines after the formula was hung and the tubes were changed.

Based on interview, record review and document review, the facility failed to ensure a physician order for specialist consultation was arranged for 1 of 35 sampled residents (Resident 6). The deficient had potential for prompt medical interventions or recommendations to be delayed.Findings include:Resident 6 (R6) was admitted on [DATE], with diagnoses including overactive bladder and morbid obesity.On 07/29/2025 at 2:00 PM, R6 verbalized just finished a round of antibiotics for treatment of a urinary tract infection (UTI). R6 indicated having frequent UTI and was concerned about taking too many antibiotics. R6 indicated the physician had ordered a urologist (a medical specialist who diagnoses and treats conditions related to the urinary tract and reproductive system) consult and R6 had been patiently waiting to hear from the staff.A Nursing Note entry dated 05/23/2025 at 3:20PM, documented the patient reported having burning sensation upon urination. It was reported to the Nurse Practitioner (NP). The NP stated R6 had been treated with different types of anti-microbial. The NP authorized a referral to a Urologist.R6's physician's order documented, Referral to Urologist: No directions specified for order dated 05/23/2025.A Progress Note entry dated 05/26/2025 at 8:06 AM, documented Alert Charting: Resident complained of burning upon urination. New orders to collect Urine for analysis. R6 had an order for Urologist consultation. Please notify the physician if the symptoms get worse.The medical record lacked documentation, the ordered consultation was scheduled or was completed.On 07/30/2025 at 3:15 PM, a License Practical Nurse (LPN) indicated any ordered outpatient consultation would be relayed in writing or verbally to the scheduler or transporter. The scheduler would notify the nurse if an appointment had been scheduled and the specifics of the appointment would be placed in the electronic health record as part of the physician order.On 07/31/2025 at 2:08 PM, the Director of Transportation reviewed R6's medical record and confirmed the order for a urology consultation was not scheduled. The Director had no explanation as to why the appointment was not scheduled. The Director explained hurdles in scheduling a consultation from insurance coverage to medical offices scheduling back log and indicated that regardless of the reason for the delay, nursing staff should be well informed so the physician would be informed as well. The facility policy titled Physician's Order revised June 2021, documented entry of orders into the electronic health record requires the license nurse to confirm the order to acknowledge the receipt of the physician's order to acknowledge receipt and physician notification and to activate the order.

Based on observation, interview, and document review, the facility failed to ensure a smoking safety assessment was completed for 1 of 35 sampled residents (Resident 137), and an Oxygen tank place inside a resident room was properly secured in a tank holder for 1 of 35 sampled residents (Resident 147). The deficient practice had the potential for placing residents' safety at risk for fire and severe injury.Findings include: 1. Resident 137 (R137) was admitted on [DATE], with diagnoses including contracture of muscles - multiple sites and muscle weakness.On 07/29/2025 at 11:10 AM, R137 was observed to be in bed waiting for the certified nursing aide (CNA) to assist the resident to get into the Geri-chair (a specialized recliner designed to provide comfort and support for individuals with mobility limitations). R137 had moderate contracture of the left hand and some impairment of mobility at the right hand. R137's pack of cigarettes and lighter was visible at the bedside table. R137 indicated was able to smoke by self even with the impairment of mobility on both hands. R137 stated wishing to be able to go out more often for more frequent smoke breaks.On 07/30/2025 at 3:44 PM, R137 was observed to be out of bed in a Geri-chair getting ready to go for a smoke break. The CNA accompanying the resident indicated R137 was able to manage handling a cigarette on the right hand and would need monitoring to ensure safety.R137's Physician admission Note dated 04/24/2025 and every succeeding physician's note documented the resident was a smoker.R137's medical record lacked documented evidence, a smoking safety assessment was completed, and a physician order was obtained.On 07/30/2025 at 4:10 PM, a License Practical Nurse (LPN) indicated the nurse completing the admission assessment was responsible for asking if an incoming new resident smokes and if the resident verbalized wanting to smoke while at the facility, a smoking assessment should have been completed. The LPN indicated any nursing staff could have completed a smoking assessment upon noticing if a resident did not have one.On 07/31/2025 at 3:13 PM, an Assistant Director of Nursing (ADON) reviewed R137's medical record and confirmed there was no smoking assessment completed. The ADON agreed it was important for R137 to have a smoking assessment, especially with contractures and limited dexterity.The facility policy titled Smoking/Tobacco Policy and procedure revised 12/05/2024, documented upon admission, resident who desires to smoke will be assessed and be informed of our smoking policy.2. Resident 147 (R147) was admitted on [DATE], with diagnoses including atherosclerotic heart disease and chronic kidney disease.On 07/29/2025 at 10:00 AM, R147 was in bed receiving Oxygen (O2) 1.5 liters via nasal canula delivered by an O2 concentrator. R147 indicated being on O2 around the clock and used an O2 tank when in a wheelchair. Against the wall at the foot of the bed of R147 was a half full O2 tank not held by any stand or secured to a fixed fixture.On 07/29/2025 at 10:10 AM, an LPN caring for R147 confirmed the O2 tank should have been placed on an O2 caddy. The LPN acknowledged an unsecured O2 was very dangerous and could severely hurt someone. On 07/31/2025 at 3:27 PM, the ADON confirmed O2 should be in a caddy even when in storage.The facility policy titled Oxygen Storage and Assembly (undated), documented Small Tank: Always place cylinder in a stand or cart.

Based on observation, interview, and document review, the facility failed to ensure a comfortable homelike environment was maintained for 2 of 35 sampled residents (Residents 215 and 12) and 3 unsampled residents (Residents 160, 33, and 65). The failure to provide a homelike environment had the potential risk to cause psychosocial distress to the residents. Findings include:On 07/29/2025 in the morning, the following was observed during a tour of the 2200 and 2300 halls:-In room [ROOM NUMBER] B the blinds were broken and missing some slats. The resident's dresser drawer was broken and coming apart, hanging down toward the floor.-In room [ROOM NUMBER] B the coaxial cable box in the wall was missing a cover and the cable wires and splitter were hanging out of the wall. The resident's dresser was missing a middle drawer. -In room [ROOM NUMBER] A the dresser drawer was broken and coming apart causing the drawer to be very loose.-In room [ROOM NUMBER] B the blinds were broken and missing some slats.-In room [ROOM NUMBER] B the blinds were broken and missing some slats.A maintenance work order was initiated and marked completed for broken blinds and missing slats for room [ROOM NUMBER] on 06/24/2025.On 07/31/2025 at 8:53 AM, the Maintenance Director reported no knowledge of the broken blinds, broken furniture, or uncovered coaxial cable holes in the wall during. The Maintenance Director was aware open holes in the walls should be covered. The Maintenance Director agreed these rooms were not currently presented as a home-like environment.On 07/31/2025 at 11:12 AM, the Assistant Director of Nursing (ADON) for the 2200 and 2300 halls was unaware of the broken blinds, broken furniture, or uncovered coaxial cable holes in the wall. The ADON explained if had known about the issues, work orders would have been submitted. The ADON confirmed these items should be continually maintained just like a homelike environment.The facility's Resident Right's Policy documented the residents had a right to a safe, clean, comfortable, and homelike environment.

Based on interview, record review, and document review, the facility failed to ensure the state mental health authority was notified after a significant change in the mental health condition of a resident with a history of mental health disorder for 1 of 35 sampled residents (Resident 12). The deficient practice had the potential to deprive residents of necessary behavioral health services.Findings include:Resident 12 (R12) was admitted to the facility 05/21/2025, with diagnoses including other schizoaffective disorders, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, and anxiety disorder. R12's admission paperwork noted the resident was admitted to a local hospital on [DATE]. The resident had been sent to the Emergency Department from a Nursing Facility on a legal hold because R12 became homicidal towards other residents in the facility. R12 had a past medical history of psychiatric diagnoses. R12 was transferred from the Emergency Department back to a skilled nursing facility on 05/21/2025 after being deemed no longer suicidal or homicidal and tolerating all medications well.A Pre-admission Screening and Resident Review (PASARR) level one document dated 08/09/2018, revealed R12 did have the dementia diagnosis, however, no other mental illness (MI), intellectual disability, (ID) mental retardation (MR) or any related condition (RC) and was deemed appropriate for nursing facility placement.A review of the resident's hospital behavioral health notes on 05/12/2025 and hospital discharge note on 05/21/2025 revealed R12's schizoaffective disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder was previously diagnosed; however, the resident had a change of condition which led the resident to become homicidal, possibly post-traumatic stress from a previous assault in 2022.On 07/30/2025 at 1:49 PM, the Director of Social Services (DSS) explained Social Services were responsible for referring residents who met criteria for PASARR level two by completing the PASARR referral in the PASARR system. The DSS indicated a diagnoses of cognitive communication deficit, bipolar disorder, anxiety disorder, and metabolic encephalopathy would be representative of mental illness, intellectual disability, dementia, or a related condition the Medicaid Service Manual documents a PASARR II must be completed. The DSS explained not necessarily as these were old past diagnoses; however, the resident being sent out on a legal hold to the Emergency Department for a change in mental condition would necessitate a PASARR level two referral. The DSS acknowledged R12 did have a legal discharge due to a psych change of condition and a referral for a PASARR level two should have been completed.The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities or related condition, a PASARR level two screening must be completed to evaluate the individual and determine if nursing facility services and/or specialized services are needed and can be provided in the nursing facility. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASARR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority.A facility document titled Pre-admission Screening and Resident Review (PASRR), dated November 2017, revealed upon a significant change in status, the facility referred residents currently diagnosed with or residents with newly evident or possible mental disorder, intellectual disability, or a related condition for a PASRR level two review.The medical record lacked documented evidence, a referral for a PASARR level two screening was completed for R12.

Based on record review, interview, and document review, the facility failed to follow physicians' orders for the application of a BiLevel Positive Airway Pressure BiPAP (a non-invasive ventilation device that facilitates breathing and improve oxygenation for conditions that impair breathing like COPD) for 1 of 8 sampled residents (Resident #3). The deficient practice had the potential to cause inadequate oxygenation, respiratory distress, or worsening of underlying conditions such as COPD, placing the resident in a risk for complications, including hypoxia, increased carbon dioxide retention, and respiratory failure. Findings include Resident #3 (R3) R3 was admitted on [DATE], with diagnoses including acute on chronic hypercapnic respiratory failure, chronic obstructive pulmonary disease (COPD) exacerbation, and history of chronic hypoxic respiratory failure. A hospital history and physical dated 01/19/2025, documented R3 was admitted to the emergency department due to complaining shortness of breath (SOB) for two days. R3 had history of home oxygen use at 4 liters per minute (lpm). The hospital discharge summary dated 01/26/2025, documented R3 was placed on nightly BiPAP to lower pCO2 levels (partial pressure of carbon dioxide measures the amount of carbon dioxide in the blood, helping clinicians assess how well the lungs are removing CO2 and maintaining proper breathing function) to less than 55 millimeters of mercury (mmHg) per pulmonologist recommendation. A physician's order dated 01/30/2029, revealed Bi-PAP to be used during hours of sleep and the resident would be assisted with the device setup. The order directed the staff to document refusal of use. An incident report investigation conducted by the facility revealed that, according to nursing staff, the BiPAP was applied to R3 on the nights of 01/30/2025 through 02/01/2025. However, the report indicated R3 went two nights without BiPAP and instead received oxygen at 2 LPM via nasal cannula, per physician orders. As part of the facility's internal investigation, an interview was conducted with LPN (LPN2), who stated the BiPAP was applied to R3 on 01/30/2025. However, on 01/31/2025, LPN2 received a report a piece of the BiPAP device was missing, resulting in the resident being unable to use the device. LPN2 acknowledged signing the Medication Administration Record (MAR) on 01/31/2025, indicating the BiPAP was applied, but noted it could have been documented as by mistake. Furthermore, LPN2 stated the attending physician was not notified, as it was believed the issue had already been reported and the facility was awaiting the replacement part. A treatment administration record for January and February 2025, revealed the BiPAP was documented as applied on 01/30/2025, 01/31/2025, 02/01/2025, and 02/03/2025. Nursing progress note dated 01/31/20245 at 2:23 AM, documented BiPAP machine was on for the night and R2 was tolerating well. Nursing progress note dated 01/31/20245 at 10:30 PM, indicated R3 had BiPAP at night. On 05/29/2025 at 2:58 PM, a Licensed Practical Nurse (LPN1) reported had received information an elbow connector (a component that enables a breathing tube to be attached to the BiPAP machine at a 90-degree angle) may have been lost when R3 was relocated to a different room on 01/31/2025. LPN1 indicated due to the missing connector, the BiPAP device could not be used. The matter was reported to the Director of Nursing (DON) and the Administrator. LPN1 further stated that they do not work night shifts and could not confirm whether the BiPAP was used without the missing elbow connector. On 05/29/2025 at 3:15 PM, the Director of Nursing (DON) stated that the elbow connector of the BiPAP device may have been misplaced during Resident R3's room transfer and could not be located. The facility attempted to replace the missing piece; however, R3's daughter called 911, leading to the resident being transported to a hospital. The DON confirmed that nursing staff did not notify the attending physician about the inability to apply the BiPAP device due to the missing connector, preventing the implementation of alternative respiratory measures. Additionally, the DON acknowledged nurses should not have documented the application of the BiPAP device when it had not been used. The most recent revision of the facility policy, titled Significant Change in Condition, Response, dated January 2022, stated if a team member recognized a change in a resident's care needs, a licensed nurse or nurse supervisor was required to be notified. According to the policy, the nurse was responsible for performing and documenting an assessment, identifying the need for additional interventions. The nurse would then determine whether to implement existing physician orders or, if necessary, communicate with the attending physician using SBAR (Situation, Background, Assessment, Recommendation) or a similar process to obtain new orders or interventions. Complaint #NV00073441

Based on interview, record review, and document review, the facility failed to provide documented evidence assistance with activities of daily living (ADL) was provided for 1 of 8 sampled residents (Resident 6). The deficient practice had the potential for the resident's skin integrity to be compromised. Findings include: Resident 6 (R6) R6 was admitted on [DATE] and discharged on [DATE] with diagnoses including end stage renal disease, muscle weakness, and type 2 diabetes mellitus. The Admission Minimum Data Set (MDS) dated [DATE], documented R6 was frequently incontinent of bowel and bladder and dependent with toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement). R6's activities of daily living (ADL) documentation for toilet hygiene lacked documented evidence the task was performed every shift on the following days: -03/21/2025 through 03/23/2025 -03/25/2025 -03/28/2025 -03/30/2025 and 03/31/2025 -04/02/2025 and 04/03/2025 -04/09/2025 and 04/10/2025 On 05/30/2025 at 8:21 AM, a Certified Nurse Assistant 1 (CNA 1), explained the process for documenting a resident's incontinent care had been provided was to document the task in the resident's chart every shift under toileting hygiene. On 05/30/2025 at 8:30 AM, a Certified Nurse Assistant 2 (CNA 2) explained resident toileting assistance and peri care were documented in the resident chart under toileting hygiene each shift. On 05/30/2025 at 8:35 AM, the MDS Coordinator explained the process for staff to document care for incontinent residents was to document under toileting hygiene. The MDS Coordinator reviewed R6's Admission MDS and confirmed R6 was frequently incontinent of bowel and bladder and dependent upon staff for assistance. The MDS Coordinator reviewed the ADL documentation for R6's toileting hygiene from March 2025 through April 2025 and confirmed there were shifts blank with no documentation of toileting hygiene. The MDS Coordinator explained if the task was blank with no documentation, then the task did not occur. The MDS Coordinator explained residents that are incontinent and require staff assistance would have a care plan indicating their needs and interventions staff were to take. The MDS Coordinator reviewed R6's care plan and verified there was no care plan for incontinence. On 05/30 2025 at 11:51 AM, the Director of Nursing (DON) explained the process for documenting toileting assistance and hygiene was for staff to document under the ADL task labeled toileting hygiene to indicate the care was provided. The DON explained the expectation was for staff to document daily and as needed (PRN). The DON explained residents who are assessed as incontinent requiring staff assistance, would have a care plan indicating the incontinence and care interventions to be provided. The DON reviewed R6's ADL toileting hygiene documentation and confirmed there were shifts with no documentation and explained no documentation indicated the task was not performed. The facility policy titled Standards of Care for CNA Practice, undated, documented the CNA would assist the resident in ADLs such as eating, drinking, turning and positioning, transfer and ambulation including walking, bathing, oral care, grooming, dressing, toileting, communication and socialization. The CNA would accurately, and timely document care provided. NV#00073877

Based on interviews, record review, and document review the facility failed to ensure a resident was free from physical restraints for 1 of 8 sampled residents (Resident 7). The deficient practice placed the resident at risk of physical and psychosocial harm. Findings include: Resident 7 (R7) R7 was admitted on [DATE] with diagnosis including dementia. A brief interview for mental status (BIMS) was conducted on 04/10/2025 and determined R7 had a score of 03 indicating R7 had severe cognitive impairment. The facility policy titled restraints (revised April 2025), documented it was the facility policy to ensure each resident was not restrained for the purpose of discipline or convenience. A restraint device assessment would be conducted to determine if the resident would be safe using the specific restraint. A physician order would be obtained indicating the type of device to be used, indication, duration, and how often it was supposed to be released. A report to the state agency documented upon admission to the facility R7 had abdominal and chest restraint applied. The report indicated the admission nurse untied the restraint to move R7 to the facility bed and then tied restraint to bed. The report concluded the admission nurse did not have a physician order for use of restraint. The facility completed the internal investigation and submitted report to the state agency on 04/14/2025 with the following timeline of events: On 04/08/2025 at approximately 9:00 PM, R7 was admitted to the facility, was assessed and indicated R7 was restrained to the bed with abdominal and chest restraint which allowed movement of upper body to sit up and lay down which confined R7 to the bed. On 04/08/2025 in the evening, the Certified Nursing Assistant (CNA1) indicated asking the Licensed Practical Nurse (LPN1) about the restraints. LPN1 verbalized being aware of restraints and instructed CNA1 to keep restraints in place after the CNA was complete with cleaning resident. CNA1 indicated LPN1 had verbalized not having time to keep checking on the resident. A thorough review of video documented LPN1 did not check on resident until it was time to start passing medications between 4:00 AM and 5: 00 AM on 04/09/2025. On 04/09/2025 at approximately 6:00 AM, there was a shift change, and a different Licensed Practical Nurse (LPN2) was responsible for R7. Through interviews with LPN2 it was discovered LPN1 did not advise LPN2 about R7 being in restraints. LPN2 discovered the restraints during assessment and immediately removed due to no physician order. LPN2 then contacted the Director of Nursing (DON). The Abuse Coordinator was notified, and investigation was initiated. On 05/30/2025 at 9:00 AM, Administrator (Abuse Coordinator) indicated R7 had been in facility previously and arrived most recently on 04/08/2025 in the evening with a variety of restraints. The administrator verbalized the facility attempts to avoid the use of restraints. The administrator confirmed the admitting nurse, LPN1, had reapplied the restraints once R7 was moved to the facility bed. The morning nurse removed restraints after assessment and notified the DON and Administrator. On 05/30/2025 at 9:15 AM, a Registered Nurse (RN) indicated the facility general practice was to not use restraints. If a resident was to arrive at facility with restraint it would be immediately removed and physician contacted. To continue with restraints, the resident would need to be assessed for use and a physician order would be needed to document the reason for restraint, which could not be determined until the resident was assessed and assessed for safety with the specific type of restraint to be used. On 05/30/2025 at 9:45 AM, the Assistant Director of Nursing (ADON) explained the facility was a restraint/lift free facility meaning the use of restraints was discouraged. The ADON indicated when a resident was admitted to the facility with a restraint it would immediately be removed until an assessment was completed. Further, the resident would be assessed for the specific type of restraint to determine if it was needed and if the resident would be safe with the restraint. The ADON verbalized it would be inappropriate to reapply a restraint without a physician order including reason for restraint, how long the restraint would be used, off time of restraint and how often it would be monitored. On 05/30/2025 at 1:02 PM, the Director of Nursing (DON) indicated the investigation was started immediately upon notification from LPN2. LPN1 was suspended by phone and initial interviews were started. The DON indicated LPN1 confirmed being aware of the restraints and acknowledged applying a restraint without a physician order. The DON explained after having reviewed the video surveillance of nursing station and based on multiple corroborating interviews LPN1 was terminated on 04/11/2025. The following actions were confirmed to have been completed by the facility to correct the deficient practice during and immediately following the investigation: - Oncoming staff immediately released restraint. - Reported to ADON, DON, Abuse Coordinator (initial to state agency on 04/09/2025, final on 04/14/2025). - Initiated investigation on 04/09/2025. - Suspended staff member on 04/09/2025. - Surveillance video reviewed with transcript of timeline. - Conducted interviews with guardian, CNA's, nurses, a few residents - Terminated staff member involved on 04/11/2025 - Reported to the Board of Nursing on 04/29/2025. - Notified state agencies, Public Guardian, family member, physician on 04/09/2025 - Education to all staff with sign in sheet and education topic provided. FRI report indicated staff education on restraint use, abuse/neglect training and education provided. Education started on 04/10/2025 and completed 04/14/2025. FRI NV00074000

Based on observation, interview, record review, and document review, the facility failed to ensure the call light buttons were within the reach of the residents for 1 of 11 sampled residents (Resident 1). The deficient practice had the potential safety risk of the resident experiencing delays in receiving necessary assistance, leading to potential safety risks like falls, discomfort, and being unable to alert staff when they need help. Findings include: Resident 1 (R1) was admitted on [DATE], with diagnoses including secondary malignant neoplasm of bone, generalized muscle weakness, repeated falls, with need for assistance with personal care. On 01/28/2025 at 10:56 AM, R1 was lying in bed and the call light was not within reach. R1's call light button was at the bedside table of adjacent resident. On 01/28/2025 at 11:01 AM, a housekeeper confirmed the call light was not within R1 reach. On 01/28/2025 at 11:13 AM, a Licensed Practical Nurse (LPN) verbalized the call light should have been within R1 reach and not on the bedside table of the adjacent resident. The LPN stated the resident was a fall risk. The LPN communicated all staff are responsible for ensuring the call light are within the resident's reach. On 01/28/2025 at 12:12 PM, the Director of Nursing stated call lights should be placed within the reach of the resident. Complaint NV00072771

Based on interviews, record review and document review, the facility failed to ensure a sampled resident (Resident #4) with severe cognitive impairment was adequately supervised and was not able to elope from the facility. The deficient practice had the potential for physical and psychosocial harm to the resident. Findings include: Resident 4 (R4) R4 was admitted to the facility on [DATE] and readmitted on [DATE]with diagnoses including bipolar disorder and dementia. A brief interview for mental status (BIMS) assessment documented a score of 03 indicating the resident had a severe cognitive impairment. A facility report investigation indicated on 10/22/2024, R4 had eloped from the facility and was out of the facility from 3:30 AM and was returned to the facility at 12:30 PM. The following was a timeline based on the investigation notes and interviews from the facility: - after video review it was determined the resident left the building at approximately 3:30 AM. - at 5:40 AM, a nurse in training entered the resident's room and documented R4 refused medication. - at 6:50 AM, a Certified Nursing Assistant (CNA) entered the room of R4 and did not report the resident was missing. - at approximately 8:00 AM, a CNA brought the breakfast tray to R4's room. - at approximately 8:50 AM, the CNA went in R4's room to pick up breakfast tray and noticed it had not been consumed. The CNA notified a nurse and a search for the resident had been initiated. - according to progress notes, a code white (missing resident) was called at 9:52 AM and a full-scale search was initiated and police contacted. On 11/08/2024 at 9:30 AM, a CNA indicated when on shift at the facility, rounds were to be made approximately every 2-3 hours, however between the CNA and nurse every resident was generally seen more frequently. The CNA explained when a resident was not in the room it was important to locate resident. If the resident was not able to be immediately located the CNA would inform the nurse. The CNA revealed it would not be appropriate to assume where a resident was located without verification. On 11/08/2024 at 9:45 AM, a Licensed Practical Nurse (LPN) verbalized checking on residents was a continuous process throughout the shift and between the nursing staff and CNAs, a resident would be observed nearly every hour. The LPN indicated the expectation would be to notify a nurse if the resident was not in the room and location of resident could not be verified. The LPN explained it would be unprofessional for a nurse to document a resident refused medication when the resident was not in room. On 11/08/2024 at 10:10 AM, an Assistant Director of Nursing (ADON) confirmed R4 had eloped from facility on 10/22/2024. The ADON explained there were several points of concern regarding the incident, including a nurse who documented the resident refused a blood glucose check when the resident had already left the building and a CNA who failed to communicate with nursing staff regarding the resident not being in the room without attempting to locate the resident. The ADON verbalized when a resident was not in the room it was expected staff would attempt to locate the resident and then inform a supervisor if the resident was not able to be found. Following the event on 10/22/2024, it was determined the facility took the following actions during the investigation and immediately following to correct the deficient practice: - the nurse in training was immediately suspended and terminated. - the CNA who did not report resident was not in room was reprimanded and provided further education. - an interdisciplinary team meeting was held to discuss additional safety concerns in the area the resident was able to elope from. - additional training regarding elopement was mandated and completed within 3 days of incident. On 11/08/2024 at 11:30 AM the Director of Nursing (DON) confirmed elopement and verified during the investigation concerns with staff actions were identified and corrected at the time the facility became aware. The DON indicated the nurse in training was suspended during investigation and terminated when it was determined the nurse had falsely documented R4 refused a blood glucose check. The first CNA to check on resident should not assume the location of the resident and should have reported to the nurse and was subsequently educated on proper procedure. The DON revealed all staff had received additional training on elopement and the facility policy. The facility policy titled Elopement/Unsafe Wandering documented, elopement was defined as occurring when a resident leaves the facility premises or a safe area without the facilities knowledge. The staff would promptly report any resident attempting to leave the premises or missing to the charge nurse or supervisor to evaluate the need for further interventions. Facility Reported Incident #NV00072512

Based on observation, interview, and document review the facility failed to ensure the walk-in freezer was maintained in safe operating condition, food items stored inside the reach-in refrigerator and freezer were labeled, dated, and not expired, the kitchen was maintained in sanitary condition and a hand washing sink was provided for the steam table set up in the main dining room for meal service. The deficient practice posed a potential risk to safety and health standards which could lead to contamination, inadequate storage, and place residents at risk of foodborne illness. Findings include: On [DATE] at 7:49 AM, an initial tour of the kitchen with the Dietary Supervisor was completed with the following findings: - significant dust build up on vents and light fixtures over the food preparation and tray line area. - in the dry storage room there were damaged cans of beans and mushrooms stored with the active food items to be used. - in the walk-in freezer there were three fans for cooling at back of freezer and one did not have a blade cover. - in the walk-in refrigerator there was a bowl with lettuce, cheese, and tomato mixed together and was not labeled or dated. In the reach in refrigerator: - no date on container containing boiled eggs. - container with chopped type of meat had no label or date. - container of blue cheese expired on [DATE]. - sliced cheese in plastic wrap was not labeled or dated. - a container of potato with egg salad expired on [DATE]. - two bowls of pre-made salad was not dated. In the storage room containing cleaning equipment there was a squirt bottle containing cleaning chemical which was not labeled. On [DATE] at 7:55 AM, in the main dining area, there was a satellite set up for warming and keeping food at temperature to serve residents during meals. There was no hand washing area in the room. The Dietary Supervisor indicated the set up was used to hold foods at proper temperature to use to prepare plates for residents eating in the main dining area. The Dietary Supervisor was advised by an Environmental Health Specialist Surveyor (inspector who inspects the facility kitchen to issue a permit to operate the kitchen) the area would need to be shut down until there was a sink in the room for observing hand hygiene practices. The Dietary Supervisor acknowledged information given. On [DATE] at 8:30 AM, the Dietary Supervisor acknowledged the concerns noted during the initial tour and verbalized the process when receiving items was to ensure they were not damaged. The Dietary Supervisor indicated when receiving items the staff was expected to ensure all items put in the refrigerators and freezers had a received date, open date, and expiration date along with label to identify item. The Dietary Supervisor confirmed the freezer had a fan blade which did not have a protective cover and it was unacceptable. The Dietary Supervisor explained it may have been knocked off when stacking items nearby, however it should have been immediately replaced. On [DATE] at 12:15 PM, the facility staff was in the dining room using the satellite steam table set up in the main dining room. There was no sink available in the dining room. On [DATE] at 12:20 PM, the facility staff was in the dining room using the satellite steam table set up in the main dining room. There was no sink available in the dining room. On [DATE] at 12:15 PM, a surveyor observed staff using satellite steam table in main dining area and using it to warm returned trays until they were used. A staff member served a tray and removed the top for resident and the resident refused tray. Cover was placed back on steam table for holding temp and then given to another resident. On [DATE] in the afternoon, the Dietary Supervisor explained not being aware food service had to immediately stop, indicated thinking the facility could notify the residents and would have a few days to stop serving from the satellite area. The Dietary Supervisor revealed when a tray had been served to a resident it could not be returned to the line and given to another resident. On [DATE] at 9:28 AM, the Infection Preventionist (IP) explained the IP was involved in the general training for kitchen staff for proper hand washing etiquette and the Dietary Supervisor followed up with additional training for proper food safety training. The IP verbalized it was not acceptable to re-use a tray which was opened for one resident and given to another resident. On [DATE] at 1:10 PM, the Administrator was advised the satellite area in main dining was still being used for warming and preparing meal trays for residents. There was no sink in the area for staff to wash hands, perform general hand hygiene and adhere to infection control practices. The administrator indicated the area was not supposed to be used until a sink was available in the room. The facility policy titled Food Storage (undated) documented sufficient storage were provided to keep foods safe, wholesome and appetizing. Food was stored, prepared, and transported at appropriate temperatures and by methods to prevent contamination or cross contamination. All foods should be covered, labeled and dated. All foods would be checked to ensure foods would be consumed by the safe use date, or frozen, or discarded.

Based on observation, interview, record review, and document review, the facility failed to secure a resident in a wheelchair when it did not ensure the pre-transport securement checklist was completed, and the shoulder strap was placed prior to transit for 1 of 20 sampled residents (Resident 1). This deficient practice led to a fall incident inside the facility bus, resulting in fractures (broken bones) of the third, fourth, and fifth metacarpal bones of the dominant right hand. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including dependence on dialysis and absence of left and right below knees. The Quarterly Minimum Data Set, dated dated dated [DATE], documented a brief interview with a mental status score of 15/15, which indicated R1's cognitive status was intact. The Nursing Progress Notes dated 09/21/2023 documented R1 falling in the facility transport bus while in transit to R1's appointment. There was an abrasion and contusion on R1's forehead and increasing swelling on the right hand, back, and palm. R1 reported pain on a scale of 10/10. A STAT (urgent) x-ray was ordered with results of acute metacarpal fractures of the right hand. The Nurse Practitioner ordered R1 to be transferred to the hospital. The Hospital Radiology Report dated 09/21/2023, documented acute metacarpal fractures to the right hand. Acute displaced fractures were noted in the third (3rd) and fifth (5th) metacarpals, with an acute nondisplaced fracture of the fourth (4th) metacarpal. The impression of the skull x-ray revealed no acute process. A Change in Condition Note dated 09/21/2023 documented symptoms or signs of a change in condition related to a fall incident inside the bus while in transit. The Nursing Progress Notes dated 09/22/2023 documented R1's right hand remained swollen and bruised. Driver #1's (D1) handwritten statement dated 09/21/2023, documented around 2:45 PM on 09/21/2023, upon entering the freeway, a car cut D1 off from the front. D1 had to brake hard, and R1 complained the hand was hurting. The Interview Record with R1 dated 09/22/2023, documented the bus was in transit to R1's appointment. D1 was cut off by a car and had to stop abruptly, half of R1's body leaned forward and R1's head hit the steel bar behind the driver. R1's right hand got stuck in the wheelchair's bar. R1 indicated had the lap belt on but not the shoulder strap. The interviewer documented R1's right hand was noted to have edema and a decreased range of motion. Injury was noted to R1's right forehead, hematoma, or contusion approximately the size of a quarter. R1 emphasized not having the shoulder safety strap while in transit, just the lap belt. The supervisor's statement dated 09/22/2023, documented D1 was interviewed and indicated while entering the freeway, a car cut D1's off and had to brake abruptly. R1 leaned forward. After the incident, R1 verbalized their fingers were broken. The Interview Record by the Assistant Director of Nursing (ADON) with D1 dated 09/25/2023, documented the shoulder strap had not been in place or secured. D1 indicated had not put the shoulder strap on anyone. D1 indicated the shoulder strap appeared broken or bent but was not reported due to unawareness the shoulder strap should be used. D1 explained the purpose of the shoulder strap was to keep the resident from leaning forward. D1 admitted to sometimes forgetting to check off the trip book or pre-securement checklist and would do it afterward. D1 indicated R1's wheelchair was locked correctly but indicated not being trained to put on the shoulder strap. D1 revealed the shoulder strap was on the checklist but was disregarded because no one else used it. A Care Plan dated 09/27/2023 documented R1 had metacarpal bone fractures, related to an injury sustained when R1's hand got stuck in the wheelchair during an abrupt stop of the facility transportation bus. On 12/12/2023 at 10:01 AM, R1 was seated in the wheelchair, verbally alert, and oriented. R1's right forehead had a brownish quarter-sized mark, the back of R1's right hand exhibited a bump or deformity. R1 recounted on 09/21/2023, R1 was picked up by D1 for an appointment. R1 described how D1 placed R1 in the bus in a wheelchair, securing the wheelchair lock and lap belt but neglecting to put on the harness or shoulder strap. R1 realized the absence of the shoulder strap after the incident. R1 indicated D1 was in a hurry, and the rush was prompted by the next resident's appointment, as explained by D1. R1 indicated during the incident, R1's head bumped against the steel bar behind the driver and half of the body leaned forward abruptly. R1 used the left hand to brace self on the bus floor while the right hand held the wheelchair. R1 explained the right hand got stuck in the wheelchair's bar, resulting in three broken fingers. R1 was transferred to the hospital due to metacarpal fractures. R1 expressed currently, the broken hand made it challenging for R1 to perform daily activities, given already had only one usable hand and no bilateral feet. On 12/12/2023 at 2:38 PM, the Driver-Trainer demonstrated the process of locking the wheelchair and securing the resident before transit. The procedure involves bringing the resident to the bus, lifting them, and securing the wheelchair with four sure-loc hooks, two in the front wheelchair and two in the back. After it was secured, the seat belt or lap belt was placed from the bottom left across the waist of the resident to cross over to the back bottom right, ensuring it was securely locked. The Driver-Trainer emphasized the shoulder strap or harness was the final pre-securement step to put across the resident's chest to prevent leaning forward, to remain safely in place, and to prevent falling during sudden stops. The Driver-Trainer indicated the serious injury from the incident was avoidable if the shoulder strap was in place. The Driver-Trainer indicated D1 received five days of training, but there was no documented evidence in place D1 completed the 5-day training. On 12/13/2023 at 9:00 AM, Driver #2 (D2) indicated the shoulder strap was used to prevent the resident from leaning forward and to keep the resident restrained from sudden stop. D2 indicated the pre-securement checklist should have been completed as a reminder for every trip prior to transit. On 12/13/2023, at 11:40 AM, the Director of Nursing (DON) confirmed the fall incident inside the bus on 09/22/2023 was investigated and substantiated. The DON indicated D1 was fully trained, and all the drivers were trained before being allowed to drive. The DON indicated D1 was suspended and later terminated due to a failure to follow transportation safety protocols. The DON indicated D1 did not return to work after the incident. On 12/13/2023 at 12:45 PM, the Director of Maintenance indicated D1 was fully trained and was expected to complete the safety checklist before every trip, but it was not done on the day of the incident. The Maintenance Director indicated the safety checklist was being audited at least weekly. The Maintenance Director conveyed R1's metacarpal fractures were caused by incident and could have been avoided if safety protocols had been followed. The Maintenance Director indicated if R1 had been properly secured with safety belts, restraints, or a shoulder strap, severe injuries could have been prevented. The Maintenance Director indicated D1 was terminated for not following the transportation safety protocol. The Maintenance Director indicated each driver was trained for 5 days, and on the fifth day, the Maintenance Director would ride on the bus with the driver to ensure the protocols had been implemented. The Maintenance Director indicated there was no documented evidence D1's 5-days training had been completed. On 12/13/2023 at 3:28 PM, the Administrator indicated the expectation was to follow the safety protocol at all times. The Administrator indicated if D1 were to put on the shoulder strap for R1, there would potentially be less risk. The Sample Securement Checklist to be completed for each leg of every trip. The Pre-Securement Steps indicated the following: 1. Ensure the resident was seated properly; the residents back completely touched the chair seatback without spaces. 2. Evaluate cushion usage for safety. 3. Check all the equipment needed for this trip: a. Verify four tie downs/securement straps per wheelchair. b. One lap belt or seat belt per wheelchair. c. One shoulder strap per wheelchair. 4. Ensure securement tracks were clean and free of debris e. Ensure all the equipment above was in good condition. The Fleet Safety Program, dated 09/28/2023, documented the Driver was responsible for ensuring the safety belts were properly secured in the vehicle at all times, using the existing harnesses and restraints. A facility policy titled Fall Management System revised 01/2022, documented the facility to provide an environment remains as free of accident hazards as possible. To provide appropriate assessments and interventions to prevent falls. FRI #NV00069494

Based on observation, interview and document review, the facility failed to ensure hot water temperatures were within safe ranges in resident rooms and a shower room which created a potential for harm to residents and to ensure fall preventive measures was followed for 2 of 40 sampled residents (Residents 195 and 41). Findings include: On 04/26/2022 at 9:05 AM, hot water temperatures obtained at bathroom sinks in resident rooms in A building on the 500-hall revealed the following: Room 501 was 167.0 degrees Fahrenheit Room 502 was 166.0 degrees Fahrenheit Room 503 was 160.4 degrees Fahrenheit Room 504 was 166.0 degrees Fahrenheit Room 505 was 161.2 degrees Fahrenheit Room 506 was 154.3 degrees Fahrenheit Room 507 was 160.4 degrees Fahrenheit Room 508 was 160.5 degrees Fahrenheit Room 509 was 162.4 degrees Fahrenheit Room 510 was 161.4 degrees Fahrenheit Room 511 was 160.6 degrees Fahrenheit Room 512 was 160.3 degrees Fahrenheit On 04/26/2022 at 11:50 AM, water temperature checks were conducted in the 500 Hall of the building A with a maintenance employee. The employee obtained the water temperature in several rooms as follow: Room 501 was 165 degrees Fahrenheit Room 506 was 156 degrees Fahrenheit Room 511 was 164 degrees Fahrenheit The maintenance employee confirmed the water temperature was over the safety parameters (110 F) and should be adjusted. On 04/26/2022 at 12:40 PM, further assessment of hot water temperatures at the bathroom sinks in resident rooms and a shower room revealed the following: Room 202 was 163.0 degrees Fahrenheit Room 204 was 117.0 degrees Fahrenheit Room 402 was 163.5 degrees Fahrenheit The 400 hall Shower room was 156.0 degrees Fahrenheit. On 04/26/22 at 11:55 AM, the boiler room was inspected with a maintenance staff member. There were two thermostats, one was set to 110 degrees Fahrenheit (F), and the second was set at 120 degrees Fahrenheit. The staff member indicated the water temperature was checked every week and indicated the Maintenance Director kept track of the water temperatures in a computer system. The staff member verbalized not having access to the temperature log since it was in possession of the Maintenance Director. The employee indicated if temperatures were over 110 degrees Fahrenheit in resident rooms and showers, the temperature should be adjusted by modifying the thermostats, then temperatures should be re-checked to ensure temperatures were within acceptable parameters. On 04/26/2022 at 11:56 AM, a resident in room 402 verbalized water in the bathroom sink was too hot and very uncomfortable and wished the facility would address the issue. The resident assumed the facility was aware of the issue. On 04/26/2022 at 12:40 PM, a Licensed Practical Nurse (LPN) attempted to wash hands at the bathroom sink in room 504 and confirmed the water was hot and verbalized seeing steam come off the hot water. The LPN confirmed the temperature taken at the bathroom sink was 161.0 degrees Fahrenheit and confirmed the hot water in room 506 was 162.0 degrees Fahrenheit. The LPN reported this could be dangerous to residents and would result in a resident being harmed by the hot water. The LPN was not aware of any hot water issues at the facility. On 04/26/2022 at 1:00 PM, an LPN verbalized having no knowledge of a hot water issue. The LPN reported maintenance requests or work orders were entered into the electronic record called TELS. On 04/26/2022 in the afternoon, the Infection Preventionist logged into the TELS system, and reviewed maintenance requests for the prior two months. There were no work orders entered regarding water temperature issues, either too hot or too cold. On 04/26/2022 at 2:20 PM, a Certified Nursing Assistant (CNA) confirmed the water had been hot but had not reported the issue to management because the CNA thought the nurses had reported the issue. The CNA reported seeing a sign in the breakroom which warned staff of hot water temperatures and to be aware. The CNA did not know when the sign was posted. The CNA verbalized the water was hot in the break room but had since been addressed. On 04/26/2022 at 2:25 PM, an LPN reported the sign in the breakroom warning staff of the hot water issue was just posted. On 04/26/22 at 2:44 PM, the Administrator and Director of Nursing verbalized being aware of hot water temperatures in the showers in A building on 04/14/2022, however the logs did not document the change in the temperature. The Administrator verbalized a local plumber was called to come to the facility. The plumber indicated the issue could be the pipes which may have been altered during an ongoing construction project. The Administrator and DON were not aware of the hot water temperatures in the resident bathrooms on the 200, 400 and 500 halls. On 04/26/2022 at 2:50 PM, the Maintenance Director was on vacation and a phone interview was conducted. The Maintenance Director verbalized being aware of the hot water issues in the shower rooms in A building on 04/14/2022, at that time there were no issues with hot water at the bathroom sinks in resident rooms. The water temperature at the showers was 140 degrees Fahrenheit which was dangerous for residents. The Maintenance Director verbalized being very concerned for the residents with water temperature of 140 degrees Fahrenheit. While on the phone with the plumber the Maintenance Director instructed maintenance staff to alert nursing to the issue and to be careful of hot-water temps in the showers. Nursing staff were instructed to ensure water was not too hot when showering residents. The plumber arrived at the facility on 04/15/2022. The plumber was still trying to figure out what the issue was, maybe new water tanks were needed. The facility relied on word of mouth to alert staff to the hot water issues. The Maintenance Director verbalized the facility should have put signs up to alert staff but were focused on telling staff verbally. The facility could not produce water temperature logs for the facility after 04/14/2022, when the hot water temperature was first identified. On 04/27/2022 at 8:40 AM, the maintenance staff verbalized the water temperatures were not checked for the last two weeks while the Maintenance Director was on vacation. On 04/27/2022 at 9:05 AM, a resident in room 512 reported to showering independently and if you were not careful the hot water could burn you. The resident did not report the issue because the resident assumed the staff knew since they give showers to residents. The facility's test and log hot water temperature tracking system entitled, Logbook Documentation, documented temperatures were obtained randomly in resident rooms and showers throughout the facility from 11/17/2021 to 04/13/2022 revealed all shower rooms and resident rooms had a water temperature of 108 degrees Fahrenheit. The facility's water temperature guidance titled, TELS Master, documented to ensure resident room temperatures were to be between 105 degrees Fahrenheit to 115 degrees Fahrenheit or as specified by state requirements (Nevada was 110 degrees Fahrenheit). The water temperature should be checked on a regular basis (weekly or monthly), best practice was for water temperature to be tested and logged weekly. Long Term Care residents may be more susceptible to [CONDITION(S)] than other individuals due to several factors, such as decreased sensitivity, communication abilities and the inability to react quickly when exposed to hot water. The facility must ensure the resident environment remains free of accident hazards as was possible and each resident receives adequate supervision and assistance devices to prevent accidents. A facility policy titled Fall Management dated 07/2017, indicated the facility would assist each resident in attaining or maintaining the highest level of function by providing the resident with adequate supervision, assistive devices, and/or functional programs, as appropriate, to minimize the risk of falls. The Interdisciplinary Team evaluates each resident's fall risks. A care plan was developed and implemented based on this evaluation, with on-going review. Resident 195 (R195) R195 was admitted on [DATE] and readmitted on [DATE], with diagnoses including [CONDITION(S)], convulsions, dementia, akathisia (muscle restlessness and inability to sit still) and a history of falling. A care plan, revised 01/12/2022, documented R195 was a high risk for falls related to unsteady gait and tremors and had an actual fall multiple times in the facility. The interventions included ensuring the call light was within reach for prompt assistance, placing the bed in the lowest position, providing non-skid socks or appropriate footwear and a high impact fall mat. The Fall Risk Assessment from February 17, 2022, documented R195 had a score of 14. R195 was a high risk of falling. The Brief Interview of Mental Status (BIMS) dated 04/01/2022, documented a score of 0/15, which indicated R195's cognitive status was severely impaired. The Situation Background, Assessment, and Recommendation (SBAR) documented R195 had an actual fall for the last quarter on the following occasions: 01/11/2022, 01/31/2022, and 02/16/2022. R195 was injured. On 04/29/2021 in the morning, R195 was in bed, incoherent and restless. The call light was not in reach, the fall mat was not in place, and the bed was in a high position. On 04/29/2021 at 3:25 PM, R195 got in and out of the bed, the fall assistive devices were not in place. A Licensed Practical Nurse 1 (LPN1) verified and confirmed the observations at bedside the call light was not in reach, R195 was not wearing non-skid socks, there were no floor mats in place, and the bed was in a high position. LPN1 indicated R195 was a fall-risk resident, and the process was to ensure the fall assistive devices were appropriately placed during rounds at least every two hours to ensure the resident's safety. LPN1 confirmed the fall assistive devices were indicated in R195's care plan but was not appropriately implemented. Resident 41 (R41) R41 was admitted on [DATE] and readmitted on [DATE], with diagnoses including dementia, repeated falls, unsteadiness of the feet, muscle weakness and [CONDITION(S)] (low blood pressure). A care plan dated 12/30/2019, documented R41 was a high fall risk for falls related to psychoactive drug use and had an actual fall multiple times in the facility. The interventions included making sure the resident could reach the call light for prompt assistance and putting the bed in the lowest setting. The BIMS, dated 04/15/2022, documented a score of 3/15, which indicated the R41's cognitive status was severely impaired. The Fall Risk assessment dated [DATE], documented a score of 13 which indicated R41 was a high risk of falling. The SBAR dated 01/11/2022 and 01/18/2022, indicated the resident had an actual fall with injuries. On 04/29/2021 in the morning, R41 was in bed. The call light was not within reach and the bed was in a high position. The staff members were going in and out of the room, but the fall prevention measures were not appropriately implemented. On 04/29/2021 at 3:39 PM, R41 was in bed and fall prevention measures were not appropriately implemented. LPN2 verified and confirmed the observation R41's call light was not within reach, and the bed was in a high position. LPN2 indicated the fall interventions were indicated in the care plan but were not followed. LPN2 explained that the nursing staff was responsible for making sure the fall prevention measures were in place during morning rounds and implemented. On 04/29/2021 at 3:45 PM, the Unit Manager indicated the staff members were expected to implement the fall prevention measures indicated in the resident's care plan. The Unit Manager confirmed R195 and R41 were high risk for falling. On 05/03/2022 at 8:15 AM, the Maintenance Supervisor indicated the fall mats were available and the request could have been placed in the facility's work order system (TELS). The Maintenance Supervisor indicated there was no pending request for fall mats. On 05/03/2022 at 8:40 AM, the Director of Nursing indicated the staff members were to ensure the fall interventions indicated in the care plan were implemented. Complaint#NV 122

Based on interview, record review and document review the facility failed to ensure change of condition was treated and monitored timely for 1 of 5 sampled residents (Resident #2). Resident #2 Resident #2 was admitted to the facility on [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. The Nursing Admission Intake Form dated 7/14/14, documented the resident had right jugular triple lumen PICC (peripherally inserted central catheter), no signs and symptoms of infection and dressing intact. The physician's order dated 7/14/14, indicated: -flush right IJ (internal jugular PICC line) every 12 hours as maintenance -flush right IJ with 55 cc (cubic centimeter) NS (normal saline) before medication administration -flush right IJ with 5 cc NS and 3 cc [MEDICATION NAME] flush 100u (unit)/ml (milliliter) after medication administration -check right IJ site every shift for signs/symptoms of infection and/or infiltrate -change right IJ dressing every week and PRN (as needed). The Head to Toe Skin Checks dated 7/18, documented "rashes with irritation on side jugular PICC line". On 7/24/14 at 12:50 PM, Director of Nursing (DON) verbalized the signs and symptoms of infection on the IV (intravenous) line included redness, swelling, pain, heat, drainage and rashes. On 7/24/14 at 1:15 PM, the DON acknowledged the Licensed Practical Nurse (LPN) identified the rashes with irritation on the resident's jugular PICC line on 7/18/14. The DON verbalized this was a new skin condition and the LPN should have informed the wound nurse or notified the physician and filled-out the Situation, Background, Assessment or Appearance, Request (SBAR) form. The DON acknowledged the facility's policy on Skin Management was not followed. On 7/24/14 at 2:15 PM, a Licensed Practical Nurse (LPN) confirmed the rashes with irritation on the resident's PICC line site were identified and documented on the Head to Toe Skin Checks form on 7/18/14. On 7/24/14 at 2:20 PM, an Assistant Director of Nursing (ADON) verbalized she identified the redness on the resident's PICC line site on 7/18/14, and instructed the LPN to check the site. On 7/24/14 at 2:25 PM, the DON verbalized Licensed Nurses were expected to monitor the IV site and document on the nurse's notes if there were abnormal conditions on the IV site. On 7/24/14 at 2:30 PM, the DON acknowledged there were no documentation on the nurse's notes the rashes on the resident's PICC line site were monitored since they were identified on 7/18/14 and the physician was notified on the resident's change of condition. The physician's order dated 7/21/14, documented "D/C (discontinue) IJ line - possible infection vs (versus) tape allergy". The physician's order dated 7/21/14 at 1830 (6:30 PM), indicated "1) Clarification: send to ER (emergency room ) to have IJ line DC'd (discontinued) and have skin under [MEDICATION NAME] assessed for possible infection vs tape allergy. The physician's order dated 7/21/14 at 2000 (8:00 PM), documented: "Clarification of Order Send to (name of facility) ER to have IJ line discontinued and assessed for possible infection @ (at) site." The Resident Transfer Form dated 7/21/14, documented: "...REASON FOR TRANSFER (i.e., What Happened?) IJ line to be removed and assessed for possible infection..." During the exit conference on 7/24/14 at 3:00 PM, the DON and the Divisional Director of Clinical Services verbalized Resident #2 was sent out to the hospital for the removal of the IJ line. They indicated the resident's IJ line was not used for medications because the resident had no IV medications since admission. Resident #2's clinical record had no physician's orders for IV medications from 7/14/14 to 7/21/14. The IV sheet dated July 2014, indicated the resident received IV flushes from 7/15/14 to 7/21/14 on the right IJ before and after medication administration. The facility's policy titled "Skin Management" revised on August 2012, documented: "...16. Skin Assessments ...d. A Change of Condition form (Briggs) is to be completed and new physician's order obtained for new incidence of compromised skin integrity..."

Based on record review, interview and document review, the facility failed to ensure 1 of 5 sampled residents (Resident #2) was assessed in a timely manner and the facility failed to ensure the route of medication administration and documentation of medication administration was completed for 2 of 5 sampled residents (Resident #2 and #4). Findings include: Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Nurse's Notes documented by the Charge RN, dated 5/11/14 at 9:00 AM, documented the resident could not be aroused. The blood sugar registered 33 milligrams per deciliter (mg/dl) (reference range for fasting glucose from laboratory is between 65 and 99 mg/dl). The Physician was notified and [MEDICATION NAME] was administered by the Licensed Practical Nurse (LPN). The Physician Telephone Orders documented by the Charge RN, dated 5/11/14 at 9:00 AM, documented: "May give [MEDICATION NAME] 1 mg (milligram) for low blood sugar B/S (blood sugar) 33 mg/dl. There was no documented evidence of the route for the administration of the [MEDICATION NAME]. The Physician Telephone Orders, dated 5/11/14 at 9:15 AM, documented: "May give [MEDICATION NAME] 1 mg for low blood sugar B/S 43 mg/dl. There was no documented evidence of the route for the administration of the [MEDICATION NAME]. The LPN did not document the administration of the [MEDICATION NAME] in the MAR indicated [REDACTED]. The Respiratory Notes, dated 5/11/14 at 9:10 AM, documented the resident was found to be unresponsive. The resident was placed on five liters of oxygen via a nasal cannula. The resident showed signs of difficulty breathing. The Respiratory Therapist (RT) directed the nurse to call 911. The RT began to manually ventilate (cause air to enter the lungs) the resident with 100 percent oxygen. The Nurse's Notes, dated 5/11/14 at 9:15 AM, documented the re-check of the blood sugar was 43 mg/dl. The resident's oxygen saturation was 83%. The Physician was notified. Another dose of [MEDICATION NAME] was administered. The Physician ordered 911 to be called if the resident did not show improvement. The Nurse's Notes documented the paramedics arrived at the facility on 5/11/14 at 9:25 AM. The resident's blood sugar was 135. On 6/5/14 at 2:35 PM, the Chief Nursing Officer (CNO) explained a discussion was held with the Charge Registered Nurse regarding not responding to assist staff as quickly as needed for emergency assessment for Resident #2. On 6/6/14 at 8:30 AM, the CNO explained the Charge Registered Nurse (RN) had notified the CNO the family was upset the resident returned to the hospital. The family did not think the resident was attended to in a timely manner. The CNO explained being told the Charge RN was notified around 7:30 AM by the Certified Nursing Assistant (CNA) of the resident's change in condition. The CNO could not be sure of the exact time the Charge RN reported the CNA notified the Charge RN. The Charge RN told the CNO the blood sugar was rechecked. The CNO was not sure if the blood sugar was checked before 9:00 AM. The CNO explained the medication nurse attended to the resident when informed the resident was unresponsive. The medication nurse checked the blood sugar and the Charge RN notified the physician. The CNO did not speak with the CNAs. The CNO asked the Assistant Director Of Nursing (ADON) to follow up with the CNA's information. The CNO acknowledged not documenting any information received during the follow up interviews. The CNO stated initially thinking the resident was attended to in a timely manner. On 6/6/14 at 9:35 AM, ADON #2 recalled on 5/12/14, CNA #4 explained when making rounds around 6:30 AM - 7:30 AM, the resident did not seem like he felt good. The CNA mentioned this to the Charge RN. The ADON explained the time frame by the CNA did not match the time frame of the Charge RN. There was no formal investigation completed. When the ADON became aware of the time frame discrepancy, the ADON took the resident's chart to the CNO and asked the CNO to review the chart with the ADON. On 6/10/14 at 7:15 AM, LPN #3 explained sometime in the morning of 5/11/14, the LPN was asked to check Resident #2's blood sugar. The Charge RN had told the LPN "when you get to his room, check his blood sugar". The LPN explained the way the Charge RN made the request, the LPN did not think it was to be done immediately. The LPN could not recall the time the Charge RN informed him to check the blood sugar. The LPN recalled passing medications in the 200 Hall at the time. The CNA reported to the LPN after the Charge RN the resident was hard to wake up. The LPN explained the resident had eyes closed, normal color and breathing was normal. The blood sugar was 33 mg/dl. The LPN reported to the Charge RN and requested a [MEDICATION NAME] injection. The LPN administered the [MEDICATION NAME] in the resident's abdomen and repeated the blood sugar. The repeat blood sugar was 43 mg/dl. The LPN administered the second [MEDICATION NAME] shot in the resident's abdomen. The LPN then returned to passing medications since the Charge RN was with the resident. The LPN acknowledged not charting the assessment in the nursing notes. The LPN explained asking the Charge RN if documentation was needed. The Charge RN told the LPN to read the charting the Charge RN entered into the medical record. The LPN felt everything was charted and did not need to chart anything else. On 6/10/14 at 10:20 AM, CNA #4 explained when passing ice, the resident was taking deep short breaths and eyes were closed. The CNA yelled the resident's name and could not wake the resident. The CNA then rubbed the resident's arms and used a cold wash cloth on the resident's face. The CNA was unable to arouse the resident. The CNA explained the first task completed each day was to pass ice to the residents. The CNA would pass the ice between 6:00 AM and 6:30 AM. The CNA explained the time in the resident's room may have been around 6:30 AM. Immediately after seeing the resident, the CNA described notifying the Charge RN. The Charge RN had been working on the schedule for the nurse assignments. The CNA relayed the Charge RN told the CNA she did not know "what his state of being was" and the resident could be in a deep sleep. The CNA was instructed to notify the floor nurse. The CNA explained being unable to notify the floor nurse, as there was no nurse assigned to the resident at the time. The CNA explained this was the first day back after days off and the CNA was not familiar with the resident. The CNA went to help another CNA and asked the other CNA (CNA #5) to check the resident. CNA #4 explained returning to the resident's room around 6:45 AM. The CNA shook the resident and tried cold water on the resident's face. The resident did not respond. The CNA reported finding the nurses in the break room. The CNA informed the Charge RN of the resident's condition. The Charge RN told the CNA she was trying to get the schedule fixed. The CNA reported around 7:00 AM - 7:15 AM, the CNA requested the Charge RN to go to the resident's room. The Charge RN and CNA #5 went with the CNA. The Charge RN told the CNA the resident was in a deep sleep and to let the resident's nurse know. The CNA explained going to the LPN who was passing medications on the 200 Hall. The CNA reported the resident was unresponsive and asked the LPN to check the resident. The LPN told the CNA he needed to pass the medications already poured for a resident first. The CNA recalled the breakfast trays arrived around 7:30 AM - 7:45 AM. The CNA went into the resident's room with the breakfast tray. The resident would not wake up to eat. The CNA then went to feed the other residents. Around 8:30 AM, the CNA observed the resident's partner enter the resident's room. The partner asked what happened. The CNA relayed the events of what occurred in the morning with the resident. The partner demanded to see a nurse. The nurses went into the resident's room. One of the nurses called the Respiratory Therapist and the RN from the B building. The CNA confirmed sharing this interview with the ADON on 5/12/14. On 6/10/14 at 10:38 AM, CNA #5 explained between 6:30 AM and 6:45 AM, CNA #4 assisted the CNA in the 100 Hall with another resident. CNA #4 requested the CNA to go see Resident #2. The CNA observed the resident's eyes rolling and making a "guttural" noise. The CNA put a cold rag on the residents head and moved the resident's arm. The CNA reported the arm was limp. The CNA went to get the Charge RN at the front desk to report the resident was not responding. The CNA reported the Charge RN went to the resident's room and said the resident was sleeping then left the room. The CNA recalled the time was around 7:00 AM. The CNA confirmed sharing this interview with the ADON on 5/12/14. On 6/11/14 at 8:20 AM, the Charge RN explained the CNA informed the Charge RN Resident #2 was "sleeping hard". The Charge RN went to assess the resident. The resident did not appear to be in distress. There was nothing in the morning report regarding any issues with the resident. The Charge RN acknowledged not charting the initial assessment due to the respirations were even, and no labored breathing noted. The Charge RN did not try to arose the resident. The Charge RN stated she thought the resident was sleeping. The Charge RN recalled around breakfast time, the CNA informed the Charge RN the resident was difficult to arouse. The Charge RN could not recall when the breakfast trays were delivered on the unit. The Charge RN told the LPN to take the resident's blood sugar. The Charge RN acknowledged not telling the LPN when to take the blood sugar. The Charge RN was at the nursing desk when the LPN informed her of the blood sugar of 33 mg/dl. The Charge RN notified the Physician and received orders. The Respiratory Therapist was notified due to the resident's oxygen saturation level was around 86 per cent. The Charge RN could not recall the exact oxygen saturation. The blood sugar was rechecked and 911 called. The Charge RN explained generally the Charge RN's document an event in the nurse's notes. The Charge RN explained informing the LPN of having already charted the event. The Charge RN could not recall the name of the CNA who reported Resident #2's condition. The Charge RN acknowledged getting two of the CNA's mixed up. The Charge RN thought the CNA may have been CNA #4. The Charge RN explained the CNA did not appear to be concerned when reporting the resident's condition. On 6/10/14 at 12:00 PM, the Vice President of Clinical Services confirmed the CNA saw the resident between 6:30 AM and 7:00 AM. The Vice President explained the CNA had clocked in to work at 6:15 AM. The Vice President of Clinical Services explained the LPN reported to the Vice President the blood sugar for Resident #2 was completed around 8:30 AM. On 6/12/14 at 8:15 AM, the CNO confirmed the Change of Condition Form was not completed for Resident #2. The CNO confirmed [MEDICATION NAME] was not transcribed on the MAR. There was no documented evidence of the time the LPN administered the [MEDICATION NAME]. The CNO acknowledged the LPN should have documented the time of administration on the MAR. Resident #4 Resident #4 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Physician order, dated 4/28/14 at 12:30 PM, did not identify a route for [MEDICATION NAME]. Review of the MAR indicated [REDACTED]. The MAR, dated 5/1/14 - 5/31/14, did not identify a route for the administration of [MEDICATION NAME]. On 6/12/14 at 8:15 AM, the CNO confirmed the physician order [REDACTED]. On 6/12/14 at 8:40 AM, the CNO stated the Charge RN and the LPN have been suspended and in the process of termination. The CNO confirmed the investigation initiated by the CNO since 6/6/14 revealed similar findings to the Bureau of Health Care Quality and Compliance's investigation. Changes in Resident Condition Policy #SSP 0103.00, revised June 2008 documented: "...Communication with the interdisciplinary team and caregivers is also important to ensure that consistency and continuity are maintained for the resident's benefit. Guidelines: 2. The Change of Condition Forms (Briggs) are used to: a. assess and document changes in condition in an efficient and effective manner; b. provide assessment information to the physician, and c. provide clear comprehensive documentation..." Laboratory Management Policy (no identified policy number), released August 2012 documented: "...PRACTICE GUIDELINES 2. Upon receipt of laboratory tests at the facility, the Licensed Nurse will: ...d. Make a decision for immediate or non-immediate notification..." Standards of Nursing Practice Policy SSP 0101.00, revised December 2005 documented: "...The delivery of nursing care in the facility is based on a thorough assessment of the resident to identify his or her care needs... GUIDELINES: 1. The steps of the nursing process are: -Assessment - The nurse collects data regarding the resident's current health status and potential risk areas. Data is obtained through direct resident assessment and health history, as well as interaction with family members and other healthcare providers..." Physician order [REDACTED]. "...PROCEDURE ...Receiving a Telephone Order (T.O.)/Verbal Order When receiving an order (telephone or verbal), the licensed nurse repeats the order back to the physician to clarify and ensure that the following necessary information is received: ...Accurate route and/or site, if applicable..." Transcribing a Telephone Order/Verbal Order... 2. After noting an order, the receiving licensed nurse transcribes in permanent ink on the MAR indicated [REDACTED] Medication Administration-General Guidelines Policy LTC 5.003, revised 3/10 documented: "...Procedure: 12. When PRN (as needed) medications are administered, the following must be documented: A. Date and time of administration (if other than oral) and, if applicable, the injection site..." Complaint #NV 215

Based on interview and record review, the facility failed to ensure one of one resident (Resident #8) received proper treatment to maintain vision ability. Findings include: Resident #8 During the initial tour on 8/5/13, at approximately 1:30 PM, Resident #8 was observed and interviewed. Resident #8 indicated that he was able to see when he was admitted to the facility, but his vision has been failing for the past four months. This resident indicated he could not see anything but black or white when he looked at the television. Resident #8 acknowledged that he could not make out any of this surveyor's features as she stood next to his bed. This resident indicated he had requested to be seen by the eye doctor for the past four months, without success. Review of the clinical record revealed Resident #8 was admitted to the facility on [DATE], with no visual problems identified. Resident #8's [DIAGNOSES REDACTED]. The initial minimum data set (MDS) Section B1000: Vision indicated the resident could see fine detail, such as regular print. This was completed 2/15/13. A quarterly MDS completed 5/17/13, revealed Resident #8's vision had deteriorated to "highly impaired, object identification in question". A care plan was created on 5/17/13, identifying the deterioration of Resident #8's vision, but there was no evidence an eye appointment was arranged. The care plan was updated on 8/7/13, indicating Resident #8 was to be seen by the contracted vision provider on 8/22/13. An interview with the social worker (Employee #22) on 8/7/13, confirmed she was assigned to this resident. Employee #22 acknowledged she was aware the resident was requesting to see the eye doctor but she could not provide any documentation to demonstrate that she was attempting to meet this resident's needs. Employee #22 acknowledged she did not document interventions timely. Review of the social service notes on 8/8/13, revealed documentation on 4/16/13 and 5/17/13, with no indication the resident was requesting an eye doctor appointment. Documentation dated 8/7/13, was entered following the interview with Employee #22. This entry summarized care provided by Employee #22. Although the documentation indicated a referral was sent for vision impairment, the facility could not demonstrate that the contracted vision service was informed of the deterioration of Resident #8's vision when the referral was made. Documentation revealed that the eye doctor's assistant was the individual who made the decision to reschedule appointment. There was no evidence of any follow-up by the social worker. The facility provided the following documentation on 8/7/13 and 8/8/13. - Resident #8 signed a consent for treatment by the contracted vision service on 4/30/13. - The contracted vision service could not schedule Resident #8 for the May appointments, but was to be seen in June. - The facility was informed the reason Resident #8 was not seen in May was because the doctor ran out of time to see patients. Resident #8 was to be rescheduled for June. - The vision contract services had determined they were an out of network provider. Resident #8 was not seen in June for this reason but the contracted vision provider did not inform the facility until after the facility visits were made in June and Resident #8 was not seen. - The contracted vision service e-mailed documentation on 8/7/13 indicating the contracted vision service was not an in-network provider, requiring Resident #8 to be seen in the office. but Resident #8 refused to leave the facility. - The facility could not provide any documentation why Resident #8 had refused to go to an office visit, or whether he had even been informed that it would be an out of pocket expense if the eye physician saw him at the facility. - The email documentation from the vision provider dated 8/7/13, revealed Resident #8 was to be seen on 8/22/13, and the facility would pay the cost, however this solution was after this was brought to the facility's attention. Cross refer F 250 Cross refer F 279

Based on observation, record review and staff interview the facility failed to identify and provide psychosocial services for one resident with mental illness (Resident #20). Findings include: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On the morning of 8/5/13, during the initial tour, the Licensed Practical Nurse (LPN-Employee #6), indicated Resident #20 was total care, was on continual bedrest, had pain issues and had behavior problems demonstrated by bouts of yelling out. The nurse explained at times the yelling behavior would set the roommate off and visa versa. The nurse indicated the resident was capable of expressing her needs and the pain issue was due to chronic back problems in which she received routine pain medication. At the time of the tour both Resident #20 and her room mate were observed quietly resting in their beds. On the afternoon of 8/6/13 Resident #20, was observed in her room yelling continually. The yelling could be heard throughout the hallway, and at the Nurse's Station at the end of the hall. At approximately 11:00 AM, on 8/7/13, Resident #20 was again observed yelling continuously. When this surveyor observed the resident, the resident was yelling out and was observed lying in bed naked. The resident was tugging at the bedding and thrashing about in bed. The resident's gown was observed on the bed halfway underneath the resident. The resident briefly stopped yelling and asked who this surveyor was. After this surveyor responded, the resident resumed yelling and thrashing about. When asked how she was doing, the resident stopped yelling and stated "today is my birthday February __, 1943," then proceeded to start yelling again. The staff member attending to the resident, Licensed Practical Nurse (LPN-Employee #25), indicated the resident had a bad night and this was typical behavior for this resident if she hadn't rested well. The nurse indicated the resident had been complaining she was hot and that she (the nurse) had been trying to accommodate the resident with a fan in the room. The roommate was observed in her bed with the covers over her head. When asked, the Licensed Practical Nurse (LPN-Employee #25), indicated Resident #20 had received her [MEDICATION NAME] and [MEDICATION NAME]. The nurse further indicated, Resident #20's physician did not want to change the resident's current medication regimen to avoid indications of chemical restraint. The nurse, who had been with the facility for eleven months, indicated during these types of episodes, which occurred frequently, they did try to address the resident's concerns, but were not always successful. When asked about getting the resident up and engaged in some activities, the nurse indicated the resident did not get up because she could not tolerate being up in a chair. When asked if the resident could be up in a reclining chair, the nurse indicated that activity staff came in daily for one on one activities in the resident's room. Review of Resident #20's medication orders included the antianxiety agent: [MEDICATION NAME] 0.25 milligrams to be administered twice a day as needed for anxiety as manifested by increased yelling, the antianxiety/[MEDICATION NAME]/sedative-hypnotic/antiemetic agent: [MEDICATION NAME] HCL 25 milligrams to be administered every eight hours as needed for itching, and [MEDICATION NAME] 5-500 milligrams every six hours for chronic pain. It was noted, the current [MEDICATION NAME] order of 0.25 milligrams was initiated on 3/20/13. The resident's physician's orders [REDACTED]. Review of Resident #20's physician progress notes [REDACTED]. Review of Resident #20's Medication Administration Record [REDACTED] -The June 2013 MAR, indicated between 6/1/13 through 6/24/13, the resident had received [MEDICATION NAME] on 14 days during this period, with a total of 20 doses having been administered. -The July 2013 MAR, indicated the resident had received [MEDICATION NAME] 23 days out of the month, with a total of 33 doses having been administered. While there was documentation which indicated there were effective results from the medication, there was also documentation in which the medication had only helped some. -The August 2013 MARs indicated between 8/1/13 to 8/7/13 the resident had received [MEDICATION NAME] on four occasions, with a total of 4 doses having been administered. On 8/7/13 at 10:00 AM it was documented [MEDICATION NAME] had been administered for continuous yelling, at 11:00 AM it was documented that the medication was not helpful. Review of Resident #20's monthly Consultant Pharmacist report indicated on 5/29/12 the resident was on [MEDICATION NAME] 0.5 milligrams, and on 8/29/12 the pharmacist had recommended [MEDICATION NAME] be reduced to 0.25 milligrams every 8 hrs as needed. There was no additional documentation to indicate why the dosage reduction had been recommended. Review of Resident #20's Comprehensive Plan of Care revealed the following: -Care plan dated 4/10/12, Problem: Resident displays inappropriate behavioral symptoms not directed towards others-screaming or other disruptive sound as evidenced by: screaming black continuously; Approaches included: Psych services as needed. The care plan was last reviewed on 6/12/13. -Care plan dated 1/17/13, Problem: Resident exhibits signs and symptoms of anxiety, resident currently takes [MEDICATION NAME] as needed, resident exhibits restlessness; Approaches included: psych services as ordered. The care plan was last reviewed on 6/12/13. -Care plan dated 6/11/13, Problem: Resident displays verbal behavior symptoms towards others by screaming; Approaches included: Psych eval if recommended. The care plan was last reviewed on 6/12/13. Review of Resident #20's Social Services notes dated 10/4/12 revealed the following note under Psychosocial Well-Being Status: No recent conflicts, however her frequent yelling disturbs other residents, see activity notes. Annual notes dated 1/4/13 and the quarterly notes dated 3/20/13, indicated under Psychosocial Well-Being Status: No issues identified at this time, patient involved in activities as tolerated. Review of Resident #20's annual Activities Evaluation dated 1/6/13, indicated under the section Psychosocial, Physical or Environmental Issues that might hinder or reduce activity participation: patient has episodes of screaming. This evaluation indicated a majority of activities which were completed on an individual basis, involving things such as watching TV or movies, occasional small group functions, and one to one activities in the resident's room. Review of the Activity Progress Notes dated 6/12/13 indicated the resident continued to be involved in room visits on one to one for sensory/mental stimulation and she continues with episodes of screaming. On 8/7/13 at approximately 11:10 AM, separate interviews were conducted with the Assistant Director of Nursing (ADON-Employee #7) and the Social Worker (SW-Employee #26). The ADON discussed Resident #20's condition and reviewed the resident's clinical record. The ADON confirmed a psychiatric evaluation had not been pursued, and additional medication review was needed. The SW indicated she had recently been working on getting a psychiatric consult for competency purposes only and had not considered a consult to address the resident's behavior or psychosocial well being. Group Interview On 8/6/13 at 11:00 AM, an interview was conducted with ten residents. Several of the residents expressed concern for residents on the second floor of the B building. The residents in the group interview reported some residents would be screaming and the staff would walk by with no attempts to calm or re-direct the screaming residents.

Based on observation, interview and record review, the facility failed to provide psychosocial evaluations, treatments and proper monitoring of behaviors for 4 of 18 sampled residents (#14, #11, #12, #13). Findings include: On 10/23/13 in the afternoon, the Director of Social Services (DSS) indicated due to the difficulty of obtaining a psychiatrist for initial assessments and follow up visits, a company was contracted to assist with the residents psychosocial needs. The company would initiate a screening in which they may refer the following: -Medication Management -Neurofeedback -Therapy -Family Therapy -Group Therapy -Psychosocial -Basic Skills -Crisis Management -Medical The facility policy titled Resident Rights regarding refusal of care or treatment, with a revised date of 5/1/13, documented: -"...The facility staff will honor the patient/resident's right to refuse care or treatment to the extent permitted by law..." -"...A patient/resident's refusal of treatment does not absolve the Facility from providing care that allows the patient/resident to maintain his/her highest practical physical, mental, and psychosocial well-being in the context of making that refusal." Resident #14 Resident #14 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident was not receiving any antipsychotic, antidepressant or antianxiety medications. Resident #13's physician orders [REDACTED]. -"Behavioral Health Services Consult to r/o (rule out) Depression." A behavioral consult was attempted on 10/7/13, on Resident #14. Resident #14's Initial Mental Health Contact and Recommendation Form dated 10/7/13, revealed the reason for the referral was due to depression and refusing care. The form was incomplete due to the resident refusing the services. On 10/24/13, the owner of the contracted company that conducted the initial screening/consultations, indicated when a resident declines mental health services, attempts to offer the services would be done weekly for thirty days. The attempts would be documented on the resident record. On 10/24/13 in the morning, a staff member from the contracted company who performed the initial behavioral screening/consult indicated if a resident declined the initial screening/consult, then "declined" would be documented on the form. The contracted company staff member was not aware weekly attempts were to be conducted if the resident initially refused the services. There was no documented evidence Resident #14 was approached every week after the resident declined the services. On 10/24/13, the owner of the contracted company that conducted the initial screening/consultation, indicated when a Behavioral Health Services Consult was ordered it would be ideal, after the screening, for a Psychiatrist to also evaluate the resident. The owner of the contracted company indicated the facility provided a list of residents who could be seen by a Psychiatrist when a Behavioral Health Service Consult was ordered. Resident #14 was not on the list. On 10/24/13, the DSS indicated not all residents who were ordered a Behavioral Health Service Consult was also seen by a Psychiatrist from the contracted company. The DSS indicated some residents were already been seen by a Psychiatrist prior to obtaining the contracted company and the residents who were already seen by a Psychiatrist did not need to be seen by the Psychiatrist from the contracted company. On 10/23/13 in the afternoon, the DSS indicated due to the lack of Psychiatrist, the difficulty of obtaining an evaluation or a follow-up visit for psychosocial issues the contracted company, who conducted the initial screening/consultations, was obtained. Prior to obtaining the services of a contracted company, Resident #14 received a Psychiatric evaluation on 7/11/13. There was no documented evidence the Psychiatrist who evaluated the resident on 7/11/13, was contacted to re-evaluate the resident again for the new rule out [DIAGNOSES REDACTED]. Resident #14's initial weight on 4/21/06 was 119 pounds. Resident #14 had been losing weight and had refused several times to be weighed. The following weights were recorded for Resident #14 during 2013: 5/1/13 - 101 pounds 6/2/13 - 93 pounds 7/1/13 - 91 pounds 8/2/13 - 86 pounds 9/4/13 - 91 pounds 10/2/13 - 89 pounds 10/6/13 - 90 pounds 10/9/13 - refused to be weighed 10/13/13 - refused 10/16/13 - 90 pounds 10/20/13 - refused 10/23/13 - 89 pounds On 10/23/13 in the afternoon, the Certified Nursing Assistant (CNA) indicated Resident #14 had been refusing her showers. On 10/23/13 in the afternoon, Resident #14 was alert and oriented. Resident #14 was able to make her needs known. With a flat affect, Resident #14 indicated she had been in the facility for over 6 years. Resident #14 indicated her appetite fluctuated at times and did not know why she did not want to eat. Resident #14's Physician's Progress Notes form dated 9/23/13, documented: -"NP (nurse practitioner) Note Discussed wt (weight) loss with RD (registered dietician) and pt (patient). Pt states she does not want an appetite stimulant. She said she wishes "people would stop bothering me and asking me" "I've always been thin" Pt prefers to smoke cigarettes and drink coffee." Resident #14's Physician's Progress Notes dated 8/14/13, documented for hospice to evaluate the resident to determine if hospice was appropriate. Resident #14's physician orders [REDACTED]. -"Hospice eval (evaluation)." Resident #14 was evaluated for hospice services on 8/19/13. The evaluation documented: -"...pt (patient) did not meet criteria for hospice. Discussed decision with (nurse practitioner (NP) name) and NP agreed that pt is not appropriate at this time..." There was no documented evidence another hospice evaluation was needed or ordered for Resident #14 after it had been determined hospice was not appropriate for the resident on 8/19/13. On 10/10/13, another hospice evaluation was performed. There was no documented evidence an order was written to evaluate Resident #14 for hospice services on 10/10/14. Resident #14's Explanation of Hospice Benefit and Service Note dated 10/10/13, documented: -"...Spoke with unit manager...regarding the current issues with this patient. Also, ADON (Assistant Director of Nursing)...was present. This patient has a 20+ wt (weight) loss recently. Plan of care is to supplement diet for wt gain, however, the patient prefers to have coffee and smoke. Supplements are being provided and pt is willing to eat items that she like, mainly sweets. Per patient interview she states that she wants to be left alone to eat and drink what she likes and is tired of test and demands. She wants to enjoy her time doing the things she likes such as Bingo..." -"...Per staff (resident name) can be stubborn and unwilling to comply..." There was no documented evidence Resident #14 was seen by a Psychiatrist to rule out depression for Resident #14 when the resident refused behavioral services on 10/7/13. Since attempts to rule out depression for Resident #14 was discontinued due to the residents refusal, there was no documented evidence if the residents weight loss was possibly due to depression. There was no documented evidence Resident #14's psychosocial needs were addressed when it was identified to r/o depression. The resident was evaluated for hospice services without first addressing her psychosocial needs. Resident #11 Resident #11 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 10/22/13 - 10/23/13, Resident #11 was in her room lying in bed. The resident could be heard yelling throughout the day and afternoon. The loud outburst could be heard throughout the hallway and nursing station. On 10/23/13 in the afternoon, the Certified Nursing Assistant (CNA) indicated Resident #11 yells all the time when the resident is lying in bed or up in a wheelchair. Resident #11's physician orders [REDACTED]. -"Behavioral Services to consult and treat for outbursts." There was no documented evidence a consult by the contracted company was performed on Resident #11 for her outburst. On 10/24/13 in the afternoon, the DSS indicated a list of 15 residents, who required a screening for behavioral health services, were given to the contracted company performing the screening. The SW indicated Resident #11's was on the list and thought Resident #11's screening was completed. The DSS confirmed Resident #11's screening was not performed. Resident #12 Resident #12 was originally admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 10/22/13 in the morning, while standing in the hallway, Resident #12 could be heard yelling from her room. The resident was yelling, "Get me out of here!" On 10/22/13 in the morning, a Certified Nursing Assistant (CNA #1) indicated you sometimes cannot understand what resident #12 yells about and the resident is always yelling. On 10/22/13 in the morning, CNA #2 indicated Resident #12 yells for attention. The CNA indicated Resident #12 yells every day during the morning and night shift. CNA#2 indicated Resident #12 sometimes does not know why she was yelling. Resident #12's physician orders [REDACTED]. -"Behavioral Services to consult and treat for outburst non-stop calling out loud ..." Resident #12's October 2013 Monthly Flow Record monitored the following behaviors for the resident: -Self-isolation -Throwing objects, diaper, clothes, blanket -Constant movement -Restlessness There was no documented evidence Resident #12's loud outburst and yelling were being monitored. Resident #12's care plan dated 5/29/13, identified the resident displayed verbal behaviors such as screaming, cursing and yelling. The care plan goal was to limit the episodes down to 3 times a week. On 10/24/13 in the afternoon, the DSS confirmed there was no documented evidence Resident #12's yelling and outburst were monitored and documented. Resident #13 Resident #13 was originally admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. On 10/23/13 in the afternoon, the Licensed Practical Nurse (LPN) indicated resident #13 occasionally yells. The LPN indicated the resident may yell 3 times in an 8 hour shift. The LPN indicated the resident sometimes did not know why he was yelling. Resident #13's physician orders [REDACTED]. -"Behavioral Services to consult and treat for outburst non-stop calling out loud ..." Resident #13's consult/screening was initiated on 10/7/13. The resident declined the services and "Declined Services" was written on the Initial Mental Health Contact Recommendation Form. On 10/23/13 in the afternoon, the DSS was not aware Resident #13 refused the mental health evaluation screening. On 10/24/13, the owner of the contracted company that conducted the initial screening/consultations, indicated when a resident declines mental health services, attempts to offer the services would be done weekly for thirty days. The attempts would be documented on the resident record. On 10/24/13 in the morning, a staff member from the contracted company who performed the initial behavioral screening/consult indicated if a resident declined the initial screening/consult, then "declined" would be documented on the form. The contracted company staff member was not aware weekly attempts were to be conducted if the resident initially refused the services. There was no documented evidence Resident #13 was approached every week after the resident declined the services.

Based on record review and interview, the facility failed to intervene in a timely manner to prevent significant weight loss for 1 of 30 sampled residents (Resident #2). Findings include: Resident #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #2's admission height was 66 inches and weight was listed at 119 pounds (lbs). Ideal body weight was listed as 130 lbs. No usual body weight was listed. A review of the weight record for the resident revealed a steady decline in the resident's weight since admission. As of January 2013 the residents's weight was listed at 100 lbs. A review of the dietary notes revealed the last note was dated 5/11/13. The note indicated the resident had gained 3 lbs. over the last 6 months. The diet order was regular diet with nutritious juice twice per day (BID) and Two Cal HN three times per day (TID). Review of intake sheets revealed consumption of 75-100% meal intake. The current diet order had been in effect since November of 2012. Weights recorded for 5/1/13, 6/2/13, 7/1/13, 8/2/13 were: 101 lbs., 93 lbs., 91 lbs., 86 lbs. respectively. A review of the nursing notes of 4/8/13 revealed Resident #2 had a urinary tract infection, fever, and was placed on intravenous (IV) antibiotics. On 5/17/13 Resident #2 was sent to the hospital for a restart of an infiltrating IV. The resident returned to the facility within a few hours and remained on IV antibiotics [MEDICAL CONDITION] and dehydration. On 6/19/13 the weekly skin assessment documentation indicated Resident #2 had an open area to the coccyx and a reddened area to the right heel. An interview with the facility dietician on 8/7/13 revealed that a new admission was weighed daily for 3 days, weekly for the 3 weeks, and then placed on monthly weights unless ordered different by the physician. The dietician indicated she reviews any weight variations each week and makes recommendations for dietary changes. A review of the facility policy titled Nutrition Polices and Procedures weighing the resident revised 9/20/12 revealed: 2. If the month-to-month weight shows more than a five-percent gain or loss, the patient/resident is reweighed within 24 hours. 4. If there is an actual 5% or more gain or loss in one month, notify the patient/resident/family, physician, and the Nutrition Services Director. Document this notification per facility protocol. 5. The facility dietician reviews the patient's/resident's nutritional status and makes recommendations for intervention in the nutritional progress notes if significant weight change is noted. The dietician indicated there should have been a dietary note in June for Resident #2, but for an unknown reason Resident #2 was not put on the significant weight variance list. A weight variance list provided by the facility on 8/5/13 did not list Resident #2. A new list generated on 8/6/13 also did not list Resident #2. The dietician did not re-evaluate Resident #2 following the 7.9% weight loss from 5/1/13 to 6/2/13 nor was the resident re-evaluated after an additional weight loss from 7/1/13 to 8/2/13 of 5.4%. Total weight loss from 5/1/13 to 8/2/13 was 14.8%. There was no evidence the physician was notified of the significant weight loss. There had not been any additional nutritional interventions evident since November 2012. According to the medical record, Resident #2 was placed on IV fluids in June 2013 for dehydration after completion of the IV antibiotics in May of 2013.

Based on observation, interview and review of clinical records the facility failed to ensure: 1) Two residents (Residents #15 and #17) were given the necessary amounts of fluid to prevent dehydration and electrolyte imbalance; and 2) One resident (Resident #18) had daily dressing changes as ordered by the physician. Findings include: Resident #15 Resident #15 was admitted on [DATE] with [DIAGNOSES REDACTED]. The History and Physical from the facility dated [DATE], for Resident #15 revealed, "...The patient is an [AGE] year old male with past history apparently significant for dementia and [MEDICAL CONDITION]. The patient was brought to the emergency room for alerted (sic) mental status, not eating for the past two days with generalized weakness. Laboratories did show evidence of dehydration with a sodium of 148.7 (normal ,[DATE]), creatinine of 1.7 (normal 0XXX,[DATE].7 milligrams/deciliter), glomerular filtration rate 41 (normal ,[DATE]) blood urea nitrogen 29 (normal ,[DATE]). He was started on IV (intravenous) fluids and deemed appropriate for transfer to (facility name) for continuing management ... " On [DATE] in the afternoon, a review of the facility policy on Hydration-Oral (date ,[DATE]) revealed the following: " PROCEDURES: 1. Recommend fluids (,[DATE] glasses per day) to patients/residents during and in-between meals and during periods of physical activity. 2. Provide fresh water and ice at bedside except when contraindicated, e.g. patient/resident on thickened liquids or a fluid restriction. 3. Closely monitor all patients/residents at risk for dehydration, who have a history of poor fluid intake and are enterally fed (NPO) (nothing by mouth) or have an indwelling catheter. I&O (intake and output) is recorded when indicated. Examples of " At risk " A. Change in mental status B. Requires extensive assistance C. Hand dexterity problems D. Frequent constipation E. Frequent use of laxatives, enemas, diuretics F. Depression, sad mood, grief reaction G. Infection, fever, vomiting, diarrhea/nausea H. Excessive urine output due to drugs or disease I. Previous [DIAGNOSES REDACTED]. 4. Patients/Residents with swallowing disorders are offered thickened liquids in the proper consistency under the direction of qualified clinical staff. Orders are obtained to provide hydration at specified intervals, for example offering of thickened liquids with each medication pass and between meals. This is documented in the care plan ... " On [DATE] a review of the CNA (Certified Nurse's Assistant)-ADL (Activities of Daily living) Tracking Form for Resident #15 dated for the month of ,[DATE], on the 2:00 PM-10:00 PM shift revealed the following documentation in the column titled, " ...Eating-How the resident eats and drinks regardless of skills. Do not include eating/drinking during medication pass. Includes intake of nourishment by other means (e.g. tube feeding, total [MEDICATION NAME] nutrition, IV fluids administered for nutrition or hydration). From [DATE]-[DATE] the documentation for those dates indicated Resident #15's intake was fair to poor. On the same form for Resident #15, in the boxes dated [DATE]; [DATE]; [DATE]; [DATE]; [DATE] through [DATE]; [DATE]; [DATE] through ,[DATE]; [DATE] and [DATE], the documentation indicated fluids were offered, however the activity did not occur. The CNA/ADL tracking form for ,[DATE] was missing from the medical record. On [DATE], The Nurses Notes for Resident #15 revealed the following: "..XXX[DATE] 11:00 AM-Reported to CNA not eating..." "..XXX[DATE] 12:00 PM-Tried to feed pt (patient). Had 30 % of meal..." There was no documentation in the Nurses Notes on Resident #15's eating or fluid intake until [DATE] when he was transferred to the hospital. There was no documentation the staff had notified Resident #15's physician or the physician's assistant that Resident #15 had difficulty swallowing or that the resident's food and fluid consumption was poor. The Physician Order Report for Resident #15 dated [DATE]-[DATE] revealed the following: "..XXX[DATE] Assist 1:1 ON ALL MEALS-with meals; 8:00, 12:00, 1700 (6:00 PM)... "..XXX[DATE] OOB (out of bed) W/C (wheelchair) for all meals..." The CNA/ADL tracking for the month of [DATE] documented for the entire month, "8" under transfer and locomotion on the unit and off the unit. On [DATE] several staff members were asked what the "8" meant. They indicated the activity did not occur. The Daily Skilled Nurse's Note For Resident #15, for the months of [DATE] and [DATE] lacked documentation that Resident #15 had difficulty chewing, poor fluid intake or poor appetite. On [DATE] at 1:17 PM, the Registered Dietician (RD) revealed she remembered Resident #15. The RD indicated Resident #15's appetite was down which she documented on [DATE]. The RD indicated she ordered healthshakes as a supplement because of Resident #15's poor appetite. The RD indicated she depended on the nurses and the physician to inform her of a resident's decreased appetite and poor fluid intake. Resident #15 was transferred to the acute care hospital by ambulance on [DATE] with [DIAGNOSES REDACTED]. The History and Physical from the acute hospital for Resident #15 dated [DATE], documented the following: "...The patient is apparently demented and non-verbal. However, over the past couple of weeks he has been refusing any p.o. (by mouth) intake. GENERAL: His oral mucosa does appear to be dry. ASSESSMENT AND PLAN: This is an [AGE] year-old gentleman admitted for failure to thrive [MEDICAL CONDITION] (high sodium) and altered mental status. 1. Altered mental status 2. [MEDICAL CONDITION] 3. Failure to thrive 4. Dehydration 5. Electrolyte disorder 6. hypercalcemia 7. Acute [MEDICAL CONDITION] 8. Elevated liver function tests 9. Elevated [MEDICATION NAME] level 10. Rhabdomyolysis 11. Abnormal [MEDICAL CONDITION] function 12. Dementia..." A [MEDICATION NAME] Consult at the hospital for Resident #15 dated [DATE] documented the following: "...HISTORY OF PRESENT ILLNESS: The patient is an [AGE] year old male admitted with poor oxygenation and [MEDICAL CONDITION] who refused to take anything by mouth. The patient was admitted with [MEDICAL CONDITION] and a sodium level of 172 (normal ,[DATE]). So far the patient is unable to take any food or fluid down and now has rectal bleeding. A consultation for Resident #15's [MEDICAL CONDITION] and acute kidney injury at the hospital dated [DATE] revealed, Resident #15 had a sodium level of 177 (normal ,[DATE]). The resident's BUN (blood urea nitrogen) WAS 72 (normal adult levels ,[DATE]) and a creatinine of 2.3 (normal adult levels 0XXX,[DATE].1). The physician indicated in consultation that Resident #15's acute injury and [MEDICAL CONDITION] resulted from severe volume depletion. He further indicated the resident's [MEDICAL CONDITION] (low blood pressure) was due to volume depletion rather than an infection. On [DATE], The physician's progress notes at the acute care hospital revealed a [MEDICAL CONDITION] tube was inserted in order for Resident #15 to receive a larger quantity of fluids. The Social Service Notes for Resident #15 dated [DATE], indicated the Social Worker spoke to Resident #15's renal physician who stated a person's sodium only gets that high when a person has no access to water. Resident #15 expired on [DATE]. Resident #17 Resident #17 was admitted on [DATE] with [DIAGNOSES REDACTED]. The facility Nurses Notes from [DATE] at 10:00 AM indicated Resident #17 was cold clammy and very pale. Resident #17's vital signs were temperature 101.8; Respirations 32; pulse rate 145. Resident #17 was transferred from the facility to the acute care hospital by ambulance on [DATE] at 11:15 AM. The resident required intubation while being transported. On admission to the emergency roiagnom on [DATE], Resident #17 was assessed and found to have severe [MEDICAL CONDITION] with a hemoglobin of "4" (normal for adult levels ,[DATE]) and severe dehydration. The resident's sodium level was 176 (normal ,[DATE]) and chloride level was 140 (normal ,[DATE]). Resident #17 had acute kidney failure. The resident's BUN was 62 (normal ,[DATE]) and creatinine was 1.6 (0XXX,[DATE].6). The emergency room ASSESSMENT AND PLAN documented the following: "...Severe [MEDICAL CONDITION]. Hemoglobin is 4 on presentation which has persisted to be less than 4 because the patient is already severely dehydrated. "...Severe hyperchloremic, [MEDICAL CONDITION]. Patient's sodium is 179 and chloride is 140..." "...Acute kidney injury. Baseline creatinine was less than 1 mg (milligram)/dL(deciliter) in 2008. This is due to dehydration. It is improving with intravenous fluids..." "...Severe [MEDICAL CONDITION]. The most likely cause is water deprivation..." "...PLAN: We will admit the patient to ICU (intensive care unit). We will change IV fluids to D5W ([MEDICATION NAME] and water) and start the patient on free water every 2 hours. We will follow the patient's sodium every 2 hours and we will adjust our fluid accordingly..." Resident #17's [DEVICE] was non-functioning and was removed at the acute care hospital on [DATE]. Resident #17 was placed on total [MEDICATION NAME] nurition. Resident #18 Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at approximately 12:25 PM, Resident #18 was interviewed. The resident stated that she had not received wound care for an abdominal wound. The resident lifted her shirt exposing a 4 x 4 gauze dressing covered with an occlusive [MEDICATION NAME] dated [DATE]. A physician telephone order dated [DATE], revealed the resident had an order to "Cleanse [DEVICE] (gastrostomy tube) removal site with NS (normal saline), pat dry, apply CA Alg (calcium alginate) and cover with DD (dry dressing) change Qday (everyday) x (times) 30 days. Resident #18's dressing was not changed in six days. Complaint #NV 829 Complaint #NV 828 Complaint #NV 891

Based on observation, interview, record and document review, the facility failed to ensure physician orders were initiated and followed regarding gastrostomy tube feedings and monitoring, dressing changes on a [MEDICATION NAME] catheter, monitoring laboratory results and properly administering diet supplements for 3 of 18 residents (Resident #10, #2, #18). Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. Review of Resident #10's medical record revealed the resident had a gastrostomy tube ([DEVICE]) and physician orders included: - Check [DEVICE] residual and record amount q (every) shift; Shift 1, Shift 2 - Flush [DEVICE] with 200 ml (milliliters) H2O (water) q 4 hours, 00:00 (12:00 AM), 04:00 AM, 08:00 AM, 12:00 PM, 16:00 (4:00 PM), 20:00 (8:00 PM) - TF (Tube feeding): [MEDICATION NAME] 1.5 @ (at) 65 ml/hr (hour) x 21 hours ...Off 09:00 AM, on 12:00 PM. a) On 4/18/12 at 9:55 AM, observed Resident #10 lying in bed in his room with the [DEVICE] feeding running at 65 cc/hr through the tube feeding pump. On 4/18/12 at 10:55 AM, observed Resident #10 lying in bed in his room with the [DEVICE] feeding running at 65 cc/hr through the tube feeding pump. On 4/18/12 at 11:30 AM, observed Resident #10 lying in bed in his room with the [DEVICE] feeding running at 65 cc/hr through the tube feeding pump. On 4/18/12 at 11:45 AM, the medication nurse (Employee #11) was asked about the timeframes for Resident #10's [DEVICE] feedings. The employee revealed the tube feedings were supposed to be turned off at 9:00 AM and turned back on at 12:00 PM. She verbalized she had turned off the [DEVICE] at 9:00 AM. When asked how the [DEVICE] was still running at this time, she answered, the CNA (Certified Nursing Assistant) may have turned the feeding back on. b) At 4/18/12 at 11:45 AM, Employee #11 turned off the feeding tube and was observed administering the water flush of Resident #10's [DEVICE]. The employee checked for placement of the [DEVICE] by auscultation and aspiration. When proper placement of the [DEVICE] was confirmed, the employee verbalized the resident received 200 cc (cubic centimeters) of water. The employee took a plastic cup and poured water into the cup. The employee did not measure the water in the cup, or when the water was placed in the large syringe attached to the [DEVICE] to be instilled in the resident. After the water was instilled through the [DEVICE], the employee stated she had been told the plastic cup held 100 cc of fluid. Since the resident was to receive 200 cc of water, the employee filled another plastic cup with water. The employee did not measure that either and instilled the remainder of the water through Resident #10's [DEVICE]. On 4/19/11 at 9:20 AM, the surveyor measured the amount of water held in the plastic cup used by Employee #11, using a 30 ml medication cup. Based on the amount of water placed in the plastic cup by the employee, the cup held 150 ml. Since the employee used two cupfuls, the total amount of water flush was approximately 300 cc, not 200 cc as ordered. c) On 4/18/12, review of Resident #10's enteral flow sheet dated April 2012, included the order to check [DEVICE] residuals and record amount q shift - Every shift. There were signatures for every date, twice a day that indicated the residuals were checked. However, there was no documentation indicating the amount of the residual, as ordered. On 4/18/12, in the afternoon, the unit manager indicated the [DEVICE] residuals may have been documented in the nurse's notes. Review of the nurse's notes for April 2012, did not reveal any [DEVICE] residuals documented. 2. On 4/18/12, review of Resident #10's care plan indicated the resident had a PICC (Peripherally Inserted Central Catheter) line in place. Approaches included: "...2) Change dressing to IV (Intravenous) site per facility policy ...8) Flush catheter/line with normal saline (N/S) and [MEDICATION NAME] per MD orders ..." On 4/18/12 in the afternoon, Resident #10's MAR (Medication Administration Record) containing IV therapy orders was reviewed. The April 2012 MAR revealed Resident #10 had a Right (R) upper chest central line in place (not a PICC line). Review of Resident #10's physician orders for March 2012, and April 2012, revealed there were no physician orders for a PICC/Central line or the maintenance of a PICC/Central line including frequency of dressing changes and PICC/Central line flushes. Documentation on the IV medication form included orders for: - Change dressing every 7 days on Sunday night shift. - Site check for S&S (signs and symptoms) of infection q shift (swelling and tenderness) Documentation on the MAR indicated the dressing had been changed on 4/1/12, 4/8/12 and 4/15/12. Documentation also indicated the site was checked twice a day as ordered. On 4/18/12 at 1:00 PM, the surveyor went with the IV nurse (Employee #4) to observe Resident #10's IV catheter. The catheter was located on the resident's right chest wall. There was a gauze dressing in place which was dated 4/9/12, confirmed by the IV nurse. The date of the last dressing, 4/9/12, did not correspond to the dressing change date documented on the IV form, 4/15/12. Resident #2 Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #2's monthly summary form dated 4/16/12, revealed the resident needed extensive assistance with bed mobility, transfers, dressing, eating and toilet use. Resident #2 was also totally dependent with bathing. On 4/19/12 at 12:15 PM, the Director of Nursing (DON) indicated abnormal laboratory results would be reported to the physician, nurse practitioner or the physician assistant. When a new order was received by phone, due to the abnormal laboratory results, a telephone order would be written. The laboratory blood work information would be placed in the laboratory binder so that the staff would be aware laboratory blood work would be drawn on the day it was ordered. The DON also indicated the information such as the abnormal laboratory results and the physician's new orders would be documented on the nursing notes in the resident's chart. Resident #2's basic metabolic panel (BMP) results dated 3/7/12, documented: -Urea nitrogen (BUN) 41 H (high) mg/dl (milligrams per deciliters) (reference range 2-20) -Creatinine 2.5 H mg/dl (reference range 0.5 - 1.5) Also, hand written, on the bottom of the 3/7/12 results form: -"...3/8 Reported to (Nurse Practitioner name) with NNO (no new orders)." Resident #2's basic metabolic panel results form dated 4/15/12, documented a high level creatinine of 2.3 mg/dl and an increasing BUN level of 48 mg/dl. Also hand written on the bottom of the form: -"...(Nurse Practitioner name) notified 4/17/12 ...push fluids recheck BMP on Thurs (Thursday)." Resident #2's Nurse's Notes form dated 4/17/12, documented: -"...4/17/12 1200 (12:00 PM) (Nurse Practitioner name) notified of res (resident) BMP results, NP (Nurse Practitioner) recommends Staff to push flds (fluids)." Orders dated 3/28/12, revealed Resident #2 was receiving bolus flushes of water of 250 ml (milliliters) every 6 hours through his [DEVICE]. Resident #2 was also able to drink fluids orally with no restrictions. There was no documented evidence an order was made on 4/17/12, to push fluids for Resident #2. There was no documented evidence an order was made on 4/17/12, to recheck laboratory blood work on Thursday for Resident #2. There was no documented evidence on 4/17/12, Resident #2's fluid bolus flushes through his [DEVICE] was increased. There was no documented evidence staff was informed to increase push fluids on Resident #2. There was no documented evidence information to draw blood work on Thursday was placed in the facility laboratory binder. On 4/19/12 at 8:55 AM, Resident #2 was lying in bed awake. He was alert and oriented to person, place and time. He was able to state his age and was using a cellular phone which was beside him on his bed. Resident #2 did not have a water container at his bedside table. The surveyor asked where his water container was and if he was thirsty. Resident #2 stated, "Yes, I get thirsty and I'm thirsty now but for the past 3 weeks my roommate takes my water pitcher and dumps my water out in the bathroom and leaves the pitcher in the bathroom. I can't get up to get water." The surveyor asked Resident #2 if he was informed to increase his oral intake of fluids for this week. Resident #2 stated, "Nobody told me to start drinking more fluids this week but I can't anyway because my roommate keeps taking my water." While the surveyor was talking with Resident #2, the roommate was pacing up and down the room from his bed to the hallway door sometimes stopping and blocking Resident #2's television. Two empty water pitchers were noted in Resident #2's bathroom. On 4/19/12 at 8:55 AM, the Surveyor asked Resident #2 if he informed the staff regarding his roommate taking his water and pouring it out. Resident #2 stated, "They have been aware of it for the past 3 weeks since I moved in this room but it's a running joke to them! Nothing is being done." On 4/19/12 at 9:10 AM, Employee #13 indicated Resident #2 was very alert and was transferred to his room about 2 to 3 weeks ago. Employee #2 confirmed she was aware his roommate was taking his water pitcher and dumping his water out in the bathroom. Employee #13 indicated she informed the nurse regarding the incident but did not know if anything was done. Employee #13 indicated Resident #2's roommate was confused and had some phobia with water. On 4/19/12 in the afternoon, the DON confirmed new orders should have been written by the nurse to recheck Resident #2's blood work on Thursday (4/19/12) and to push fluids for the resident due to the abnormal BUN and Creatinine results on 4/17/12. The DON indicated she was not aware Resident #2's roommate was taking his water and dumping it in the bathroom. The DON indicated if the staff was aware then something should have been done. Resident #18 Resident #18 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. On 4/18/12, review of Resident #18's medical record revealed an order for [REDACTED]. Resident #18 was on a puree diet with thin liquids and was assisted 1:1 with all meals. On 4/18/12 at 12:15 PM, Resident #18 noon meal was observed. Resident #18's meal tray consisted of pureed roast pork with gravy, bread dressing, season vegetable blend, ? cup blushed apple sauce, 6 oz (ounce) cup lemonade and a 4 oz health shake. On 4/18/12 at 12:20 PM, the Certified Nursing Assistant (CNA) gave Resident #18 a sip of lemonade. Resident #18 verbalized, "I don't like the lemonade. I want milk." The CNA stated "you have a milk shake. Let's try your milk shake." Resident #18 verbalized, "I don't want the shake. I don't like it. I'm not gonna drink it." At this time, the CNA picked up Resident #18's tray and said she would get some milk. The CNA covered Resident #18's meal tray and placed it in the holding cart. On 4/18/12 at 12:25 PM, the CNA returned with a small carton of milk and Resident #18's meal tray. Resident #18 ate two (2) spoonfuls of dressing, one (1) spoonful of vegetables, and two (2) spoonfuls of applesauce, then drank a few sips of milk. Resident #18 verbalized, "I don't want anymore. I'm full." The CNA took Resident #18's tray leaving the milk on the bedside table. On 4/19/12 at 12:40 PM, review of Resident #18's Medication Administration Record (MAR) revealed documentation Resident #18 had a health shake with the noon meal and dinner on 4/18/12. On 4/19/12 at 12:45 PM, Resident #18 was observed sitting in bed. When asked about the type of drink she had with lunch, Resident #18 verbalized, "I had lunch. Yes, I had lunch, I had milk. I like regular milk. I don't like the shake. I don't like it. I won't drink it. No, no I won't drink it." A cup of milk was observed on the Resident #18's bedside table. On 4/19/12 at 1:20 PM, the License Practical Nurse (LPN) was interviewed regarding Resident #18's health shake. The LPN looked at Resident #28's MAR and stated she gets a nutritious juice with breakfast and a milk shake with lunch and dinner. The LPN verbalized,"I pass the resident's shakes out myself or I put it on the tray to make sure she gets it." When questioned about Resident #18's ordered health shake, the LPN verbalized, "Resident #18 had her health shake on yesterday. I gave her the shake." The LPN verified the initials on the MAR for 4/18/12 were hers. The LPN acknowledged she documented Resident #18 had a health shake with lunch and dinner on 4/18/12. The LPN was informed Resident #18's noon meal was observed on 4/18/12 and the resident refused the health shake. The LPN was also informed Resident #18 stated she did not drink the health shake at the noon meal on 4/19/12. The LPN confirmed she did not give Resident #18 the milk shake on 4/18/12 and 4/19/12. The LPN acknowledged she saw the CNA bring tray to the meal cart and assumed Resident #18 drank the shake. The LPN verbalized, "I thought milk shake was in the resident's cup." The LPN stated the CNA did not report Resident #18 did not drink the shake on 4/18/12. The LPN acknowledged Resident #18 did not receive the health shake as ordered on [DATE] and with lunch on 4/19/12. The LPN stated, "I will write refused on Resident #18's MAR for the noon meal dated 4/19/12." The LPN acknowledged she was not sure if Resident #18 drank the health shake on other days. At this time, the Unit Manager was informed and acknowledged the LPN's inaccurate documentation regarding Resident #18's health shake order. The Unit Manager indicated the dietitian and physician would be notified and Resident #18's plan of care would be reviewed. The facility's policy entitled,"Medication Administration - General Guidelines" page 2 of 5, (Revised 3/2010) indicated: "13. If a dose of regularly scheduled medication is withheld, refused, or given at another time.......the space provided on the front of the MAR/TAR for that dosage administration is initialed and circled. An explanatory not is entered on the reverse side of the record provided for PRN documentation. If several doses of vital medication are withheld or refused, the physician and responsible party are notified and documentation of the notification made." The facility failed to provide Resident #18 with the health shakes as ordered.

Based on observation, interview, record review, and document review, the facility failed to follow physician orders [REDACTED].#15, #18). Findings include: Resident #15 Resident #15 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #15 had a written order for pharmacy consult dated 4/20/2010 documented: -"[MEDICATION NAME] per pharmacy to monitor/dose: vanco ([MEDICATION NAME]) trough = 6.5 on 4/19/11 discontinue current vanco dose start vanco 1.5 gm (gram) iv (intravenous) q(every)36h (hours) thru 4/25/2011 draw vanco trough prior to dose on 4/22/11 per (physician name) written order for pharmacy consult/The Pharmacy/..." Resident #15's Telephone Orders form dated 4/20/11 and signed by the physician documented: -"...Draw vanco trough prior to dose on 4/22/11..." There was no documented evidence a [MEDICATION NAME] trough was drawn as ordered. On 5/5/2011 in the afternoon, the Director of Nursing (DON) confirmed that the order to obtain a [MEDICATION NAME] trough from Resident #15 on 4/22/11 was missed. Resident #18 Resident #18 was originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. On 5/5/2011 in the afternoon, Resident #18's wife indicated her husband's medications were not being given on the times they were ordered. She indicated her husband's medications were being given 1 hour 45 minutes to 2 hours and 30 minutes late. She indicated that the the facility did not staff properly and nurses had too many residents to take care of, making the nurses pass out medications late. Resident #18's Physician order [REDACTED].[REDACTED] -"...recapped: 3/2/11 [MEDICATION NAME] acid 500 mg (milligrams) via peg QD (everyday) -3/2/11 [MEDICATION NAME] 20 mg via peg QHS (every night) -[MEDICATION NAME] 20 mg peg QD -...vit (vitamin) B complex...QD -[MEDICATION NAME] (twice a day) -[MEDICATION NAME] 20 mg...QD..." The Henderson Healthcare Center 8 Hour Shift Med Pass Times form dated 9/28/04 documented: -"...The following is a list of times and descriptions that are currently in use. If for some reason the time the medication is being given does not correspond with the physician order, please have the order clarified by the physician... -...QD 0800... -...BID 0800 1600 -...QHS 2000 (8:00 PM)..." The facility policy titled Medication Management Program and dated 3/2006 documented: -"...Medications are administered one (1) hour before or one (1) hour after the designated medication pass time..." On 5/5/2011 in the afternoon, the DON confirmed the window period when administering medications would be one hour before or one hour after the medication was due. Resident #18's wife kept a detailed log of when medications were being administered late. In her diary, she kept the date, time, and name of the staff members administering medications late to her husband. On 5/5/2011 in the afternoon, Resident #18's wife read through her log and indicated on 4/27/2011, her husbands medications that were due at 8:00 PM were given at 9:45 PM. She indicated the medications were one hour and forty five minutes late. On 5/5/2011 in the afternoon, Resident #18's wife read through her log and indicated on 5/2/2011, her husbands medications that were due at 8:00 AM were given at 9:40 AM. On 5/5/2011 in the afternoon, the DON was given the two dates, 4/27/2011 and 5/2/2011, in which medications were administered late for Resident #18. The names of the nurses who were involved were given to the DON. The DON was asked to contact the two nurses and ask why the medications were given late. The facility schedule dated 4/27/2011, documented there were three medication nurses working in the B1 area. Resident 18's room was located in B1 on 4/27/2011. The Staff Coordinator indicated that there were 55 residents in the B1 area for the 6:00 PM - 6:00 AM shift. The Staff Coordinator indicated out of the three medication nurses scheduled to work, one nurse called in sick. The Staff Coordinator indicated attempts were made to contact a replacement nurse but was unsuccessful. There were only 2 nurses passing medications instead of three nurses on that shift. On 5/5/2011 in the afternoon, the DON was able to contact the nurse working in area B1 during the night shift on 4/27/2011. The nurse informed the DON that one of the medication nurse called in and she may have been late with passing out medications. The facility schedule dated 5/2/2011, documented that there were three nurses scheduled to work at area B1 from 6:00 AM - 6:00 PM. The census for B1 was 52. The DON indicated one medication nurse was flexed off due to the census going below 55 residents, leaving two medication nurses to work in the area. On 5/5/2011 in the afternoon, the DON was able to contact the nurse working in area B1 during the day shift on 5/2/2011. The nurse informed the DON that the third scheduled nurse was flexed off due to the low census and also indicated she was probably late giving medications to Resident #18, since he was one of the last residents on her run. Complaint #NV 263

Based on observation, interview, record review and document review, the facility failed to ensure services were provided to maintain residents' highest practicable physical, mental, and psychosocial needs for 4 of 30 residents (Residents #11, #19, #2, and #22). Findings include: Resident #11 Resident #11 was a [AGE] year old female originally admitted to the facility on [DATE], and last readmitted on [DATE], with [DIAGNOSES REDACTED]. The resident was on hospice. The physician's history and physical dated 10/22/10, documented the resident was transferred from the acute care facility due to chronic pain and monitoring of lab values. The physician's plan included: - "Follow up baseline labs (laboratory) to be obtained - ammonia levels will be checked - She will continue on [MEDICATION NAME]" The initial nurse's assessment dated [DATE], indicated Resident #11 was alert and responsive "but becomes drowsy at times." The initial assessment by the hospice nurse dated 10/25/10, documented Resident #11 was A&O x3 (alert and oriented to person, place and time), complained of intermittent back pain, and became drowsy at times. Over the course of the next several months, the nurse's notes documented Resident #11 experienced increased confusion and agitation, resulting in Resident #11 being transferred to the acute care facility on 1/22/11 to rule out a psychiatric diagnosis. Nurse's notes documented: - "11/9/10, 6 AM to 6 PM - Resident alert with confusion. Talking out loud to herself at times..." - "12/31/10, 6AM to 6PM - Severe agitation this shift... Pt (patient) with hallucinations, screaming, cursing, yelling for staff to "get off her property... Wandering..." - "01/2/11, 02:30 (2:30 AM) - Severely agitated. Attempted to open fire door..." - "01/21/11, 06:15 AM - ...patient is so agitated, banging her head on the wall, hallucinating, screaming, combative and danger to herself..." - "01/22/11, 07:30 AM - ... starting to be agitated, hallucinating, screaming. [MEDICATION NAME] 1 mg (milligram) given and then [MEDICATION NAME] 0.5 mg...Patient still continuing crying, hallucinating...Patient wandering and screaming in hallways... Hospice called and decided to send her Legal 2000 (Psychiatric Hold)." The physician's orders [REDACTED]. "10/23/10 - CBC, Liver panel, Ammonia level 11/16/10 - Need labs done on 11/16/10; CBC Liver Panel, TSH, BMP, Ammonia level 11/24/10 - Ammonia level in AM 01/20/11 - Ammonia level" Documentation in the medical record included : - Lab report dated 10/24/10, revealed "Ammonia test not performed. Specimen unsuitable for testing due to hemolysis." The physician was notified, however, there was no documented evidence the ammonia level was obtained. The nurse's notes dated 11/25/10 at 6:00 AM, documented "Unable to draw blood for ammonia level due to poor vein access, after several attempts made. RN (Registered Nurse) also tried but unsuccessful." There was no documented evidence the physician was notified or the ammonia level was ever obtained. On 3/3/11 in the afternoon, the medical records staff confirmed there were no ammonia level results in the computer system for Resident #11, and the last level that was drawn was on 10/24/10. The physician's orders [REDACTED]. - "[MEDICATION NAME] 30 cc (cubic centimeters) po (by mouth) daily prn (as necessary) for constipation" The physician's orders [REDACTED]. - "[MEDICATION NAME] 30 cc po now then 30 cc routine daily elimination." Resident #11's Medication Administration Records documented the resident received [MEDICATION NAME] only on 1/20/11 and 1/21/11. There was no documented evidence Resident #11 received [MEDICATION NAME] or was offered and refused [MEDICATION NAME], in October, November or December, 2010. The physician's History and Physicial (H&P) at the acute care facility dated 1/23/11 documented: - "...She appeared more aggressive and agitated, and verbal altercations with the nursing staff at (SNF)." - "...An ammonia level was noted to be elevated to 133. (Normal ammonia levels 15 - 60 mcg/dL (micrograms per deciliter) or 21 - 50 mcmol/L (micromoles per liter)) She has been on [MEDICATION NAME] there at (SNF), but she has been refusing to take the [MEDICATION NAME] recently..." - "...She was initially put on legal hold, but at this point it is felt that she does not need a legal hold...She is somewhat confused and lethargic, with some slurred speech, again as a result of some baseline [MEDICAL CONDITION]." - ..."Plan: She will continue on the [MEDICATION NAME] for the elevated ammonia levels..." physician's orders [REDACTED]. - "[MEDICATION NAME] 10 mg (milligrams)/15 ml (milliliter) 30 ml po (by mouth) qid (four times a day)" The physician's discharge summary dated 1/31/11 documented: - "...Here, she was put back on [MEDICATION NAME]. Ammonia level has shown improvement...over the past 24 to 48 hours, she has at least been more calm...She is able to at least answer questions and carry on a conversation..." The National Institute of [MEDICAL CONDITION] and Alcoholism (NIAAA) publication titled Hepatic [MEDICAL CONDITION] (HE) - A Serious Complication of Alcoholic Liver Disease, dated 7/2004 revealed: "HE is a serious complication of alcoholic liver disaese that contributes to cognitive dysfunction in chronic alcoholic patients. In patients with HE, the damaged liver can no longer remove neurotoxic substances such as ammonia and [MEDICATION NAME] from the blood. As a result, these molecules may enter the brain, where they can exert a variety of harmful effects that interfere with normal neurotransitter activity, impair motor functions, and cause structural alterations in the astrocytes. To prevent or treat HE in alcoholic patients with [MEDICAL CONDITION], physicians currently rely primarily on strategies to lower blood ammonia concentrations as well as on liver transplantation in patients with end-stage liver disease..." "treatment of [REDACTED]. One approach - administering certain sugar molecules (e.g. , [MEDICATION NAME]) or antibiotics (e.g., [MEDICATION NAME]) - reduces the production of ammonia in the gastrointestinal tract..." In summary: - Resident #11 had 4 physician orders [REDACTED]. - There was no documented evidence ammonia levels were obtained during the admission. - The physician was notified only one time, on 10/25/10, of the inability to obtain the ammonia levels. - Resident #11 had a significant change in cognitive function due to increased ammonia levels, which required an acute care hospitalization . - Resident #11 was treated with [MEDICATION NAME] to reduce the ammonia levels in the acute care facility and returned to the skilled facility when the ammonia levels had decreased and her cognitive function improved. Resident #19 Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #19's diet order was "NPO (nothing by mouth); enteral feeding: Glucerna 1.2 x 70 ml (milliliters) per hour x 21 hours, to provide 1764 calories each day; special instructions: on at 1200 and off at 0900." On 3/3/11 at 8:35 AM, Resident #19 was observed to be receiving a tube feeding of Glucerna. The time of 1845 was written on the 1500 ml bottle. There was 1100 ml of formula remaining in the bottle, and this was confirmed by the Unit Nurse, Employee #12. If the feeding had been running since 6:45 PM on 3/2/11, at a rate of 70 ml per hour, there should have been 555 ml left in the bottle. On 3/3/11 at 9:00 AM, a licensed nurse on the 500 Hall (Employee #38) was interviewed. The nurse confirmed a new Glucerna bottle for Resident #19 was started at 1845, because the previous bottle ran out at that time. The nurse could not explain why the feeding did not run through the night. The nurse reported the resident's tube feedings were not always started at 12:00 PM and turned off at 9:00 AM as ordered. Resident #2 Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #2's medical record documented a physician's orders [REDACTED].r.n (as needed) if no bowel movement (BM) in 3 days. [MEDICATION NAME] suppository 10 milligram p.r.n per rectum if MOM is ineffective in 12 hours The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The resident then received MOM 30 cc orally for the complaint of constipation on 12/9/10 at 9:00 AM. On 3/1/11 at 1:45 PM, a Licensed Nurse (LN) stated according to the physician's orders [REDACTED]. The LN verbalized the physicians' orders had not been followed. Resident #22 Resident #22 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The medical record contained a physician's orders [REDACTED]. Hold for systolic blood pressure less than or equal to 110 and a pulse rate less than or equal to 60. The facility's reference book titled, "30th Anniversary Edition Nursing 2010 Drug Handbook" pages 385-387 documented "always check a patient's apical pulse rate before giving the drug. If it's slower than 60 beats per minute with hold the drug and call the prescriber immediately." Resident #22's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. On 3/3/11 at 2:25 PM, a Licensed Nurse (LN) stated the drug [MEDICATION NAME] "lowers the blood pressure and heart rate. The heart rate and blood pressure should be taken before the medication was given." The LN stated if the medication was given to a resident with a low blood pressure/or heart rate the medication would cause them to drop further and could cause dizziness or a fall. The LN reviewed the MAR for 2/11 and stated the physician's orders [REDACTED].