Every finding on record at Highland Manor of Fallon Rehabilitation LLC

Based on observation, interviews, clinical record review, and document review, the facility failed to 1) ensure that 1 of 4 residents (Resident #97) investigated for abuse and/or neglect received the necessary care and services to prevent a wound from deteriorating and becoming infected, resulting in the resident requiring emergent care for sepsis at an acute care hospital, where the resident subsequently expired due to sepsis and 2) protect residents' right to be free from neglect when signs and symptoms of infection and a change in skin condition in 1 of 18 sampled residents (Resident #24) were not reported timely to the physician by a Licensed Practical Nurse (LPN), resulting in the resident experiencing testicular pain and swelling and developing an infection that required intravenous antibiotic treatment at an acute care hospital. This deficient practice resulted in harm to both residents, including one death and one hospitalization. Findings include: Resident #97 Resident #97 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including cellulitis, unspecified, idiopathic progressive neuropathy, localized edema, unspecified dementia, severe, with anxiety and paranoid schizophrenia. Resident #97's Order Summary Report documented the following orders: -Wound culture to left leg related to cellulitis, with an order date of [DATE]. There was not documented evidence of a culture being completed after this date. - A wound care order with a start date of [DATE], documented to cleanse and soak left dorsal foot venous statis ulcer with wound cleanser, dry, apply Medihoney, hydrofera blue (HFB), abdominal pad (ABD) wrap with Kerlix and Coban, every Wednesday, Friday, and Sunday (W/F/S) and as needed (PRN) soiling and dislodgement. Wound clinician to change on Wednesdays. -A wound care order with a start date of [DATE], documented to soak and cleanse the left lower extremity (LLE) with wound cleanser, pat dry, apply Medihoney to the affected areas of the lower extremity, cover with ABD pad, wrap with Kerlix, secure with Coban and tape on Wednesdays and Sundays and PRN soiling and/or dislodgement. Wound clinician to change on Wednesdays. The record did not specify lateral or posterior wounds and did not include a stop/end date for the order. -A wound care order dated [DATE], with a start date of [DATE], documented to cleanse the lateral LLE venous stasis ulcer with wound cleanser, apply HFB, cover with ABD pad, wrap with Kerlix every W/F/S and PRN soiling and/or dislodgement. Wound clinician to change on Wednesdays. -A wound care order dated [DATE], with a start date of [DATE], documented to cleanse the posterior LLE venous stasis ulcer with wound cleanser, apply HFB, cover with ABD pad, wrap with Kerlix and Coban every W/F/S and PRN soiling and/or dislodgement. -A wound care order dated [DATE], with a start date of [DATE], documented to cleanse and soak left dorsal foot venous statis ulcer with wound cleanser, dry, apply HFB, ABD pad wrap with Kerlix and Coban, every W/F/S, PRN soiling and/or dislodgement. Wound clinician to change on Wednesdays. Resident #97's Treatment Administration Record (TAR) for [DATE], documented wound care was not provided as ordered on [DATE], and [DATE] to the resident's left dorsal foot venous statis ulcer, lateral LLE wounds and posterior LLE wounds. A physician's order dated [DATE], documented to monitor the identified target behaviors related to antianxiety medication: 1) uncontrollable screaming/yelling out, 2) agitation, 3) other (document in a progress note), and 4) none noted, every shift for psychotropic symptom monitoring. Resident #97's TAR for [DATE], did not include evidence of monitoring for the resident's targeted behaviors related to antianxiety medications on 09/01, 09/03, 09/09, 09/10, 09/12, 09/13, 09/17, 09/18, 09/19, 09/20, 09/25, and [DATE] during day shift. A physician's order dated [DATE], documented an order for doxycycline hyclate oral tablet, 100 milligrams (mg), give one tablet by mouth two times per day for bacterial infection, for 10 days with a start date of [DATE], and a stop date of [DATE]. Resident #97's Medication Administration Record (MAR) documented doxycycline, and antibiotic medication, was not available at the facility on 09/14 and [DATE]. The first dose of the medication was administered on [DATE], and the last dose of the medication was administered on [DATE]. As a result, the resident received only eight days of the prescribed 10-day course. A nurse progress note dated [DATE], documented Resident #97 “uncontrollably” yelled in pain all day and nothing helped the resident's pain. Resident #97's left lower extremity (LLE) dressing was changed because the dressing was wet with a moderate amount of purulent drainage and a strong odor. Orders were obtained to send the resident to the emergency room for evaluation. A Nurse Progress note dated [DATE], related to antianxiety medication monitoring, documented Resident #97 continued to yell out and scream for help. The resident yelled uncontrollably, and the topics did not make sense. The resident appeared paranoid and complained of people trying to hurt the resident, being ignored, and the pain the resident was experiencing. A Nurse Progress note dated [DATE], documented Resident #97 shouted “can someone help me, can anyone help me, why won't nobody help me,” and “he is going to kill me, and you are going to kill me” for approximately two hours prior to falling asleep. The resident could not be redirected. A Behavior Note dated [DATE], written by the Assistant Director of Nursing (ADON) documented Resident #97 had yelled all day. The resident yelled “help me, why won't someone help me.” The resident verbalized the resident's legs “hurt so bad.” The wound dressing to Resident #97's right lower extremity (RLE) was soaked with purulent drainage. A Wound Note dated [DATE], documented a dressing change was completed for Resident #97's LLE lateral and posterior wounds, and the left dorsal foot. The resident was “noncompliant” and threatened, yelled, and screamed at staff. The resident flailed and kicked at staff prior to the completion of the wound care. The wound note did not document the characteristics of the wound including slough, drainage, odor, condition of the peri-wound, and/or size of the wound. A Nurse Note dated [DATE], documented Resident #97 “yelled and screamed” all night. The resident yelled “I need help, help me, I want you to be my friend, why are you mean to me, and my legs hurt.” Pain medication was given but did not appear to help. The resident could not be redirected. A Nurse Note dated [DATE], documented Resident #97 was taken to [NAME] City for an appointment and upon return transportation staff told the nurse Resident #97 had left a “puddle” of clear, no odorous drainage on the floor of the van. The drainage was from the resident's lower extremities and occurred during the few hours the resident was transported to [NAME] City and then back to the facility. A Wound Note dated [DATE], documented Resident #97's wound care could not be completed due to the resident's erratic behaviors. A Nurse Note dated [DATE], documented the dressing on Resident #97's left leg was saturated. The dressing was replaced but “got wet very quickly.” A Nurse Progress note dated [DATE], documented Resident #97's dressings applied on the afternoon of [DATE], appeared clean and dry with no visible drainage throughout the day. The resident complained of pain to both legs and the pain was relieved with scheduled and as needed (PRN) pain medications. A Wound Note dated [DATE], documented the dressings on Resident #97's LLE and the left dorsal foot had loose, green slough. The wound was soaked in wound cleanser and cleaned as much as possible. Medihoney was applied to all affected areas, covered with hydrofera blue. The venous stasis ulcers to the resident's LLE, posterior and lateral wounds, had decreased slough which was still green in appearance. A Nurse Note dated [DATE], documented Resident #97's dressings appeared soiled with clear fluid and the resident was leaving “wet marks” on the floor with the resident's heels. The note documented the resident refused a dressing change and yelled out “you are not going to touch me, you are going to hurt me, and you are going to kill me.” The note documented the resident was able to be redirected for short periods of time but did not document if wound care was or was not completed. A Nurse note dated [DATE], documented the dressings to Resident #97's bilateral lower extremities (BLE) were “soaking wet.” The bottom of the resident's left foot was macerated and the “top of the LLE was covered with thick slough.” The side of the resident's left foot had macerated tissue, and the tissue came off with the hydrofera blue. A thick layer of barrier cream was applied to the bottom of the resident's foot and covered as ordered. The note did not document the characteristics of the slough and drainage such as color, amount, and/or odor. A progress note dated [DATE], documented Resident #97 only slept for approximately one hour throughout night shift. The resident yelled and screamed “please help me, don't hurt me, somebody help me in the name of Jesus, and why can't you help me. Attempts to redirect the resident were not effective. A Wound note dated [DATE], documented Resident #97's wounds had increased green drainage and increased green slough. The wounds were minimally cleaned due to the resident would not allow debridement. A Physician's note, dated [DATE], documented Resident #97 verbalized being in severe pain and requested to be helped urgently. The resident pointed at the wounds on the resident's legs and verbalized the location of the pain was “down there.” The wounds were wrapped but leaking. The provider could not assess the wounds due to the resident moved backwards and verbalized “don't touch me.” The assessment notes follow up plan documented the resident was in significant pain and requested additional analgesia. The provider documented the resident's root of behavior arose from the resident needing to have psychiatric medications evaluated and treated by behavioral health. It was concerning due to the resident's refusal of wound care including debridement of the wound the resident may become septic, amputation was also likely. A Nurse Note dated [DATE], documented Resident #97 appeared to be doing mildly better following an increase in Ativan from 0.5 mg to 1.0 mg but did not effectively ease the resident's anxiety. A Nurse Note dated [DATE], documented Resident #97 had been crying out for several hours. The resident was in a lot of pain, and the prescribed pain medication appeared to be insufficient at allowing the resident to cope with the resident's pain. The resident's wound dressings were changed by the previous shift but were dripping wet by the middle of the following shift and new dressings had to be applied to the resident's LLE and foot. A Nurse Note dated [DATE], documented an increase in Ativan had not produced the desired effect. The resident had been begging for help and asking the nurse to not hurt or kill the resident. A Nurses Note, dated [DATE], written by ADON, documented Resident #97's dressing was soaking wet, and the resident was leaving wet marks on the floor. The wounds were cleansed with wound cleanser, barrier cream was applied to the peri-wound, and the wounds were covered. The wound bed to the top of the resident's left foot was covered with thick slough. The lateral side of her left foot was raw from maceration. The wounds had a large amount of drainage, and the resident appeared to have severe pain with dressing changes. A Nurses Note dated [DATE], at 4:35 PM, documented a Certified Nursing Assistant (CNA) reported to a nurse, Resident #97 was not “in the resident's normal state.” The resident was yelling out loud, pupils were not dilating, blood pressure was 64/44, heart rate was 66, and the resident's skin was hot to the touch. The resident had a temperature of 101.5. The resident was staring out into the distance and did not focus or track. Emergency Medical Services (EMS) was called and upon assessment could not get a reading of the resident's vital signs. The resident was transported by EMS to an acute care hospital. On [DATE] at 10:32 AM, the Director of Nursing (DON) explained the expectation was when a wound had copious drainage the wound care order would include a super absorbent dressing such as “Opti-lock” and additional padding such as an ABD pad. Alginates could be used to help facilitate drainage management. The DON verbalized the DON would expect to see an order for something to protect the peri-wound. The DON verbalized an attempt should be made to determine the cause of the excess drainage such as infection. The DON verbalized the DON's area of specialty was wound care. On [DATE] 10:36 AM the DON verbalized maceration indicated either the dressing was not changed often enough, or the correct dressing was not being used. The DON explained if honey was being used, the provider would be notified, and the honey would be discontinued. On [DATE] at 10:38 AM, the DON explained wound were only cultured if three symptoms were present such as heat from the wound, change in type of drainage, deterioration of the wound such as friable skin, and/or not responding to treatment. A topical dressing such as HFB or silver would be tried first due to antimicrobial properties and a culture and sensitivity would be ordered if the wound did not respond. The DON verbalized friable tissue was a sign of infection. On [DATE], at 1:35 PM, the DON confirmed wound care was not completed on 09/18 and [DATE] per TAR documentation and physician orders for Resident #97's wounds to the left dorsal foot, posterior LLE, and lateral LLE wounds. The DON confirmed if wound care could not be provided for any reason such as refused, it should be documented on the TAR. On [DATE] at 2:10 PM, the DON confirmed the last wound culture done for Resident #97 was documented as completed on [DATE], and there were not any additional lab values available during August and [DATE], including wound cultures. On [DATE] at 2:13, the DON confirmed wound care was not provided as ordered and confirmed drainage from the wound had not been well managed. The concern was the lack of management of the wound led to maceration and could have caused the deterioration of the wound and created an infection control concern. On [DATE] at 2:15 PM, the DON explained the presence of bacteria in a wound can cause wound healing to stall and result in the wound not being able to heal. [NAME] drainage indicated an infection, generally pseudomonas. Untreated infections could continue to spread, stall wound healing and place the resident at risk for sepsis. The DON confirmed when the wounds started to have green drainage a culture should have been completed and explained re-culturing the wound could have led to better wound management. On [DATE] at 2:40 PM, a Licensed Practical Nurse (LPN), who was the ADON during the time Resident #97 resided at the facility, recalled Resident #97's wounds were “pretty bad” and explained the resident often would not allow wound care. The LPN explained the resident refused wound care because it was so painful, and confirmed the resident had a lot of pain with her legs. The LPN recalled the resident would yell out regarding the resident's legs and explained the resident's legs looked “really bad” and were macerated. On [DATE] at 2:53 PM, the LPN verbalized a provider was in the facility throughout each day and had seen what was going on with the resident's legs and assessed the resident. On [DATE] at 2:54 PM, the LPN recalled seeing drainage on the floor but did not recall the color of the drainage. The LPN confirmed it did not take long for Resident #97's wound dressings to become soaked. The LPN explained the wounds would become saturated after approximately eight hours and the resident would leave a trail on the floor in the hallways and common areas. The resident never wanted to be in the resident's room. On [DATE] at 2:58 PM, the LPN recalled seeing drainage from Resident #97's wounds on the floor and described it as “dripping” onto the floor. The LPN explained staff tried to keep towels on the floor under the resident's feet/legs, but it was difficult because the resident would “freak out” when anyone got too close to the resident's legs, it was a constant struggle. The LPN confirmed placing towels on the floor under the resident's legs/feet was not an “effective form of infection control.” A hospital Discharge summary dated [DATE], documented Resident #97 was admitted to the acute care hospital on [DATE]. The resident was brought to the hospital by ambulance from the facility. Resident #97 was awake but had an altered mental status and was noted not to be at base line by hospital staff who were familiar with the resident. The resident was examined by an emergency room (ER) physician who documented the resident's lower extremity wound dressings appeared to have been there for quite some time. The resident was previously seen at the ER on [DATE], and the wounds were cleaned and dressed during the visit. The physician was concerned due to the appearance of the dressings; they had not been changed since they were applied in the ER. The resident was febrile with a temperature of 102.9 and was tachycardic with a heart rate of 126. The physician documented the resident was soiled and in pretty bad shape upon arrival. When the dressing was removed, flies came out from the wounds on the resident's legs. The resident was given Ativan, Toradol and other pain medications and was admitted to the hospital. The resident was suspected to have sepsis and was started on two antibiotics, vancomycin and Unasyn. The wounds to the resident's legs were described as denuded with the left leg worse than the right and wound cultures were collected. The report documented the resident had a high risk for morbidity. The Discharge Summary Report further documented on [DATE], Resident #97 passed away. The cause of death was sepsis secondary to lower extremity cellulitis, which was secondary to peripheral vascular disease. The facility policy titled “Infection Prevention and Control Program” reviewed on [DATE], documented the facility had established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Cross reference with F656 CPT 2289187 Resident #24 Resident #24 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including cerebral palsy, unspecified, other signs and symptoms involving cognitive functions and awareness, developmental disorder of speech and language, unspecified, and personal history of urinary tract infections. Resident #24's clinical record documented the resident was transferred and admitted to an acute care hospital on [DATE]. Resident #24's Care Plan documented the following focus areas, goals, and interventions/tasks: -Skin: Resident has the potential for altered skin integrity related to immobility, impaired cognition, malnutrition, and incontinence. Goal: Resident will not have new or worsening skin breakdown through next review. Interventions/Tasks: Nurses to perform weekly skin assessments, notify physician of any new skin impairments and obtain treatment orders as indicated. Monitor for and report to physician any signs/symptoms (s/s) of infection to skin impairments, for example: redness, warmth, swelling, drainage, odor, or elevated temperature. -Foley catheter: Resident has an indwelling catheter, 16 French, ten cubic centimeter (cc) balloon. Interventions/Tasks: Monitor/document for pain/discomfort due to catheter. A Nurses' Note dated [DATE], documented Resident #24 had leaking from the resident's indwelling catheter and sediment was noted in the catheter tubing. The nurse attempted to flush and aspirate the catheter, however, was unsuccessful as the catheter appeared to be clogged. A new catheter was inserted using aseptic technique. 100 cc of dark yellow urine returned. A Skilled Charting Note dated [DATE], documented 300 milliliters (ml) of dark/amber colored urine were drained from Resident #24's Foley catheter bag. A Nurses' Note dated [DATE] at 12:19 AM, documented Resident #24's scrotum was red and painful to the touch. Physician notified via book. A Nurses' Note dated [DATE] at 11:13 AM, documented during a bed bath staff noticed Resident #24's scrotum was enlarged and red, a nurse observed the area and noted the scrotum was red, warm, swollen, hard, and had purulent drainage in the penile area. Emergency Medical Services (EMS) was called at 10:42 AM and the resident left the facility via EMS at 11:04 AM. A Nurses' Note dated [DATE] at 11:27 AM, documented the nurse was notified of a change in Resident #24's condition. The resident's testicles were swollen to the size of a grapefruit, very hard, red, and hot to the touch. Purulent drainage was coming from around the resident's Foley catheter. Urine in the catheter drainage bag was amber with a moderate amount of sediment. The Director of Nursing (DON) was notified, report was given to the emergency room (ER) nurse and EMS was called for transport. A Hospital Medicine Daily Progress Note from an acute care hospital, dated [DATE], documented Resident #24 was admitted on [DATE] with testicular pain, epididymitis and orchitis consistent with pyocele. Urine cultures were positive for Pseudomonas and Enterococcus. The resident required treatment with intravenous Levaquin and enteral Amoxicillin. On [DATE] at 2:28 PM, the LPN/ADON verbalized if staff noted a change in a resident's skin or the resident was exhibiting s/s of possible infection, staff were to notify the resident's physician, enter a progress note, notify the resident's responsible party, and pass the information on in report to the next shift. The LPN/ADON verbalized nurses could contact the physician via phone or use the communication binder. If the notification was for a resident's change in condition such as a fall, change in mental status, or increased/decreased urinary output, the LPN/ADON verbalized the LPN/ADON would call the physician instead of using the communication binder. On [DATE] at 3:28 PM, the DON verbalized neglect was failure to provide things to a resident which could lead to inadequate quality of life and not providing the care and treatment the resident was supposed to have or was ordered by the physician. Training related to abuse and neglect was provided to staff every month and the Administrator was the facility's abuse coordinator. The DON explained a change in condition was anything different from the resident's baseline. The DON verbalized the DON would consider a newly identified area of redness and tenderness on a resident's skin a change in condition. The DON verbalized the DON's expectation of staff if there was a change in a resident's skin or the resident exhibited s/s of a possible infection was to notify the physician and facility management. Staff could contact the physician via phone or the facility's book which was reviewed by the physician on Fridays. The DON verbalized if a change in condition was urgent, placed the resident at risk or needed the physician's immediate attention staff were to call the physician and not use the communication book. The DON confirmed staff's failure to report a change in condition timely to the physician would be considered neglect. The DON reviewed Resident #24's clinical record and confirmed the Nurses' Note dated [DATE] at 12:19 AM documented the resident's scrotum was red and painful to touch and the physician was notified via book. On [DATE] at 9:52 AM, the DON verbalized the DON attempted to locate documentation of the physician notification regarding Resident #24's change in condition. The DON explained the facility did not retain the information communicated in the book after the physician reviewed it and the notes were not entered or scanned into the resident's clinical record. The DON confirmed the physician should have been notified via phone of Resident's #24's condition documented on [DATE] at 12:19 AM due to the resident exhibiting s/s of possible infection. On [DATE] at 11:51 AM, an LPN2 confirmed the LPN2 was familiar with Resident #24 and recalled the LPN2 had to send the resident to the hospital in the past. The LPN2 explained the nurse assigned to Resident #24 had gone on a break when a Certified Nursing Assistant (CNA) asked the LPN2 to assess the resident. Upon assessment, the LPN2 verbalized the LPN2 felt the resident needed to be transported to the ER immediately due to resident's testicles being swollen and red. The LPN2 called the physician, reported the condition of the resident, and received instruction to send the resident to the ER. The LPN2 verbalized the LPN2's concern at the time of the assessment was Resident #24 may have been experiencing a medical emergency such as testicular torsion or an infection. On [DATE] at 12:13 PM, during an interview with the Administrator and the Administrator in Training, the Administrator verbalized neglect was anything harming or affecting a resident in a negative way. The Administrator confirmed staff's failure to notify the physician timely of a change in a resident's condition or s/s of possible infection would be considered neglect. The Administrator explained if the facility had suspicion or an allegation of neglect or abuse was reported, the Administrator would initiate an investigation. Hospitalizations were reviewed by the interdisciplinary team for possible abuse and neglect. The Administrator verbalized the Administrator was familiar with Resident #24 and recalled the resident being hospitalized in [DATE] due to concern about the resident's scrotum. The Administrator believed the hospitalization was reviewed by the facility for possible abuse and neglect however, could not recall what was reviewed or the team's discussion and was unsure if the Administrator had documentation of the review. The Administrator verbalized notifying the physician of a change in a resident's condition through the communication book, as documented in the [DATE] at 12:19 AM Nurses' Note, was an “old” process and the Administrator believed the nurse who wrote the note may have written it in error. On [DATE] at 1:03 PM, the Administrator denied having documentation of the facility's review or investigation of Resident #24's hospitalization for potential abuse or neglect and denied having any additional documentation related to the physician being notified of the change in condition. The Administrator explained the interdisciplinary team's review process when a resident was transferred to the hospital typically included clinical record review. The intent was to identify anything the facility may have missed or the facility could have done better to prevent the hospitalization. The Administrator verbalized if during the review, the team were to see the physician was notified via book, the team would investigate as the book was not the correct way to notify the physician. The facility document titled Job Description: Licensed Practical Nurse or Registered Nurse, documented the primary purpose of the position was to identify and meet the medical, physical, and psychosocial needs of each resident. The nurse was to communicate changes in resident condition to the director of nursing, resident's provider, and resident's representative as indicated. Changes in resident condition included but were not limited to medical, cognitive or physical condition from the resident's baseline, new skin conditions, accidents/incidents, and changes in behavior which may require a change in the plan of care. The facility policy titled Notification of Changes, dated [DATE], documented the facility was to promptly inform the resident and consult with the resident's physician when there was a change requiring notification. Circumstances requiring notification included but were not limited to a significant change in the resident's physical, mental or psychosocial condition such as deterioration in health status, life-threatening conditions, clinical complications, and circumstances which required a need to alter treatment. Altering treatment included a new treatment or discontinuation of current treatment. The need to alter treatment significantly was defined as a need to stop a form of treatment due to adverse consequences or commence a new form of treatment/procedure/therapy to deal with a problem. The facility policy titled Abuse, Neglect, and Exploitation, dated [DATE], documented it was the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures which prohibited and prevented abuse, neglect, exploitation, and misappropriation of resident property. Neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident which were necessary to avoid physical harm, pain, mental anguish, or emotional distress. Possible indicators of abuse included but were not limited to physical injury of a resident of unknown source and failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning, and positioning. The facility policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, dated [DATE], documented the facility would identify events, occurrences, patterns, and trends which may constitute neglect or abuse. An alleged violation was defined as a situation or occurrence observed or reported by staff, resident, relative, visitor, or others but had not yet been investigated and, if verified, could be noncompliance with the federal requirements related to mistreatment, exploitation, neglect, or abuse including injuries of unknown source. The facility would investigate all allegations and types of incidents as listed above in accordance with facility procedure for reporting/response. CPT 2587748

Based on clinical record review, personnel record review, document review, and interviews, the facility failed to 1) ensure that Minimum Data Set (MDS) 3.0 Resident Assessments for 16 of 18 sampled residents (Resident #3, #4, #7, #23, #24, #42, #78, #90, #99, #101, #5, #9, #10, #21, #34, and #84) accurately reflected each resident's status and were completed with appropriate participation from qualified health professionals, 2) ensure the MDS assessment was completed accurately for 1 of 18 sampled residents (Resident #34). These deficient practices had the potential to affect the accuracy of MDS assessments for the entire resident census by allowing unqualified or insufficiently trained staff to complete critical assessment sections and had the potential to result in inaccurate care planning and delivery, which could negatively impact resident outcomes.Findings include: Employee #8 Employee #8 was originally hired on 07/24/2024 in Medical Records and took the position of Resident Advocate on 07/07/2025. Employee #8's signed job description for Resident Advocate, dated 07/09/2025, documented a minimum qualification as being a high school graduate or having a high school equivalent (GED-General Education Development). Higher education with a social services related college degree was preferred. Prior social services related experience was preferred, with some of the experience in a long-term facility. The position description documented the primary purpose of the position was to plan, organize, develop, and direct the operations of the social services department in accordance with federal, state and local standards, guidelines and regulations to ensure the emotional needs of the residents were maintained. The job description documented the principal job responsibilities were to complete all social services related documentation in each resident's medical record, including assessments, progress notes, and care plans. Employee #8's resume, undated, documented the employee had obtained a GED and listed the employee's certifications and licenses to include a food handler certification, a driver's license, and a cardiopulmonary resuscitation (CPR) certification. The employee's resume documented a work history including receptionist, food service supervisor, concierge, delivery driver, and a youth development professional. The employee record lacked documentation the employee had obtained any higher education or additional experience or knowledge in a clinical, health, or social services setting. On 09/03/2025 at 3:24 PM, the Business Office Manager verbalized a Resident Advocate was considered an unlicensed social worker. On 09/04/2025 at 9:22 AM, the Business Office Manager confirmed the undated resume for Employee #8 was the only resume in the employee's record and was used to hire the employee as a Resident Advocate on 07/07/2025. Employee #8's Resident Advocate Competency Checklist signed by the employee on 07/07/2025, and signed by the Trainer/Administrator on 07/09/2025, documented a total of 56 training skill modules. 42 skill modules had a completion date of 07/07/2025 and 14 had a completion date of 07/09/2025. None of the skills modules documented a length of time for each of the trainings. The following skills modules were documented as having been completed and signed off by the Trainer/Administrator and the employee after each section: -07/07/2025-Centers for Medicare & Medicaid Services (CMS) regulations pertinent to social work department: Where to find. -07/07/2025-Minimum Data Set (MDS)-Section Q. -07/07/2025-Social history and social determinates of health user-defined assessments. -07/07/2025-Assessment: opening, saving, signing, locking, editing, and deleting. -07/09/2025-Mentally ill/dementia population: symptoms, behavior management, de-escalation. Employee #8's Resident Advocate Competency Checklist documented the Administrator as having been the Trainer of each of the modules for both days and signed as both the Trainer and the Administrator on the form. On 09/04/2025 at 9:34 AM, Employee #8 confirmed having been a Resident Advocate and was trained by Employee #9 prior to Employee #9 leaving the position. Employee #8 confirmed having completed face-to-face interviews with residents to complete the mental health and psychosocial MDS evaluations. Employee #8 verbalized having interviewed residents to determine if the residents were depressed and had completed interviews with a resident with a trauma diagnosis. Employee #8 confirmed having been trained to complete MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting, and to enter the evaluations into the residents MDS Resident Assessment and had reviewed the Resident Assessment Instrument (RAI) Manual Sections the employee was responsible to complete. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, bipolar disorder, unspecified, and depression, unspecified. Resident #3's quarterly MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, J-Health Conditions, K-Swallowing/Nutritional Status, N-Medications, and O-Special Treatments, Procedures, and Programs. Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including muscle wasting and atrophy, not elsewhere classified, multiple sites, muscle weakness, generalized, cognitive communication deficit, depression, unspecified, and anxiety disorder, unspecified. Resident #4's admission MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, K-Swallowing/Nutritional Status, N-Medications, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with other diabetic kidney complication, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and major depressive disorder, recurrent, unspecified. Resident #7's annual MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed portions of MDS Section Q-Participation in Assessment and Goal Setting. Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit, dysphasia, unspecified, and other unspecified anxiety disorders. Resident #23's admission MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed portions of MDS Sections C-Cognitive Patterns, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #24 Resident #24 was admitted to the facility on [DATE], with diagnoses including cerebral palsy, unspecified, developmental disorder of speech and language, unspecified, and cognitive communication deficit. Resident #24's significant change in status MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #42 Resident #42 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, anxiety disorder, unspecified, and cognitive communication deficit. Resident #42's quarterly MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #78 Resident #78 was admitted to the facility on [DATE], with diagnoses including non-traumatic subarachnoid hemorrhage, unspecified, fracture of unspecified part of neck of left femur, initial encounter for closed fracture, and displaced intertrochanteric fracture of left femur, initial encounter for closed fracture. Resident #78's quarterly MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed MDS Sections C-Cognitive Patterns, D-Mood, and Q-Participation in Assessment and Goal Setting. Resident #90 Resident #90 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, and unspecified dementia, unspecified severity, with other behavioral disturbance. Resident #90's quarterly MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #99 Resident #99 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified, dysphagia, unspecified, and cognitive communication deficit. Resident #99's admission MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #101 Resident #101 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm of brain, unspecified, chronic kidney disease, stage IV, severe, and metabolic encephalopathy. Resident #101's admission MDS Resident assessment dated [DATE], documented Employee #8 e-Signed with the title of Social Worker as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Employee #9 Employee #9 was originally hired on 01/23/2025 as a Transportation Driver and took the position of Resident Advocate on 05/06/2025. Employee #9's record lacked a signed job description for the Resident Advocate position. On 09/03/2025 at 3:24 PM, the Business Office Manager verbalized a Resident Advocate was considered an unlicensed social worker. The Business Office Manager confirmed not having a signed job description for the Resident Advocate position for Employee #9. Employee #9's resume, undated, documented the employee had obtained a high school diploma with a work history including pawnbroker and a maintenance technician/supervisor. The employee's resume documented education including healthcare training online with a focus on healthcare management. The online training provider documented in Employee #9's resume, documents on their website (www.ultimatemedical.edu) the healthcare management online training program would teach students specific skills including understanding medical billing systems, preparing budgets, constructing business documents, and helping resolve workplace conflict. The employee's resume lacked documentation of a certification or license, or any higher education or additional experience or knowledge in a clinical, health, or social services setting. Employee #9's training certificates were as follows with the date of completion and the name of the training: -01/21/2025-Cultural Competency Training Program-three hours. -01/23/2025-Elder Abuse Training-no time documented on certificate. -01/27/2025-Dementia Training-eight hours. -04/06/2025-All Staff In-Service Education-Behavioral-one hour. -05/09/2025-Inter Disciplinary Team, Abuse Investigation Packets-30 minutes. -06/18/2025-All staff, Abuse Training- no time documented on signature sheet or training material. On 09/04/2025 at 12:48 PM, the Administrator verbalized Employee #9 was a transportation driver and was not clinical. The Administrator verbalized the employee had been trained to complete the Brief Interview for Mental Status (BIMS) evaluations for resident assessments, but the employee was no longer doing so and returned to being a transportation driver. On 09/04/2025 at 10:33 AM, the Administrator verbalized the Administrator had interviewed Employee #9 and had kept the employee's application and job description on the Administrator's desk and had not forwarded the documents to Human Resources. On 09/04/2025 at 10:02 AM, the MDS Coordinator confirmed having personally trained Employee #9 on completing sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting of the MDS Resident Assessments. The MDS Coordinator verbalized the facility's corporate office had sent the employees training modules on those sections of the MDS to be completed. The MDS Coordinator verbalized receiving directions from the corporate office to train the Resident Advocates on those sections. On 09/04/2025 at 10:09 AM, the MDS Coordinator verbalized having confirmed via telephone with the corporate office the Resident Advocates were to only be trained on MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. The MDS Coordinator verbalized having trained Employee #9 how to conduct the evaluations and enter the evaluations into the MDS record and would consider the evaluations an assessment. On 09/04/2025 at 10:39 AM, the MDS Coordinator confirmed the facility followed the RAI Manual for MDS Resident Assessment completion. On 09/04/2025 at 11:13 AM, Employee #9 confirmed having been in the Resident Advocate position for the months of May and June 2025. The employee confirmed having been trained by the MDS Coordinator on the completion of MDS sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting, and how to have face-to-face interactions with residents to complete the sections and had completed a signature sheet related to the training but did not give the sheet to Human Resources. The employee confirmed not having been a social worker or had any prior experience or education in social work. The employee verbalized having had a psychosocial training via an online meeting with a Licensed Social Worker at a different corporation skilled nursing facility. On 09/04/2025 at 1:56 PM, the Administrator confirmed Resident Advocates interview resident to obtain information to enter and complete Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting of the MDS Resident Assessments. The Administrator verbalized having believed an individual with a high school diploma or a GED was considered professional with additional training and experience and with nurse training, anyone can complete the BIMS and cognitive resident interviews. On 09/04/2025 at 2:01 PM, the Administrator confirmed Employee #8 and Employee #9 were not social workers and verbalized having hired them based on their work in the facility and how they interacted with residents. The Administrator verbalized having believed the employees were qualified to complete the resident cognitive assessments based on the MDS Coordinator's training. The Administrator verbalized the employees had passed the screening for the position as the screening was the Administrator's interview. On 09/04/2025 at 2:05 PM, the Administrator confirmed Employee #8 and Employee #9 had only been trained on the completion of MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting by the MDS Coordinator and verbalized not having any documentation of the completion of the training. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder, chronic, major depressive disorder, recurrent, moderate, anxiety disorder, unspecified, conversion disorder with motor symptom or deficit. Resident #5's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed with the title of Social Worker as having completed portions of MDS Sections C-Cognitive Patterns, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including cerebral palsy unspecified, muscular dystrophy, unspecified and epilepsy, unspecified. Resident #9's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed with the title of Social Worker as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, and unspecified psychosis not due to a substance or known physiological condition. Resident #10's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed with the title of Social Worker as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, severe, with other behavioral disturbance, dysphasia, oropharyngeal phase, and anxiety disorder due to known physiological condition. Resident #21's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed with the title of Social Worker as having completed portions of MDS Sections C-Cognitive Patterns, D-Mood, and Q-Participation in Assessment and Goal Setting. Resident #34 Resident #34 was admitted to the facility on [DATE], with diagnoses including peripheral vascular disease, unspecified, acquired absence of right leg below knee, and atherosclerotic heart disease of native coronary artery without angina pectoris. Resident #34's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed with the title of Social Worker as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, N-Medications, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. Resident #84 Resident #84 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #84's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed with the title of Social Worker as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. On 09/04/2025 at 2:10 PM, the Administrator confirmed both Employee #8 and Employee #9 had e-Signed on the above MDS Resident Assessment Sections with a title of Social Worker, and confirmed the employees had not been trained to complete MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, K-Swallowing/Nutritional Status, N-Medications, and O-Special Treatments, Procedures, and Programs, and should not have completed or signed off on those sections, and not have e-Signed as Social Workers. The Administrator verbalized it was the MDS Coordinator's responsibility to oversee the accuracy of the MDS Resident Assessments and confirmed the Administrator was responsible for oversight of the MDS Coordinator. On 09/04/2025 at 2:23 PM, the Business Office Manager confirmed it was the Business Office Manager who entered the employee titles into the resident electronic health record (EHR) system. The Business Office Manager verbalized due to the Resident Advocate title not having been a selection to populate into the EHR system and as the Resident Advocates worked closely with social services, the Business Office Manager confirmed having selected the title of Social Worker for Employee #8 and Employee #9 in the EHR system. The Business Office Manager verbalized having notified the Administrator of the Resident Advocate title not having been a selection to populate into the EHR system. On 09/04/2025 at 2:26 PM, the Administrator confirmed having been made aware of the title discrepancy in the EHR system but was unsure who or when the Administrator communicated with at the corporate office and was unsure how, it initially fell through the crack. Complaint 2289182 Cross reference with Tags F835 and F839 Resident #34 Resident #34 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acquired absence of right leg below knee, left knee contracture, and right knee contracture. Resident #34's quarterly MDS Assessment, dated 07/08/2025, section O0500 (Special Treatments, Procedures, and Programs-Restorative Nursing Programs), documented the restorative programs were performed zero days within the seven-day look-back period. A restorative program note, dated 07/03/2025, documented Resident #34 was assisted with passive range of motion (PROM) to upper left body extremities for 15 minutes. On 09/04/2025 at 10:19 AM, the MDS Coordinator verbalized referring to the RAI manual to assist in completing resident MDS assessments. The MDS Coordinator explained collecting data for MDS assessments through interaction with residents and staff as well as review of the resident's clinical record. The MDS Coordinator used progress notes to determine if a resident received restorative nursing services. The MDS Coordinator verbalized Resident #34's progress notes included documentation of restorative nursing services provided on 07/03/2025 and confirmed the 07/08/2025 MDS Assessment lacked documentation of the restorative nursing services received. The CMS, Long-Term Care Facility RAI 3.0 User's Manual, Version 1.18.11, Effective October 1, 2023, CHAPTER 1.3: RESIDENT ASSESSMENT INSTRUMENT (RAI), Completion of the RAI, documented given the requirements of participation of appropriate health professionals, completion of the RAI was best accomplished by staff with varied clinical backgrounds, combined with experience and knowledge to provide an understanding of the strengths, needs and preferences of a resident population to ensure the best possible quality of care and quality of life. Identification of resident problems, needs, and strengths, monitoring resident conditions on an on-going basis, and documenting treatments and response to treatments, was a matter of good clinical practice and an expectation of trained and licensed health care professionals. A facility was responsible to ensure the MDS was validated for accuracy and all participants in the assessment process had the requisite knowledge to complete an accurate assessment. Cross reference with F656 and F688.

Based on observation, interview, clinical record review, and document review the facility failed to ensure medications were administered with an error rate of less than five percent (%). There were 26 opportunities and 9 administration errors including administration of an incorrect medication, failure to administer medications in accordance with professional standards and principles, omission, and incorrect timing. The error rate was 34.62%.Findings include:Resident #30Resident #30 was admitted to the facility on [DATE], with a diagnosis of constipation, unspecified.On 08/28/2025 at 8:02 AM, a Licensed Practical Nurse (LPN) began preparing medications for Resident #30. The medications prepared included two tablets of Senna S (Docusate 50 milligrams (mg)/ Sennosides 8.6 mg).On 08/28/2025 8:14 AM, the LPN administered the medications to Resident #30.A Physician's Order dated 08/07/2025, documented Sennosides oral tablet 8.6 mg, give two tablets by mouth one time a day for constipation.Resident #100Resident #100 was admitted to the facility on [DATE], with diagnoses including urinary tract infection, site not specified and other seizures.On 08/28/2025 at 8:22 AM, the LPN began preparing medications for Resident #100. The medications prepared included one tablet of Mirabegron 25 mg, Extended Release (ER).On 08/28/2025 at 8:28 AM, Resident #100 asked what Mirabegron was. The LPN reviewed the order displayed on the resident's Medication Administration Record (MAR) and verbalized the medication was an antispasmodic. Resident #100 asked if the medication was for seizures. The LPN affirmed the Mirabegron was for seizures.On 08/28/2025 at 8:46 AM, the LPN administered the medications to Resident #100. After swallowing the medications, Resident #100 verbalized the resident thought the physician was going to prescribe a medication for the resident's urination. The LPN explained the LPN would have to contact the physician.A Physician's Order dated 08/20/2025, documented Mirabegron 25 mg ER oral tablet, give one tablet by mouth one time a day for antispasmodics.Resident #40Resident #40 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing and pain, unspecified.On 08/28/2025 at 8:49 AM, the LPN began preparing medications for Resident #40. The LPN verbalized a supply of the physician ordered Desloratadine was not available in the facility. The LPN searched Desloratadine on the LPN's computer, using Google, and explained the LPN was attempting to determine if Desloratadine was the same medication as Loratadine. The LPN verbalized it looked like both medications were used to treat the same condition, however, did not have the same ingredients and the LPN would have to contact the physician to clarify the order.The LPN explained the LPN was unable to locate a supply of the physician ordered Esomeprazole Magnesium in the medication cart. The LPN verbalized the LPN had administered the last tablet the previous day, was unsure if the facility had received additional supply.On 08/28/2025 at 9:13 AM, the LPN entered Resident #40's room and asked the resident to rate the resident's pain. Resident #40 verbalized the resident's pain was a two (out of ten). The LPN administered the prepared medications to Resident #40. The LPN asked if the resident wanted pain medication prior to going to Physical Therapy (PT). Resident #40 verbalized the resident would like to receive pain medication prior to PT.On 08/28/2025 at 9:21 AM, the LPN administered one tablet of Oxycodone 5 mg to Resident #40. Resident #40's clinical record documented the following physician orders:-Desloratadine 5 mg oral tablet, give one tablet by mouth one time a day for congestion. The start date was 08/09/2025.-Esomeprazole Magnesium 40 mg capsule delayed release, give one capsule by mouth one time a day for Gastroesophageal Reflux Disease (GERD). The start date was 08/09/2025.-Oxycodone HCl 5 mg oral tablet, give one tablet by mouth every six hours as needed for moderate to severe pain related to fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. The stat date was 08/12/2025.Resident #90Resident #90 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations and unspecified dementia, unspecified severity, with other behavioral disturbance.On 08/28/2025 at 9:48 AM, the LPN began preparing medications for Resident #90. The medications prepared included:-One tablet of Donepezil 10 mg.-One tablet of Carbidopa-Levodopa 25-250 mg.-Three capsules of Divalproex Delayed Release (DR) 125 mg sprinkles.-One tablet of Buspirone HCl 10 mg.The LPN crushed all the prepared medications, except for the Divalproex DR sprinkle capsules, placed the medications in a medication cup and mixed with a spoonful of chocolate pudding.On 08/28/2025 at 10:16 AM, the LPN entered Resident #90's room to administer the prepared medications.Resident #90's August 2025 MAR documented the following:-Donepezil HCl 10 mg oral tablet, give 10 mg by mouth in the morning for dementia. The order date was 05/12/2025 and the administration time was 08:00 AM.-Carbidopa-Levodopa 25-250 mg tablet, give one tablet by mouth three times a day for Parkinsons disease. The order date was 07/10/2025 and the administration times were morning (AM) medication pass, noon, and at bedtime (HS) medication pass.-Depakote sprinkles 125 mg oral capsule DR (Divalproex), give three capsules by mouth three times a day. The order date was 07/09/2025 and the administration times were AM medication pass, noon, and HS medication pass.-Buspirone HCl 5 mg tablet, give two tablets by mouth two times a day. The order date was 05/08/2025 and the administration times were AM medication pass and HS medication pass.On 08/28/2025 at 3:01 PM, the LPN retrieved the bottle of medication administered to Resident #30 for constipation during the morning medication pass. The LPN confirmed the bottle contained a combination medication, Docusate and Sennosides. The LPN reviewed the physician's order and confirmed the medication administered to Resident #30 did not match the physician's order.The LPN recalled informing Resident #100 Mirabegron was an antispasmodic. The LPN verbalized the LPN believed the indication for Mirabegron for Resident #100 was muscle spasms in the resident's legs however, the LPN was not certain.The LPN verbalized if the LPN was not familiar with a medication during medication pass, the LPN would use the internet as a resource of information. The LPN demonstrated typing the name of a medication into the search bar on Google and verbalized the LPN would typically use WebMD or whatever website popped up first.On 09/03/2025 at 2:58 PM, the Director of Nursing (DON) explained the DON's expectation of staff when administering medication to residents was to ensure the correct medication, in the correct dose/strength, was being administered to the correct resident at the correct time. Medications were to be given or held according to parameters in the physician's order, if applicable.The DON verbalized many of the medications in the facility had a two-hour administration window and the window was indicated on the MAR. For example, many morning medications were able to be given between 7:00 AM and 9:00 AM, unless the physician's order included a specific time. Other medications such as those ordered multiple times per day or for certain diagnoses such as seizures were to be administered as close to the scheduled time on the MAR as possible. Timely administration would ensure doses were not given too close together and blood work results for drug levels, often used to determine dosing of medications, were accurate.The DON explained nurses were expected to know what a medication was prescribed for, what the intended effect of the medication was, and side effects to monitor for prior to administering a medication. The nurse was to explain to the resident what each medication was, side effects to watch for, and instruct the resident to notify the nurse if the resident was experiencing side effects.The DON verbalized a medication administration error included administering the wrong medication, the wrong dose, to the wrong resident or at the wrong time, a missed dose, and failure to notify the physician if a resident was outside parameters in the physician's order. The DON denied it would be appropriate to administer pain medication to a resident with a pain rating of two out of ten if the physician's order documented the medication was to be given for moderate to severe pain. Moderate pain was considered a rating of four to six and severe pain was seven or higher. If a resident was to be medicated for pain prior to PT, instructions would have been included in the physician's order.The facility policy titled Medication Administration, dated 08/06/2025, documented medications were to be administered as ordered by the physician and in accordance with professional standards of practice. Staff were to ensure the six rights of medication administration were followed, including: right resident, right drug, right dosage, right route, right time, and right documentation. If the nurse was unfamiliar with the medication, including its mechanism of action or common side effects, the nurse was to refer to drug reference material. Medications were to be administered within 60 minutes prior to or after scheduled time unless otherwise ordered by the physician.The facility utilized flexible medication pass times. AM administration was 07:00 AM to 09:00 AM. Not all medications were flexible. Medications which were not to be flexed included but were not limited to medications ordered at specific intervals, and anti-seizure medications.The facility policy titled Medication Errors, dated 04/11/2025, documented a medication error was the observed or identified preparation or administration of medications or biologicals which were not in accordance with the prescriber's order, manufacturer's specifications, or accepted professional standards and principles. Factors indicating errors in medication administration included but were not limited to: medication administered not in accordance with the prescriber's order, incorrect dose, incorrect time, omission of a medication, incorrect medication, and administration not in accordance with professional standards and principles.Cross reference tag F658.

Based on observation, interview, and document review, the facility failed to ensure expired medications were removed from 1 of 1 medication storage rooms and 2 of 3 medication storage carts inspected. This deficient practice had the potential to result in expired medications being administered to residents.Findings include: On 08/27/2025 at 1:46 PM, during an inspection of the medication storage room and in the presence of the Director of Nursing (DON), the following items were found:-One Gvoke (glucagon) injection pen. The expiration date printed on the package was 12/2024.-Two bottles of Melatonin 1 milligram (mg) tablets with 60 tablets in each bottle. The expiration date printed on both bottles was 03/2025. The DON confirmed the expiration dates printed on the Gvoke injection pen and the bottles of Melatonin had passed, and the medications were expired. The DON explained nurses were supposed to check the medications stored in the medication carts each day and the medication storage room was inspected weekly for any expired or discontinued medications or medications with broken packaging. If any were found, staff were to remove and discard the medication immediately. On 08/27/2025 at 3:00 PM, during an inspection of the 200 hall medication cart and in the presence of a Licensed Practical Nurse (LPN), the following items were found:-One bubble pack of Isosorbide Monotitrate extended release 60 mg tablets, with seven tablets remaining. The expiration date printed on the bubble pack was 07/12/2025. -One bottle of Premium Saline nasal spray. The expiration date printed on the bottle was 05/24/2025. The LPN confirmed the expiration dates printed on the bubble pack of Isosorbide Monotitrate and bottle of Saline nasal spray had passed, and the medications were expired. The LPN verbalized if an expired medication was administered to a resident the medication could have decreased therapeutic effect. On 08/27/2025 at 3:27 PM, during an inspection of the 100 hall medication cart and in the presence of an LPN2, the following items were found:-One bottle of Pepto-Bismol 525 mg/ 30 milliliters (ml). The expiration date printed on the bottle was 09/2024. -One tube of Nystatin cream 100,000 units per gram. The expiration date printed on the tube was 07/2025. The LPN2 confirmed the expiration dates printed on the Pepto-Bismol and Nystatin cream had passed, and the medications were expired. The facility policy titled Medication Storage, dated 04/11/2025, documented medication carts and medication rooms were to be routinely inspected by the consultant pharmacist or designee for discontinued, outdated, defective, or deteriorated medications with worn, illegible or missing labels. These medications were to be destroyed in accordance with the Destruction of Unused Drugs Policy.The facility policy titled Destruction of Unused Drugs, dated 04/11/2025, documented unused, unwanted, and non-returnable medications were to be removed from the storage area and secured until destroyed.

Based on clinical record review, document review and interview, the facility failed to ensure residents or resident representatives were informed of the benefits, risks and alternatives of an antidepressant medication for 1 of 18 sampled residents (Resident #5), and of an antianxiety medication for 1 of 18 sampled residents (Resident #10). This deficient practice had the potential to result in residents receiving an antidepressant or antianxiety medication not having been informed of the risks and benefits of the medication or the option to decline the medication prior to administration.Findings include: Resident #5 Resident #5 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, recurrent, moderate. A physician's order dated 04/24/2025, documented Duloxetine Hydrochloride Oral Capsule Delayed Release Sprinkle 60 milligrams (mg). Give one capsule by mouth one time a day related to major depressive disorder, recurrent, moderate. Resident #5's Medication Administration Record (MAR) dated 08/01/2025 through 08/31/2025, documented Duloxetine Hydrochloride Oral Capsule Delayed Release Sprinkle 60 mg was administered per the physician's order. Resident #5's Care Plan, last reviewed 06/26/2025, documented the resident had depression and required the use of antidepressants. An intervention documented the facility was to obtain an informed consent for use of antidepressant medication. Resident #5's clinical record lacked documentation the resident had been informed of the benefits, risks and alternatives of Duloxetine Hydrochloride. On 08/27/2025 at 3:03 PM, the Regional Nurse Consultant confirmed Resident #5's clinical record lacked documentation the resident had been informed of the benefits and risks of the antidepressant medication. Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including anxiety disorder, unspecified, and schizoaffective disorder, unspecified. A physician's order, dated 08/19/2025, and discontinued on 08/28/2025, documented Ativan Oral Tablet 1 mg. Give one tablet by mouth every six hours as needed for agitation or anxiety related to infection for 14 days. Resident #10's care plan, last revised 04/11/2025, documented the resident had a diagnosis of schizoaffective disorder and required the use of psychotropics. An intervention documented the facility was to obtain an informed consent for use of psychotropic medication. Resident #10's clinical record included a Psychotropic Medication Informed Consent form for Ativan dated 08/28/2025, however lacked documentation the resident had been informed of the benefits, risks and alternatives of Ativan prior to or upon order of the medication. On 09/04/2025 at 11:05 AM, the Director of Nursing (DON) verbalized the facility should not initiate a psychotropic medication without first documenting informed consent by the resident or their representative. The DON explained the facility recently became aware the facility did not collect psychotropic medication informed consents consistently. The DON confirmed Resident #10's Ativan was ordered 08/19/2025, and the psychotropic medication informed consent was collected 08/28/2025, 9 days after the psychotropic was ordered. The facility policy titled, Use of Psychotropic Medications, revised 04/28/2025, documented the resident or resident's representative would be informed in advance of the risks and benefits of the proposed treatment, treatment alternatives, and the preferred option to accept or decline the proposed treatment. The facility was required to document the risks and benefits and the preferred option to accept or decline the proposed treatment in the resident's record. The facility policy titled, Resident Rights, dated 07/07/2025, documented the resident had the right to be informed in advance of the care to be furnished and be informed of the risks and benefits of the proposed care, of treatment options and alternatives, and to choose the alternative or option the resident preferred.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure upper side rails attached to a resident's bed were not used as a restraint with the intent to prevent a resident from ambulating on their own for 1 of 18 sampled residents (Resident #21). This deficient practice had the potential for a resident to experience psychosocial or physical harm from the resident's freedom of movement and activity being unnecessarily prohibited.Findings include: Resident #21 Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, severe, with other behavioral disturbance, muscle weakness (generalized), and anxiety disorder due to known physiological condition. On 08/25/2025 at 10:57 AM, Resident #21 was sleeping in the resident's bed. The bed had upper rails attached to both sides of the bed and the rails were in the up position. A Physician's order, dated 04/24/2024, documented upper, half side rails could be used as an enabler to aid in repositioning and bed mobility. An Assistive Device/Potential Restraint Initial Evaluation, dated 09/26/2024, documented repositioning bars were to be used for the indication of preventing the resident from attempting to ambulate on their own. A care plan for Bed Mobility/Device Use, initiated 06/06/2024, documented to evaluate the need for ongoing use of bilateral upper half siderails at least quarterly and as needed. On 08/27/2025 at 9:02 AM, the Director of Nursing (DON) verbalized bed rails should only be used as an assistive device and should not be used as a restraint. The DON explained a resident would need to demonstrate safety with the use of bed rails. The DON verbalized maintenance was responsible for installing and removing the bed rails and residents would be evaluated for bed rail use upon admission and with any changes in condition. The DON confirmed the most recent side rail evaluation was completed on 09/26/2024 and documented the side rails were being used to prevent the resident from attempting to ambulate on their own. The DON verbalized the resident needed to be reassessed for appropriateness and the indication on the most recent assessment was pretty close to a restraint. The DON verbalized the Minimum Data Set (MDS) Registered Nurse (RN) was responsible for completing the side rail assessments. On 08/27/2025 at 9:19 AM, the MDS RN verbalized Resident #21 had side rails because they were requested by the resident's family member, and the resident was a fall risk. The MDS RN verbalized the reasoning documented on the most recent side rail assessment, indicating the use of the side rails was to prevent the resident from getting out of bed independently, suggested the side rails were being used as a restraint. On 08/27/2025 at 3:16 PM, the resident was lying in bed with the side rails up on either side of the upper bed. The Licensed Practical Nurse for Resident #21 verbalized the resident was not able to put the side rails down independently. The facility policy titled Proper Use of Bed Rails, implemented 04/11/2025, documented a physical restraint would be any device attached or adjacent to the resident's body which could not be removed easily by the resident, and restricted the resident's freedom of movement. The facility policy titled Restraint Free Environment, implemented 04/11/2025, documented a physical restraint referred to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Physical restraints included using bed rails to keep the resident from voluntarily getting out of bed. The resident had the right to be treated with respect and dignity, including the right to be free from any physical restraint not required to treat the resident's medical symptoms. Falls did not constitute self-injurious behavior or a medical symptom warranting the use of physical restraints. Cross reference with F656 and F909

Based on interview, clinical record review, and document review, the facility failed to ensure a bed hold notification was provided to a resident/resident representative, and the resident, the resident representative, and the Ombudsman were notified of the reason for transfer in writing when a resident was transferred to an acute care hospital for inpatient care for 1 of 12 sampled residents (Resident #40) and 1 of 3 residents reviewed for closed records (Resident #2) and/or the residents representative were provided notification of the facility's bed hold policy upon transfer to an acute care hospital. This deficient practice had the potential to result in a resident or the resident's representative not being aware of the facility's bed hold policy when the resident required hospitalization, and the resident/resident representative and the Ombudsman not being aware of the reason for transfer, date of transfer and the resident's rights related to transfers. Findings include: Top of Form Resident #40 Resident #40 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, essential (primary) hypertension, and unspecified atrial fibrillation. A Progress Note dated 08/12/2025, documented the resident appeared mildly diaphoretic and complained of abdominal and back pain, which 10 out of 10 on numeric scale of 10. The resident had tenderness to the right upper quadrant and had been vomiting. The resident became significantly worse and was diaphoretic and mildly confused. The resident was assessed at bedside by a provider and an order to transfer the resident to an acute care hospital was received. The clinical record for Resident #40 lacked documentation the notification of the facility's Bed-Hold policy was provided to the resident and lacked documentation the resident, the resident representative and the Ombudsman were notified in writing of the reason and date of transfer and the resident's rights related to the transfer process. On 08/28/2025 at 8:12 AM, the Administrator explained the facility had not been providing transfer and bed hold notifications to residents and/or the resident representative when residents were discharged from the facility with return anticipated. The Ombudsman was notified verbally about transfers when the Ombudsman came to the facility. The Administrator confirmed Resident #40 and/or the Resident Representative were not provided a copy of the bed hold policy when the resident was admitted to the hospital on [DATE]. The Administrator confirmed the resident/resident representative and the Ombudsman were not notified in writing of the reason for transfer, the date of transfer, and policy requirements related to transfers when Resident #40 was transferred to an acute care hospital on [DATE]. The facility policy titled Bed Hold Notice, implemented 04/11/2025, documented at the time of a transfer to the hospital provided the resident and/or resident representative written information which specified the duration of the bed hold policy in which the resident was permitted to return and resume residency at the facility, the reserve bed payment if any, policies regarding bed-hold periods to include return to the next available bed, and conditions upon which the resident could return to the facility. In the event of an emergency transfer the resident and/or resident representative was notified within 24 hours. The facility policy titled Transfer and Discharge (including AMA), implemented 04/11/2025, documented a transfer/discharge notice was provided to the resident and resident representative, in a language and manner they could understand. The notice included the specific reason and date of transfer, the location of the transfer, an explanation of the right to appeal, and the contact information for the Ombudsman. The facility maintained evidence the notice as sent to the Ombudsman. Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses including anxiety disorder, unspecified and pain, unspecified. A Progress Note, dated 08/20/2025, documented the resident was discharged to an inpatient psychiatric hospital. The clinical record for Resident #2 lacked documentation of notification of the facility's Bed-Hold policy provided to the resident. On 08/27/2025 in the afternoon, the Administrator provided a notice, signed by the Administrator. The notice documented the facility agreed the patient would return to the facility when the inpatient psychiatric hospital deemed the patient's treatment was complete. The Administrator verbalized the inpatient psychiatric hospital where the resident was transferred required the agreement for patients to return prior to accepting the resident. The Administrator confirmed the notice had not been signed by the resident or the resident's representative and the notice was not a copy of the facility's bed hold notification. The facility policy titled Bed Hold Notice, implemented 04/11/2025, documented the facility would provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of a transfer for hospitalization. The facility would keep a signed and dated copy of the facility's bed-hold notice information given to the resident and/or resident representative in the resident's file and/or medical record. The policy had a section titled Acknowledgment of Receipt with spaces for both the resident and/or resident representative signature and a facility representative signature.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a level II Pre-admission Screening and Resident Review (PASARR) resident was referred for level II resident review upon diagnosis of new mental disorders for 1 of 18 sampled residents (Resident #10). This deficient practice had the potential to result in service not provided to assist in maintaining the resident's highest practicable level of functioning, placement in an inappropriate level of care, and avoidable psychosocial harm to the resident.Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including schizoaffective disorder, unspecified, cognitive communication deficit, unspecified psychosis not due to a substance or known physiological condition, unspecified dementia, unspecified severity, with other behavioral disturbance, and violent behavior. A Level II Resident Review, dated 11/06/2024, documented to retain the resident's existing PASARR New diagnoses were documented into Resident #10's clinical record on the following dates-On 12/20/2024, anxiety disorder unspecified.-On 01/08/2025, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.-On 01/08/2025, unspecified mood disorder.-On 02/05/2025, generalized anxiety disorder.-On 02/05/2025, other symptoms and signs involving cognitive functions and awareness A care plan revised on 07/14/2025, documented Resident #10 had a history of and remained at risk for verbal and physical behaviors toward staff and other residents. Resident #10 carried a diagnosis of dementia with episodes of physical and verbal behaviors towards staff and other residents. On 09/03/2025 at 2:53 PM, a Certified Nursing Assistant (CNA), verbalized Resident #10 often exhibited aggressive behaviors such as screaming, kicking, yelling out, punching, and scratching at facility staff. Resident #10 was involved in multiple verbal and physical arguments with other residents in the facility and resident families, requiring the resident to be supervised by facility staff as often as possible. On 09/03/2025 at 3:02 PM, a Licensed Practical Nurse (LPN) verbalized Resident #10 exhibited behaviors frequently. Resident #10 had a diagnosis of unspecified psychosis and was treated with psychotropic medications. Resident #10 often requested one to one attention and was triggered when staff were needed elsewhere. On 09/03/2025 at 3:20 PM, the Admissions Coordinator explained PASARR Level II reviews were to be completed when a resident was diagnosed with a new mental disorder. It was important PASARR screenings were completed to ensure residents were placed in the correct level of care appropriate for the resident's needs. The Admissions Coordinator verbalized Resident #10's last PASARR Level II resident review was completed on 11/07/2024. The Admissions Coordinator verbalized Resident #10 was diagnosed with anxiety, dementia, and other mood disorders after the last resident review. The Admissions Coordinator verbalized a new PASARR Level II review should have been submitted after Resident #10's new diagnoses were identified.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's baseline care plan included the necessary care to provide for a resident with a skin condition requiring medicated cream to treat symptoms of swelling and itching for 1 of 18 sampled residents (Resident #99). This deficient practice had the potential to result in facility staff not being aware of a resident's need for a prescribed treatment resulting in the resident experiencing increased discomfort and skin irritation. Findings include: Resident #99 Resident #99 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other psoriatic arthropathy (a type of inflammatory arthritis affecting persons who have psoriasis, a skin condition characterized by red, scaly patches) and other idiopathic peripheral autonomic neuropathy. On 08/25/2025 at 11:02 AM, the resident was sitting in a chair in the resident's room. The resident's hands appeared red and swollen with dry, flaky skin. The resident verbalized the resident had a medication the resident would apply to the resident's hands and arms prior to being admitted to the facility but the resident had not received the medication since admission. The resident described the skin on the resident's hands as painful and stinging. A Medication Order, dated 08/22/2025, documented triamcinolone acetonide external cream 0.1 percent (%) (a prescription corticosteroid used to relieve skin inflammation, itching, and redness). Apply to affected areas three times a day. The care plan for Resident #99, initiated 08/23/2025, documented the resident had the potential for altered skin integrity but did not include the resident's skin condition or the need to apply medicated cream to the affected areas. The August 2025 Medication Administration Record documented the medication had not yet been administered as of 08/27/2025. The reason documented was the medication was not available or was on order from the pharmacy. On 08/27/2025 at 1:36 PM, the Licensed Practical Nurse (LPN) for Resident #99 verbalized the LPN knew the resident had a cream ordered for itching and thought the medication was supposed to be applied to the resident's hip. The LPN was able to locate the cream in the medication cart. On 08/27/2025 at 2:00 PM, the LPN verbalized the LPN had contacted the Provider and clarified the triamcinolone cream was supposed to be applied to the resident's hands. On 08/27/2025 at 2:58 PM, the Director of Nursing verbalized the resident's skin condition should have been care planned as it was an active concern upon admission. The facility policy titled Baseline Care Plan, implemented 04/23/2025, documented the facility would develop and implement a baseline care plan for each resident. The Baseline Care Plan would include the instructions needed to provide effective and person-centered care of the resident. Cross reference with F658 and F684

Based on observation, interview, clinical record review, and document review, the facility failed to 1) implement the care planned intervention for a resident with side rails installed on the resident's bed leading to the side rails not being reevaluated at least quarterly for 1 of 18 sampled residents (Resident #21). This deficient practice had the potential to result in a resident experiencing physical harm from entrapment due to the risks not being reevaluated as care planned. 2) identify and document a resident's trauma-specific interventions for a resident with a trauma diagnosis for 1 of 18 sampled residents (Resident #5). This deficient practice had the potential to result in a resident experiencing re-traumatization due to the lack of trauma-specific interventions not having been documented in the care plan. 3) ensure 1 of 18 sampled residents (Resident #4) had a care plan related to urinary tract infection (UTI) and the use and monitoring of the antibiotic prescribed to treat the UTI. This deficient practice had the potential to result in the resident not receiving the care and monitoring necessary to ensure the infection did not progress to sepsis and was not spread to other residents throughout the facility and the lack of a care plan for antibiotic use increased the risk of an undetected adverse reaction to the prescribed medication. 4) ensure 1 of 18 sampled residents (Resident #101) had a care plan in place for the treatment and monitoring of potential pressure injury. This deficient practice had the potential to result in the exacerbation of the wound and increased pain for the resident. 5) ensure 1 of 18 sampled residents (Resident #84) nutritional care plan was updated to reflect a change in the resident's diet from regular to puree with thickened liquids. This deficient practice had the potential to result in lack of safety monitoring and the potential to result in the resident choking and/or aspirating food and fluids. 6) ensure a care plan related to restorative nursing services was developed and implemented for 1 of 18 sampled residents (Resident #34). This deficient practice had the potential to result in unmonitored resident care, a decline in mobility functions, and avoidable physical harm to the resident. Findings include: Resident #21 Resident #21 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, severe, with other behavioral disturbance, muscle weakness (generalized), and anxiety disorder due to known physiological condition. On 08/25/2025 at 10:57 AM, Resident #21 was sleeping in the resident's bed. The bed had upper rails attached to both sides of the bed and the rails were in the up position. A Physician's order, dated 04/24/2024, documented upper, half side rails could be used as an enabler to aid in repositioning and bed mobility. An Assistive Device/Potential Restraint Initial Evaluation, dated 09/26/2024, documented repositioning bars were to be used for the indication of preventing the resident from attempting to ambulate on their own. A care plan for Bed Mobility/Device Use, initiated 06/06/2024, documented to evaluate the need for ongoing use of bilateral upper half siderails at least quarterly and as needed. The staff responsible for the intervention were the Licensed Nurse and the Registered Nurse (RN). On 08/27/2025 at 9:02 AM, the Director of Nursing (DON) confirmed the most recent side rail evaluation was completed on 09/26/2024 and documented the side rails were being used to prevent the resident from attempting to ambulate on their own. The DON confirmed the care plan documented the resident would be evaluated at least quarterly for the need for ongoing use of the siderails. The facility policy titled Comprehensive Care Plans, implemented 04/11/2025, documented the facility would implement a comprehensive person-centered care plan for each resident. Cross reference with F604 and F909 Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder (PTSD) and conversion disorder with motor symptom or deficit. Resident #5's Care Plan, last reviewed 06/26/2025, documented the focus care area: Psychosocial Disorders: the resident had a mental health disorder of PTSD, with an intervention to contact the physician if the resident's mental health symptoms became unmanageable. The focus care area lacked documentation of trigger-specific interventions related to trauma. The focus care area: PTSD, last reviewed 06/26/2025, documented the resident had experienced a traumatic event prior to admission with interventions including encouraging the resident to participate in relaxation exercises, maintaining a calm manner when working with the resident and observing increased levels of anxiety in the resident. The focus care area lacked documentation of trigger-specific interventions related to trauma. A Psychosocial Assessment, completed on 06/26/2025, documented Resident #5 had a diagnosis of PTSD generalized anxiety disorder and a trigger identified as having anything related to a previous relationship. The assessment did not document any additional triggers. On 08/28/2025 at 11:30 AM, the DON confirmed Resident #5 had a diagnosis of PTSD upon admission and the resident's care plan did not document the trigger identified from the Psychosocial Assessment completed on 06/26/2025. The DON confirmed the 06/26/2025 assessment was the only documented Psychosocial Assessment completed for the resident and verbalized having been unsure why additional assessments had not been completed prior to 06/26/2025 as the resident had been in the facility since 09/10/2024 with a PTSD diagnosis. The DON verbalized it was important to identify the triggers of trauma and have them documented in the care plan so staff would be aware of what to watch for and take necessary steps to address. The facility policy titled, Trauma Informed Care, dated 04/11/2025, documented the facility would identify triggers which may re-traumatize residents with a history of trauma and trauma-specific care, including trigger interventions, and would be documented on the care plan. In situations where the resident was reluctant to share their history, the facility would still attempt to identify triggers and develop care plan interventions to minimize or eliminate the effect of the trigger on the resident. The facility policy titled, Comprehensive Care Plans, dated 04/11/2025, documented the facility would develop and implement a comprehensive person-centered care plan for each resident and individualized interventions for trauma survivors. Trigger-specific interventions would be used to identify ways to decrease the resident's exposure to triggers which could re-traumatize the resident and identify ways to mitigate or decrease the effect of the trigger on the resident. Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of acute and chronic respiratory failure with hypoxia. A diagnosis of urinary tract infection, site not specified was added on 08/28/2025. A physician's order dated 08/13/2025 documented an order for Sulfamethoxazole-Trimethoprim 800-160 milligram (mg) tablets. Give one tablet by mouth every 12 hours for UTI for seven days. On 09/04/2025 at10:00 AM, the DON confirmed Resident #4's clinical record did not include a care plan related to the care and monitoring of a UTI and did not include a care plan related to the use and monitoring of Sulfamethoxazole-Trimethoprim, the antibiotic prescribed for the treatment of the UTI. Cross reference with F600 Resident #101 Resident #101 was admitted to the facility on [DATE], with a diagnosis of metabolic encephalopathy, malignant neoplasm of brain, unspecified, chronic kidney disease, stage IV (severe), and pain, unspecified. On 08/25/2025 at 2:49 PM, Resident #101 verbalized the resident had a new wound on the resident's lateral right ankle. The area was covered with a Mepilex dressing dated 08/24/2025. Resident #101's clinical record did not include documentation of the wound including care and monitoring. On 08/28/2025 at 10:19 AM, a Licensed Practical Nurse (LPN) verbalized the nurse was not aware of a wound on the resident's ankle. The nurse reviewed the resident's chart and did not find an order for wound care, progress notes about the wound, or care plan. On 08/28/2025 at 10:24 AM, the LPN assessed the wound on Resident #101's ankle. The wound was red but blanchable, warm to touch, and was approximately the size of a silver dollar. On 08/28/2025 at 12:23 PM, the DON verbalized the expectation was new wounds would be reported to a provider and the DON. Orders for wound care expected to be entered, the wound should be assessed daily and documented in the resident's electronic health record. The DON confirmed a care plan related to the wound/area of redness on Resident #101's right ankle should have been care planned to ensure the area was monitored and the redness did not progress into a pressure injury. Cross reference with F686 Resident #84 Resident #84 was admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses including Alzheimer's disease, unspecified, and other lack of coordination cognitive communication deficit. A Physician's order dated 06/09/2025, documented a regular diet, level IV, pureed (PU4) texture, and nectar, level II mildly thick consistency due to the resident's remaining teeth had been pulled. Resident #84's clinical record included a nutrition care plan. The care plan documented the resident was on a regular diet and did not match the resident's current diet order. On 09/04/2025 at 10:19 AM, the DON confirmed Resident #84's care plan regarding the resident's diet should have been updated to reflect the change to a puree diet with nectar thick liquids and confirmed the care plan should have been updated when the resident's diet was changed. Resident #34 Resident #34 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acquired absence of right leg below knee, left knee contracture, and right knee contracture. A physician's order, dated 04/19/2024, documented monthly summary/monthly restorative summary. August 2025 restorative program notes, dated the following, documented the restorative nursing assistant assisted with passive range of motion (PROM) to upper left body extremities for 15 minutes: -08/03/2025 -08/05/2025 -08/06/2025 -08/09/2025 -08/10/2025 -08/11/2025 -08/12/2025 -08/17/2025 -08/18/2025 -08/19/2025 Resident #34's clinical record lacked documented evidence of a discontinued or current care plan related to restorative nursing services. On 08/27/2025 at 1:12 PM, the DON verbalized residents receiving restorative nursing services should have a care plan to guide resident care from the restorative aides. The DON confirmed Resident #34 was on the restorative nursing program. On 08/28/2025 at 9:14 AM, the Regional Nurse Consultant verbalized Resident #34 did not have a care plan for restorative nursing services. The facility policy titled Restorative Nursing Program, dated 04/11/2025, documented the restorative nursing plan would include the problem, need or strength restorative tasks were to address, the type of activities to be performed, frequency of activities, duration of activities, measurable goals, and a target date. Cross reference with F641 and F688.

[NAME] based on Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) a resident's prescription topical cream was applied as ordered for 1 of 18 sampled residents (Resident #99), 2) a Licensed Practical Nurse (LPN) administered medications in accordance with physician orders and 3) an LPN was knowledgeable regarding indications for medications and potential side effects to monitor for and provided accurate information to residents prior to administering medications to 2 of 5 residents observed for medication administration (Resident #100 and #40). This deficient practice had the potential to result in a resident experiencing unnecessary discomfort and worsening of an existing skin condition due to the prescribed cream not being applied as ordered, inadequate monitoring for effectiveness and/or side effects of medications, and residents' inability to make informed decisions regarding the medications being administered. Findings include: Resident #99 Resident #99 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other psoriatic arthropathy (a type of inflammatory arthritis affecting persons who have psoriasis, a skin condition characterized by red, scaly patches) and other idiopathic peripheral autonomic neuropathy. On 08/25/2025 at 11:02 AM, the resident was sitting in a chair in the resident's room. The resident's hands appeared red and swollen with dry, flaky skin. The resident verbalized the resident had a medication the resident would apply to the resident's hands and arms prior to being admitted to the facility but the resident had not received the medication since admission. The resident described the skin on the resident's hands as painful and stinging. A Medication Order, dated 08/22/2025, documented triamcinolone acetonide external cream 0.1 percent (%) (a prescription corticosteroid used to relieve skin inflammation, itching, and redness). Apply to affected areas three times a day. The August 2025 Medication Administration Record documented the medication had not yet been administered as of 08/27/2025. The reason documented was the medication was on order from the pharmacy. On 08/27/2025 at 1:36 PM, the Licensed Practical Nurse (LPN) for Resident #99 verbalized the LPN knew the resident had a cream ordered for itching and thought the medication was supposed to be applied to the resident's hip. The LPN was able to locate the cream in the medication cart. On 08/27/2025 at 2:00 PM, the LPN verbalized the LPN had contacted the Provider and clarified the triamcinolone cream was supposed to be applied to the resident's hands. The LPN explained the medication had been delivered by the pharmacy on 08/27/2025, and the medication had previously been unavailable. A Consolidated Delivery Sheet from the facility's contracted pharmacy, dated 08/23/2025, documented the pharmacy had delivered 30 grams of triamcinolone 0.1% cream for Resident #99. On 08/27/2025 at 2:58 PM, the Director of Nursing (DON) verbalized nursing staff were instructed to notify the DON when a medication was not delivered by the pharmacy, and the DON would make arrangement to obtain the medication from a local pharmacy. The DON verbalized medication orders for topical medications should have been specific to the area being treated and nursing staff were expected to contact the provider for clarification if the area to treat was not included in the order. The DON confirmed the pharmacy delivery sheet for 08/23/2025, indicated the medication had been delivered on 08/23/2025. The DON confirmed the medication was not administered and had been documented as on order from the pharmacy while the medication was available. Cross reference with F655 and F684 Resident #100 Resident #100 was admitted to the facility on [DATE], with diagnoses including urinary tract infection, site not specified and other seizures. On 08/28/2025 at 8:22 AM, an LPN began preparing medications for Resident #100. The medications prepared included one tablet of Mirabegron 25 mg, Extended Release (ER). On 08/28/2025 at 8:28 AM, Resident #100 asked what Mirabegron was. The LPN reviewed the order displayed on the resident's MAR and verbalized the medication was an antispasmodic. Resident #100 asked if the medication was for seizures. The LPN affirmed the Mirabegron was for seizures. On 08/28/2025 at 8:46 AM, the LPN administered the medications to Resident #100. After swallowing the medications, Resident #100 verbalized the resident thought the physician was going to prescribe a medication for the resident's urination. The LPN explained the LPN would have to contact the physician. A Physician's Order dated 08/20/2025, documented Mirabegron 25 mg ER oral tablet, give one tablet by mouth one time a day for antispasmodics. Resident #40 Resident #40 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing and pain, unspecified. On 08/28/2025 at 9:13 AM, the LPN entered Resident #40's room and asked the resident to rate the resident's pain. Resident #40 verbalized the resident's pain was a two (out of ten). The LPN asked if the resident wanted pain medication prior to going to Physical Therapy (PT). Resident #40 verbalized the resident would like to receive pain medication prior to PT. On 08/28/2025 at 9:21 AM, the LPN administered one tablet of Oxycodone 5 mg to Resident #40. A Physician's Order dated 08/12/2025, documented Oxycodone HCl 5 mg oral tablet, give one tablet by mouth every six hours as needed for moderate to severe pain related to fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing. On 08/28/2025 at 3:01 PM, the LPN verbalized if the LPN was not familiar with a medication during medication pass, the LPN would use the internet as a resource of information. The LPN demonstrated typing the name of a medication into the search bar on Google and verbalized the LPN would typically use WebMD or whatever website popped up first. The LPN recalled informing Resident #100 Mirabegron was an antispasmodic. The LPN verbalized the LPN believed the indication for Mirabegron for Resident #100 was muscle spasms in the resident's legs however, the LPN was not certain. On 09/03/2025 at 2:58 PM, DON explained the DON's expectation of staff when administering medication to residents was to ensure the correct medication, in the correct dose/strength, was being administered to the correct resident at the correct time. Medications were to be given or held according to parameters in the physician's order, if applicable. The DON verbalized nurses were expected to know what a medication was prescribed for, what the intended effect of the medication was, and side effects to monitor for prior to administering a medication to a resident. The nurse was to explain the information to the resident and instruct the resident to notify the nurse if the resident was experiencing side effects. If a nurse was not familiar with a medication, the nurse was to contact the facility's contracted pharmacy. A pharmacist was available via phone at all times. Additionally, staff could go to the drug manufacturer's website for information. The DON explained it would not be appropriate for staff to use Google or WebMD as a resource for information during medication pass as the information was not always 100 percent accurate. The DON denied it would be appropriate to administer pain medication to a resident with a pain rating of two out of ten if the physician's order documented the medication was to be given for moderate to severe pain. Moderate pain was considered a rating of four to six and severe pain was seven or higher. If a resident was to be medicated for pain prior to PT, instructions would have been included in the physician's order. The facility policy titled Medication Administration, dated 08/06/2025, documented medications were to be administered as ordered by the physician and in accordance with professional standards of practice. Staff were to ensure the six rights of medication administration were followed, including: right resident, right drug, right dosage, right route, right time, and right documentation. If the nurse was unfamiliar with the medication, including its mechanism of action or common side effects, the nurse was to refer to drug reference material. Cross reference tag F759.

Based on observation, interview, clinical record review, and document review, the facility failed to 1) ensure neurological assessments were documented for a resident with a fall and loss of consciousness for 1 of 18 sampled residents (Resident #98), and 2) ensure a resident with a skin condition requiring medicated cream for treatment had an accurate skin integrity assessment completed upon admission to the facility for 1 of 18 sampled resident (Resident #99). These deficient practices had the potential to result in 1) unmonitored and avoidable physical harm to the resident, and 2) the resident's skin condition not being treated timely and potentially worsening without a baseline assessment for comparison or accurate assessment information to communicate to all staff responsible for the resident's care. Findings include: Resident #98 Resident #98 was admitted to the facility on [DATE], readmitted on [DATE], and discharged on 07/20/2025, with a diagnosis of muscle weakness. A progress note dated 05/15/2025 at 3:45 AM, documented Resident #98 appeared to have fallen asleep or lost consciousness and fell forward out of the resident's shower chair. A progress note dated 05/15/2025 at 10:15 am, documented Resident #98 complained of headaches and recounted the fall. The resident was unsure why the resident fell, but the resident was showering, felt dizzy, and passed out. A progress note, dated 05/19/2025 at 2:27 PM, documented the resident was sent to the emergency room and no injuries were noted. The facility would continue to monitor. An Emergency Department Pertinent Report, dated 05/15/2025, documented after a fall Resident #98 presented with a closed head injury with brief loss of consciousness and acute headache. Resident #98's clinical record lacked documented evidence neurological checks were completed. On 09/03/2025 at 10:45 AM, a Certified Nursing Assistant (CNA) verbalized after a resident fell, neurological checks would be completed, measuring vitals every 15 minutes then every 30 minutes. On 09/03/2025 at 12:17 PM, a Licensed Practical Nurse (LPN) explained if a resident had a fall, the facility would initiate neurological checks every 15 minutes using a neurological flow form. On 09/03/2025 at 1:50 PM, the Director of Nursing (DON) explained if a resident had an unwitnessed fall, the facility would initiate neurological checks on a neurological flow form every 15 minutes for the first hour, every 30 minutes for two hours, then every hour for four hours. Neurological checks included measuring vital signs, resident orientation, and were reviewed in interdisciplinary team meetings. Once completed, neurological checks were to be scanned into the resident's electronic health record. The DON verbalized Resident #98 was usually very independent, preferred to shower late and in private. On the night Resident #98 fell, the resident was in the shower. Resident #98 informed staff the resident bent down to collect hygiene items, felt dizzy, fell, and hit the resident's head. The DON verbalized Neurological checks should have been initiated immediately after the fall. On 09/04/2025 at 11:30 AM, the DON confirmed the neurological checks from the 05/15/2025 fall were not scanned into Resident #98's electronic health record. On 09/04/2025 at 3:39 PM, the Administrator verbalized the facility was unable to locate Resident #98's neurological checks from the 05/15/2025 fall. A blank Neurological Flow Sheet Form documented to perform vital signs and neurological checks at a minimum every four hours for 24 hours. These included level of consciousness (LOC), movement, hand grasp, pupil size and reaction, speech, pulse, respirations, temperature, oxygen saturations and a place to document other abnormalities such as a headache. The facility policy titled Vital Signs, implemented 04/11/2025, documented vital signs would be obtained when a resident's general condition changes and following an accident such as a fall or other incident. CPT 2289185 Resident #99 Resident #99 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including other psoriatic arthropathy (a type of inflammatory arthritis affecting persons who have psoriasis, a skin condition characterized by red, scaly patches) and other idiopathic peripheral autonomic neuropathy. On 08/25/2025 at 11:02 AM, the resident was sitting in a chair in the resident's room. The resident's hands appeared red and swollen with dry, flaky skin. The resident verbalized the resident had a medication the resident would apply to the resident's hands and arms prior to being admitted to the facility but the resident had not received the medication since admission. The resident described the skin on the resident's hands as painful and stinging. A Medication Order, dated 08/22/2025, documented triamcinolone acetonide external cream 0.1 percent (%) (a prescription corticosteroid used to relieve skin inflammation, itching, and redness). Apply to affected areas three times a day. On 08/27/2025 at 1:36 PM, the LPN for Resident #99 verbalized the LPN knew the resident had a cream ordered for itching and thought the medication was supposed to be applied to the resident's hip. The Admit/Readmit Screener, dated 08/22/2025, documented the resident's skin was normal and no concerns were documented under the section for skin integrity. The care plan for Resident #99, initiated 08/23/2025, documented the resident had the potential for altered skin integrity but did not include the resident's skin condition or the need to apply medicated cream to the affected areas. On 08/27/2025 at 2:00 PM, the LPN verbalized the LPN had contacted the Provider and clarified the triamcinolone cream was supposed to be applied to the resident's hands. The LPN verbalized skin assessments would be completed upon admission, and any skin concerns or abnormalities would be documented. On 08/27/2025 at 2:58 PM, the DON verbalized a skin assessment was part of the admission assessment. The DON confirmed the skin assessment for Resident #99 did not include the resident's dry, red, and swollen skin to the resident's hands and arms. The facility policy titled “Skin Assessment,” implemented 04/11/2025, documented a full body, or head to toe, skin assessment would be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The resident's skin would be thoroughly examined for skin conditions, including redness. The observations would be documented. Cross reference with F655 and F658

Based on observation, clinical record review, interview and document review, the facility failed to ensure nursing staff reported a wound to a physician/provider for 1 of 18 sampled residents (Resident #101), obtained an order for the care and monitoring of the wound, and continued to reassess the wound during daily skin assessments. This deficient practice had the potential to result in worsening of the wound including infection and increased pain for the resident. Findings include:Resident #101Resident #101 was admitted to the facility on [DATE], with diagnoses including metabolic encephalopathy, malignant neoplasm of the brain, and chronic kidney disease, stage IV (severe). On 08/25/2025 at 2:49 PM, Resident #101 verbalized the resident had a wound on the resident's lateral right ankle. The resident explained the wound was noticed by staff the previous day and was told the wound was a pressure injury (PI). The resident was not sure if the wound was open or closed and did not recall what stage the nurse told the resident the wound was. The wound was covered with a Mepilex dressing, (a self-adhering foam dressing), the dressing was initialed and dated 08/24/2025.Resident #101's clinical record did not include documentation of a wound, including PI, to Resident #101's right lateral ankle, including a diagnosis, an order for wound care and/or wound monitoring, or a care plan related to the wound. On 08/28/2025 at 10:19 AM, a Licensed Practical Nurse (LPN) verbalized the LPN was not aware of a wound on the resident's right lateral ankle and explained no one had notified the nurse of a wound. The LPN reviewed the resident's electronic health record (EHR) and did not find an order for wound care, a progress notes related to a wound, or care plan for the provision of care and/or monitoring of a wound for Resident #101. On 08/28/2025 at 10:24 AM, the LPN assessed Resident #101's right lateral ankle for wounds. The ankle resident's right lateral ankle had a blanchable reddened area approximately six centimeters (cm) in diameter. The LPN verbalized the reddened area was warm to touch. On 08/28/2025 at 12:23 PM, the Director of Nursing (DON) verbalized when a new wound was identified the expectation was the physician/provider, the DON and the resident's responsible party would be notified, orders for care and monitoring would be obtained and entered into the resident's clinical record. The wound was to be assessed daily and documented in the resident's clinical record. The DON confirmed nurses were expected to assess residents' skin/wounds daily and explained in skilled nursing, residents should be assessed every day including a head-to-toe skin assessment. Interventions were expected to be documented and entered into the resident's care plan.The facility policy titled Wound Treatment Management implemented 04/11/2025, documented in the absence of treatment orders, the licensed nurse notified the physician to obtain treatment orders. Treatment decisions were based on the etiology, characteristics, and location of the wound.Cross reference with F656

Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with limited range of motion received appropriate services to maintain or improve mobility for 1 of 18 sampled residents (Resident #34). This deficient practice resulted in increased resident pain and had the potential to result in avoidable mobility decline.Findings include:Resident #34 Resident #34 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including peripheral vascular disease, unspecified, acquired absence of right leg below knee, left knee contracture, right knee contracture, chronic pain syndrome, and need for assistance with personal care. An active physician's order, dated 04/19/2024, documented monthly summary/monthly restorative summary.Resident #34's clinical record lacked documented evidence of the following items:-A restorative evaluation.-A monthly restorative summary.-A discontinue order for the monthly restorative summary.-A physician's order for restorative nursing services to include the type of restorative nursing services performed and how often.-A care plan related to restorative nursing services.-Physical therapy services.August 2025 restorative program notes, dated the following, documented the restorative nursing assistant assisted with passive range of motion (PROM) to upper left body extremities for 15 minutes:-08/03/2025-08/05/2025-08/06/2025-08/09/2025-08/10/2025-08/11/2025-08/12/2025-08/17/2025-08/18/2025-08/19/2025On 08/25/2025 at 2:57 PM, Resident #34 verbalized the resident was previously involved in the facility's restorative nursing program (RNP) where the facility staff stretched and massaged the resident's arm to increase blood flow. Recently, the RNP was discontinued due to low staffing. Resident #34 stopped receiving mobility services to the resident's arm, and the resident experienced increased swelling and pain to the resident's arm. Resident #34 verbalized being in constant pain.On 08/26/2025 at 3:35 PM, the Administrator verbalized the facility discontinued the RNP approximately one week prior due to short staffing. On 08/27/2025 at 10:02 AM, a Licensed Practical Nurse (LPN) verbalized approximately one week prior, the facility discontinued the RNP. The LPN explained the RNP was designed to maintain the resident's optimal level of independence and to prevent decline in physical mobility. The LPN explained, under the supervision of the Director of Nursing (DON), restorative aides assisted residents with exercising and activities. To determine if a resident was a candidate for the RNP, the resident would be reviewed by the interdisciplinary team (IDT). Residents requiring PROM should have a physician's order documented in their clinical record. On 08/27/2025 at 10:27 AM, the DON explained the RNP was designed to prevent residents from having a decline in condition and to maintain the highest physical and mental capabilities. However, facility did not have enough restorative aides, so the RNP was discontinued. The DON believed all residents previously on the RNP were provided physical therapy services. The DON believed the RNP operated under the supervision of the LPN. The lack of an RNP would be considered a shortcoming of the facility. On 08/27/2025 at 11:06 AM, the Director of Rehabilitation verbalized the physical therapy program was not involved with the RNP and was unaware the RNP was discontinued. On 08/27/2025 at 11:17 AM, the Director of Rehabilitation explained physical therapy did not provide any additional services to residents previously receiving restorative nursing services once the RNP was discontinued.On 08/27/2025 at 12:04 PM, a Certified Nursing Assistant (CNA) verbalized Resident #34 was unable to move the resident's left side and required a two-person assist with transfers. On 08/27/2025 at 12:06 PM, the LPN explained Resident #34 was a two-person assist with transfers however sometimes required the use of a Hoyer lift when not weight bearing. Resident #34 had a history of stroke causing the resident's upper left extremity to be flaccid. The LPN explained, without mobility assistance, Resident #34 was at greater risk for contracture. On 08/27/2025 at 1:12 PM, the DON explained candidates for the RNP were identified through an IDT or physical therapy evaluation. The DON was unsure what might make someone a candidate for the RNP. Residents on the RNP would be expected to have a care plan to guide services from restorative aides, as well as an order outlining the type of restorative nursing services required and how often services were performed. Once a restorative aide provided restorative services, the restorative aide would document what services were performed in resident progress notes. The DON verbalized Resident #34 required use of a wheelchair and assistance with transfers due to a stroke on the resident's left side. Resident #34's left arm was immobile and was laid in the resident's lap. Resident #34 has expressed being in some pain. The DON confirmed Resident #34 was previously in the RNP and the resident had an order for monthly restorative summaries. However, the DON was unsure what monthly restorative summaries were. On 08/27/2025 at 2:46 PM, the Administrator verbalized the facility did not retain a list of residents previously on the RNP. On 08/28/2025 at 9:14 AM, the Regional Nurse Consultant verbalized Resident #34's clinical record included an active physician's order for a monthly restorative summary, however, was unable to identify where the restorative summaries were to be documented. Additionally, Resident #34's clinical record lacked documented evidence of an IDT of physical therapy restorative evaluation and a care plan related to restorative nursing services.On 08/28/2025 at 9:14 AM, the Regional Nurse Consultant verbalized the facility discontinued the RNP approximately two weeks prior. The facility did not have a list of residents previously on the RNP nor residents who may have been a candidate for restorative nursing services. The facility identified residents in need of additional mobility services by evaluating who had a decline since discontinuing the RNP.The Regional Nurse Consultant verbalized the facility was not completing restorative evaluations, care plans for restorative nursing services, orders to include the type of restorative nursing services and how often those services were to be provided. Additionally, the facility did not have any other process for maintaining highest practicable level of functioning and preventing a decline in mobility for any resident in the facility. On 08/28/2025 at 11:10 AM, the Minimum Data Set 3.0 (MDS) Coordinator explained being responsible for collecting data for the MDS resident assessment and managing resident care plans. The MDS Coordinator verbalized using IDT meetings to drive the completion of MDS assessments and care plans. The IDT consisted of the Administrator, the DON, the Assistant DON, therapists, medical records administration, and the MDS Coordinator. The MDS Coordinator verbalized the MDS Coordinator did not play a part in the RNP and the RNP was not discussed in the IDT meetings. On 08/28/2025 at 12:33 PM, the DON verbalized the MDS Coordinator used IDT meetings to collect information for the MDS assessment and care plans. The MDS Coordinator and MDS assessments did not play a role in determining RNP candidacy. The DON confirmed the facility policy for the RNP documented the resident assessment would be used to determine RNP candidacy. The DON verbalized being unsure whether restorative aides had administrative oversight as they did not report to the DON. Additionally, there was a gap in time between when the LPN ceased participation in the RNP and when the restorative aides ceased providing restorative nursing services. The DON confirmed the DON was ultimately responsible for all nursing services provided in the facility. The facility policy titled Activities of Daily Living (ADLs), dated 04/11/2025, documented the facility would provide a maintenance and restorative program to assist the resident in achieving and maintaining the highest practicable outcome based on the comprehensive assessment. The facility would identify resident triggers through the care area assessment process to assess causal factors for decline, potential decline or lack of improvement. The facility would maintain individual objectives of the care plan and periodic review and evaluation. The facility policy titled Prevention of Decline in Range of Motion, dated 04/11/2025, documented the facility would establish and utilize a systematic approach for prevention of decline in range of motion, including an assessment, appropriate care planning, and preventative care.The facility policy titled Restorative Nursing Program, dated 04/11/2025, documented the residents identified during the comprehensive assessment process would receive services from restorative aides when assessed to have a need for restorative nursing services. These services may include passive or active range of motion, splint or brace assistance, bed mobility training, transfers and walking training, dressing and grooming training, and amputation prosthesis care. The restorative nurse was responsible for maintaining a current list of residents who required restorative nursing services. A restorative nursing plan would include the problem, need or strength restorative tasks were to address, the type of activities to be performed, frequency of activities, duration of activities, measurable goals, and a target date.

Based on observation, interview, clinical record review, and document review, the facility failed to ensure the resident environment was free from accident hazards when a resident was observed smoking a cigarette inside the facility for 1 of 18 sampled residents (Resident #42). This deficient practice had the potential to result in harm to all residents of the facility.Findings include: Resident #42 Resident #42 was admitted to the facility on [DATE], and readmitted on [DATE], with a diagnosis of shortness of breath. On 08/25/2025 at 2:15 PM, a no smoking oxygen in use sign was posted at the entrance to Resident #42's room. The door was closed. An idle oxygen concentrator was placed in the far-left corner of the resident's room. Resident #42 was seated in the resident's wheelchair with a lit cigarette in the resident's hand. Resident #42's last comprehensive Minimum Data Set 3.0 (MDS) Assessment, dated 04/17/2025, section J1300 (Health Conditions-Current Tobacco Use), documented 1 for Yes under current tobacco use. A care plan, revised 07/28/2025, documented Resident #42 was at risk for injury and complications related to smoking. Interventions documented Resident #42 was to adhere to the facility smoking policy at all times and staff would be in control of Resident #42's cigarettes and ignition source. Resident #42 was assessed and determined to have supervised smoking privileges. A Facility Smoking Protocol contract, dated 08/25/2025, signed by Resident #42, documented all cigarettes, lighters, and matches must be kept at the nursing station. Residents were not permitted to keep smoking materials in their rooms or on their person at any time. Residents were only permitted to smoke in the facility's designated smoking area under staff supervision, and smoking in any other area was strictly prohibited. On 08/25/2025 at 2:15 PM, Resident #42 verbalized there was a designated smoking area outside the facility past a yellow line. Resident #42 explained the resident usually kept the cigarettes with the resident, and the cigarettes were not retained by the facility upon re-admission. On 08/25/2025 at 2:17 PM, the Director of Nursing (DON) verbalized Resident #42 was out of the facility for approximately one week and returned to the facility the morning of 08/25/2025. The facility was aware the resident smoked cigarettes. Residents should never smoke in the facility. Instead, residents were asked to smoke in the designated smoking area outside. The DON confirmed Resident #42 was smoking inside the facility. On 09/03/2025 at 10:11 AM, a Certified Nursing Assistant (CNA) verbalized smoking residents were expected to give all smoking paraphernalia to the nursing staff for secure keeping. Smoking was not permitted in the facility as it posed a fire hazard. Additionally, residents smoking with or near an oxygen concentrator risked triggering an explosion. On 09/03/2025 at 10:45 AM, another CNA verbalized Resident #42 used oxygen while asleep and kept the oxygen concentrator stationed in the resident's room. Resident #42 was known to smoke. On 09/03/2025 at 1:22 PM, the DON explained upon admission, residents were immediately informed of the smoking policy, and all cigarettes and lighters were retained by the facility to be placed in a secured area. Residents were not supposed to keep smoking paraphernalia in resident rooms. When residents wanted to smoke, they would inform a staff member, collect their cigarettes and lighters, and smoke outside in the designated smoking area past the yellow line. Smoking was not permitted inside the facility because it posed a fire hazard. Smoking Protocol contracts were required for all smoking residents. The DON explained Resident #42 primarily used the oxygen concentrator at night and confirmed when Resident #42 was found smoking, the concentrator was present in the room. The DON confirmed when Resident #42 was readmitted , the resident's smoking paraphernalia was not retained by the facility. The facility policy, titled Resident Smoking, dated 04/11/2025, documented smoking was prohibited in all areas except the designated smoking area. Smoking materials of residents requiring supervision with smoking would be maintained by nursing staff.

Based on clinical record review, document review and interview, the facility failed to ensure a resident with a trauma diagnosis was assessed for the facility to recognize and respond to the effects of the trauma for 1 of 18 sampled residents (Resident #5). This deficient practice had the potential to result in a resident experiencing re-traumatization due to the lack of assessments to recognize trauma-specific interventions. Findings include:Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder (PTSD) and conversion disorder with motor symptom or deficit.Resident #5's Care Plan dated 12/09/2024, documented the focus care area: PTSD, the resident had experienced a traumatic event prior to admission with an intervention to assess for suicidal or homicidal ideations when applicable. A Psychosocial Assessment, completed on 06/26/2025, documented Resident #5 had a diagnosis of PTSD generalized anxiety disorder. Resident #5's clinical record lacked documentation a Psychosocial Assessment had been completed prior to 06/26/2025. A Psychosocial Progress Note dated 07/23/2025, documented Resident #5 had communicated to a family member the resident had threatened to kill themselves. Resident #5's clinical record lacked documentation a Psychosocial Assessment had been completed after the 07/23/2025 incident. On 08/28/2025 at 11:30 AM, the Director of Nursing (DON) confirmed Resident #5 had a diagnosis of PTSD upon admission and confirmed the 06/26/2025 assessment was the only documented Psychosocial Assessment completed for the resident. The DON verbalized having been unsure why additional assessments had not been completed prior to 06/26/2025, as the resident had been in the facility since 09/10/2024 with a PTSD diagnosis. The DON verbalized a Psychosocial Assessment should have been completed after the incident on 07/23/2025 and confirmed one had not been completed. The DON verbalized it was important to assess the resident and identify the triggers of trauma so staff would be aware of what to watch for and take necessary steps to address. The facility policy titled, Trauma Informed Care, dated 04/11/2025, documented the facility would use screening and assessment tools to assist with recognizing, understanding and responding to all types of trauma and incorporate a trauma-informed approach to avoid re-traumatization.

Based on observation, interview, and document review, the facility failed to ensure a refrigerator was maintained at a safe storage temperature in 1 of 4 satellite kitchens of the facility. This deficient practice had the potential to harm residents by increasing the risk of infection and foodborne illnesses.Findings include:On 08/25/2025 at 10:36 AM, during a tour of the 100-hall satellite kitchen, the refrigerator internal thermometer measured 50 degrees Fahrenheit (F). The following perishable food items were inside the refrigerator:-Four meat sandwiches.-Three four-ounce yogurt cups.-Two one-gallon jugs of milk.-Six pre-poured glasses of milk.-One tub cream cheese spread.On 08/25/2025 at 10:36 AM, the Dietary Supervisor verbalized refrigerator temperatures were to be maintained between 38 to 41 F. the Dietary Supervisor confirmed the refrigerator thermometer reflected 50 F and the food items containing animal products would need to be thrown out. The facility policy titled Monitoring of Cooler/Freezer Temperature, dated 04/11/2025, documented all refrigerated storage must be maintained at or below 41 F.

Based on interview, clinical record review, and document review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee identified a widespread concern with completion of Minimum Data Set (MDS) 3.0 assessments by non-qualified individuals. This deficient practice had the potential to result in residents not receiving the required care or services due to the potential for inaccurate care plans generated from the MDS assessment. Findings include: On 09/04/2025 at 4:58 PM, the Administrator verbalized the QAPI committee had been unaware of the concern with non-qualified individuals completing portions of the MDS assessments. The Administrator confirmed the MDS Coordinator was a part of the QAPI committee. The Administrator explained the MDS Coordinator was responsible for conducting audits on the MDS data and shared the audit findings with the QAPI committee during meetings. The Administrator verbalized the QAPI committee could have caught the concern prior to the annual recertification. The facility document titled Facility QAPI Plan, dated 04/23/2025, documented the objectives of the QAPI plan included establishing a process to identify opportunities for improvement through continuous attention to quality of care, addressing gaps in systems or processes, and ensuring adequate provision of staffing and technical training resources. Cross reference with F641

Based on clinical record review, personnel record review, document review, and interview, the Administrator failed to ensure employees identified to complete sections of the Minimum Data Set (MDS) 3.0 Resident Assessments (Employee #8 and #9) had the experience and knowledge to complete accurate resident evaluations, and failed to ensure the accuracy of the MDS assessments after having learned of a title discrepancy in the resident electronic health record (EHR) system. This deficient practice had the potential to affect the accuracy of MDS assessments for the entire resident census by allowing unqualified or insufficiently trained staff to complete critical assessment sections and had the potential to result in inaccurate care planning and delivery, which could negatively impact resident outcomes.Findings include: The Centers for Medicare & Medicaid Services (CMS), 42 CFR 483.20 (g) Resident assessment, defined the Accuracy of Assessments as meaning the appropriate, health professionals correctly documenting the resident's medical, functional, and psychosocial problems and identifying resident strengths to maintain or improve medical status, functional abilities, and psychosocial status. Facilities are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. Employee #8 Employee #8 was originally hired on 07/24/2024 in Medical Records and took the position of Resident Advocate on 07/07/2025. Employee #8's signed job description for Resident Advocate, dated 07/09/2025, documented a minimum qualification as being a high school graduate or having a high school equivalent (GED-General Education Development). Higher education with a social services related college degree was preferred. Prior social services related experience was preferred, with some of the experience in a long-term facility. The position description documented the primary purpose of the position was to plan, organize, develop, and direct the operations of the social services department in accordance with federal, state and local standards, guidelines and regulations to ensure the emotional needs of the residents were maintained. The job description documented the principal job responsibilities were to complete all social services related documentation in each resident's medical record, including assessments, progress notes, and care plans. Employee #8's resume, undated, documented the employee had obtained a GED and listed the employee's certifications and licenses to include a food handler certification, a driver's license, and a cardiopulmonary resuscitation (CPR) certification. The employee's resume documented a work history including receptionist, food service supervisor, concierge, delivery driver, and a youth development professional. The employee record lacked documentation the employee had obtained any higher education or additional experience or knowledge in a clinical, health, or social services setting. On 09/03/2025 at 3:24 PM, the Business Office Manager verbalized a Resident Advocate was considered an unlicensed social worker. On 09/04/2025 at 9:22 AM, the Business Office Manager confirmed the undated resume for Employee #8 was the only resume in the employee's record and was used to hire the employee as a Resident Advocate on 07/07/2025. Employee #8's Resident Advocate Competency Checklist signed by the employee on 07/07/2025, and signed by the Trainer/Administrator on 07/09/2025, documented a total of 56 training skill modules. 42 skill modules had a completion date of 07/07/2025 and 14 had a completion date of 07/09/2025. None of the skills modules documented a length of time for each of the trainings. The following skills modules were documented has having been completed and signed off by the Trainer/Administrator and the employee after each section: -07/07/2025-Centers for Medicare & Medicaid Services (CMS) regulations pertinent to social work department: Where to find.-07/07/2025-Minimum Data Set (MDS)-Section Q.-07/07/2025-Social history and social determinates of health user-defined assessments.-07/07/2025-Assessment: opening, saving, signing, locking, editing, and deleting.-07/09/2025-Mentally ill/dementia population: symptoms, behavior management, de-escalation. Employee #8's Resident Advocate Competency Checklist documented the Administrator as having been the Trainer of each of the modules for both days and signed as both the Trainer and the Administrator on the form. On 09/04/2025 at 9:34 AM, Employee #8 confirmed having been a Resident Advocate and was trained by Employee #9 prior to Employee #9 leaving the position. Employee #8 confirmed having completed face-to-face interviews with residents to complete the mental health and psychosocial MDS evaluations. Employee #8 verbalized having interviewed residents to determine if the residents were depressed and had completed interviews with a resident with a trauma diagnosis. Employee #8 confirmed having been trained to complete MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting, and to enter the evaluations into the residents MDS Resident Assessment and had reviewed the Resident Assessment Instrument (RAI) Manual Sections the employee was responsible to complete. Resident MDS Assessments documented from 07/14/2025 to 08/26/2025, Employee #8 had e-Signed with the title of Social Worker as having completed portions of MDS Assessments. Employee #9 Employee #9 was originally hired on 01/23/2025 as a Transportation Driver and took the position of Resident Advocate on 05/06/2025. Employee #9's record lacked a signed job description for the Resident Advocate position. On 09/03/2025 at 3:24 PM, the Business Office Manager verbalized a Resident Advocate was considered an unlicensed social worker. The Business Office Manager confirmed not having a signed job description for the Resident Advocate position for Employee #9. Employee #9's resume, undated, documented the employee had obtained a high school diploma with a work history including pawnbroker and a maintenance technician/supervisor. The employee's resume documented education including healthcare training online with a focus on healthcare management. The online training provider documented in Employee #9's resume, documents on their website (www.ultimatemedical.edu) the healthcare management online training program would teach students specific skills including understanding medical billing systems, preparing budgets, constructing business documents, and helping resolve workplace conflict. The employee's resume lacked documentation of a certification or license, or any higher education or additional experience or knowledge in a clinical, health, or social services setting. Employee #9's training certificates were as follows with the date of completion and the name of the training: -01/21/2025-Cultural Competency Training Program-three hours.-01/23/2025-Elder Abuse Training-no time documented on certificate.-01/27/2025-Dementia Training-eight hours.-04/06/2025-All Staff In-Service Education-Behavioral-one hour.-05/09/2025-Inter Disciplinary Team, Abuse Investigation Packets-30 minutes.-06/18/2025-All staff, Abuse Training- no time documented on signature sheet or training material. Resident MDS Assessments documented from 06/24/2025 to 07/10/2025, Employee #9 had e-Signed with the title of Social Worker as having completed portions of MDS Assessments. On 09/04/2025 at 12:48 PM, the Administrator verbalized Employee #9 was a transportation driver and was not clinical. The Administrator verbalized the employee had been trained to complete the Brief Interview for Mental Status (BIMS) evaluations for resident assessments, but the employee was no longer doing so and returned to being a transportation driver. On 09/04/2025 at 10:33 AM, the Administrator verbalized the Administrator had interviewed Employee #9 and had kept the employee's application and job description on the Administrator's desk and had not forwarded the documents to Human Resources. On 09/04/2025 at 10:02 AM, the MDS Coordinator confirmed having personally trained Employee #9 on completing sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting of the MDS Resident Assessments. The MDS Coordinator verbalized the facility's corporate office had sent the employees training modules on those sections of the MDS to be completed. The MDS Coordinator verbalized receiving direction from the corporate office to train the Resident Advocates on those sections. On 09/04/2025 at 10:09 AM, the MDS Coordinator verbalized having confirmed via telephone with the corporate office the Resident Advocates were to only be trained on MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. The MDS Coordinator verbalized having trained Employee #9 how to conduct the evaluations and enter the evaluations into the MDS record and would consider the evaluations an assessment. On 09/04/2025 at 10:39 AM, the MDS Coordinator confirmed the facility followed the RAI Manual for MDS Resident Assessment completion. On 09/04/2025 at 11:13 AM, Employee #9 confirmed having been in the Resident Advocate position for the months of May and June 2025. The employee confirmed having been trained by the MDS Coordinator on the completion of MDS sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting, and how to have face-to-face interactions with residents to complete the sections and had completed a signature sheet related to the training but did not give the sheet to Human Resources. The employee confirmed not having been a social worker or had any prior experience or education in social work. The employee verbalized having had a psychosocial training via an online meeting with a Licensed Social Worker at a different corporation skilled nursing facility. On 09/04/2025 at 1:56 PM, the Administrator confirmed Resident Advocates interview resident to obtain information to enter and complete Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting of the MDS Resident Assessments. The Administrator verbalized having believed an individual with a high school diploma or a GED was considered professional with additional training and experience and with nurse training, anyone can complete the BIMS and cognitive resident interviews. On 09/04/2025 at 2:01 PM, the Administrator confirmed Employee #8 and Employee #9 were not social workers and verbalized having hired them based on their work in the facility and how they interacted with residents. The Administrator verbalized having believed the employees were qualified to complete the resident cognitive assessments based on the MDS Coordinator's training. The Administrator verbalized the employees had passed the screening for the position as the screening was the Administrator's interview. On 09/04/2025 at 2:05 PM, the Administrator confirmed Employee #8 and Employee #9 had only been trained on the completion of MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting by the MDS Coordinator and verbalized not having any documentation of the completion of the training. On 09/04/2025 at 2:10 PM, the Administrator confirmed both Employee #8 and Employee #9 had e-Signed MDS Resident Assessment Sections with a title of Social Worker, and confirmed the employees had not been trained to complete MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, K-Swallowing/Nutritional Status, N-Medications, and O-Special Treatments, Procedures, and Programs, and should not have completed or signed off on those sections, and not have e-Signed as Social Workers. The Administrator verbalized it was the MDS Coordinator's responsibility to oversee the accuracy of the MDS Resident Assessments and confirmed the Administrator was responsible for oversight of the MDS Coordinator. On 09/04/2025 at 2:23 PM, the Business Office Manager confirmed it was the Business Office Manager who entered the employee titles into the resident electronic health record (EHR) system. The Business Office Manager verbalized due to the Resident Advocate title not having been a selection to populate into the EHR system and as the Resident Advocates worked closely with social services, the Business Office Manager confirmed having selected the title of Social Worker for Employee #8 and Employee #9 in the EHR system. The Business Office Manager verbalized having notified the Administrator of the Resident Advocate title not having been a selection to populate into the EHR system. On 09/04/2025 at 2:26 PM, the Administrator confirmed having been made aware of the title discrepancy in the EHR system but was unsure who or when the Administrator communicated with at the corporate office and was unsure how, it initially fell through the crack. The CMS, Long-Term Care Facility RAI 3.0 User's Manual, Version 1.18.11, Effective October 1, 2023, CHAPTER 1.3: RESIDENT ASSESSMENT INSTRUMENT (RAI), Completion of the RAI, documented given the requirements of participation of appropriate health professionals, completion of the RAI was best accomplished by staff with varied clinical backgrounds, combined with experience and knowledge to provide an understanding of the strengths, needs and preferences of a resident population to ensure the best possible quality of care and quality of life. Identification of resident problems, needs, and strengths, monitoring resident conditions on an on-going basis, and documenting treatments and response to treatments, was a matter of good clinical practice and an expectation of trained and licensed health care professionals. A facility was responsible to ensure the MDS was validated for accuracy and all participants in the assessment process had the requisite knowledge to complete an accurate assessment. Complaint 2289182 Cross reference with Tags F641 and F839

Based on clinical record review, personnel record review, document review, and interview, the facility failed to ensure employees trained to complete sections of the Minimum Data Set (MDS) 3.0 Resident Assessments for 16 of 18 sampled residents (Resident #3, #4, #7, #23, #24, #42, #78, #90, #99, #101, #5, #9, #10, #21, #34, and #84) were qualified for 2 of 2 employees trained to complete sections of the MDS Resident Assessments (Employee #8 and #9). This deficient practice had the potential to affect the accuracy of MDS assessments for the entire resident census by allowing unqualified or insufficiently trained staff to complete critical assessment sections and had the potential to result in inaccurate care planning and delivery, which could negatively impact resident outcomes.Findings include: Employee #8 Employee #8 was originally hired on 07/24/2024 in Medical Records and took the position of Resident Advocate on 07/07/2025. Employee #8's signed job description for Resident Advocate, dated 07/09/2025, documented a minimum qualification as being a high school graduate or having a high school equivalent (GED-General Education Development). Higher education with a social services related college degree was preferred. Prior social services related experience was preferred, with some of the experience in a long-term facility. The position description documented the primary purpose of the position was to plan, organize, develop, and direct the operations of the social services department in accordance with federal, state and local standards, guidelines and regulations to ensure the emotional needs of the residents were maintained. The job description documented the principal job responsibilities were to complete all social services related documentation in each resident's medical record, including assessments, progress notes, and care plans. Employee #8's resume, undated, documented the employee had obtained a GED and listed the employee's certifications and licenses to include a food handler certification, a driver's license, and a cardiopulmonary resuscitation (CPR) certification. The employee's resume documented a work history including receptionist, food service supervisor, concierge, delivery driver, and a youth development professional. The employee record lacked documentation the employee had obtained any higher education or additional experience or knowledge in a clinical, health, or social services setting. On 09/03/2025 at 3:24 PM, the Business Office Manager verbalized a Resident Advocate was considered an unlicensed social worker. On 09/04/2025 at 9:22 AM, the Business Office Manager confirmed the undated resume for Employee #8 was the only resume in the employee's record and was used to hire the employee as a Resident Advocate on 07/07/2025. Employee #8's Resident Advocate Competency Checklist signed by the employee on 07/07/2025, and signed by the Trainer/Administrator on 07/09/2025, documented a total of 56 training skill modules. 42 skill modules had a completion date of 07/07/2025 and 14 had a completion date of 07/09/2025. None of the skills modules documented a length of time for each of the trainings. The following skills modules were documented has having been completed and signed off by the Trainer/Administrator and the employee after each section: -07/07/2025-Centers for Medicare & Medicaid Services (CMS) regulations pertinent to social work department: Where to find.-07/07/2025-Minimum Data Set (MDS)-Section Q.-07/07/2025-Social history and social determinates of health user-defined assessments.-07/07/2025-Assessment: opening, saving, signing, locking, editing, and deleting.-07/09/2025-Mentally ill/dementia population: symptoms, behavior management, de-escalation. Employee #8's Resident Advocate Competency Checklist documented the Administrator as having been the Trainer of each of the modules for both days and signed as both the Trainer and the Administrator on the form. On 09/04/2025 at 9:34 AM, Employee #8 confirmed having been a Resident Advocate and was trained by Employee #9 prior to Employee #9 leaving the position. Employee #8 confirmed having completed face-to-face interviews with residents to complete the mental health and psychosocial MDS evaluations. Employee #8 verbalized having interviewed residents to determine if the residents were depressed and had completed interviews with a resident with a trauma diagnosis. Employee #8 confirmed having been trained to complete MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting, and to enter the evaluations into the residents MDS Resident Assessment and had reviewed the Resident Assessment Instrument (RAI) Manual Sections the employee was responsible to complete. Resident #3 Resident #3 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, bipolar disorder, unspecified, and depression, unspecified. Resident #3's quarterly MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, J-Health Conditions, K-Swallowing/Nutritional Status, N-Medications, and O-Special Treatments, Procedures, and Programs. Resident #4 Resident #4 was admitted to the facility on [DATE], with diagnoses including muscle wasting and atrophy, not elsewhere classified, multiple sites, muscle weakness, generalized, cognitive communication deficit, depression, unspecified, and anxiety disorder, unspecified. Resident #4's admission MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, K-Swallowing/Nutritional Status, N-Medications, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. Resident #7 Resident #7 was admitted to the facility on [DATE], with diagnoses including type II diabetes mellitus with other diabetic kidney complication, vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and major depressive disorder, recurrent, unspecified. Resident #7's annual MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed portions of MDS Section Q-Participation in Assessment and Goal Setting. Resident #23 Resident #23 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit, dysphasia, unspecified, and other unspecified anxiety disorders. Resident #23's admission MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed portions of MDS Sections C-Cognitive Patterns, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #24 Resident #24 was admitted to the facility on [DATE], with diagnoses including cerebral palsy, unspecified, developmental disorder of speech and language, unspecified, and cognitive communication deficit. Resident #24's significant change in status MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #42 Resident #42 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, severe with psychotic symptoms, anxiety disorder, unspecified, and cognitive communication deficit. Resident #42's quarterly MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #78 Resident #78 was admitted to the facility on [DATE], with diagnoses including non-traumatic subarachnoid hemorrhage, unspecified, fracture of unspecified part of neck of left femur, initial encounter for closed fracture, and displaced intertrochanteric fracture of left femur, initial encounter for closed fracture. Resident #78's quarterly MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed MDS Sections C-Cognitive Patterns, D-Mood, and Q-Participation in Assessment and Goal Setting. Resident #90 Resident #90 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, and unspecified dementia, unspecified severity, with other behavioral disturbance. Resident #90's quarterly MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #99 Resident #99 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified, dysphagia, unspecified, and cognitive communication deficit. Resident #99's admission MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #101 Resident #101 was admitted to the facility on [DATE], with diagnoses including malignant neoplasm of brain, unspecified, chronic kidney disease, stage IV, severe, and metabolic encephalopathy. Resident #101's admission MDS Resident assessment dated [DATE], documented Employee #8 e-Signed as having completed MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. Employee #9 Employee #9 was originally hired on 01/23/2025 as a Transportation Driver and took the position of Resident Advocate on 05/06/2025. Employee #9's record lacked a signed job description for the Resident Advocate position. On 09/03/2025 at 3:24 PM, the Business Office Manager verbalized a Resident Advocate was considered an unlicensed social worker. The Business Office Manager confirmed not having a signed job description for the Resident Advocate position for Employee #9. Employee #9's resume, undated, documented the employee had obtained a high school diploma with a work history including pawnbroker and a maintenance technician/supervisor. The employee's resume documented education including healthcare training online with a focus on healthcare management. The online training provider documented in Employee #9's resume, documents on their website (www.ultimatemedical.edu) the healthcare management online training program would teach students specific skills including understanding medical billing systems, preparing budgets, constructing business documents, and helping resolve workplace conflict. The employee's resume lacked documentation of a certification or license, or any higher education or additional experience or knowledge in a clinical, health, or social services setting. Employee #9's training certificates were as follows with the date of completion and the name of the training: -01/21/2025-Cultural Competency Training Program-three hours.-01/23/2025-Elder Abuse Training-no time documented on certificate.-01/27/2025-Dementia Training-eight hours.-04/06/2025-All Staff In-Service Education-Behavioral-one hour.-05/09/2025-Inter Disciplinary Team, Abuse Investigation Packets-30 minutes.-06/18/2025-All staff, Abuse Training- no time documented on signature sheet or training material. On 09/04/2025 at 12:48 PM, the Administrator verbalized Employee #9 was a transportation driver and was not clinical. The Administrator verbalized the employee had been trained to complete the Brief Interview for Mental Status (BIMS) evaluations for resident assessments, but the employee was no longer doing so and returned to being a transportation driver. On 09/04/2025 at 10:33 AM, the Administrator verbalized the Administrator had interviewed Employee #9 and had kept the employee's application and job description on the Administrator's desk and had not forwarded the documents to Human Resources. On 09/04/2025 at 10:02 AM, the MDS Coordinator confirmed having personally trained Employee #9 on completing sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting of the MDS Resident Assessments. The MDS Coordinator verbalized the facility's corporate office had sent the employees training modules on those sections of the MDS to be completed. The MDS Coordinator verbalized receiving direction from the corporate office to train the Resident Advocates on those sections. On 09/04/2025 at 10:09 AM, the MDS Coordinator verbalized having confirmed via telephone with the corporate office the Resident Advocates were to only be trained on MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting. The MDS Coordinator verbalized having trained Employee #9 how to conduct the evaluations and enter the evaluations into the MDS record and would consider the evaluations an assessment. On 09/04/2025 at 10:39 AM, the MDS Coordinator confirmed the facility followed the RAI Manual for MDS Resident Assessment completion. On 09/04/2025 at 11:13 AM, Employee #9 confirmed having been in the Resident Advocate position for the months of May and June 2025. The employee confirmed having been trained by the MDS Coordinator on the completion of MDS sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting, and how to have face-to-face interactions with residents to complete the sections and had completed a signature sheet related to the training but did not give the sheet to Human Resources. The employee confirmed not having been a social worker or had any prior experience or education in social work. The employee verbalized having had a psychosocial training via an online meeting with a Licensed Social Worker at a different corporation skilled nursing facility. On 09/04/2025 at 1:56 PM, the Administrator confirmed Resident Advocates interview resident to obtain information to enter and complete Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting of the MDS Resident Assessments. The Administrator verbalized having believed an individual with a high school diploma or a GED was considered professional with additional training and experience and with nurse training, anyone can complete the BIMS and cognitive resident interviews. On 09/04/2025 at 2:01 PM, the Administrator confirmed Employee #8 and Employee #9 were not social workers and verbalized having hired them based on their work in the facility and how they interacted with residents. The Administrator verbalized having believed the employees were qualified to complete the resident cognitive assessments based on the MDS Coordinator's training. The Administrator verbalized the employees had passed the screening for the position as the screening was the Administrator's interview. On 09/04/2025 at 2:05 PM, the Administrator confirmed Employee #8 and Employee #9 had only been trained on the completion of MDS Sections C-Cognitive Patterns, D-Mood, E-Behavior, and Q-Participation in Assessment and Goal Setting by the MDS Coordinator and verbalized not having any documentation of the completion of the training. Resident #5 Resident #5 was admitted to the facility on [DATE], with diagnoses including post-traumatic stress disorder, chronic, major depressive disorder, recurrent, moderate, anxiety disorder, unspecified, conversion disorder with motor symptom or deficit. Resident #5's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed as having completed portions of MDS Sections C-Cognitive Patterns, E-Behavior, and Q-Participation in Assessment and Goal Setting. Resident #9 Resident #9 was admitted to the facility on [DATE], with diagnoses including cerebral palsy unspecified, muscular dystrophy, unspecified and epilepsy, unspecified. Resident #9's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. Resident #10 Resident #10 was admitted to the facility on [DATE], with diagnoses including schizoaffective disorder, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance, and unspecified psychosis not due to a substance or known physiological condition. Resident #10's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. Resident #21 Resident #21 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, severe, with other behavioral disturbance, dysphasia, oropharyngeal phase, and anxiety disorder due to known physiological condition. Resident #21's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed as having completed portions of MDS Sections C-Cognitive Patterns, D-Mood, and Q-Participation in Assessment and Goal Setting. Resident #34 Resident #34 was admitted to the facility on [DATE], with diagnoses including peripheral vascular disease, unspecified, acquired absence of right leg below knee, and atherosclerotic heart disease of native coronary artery without angina pectoris. Resident #34's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, N-Medications, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. Resident #84 Resident #84 was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, unspecified, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #84's quarterly MDS Resident assessment dated [DATE], documented Employee #9 e-Signed as having completed portions of MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, C-Cognitive Patterns, D-Mood, E-Behavior, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, O-Special Treatments, Procedures, and Programs, and Q-Participation in Assessment and Goal Setting. On 09/04/2025 at 2:10 PM, the Administrator confirmed both Employee #8 and Employee #9 had e-Signed on the above MDS Resident Assessment Sections, and confirmed the employees had not been trained to complete MDS Sections A-Identification Information, B-Hearing, Speech, and Vision, GG-Functional Abilities, I-Active Diagnoses, J-Health Conditions, K-Swallowing/Nutritional Status, N-Medications, and O-Special Treatments, Procedures, and Programs, and should not have completed or signed off on those sections. The Administrator verbalized it was the MDS Coordinator's responsibility to oversee the accuracy of the MDS Resident Assessments and confirmed the Administrator was responsible for oversight of the MDS Coordinator. The CMS, Long-Term Care Facility RAI 3.0 User's Manual, Version 1.18.11, Effective October 1, 2023, CHAPTER 1.3: RESIDENT ASSESSMENT INSTRUMENT (RAI), Completion of the RAI, documented given the requirements of participation of appropriate health professionals, completion of the RAI was best accomplished by staff with varied clinical backgrounds, combined with experience and knowledge to provide an understanding of the strengths, needs and preferences of a resident population to ensure the best possible quality of care and quality of life. Identification of resident problems, needs, and strengths, monitoring resident conditions on an on-going basis, and documenting treatments and response to treatments, was a matter of good clinical practice and an expectation of trained and licensed health care professionals. A facility was responsible to ensure the MDS was validated for accuracy and all participants in the assessment process had the requisite knowledge to complete an accurate assessment. Complaint 2289182 Cross reference with Tags F641 and F835

Based on interview, clinical record review, and document review, the facility failed to ensure a significant medication error did not occur when a resident was administered a penicillin antibiotic when the resident had a known penicillin allergy for 1 of 7 sampled residents (Resident #1). This deficient practice resulted in the resident being hospitalized after developing symptoms of an allergic reaction. Findings include: Resident #1 Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including colostomy status, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and Alzheimer's disease, unspecified. A hospital Discharge Summary, dated 06/14/2024, documented the resident had anaphylactic reactions to penicillin. The allergies documented in the resident's electronic health record upon the resident's initial admission to the facility on [DATE], were morphine, sulfa antibiotics, and codeine. An Order Summary Report for Resident #1 documented amoxicillin-potassium clavulanate (Augmentin) 875-125 milligram tablets, give one tablet by mouth two times a day for colostomy wound infection for five days. The order start date was 06/26/2024. The June 2024 Medication Administration Record for Resident #1 documented the resident had received the Augmentin on the afternoon of 06/26/2024 and then twice daily from 06/27/2024 through 06/29/2024. The 06/30/2024 morning dose had been held because the resident was hospitalized . A Nurse's Note, dated 06/30/2024, documented the resident had rashes noted on the resident's entire back, upper extremities, and thigh. The resident's blood pressure was 90/50. A hospital Discharge Summary, dated 07/06/2024, documented the resident had presented to the Emergency Department on 06/30/2024, after the resident had been placed on Augmentin and developed a subsequent maculopapular (a mix of flat, discolored areas of skin and small raised bumps), pruritic (itching), diffuse rash with generalized weakness, nausea, and vomiting. The resident received intravenous methylprednisolone (a medication used to treat severe allergic reactions). A Nurse's Note, dated 07/06/2024, documented the resident was readmitted after being hospitalized for a rash related to antibiotic use. On 11/12/2024 at 1:49 PM, the Director of Nursing (DON) verbalized the hospital discharge summary would be reviewed for allergies when a resident had dementia and was a poor historian, such as Resident #1. The DON verbalized the resident had developed an infection around the resident's colostomy site and received Augmentin (an antibiotic belonging to the penicillin class of antibiotics) in the afternoon on 06/26/2024, and then a morning and afternoon dose on 06/27/2024 through 06/29/2024. The resident was sent to the hospital on the morning of 06/30/2024 after the resident developed a rash. The DON confirmed the hospital discharge summary, dated 06/14/2024, from the resident's hospital stay prior to the resident's initial admission to the facility on [DATE], documented the resident had an allergy to penicillin and the resident's allergies in the facility's electronic health record had not included the resident's allergy to penicillin. The DON confirmed the resident should not have received Augmentin if the resident had a penicillin allergy. The facility policy titled Administering Medications, revised 12/2012, documented allergies to medications would be checked and verified for each resident prior to administering medications. Complaint #NV00072366

Based on observation, interviews, record review and document review, the facility failed to implement the facility policy and procedure for abuse prevention, when 2 of 15 sampled residents (Resident #7, #13), and two unsampled residents (Resident #16, #17) were physically or verbally abused by Resident #6 and ensure adequate measures to protect residents from potential further abuse by Resident #6 were put into place. An Immediate Jeopardy was identified on 03/15/17 at 3:45 PM, due to a lack of protection for residents to prevent physical abuse from one resident. The Administrator was notified. The Immediate Jeopardy was abated at 4:50 PM on 03/15/17. Findings include: Resident #6 Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #6's clinical record indicated the following: The Quarterly Minimum Data Set assessment, dated 1/24/17, indicated Resident #6 exhibited an 8 out of 15 points score on a brief interview for mental status, indicating moderate impairment of memory function and orientation to time. The assessment further indicated Resident #6 exhibited behaviors including verbal and physical aggression, was unable to walk independently, and needed limited assistance from one person for locomotion on the unit in a wheel chair. Review of nursing and interdisciplinary team progress notes indicated the following: On 1/16/17 at 8:15 AM, a Certified Nursing Assistant (CNA) reported Resident #6 slapped a female resident (Resident #16) on the face, first with two fingers, then with an open hand, in a hallway area of the facility. The victim was Resident #6's room mate. No injuries to the victim were noted. Resident #6 gave no explanation and stated she did not do it. On 1/25/17 at 1:37 PM, an Interdisciplinary Team Meeting/Behavioral meeting was held regarding Resident #6. The note indicated Resident #6 was started on [MEDICATION NAME] (a psychoactive medication) 250 milligrams (mg) twice a day on 1/6/17, and was using [MEDICATION NAME] (an anti-anxiety medication) 0.5 mg twice a day routinely, and every 6 hours as needed. The note indicated the resident was on [MEDICAL CONDITION] medications for behavior such as yelling out and striking other residents. The note indicated a recommendation to attempt to reduce [MEDICATION NAME] to 0.5 mg twice a day and every 8 hours as needed. Non pharmacological interventions recommended included meeting the resident's needs and redirecting the resident. The clinical record lacked documented evidence of any additional Interdisciplinary Team Meetings regarding Resident #6's verbal or physical aggression. On 2/5/17 at 8:00 PM, Resident #6 rolled up to a male resident (Resident #17) in the hallway and stated If you don't shut the f*** up right now, I'm going to b**** slap you. Resident #6 slapped Resident #17. The residents were separated. The note indicated Resident #6 was constantly going into other resident rooms, and screaming and yelling at staff and residents, calling them b****** and wh****. The note indicated the resident was redirected with minimal to no success. On 2/6/17 at 5:05 AM, Resident #6 struck a staff member on the face several times and called the staff member a stupid b****. The note indicated the resident was redirected with minimal success. The note indicated the resident continued to roam around the facility, and go into other resident's rooms and became agitated when removed by staff. On 2/6/17 at 11:05 AM, Resident #6's family member was notified regarding Resident #6 striking another resident. The note indicated the family member stated Resident #6 had been having spells during which she cursed and hit, off and on for years. On 2/6/17 at 7:20 PM, a CNA witnessed Resident #6 telling another resident (Resident #7) to shut up, then Resident #6 took off her shoe and hit Resident #7 in the mouth with it. The resident sustained [REDACTED]. The note indicated Resident #6 was separated from other residents by being kept in view of nurses. The note indicated the Director of Nursing was notified. A nursing progress note dated 2/10/17, documented Resident #6 was seen by a psychiatrist to evaluate behavior. The note indicated orders were written to discontinue [MEDICATION NAME] (an antipsychotic medication) and increase [MEDICATION NAME] to 250 mg three times a day. On 2/18/17 at 8:27 AM, Resident #6's room mate (Resident #13) was yelling for help. The nurse entered the room and noted Resident #6 standing over Resident #13 punching her in the face with a closed fist. Resident #6 was removed from the room and asked why she was hitting her room mate. The note indicated Resident #6 stated she struck her room mate because she was running her trap. The note indicated Resident #6 was told she could not put her hands on anyone for any reason. Resident #6 stated,Well, she should shut her trap or I'll do it again. The note indicated Resident #6 calmed down. The Administrator, the Director of Nursing, and the medical provider were notified. On 2/18/17 at 10:45 AM, Resident #6 was placed on a legal hold for threat to others, and local police came to the facility to investigate the incident. Resident #6 was transported to a local acute hospital Emergency Department. On 2/18/17 at 1:27 PM, Resident #6 returned to the facility. The note indicated the legal hold was lifted due to the resident's [DIAGNOSES REDACTED]. On 3/3/17 at 10:48 AM, the note indicated Resident #6 does yell out and curse at staff and other residents. Other documentation regarding behavior indicated the following: Behavior Tracking Forms were initiated for Resident #6 on 2/8/17. The forms for the months of February 2017 and March 2017, indicated the resident was monitored for behaviors including yelling out, use of profanity, refusal of care, and physically aggressive behavior towards others, due to a [DIAGNOSES REDACTED]. The February 2017 form documented Resident #6 had an episode of aggression towards other residents on 2/12/17, which lasted for 8 hours on the evening shift. Interventions included intervene immediately if loud voices or noises are heard. The form indicated the intervention was tried and was not successful. The incident was described as severe. The March 2017 form documented Resident #6 had episodes of being physically aggressive towards others on 3/2/17 and 3/3/17, on the night shift, and on 3/10/17 for day, evening, and night shifts. No interventions were documented. No duration of the episodes or the severity was documented. No information regarding whether the resident was physically aggressive towards staff only, or towards other residents was documented. The clinical record lacked documented evidence a care plan was developed regarding Resident #6's aggressive behavior prior to 3/13/17. The care plan initiated on 3/13/17, indicated a problem of physical and/or verbal aggression towards other residents when they irritate her. The long term goal was to decrease aggressive behaviors. Approaches included assure resident did not get assigned a room mate, assure resident was removed from the area of residents who may be irritating her, and remind resident it was not permissible to yell at or threaten other residents. The care plan was to be implemented by Nursing, Social Services, and All Staff. The clinical record lacked documented evidence of any physician orders [REDACTED].#6. On 3/14/17 at 10:00 AM, a group meeting with nine residents took place. Four of nine residents attending the meeting verbalized a concern regarding a resident who was hitting people, sometimes even while the resident was sleeping. All nine residents at the meeting agreed this was a concern. One of the residents stated If you were a resident here and did not have your wits about you, I would be afraid. On 3/15/17 at 9:50 AM, the Director of Nursing (DON), explained the following: Resident #6 had been involved in four resident to resident altercations in which Resident #6 was the aggressor. The DON expressed the facility was not aware of a history of aggressive behavior prior to admission of the resident. The first incident involving Resident #6's room mate, Resident #16 on 1/16/17, the trigger was not known. The facility responded by moving Resident #16 to another room. The incident involving Resident #17 on 2/3/17, the trigger was determined to be the resident was yelling and Resident #6 was bothered by the yelling. After this incident Resident #6 was referred to a psychiatrist to assess behaviors. The incident involving Resident #7 on 2/6/17, the trigger was the resident was yelling. After this incident Resident #6 was referred for transfer/placement to two inpatient psychiatric facilities, however these facilities declined to admit Resident #6, and the medical provider adjusted Resident #6's medications. The incident involving Resident #6's room mate, Resident #13 on 2/18/17, the trigger was unknown. Resident #13 sustained black eyes. After the incident, Resident #6 was sent to the hospital on a legal hold for danger to others, and police were notified. The DON explained Resident #6 had shown prior aggression only to residents who had behaviors of repetitive screaming and calling out, and Resident #13 did not exhibit that behavior. Further, the two residents had gotten along well. The DON reported nevertheless Resident #13 was offered another room and declined, so a decision was made not to compel Resident #13 to move. The DON revealed subsequently, Resident #6 assaulted Resident #13 in the middle of the night. The DON stated I made a decision which was the wrong move. After the incident Resident #13 was moved to a different room. Regarding the protection of other residents from being harmed by Resident #6, the DON stated the nurses were keeping Resident #6 under observation as they worked in the hallways, or kept the resident under observation near the nurses station. Nursing staff including CNA's intervened if Resident #6 was near other residents. The DON explained continuous 1:1 supervision could not easily be done with available staff. The DON expressed continuous 1:1 supervision would have been given if resources were available. The DON reported Resident #6 had not been aggressive towards other residents since 2/18/17, and was showing fewer behaviors after changes in the resident's medication regimen. On 3/15/17 at 10:50 AM, a Certified Nursing Assistant (CNA) stated she was familiar with Resident #6. The CNA described Resident #6 as a busy lady who could be aggressive with staff and other residents. The CNA reported staff took care to monitor Resident #6 as much as possible, and kept her from getting close to other residents. On 3/15/17 at 10:55 AM, a CNA expressed Resident #6 continued to pose a hazard to other residents. The CNA stated she believed one resident in particular, who had a behavior of frequently calling out, would be the next person to get hit. On 3/16/17 at 10:40 AM, the Registered Nurse (RN) revealed Resident #6 had impulsive behaviors including attempting to walk by herself without assistance. Resident #6 often sat in a reclining chair in the library room adjacent to the nurses station, but could suddenly exit from the chair and get back in to her wheel chair very quickly. The RN reported on 2/18/17, following an altercation with Resident #13 which occurred on the night shift, she received an order to send Resident #6 to the hospital on a legal hold. The hospital lifted the legal hold and discharged the resident back to the facility. The resident returned to the facility the same day, and had no episode of aggressive behavior since. On 3/16/17 at 1:10 PM, Resident #6 was seated in a wheel chair in her room. The resident was calm and was able to answer questions appropriately. Resident #6 did not recall the incidents with Resident #16 or Resident #17. Regarding the incident with Resident #7, Resident #6 stated Yes, I belted her. She was being bossy. Nobody bosses me around. Resident #6 stated regarding Resident #13, I also hit her, in the middle of the night. I'm not sure why. She was in the other bed. Maybe she startled me. Resident #6 denied being bothered by noisy residents and stated she could sleep through that. The facility policy and procedure titled Abuse Prohibition, revised on 10/15, indicated the purpose of the policy was to protect residents from any kind of abuse. The definition of physical abuse included infliction of injury on a resident that occurs other by accidental means. Physical abuse may include such acts as hitting and slapping. The definition of verbal abuse included language used disparaging or derogatory terms to a resident within hearing or seeing distance, regardless of the resident's ability to comprehend. The policy and procedure indicated if another resident was the suspected perpetrator of the abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from all other residents until further orders.

Based on interview, record review, and document review, the facility failed to ensure a resident (Resident #16) was free from verbal aggression, humiliation, and harassment by another resident (Resident #3). Findings include: Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/25/16 at 8:45 AM, Resident #16 approached this surveyor with the desire to report a situation the resident had been experiencing. Resident #16 stated, another resident stirs up trouble. Resident #16 recounted examples of incidents the resident had experienced by Resident #3 as follows. -Resident #3 called Resident #16 a witch. -Resident #3 informed Resident #16 he was going to punch her in the face. -Resident #16 passed out utensils in the dining room and left a set rolled in a cloth napkin at the table for Resident #3. Upon finding out the utensils had been left by Resident #16, Resident #3 stated that's why it smells. -Resident #16 had been tasked with informing the residents about the upcoming Group Interview for the survey process. Resident #16 was seated at Resident #3's place at a table in the dining room before Resident #3 had arrived. Resident #3 arrived in the dining room and began to holler at Resident #16 for being in Resident #3's spot at the table. Resident #16 stated the situations with Resident #3 had been occurring for over a year and something has to change. Resident #3's Care Plan with a start date of 12/18/14, documented the problem as Resident #3 could become irritable and make rude comments towards other residents in the dining room. The indicated approach with a start date of 10/28/15, documented if Resident #3 becomes irritable and makes rude statements toward other residents in the dining room, ask him to leave the dining room for the remainder of the meal. Bring his meal to his room so he can finish it. Remind him that this behavior is not appropriate. On 2/25/16 at 10:25 AM, a Restorative Assistant (RA) reported she assisted in the 100 hall dining room for lunch and dinner. The RA reported hearing comments from Resident #3 and Resident #16. The RA indicated they were grumpy and did not want to hear the other one. The RA recalled hearing them call names but could not remember who called what name. The RA expressed she had not received training on how to deal with the negative interactions between Resident #3 and Resident #16. On 2/25/16 at 10:35 AM, a Registered Nurse (RN) recounted three incidents' between Resident #3 and Resident #16: - Resident #3 called Resident #16 a witch. - Resident #3, with a raised voice, told Resident #16 to get away. - Resident #3 called Resident #16 a derogatory name. The RN explained her instructions had been to attempt to deescalate Resident #3 with verbal reminders the behaviors were inappropriate. Resident #3 was to be instructed to eat in the resident's own room if the resident was unable to calm self down. The RN acknowledged the incidents usually occurred in the dining room. The RN verbalized Resident #3 had provoked altercations with Resident #16. Resident #16 was described by the RN as clamming up in response to Resident #3's remarks. Resident #3 keeps at it if Resident #16 did not have a reaction. Resident #16 would yell back eventually. On 2/25/16 at 10:47 AM, a Certified Nursing Assistant (CNA) recounted an interaction had occurred on 2/23/16 between Resident #3 and Resident #16 in the 100 hall dining room. The CNA explained Resident #3 told Resident #16 you are in my spot, get out of my way. Resident #16 responded to Resident #3, I'm just trying to tell about the meeting. The CNA described Resident #16 as actually crying and hyperventilating. The CNA declared the interventions to assist Resident #3 and Resident #16 with their personal altercations had not been discussed with her. On 2/25/16 at 11:12 AM, a Unit Coordinator recounted an incident between Resident #3 and Resident #16 had occurred in the 100 hall dining room. The Unit Coordinator explained Resident #16 had been passing out the silverware to the residents. Resident #3 was yelling at Resident #16 to get away. Resident #3 verbalized about Resident #16, I smell her. The Unit Coordinator described Resident #16 as being upset and crying with tears welling in the resident's eyes. The Unit Coordinator indicated she not been made aware of any issues between Resident #3 and #16, and had not been advised by the staff on how to handle the situation. On 2/25/16 at 1:00 PM, the Social Services (SS) Designee verbalized Resident #16 approached her on 2/24/16 and wanted to write a complaint against Resident #3. Resident #16 was headed to an appointment and was unable to complete the complaint process on 2/24/16. The SS Designee did not contact Resident #16 regarding the complaint. The SS Designee provided the following information regarding the situation between Resident #3 and Resident #16: -Resident #3 continued to call Resident #16 a witch. -Resident #16 was talking at the table and Resident #3 yelled at her. -Described Resident #16 as tired of being yelled at by Resident #3. The yelling makes Resident #16 mad. Resident #16 had a difficult time ignoring Resident #3 when the yelling had occurred. The SS Designee explained she told Resident #16 if the resident feels threatened by Resident #3, she would talk to Resident #3. On 2/25/16 at 2:30 PM, the Administrator verified she was the Abuse Coordinator for the facility. The Administrator stated Resident #3 and #16 were like brothers and sisters and do not like each other. The Administrator explained she was present for a situation when Resident #16 passed out silverware to the other residents and Resident #3 stated, I knew something stunk. The Administrator verbalized she had heard Resident #3 call Resident #16 a witch on multiple occasions. The Administrator recounted a time Resident #16 was in the hallway seated in a wheelchair awaiting a shower. Resident #3 came out of resident's own room and told Resident #16 not to wait in the hallway because Resident #3 did not want Resident #16 there. The Administrator stated Resident #3 starts it 90% of the time with Resident #16. The Administrator reported Resident #16 had told her Resident #3 made the resident so mad she can't stand it. The Administrator verbalized she had been aware of the problems between Resident #3 and Resident #16 since her arrival at the facility in May 2015. The Administrator conveyed Resident #16 had made a formal complaint to Social Services in the past three weeks. The Administrator was unable to provide documented evidence of a formal complaint on behalf of Resident #16. The Administrator explained she had not considered the verbal altercations abuse and had thought of it as a verbal argument. On 2/25/16 at 3:30 PM, an RN provided Resident #3's Behavior Tracking Form for 02/2016. Making rude comments to others in dining room was the specific behavior tracked on this form. The RN explained the expectation was the CNA's track Resident #3's dining room behavior every shift. The form lacked documented evidence the CNA's observed behaviors for Resident #3 in the dining room from 02/01/16-02/24/16. There were 22 of 48 shifts documented as no behaviors. The other 26 expected entries were missing. Resident #3's nursing progress notes dated 12/10/15, indicated the resident was in a verbal altercation with Resident #16 in the dining room. Resident #3's progress note documented the resident stated Resident #16 got into my space so I told her to get out of my space. She called me a (offensive term) so I called her one. Then she went into hallway to talk to someone. Resident #16's nursing progress notes dated 12/10/15, indicated the resident was in a verbal altercation with Resident #3 in the dining room. Resident #16's progress note documented the resident stated Resident #3 had yelled at Resident #16 to stay out of the resident's business. Resident #16 explained I didn't say anything to him, it was another resident. I came over to tell him it wasn't me. He called me a (offensive term) so I called him one. Then you came and got me and I went to my table. The Resident Council Meeting Agenda dated 12/14/15 documented the Activity Director was in attendance when the New Business section revealed Resident #3 is still being nasty in dining room especially towards Resident #16. Resident #16 feels threatened by Resident #3 and this makes for a disruptive dining experience. Resident #3 is served first and eats three times more anyone. The facility was unable to provide documented evidence of reports or investigations conducted into the allegations from Resident #16 feeling threatened. Resident #16's Social Services progress note dated 02/05/16, documented Resident #16 came into my office today with a concern regarding another resident. She said an incident occurred yesterday when she was in the hallway and another resident accused her of 'stalking' outside his room while she was waiting for the CNA to give her a bath. This has not been substantiated; however, these two residents have a history of not getting along. Resident #3's Social Services progress note dated 02/05/16, documented I spoke with Resident #3 regarding a complaint that another resident made about him concerning a verbal incident that allegedly occurred yesterday outside of his room. He denies having said anything to the other resident, but admitted that he does not like that resident and they don't get along. The facility was unable to provide documentation of this complaint and the process the staff followed to resolve the complaint. Resident #16's Social Services progress note dated 2/18/16, documented resident got into a verbal disagreement with another resident at breakfast. I spoke with both of them that they needed to work harder at not trying to argue with one another. Resident #3's Social Services progress note dated 2/18/16, documented resident got into a verbal disagreement with another resident at breakfast. I spoke with both of them and told them that they needed to work harder at not trying to argue with one another. The Behavior Form for Resident #3 dated 02/2016 did not reflect this incident in the dining room. The facility policy titled, Abuse Prohibition, last revised 10/2015, documented the purpose of the policy was to protect residents from any kind of abuse such as verbal, sexual, physical, including corporal punishment, neglect, misappropriation of property and involuntary seclusion. Prevention of abuse would occur with special attention given to identifying behaviors that increase residents potential for abusing self or others or being the victim of abuse. These behavior include residents with a history of aggressive behaviors. Appropriate interventions to address identified behaviors would be included on the resident's care plan. The interactions between residents would be communicated to the direct care staff and any other staff as appropriate. During the initial reports of abuse, if the alleged abuse and substantiated evidence indicated another resident of the facility is the perpetrator of the abuse, the Administrator shall take steps necessary to protect all residents in the facility from abuse until the alleged perpetrator could be evaluated. During the investigation process, if a resident is the suspected perpetrator of the abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from all other residents until further orders. Attachment #1 of the policy defined the following: Verbal abuse means the use of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation , or offensive physical contact by an employee or agent.

Based on interview, record review, and document review, the facility failed to implement the Abuse Policy once the staff became aware of occurrences and allegations for one resident (Resident #16). Findings include: Resident #16 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 2/25/16 at 8:45 AM, Resident #16 approached this surveyor with the desire to report a situation the resident had been experiencing. Resident #16 stated, another resident stirs up trouble. Resident #16 recounted examples of incidents the resident had experienced with Resident #3. -Resident #3 called Resident #16 a witch. -Resident #3 informed Resident #16 he was going to punch her in the face. -Resident #16 passed out utensils in the dining room and left a set rolled in a cloth napkin at the table for Resident #3. Upon finding out the utensils had been left by Resident #16, Resident #3 stated that's why it smells. -Resident #16 had been tasked with informing residents about the upcoming Group Interview for the survey process. Resident #16 was seated at Resident #3's place at the table in the dining room before Resident #3 had arrived. Resident #3 arrived in the dining room and began to holler at Resident #16 for being in Resident #3's spot at the table. Resident #16 stated the situations with Resident #3 had been occurring for over a year and something has to change. Resident #3's Care Plan with a start date of 12/18/14, documented the problem as Resident #3 could become irritable and make rude comments towards other residents in the dining room. The indicated approach with a start date of 10/28/15 documented if Resident #3 becomes irritable and makes rude statements toward other residents in the dining room, ask him to leave the dining room for the remainder of the meal. Bring his meal to his room so he can finish it. Remind him that this behavior is not appropriate. On 2/25/16 at 10:25 AM, a Restorative Assistant (RA) reported she assisted in the 100 hall dining room for lunch and dinner. The RA reported hearing comments from Resident #3 and Resident #16. The RA indicated they were grumpy and did not want to hear the other one. The RA recalled hearing them call names but could not remember who called what name. The RA expressed she had not received training on how to deal with the negative interactions between Resident #3 and Resident #16. On 2/25/16 at 10:35 AM, a Registered Nurse (RN) recounted three incidents' between Resident #3 and Resident #16: - Resident #3 called Resident #16 a witch. - Resident #3, with a raised voice, told Resident #16 to get away. - Resident #3 called Resident #16 a derogatory name. The RN explained her instructions had been to attempt to deescalate Resident #3 with verbal reminders the behaviors were inappropriate. Resident #3 was to be instructed to eat in the resident's own room if the resident was unable to calm self down. The RN acknowledged the incidents usually occurred in the dining room. The RN verbalized Resident #3 had provoked altercations with Resident #16. Resident #16 was described by the RN as clamming up in response to Resident #3's remarks. Resident #3 keeps at it if Resident #16 did not have a reaction. Resident #16 would yell back eventually. On 2/25/16 at 10:47 AM, a Certified Nursing Assistant (CNA) recounted an interaction had occurred on 2/23/16 between Resident #3 and Resident #16 in the 100 hall dining room. The CNA explained Resident #3 told Resident #16 you are in my spot, get out of my way. Resident #16 responded to Resident #3, I'm just trying to tell about the meeting. The CNA described Resident #16 as actually crying and hyperventilating. The CNA declared the interventions to assist Resident #3 and Resident #16 with their personal altercations had not been discussed with her. On 2/25/16 at 11:12 AM, a Unit Coordinator recounted an incident between Resident #3 and Resident #16 had occurred in the 100 hall dining room. The Unit Coordinator explained Resident #16 had been passing out the silverware to the residents. Resident #3 was yelling at Resident #16 to get away. Resident #3 verbalized about Resident #16, I smell her. The Unit Coordinator described Resident #16 as being upset and crying with tears welling in the resident's eyes. The Unit Coordinator indicated she not been made aware of any issues between Resident #3 and #16 and had not been advised by the staff on how to handle the situation. On 2/25/16 at 1:00 PM, the Social Services (SS) Designee verbalized Resident #16 approached her on 2/24/16 and wanted to write a complaint against Resident #3. Resident #16 was headed to an appointment and was unable to complete the complaint process on 2/24/16. The SS Designee did not contact Resident #16 regarding the complaint. The SS Designee provided the following information regarding the situation between Resident #3 and Resident #16: -Resident #3 continued to call Resident #16 a witch. -Resident #16 was talking at the table and Resident #3 yelled at her. -Described Resident #16 as tired of being yelled at by Resident #3. The yelling makes Resident #16 mad. Resident #16 had a difficult time ignoring Resident #3 when the yelling had occurred. The SS Designee explained she told Resident #16 if the resident feels threatened by Resident #3, she would talk to Resident #3. On 2/25/16 at 2:30 PM, the Administrator verified she was the Abuse Coordinator for the facility. The Administrator stated Resident #3 and #16 were like brothers and sisters and do not like each other. The Administrator explained she was present for a situation when Resident #16 passed out silverware to the other residents and Resident #3 stated, I knew something stunk. The Administrator verbalized she had heard Resident #3 call Resident #16 a witch on multiple occasions. The Administrator recounted a time Resident #16 was in the hallway seated in a wheelchair awaiting a shower. Resident #3 came out of resident's own room and told Resident #16 not to wait in the hallway because Resident #3 did not want Resident #16 there. The Administrator stated Resident #3 starts it 90% of the time with Resident #16. The Administrator reported Resident #16 had told her Resident #3 made the resident so mad she can't stand it. The Administrator verbalized she had been aware of the problems between Resident #3 and Resident #16 since her arrival at the facility in May 2015. The Administrator conveyed Resident #16 had made a formal complaint to Social Services in the past three weeks. The Administrator was unable to provide documented evidence of a formal complaint on behalf of Resident #16. The facility failed to self-report the verbal abuse to required outside agencies. The Administrator explained she had not considered the verbal altercations abuse and had thought of it as a verbal argument. On 2/25/16 at 3:30 PM, an RN provided Resident #3's Behavior Tracking Form for 02/2016. Making rude comments to others in dining room was the specific behavior tracked on this form. The RN explained the expectation was the CNA's track Resident #3's dining room behavior every shift. The form lacked documented evidence the CNA's observed behaviors for Resident #3 in the dining room from 02/01/16-02/24/16. There were 22 of 48 shifts documented as no behaviors. The other 26 expected entries were missing. Resident #3's nursing progress notes dated 12/10/15, indicated the resident was in a verbal altercation with Resident #16 in the dining room. Resident #3's progress note documented the resident stated Resident #16 got into my space so I told her to get out of my space. She called me a (offensive term) so I called her one. Then she went into hallway to talk to someone. Resident #16's nursing progress notes dated 12/10/15, indicated the resident was in a verbal altercation with Resident #3 in the dining room. Resident #16's progress note documented the resident stated Resident #3 had yelled at Resident #16 to stay out of the resident's business. Resident #16 explained I didn't say anything to him, it was another resident. I came over to tell him it wasn't me. He called me a (offensive term) so I called him one. Then you came and got me and I went to my table. The Resident Council Meeting Agenda dated 12/14/15 documented the Activity Director was in attendance when the New Business section revealed Resident #3 is still being nasty in dining room especially towards Resident #16. Resident #16 feels threatened by Resident #3 and this makes for a disruptive dining experience. Resident #3 is served first and eats three times more anyone. The facility was unable to provide documented evidence of reports or investigations conducted into the allegations from Resident #16 feeling threatened. Resident #16's Social Services progress note dated 02/05/16, documented Resident #16 came into my office today with a concern regarding another resident. She said an incident occurred yesterday when she was in the hallway and another resident accused her of 'stalking' outside his room while she was waiting for the CNA to give her a bath. This has not been substantiated; however, these two residents have a history of not getting along. Resident #3's Social Services progress note dated 02/05/16, documented I spoke with Resident #3 regarding a complaint that another resident made about him concerning a verbal incident that allegedly occurred yesterday outside of his room. He denies having said anything to the other resident, but admitted that he does not like that resident and they don't get along. The facility was unable to provide documentation of this complaint and the process the staff followed to resolve the complaint. Resident #16's Social Services progress note dated 2/18/16, documented resident got into a verbal disagreement with another resident at breakfast. I spoke with both of them that they needed to work harder at not trying to argue with one another. Resident #3's Social Services progress note dated 2/18/16, documented resident got into a verbal disagreement with another resident at breakfast. I spoke with both of them and told them that they needed to work harder at not trying to argue with one another. The Behavior Form for Resident #3 dated 02/2016 did not reflect this incident in the dining room. The facility policy titled, Abuse Prohibition, last revised 10/2015, documented the purpose of the policy was to protect residents from any kind of abuse such as verbal, sexual, physical, including corporal punishment, neglect, misappropriation of property and involuntary seclusion. Prevention of abuse would occur with special attention given to identifying behaviors that increase residents potential for abusing self or others or being the victim of abuse. These behavior include residents with a history of aggressive behaviors. Appropriate interventions to address identified behaviors would be included on the resident's care plan. The interactions between residents would be communicated to the direct care staff and any other staff as appropriate. During the initial reports of abuse: -The facility employee who became aware of alleged abuse or neglect of a resident should immediately report the matter to the facility Administrator, Abuse Investigative Coordinator, or designee. -The Administrator or designee is to report alleged abuse or neglect to The Nevada Bureau of Licensure and Certification and The Division of Aging Services Ombudsman Office with initial notice. This notification occurs by submitting the State's Self Report Form of the incident to both regulatory agencies within 24 hours of becoming aware of incident. -If the alleged abuse and substantiated evidence indicated another resident of the facility is the perpetrator of the abuse, the Administrator shall take steps necessary to protect all residents in the facility from abuse until the alleged perpetrator could be evaluated. During the investigation process: -Interviews with all involved parties or potential witnesses will be completed. -Signed statements will be taken from the suspect, the person making the accusations, the resident abused or neglected, and other staff or witnesses. -The Administrator shall keep copies of all notes from the interviews conducted in the course of the investigation. -The Administrator or designee shall be responsible for supervising the investigation and ensuring the final result of the investigation are reported to the Bureau of Licensure and Certification within five working days. Results must also be sent to the Ombudsman Program. -The Administrator is responsible for the residents protection from retaliation during and after the investigation. -An abuse investigation checklist will be utilized when necessary. During abuse or neglect examination and protection: -The shift nurse who is made aware of any allegation of abuse or neglect concerning any resident shall immediately examine the resident involved to determine whether he resident is in any distress or has suffered any injury. The nurse will take steps necessary to protect the resident from danger and document as necessary. -The shift nurse shall assure that the suspected abuser have no further contact with the resident involved or with any further resident. -If a resident is the suspected perpetrator of the abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from all other residents until further orders. -The shift nurse shall call the Director of Nursing as soon as possible to notify him/her of the alleged abuse or neglect. The Director of Nursing shall call the Administrator. -The shift nurse shall call the resident's attending physician and the resident's Guardian, Medical Power of Attorney or responsible party. -The shift nurse shall complete the Accident/Incident Tracking Log. The resident's medical record will have the following documentation: A The nature and extent of any injuries sustained or the condition resulting from the alleged incident. B. Whether the resident was sent to the hospital. C. Whether the residents physician was called. -Once the internal investigation is completed and if the allegations are substantiated, the Administrator will report the findings to the appropriate outside agencies. Attachment #1 of the policy defined the following: Verbal abuse means the use of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation , or offensive physical contact by an employee or agent.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure that staff provided immediate care for one of three sampled residents (Resident #1) at the onset of breathing distress. On [DATE] during breakfast in the 200 Hall Dining Room the Charge Nurse was notified by Certified Nursing Assistant (CNA) 'B' that Resident #1 was gasping for breath and turning color. Due to facility staff neglecting to provide immediate care to Resident #1's change in condition, the resident eventually died . It was determined there were 36 other residents with a [DIAGNOSES REDACTED]. It was determined the facility had not provided guidance to staff regarding emergency procedures for choking victims, from the time of the incident (that resulted in Resident #1's death) through the time of this complaint investigation. An immediate jeopardy was identified and facility representatives were notified of the immediate jeopardy on [DATE] at 2:40 PM. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident had been in the hospital from [DATE] - [DATE] and came back to the facility with [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. Resident #1's Minimum Data Set (MDS), dated , [DATE], documented the resident had memory problems, and was extensive assistance with one person for eating and drinking. The MDS documented the resident was on a mechanically altered diet. Review of Resident #1's progress notes revealed there were 2 documentations by the charge nurse regarding the incident that resulted in Resident #1's death as follows: Resident was in dining room this morning, one of the CNA's noticed the resident had a change in status, she notified this nurse, we immediately took the resident to her room for assessment, DON (Director of Nursing) notified, resident was pronounced dead at 8:13 AM by DON. Family notified at 8:45 AM. at 8:00 AM resident was in dining room, a staff member informed this nurse that resident was holding food in her mouth, upon assessment dyspnea was noted, this nurse took resident to her room, finger sweep with oral suction initiated, copious amounts of pureed food was removed, resident was a Do Not Resuscitate code status, DON notified, no carotid pulse, pupils fixed and dilated, resident was pronounced at 08:13 AM by DON, family notified 8:45 AM. Review of the Facility's Activity Report, dated [DATE]/- [DATE], which documented incidents during this timeframe, there was no evidence of the incident involving Resident #1. The Director of Nursing confirmed there was no incident report. Interviews regarding the events leading to Resident #1's death were conducted from [DATE] through [DATE] with the Director Of Nursing (DON), Charge Nurse, Licensed Practical Nurse (LPN) 'B', Certified Nursing Assistants (CNAs) 'A', 'B', 'C' and 'D' and Nurse Aide in Training 'A'. These interviews revealed the events occurred as follows: On [DATE] at approximately at 8:00 AM Resident #1 was observed in the dining room in distress by CNAs 'A' and 'B'. The CNAs described Resident #1's condition as turning bluish and gasping for breath, Resident #1 looked like she was choking, as if she was trying to get air in and looked frantic. The Charge Nurse was summoned to assist. The Charge Nurse observed the resident briefly and told others to get a crash cart. The Charge Nurse began wheeling the resident to her room. CNA 'A' indicated that Resident #1 quit grasping our hands about halfway down the hall to her room. Resident #1 was placed on the bed with a back board. Resident #1's mouth was finger swept and pureed food was found in the resident's mouth. Suction was applied via a suction machine, but the suction was not sufficient, so another suction machine was obtained. The resident was described as unresponsive the entire time while she was in her room. At some point cardiopulmonary resuscitation (CPR) was initiated. Chest compressions were initiated and an Ambu bag was used. After determining the resident had a Do Not Resuscitate order, CPR was ceased. Resident #1 had no pulse, no respirations and no blood pressure, pupils were fixed and dilated. Resident #1 was pronounced dead. Review of the Facility's Emergency Policy No.3.06, revised May of 2014, documented under section 2. Immediate Care I. Foreign Body aspiration - Clinical Manifestations the following: 1. Inability to speak or breathe 2. Paleness- deep cyanosis 3. Collapse- death occurs in ,[DATE] minutes. [MEDICATION NAME] Maneuver: 1. Stand behind the resident and wrap your arms around his/her waist. 2. Make a fist with one hand and grasp the fist with your other hand. Place the thumb side of your fist against the resident's abdomen slightly above the naval and below the rib cage. 3. Press your fist in the resident's abdomen with a quick upward thrust 4. This action may be repeated several times. If the Resident is Sitting: 1. Stand behind the resident's chair and perform the maneuver in the same manner. During an interview with the Charge Nurse on [DATE] at 12:10 PM, the Charge Nurse said that all he did in the dining room was look at Resident #1 and had the CNAs take her to her room. He said that he could not tell whether she was breathing or not. The Charge Nurse also said that he was not aware of any changes, including in-services that had been provided since the incident with Resident #1. During an interview with Charge Nurse on [DATE] at 10:25 AM, when asked why no immediate care was initiated in the dining room for Resident #1, the Charge Nurse said he did not feel like it would be good for the other residents to see. The Charge Nurse also said he thought he should have performed the [MEDICATION NAME] maneuver but just did not. Review of the Charge Nurse's personnel file revealed his CPR certification was current and did not expire until [DATE]. During an interview with the DON on [DATE] at 10:00 AM, when asked what she felt needed to happen during the incident that did not. The DON said that the resident should have been taken care of in the dining room and that the Charge Nurse should have cleaned her airway in the dining room. During an interview and review of Nurse Aide in Training 'A' written statement on [DATE] at 1:55 PM, Nurse Aide in Training 'A' said during the [DATE] incident that Resident #1 was pulled to the middle of the dining room and that the Charge Nurse was looking at the resident's mouth. Nurse Aide in Training 'A' indicated that Resident #1's head was positioned upwards and Nurse Aide in Training 'A' did not recall the Charge Nurse doing anything physically to the resident. Nurse Aide in Training 'A' said that she was CPR certified and that they should have swept her mouth and done the [MEDICATION NAME] maneuver on Resident #1. Observation of the distance from Resident #1's room, room [ROOM NUMBER] to where she sat in the dining room is approximately 40 feet. During an interview with the Administrator and DON on [DATE] at 2:45 PM, they said that the facility's Quality Assurance Assessment Committee met on [DATE] and they only discussed the posting of the code statuses in the nurse's breezeway, but there was no discussion of emergency care policies or procedures. During an interview and review of CNA 'D's' written statement on [DATE] at 2:03 PM, CNA 'D' said the only thing she was aware that changed since the incident was the facility had implemented posting of the residents code statuses at the Nurse's Station in the breezeway.

Based on observations, interviews and record reviews, it was determined the facility failed to ensure that staff implemented the facility's policies and procedures on neglect and providing immediate care for one of three sampled residents (Resident #1). On [DATE] during breakfast in the 200 Hall Dining Room the Charge Nurse was notified by Certified Nursing Assistant (CNA) 'B' that Resident #1 was gasping for breath and turning color. Due to facility staff neglecting to implement policies regarding immediate care to Resident #1, the resident eventually died . It was determined there were 36 other residents with a [DIAGNOSES REDACTED]. It was determined the facility had not provided guidance to staff regarding policies and emergency procedures for choking victims, from the time of the incident (that resulted in Resident #1's death) through the time of this complaint investigation. An immediate jeopardy was identified and facility representatives were notified of the immediate jeopardy on [DATE] at 2:40 PM. Findings include: Interviews regarding the events leading to Resident #1's death were conducted from [DATE] through [DATE] with the Director Of Nursing (DON), Charge Nurse, Licensed Practical Nurse (LPN) 'B', Certified Nursing Assistants (CNAs) 'A', 'B', 'C' and 'D' and Nurse Aide in Training 'A'. These interviews revealed the events occurred as follows: On [DATE] at approximately at 8:00 AM Resident #1 was observed in the dining room in distress by CNAs 'A' and 'B'. The CNAs described Resident #1's condition as turning bluish and gasping for breath, Resident #1 looked like she was choking, as if she was trying to get air in and looked frantic. The Charge Nurse was summoned to assist. The Charge Nurse observed the resident briefly and told others to get a crash cart. The Charge Nurse began wheeling the resident to her room. CNA 'A' indicated that Resident #1 quit grasping our hands about halfway down the hall to her room. Resident #1 was placed on the bed with a back board. Resident #1's mouth was finger swept and pureed food was found in the resident's mouth. Suction was applied via a suction machine, but the suction was not sufficient, so another suction machine was obtained. The resident was described as unresponsive the entire time while she was in her room. At some point cardiopulmonary resuscitation (CPR) was initiated. Chest compressions were initiated and an Ambu bag was used. After determining the resident had a Do Not Resuscitate order, CPR was ceased. Resident #1 had no pulse, no respirations and no blood pressure, pupils were fixed and dilated. Resident #1 was pronounced dead. Review of the Facility's Emergency Policy No.3.06, revised ,[DATE], documented under section 2. Immediate Care I. Foreign Body aspiration - Clinical Manifestations the following: 1. Inability to speak or breathe 2. Paleness- deep cyanosis 3. Collapse- death occurs in ,[DATE] minutes. [MEDICATION NAME] Maneuver: 1. Stand behind the resident and wrap your arms around his/her waist. 2. Make a fist with one hand and grasp the fist with your other hand. Place the thumb side of your fist against the resident ' s abdomen slightly above the naval and below the rib cage. 3. Press your fist in the resident ' s abdomen with a quick upward thrust 4. This action may be repeated several times. If the Resident is Sitting: Stand behind the resident ' s chair and perform the maneuver in the same manner. During an interview with the Charge Nurse on [DATE] at 12:10 PM, the Charge Nurse said that all he did in the dining room was look at Resident #1 and had the CNAs take her to her room. During an interview with Charge Nurse on [DATE] at 10:25 AM, when asked why no immediate care was initiated in the dining room for Resident #1, the Charge Nurse said he did not feel like it would be good for the other residents to see. The Charge Nurse also said he thought he should have performed the [MEDICATION NAME] maneuver but just did not. During an interview with the DON on [DATE] at 10:00 AM, when asked what she felt needed to happen during the incident that did not. The DON said that the resident should have been taken care of in the dining room and that the Charge Nurse should have cleaned her airway in the dining room. During an interview and review of Nurse Aide in Training 'A' written statement on [DATE] at 1:55 PM, Nurse Aide in Training 'A' said during the [DATE] incident that Resident #1 was pulled to the middle of the dining room and that the Charge Nurse was looking at the resident's mouth. Nurse Aide in Training 'A' indicated that Resident #1's head was positioned upwards and Nurse Aide in Training 'A' did not recall the Charge Nurse doing anything physically to the resident. Nurse Aide in Training 'A' said that she was CPR certified and that they should have swept her mouth and done the [MEDICATION NAME] maneuver on Resident #1. During an interview with the Administrator and DON on [DATE] at 2:45 PM, they said that the facility's Quality Assurance Assessment Committee met on [DATE] and they only discussed the posting of the code statuses in the nurse's breezeway, but there was no discussion of emergency care policies or procedures.

Based on observations, policy review, maintence log review, and staff interviews the facility failed to ensure exit doors and corridor exit discharge was maintained in safe operating conditions as required by 42 CFR 48.70(a) National Fire Protection Association (NFPA) 101, Life Safety Code (LSC) (Tag K038) Section 19.2.1 Every aisle, passageway, or corridor exit discharge, exit locations, and access shall be in accordance with Chapter 7. Exception: As modified by 19.2.2 through 19.2.11. Findings include: An initial tour of the secured unit known as the Garden Court was conducted with the Administrator and the Director of Nursing at 9:30 AM on 9/11/3. The Garden Court consisted of rooms 311-323, with a secured access double door from the 300 wing of the facility. Although access into the Garden Court was unrestricted, a keypad code was required to leave the unit. The capacity of the Garden Court was 26 residents. There were two other exits from the Garden Court. One was identified as a fire exit, located on the outside wall of the dining room, common group area (Door #5). The second exit was a secured door, accessed only by keypad code. This door opened out into a secured patio with locked gate to prevent exit (Door #4). Door #4 had a sign on the inside, indicating this was not an exit. There was a keypad located inside on the wall to the left of the door. Door #4 had a push bar release that would open the door. An attempt to open the door at the time of the tour revealed pushing on the bar would not open the door. In addition, an alarm was sounded and had to be manually turned off by entering a specific code into the key pad. The door would not release to open unless the keypad was turned off. A second keypad was located on the outside wall next to the door. This keypad allowed access from the patio to the unit. Immediately prior to evaluating Door #5's egress and alarm system, the surveyors were informed the facility could not provide any more access to the Garden Court wing per the Administrator. The Administrator informed the surveyors that the facility could not comply with any requests or assist with any further interviews needed by the surveyors. Requests for maintenance logs of the fire alarm/security system, map of facility, policies regarding maintenance, work orders, fire drills or other emergency policies were denied. On 9/11/13: at 9:50 AM, surveyors informed their supervisors regarding the facility's refusal to comply with the investigation. The surveyors were not asked to leave the building but were restricted from any further activity within the facility. On 9/11/13 at 10:50 AM, the Administrator was asked if the facility could assure the surveyors that all the exits were currently working properly and were residents safe (regarding need for evacuation) to which the Administrator replied "I cannot answer that right now" because it related to a complaint (police) investigation. On 9/11/15 at 11:15 AM, the Administrator confirmed she had a conference with the facility attorney and confirmed the following: The facility could not comply with the requests of the surveyors for: 1) maintenance log for door alarms 2) door check logs 3) policies for work orders, process for completing repairs as well as : 4) Inspectors were prohibited from interviewing any employees. The administrator was asked to put these directions from the attorney in writing for the surveyors. On 9/11/3 at 11:45 AM, a second request was made for the items listed above and a request for a written statement from the Administrator regarding the instructions from the facility attorney. The Administrator replied she would not comply with that request. On 9/11/13 at 1:15 PM, surveyors were directed by the State's Bureau office: 1) investigate as much as possible within the restrictions 2) the doors need to be assessed for public safety. On 9/11/13 at 1:30 PM, informed the Administration that tour of fire exits needed to be conducted to ensure safety of all residents regarding fire and/or evacuation need. The Administrator was asked for a facility floor plan map and either Administrator or maintenance staff could accompany surveyors. On 9/11/13 at 2:00 PM, the Administrator acknowledged she would accompany surveyors on tour. On 9/11/13 at 2:30 PM, the Administrator was again requested to provide the facility floor plan map for initiation of the facility and unit tour. On 9/11/13 at 3:00 PM, the Administrator was informed the surveyors were going to start the tour with or without map and staff accompaniment. The Administrator provided the facility floor plan map and stated she would accompany the surveyors. On 9/11/13 at 3:10 PM, the Administrator provided a facility floor plan map and informed the surveyors she would accompany the surveyors at this time. 9/11/13 3:10 PM Tour started at 200 hall and concluded at 3:50 PM. The tour included the Administrator, Director of Nursing and both surveyors. The maintenance supervisor joined the tour at approximately 3:30 PM. Conclusion of the tour: Attempts to open all doors whether they were fire doors or not to evaluate if they were alarmed, was the alarm functioning, did the key pad function appropriately, were the alarms reset appropriately and how safe were the doors to prevent residents, regardless of which wing the residents resided on; from wandering into unmonitored areas. Each door was attempted to be opened the same way: Doors indicated as exits with Exit sign overhead were indicated as fire exits. These doors contained signs mounted on the doors directing "push on bar, alarm will sound, door will release in 15 seconds". Two fire exit doors on 200 Hall. 1) The door from the hallway opened out into a open unrestricted public area. 2) The door from the dining room would not open, nor did an alarm beep or sound. -Fire Exit from East Living room: opened out to open unrestricted public area. -Fire Exit from 300 dining room would not open, nor did an alarm beep or sound. -Exit from 400 hall into employee area: required key pad access, would not open otherwise. -Fire Exit from employee area to exit: opened into parking lot -Fire Exit from 400 hall opened out into public, parking area. -Double Doors to Assisted living facility: no keypad, no alarms, no security to prevent unrestricted passage of residents, visitors or other individuals from either direction. -Exit from West living room opened into enclosed courtyard that is shared with assisted living facility. It was confirmed that there is no keypad security to prevent entrance into assisted living from courtyard. -Exit from main entrance, motion sensitive power doors with keypad locked doors after 6:00 PM. On 9/11/13 at approximately 4:00 PM, surveyors asked the facility to provide a fire alarm test to determine if the two fire exits identified on 200 hall dining room and Garden Court dining room would function properly in a fire/evacuation. Fire Alarm/Door release system was tested with a surveyor standing by each of the specific doors of Garden Court dining room door and 200 hall dining room door in question. Garden court door: Once fire alarm sounded, mesh "Stop" sign removed from across door and door release bar pushed with steady pressure for 60 seconds (wall clock with second hand used). Door did not open. 200 Hall Dining Room door exit: Once fire alarm sounded the door release bar was pushed applying steady pressure for approximately 20 to 30 seconds, the door failed to open. While the alarm continued, a second attempt to open the door was made, this attempt was also unsuccessful. 9/11/13 5:00 PM Maintenance staff repairing fire exits of 200 hall dining room and Garden Court dining room. An interview with the Maintenance supervisor revealed he had determined that the failure of the doors to open were because the magnet spring was too weak to engage alarm system and release doors in question. 9/11/13 6:08 PM Surveyors evaluated staff response to unsupervised egress from 200 hall fire exit. This was performed by one surveyor attempting to open door, and second surveyor remaining at nurses station to observe staff in 200 hall. It was determined that staff cannot hear alarm at nurses station. A computer screen at the "east" nurses' station indicated that door was triggered but computer on east side only indicated doors on east side. The "west" nurses' station computer only indicated doors on west side. Two nurses sitting at west side nurses station were not aware of east side door being accessed. It appeared to take two nurses who were in the 200 hall approximately 3-4 minutes to respond to alarm although they were in this hall at the time of the test. A random interview with one of these nurses revealed she did not initially hear the door alarm because she has hearing loss. 9/11/3 7:45 PM Surveyors were informed the Garden Court fire door in the dining room was working properly, that the alarm will sound when bar release pushed, and will release in 15 sec. Maintenance staff demonstrated that it was working. However, an attempt by the surveyor to open this door was unsuccessful. No alarm sounding, no release after 15 seconds. Several attempts were done with the same result. Maintenance staff then instructed surveyor that release bar has to be pushed forcefully, demonstrated procedure and door functioned properly. Surveyor followed instructions and door did function properly. Surveyor did have to use more force than previous. Surveyor approached random staff member (CNA) who was approximately 30 feet from exit and instructed her to open the dining room exit door. Staff immediately went to keypad to unlock door. Staff stopped and told not to use keypad, that she was to use door bar, as she would in a fire. Staff pushed on door release bar without success of alarm sounding or door release engaged. The Administrator and the Director of Nursing were present at time of these demonstrations and were informed that nursing staff were not able to demonstrate that they could open the door as the maintenance staff indicated they should open it. It was further confirmed that fire doors should be opened with only 15 pounds of pressure required. 9/11/13 Approximately 4:30 PM. An interview with charge nurse on the Garden Court revealed he did not have the key to the gate in the secured patio, nor did he know where the key was. He indicated he thought maintenance had it. The maintenance supervisor indicated during an interview while on the tour that he did not know whether he had a key to this gate. He attempted to open gate with keys on his facility key ring without success. The maintenance supervisor acknowledged he did not have key for this gate on his key ring. He stated he thought the key may be located in "key box" in maintenance office. An interview with a maintenance staff employee fixing the Garden Court fire exit revealed he thought he might have the key on his key ring but that key ring was at his home residence. There was no explanation why the key ring was at this staff person's home. A telephone interview was conducted in the presence of the surveyor by the Assistant Director of Nursing (ADON) and the Garden Court unit manager/supervisor regarding denied possession and/or location of the key to locked gate. The Garden Court supervisor thought maintenance had the key. The facility was informed the gate that egress to the public way area of the parking lot and common grounds for fire evacuation.

Based on review of facility documents, facility policies, self report investigation, clinical record review, on-site observations, staff interviews and interviews with the State Ombudsman office, the facility failed to follow their policy regarding: 1) the prevention of resident neglect, specifically allowing residents to wander outside onto a fenced patio, 2) identifying possible neglect regarding failure to monitor security systems, 3) demonstrate thorough resident event investigation, and 4) reporting of suspected neglect resulting in significant resident injury to state agencies in accordance with State Law for 1 of 1 resident (Resident #1). Findings include: Resident #1 Resident #1 was a resident on the Garden Court dementia unit since 4/2011. This resident was identified with exit seeking behaviors, identified by standing at the secured doors to the unit or opening and closing individual resident rooms. Staff confirmed this resident would also access the fenced patio, going out the unsecured door without supervision. The facility reported that on 8/31/13, Resident #1 eloped out of the facility into a fenced patio, and required acute care hospitalization . Review of the facility policies for Missing Resident 1.22, adopted 1/99 and last revised 12/02, included the following: 1) All exterior doors shall be equipped with a signal that will alert staff if a resident leaves the building. Any exterior door that is supervised during certain periods may have a disconnect devise. 2) Residents at risk for wandering shall be assessed and addressed on the care plan. 3) Prevention protocols included checking and testing door alarms regularly, train staff on on-going basis, test staff response to alarms and monitor residents at risk. This policy did not indicate that Elder Protective Services (EPS) were to be informed of any missing residents or if a resident had injuries related to an unsupervised exit of the building. Review of the facility policies for Abuse Prohibition 1.13, adopted 11/99 and last revised 6/12, revealed the following: Page 1: "Procedure": "The physical environment will be assessed and high risk areas will be identified. This would include evaluation of security devises as to capability and functionality of systems." Page 2: "Initial Steps and reports: ...The Administrator shall provide both the Nevada Bureau of Licensure and Certification and the Division of Aging Services Ombudsman (EPS)office with initial notice of the alleged abuse or neglect." Page 3 "...the Administrator shall be responsible for supervising the investigation and reporting the results of the investigation to" the above named agencies. Review of self report submissions regarding this event revealed the facility reported this event as a resident elopement. The event happened on 8/31/13. The report described Resident #1, a resident on a secured unit was identified as missing at approximately 12:45 PM. A search of the secured unit was initiated. Resident #1 was found collapsed on a patio outside the secured unit. Resident #1 was assessed by the APN (advanced nurse practitioner) who determined the resident required immediate transfer to an acute care facility. The facility filed the initial report on 9/1/13, and the final report was submitted 9/5/13. The self report form indicated availability to document whether other state agencies, law enforcement, responsible parties, physician or other entities were informed of the incident. Neither the initial or final report indicated aging and disability (Elder Protective Services-EPS) services were informed. Neither the initial or final report indicated how Resident #1 was able to access a patio without supervision through a secured door. Two interviews with the Administrator on 9/11/13, and on 9/16/13, revealed the Administrator confirmed the keypad system at the exit door to the patio was not functioning at the time of the event. The Administrator confirmed her investigation revealed staff had not informed her that the system needed repaired. Review of the completed self-report revealed there was no evidence the facility identified the keypad system was not functioning and allowed unrestricted and unsupervised access by residents in the dementia unit to the fenced patio, or that staff failed to inform the Administrator that repairs were needed. Multiple interviews on 9/11/13, 9/16/13 and 9/17/13, with direct care staff assigned to the Garden Court unit, maintenance staff and the Garden Court supervisor/unit manager confirmed they were aware of the keypad access, used to secure the exit door to the fenced patio, did not function properly and a motion sensor was used in place of the secure keypad device. This enabled the door to be unsecured even when no staff was available to supervise resident activity at the exit. Staff acknowledged that without any secure exit, residents could freely go out onto the patio without supervision. Staff acknowledged Resident #1 was one of the residents who had been found unsupervised outside in the patio but could not recall specific dates. Staff acknowledged Resident #1 had exit seeking behaviors. Staff could not confirm the length of time this situation existed but acknowledged it was more than a month, possibly three or four months or longer. The facility could not provide any documentation to demonstrate work orders were initiated to repair the keypad, unable to provide any purchase orders to demonstrate when the motion sensor was purchased or any in-service record to demonstrate staff were trained on the motion sensor purpose or sound. Staff acknowledged the motion sensor sounded frequently due to it's close proximity to two resident bathrooms, but there was no evidence the staff requested the motion sensor to be more appropriately placed to minimize false alerts. Interviews with the Administrator and the Director of Nursing on 9/11/13, revealed they had not been informed about the faulty functioning of the key pad and use of a motion sensor by any of the direct care staff, the supervisor/unit manager for Garden Court or maintenance staff. An interview with a Certified Nursing Assistant (Employee #7) in the afternoon on 9/16/13, confirmed that although she had worked at the facility since 2011, she was not familiar with the missing resident policy and had not attended any missing person drills. Review of Resident #1's clinical record revealed that although this resident was identified as a wanderer, had actually wandered outside the unit into the main facility (6/24/13) and was known to go outside and unsupervised to the patio through the unsecured door, there was no care plan created to identify specific methods for monitoring this resident. In addition, other residents identified as wanderers who resided on the Garden Court unit, revealed no specific methods for monitoring the specific residents after the 8/31/13 event. The facility could not provide any evidence staff was periodically checking the fenced patio to ensure residents had not wandered outside. Interviews with EPS services on 9/19/13 and 10/4/13, confirmed this agency did not receive any documentation from the facility regarding a missing resident, significant injury or possible neglect. Cross refer Tags F 309 and F323.

Based on review of clinical records, facility policies, interviews, review of assignments, facility alarm monitoring and personnel training records, the facility failed to ensure two residents received the necessary care and services to ensure their physical well-being and protect them from unnecessary risks (Resident #1 and #2) . Findings include: Resident #1 Review of the face sheet and care plan revealed Resident #1's initial admission occurred in 2011. Patient #1 required hospitalization ,[DATE]-[DATE] with [MEDICAL CONDITION], and returned to the facility on [DATE]. Resident #1 resided in room [ROOM NUMBER], on the Garden Court unit, a secure dementia unit. Review of the ordered medications revealed Patient #1 was receiving five medications that increased sun sensitivity exposure. These medications were [MEDICATION NAME] and [MEDICATION NAME], which were ordered 8/14/13, and [MEDICATION NAME], HCTZ/[MEDICATION NAME] and [MEDICATION NAME] which the resident had been receiving since April, 2013. Review of Resident #1's care plans revealed identified problems of exit seeking, psych meds and falls, but did not identify increased risks of sun exposure/sun sensitivity related to her medications. There were no specific interventions regarding monitoring due to exit seeking, although Resident #1 had been found wandering in the main facility on 6/24/13. Multiple interviews with direct care staff on 9/16/13 and 9/17/13, revealed the resident would stand by the secure double doors to the main facility and also open and close individual resident room doors. The direct care staff acknowledged they were aware Resident #1 would go outside to a secured patio and come back in independently. It was confirmed that up until 8/31/13, this patio was accessed by a exit door that did not have a secured functioning lock, which enabled any resident to access the patio area without supervision It was also confirmed that a motion sensor was present but did not require any type of reset if the exit door was opened. Review of facility policies revealed 1) Policy: Call System (Alternate) revised 1/2004, was for the purpose of monitoring residents unable to use a call light system, indicated that "All staff " ...Residents will be checked approximately every 30 minutes." Interviews with Administration and clinical nursing staff acknowledged that there was no process in the clinical record to document that this was being done. Intershift documentation used by the CNAs to document behaviors, activities, problems or physical events for the month of August 2013, were reviewed. Resident #1 was identified as exhibiting wandering and exit seeking behaviors. Review of the certified nursing aide duty sheet for 8/31/13, revealed that two CNAs were assigned to the dementia unit. The assignment indicated CNA #10 was assignment 311-317 A and CNA #7 was assigned 317 B-323. Both CNAs and the RN confirmed that although the assignment indicated a specific resident assignment, the staff worked as a team and saw to all residents needs, not just the ones assigned to them. It could not be determined who would be responsible for the 30 minute checks. An interview with Employee #10 revealed she took emergency leave due to a family emergency, leaving the facility at 12:43 PM. Employee #8 relieved Employee #10. Employee #8 assisted with meal service at approximately 12:30 PM. It was also determined that Employee #7 left the unit for an unspecified reason at approximately 12:30 PM. It could not be determined when Resident #1 was last visually checked by any of the three CNAs. Cross refer F 225 Cross refer F 323 Sun Exposure Resident #2 Resident #2 was admitted to the facility on [DATE], with a re-admission on 3/5/13. The resident's [DIAGNOSES REDACTED]. Resident #2 was identified as alert, oriented, able to communicate their needs, and needed assistance with a number of activities of daily living. The resident smoked and enjoyed going outside to the smoking area, which was located directly across from the main nurse's station. Due to a number of chronic conditions which tired the resident, the resident frequently required assistance getting about in the wheel chair, including in and out to the designated smoking area. Resident #2's medications included the antibiotic, Bactrim DS 800-160 milligrams to be given twice a day which was started on 6/28/13. The current course of antibiotic treatment was to continue through 7/5/13. It was also noted the resident had previously been on Bactrim DS 800-160 milligrams twice a day from 6/4/13 through 6/11/13. In review of the drug reference books Mosby's 2012 Nursing Drug Refence and Nursing 2011 drug handbook, the side effects, precautions, interactions, nursing considerations and patient teaching for the drug Bactrim DS include the following: - Side effects, Integumentary (skin) system: photosensitivity, photosensitivity reactions. - Interactions, drug-lifestyle: sun exposure-may cause photosensitivity reactions; advise patient to avoid excessive sun light exposure. - Precautions: UV (ultraviolet) exposure. - Nursing consideration/patient teaching: avoid sunlight or use sunscreen to prevent burns; advise patient to avoid prolonged sun exposure, wear protective clothing and use sun screen. Review of Resident #2's medical record, the facility's self report and emergency room /hospital records indicated the resident had been discharged from the facility on 7/1/13, following an incident where the resident was left unsupervised out in the direct sun for over an hour, and was found to be unresponsive. The facility's self report indicated on 7/1/13, at Resident #2 request, the resident was taken out to the smoking area, by a nursing assistant in training (NAT) at approximately 10:30 AM. The report indicated the NAT had gone back to check on the resident at approximately 11:00 AM, at which time the resident indicated they wanted to stay out a while longer. The NAT asked another NAT to check on the resident when she left to take her lunch break. At 11:52 AM a Certified Nursing Assistant (CNA) noticed the resident was not in the dining room. Knowing the resident's habits, the CNA went out to the smoking area and found the resident unresponsive. Resident #2 was taken to the emergency room and later admitted to the inpatient section of the hospital. The resident was diagnosed with [REDACTED]. Review of Resident #2's care plan failed to identify or address, concerns and precautions to be taken in relation to the increased risks of sun sensitivity and exposure, while the resident had been on Bactrim DS. Review of Resident #2's progress notes failed to provide any evidence that protective clothing, sun screen, or a shaded area, or special instructions had been provided to the resident when the resident went out doors to the smoking area during daytime hours. On 9/11/13 between 9:30 AM to approximately 1:15 PM, observations of the smoking area across from the main nurses' station and resident library, which was routinely used by Resident #2, revealed the area was in full sunlight. There were no benches, tables, umbrellas, trees or other types of structures for providing shade. While there were large windows looking out to the smoking area from the library and if one was in close proximity to knock on the door or window, there was no door bell or other means to call for assistance once one was outside. Cross reference Tag F279.

Based on document review and staff interviews, the facility failed to ensure a resident with photo sensitive medication was identified and provided with appropriate care and services due to a lack of assessment, care plan and staff notification and training as outlined within the correction period of 12/3/13, for 1 of 10 residents (Resident #10), and to identify a formal process to ensure sustained compliance. Findings include: Resident #10 Resident #10 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medications included [MEDICATION NAME] with the most current order date of 7/29/13. [MEDICATION NAME] is an anti-psychotic medication, for which it is recommended additional precautions should be taken during hot weather as there is an increased potential for heat stroke. Based on the signed consent form for [MEDICATION NAME] dated 2/27/13, and further record review indicated the resident had been on [MEDICATION NAME] starting back in February 2013. The resident's care plan dated 10/11/13 and the Resident Centered Care Information sheet, which was undated, indicated the resident attempts to leave the secured unit and had "elopement potential". On 12/10/13, Resident #10's medical record failed to reveal: 1) an assessment had been completed for the at risk weather related medication ([MEDICATION NAME]), or that 2) a related care plan outlining preventative approaches needed during sun and/or weather exposure, had been developed and/or appropriate measures were implemented. The resident's undated Resident Centered Care Information sheet, which was used by staff to provide care and services to the resident, failed to identify weather exposure risk and preventive measures to be used in caring for the resident. On the morning of 12/11/13, an interview was conducted with the Director of Nursing (DON-Employee #2). The DON confirmed Resident #10 had not been identified for at risk weather related medication and preventive measures had not been addressed or communicated to staff prior to 12/10/13. Following this interview, the Administrator (Employee #1) was interviewed. The Administrator was asked if the facility had developed any written guidelines or policy for: 1) following a routine process to ensure comprehensive medication review was completed to identify potential at risk medications, 2) to ensure at risk situations were care planned in a timely manner, and 3) to ensure direct care staff were kept updated of residents' needs. The Administrator indicated the facility had not identified the need to develop such guidelines and/or policy. Review of the facility's training materials, which had been used to address at risk medications, failed to specifically address the situation or processes to use in the identification of at risk medications and the implementation of preventive measures. In discussion with the DON, the DON confirmed the training had been addressed from a general approach to medications and side effects. Review of the Resident Centered Care Information Sheet, with the revised date of 08/12, failed to allow for the identification of medication for at risk for weather related side effects and the implementation of necessary precautions during exposure (long sleeves, hat, etc..). In multiple random interviews with direct care staff, including nursing assistants, on the 100, 200, 300 and 400 Halls, staff indicated they used either or both the resident's care plan and the Resident Centered Care Information Sheets for providing resident specific care. Cross reference Tag F 279.

Based on review of clinical records, observations, interviews, facility policy and safety/maintenance records the facility failed to ensure the resident environment, specifically access to an outside fenced patio on the Garden Court dementia unit, was secure from unsupervised access for 1 of 1 resident (Resident #1) and provided protection from the sun for 2 of 2 residents (Resident #1 and #2). Findings include: Resident #1 Resident #1 was a resident on the Garden Court dementia unit since 4/2011, with primary [DIAGNOSES REDACTED]. Interviews with direct care staff confirmed verbally that Resident #1 exhibited exit seeking behaviors such as standing at the secured doors to the unit or opening and closing individual resident rooms. Direct care staff also confirmed this resident would also access the fenced patio, going out the unsecured door without supervision. Review of the clinical record revealed no specific plan to protect Resident #1's when exiting the unit unsupervised. The clinical record revealed that on 8/31/13, Resident #1 was found outside in the fenced patio at approximately 12:55 PM. This resident was found unresponsive and slumped face down over a picnic table/bench. Resident #1 was transferred to an acute care facility with primary [DIAGNOSES REDACTED]. It was identified Resident #1 had 35-40% second degree burns of her back, buttocks, calves, posterior arms, scalp and neck. It could not be determined how long the resident was alone on the patio. It was also confirmed that the outside air temperature at the time of the event was 92 degrees F. Observations conducted at 9:15 AM on 9/11/13 of the fenced concrete patio, revealed an area approximately 20 by 30 feet surrounded with an iron fence approximately five feet high. There was a gate incorporated into the fence that was locked. The patio had no shade, either temporary (such as umbrellas) or permanent (such as awnings or trees). The only two objects on the patio were a trash receptacle for cigarettes and a picnic table/bench combination. The picnic table was a meshed steel-like metal oblong picnic table with attached meshed metal benches on either long side. There was no protective covering on either the table or bench surfaces to prevent possible thermal burns if contact with skin was made. The table/bench was located in a position that enabled it to be visible through the windows of the activity/sitting/dining room of the secure unit. It was also observed there were draperies on the windows that obscured observation through the window. An interview with the Administrator at the time of this observation confirmed the patio was exactly as it appeared on 8/31/13. This included the location of the table/bench. The Administrator confirmed there was no shade available at the time of the event. The Administrator confirmed that the draperies were closed in the activity/sitting/dining area, preventing visual observation of the patio. Interviews with the Administrator and Director of Nursing on 9/11/13, 9/16/13 and 9/17/13 confirmed that the initial investigation conducted on 8/31/13, revealed the keypad door access to the fenced patio was not working properly. This enabled the door to be opened from either side without any alarm or locking mechanism. A motion sensor had been placed near the exit door on the inside, under the keypad. This sensor would indicate if someone got near this door, but the sensor chime did not need any reset or staff action. These interviews also revealed the location of the motion sensor also detected motion at the two bathrooms located adjacent to the patio door. Review of the maintenance logs revealed weekly checks of door alarms were conducted. There was no evidence the key pad for this door had been identified as not working. Nor was there any evidence the facility was aware that the door allowed easy and unrestricted access to the fenced patio without any alarms being triggered or the door locking mechanisms to not function. Interviews were conducted on 9/16/13 and 9/17/13, with Certified Nursing Assistant (CNA-Employee #7), CNA (Employee #10), Registered Nurse (RN-Employee #9), Garden Court Supervisor/Unit Manager (Employee #4), CNA (Employee #5) and Maintenance Staff (Employee #11). These employees confirmed they were usually assigned to the Garden Court unit. They were familiar with Resident #1. These interviews also revealed staff were aware Resident #1 would exhibit exit seeking behaviors and would be found out in the patio without staff supervision. These employees acknowledged they were aware the door to the patio could be opened without difficulty, allowing residents to exit without restriction. The staff confirmed they were aware the key pad was not functioning, although it could not be substantiated whether this was due to the key pad purposely turned off or was not working properly. All staff acknowledged a motion sensor was placed near the door. Staff identified this sensor as an "alarm". On 9/1/13, it was confirmed the key pad was now working and the motion sensor had been moved to better identify attempts to open the patio door. Interviews with maintenance staff on 9/16 and 9/17/13, revealed there had been a problem with the key pad security for the patio exit door which was why the motion sensor had been in place. It could not be determined how long the motion sensor had been in place or why the keypad had not been repaired. Resident #2 Resident #2 was admitted to the facility on [DATE], with a re-admission on 3/5/13. The resident's [DIAGNOSES REDACTED]. Resident #2 was identified as alert, oriented, able to communicate their needs, and needed assistance with a number of activities of daily living. The resident smoked and enjoyed going outside to the smoking area, which was located directly across from the main nurse's station. Due to a number of chronic conditions which tired the resident, the resident frequently required assistance getting about in the wheel chair, including in and out to the designated smoking area. Resident #2's medications included the antibiotic, Bactrim DS 800-160 milligrams to be given twice a day which was started on 6/28/13. The current course of antibiotic treatment was to continue through 7/5/13. It was also noted the resident had previously been on Bactrim DS 800-160 milligrams twice a day from 6/4/13 through 6/11/13. In review of the drug reference books Mosby's 2012 Nursing Drug Reference and Nursing 2011 Drug Handbook, the side effects, precautions, interactions, nursing considerations and patient teaching for the drug Bactrim DS include the following: - Side effects, Integumentary (skin) system: photosensitivity, photosensitivity reactions - Interactions, drug-lifestyle: sun exposure-may cause photosensitivity reactions; advise patient to avoid excessive sun light exposure. - Precautions: UV (ultraviolet) exposure. - Nursing consideration/patient teaching: avoid sunlight or use sunscreen to prevent burns; advise patient to avoid prolonged sun exposure, wear protective clothing and use sun screen. Review of Resident #2's medical record, the facility's self report and emergency room /hospital records indicated the resident had been discharged from the facility on 7/1/13, following an incident where the resident was left unsupervised out in the direct sun for over an hour, and was found to be unresponsive. The facility's self report indicated on 7/1/13, at Resident #2 request, the resident was taken out to the smoking area, by a nursing assistant in training (NAT) at approximately 10:30 AM. The report indicated the NAT had gone back to check on the resident at approximately 11:00 AM, at which time the resident indicated they wanted to stay out a while longer. The NAT asked another NAT to check on the resident when she left to take her lunch break. At 11:52 AM a Certified Nursing Assistant (CNA) noticed the resident was not in the dining room. Knowing the resident's habits, the CNA went out to the smoking area and found the resident unresponsive. Resident #2 was taken to the emergency room and later admitted to the inpatient section of the hospital. The resident was diagnosed with [REDACTED]. Review of Resident #2's care plan failed to identify or address, concerns and precautions to be taken in relation to the increased risks of sun sensitivity and exposure, while the resident had been on Bactrim DS. Review of Resident #2's progress notes failed to provide any evidence that protective clothing, sun screen, or a shaded area, or special instructions had been provided to the resident when the resident went out doors to the smoking area during daytime hours. On 9/11/13 between 9:30 AM to approximately 1:15 PM, observations of the smoking area across from the main nurses' station and resident library, which was routinely used by Resident #2, revealed the area was in full sunlight. There were no benches, tables, umbrellas, trees or other types of structures for providing shade. While there were large windows looking out to the smoking area from the library and if one was in close proximity to knock on the door or window, there was no door bell or other means to call for assistance once one was out side. Cross Reference Tags F309 and F456.

Based on observation, interview, record, facility policy and manufacturer's instruction review, the facility failed to ensure residents were adequately supervised during a mechanical lift transfer for 1 of 17 residents (Resident #16) and failed to identify and care plan for multiple falls for 1 of 17 residents (Resident #6). Findings include: Resident #16 Resident #16 was admitted to the facility on [DATE] with a current re-admission date of [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #16's record revealed an order written [REDACTED]." The resident's care plan for falls was updated on [DATE] to include, "to be transferred with mechanical lift at all times and 2 person staff assist." Review of Resident #16's record revealed progress notes written at 6:20 AM on [DATE] the nurse was "summoned to room by CNA (certified nursing assistant). At this time found resident lying slightly on Lt (left) side with open wound to Lt forehead bleeding profusely. Applied pressure to wound and stabilized head. Resident alert and crying, able to move arms and legs. Sling removed from between legs. Resident asked if any pain and said yes. Unable to voice location. Wound approximately 2 in (inches) x ,[DATE] in cont (continuous) pressure. EMT (emergency medical technician) arrived and assisted with care. Head and neck stabilized. EMT placing c-spine (cervical) collar resident had seizure lasting approximately ,[DATE] sec. EMT giving care and stabilizing resident. Assisted transfer to back board and transferred to (hospital) emergency room via ambulance. When asked CNA about incident said resident possible slid from sling hitting head on floor." Review of Resident #16's record from the acute care hospital revealed the resident expired on [DATE] at 3:40 PM. The causes of death were listed as cardiopulmonary arrest and intracranial hemorrhage secondary to head trauma. On [DATE], in the morning, the Licensed Practical Nurse (LPN) (Employee #11) who was called to the room, was interviewed and reported the sling was still on Resident #16 when she entered the room. The LPN reported the resident had hit her head on the floor, and she was alert and crying and her pupils were reactive to light. The LPN recalled the EMTs arrived very quickly and that Resident #16 had a possible seizure after their arrival. The resident's eyes rolled back in her head and she became less responsive at that time. On [DATE], in the morning, the CNA (Employee #7) who was assisting Resident #16, was interviewed and reported she had assisted with transferring Resident #16 using the mechanical lift many times. The CNA reported on that morning, [DATE], the orange lift sling for the resident had been put into place by the night shift. The CNA reported she and another CNA (Employee #8), worked together when using the mechanical lift. Employee #7 reported she was the one who was operating the lift. Employee #7 explained the lift legs had to be opened to fit under the bed. Employee #7 demonstrated the lift technique in an empty room. Employee #7 explained the loops on the sling were attached to the sling arm of the lift. Employee #7 reported they were going to put Resident #16 in the wheelchair and somehow Resident #16 fell forward out of the sling while they were trying to transfer her, and she hit her head on the floor. Employee #7 reported she tried to grab the resident, but was not able to hold onto her. On [DATE] in the morning, the second CNA (Employee #8) who had been in the room at the time of the incident, was interviewed and reported they re-positioned the sling under the resident and attached all the loops, using the red loops, on the sling to the sling arm and were in the process of transferring the resident. Employee #8 indicated Resident #16 tended to lean to the left. Employee #8 reported when the lift was about one and a half feet from the bed, Employee #8 was at the end of the bed and was on her way around the bed to assist with the resident's legs when Employee #7 screamed. Employee #8 reported the lift "jerked" and she ran to try to assist, but Employee #7 jumped in front of her from the operating end of the lift to try to grab Resident #16. Employee #8 reported the resident slipped again, and Employee #7 continued to try to grab the resident a second time, but was only able to grab her legs. Employee #8 reported the resident had somehow slipped out of the sling on the left side and hit her head on the floor. Employee #8 reported she then told Employee #7 to lower the resident all the way to the floor and she yelled for help. Employee #8 indicated the resident did not have a seizure while in the sling. Review of the facility's investigation of the incident revealed Employee #8's written statement: "...Hooked up the top straps and sides. We began to lift her in to the air. The legs on the hoyer were closed and (Employee #7) was opening them. I (Employee #8), then came around the side of the bed to get (Resident #16's) legs off. (Employee #7) was slowly pulling hoyer out from under the bed. I asked (Employee # 7) to open the legs of the hoyer. (Employee #7) did. As were were getting ready to turn hoyer to put (Resident #16) into her wheelchair. (Resident #16) had fell out of the hoyer sling. She had her head on the floor." On [DATE], the facility administrator was interviewed and reported the conclusion of the investigation was an unfortunate accident. On [DATE], the survey team asked for a demonstration of the lift using the same sling that had been used on Resident #16 on [DATE]. The mechanical lift was observed to be an Ultralift machine with boom and a sling arm, which was noted to be free swinging and had two aluminum arm attachments with three hook areas, one at each end of the arm, and one in the middle. The demonstration was completed by the Certified Occupational Therapy Assistant (COTA) in an empty room. The sling was observed to be basically U shaped. Surveyor #1, the approximate height and weight of the resident, volunteered to act as the resident. Surveyor #1 was on the bed, and the sling was adjusted for her. The seat belt was fastened and the U flaps were criss crossed and attached to the sling arm. The remaining loops were attached to the sling arm hooks. The red loops were used in the same manner as described by the CNAs to transfer Resident #16. Surveyor #1 was noted to be sitting very upright in the sling. The COTA explained the legs of the lift had to be opened all the way in order for the lift to be stable. The COTA further explained the legs should be in the open position before attempting to move the resident. She then demonstrated how Surveyor #1 would be transferred from the bed to a chair. It was noted with all the straps attached to the sling arm, Surveyor #1 was secure in the lift sling. Surveyor #1 reported the only way she felt she could possibly fall out was through the bottom opening of the sling. The COTA reported to the survey team all staff were inserviced on the use of the lifts to transfer residents after the [DATE] incident. The COTA reported if the lift was used as demonstrated, she had no idea how Resident #16 could have fallen out of the sling. On [DATE], the room where Resident #16 resided, was observed. The floor of Resident 16's room was observed to have a gouge approximately 17.5 centimeter (cm) by 4 millimeter (mm) wide on the floor located approximately two feet from the bed. A second scratch, noted to be approximately 29.9 cm by 1.5 mm was noted to be closer to the bed and night stand, and not as deep as the first scratch. A third scratch, approximately 8.9 cm in length was noted to be on the far side of the night stand. The scratches did not have any dirt or wax build up, and appeared to be fairly recent. On [DATE], the Users' Manual for the electric patient lifter was reviewed and did not contain a step by step procedure on how to safely use the lift. The users' manual recommendation was to "follow a training program designed by your training office." On [DATE], the facility's policy 3.40 (NV), "Lifting Devices" adopted ,[DATE] and revised ,[DATE], was reviewed. The policy outlined: "2. All staff will be instructed on the proper use of the lifts, and each staff person will do a return demonstration in the proper techniques of using the lifts. 3. Each staff person will be trained in the use of the lifts and know the disciplinary action that will be taken if the Policy is not followed." The facility's policy did not provide a step-by-step procedure for the use of the lift. On [DATE], the personnel records of Employee #7 and #8 were reviewed. Employee #7 had a hire date of [DATE]. Review of Employee #7's orientation to the facility did not reveal evidence that use of a mechanical lift had been evaluated. Employee #8 had a hire date of [DATE]. Review of Employee #8's orientation to the facility did not reveal use of the mechanical lift had been evaluated. Review of Employee #8's annual performance evaluation did not include evidence she had been re-inserviced on use of the mechanical lift prior to [DATE]. Complaint #NV 108 Resident #6 Resident #6 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review revealed the following resident falls: -On [DATE], records revealed Resident #6 was found on the floor in the sitting position. The event report, initiated [DATE] and closed [DATE] revealed the resident reported no injury. -On [DATE], Resident #6 fell again. The safety event-falls report initiated [DATE] and closed on [DATE] revealed the resident was found on the floor in front of the dresser trying to button his pants. The resident suffered a skin tear to the left elbow which was cleaned with saline and steri strips were applied. The safety event-falls report revealed preventative interventions were planned but did not identify the interventions to be taken. -On [DATE], Resident #6 fell from his wheelchair. The safety events-falls report initiated [DATE] and closed [DATE] revealed the resident was sent to the hospital emergency room for evaluation. Left forehead and left shoulder abrasions were noted. His forehead was noted to be slightly swollen. -On [DATE], Resident #6 experienced a witnessed fall from his wheelchair and hit his head. The safety events-falls report initiated [DATE] and closed on [DATE], revealed the resident experienced an abrasion to the left upper forehead and skin tears to the top of his head and to the bilateral index finger knuckles. The resident was found to have a blood pressure of ,[DATE]. He was noted to refuse a tabs alarm at the time of the report. The report indicated preventative interventions were planned but did not specify the interventions identified to help prevent future falls. Record review revealed a fall risk assessment was conducted on Resident #6 on [DATE], following the resident's four falls. The assessment revealed the resident was at high risk for falls. The assessment indicated the resident experienced two falls in the past three months when he had actually experienced four falls during the time period. The assessment revealed the resident had a decline in functional status. The resident's prior fall risk assessments dated [DATE] and [DATE] did not identify the resident as high risk for falls. Resident #6's care plan did not reveal his high fall risk as a problem and no interventions were identified to reduce the risk of falls. The use or refusal of the tabs alarm was not addressed in the care plan. No order for the use of a tabs alarm was found. The certified nursing assistants (CNAs) maintained copies of residents' care plans at the nurse's stations to use as a guide in providing care. This resident's care plan did not identify the resident's fall risk or interventions to prevent falls. Review of physical therapy and occupational therapy notes from [DATE] through [DATE] revealed Resident #6 needed supervision and verbal cues for safe transfers. An interview was conducted on [DATE] at 2:30 PM with the CNA assigned to provide Resident #6's care. The CNA revealed the resident was independent in his transfers and did not need supervision.

Based on interview and record review, the facility failed to provide for pacemaker checks as required by the manufactures guidelines for 1 of 11 residents (Resident #8). Findings include: Resident #8 Resident #8 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Records revealed the resident had a Biotronik cardiac pacemaker inserted on 4/30/01. The presence of the pacemaker was noted on Resident #8's history and physical completed in May of 2005. The physical indicated the resident required the pacemaker due to third degree [MEDICAL CONDITION] ventricular heart block. Subsequent physicals dated 6/19/09 and 7/7/09 and 8/1/09 also revealed the resident had a cardiac pacemaker. Review of Resident #8's nursing care plan identified he was at risk for alteration in cardiac status related to the use of a cardiac pacemaker. The start date for the identified problem was 3/1/07. The interventions to prevent the potential cardiac problem was to observe for signs of pacemaker failure and arrange for pacemaker tracings via telephone as ordered. The goal was to provide the resident with pacemaker monitoring checks per schedule by facility and by the medical doctor by next review, with a goal target date of 9/3/08. A nurse's note dated 6/4/09, recorded as a late entry on 6/8/09, revealed social services was to check on whether the resident's pacemaker needed a periodic check. The note indicated Resident #8's care plan was reviewed as part of the quarterly Minimum Data Set (MDS). Record review revealed no evidence the social worker checked on the need for pacemaker checks. Review of physician orders [REDACTED].#8's admission on 7/5/05 to 10/5/09 following the insertion of a new pacemaker. Resident #8's records did not reveal pacemaker checks were done following the 10/5/09 order for the pacemaker checks on a yearly basis. Record review revealed on 8/21/09, Resident #8 yelled for help and was very unsteady on his feet. The resident reported he was very weak and his pulse was found to be 42 beats per minute. He was sent to the nearby hospital for evaluation. The hospital sent the resident via care flight to a larger hospital in another city due to pacemaker failure. The Director of Nurses (DON) was interviewed on 12/9/10. The DON reported she did not know Resident #8 had a pacemaker prior to August 2009. The DON did not know if the current pacemaker had been checked since insertion but thought that the Veterans Administration (VA) might have done a check of the device. The family was contacted and they reported the VA did not check the resident's pacemaker. Resident #8's physician, who was also the facility's medical director, was interviewed on 12/21/10. The physician reported the resident's pacemaker should have been checked yearly and more often as the device approached it's expected replacement date. The pacemaker manufacturer, Biotronik, was contacted on 12/28/10. The company representative reported the model of pacemaker Resident #8 received on 4/30/01 had an average life of six years. The representative indicated the pacemaker should have been checked yearly and more often as the pacemaker approached its expected replacement date. Complaint #NV 564